By Professor Satya Narayan Misra in Bhubaneswar, March 6. 2025: As the strike by about 26000 Accredited Social Health Activists (ASTHA) enters its 21st day in front of the Kerala Secretariat, the Centre and State’s lack of sensitivity towards this marquee Scheme to connect the marginalized community to the health care system has become manifest.

The ASHA workers are pleading to be recognized as workers and given their fair due by increasing their honorarium and improving their retirement benefits. Similar strikes were noticed in Bihar, Jharkhand, and Haryana earlier. The genesis of these ‘volunteer community leaders’ and their contribution are fascinating stories rarely played out in mainstream media and are obsessed with political slugfests or corporate glitterati.

The ASHA worker initiative was mooted as part of NRHM (National Rural Health Mission) in 2005, with an ASHA in every village as a port of call for any health-related requirement of the marginalized sections of the community to act as a bridge between them and the district health centers. ASHAs are the first entry point for health services relating to women and children, creating community awareness on nutrition, sanitation & hygiene as well as promoting good health practices and conducting referrals to district hospitals.

Considered as ‘voluntary community leaders,’ their onerous mission includes motivating women to give birth in hospitals, bringing children to immunization clinics, and encouraging birth control. They are the depot holders for ORS therapy, IFA tablets for combating anemia, oral pills, and condoms. They guide communities on health, sanitation, and nutrition and support material and child health by facilitating immunization and safe deliveries.

With a minimum educational qualification of 10th grade, they receive a fixed salary of Rs 4000 per month, with an incentive of Rs 600 per institutional delivery. Presently there are about 9.39 lakh ASHA workers, which should ideally be about a million. Recognizing and lauding the tremendous efforts of a million ASHA workers towards surveillance, contact tracing, awareness generation, and COVID-related duties during the pandemic, the WHO 2022 honored them with the Global Health Leaders Award.

The institutional delivery % has improved from 38.7% in 2005-2006 to 88.6% in 2019-21 as per NFHS Surveys, largely due to their pioneering efforts at the grassroots. Though they play a crucial role in India’s health care system, particularly in rural areas, they are often the butt of harassment, being called too far away villages under the pretext of medical emergencies and facing harassment for the distribution of condoms and promoting sex education.

Some of the key issues affecting ASHA workers are low wages and irregular payments, lack of social security benefits, poor working conditions, limited training, vulnerability to harassment, and scant career advancement opportunities. The COVID-19 pandemic exacerbated the challenges faced by ASHA workers, with the increased workload, risk of infections, and inadequate protective measures. Thomas Piketty had termed COVID19 as a timely’ wake-up call for every country to look at its health policy improvements in health infrastructure’.

A study was undertaken by the author under the aegis of an ICSSR (GOI) project to study the ‘’role and impact of ASHA workers in combating COVID119 in the Khordha district of the state of Odisha. An in-depth study in urban, semi-urban, and rural areas was conducted with samples of 360 (210 ASHA workers and 150 beneficiaries) using stratified random sampling and cluster sampling methods. Questionnaires were prepared to ascertain usefulness, difficulties, and suggestions and evaluated based on a SERVQUAL model introduced by Parasuraman, Zeithami and Berry (1988).

About 74% of the beneficiaries agreed that ASHAs responded immediately in case of emergency while 88% felt they were courteous, helpful, and recorded the details. They played a crucial role in explaining the importance of safety measures like social distancing and hand washing. 83% reported that they took active measures during mass vaccination. The major components of the SERVQUAL model are reliability, assurance, tangibility, empathy, and responsiveness. 88% voted that the services provided were reliable, 84% voted for assurance and 79% were empathetic and responsive in providing services, even as late as 2 am in the night in the event of emergency.

The study showed that no PPE kit consisting of a thermal gun to check for temperature, oximeter, or apron, was provided. Only sanitizers and masks were made available to them. The essential items were to be bought from RS 10000 provided by the state government. The masks provided were of poor to very poor quality as reported by a majority of 51 % of Asha workers. The study recommended that technology can be a powerful tool in the hands of ASHAs in record keeping (tracking immunization, health chart, etc) that will lessen the tedious paperwork in practice.

Three types of technologies can be useful to the ASHA workers, viz assistive, facilitative, and connecting. The assistive technologies can be in the form of smart phones or tablets, duly supported by facilitative technology that deals with the software front. The connecting technology will help supervisors to monitor and the beneficiaries can reach the ASHAs online. This will take primary health care to a transformational level.

Raghuram Rajan in his widely acclaimed book “The Third Pillar” said how the state and market are leaving behind the community and the need to have a synthesis between these three pillars. ASHA workers are a critical pillar of community health care in India. Through enhanced training, technology integration, and policy support, ASHA workers can transform into empowered agents of change. The famous biologist EO Wilson has presciently observed: “We have stumbled into the 21st century with stone age emotion, medieval institutions and Godlike technology.’

Given the apathy of our institution and general lack of accountability, mobile applications for data collection, telemedicine for remote consultations, the AI-empowered tools for diagnosis can enhance capacities and improve the accuracy of health care services. There is a need to engage with the ASHA workers’ organizations to develop better pay regimes with the right to decent work and recognize them as workers with the right.

By transforming ASHA workers into informed health educators, digital health champions, and integral components of the healthcare ecosystem, India can move closer to achieving the SDG 3 Goal of Health Care for All. The commitment, perseverance, and compassion, as studies have shown, have been the foundation of our community health volunteer program’s success, despite the heaviest odds, deprivations, and lack of parity and rights that they suffer.

As we celebrate Women’s Day, a comprehensive approach rather than a confrontational political approach, is needed that integrates the ASHA workers into the broader mosaic of the healthcare system and will pave the way for a healthier and more equitable India, particularly for the vulnerable and marginalized communities.