That day, KP Rosamma’s electricity at home in Vizhinjam would be cut. Bina of Puthenthope would again face the landlord’s wrath for delaying the rent for the second month. Sini from Vithura would see a doctor at the government hospital where she works but not be able to buy the medicines prescribed. All three of them could not afford to meet these basic needs because the little honorarium they were to get for working as the government’s Accredited Social Health Activists (ASHAs) had again been delayed for two months, and the incentives missing for three.
ASHAs come under the National Health Mission scheme to provide every village with a 'female community health activist' to work as an interface between the community and the public health system. Apart from providing basic awareness on health matters, ASHAs take special care of pregnant women and young children in the ward they are assigned to. Many of the women who have taken out a protest in Thiruvananthapuram this February have been working as ASHAs for 18 years since the programme was launched in the state in 2008.
On February 17, when TNM met the women who were forced to take out yet another strike in front of the Thiruvananthapuram secretariat, they only had the minimum demands to make.
“Pay our pending dues, change the honorarium scheme (from Rs 7,000 a month) and give us the minimum wages of Rs 21,000, and allow retirement benefits for those they have now asked to retire on reaching the age of 62,” says Rosamma, who is the district president and state vice president of the Kerala Asha Health Workers Association. The KAHWA has been sitting on protest, raising a few banners and slogans, since February 10, with ASHAs joining the strike from across the state, as far as Wayanad.
On February 18, the ninth day of the strike, reports came out that Finance Minister KN Balagopal sanctioned the funds for paying the pending honorariums of two months. By February 19, Health Minister Veena George stated that it has been decided to give honorariums of three months to the ASHAs, without conditions, from Wednesday. There is no word yet on the pending incentives (of Rs 2,000 a month) that are to come from the Union government. The ASHAs say that they will continue the strike till their demands are met.
Hundreds turn up every day to sit under the scorching sun, even as they find it hard to afford the trip from home to the protest site. Sini, who had missed buying her medicines, still spent the Rs 100 it would take her to come to protest. “After spending days under the sun, I have become unwell. But even at the hospital I work at, I need to take an OP ticket for Rs 5 to see the doctor, and sometimes we would not even have that left in our purses,” she says.
How the honorarium and incentive works
Their woes are in no way exaggerated if you take into account the terms in which they even get the honorarium of Rs 7,000 from the state and the incentive of Rs 2,000 from the Union government every month. “We have a number of different tasks to complete every month, for each of which we earn a certain amount. Only if we complete all these tasks – attending meetings, helping with OP duty, palliative visits, and so on – would we get the full honorarium. Often this is reduced to Rs 5,500 or so when some of the ASHAs are unable to complete all the tasks. After 10 days of finishing all these tasks, we do fieldwork—house visits for checking on the health issues of people, making sure babies are taken for vaccines, and submitting reports every day. Sometimes it takes multiple visits and a lot of time to get one baby’s injection done, and for this single task, we would get Rs 20. Ten such injections would bring Rs 200. That is how our incentives work,” says Sheeja, an ASHA from Puthukurichy.
In recent years, the ASHAs have been asked to use the Shaili app, launched by the State Digital Health Mission, to carry out risk assessments for lifestyle diseases. “We have to install this app but we are not given smartphones for it. We are expected to have them and have a postpaid connection,” says Sini.
The ASHAs are allotted Rs 200 a month for charging their phones, but this, they say, in no way covers the calls they need to make to finish their tasks. “For ensuring a single child’s vaccination, I may need to make calls worth Rs 150. So for the rest of the month, I will need to pay on my own for all the work calls,” Sheeja says.
Like Sini, Saju from Vizhinjam too had been unwell after a uterus surgery some months ago. “But still I am tasked with climbing uphill with junior health inspectors to work on another app issued by the Health Department, after the Shaili app. We can’t raise this with anyone for fear of losing our jobs,” she says.
Talks with government
The women are not happy with the talks they have had with the Minister of Health Veena George or with the statements of the Finance Minister KN Balagopal in the past few days. While both of them pledged their support for the ASHAs, their responses have not gone down well with the protesting workers.
“We told the minister (Veena) she could create history if she withdrew the (now on-hold) directive asking ASHA workers to retire by the age of 62. We joined this cause when it was launched in 2008. Many of us have been working as ASHAs for 18 years now. In the beginning, it was voluntary when we needed to work only according to our convenience and help the health centres with a few basic tasks – such as reporting about the pregnant women in a ward, about the births and deaths, and about children needing vaccination. In the years afterwards, they began giving an honorarium of Rs 500 and raising it while increasing the number of tasks and reducing the number of ASHAs per ward to one. We were told that we would be with the project for as long as it lasted and there would be no age limit. Now we have to work seven days a week and be available every hour with our diary updates, but we have to retire without any retirement benefits?” asks Rosamma.
In a statement released by the Union Ministry of Health and Family Welfare in November 2024, the government has approved an amount of Rs 20,000 to be given to the ASHAs who leave the programme after working for a minimum of 10 years. The protesting workers outside the Secretariat say that this retirement age of 62 has been sprung on them without the promise of any benefits or pension. “We have been working for 18 years and many of the women have worn their legs down from all the walking we have done for all this time. After spending all our prime years with the Health Department, they want us to leave now without any benefits. There are widows among us, women without partners, and women living alone away from their children. The government should at least give an amount of Rs 5 lakh as retirement benefits so the ASHAs can live the rest of their lives with dignity and not depend on anyone else or be abandoned on the street,” says Jaya, an ASHA worker from Thiruvananthapuram.
On top of the retirement concerns, Minister Balagopal’s insinuation that the ASHA workers may have been politically driven by other “agencies” has offended some of the protestors, who ask if the minister meant that women could not think or act on their own. “We do not wish to strike against the government; we are forced to every time our pay is delayed and it is only when we protest that we get it,” Rosamma says.
The ASHAs have held several strikes before, mostly for the same reasons of pending dues. Balagopal said that the delay comes because the Union government had not been allotting funds for the incentives and the state had to bear that too in previous months. Minister Veena commented that she had been asking the Union government for an increase in honorarium for the ASHAs and Kerala is already the state that gives out the maximum honorarium in the country.
A release by the National Health Mission said that the Union government had not transferred any funds to the state in 2023-24 for giving incentives, and the state had paid those, in addition to the honorarium. However, the ASHAs say that the NHM claim that they earn a monthly income of about Rs 13,000 is incorrect since they hardly even get the basic honorarium and incentive (if all tasks are met, it will come to less than Rs 10,000).
"Not a paisa has increased in the incentive for all these years. We have to shell out everything from our purses. Not a paper or pen is given, no umbrellas or bags are provided when we need to walk in the sun for so long every day, not even travel expenses. The government is always talking about women empowerment, but this is what has been happening," says Komalakumari from Vizhinjam.
On February 20, the striking workers will hold a protest march around the Secretariat with their families.