The Accredited Social Health Activists (ASHA) of Kerala have been striking in front of the state Secretariat since February 9, demanding better wages and benefits, including an increase in their honorarium from Rs 7000 to Rs 21,000, and a retirement benefit of Rs 5 lakh. The immediate trigger for the protest is the non-payment of dues to over 26,000 ASHA workers in the state.
The strike is aligned with a series of similar protests that have been held across various Indian states by community health workers.
This article draws from the authors’ work with community health workers (CHW) of Kerala, Tamil Nadu, Madhya Pradesh, and Andhra Pradesh, and aims to situate the ASHAs’ struggles within the context of gendered neoliberal healthcare, affective labour, volunteerism, and care work.
Neoliberal economic policies produce, and reproduce, social and economic inequalities, with informalisation of labour as one of its tools. This has resulted in the proliferation of precarious work with subsequent dilution of labour rights.
Precarious work thrives on affective labour, which is often invisibilised and exploited, and disproportionately targets women, since it is considered a ‘natural’ extension of their gendered roles as ‘carers’ and ‘nurturers’. Volunteerism involving unpaid or underpaid work is built on the idea of affective labour and is often regarded as a moral duty of civic engagement.
As neoliberal economic policies have systematically dismantled public welfare frameworks, the State has actively encouraged volunteerism as an alternative to publicly funded care and social services. Consequently, the responsibility of collective welfare has been transferred to individuals, groups, or communities, effectively obscuring the State’s withdrawal from providing social support.
For instance, initiatives such as AmeriCorps in the United States of America and the Big Society programme in the United Kingdom (2010–2016) encouraged volunteer efforts to address deficiencies in education, elder care, and poverty alleviation, often with the help of women and marginalised communities who were already burdened with unpaid caregiving responsibilities.
Today, even formal care sectors, such as nursing or childcare, remain low-wage, with women constituting 70-80% of global care workers. In the USA, Black and immigrant women continue to bear the disproportionate share of home health aide positions, subsisting at meagre salaries.
Further, through the glorification of unpaid care to the status of a moral virtue, neoliberalism obscures its dependence on exploited labor, especially the emotional and reproductive work of women.
In the wake of the COVID-19 pandemic, efforts like the UK’s NHS Volunteer Responders programme recruited 7,50,000 volunteers, many of them women, to deliver groceries and medicines — tasks once handled by paid professionals.
In a similar vein, initiatives such as food banks, which have become widespread in countries facing austerity like the UK, rely significantly on volunteers, often women, to tackle food insecurity, making charity a standard response instead of advocating for fair wages or wealth redistribution.
Nurses are frequently celebrated as ‘angels’ for their compassionate care in emergencies such as the COVID-19 pandemic, but their emotional contributions are still not financially recognised. These instances clearly exemplify how women’s emotional labour is undervalued under the garb of ‘care’ work.
It then appears that neoliberal volunteerism embodies a contradiction — it honors altruism while facilitating systemic exploitation, perpetuating gendered and class-based hierarchies under the pretense of civic responsibility. It is idealised as a moral obligation while masking systemic exploitation, especially of women, by presenting care as a communal duty instead of an economic one.
Unsurprisingly, healthcare systems have increasingly adopted the principles of neoliberal public management, to informalise and, in turn, exploit the affective labour predominantly performed by women. Despite being 70% of the health workforce, women occupy less than a quarter of the senior management positions.
A recent document by the World Health Organisation succinctly states, that the health sector is delivered by women and led by men.
Engaging women as volunteers in the delivery of healthcare services has a long history and is a global phenomenon. The Alma Ata Declaration of 1978 centred the idea of comprehensive primary healthcare (CPHC) around CHWs with them playing an indispensable role in the delivery of basic care services.
However, the neoliberal restructuring of the healthcare system and the consequent insufficient investment in the public health sector have led to the continued reliance on low or unpaid voluntary work by CHWs, the majority of whom are women.
Within this framework, ‘good health at low cost’ has been employed as a rhetoric to ‘(dis)empower’ women who possess an “inherently altruistic, acquiescent, and apolitical nature” who can manage their own health as well as their families and communities. Further, their unpaid, affective labour has been projected as a reflection of the ‘autonomy’ of these dutiful, accountable actors.
The gender-based segregation in jobs in the healthcare system, both vertical and horizontal, vividly demonstrates its patriarchal and neoliberal influences. Gender norms and stereotypes severely constrain women’s representation in positions of power, and predominantly relegate them to jobs that are mostly undervalued and underpaid.
Further, it restricts their opportunities to meaningfully engage with their work when compared to their male counterparts working in the same cadres or grades.
An excellent example of this would be the clear differentiation in the responsibilities practically delivered by the male Junior Health Inspectors (JHI) and female multipurpose workers called Junior Public Health Nurses (JHPN) in the primary health centres of Kerala. Although both categories of workers have a significant role in delivering comprehensive primary health care, in practice, the JPHNs are overburdened by myriad responsibilities including documentation.
On the other hand, in many settings, the JHIs hold a powerful position as bridges between the healthcare system and the local self governments. The human resource shortage adds to the workload of JPHNs, leading them to feel marginalised and sidelined from the planning process that is part of decentralised governance in the state.
This marginalisation gets multiplied when gender intersects with caste, race, ethnicity, or religion. A clear demonstration of this disadvantage is the precarious labour – insecure jobs, inadequate incentivisation, poor working conditions, and lack of social security and protection – experienced by CHWs from the healthcare systems across the globe.
Some of these challenges include lack of or inadequate remuneration, denial of stipends to support work-related travel, resource deficits affecting their credibility in the community such as stock out of medicines, lack of uniform and badges for identification as health workers, poor supervision and inadequate training to provide the services needed in their communities.
The volunteers say that their actual responsibilities significantly outweigh what was initially outlined in terms of number of tasks, difficulty level of work involved, and the hours required. This naturally clashes with their gendered domestic responsibilities, necessitating family or spousal support as an essential prerequisite to continue working.
CHWs across the world face judgement, stigma, harassment, and other gendered challenges to personal safety, as part of their work.
The ‘volunteer’ status of CHWs precludes any accountability from the system towards their comfort, safety, or security. The lack of support from the system, which fails to provide opportunities for career advancement, improved financial independence, or poor integration within the very system they toil for, has deeply unsettled this group of workers, who in many settings, form the foundation of CPHC.
Accredited Social Health Activists were introduced in India as a new cadre of CHWs, under the National Rural Health Mission in 2005, to strengthen the CPHC with an emphasis on improving maternal and child health of deprived sections of the population. As per the latest data, there are approximately one million ASHAs in the country, forming the world’s largest government-led CHW programme.
While the basic idea was to bridge the gap between the healthcare system and the community, ASHAs were never conceived as workers of the healthcare system, despite them performing services for the system under the instruction of public health officials. Rather, they were categorised as activists who should be situated in the community and work as ‘honorary volunteers’ with no regular salary or employment benefits.
A typical day of an ASHA involves around 8–12 hours of work, entailing long travels between villages, often times in extreme weather conditions, yet without access to any protective gear or healthcare support from the health system in times of illness, all with the promise of a meagre honorarium barely enough to support a family. Their honorarium, which varies across states, (ASHAs from Kerala receive Rs. 7000 per month) is complemented by performance-based incentives.
Much has been discussed about the significant contribution of ASHAs in implementing multiple national health programmes and campaigns, and in improving the health of communities in general and deprived sections in particular. Through the Global Health Leaders Award, the WHO has recognised their contributions in shouldering the COVID-19 pandemic. ASHAs incessant work during the pandemic to deliver basic services to those in quarantine, and to compensate for the disruption of routine services has been appreciated.
However, in the process, they continue to bear the cost for it in the form of extreme risk to themselves and to families, loss of lives, and experiences of stigma, as well as social boycotts from the families and communities, with no additional incentives.
While there is no denying the fact that ASHAs have managed to gain recognition in the community owing to their link with the system, this is just one side of the story. Given the enormous amount of work they routinely undertake, especially within the target-oriented framework of neoliberal public management, continuing to label them as ‘volunteers’ rather than ‘workers’ is perhaps the greatest irony of all. The nature of their work makes it completely unjust to assess their contributions merely based on measurable targets or tasks.
The public healthcare systems of south Indian states such as Kerala and Tamil Nadu are much celebrated for their health indicators, attributable to their functional primary health care systems. However, beyond the rhetoric, it is debatable whether these systems truly recognise the invaluable contributions of community health workers in maintaining the functionality of the system on a day-to-day basis, as they navigate numerous systemic and community-level challenges.
ASHAs’ work in delivering routine maternal and child health services including universal immunisation and documentation, along with other permanent cadres of CHWs, particularly in remote and hilly terrains of Wayanad or Nilgiris is unparalleled. In addition to the personal costs of the work such as reduced family time, leading to marital and other familial discord, many also bear huge economic costs due to the inadequate and irregular remuneration.
The fact also remains that the list of targets added to ASHAs routine work seem to be never ending. Every new initiative has an additional task etched out for the ASHAs, some of the examples being their newly added tasks in the National Tuberculosis Elimination Programme, prevention and control of non-communicable diseases, both at the national level and as part of state level schemes like Makkalai Thedi Maruthuvam.
The multifaceted roles assigned to ASHAs in Kerala’s reformed CPHC scheme under the Ardram Mission reiterates the state’s dependence on their labour.
Digitisation is another initiative that consumes a lion's share of the work hours of ASHAs. While initially propagated as a way to ease out their workload, multiple reports from various states have highlighted their struggle in the digital documentation process, owing to inadequate digital literacy, limited or no training, poor infrastructure and connectivity, to double documentation and added burden.
Working with communities is fraught with challenges. The community perceives ASHAs as representatives of the healthcare system. In situations where the credibility of the public health system is questioned, such as during a pandemic, ASHAs often encounter the disdain and frustration of the communities.
Tragically, the same system labels them as ‘volunteers’ and keeps them at bay. Many ASHAs continue the work despite debts and financial constraints as they realise the significance of their work to the community, and value the social bonds and recognition they have earned through their work.
Although the job description expects them to work for about 2-3 hours per day, the truth remains that more often than not, they are overburdened with tasks and targets that they have hardly any time left to take up an alternate employment to meet their needs.
It is a well-established fact for decades now that the vision of CPHC cannot be achieved without ASHAs, as they perform one of the most challenging forms of care work, necessitating a healthcare provider to rely on her soft as well as hard skills.
While the Indian State aspires to provide last mile care to all by using these skills, it exploits ASHAs’ affective labour and in the process undervalue and invisiblise them. This is nothing new, but yet another instance of a gendered neoliberal governance, one that uses rhetoric to romanticise women’s unpaid labour while denying them opportunities of upward social mobility.
We agree with the argument of the Kerala state and its allied trade unions that the pending honorarium and the demand for better wages for ASHAs are to be met by the union government. Having said this, the dispassionate stance of the government toward the ASHA strike is disheartening on several accounts.
The insinuations of the political and trade union leaders that this is a politically motivated strike looks unfounded as these demands have been repeatedly raised by ASHAs across India for over a decade now. It is one thing to be unable to meet their demands, but it is an entirely different matter to invalidate their struggles.
The least the state could do is extend camaraderie and solidarity with this strike. The government’s response, instead, reflects a form of benevolent patriarchy that romanticises women’s achievements and struggles as long as they silently serve the system. But the moment they question the system, they are met with abuse, humiliation and even denial of basic respect.
The government needs to remember that the foundations of Kerala's internationally lauded public healthcare system are built on the foundations laid by these women.
Now that medical professionals have come out in support of their strike, it is imperative that the government realises that the repercussions of this strike could not only affect the motivations of healthcare professionals in the public health sector, but also sabotage hard earned achievements.
Malu Mohan is a Chennai-based independent public health researcher.
Sapna Mishra is an assistant professor at Easwari School of Liberal Arts, SRM University, Andhra Pradesh.
Sreenidhi Sreekumar is a post-doctoral fellow at the Institute of Public Health, Bengaluru.
Views expressed are the authors’ own.
