Despite shouldering multiple responsibilities, they are at the bottom of the health services hierarchy.

The feisty army of women ASHA (accredited social health activists) workers are at the frontline of India’s healthcare system. During the peak of the Covid-19 pandemic, for instance, these women performed the crucial but unpopular task of identifying and getting infected patients tested and isolated, even as they battled large-scale vaccination hesitancy.

Despite their immense contribution, the ASHA workers have a raw deal. They have no regular income but a string of incentives, which are paidafter much red tape and delays. It is, in short, a thankless job that comes with economic and emotional violence as well as societal disrespect and disregard.

Ever since the National Rural Health Mission was enacted (2005), the role of the ASHAs has only widened. From child immunisation to handling deliveries and providing family planning guidance, from malnutrition to identifying TB patients, these women have discharged their duties with no regular compensation. And yet, the health system takes pride in noting that the 10.47 lakh ASHA workers nationwide constitute what must be the world’s largest community health force.

Of late, ASHA workers have been in the news for striking work in several states, demanding fair wages. While a lot is known about the ‘tasks’ an ASHA worker is expected to perform, very little is known about what she faces in her personal and professional life in the course of duty, given the deep patriarchal mindset in both rural and urban India. Recent reports from Maharashtra spoke of how some of them were harassed for using a plastic penis that was part of the medical kit to counsel young couples about family planning. “They are corrupting our wives,” was the oft-quoted comment.

Researchers from the Karnataka Health Promotion Trust (KHPT), University of Manitoba, Winnipeg, Canada, and the MS Ramaiah University of Applied Sciences have recorded the travails of the ASHA worker in their report ‘Investigating violence against Accredited Social Health Activists (ASHAs)‘, published in the Journal of Global Health Reports. The mixed methods study involving a survey of 396 workers from the two rural districts of Bagalkot and Koppal in North Karnataka reveals some shocking facts about the lives of ASHA workers.

It showed that 88 per cent of ASHAs reported economic violence perpetrated largely by beneficiary families and senior co-workers. These included nurses and doctors. The report noted that since “the ASHA is the intermediary between patients and senior healthcare staff, she is exploited into requesting money from patients on behalf of those above her.” At another level, official health workers who supervise the ASHAs write adverse reports out of spite to block payments. And beneficiary families of health schemes hold the ASHAs responsible for any delay or shortcomings in payments or compensation. They are also blamed for the higher `fee’ or bribes demanded by staff at primary health centres (PHCs).

Many of the 73 per cent who reported emotional violence ascribed it to the disrespect shown by families of beneficiaries due to “their positioning as women challenging traditional power dynamics and household practices” when it came to family planning and guidance provided to pregnant women. Disrespect was also shown by co-workers who considered them at the bottom of the hierarchy. Thirty-two per cent ASHAs said they experienced sexual violence and 26 per cent physical violence. The last two were mostly at the hands of their husbands.

Says Mallika Tharakan, lead, knowledge management, KHPT, “The ASHAs stand like lone warriors in the villages. But the community and the state have the responsibility to provide her a safe space and supportive environment where her services are valued, and she is respected.”

Adds Mohan HL, CEO, KHPT, “They need to be viewed as part of the community and not as an outreach health worker from the health department. ASHAs should work closely with community structures and panchayati raj. This will help her extend her reach, get more incentives and community support.”

Clearly, formalising their work and providing regular compensation could go a long way in improving their situation.