(Research Scholar)
Who stands between a poor village woman and the health system?
Across rural India, the answer is often an ASHA (Accredited Social Health Activist ) worker. She is one of more than a million women recruited under the National Rural Health Mission since 2005. She escorts mothers to facilities and promotes immunisation for their children. In May 2022, the World Health Organisation honoured ASHAs with its Global Health Leaders Award. The Prime Minister said they stand at the forefront of a healthy India. Yet in Parliament, the same government describes them as community health activists entitled to task-based incentives. They are not workers. They are volunteers. That single word explains why a million women can be praised on stage and underpaid in villages.
This is not merely a story about low pay. It is a story about how the Government decides whose labour deserves to be paid and who to thank. ASHAs are mainly rural women who provide essential health services to marginalised communities. It reflects a deeply gendered assumption that caregiving naturally remains solely within the female domain, a duty deemed unworthy of fair pay or professional dignity. This assumption is particularly important for ASHAs, many of whom are married, widowed or divorced, and many belong to Dalit and Adivasi communities. Thus, both the caregiver and the recipient occupy marginalised positions within the healthcare system and society, too. When the government depends on the underpaid and insecure care of ASHAs, it ultimately compromises its obligations to those marginalised people receiving the care.
The Making of a “Volunteer”
Launched in 2005 by the union government, the ASHA programme has a primary objective of enhancing maternal, reproductive and child health. The program was designed around female volunteers who were closely connected to their own communities and villages. This choice was reflected in policymakers' policy assumption that maternal and child healthcare was primarily a woman's responsibility. Gender was therefore not merely a feature of the program; it shaped the design from the start. Finance Ministry officials avoided creating a large cadre with lifelong jobs and pensions. There were concerns about placing ASHAs on a fixed salary, as it might lead to underperformance, similar to that of Anganwadi workers. Performance-based pay was intended to maintain high productivity while preserving the program’s adaptability. Others saw the mission as temporary. The Union government anticipated that regional governments would grow stronger and eventually take full responsibility.
The assumption that poor women can spare time for volunteer work is deeply problematic. The cost of that assumption falls on women. Meanwhile, the number of paid tasks for ASHAs rose from 6 in 2005 to 38 in 2017. The work grew, but the status did not. An analysis in The News Minute (2025) says ASHAs were never conceived as health system workers. Yet they perform services for the system under the officials' instruction.
The Work Behind the Word “Volunteer”
Look at what an ASHA actually does. She is often the first port of call for women and children. Her tasks are many and varied. She refers and escorts women to facilities, counsels them on safe delivery and breastfeeding, and promotes immunisation. Studies credit ASHAs with more institutional deliveries, earlier newborn visits, and wider vaccination coverage. Some Governments also ask them to list people with hypertension, diabetes and cancers, and to encourage screening. Yet some of those tasks carried no incentive.
Then COVID-19 arrived, and ASHAs tracked and monitored patients and visited quarantine centres twice a day. They also surveyed 25 to 50 households daily. Estimated hours of working rose from two or three a day to about twelve. Some walked long distances in temperatures as high as 46 degrees. Protective gear was inadequate, and handkerchiefs or dupattas sometimes stood in for masks. Some ASHAs were even asked why they needed masks. When extra masks became available, they often went to higher-level health staff instead.
Now set that workload beside the pay. ASHAs are paid for time only in narrow cases, such as training and monthly meetings. Otherwise, they earn incentives per task. Parliament was told in March 2025 that the fixed monthly incentive was ₹2,000. One example is one rupee per oral rehydration packet. Payments can take months to arrive, and many ASHAs pay travel costs from their own pockets. Many take second jobs to feed their families. Call it honorific labour: work paid in praise, not in wages.
When the Law Looks Away
Labour law protects workers, and the volunteer label keeps ASHAs outside it. A study published in the Health and Human Rights Journal calls that designation deliberate. They add that ASHAs may be the least empowered cadre of India's workforce. If a grievance procedure fails them, ASHAs have no legal safeguards to fall back on. Governments, the authors add, can design incentives with minimal accountability. The same authors say the Code on Wages Bill left honorarium-paid volunteers out of its definition of worker. The gap is legal, not accidental.
In May 2013, the 45th Indian Labour Conference discussed scheme workers, including ASHAs. Advocacy reports say it urged recognising them as workers. They add that minimum wages and social security should follow. Yet Parliament still calls ASHAs volunteers. In October 2018, The Leaflet reports, ASHAs in Madhya Pradesh besieged the chief minister's house. They demanded minimum wages and, it says, were lathi-charged.
Courts have looked at a neighbouring scheme differently. In April 2022, the Supreme Court held that anganwadi workers and helpers are entitled to gratuity: that ruling concerned anganwadi workers, not ASHAs. Still, the Supreme Court treated their honorarium as wages under the Payment of Gratuity Act in 2022. An honorary label did not end its inquiry. The Gujarat High Court later set aside a direction to frame a regularisation scheme for such workers. It found absorption into Class III and IV posts unfeasible. So, the courtroom offers ASHAs only a partial and uncertain path forward. WHO's 2018 guideline points the same way. It recommends pay commensurate with job demands, and written agreements for paid workers covering duties and rights.
Gender, Caste and the Price of Speaking
Gender runs through every layer of this story. Ved and colleagues in the journal Human Resources for Health use a scale that ranges from gender-blind to gender-transformative. Where does the ASHA programme sit? Its early design, they write, was instrumentalist, built to serve health system demands. Later reforms widened access to income and safety. Yet tensions around gendered social and employment status remained, the authors conclude. Some stakeholders doubted ASHAs' demands for higher pay. That doubt reveals an expectation that women health workers stay altruistic, acquiescent, and apolitical. The selfless woman is a convenient figure for any budget.
Caste cuts through the ranks of ASHAs, too. Lower-caste ASHAs were sometimes unable to visit higher-caste homes and faced discrimination from other health workers. Higher-caste ASHAs sometimes avoided lower-caste areas. Becoming an ASHA does not change a woman's caste identity. So the subaltern is layered, not uniform. Ved and colleagues record sexual harassment by other health workers and community members. In 2016, an ASHA was gang-raped and died afterwards. Family members sometimes belittled ASHAs when pay arrived late or proved extremely low. Heavy domestic duties and movement restrictions also curtail their work.
Speaking up has carried a price for ASHAs. In 2020, Madhya Pradesh threatened to dismiss 22 ASHAs after they demanded better pay and protective gear. Haryana and Delhi filed police cases threatening termination for absence on protest days. On 21 January 2026, thousands of ASHAs protested in Kolkata to demand a fixed monthly honorarium of ₹ 15,000. The protest turned into clashes with the police. Opposition parties alleged police atrocities, while officials promised to clear pending dues. The meeting brought no assurance on the ₹15,000 demand. Here, the act of speaking invites threat and delays.
Two Governments, One Underpaid Woman
Ask who should pay ASHAs, and two governments point at each other. The Centre told the Rajya Sabha in March 2025 that support for ASHAs lies with the Governments. Governments may add incentives of their own. In July 2025, Parliament heard that the Centre had raised its fixed monthly incentive to ₹3,500. The Ministry said that further wage hikes fall mainly under the Government's jurisdiction. In the Andaman and Nicobar Islands, the NHM incentive rose from ₹2,000 to ₹5,000 from April 2026. The local MP said the change followed his representation. Such discretion shows how far pay depends on negotiation rather than entitlement.
Kerala shows the cost of this arrangement most clearly. ASHAs began a day-and-night protest outside the Secretariat on 10 February 2025. Their demand was a ₹21,000 honorarium and ₹5 lakh for retirement benefits. As reported, approximately 26,000 ASHAs in Kerala were facing extensive delays in the payment of honoraria and incentives. Marking the 50th day of demonstrations, protesters shaved their heads. A hunger strike was called off after 43 days. The sit-in itself ran 266 days, ending on 1 November 2025.
Days earlier, the Government had added ₹1,000. That lifted the honorarium to ₹7,000, which leaders called a partial victory. The union said the state Government had pointed to the Central Government. Earlier, in March 2025, the Health Minister said Kerala had not provided a utilisation certificate. A Kerala MP said the minister had misled the House. According to a May 2026 report by Kerala Kaumudi, the newly elected government approved a further ₹3,000 hike.
The same story repeats across Governments. In Telangana, over 28,000 ASHAs urged the Government to release the pending July honorariums. Many said payments never reached their accounts. They receive an honorarium of ₹9,900 and demand a fixed salary of ₹18,000 with PF and ESI. They also ask for job security. In Mysuru, about 1,800 ASHAs reported that their honoraria were delayed for three months in January 2026. Many depend entirely on those payments for their livelihood. In Srinagar in February 2026, a union demanded coverage under the Minimum Wages Act. One protester said a couple of thousand rupees cannot sustain a family.
These protests span Kerala, West Bengal, Telangana, Karnataka, Jammu and Kashmir and Madhya Pradesh. The problem is structural, not the failure of one government. A fair critique cannot spare the Left-led government that then ruled Kerala. The subaltern deserves that honesty from their advocates.
What the Government Has Done Right
A fair account must also credit the Government. Several changes have improved ASHAs' position, even if they stop short of worker status. In 2018, the Prime Minister announced doubling routine incentives. Free insurance cover under two national schemes was announced alongside it. In 2025, the Centre raised the fixed incentive to ₹3,500. ASHAs may also earn team-based incentives of up to ₹1,000 a month. The recognition amount for ten years rose from ₹20,000 to ₹50,000. Ayushman Bharat health cover was extended to ASHAs, anganwadi workers and helpers in February 2024. By September 2026, over 44.81 lakh cards had been issued to these three groups.
This further includes gains such as scholarships, residential training with crèches, and a role on a village committee. Bank transfers reduced skimming by higher-level functionaries, the same study notes. Health facilities were also required to create safe overnight restrooms for ASHAs. These are real gains, and they deserve acknowledgement. Yet each gain came through executive decisions, not through a statutory right. The health cover carried no extra budget. According to the central government’s own reply, ASHAs are still health activist and their incentives are also piece rate.
The increase in ASHAs' incentives is not necessarily adequate in remuneration for them. The insurance coverage that they get does not compensate for low or irregular payments. A one-time recognition amount cannot replace long-term financial security. The Centre's maintained classification of ASHAs as health activists also raises a fundamental question: if their work is essential to the public health system, why does that contribution not translate into stronger employment protections? If welfare provisions are governed strictly by administrative decisions and shifting regulations, what legal or institutional remedies do workers have when payments are delayed, benefits are denied, or policies are changed? The core issue is not an outright lack of government intervention, but that state measures have fallen short of resolving the systemic vulnerability in ASHA work. Recognition by a medal is not recognition by law.
The Other Side of the Argument
Serious objections are entitled to a rigorous and objective review. The first argument is financial, since raising compensation levels might divert essential resources away from alternative health services. Primary care accounts for 44 per cent of health spending. The second argument is that formal employment might turn ASHAs into routine government extension workers, diluting their organic community focus that makes them successful in the first place. The third argument is that absorbing a workforce of this scale into government posts may not be feasible.
Nevertheless, none of these points justifies that ASHAs should be left completely without a baseline level of social or financial protection. It means that altruism and labour protection can coexist. Salaried health workers are already active in remote, underdeveloped, and hard-to-reach communities across India.
Ultimately, the question is not whether governments are subject to financial and administrative constraints. Rather, it centres on how those constraints are structurally distributed. If the public health system relies fundamentally on ASHAs to bridge the gap with local communities, why should the workers themselves bear so much of the financial risk? Why should they have to protest repeatedly to get better remuneration, and what institutional mechanisms are available when their grievances are ignored? The Centre and state governments must move beyond recognising ASHAs as indispensable in policy statements and establish what they owe these workers in practice. The long-term sustainability of the public health system requires not only the commitment of its workers but also a reciprocal commitment to their financial security and dignity.
What Recognition Would Look Like
What would constitute an equitable resolution? To begin with, it requires acknowledging ASHAs as official workers, as the 2013 Labour Conference reportedly urged, guaranteeing them minimum wages and social security benefits. Second, guarantee on-time payment, without months of delay. Third, give ASHAs a written agreement covering duties, working conditions, pay and rights, as WHO advises; fourth, end threats of dismissal against ASHAs who protest. Fifth, enforce the safety measures that national guidelines already promise. Sixth, let ASHA unions help shape their work. Each step costs money, yet the government has already demonstrated it can secure some funding.
Praise Is Not a Wage
Return to the medal, the speech and the accolade. What ASHAs demand again and again is equitable remuneration and legal recognition as workers. While verbal praise costs little, they have heard plenty of it. In Kerala, they sat outside the Secretariat for 266 days and shaved their heads. These women endure with a double marginalisation. They stand at the village margin and at the margin of the labour hierarchy. Yet they carry the Government's health promise to other margins. A government that asks so much of them owes them more than a medal.
The designation of "activist" hides the work, the actual labour performed. Calling ASHAs volunteer while paying them per task and treating their professional work as a “gift”. The volunteer label is not a loophole; rather, it is intentionally designed in that way. The feminisation of labour highlights how gender stereotypes associate women with care, service and self-sacrifice. This association reinforces workplace inequalities and makes women's work appear to be altruistic duties rather than matters of fair remuneration and formal recognition. Real recognition arrives as a wage, financial security, a contract and a legal right. Until they get that, every medal, the speech and the accolades are only a polite thank-you.
References.
Academic
• Ved R, Scott K, Gupta G, Ummer O, Singh S, Srivastava A, George AS (2019). How are gender inequalities facing India's one million ASHAs being addressed? Human Resources for Health 17:3. https://doi.org/10.1186/s12960-018-0338-0
• Shanthosh J, Durbach A, Joshi R (2021). Charting the Rights of Community Health Workers in India: The Next Frontier of Universal Health Coverage. Health and Human Rights Journal 23(2). https://hhrjournal.org/?p=13676
• Wichterich C (2021). Protection and Protest by “Voluntary” Community Health Workers: COVID-19 Authoritarianism in India. Historical Social Research. https://www.ssoar.info/ssoar/handle/document/75997
• Marwah V (2020). Wages of Liminality: How an In-between Status Lowers the Earned Wages of Women Health Workers. https://law.utexas.edu/humanrights/projects/wages-of-liminality-how-an-in-between-status-lowers-the-earned-wages-of-women-health-workers/
• ePaper on ASHAs in New Delhi, Graduate Institute repository (abstract). https://repository.graduateinstitute.ch/record/320298
Government, courts and international bodies
• Lok Sabha reply on remuneration to ASHA workers. https://eparlib.nic.in/bitstream/123456789/985262/1/AU5049.pdf
• Rajya Sabha Unstarred Question 2233, 19 March 2025. https://rsdebate.nic.in/bitstream/123456789/757611/1/PQ_267_19032025_U2233_p489_p494.pdf
• Lok Sabha reply on the Indian Labour Conference, 9 December 2013. https://eparlib.nic.in/bitstream/123456789/649642/1/148861.pdf
• WHO India, India's ASHA workers win Global Health Leaders Award. https://www.who.int/india/india-asha-workers
• PTI, ASHA workers at forefront of ensuring healthy India: PM (23 May 2022). https://english.udayavani.com/article/asha-workers-at-forefront-of-ensuring-healthy-india-pm/1279409
Analysis, advocacy and legal reporting
• The News Minute, Who cares for the carers? https://www.thenewsminute.com/amp/story/kerala/who-cares-for-the-carers-calling-out-the-exploitation-of-ashas
• SabrangIndia, Dignify our Work, Recognise us as Workers: ASHA workers tell Govt. https://sabrangindia.in/dignify-our-work-recognise-us-workers-asha-workers-tell-govt/
• The Leaflet, Fair wage is about the rights of anganwadis, so why are ASHA workers denied minimum wages and benefits? https://theleaflet.in/fair-wage-is-about-rights-of-anganwadis-so-why-are-asha-workers-denied-minimum-wages-benefits/
• LiveLaw, Anganwadi Workers & Helpers Are Entitled To Payment Of Gratuity: Supreme Court (25 April 2022). https://www.livelaw.in/amp/top-stories/anganwadi-workers-helpers-are-entitled-to-payment-of-gratuity-supreme-courtmaniben-maganbhai-bhariya-197496
• SCC Online, Guj HC: Anganwadi workers entitled to living wage (26 August 2025). https://www.scconline.com/blog/post/2025/08/26/guj-hc-anganwadi-workers-entitled-to-living-wage/
• HIFA, Thematic Discussion on Community Health Workers, Part 2 (WHO guideline recommendations 7 and 8). https://hifa.org/node/96840091
News reports
• Onmanorama, Fixed monthly incentive for ASHA workers hiked to ₹3,500 (25 July 2025). https://www.onmanorama.com/news/kerala/2025/07/25/asha-worker-incentive-increase-centre-health-ministry.amp.html
• Nicobar Times, Monthly incentive for ASHA workers in Andaman & Nicobar enhanced to ₹5,000 (22 July 2026). https://nicobartimes.com/local-news/monthly-incentive-for-asha-workers-in-andaman-mp-welcomes-decision/
• PTI, ASHA workers end protest outside Kerala secretariat after 266 days (1 November 2025). https://www.theweek.in/wire-updates/national/2025/11/01/mes19-kl-asha-protest.html
• Onmanorama, ASHA workers' protest to end on November 1 (31 October 2025). https://www.onmanorama.com/news/kerala/2025/10/31/asha-workers-protest-to-end-on-november-1.html
• Kerala Kaumudi, 266 days in front of the secretariat; day-and-night strike of ASHA workers to end today. https://keralakaumudi.com/en/kerala/general/266-days-in-front-of-secretariat-day-and-night-strike-of-asha-workers-to-end-today-1638767
• Kerala Kaumudi, ASHA workers call off 266-day protest following honorarium hike (May 2026). https://www.keralakaumudi.com/en/kerala/general/asha-workers-call-off-266-day-protest-following-honorarium-hike-actor-premkumar-joins-victory-celebrations-1750890
• News Arena, Kerala: ASHA workers shave heads on 50th day of protest. https://www.newsarenaindia.com/states/kerala-asha-workers-shave-heads-on-50th-day-of-protest/40259
• Asianet Newsable, Kerala ASHA workers intensify protest on May Day. https://newsable.asianetnews.com/kerala-news/kerala-asha-workers-intensify-protest-on-may-day-set-to-rally-from-kasargod-to-thiruvananthapuram-auk/articleshow-0mbwdvc
• Onmanorama, Health minister assures hike in ASHA workers' pay, says all dues to Kerala settled (11 March 2025). https://www.onmanorama.com/news/kerala/2025/03/11/health-minister-jp-nadda-asha-workers-pay-kerala-dues-settled.amp.html
• Telangana Today, Telangana ASHA workers seek release of pending July honorariums (August 2026). https://telanganatoday.com/telangana-asha-workers-seek-release-of-pending-july-honorariums
• The People's Board, ASHA workers stage protest over pending honorarium (9 January 2026). https://www.thepeoplesboard.com/news/asha-workers-stage-protest-over-pending-honorarium/
• Greater Kashmir, ASHA workers stage protest in Srinagar (12 February 2026). https://m.greaterkashmir.com/article/asha-workers-stage-protest-in-srinagar/478084
• All India Radio News, ASHA workers stage protest in Kolkata seeking Rs 15,000 monthly honorarium (21 January 2026). https://www.newsonair.gov.in/asha-workers-stage-protest-in-kolkata-seeking-rs-15000-monthly-honorarium
• Deccan Herald, Centre hikes honorarium (September 2018). https://www.deccanherald.com/national/centre-hikes-honorarium-692267.html
• Outlook Money, Interim Budget 2024: Ayushman Bharat Now Covers ASHA, Anganwadi Workers, Without A Specified Budget Allocation. https://outlookmoney.com/insurance/interim-budget-2024-ayushman-bharat-now-covers-asha-anganwadi-workers-without-a-specified-budget-allocation
• Asianet Newsable, PM-JAY completes 8 years (September 2026). https://newsable.asianetnews.com/india/pm-jay-completes-8-years-covers-over-60-crore-people-jp-nadda-articleshow-koqhsrq