India’s Public Health Labour Crisis

For over two months now, a section of Kerala’s 26,125-strong community of Accredited Social Health Activists (ASHAs) have been on a day-night agitation on the streets demanding better remuneration and retirement benefits. While the agitation gained much attention and was also raised in Parliament, the issues raised by the ASHAs remain unresolved.

Who are ASHA workers?

• ASHAs or Accredited Social Health Activists are female health workers who work at the village level.
• They are part of the National Health Mission which started in the year 2005.
• Their key tasks include:

  • Mobilising women for institutional deliveries and antenatal care

  • Supporting immunisation and family planning

  • Promoting hygiene and nutrition

  • Managing basic health data

  • Supporting outreach during public health emergencies, as seen during COVID-19

• India has more than ten lakh ASHA workers. They form the backbone of the rural health system, especially in states with low doctor-patient ratios and limited infrastructure. Yet, they are still legally considered "volunteers", which means they do not get a fixed salary, job security, or social protection.

Key Issues in Focus

• Informalisation of Public Sector Work: ASHAs are technically government service providers but legally remain outside the formal workforce. This blurs the line between volunteerism and labour exploitation. It reflects a broader trend of informalisation of work in essential public services.
• Gender and Labour Rights: ASHAs are all women, and their under-compensated work reflects the undervaluation of women's labour, especially in care work. This also reinforces systemic gender inequality in the labour market.
• Centre-State Fiscal Politics: Health is a state subject under the Constitution. But national schemes like NHM depend on central funding. When the Centre delays payments or caps its share, states are forced to make tough choices. This case shows how vertical fiscal imbalance impacts service delivery and labour welfare.
• Public Health Capacity and Soft Infrastructure: ASHAs are essential for India’s health outcomes — from maternal care to vaccination drives. Yet, their working conditions show a mismatch between policy intent and state capacity. Without investing in this soft infrastructure, public health goals cannot be achieved.

Required Measures (Way Forward)

• Regularisation with Safeguards: The government can gradually absorb ASHAs into the health system as contract or auxiliary staff with job protections, insurance, and pensions.
• Reform NHM Employment Model: The National Health Mission should be restructured to ensure guaranteed payments, annual revision of incentives, and a clear grievance redressal mechanism.
• Ensure Centre-State Financial Coordination: Timely release of NHM funds and a more flexible funding model is essential. States should be allowed to innovate while the Centre guarantees minimum standards.
• Institutional Dialogue: Instead of ignoring or discrediting unions like the Kerala ASHA Health Workers’ Association, governments should engage with them to develop sustainable models of worker inclusion and welfare.