Kerala ASHA workers live on hope as promised wage hike remains elusive

As women health care workers' protest enters 30th day amid political blame game, ADITI PHADNIS explores the Centre-state funding ratio debate

Since their cohort was created in 2005, Accredited Social Health Activist (ASHA) workers have been a bulwark of India’s basic health care delivery system. But as their strike in Kerala enters its 30th day, activists camping under makeshift tents outside the Thiruvananthapuram Secretariat have pledged to escalate their protest. At its core is a single demand: “Pay us what you promised.” 

Kerala has around 26,000 ASHA workers, a small fraction of the 1.1 million nationwide. Yet, their protest has drawn extensive attention, particularly from the Opposition in the state.

  Last week, several senior Bharatiya Janata Party (BJP) leaders, including Shobha Surendran and P K Krishnadas, endorsed the strike, calling on the state government to take responsibility. Union Minister Suresh Gopi joined the workers in the pouring rain. Leaders from the Congress-led United Democratic Front (UDF), including Ramesh Chennithala and P K Kunhalikutty, have visited the protest site and criticised the Left Democratic Front (LDF) government for ignoring the workers’ concerns.  Meanwhile, the Centre of Indian Trade Unions (CITU) has dismissed the strike as “anarchist” and “politically motivated”.

  The LDF government, now in its second consecutive term, had promised in its 2021 manifesto in 2021 to increase ASHA workers’ daily honorarium to ₹700, up from ₹232 they currently receive. This would amount to around ₹21,000 a month.

  However, the state government blames the Centre for the delay in enhanced wages. A statement from State Health Minister Veena George’s office said the Centre was yet to release ₹636.88 crore as its share for National Health Mission (NHM) schemes in 2023-24 citing Kerala’s failure to meet its “co-branding” commitment. Others in the Communist Party of India (Marxist) (CPI(M)) term the ASHA workers’ demands “unreasonable”.

  Leader of Opposition V D Satheesan told Business Standard that this was a spurious argument. “Since health is a state subject, it is the state’s responsibility to address the honorarium issue,” he said, pointing out that CITU leaders had raised the same issue in Haryana during an ASHA workers’ strike there, arguing that health is a state subject.

  In Parliament and outside, the Union government maintains that it has not neglected Kerala in disbursing ASHA scheme funds, stating that the state is set to receive ₹636 crore under the NHM for 2023-24, including incentives for ASHA workers.

“Both the Centre and the state government are responsible, and they have to sit together to find a solution. Our issue is that we cannot survive on ₹232 per day. Right now, we can say this to the state government. When we get time, we will tell the Centre also,” one of the protesting ASHA workers told local reporters.

  S Mini, founder of the Kerala ASHA Health Workers' Association, said: “ASHA workers are working for the state. It is the responsibility of the state government to meet their basic needs.”

  According to former Union health secretary Rajesh Bhushan, the ASHA scheme was designed to utilise the services of local women as health motivators. “They were seen as the foot soldiers of health care, which was in distinct contrast to the western clinic-based model where the sick are supposed to go to the clinic,” he told Business Standard.

  “As ASHA workers were a decentralised force, they were seen as addressing the health needs of a microscopic minority. Each ASHA had the responsibility of around 250 people, or around 50 households. In hill states, where hamlets are far-flung, the Centre funds the programme in a 90:10 ratio. Kerala has a 60:40 ratio where the state government is expected to pay 40 per cent of the costs,” he said, adding that expenditure on ASHA is a subcomponent of the entire health bill of a state government.

However, he said ASHA workers are not permanent employees of either the central or state governments. He conceded that nothing in the programme prevents states from increasing their pay and that the workload of ASHA workers has increased over time. “Originally, core activities would take around three hours per day. But when you add to their responsibilities, their work-load goes up. They say they can spend nearly a full working day travelling as part of their work. So, they must be paid accordingly,” Bhushan said. 

Until 2016, ASHA workers were paid a monthly honorarium of ₹1,000. This was later raised to ₹7,000, a fixed sum paid by the state government. Additionally, they receive ₹3,000 from the central government (shared in the 60:40 ratio in Kerala).

Additional incentives for tasks, such as immunisation, can bring in another ₹3,000, depending on workload. However, ASHA workers argue that this is still not enough. 

Some state governments view their demands with sympathy. Last week, the Andhra Pradesh government announced it would pay a gratuity for ASHA workers, an enhanced retirement age from 60 to 62 years, and 180 days paid maternity leave. Each ASHA worker will get ₹1.5 lakh at the time of retirement after serving for 30 years. 

But according to Bhushan, there is a strong case for scaling up the ASHA programme and building capacity. This could be an alternative to the politically popular untargeted direct cash transfer scheme that many states have adopted for women. 

ASHAs have gone on strike before, including in Rajasthan and Maharashtra, demanding better wages. But in Kerala, many feel betrayed because an explicit manifesto promise has not been kept. 

J Devika, an academic at the Centre for Development Studies in Thiruvananthapuram, said: “If the LDF government considers the demand unreasonable, they shouldn’t have made the promise in their manifesto.”