As ASHAs protest across multiple states, demanding enhanced remuneration and recognition, fixed working hours, retirement benefits, and workers’ rights, it is imperative to reiterate their pivotal contributions to public health in the country.  We need an emboldened frontline health workforce built on respect, recognition, and rights to meet the emerging health needs of India’s cities, constituting more than 30 percent of India’s population.

Sitting on the floor, in a small circle, with about 12-15 women, in an Ayushman Arogya Mandir (AAM) in Bhairopur*, a Nagar Panchayat in Uttar Pradesh, discussing the role of the local frontline health workers in the newly-minted urban area for a research, the ASHAs catch our attention instantly. Not only because their off-white sarees shone bright against the pale-yellow walls, but because they instantly eased into sharing insights and stories of the joys and sorrows of being a health activist. Their deep sense of responsibility towards the families they served became palpable; the perils of working in a far-from-perfect health system was obvious. 

The cadre of the Accredited Social Health Activist was instituted in 2005, scaled up from the Mitanin initiative in Chhattisgarh, with the introduction of the National Rural Health Mission (NRHM). Women from the communities were chosen as health workers, one per thousand population, to bring healthcare to people’s doorsteps. In a mere span of 20 years, the ASHA has become a trusted health and wellbeing champion, pioneering the health of women, children and families. They are the bridge between communities and the health system, which can be distant and inaccessible for many.

The breadth and depth of the ASHAs’ experience were evident as they outlined their duties. Ranjeeta, in her mid-forties, highlights her work in ensuring antenatal care to expecting mothers in her community, registering pregnancies as early as possible, ensuring timely vaccinations and supplements are received by pregnant women and identifying high-risk pregnancies (HRPs) earliest possible. She catches a quick breath, and adds, “…and all of this is not easy. It is not only a medical job; it is a social job. We do household visits, multiple times. There is a lot of convincing and conversation, and answering incessant questions. Not only convincing the labhaarthi, but her mother-in-law, her husband and sometimes, even the father-in-law”. India’s burden of maternal mortality has witnessed a remarkable improvement in the last three decades, the Maternal Mortality Rate declined in India by about 70% from 398/100 000 live births in 1997-98 to 99/100 000 in 2020, and the 1.05 million ASHAs, like Ranjeeta, indeed form the beating heart of this revolution.

“Our role actually begins much before a woman even conceives. We raise awareness on family planning, different contraceptive methods, do counselling on birth control, spacing between children, and the nutrition and care important for women to become healthy mothers to healthy children”, adds Sujata, an ASHA from a neighbouring area. However, being the first line of healthcare providers does not come easy, especially when availability and accessibility of health facilities remains uneven. “If we have to take a woman to the hospital for an ultrasound, we spend from our own pockets for the bus or auto rickshaw. We feel it’s a small price to pay for someone’s health, isn’t it?”, Sujata added.  In several other instances, amongst the 50 ASHAs we spoke to, they often went out of their way to fulfil their responsibilities, like buying a weighing scale off amazon to weigh new born babies, if they didn’t have a functional one in their ASHA kits.

Through their care labour, ASHAs build community health, delivering several government schemes and collecting data for critical health indicators. ASHAs shoulder the responsibility of ensuring child health, and combating child malnutrition, a persistent public health concern in India. “During our home visits, we identify children with kuposhan, and ask their mothers to bring them for the next VHSND session, where we along with ANM and Anganwadi, measure the height and weight of the child, and refer them to a higher health facility, as needed, “ explained Mala, an ASHA in a Nagar Panchayat in UPs Sonbhadra district, one of the country’s least developed regions. 

The growing gamut of responsibilities sans recognition, rights and remuneratio

In the wake of India’s demographic and epidemiological shifts, the ASHA remains the eyes and ears of the public health system, amidst its diverse communities and difficult terrains. However, the growing healthcare needs of the community mean added responsibilities for the ASHA. “Humare kaam ka list toh bohot lamba hai (the list of our work is very long). Now, we do population enumeration for NCDs screening, fill the CBAC forms and also raise awareness about Non-communicable Diseases in the communities, especially during the VHSND sessions. But for me the most difficult work is to enter data on the mobile phone, I find it so tough, I just let my granddaughter do it”, Malti Devi, an ASHA well into her 50s tells us, a grievance which resonates with many. 

“Sarkar ki ya department ki koi bhi campaign ho, usmein humari duty sabse pehle lagti hai. Nikshay Diwas, Dastak, Sanchari Rog, aisi kai nayi cheezein humare kaam mein judti rehti hai, ek minute ka bhi samay nahi milta hai. Der saver, 24 ghante humein uplabdh rehna hai, yeh asaan toh nahi hai”, another ASHA from the Gorakhpur district explained. While workload for the ASHA has considerably increased in the past 20 years, their status as “volunteers” rather than employees of the health department puts them in a disadvantaged position. With a fixed incentive of 2000 rupees every month, Sudha, tells us that for them income rarely exceeds 3,000-4,500 rupees a month, despite the growing burden of responsibilities. The challenges of ASHAs is not limited to financial precarity, though, and an everyday threat of violence and concerns of safety is expressed by many. 

ASHAs describe the daily reality of navigating long distances alone, sometimes in remote areas at night shouldering the responsibility for critically ill patients. ‘If any mishap happens, we are held responsible, even when nothing is in our control,’ one ASHA shared. ‘Doctors are not held accountable, the system is not held accountable.’ As they march within a health system with several challenges, being a “volunteer” does little to protect the ASHA and safeguard her rights as a health worker. “People express their anger against the ASHA without restraint. Once when a woman passed away in childbirth, the husband threatened the ASHA, “I will keep you with me now”, that is the kind of violent threats we face every day, and no one comes to help us”. More subtle forms of indignant behaviour are more common. “In upper caste households, they will shut the door, the moment they see the ASHA walking into the street. They won’t even ask for a glass of water, just say there is no work for you”. These instances of workplace violence are reflective of the structural realities inherent within a casteist-patriarchal milieu and how intersectional vulnerabilities arising from gender and caste significantly determine the lived experiences of ASHAs.

The ASHA in Urban India: Adapt or Perish?

Initially conceptualised for rural areas, the ASHA has been extended to urban areas through the National Urban Health Mission 2013. A significant role is envisaged for the urban ASHAs, serving as an effective link for generating demand between urban residents and health facilities, acting as the much-needed drivers of community-based care and promoters of positive health-seeking behaviours, particularly within urban vulnerable, low-income, and slum communities.

However, ASHAs in urban areas are faced with mammoth challenges. The urban population is diverse, characterised by transient communities, complex social structures, differences of language, culture and beliefs, religion, occupation and caste, making it difficult for ASHAs to establish trust-based ties with the community. Beyond the population, the challenge of urban health is complex. Experts argue that urban areas witness the triple burden of public health infectious diseases, non-communicable diseases, and injuries and interpersonal violence.  Climate change and its intersections with health further make the urban poor and vulnerable at the risk of severe health implications. Though urban ASHAs have been provided training in non-communicable disease modules and the services under the Comprehensive Primary Health Care (CPHC), concerns of adapting to the dynamic health needs of urban communities persist. In addition to the epidemiological burden of disease, the social determinants of health in cities are also multifaceted, with aspects like occupation, sanitation, water and housing becoming key drivers of people’s health and wellbeing, as people’s access to safe, formal, affordable and adequate basic facilities is a major gap in cities. 

Urban health systems, characterized by a complex network of public and private healthcare providers, often fall short of ensuring equitable access for vulnerable populations. Despite service availability, barriers such as cost, extended wait times, and limited health literacy impede access. The significant presence of migrants in urban areas highlights the persistent challenge of ensuring continuity of care, particularly across the rural-urban continuum, posing a challenge to be resolved. Moreover, India’s urban landscape, itself, is undergoing substantial change, with disparate urbanization processes resulting in unique development trajectories for different places. The metro cities, their population and needs, vary drastically from the small cities rapidly emerging within the context of rural- urban transitions. And, the adaptation of the concept, role and mere utility of the ASHA across the urban spectrum needs thoughtful consideration and planning. 

The limited number of 79,000 urban ASHAs nationwide, coupled with vacancy rates exceeding 80% in some cities after more than a decade, underscores the seething systemic failures hindering the implementation of the National Urban Health Mission, for which ASHAs are critical. The many emergent ‘urbans’ in India require a reimagination of the role, responsibility and strategies of the ASHA cadre. Facilitating the adaptation of the ASHA model to urban areas, rooted in local context and socio-political realities emerges as the key to understanding and engaging with the ‘community’ and its heterogeneity in India’s cities.