India's frontline health workers fight for better pay and recognition

Thousands of frontline healthcare workers in southern India's Kerala state, who have been holding demonstrations for the past month seeking better pay and recognition, have vowed to continue their protest.

Kerala's 26,225 female workers, known as Accredited Social Health Activists or Ashas (Hindi for hope), have been holding protests near the state government headquarters in the capital city of Thiruvananthapuram.

The protesters, who provide crucial medical support in the country's rural areas, say they plan to "lay siege" to the state secretariat in the coming week, if authorities continue to ignore their demands.

The Ashas, who number more than a million across the country, are fighting for better salaries and for official "worker" status.

The women are currently categorised as volunteers, which means they are not guaranteed any benefits from the government, despite playing a crucial role in delivering healthcare in rural and underserved areas.

On Monday, Shashi Tharoor, an MP from Kerala, said the Asha volunteers were "unsung heroes" of India's healthcare system and the "protests highlight the systemic undervaluation of community health workers in India and in particular in Kerala".

India's federal health minister recently told parliament that the government would raise incentives for the workers. Authorities in Kerala, meanwhile, have released three months of pending payments.

The state's health minister also said Kerala would request the federal government to recognise these women as regular workers and not volunteers.

The state government, however, has insisted that the money it offers to the Ashas is the highest in the country.

But the protesters said state authorities had not engaged in talks with them and accused them of instead employing tactics to suppress their protest.

This week, police removed the plastic tarpaulin sheet the protesters had tied overhead at the site of their sit-in demonstration, exposing them to direct sun.

The Ashas - who get an honorarium of 7,000 rupees and not a salary because they are volunteers and not workers - say they want the payment to be increased to 21,000 rupees ($240.8; £186.2) and retirement benefits.

The state's Health Minister Veena George, however, says that 90% of the Ashas earn between 10,000-13,500 rupees per month, including incentives.

"They are entitled to maternity leave, and measures are taken to prevent excessive workload," she said.

But some of the protesting women counter these claims.

Kuzhipparamba Thankamony, one of the protesters, said she received only 6,300 rupees as honorarium in October 2024.

"They deducted 700 rupees for a meeting I missed because I was sick and had to go to hospital."

When the 45-year-old joined the Ashas 17 years ago, she worked only for an hour or two a day, she said.

"Now I am so burdened with work that a whole day does not suffice," she told the BBC.

"This is a matter of social justice," Saboora Arifa, one of the Asha protest co-ordinators told the BBC. "Those who work eight hours a day are not volunteers. We have every right to get worker status."

In a country where millions of Indians, especially in the remote areas, do not have access to quality healthcare, the Asha workers have played a vital role over the years.

Their job involves going door-to-door to raise awareness about nutrition, sanitation, immunisation and providing neonatal and antenatal care, among other things.

They played a crucial role during the Covid pandemic, especially in Kerala which was first to report a Covid case, and have been credited for successfully containing outbreaks of Zika and Nipah viruses.

Dr Joe Thomas, a Melbourne-based public health policy analyst, believes India should change its perception of these community health workers whose contribution to primary health is universally recognised.

These workers are doing the job of midwives in Kerala after the state's health authorities froze recruitment of midwives, he told the BBC. "The maternity care support has slowly been shifted to Ashas."

According to him, 90% of the women in Kerala get prenatal care like testing, nutrition supplements and advice from Asha volunteers.

"Kerala takes pride in achieving 99% vaccination," says Dr Thomas. "The credit for its vaccination success goes to the Ashas. Their contribution to primary health in Kerala is that they are the only people working on prevention."

The protest in Kerala is only the latest in a series of protests by these community health workers across India.

Earlier this year, neighbouring Karnataka state increased its honorarium amount to 10,000 rupees after Asha volunteers went on strike.

And last year, volunteers in Andhra Pradesh held several state-wide protests. This month, the state became the first in the country to give its workers a gratuity of 150,000 rupees ($1,723; 1,330), along with paid maternity leave of 180 days, and raised retirement age from 60 to 62.