August 12th, 2023 marked a historic victory for striking ASHAs (Accredited Social Health Activists) in Bihar with the state government agreeing to increase the monthly payment by Rs. 1,500 per month and providing the payment as ‘honorarium’, instead of ‘reward’ (paritoshik). The 31-day long indefinite strike of around 1 lakh ASHA workers and ASHA facilitators across Bihar had begun on July 12th, 2023 under the joint banner of ASHA Samyukta Sangharsh Manch, with Bihar Rajya ASHA Karyakarta Sangh – Gope-Group (AICCTU), and ASHA and ASHA Facilitators Union at the forefront.
Shashi Yadav, general secretary of Bihar Rajya ASHA Karyakarta Sangh – Gope-Group explained that the strike by ASHAs had been the largest women workers movements in recent history of Bihar with tens of thousands of ASHA workers uniting for this massive movement.
The strike continued for 31 days in almost all Primary Health Centres (PHC), Community Health Centres (CHCs) and Referral Hospitals across of all districts in Bihar. PHCs became rallying spots for ASHAs and ASHA facilitators. Despite the strike, ASHA workers ensured that emergency work as well as cases of childbirth were not adversely affected.
“The major victory for the movement was that government had agreed to pay an ‘honorarium’ rather than a ‘reward’ to ASHA workers. The payment of their work as reward (paritoshik) was derogatory and it demeans the labour done by ASHAs; honorarium recognised ASHAs as workers,” said Shashi Yadav.
ASHAs, who are frontline health workers and are the backbone of country’s rural health and vast immunisation programmes have been playing a vital role in ensuring proper access to healthcare and fight against the COVID-19 pandemic. But in Bihar and across the country, they have been forced to work for a pittance, where there have been instances of ASHAs walking several kilometres on inhospitable roads in villages to meet their targets.
“Though the increase of Rs. 1500/- is less than what we had demanded, we consider this as the first victory in the battle for rights of ASHA workers,” she added. ASHAs and ASHA Facilitators will now receive a fixed amount of Rs. 2,500 per month from the State and Rs. 2,000 per month as central government contribution, along with other performance-based incentives.
It was also agreed in the negotiations that a recommendation based on the demands to increase the incentive rates under the scheme will be sent to the central government by the Bihar state government. The incentive amounts being given for various types of works for ASHAs under the scheme have remained stagnant for decades and need to be urgently revised and increased by at least 300% in view of the skyrocketing inflation.
The payments due since the pandemic period will also be paid by the government. The other demands of a nine-point charter will be resolved through bipartite discussions with the state government. Furthermore, the cases lodged against ASHA workers during the strike will also be withdrawn.
The CITU and ASHA Facilitators’ leader Vishwanath Singh termed this gain a victory, but the struggle will continue as the government has not agreed to pay Rs. 10,000 as honorarium, which was the demand. ASHA leader Sudha Suman said that another important demand of pension and retirement benefits is being taken by the government for consideration.
Rambali Prasad, Honorary President of Employees’ Federation (Gope) and Ranvijay Kumar, State Secretary, AICCTU noted that the demand put forward by ASHA workers had been part of the Mahagathbandhan manifesto during the assembly election in 2020. Despite several rounds of failed negotiations and bureaucratic hurdles, the determination and courage of ASHAs have finally led to a victory in this struggle.
The Striking Moment- Rally of August 3rd
As the strike entered its fourth week, on August 3rd, tens of thousands of ASHA workers and ASHA facilitators gathered at Patna’s Gardanibagh with their demands. The massive ‘Mahajutan’ (huge gathering) painted the streets of Gardanibagh in pink (uniform of ASHAs) with the place reverberating with the calls for dignity, respect and rights.
Their negotiations with the government in two rounds earlier had yielded no result, and faced threats of retrenchment, filing of criminal cases against striking leaders. Deputy CM Tejaswi Yadav, who heads the health portfolio, had agreed to change the monthly payment from paritoshik to an honorarium and raise the amount, but the promise was not kept in spite of the repeated reminders and memorandums.
It was unfortunate that despite the long struggle and deteriorating health condition of ASHA workers, there was no move by the state government to solve the issue. An ASHA worker from Siwan, Saraswati Devi, died while sitting on protest.
“The protest gathering of ASHA workers marked a striking moment in this battle,” explained Kunal, Bihar State Secretary of CPIML Liberation. Faced with an increasing resistance by ASHA workers and halt of rural health services, the government finally agreed to reach an agreement with ASHA workers.
The unions condemned the attitude of the state government who ignored and threatened manoeuvres and asked the government to honour its agreement with ASHA unions made in January 2019 and to implement the government’s own promises made during the budget session in the Bihar Assembly and start negotiations immediately with the ASHAs on their nine major demands.
The gathering also witnessing a massive wave of solidarity with several leaders of left parties and civil society, including Mahboob Alam, Satyadev Ram, Gopal Ravidas, Rambali Singh Yadav, Amarjit Kushwaha of CPIML and Ajay Kumar and Satyendra Yadav of CPIM addressed this rally along with AIPWA general secretary Mina Tiwari, Saroj Chaube, joining to stand with the striking ASHA workers.
Backbone of India’s Healthcare System
More than one million ASHA workers form the most important link in India’s health infrastructure. They perform many tasks like antenatal and postnatal care for women, facilitate institutional child birth, make home visits for the new-born and postpartum mother, and they also work on malaria and diarrhoea control, distribute ORS, monitor growth of children, immunisation of children, helps in birth control and family planning, and lot of other such essential work. The government calls them ‘community activists’. However, they are not just activists, but frontline workers. They attend meetings and camps at block and district level regularly, maintain village-level health registers, prepare lists of children to be immunised, for antenatal care beneficiaries and eligible couples. It is their job to reach out to adolescent girls and organise monthly meetings pertaining to menstrual hygiene, and also to take part in various health related programmes, including tuberculosis control, leprosy eradication, vector borne disease control, and to motivate households to construct toilets and use clean piped water.
The government calls ‘community intervention’ the work of ASHAs which is supposed to be a ‘mission’ (NHM, NRHM and NUHM) and not a proper job, but they have to perform more than 60 different kinds of work like a regular employee, however their remuneration is based on small incentives. Their working hours range anywhere between 4 to 8 hours on an everyday basis, occasionally even more, and during the pandemic, they had to work day and night without any safety equipment. Moreover, since the payments are incentive based, which is a new form of piece-rate work, it forces them to work more to ensure sufficient earning for minimum sustenance. Interestingly, they are not considered workers but are eligible for the Pradhan Mantri Shram Yogi Maan Dhan Yojana, an insurance scheme for the unorganised sector workers. This exposes the hypocrisy in the treatment meted out to the ASHA workers.
ASHA workers make the core of NHM strategy for providing access to healthcare at the doorstep as ‘honorary volunteers’ without any salary. The incentives being given to them come under the head ‘community intervention’, while the regular employees of NHM get a salary under the head of ‘Human Resources’. This characterisation as volunteers or activists devalue women’s work and signals government’s unwillingness to invest in a regular cadre for public health services in rural India (Shruti Ambast, CBGA, 2021).
Even though ASHAs across the country do the same type of work, payments made to them vary from state to state. For some routine and recurring activities they were getting Rs. 1,000 incentive till 2018 by the Centre. This was raised to Rs. 2,000. Since NHM is jointly funded by the Centre and the State in a ratio of 60:40, state governments have added their share of incentives which varies to a great extent. In Bihar, this incentive stood at Rs. 1,000 a month till this successful strike took place. As per a Rajya Sabha question answered on March 22nd, 2022, in UP this is Rs. 750 per month for a specified 5 core activities. Andhra Pradesh provides Rs. 10,000 per month by topping up the remaining amount to the total incentives earned by ASHAs, whereas Telangana provides the balance amount to match the total incentives at Rs. 6,000 per month. Delhi gives Rs. 3,000 per month for 12 core activities in addition to the incentives earned for other non-core activities. Gujarat gives 50% top up over and above the earned incentives, while in Chhattisgarh this is 75% top up. In Uttarakhand this is Rs. 1,000 per month and an additional Rs. 5,000 per year!
Bihar ASHAs will now get Rs. 2,500 per month as state’s share against the designated core activities, along with the Centre’s Rs. 2,000 and incentives for many non-routine and non-recurring jobs. With all kinds of incentives combined, the ASHA workers get monthly payments which usually is much less than the prescribed minimum wage in respective states. The minimum wage for skilled workers in Bihar is Rs 12,766 per month, and the payments received by most of the ASHAs usually doesn’t cross the halfway mark of this amount. Comrade Shashi Yadav said that total payments earned depend on the location and the number of jobs assigned. Out of the 90,000 ASHAs in the state, nearly 85% get a monthly income around Rs. 6,000 which is less than half of the minimum wage. This is after a full day’s work on a daily basis.
An additional pandemic allowance of Rs. 1,000 per month was added during the COVID-19 period after countrywide agitations and strikes by ASHA workers. But this was not implemented and more than one third ASHAs are still struggling to receive the promised amount. In Bihar too this remained on paper, despite repeated requests and agitations. Now, the state government has agreed to pay the due amount to all.
By not recognising scheme workers as employees, the mindset of the State is exposed with their regressive patriarchal mindset that devalues women’s labour making them more vulnerable and insecure, huge economic exploitation is just one dimension of a bigger problem. When the struggle is on-going with the demand to replace ‘honorarium’ with regular pay and other benefits, the BJP ruled states further downgraded the honorarium by renaming it as ‘paritoshik’ which was opposed vehemently by ASHAs in Bihar. The Bihar government has renamed it back to honorarium, while in Uttarakhand it continues to be termed paritoshik.