Kerala owes much of its human development achievements, particularly the improvement in its health indicators, to the contribution of its grassroots health workers, which includes Accredited Social Health Activists, or ASHAs. For instance, Kerala was one of the better performing states against Covid-19, and its foot soldiers in the battle against the pandemic were ASHAs. From conducting door-to-door surveys to ensuring proper quarantine of facilities for affected people, they were everywhere and even praised by the media as “angels of hope”. As an ASHA worker puts it, “We had fear during Covid, but we still went and did our duty, often without any PPE (personal protective equipment) kits. We are still needed everywhere for all kinds of work.”

Despite their contributions during the pandemic and the Wayanad landslide in July 2024, ASHAs in Kerala and elsewhere are not considered government employees but “volunteers” or “activists”. Instead of regular wages, they receive honorariums and performance-based incentives—the first decided and paid by the state government and the second by the union government.

Various trade unions and associations have been demanding that the ASHAs be recognised as “workers”. ASHAs in Kerala had been hoping that the state budget for 2025-26, which was presented on 7 February 2025, would address some of their demands. However, the budget was silent on these issues.

As a result, since 10 February, ASHAs led by the Kerala ASHA Health Workers’ Association (KAHWA) have been staging a protest in front of the Secretariat in Thiruvananthapuram. They are demanding a rise in the honorarium, flexibility in the retirement age, a retirement allowance, and access to a pension scheme.

This article focuses on the ongoing struggle of ASHAs in Kerala and highlights the tendency of society as a whole to devalue women’s work. The first section draws attention to the roles that ASHAs perform, by drawing on interviews and group discussions with the protestors. The following section emphasises the triple burden borne by underpaid ASHAs, who are also expected to do unpaid domestic and care work in their households. The final section discusses the demands of ASHAs in Kerala and the state government’s response to them.

Perils of Voluntary Schemes

When the National Rural Health Mission (NRHM) was introduced in 2005, ASHAs were recruited as voluntary workers who could do the work during their free time for an honorarium of Rs. 500. Their work focused on three main tasks—immunisation, promoting hospital births, and reducing child and maternal mortality. But, over the years, both the nature of their job and their functions have changed drastically.

Now, being an ASHA is a full-time job, and these women are not allowed to participate in projects under the Mahatma Gandhi National Rural Employment Guarantee (MGNREGA). However, some ASHAs are panchayat members, as they were given tickets by different political parties since these women are familiar faces due to their relentless work in the community. In any case, it can be argued that the term “voluntary” does not in any way describe the current roles and responsibilities of ASHAs. Apart from having to fulfil their usual responsibilities, ASHAs are frequently called in for ad-hoc tasks at the community level.

“We get called in to fill seats during programmes with ministers as guests,” an ASHA said. “We also get called in to organise yoga demonstrations, walks, and cookery shows. Our fellow workers have had to clean dead bodies for funerals. We have cleaned worm-infected wounds for patients. We have done it all but cannot do more of it without getting fair wages.” Another added, “Everyone calls ASHAs for all the work—be it block development officers, ward members, or police officers. They need us to always be available on call, but are unwilling to pay.”

A senior ASHA remarked, “When I began working, these sandals cost Rs. 125. It’s now Rs. 400 and I am still earning the same though I work all the time.”

Wichterich (2020) has noted there is financial extraction involved in the case of ASHAs, who often have to make payments on behalf of their patients. This could be for transporting pregnant women to the clinic, or to buy essential medicines for some patients. These are out-of-pocket expenses for ASHAs who do not earn much. “When we go to buy medicine for patients, we have to pay at least Rs. 5 at the hospital to get the chit,” an ASHA pointed out. “We cannot ask this Rs. 5 from patients who do not even have money for a meal. We keep paying this from our money.”

ASHAs in Kerala currently get a monthly honorarium of Rs. 7,000, which means they earn Rs. 232 a day in a state where the minimum wage is Rs. 700 a day. Incentives paid by the union government are tied to specific activities such as promoting immunisation and providing services for reproductive and child health services. ASHAs in Kerala are at a disadvantage because the state has a good healthcare infrastructure, which means many of the incentive-based tasks are not there. A senior ASHA remarked, “When I began working, these sandals cost Rs. 125. It’s now Rs. 400 and I am still earning the same though I work all the time.” In short, the earnings of ASHAs differ depending on the tasks performed by them and the incentives associated with each task.

Ground Reality

The ASHAs interviewed complained that they do not often get the state-mandated honorarium of Rs 7,000 in full because they are fined if they miss any tasks. “There is a fine of Rs. 500 for missing ASHA meetings, Rs. 700 for missing panchayat meetings, Rs. 500 for missing centre duty. We never get the Rs. 7,000,” said an indignant ASHA worker. “There is a fine if we forget to bring our diary to meetings or if there is a delay in giving data or reports. There is always a cut.”

Further, they said that the honorarium is never on time and is delayed for as late as four to five months. This forces them to borrow money from others. “Often, there are messages in our district group of ASHA workers asking officials about the pay. It becomes almost impossible to continue without getting anything for months,” added the ASHA. After the protest began, the state government cleared three months of pending dues to ASHAs on 27 February but their core demands remain unmet.

Women’s Triple Burden

Studies such as Joshi et al. (2025) have argued that there is an increasing trend of feminisation of the health workforce in low or middle-income countries where socio-economically marginalised women increasingly fill up the lower ranks. As a result, under neoliberal regimes, we see “care extractivism” (Wichterich, 2020)—a trend that turns labour in social reproduction into a commodity. This approach relies on community work to handle crises without burdening the state or the health industry with additional costs and responsibilities.

The long and uncertain working hours take a toll on these women workers, who record most of the data at the ground level and also have to do unpaid domestic and care work in their households.

Feminist scholarship has identified community work as the “third burden” (Moser 2012) that women shoulder beyond their “reproductive” and “productive” work. Scholars have noted the trend of drawing on unpaid/underpaid work done by women to carry out plans laid out by the state (Devika, 2016). Women from low and middle-class households are expected to have the right balance between selflessness and empowerment, motivating them to take up this third burden voluntarily with little to no payment.

Many ASHAs take on additional responsibilities in positions where there is an ASHA vacancy, in the hope of earning more. However, in such cases, they only get small amounts as incentives and no extra honorarium. The long and uncertain working hours take a toll on these women workers, who record most of the data at the ground level and also have to do unpaid domestic and care work in their households. In a patriarchal society, community work is often seen as a “natural” extension of unpaid domestic duties. This ideology, and also non-recognition, is reflected in the nomenclature where ASHAs are “activists” and not “workers”.

Struggle of Kerala ASHAs

In a welfare state historically known for prioritising the needs of the marginalised and its people-centric policies, the protest by ASHAs has been continuing for more than a month. Following the failure of negotiations with the state government, three ASHAs began an indefinite hunger strike on 20 March. A mass hunger strike was organised in front of the Secretariat in the capital Thiruvananthapuram on 24 March.

ASHAs in Kerala are paid an honorarium of Rs. 7,000, but to receive it in full, they had to fulfil at least five of 10 defined “criteria” such as preparing a ward health report; participating in a review meeting at the panchayat or hospital; conducting a monthly clinic for women, children, and adolescents; and so on. On 17 March, the government announced it was withdrawing the 10 criteria to receive full payment. However, ASHAs allege that these criteria have now been added to the revised criteria for fixed incentive payment.

The ASHAs in Kerala are demanding that

a) the honorarium be increased from Rs. 7,000 to Rs. 21,000;

b) the order mandating ASHA workers retire at the age of 62 be withdrawn, with an option to retire between the ages of 62 and 65, and all ASHA workers be paid an allowance of Rs. 5 lakh on retirement; and

c) ASHA workers have a pension scheme since they do not have access to any welfare board benefits.

It is ironic that the Left Democratic Front government in Kerala is using non-recognition by the union government as an excuse to argue that the Minimum Wages Rules of 1958 do not apply to community activists.

The KAHWA noted that recognising ASHAs as “workers” has been a long-standing demand of various trade unions as the union government can mandate a nationwide standard of fair pay and recognition as “workers”. However, at the same time, the state government cannot deny their demand for an increase in honorarium because this falls under the state’s jurisdiction and is not contingent upon recognising ASHAs as “workers”.

At the 45th Indian Labour Conference on 17-18 May 2013 in New Delhi, representatives of various trade unions, including the Centre for Indian Trade Union (CITU), advocated for the recognition of ASHAs as “workers” to ensure their access to minimum wages. It is ironic that the Left Democratic Front government in Kerala is using non-recognition by the union government as an excuse to argue that the Minimum Wages Rules of 1958 do not apply to community activists. The state government has again said that it will request the union government to make ASHAs a part of the regular workforce, and asked them to withdraw the protest since it has relaxed the conditions to claim the honorarium.

The case of ASHAs in Kerala demanding better workers’ rights has to be placed in the larger context of a patriarchal state exploiting women’s labour. The devaluation of women’s labour, which is now highlighted in the case of ASHAs, has been a longstanding issue with anganwadi workers in different states.

In the current scenario, the union and the state governments keep blaming each other for the precarious condition of the workers to score political points. At the same time, none of them addresses any of their demands, including recognising them as workers. Further, in Kerala, it is unfortunate that we are witnessing a complete lack of empathy from left leaders in power towards a workers’ protest, starting with denying them permission to put up a temporary shed for shelter from the scorching sun at the protest site to slut shaming and alleging that the protesting ASHAs are getting paid in cash and kind.

Even if the elected state government in Kerala firmly believes that the solution lies in the hands of the union government, it has the moral and political responsibility to stand by these women workers and support them in their struggle against systemic injustice. Instead of disregarding the struggles of ASHAs on the grounds of having no additional funds, the state government has to initiate a dialogue with them to reasonably discuss all their demands.

We acknowledge the support of Professor J. Devika and thank the Kerala ASHA Health Workers’ Association (KAHWA) and all the ASHA workers who spoke to us.

Ayana Krishna D., Shraddha Jain, and Srimanjori Guha are PhD scholars at the Centre for Development Studies, Thiruvananthapuram.