ASHAs overworked, not paid on time, says study

Accredited Social Health Activists (ASHAs), who form the backbone of many state health initiatives, are burdened by overwork affecting their productivity and quality of life, a recent study shows.

The study was held among 538 ASHAs in Mysuru, Koppal and Raichur districts by the Bengaluru-based Indian Institute of Health Management Research and the India Health Systems Collaborative, Delhi. The findings were published in the Journal of Health Management.

The study found that many ASHAs put in nearly double the hours they are supposed to. As per ASHA operational guidelines, their standard working hours would come to 16 hours per week (2-3 hours daily). But data from 75 ASHAs showed that none of them could limit work to 16 hours. Eighty-three per cent of them worked over 30 hours per week, while the rest worked 17-30 hours.

The ASHA programme was introduced under the National Rural Health Mission in 2005. The NRHM guidelines say that each ASHA can cater to a population of 1,000. But data from 130 ASHAs showed that the average population they served was 1,923 — nearly double their target. The burden was higher among urban ASHAs.

ASHAs’ monthly pay, which includes a fixed honorarium and an incentive component, usually doesn’t exceed Rs 10,000. But this meagre payment gets delayed too. Despite this, their task list has swelled over the years. While the original focus of the ASHA programme was on maternal and child health, they now handle over 30 tasks including non-health ones.

The study found that ASHAs were doing tasks that were to be done by other health workers. For example, sputum sample collection from the community is ASHAs’ responsibility, but its transportation is to be done by male health workers. But ASHAs are often assigned both tasks.

They are also supposed to do multiple surveys, including app-based surveys and online data entry work, despite their lack of training and skills. Of the ASHAs surveyed, only 13% had education above the secondary school level, and 8.4% were illiterate. A majority (72%) were from lower socioeconomic backgrounds.

ASHAs also pay out of their pockets for data recharge, transporting pregnant women to health facilities, buying and photocopying survey notebooks, etc. The study recommends shifting to or sharing some of the tasks of ASHAs with other health workers.

What govt says

T K Anil Kumar, Principal Secretary (Health), said ASHAs were supposed to be activists from within the community and were not treated as regular employees. However, he says the department is planning to smoothen the honorarium disbursal process.

“The main grouse of ASHAs is about delayed payment. Karnataka is one of the better states in paying them a fixed honorarium. The incentive component from the National Health Mission gets delayed because details of every task they do should be entered online and multiple levels of approval are needed. We are planning to reduce the level of approvals needed from four to three.”