ASHA Struggle in Kerala: An Overview of Unmet Demands and Systemic Impediments

The 60-day ASHA struggle gains massive public support

Accredited Social Health Activists (ASHA) workers have been on strike in Kerala since February 10, 2025. The struggle has taken the form of a sit-in in front of the Kerala state secretariat in Thiruvananthapuram, the state capital. ASHAs are demanding from the state government a hike in honorarium, retirement benefits, improved service conditions, and payment of dues. 

The ASHAs struggle has acquired tremendous support from various sections of the society. Bharatiya Janata Party (BJP) MP from Trissur, Kerala, Suresh Gopi, visited the protest site many times and extended support. The Indian National Congress (INC)-led opposition political parties have extended their support to the struggle and demanded that the state government must accept the demands raised by the ASHAs. The struggle by women ASHAs has touched the social, political and empathetic consciousness of the people of Kerala and acquired unprecedented support from various sections of the society. The expression of solidarity was most evident on March 8, International Women’s Day, and when the struggle entered its 27th day. J Devika narrates how filmmakers and stars like Kani Kusruti, Divya Prabha, Rima Kallingal, Jolly Chirayath, Leena Manimekalai and Paromita Vohra, and writers Arundhati Roy, Sara Joseph, and Rosemary, feminist academics Nivedita Menon and Janaki Nair, and civil society organisations Dalit Human Rights Movement and Pomblai Otrumai, United Nurses Association and ASHA union representatives from Tamil Nadu and Karnataka attended and supported the demands of ASHAs.^[1] Shashi Tharoor, K C Venugopal from INC and N K Premachandran from RSP raised the issue in the Parliament and demanded the central government’s intervention in ending the strike.^[2] A group of Doctors signed a petition to the state government seeking resolution of the issue.^[3]

The Left Democratic Front government of Kerala, led by the Communist Party of India Marxist (CPIM), apparently, has not taken convincing steps to find a resolution of the struggle. They have expressed irritation at the fact that the struggle is being led by the Socialist Unity Centre of India –  Communist SUCI(C). Veena George, Minister of Health, while acknowledging the pivotal role being played by ASHAs, said in the Kerala Assembly that the state gives the highest incentive to ASHAs and that their dues have been cleared off. She called for the withdrawal of the ongoing strike. She has also observed that the responsibility is with the central government to deal with the demands being raised by the ASHA workers.^[4]

This note briefly looks into (i) when and for what the Accredited Social Health Activists have been introduced, (ii) the nature of classification of ASHAs, (iii) their remuneration system and (iv) how the structural and institutional constraints have been used by the governments to escape from responsibilities.

ASHA: Brainchild of Congress-led UPA-1 Government

Accredited Social Health Activist was a part of the National Rural Health Mission (NRHM) launched by the Congress-led United Progressive Alliance (UPA) government at the Centre in 2005. Dr. Anbumani Ramadoss was the Union Minister for Health and Family Welfare. Launching NRHM on April 12, the then Prime Minister, Dr. Manmohan Singh, talked about a break from the top-down approach and called for a community-centric approach and that the monitoring systems be outward towards the community and not upward towards bureaucracy. He argued for a delivery model that pays attention to the public health issue and the possibilities of social and preventive medicine rather than a ‘delivery model that fragments resources and dissipates energies’.^[5]

Introducing Accredited Social Health Activist (ASHA), he said that many villages in India did not have even a rudimentary healthcare provider. He further said that the lowest unit of healthcare delivery of the Sub-Health Centre has been planned for a population norm and not a habitation norm and that the ANM (Auxiliary Nurse and Midwife) tends to work to a duty chart from above and not to respond to local felt health needs. He qualified ASHA as a key component of the mission and hoped that they will ‘help all those villages which are today unserved by the health professionals’. He affirmed the importance of ASHA being women. ‘The fact that this person is going to be a woman who is trained and also incentivised by the government should effectively establish her as a change agent for health in our villages.’ The Prime Minister also quoted the Bhore Committee report on health (1946) and said that the government sees the health activists “as fingers of the community moving up and not as fingers of the government going down”.

Manmohan Singh led UPA government could have been responding to the health management system prevailing in India then, after 58 years of India’s independence. Ashok Vikhe Patil et al. in their article Current Health Scenario in Rural India (2002) summarise the situation succinctly. The study says, “About 75% of health infrastructure, medical manpower and other health resources are concentrated in urban areas where 27% of the population live. Contagious, infectious and waterborne diseases such as diarrhoea, amoebiasis, typhoid, infectious hepatitis, worm infestations, measles, malaria, tuberculosis, whooping cough, respiratory infections, pneumonia and reproductive tract infections dominate the morbidity pattern, especially in rural areas.”^[6] The PHCs established since 1952 remained vertical programmes and failed to meet the basic requirements of decentralised people-based, integrated curative, preventive and promotive services. Of the 1.1 million registered medical practitioners of various medical systems, over 60% are located in urban areas and as many as 75% allopathic practitioners are in cities.

ASHAs and the WHO’s Community Health Workers (CHWs)

Nevertheless, the concept of ASHA cannot be attributed exclusively to the imagination of the Congress led UPA government. The idea of social health activists based in the community has a global origin. To address the shortages in medical practitioners and the increasing health risks in developing and least developed countries, the World Health Organisation (WHO) had been propagating the concept of Community Health Workers (CHW). In a document (Community health workers: what do we know about them?) published by the WHO in 2007, acknowledges that Community Health Worker is an umbrella term, it reaffirms the definition of the term proposed by the WHO study group in 1989:

“Community health workers should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organisation, and have shorter training than professional workers.”^[7]

This definition rhymes well with the conceptual understanding of ASHA workers in India. Cementing the conceptual congruity between ASHA in India and CHW internationally, a 2020 WHO report (What do we know about community health workers? A systematic review of existing reviews) discusses in detail a number of studies on the functioning of ASHAs. This report talks about how the integration of CHW programmes into national health systems makes it possible to have the potential to achieve universal coverage.^[8] In a 2021 report, WHO characterised ASHA as the driving force behind India’s public health services,^[9] which culminated in the 75th World Health Assembly on 22 May 2022 conferring to India’s Accredited Social Health Activist (ASHAs) the WHO Director-General’s Global Health Leaders Award for their outstanding contribution towards protecting and promoting health.^[10]

The history of CHW indicates four phases in its development.^[11] The first phase corresponds to the ‘’Farmer Scholars’’, who were trained in China in the 1930s and were later called the Barefoot Doctors. By 1972, there was an estimated one million barefoot doctors serving a rural population of 800 million people in the People’s Republic of China (or roughly one per 800 people). In the second phase, in the 1960s and 1970s, small CHW programmes began to emerge in various countries, particularly in Latin America. In the third phase, in the 1980s, larger CHW programmes emerged in many countries. For example, Brazil national health care program (i.e., Special Service for Public Health – Serviço Especial de Saúde Pública, or SESP), which started in 1987, gradually achieved universal coverage of PHC services. In the mid-1970s, Bangladesh had started a community-based family planning (FP) programme complemented by NGO CHWs working in FP. However, the CHW programmes launched in the 1980s and 1990s failed to succeed because of several factors, including the global recession after the oil crisis, and governments were forced to take away investments from public sector financing, including public health by the World Bank and other international donors subsequent to the privatisation and liberalisation policies. The fourth phase of the CHW programmes in 2000s evolved globally in this context, where governments were challenged by the increasing disparity in the health status of the minuscule better-off segments and the majority of the population and the growing evidence of the contribution of CHWs to the health status of populations.

The introduction of ASHA by the UPA government in India fits into this framework. In the 1990s Congress-led government of India pushed for liberalisation and privatisation, which impacted health services too, as explained earlier. The community-based ASHA programme emphasised the decentralisation of health services and the expansion of the services to the rural areas. This was a balancing act by the UPA government in the context of outright globalisation, liberalisation and privatisation policies pursued by the Congress government in the 1990s, under Manmohan Singh, the finance minister. The UPA government also came up with the National Rural Employment Guarantee Act and the Right to Information Act in 2005.

In 2013, under the second innings of the UPA government, the National Health Mission (NHM) was launched, merging the National Rural Health Mission (NRHM) and the National Urban Health Mission (NUHM). The initiative was taken by the Ministry of Health and Family Welfare under the leadership of the then Union Minister for Health and Family Welfare, Ghulam Nabi Azad. Now, technically, the ASHA programme falls under NHM.

Basic characteristics of ASHAs as proposed in 2005

The UPA government came up with the Unorganised Workers’ Social Security Act in 2008, but it did not guarantee any justiciable right to social security for unorganised workers, did not contain any provision for the creation of a social security fund, and excluded more than 90 per cent of workers by delimiting eligible unorganised workers as only those living below the poverty line. Similarly, the ASHA programme too had structural and institutional constraints. ASHAs, by definition, are not workers; they are activists or volunteers. The compensation for their time and effort is not wages but incentives. They are not protected by the provisions of the labour laws. Though the ASHAs were created as part of the National Rural Health Mission, the incentives for the ASHAs have to be shared between the Centre and State, health being a State subject under the Indian constitution.

The document ‘National Rural Health Mission…Framework for Implementation 2005-2012‘, published in 2005 by the Ministry of Health and Family Welfare, Government of India, defines and institutionalises the non-worker status of the ASHAs.^[12] The document says,

“A trained female community health worker – ASHA – is being provided in each village in the ratio of one per 1000 population. For tribal, hilly, desert areas, the norm could be relaxed for one ASHA per habitation depending on the workload. ASHA must be a primary resident of the village with formal education up to Class VIII and preferably in the age group 25-45. She would be selected by the Gram Sabha following an intense community mobilisation process. She would be fully accountable to Panchayat. Though she would not be paid any honorarium, she would be entitled for performance based compensation.” (pp. 60)

ASHA’s description resonates with the global idea of CHWs; but with India-specific configurational and procedural prescriptions:

1. ASHA will be a female, preferably in the age group of 25-45.
2. One ASHA in each village in the ratio of one per 1000 population
3. ASHA should be a primary resident of the village.
4. ASHA must have formal education at least up to Class VIII.
5. ASHA will be selected by the Gram Sabha and will be fully accountable to the Panchayat.
6. Though the document uses the phrase ‘female community health worker’, it says that ASHA will not be paid any honorarium, and she would be entitled for performance based compensation. It presumes that ASHA, working with reasonable efficiency, would be able to earn Rs. 1000 per month.
7. ASHAs will work in close coordination with the AWW; she would be fully anchored in the Anganwadi system.

The document further outlines the tasks to be performed by ASHA workers:

1. ASHAs would reinforce community action for universal immunisation, safe
2. delivery, newborn care, prevention of waterborne and other communicable diseases, nutrition and sanitation.
3. She will help the villagers promote preventive health by converging activities of nutrition, education, drinking water, sanitation, etc.
4. ASHAs would provide immediate and easy access for the rural population to essential health supplies like ORS, contraceptives, and a set of ten basic drugs, and she would have a health communication kit and other IEC materials developed for villages.

The responsibilities of ASHAs^[13] are broadly threefold: (i) of a link worker who facilitates access to health facilities and promotes good health practices, (ii) of a health activist who creates health awareness and mobilises the community and (iii) of a community health worker who acts as a depot-holder for essential medicines.^[14]

The NRHM (Framework for Implementation 2005-2012) had identified 18 States, with weak public health indicators and/or weak health infrastructure for special attention. The high-focused states of Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu & Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh were supported for having an ASHA in all villages with a population of 1000. The target during the period was to provide more than 400,000 ASHA/CHWs to improve the health outcomes of the rural areas. (pp.30) ASHAs were supposed to work in close coordination with Anganwadi workers and work from the Anganwadi Centres. A report on the evaluation of the ASHA programme conducted by the National Health Systems Resource Centre in 2011 says that in the non-high-focus states and Union territories, the guidelines allowed the selection of ASHA in tribal, coastal or other difficult districts. The decision to extend the programme within even the non-high-focus states to cover the entire state was taken in January 2009. The evaluation report, which is a mixed bag, strongly locates ASHA within voluntarism and activism and has been cautious when addressing possibilities of their regularisation and compensation. While discussing factors that push ASHAs to the job, the evaluation emphasises ‘community service as being her main motivating element’ and not monetary compensation (pp. 37).^[15] The report reiterates the definition of ASHAs in the Guidelines on Accredited Social Health Activists published by the MHFW in 2005: ‘ASHA would be an honorary volunteer and would not receive any salary or honorarium’. According to the guidelines, ASHAs will be compensated for her time in specific situations such as training attendance, monthly reviews, and other meetings. Further, she is eligible for incentives offered under various national health programmes and could be compensated out of the untied funds at the Village Health and Sanitation Committee (VHSC) for specific outcomes.^[16] The 2011 evaluation report acknowledges the demand for unionisation and for regularisation of services of ASHA workers prevalent even in those early years but nullifies them by a contrary argument:

“The challenge would be to ensure that the ASHA’s potential to facilitate change is not undermined by the quest for her rights and that her service towards saving lives and mobilising for change is not undermined by the denial of her rights.” (pp.22)

The Incentives for ASHA

In the case of ASHAs, two factors – the support structures and the incentives – are interlinked. This clarifies and, at the same time, complicates the relationship between the Centre and the States in the execution of the ASHA programme and in the ways in which ASHAs are compensated for their services. The implementation responsibilities of the ASHA, a national programme under NHM, are with the states, and the states carry this out through the processes of selection, training, and strengthening of support structures. The support structures include, (i) at the state level, the Community Processes Resource Centre (CPRC), led by a team leader, which has a team of programme managers and consultants for the ASHA programme, VHSNC, Communications and Documentation, Training and Regional/Zonal coordinators. (ii) At the district level, the team of a district nodal officer supported by a district community mobiliser and data assistant is expected to manage the community processes implementation. (iii) At the block level, a Block Nodal Officer and ASHA facilitators (one ASHA facilitator for 10 to 20 ASHAs) to provide support and supervision. (iv) At the village level, the Village Health Sanitation and Nutrition Committee (VHSNC), the Anganwadi worker and the Auxiliary Nurse Midwife (ANM). Untied funds to the subcentre and to the VHSNC are provided by the Centre to leverage their functions as avenues for public participation in monitoring and decision-making.

What are the incentives designed for ASHAs, and how do they get them? The first Mission Steering Group (MSG) meeting of the National Health Mission, held on 20 December 2013 under the chairmanship of Ghulam Nabi Azad, approved several incentives for the ASHA programme. The MSG delinked incentives for routine activities from programme-specific incentives and approved an incentive amount of Rs. 1000 for a set of routine and recurrent activities regardless of population.^[17] What is the set of routine activities?^[18]  Those included mobilising for Village Health & Nutrition Day (VHND), facilitating or guiding the Village Health Sanitation and Nutrition Committee (VHSNC) meeting, attending Public Health Committee (PHC) review meetings and maintaining village health records (inclusive of line listing of households done at the beginning of the year and updated every six months, maintaining village health register supporting universal registration of births and deaths, preparation of due list of children to be immunised and updated on a monthly basis, and preparation of list of eligible couples updated on a monthly basis). The support structures and related activities mentioned above play a role in extending the incentives for ASHAs. Respective incentive amounts that have been assigned for these activities are Rs. 200 for the VHND, Rs. 150 each for the VHSNC and PHC review meeting and Rs. 500 for maintaining village health records.

ASHAs under the BJP Regime

The Bharatiya Janata Party (BJP) led National Democratic Alliance (NDA) that came to power in 2014 under the leadership of Narendra Modi has accepted the UPA’s ASHA programme in its entirety. The BJP government did not raise questions on the classification of ASHAs as honorary volunteers or on their compensation methods. Update on ASHA programme by the National Health Systems Resource Centre for the National Health Mission, Ministry of Health and Family Welfare in 2017, recognises that “ASHAs have emerged as an important human resource at the community level, as the key frontline health worker who is able to deliver health services at the village level, even in the most remote areas and to the marginalised”.^[19] The government introduced new incentives under child health and family planning programmes, which also meant that while increasing the workload for ASHAs, their compensation remained incentive-based. The heads of compensation in 2017 included 26 activities under maternal health, child health, immunisation, family planning, adolescent health, the revised national tuberculosis control programme, the national leprosy eradication programme, the national vector borne disease control programme, the incentive for routine recurrent activities and drinking water and sanitation.

There has not been any change in the approach to ASHA programme when BJP led NDA came back to power in 2019 and in 2024. In a reply given to M K Raghavan in the Lok Sabha on 22 July 2022, the Minister of State in the Ministry of Health and Family Welfare acknowledges that the ASHA programme is vital to achieving community engagement with the health system and is one of the key components of the NHM.^[20] At the same time, he affirms, “ASHAs are envisaged to be community health workers and only entitled to the task-based incentives.” He repeats the distinction between ‘routine and recurring’ activities and ‘performance-based’ activities, both to be administered by the states, and he gives the list of both. The minister gives as Annexure I a list of routine and recurring activities, which are the same as envisaged by the UPA government, and corresponding incentives adding up, now, to a total of Rs.2000 (Table 1). Continuing the appreciation of ASHA workers, Union Health Ministry hosted 250 ASHAs who are special invitees at the 76th Republic Day celebrations (26 January 2025). The press statement said, “This recognition not only uplifts the morale of these dedicated health workers but also underscores the crucial value of their contributions, setting a strong precedent for acknowledging their essential role. It highlights the significance of their work in advancing public health across India, reinforcing the vital impact they have in improving healthcare access and outcomes.”^[21]

Annexure II in the Minister’s reply gave a list of 35 performance-based activities under 10 main heads against which ASHAs are provided additional incentives. These include maternal health, child health, immunisation, family planning, adolescent health, the revised national tuberculosis control programme, the national leprosy eradication programme, the national vector borne disease control programme, incentives under (CPHC) and universal NCDs screening, drinking water and sanitation.

The performance-based activities increase to more than 65 under 14 main heads in 2024, which primarily means a significant increase in the workload of ASHAs.^[22] This in no way meant that there had been an increase in the incentives to the ASHAs from the Government of India. Consequently, there is grave disproportionality between the work and compensation; ASHAs work for 8-12 hours a day, travelling across villages, often in extremely harsh climates, with no healthcare support when they suffer from illness due to their job. The incentives they receive for their work compensate for the time and effort they put in, and it is not enough to meet the basic expenses of their families.

Additional Incentives by the States

As we have noticed, there are three levels of incentives. At the first level are the routine and recurring activities for which ASHAs receive a payment of Rs.2000 from the Central government; at the second level are performance-based incentives by the Centre executed through agencies of the State; and at the third level are the additional incentives by the States for any of the activities. Since the first, second and third level payments are incentive-based, ASHAs never receive a fixed pay.

In a reply to G. Kumar Naik in Lok Sabha on 07 February 2025, Pratap Rao Jadhav, Minister of State in the MOHFW, gives a list of additional incentives being given by the state governments to the ASHAs in the respective states^[23]  (Table 2).

In the same reply, Minister Pratap Rao Jadhav clarifies that the additional monetary incentives/honorarium to ASHAs must be from the state’s own resources. Since states’ perceived resources and their willingness to contribute from their resources vary, there is no uniformity in the incentives given by various states, as seen in the table above.

Collective Struggles of ASHAs in Various States

According to the data available on National Health System Resource Centre data, there are 10,03,790 ASHAs operating in India in 2025 (Table 3).^[24]

For ASHAs anywhere in India, the first port of call is the respective state governments. All their support structures are from within the states. Over the last few years, ASHAs across the country have begun to raise their voices against the exploitative practices to which they have been subjected. Everywhere they demand that they be recognised as workers and be compensated fairly for the work they render. ASHAs have gone on strike in Bihar, Maharashtra, Uttar Pradesh, Odisha, Delhi, Andhra Pradesh, West Bengal and Kerala. In 2018, ASHAs struck work for 28 days in Bihar. In 2023, they again struck work for 32 days in Bihar, and in response, the state government increased their honorarium to Rs. 2500. Mumbai’s Azad Maidan was a scene for a 21-day strike by thousands of ASHAs from across 36 districts of Maharashtra beginning February 9, 2024, demanding better compensation and on-time payments.^[25] Hundreds of ASHA workers demonstrated in Bhubaneswar, Odisha, on 19 December 2024, demanding a minimum monthly honorarium of Rs 26,000, compensation of Rs 10 lakh on death during duty or on superannuation from the job, a monthly pension of Rs 10,000 and recognition as permanent health workers under govt schemes.^[26] Hundreds of ASHA workers undertook an indefinite strike from August 28, 2023, in Delhi, demanding regularisation of work, a fixed salary of Rs15,000 a month or the state minimum wage, deciding on a retirement age with a fixed pension, gratuity and health benefits.^[27] They demanded the Delhi government to do away with the incentive system of remuneration. ASHA workers of Uttar Pradesh carried out a two-day protest at Eco Garden, Lucknow on February 19, 2024, in continuation of a three day strike, Mahapadav, from January 31 to February 2 in Lucknow in which thousands of ASHA workers from the state, including Banda, Prayagraj, Ballia, Azamgarh, and western Uttar Pradesh, participated.^[28] ASHAs demanded regularisation of work, discontinuation of incentive system, a minimum wages of Rs.26,000 per month and social security benefits like provident fund, gratuity and health insurance. In West Bengal, ASHAs participated in a demonstration on 12 August 2022 in Bidhannagar, Kolkata demanding a minimum salary of Rs 21,000 and a monthly pension of Rs 10,000 by implementing the recommendations of the 46th Labour Commission.^[29] Hundreds of ASHA workers staged a demonstration in Vijayawada, Andhra Pradesh on November 18, 2024 demanding that they be recognised as workers by the government.^[30] They demanded retirement at 62-year of age policy, ASHA worker group insurance, medical leaves, maternity leaves, and a variety of other benefits like ₹60,000 for retirement benefits, ₹20,000 for expenditure, and insurance coverage of ₹2 lakh for natural death and ₹6 lakh for accidental death. The struggles of ASHA workers of West Bengal and Andhra Pradesh were ASHA workers union led by the Centre of Indian Trade Unions (CITU) making similar demands as being raised by the ASHA workers on strike in Kerala.

Though the articulations of demands of ASHAs are to the Governments of the respective States, those are broadly the same. The demands could be summarised as follows:

1. ASHAs wants dignity at work
2. ASHAs wants their work to be regularised and wants them to be recognised as regular workers.
3. ASHAs want the incentive-based remuneration system to the stopped forthwith
4. ASHAs want to be fairly compensated on a monthly basis and prefer to receive at least the minimum wages set by the respective State governments
5. ASHAs want their retirement age to be fixed.
6. ASHAs would like to receive defined social security benefits including gratuity, ESI, pension and health benefits.
7. ASHAs, after their retirement, want a fixed pension

ASHAs in Periodic Labour Force Survey (PLFS)

In early March 2025, Chandrababu Naidu, Chief Minister of Andhra Pradesh approved the payment of gratuity of Rs. 1.50 lakh for each ASHA worker with 30 years of service. He raised the retirement age to 62 years and assured paid maternity leave to ASHA workers, besides enhancing their retirement age to 62 years from the existing 60.^[31] These are important announcements. However, it is not clear whether the gratuity the Chief Minister has announced is as per the provisions of the Payment of Gratuity Act 1972, which entails the recognition of ASHAs as employees and the government as their employer.^[32] The Act defines “employee” as any person (other than an apprentice) employed on wages. The statements by the Government of Andhra Pradesh have not given any indication of changing the status of ASHAs from that of a volunteer activist to a regular worker. The payment of gratuity act further entails that an employee who completes five years of service is eligible for gratuity and not service for a period of 30 years.

This systemic dilemma raises another fundamental question. How do the Periodic Labour Force Survey (PLFS) reports capture the services being rendered by the ASHAs. According to the industrial classification, ASHAs could be enumerated under ‘Human health and social work activities’ as per NIC 2008 classification. The impact of ASHAs activities in enhancing the health status of workers gets captured in the PLFS reports. Whether ASHAs fall under the definition of ‘worker’ and ‘labour force’ in the statistical surveys is an area that requires further clarity. It is the National Health System Resource Centre, part of National Health Mission, that provides us with information on the data on ASHAs. Further clarity is required on whether ASHAs are considered unincorporated enterprises. The Annual Survey of Unincorporated Enterprises (ASUSE) 2023-2024 does not give specific mention of services offered by ASHAs.

Coming back to ASHA workers struggle in Kerala

Given the structural and institutional boundaries within ASHAs had been created and have been operating and given the articulations of ASHAs all over India regarding their aspirations, it appears that the demands by ASHAs who are doing a sit-in strike in front of the Kerala secretariat are largely state-specific. To recall their main demands again – the Kerala ASHA Health Workers Association (KAHWA) wants the release of pending dues, an increase in the honorarium from the current Rs 7,000 to Rs 21,000, an increase in the retirement age from the current 62 years and retirement benefits of Rs 5 lakh. KAHWA has not raised fundamental demands for change in the status of ASHAs to workers and the replacement of the incentive system of compensation by payment of regular wages, which are the prerogatives of the Central Government. Incidentally, these are among the demands raised by ASHAs in other states, as discussed above.

The state government has not addressed the demands raised by ASHAs even after three rounds of negotiations the KAHWA had with Veena George, the Kerala Minister of Health. On April 8, 2025, the KAHWA submitted a memorandum to V Sivankutty, Minister of Labour, raising the same demands.^[33] However, the minister said that the government had already made the maximum possible concessions and that no further compromises would be made. The Government of Kerala has not come out clearly whether the reluctance to accept or negotiate the demands of ASHAs is because of financial constraints of the state. A statement that money must come from the central government does not validate the financial constraints of the state. The KAHWA, apparently, has carefully raised demands within the domain of incentives by the state. There could be a false consciousness regarding a jurisdictional overreach by a trade union other than CITU in mobilising the ASHAs and sustaining their struggle for more than two months. The ASHA Workers and Facilitators’ Federation of India (AWFFI), affiliated with the Centre of Indian Trade Unions (CITU) in a press release issued on March 3, 2025, said, “The strike is not representative of ASHA workers in general but is led by a minority union with vested interests.”^[34] The press release said that the strike, led by the Socialist Unity Centre of India (Communist) SUCI, was “politically motivated” and undermining the broader struggle for the rights of ASHA workers across the country. Such a perspective on ASHA strike has been given by the Communist Party of India (Marxist) [CPI(M)] leader and former Kerala minister Elamaram Kareem in February 2025, who said that “anarchist organisations” were behind the ongoing strike by ASHA workers in the state capital.^[35] As observed earlier, the struggle has obtained unprecedented support from various segments of Kerala society. Though it has not been substantiated by the statements of official representatives of the Government of Kerala, it had been mentioned in the report of the National Health Mission, 2017 (pp.28) that in Kerala, a decision was taken despite a significant shortfall that no new ASHA would be selected, given the widespread availability of Kudumbashree volunteers. The number of ASHAs in Kerala reduced from 30,113 in 2020 to 26,448 in 2025 (see Table 3).

It is imperative that the state government negotiate with ASHA workers to find an amicable solution to the state-specific demands raised by ASHAs. If the state-specific demands have financial and institutional implications beyond the state, then the state government must come up with a position paper clarifying its position. More importantly, to be liberated from the structural and institutional barriers the ASHAs are facing, ASHAs from all the states must ask the central government to recognise ASHAs as regular workers, replace incentives with regular fair wages and provide adequate social security. It calls for transparent alliances among trade unions strategically integrating the immediate and structural perspectives.

Table 1: Routine and Recurring Activities Given to ASHAs

Table 2: State-specific ASHA Incentives as of February 2025

Table 3: State-wise List of ASHA Workers

References

J John is Editor, Labour File, and Former Executive Director of CEC, New Delhi

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[2] PTI (2025). Congress Lok Sabha members raise issue of lack of remuneration for ASHA workers. The Hindu, Kerala. https://www.thehindu.com/news/national/kerala/congress-lok-sabha-members-raise-issue-of-lack-of-remuneration-for-asha-workers/article69312911.ece

[3] Express News Service (2025). ASHA workers to march to assembly as protest enters 21st day. The New Indian Express, Kerala. https://www.newindianexpress.com/states/kerala/2025/Mar/03/asha-workers-to-march-to-assembly-as-protest-enters-21st-day

[4] Ganga, A. (2025). Veena George Rejects Opposition Allegations, Affirms Government’s Dedication to ASHA Workers. Deshabhimani, Kerala. https://www.deshabhimani.com/english/kerala-news/asha-workers-strike-31045

[5] Dr. Manmohan Singh. (2005). PM launches “National Rural Health Mission”. https://archivepmo.nic.in/drmanmohansingh content_print.php nodeid=96&nodetype=2

[6] Ashok Vikhe Patil, K. V. Somasundaram and R. C. Goyal. (2002). Current Health Scenario in Rural India. Australian Journal of Rural Health, 10, 129–135. https://www.sas.upenn.edu/~dludden/WaterborneDisease3.pdf

[7] Uta Lehmann and David Sanders. (2007). Community health workers: what do we know about them? https://chwcentral.org/wp-content/uploads/2013/07/Community-Health-Workers-What-do-we-know-about-them.pdf

[8] WHO. (2020). What do we know about community health workers? A systematic review of existing reviews. https://iris.who.int/bitstream/handle/10665/340717/9789241512022-eng.pdf?sequence=1

[9] WHO. (2021). ASHA — the driving force behind India’s public health services. https://www.who.int/india/news/feature-stories/detail/asha-the-driving-force-behind-india-s-public-health-services

[10] WHO. (2022). India’s ASHA workers win Global Health Leaders Award. https://www.who.int/india/india-asha-workers

[11] Perry, H. (2013). A Brief History of Community Health Worker Programs. https://www.mchip.net/sites/default/files/mchipfiles/02_CHW_History.pdf

[12] Ministry of Health and Family Welfare, Government of India. (2005). National Rural Health Mission, Meeting people’s health needs in rural areas. Framework for Implementation 2005-2012. Ministry of Health and Family Welfare, Government of India. https://nhm.gov.in/WriteReadData/l892s/nrhm-framework-latest.pdf

[13] Ministry of Health and Family Welfare. (2005). Guidelines on Accredited Social Health Activitsts (ASHA). https://nhm.gov.in/images/pdf/communitisation/task-group-reports/guidelines-on-asha.pdf

[14] Farah N. Fathima, Mohan Raju, Kiruba S. Varadharajan, Aditi Krishnamurthy, S.R. Ananthkumar, Prem K. Mony. (2015). Assessment of ‘Accredited Social Health Activists’—A National Community Health Volunteer Scheme in Karnataka State, India. Journal of Health, Population and Nutrition, Volume 33, Number 1. https://pmc.ncbi.nlm.nih.gov/articles/PMC4438657/#:~:text=Most%20(73.1%25)%20ASHAs%20had,to%20socially%2Ddisadvantaged%20caste%20groups.

[15] National Health Systems Resource Centre (NHSRC). (2011). ASHA: Which way Forward? Executive Summary. Evaluation of ASHA Programme. https://nhsrcindia.org/sites/default/files/2021-03/Evaluation%20of%20ASHA%20Program%202010-11%20Executive%20Summary.pdf

[16] Ministry of Health and Family Welfare. (2005). Guidelines on Accredited Social Health Activitsts (ASHA). https://nhm.gov.in/images/pdf/communitisation/task-group-reports/guidelines-on-asha.pdf

[17] National Health Systems Resource Centre, Technical Support Institute with National Health Mission. (2014). Update on ASHA Programme. https://nhsrcindia.org/sites/default/files/2021-03/Update%20on%20ASHA%20Program%20January%202014.pdf

[18] ibid pp.1

[19] National Health Mission. (2017). Update on ASHA Programme. https://nhsrcindia.org/sites/default/files/2021-06/ASHA%20Update%20January-2017.pdf

[20] Dr. Bharati Pravin Pawar, The Minister of State in the Ministry of Health and Family Welfare (2022). Honorarium to ASHA Workers. In. New Delhi: Lok Sabha, Unstarred Question No.1118, To be answered on the 22nd July, 2022. https://sansad.in/getFile/loksabhaquestions/annex/179/AU1118.pdf?source=pqals

[21] PIB, Ministry of Health and Family Welfare. (2025). Special Guests at Republic Day: Union Health Ministry hosts ASHAs and applauds their contributions towards the success of various health initiatives. https://pib.gov.in/PressReleaseIframePage.aspx?PRID=2096075

[22] National Health Systems Resource Centre, Technical Support Institute with National Health Mission. (2024). ASHA Incentives- April 2024. https://nhsrcindia.org/sites/default/files/2024-01/ASHA%20Incentives.pdf

[23] Prataprao Jadhav, The Minister of State in the Ministry of Health and Family Welfare (2025). Remuneration for ASHA Workers. In. New Delhi: Lok Sabha, Uunstarred Question No. 902, To be Answered on 07.02.2025. https://sansad.in/getFile/loksabhaquestions/annex/184/AU902_hA8S4p.pdf?source=pqals

[24] National Health Systems Resource Centre, Technical Support Institute with National Health Mission. (2025). Total ASHAs. https://nhsrcindia.org/asha-map-table

[25] Ritu Sharma and Swadesha Sharma. (2024). State reassures protesting ASHAs.once again. https://ruralindiaonline.org/article/state-reassures-protesting-ashasonce-again

[26] Singha, M. (2024). Asha workers’ stir demanding higher pay. The Times of India. https://timesofindia.indiatimes.com/city/bhubaneswar/asha-workers-stir-demanding-higher-pay/articleshow/116478843.cms

[27] Gupta, R. (2023). Asha workers on stir over working conditions, pay. The Times of India. https://timesofindia.indiatimes.com/city/delhi/asha-workers-on-stir-over-working-conditions-pay/articleshow/103456079.cms

[28] Jafri, A. A. (2024). UP: 3-day Mahapadav of ASHA Workers Ends, Threat to Intensify Stir. Newsclick. https://www.newsclick.in/3-day-mahapadav-asha-workers-ends-threat-intensify-stir

[29] Peoples Reporter (2022). WB: ASHA Workers Protest, Demand Permanent Status, Minimum Wages. NEWS Click. https://www.newsclick.in/WB-ASHA-workers-protest-demand-permanent-status-minimum-wages

[30] G.V.R. Subba Rao (2024). ASHA workers stage protest in Vijayawada over long-pending demands. The Hindu, Andhra Pradesh. https://www.thehindu.com/news/national/andhra-pradesh/asha-workers-stage-protest-in-vijayawada-over-long-pending-demands/article68882822.ece

[31] Lanka, V. (2025). Andhra becomes 1st state to give Asha workers gratuity. The Times of India, India News. https://timesofindia.indiatimes.com/india/andhra-becomes-1st-state-to-give-asha-workers-gratuity/articleshow/118654843.cms

[32] Government of India. Payment of Gratuity Act, 1972. https://clc.gov.in/clc/sites/default/files/PaymentofGratuityAct.pdf

[33] (2025). ‘Govt compromised a lot, nothing more could be done’; Sivankutty on ASHA workers strike. Kaumudi Online, General. https://keralakaumudi.com/en/news/news.php?id=1513677&u=‘govt-comprised-a-lot-nothing-more-could-be-done-sivankutty-on-asha-workers-strike-1513677

[34] Web Desk (2025). AWFFI Criticises Politically Motivated ASHA Workers Strike in Kerala. Deshabhimani, Kerala. https://www.deshabhimani.com/deshabhimani-english-/kerala-news/awffi-press-release-90945

[35] TNM Staff (2025). CPI(M) leader criticises ASHA workers strike in Kerala, calls it politically motivated. The News Minute. https://www.thenewsminute.com/kerala/cpim-leader-criticises-asha-workers-strike-in-kerala-calls-it-politically-motivated