Recognizing the Labour Behind Care—The Fight for Dignity and Rights Among South Asia’s Community Healthcare Workers

By guest contributors Vaishnavi Mangal, Roosa Sofia Tikkanen, and Deepika Saluja

The recent Accredited Social Health Activists (ASHA) worker’s protest in Kerala has sparked an urgent conversation around work, dignity, and fair compensation for community-level healthcare workers in India. These frontline workers— almost all women—act as foot soldiers of the health system, bringing healthcare to the doorstep. Often regarded as “heroes” and celebrated globally (such as the ASHA workers receiving the WHO’s Global Health Leaders Award in 2023), they continue to work under deep precarious conditions. Their roles remain incentive-based and vastly under-compensated, with little to no provision for protective gear, social protection, timely income, and inflation-adjusted increments. Similar to Community Health Workers (CHWs) at large, who the International Labor Organization recognizes as an “often overlooked component of the health workforce”, they are subjected to difficult and dangerous working conditions and often lack adequate protection.

The recent ASHA worker’s strike in Kerala was quickly labeled as “anti-government”, to delegitimize the protest, and consequently, their demands. This raises a bigger question: how the labour of CHWs is being recognized—or erased—across South Asia?

In this Labour Day blog post, we examine this question by focusing on the labour rights’ movements in three countries of South Asia namely, ASHAs in India, Female Community Health Volunteers (FCHVs) in Nepal and Lady Health Workers (LHWs) in Pakistan. These women have been labor organizing for decades, with variable success. Their work continues to be shaped by the gendered division of labour in society, because care and social reproduction are seen as natural extension of women’s role in homes, they are continued to be undervalued and underpaid. 

CHWs worldwide are most often only informally attached to their health systems. Volunteering is commonplace and is also the case for Nepal’s FCHVs. The exception to this is Pakistan’s LHWs, who were granted civil servant status through a 2010 Supreme Court ruling that was in part fueled by union-led protests. In India, ASHAs have ‘honorary worker’ status, which means they – similar to Nepal’s FCHVs – are not recognized as ‘workers’ and thus lack access to labour rights such as minimum wage, pensions, maternity leave, or accident insurance provisions by health system. Indian feminist economist Padmini Swaminathan argues that the informal work mode by ASHAs is continued by the Indian state in the guise of ’empowering women’, but perpetuates gender injustices at large.

A second layer of precarity among CHWs lies in the nature of their work being deeply embedded within communities, typically going door-to-door. Compared to other facility-based health workers, CHWs work in community settings, which exposes them to community violence and environmental hazards like heat, floods etc. Most community-based health activities and programs implemented by the government fall on the shoulders of these workers in South Asia. This ever-increasing workload constantly exposes them to various occupational hazards, immense psychosocial burden along with the physical challenges caused by rapid climate crises including flooding, droughts, landslides, just to reach the communities. India’s ASHAs, Pakistan’s LHWs, and Nepal’s FCHVs have all been subjected to harassment and violence from community members, with much of this being gendered violence. In Pakistan, LHWs have even been murdered while on duty.

The experience of precarity, and their nascent identity as ‘workers’, is what has driven South Asia’s CHWs to organize and demand dignity and rights in their working conditions. In the case of India’s ASHAs, labor organizing has been more prevalent in states where they themselves feel under-supported by the health systems. The COVID-19 pandemic fueled these protests as these workers faced stigmatization and violence by the community members while risking their lives, without adequate personal protective equipment and other institutional support.

The labor unions of South Asia’s all-female CHW cadres have come together to demand labor rights and be recognized as ‘workers’. While the response from the national government is not always as expected, several wins have been made at the subnational level. In India, individual states like Andhra Pradesh have conferred some of social benefits as a result of union activity. In Nepal, FCHVs elected to local government have succeeded in including themselves within the nation’s social security scheme. In Pakistan, the LHW union in Sindh province has been particularly active, and this province was the first to regularize LHWs.

As we mark the Labour Day—a day meant to honor the contributions and struggles of workers—we urge the recognition of CHWs not just as “heroes”, but as workers. Protecting their labor rights is not only a matter of justice but also their health. Furthermore, it is essential for achieving a resilient and equitable health system. On this Labor Day, we urge South Asian leaders to adopt recommendations by the International Labor Organization and the World Health Organization, to pay CHWs a living wage, ensure their health and safety, as well as their representation in matters pertaining to their working conditions in line with Sustainable Development Goal (SDG) 8.5 of Decent Work.

About the authors

Vaishnavi Mangal is a public health researcher, and is currently pursuing her PhD at Norwegian University of Science and Technology, Ålesund, Norway. She has been researching digital health policies and their impact on the work of frontline healthcare workers in India.

Roosa Sofia Tikkanen is a PhD Fellow at the Norwegian University of Science and Technology in Trondheim, Norway, where she studies community health worker labor policies from a gender perspective. A trained neuroscientist, her 15-year career in health policy has focused on health inequalities, international comparisons of health care systems, universal coverage, women’s and maternal health, and primary care.

Dr. Deepika Saluja has a PhD in public health policy with a decade of experience working in health and gender space. Deepika is the co-founder and chair of Women in Global Health India Chapter and currently working with the George Institute for Global Health

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.