ASHA workers at the crossroads: navigating volunteerism and formalisation in the changing public health landscape

Summary box.

• The Accredited Social Health Activist (ASHA) programme, launched in 2005, is the world’s largest public-sector community health worker (CHW) initiative, playing a pivotal role in advancing maternal, child and public health in India.

• Despite being designated as ‘volunteers’, ASHA workers have undergone a process of ‘informal formalisation’, with their roles progressively expanding to include structured, institutionalised duties far beyond the original voluntary scope.

• ASHA workers face systemic challenges, including inadequate and inconsistent remuneration, increasing workloads, role ambiguity and lack of formal job security, leading to sustained protests and calls for reform over the past decade.

• ASHA programme needs to evolve to align with WHO guidelines on CHWs, particularly regarding written contracting arrangements, adequate remuneration and defined career progression pathways.

• Going forward, the ASHA programme requires a uniform national framework with semi-formalised pay structures, workload rationalisation and robust grievance redressal mechanisms to ensure dignity, equity and sustainability for this critical health workforce.

Introduction

Effective service delivery is a cornerstone of public health efforts, ensuring that essential healthcare reaches even the most underserved populations.¹ However, it is often hindered by an interplay of factors, including workforce shortage, poor accessibility, cultural influences and mistrust/distrust in health systems, particularly in remote and rural areas.^{2 3} These barriers can adversely affect the equitable distribution of health resources and weaken the overall impact of public health initiatives. To address these challenges, various community health worker (CHW) models have been implemented globally, tailored to the unique health needs and sociocultural contexts of different regions, with the aim of advancing ‘health for all’.⁴

India has a globally recognised CHW model, viz. the Accredited Social Health Activist (ASHA) programme, introduced under the National Rural Health Mission in 2005.^{5 6} The programme was inspired by the success of the Mitanin (meaning female friend) programme in the Indian state of Chhattisgarh, which demonstrated the effectiveness of CHWs in bridging gaps between formal health systems and rural communities.⁷ ASHAs have since become an integral part of India’s public health framework, playing a pivotal role in mobilising communities, promoting health awareness and facilitating access to essential health services.⁸

ASHAs are ‘trained female community health activists’ selected from the village that they are designated to serve. They undergo a series of training programmes to integrate themselves into the healthcare roles expected of them and are envisioned as the bridge between the community and the healthcare system. Positioned as health activists who serve as the first contact of marginalised sections with poor access to health services, ASHA workers provide information on determinants of health and health services, thereby assisting the community on timely utilisation of services.⁵

The ASHA programme is the world’s largest public-sector CHW initiative, with almost a million trained personnel, and studies have shown that their services have led to a significant increase in population health, particularly reproductive, child and maternal health.^{9 10} ASHAs were one of the six recipients of the WHO Director-General’s Health Leaders Award in 2022 for their contributions to health promotion, indicating the global recognition of their work.¹¹ Despite these impressive contributions to India’s healthcare system, there have been consistent reports of challenges faced by ASHA workers, including inadequate compensation, lack of job security and an increasing burden of responsibilities.^12–16 There is an increasing workload and formalisation of their roles, despite being labelled as ‘volunteers’. The authors, while engaging in a population-based health survey in rural Puducherry (a union territory in southern India) as part of the Model Rural Health Research Unit programme, worked closely with ASHA workers to elicit community participation.¹⁷ During our interaction with them, we came across their dilemma of being placed outside the healthcare system by being labelled as ‘volunteers’ but increasingly being technically bound to protocol and formal processes. This role precarity makes them occupy a hybrid space between informality and institutionalisation within the health system. This article critically analyses the ASHA programme to highlight the evolving roles and challenges faced by ASHA workers, particularly focusing on the unintended and gradual transition towards formalised roles and the systemic gaps that can undermine their effectiveness as CHWs. While previous studies have reported the programmatic challenges and practical difficulties faced by ASHA workers, this study examines the tension between the voluntary nature of the ASHA programme and its increasing formalisation through the analytical lens of ‘informal formalisation’.

Methods and materials

This study employed a document review of grey literature, focusing on news media coverage of ASHA worker protests. Newspaper reports were selected as the data source, as the study aimed to track the collective demands of ASHA workers against the backdrop of ‘informal formalisation’, which is not documented in peer-reviewed publications or government records. A systematic search was conducted using the ‘Advanced Search’ option of the Google search engine with the keywords ‘ASHA’ and ‘Protest’, and the filter option to restrict results to English-language pages and dates from January 2015 to March 2025 to capture results from the last 10 years. The keywords were limited to maintain search precision and capture reports that explicitly linked ASHA workers to collective action. A total of 80 result pages were generated, with 10 results per page, that is, around 800 results in total. All search results were listed and screened based on their content relevance. To eliminate duplication of the same news event reported by multiple media outlets, only the first retrieved result for each distinct protest event was retained, resulting in 30 unique records. Each retrieved article was read in full, and relevant information was extracted and recorded in online supplemental file 1. The content was then evaluated from the lens of ‘informal formalisation’ and compared with the WHO guidelines on CHWs to assess alignment and identify systemic gaps. However, the compilation is representative rather than exhaustive, given limitations including the exclusion of regional-language reports, potential underrepresentation of protest events and search engine limitations.

Volunteerism versus formalisation: the changing dynamics

Central to the concept of ASHA is the nature of their engagement as ‘voluntary’ CHWs.¹⁸ The guidelines on ASHA by the National Health Mission (NHM) state that ‘ASHA would be an honorary volunteer’¹⁹ and in response to a question raised in the Rajya Sabha (the upper house of the Indian parliament) in 2022, it was stated that ‘ASHAs are envisaged to be community health volunteer[s] and are only entitled to task/activity based incentives’.²⁰ The placement of ASHA workers as voluntary CHWs and the limiting of their roles to a few key domains, with an incentive-based remuneration model, allowed them to effectively complement the healthcare system while maintaining their voluntary essence.^{8 14} This strategic decision mitigated community resistance and encouraged participation, as ASHAs were perceived as trusted members of their villages rather than external authorities, allowing them to mobilise communities and promote health awareness without being constrained by the rigid structures of the bureaucracy and protocols. However, there were administrative reasons as well behind the decision, including underperformance by administrative and monitoring structures in the rural health system, resistance to creating a large new cadre of government employees entitled to lifelong employment and pensions, and concerns that the intended community orientation of ASHAs could be compromised by a salaried employee model.²¹ In the initial stages, volunteerism was attractive to the ASHA workers as the tasks were limited, with maternal and child healthcare as the primary focus.

While the voluntary status comes with a set of positive public health impacts, it also means that ASHAs are not entitled to a fixed formal pay. Instead, they receive a minimal monthly payment for completing a set of predefined tasks, including data collection and the promotion of maternal and child health, along with incentives for completing additional tasks and are also provided with free insurance coverage.¹⁹ At inception, the system was appropriate, with ASHAs having only limited tasks that mostly fell within the capacity of a community volunteer. However, over the years, the responsibilities of ASHAs have expanded significantly. Initially tasked with promoting immunisation and maternal health, ASHAs now find themselves managing a broader range of activities (table 1). This includes recurring tasks like health surveys to frontline emergency tasks like COVID-19 vaccination drives.¹³ Along with the evolution of the nature of the tasks assigned and responsibilities entrusted, there have been unintended and undesirable shifts in the form of formalisation of roles over the years, with the work allocation increasingly becoming structured with a diminishing ‘activist’/‘volunteer’ component. This evolution raises concerns about the erosion of the volunteer essence, as ASHAs find themselves navigating a quasi-formal employment framework without adequate recognition or remuneration. While there exist documented incentive rates for the specific tasks, they are often low, whereas the work has evolved to be systematic and institutional. While the list of tasks and the incentive for each task reflect an acknowledgement of the contributions of ASHAs, it also reflects how the roles have outgrown the originally envisioned ones and have become institutionalised.²² This role expansion often pairs with gaps and delays in allocated payments, due to systemic inconsistencies, despite the directives on remuneration.^23–25 This ambiguity surrounding their status leaves them vulnerable to systemic exploitation, contributing to dissatisfaction and burnout.

Table 1. Evolution of ASHA workers’ nature of engagement.

Period	Nature of engagement	Key tasks	Role evolution
2005–2010 (initial phase)	Incentive-based volunteer, with health promotion roles	Health promotion, immunisation awareness, antenatal care counselling and health promotion for institutional delivery.	Emphasis on community mobilisation; strong activist identity rooted in volunteerism.
2011–2015 (expansion phase)	Incentive-based volunteer with added surveillance tasks	Added responsibilities for family planning, TB surveillance and health surveys.	Increasing administrative monitoring and reporting; and task diversification.
2016–2019 (integration phase)	Semi-structured engagement	Introduction of digital data entry (RCH portal, mHealth), NCD screening, mental health awareness.	Gradual transition towards structured work with reduced activist flexibility.
2020–2022 (COVID-19 response phase)	Highly formalised under crisis response	Contact tracing, vaccination drives, data management, surveillance, risk communication.	Functionally equivalent to frontline staff; workload and risk significantly increased.
2023–2025 (current phase)	Informally-formalised	Routine public health services, NCD follow-up, health insurance enrolment, digital reporting.	Reduced autonomy, formalised scheduling, limited activist identity; push for regularisation.

Source: –, online supplemental table 1

ASHA, Accredited Social Health Activist; mHealth, mobile health; NCD, non-communicable disease; RCH, Reproductive and Child Health; TB, tuberculosis.

Neither gig nor formal: hybridity, role ambiguity and calls for change

As mentioned in the previous sections, the ASHA programme does not align with the traditional employment categories and was designed not to interfere with their regular livelihood.¹⁹ While some of the tasks they engage in are remunerated very similarly to those in gig work, they cannot be categorised as gig workers as their roles demand a sustained, long-term commitment to public health services. This effectively places them in a state of precarity, where they are simultaneously indispensable to the health system and structurally marginalised within it. Their work exemplifies a form of hybridity, caught between volunteerism and formal labour, where the obligations and expectations of their role increasingly mirror formal employment, but without the corresponding recognition or rights.¹⁴ Without the flexibility of gig work or the stability of formal employment, ASHAs face unique challenges. With the evolving role dynamics, they are required to adhere to rigid protocols and engage in extensive community outreach, all while receiving minimal financial and institutional support.²⁶ The absence of a uniform policy framework exacerbates disparities in their working conditions.²⁷ While some states have introduced additional benefits, these measures remain inconsistent across India. ASHAs have been vocal about their demands for better pay, job security and formal recognition and have been consistently engaging in demonstrations and protests towards this cause (online supplemental table 1).

The demand is relevant, given the fact that ascribing a ‘voluntary’ tag effectively nullifies the obligation to pay minimum wages ensured by the Minimum Wages Act.²⁸ In some states, the amount drawn by the ASHA workers is even less than that earned as daily wages under the Mahatma Gandhi National Rural Employment Guarantee Act (a rural employment programme for unskilled labourers in India), in stark contrast to the WHO guideline that recommends decent remuneration to CHWs.^{27 29} One of the shortcomings of the incentive-based programme is the lack of a single budget for ASHA’s remuneration. Since each incentive originates from a different activity, funds are allocated from different financial pools leading to delays in the transfer of payments.³⁰ The poor and inconsistent remuneration pairs with the ever-increasing workload, legitimising the claim for formalisation.²³ While initially envisioned to be working for 2–3 hours, four days a week, on limited predefined tasks, ASHAs now work well beyond the originally envisioned duration due to the piling up of additional tasks they are newly assigned to.³⁰ The exploitation of ASHA workers by the formal workforce by assigning tasks unrelated to their work profile further exacerbates the situation.³¹

The protests and calls for action by the ASHAs and advocacy groups over the years have yielded nominal results, with small hikes in the honorarium and health insurance in a few cases. However, these measures have fallen short of addressing the systemic issues faced by ASHA workers. The lack of a comprehensive policy framework continues to leave them vulnerable to exploitation and undercompensation. Despite their critical role in the healthcare system, their contributions remain undervalued and overlooked. The continued protests and advocacy efforts underscore the urgent need for reform. However, the formalisation of the ASHA workforce is a debatable topic, as volunteerism is at the heart of the ASHA programme.

Navigating the dilemma: future directions and challenges for sustainability

The ASHA programme stands at a critical juncture, embodying the tension between its origins as a voluntary initiative and the realities of its informal institutionalisation. While the programme’s success in advancing public health outcomes is undeniable, the systemic gaps in its operational framework threaten to undermine its sustainability.^32–34 Addressing these gaps requires a paradigm shift that balances the principles of volunteerism with the imperatives of formal recognition and compensation. The authors recommend the following actions in this regard, which stem from an analysis of the demands laid down by the ASHA workers protests in the last 10 years (online supplemental table 1) and an assessment of the WHO guideline on CHWs (table 2)²⁹

Table 2. Comparative analysis of ASHA programme and WHO guidelines on community health workers.

WHO recommendation (2018)	Description	India’s ASHA programme (status 2005–2025)	Level of alignment	Key strengths/gaps
Rec. 1A: Gender equity appropriate to the context	Preferential selection of women for empowerment.	Entirely female cadre	Complete	Adequate women representation.
Recommendation 7: remuneration	CHWs should receive financial packages commensurate with workload, avoiding performance-only models and gender disparities.	Incentive-based payments from multiple budget lines; no fixed salary or wage floor.	Partial	Reliance on task-based incentives undermines income stability; gendered pay gap persists.
Recommendation 8: contracting arrangements	CHWs should have written agreements specifying roles, working hours and entitlements.	Roles are defined through national guidelines, but no written contracts.	Weak	Lack of enforceable contracts leads to ambiguity and role exploitation.
Rec. 9: career progression	National systems should define pathways for advancement, training and promotion.	Limited career progression opportunities; some states offer ANM bridge courses.	Partial	No uniform national career structure.
Rec. 6: supportive supervision	CHWs should receive regular and quality supervision and feedback, from trained supervisors.	Exists through ASHA facilitators and PHC staff, but with variable quality.	Partial	Supervisory roles are often ad hoc.
Operational aspect 10.2.2 – policy coherence	CHW policies should be integrated into national health workforce planning.	Integrated into NHM but lacks a dedicated funding line and a clear HR policy.	Partial	Fragmented funding and absence of a national pay framework.

Source –:

HR, Human Resource

ANM, auxiliary nurse midwife; ASHA, Accredited Social Health Activist; CHW, community health worker; NHM, National Health Mission; PHC, primary health centre; Rec., Recommendation.

a. Policy reforms: Central to the current crisis is the lack of a uniform national framework that ensures consistent remuneration, benefits and job security. Guideline 9 in the Guidelines on Accredited Social Health Activists states that the ‘work would be so tailored that it does not interfere with her normal livelihood’ and the ASHA workers ‘would not receive any salary or honorarium’.¹⁹ While these guidelines may have been the practical paradigm at the time of inception, they require revisions, acknowledging the pivotal contributions ASHA workers make to public health. The ASHA benefit package proposed in 2018, involving life insurance and a joint pension scheme, and the recent introduction of health insurance for all ASHA workers in 2024 are welcome changes in this direction but are inadequate. The guidelines need to establish rational roles and salaries that account for workload. Central to the demands of agitating ASHA workers (online supplemental table 1) is the need for a uniform policy regarding role definitions and basic pay. This aligns with the WHO guideline, recommendations 6, 7A and 8, which emphasise clear contracting agreements, adequate remuneration and supportive supervision to optimise community health worker performance.²⁹ Implementing such a policy ensures sustainable growth and consistency for the ASHA programme.

The aspect of policy reforms, however, leads to the question of ‘governance actors for reform’. Since the ASHA programme operates with a multilevel government system, with the central government supporting standard-setting, resource allocation and policy frameworks and the state governments bearing the responsibility for operationalising recruitment, training, supervision and day-to-day management of ASHA workers.¹⁹ Policy reforms, hence, require coordination mechanisms where the central government provides normative guidance and funding envelopes, and state governments implement context-specific adaptations, financing and monitoring, aligning with the WHO’s health system strengthening approach.²⁹ This also leads to the question of ‘sustainable financing’. The WHO guideline on optimising CHW programmes recommends that financing should be integrated as a core component of national health budgets rather than relying predominantly on donor or short-term grants,²⁹ which is large-scale and challenging, given India’s low spending on health. However, the ASHA programme has reached a stage where it requires a larger budgetary allocation and stronger commitment from the state actors.

b. Workload rationalisation: The increasing workload of ASHA workers, coupled with vague job descriptions, has led to burnout, dissatisfaction and exploitation. Originally envisioned to work 4–5 hours daily on predefined tasks, ASHAs now juggle a wide range of activities, many of which exceed their intended scope. Unauthorised task assignments further exacerbate their plight. To address these issues, it is imperative to clearly define the scope of ASHA responsibilities in consultation with ASHA workers, healthcare administrators and policymakers. Task allocation frameworks must prioritise core public health activities, avoiding the imposition of ancillary duties. Additionally, implementing a robust grievance redressal system could empower ASHA workers to report unauthorised assignments and workload-related concerns without fear of retribution. Periodic workload assessments and task reassignments based on regional priorities could also help balance the distribution of responsibilities across ASHAs. Formal written agreements specifying roles, responsibilities and working conditions in line with WHO guidelines on CHWs, recommendation 8 on contracting agreements, can be a positive step in this direction.²⁹

Semi-formalised pay and activist role: Integrating ASHA workers into the healthcare system while preserving their grassroots connection is an essential step in restructuring the roles of ASHA workers in the evolving public health landscape. ASHAs have earned community trust by operating as local health activists rather than bureaucratic agents.^{7 15 21} Granting ASHA workers semi-formal status under the NHM can be a step towards acknowledging them as part of the healthcare system while preserving the voluntary essence of their roles. This also aligns with the WHO guideline on CHWs, section 10.2.2 on policy alignment.²⁹ This status would strike a balance between formal recognition and grassroots connectivity. It can also restrict the informal task reallocation by other healthcare staff in supervisory positions. A guaranteed base honorarium is essential to ensure a minimum, predictable income for ASHA workers, offering them financial security and dignity. The addition of performance-based incentives for completing specific tasks could complement this fixed income, promoting accountability and rewarding exceptional contributions. While the current system has a fixed payment option, it functions erratically. A centralised approach to ensure fixed payment, complemented by incentives, will be effective in this regard. To support this model, a streamlined payment mechanism with dedicated financial pools for ASHA honorariums and incentives should be established.

The recommendations also call for India to adopt sustainable elements from some of the prominent global CHW models (table 3). For instance, formal CHW cadres in Brazil and Sri Lanka provide professional status and career paths to the CHWs. Also, Brazil, Sri Lanka, Bangladesh and Nigeria provide minimum wages for their CHW workforce with legal protection to a certain extent. In Rwanda and South Africa, semi-formal cadres blend state support with community-rootedness, offering some stability but facing their own gaps in support and recognition.^{35 36} Drawing from the strengths of these models, the Indian CHW programme can work towards semi-formalised pay structures, grievance mechanisms and workload rationalisation. In addition, the WHO guideline on CHW recommends decent wages for the CHWs and cautions against the adoption of performance-based incentives as the predominant remuneration method and suggests that since the entire CHW workforce in India is women, voluntary status could ‘perpetuate gender disparities in access to income and opportunities’.²⁹ The gender element is particularly important, as the ASHA workers’ liminal status as paid volunteers intersects with the persistent gender wage gap. ³⁷ Often, as women from marginalised backgrounds, ASHA workers experience persistent wage gaps leading to structural devaluation that not only undermines ASHAs’ economic rights and professional recognition but also perpetuates gendered inequities in the health workforce.²¹ Considering the intersection of the liminal status and the gender wage gap, the reforms need to be a priority for the state.

Table 3. Global community health worker programmes: comparison of roles, compensation and institutional arrangements.

Sl. no.	Country	CHW programme	Roles of the CHW	Remuneration model	Employment status
1	Brazil	Agente Comunitário de Saúde (ACS)	Promotive, preventive, curative and rehabilitative services	Salary	Formal
2	Ghana	Community Health Volunteers (CHVs)	Disease surveillance, health promotion, minor ailments management, referrals	None (non-monetary incentives)	Voluntary
3	Nigeria	Community Health Extension Workers (CHEWs)	Curative services, referral, health promotion	Salary (with public sector wage floor)	Formal
4	Rwanda	Binômes	Basic care for selected conditions, screening, contraceptive provision	Performance-based incentives	Semi-formal
5	South Africa	Community Health Workers (CHWs)	Prevention, promotion, chronic care support, screening, referral	Salary (highly variable)	Semi-formal
6	Bangladesh	Shasthya Shebika (SS)	Health promotion, maternal/newborn care, TB and malaria management, sanitation education	Incentive and entrepreneurship model	Voluntary
		Shasthya Kormi (SK)	Supervisory, maternal/newborn care, adolescent health, NCD screening	Salary and incentives	Semi-formal
7	India	Accredited Social Health Activist (ASHA)	Maternal/child health, family planning, NCD risk assessment	Performance-based incentives	Voluntary
8	Nepal	Female Community Health Volunteers (FCHVs)	Health education, maternal/child health, childhood illness treatment	None (small allowances)	Voluntary
9	Sri Lanka	Public Health Midwives (PHMs)	Maternal/child health, family planning, immunisation, NCD prevention	Salary	Formal

Compiled by the authors from Ballard et al, 2021; Shrestha et al, 2024.

NCD, non-communicable disease; TB, tuberculosis.

While these recommendations represent a practical bridge between the demands of ASHA workers and the WHO guidelines on CHWs, there are challenges in implementation. Two of the most significant challenges in this regard are political will and long-term financing.²⁸ With shifting government priorities undermining sustained focus and funding constraints due to fragmented and insufficient financial resources, ASHA workers are often not a priority for the political leadership. Also, the spending on health accounts for only 2.1 per cent of the Indian gross domestic product.³⁸ Ensuring a formalised pay structure for a million ASHA workers would place a significant burden on the state and require sustainable resources and political will. However, political action often results from sustained advocacy and social action that strategically communicates the instrumental value of ASHAs to public health programmes. The advocacy messaging should communicate how the ASHA programme has improved health outcomes, particularly maternal and child health among marginalised communities.^{9 10} Additionally, regional disparities in governance and resource allocation hinder uniform adoption of policies, while resistance to change from stakeholders, including supervisors and administrators, poses challenges to redefining roles and payment structures. Overcoming these barriers requires advocacy, sustainable funding mechanisms and political will. The advocacy and policy recommendations are intended to complement the efforts of stakeholders at multiple levels. At the regional policy level, the recommendations call upon the central and state government apparatus to refine guidelines and standardise remuneration frameworks, which fall within the purview of the bureaucracy and the legislature. At the advocacy level, the recommendations call for sustained advocacy and grassroots mobilisation by civil society organisations for formal recognition, fair compensation and improved working conditions. Globally, the recommendations seek to complement the WHO guidelines for CHWs, situating India’s ASHA experience as a model for rights-based reform.

Limitations of the study

This study has certain methodological limitations that should be taken into account. The first methodological limitation is the search engine’s indexing bias, which can limit online visibility and be region-specific. Second, restricting the search to English-language reports has excluded regional-language reports. Hence, the compilation is mostly representative, rather than exhaustive. Third, news media come with reporting biases common in journalism, and hence, the selection of news reports as the primary data source for tracking the demands of ASHA workers has its limitations.

Conclusion

The ASHA programme stands as a transformative model in community health, significantly advancing public health outcomes in India. Currently, the programme is evolving with an expanding scope, and the ASHA workers face a conflict in their voluntary status and the increasing formalisation of tasks. Systemic challenges, including inadequate compensation, undefined roles and increasing workloads, threaten the sustainability of the programme and the welfare of ASHA workers. To bridge these gaps, we advocate for reforms grounded in WHO recommendations and the demands of ASHA workers. Central to these reforms is the adoption of a uniform national framework ensuring fair remuneration, well-defined roles and consistent benefits across states. Additionally, semi-formalisation of pay structures, streamlined grievance mechanisms and workload rationalisation are critical to addressing exploitation and enhancing job satisfaction. With political will, strategic resource allocation and a commitment to reform, the ASHA programme can continue to serve as a cornerstone of India’s public health infrastructure, promoting health equity while upholding the dignity and rights of its workforce.

Data availability statement

There are no data in this work.