In the southern Indian state of Kerala, long celebrated for its robust public healthcare model, hundreds of women health workers are on the streets outside the state secretariat. As of May 1, they are in the third month of a 24/7 sit-in protest and the second month of an indefinite hunger strike. The protesting health workers, known as Accredited Social Health Activists, or ASHAs, consist solely of women. Despite forming the foundation of India’s grassroots public health system, they are not formally recognised as “workers” under Indian labour laws, as a result of which the state pays them a paltry wage termed an “honorarium.” Now, after decades in service, these women—essential to the state’s lauded public health system—are demanding a pay hike and retirement benefits, among other demands.

The ASHAs are part of the National Health Mission, envisioned to engage communities in delivering healthcare. These women move through alleys, fields, and villages, collecting information on diseases and deaths, adding to the database that public healthcare runs on. For all this work, they are paid a monthly honorarium of just Rs 7,000—approximately USD 82—and a fixed incentive of Rs 3,000, based on routine and recurring tasks like facilitating community health services and maintaining village health records. The incentive is paid jointly by the Centre and the state.

Led by the Kerala ASHA Health Workers’ Association (KAHWA), the protest is held outside the state secretariat in the capital of Thiruvananthapuram, and attended by about a hundred ASHA workers each morning and around 25 at night. The ASHAs even laid siege to the secretariat on March 17, blockading gates, but the administration did not budge.

The protesters’ demands are notably basic: a liveable wage, a flexible retirement age, a pension, and formal acknowledgement as workers. Currently, they are called “activists” and receive fixed and performance-based incentives rather than regular salaries. Being classified as formal workers would necessitate the government to acknowledge the systematic undervaluation of ASHA labour in the country’s public health infrastructure. Their classification as “volunteers” allows the state to deny them formal labour rights, creating a system of informalisation that leads to exploitation. Thus, they are systematically invisibilised as a legitimate workforce despite being crucial frontline workers.

“This work comes with a lot of anxiety,” an ASHA worker outside the Malappuram Civil Station told me, requesting not to be identified. “If today we are entering the details of a woman whose delivery date is due, and tomorrow she goes into labour, we have to be on our toes to feed in that data.” 

The protest by Kerala’s ASHA workers reveals a deepening crisis in India’s public health system, where frontline women healthcare providers are trapped between expanding digital responsibilities and shrinking compensation. Their demand for dignified wages also shows how fiscal federalism constraints by the central government have pushed Kerala to cut down on essential services while devaluing women’s labour in healthcare.

ASHA: An overburdened and underpaid women’s cadre

The current concerns of the ASHAs are tied to the origin and establishment of this institution of India’s frontline health workers. In 1975, the central government constituted a committee led by Dr. J. B. Shrivastav, the then director general of the government’s Health Services, to address India’s rural health crisis. The Shrivastava Committee proposed the creation of Community Health Workers (CHWs) as a sustainable and culturally rooted solution. But the committee added that these “para-professional” functionaries should not be integrated into the government’s healthcare cadre that receives remuneration from state funds, lest they become “bureaucrats.” It warned that salaried roles could alienate them from their communities. Instead, CHWs were to work voluntarily, relying on the trust and acceptance they locally generated. The committee believed their effectiveness lay in their community ties, cultural understanding, and personal commitment, positioning them as key to improving health literacy, promoting preventive care, and linking underserved populations with formal health services.

The committee called for the dais (midwives) and other women to carry the weight of healthcare, to walk the miles, to knock on doors, to deliver babies on floors, to record the illnesses and deaths for government reports. And so they came—the Auxiliary Nurse Midwives, the Multi-Purpose Health Workers, the Anganwadi workers, and then, in 2005, under the National Health Mission, the ASHAs. Yet, instead of a well-funded, salaried cadre of health workers, what emerged was an underpaid, overburdened workforce.

“We walk under the scorching sun, through heavy monsoons,” an ASHA worker at Malappuram said. “We visit homes, ask questions, and note symptoms. But there are no uniforms, umbrellas, or coats for us.” Another ASHA joined the conversation: “We are paid Rs 233 per day, or sometimes once in two or three days. With no money in our hands, life is difficult.”

“Our demand is simple,” said VK Sadanandan, the KAHWA president. “An honorarium of Rs 21,000 per month—Rs 700 per day. This is not an impossible ask. If migrant labourers can be paid an average of Rs 700, why not ASHA workers? Kerala is not like other states. Here, to live a dignified life, to send children to school, to run a household, Rs 7,000 a month is not enough. Not when inflation keeps rising.”

While these have been ongoing concerns, the situation for the health activists worsened after the Kerala government passed an order in 2023, stipulating the age of retirement of ASHA workers at 62, without any benefits or superannuation as given in states like West Bengal. The 2023 order further mandated performance-based termination rules, such as ASHA workers earning under Rs 500 for three months may be fired, except in tribal areas. It further imposed a condition on full payment of their honorarium.

One month into the protest, the Kerala government, possibly to assuage the protesters, issued a new order on 14 March 2025, amending the 2023 order and removing the condition imposed on the payment of full monthly honorariums. Another amendment order issued in April froze the termination clause that mentioned the age of retirement as 62. It is a small victory for the women, but the battle is not yet won. ASHA workers in Kerala continue to demand retirement benefits like pensions, and an increased honorarium—echoing the 2024 protests by their counterparts in Maharashtra, who called for provident fund contributions along with pensions. 

At the end of March, the protest hit the headlines again as the hunger strike entered its third week and protests intensified with ASHAs publicly chopping off their hair. The Right to Food Campaign and Public Services International (PSI) issued strong statements of solidarity with the ASHAs. The Right to Food Campaign highlighted that the centrally designed ASHA programme undervalues care work by classifying workers as “volunteers” and offering only Rs 2,000 as incentive pay (from central contribution), absolving the centre of responsibility while burdening state budgets. It urged the Kerala government to engage in dialogue and advocate with the centre to ensure dignified working conditions for ASHAs nationwide. In a letter to the chief minister of Kerala, Pinarayi Vijayan, the PSI called for urgent action to uphold the labour rights of the ASHAs. Meanwhile, KAHWA is launching a 45-day state-wide strike march from Kasaragod to Thiruvananthapuram, starting May 5, to demand liveable honorarium and retirement benefits for ASHAs. 

The Kerala government’s reluctance to address the issue of pensions indicates that the state may be facing fiscal constraints in accommodating the demands for pensions and benefits through revenue expenditure. The pensions are likely to be taken out of the state’s revenue expenditure while the Kerala government claims it is not being compensated by the central government. This would put additional stress on the state’s already strained revenue expenditure. Nearly 80% of the state’s revenue goes into paying salaries, pensions, and interests, with shrinking borrowing limits creating a fiscal challenge.

From care workers to data collectors

While ASHAs are heavily underpaid, the central and various state governments keep expanding their responsibilities, which were supposed to be confined to mobilisation, awareness, and service. The list kept growing: maternal health, child health, institutional deliveries, immunisation, first aid, sanitation, communicable diseases, nutrition, family planning, and so on. And then it was digitalisation—a quiet and controversial expansion of their workload. Since 2018, the push for digital infrastructure following the demonetisation of certain denominations has tripled their workload, the ASHAs say.

The health activists report to Junior Public Health Officers and Junior Health Assistants, who in turn report to Mid-Level Service Providers. Despite the multi-level chain of command, the ASHAs are now drowning in digital applications—outpatient apps, health surveillance apps, data entry apps. They are required to input numbers into various systems, each tracking different metrics: contraceptives, unorganised sector workers, reproductive and child health, and malaria surveillance. The government calls it integration—a sleek, digital dream of the Ayushman Bharat Digital Mission. However, the ASHA worker at Malappuram told me, “We hardly have time for anything. We wake up, and our day is already gone. Eighteen hours, sometimes more. We collect data, then come home and upload it onto apps. Since the Junior Public Health Officers and Junior Health Assistants depend on our data, we have to ensure it’s all done. We barely get to sleep.”

In Kerala, the ‘Shaili’ App—which means lifestyle in Malayalam—became another tool of surveillance and coercion. In 2024, Shaili 2.0 expanded its reach, requiring ASHAs to input more data of people in their assigned localities—Aadhaar numbers, occupation, age, gender, medical history, sexual health, menstrual cycles, alcohol consumption, tobacco use, night sweats, weight loss, breathing issues, and mental health. 

What appears to be a mere technological advancement is, in reality, a reconfiguration of power, where data, instead of empowering ASHAs, becomes a tool for extracting more labour from the overburdened workers. An ASHA worker in her 40s said, “I have epilepsy. I struggle to manage my health, and after a point, I simply can’t work more.”

A 2024 research study by the Institute of Social Studies Trust (ISST), Digitalisation at the Frontlines, examines how the integration of digital technologies into India’s public healthcare system has transformed the work of ASHAs across different states. The ISST study is a qualitative, empirical research that explores the ASHAs’ experiences with digital tools, highlighting how digitalisation has improved efficiency and access to healthcare data, but has simultaneously increased their workload, introduced surveillance mechanisms and widened the digital divide. 

The study also highlights how digitalisation has shifted ASHAs’ focus from community care to data entry, with tools like the MDM Shield 360 app in Haryana being used to monitor their activities. This has led to concerns about privacy, worker autonomy, and the ethical implications of government-led digital surveillance. The Asha Workers Union (Haryana) conveyed back in 2021 that the workers, over 20,000 in strength, refused to use the MDM Shield 360 app, fearing breach of privacy and increased harassment from officials, among other concerns. They called it a “surveillance app.” The mobile application enabled supervisors to restrict access to non-work-related mobile apps. The resistance led to the app’s eventual withdrawal.

The research explores the state-corporate collaboration in healthcare digitalisation, showing how the Indian government increasingly relies on private technology firms to build and manage digital health infrastructure, particularly under initiatives like the Ayushman Bharat Digital Mission. This collaboration enables large-scale data extraction from ASHAs and the communities they serve, often without clear data protections. 

Apps like Asha Soft in Rajasthan have streamlined payment processes, but they also log every activity, turning ASHA workers into continuously monitored subjects. The challenge of navigating new technologies is compounded by inadequate training, low levels of digital literacy, and a reliance on family members, particularly for older or marginalised ASHAs. 

While ASHA workers were once envisioned as bridges between communities and public health services, today they have quietly been transformed into doing unpaid digital drudgery. The government calls it integration, but for many ASHAs, it feels like surveillance with their roles shifting from caregivers to data collectors, their community trust repurposed to feed a bureaucratic machine.

This shift is not accidental—it reflects a deeper act of dispossession. As neoliberal reforms shrink the welfare state and expand private control, the ASHAs’ work—cognitive and affective—is undervalued and systematically captured and then converted into raw material for data harvesting without compensation. Care has been turned into code; health of populations into data; and the health activist into an instrument of this data extraction. In this regime, the state’s gaze is constant, but support is absent, further invisibilising the struggles of ASHAs.  Behind every new app or unpaid data entry task lies a larger political economy—shrinking public spending, centralised control, and weakened state autonomy. To fully understand the erosion of worker protections, the fiscal federalism crisis unfolding in India has to be addressed.

Effects of eroding fiscal federalism 

The scholar Louise Tillin, in her book Indian Federalism, argues that neoliberalism has reshaped Indian federalism by centralising economic power, restricting states’ fiscal autonomy, and forcing them into financial dependence on the centre. 

The introduction of the Goods and Services Tax, conditional welfare schemes, and borrowing limits has weakened states’ ability to implement independent welfare policies, particularly in opposition-ruled regions like Punjab, West Bengal, Kerala, Karnataka, Telangana and Tamil Nadu. This shift has increased the debts of southern states by limiting their revenue sources while imposing fiscal austerity measures that restrict borrowing, even as the centre itself exceeds borrowing limits. As a result, welfare-heavy states are pushed into financial crises, forcing them to privatise public services to stay afloat. It also curbs the states’ ability to tailor welfare policies to their own needs and makes them dependent on the Centre’s discretion. 

Kerala’s 2024-25 budget marked a significant shift toward increased privatisation through Public-Private Partnerships (PPPs) in critical sectors including infrastructure, healthcare, and education. The budget significantly broadens the application of PPP models and private sector investment compared to the 2023-24 budget. While the 2023 budget primarily focused on PPPs in infrastructure—such as Vizhinjam Port, industrial corridors, and EV parks—the 2024 budget expands PPPs into sectors like education, healthcare, agriculture, tourism, care economy (elderly care), retail trade, and sports. It introduces special development zones, a concept absent in 2023, and emphasises attracting Rs 3 lakh crore in investments through new models like REITs, InvITs, and joint ventures. This marks a shift from infrastructure-centric planning in 2023 to a more sectorally diversified and structurally reformist approach in 2024.

The centre’s financial constraints on Kerala, including borrowing limits and conditional fund transfers, have weakened the state’s autonomy, forcing it to underfund welfare schemes like ASHA, which operates under a 60:40 (centre:state) cost-sharing funding model. However, in practice, the central government contributes only a fixed monthly incentive of Rs 2,000 to each ASHA worker, regardless of their workload or regional variations. This leaves the responsibility of paying the remaining and often higher portion of the honorarium entirely on the state governments, pushing the burden onto their already strained revenue budgets.

Amid this, in the 2025 budget, the National Health Mission saw only a 3.4% increase, effectively declining in real terms. Though the government increased the budget from Rs 36,000 crores in FY24 to Rs 37,223 crores in FY25, rising prices—the inflation rate for 2025-26 is estimated at 4.2%—mean the value has not actually gone up. Adjusted for inflation, the allocation should have been Rs 37,512 crore just to maintain last year’s level. 

The 15th Finance Commission allocated 1.925% of the centre’s divisible tax pool to Kerala, down from 2.5% under the 14th Finance Commission. This reduction was due to Kerala’s higher per capita income, population control achievements, and the revised devolution formula emphasising income distance and demographic performance. Kerala is advocating for a reassessment in the 16th Finance Commission to better reflect its fiscal needs. Kerala claims that out of the Rs 826.02 crore expected from the centre for the financial year 2023-24, only Rs 189.15 crore was received, leaving Rs 636.88 crore, which includes funds for ASHA workers’ incentives, undisbursed. On 11 March, 2025, the union health minister JP Nadda addressed the Rajya Sabha, denying the accusation and stating that the centre had cleared all dues while also announcing an increase in incentives for ASHA workers. 

On April 1, Kerala’s health minister Veena George met Nadda to discuss the ASHA workers’ demands. She reportedly urged the centre to increase its share of incentives and release the pending NHM funds. Nadda is said to have assured that the issues were under serious consideration, but ASHA workers remain sceptical.  

The ASHA workers’ protests expose the fault lines and contradictions of the system that thrives on their invisibility yet depends entirely on their labour. As austerity deepens, digital governance expands, and fiscal autonomy collapses, care work becomes the victim of neoliberal efficiency. With the workers amping up the protests, the heat felt by the state government, the path ahead is uncertain. But it ultimately reflects broader tensions between fiscal constraints and the value of investing in frontline healthcare workers who provide essential services to millions of Indians, especially in rural and underserved areas, and recognise them as actual workers.