In Kerala, a state renowned for its robust public healthcare system, a storm is brewing. At the heart of this unrest are the Accredited Social Health Activists (ASHA) workers—often overlooked yet essential healthcare providers who serve as the first point of contact for many. These dedicated workers raise awareness, deliver critical services such as disease screening and immunization, assist with maternal and child care, and navigate difficult terrains, all for minimal pay. Once voices of service, they are now united in a collective demand for fair wages, better working conditions, and rightful recognition. The ongoing protests in Kerala not only underscore the crucial role of these frontline workers but also reveal the systemic flaws they endure. Central to the unrest are issues of inadequate compensation and recognition, exacerbated by ongoing funding disputes between the state and central governments.

Celebrated abroad, undervalued at home

ASHA workers are vital to India’s healthcare system, especially in rural and underserved areas. Established in 2005 under the National Rural Health Mission (NRHM), the ASHA program aims to enhance healthcare access, promote healthier practices, and raise awareness about government health services in remote regions. ASHAs, who are typically women from the communities they serve, build trust and strong connections with local populations. They perform a wide range of duties that directly influence public health outcomes, including supporting pregnant women and new mothers with prenatal and postnatal care. During health crises like the COVID-19 pandemic, ASHAs have played a crucial role in spreading accurate information, coordinating vaccination efforts, and ensuring adherence to preventive health measures

In May 2022 the World Health Organization (WHO) awarded India’s ASHA workers the Director-General’s Global Health Leaders Award, acknowledging their exceptional contributions to global health. However, this international recognition is in stark contrast with the ongoing challenges they face within India.

Indeed, despite their essential role and international recognition, ASHAs are frequently underpaid and face difficult working conditions with limited resources. Classified as voluntary health workers, they are not salaried employees and instead receive performance-based incentives for specific services. Typically, an ASHA earns between ₹3,000 and ₹10,000 (35- 115 USD) per month, depending on the number of tasks completed and their success in meeting health targets. However, this income is inconsistent and varies widely across states.

Only a Kerala issue or a broader problem?

The ASHA workers’ strike, which began on February 10, 2025, is a call for fair pay and recognition. On March 31, 2025, Kerala’s ASHAs marked the 50th day of their protest with a powerful demonstration outside the Secretariat in Thiruvananthapuram. In a dramatic act of solidarity and frustration, hundreds of women symbolically cut their hair to express their emotional distress and disillusionment with the ongoing deadlock. This protest underscores the growing urgency among ASHAs, who feel their crucial role in the public health system is being overlooked. The continued strike highlights the pressing need for the government to address their demands for better wages and working conditions.

While ASHA workers across India face similar challenges—low pay, lack of job security, and poor working conditions—the large-scale, sustained strike currently unfolding in Kerala is unique. This isn’t because ASHA workers in other states are more satisfied, but rather because Kerala provides a distinct socio-political context that enables and amplifies collective action. Kerala has a long history of strong labor movements, high political consciousness, and grassroots organizing—especially among women. ASHA workers in the state are better connected through unions and welfare associations, and there is a relatively more responsive media and public discourse that gives visibility to such protests. Moreover, expectations are higher in Kerala, given its reputation for a robust public health system. When that system fails its frontline workers, the contrast is stark—and more likely to spark action.

For health workers in the rest of India, the Kerala strike could thus serve as both an inspiration and a wake-up call. It shows that collective action can shine a spotlight on long-ignored issues. However, it may also expose the limitations of fragmented organizing, lack of union support, and political will in other regions. Unless these structural barriers are addressed, many ASHA workers elsewhere may continue to suffer in silence—even as their peers in Kerala raise their voices louder than ever.

If we zoom out even more, the fight for recognition and fair pay for community health workers is actually a global one, affecting frontline workers across Asia and Africa.

Countries like Brazil and Pakistan offer valuable models for reform. Brazil recognized Community Health Workers as professionals in 2002, ensuring minimum training, fair wages, protective gear, and inflation-linked pay. In Pakistan, the services of Lady Health Workers were regularized after sustained protests and a landmark Supreme Court ruling raised their wages. These global cases show that collective action can lead to meaningful change. In contrast, India’s recognition of ASHAs—despite global awards—has yet to translate into improved working conditions or fair compensation.

Breaking the deadlock

Despite several rounds of negotiations, the Kerala government’s response to the ASHA workers’ strike has yet to yield a meaningful resolution. This ongoing stalemate has left workers feeling ignored and undervalued, pushing them toward increasingly drastic forms of protest, including symbolic acts like hair-cutting and hunger strikes.

By now, the prolonged ASHA strike has serious consequences—disrupting rural health services, increasing future healthcare costs, straining the formal system, and leaving vulnerable communities without vital support.

Given the essential role ASHA workers play and the systemic issues their protests highlight, they must be guaranteed fair salaries, legal protections, and the tools needed to work safely and effectively. Drawing from successful international models, India should prioritize high-quality, regularly updated, and culturally relevant training, along with continuous professional development to keep ASHAs informed and capable. Structured career pathways—offering leadership roles or specializations—can boost motivation and retention. It is equally critical to address chronic resource shortages and ensure ASHAs have safe, reliable ways to report grievances and resolve issues around pay and working conditions without fear of retaliation.

Recognizing ASHA workers as essential professionals and committing to their support through concrete investments and policy reforms is not just a matter of fairness—it’s a strategic imperative. By acting on these recommendations, India has the opportunity to fortify its primary healthcare system, promote health equity, and genuinely value the tireless contributions of these frontline health champions.