Ek ASHA, Sau Farmaan

Soni Begum from Soherwa, Chittaura block in Uttar Pradesh says that she wakes up before sunrise, the house still dark, as she quickly finishes her morning chores. Her mom fixes breakfast for her. She sweeps the courtyard just beyond her electric blue doors and fills a bucket with water for her bath. As she sits down with her first cup of tea, her phone rings.

It’s a block coordinator from a civil society organization reminding her to ensure full attendance at the upcoming Village Health, Sanitation, and Nutrition Day (VHSND). She sighs, knowing what’s coming. I meet her at around 09:45AM, and we start our day together. We sit together and map the number of households that we have to visit—4 pregnant women and 3 newborn babies.

Work Begins

Within the hour, we step out of her house and start walking.

She is dressed in her ASHA uniform—white and brown kurta and blue dupatta draped loosely over her head, a battered register tucked neatly in a polythene bag. The heat is already rising as she sets off on her route—an approximate nine-kilometer walk across scattered purwas (hamlets). People refer to her as “Baaji” fondly, and it is quite evident that she is the kind of popular every teenage girl would like to be. She greets every passerby, stopping to check on pregnant women, adolescent girls, and new mothers, plays with the babies, and remembers the names of each and every child, making sure to ask a follow-up question since she last met them.

“Ab diarhea toh nahi ho raha hai, Salim ko? Koi machli (discomfort) toh nahi hai, pehli teeh maahi mein common hai. Nimbu paani piyo, theek ho jayega.”

Close to the chabutra, right next to the well, is a neem tree from under which a Dhatri woman calls out, “Baaji!” She is holding her baby’s arm out for Soni to inspect. “The BCG vaccine spot has swollen, look!” It’s been a month since he got the dose. This is unlikely. The tiny red lump is irritated, and the mother’s face is tense with worry. Soni Begum stops momentarily, kneels beside her, inspects the site, and continues to calmly explain how to cool it with a clean cloth and what danger signs to look out for.

Further down the road, she spots an elderly woman, a daadi, shaking her head in disapproval. “You didn’t bring my money from the Janani Suraksha Yojana (JSY) scheme,” she scolds. Soni tries to explain—the portal has been down for weeks—but the daadi has already turned away, muttering about how ASHAs are useless and a child could do a better job.

Acchi Maa

By noon, we have covered three households of pregnant women and are just entering the fourth one’s house. “Are you breastfeeding the child?”

“No.”

“Why?”

The new mother lifts her blouse and shows us. She explains how the skin around her areola has torn and that she has been bleeding from her nipples. Breastfeeding is painful, but she is also afraid the child may ingest some dirty blood. Soni Begum nods her head and understands. She picks the child up and cradles her in her arms, asking the mother to show her how she breastfeeds. After some role play, Soni Begum realizes that the mother has not been latching the child properly.

“Nipple to nose, until the child opens its mouth completely. Sandwich your breasts and push the breast into the child’s mouth until the entire dark part is inside. The child will start sucking on its own. Watch out for some signs—the child should gulp audibly, and its chin should be visibly moving.”

She advises the woman to put on some ointments and comforts her. “Koi baat nahi, pehli baar koi kese samajh payega, karte karte seekh jaogi.”

We leave the mother’s house, and Soni Begum tells me that it is quite common for first-time mothers, who do not have a saas-maa to guide them, to have some problems adjusting to breastfeeding. “Inko lagta hai ye achi maa nahi hai, but sab ko nahi hota hai toh nahi hota hai.”

We have already been walking in the sweltering sun for hours, trying to convince mothers to attend tomorrow’s VHSND session and visit households to counsel them, but many have household chores and fieldwork that keep them away. They all say they will try to come, and it is true. They will.

Hunger

Her own stomach growls, and my stomach resonates to it like a mating call, but we will yet again have no time for lunch today. Instead, we move on to our next task: weighing a low-birth-weight baby. The baby, born at 2kg 200g, was so tiny and blue. If I liked babies less, I would compare it to a raisin. We advise the mother to follow the kangaroo mother care method—skin-to-skin touch of the caregivers and the child’s chest—and weigh the child’s weight. It had lost some since after birth—200-300g is normal, but this child had lost 600grams.

She counsels the woman and scolds the family members for not taking better care of both the mother and the child. There are still some home visits left before the sun sets, and she knows that by the time she returns home, her family will already be eating dinner. She still doesn’t know if tomorrow’s VHSND session will have a 100% turnover rate.

Droupadi didi from Chittaura, usually clad in a white and brown saree, jokes about how much her husband dislikes her name and that she, too, used to dislike being teased about having five husbands when she was growing up but has now really come to not mind it, unlike her husband. Her house’s door is also blue in colour, and she makes a mean cup of tea—so strong on the masale, it’s almost spicy.

Increase Numbers

We had just wrapped up a VHSND session in her Gram Panchayat, and the turnover rate had been very low—only 3 out of 24 had shown up today. ASHA didi will have to hear some scolding from someone about it. With rising pressures to increase nasbandhi, increase early identification of women in the first trimester, increase IFA consumption, and increase complete ANC checks, this is just another thing—slightly minor in nature—that she will be scolded by the Adhikaari about.

I suggest I drop her home and then catch an auto from close to her house—it’s on the main road either way.

“Aap ASHA kyu bane didi?” (Why did you become an ASHA, didi?)

“I just like working. I like being able to hold my expenses on my own.” Married at 15, she has 3 daughters and two sons. She is very curious about why I am not married still.

“16 somwaar ka vrat rakho toh acha pati milega.” She tells me that a good husband takes care of his wife like a child. “Ek pati mein saare roop hote hain.”

His Support

I ask her if her husband supports her decision to be an ASHA. She tells me that he always has been. “I joined because I liked working, and my husband was okay about it, and my kids were all grown up, so I could work whenever I wanted to. Meri marzi mein jab kaam karoon.”

“Itne saal ho gaye didi, ab bhi maza aata hai?”

“Maza toh bahut aata hai, aur 4000 rupee toh pakka account mein aate hain.” She smiles. “Bas mera pati thoda gussa karta hai kabhi kabhi.” He thought this was a commitment that I volunteer my time to. “Swaechetta se,” she said. “He feels jealous sometimes.”

She mischievously squints her eyes, loops her arms in mine, and tells me, “Par didi, aap bataiye? Hum insaan hain ki nahi? Aap sanstha wale, adhikari log sab aa jate hain har doosre roz kaam karwane, mere man se kaam toh nahi hua na ye phir?” She retorts in her signature Bhojpuri accent.

I stiffen because she is right. She realizes and changes the topic.

We talk about the husband who shushed his wife at the session today and how rude it was of him to do so.

“Didi, mujhe lagta hai ki 16 somwaar ka vrat rakh hi leti hoon, shayad phir esa pati mile jo chaar logon ke saamne mujhe chup rehne ko na bole.”

She stays quiet for a bit. “Mat hi karo. Vrat rakhne ke baad bhi waisa mil gaya toh kya karogi?”

Just like fasting doesn’t ensure a good marriage, hard work as an ASHA doesn’t ensure fair treatment. Her phone rings then. It is the BCPM.

“Ek ASHA, Sau Farmaan,” Didi sighs and picks up the call.

The Hidden Cost Of Community Cadre Based Systems

ASHA didis like Soni Begum and Droupadi are called a ‘volunteer,’ but the reality of her work is anything but voluntary. The system expects her to be available at all times, yet it does not compensate her as a full-time worker. Her pay is task-based, unpredictable, and inconsistent, dependent on meeting numerical targets rather than acknowledging the emotional and physical labor she puts in daily.

The very flexibility that was promised to her has been taken away. She does not choose when or how to work—her time is dictated by the mandates of government schemes, NGO expectations, and community demands. The power to decide how to structure her own day, the very essence of what made these roles ‘community-led,’ has slowly eroded under increasing pressure.

ASHAs are paid per task, making their earnings uncertain and often delayed. Workers are expected to be always available, yet they have no formal work contracts. ASHAs and CRPs bear the brunt of community frustrations (such as delays in JSY payments) while having no power to change systemic inefficiencies and still be accountable upwards (to government health departments or their respective CSOs) and downwards (to the community). When they speak out against delayed payments, exploitative working conditions, or flawed health policies, they engage in a form of labor activism—even though the system does not recognize them as workers with rights. 

Activists To Foot Soldiers

Community-based workers like Soni Begum and Droupadi didi are the backbone of health and development programs but the system has shifted them from activists to foot soldiers. 

If the goal of community-based cadre systems is to empower, then the first step must be to restore decision-making power to the very workers who sustain these programs. Until ASHAs, CRPs, and others community based cadres have true autonomy over their time and fair compensation for their labor, these systems will remain exploitative rather than empowering.

Disclaimer: Inspired by real events, some parts of the story are fictional.