NIHR Global Health Research Unit on Respiratory Health (RESPIRE)

Voluntary Community Health Workers in India struggle to balance their key health work and domestic tasks, study finds

RESPIRE project assessing the workload of Indian Accredited Social Health Activists has found they had to juggle household tasks, and other paid jobs alongside their voluntary health care activities

A study from the RESPIRE Collaboration published in Human Resources for Health has found that Indian Accredited Social Health Activists (ASHAs) struggle to balance their health care activities and domestic tasks. Despite their pride in benefitting their communities, and high job satisfaction, and increasing range of activities contributed to feelings of being rushed and tiredness.

Accredited Social Health Activists (ASHAs)

The Accredited Social Health Activist (ASHA) programme is India’s largest public-sector community health worker initiative, launched by the Government of India in 2005 to provide accessible, affordable and quality healthcare to the rural population.

ASHAs serve as key facilitators of the healthcare system in India’s rural populations. ASHAs are voluntary workers, not employees, tasked with implementing a number of government health programmes at a village level.

There are currently more than one million ASHAs in India and act as a key link between the health system and the population. With an increasing range of activities, the aim of this paper was to asses and explore the ASHAs’ perspectives of their workload.

The study

The study used a mixed-methods design in two Primary Health Centres, one rural and the other tribal (often remote), in the Pune district of Western Maharashtra, India.

The ASHAs answered questionnaires focusing on the time spent on ASHA work and travel, their perceptions of workload and its impact on them and their family. They were also asked about their remuneration, their job satisfaction and family support.

Alongside these questionnaires, eight ASHAs took part in in-depth interviews which explored their workload and its effect on the ASHAs family and self. Age, training, education, experience, work setting, incentives and other occupations were highlighted as influencing factors. When interpreting prioritisation of their work, the volunteer status of ASHAs was important.

Prioritising ASHA and other work

It was found that ASHAs work up to 20 hours a week in their village of residence, with an increasing range of activities to carry out. This workload contributed to them feeling rushed and tired, meaning they have to prioritise between ASHA and other work.

The sense of benefitting the community and the ‘pride of ASHA work’ brought them job satisfaction and happiness. They preferred to describe themselves as ‘ASHA workers’, a term closer to ‘Community Healthcare Workers’ than “Health Activist”

I feel proud (“abhimaan”) to work as ASHA worker. I feel I am doing social work and feel satisfied.

Rural ASHA

I wish to do full time ASHA work only, but for that I need to get a fixed salary.

Tribal ASHA

Implications of the research

This study has implications for advocacy and policy within India. Although the ASHA have a positive attitude towards their voluntary work, this could be enhanced by providing them with predictable financial and non-financial incentives.

The research has uncovered the changing role for ASHAs, which means the design of the ASHA programme should be reviewed at a policy level to reflect this change. The voluntary status and activist role of ASHAs need to be understood and address if ASHAs are to remain a key role in achieving universal health coverage in India.

Keeping voluntary status of ASHAs, strategies to recruit, train, skills enhancement, incentivise and retain ASHAs need to be prioritised if ASHAs are to be remain a key component in achieving universal health coverage in India

Dr Anand KawadeLead author on the paper, and principal investigator on the RESPIRE ASHA workload assessment project

Dr Kawade is based at King Edward Memorial (KEM) Hospital Research Centre, Pune in India.

Read the paper

The publication is available from Human Resources for Health

Cite as

Kawade, A., Gore, M., Lele, P. et al. Interplaying role of healthcare activist and homemaker: a mixed-methods exploration of the workload of community health workers (Accredited Social Health Activists) in India. Hum Resour Health 19, 7 (2021).


Find out more about the ASHA workload project