1On 23 May 2022 the World Health Organisation announced six recipients of the prestigious Global Health Leaders Award. Among these recipients were the Accredited Social Health Activists (ASHAs) from India. Numbering close to one million women, this is the largest group of community health workers in the world (see Kane et al., 2021).

2The ASHA scheme was launched in 2004 with the intention of creating a system of community health workers who would form an interface between the public and the healthcare system. Begun as a rural community health programme, the ASHA scheme initially aimed to have one ASHA per 1000 population in rural areas. The ASHAs are women from the community who have attained a basic level of education, and go through a selection process of a written test and interview. Following this, they are given basic training in community health engagement and increasing healthy practices within their localities. Tasked primarily with basic care, monitoring of women and sexual and reproductive health of their communities, the responsibilities of the ASHAs have increased, especially since the ASHA scheme has now been piloted in urban areas as well.1

3The ASHAs are now also required to take surveys of their allocated areas for various diseases such as leprosy and tuberculosis, and are also responsible for mobilising members of their community to get vaccinated periodically. During the pandemic, these community health workers were responsible for conducting surveys of COVID positive individuals, distributing hygiene kits, educating their communities in safety practices, and assisting in vaccination drives. The WHO awarded the ASHAs for their ‘crucial role in connecting the community with the health system to ensure primary health services.’

The proximity of ASHA workers [...] to the community proved to be of considerable advantage during the pandemic. [...] [C]ontinued to perform [...] routine duties of facilitating uninterrupted delivery of services to the community and, along with other healthcare workers, also supported efforts to screen, refer and create awareness about COVID-19. (WHO, 2021)

4The news of the WHO award came in the midst of a flood of reports and articles being published in India about the abysmal treatment of ASHAs and their dangerous working conditions. News outlets such as The Wire in particular, published several articles based on in-depth interactions with ASHAs nationwide, highlighting the kind of duties that were thrust upon them at the height of the pandemic, and the additional problems of social apathy, overwork, and lack of payment that came hand in hand with these demands and expectations.

5Despite the increased burden of community engagement and basic healthcare that is placed on the ASHAs, they are not considered to be government employees. This means that not only do they not receive a formalised, fixed salary per month, but they also do not get benefits such as vacation days, overtime, or any other social security benefits. There is also very little scope for the upward mobility of ASHAs within the Indian healthcare system - while certain states of India have attempted to launch programmes in which senior ASHAs (who have been a part of the scheme for ten years or more) get preferential treatment if they apply for nursing school, there is little evidence that these measures have been implemented adequately.

6The ways in which the government has treated community health workers such as the ASHAs is not new information per se:

Problems of irregular pay, lack of family support and lack of time which have been amplified [...] might add to increased attrition in the future. Therefore, it would not be wrong to say that the health system of the country is equally responsible for not only the recruitment and training of ASHA workers but also retaining them. The highly questionable role of workers of the private health sector makes a strong case for the government to make the public health system more robust and responsive to the needs of these “low-level health workers”. (Bisht and Menon, 2020)

7What is also of growing interest to many however, is the fact that ASHAs are termed voluntary ‘activists’, honorary workers, or simply volunteers rather than employees or workers. As Kasliwal (2020) articulates, ‘When you call the flagbearers of providing care mere volunteers and not full-time employees of the government, you do send the message that care, despite being a public good, isn’t valuable enough to be paid properly, and women only deserve equal pay in theory.’ These ideologies of service also further trickle down into the ways in which not only the state, but the ASHAs themselves perceive work and community, creating competing definitions of their role within the public health system.

8During the COVID pandemic, many ASHAs who had to juggle the demands of their family and their increased workload had to resort to measures such as bringing their children with them on their rounds as they did not have the care provisions to leave them at home. The workers were therefore expected to risk not only their own wellbeing, but often were put in situations where their immediate family were also put directly in harm’s way (Mohan et al., 2021).

9The nomenclature of ASHAs is therefore only a part of the way in which women’s labour within the public health system is devalued or undervalued by the state. A closer look at documents from the National Rural Health Mission (NRHM) and the state governments for example, points at a particular way in which service and care are articulated through the programme, which relies on the labour of women in exchange for incentives rather than payment or material support: ‘She is primarily an “honorary volunteer” but is compensated for her time in specific situations (such as training attendance, monthly reviews and other meetings). The voluntary nature of the ASHA programme needs to be preserved in the second phase of NRHM.’

Social recognition also takes place at a group level. The state must invest in TV and Radio programmes, in hoardings and public displays, which project the ASHA as a person holding immense responsibility and an important community resource to overcoming barriers to accessing health care services. This in itself would be an incentive. (GoI, 2014)

10Having worked with various NGOs in the public health sector in India during my undergraduate years, I had a basic level of familiarity with the primary health system. However, it was while interning with the Centre for Health and Social Justice in August 2020 that I got the chance to interview a few ASHAs across the country. During this time, we spoke about the many issues they were facing: as this was in the middle of the pandemic the ASHAs were critically overworked, and many spoke about how they were still not recognised as full employees. These interactions, along with closely following the various protests and strikes2 organised by the ASHAs around this time sparked my interest in understanding their situation further, exploring how the demarcations of worker and volunteer are constructed, maintained, and negotiated.

11The original research question for this paper was based on understanding what the distinction is between being a volunteer and being a worker. Furthermore, when and why does this distinction get blurred? During fieldwork, certain themes emerged which changed the direction of the research in subtle but powerful ways. While the question of volunteerism vs. labour remains important to the paper, what struck me was how the ASHAs navigate these challenges through the idea of doing good.

12While articulating that viewing their work as a service to the community was equally important to them as seeing it as a form of employment, the ASHAs also spoke about how doing this sort of work in particular allowed them to create an image of themselves, both for themselves and for the community, of the ASHA as a good person. The paper seeks to weave together the everyday ethics of doing good as observed through the ASHA workers in Seelampur. Seva, or service, is commonly used both by the ASHA and the state to refer to ASHA work. This paper extends and to a certain extent complicates the notion of seva by arguing that serving the community and ‘doing good’ are linked in numerous ways to being, or projecting oneself to be a good person. Therefore, this paper attempts to go beyond the current discourses of payment and paid work to understand how the ideologies that lead to the construction of an ASHA are mediated and negotiated by the actors involved, namely the ASHAs themselves and the Indian government, which lays out the rules and regulations for their work. Drawing on qualitative ethnographic data, my attempt in this research is to ask how ASHAs negotiate with themselves, their communities, and the state through existing paradigms of care, service, and gendered work.