The ASHA worker’s mental health paradox

Netradipa Patil, an ASHA worker from Kolhapur, looks at 52-year-old Haseena Atar as a daughter she brought back to life. In 2019, when Atar lost her entire family within a year, she sank into depression. Patil and two other colleagues, trained in mental health awareness, stepped in. They conversed with Atar, visited her regularly and cleaned her home, brought food, and ensured she took her medicines on time.

Today, Atar has regained her health and independence to a great extent, thanks to the three ASHA workers who went beyond their call of duty.

Stories like these reveal the emotional labour that India’s 10.4 lakh Accredited Social Health Activists (ASHAs) perform daily. Despite being a voluntary workforce, ASHAs are often the first point of contact in rural healthcare. They juggle maternal and child health, immunisation, TB monitoring, non-communicable disease surveys, record-keeping (online and offline), and countless other tasks. And their meagre monthly pay, varying by State — from ₹6,400 in Madhya Pradesh to ₹13,000 in Maharashtra — is often delayed.

Kolhapur resident Haseena Atar (left) with Netradipa Patil, the ASHA worker who nursed her back to health.
| Photo Credit:
Courtesy Netradipa Patil

Recently, in some regions, ASHAs have taken on the duty of ‘mental health gatekeepers’ under both government and NGO programmes. The National Health Mission (NHM) has started integrating mental health modules into ASHA training nationwide. ASHAs are being asked to counsel adolescents, identify depression, anxiety and suicide risk, creating crucial awareness even as they themselves remain overburdened and underpaid.

Distress calls

Over 56 million Indians live with depression and 38 million with anxiety disorders. The National Crime Records Bureau recorded 1,71,418 suicides in 2023. Despite the 2017 Mental Healthcare Act decriminalising suicide, rural mental health support continues to be limited and is often stigma-ridden. This is where ASHAs, with their deep-rooted community knowledge, come in. “Specialised training is provided in areas where mental health issues are more prevalent. ASHAs are capable of handling this training as they understand their community well, which gives them an advantage,” says Mohd. Sadiq Khan, a trainer with the National Health Systems Resource Centre in Jammu and Kashmir.

At NIMHANS, Bengaluru, Dr. Anish V. Cherian leads Project Suraksha, a community-based suicide prevention initiative in nearby Channapatna Taluk. NIMHANS has trained over 1,000 ASHAs and Anganwadi workers to raise suicide awareness, identify people at risk, “reduce access to means like pesticides and alcohol”, and link them with mental healthcare options. “We’ve already identified over 800 cases of attempted suicide, many through ASHAs. Suicide is rarely impulsive, so identifying attempters and providing timely interventions is key,” says Dr. Cherian.

ASHA workers doing paperwork in Daboh, Madhya Pradesh.
| Photo Credit:
Reshmi Chakraborty

Anusuya Lokesh now recognises symptoms like hallucination, anxiety, excessive anger and restlessness as possible signs of mental illness. These would be attributed to superstitious beliefs earlier. “Now we know it’s brain chemistry. And there’s no shame, treatment is possible,” says the ASHA worker from Rampura, Channapatna.

In Madhya Pradesh, 14,570 ASHAs have been trained in mental health, neurological disorders, and substance abuse since 2020, says Dr. Prabhakar Tiwari, Senior Joint Director, National Health Mission. Though there is no data yet, mental health clinics in the State are showing evidence of this awareness initiative “percolating to rural areas,” he says.

For most ASHAs, mental health is new terrain. “I didn’t know we could talk and make someone feel better,” says Sita Chaurey, an ASHA from Narmadapuram, who was trained by Sangath, a mental health non-profit working with the Madhya Pradesh government. Since 2019, about 5,000 ASHAs have been trained across several districts, says Dr. Anant Bhan, principal investigator at Sangath. The organisation pays the ASHAs a small sum for their work.

Chaurey and her peers screen pregnant and postpartum women using the PHQ-9, a question-based depression checklist. “Building trust is essential,” she says. “We visit often, share songs or books to lift their mood, talk about our own struggles too until they open up.” Even then, it isn’t always easy. “Once, a mother-in-law picked up a stick to threaten us when we tried to counsel her young daughter-in-law,” recalls Deepti Dubey, a Sangath research assistant. “The ASHAs calmly explained the situation and eventually gained her trust.”

ASHA workers (in purple) from Narmadapuram, Madhya Pardesh, with mental health trainers from Sangath.
| Photo Credit:
Reshmi Chakraborty

In some cases, the mental health training is at best perfunctory. “Our online mental health training lasted just an afternoon,” says Laxmi Kaurav, an ASHA supervisor and union president from Daboh in Madhya Pradesh. “It was full of English medical jargon. I had to keep asking them to repeat and even Googled some terms.” As such, Laxmi is wary of ASHAs being used to survey rural mental health. “We are expected to notice when someone is in distress and take steps to prevent a suicide. It is a big responsibility. But we don’t get paid for this,” she adds.

Self help is the best help?

While they are expected to care for others with little or no monetary benefit, the bigger paradox is that the emotional distress faced by ASHAs often goes unnoticed. As the lowest rung in the healthcare chain, they barely have any self-care support. Some non-profits are now beginning to address this gap.

The Resilience Collaborative (TRC) by the George Institute for Global Health in New Delhi engages with healthcare workers to improve their well-being. Programme manager Varadharajan Srinivasan says ASHAs face stressors such as having to be constantly available, for instance. “ASHAs assess individuals for mental health issues and enable referrals but there’s no defined incentive, definitely a sore point,” he says. 

TRC is now co-designing a digital wellbeing tool with ASHAs in Gorakhpur, Uttar Pradesh. Hemlata George, an ASHA from Indore, helped test an earlier TRC app featuring psychoeducation, meditation, and yoga videos. “It was easy to understand, especially the videos from influencers speaking on mental health. They felt more relatable,” she says.

While working on self-care tools with ASHAs across regions, Vardharajan discovered that many of these women have their own self-care methods. While some find strength in spiritual practices or outings with friends, others take comfort in their family members. Many also find purpose in their work even if it is challenging as it gives them a sense of agency.

ASHA workers with The Live Love Laugh Foundation‘s Anisha Padukone (back row, centre) and her sister, actor Deepika Padukone, in Bengaluru.
| Photo Credit:
The Live Love Laugh Foundation

Positive recognition, respect and social appreciation boosts the morale and self-worth of ASHA workers. “We acknowledge the ASHA’s contributions, and organise events to celebrate their work. Through our support group meetings and training sessions, we continuously motivate and encourage them,” says Anisha Padukone of Bengaluru-based The Live Love Laugh Foundation, which has engaged ASHAs in their rural community mental health programme since 2016.

NIMHANS’ Project Suraksha also offers stress management and self-care training to the community health workers on a need basis.

In Madhya Pradesh, Sangath has piloted SAMBHAV, a self-guided mental health app based on a WHO self-care model, among 40 ASHAs in Sehore district in 2022-23. “We hope that the government will integrate these learnings into regular programmes and build incentives for ongoing activities, ensuring continued delivery of mental health support,” says Dr. Bhan.

Though she is thankful for such interventions, Hemlata says true mental wellbeing depends on fair pay and stability. Last year, after waiting for three months, she received an incentive of ₹4,200 in September. It was less than half her usual earnings. She says, “Last Diwali, some ASHAs couldn’t even buy new clothes for their children. In mental health training, we are taught to keep our minds healthy so we can help others. But how can we stay well when our own situation is unstable?”

(Assistance for overcoming suicidal thoughts is available on these 24×7 helplines: KIRAN 1800-599-0019 and Aasra 9820466726)

The writer is a freelance journalist and co-author of Rethink Ageing.