Is digitalisation a double-edged sword for workers in India's public healthcare system?

While technology is often celebrated as a solution to healthcare inefficiencies, its impact on India’s Accredited Social Health Activists (ASHAs) tells a more complex story. Drawing on qualitative research conducted across four states, this note examines the uneven experiences of digitalisation among ASHAs, with digital tools both improving work processes and creating new burdens and inequities.

Amid the recent push for digitalisation of healthcare, prominently highlighted during India’s G20 presidency last year, the experiences of Accredited Social Health Activists (ASHAs) – female health workers who are the backbone of last-mile community health delivery – reveal a critical and often overlooked tension. Technology is often seen as a panacea for inefficiencies in healthcare delivery, particularly in resource-constrained settings. The Ayushman Bharat Digital Mission (ABDM), a flagship initiative of the Indian government, exemplifies this approach by seeking to optimise and streamline public healthcare systems through digital platforms. As part of these efforts, digital tools for ASHAs – such as smartphones, health data collection apps, and access to other digital platforms – have been introduced as a step towards modernising community healthcare (Ismail et al. 2022).

Drawing on multi-method qualitative research across four states, our report “Digitalisation at the Frontlines: ASHAs’ Experiences Across Haryana, Rajasthan, Kerala, and Meghalaya” (Sreerupa, Makkad and Rajeev 2024) examines ASHAs’ lived experiences and their perspectives on the digitalisation of their work and its broader implications. Using in-depth interviews with ASHAs, union leaders, and key informants in the public health system, along with focus group discussions and participatory workshops with ASHAs, we find that digitalisation is transforming their work and lives in ways that come with both opportunities and inequities. While our recently released report offers a detailed analysis, this note underscores the urgent need to critically examine the impact of digitalisation on workers at the frontline of community care work.

The promises and perils of digitalisation

ASHAs are frontline healthcare workers who serve as a critical link between underserved rural communities and India’s public health system (Garg et al. 2013). Introduced into the public health system in 2005 under the National Rural Health Mission, their key responsibilities include maternal and child health promotion, immunisation drives, and raising awareness about public health schemes, among others. While the introduction of digital tools was intended to streamline and optimise their community healthcare work, our study finds that digitalisation has neither been uniformly implemented nor uniformly received across India’s diverse states.

In Rajasthan, which has pioneered digitalisation efforts for ASHAs, technology has largely been an enabling tool. ASHAs reported that digital tools such as PCTS (Pregnancy, Child Tracking and Health Service Management System) app have been game changers. The app has enabled them to track pregnancies and vaccinations more efficiently, access timely updates on their tasks, and has helped improve healthcare delivery in their communities. One worker noted: “Through this app, we get to know about the due date of vaccinations of children and then we call their parents to get their vaccination done. This has made our work so much more easy”.

Similarly, in Kerala, a state-provided digital literacy programme called Akshaya project, has equipped ASHAs, including older ones, to use digital tools effectively, fostering a sense of confidence and professional pride. ASHAs have also leveraged platforms like WhatsApp to mobilise communities, share health updates, and increase awareness. “I have saved the mobile numbers of each household in my ward and made a WhatsApp group. The group is called 'Ward Health'”, said an ASHA in Kerala. “When clinics and camps are conducted, we inform them through these groups to get messages across quickly. There was an eye camp for which we messaged in the group and there was a huge turnout beyond our expectations”. These experiences underscore the potential of digitalisation to enable frontline health workers – when combined with robust infrastructure, worker-friendly apps, effective training, and supportive systems.

However, these successes are far from universal. In Haryana, ASHAs reported a far less favourable experience. The proliferation of apps for various surveys, combined with poor internet connectivity, technical glitches, and lack of access to quality smartphones¹, have forced many workers to maintain paper records in addition to the digital ones. This effectively doubles their workload without any additional compensation. Even more concerning, some digital tools – such as the MDM360 Shield app launched by the state government in 2021 to monitor ASHAs’ work and daily activities – were perceived as surveillance tools because of their location-tracking features. Remarkably, ASHAs’ collective action against this mandatory app, ultimately led to its recall. Rather than supporting workers, such tools fostered feelings of anxiety and distrust.

In Meghalaya, digitalisation has been uneven due to the region’s infrastructural and geographical challenges. Poor connectivity in remote areas has rendered digital tools ineffective – a reality shared by many rural regions across India. For numerous ASHAs, the promise of digitalisation has remained unrealised, highlighting the gap between policy design and on-the-ground realities.

Gender, intersectionality, and precarious work

Across states, the challenges ASHAs face with digitalisation are deeply entrenched in existing gendered and intersectional inequalities. These workers, predominantly women from lower-caste and marginalised communities, often lack access to the resources necessary for meaningful digital inclusion. For instance, training programmes, when offered, were frequently one-size-fits-all and failed to account for varying literacy levels, language barriers, or a lack of prior exposure to technology. A young ASHA from Rajasthan explained: “Older women are not familiar. They are not as educated and they do not know how to use phones. They face a lot of problems. They do come for the training and try their best to understand. But if they still do not understand then we help them”. An ASHA from Meghalaya highlighted the language barrier in training programmes and suggested: “For those who understand Khasi [a language spoken in districts of Meghalaya], keep one training session for them and keep a separate training session the next day for those who understand English. Some of them do not know either English or Khasi and only understand Hindi. For them a separate training session in Hindi is necessary. The most challenging aspect of our training is addressing the language issue”.   

Additionally, gendered social norms further complicate ASHAs’ adoption of digital tools. Many ASHAs spoke of the initial excitement of owning a smartphone, a device that symbolised both professional and personal empowerment. Yet, this sense of empowerment was often tempered by their need to navigate patriarchal restrictions. For many, using a phone for work invited criticism from family members or their communities about their ‘overuse’ of technology, reflecting broader societal anxieties about women’s increasing access to and autonomy in using digital tools. Balancing household and care responsibilities alongside additional digital tasks often meant working late into the night, contributing to stress and exhaustion.

These challenges are further compounded by the precarious nature of ASHAs’ engagement. Officially classified as volunteers, ASHAs do not receive fixed salaries and are instead provided with a small honorarium of Rs. 2,000 per month for routine and recurring activities and are entitled to task-based incentives upon completing specific activities under various National Health Programmes. Their work remains underpaid as it is framed as gendered community service – an extension of domestic work and female caregiving (Wichterich 2020). The lack of financial compensation for additional digital work exacerbates their precarity, as the extra hours spent on reporting and troubleshooting app issues go unrecognised, leaving workers feeling overburdened and alienated.

Need for an inclusive approach to digitalisation

Digitalisation is often presented as a cure-all for healthcare challenges, but without addressing the inequities it amplifies, it risks becoming another tool of exploitation. As India continues to invest in its digital health infrastructure under initiatives like ABDM, it is imperative that the very workers who sustain the community healthcare system are not left behind – or worse, further burdened. Our forthcoming report will provide detailed recommendations to address these challenges. Some of the key priorities suggested include:

Investing in robust digital infrastructure, ensuring reliable connectivity and access to good quality devices.
Providing comprehensive digital skilling tailored to diverse needs, similar to the approach in Kerala, accounting for literacy levels, language barriers, and age differences.
Designing an integrated worker-friendly digital tool to streamline data collection and provide ASHAs with easy access to data to support their community care work, similar to the PCTS app in Rajasthan.
Recognising and remunerating the additional time and effort involved in digital reporting.
Promoting gender-sensitive approaches that address social norms limiting women's use and access to technology.

In conclusion, adopting an intersectional, bottom-up approach to digitalisation, grounded in the lived realities and diverse needs of marginalised ASHAs, can ensure that the essential work of community care is carried out in a way that empowers both the workers and the communities they serve.

Note:

Haryana is one of the first states to provide smartphones to ASHAs. While a few other states have also started distributing smartphones, the lack of access to quality devices forces ASHAs across the country to purchase or borrow smartphones for their work.