Gouri Hazra Dey begins her working day at 9am. Usually, she won't return to her small home, in Bhatar, a village in West Bengal, until 10pm. Right now, her main focus is vaccination duty; she might be tackling vaccine hesitancy, registering people for their jab, conducting surveys and verifying the identification card numbers of people admitted to hospital.

She performs these pandemic-related duties in addition to her usual work, which includes assisting at births, immunization drives and 'sterilisation camps' for migrant labourers returning to their villages, and carrying out primary healthcare in her own village.

Gouri is an Accredited Social Health Activist, or "ASHA worker", as they are known across India. She is among the millions of ASHAs - all women - who form the backbone of the country's healthcare system, especially away from urban centres.

The Indian government's National Rural Health Mission (NRHM), launched in 2005, created the role of the ASHA to work on the ground with rural, often marginalised communities. They are an indispensable part of the country's healthcare system.

ASHA workers are a one-stop healthcare shop; they stock medicine, treat minor ailments, provide advice on contraception and pregnancy and facilitate access to medical centres (and, if necessary, accompany women and children to appointments). Their job is to increase healthcare awareness, and in many communities they're the most trusted medical figure.

The sheer scale of their work is clearly visible; the efficacy of India's childhood immunisation drives is often credited to these legions of frontline healthcare workers. Over the past year, they've also become the first line of defence against COVID-19 for rural communities. But despite everything they do, ASHAs say they are struggling to get recognition - or fair recompense - and are being treated as an afterthought by the government.

According to an Oxfam India survey of PPE distribution, conducted last September, 75% of ASHAs received masks, 62% received gloves and only 23% received full bodysuits. All these items, as well as face shields, head caps and sanitiser, were supposed to be provided by the Ministry of Health and Family Welfare.

"We weren't provided with personal protective equipment (PPE) kits by the government, and even sanitisers were in short supply. ASHA workers are called volunteers, but villagers often depend on us for all their healthcare needs," said Aruna Sarkar, an ASHA worker with a focus on maternity care, based in Raipur village in West Bengal.

Poor pay for too much work

ASHA workers do not have permanent status and receive few or no benefits (such as pensions or holiday pay). The state government pays them a paltry sum of Rs 1,000-4,000 (roughly £10-39) per month, plus "incentives" for specific health outcomes - for example, Rs 100 (£1) for every immunisation jab and COVID-19 vaccination. But ASHA workers say they are treated as volunteers and paid less than the minimum wage.

Because ASHAs are paid on an incentive basis, their incomes fluctuate from month to month. ‌Although their basic monthly salaries are paid on time, ASHA workers often won't see any money from the incentives for months on end.

"We don't receive any incentive money or sometimes we receive six months of incentive money at once. Many ASHA workers depend on this extra income for running their household. Sometimes they even have to pawn their jewellery to have food in their home," says Aruna.

Each ASHA worker serves up to 1,500 people. Many rural communities, which often include Indigenous Indian peoples such as the Adivasis, often have no access to medical facilities apart from the ASHA.

"Most of the people in my village love and respect us. They often say that they will do whatever ASHA didi [auntie] tells them to do, because they trust us to that extent. We get more respect than the doctors who work in our village," says Aruna.

In theory, ASHA workers are supposed to work only three to four hours a day, not including the time spent on travelling. But, as Aruna explains, they don't have regular hours and when they are summoned to work, they have to drop everything and go, day or night, because it could be a medical emergency.

"I have a scooter so I can get home without depending on public transportation, but many women are left without any means to reach home safely," says Gouri, adding that the government now provides a carpool system after ASHA workers raised safety concerns.

Now, ASHA employees want a change in their status. Last year, around 600,000 ASHAs, supported by various trade unions in India, went on strike demanding improved working conditions, better pay and the benefits of a permanent government employee. The fight is ongoing - in June, 70,000 ASHA workers in Mumbai called off a strike after they were promised a pay rise.

"We work more hours than any government employee, but are not compensated like full-time staff. When will the government recognise the importance of our work?" says Gouri.

They have also faced additional challenges during the pandemic. Fear and mistrust due to garbled messaging has led to pushback against vaccination in certain communities. Meanwhile, PPE shortages persist. An ASHA sangini in Lucknow, who supervises the work of other ASHA workers, stated that three of her staff have refused to work because of the professional and personal hazards they face at the moment.

At least 44 ASHA workers in India have died from COVID-19 - though the real number could be far higher than the official figures, which have been criticised for underreporting deaths. Colleagues say that the families of the employees who died as a result of COVID-19 have yet to be compensated.

It's important to note that the struggles of ASHA workers are not limited to just one state or region, but have spread across the country. Strikes have happened in several states due to issues ranging from non-payment of incentives to not receiving promised benefits.

Despite this, many ASHA workers say they are too fearful of the impact upon the communities they serve to undergo a mass strike. "I have discussed with my fellow ASHA workers about organising a protest, but the more disadvantaged among us are too scared to do anything in case they lose their job," says Aruna. "But we see protests taking place in other states, and I'm hopeful that ASHA workers will get their due one day."

From openDemocracy