Rural Indian health care worker Jyoti Pawar visits a general store in Walhe, India, to check on the health of the occupants.
Walhe, Maharashtra, India CNN  — 

Jyoti Pawar, 40, starts her day early when the sun is still low in Walhe, a village in the western Indian state of Maharashtra.

She’s racing to beat the midday heat and a government-issued deadline to visit 30 to 40 households before noon.

Wearing a standard-issue pink jacket and a homemade cloth mask, she goes door to door, checking for cases of Covid-19.

Pawar is one of more than a million Accredited Social Health Activists – or ASHA workers – Indian women who act as a liaison between people and the public health care system in rural areas. It’s considered the largest community health worker program in the world. In Hindi, ASHA means “hope.”

The government considers ASHAs voluntary community health providers and pays them a monthly amount of Rs. 2,000 ($26.40), though in some states they can earn as much as Rs. 6,000 ($79.25) with additional task-based incentives, though the work is sporadic and unpredictable.

For years, ASHA workers and the unions that represent them have been pushing for more recognition – and pay.

They say the coronavirus pandemic shows how important they are to India’s health system, yet as voluntary workers they’re not entitled to benefits like health care, insurance, paid leave, nor pensions.

“They are not considered workers and that is at the root of the problem,” said Somashekhar Yadagiri, the state secretary of All India United Trade Union Centre. “They dedicate their lives to community health, but their lives are not secure. The government is exploiting them.”

ASHAs from Yadgir district in Karnataka staged a mass protest in January for better pay.

‘That’s how little our lives are worth’

ASHAs started appearing in 2005, as part of the National Rural Health Mission (NRHM). The women are chosen from the communities they serve and over time they become intimately acquainted with the health histories of every family.

Each ASHA is assigned to 1,000 to 1,500 villagers and they are often the first point of contact for local health services – especially women and children.

An ASHA worker’s task list is substantial: conduct surveys, provide information about health schemes, check on pregnant women and newborns, deliver medicines for chronic and communicable diseases to the sick and the elderly, advise teenage girls on menstruation, register births and deaths, file daily reports, and coordinate with local health authorities.

During the coronavirus crisis, they are being asked to perform new tasks: survey residents on their travel histories and health symptoms, help with contact tracing and arrange testing.

The government is paying them an extra Rs.1,000 a month for their Covid-19 work – around $13.20 a month or a little more than Rs. 33 (43 cents) a day. They’re also receiving life insurance cover of Rs. 50 lakh ($65,825) – in case they contract the virus, but like the incentive payment, it expires in June.

Rohini Pawar notes down the details of a brick kiln worker in Walhe, India.

“The government pays us Rs.1,000 a month for putting ourselves at the frontlines of Covid-19 work. That’s how little our lives are worth,” says Rohini Pawar, 32, a community health worker in Walhe, who is not related to Jyoti. As many as 10 ASHA workers across India have tested positive, though there is no confirmed data, according to BV Vijaylakshmi, the general secretary of the National Federation of ASHA Workers.

ASHA workers undergo continuous training for their regular work, but for Covid-19 they received a 2.5-hour training session over a video conference. Some ASHA workers told CNN they only received basic personal protective kits after repeated requests.

“We started the Covid-19 survey on March 15 and got masks only in April,” said an angry Jyoti Pawar. “Instead of N-95 masks, they gave us two thick bed sheets to use as fabric.”

Pawar, who also works as a tailor to supplement her income, stitched these into 70 masks for her fellow ASHA workers and supervisors over two days. Other ASHAs use dupattas (traditional scarves) as head covers and makeshift masks.

Masks stitched by Jyoti Pawar for fellow ASHAs.

Many have bought hand sanitizers and extra pairs of masks with their own money, and some are covering the cost of fuel to do their work, as all public transport stopped during the lockdown.

“We received a 200 ml bottle of sanitizer, two caps, and four masks. How is this adequate?” asked Rohini Pawar, who said she fears infecting her 3-year-old daughter.

“They call us warriors and shower rose petals on hospitals and clinics to honor frontline health workers, but won’t equip us for the fight.”

A senior official in the Ministry of Health and Family Welfare, who did not want to be identified, told CNN that state governments had been asked to pay the ASHAs their full monthly payment of Rs. 2000, despite the decline in general work during the coronavirus lockdown.

The official said​, if the package is ultimately approved, the extra Rs. 1,000 payment would be paid as long as ASHAs are performing Covid-19-related tasks. He also said the government is considering extending the insurance for India’s 2.2 million frontline health workers, including ASHAs, for a few more months.

​The official was not able to speak on the record because he was not authorized to speak publicly about proposals that have yet to be finalized.

Anup Yadav, the commissioner of health services in Maharashtra, the state with the highest number of Covid-19 cases, said ASHAs were receiving protective equipment and training.

“We are ensuring that they get protective gear as per Indian government protocol – including triple layer masks and sanitizers, apart from behavioral training in conducting surveys and social distancing,” he said. He did not respond to claims of PPE shortages.

Their own families can sometimes turn hostile

In Walhe village, squat, flat-roofed houses painted in pop colors line narrow, deserted streets.

When India went into lockdown on March 25, vendors packed up the tea stalls that sell biscuits, cigarettes, and snacks. Few people now venture outdoors, except the ASHAs.

One day while doing her rounds, Jyoti Pawar said she received an unexpected call urging her to rush to the quarantine center at the village high school.

“I had to counsel a visitor and stop him from entering the village,” she said. Many villages in India have barred entry to outsiders to stop the spread of the virus. The visitor agreed to go into quarantine without fuss, but not everyone is as amenable.

Rohini Pawar fixes a  Covid-19 awareness banner in Walhe, a village in the Indian state of Maharashtra.

ASHAs are often the first point of contact for those who might need quarantining. This leaves them vulnerable to aggression, verbal attacks, threats, coercion – or even physical abuse.

Their own families can sometimes turn hostile, due to the fear of transmission and the long work hours they have to put in.

“The community often turns on us if we send a family into quarantine. Our families are unhappy that we are stepping out and putting everyone at risk while earning so little. (And) the government reprimands us if we accidentally miss reporting a case,” said Rohini Pawar, who also works as a community correspondent for Video Volunteers, a media non-profit.

Across India, ASHA workers’ trade unions have been demanding better wages and conditions during the coronavirus pandemic.

Their ongoing demands include permanent employment status for the women, a fixed minimum wage, regular work hours, and benefits such as free health care, life insurance and paid leave. They also want more pay for their Covid-19 duty.

The workers aren’t new to agitation, said Suman Pujari, the president of Maharashtra ASHA Workers Union. For the past 10 years, they’ve fought for higher pay and an end to payment delays. In some cases, they’ve won. For instance, the fixed payment in Karnataka state used to be Rs. 1,000 a month ($13.20) and it’s now gone up to Rs. 4,000 a month ($52.80).

Across India, ASHAs are paid Rs 400 ($5.30) for facilitating a hospital delivery and being with the expectant mother for 24 hours further earns them Rs. 300 ($4.00). Checking in on a newborn, over six visits, fetches an incentive of Rs 250 ($3.30). Complete vaccination of a one-year-old gets them Rs. 100 ($1.30) and they are paid Rs. 1 (less than a cent) each time they distribute sanitary napkins to teenage girls.

“ASHAs are one of the pillars of the NHM and bring community connect to primary health care,” points out K Srinath Reddy, president of Public Health Foundation of India, a health advocacy non-profit.

“The rise in institutional delivery rates owes much to them. Even during Covid-19, they are providing support for contact tracing and syndromic surveillance. Every health program wants to engage ASHAs but does not recognize them as part of the health system,” Reddy said.

In the last two decades, there has been a “significant decline” in infant mortality rates in India due to ASHAs, according to a study published in 2014. Last year, another study linked the work of ASHAs to a rise in antenatal care visits and a near doubling of institutional deliveries, or babies born inside a health facility.

Jayamma, an ASHA worker from HD Kote village in Mysore, Karnataka, said she gave up her second job as a tailor six years ago to focus on her work as an ASHA.

“Though I made more money, I find this work more fulfilling. It allows me to interact with people from all walks of life. I live in hope that someday, this will turn into full-time employment,” she said.

Yadav, the Maharashtra health services commissioner, said the extra Rs. 1,000 payment was a “welcome move” by the government. He said ASHAs were receiving the fixed amount because the Covid surveillance would take a “few months,” but he didn’t comment on whether it would be increased.

As the number of Covid-19 cases climbs past 190,000 in India, the quantum of work for ASHA workers is likely to increase in the coming months. Despite the challenges, they know what they do saves lives so say they have little choice but to keep going.

“At the start of this pandemic, when the union suggested that they stop work without adequate safeguards, they refused,” said Yadgiri, from the All India United Trade Union Centre.

“Their fight is with the government; but they insist they can’t abandon the communities that have come to depend on them.”