Working as frontline health facilitators, service providers, program supporters, and social health activists in Indian hilly terrain areas: A qualitative study of accredited social health activists’ experiences before and during the COVID-19 pandemic

Abstract

Background Community health workers (CHW) contribute to achieving health targets of the Sustainable Development Goals (SDG) and Universal Health Care (UHC) in low- and middle-income countries (LMICs). In India, accredited social health activists (ASHAs) function as health facilitators, service providers, and programme supporters for rural and tribal communities and are at the frontline during the COVID-19 pandemic. We aimed to describe the ASHAs’ work roles both before and during the COVID-19 pandemic, explore the tasks ASHAs performed throughout the pandemic, and understand its effects on the evolving role of ASHAs. Methods We used qualitative data from a pre-COVID-19 study conducted in 2018-2019 including face-to-face interviews with purposively sampled ASHAs and their health care supervisors (n = 18) from rural Maharashtra state (India), and a follow-up study during the COVID-19 pandemic using telephonic interviews with a subset of participants from the pre-COVID-study (n = 8). Data were analysed thematically using MAXQDA v11.00. Results The primary theme in the pre-COVID-19 study was ASHAs’ role as described above, except as social health activists, linking beneficiaries to the local maternal and child health care services, distributing medicines for common illnesses, access to government schemes, and engaging in multiple health surveys. During the pandemic, raising awareness, screening of at-risk populations, arranging referrals, providing treatment and follow-up to COVID-19 patients, and supporting their family members. These activities increased the workload and health risks to ASHAs and their family, causing stress and tension among them. However, they had effectively carried out the new duties. ASHAs have improved their status, earning praise from families, society, and the government. They were honoured with the Global Health Leaders Award at the 75th World Health Assembly. Conclusion ASHAs’ contribution to the health system improved the indicators related to maternal and child health during the pre-COVID-19 pandemic. Additionally, they maintained frontline health care during the COVID-19 pandemic, demonstrating resilience despite the challenges of increased workload and stress. However, the COVID-19 pandemic highlights the need to respond to and understand the implications of ASHAs’ evolving roles.

The effectiveness of rural community health workers in improving health outcomes during the COVID-19 pandemic: a systematic review

“…There was a cost-effectiveness study [ 35 ] and interventional studies [ 36 , 38–42 , 44 , 45 , 47 ]. In addition, there were mixed-methods studies [ 37 , 46 , 48 ] and qualitative assessments of rural CHW interventions in India and Ethiopia [ 3 , 47 ].…”

“…CHW interventions were heterogeneous across the 15 studies. Interventions included a low literacy checklist to maintain access to prenatal care during the COVID-19 pandemic in Guatemala and CHW training in COVID-19 in Thailand, India, Nepal [ 36 , 38 , 42 , 44 , 47 ]. There were CHW interventions that leveraged previously established CHW programmes to respond to the COVID-19 pandemic in hard-to-reach communities in Peru and India [ 37 , 43 ].…”

“…Stakeholders included CHWs, programme implementers, and programme evaluators. Stakeholder perspectives were diverse and highlighted concerns about COVID-19 vaccine misinformation, lack of PPE and testing kits, increased rural CHW workload and vulnerability to COVID-19 infection, and the suspension of antenatal and postnatal visits during the COVID-19 pandemic [ 37 , 47 ]. In Bangladesh, poor CHW training was seen as a hindrance to CHW effectiveness during the COVID-19 pandemic by CHWs [ 46 ].…”