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

Methods
We used qualitative data from two sources: a ‘pre-COVID-study’ conducted in 2018-2019 including face-to-face interviews with purposively sampled ASHAs and their healthcare supervisors (n=18) from rural Maharashtra state (India), and a follow-on study during the ‘COVID-19 pandemic using telephonic interviews with a sub-set (n=8) of participants from the pre-COVID-study. Data were analyzed thematically using MAXQDA v11.00.
Findings
In the pre-COVID study, the primary theme 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 pandemic, raising awareness, screening of ‘at-risk’ population, arranging referrals, providing treatment and follow up to COVID-19 patients and supporting family members. These activities increased the workload and health risks to ASHA and their family, causing stress and tension among them. However, they had effectively carried out the new duties. ASHAs have improved their status and earned praise from family, society, and government. They were honored with ‘Global Health Leaders Award’ at the 75th World Health Assembly.
Conclusion
ASHA’s contribution to the health system improved the indicators related to maternal and child health during the pre-COVID pandemic. Additionally, they maintained frontline healthcare during the COVID-19 pandemic demonstrating resilience despite challenges of increased workload and stress. However, the COVID-19 pandemic highlights the need to understand, and respond to the implications of the evolving roles of ASHA.