COVID-19 Pandemic and Frontline Health Workers in Assam (India): Roles and Challenges faced by the Accredited Social Health Activists (ASHAs)

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Health workers were at the forefront, responding to the crisis, saving millions of lives. Faced with an unprecedented situation, India’s frontline health workers (FHWs) in the public health system, played a critical role as first responders. There are limited studies that have explored and documented their contribution from the north eastern states of India. Methods: In this qualitative study, we discuss the roles of FHWs during COVID-19, and the challenges they faced while working at the primary level public health facilities. The study was conducted in Dibrugarh, Dhubri, Kamrup and Kamrup Metropolitan districts representing spatial, socio-economic and geographical diversity and disparity of the state. Multiple modes of inquiry (in-depth interviews, group discussions, and telephonic interviews) were conducted with the ASHAs and other stakeholders. Findings: The ASHAs have performed different roles in terms of creating awareness, health education, adopting preventive measures, disease surveillance, testing, quarantine and isolation of patients. They were instrumental in continuation of the essential health services and COVID-19 vaccination. Tremendous increase in their tasks, long working hours without proper break, insecure and risky work conditions without adequate safety measures, stigma, violence, and discrimination at community level, frequently changing guidelines, delayed and inadequate compensation were some of the main challenges faced by the ASHAs in Assam. Conclusions: Working at the bottom of the public health system hierarchy, the ASHAs in rural and urban areas performed most of their responsibilities despite risks. Their contribution in increasing the community’s trust in the public health system, through their educational role and by being the first point of healthcare providers has been phenomenal. COVID-19 pandemic Roles and Contribution Challenges Assam-India First Responders Women in Public Health Health Care Workers Health Systems Background Health workers across the world were mobilized to respond to the COVID-19 pandemic. Several countries roped in the frontline health workers in responding to the crisis [ 1 , 2 ]. FHWs have played a critical role undertaking community-level surveillance, creating awareness about preventive measures, providing health education and ensuring access to curative health services [ 3 ]. They were also at the forefront ensuring continuation of essential health services. The World Health Organization (WHO), recognizing this contribution of the health workers had declared 2021 as the “International Year of Health and Care Workers.” The campaign focused on the need for government to invest in readiness of health workforce, education as well as learning to manage the COVID-19 pandemic [ 4 ]. The FHWs have a central role in realizing the primary health care goal under Health for All [ 5 ]. Acting as an interface between the community and the health system, FHWs are critical in empowering individuals and communities to take charge of their lives [ 2 ]. Embedded within the communities they work, FHWs are seen as agents of social change striving to bring health services closer to the communities by providing culturally appropriate, physically accessible, preventive, promotive and basic curative services [ 6 , 7 ]. As the COVID-19 pandemic struck India, public health systems were geared up to respond to the crisis [ 8 ]. While there were efforts to increase hospital capacities, primary focus was on community-centred interventions with the involvement of ASHAs. ASHAs were mobilized to create awareness about the disease, track returning migrants, ensure mandatory home quarantine, mobilize people for testing and undertake contact tracing. They were also required to arrange ambulance facilities for shifting positive cases to isolation facilities. To a large extent, ASHAs undertook these functions without adequate training or proper safety precautions [ 9 , 10 ]. Often FHWs are praised as warriors fighting the deadly virus. However, working at the lowest level of health systems hierarchy, they were in an extremely challenging and vulnerable situation, risking their own lives. In this context, the present study documents the role of ASHAs during the pandemic in Assam, India. Methods The Study Setting: Assam is considered as a gateway to the Northeast India. As per India’s 2011 census, population of the state was 31.2 million. Around 86% of its population reside in rural areas [ 12 ]. The state presents huge geo-spatial diversities that include plains, valleys and hilly areas, tea gardens and riverine areas known as “Chars”. The state also perennially suffers from annual floods [ 13 ]. Demographically, the state has multi-ethnic, multi-lingual and multi-religious communities. For a long period, the state witnessed several ethnic assertions resulting in conflicts and insurgency [ 14 ]. The socio-geographical disparities along with ethnic conflict has also impacted the delivery of health services in the state[ 13 ]. Assam also suffers high infant, child and maternal mortality [ 15 , 16 ]. Its response to the COVID-19 pandemic has to be analysed in its socio-economic and health status context. Health system in Assam is a mix of public, private and informal health care providers. The state has a weak and fragile public health system with severe deficiencies of health infrastructure and health workers[ 13 ]. The study was conducted in four districts - Kamrup Metro, Kamrup Rural, Dhubri and Dibrugarh based on the highest COVID-19 case load briefed in public portals. These districts also represented diverse demographic, spatial, and geographical heterogeneity of the state. Dibrugarh and Dhubri have a high incidence of tea gardens and Chars [ 17 ]. Kamrup Metro (Dispur), the State’s capital, had the highest burden of COVID-19 in the state. Kamrup Rural, the periphery of State capital, was selected to understand the response to COVID-19 in the immediate vicinity of the State capital. Assam, with its socio-economic and geographical vulnerabilities, presented a unique site for studying role of frontline health workers in the wake of a public health emergency such as COVID-19. In-depth interviews were conducted with ASHAs at the sub centres, health and wellness centres and primary health centres in rural and urban areas. Focus group discussions were also conducted at the facility level. Due to the dynamic and changing travel restrictions, in-depth interviews were substantiated with telephonic interviews. Field work was done during July-October, 2021. We interviewed 82 ASHAs and held discussions with Auxiliary Nurse Midwives (ANMs) and ASHA Supervisors at the primary health facilities (Refer Tables 1 to 6 for districtwise respondents, socio-demographic respondents of ASHAs and number of health facilities visited). Table 1 Districtwise respondents of the study: Districts Dhubri Dibrugarh Kamrup Metro Kamrup Rural Total ASHAs 21 15 19 27 82 Source : Field study data Table 2 Age Distribution of the ASHAs Age Group No. of ASHAs 21–30 7 31–40 26 41–50 34 51–60 14 61–70 1 Total 82 Table 3 Educational Status of ASHAs Educational Status No. of ASHAs Primary level (Class 1–8) 19 Secondary level (Class 9–10) 51 Higher Secondary (Class 11–12) 11 Graduation & above 1 Total 82 Table 4 Religion Wise Distribution of ASHAs Hindus Muslim Christian Total 62 19 1 82 Table 5 Social Category Wise Distribution of ASHAs . GEN OBC MOBC SC ST Total 40 21 3 16 2 82 Table 6 Number of health facilities visited across four districts: Districts/ Health Facilities Dhubri Dibrugarh Kamrup Metro Kamrup Rural Total Sub Centres 1 1 - 3 5 Health Wellness Centres 3 1 - 3 7 PHCs 0 3 - 1 4 Urban State Dispensaries - - 2 - 2 Urban PHCs - - 2 - 2 Urban Maternity Hospital - - 1 - 1 Tea Garden Hospital - 1 - - 1 State Dispensary and Urban Health Centre - 1 - - 1 Total 4 7 5 7 23 Confidentiality of the Respondents: Informed consent was taken from the participants to participate in the study. The respondents were interviewed after informed consent, both oral and written. The in-person and telephonic interviews took place under high-stress and difficult work conditions. The COVID-19 norms of physical distance and face masks were followed while conducting interviews. Ethical clearance for the study was obtained from the Institute Human Ethics Committee of the Indian Institute of Technology (IIT) Guwahati. The findings are arranged based on thematic analysis. COVID-19 in Assam: The first case of COVID-19 in Assam was reported on 31st March 2020. Since then, the state machinery coordinated efforts to reduce the spread of the disease with a claim of adopting a multi-pronged strategy - Track, Trace, Treat [ 12 ]. Institutional quarantine of 14 days for people with travel history was made compulsory. Those who tested positive during the quarantine period were shifted to designated hospitals. The quarantine policy of the state was known as “ruthless quarantine with human heart” [ 12 ]. The Government also ramped up the testing facilities in the state and by May 2020, the state could undertake around 90,000 tests per day. Findings: The Roles of ASHAs in COVID-19 response: ASHAs have performed multiple roles and responsibilities, which was beyond the regular call of their work duties. ASHAs were instrumental in surveillance activities at the community level, creating awareness about preventive measures of the disease, facilitating home quarantine, isolation and transfer of patients to institutional facilities along with fulfilling their routine maternal and child healthcare activities. Assam Community Surveillance Plan (ACSP), 2020 and Assam Targeted Surveillance Plan (ATSP), 2021: A unique feature of the response of Government of Assam (GoA) to the COVID-19 pandemic was implementation of ACSP in 2020, and ATSP in 2021. Intending to understand the spread of the disease in the community, the ACSP and ATSP were critical in identifying Influenza-Like Illnesses (ILIs), Severe Acute Respiratory Illnesses (SARIs), Malaria, Japanese Encephalitis along with COVID-19. ASHAs were at the forefront of the ACSP, undertaking community mobilization for screening to facilitating isolation of COVID-19 patients, ensuring access to medical care for ILIs. ASHAs undertook door to door visits a day before the visit of the surveillance team. The surveillance team comprised ANMs, Multi-Purpose Workers (MPWs), ASHAs and Community Health Officers (CHOs) that would conduct screening of ILIs. [ 12 ]. Challenges faced by ASHAs during COVID-19: At the time of the pandemic, ASHAs were seen as important health “volunteers”. However, their work was fraught with immense risk to their health and security. In the early phase of the pandemic, ASHAs had to spread awareness about new disease at the community level. They conducted "line listing" of the households to collect information about the persons who had recently immigrated. They had to put up stickers of home quarantine to minimize community interaction of people with travel history. They also had to mobilise symptomatic people for testing and ensure positive cases were sent to institutional facilities for isolation. Conducting the above tasks required coordination with the ANMs, MPWs and CHOs at the primary health facilities. Increase in the Workload: Given Assam’s priority of containing its high maternal and child mortality rates [ 17 ] even before the pandemic, the ASHAs had a high workload. The pandemic-related surveillance and coordination, therefore, came as an additional burden. At times, they had to report beyond duty hours to attend delivery cases or shift COVID-19 patients to hospitals. Inadequate and Irregular Access to Masks and Sanitizers: In March 2020, there was a considerable shortage of masks and sanitizers in the country. All the ASHAs reported about irregular and inadequate supply of masks and sanitizers. They depended on their own resources while managing a public health emergency. Although masks were provided much later from the PHCs, even in 2021 many complained of irregular supplies of essential precautionary items. Frequently Changing COVID-19 Guidelines: To reduce the burden on the health system, on 11th July 2020, GoA reluctantly allowed conditional home isolation of patients for those voluntarily opting so [ 18 , 19 ]. The conditions were that persons should be asymptomatic, absence of older adults above 60 years in the family, separate room with a toilet for isolation, and absence of co-morbidity. The patients in home isolation were required to possess oximeter and thermometer. The patient had to sign an undertaking that he/she is under voluntary home isolation and the government will not be held responsible for any complications arising during home isolation. The home isolation guideline with the above conditions was implemented in Assam from July 2020 till May 2021 [ 19 ]. Due to the change in guideline, the burden of routine follow up of patients also fell on ASHAs. Challenge of contact tracing: Quarantining and isolating people in the community, identifying families suffering from COVID-19 did not often take place smoothly. In Dibrugarh and Kamrup Metro, severe backlash from the community members were reported. The fast pace of transmission of the disease and rumour mongering regarding forceful shifting of patients to COVID Care Centres (CCCs) or being separated from family, made the ASHA volunteers bear the wrath of the community. Public backlash was also experienced by health workers posted at bus terminals, railway stations and check posts. For ASHA volunteers, the backlash affected their long-standing relationship with community members. Stigma, Discrimination and Violence: There was a high level of stigma attached to the disease. Due to their exposure to COVID-19 patients at the community level, people were fearful to interact with ASHAs when they undertook surveillance to collect information or mobilise people for testing. Some even encountered threats, physical attacks and harassment, especially when people were tested positive. ASHAs also had to ensure that the positive persons were shifted to the CCC, but they ended up facing harassment as people feared moving out of their house. Due to their long years of community engagement, ASHAs understood the differential impact of the pandemic on community members. In response, they addressed the crisis within the social-economic context. ASHAs in Dibrugarh discussed the difficulties a daily wage worker of a tea garden to undergo home isolation and the impact of wage loss on livelihood. In solidarity and empathy, they ensured that the dry rations provided by the District Administration reached family members under quarantine timely. They mobilized and contributed money to buy food and ration for the families under quarantine. In the slums of Kamrup Metro, ASHAs understood how poverty impacted household supplies of essential commodities. In response, ASHAs mobilized funds and distributed masks, sanitizers, and soaps. Challenges in the Delivery of Essential Health Services: Indian government announced stringent lockdowns since 24th March 2020 which impacted routine essential health services provided at the primary health facilities. However, from June 2020, essential health services resumed under the supervision and guidance of health officials. In tea garden areas of Assam, where maternal and child mortality are very high, the continuation of maternal and child health services was top priority. Some ASHAs were exclusively allotted maternal and child health duties while others undertook COVID-19 duties. In 2021, Dibrugarh district saw a rapid transmission of the virus and high caseload. The ASHAs faced resistance from the community when providing home-based new-born care (HBNC). Child immunization services were severely affected in the study districts. By end of June 2020, when immunization services resumed, many children had missed their scheduled vaccinations. ASHAs and ANMs ensured proper seating arrangements with physical distance at the facilities during routine immunization. Mothers and young children were called in batches of two or three and allotted scheduled timings to attend the health facilities. Sometimes vaccines were administered in open spaces as people were hesitant to visit health facilities. ASHAs and COVID-19 Vaccination: The COVID-19 vaccination programme from January 2021 was an addition to already existing work load. They had to make a list of persons eligible for vaccination. ASHAs allayed public fear and hesitation towards vaccination by counselling. Such intensive engagement with the community however hampered their routine tasks. Overworked, Underpaid and Delay in receipt of Incentives: ASHA volunteers in India receive incentives as opposed to a salary. In order to claim their performance incentives, ASHAs have to submit claim form, along with number of supporting documents which are to be verified and signed by other health workers and officials. There was a delay in the payment of regular incentives both in rural and urban areas. This was primarily because most of the ANMs and Medical Officers (MOs) were posted at the CCCs, quarantine centres and designated COVID-19 health facilities from April to November 2020. In some cases, ANMs and block level officials were infected by COVID-19 and hence it delayed the administrative procedure of getting the documents verified. In Kamrup Metro, the working-class population who lived in slums left for their villages fearing the pandemic. Hence, the number of beneficiary households had reduced tremendously for ASHAs, resulting in low incentives. Almost all the ASHAs complained about meagre incentives and huge workload during the pandemic. Discussion COVID-19 crisis highlighted the central role of public health facilities during health emergencies [ 8 ]. Our study makes evident the indispensable and varied roles played by ASHAs as frontline responders. Right from the early stages of the pandemic, the ASHAs worked tirelessly as the first line of defence, taking care of sick people, saving lives, and breaking the chain of COVID-19 transmission. Working at the bottom of the public health system hierarchy, ASHAs contributed in different capacities within a resource crunch health system, and ensured that health programmes reached the last mile. This finding is similar to other studies on FHWs during pandemic [ 3 ]. The contribution of ASHAs in increasing the communities’ trust in the public health systems has been phenomenal, emerging as a pillar of the health system during crisis. When community members experienced medical emergencies during a complete enforced lockdown, ASHAs ensured that people have timely access to healthcare. When there were restrictions on mobility, an ASHA's presence in her uniform and identification card provided assurance to people about ready availability of care and essential services. During the pandemic, ASHAs have worked at the grassroots, amidst rapidly changing guidelines and resource crunch. They were always the last to receive masks, sanitizers, or gloves. Systemic hierarchies were at work such that ANMs of the same health facilities received N95 masks while ASHAs got disposable masks. The ASHAs shared a feeling of invalidation for not being acknowledged by the people and by the system at large despite being equally at the risk of contracting the disease. Many of them were scared of passing on the infection to their family members, and hence never entered their own homes directly after work. They took hot water baths, washed their ASHA uniforms, sanitized mobile phones, and then got in. Majority of the ASHAs informed that apart from incurring such expenditure for their safety, their household expenditure increased due to excessive use of detergent powders and bathing soaps. ASHAs received fixed performance-based incentives as they are “volunteers” within the health system[ 11 ]. Every national health programme that the MoHFW implements, ASHAs undertakes the activities listed. Before the pandemic itself, their burden had increased, as they had to perform every new programme at the community level[ 10 ]. Despite undertaking many and long-duration tasks, they were paid only Rs 2000 to Rs 3000 during the initial months of the lockdown. ASHAs felt the Government had abandoned them, as their compensation was the least priority. In the times of lockdown and rising prices of essential food items, it was challenging for them to manage their households, many of whom were the sole earning member. COVID-19 has been deeply disruptive, especially of livelihoods and sustained incomes. It is important for governments to recognize their central role in pandemic management and institutionalize a system of payment which is commensurate to their work. While it is easy to glorify their roles as “COVID-19 warriors”, public health emergency management has shown that they be regularized, compensated adequately and provided social security. Conclusion This study makes it evident that ASHAs have performed multiple roles and responsibilities, which was beyond the regular call of their work duties. They were instrumental in surveillance activities at the community level, facilitating home quarantine and isolation and transfer of patients to institutional facilities along with fulfilling their routine maternal and child healthcare activities. High work burden coupled with the absence of work-related leaves, low compensation and difficult working conditions have resulted in extreme burnout, exhaustion, and adverse mental health consequences amongst the ASHAs. The pandemic has highlighted that health systems, led by health workers closer to the communities are most effective in responding in times of public health crisis. Abbreviations ACSP Assam Community Surveillance Plan ANM Auxiliary Nurse Midwives ATSP Assam Targeted Surveillance Plan CHOs Community Health Officers CCC COVID Care Centres GEN General caste GoA Government of Assam HBNC Home-Based Newborn Care ILI:Influenza-Like Illnesses MOBC Most Other Backward Caste MPWs Multi-Purpose Workers NRHM National Rural Health Mission NHM National Health Mission OBC Other Backward Caste SC Scheduled Caste ST Scheduled Tribe Declarations Ethics approval and consent to participate : Ethical approval was obtained from Institute Human Ethics Committee at IIT Guwahati. Informed consent was taken from the participants to participate in the study. Consent for publication: Not applicable Availability of data and materials: The field data and materials, including consent forms, can be made available from Indian Institute of Technology Guwahati on reasonable request. Competing interests: The authors declare that they have no competing interests Funding : The study was funded by the WHO, India Office Authors' contributions: All the authors have contributed to the study in, designing the tools of the data, data collection, analysis of data and writing the manuscript. All the authors have read and approved the final manuscript. Acknowledgements: We want to express our gratitude to the FHWs in four districts of Assam and all the block, district and state level officials working with NHM Assam. We are also grateful to NHM Assam for their support in conducting this study. Authors' information (optional): DP had worked at Dept of Humanities and Social Sciences, IIT Guwahati till December 2023 before joining D Y Patil University, Navi Mumbai, Mumbai, Maharashtra, India; RB works at the Department of Humanities and Social Sciences, IIT Guwahati, Guwahati Assam, India. HD, BS and DS work with WHO, India Office, Delhi, New Delhi, India. 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BMJ 2021. 8; 375. https://doi.org/10.1136/bmj.n2509. Mishra A and Santosh S. Arent we the frontline warriors: experiences of grassroots health workers during COVID-19 . 2021 Azim Premji University. Bangalore. Bhatia S, Pal S and Saha S. Challenges faced by community health workers in COVID-19 containment efforts. 2021. available at https://www.ideasforindia.in/topics/money-finance/challenges-faced-by-community-health-workers-in-covid-19-containment-efforts.html accessed 12th August, 2021. GoA. COVID-19(Novel Coronavirus Disease) The Assam Story: A Compendium of Administrative and Scientific Approaches and Camaraderie, National Health Mission, Guwahati Assam. 2021. GoA. Human Development Report Assam , OKD Institute of Social Change and Development, Guwahati, Institute for Human Development, New Delhi for Planning Commission and Government of Assam, New Delhi. 2014. Rai S. Ethnic Conflict in Assam: Issues, Causes and State Responses , The Eastern Anthropologist . 2014. 71(3&4)382-397. Government of India(2022) Special Bulletin on Maternal Mortality in India: 2018-20, Sample Registration System, Office of the Registrar General, India. International Institute of Population Sciences and ICF (2021) National Family Health Survey (NFHS-5) India, 2019-21-Assam.s Mumbai, IIPS. Lisam S. Rural health practitioners in Assam: Mid-level care provider for comprehensive service delivery in sub centres. Undated. Available at http://164.100.117.80/sites/default/files/Rural%20Health%20Practitioners%20in%20Assam%20-%20Mid%20Level%20Care%20Provider.pdf. Accessed 12 th September, 2021. Government of Assam.Master Covid Sheet, Information Provided by NHM Assam. 2020. Government of Assam. Order No HLA 269/2020/25 Dated: 11 th July 2020, Health and Family Welfare Department, Dispur.2020. Footnotes Note that Census of 2011 uses Kamrup and not Kamrup Rural. However, Kamrup Rural continues to be used in official circles so as to differentiate between Kamrup metro (as the urban agglomeration) and Kamrup rural (as the rural). We have used Kamrup Rural in alignment with official use. A critical component of the NRHM was to provide, in every village, a woman volunteer known as ASHAs to deliver primary health care services to the communities with a focus on delivery of reproductive and child health services for women and children. ASHAs are selected from within the village and trained by the public health system working towards improving the health outcomes at the community level. ASHAs are considered ‘volunteers’ and are paid performance-based incentives for the various tasks they undertake at the community. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3859387","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":268570069,"identity":"24f56339-ecbc-4c98-af1d-09433ca63386","order_by":0,"name":"Daksha Parmar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIiWNgGAWjYDCCA2wMzAheBYR94AEDA2MDcVrOgNjMDAcSiNbC2AbRwoBPC9/xY8mfC2oY8vhnn078XDnPOnE7+/mDQFtsZDccwK5F8kzaMekZxxiKJc7lbpY8uy09cWdPMshhaca4tBgcSG9j5mFjSGw4w7tBsnHb4cQNB8BaQAwcWs4/b/7M848hcf4Z3s0/G+cAVZ5/DNLyH7eWG2kHpHnbGBI3nOHdJtnYANRyA2zLAZxaJG88S5Pm7ZMoNgRqsWw4lm68c8ZjgwMJBsnGM3Fo4TufZvyZ55tNnhzQYTcbaqxlt/MnPv7wocJOtg+HFiiQSICxHDdAHIxXORjAtdgToXgUjIJRMApGGAAAa6BrkyV/RF0AAAAASUVORK5CYII=","orcid":"","institution":"D.Y. Patil University","correspondingAuthor":true,"prefix":"","firstName":"Daksha","middleName":"","lastName":"Parmar","suffix":""},{"id":268570070,"identity":"e931ae62-efb9-4dfd-8f38-54844812d496","order_by":1,"name":"Rajshree Bedamatta","email":"","orcid":"","institution":"Indian Institute of Technology Guwahati","correspondingAuthor":false,"prefix":"","firstName":"Rajshree","middleName":"","lastName":"Bedamatta","suffix":""},{"id":268570071,"identity":"e4009567-3604-4238-a060-302c40c6c60e","order_by":2,"name":"Hilde Graeve","email":"","orcid":"","institution":"World Health Organization - India","correspondingAuthor":false,"prefix":"","firstName":"Hilde","middleName":"","lastName":"Graeve","suffix":""},{"id":268570072,"identity":"b39a04a1-dac4-4229-8f4d-6322379a1d5b","order_by":3,"name":"Biraj Kanti Shome","email":"","orcid":"","institution":"World Health Organization - India","correspondingAuthor":false,"prefix":"","firstName":"Biraj","middleName":"Kanti","lastName":"Shome","suffix":""},{"id":268570073,"identity":"a1d686b0-4e37-4d99-93a4-83e8009d0b1f","order_by":4,"name":"Dilip Singh Mairembam","email":"","orcid":"","institution":"World Health Organization - India","correspondingAuthor":false,"prefix":"","firstName":"Dilip","middleName":"Singh","lastName":"Mairembam","suffix":""}],"badges":[],"createdAt":"2024-01-13 07:44:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3859387/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3859387/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84939974,"identity":"80362a0d-3fb0-4c8e-86bb-71a07d6834f4","added_by":"auto","created_at":"2025-06-19 04:53:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":902258,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3859387/v1/b03a0d7c-ba83-47fa-8f5a-19ec77e68f2d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"COVID-19 Pandemic and Frontline Health Workers in Assam (India): Roles and Challenges faced by the Accredited Social Health Activists (ASHAs)","fulltext":[{"header":"Background","content":"\u003cp\u003eHealth workers across the world were mobilized to respond to the COVID-19 pandemic. Several countries roped in the frontline health workers in responding to the crisis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. FHWs have played a critical role undertaking community-level surveillance, creating awareness about preventive measures, providing health education and ensuring access to curative health services [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. They were also at the forefront ensuring continuation of essential health services. The World Health Organization (WHO), recognizing this contribution of the health workers had declared 2021 as the \u0026ldquo;International Year of Health and Care Workers.\u0026rdquo; The campaign focused on the need for government to invest in readiness of health workforce, education as well as learning to manage the COVID-19 pandemic [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe FHWs have a central role in realizing the primary health care goal under Health for All [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Acting as an interface between the community and the health system, FHWs are critical in empowering individuals and communities to take charge of their lives [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Embedded within the communities they work, FHWs are seen as agents of social change striving to bring health services closer to the communities by providing culturally appropriate, physically accessible, preventive, promotive and basic curative services [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs the COVID-19 pandemic struck India, public health systems were geared up to respond to the crisis [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. While there were efforts to increase hospital capacities, primary focus was on community-centred interventions with the involvement of ASHAs. ASHAs were mobilized to create awareness about the disease, track returning migrants, ensure mandatory home quarantine, mobilize people for testing and undertake contact tracing. They were also required to arrange ambulance facilities for shifting positive cases to isolation facilities. To a large extent, ASHAs undertook these functions without adequate training or proper safety precautions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOften FHWs are praised as \u003cem\u003ewarriors\u003c/em\u003e fighting the deadly virus. However, working at the lowest level of health systems hierarchy, they were in an extremely challenging and vulnerable situation, risking their own lives. In this context, the present study documents the role of ASHAs during the pandemic in Assam, India.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eThe Study Setting:\u003c/h2\u003e \u003cp\u003eAssam is considered as a gateway to the Northeast India. As per India\u0026rsquo;s 2011 census, population of the state was 31.2\u0026nbsp;million. Around 86% of its population reside in rural areas [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The state presents huge geo-spatial diversities that include plains, valleys and hilly areas, tea gardens and riverine areas known as \u0026ldquo;Chars\u0026rdquo;. The state also perennially suffers from annual floods [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Demographically, the state has multi-ethnic, multi-lingual and multi-religious communities. For a long period, the state witnessed several ethnic assertions resulting in conflicts and insurgency [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The socio-geographical disparities along with ethnic conflict has also impacted the delivery of health services in the state[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Assam also suffers high infant, child and maternal mortality [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Its response to the COVID-19 pandemic has to be analysed in its socio-economic and health status context. Health system in Assam is a mix of public, private and informal health care providers. The state has a weak and fragile public health system with severe deficiencies of health infrastructure and health workers[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study was conducted in four districts - Kamrup Metro, Kamrup Rural,\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e Dhubri and Dibrugarh based on the highest COVID-19 case load briefed in public portals. These districts also represented diverse demographic, spatial, and geographical heterogeneity of the state. Dibrugarh and Dhubri have a high incidence of tea gardens and \u003cem\u003eChars\u003c/em\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Kamrup Metro (Dispur), the State\u0026rsquo;s capital, had the highest burden of COVID-19 in the state. Kamrup Rural, the periphery of State capital, was selected to understand the response to COVID-19 in the immediate vicinity of the State capital. Assam, with its socio-economic and geographical vulnerabilities, presented a unique site for studying role of frontline health workers in the wake of a public health emergency such as COVID-19.\u003c/p\u003e \u003cp\u003eIn-depth interviews were conducted with ASHAs at the sub centres, health and wellness centres and primary health centres in rural and urban areas. Focus group discussions were also conducted at the facility level. Due to the dynamic and changing travel restrictions, in-depth interviews were substantiated with telephonic interviews. Field work was done during July-October, 2021. We interviewed 82 ASHAs and held discussions with Auxiliary Nurse Midwives (ANMs) and ASHA Supervisors at the primary health facilities (Refer Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e to \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e for districtwise respondents, socio-demographic respondents of ASHAs and number of health facilities visited).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistrictwise respondents of the study:\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistricts\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDhubri\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDibrugarh\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKamrup Metro\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKamrup Rural\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASHAs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eSource\u003c/em\u003e: Field study data\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAge Distribution of the ASHAs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo. of ASHAs\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e41\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e51\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e61\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e82\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEducational Status of ASHAs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational Status\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo. of ASHAs\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary level (Class 1\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary level (Class 9\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher Secondary (Class 11\u0026ndash;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduation \u0026amp; above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e82\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReligion Wise Distribution of ASHAs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHindus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChristian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eSocial Category Wise Distribution of ASHAs\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGEN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOBC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMOBC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eST\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumber of health facilities visited across four districts:\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistricts/\u003c/p\u003e \u003cp\u003eHealth Facilities\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDhubri\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDibrugarh\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKamrup Metro\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKamrup Rural\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSub Centres\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Wellness Centres\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePHCs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban State Dispensaries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban PHCs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban Maternity Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTea Garden Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eState Dispensary and Urban Health Centre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e23\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eConfidentiality of the Respondents:\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eInformed consent\u003c/strong\u003e \u003cp\u003ewas taken from the participants to participate in the study. The respondents were interviewed after informed consent, both oral and written. The in-person and telephonic interviews took place under high-stress and difficult work conditions. The COVID-19 norms of physical distance and face masks were followed while conducting interviews. Ethical clearance for the study was obtained from the Institute Human Ethics Committee of the Indian Institute of Technology (IIT) Guwahati. The findings are arranged based on thematic analysis.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eCOVID-19 in Assam:\u003c/h2\u003e \u003cp\u003eThe first case of COVID-19 in Assam was reported on 31st March 2020. Since then, the state machinery coordinated efforts to reduce the spread of the disease with a claim of adopting a multi-pronged strategy - \u003cem\u003eTrack, Trace, Treat\u003c/em\u003e [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Institutional quarantine of 14 days for people with travel history was made compulsory. Those who tested positive during the quarantine period were shifted to designated hospitals. The quarantine policy of the state was known as \u0026ldquo;ruthless quarantine with human heart\u0026rdquo; [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The Government also ramped up the testing facilities in the state and by May 2020, the state could undertake around 90,000 tests per day.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eFindings: The Roles of ASHAs in COVID-19 response:\u003c/h2\u003e \u003cp\u003eASHAs have performed multiple roles and responsibilities, which was beyond the regular call of their work duties. ASHAs\u003ca class=\"FNLink\" href=\"#Fn2\" id=\"#FNLinkFn2\"\u003e\u003c/a\u003e were instrumental in surveillance activities at the community level, creating awareness about preventive measures of the disease, facilitating home quarantine, isolation and transfer of patients to institutional facilities along with fulfilling their routine maternal and child healthcare activities.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eAssam Community Surveillance Plan (ACSP), 2020 and Assam Targeted Surveillance Plan (ATSP), 2021:\u003c/h2\u003e \u003cp\u003eA unique feature of the response of Government of Assam (GoA) to the COVID-19 pandemic was implementation of ACSP in 2020, and ATSP in 2021. Intending to understand the spread of the disease in the community, the ACSP and ATSP were critical in identifying Influenza-Like Illnesses (ILIs), Severe Acute Respiratory Illnesses (SARIs), Malaria, Japanese Encephalitis along with COVID-19. ASHAs were at the forefront of the ACSP, undertaking community mobilization for screening to facilitating isolation of COVID-19 patients, ensuring access to medical care for ILIs. ASHAs undertook door to door visits a day before the visit of the surveillance team. The surveillance team comprised ANMs, Multi-Purpose Workers (MPWs), ASHAs and Community Health Officers (CHOs) that would conduct screening of ILIs. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eChallenges faced by ASHAs during COVID-19:\u003c/h2\u003e \u003cp\u003eAt the time of the pandemic, ASHAs were seen as important health \u0026ldquo;volunteers\u0026rdquo;. However, their work was fraught with immense risk to their health and security. In the early phase of the pandemic, ASHAs had to spread awareness about new disease at the community level. They conducted \"line listing\" of the households to collect information about the persons who had recently immigrated. They had to put up stickers of home quarantine to minimize community interaction of people with travel history. They also had to mobilise symptomatic people for testing and ensure positive cases were sent to institutional facilities for isolation. Conducting the above tasks required coordination with the ANMs, MPWs and CHOs at the primary health facilities.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eIncrease in the Workload:\u003c/h3\u003e\n\u003cp\u003eGiven Assam\u0026rsquo;s priority of containing its high maternal and child mortality rates [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] even before the pandemic, the ASHAs had a high workload. The pandemic-related surveillance and coordination, therefore, came as an additional burden. At times, they had to report beyond duty hours to attend delivery cases or shift COVID-19 patients to hospitals.\u003c/p\u003e\n\u003ch3\u003eInadequate and Irregular Access to Masks and Sanitizers:\u003c/h3\u003e\n\u003cp\u003eIn March 2020, there was a considerable shortage of masks and sanitizers in the country. All the ASHAs reported about irregular and inadequate supply of masks and sanitizers. They depended on their own resources while managing a public health emergency. Although masks were provided much later from the PHCs, even in 2021 many complained of irregular supplies of essential precautionary items.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFrequently Changing COVID-19 Guidelines:\u003c/h2\u003e \u003cp\u003eTo reduce the burden on the health system, on 11th July 2020, GoA reluctantly allowed conditional home isolation of patients for those voluntarily opting so [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The conditions were that persons should be asymptomatic, absence of older adults above 60 years in the family, separate room with a toilet for isolation, and absence of co-morbidity. The patients in home isolation were required to possess oximeter and thermometer. The patient had to sign an undertaking that he/she is under voluntary home isolation and the government will not be held responsible for any complications arising during home isolation. The home isolation guideline with the above conditions was implemented in Assam from July 2020 till May 2021 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Due to the change in guideline, the burden of routine follow up of patients also fell on ASHAs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eChallenge of contact tracing:\u003c/h2\u003e \u003cp\u003eQuarantining and isolating people in the community, identifying families suffering from COVID-19 did not often take place smoothly. In Dibrugarh and Kamrup Metro, severe backlash from the community members were reported. The fast pace of transmission of the disease and rumour mongering regarding forceful shifting of patients to COVID Care Centres (CCCs) or being separated from family, made the ASHA volunteers bear the wrath of the community. Public backlash was also experienced by health workers posted at bus terminals, railway stations and check posts. For ASHA volunteers, the backlash affected their long-standing relationship with community members.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStigma, Discrimination and Violence:\u003c/h2\u003e \u003cp\u003eThere was a high level of stigma attached to the disease. Due to their exposure to COVID-19 patients at the community level, people were fearful to interact with ASHAs when they undertook surveillance to collect information or mobilise people for testing. Some even encountered threats, physical attacks and harassment, especially when people were tested positive. ASHAs also had to ensure that the positive persons were shifted to the CCC, but they ended up facing harassment as people feared moving out of their house.\u003c/p\u003e \u003cp\u003eDue to their long years of community engagement, ASHAs understood the differential impact of the pandemic on community members. In response, they addressed the crisis within the social-economic context. ASHAs in Dibrugarh discussed the difficulties a daily wage worker of a tea garden to undergo home isolation and the impact of wage loss on livelihood. In solidarity and empathy, they ensured that the dry rations provided by the District Administration reached family members under quarantine timely. They mobilized and contributed money to buy food and ration for the families under quarantine. In the slums of Kamrup Metro, ASHAs understood how poverty impacted household supplies of essential commodities. In response, ASHAs mobilized funds and distributed masks, sanitizers, and soaps.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eChallenges in the Delivery of Essential Health Services:\u003c/h2\u003e \u003cp\u003eIndian government announced stringent lockdowns since 24th March 2020 which impacted routine essential health services provided at the primary health facilities. However, from June 2020, essential health services resumed under the supervision and guidance of health officials. In tea garden areas of Assam, where maternal and child mortality are very high, the continuation of maternal and child health services was top priority. Some ASHAs were exclusively allotted maternal and child health duties while others undertook COVID-19 duties. In 2021, Dibrugarh district saw a rapid transmission of the virus and high caseload. The ASHAs faced resistance from the community when providing home-based new-born care (HBNC).\u003c/p\u003e \u003cp\u003eChild immunization services were severely affected in the study districts. By end of June 2020, when immunization services resumed, many children had missed their scheduled vaccinations. ASHAs and ANMs ensured proper seating arrangements with physical distance at the facilities during routine immunization. Mothers and young children were called in batches of two or three and allotted scheduled timings to attend the health facilities. Sometimes vaccines were administered in open spaces as people were hesitant to visit health facilities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eASHAs and COVID-19 Vaccination:\u003c/h2\u003e \u003cp\u003eThe COVID-19 vaccination programme from January 2021 was an addition to already existing work load. They had to make a list of persons eligible for vaccination. ASHAs allayed public fear and hesitation towards vaccination by counselling. Such intensive engagement with the community however hampered their routine tasks.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eOverworked, Underpaid and Delay in receipt of Incentives:\u003c/h2\u003e \u003cp\u003eASHA volunteers in India receive incentives as opposed to a salary. In order to claim their performance incentives, ASHAs have to submit claim form, along with number of supporting documents which are to be verified and signed by other health workers and officials. There was a delay in the payment of regular incentives both in rural and urban areas. This was primarily because most of the ANMs and Medical Officers (MOs) were posted at the CCCs, quarantine centres and designated COVID-19 health facilities from April to November 2020. In some cases, ANMs and block level officials were infected by COVID-19 and hence it delayed the administrative procedure of getting the documents verified. In Kamrup Metro, the working-class population who lived in slums left for their villages fearing the pandemic. Hence, the number of beneficiary households had reduced tremendously for ASHAs, resulting in low incentives. Almost all the ASHAs complained about meagre incentives and huge workload during the pandemic.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eCOVID-19 crisis highlighted the central role of public health facilities during health emergencies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Our study makes evident the indispensable and varied roles played by ASHAs as frontline responders. Right from the early stages of the pandemic, the ASHAs worked tirelessly as the first line of defence, taking care of sick people, saving lives, and breaking the chain of COVID-19 transmission. Working at the bottom of the public health system hierarchy, ASHAs contributed in different capacities within a resource crunch health system, and ensured that health programmes reached the last mile. This finding is similar to other studies on FHWs during pandemic [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe contribution of ASHAs in increasing the communities\u0026rsquo; trust in the public health systems has been phenomenal, emerging as a pillar of the health system during crisis. When community members experienced medical emergencies during a complete enforced lockdown, ASHAs ensured that people have timely access to healthcare. When there were restrictions on mobility, an ASHA's presence in her uniform and identification card provided assurance to people about ready availability of care and essential services.\u003c/p\u003e \u003cp\u003e During the pandemic, ASHAs have worked at the grassroots, amidst rapidly changing guidelines and resource crunch. They were always the last to receive masks, sanitizers, or gloves. Systemic hierarchies were at work such that ANMs of the same health facilities received N95 masks while ASHAs got disposable masks. The ASHAs shared a feeling of invalidation for not being acknowledged by the people and by the system at large despite being equally at the risk of contracting the disease. Many of them were scared of passing on the infection to their family members, and hence never entered their own homes directly after work. They took hot water baths, washed their ASHA uniforms, sanitized mobile phones, and then got in. Majority of the ASHAs informed that apart from incurring such expenditure for their safety, their household expenditure increased due to excessive use of detergent powders and bathing soaps.\u003c/p\u003e \u003cp\u003eASHAs received fixed performance-based incentives as they are \u0026ldquo;volunteers\u0026rdquo; within the health system[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Every national health programme that the MoHFW implements, ASHAs undertakes the activities listed. Before the pandemic itself, their burden had increased, as they had to perform every new programme at the community level[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Despite undertaking many and long-duration tasks, they were paid only Rs 2000 to Rs 3000 during the initial months of the lockdown. ASHAs felt the Government had abandoned them, as their compensation was the least priority. In the times of lockdown and rising prices of essential food items, it was challenging for them to manage their households, many of whom were the sole earning member.\u003c/p\u003e \u003cp\u003eCOVID-19 has been deeply disruptive, especially of livelihoods and sustained incomes. It is important for governments to recognize their central role in pandemic management and institutionalize a system of payment which is commensurate to their work. While it is easy to glorify their roles as \u0026ldquo;COVID-19 warriors\u0026rdquo;, public health emergency management has shown that they be regularized, compensated adequately and provided social security.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study makes it evident that ASHAs have performed multiple roles and responsibilities, which was beyond the regular call of their work duties. They were instrumental in surveillance activities at the community level, facilitating home quarantine and isolation and transfer of patients to institutional facilities along with fulfilling their routine maternal and child healthcare activities. High work burden coupled with the absence of work-related leaves, low compensation and difficult working conditions have resulted in extreme burnout, exhaustion, and adverse mental health consequences amongst the ASHAs. The pandemic has highlighted that health systems, led by health workers closer to the communities are most effective in responding in times of public health crisis.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACSP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAssam Community Surveillance Plan\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAuxiliary Nurse Midwives\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eATSP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAssam Targeted Surveillance Plan\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCHOs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity Health Officers\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCOVID Care Centres\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGEN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral caste\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGoA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGovernment of Assam\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHBNC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHome-Based Newborn Care ILI:Influenza-Like Illnesses\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMOBC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMost Other Backward Caste\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMPWs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMulti-Purpose Workers\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNRHM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Rural Health Mission\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNHM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Health Mission\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOBC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOther Backward Caste\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eScheduled Caste\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eST\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eScheduled Tribe\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: Ethical approval was obtained from Institute Human Ethics Committee at IIT Guwahati. Informed consent was taken from the participants to participate in the study.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for publication: \u0026nbsp;\u003c/strong\u003eNot applicable\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe field data and materials, including consent forms, can be made available from Indian Institute of Technology Guwahati on reasonable request.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests: \u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: The study was funded by the WHO, India Office\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u0026nbsp; All the authors have contributed to the study in, designing the tools of the data, data collection, analysis of data and writing the manuscript. All the authors have read and approved the final manuscript.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e We want to express our gratitude to the FHWs in four districts of Assam and all the block, district and state level officials working with NHM Assam. We are also grateful to NHM Assam for their support in conducting this study.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAuthors\u0026apos; information (optional):\u003c/strong\u003e DP had worked at Dept of Humanities and Social Sciences, IIT Guwahati till December 2023 before joining D Y Patil University, Navi Mumbai, Mumbai, Maharashtra, India; \u0026nbsp;RB works at the\u0026nbsp;Department of Humanities and Social Sciences, IIT Guwahati, Guwahati Assam, India. HD, BS and DS work with\u0026nbsp;WHO, India Office, Delhi, New Delhi, India.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWorld Health Organisation(WHO). WHO guideline on health policy and system support to optimize community health worker programmes.2021. WHO. Geneva. https://www.who.int/publications/i/item/9789241550369 accessed on 6\u003csup\u003eth\u003c/sup\u003e September 2021.\u003c/li\u003e\n \u003cli\u003eBallard M, Bancott E, Nestbit J, Johnson A, Holemann, I et al. Prioritising the role of community health workers in the COVID-19 response. BMJ Global Health\u003cem\u003e.\u003c/em\u003e2020;5:1-7 http://dx.doi.org/10.1136/bmjgh-2020-002550\u003c/li\u003e\n \u003cli\u003eWHO Regional Office for South-East Asia. Roles of community health workers in advancing health security and resilient health systems: emerging lessons from the COVID-19 response in the South-East Asia Region, WHO South-East Asia Journal of Public Health. 2021 10, S1:41-48. https://apps.who.int/iris/handle/10665/351484.\u003c/li\u003e\n \u003cli\u003eEditorial. Health and care workers are owed a better future. The Lancet. 397:347. https://doi.org/10.1016/S0140-6736(21)00179-3\u003c/li\u003e\n \u003cli\u003eNandi S and Schneider H. Addressing the Social Determinants of Health: A Case Study from the Mitanin (Community Health Worker) Programme in India, Health Policy and Planning. 2014. 29:ii71-ii80. 10.1093/heapol/czu074\u003c/li\u003e\n \u003cli\u003eSchaaf M, Warthin C, Freedman L, Topp S. The community health worker as service extender, cultural broker and social change agent: a critical interpretive synthesis of roles, intent and accountability. \u003cem\u003eBMJ Global Health\u003c/em\u003e 2020. 5(6).1-13. 10.1136/bmjgh-2020-002296\u003c/li\u003e\n \u003cli\u003eNepomnyashciy L, Dahn B, Saykpah R, Raghavan M. COVID-19: Africa needs unprecedented attention to strengthen community health systems, The Lancet\u003cem\u003e,\u003c/em\u003e 2020. 396(10245).P150-152. https://doi.org/10.1016/S0140-6736(20)31532-4.\u003c/li\u003e\n \u003cli\u003eShukla. A. What lessons does the Covid-19 pandemic hold for India\u0026rsquo;s health system? 29\u003csup\u003eth\u003c/sup\u003e May 2020. https://scroll.in/article/962794/what-lessons-does-the-covid-19-pandemic-hold-for-indias-health-system accessed 13th October 2021.\u003c/li\u003e\n \u003cli\u003eJain S. India\u0026rsquo;s army of unrecognized, unpaid female health workers. BMJ 2021. 8; 375. https://doi.org/10.1136/bmj.n2509.\u003c/li\u003e\n \u003cli\u003eMishra A and Santosh S. \u003cem\u003eArent we the frontline warriors: experiences of grassroots health workers during COVID-19\u003c/em\u003e. 2021\u003cem\u003e\u0026nbsp;\u003c/em\u003eAzim Premji University. Bangalore.\u003c/li\u003e\n \u003cli\u003eBhatia S, Pal S and Saha S. Challenges faced by community health workers in COVID-19 containment efforts. 2021. available at https://www.ideasforindia.in/topics/money-finance/challenges-faced-by-community-health-workers-in-covid-19-containment-efforts.html accessed 12th August, 2021.\u003c/li\u003e\n \u003cli\u003eGoA. COVID-19(Novel Coronavirus Disease) The Assam Story: A Compendium of Administrative and Scientific Approaches and Camaraderie, National Health Mission, Guwahati Assam. 2021.\u003c/li\u003e\n \u003cli\u003eGoA. \u003cem\u003eHuman Development Report Assam\u003c/em\u003e, OKD Institute of Social Change and Development, Guwahati, Institute for Human Development, New Delhi for Planning Commission and Government of Assam, New Delhi. 2014.\u003c/li\u003e\n \u003cli\u003eRai S. Ethnic Conflict in Assam: Issues, Causes and State Responses\u003cem\u003e, The Eastern Anthropologist\u003c/em\u003e. 2014. 71(3\u0026amp;4)382-397.\u003c/li\u003e\n \u003cli\u003eGovernment of India(2022) \u003cem\u003eSpecial Bulletin on Maternal Mortality in India: 2018-20,\u0026nbsp;\u003c/em\u003eSample Registration System, Office of the Registrar General, India.\u003c/li\u003e\n \u003cli\u003eInternational Institute of Population Sciences and ICF (2021) \u003cem\u003eNational Family Health Survey (NFHS-5) India, 2019-21-Assam.s\u003c/em\u003e Mumbai, IIPS.\u003c/li\u003e\n \u003cli\u003eLisam S. Rural health practitioners in Assam: Mid-level care provider for comprehensive service delivery in sub centres. Undated. Available at http://164.100.117.80/sites/default/files/Rural%20Health%20Practitioners%20in%20Assam%20-%20Mid%20Level%20Care%20Provider.pdf. Accessed 12\u003csup\u003eth\u003c/sup\u003e September, 2021.\u003c/li\u003e\n \u003cli\u003eGovernment of Assam.Master Covid Sheet, Information Provided by NHM Assam. 2020.\u003c/li\u003e\n \u003cli\u003eGovernment of Assam. Order No HLA 269/2020/25 Dated: 11\u003csup\u003eth\u003c/sup\u003e July 2020, Health and Family Welfare Department, Dispur.2020.\u003cstrong\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Note that Census of 2011 uses Kamrup and not Kamrup Rural. However, Kamrup Rural continues to be used in official circles so as to differentiate between Kamrup metro (as the urban agglomeration) and Kamrup rural (as the rural). We have used Kamrup Rural in alignment with official use.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e A critical component of the NRHM was to provide, in every village, a woman volunteer known as ASHAs to deliver primary health care services to the communities with a focus on delivery of reproductive and child health services for women and children. ASHAs are selected from within the village and trained by the public health system working towards improving the health outcomes at the community level. ASHAs are considered \u0026lsquo;volunteers\u0026rsquo; and are paid performance-based incentives for the various tasks they undertake at the community.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"COVID-19 pandemic, Roles and Contribution, Challenges, Assam-India; First Responders, Women in Public Health, Health Care Workers, Health Systems","lastPublishedDoi":"10.21203/rs.3.rs-3859387/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3859387/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCOVID-19 was one of the most devastating health crises that the world witnessed in contemporary times. Health workers were at the forefront, responding to the crisis, saving millions of lives. Faced with an unprecedented situation, India’s frontline health workers (FHWs) in the public health system, played a critical role as first responders. There are limited studies that have explored and documented their contribution from the north eastern states of India.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e In this qualitative study, we discuss the roles of FHWs during COVID-19, and the challenges they faced while working at the primary level public health facilities. The study was conducted in Dibrugarh, Dhubri, Kamrup and Kamrup Metropolitan districts representing spatial, socio-economic and geographical diversity and disparity of the state. Multiple modes of inquiry (in-depth interviews, group discussions, and telephonic interviews) were conducted with the ASHAs and other stakeholders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings:\u003c/strong\u003e The ASHAs have performed different roles in terms of creating awareness, health education, adopting preventive measures, disease surveillance, testing, quarantine and isolation of patients. They were instrumental in continuation of the essential health services and COVID-19 vaccination. Tremendous increase in their tasks, long working hours without proper break, insecure and risky work conditions without adequate safety measures, stigma, violence, and discrimination at community level, frequently changing guidelines, delayed and inadequate compensation were some of the main challenges faced by the ASHAs in Assam.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eWorking at the bottom of the public health system hierarchy, the ASHAs in rural and urban areas performed most of their responsibilities despite risks. Their contribution in increasing the community’s trust in the public health system, through their educational role and by being the first point of healthcare providers has been phenomenal.\u003c/p\u003e","manuscriptTitle":"COVID-19 Pandemic and Frontline Health Workers in Assam (India): Roles and Challenges faced by the Accredited Social Health Activists (ASHAs)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-24 08:49:55","doi":"10.21203/rs.3.rs-3859387/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"86577496-4582-4c59-9a3b-bd9de71cefbe","owner":[],"postedDate":"January 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-19T04:53:14+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-24 08:49:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3859387","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3859387","identity":"rs-3859387","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}