How are gender inequalities facing India’s one million ASHAs being addressed? Policy origins and adaptations for the world’s largest all-female community health worker programme
Tóm tắt
India’s accredited social health activist (ASHA) programme consists of almost one million female community health workers (CHWs). Launched in 2005, there is now an ASHA in almost every village and across many urban centres who support health system linkages and provide basic health education and care. This paper examines how the programme is seeking to address gender inequalities facing ASHAs, from the programme's policy origins to recent adaptations. We reviewed all publically available government documents (n = 96) as well as published academic literature (n = 122) on the ASHA programme. We also drew from the embedded knowledge of this paper’s government-affiliated co-authors, triangulated with key informant interviews (n = 12). Data were analysed thematically through a gender lens. Given that the initial impetus for the ASHA programme was to address reproductive and child health issues, policymakers viewed volunteer female health workers embedded in communities as best positioned to engage with beneficiaries. From these instrumentalist origins, where the programme was designed to meet health system demands, policy evolved to consider how the health system could better support ASHAs. Policy reforms included an increase in the number and regularity of incentivized tasks, social security measures, and government scholarships for higher education. Residential trainings were initiated to build empowering knowledge and facilitate ASHA solidarity. ASHAs were designated as secretaries of their village health committees, encouraging them to move beyond an all-female sphere and increasing their role in accountability initiatives. Measures to address gender based violence were also recently recommended. Despite these well-intended reforms and the positive gains realized, ongoing tensions and challenges related to their gendered social and employment status remain, requiring continued policy attention and adaptation. Gender trade offs and complexities are inherent to sustaining CHW programmes at scale within challenging contexts of patriarchal norms, health system hierarchies, federal governance structures, and evolving aspirations, capacities, and demands from female CHWs. Although still grappling with significant gender inequalities, policy adaptations have increased ASHAs’ access to income, knowledge, career progression, community leadership, and safety. Nonetheless, these transformative gains do not mark linear progress, but rather continued adaptations.
Tài liệu tham khảo
Schneider H, Okello D, Lehmann U. The global pendulum swing towards community health workers in low- and middle-income countries: a scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014. Hum Resour Health. 2016;14(1):65.
Maher D, Cometto G. Research on community-based health workers is needed to achieve the sustainable development goals. Bull World Health Organ. 2016;94(11):786.
NHSRC. Update on ASHA programme, January. New Delhi; 2017. Available from: http://nhsrcindia.org/sites/default/files/Update%20on%20ASHA%20Programme-%20January-2017.pdf. Accessed 10 Apr 2017.
George A. Nurses, community health workers, and home carers: gendered human resources compensating for skewed health systems. Glob Public Health. 2008;3(Suppl 1):75–89.
George AS. Human resources for health: a gender analysis. Review Paper prepared for the Women and Gender Equity, and Health Systems, Knowledge Networks Networks (KNs) of the WHO Commission on the Social Determinants of Health. 2007. Available from: https://www.who.int/social_determinants/resources/human_resources_for_health_wgkn_2007.pdf.
Standing H. Gender - a missing dimension in human resource policy and planning for health reforms. Hum Resour Heal Dev J. 2000;4(1):27–42.
Newman CJ. Time to address gender discrimination and inequality in the health workforce. Hum Resour Health. 2014;12(1):25.
Kok MC, Kane S, Tulloch O, Ormel H, Theobald S, Dieleman M, et al. How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature. Heal Res Policy Syst. 2015;13(1):13.
Steege R, Taegtmeyer M, McCollum R, Hawkins K, Ormel H, Kok M, et al. How do gender relations affect the working lives of close to community health service providers? Empirical research, a review and conceptual framework. Soc Sci Med. 2018;209(April):1–13.
WHO. WHO Gender Mainstreaming Manual for Health Managers: a practical approach [Internet]. Geneva; 2011. Available from: http://www.who.int/gender-equity-rights/knowledge/health_managers_guide/en. Accessed 30 Jan 2018.
USAID/PACE/IGWA. The gender integration continuum. Washington, DC: USAID; 2017.
Bajpai N, Sachs JD, Dholakia RH. Improving access, service delivery and efficiency of the public health system in rural India: Mid-term evaluation of the National Rural Health Mission. Vol. No. 37, CGSD Working Papers. New York: Center on Globalization and Sustainable Development; The Earth Institute at Columbia University; 2009.
MoHFW. Guidelines for antenatal care and skilled attendance at birth by ANMs/LHVs/SNs. New Delhi: Ministry of Health and Family Welfare, Government of India; 2010.
MoHFW India. National Rural Health Mission (2005–2012): Mission Document [Internet]. New Delhi; 2005. Available from: http://www.nhm.gov.in/images/pdf/about-nrhm/nrhm-framework-implementation/nrhm-framework-latest.pdf. Accessed 10 Apr 2017.
NRHM. Letter from GC Chaturvedi, Additional Secretary and Mission Director (NRHM), Subject: Performance based payment to ASHAs. D.O. No A. 11033/61/2007-Trg. Letter dated 19th Sept 2008. New Delhi: Ministry of Health and Family Welfare, Government of India; 2008.
MoHFW India. ASHA Guidelines. New Delhi: National Rural Health Mission, Ministry of Health and Family Welfare, Government of India; 2006.
NHSRC. ASHA: which way forward? Evaluation of the ASHA Programme. Mission NRH, editor. New Delhi: National Health Systems Resource Centre; 2011.
Gopalan SS, Mohanty S, Das A. Assessing community health workers’ performance motivation: a mixed-methods approach on India’s Accredited Social Health Activists (ASHA) programme. BMJ Open. 2012;2(5):e001557.
Roalkvam S. Health governance in India: citizenship as situated practice. Glob Public Health. 2014;9(8):910–26.
Scott K, Shanker S. Tying their hands? Institutional obstacles to the success of the ASHA community health worker programme in rural North India. AIDS Care. 2010;22(Suppl 2):1606–12.
Pandey J, Singh M. Donning the mask: effects of emotional labour strategies on burnout and job satisfaction in community healthcare. Health Policy Plan. 2016;31(5):551–62.
Saprii L, Richards E, Kokho P, Theobald S, Greenspan J, McMahon S, et al. Community health workers in rural India: analysing the opportunities and challenges accredited social health activists (ASHAs) face in realising their multiple roles. Hum Resour Health. 2015;13(1):95.
Sundararaman T. Community health-workers: scaling up programmes. Lancet. 2007;369(9579):2058–9.
Nandi S, Schneider H. Addressing the social determinants of health: a case study from the Mitanin (community health worker) programme in India. Health Policy Plan. 2014;29:ii71–81.
Deshpande S, Bhanot A, Maknikar S. Assessing the influence of a 360-degree marketing communications campaign with 360-degree feedback. Soc Mark Q. 2015;21(3):142–51.
Srivastava D, Prakash S, Ashish V, Nair K, Gupta S, Nandan DA. Study of Interface of ASHA with the community and the service providers in eastern Uttar Pradesh. Indian J Public Health. 2009;53(3):133.
Shukla A, Bhatnagar T. Accredited social health activists and pregnancy related services in Uttarakhand, India. BMC Proc. 2012;6(Suppl 1):1–2.
Pala S, Kumar D, Jeyashree K, Singh A. Preliminary evaluation of the ASHA scheme in Naraingarh block, Haryana. Natl Med J India. 2011;24(5):315–6.
Mahanta TG, Islam S, Sudke AK, Kumari V, Gogoi P, Rane T, et al. Effectiveness of introducing home-based newborn care (HBNC) voucher system in Golaghat District of Assam. Clin Epidemiol Glob Heal. 2016;4(2):69–75.
Praveen D, Patel A, Raghu A, Clifford GD, Maulik PK, Mohammad Abdul A, et al. SMARTHealth India: development and field evaluation of a mobile clinical decision support system for cardiovascular diseases in rural India. JMIR mHealth uHealth. 2014;2(4):e54.
Sharma R, Webster P, Bhattacharyya S. Factors affecting the performance of community health workers in India: a multi-stakeholder perspective. Glob Health Action. 2014;7(1):1–8.
Gopalan SS, Durairaj V. Addressing maternal healthcare through demand side financial incentives: experience of Janani Suraksha Yojana program in India. BMC Health Serv Res. 2012;12(1):319.
Bhatia K. Performance based incentives of the ASHA scheme: stakeholders’ perspectives. Econ Polit Wkly. 2014;49(22):145.
Bhatia K. Community health worker programs in India: a rights-based review. Perspect Public Health. 2014;134(5):276–82.
Nambiar D, Sheikh K, Verma N. Scale-up of community action for health: lessons from a realistic evaluation of the Mitanin program in Chhattisgarh, India. BMC Proc 2012;6; 5(Suppl 5):026.
Dasgupta J, Velankar J, Borah P, Nath GH. The safety of women health workers at the frontlines. Indian J Med Ethics. 2017;2(3):209–13.
Gangotri, Pritisha, Bhargava R, Rehana Adib, Velankar J, Dasgupta J. Report of independent fact-finding into the incident of gang-rape and death of an ASHA worker Somwati Tyagi in Muzaffarnagar District, Uttar Pradesh, India. National Alliance for Maternal Health and Human Rights & Healthwatch Forum Uttar Pradesh. 2016.
Ministry of Finance. Payment of monthly honorarium @ Rs.500, to ASHA in addition to performance incentives available under various programmes, no. 17(10)/PF-II/2004(Vol. IV); 13/04/2009. New Delhi: Ministry of Finance, Government of India; 2009.
MoHFW India. Letter from the principal secretary (health and family welfare) to the states and UTs. Revision of financial norms for implementing UIP-MSG, T.13011/01/2012-CC&V, 25/05/2012. New Delhi: Ministry of Health and Family Welfare, Government of India; 2012.
NRHM. Old age income security proposed for ASHA under National Pension System, Swavalamban scheme, D.O. no. 7(205)/2012-NRHM.I, 04/09/2012. New Delhi: Ministry of Health and Family Welfare, Government of India; 2012.
NRHM. Implementation of recommendations of parliamentary committee on working conditions of ASHA, DO no. H-11014(2)/2010-NRHM-I, 15/02/2011. New Delhi: Ministry of Health and Family Welfare, Government of India; 2011.
NRHM. Letter from additional Secretary & Mission Director (NRHM) to states, incentive to ASHAs for Routine & Recurring Activities - MSG approval, D. O. no. P17018/14/13-NRHM-IV, 03/01/2014. New Delhi: Ministry of Health and Family Welfare, Government of India; 2014.
NHM. Guidelines for accreditation of training sites and trainers for ASHA training under the National Health Mission, 18/05/2015. New Delhi: Ministry of Health and Family Welfare, Government of India; 2015.
NRHM. Career progression for the ASHA, D.O. no. Z28014/1/13-NRHM-IV, 18/09/2013. New Delhi: Ministry of Health and Family Welfare, Government of India; 2013.
Scott K, George AS, Harvey SA, Mondal S, Patel G, Sheikh K. Negotiating power relations, gender equality, and collective agency: are village health committees transformative social spaces in northern India? Int J Equity Health. 2017;16:84.
NHM. Safety measures for ASHAs, D. O. no. 7(12)/2016-NRHM-I, 09/01/2016. New Delhi: Ministry of Health and Family Welfare, Government of India; 2016.
NHM. Mobilizing for action on violence against women. New Delhi: Ministry of Health and Family Welfare, Government of India; 2016.
Schneider H, Lehmann U. From community health workers to community health systems: time to widen the horizon? Heal Syst Reform. 2016;2(2):112–8.
Scott K, Beckham S, Gross M, Pariyo G, Rao K, Cometto G, et al. What do we know about community-based health programs? A systematic review of existing reviews on community health workers and their integration with health systems. Hum Resour Health. 2018:1–17.
Feldhaus I, Silverman M, Lefevre AE, Mpembeni R, Mosha I, Chitama D, et al. Equally able, but unequally accepted: gender differentials and experiences of community health volunteers promoting maternal, newborn, and child health in Morogoro Region, Tanzania. Int J Equity Health. 2015:1–11.
Viswanathan K, Hansen P, Rahman M, Steinhardt L, Edward A, Arwal S. Can community health workers increase coverage of reproductive health services? J Epidemiol Community Health. 2012;66:894–900.
Kohli C, Kishore J, Sharma S, Nayak H. Knowledge and practice of accredited social health activists for maternal healthcare delivery in Delhi. J Fam Med Prim Care. 2015;4(3):359–63.
Mishra A. ‘Trust and teamwork matter’: community health workers’ experiences in integrated service delivery in India. Glob Public Heal An Int J Res Policy Pract. 2014;9(8):960–74.
Nordfeldt C, Roalkvam S. Choosing vaccination: negotiating child protection and good citizenship in modern India. Forum Dev Stud. 2010;37(3):327–47.
Parveen K. Performance evaluation of community health workers during CCSP training programme. Indian J Public Heal Res Dev. 2016;7(1):91–4.
Mumtaz Z, Salway S, Waseem M, Umer N. Gender-based barriers to primary health care provision in Pakistan: the experience of female providers. Health Policy Plan. 2003;18(3):261–9.
Portella A, Gouveia T. Social health policies: a question of gender? The case of community health agents from Camaragibe municipality. Recife: SOS CORPO; 1997.
Maes K, Closser S, Vorel E, Tesfaye Y. Using community health workers: discipline and hierarchy in Ethiopia’s women’s development Army. Ann Anthropol Pract. 2015;39(1):42–57.
Daniels K, Van Zyl H, Clarke M, Dick J, Johansson E. Ear to the ground: listening to farm dwellers talk about the experience of becoming lay health workers. Health Policy (New York). 2005;73:92–103.
Glenton C, Scheel IB, Pradhan S, Lewin S, Hodgins S. The female community health volunteer programme in Nepal: decision makers’ perceptions of volunteerism, payment and other incentives. Soc Sci Med. 2010;70(12):1920–7.
Health Survey and Development Committee. Report of the national health survey and development committee (Bhore Committee Report). New Delhi; 1946. Available from: https://www.nhp.gov.in/sites/default/files/pdf/Bhore_Committee_Report_VOL-1.pdf. Accessed 3 July 2017.
MoHFW India. Srivastava committee report: health services and medical education: a program for immediate action. Bombay: Indian Council of Social Science Research; 1975.
Leslie C. What caused India’s massive community health workers scheme: a sociology of knowledge. Soc Sci Med. 1985;21(8):923–30.
MoHFW India, MoHFW. National rural health mission: framework for implementation (2005–2012) [Internet]. New Delhi; 2005. Available from: http://www.nipccd-earchive.wcd.nic.in/sites/default/files/PDF/NRHM%20-%20Framework%20for%20Implementation%20-%20%202005-MOHFW.pdf. Accessed 22 Mar 2017.
National Health Mission. Minutes of 5th Meeting of the Mission Steering Group, National Health Mission, February, 2018. New Delhi; 2018. Available from: http://nhm.gov.in/New_Updates_2018/Monitoring/MSG/5th-MSG-of-NHM-Minutes.pdf. Accessed 5 Mar 2018.
National Health Mission. Minutes of 4th Meeting of the Mission Steering Group, National Health Mission, January, 2017. New Delhi; 2017. Available from: http://nhm.gov.in/images/pdf/monitoring/mission-steering-group/Minutes_of_4th_MSG_of_NHM.pdf. Accessed 22 Mar 2017.
MoHFW India. Guidelines for community processes. New Delhi: Ministry of Health and Family Welfare, Government of India; 2013.