Abstract
BackgroundIndia’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.MethodsWe 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.ResultsGiven 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.ConclusionsGender 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.
Highlights
Introduction of Home Based New BornCare (HBNC) Scheme through accredited social health activist (ASHA)30 Dr Ajay Khera, Deputy Commissioner, Child Health and ImmunizationGuidelines for implementation of IMNCI strategy and Module 6 & 7 training for ASHA NHSRCProgram Evaluation of the Janani Suraksha Yojana Ministry of Health and Family Welfare (MoHFW)Fifth Common Review Mission MoHFWHome Based New BornCare (HBNC) Operational Guidelines MoHFWOperational Guidelines on Facility Based Management of Children with Severe Acute Malnutrition
Gender trade offs and complexities are inherent to sustaining community health worker (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
We trace the evolution of the ASHA programme from its instrumentalist origins that focused on ASHAs as a tool to enable the health system meet its goals, to increasing attention to the empowering potential of the programme despite the challenges faced by the ASHAs
Summary
Introduction of Home Based New BornCare (HBNC) Scheme through ASHA30 Dr Ajay Khera, Deputy Commissioner, Child Health and ImmunizationGuidelines for implementation of IMNCI strategy and Module 6 & 7 training for ASHA NHSRCProgram Evaluation of the Janani Suraksha Yojana MoHFWFifth Common Review Mission MoHFWHBNC Operational Guidelines MoHFWOperational Guidelines on Facility Based Management of Children with Severe Acute Malnutrition. India’s accredited social health activist (ASHA) programme consists of almost one million female community health workers (CHWs). Every decision in designing, implementing and adapting CHW programmes has gendered implications: from deciding whose health to prioritize, which community members are selected with implications for livelihoods, safety, and job security, to (re)constructing gendered norms of caregiving and decision-making in families, communities, and healthcare systems. No comprehensive gender disaggregated data exists for CHW programmes, several countries have CHW programmes that are all-female by design. This is the case of the Lady Health Workers in Pakistan, the Women’s Development Army in Ethiopia, and India’s nearly one million-worker strong accredited social health activist (ASHA) programme (Table 1) [3]
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