Journal Article

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

Gupta, G., Ummer, O., Srivastava, A., Ved, R., Singh, S., Scott, K., George, A. S.

2019

Overview

Background 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. Methods 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. Results 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. Conclusions 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.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Accreditation / Activists / Analysis / Beneficiaries / Child health / Childrens health / Community / Community health aides / Community Health Services / Community Health Workers / Decision making / Delivery of Health Care / Education / Employment / Family Characteristics / Female / Gender / Gender equality / Gender equity / Gender Identity / Government Programs / Health Administration / Health care / Health care reform / Health education / Health Policy / Health services / Health Services Research / Health surveys / Human Resource Development / Human Resource Management / Human resources / Human resources for health / Humans / India / Medical personnel / Medical personnel training / Medicine / Medicine & Public Health / Musicians / Policy analysis / Power, Psychological / Practice / Practice and Hospital Management / Primary care / Scholarships (Financial aid) / Sexism / Social Policy / Social security / Socioeconomic Factors / Surveys and Questionnaires / Violence / Volunteers / Wellness programs / Women / Women's health / Women's Rights / Workers / Working women