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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.
Hum Resour Health. 2019 01 08; 17(1):3.HR

Abstract

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.

Authors+Show Affiliations

National Health Systems Resource Centre, National Institute of Health & Family Welfare Campus, Baba Gangnath Marg, Munrika, New Delhi, Delhi, 110067, India.Independent researcher, Bangalore, India. kscott26@jhu.edu. Johns Hopkins School of Public Health, 615 N Wolfe Street, Baltimore, 21205, Maryland, USA. kscott26@jhu.edu.National Health Systems Resource Centre, National Institute of Health & Family Welfare Campus, Baba Gangnath Marg, Munrika, New Delhi, Delhi, 110067, India.National Health Systems Resource Centre, National Institute of Health & Family Welfare Campus, Baba Gangnath Marg, Munrika, New Delhi, Delhi, 110067, India.National Health Systems Resource Centre, National Institute of Health & Family Welfare Campus, Baba Gangnath Marg, Munrika, New Delhi, Delhi, 110067, India.National Health Systems Resource Centre, National Institute of Health & Family Welfare Campus, Baba Gangnath Marg, Munrika, New Delhi, Delhi, 110067, India.School of Public Health, University of the Western Cape, Robert Sobukwe Rd, Bellville, Cape Town, 7535, South Africa.

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, Non-P.H.S.

Language

eng

PubMed ID

30616656

Citation

Ved, R, et al. "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." Human Resources for Health, vol. 17, no. 1, 2019, p. 3.
Ved R, Scott K, Gupta G, et al. 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. Hum Resour Health. 2019;17(1):3.
Ved, R., Scott, K., Gupta, G., Ummer, O., Singh, S., Srivastava, A., & George, A. S. (2019). 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. Human Resources for Health, 17(1), 3. https://doi.org/10.1186/s12960-018-0338-0
Ved R, et al. 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. Hum Resour Health. 2019 01 8;17(1):3. PubMed PMID: 30616656.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - 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. AU - Ved,R, AU - Scott,K, AU - Gupta,G, AU - Ummer,O, AU - Singh,S, AU - Srivastava,A, AU - George,A S, Y1 - 2019/01/08/ PY - 2018/07/13/received PY - 2018/12/05/accepted PY - 2019/1/9/entrez PY - 2019/1/9/pubmed PY - 2019/8/6/medline KW - Community health workers KW - Gender KW - Human resources for health KW - India KW - Policy analysis SP - 3 EP - 3 JF - Human resources for health JO - Hum Resour Health VL - 17 IS - 1 N2 - 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. SN - 1478-4491 UR - https://www.unboundmedicine.com/medline/citation/30616656/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_ L2 - https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-018-0338-0 DB - PRIME DP - Unbound Medicine ER -