Tying their hands? Institutional obstacles to the success of the ASHA community health worker programme in rural north India

Abstract

This paper is a contribution to the growing literature on how best to design and support community health worker (CHW) programmes to maximise their positive impact. CHWs are laypeople trained to promote health among their peers. To do so they are commonly tasked with providing basic curative services, promoting the use of existing health services, facilitating cultural mediation between communities and healthcare providers and encouraging critical reflection and dialogue on social health issues. This paper presents a case study of a CHW project in rural Uttarakhand, north India, called the Accredited Social Health Activist (ASHA) programme. While the ASHA programme is not specifically targeting HIV/AIDS, CHW programmes have been flagged as a key means of addressing health resource shortages in poor countries, especially in relation to HIV/AIDS. This study of the ASHA programme provides insights into how best to support CHW programmes in general, including those focused on HIV/AIDS. The research involved 25 interviews and five focus groups with ASHAs, health professionals and community members as well as over 100 hours of non-participant observation at public health centres. The research investigated contextual features of the programme that are hindering the ASHAs' capacity to increase quantitative health outcomes and act as cultural mediators and agents of social change. Research found that ASHAs were institutionally limited by: (1) the outcome-based remuneration structure; (2) poor institutional support; (3) the rigid hierarchical structure of the health system; and (4) a dearth of participation at the community level. The conclusion suggests that progressive policy on CHW programmes must be backed up by concrete institutional support structures to enable CHWs to fulfil their role.

Keywords:

• ASHA programme in India
• community health workers
• primary healthcare
• reproductive health
• thematic network analysis

Acknowledgements

The authors thank Lipi Mehta, Vidushi Shanker, Dr Binoy Prasad and Mrs. Reeta Prasad for their transcription and translation assistance. They also thank their hosts in Sukhir as well as all the participants. The Commonwealth Scholarship provided a contribution towards travel for this research. Finally, the authors are grateful to Prof. Catherine Campbell, Dr Flora Cornish and Sara Street for their inputs.

Notes

1. ANMs are full-time, salaried, government health workers who focus on maternal and child health. ANMs are especially trained to provide skilled attendance at deliveries, post-partum care, contraception advice and immunisation. They are often referred to simply as nurses by local people (Community Monitoring of NRHM 2007).

2. Approximately £7.50. Current conversion rate is Rs. 72 to £1.

3. All town, city and village names have been changed for confidentiality.

4. Anganwadi centres serve as pre-school education centres and also nutrition centres where children are weighed regularly, and children, adolescent girls, and pregnant and nursing women are given supplementary food.

5. Ayurveda is traditional Indian medicine.