Challenges facing the ASHA female community health workers

Enisha Sarin

Senior Research and Evaluation Advisor, India, USAID ASSIST Project/URC

The USAID ASSIST India Project is working in 27 high priority districts along the RMNCH+A continuum.  As we moved from facility to community-based quality improvement, we wanted to understand the challenges faced by ASHAs (Accredited Social Health Activist), a cadre of community health workers with whom we would closely engage in improvement work and resources they have in their health promotion work. We decided to undertake a qualitative investigation, interviewing 49 ASHAs and their family members (34 spouses, 13 mothers-in-law, one sister-in-law and one son) in two districts from June to July 2014.

The results revealed findings that will have an influence on our community-based improvement work. We found that the ASHAs became more self-confident after they started engaging in ASHA work. Positive changes at the household level and recognition in the community helped shape ASHAs’ agency, which, in turn, allowed them to address challenges in their work environment in promoting health behaviors in the community.

One ASHA told us, “After I became an ASHA people from the village come to me; they call me and they respect me. Everyone asks me how to do this, how to do that, what not to do so everything has changed after I became an ASHA.”

However, since the ASHAs worked within bounded socio-cultural, gender and religious contexts, they were constantly challenged by norms existing within these contexts.

Within the family, because of the ASHA’s extra income and social prestige brought with her job, we found that family support increased related to the distribution of domestic chores among family members including husbands. There was also an increase in direct support in an ASHA’s work such as her husband accompanying her to distant villages for conducting surveys or handing out condoms to male community members.

Yet ASHAs were found to be also limited in their movements. An ASHA needed a male member to accompany her for night deliveries and had to negotiate for going out and performing her duty at night.

One ASHA reported, “In the beginning when I was going alone at night I felt that he (husband) was not feeling good about it. Then I thought rather than messing up my family life, I told him to come with me when I had to go out at night. Then he understood. Now, he gives full co-operation to me.”

Since ASHAs’ work is incentivized, it played a role in the husbands’ help and support. Yet the same was also a source of conflict. As one ASHA reported, “The problem is that when I go for deliveries at night my husband taunts me saying ‘You have no substantial salary and still you step out at night to get deliveries done, don’t you have any respect’.”

The ASHA navigated this challenge by assuring her husband that she would get a regular salary in the future. But this creates false expectations and in the event that salaries are not regularized, which is likely, the ASHAs may face more difficulties in negotiating their work and personal lives.

In the community, challenges were found to include low decision-making power and mobility of women in the community that precludes them from accessing health care. Furthermore, while the ASHA recognized the importance of male involvement, they were unable to directly engage with male partners and family members.

As one ASHA reported, “Women come to get information regarding family planning. Males do not come. Even I feel a hesitation in explaining to them (males). Males sometimes get information from my husband.”

The study also found that prevalent norms of son preference made the ASHAs’ work challenging as families of pregnant women whose first child was female refused to disclose pregnancy due to taboos around expecting a second child to be male, and this hindered early registration and early identification of high-risk cases. The ASHAs’ internalization of social values such as son preference, also could very well hinder her ability to be a good role model and to promote early registration of pregnancy.

One ASHA told us her own story about this important gender issue. “I want one more son…when there was a second daughter, I started weeping. But he (husband) told me not to weep as he said he will love his daughter.”

ASHAs also faced challenges at the health system level. The disrespect shown by hospital staff and lack of access to essential medicines and pregnancy testing kits led to the loss of credibility among ASHAs, which affected their work performance.

ASHAs are an important part of the health system in India and, in turn, they influence their family and society’s view of them which gives ASHAs the necessary motivation and support to do their work. However, an ASHA’s environment forces her to confront very real gender-related barriers, which she must attempt to work around.  An ASHA must develop strategies for male engagement and utilize the help of her family and superiors to deliver services, all while being unable to address gender norms in a direct way, and with a limited ability to circumvent health system barriers.

This highlights the importance of the community work of the USAID ASSIST Project in India as it works toward strengthening ASHAs’ role as health promoters, and thus, moves a little closer to achieving the goals of safe motherhood and safe childhood in the community.

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