Taking stock of 10 years of published research on the ASHA programme: examining India’s national community health worker programme from a health systems perspective

Abstract

Background: As India's accredited social health activist (ASHA) community health worker (CHW) programme enters its second decade, we take stock of the research undertaken and whether it examines the health systems interfaces required to sustain the programme at scale. Methods: We systematically searched three databases for articles on ASHAs published between 2005 and 2016. Articles that met the inclusion criteria underwent analysis using an inductive CHW-health systems interface framework. Results: A total of 122 academic articles were identified (56 quantitative, 29 mixed methods, 28 qualitative, and 9 commentary or synthesis); 44 articles reported on special interventions and 78 on the routine ASHA program. Findings on special interventions were overwhelmingly positive, with few negative or mixed results. In contrast, 55% of articles on the routine ASHA programme showed mixed findings and 23% negative, with few indicating overall positive findings, reflecting broader system constraints. Over half the articles had a health system perspective, including almost all those on general ASHA work, but only a third of those with a health condition focus. The most extensively researched health systems topics were ASHA performance, training and capacity-building, with very little research done on programme financing and reporting, ASHA grievance redressal or peer communication. Research tended to be descriptive, with fewer influence, explanatory or exploratory articles, and no predictive or emancipatory studies. Indian institutions and authors led and partnered on most of the research, wrote all the critical commentaries, and published more studies with negative results. Conclusion: Published work on ASHAs highlights a range of small-scale innovations, but also showcases the challenges faced by a programme at massive scale, situated in the broader health system. As the programme continues to evolve, critical comparative research that constructively feeds back into programme reforms is needed, particularly related to governance, intersectoral linkages, ASHA solidarity, and community capacity to provide support and oversight.

Using mHealth to improve health care delivery in India: A qualitative examination of the perspectives of community health workers and beneficiaries

“…Scott et al developed a framework of the CHW-health system based on a review of 122 articles specific to the Indian CHW program [23]. The framework is situated within the context of the larger health system, as most publications have been authored from a health systems perspective.…”

“…For example, within the CHW-community interface, 34 articles addressed community engagement with CHWs, and within CHW profile/agency, only 14 articles addressed CHW empowerment and personal growth. In this study, we adapted this framework as depicted in Fig 1 to incorporate the beneficiary perspectives, including beneficiary acceptance of the CHW and their use of CAS for interactions, perceptions of CHW communication, and community-embeddedness and trust [23].…”

Does engagement with frontline health workers improve maternal and child healthcare utilisation and outcomes in India?

“…Firstly, previous research from India has focused mainly on the quality of service delivery system by FHWs [39][40][41], their impact on health inequality [31,42,43], maternal and newborn health [14,30], and maternity care [13,18]. However, a review conducted by [44] suggests that these studies use data that are based on small samples, experimental or case studies, and reviews studies, which makes it difficult to generalise their findings to the national level. Providing national-level evidence on the influence of FHWs on MCH outcomes is particularly critical from a policy perspective, given the heterogeneity across various geographical regions, socio-economic, and demographic groups.…”

A Mixed-methods Evaluation of a Person-centered Family Planning Intervention for Community Health Workers in India on Family Planning Outcomes

“…As of 2015, there is approximately 1 ASHA for every 1,000 people across the nation (10). This spread puts ASHAs in a unique position to extend the availability of family planning services to hard to reach communities, rural and urban alike.…”