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Santosh S, Kane S. Extending Kingdon's Multiple Streams Policy Framework Through an Analysis of How Community Health Workers in India Are Driving Policy Changes. COMMUNITY HEALTH EQUITY RESEARCH & POLICY 2023:2752535X231222654. [PMID: 38105229 DOI: 10.1177/2752535x231222654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
In this paper we develop and provide a novel account of the process through which the Accredited Social Health Activists (ASHAs), a cadre of seemingly powerless community health workers in India, are navigating a complex policy process to incrementally achieve their goals. ASHAs have been demanding better working conditions, better compensation, and regularisation as public service employees through protests and strikes and have managed to gain concessions from both the Central and various State governments. We observed two important aspects that emerged: (a) ASHAs achieved incremental increases in their wages despite being the lowest in the health system hierarchy, and, (b) major gains were made during the 2 years of the pandemic. We examine and analyse ASHAs' engagement and strategies used, both overt and covert, sometimes with the government, and the role of other actors in determining these policy outcomes. We do so by drawing on academic literature and news media reports; we trace the changes in ASHAs' wages by tying together key events, 'windows of opportunity', and actions of 'policy entrepreneurs' involved in the process.In doing so, we further develop and propose an extension to Kingdon's multiple streams policy framework through the addition of a 'narrative stream'.
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Affiliation(s)
- Sanjana Santosh
- Centre for Health Policy and Systems, Gokhale Institute of Politics and Economics, Pune, India
| | - Sumit Kane
- Centre for Health Policy and Systems, Gokhale Institute of Politics and Economics, Pune, India
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
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Closser S, Sultan M, Tikkanen R, Singh S, Majidulla A, Maes K, Gerber S, Rosenthal A, Palazuelos D, Tesfaye Y, Finley E, Abesha R, Keeling A, Justice J. Breaking the silence on gendered harassment and assault of community health workers: an analysis of ethnographic studies. BMJ Glob Health 2023; 8:bmjgh-2023-011749. [PMID: 37208121 DOI: 10.1136/bmjgh-2023-011749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 04/21/2023] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Across a variety of settings, women in tenuous financial circumstances are drawn to community health work as a way to advance themselves in the context of limited employment options. Female Community Health Workers (CHWs) are often preferred because they can more easily access mothers and children; at the same time, gender norms are at the heart of many of the challenges and inequities that these workers encounter. Here, we explore how these gender roles and a lack of formal worker protections leave CHWs vulnerable to violence and sexual harassment, common occurrences that are frequently downplayed or silenced. METHODS We are a group of researchers who work on CHW programmes in a variety of contexts globally. The examples here are drawn from our ethnographic research (participant observation and in-depth interviews). RESULTS CHW work creates job opportunities for women in contexts where such opportunities are extremely rare. These jobs can be a lifeline for women with few other options. Yet the threat of violence can be very real: women may face violence from the community, and some experience harassment from supervisors within health programmes. CONCLUSION Taking gendered harassment and violence seriously in CHW programmes is critical for research and practice. Fulfilling CHWs' vision of health programmes that value them, support them and give them opportunities may be a way for CHW programmes to lead the way in gender-transformative labour practices.
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Affiliation(s)
- Svea Closser
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Marium Sultan
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Roosa Tikkanen
- Sociology and Political Science, Norwegian University of Science and Technology, Trondheim, Trøndelag, Norway
| | - Shalini Singh
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Arman Majidulla
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kenneth Maes
- Anthropology, Oregon State University, Corvallis, Oregon, USA
| | - Sue Gerber
- Independent Consultant, Truchas, New Mexico, USA
| | - Anat Rosenthal
- Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Southern, Israel
| | - Daniel Palazuelos
- Blavatnik Institute of Global Health and Social Medicine, Harvard University, Cambridge, Massachusetts, USA
| | | | - Erin Finley
- Psychiatry and Behavioral Sciences, UT Health San Antonio, San Antonio, Texas, USA
| | - Roza Abesha
- Independent Consultant, Gondar, Amhara, Ethiopia
| | | | - Judith Justice
- Institute for Health and Aging, University of California at San Francisco, Berkeley, California, USA
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Reproductive Burden and Its Impact on Female Labor Market Outcomes in India: Evidence from Longitudinal Analyses. POPULATION RESEARCH AND POLICY REVIEW 2022. [DOI: 10.1007/s11113-022-09730-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
AbstractWe use nationally representative data from two waves of the Indian Human Development Survey to examine the role of inter-temporal changes in fertility behavior in influencing female labor market outcomes. Our multivariate regression estimates show that an increase in the number of children reduces labor force participation and earnings. We further investigated the impact of fertility changes on transitions from the labor market. The results show that women who had more than three children in both rounds of the survey had a 3.5% points higher probability of exiting from the labor market than their counterparts with two or fewer children net of other socio-demographic factors. Disaggregated analyses by caste, economic, educational status, and region show that the probability of dropping out of the labor market due to fertility changes varies by region and is greater for non-poor and primary to secondary schooling women and those from socially disadvantaged castes than poor, non-educated, and socially advantageous women.
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