"I pray to God that greed never sets in": Community health workers' reflections on "care" during the Covid-19 pandemic.

BACKGROUND: Care provision received renewed attention during the Covid-19 pandemic as several healthcare providers vied for the coveted title of "frontline warrior" while they struggled to provide care efficiently under varying health system constraints. While several studies on the health workforce during the pandemic highlighted their difficulties, there is little reflection on what "care" or "caring" itself meant specifically for community health workers (CHWs) as they navigated different community and health systems settings. The aim of the study was to examine CHWs' care-giving experiences during the pandemic. METHODS: Twenty narrative interviews with CHWs including ASHAs (Accredited Social Health Activists) and ANMs (Auxiliary Nurse Midwives) were conducted in different states between July and December 2020. RESULTS: Our findings highlight the moral, affectual, and relational dimensions of care in the CHWs' engagement with their routine and Covid-19 related services, as well as the "technical" aspects of it. In this article, we argue that these two aspects are, in fact, enmeshed in complex ways. CHWs extend this moral understanding not just to their work, but also to their relationship with the health system and the government, as they express a deep sense of neglect and the lack of "being cared for" by the health system. CONCLUSION: CHWs' experiences demand a more nuanced understanding of the ethics of care or caring that challenges the binaries between the "technical" and moral aspects of care.

Extending Kingdon's Multiple Streams Policy Framework Through an Analysis of How Community Health Workers in India Are Driving Policy Changes.

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'.