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- Convenors:
-
Ian Harper
(University of Edinburgh)
Sumeet Jain (University of Edinburgh)
- Formats:
- Panels
- Stream:
- Medical
- Location:
- Magdalen Oscar Wilde Room
- Start time:
- 20 September, 2018 at
Time zone: Europe/London
- Session slots:
- 2
Short Abstract:
This panel explores the roles of Community Health Workers (CHWs) in the context of social development. As the link between communities and programmes, theoretical and ethnographic papers will showcase how they translate and adapt in differing socio-political, religious and gendered spaces.
Long Abstract:
Health care workers act at the interface of the biological, social and material. In Lower-middle income countries health care interventions in the context of social development are increasingly fragmented and run as short-term projects. Reasons include the outsourcing of implementation to the private sector in the name of efficiency; that private sector companies need to demonstrate "corporate social responsibility"; and the need to generate metrics for proving impact. Within this context there is growing reliance on lower level, often unpaid and frequently female Community Health Workers (CHWs) to actually implement. Deemed as the link between communities and programmes, they translate programmes into culturally accepted forms, and report back in acceptable ways to institutional funders. The context within which these workers are expected to work vary across and within countries, with differing religious, socio-political and gendered relations. In this panel we seek theoretical, ethnographic and empirical papers that address this phenomena. Questions that may be addressed could include: How are understandings of 'care' appropriated and manipulated by development programmes? How is religion mobilised, understood and appropriated in these contexts? How do CHWs manage their multiple and often competing roles? What impact - social, political, and health related - does this have on the community workers themselves? What is the potential for empowerment and exploitation? How do these workers relate, translate and appropriate the programmes to the diverse contexts within which they live? And what disciplinary entanglements do anthropologists have to navigate to both research these issues, and, if necessary, intervene?
Accepted papers:
Session 1Paper short abstract:
This paper explicates the precarious situations of vaccination teams in Pakistan, who are performing their roles, despite the dangers of being killed.
Paper long abstract:
Vaccination in Pakistan is not free from rumors, resistance, resentment and dangers. It has been linked with (bio and geo) politics, hence, people refuse and resent. This, ultimately, has led towards the attacks on the vaccination teams. Owing to that the country's government employed security with the such teams, which nonetheless has not brought any significant difference. Attacks as yet continue; the vaccination teams and their escorting security are killed, as more than hundred have been killed, so far. Despite the precarious situations, they are performing their roles and responsibilities, in the form of mobile and fixed teams. They do cover far-flung areas without taking care of 'harsh' environments. Also, they are 'under' paid employees and sometimes hired on the daily basis. The paper, therefore, elaborates the situation of these teams and what dangers loom around. What and how do they feel? This paper draws on my PhD fieldwork conduced mainly in 2014 in the Sindh province of Pakistan.
Paper short abstract:
Based on an ethnographic fieldwork, this paper examines care work and monetary transactions among Accredited Social Health Workers (ASHAs) in urban India. It shows how ASHAs' monetary incentives and informal payments by their neighbours are intrinsic to their neighbourly relations of care.
Paper long abstract:
This paper examines care work and monetary transactions among Accredited Social Health Workers (ASHAs) in India, working under National Health Mission. It is based on a long-term ethnographic fieldwork in a Delhi's urban poor neighbourhood, an area where ASHA workers and a governmental dispensary provides a large portion of health services. The NHM mobilizes ASHAs to educate, rise awareness and facilitate access to public health among their own neighbours. Their main tasks include maternal and child health issues, such as pre- and post-natal care, institutional deliveries, and vaccination. Instead of receiving stable salaries, ASHAs are remunerated with monthly monetary incentives for each specific completed task. This has resulted in ASHAs being underpaid and caused their nation-wide protests. Starting with an exploration of ASHA role as that of a neighbour, and not only a governmental worker, the paper shows how ASHAs' monetary incentives and informal payments by their neighbours are not antithetic, but intrinsic to their neighbourly relations of care. Engaging with feminist literature on payments and care work, the paper contributes to the understanding of how community health work can be underlined by affective ties of care without being underpaid.
Paper short abstract:
This paper explores how frontline psychosocial workers in rural Nepal strategically broker between global and local illness categories to facilitate access to care. Findings highlight a need for greater attention to the role and contributions of frontline workers within global mental health.
Paper long abstract:
Critics have warned that mental health and psychosocial (MHPSS) intervention in low-income post-disaster contexts can undermine local therapeutic knowledge and care systems. Following the 2015 earthquakes in Nepal, MHPSS interventions relying mainly on 'task shifting' to non-specialist health and psychosocial workers proliferated across rural affected areas of the Himalayan foothills. My doctoral research treats this post-disaster MHPSS response as a window onto the processes through which globalized therapeutic discourses and practices are assimilated within diverse local ecologies of care. Over fourteen months of ethnographic fieldwork, I traced the multiple translations and transformations MHPSS care underwent on the journey from international guidelines to implementation in rural earthquake-affected villages. This paper examines the strategies through which frontline psychosocial workers communicated the scope and object of MHPSS care to potential clients and lay people in rural communities. By gathering familiar afflictions and idioms of distress-ranging from headaches to spirit possession-under the loose and flexible heading of 'heart-mind problems', these clinicians were able to establish new explanatory frameworks and pathways to care without undermining or supplanting local ontologies of suffering. In effect, frontline psychosocial workers engaged in a creative act of brokerage that rendered global and local illness categories commensurable in the interest of broadening the repertoire of therapeutic resources to which individuals had recourse. These findings challenge common critiques of MHPSS intervention and highlight a need for greater attention to the role and contributions of frontline clinicians within the field of global mental health.
Paper short abstract:
Community health workers (CHWs) played a central role in implementing a visual mental health recovery tool in northern India. This paper analyses the role of CHWs in enabling social recovery.
Paper long abstract:
Approaches to mental health recovery should reflect local context and priorities. This study aimed to strengthen knowledge and skills in mental health recovery among people with psycho-social disability (PPSD), caregivers, community leaders, mental health practitioners in Uttarakhand state, India through co-production of a visual tool for recovery. The piloting of the tool led to a statistically significant reduction in self-reported mental health and qualitative results suggested the tool led to better engagement with clients. Community health workers (CHWs) played a central role in implementing the tool. This paper analyses the role of CHWs in enabling social recovery.
Set in Burans, a community mental health project in Uttarakhand, the research employed a participatory action research framework to develop the tool, in partnership with experts by experience (EBE). The role of CHWs is analysed through thematic analysis of client case notes, participant observation of tool implementation, and in-depth interviews with CHWs to better understand their role in enabling recovery amongst a group of 30 clients who were involved in piloting the tool.
Preliminary analysis of data suggests several findings and areas for exploration. The nature of the relationship between the community health worker and the person with psycho-social disability appears crucial to enabling recovery. Analysis of data will focus on dissecting the processes of developing these relationships and the role of an engaging visual tool impact on 'recovery' outcomes. It will also address how the nature of the CHW relationship and the tool impacts on 'recovery' amongst clients with varied 'recovery' outcomes.
Paper short abstract:
This paper engages with the ways in which "patienthood" is physically and discursively enacted by community health workers in Roma communities in Romania.
Paper long abstract:
Across a number of health domains, but especially when so-called "hard-to-reach" groups are concerned, the participation of communities in health care provision has become an article of faith. Taking the example of Roma health mediators (Roma women employed to act as links between their communities and the health system), I discuss how in practice community involvement may facilitate state governing of these "hard-to-reach" communities.
Following a year of participant observation of Roma health mediation, I analyse the tensions and ambivalences that arise from interactions between mediators, community members, health professionals, and local authorities.
I show how participants map concepts of "good" and "bad" patients onto Roma ethnicity. I discuss how mediators use their own Roma identity and community involvement to transform "bad patients" into "good patients." I show how community members respond by participating, resisting, negotiating, or perpetuating their positions within these classifications. While acknowledging the important contribution that this community health programme brings to accessing health care, I discuss mediators' competing role in promoting a neoliberal approach to governing Roma communities that serves state rather than community interests. By conflating Roma ethnicity with a failure to conform to "correct" forms of patienthood, mediators risk fuelling existing prejudice and racism towards Roma communities. I suggest that Roma health mediation could learn from dialogical and emancipatory approaches to participatory interventions in health, which aim for transformative encounters between parties while also fostering critical consciousness and aiming to change communities' material environment.
Paper short abstract:
This paper shows as to how ASHA workers among Kondh community in Odisha 'blur' the oft-presumed boundaries of the State-sponsored modern healthcare system and indigenous health practices.
Paper long abstract:
India's National Rural Health Mission (NRHM) mandates to improve the access and affordability of quality health care and reduce maternal mortality rate (MMR) and infant mortality rate (IMR). Accredited Social Health Activists or ASHA workers, under this scheme, are female members of the community that act as the link between the larger developmental machinery of the State (viz., PRIs, AWWs and ANMs). Studies on ASHA workers have mostly stressed on issues like location of primary health care centres and funding bottlenecks (Husain 2011 and Bajpai 2010). But following Sharma and Gupta (2006), I argue, in this paper that the ASHA worker does not merely act as an appendage, that merely facilitates institutional deliveries, child care and family planningthrough the provisioning of cash incentives. Instead, as seen among the tribal women of the Kondh community in Odisha, they 'blur' the oft-presumed boundaries of the State-sponsored modern healthcare system and indigenous health practices. In other words, the ASHA worker in such areas has helped to prioritize three key themes within the prevailing discourse on contemporary health practices: (a) a subtle appreciation of alternative therapies like AYUSH (b) invoking an epidemiological logic in investment pattern and finally (c) laying a stress on the appropriateness of technology and diffused decentralization of healthcare. Further, there are many untapped potentialities of the ASHA worker vis-à-vis its ability to emerge as a legitimate voice of the community, which the paper promises to reflect on as well.
Paper short abstract:
This paper explores the tension between the contradictory demands of 'participation' and 'bureaucratization' in Pakistan's HIV sector. The ethnography shows that regardless of their relevance to local populations, projects that cannot produce measurable impact lose support from donors.
Paper long abstract:
Colleagues in Pakistan's HIV prevention sector who appear to rationalize their work privately, in terms of its intrinsic worth, or their emotional investment in it, subscribe in their professional lives to the instrumental rationality of the development sector in order to attain calculable ends using means—a rationality that travels (Mosse 2011) the globe, reducing people and their lives and deaths into measurable quantities. Local models of relatedness and personhood, informal networks in communities, and the particular social and emotional skills of development workers are co-opted under the rubric of 'participation' while rolling-out projects, yet the relations of affect, trust and confidence built by these workers during the work of HIV prevention are not translated into templates for reporting-up because they are not measurable in term of head (or body) counts or demonstrable for their impact in the form of diagrams/graphs. This paper explores the tension between the contradictory demands of 'participation' and 'bureaucratization' in Pakistan's HIV sector. The ethnography shows that regardless of their relevance to local populations, projects that cannot produce measurable impact lose support from donors. The staff and community-based organizations who are less equipped in the technical demands of the sector are either forced to extend their roles into report-writing, template-filling and indicator-measuring or are driven out of the sector altogether regardless of their interpersonal qualities. This can be regarded as a violence of aid bureaucratization and raises questions about the value of the 'intermediaries of development' and their unquantifiable work in international aid and development.
Paper short abstract:
This paper looks at the way Community Health Workers operationalize the 'indigent' label in Eastern DR Congo (which officially entitles to rights), and how this affects their actions and positioning in their own communities.
Paper long abstract:
One of the poorest countries on earth, DR Congo nevertheless has a social protection system that officially entitles the most vulnerable fringes of the population, the so-called 'indigents', to free health-care and social services. The determination of who is an 'indigent' and who isn't is usually left to the communities and, in particular, their official Community Health Workers (CHWs -the 'relais communautaires' set up as part of the health system, who also double as Health Facility Committee members). In a context where public funding is very limited, when not simply inexistent, and where health facilities are often hard to reach and disconnected from health district officials, those CHWs are also the ones who determine and implement the indigent policy and coordinate efforts towards the indigents. Reflecting on an NGO intervention designed to increase CHWs' ability to dismantle the social and financial barriers the indigents face in accessing health-care, this paper explores CHWs' understanding of vulnerability/indigence, the concrete indigent-related activities they organise, and their positioning within their communities. The research is located in rural zones of South Kivu, an unstable and violent province of Eastern DR Congo. It shows how indigent-related CHW work provides them with a vehicle for acquiring power and recognition within their community; it also questions the effects of the deliberate and de facto co-optation of "indigents" as CHWs.