Community Health Workers as Street-Level Bureaucrats in the US and India

• In Event: New Theoretical Lessons for Health Politics from the Global South

Abstract

Studies of health policy implementation commonly call attention to the role of frontline health workers who put policy into practice and deliver services, often forming the first point of contact between people and the health system. To conceptualize frontline health workers’ practices and challenges in low- and middle-income countries, researchers have begun to apply street-level bureaucracy theory, long used in studies of the welfare state in advanced industrialized countries. In this paper I explore how this theory travels across country contexts (low- vs high-resource health systems, state-provided vs market-delivered health care).

To do so, I analyze the implementation of community health worker (CHWs) models in the United States, where CHWs have gained policy attention in recent decades, including under the 2010 Affordable Care Act, and in India, where they re-emerged in importance following the 2005 National Rural Health Mission. The broad definition of a CHW—a frontline lay or paraprofessional public health worker who belongs to or has a close understanding of the community served—is similar across health systems. However, the roles CHWs play and may be expected to play (by medical professionals, insurers, and community health advocates, among other health system actors) vary across and within health systems. I review government reports, policy analyses, academic research, and narrative case studies on CHW implementation in the two countries. I integrate institutional analysis with an ethnographic sensibility to the texts, attending to CHWs’ experiences as well as the meanings embedded in health system actors’ perceptions and in institutional views about CHWs.

I propose that by juxtaposing CHW implementation in different health systems, we more sharply render the distinct service-delivery dilemmas that CHWs confront and the historical-institutional elements that condition the dilemmas in each case. The analysis prompts conceptual and interpretive adjustments in each case, suggesting the need for context-specific extensions to theories of street-level policy implementation.

Author

• Radhika Gore, NYU School of Medicine