Women Becoming Health Workers in India

For the Public Good: Women, Health, and Equity in Rural India, by Patricia Antoniello (Nashville: Vanderbilt University Press, 2020)

Reviewed by Neymat Chadha, Indian Institute of Technology, New Delhi

Amidst the COVID-19 crisis and the incredible role rural women health workers played in combatting the pandemic, Patricia Antoniello’s For the Public Good arrives as a timely contribution to India’s ongoing public health discourse. In the context of rural India, public health is often seen as a state issue alone, and yet this area benefits from a critical gaze that identifies deep-rooted prejudices and injustices that impact the lives of the majority of India’s rural population and particularly women. Patricia Antoniello’s remarkable ethnographic study of the Comprehensive Rural Healthcare Project (CRHP) in the Indian state of Maharashtra brings attention to the often-unaccounted social inequalities that affect health and the adequate provision of healthcare in rural India.

Launched in 1970, the CRHP was started by doctors Mabelle and Rajanikant Arole in Jamkhed, Maharashtra, an area where much of the population lives below the poverty line (BPL). Relying on the principles of equity, integration and empowerment, CRHP has today become an internationally recognized healthcare program working towards overcoming the triple burden of caste, class, and gender inequity by transforming rural women into crucial stakeholders for steering India’s changing health discourse through increased community participation and capacity building.

Employing life-history interviews and participant observation as key ethnographic tools, the book follows Antoniello’s nine-year-long longitudinal fieldwork in Jamkhed. Adopting a gendered and rights-based approach, For the Public Good offers a nuanced account of what an inclusive and engaged health policy would demand. She draws from anthropological approaches, public health studies and Dalit literature to turn the reader’s attention to a challenging question: how is the agency of the universal category of a “woman” attained by people who, despite being caught within the grids of gender, class, and caste, resist norms of obedience and strive for broadened self-sufficiency?

Antoniello introduces the book by arguing for the need to explore more deeply the position of women in a local community, as this is entangled with larger political and economic processes and rooted in caste discrimination and gender oppression. It is within these exploitative historical patterns that For the Public Good invites the reader to locate the official category of a “village health worker” (VHW). Antoniello positions “becoming VHWs” as an experience through which local women transition from household wives into health workers and leaders, thus dismantling traditional relations of power, tackling critical global health concerns, and helping to eradicate endemic health problems faced by women and children.

Antoniello develops the book’s conceptual contribution by closely engaging with the diverse range of community and health development innovations that led to the formation of the “Jamkhed model,” which rather than using advanced biotechnology is built on the everyday labor-intensive efforts of the VHWs (Chapters 1 and 2). She further lays the ground for the reader to understand how issues of caste and gender are hidden in the daily lives of rural women and how CRHP addresses the complexity of these lived inequalities. She notes that the project has been successfully able to establish a correlation between the need for reducing social inequalities and ensuring equitable healthcare. In 2016, while the national infant mortality rate (IMR) was 41/1000 live births, it was 18/1000 in the CRHP villages (p. 38).

Rich in ethnographic details, For the Public Good dwells on the ingenuity of the Jamkhed Model. While education and health advocacy are central to the CRHP approach to help women conquer societal restrictions, its uniqueness lies in mobilizing women from different generations, religions and castes (Chapters 3 and 4). Through narrative accounts of women “becoming VHWs,” Antoniello shows that the CRHP aims to view women “not as objects but as subjects of their own invention” (p. 72). This is achieved by facilitating their involvement in the collaborative process of creating new ways of learning through songs and folklore and simultaneously employing these methods in CRHP classrooms to create a space where traditional everyday practices such as pallu (covering the head) are challenged across religions (p. 92).

Further, Antoniello provides a detailed account of how VHWs’ resilience and intellect are vital elements in the program’s success at reducing infant mortality, evident in thousands of safe at-home deliveries over the years (Chapter 5). Through stories of prenatal care, neonatal death and changing medical technologies, she elaborates how VHWs’ integrate appropriate biomedical and social approaches with everyday practices to address seemingly intractable problems of reproductive health—thus bringing in incremental improvements in the village healthcare system.

The uniqueness of CRHP lies in its inauguration of self-help groups such as Mahila Vikas Mandals (Women’s Empowerment Groups), supporting income-generating practices such as dairy communes and tailoring that secure women’s financial autonomy and, in turn, help ensure health security (Chapters 6 and 7). Antoniello develops this argument by emphasizing that women can only improve the circumstances of their families when they can exercise control over their financial resources—“when money is in their hands” (p. 153). Thus, For the Public Good tells a tale of women empowerment not as one of “autonomy” or “self-determination” but one defined by the strategies long ago adopted by CRHP, which are now inseparable from and entangled with the everyday resistance of the rural women in Jamkhed.

CRHP predates by over three decades the nationwide recruitment of Accredited Social Health Workers through the ASHA program, and it anticipates many broader changes in rural health provision. However, one missed opportunity in this book is reflected in the complete absence of ASHA workers in Antoneillo’s ethnography. As of 2019, over 60,000 ASHA workers were recruited in Maharashtra alone. Readers would have benefited from a note on the similarities and differences between the everyday functioning of ASHAs and VHWs. A detailed description of CRHP’s engagement with the State and National level programs, such as their direct partnership with the Maharashtra State Government to train ASHAs by conducting family-planning camps, could also have contributed to understanding the implications of global healthcare policy debates for local problems faced by rural women.

This book is recommended to public health practitioners, anthropologists, policymakers, and state actors interested in understanding the role of women in implementing a participatory community model that has emerged as a powerful tool to address the global health crisis and contribute towards a social change “for the public good.” While Antoniello asserts the need for an engaged and explicit healthcare policy, she also brings our attention to the quotidian lives of women, people and workers who form an undervalued backbone of the local health economy—strategically reconstituting the contours of neoliberalism and global health and yet excluded from much public policy debate and often passed over by broader considerations of public health.