Urban community health workers in Punjab, India: A qualitative study of ASHAs’ roles in the health system

The Accredited Social Health Activist (ASHA) program is the world's largest all-female community health worker (CHW) initiative. While most CHW programs have been extensively studied in rural contexts, little is known about how ASHAs and CHWs operate in urban settings. Research on urban programs globally remains limited with a primary focus on single-disease interventions. A more holistic understanding of urban ASHAs' roles is needed to more comprehensively understand urban health delivery. This study explores the experiences, challenges, support systems, and systemic barriers faced by urban ASHAs in Punjab, India. This qualitative study was conducted in one urban and one peri-urban site. Data collection included 25 in-depth interviews, participant observation with 28 ASHAs over three months, and community-level focus group discussions. Data were analyzed using thematic coding with MAXQDA software. A half-day financial participatory session was implemented to document the financial aspects of urban ASHAs' work. This study documented that urban ASHAs play a vital role in connecting vulnerable populations to healthcare and promoting government health services. Despite this, they face challenges including overseeing populations that far exceed the limits set by guidelines, limited training opportunities, low community engagement, and insufficient financial compensation. Systemic barriers, such as unfilled supervisory positions and minimal collaboration with community engagement structures exacerbate these issues. To maximize the impact of the urban ASHA program, policy makers and implementers may consider strengthening governance, refining ASHA selection processes, enhancing community engagement, addressing staff shortages, providing targeted training, and revising financial incentives. Implementing these recommendations may strengthen urban ASHAs' ability to deliver equitable healthcare in Punjab and provide a model for improving urban health delivery across India.