India’s National Health Policy 2017 advocated for comprehensive primary healthcare (CPHC). Subsequently, Ayushman Bharat Program 2018 led to the upgradation of existing Sub-Health Centres and Primary-Health Centres into Health & Wellness centres (HWCs) to operationalize CPHC. However, to improve the performance of these HWCs, close supportive supervision is required.
Supportive supervision in its traditional form emphasizes more on authoritarian overseeing of healthcare workers and health systems performance at large. However, its contemporary mechanism facilitates Socratic communication and fosters a collaborative approach between the health systems supervisors and supervisees. Good supportive supervision hinges upon monitoring, evaluation, governance of health systems performance and continuous collaborative intervention for the same. However, given the complexities in micro-meso-macro systems with logistical add-ons, especially in lower-middle-income countries, the efforts of supportive supervision have been lauded as fragmented and some of the new approaches have been put forward including the “supervisee-initiated supportive supervision” in which supportive supervision needs to be sought by supervisees.
Over the last one year I’ve been working in a rural district of Chhattisgarh, India as CPHC district consultant to scale up the performance of HWCs. One of my key responsibilities is to monitor the appointed healthcare workers at HWCs and overall centres for continuous intervention. When I started working, I realized that staff absenteeism, partial maintenance of drugs & diagnostics, patient’s rights breaches, poor record maintenance, skewness of service delivery, and low community engagement for health prevention and promotion are some of the prime challenges associated with poor performance of several HWCs and none of the above mentioned contextual crises could have been addressed by the idea of “supervisee-initiated supportive supervision” as they were supervisee initiated obstacles in healthcare delivery. Given the context, constant monitoring of the centres were required and for that I needed grounded informants.
In the year 2022, ASHA workers were recognized for their contribution to linking the community with primary health care including preventive and promotive aspects of it, and were awarded the Global Health Leaders award. Collectively they’re not merely frontline health workers but they also defend the social and economic rights of the community. Having understood their structured ground presence and their collective identity, working closely in collaboration seemed a perfect recourse to me for constant monitoring of the HWCs. I started getting in touch with their district coordinators, block coordinators and, trainers, to the ASHAs. ASHAs who link people with primary healthcare, also keep a very close eye on the healthcare centres. They are proximal in observing whether these centres are functional and delivering the services intended or not. They also arrange multiple meetings, and gathering sessions, known as “baithaks” with the community for health education, promotion, and listening to people’s grievances in relation to their challenges associated in seeking healthcare services.
I therefore utilised ASHA workers as informants to help monitor the HWCs, so that the functioning status of these HWCs across the district can be understood and required interventions (vis-à-vis supportive supervision) can be done. I began to be a part of their ground-level gathering sessions and official meetings, and requested them to keep sharing the status of their respective HWCs with me and soon my contact number started seeping into their cohorts. While some reached out telephonically others kept conveying information in the meetings, related to various issues such as when a HWC isn’t delivering the services intended or that the concerned healthcare workers were careless towards their duties. I then started conducting a physical assessment of the centres, documenting the findings and working closely with healthcare workers and concerned officials for required interventions to improve the situation. Afterward, I kept following up the ASHA workers and concerned healthcare workers to track the progress made. Overall, it became easy for me to constantly monitor and provide more robust supportive supervision to the concerned centres at once and that led to improve primary healthcare performance. Intrinsically, keeping their identities confidential have been crucial to me to avoid any dent on their work relation. However, as they are not the formal employees and their work is voluntary in nature, the degree of autonomy enjoyed by them is likely to supersede any possible repercussions. From the health system’s point of view, governance and leadership is one of the vital health systems’ building blocks. It’s been made pretty clear to me that this always requires a tailored approach to address the health system’s contextual ambiguities. In this case, the role of the ASHA workers became instrumental and provided a new insight and appreciation into the value of their work in improving our health systems.
About the author: Mohammed Ahmed holds a Master’s in Public Health from the University of Hyderabad and presently working as a District Consultant in a rural district of Chhattisgarh to operationalize and strengthen comprehensive primary health care.
Conflicts of Interest: None
Handling Editor: Neha Faruqui