Marginalized communities in rural and urban India still face shortage of access to essential healthcare. However, silent guardians are watching over them: Community Health Workers (CHWs). CHWs are the backbone of India’s grassroots healthcare movement. But are we doing enough to empower them as healthcare leaders?
While synonymous with Accredited Social Health Activists (ASHAs) in India, Community Health Workers (CHWs) encompass a broader range of frontline healthcare providers. This article includes Auxiliary Nurse Midwives (ANMs) and Anganwadi Workers (AWWs) who bridge the gap between formal health systems and communities. As of 2018 there were approximately 0.2 million ANMs, 1.3 million AWWs, and 0.97 million ASHA. The number of CHWs has likely increased significantly since then due to ongoing government efforts to expand healthcare access.
Stationed at community hubs like Anganwadi centers and sub-centers, CHWs engage with the community and deliver a comprehensive range of health, growth monitoring, and preventive and basic curative services to the most marginalized populations. The ASHA program’s inception coincides with a significant decline in both maternal and infant mortality rates in India, nearly halving from baseline levels.
Despite their successes, community health workers (CHWs) in India, who are predominantly women, face systemic barriers and occupational challenges that hinder their effectiveness. While this gender dynamic is prevalent in India, it is important to note that CHW roles can vary across different countries and regions, with some countries like Rwanda having a more balanced gender representation.
Creating a more enabling environment for them to function is critical. CHWs play a critical role in enabling the most vulnerable to navigate the complex health system, seek care, and advocate for their communities’ needs. This, in turn, could equalize health outcomes and accelerate progress towards health goals.
Gender Realities and Role Expectations
- Limited Mobility: Societal expectations and safety concerns can restrict a CHW’s movement, hindering service delivery.
- Work-Life Balance: The demanding nature of the job, combined with domestic responsibilities, creates significant work-life conflict and overwhelm.
- Gender Bias: Undervaluing of CHWs’ contributions within the system due to gender bias limits their authority and career advancement opportunities.
Occupational challenges and setbacks
- Limited Training: CHWs lack adequate training on behavior change strategies for vulnerable communities, hindering their ability to promote positive health practices.
- Insufficient Resources: A lack of essential equipment (e.g., weighing scales) and supplies (e.g., educational materials, medications) limits their capacity to address emerging health issues.
- Emotional Burden: Dealing with sensitive topics and limited resources creates a significant emotional toll on CHWs.
- Precarious Employment: The part-time, volunteer status assigned to most CHWs, despite their demanding workload, fails to reflect their true contributions.
- Financial Strain: Inadequate remuneration (honoraria instead of salaries), poor social security, and irregular payments lead to significant financial hardship for CHWs.
Despite facing challenges, CHWs persevere thanks to their dedication and the sense of social recognition they receive within their communities. This respect fuels their motivation, but motivation alone can’t sustain them without adequate systemic support structures. We need to re-evaluate how we, as a nation, support and recognize CHWs. By ensuring they are valued as essential contributors, we can shape a healthier future together.
Supporting CHW Beyond Financial Incentives
According to the World Health Organization (WHO), adequate pay and social security are crucial pieces of the puzzle along with effective supportive supervision. While state and national governments are gradually prioritizing these actions and considering financial sustainability in India, a fundamental shift in support structures is crucial to enable CHWs to truly thrive.
A critical review of supportive supervision for CHWs in India is urgently needed. The responsibility often falls on overburdened health staff, leading to cursory compliance checks that do little to foster CHW learning and development. Existing supervisory plans, even those involving peers or village committees, prioritize checklists providing targeted coaching and support to address specific CHW deficiencies. This approach creates a culture of fault-finding, hindering growth.
The goal of supervision is to improve the performance of health workers through ongoing support and development, but instead mostly it has been practiced as that of inspection or control2.
To fully leverage the skills and knowledge of CHWs, we need to establish and shift towards comprehensive support structures. Researching successful, locally adapted innovations implemented at the state level in India can provide transformative insights. This knowledge could be used to empower communities and ensure their CHWs are effective.
A promising opportunity exists by leveraging India’s Localization of Sustainable Development Goals (LSDGs) initiative to strengthen support system for CHWs. While the LSDG program underscores the pivotal role of Gram Panchayats (local governing bodies) in providing supportive supervision to CHWs, emphasizing capacity building, community involvement, and a structured approach to monitoring and evaluation as essential components for success, its implementation is yet in early stages. This is where the potential lies, the leveraging LSDGs approach specifically for CHWs, we can establish a robust layer of community-level oversight by Panchayats at various levels (village, block, district, and state).
The unique positioning of Panchayats in the LSDGs program provides a framework for supervising CHWs, which, if strengthened, could significantly enhance their impact. By leveraging resources across various programs, Panchayats can prioritize both village needs, and the challenges faced by health workers. This collaborative approach, fostering strong relationships between CHWs and supervisors (Panchayats), and communities can create supportive environment for CHW success. Engaging communities in holding CHWs accountable, while simultaneously providing resources and constructive feedback has the potential to significantly improve CHW performance and ultimately lead to better health outcomes.
Conclusion
Empowering CHWs is critical for strengthening healthcare access in India and offers valuable lessons for other Low- and middle-income countries (LMICs). This article highlights the challenges faced by CHWs, including gender bias, limited resources, and inadequate training. However, by acknowledging these realities and implementing solutions like community-engaged supportive supervision, we can unlock the full potential of this dedicated workforce.
This model, drawing on the strengths of Panchayats for capacity building, resource mobilization, and local problem-solving, fosters collaboration and trust within communities. Furthermore, research on similar community engaged supervision models in other Low-Income and Middle-Income Countries (LMICs) contexts can provide additional insights for wider implementation. In Uganda, for example, communities play a crucial role in defining and managing quality standards for CHWs. They provide feedback, track CHW activity, and play a significant role in implementing incentives and sanctions. Similarly, in Indonesia, while sub-district centers (puskesmas) offer technical guidance and support, the primary accountability of CHWs lies with the village committee that appointed and supports them.
Investing in CHW empowerment through supportive supervision, improved training, and financial incentives is not just morally imperative; it’s a strategic investment in a healthier future for all. Policymakers, healthcare professionals, and communities must come together to ensure CHWs are empowered leaders, not just participants, who can effectively navigate the complex healthcare system, advocate for their communities, and ultimately contribute to achieving equitable health outcomes.
Authors
Jasmine Maringmei
Jasmine Maringmei is a tribal youth belonging to the Rongmei Naga community from Manipur, Northeast India. She is a Policy Analyst, currently working as a Health Systems and Policy Research Specialist at IAVI, specializing in qualitative research focused on child and maternal health.
Beyond her professional work, Jasmine is actively involved in youth networks focused on education, peacebuilding, and protection. She is also the 2024 Atlantic Fellows for Health Equity offered by the George Washington University. Jasmine holds an MPhil degree in Planning and Development from Indian Institute of Technology Bombay, and a Master of Sociology from Delhi School of Economics.
Dr. Drishti Sharma
Dr. Drishti Sharma is a seasoned public health professional with over 10 years of experience in health systems research and policy. Her expertise lies in improving healthcare access and outcomes, particularly for marginalized communities.
At IAVI, a leading global health organization, Dr. Sharma has led impactful projects focused on child and maternal health, and vaccine access. She has also made significant contributions to the field of cyberbullying and digital safety. Dr. Sharma has a strong track record of conducting rigorous research, publishing in peer-reviewed journals, and collaborating with government agencies and NGOs. Her commitment to advancing public health in India is evident in her work on data-driven evidence-based policy support and her dedication to mentoring the next generation of health professionals.
Declaration of interests
We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.