A Health system comprises all organizations, institutions and resources that produce actions whose primary purpose is to improve health (WHO report, 2000). This includes efforts to influence determinants of health as well as more direct health-improvement activities. The health system delivers preventive, promotive, curative and rehabilitative interventions through a combination of public health actions and the pyramid of health care facilities that deliver personal health care — by both State and non-State actors.  

Role of Community Health Workers in a Health System. 

A well-trained workforce is the backbone of a flourishing health system, but there has been a severe shortage of well-equipped personnel especially in rural and underdeveloped regions. This acute shortage of workforce is due to a number of factors: growing population, increase in brain drain, poor infrastructure, spread of infections, increase in mortality, and morbidity cases amongst many others. Therefore, to fill the gap in this direction in 1977 the Central Government introduced the ‘Community Health Workers’ scheme. These CHWs provide certain basic health care services and are a valuable contribution to the health system. They improve access and coverage of basic health services to the unattended (marginalised communities) population. CHW is an umbrella term and they are known by different names globally. In India we have different types:  Anganwadi workers, Accredited Social Health Activists (ASHAs), Auxiliary nurse – midwives (ANMs) and Mithanin to name a few.  

The WHO Study Group defines CHWs as follows: “Community health workers should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers”.  

Lehmann and Sanders make a differentiation between generalist and specialist CHWs. A review of CHW programmes shows that specialist CHWs have been used in aspects of mother and child health, TB and HIV/AIDS care, malaria control and treatment of acute respiratory infections. The generalist CHW performs a wide range of activities which includes preventive, promotive and curative services across issues of drinking water, nutrition, sanitation and community development in addition to maternal and child health, disease control, and surveillance. 

India has three cadres of CHWs. The first type is the Auxiliary Nurse- Midwife (ANM), a village-level female health worker who is situated at the sub-centre. They are multipurpose workers, their work includes maternal and child care, family planning services, nutrition education, immunization, treatment of minor injuries, first aid in emergencies.  

The second type is the Anganwadi workers, a functionary of Integrated Child Development Scheme (ICDS) and in charge of managing Anganwadi (a mother and child healthcare centre). They provide a comprehensive package of healthcare for children from 0-6years old. Their duties consist of disseminating information on health, nutrition, maintaining records and assisting at primary health care centres. The final cadre are the ASHAs who are the all-female cadre of CHWs constituted by National Rural Health Mission (NRHM). They are the first point of contact for health-related issues in the rural spaces for the deprived sections of the society (especially women and children). ASHAs are trained female community health activists that are selected by the community and are accountable to the community itself.  

ASHAs create awareness on health (universal immunization, sanitation) and its social determinants. They counsel women on birth preparedness, importance of institutional delivery, complementary and breastfeeding, common infections, contraception. ASHAs mobilise and facilitate the community in accessing services such as Antenatal Check-up (ANC), Postnatal Care. They accompany pregnant women and children to the nearest PHC, informs about the births and deaths in the village to the sub centres/ Primary health Centres, the states have innovated the roles of ASHAs for example in Punjab, ASHAs are employed for cancer detection and in Kerala, for counselling and fighting for gender-based violence. In 2018 Kerala government had hired almost 70 ad hoc workers to fight Nipah Virus. ASHA workers conducted door to door awareness campaigns and effective risk communication to allay public fears. Moreover, CHWs such as traditional birth attendants, traditional healers, community health healers, played an important role despite the lack of formal training during the Ebola outbreak.  

Resilience in Health Systems 

The vulnerability of the health systems has never been of so much importance as it is today. After the onset of the COVID-19 pandemic we have witnessed many deaths, a massive crash of economies/social relations and most importantly disruption in access to basic health care services. In other words, we observed a lack of resilience. Therefore, Margaret E Kruk’s proposed framework of what a resilient health system is holds significance. Health systems’ resilience can be defined as “The capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganise if conditions require it”.  

There are certain preconditions for resilience in Health Systems. The first is to recognise that there are severe health crises that are global in nature hence require coherence in the roles of the stakeholders at all levels of the global health system. Health resilience system has to be understood as a global public good and needs response from the global community. The second is a legal and policy foundation to guide the response and establish accountability in the health system. Third is to build a strong and committed workforce, alongside a strong social capital before the onset of a health crisis. For example, Kerala has a strong health system at the primary level of health care which gives them a powerful resilience advantage at the onset of the crisis.  

Resilient systems may comprise five components: First, resilient systems are aware of potential health threats and risks to the population from biological and non-biological sources. The system should be up to date in all the possible domains such as Information technology, Health care (speciality care, pharmaceuticals, epidemics) and geography (flood/arid regions). A strong strategic health information system is one that can report and respond to health threats in real time.  

Second, they should be diverse. The system should be capable of handling diverse health challenges in normal times. Unusual symptoms should be treated and not be dismissed especially at the first point of contact (primary level) because this will help treat or diagnose a new health threat. This element of diversity is more achievable by having Universal Health (UH) in place. UH addresses the healthcare needs of the unattended and poor communities by endorsing a broad range of health services. Third, it should be self-regulating, the system should have the capability to insulate and segregate health hazards without hampering the delivery in core healthcare services. For the system to be self-governed vigorously it should invest in structural variables such as infrastructure, training of healthcare workers regularly and quick variables (isolation centres, mobile vaccine booths) to strengthen response. Fourth CHWs should be integrated; the system should engage state and non-state actors to formulate solutions. For example: building a road to a far-flung area to access adequate primary healthcare will require proper communication, coordination and feedback amongst the residents of the village (Panchayat), forest department, State transport ministry, state health ministry. Strong connections with global partners (GAVI Alliance) for quick disposal of funds and resources when the need arises. Lastly, they should be adaptive. For instance,  

Health systems may need to adapt to respond to the health needs of refugees, migrants.   

Conclusion 

CHWs should be included in long term planning & should be recognised as an integral component of the resilient health system. Therefore, planning for, empowering & mobilizing the CHW’s as part of overall health care systems is important. In the next part of the article we will focus on the resilience of CHWs during COVID response and what was the recent strategy of GOI to combat the 2nd wave of COVID in rural areas.  

Sushmita Solanki is a second-year Masters Student at the Jindal School of Government and Public Policy. Her research interest areas are Urban housing, Health system financing, and Sustainable Development.