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The answer to improved community healthcare? Capacity building

Community health workers act as a vital human link between public health systems and patients the world over. How could this cadre of caring hands be made even more powerful and effective?

Community health workers (CHWs) play an important role in bridging the gap between public health systems and the wider communities that they serve around the world, helping to provide critical services such as immunisation programmes and pre- and post-natal care.

One such CHW is mother of three Kola Lakshmi, who lives in Penjerla, a village near the city of Hyderabad, southern India’s tech powerhouse. Lakshmi is proud to call herself an Accredited Social Health Activist (ASHA), a role introduced by the Indian government in 2005 to serve the needs of rural communities as part of its National Rural Health Mission (NRHM).

Kola Lakshmi, an Accredited Social Health Activist (ASHA), accompanies women in labour to the district hospital and then follows up with new mothers at home

Lakshmi was hired in 2006 following a conversation between the head of her village and the district health supervisor, who identified the need for a female CHW who could work to improve maternal health and the delivery of childhood immunisations locally. 

The breadth of Lakshmi’s responsibilities not only underlines the critical public health role that ASHAs play but also the importance of ensuring that ASHAs and other CHWs are well trained to provide a range of health services that their communities need and increasingly expect. This is especially the case in rural communities where 69 per cent of India’s population resides and access to healthcare is limited.

While the World Health Organization (WHO) recommends CHWs everywhere receive ongoing training to maximise their potential impact, there is no commonly held view of how this is best delivered or how success might be measured. Surveys of approaches to training around the globe have shown that in-person mentoring tends to be favoured over mobile technologies, despite the prevalence of mobile phone usage across Africa and India, for example.

Here, Lakshmi teaches a group of children how to wash their hands to help protect them from diseases such as Covid-19

In 2018, to promote a preferred approach to CHW training, the WHO published a series of recommendations which included using e-learning, face-to-face learning and community-based training to teach: interpersonal skills; an understanding of health promotion and disease prevention; data collection; personal safety; and a balance of medical theory and hands-on practical skills. It also recommended competency-based formal health qualifications for further career progression where appropriate. 

Lakshmi herself received one month’s basic training when she first started her work as an ASHA, followed by a week’s refresher course in 2012, 2013 and 2016, as well as hands-on training with more experienced medical personnel. Adequate supervision and mentoring is another WHO recommendation for practising CHWs. 

Every day, Lakshmi notes down the details of her work in her diary. The diary is periodically reviewed by her supervisors

Today, Lakshmi is a well-respected member of her village who liaises with other health officials, teachers and community leaders.  “The community calls me ASHA amma [mother] and ASHA akka [older sister],” she says. “I visit 35 to 50 households per day on foot for antenatal visits.” 

As an ASHA, Lakshmi has also been called upon to play a part in India’s response to the Covid-19 pandemic. This public health emergency has illustrated the dynamic nature of CHWs’ work and the inherent need for continuous training and capacity building to keep local skills in line with local needs. It also reveals the ways in which CHWs have become more professional; as communities rely upon their services (as Penjerla village relies upon Lakshmi), CHWs have had to become more adept at data management as well as monitoring non-communicable conditions and preventing diseases such as malaria at community level.

The World Health Organization recommends community health workers receive ongoing training to maximise their potential impact. Lakshmi has received hands-on training from experienced medical personnel

Every week is a busy one for Lakshmi, as she explains: “On Monday, I make door-to-door visits to meet pregnant and lactating mothers; on Tuesday, I discuss couples’ family planning; Wednesday is immunisation day and Village Health Nutrition Day at the local health centre; Thursday is usually for the school health programme but due to Covid-19 we are conducting a fever survey; Friday is dry day in schools [to ensure that there is no standing water] to control vector-borne diseases [such as dengue and malaria]; Saturday is scheduled for outreach immunisation and personal hygiene awareness in targeted communities.”

The scope of her work shows both the need for specific medical training and the degree to which ASHAs have become integrated into public healthcare systems. “I learnt the basics of maternal and child health services,” says. “I also gained knowledge about general health issues, especially related to common infections, and I am able to provide general medicines for the immediate relief of minor illnesses such as fever and headaches.”

In an ideal world, Lakshmi says, she would like more training to be delivered both in person and online; a view that shows the value of integrating CHWs into designing training best suited to their own specific and individual needs. For example, Lakshmi believes her mobile phone is a useful tool enabling her to communicate more effectively via instant messaging platform WhatsApp, as well as allowing her to access more job-specific tools such as the Covid-19 vaccination registration app.

Having served her community as an ASHA for 15 years, Lakshmi is an extremely well-respected member of her village. The community calls her ASHA amma (mother) and ASHA akka (older sister).

“Technology is beneficial,” she says. “It has removed time delays in communication and made it possible to do work without any interruptions.”

Lakshmi is clearly passionate about her work and her thirst for training is rooted in her desire to do the best for her community. What motivates her to complete her rounds day in, day out are the human interactions and the sense of achievement that her work gives her. “The birth of a healthy baby makes [me] joyful,” she says. “When I look at children in good health after vaccination, I feel happy.”

As an ASHA working in a rural village, Lakshmi’s story illustrates the willingness of CHWs to go the extra mile in the service of their communities – literally in the case of home visits to deliver maternal care. The only ceiling in the value to their contribution is perhaps continued investment and training that would enable CHWs to address the healthcare needs of their communities.

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1 The World Health Organization. Community health workers: What do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. 2007