COMMUNITY HEALTH WORKER TRAINING LINKING PEDAGOGY AND PRACTICE REPORT
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- COMMUNITY HEALTH WORKER TRAINING LINKING PEDAGOGY AND PRACTICE REPORT
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Community Health Worker Training- Linking
Pedagogy and Practice Report
A National Workshop Report
10Lh to 12th April 200G
Tata Management Training Center, Pune
organised by
The Foundation for Research in Community Health (FRCH)
in partnership with
1'he Early Child Health Team of the Social Initiatives Group (SiG),
ICICI Bank
About this document
A National Workshop titled, "Community Health Worker Training: Linking
Pedagogy and Practice" was organised by the Foundation for Research in
Community Health (FRCH) in partnership with the Early Child Health Team of the
Social Initiatives Group (SIG), ICICI Bank on April 10 - 12, 2006.
The broad objectives of the Workshop were:
1. To share and consolidate innovations and learnings in community health
worker training across programmes over the last three decades.
2. To discuss and develop initiatives for mainstreaming these innovations and
learnings towards extending coverage and enhancing quality of community
health worker training.
3. To initiate dialogue and create networks between various health worker
training programmes, and between civil society groups and the National
Rural Health Mission.
The following is a detailed compilation of all the documents relevant to the
workshop. These contain:
•
A background paper titled. Training Community Health Worker - Where do
we stand?
•
The workshop Programme Schedule
•
A comprehensive report on the capturing the minutes of the workshop
•
A set of Reflections and Recommendations circulated to the Ministry of
Health and Family Welfare
•
An analytical article covering the thematic debates rose during the workshop.
I he article is titled, Community Health Worker: the scope and hopes from
ASHA
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Handout prints of Power Point presentations made by all the participants
®
Participant contact details
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TRAINING COMMUNITY HEALTH WORKERS - WHERE DO WE STAND?
Back ground paper prepared for the Community Health Worker training workshop - April 10-12 2006.
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INTRODUCTION
As noted in the report titled "Training Community Health Workers"1, "Training is
only one element in the implementation of primary health care, and much of its
content and methods must reflect the programme as a whole. Some training
designers become overly engrossed in tangible implementation details rather than
in broad policy and resource questions - yet the latter are often more critical."
Further the report notes, "Planners must resolve training issues for themselves.
They must understand how training fits into their program and decide how much
effort to invest, given competing priorities. It is easy to be didactic about training
ideals, but a more difficult task is to adapt ideals to field situations and to balance
training with management and technical support, provision of supplies, and all the
other elements which make primary health care effective."1
While Community Health Worker training has been going on at different scales
and in different programmes over the last few decades, and has more recently
started at the national level as part of the National Rural Health Mission, there is
a need to look at certain issues that go beyond the traditionally discussed issues
of content, methodology and human resources and indeed influence and shape
these critical aspects of the training process. This paper attempts to raise some of
these questions in the light of some accepted principles and guidelines and some
potential new approaches and relationships.
LINKING TRAINING TO OVERALL PROGRAMMES
Post the 1960s "technology transfer" phase of development thinking, and learning
from its failures, building up community participation and capacity have been
central strategies for most programmes attempting to facilitate development. This
move has been reflected in the health field as well with numerous community
based projects mushrooming all over the world including India during the 1960s
and 70s. The main aim of these programmes has been strengthening the people's
capacity in planning and implementing development programmes.
As part of this overall strategy of increasing community involvement most
programmes have adopted strategies that included the training of an individual
from the community to act as a 'link worker' or 'extension worker'. This was done
with the expectation that such workers would help in translating 'expert'
knowledge and interventions into culturally and socially acceptable forms to
increase community acceptance and thus increase community ownership of
programmes. While the many programmes saw participation as merely one way
of increasing the efficiency of systems, more radical interpretations saw
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community involvement as a process that was <essentially empowering and that
ultimately led to a redistribution of power and control
... _l over resources.
In the health field numerous approaches to community health worker based
programmes have been tried. While many projects have adopted an extension
approach where health workers are trained in preventive and curative medicine to
fill-the-gap' as it were, other programmes saw health workers as activists who
by challenging medical hierarchies and demystifying medicine and its
interventions would facilitate mobilization and organization of communities to
demand health as a human right.
The World Health Organization has defined Community Health workers as workers
who live in the community they serve, are selected by that community are
accountable to the community they work within, receive a short, defined training
1989)re nOt necessarily attached to any formal institution (WHO Study Groups
Training of community health workers, regardless of the ultimate perspective of
the programme is obviously a crucial aspect of any community based health
programme and necessarily reflects the overall philosophy of the programme
managers / initiators and also to a large extent defines the overall and ultimate
outcomes and impacts of the project.
Given the complexity of such social processes and the status-quo challenoinq
nature o, most such programmes, most demonstration and learnings '
innovations from such projects are necessarily context specific. Thus whi'e such
programmes have been extremely creative, the generalizability and scalability of
many of these have always been questioned.
Whi'e the challenges of programmes attempting to create change agents have
included the transference and sustenance of vision, social analysis, organizing
capacity, leadership skills and negotiating skills to the health workers, the
challenges of programmes that have conceptualised their workers largely as
service providers are demystification of medicine, teaching diagnostic and
t .erapeutic skills, standardizing approaches and maintenance of records and
quality control. Obviously the two approaches need not be exclusive However the
methodology for each of the knowledge, skill and attitude components are very
different and require very different competencies on the part of the trainers and
are very sensitive to the context within which they are taught. They obviously
also require very different monitoring, support and evaluative skills.
SOME ISSUES
Three conceptual issues are raised here:
1. One of the crucial issues and one that need to be raised constantly is
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regarding the approach to training taken by the programme managers /
initiators. Is training seen as a charity doled out, or is it seen as an enabling
process that helps redistribute power and control over resources and infuse
confidence into communities? Even if it seen as an empowering process we
need to look carefully at the definition of empowerment we are using. Are
we defining empowerment as enabling people to negotiate the dominant
system better (a so called status-quo non-challenging empowerment) or to
challenge and transform the system?
2. George Foster notes, "The striking thing about these questions is that
almost all assume that effective health care can be achieved only when
members of traditional communities change their health behavior (so that
they accept whatever is offered to them by health bureaucracies). Rarely, if
ever, the question is asked: "How can anthropologists help to change
bureaucratic behaviour that inhibits the design and operation of the best
(people centered) health care system" 2 (brackets added).
This is an important question for the approaches to all aspects of training
including content, methodology and human power and logistics. The
ultimate choice of each of these depends on whether we are trying to
manipulate people and communities to change behaviors to suit the
developed technologies or are we inviting communities to organize and
demand technologies that are in line with their values and priorities?
3. There seems to be an underlying assumption that we are 'teaching' the
people something new - something without which they can't 'develop'.
Something that is crucial for their overall development. It is almost as
though we are doing them a favor. However clearly 'training' is not a
'favour' to anybody by any stretch of the imagination (as is sometimes
argued by those arguing for voluntary workers) - given the fact that it is
the people who are subsidizing both training and research of / by
professionals - it is their right that this knowledge / benefits of the
knowledge reach them.
These questions are not merely theoretical exercises but will be the foundation
upon which the whole approach to training is based.
PRINCIPLES AND LEARNINGS
While there have been many programmes training community health workers the
following are some of the common lessons learnt / principles that are followed.
It has been well recognized that while training community health workers one has
to follow the principles of adult learning. As per a recently published module by
CEDPA3 they are as follows:
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Adult learning occurs best when it:
• Is self-directed
Adults can share responsibility for their own learning because they know their own needs
• Fills an immediate need
Motivation to learn is highest when it meets the immediate needs of the learner
• Is participative
Participation in the learning process is active, not passive.
• Is experiential
The most effective learning is from shared experience; learners learn from each other, and the trainer often
learns from the learners.
• Is reflective
Maximum learning from a particular experience occurs when a person takes the time to reflect back upon it
draw conclusions, and derive principles for application to similar experiences in the future
• Provides feedback
Effective learning requires feedback that is corrective but supportive
• Shows respect for the learner
Mutual respect and trust between trainer and learner help the learning process.
• Provides a safe atmosphere
A cheerful, relaxed person learns more easily than one who is fearful, embarrassed or angry
• Occurs in a comfortable environment
’
pffcrt500 Wh° IS hun9ry' tired’ cold'
or otherwise physically uncomfortable cannot learn with maximum
I vvllVul itdoo.
Apart from the above, experiences in various other training programmes have
come up with many accepted principles of teaching adults and especially teaching
them to take on the roles of a change agent as well as a service provider. An
example of such a set of principles is that developed by the SEARCH4 programme,
1.
2.
3.
4.
5.
Training is not only for “knowing more”, but is also for “behaving differently". Our focus is not upon
information, but is upon attitude and skills.
Training must be meaningful to trainees, it must start from where the trainees are, and must respond to
their evolving needs, both as individuals and as a group.
Effective learning comes from personal experience.
To be effective as an agent of change, the individual should have experienced change himself
i he processes, the issues, the forces and the learning in the group under training are similar to those in
other groups, in a community and in society at large.
herTJndnow^ ~ methodology is exPerience based, open ended, individual and group centered and largely
Similarly in a review5 of the various projects that have been reported in the
Anubhav series the following has been noted as far as training is concerned.
•
Aim not only to impart skills, but also to change attitudes, and do so through novel ways of
communication, such as street theatre and use of symbols, so as to include even illiterate women in
community participation.
Acceptance of the need for local health workers brought with it need for 'innovative training methods.’
o
o
o
o
o
For a primarily illiterate group of trainees simplified systems of training, testing and monitoring
had to be devised like in CHDP-Pachod.
Intensive and repeated training
Quality of training is a major factor for success.
Short, simple and imaginative training courses at various levels and varying intervals
Pre-job, on-the-job training and refresher courses.
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Some of the projects took over the existing government staff in an area retrained them.
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The worker is as good as his or her training
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to
eS ”! “ Snd 'n-Serei“
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"GOALS - considering the goal of health for ALL the policy for education for health must
Samani of buid,„g a Josf
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and equiiabte socjely,i,UenlhUman
•
Aim at building up and sustaining a health system that,
•
is people oriented, helping the people to cope with their problems in health•
is available and accessible preferentially to the poorest sector
’
t0 enabl,e.and emPower them t0 participate in their own health care by sharing in decision
making, control, financing and evaluation with regard to their choice of health system’
benpXS|OnanCe W'th thS CU'tUre and tradltional Practices, when these are constructive and
’"0 “ »"
uciiciiciai,
•
uses the resources better, with appropriate technology which serves the people.
h^h^rnfe STRAy.EGIEL.S ", Elation for health should be community -oriented and people-based so that the
ealth professional / worker is able to equip and enable the people to cope with their health problems.
gompetence based leaming^The health personnel at different levels should be trained with appropriate '-kills
attitudes and knowledge to function effectively in the area of work, encouraging competence based learning.
Opportunities should be provided for learning outside the training institution or organisation in the health cam
PfoXp sys
at various levels- One way of achieving these objectives will be through the greater use of
electives in the community with government and voluntary health and development projects.
Sh
3nd Ncln--a^-ernmental Programmes. It is the primary responsibility of the government to orovide
health care services, while the NGO sector also has its increasing role. To achieve theoptimum mix 2th
respect to numbers, types and qualities of health workers and effective training programmes all efforts should
ofTalrJ others effortr0110'
g0Vernmental and non-governmental sectors, learning from and supportive
Sr °f Hea'th' Care 3nd Med'C'ne' A" training Programmes must take into consideration peoples' health
What ever be the focus of the system of health care and medicine, in a training programme there is need for
mspeft for ^sJXml
°f
SyS'emS
traditi°nS in ‘he C0Untry and en“^age a healthy
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themselves.
£S°ITTha!rS; ThereJS tnueed f°r imProvin9 training of trainers for community based people-oriented
"'°delslhe
Fo'a" for"“l
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function as torch bearers of innovation should be accountable to the people in this role.
P
SXIX'n““n^S“’',S in”IVBd " Pr°™6n9 ,e,'’'an, ™0’a,i”s
The very process of training and gaining knowledge and perspectives that are
usually beyond the reach of the average rural woman is itself a very transforming
process. It greatly increases the recognition of inequities, social analysis and
aspiradon and confidence. In fact one of the common refrains that is heard from
programmes all over the country is that, "if nothing else, at least we have 'x'
number of confident and transformed women".
Thus the content and methodology of training as well as the very fact of going
outside the home to learn new knowledge and skills are great transforming
events. However in terms of overall goals of training, the ultimate impact is
aimed at the community that the health worker serves and not onlv the individual
and the family.
This translation of individual transformation into community level empowerment
is dependent not only on a set of unique skills that the health worker may have,
out aiso on certain systemic and community wide processes. Merely giving inputs
to a particular individual, without any systemic'and community level facilitation
will be totally non-productive and community mobilization, organization and
empowerment will be left to random events to trigger off. Moreover this sort of
individual training can lead to the creation of new centers of power rather than
facilitating the redistribution of power as originally intended. This risk is well
reflected by Paulo Friere when he says7, "As soon as they complete the course
and return to the community with resources they did not formerly possess, they
either use these resources to control the submerged and dominated
consciousness of their comrades, or they become strangers in their own
communities and their former leadership position is thus threatened. In order not
to lose their leadership status, they wiii probably tend to continue manipulating
the community, but in more efficient ways."
TRAINING AND THE LARGER CONTEXT
Apart from these there are several issues regarding the changing context within
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which training programmes are now being implemented that have a bearing on
the overall approach chosen and the effectiveness of the training imparted. A few
are highlighted here:
1. The changing context of the community health field. These include changes
in the local level and national level like increasing urbanization, increased
industrialization, a marketization of the economy, fracturing of the
community along
newer faultlines, fluctuating political will, and
internationally by the move towards increasing globalization, increasing
powers of the multinational corporations and homogenization of economies
and cultures.
2. The pressure towards sustainability and scalability as crucial components of
any programme.
3. Renewed interest shown by governments to start statewide / nationwide
community health worker programmes.
As noted above the context within which training occurs has changed quite
radically since the early programmes of the 70's. It is very important to re-look
at our approaches and experiences in the light of these changes.
CHW TRAINING: DEVELOPING INNOVATIVE WAYS TO WORK ON AND AT SCALE
Training is well recognized as a crucial input into any programme, while the
principles of training and approach to training are broadly accepted, the actual
translation of these inputs into content, and linked to this, methodologies has till
now been, and is of necessity extremely context and programme specific. With
the initiating of the NRHM and large-scale national and state-wide programmes,
there is an urgent need to reflect on past experiences and critically develop ways
to improve the design and implementation of such programmes. In this context,
some of the important questions that need to be asked include:
• Is there a possibility of coming up with guidelines and processes for
development of content, methodology and the planning of human power?
o What can we adapt based on learnings from past experiences and in
what ways can we develop new methodologies for training CHWs in
large-scale programmes?
o How can a large-scale programme ensure the creation of high quality
and sensitively contextualized training content?
o In large-scale programmes, who are the trainers and how should they
be selected, trained, mentored and supported in their critical roles as
facilitators and participants in processes of health empowerment?
• Is there potential to come up with methods to make the program learn as it is
implemented and to incorporate these learnings as we move along?
• Is there a
method
by which the different stakeholders can create new
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paradigms of engagement and partnership and together focus clearly on
facilitating a people's movement?
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THIS WORKSHOP
This workshop is an attempt to initiate a dialogue between the various
stakeholders who are deeply engaged in developing and implementing CHW
programmes across India. It aims to bring together representatives from NGOs,
national and state governments, funding agencies, and researchers to share
various experiences as well as re-examine them from both the specific
perspectives of scaled programmes, as well as in the changing context of the 21st
century. In doing so, the workshop attempts to go beyond the dichotomy of
innovation and upscaling, towards evolving instead a process of "innovating at
scale, in which the creativity and sensitivity of a rich history of community-based
health experiences is combined with the historic imperative and opportunity to
ensure access to health across the vast geographies and social contexts of India,
We also hope that this dialogue, in the context of the evolving National Rural
Health Mission will provide a space to begin to forge new paradigms of
engagement between the various stakeholders in the field of health.
REFERENCES
1. Training Community Health Workers. Information for action issue paper.
UNICEF. 1983
2. George Foster. 1982. Applied anthropology and international health:
Retrospect and prospect. Human Organization. Vol. 41, 3, 189-97. As
quoted in Banerji D. 1986. Social sciences and health service development
in India. Lok Paksh. New Delhi.
3. Training Trainers for Development. The CEDPA Training manuals series.
Volume 1. CEDPA. Washington USA.
4. Staley John 1982. People in development. A trainers manual for groups.
SEARCH Bangalore.
5. Pachauri Saroj, Reaching India's Poor: Non-Governmental Approaches to
Community Health, Sage Publications, 1994
6. Community Health Cell, Community Health Trainers Dialogue - Towards an
Education Policy for Health Sciences, Bangalore, October 1991,
mimeographed report.
7. Friere Paulo. Pedagogy of the Oppressed. Harmondsworth: Penguin, 1972
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Community Health Worker Training: Linking Pedagogy and Practice
A National Workshop
April 10-12, 2006
Tata Management Training Centre, Pune
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Day I (April 10, 2006)
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Community Health Worker Training: An Introduction ’
12:00- 12:30
Arrival & registration of participants
12:30 - 13:00
Welcome Address by Dr. N.H. Antia, Director, Foundation for Research in
Community Health, Pune
Lunch
14:00- 14:30
Introductory Key Note: Historical overview of CHW programmes
internationally
Speaker: Prof. David Sanders, University of Western Cape, South Africa
14:30 - 15:00
Introductory Key Note: The Community Health Workers of India - Training
Extension Workers or Activists?
j Speaker: Dr. Ravi Narayan, Community Health Cell, Bangalore
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Tea
j 15:15 - 15:30
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i he National Rural Health Mission: an overview
Speaker. Mr. Amaijeet Sinha, Director, NRHM, MoHFW, Government of
India
I 15:30 - 15:45
Presentation by Health Workers
i 15:45 - 16:30
Film on "Life of a CHW:Reflections on training programmes and policies'
followed by discussion
Director: Dr. Parvez Imam, f20 Communications, Delhi
i 16:30 - 17:00
-------------------------------------------------------------------------------I Setting the agenda of the Workshop
i Speaker. Dr. Rakhal Gaitonde, Foundation for Research in Community,
Health, Pune
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Day 11 (April 11, 2006)
Innovations in Training Content & Methodologies in Community Health Worker
Programmes
09:00-09:30
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I Key Note: Adult learning principles - How community health workers learn
I Speaker: Dr. K. Balasubramanium, Commonwealth of Learning
Session I: Panel Discussion
09:30- 10:30
—
10:30- 11:30
.
Approaches to training: Focus on content, methodology and human
resources for training
Speakers: Dr. R. Arole, Comprehensive Rural Health Project, Jamkhed
Mr. V.R. Raman, Mitanin Programme, State Health Resource
Centre, Chhattisgarh
Dr. N. Mistry, Foundation for Research in Community Health,
Pune
Discussion
Discussants: Dr. Abhay Shukla, SATHI - CEHAT, Pune
Dr. D.C. Jain, Deputy Commissioner, Child Welfare &
Training, MoHFW, Government of India
Dr. Shyam Ashtekar, Yeshwantrao Chavan Memorial Open
University, Nasik
_____
;Tea
Session II; Presentation pf Case Studies
Teaching clinical skills to CHWs
Speaker: Dr. Shyam Ashtekar, Yeshwantrao Chavan Memorial Open
University, Nasik
I 12:00 - 12:15
Training CHWs for behaviour change communication
Speaker: Maj. S. Menon, Kripa Foundation, Mumbai
112:15 - 13:00
Discussion
Discussants: Dr. Yogesh Jain, Jan Swasthya Sahyog, Chhattisgarh
Dr. S.C. Mathur, SIHFW, Rajasthan
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; Gender & social exclusion in CHW training
Soeaker: Dr. Lindsay Barnes, Jan Chetna Manch, Jharkhand
14:15 - 14:30
i Training CHWs with low literacy levels
Speaker: Dr. Abhay Shukla/ Dr. Anant Phadke, SATHI-CEHAT, Pune
14:30 - 14:45
Training CHW's in the context of political strife
Speaker: Dr. Sunil Kaul, Action Northeast Trust, Assam
i 14:45 - 15:45
; Discussion
'Discussants: Dr. Narendra Gupta,. Prayas, Rajasthan
Ms. Arzoo Dutta, State Facilitator, NRHM, Nagaland
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Day II (April 11,2006)
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Innovations in Training Content & Methodologies in Community Health Worker
Programmes
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C. Partnerships for Community Health Worker Training
15:45 - 16:00
Partnerships for innovations in training CHWs in state programmes
Speakers: Dr. Alok Shukla, Secretary of School Education, Chhattisgarh &
former Secretary of Health, Chhattisgarh
Mr. Biraj Patnaik, Principal Advisor, Office of the
Commissioners of the Supreme Court, Delhi
16:00 - 16:30
Discussion
Discussants: Mr. Amarjeet Sinha, Director, NRHM, MoHFW, Government
of India
Dr. Peter Berman, The World Bank, New Delhi
Tea
Session III: Evaluating Training.*
16:45-17:15
Evaluation and monitoring of the training process
Speaker: Ms. S. Deodhar, Foundation for Research in Community Health
Pune
17:15 - 17:45
Discussion
Discussant: Dr. Nandita Kapadia, Institute of Health Management, Pune
17:45 - 18:15
Pedagogy and Social Context of Empowerment - a Peoples' Health
Movement Reflection
Speaker: Dr. Ravi Narayan, Community Health Cell, Bangalore
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Day III (April 12, 2006)
Training Content & Methodologies for Community Health Workers at Scale
09:00-09:30
Key Note: Approaches to achieving scale: Missions and Movements
Speaker: Dr. T. Sundararaman, State Health Resource Centre,
Chhattisgarh
Session I: Group Discussions
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09:30-09:45
Introduction to group processes by Mekhala Krishnamurthy, Social
Initiatives Group, ICICI Bank, Mumbai
09:45 - 11:15
Group Discussions on aspects of CHW training at scale
Chair: Prof. David Sanders, University of Western Cape, South Africa
I opics:
Content, methodology & human resources for CHW training at scale
Partnerships at scale - focus on training CHWs
Support^tructures for CHW programs at scale
Monitoring training processes & outcomes at scale
Tea
111:30- 13:00
Presentation by Groups
I---------------------|Lunch
Session t!: Panel Discussion'
I 14:00 - 15:00
Discussion on group presentations
Discussants; Dr. T. Sundararaman, State Health Resource Centre,
Chhattisgarh
Mr. J.P. Mishra, European Commission Technical Assistance,
Delhi
Dr. Abhay Shukla, SATHI - CEHAT, Pune
i 15:00 - 15:30
! Open Discussion
15:30 - 15:45
; Open House: Participants' suggestions for future directions
15:45 - 16:15
Discussion
; Chair: Dr. N. Mistry, Foundation for Research in Community Health, Pune
Dr. Narendra Gupta, Prayas, Chittorgarh
Tea
16:30 - 16:45
Reflections on the Workshop
i Speaker: Prof. David Sanders, University of Western Cape, South Africa
16:45 - 17:00
Concluding remarks
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TRAl NIN G COMMUNITY HEALTH WORKERS - WHERED^V^TAND ’
Workshop on Community Health Worker Training: Linking Pedagogy and
Practice
__
April 10-12 2006, Pune
INTRODUCTION
As noted in the report titled "Training Community Health Workers"1, "Training is only one
element in the implementation of primary health care, and much of its content and
methods must reflect the programme as a whole. Some training designers become overly
engrossed in tangible implementation details rather than in broad policy and resource
questions - yet the latter are often more critical."
Further the report notes, "Planners must resolve training issues for themselves. They
must understand how training fits into their programme and decide how much effort to
invest, given competing priorities. It is easy to be didactic about training ideals, but a
more difficult task is to adapt ideals to field situations and to balance training with
management and technical support, provision of supplies, and all the other elements
which make primary health care effective."1
While Community Health Worker training has been going on at different scales and in
different programmes over the last few decades, and has more recently started at the
national level as part of the National Rural Health Mission, there is a need to look at
certain issues that go beyond the traditionally discussed issues of content, methodology
and human resources and indeed influence and shape these critical aspects of the
training process. This paper attempts to raise some of these questions in the light of
some accepted principles and guidelines and some potential new approaches and
relationships.
LINKING TRAINING TO OVERALL PROGRAMMES
Post the 1960s "technology transfer" phase of development thinking, and learning from
its failures, building up community participation and capacity have been central
strategies for most programmes attempting to facilitate development. This move has
been reflected in the health field as well with numerous community based projects
mushrooming ail over the world including India during the 1960s and 70s. The main aim
of these programmes has been strengthening the people's capacity in planning and
implementing development programmes.
As part of this overall strategy of increasing community involvement most programmes
have adopted strategies that included the training of an individual from the community to
act as a link worker or extension worker'. This was done with the expectation that such
workers would help in translating 'expert' knowledge and interventions into culturally and
socially acceptable forms to increase community acceptance and thus increase
community ownership of programmes. While the many programmes saw participation as
merely one way of increasing the efficiency of systems, more radical interpretations saw
community involvement as a process that was essentially empowering and that
ultimately led to a redistribution of power and control over resources.
5
In the health field numerous approaches to community health worker based programmes
have been tried. While many projects have adopted an extension approach where health
workers are trained in preventive and curative medicine to 'fill-the-gap' as it were, other
programmes saw health workers as activists, who by challenging medical hierarchies and
demystifying medicine and its interventions would facilitate mobilization and organization
of communities to demand health as a human right.
The World Health Organization has defined Community Health workers as workers who
live in the community they serve, are selected by that community, are accountable to the
community they work within, receive a short, defined training, and are not necessarily
attached to any formal institution (WHO Study Group, 1989).
Training of community health workers, regardless of the ultimate perspective of the
programme is obviously a crucial aspect of any community based health programme and
necessarily reflects the overall philosophy of the programme managers / initiators and
also to a large extent defines the overall and ultimate outcomes and impacts of the
project.
Given the complexity of such social processes and the status-quo challenging nature of
most such programmes, most demonstration and learnings / innovations from such
projects are necessarily context specific. Thus while such programmes have been
extremely creative, the generalizability and scalability of many of these have always
been questioned.
While the challenges of programmes attempting to create change agents have included
the transference and sustenance of vision, social analysis, organizing capacity, leadership
skills and negotiating skills to the health workers, the challenges of programmes that
have conceptualised their workers largely as service providers are demystification of
medicine, teaching diagnostic and therapeutic skills, standardizing approaches and
maintenance of records, and quality control. Obviously the two approaches need not be
exclusive. However the methodology for each of the knowledge, skill and attitude
components are very different and require very different competencies on the part of the
trainers and are very sensitive to the context within which they are taught. They
obviously also require very different monitoring, support and evaluative skills.
SOME ISSUES
Three conceptual issues are raised here:
1. One of the crucial issues and one that need to be raised constantly is regarding the
approach to training taken by the programme managers / initiators. Is training
seen as a charity doled out, or is it seen as an enabling process that helps
redistribute power and control over resources and infuse confidence into
communities? Even if it seen as an empowering process we need to look carefully
at the definition of empowerment we are using. Are we defining empowerment as
enabling people to negotiate the dominant system better (a so called status-quo
non-challenging empowerment) or to challenge and transform the system?
2. George Foster notes, "The striking thing about these questions is that almost all
assume that effective health care can be achieved only when members of
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traditional communities change their health behavior (so that they accept
whatever is offered to them by health bureaucracies). Rarely, if ever, the question
is asked: "How can anthropologists help to change bureaucratic behaviour that
inhibits the design and operation of the best (people centered) health care system"
2 (brackets added).
This is an important question for the approaches to all aspects of training including
content, methodology and human power and logistics. The ultimate choice of each
of these depends on whether we are trying to manipulate people and communities
to change behaviors to suit the developed technologies or are we inviting
communities to organize and demand technologies that are in line with their values
and priorities?
3. There seems to be an underlying assumption that we are 'teaching' the people
something new - something without which they can’t 'develop'. Something that is
crucial for their overall development. It is almost as though we are doing them a
favor. However clearly 'training' is not a 'favour' to anybody by any stretch of the
imagination (as is sometimes argued by those arguing for voluntary workers) given the fact that it is the people who are subsidizing both training and research
of / by professionals - it is their right that this knowledge / benefits of the
knowledge reach them.
These questions are not merely theoretical exercises but will be the foundation upon
which the whole approach to training is based.
PRINCIPLES AND LEARNINGS
While there have been many programmes training community health workers the
following are some of the common lessons learnt / principles that are followed.
It has been well recognized that while training community health workers one has to
follow the principles of adult learning. As per a recently published module by CEDPA3
they are as follows:
Adult learning occurs best when it:
• Is self-directed
Adults can share responsibility for their own learning because they know their own
needs.
• Fills an immediate need
Motivation to learn is highest when it meets the immediate needs of the learner.
• Is participative
Participation in the learning process is active, not passive.
• Is experiential
The most effective learning is from shared experience; learners learn from each other,
and the trainer often learns from the learners.
• Is reflective
Maximum learning from a particular experience occurs when a person takes the time to
reflect back upon it, draw conclusions, and derive principles for application to similar
experiences in the future.
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• Provides feedback
Effective learning requires feedback that is corrective but supportive.
• Shoves respect for the learner
Mutual respect and trust between trainer and learner help the learning process.
• Provides a safe atmosphere
A cheerful, relaxed person learns more easily than one who is fearful, embarrassed, or
angry.
• Occurs in a comfortable environment
A person who is hungry, tired, cold, ill, or otherwise physically uncomfortable cannot
learn with maximum effectiveness.
Apart from the above, experiences in various other training programmes have come up
with many accepted principles of teaching adults and especially teaching them to take on
the roles of a change agent as well as a service provider. An example of such a set of
principles is that developed by the SEARCH4 programme,
1. Training is not only for "knowing more", but is also for "behaving differently". Our
focus is not upon information, but is upon attitude and skills.
2. Training must be meaningful to trainees, it must start from where the trainees are,
and must respond to their evolving needs, both as individuals and as a group.
3. Effective learning comes from personal experience.
4. To be effective as an agent of change, the individual should have experienced
change himself.
5. The processes, the issues, the forces and the learning in the group under training
are similar to those in other groups, in a community and in society at large.
Thus to sum up - methodology is experience based, open ended, individual and group
centered and largely here and now."
Similarly in a review5 of the various projects that have been reported in the Anubhav
series the following has been noted as far as training is concerned.
•
Aim not only to impart skills, but also to change attitudes, and do so through novel
ways of communication, such as street theatre and use of symbols, so as to
include even illiterate women in community participation.
•
Acceptance of the need for local health workers brought with it need for
'innovative training methods/
For a primarily illiterate group of trainees simplified systems of training,
testing and monitoring had to be devised like in CHDP-Pachod.
o Intensive and repeated training
o Quality of training is a major factor for success.
o Short, simple and imaginative training courses at various levels and varying
intervals.
Pre-job, on-the-job training and refresher courses.
o
Some of the projects took over the existing government staff in an area retrained
them.
o
•
The worker is as good as his or her training.
o In the 12 case studies of Anubhav series the workers have been trained in
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different aspects of maternal and child health, preventive and curative care,
and their repeated in-service training.
Training is functional not didactic and in-service training and supportive
supervision helps to further develop existing skills.
There have been two major community health worker trainers' conferences in the past in
India; the more recent one in 1990 ended with the following 'Statement of shared
concern and evolving collectivity'1 from which the following sections are quoted6:
"GOALS - considering the goal of health for ALL the policy for education for health must
. See health as a constituent part of human development and as an integral
instrument of building a just and equitable society.
• Aim at building up and sustaining a health system that,
• is people oriented, helping the people to cope with their problems in health;
• is available and accessible preferentially to the poorest sector;
. strives to enable and empower them to participate in their own health care
by sharing in decision making, control, financing and evaluation with regard
to their choice of health system;
• is in consonance with the culture and traditional practices, when these are
constructive and beneficial;
• uses the resources better, with appropriate technology which serves the
people.
"TRAINING STRATEGIES - Education for health should be community -oriented and
people-based so that the health professional / worker is able to equip and enable the
people to cope with their health problems.
Competence based learning, ihe health personnel at different levels should be trained
with appropriate skills attitudes and knowledge to function effectively in the area of work,
encouraging competence based learning.
Opportunities should be provided for learning outside the training institution or
organisation in the health care delivery system at various levels. One way of achieving
these objectives will be through the greater use of electives in the community with
government and voluntary health and development projects.
Value Orientation. The training programmes at all levels should lay emphasis on values
and ethics including conduct and relationships at the personal level and right to health
and distributive justice at the social level.
Health and Culture. All training programmes should take into consideration the way of
life of the people and their practices, learn from it and build on it. Both trainers and
trainees must approach this area with an attitude of learning.
Governmental and Non-governmental programmes. It is the primary responsibility of the
government to provide health care services, while the NGO sector also has its increasing
role. To achieve the optimum mix, with respect to numbers, types and qualities of health
workers and effective training programmes, all efforts should be made to have
mteraction between governmental and non-governmental sectors, learning from and
supportive of each others efforts.
5
Systems of Health care and Medicine.
consideration peoples' health culture.
All
training
programmes
must
take into
What ever be the focus of the system of health care and medicine, in a training
programme, there is need for generating awareness of the plurality of health systems
and traditions in the country and encourage a healthy respect for all systems.
Evaluation. All training programmes should be evaluated for their effectiveness to
achieve their goals, including their cost effectiveness. The process of evaluation should
encourage evaluation by the trainees and the people themselves.
Training of Trainers. There is a need for improving training of trainers for community
based, people-oriented health care. The trainers should be role models for the trainees.
For all formal courses, the trainers should devote their full-time for the training.
Methodologies of training. Different methodologies of learning and training, appropriate
to the situation should be used. To the extent possible, all training should be more
experiential.
Innovative programmes. To meet the requirements of health for all, innovative training
programmes should be encouraged and supported, whether in the governmental or
voluntary sectors. National institutes set up to function as torch bearers of innovation
should be accountable to the people in this role.
Networking of individuals / institutions involved in promoting relevant innovations in
training should be encouraged and strengthened.
The very process of training and gaining knowledge and perspectives that are usually
beyond the reach of the average rural woman is itself a very transforming process. It
greatly increases the recognition of inequities, social analysis and aspiration and
confidence. In fact one of the common refrains that is heard from programmes all over
the country is that, "if nothing else, at least we have 'x' number of confident and
transformed women".
Thus the content and methodology of training as well as the very fact of going outside
the home to learn new knowledge and skills are great transforming events. However in
terms of overall goals of training, the ultimate impact is aimed at the community that the
health worker serves and not only the individual and the family.
This translation of individual transformation into community level empowerment is
dependent not only on a set of unique skills that the health worker may have, but also on
certain systemic and community wide processes. Merely giving inputs to a particular
individual, without any systemic and community level facilitation will be totally non
productive and community mobilization, organization and empowerment will be left to
random events to trigger off. Moreover this sort of individual training can lead to the
creation of new centers of power, rather than facilitating the redistribution of power as
originally intended. This risk is well reflected by Paulo Friere when he says7, "As soon as
they complete the course and return to the community with resources they did not
formerly possess, they either use these resources to control the submerged and
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dominated consciousness of their comrades, or they become stranoen; in t-hair
“7™^ieShand'heir former 'e^ershlp position Is thus threatened In o?de? notTo
but in more'efficfent wiys -y W'" Pr°bably te"d t0 “ntlnUe ma'’iPula«"9
community.
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TRAINING AND THE LARGER CONTEXT
Apart from these there rare several‘ ‘issues regarding the changing context within which
training programmes are
s inow being implemented that have a bearing on the overall
approach chosen and the effectiveness of the
—
training imparted, A few are highlighted
here:
1. The changing context of the community health
field. These include changes in the
local
level
and
national
level like
increasing
urbanization,
increased
industrialization, a marketization of the
towna9rdseWer faUltlineS' fl“ctuating Political^ilbTn'dintemadon^ll^by^hTmoJe
towards mcreasing globalization, increasing powers of the multinational
corporations and homogenization of economies and cultures
JrogrPamme"6
SUStainability and scalability as crucial components of any
3. Renewed interest shown by governments
community health worker programmes.
to
start statewide /
nationwide
fhS ™te,d ab°Ve the “ntext within whlch gaining occurs has changed quite radically since
the early programmes of the 70's, It Is very important to re-look at our approaches and
experiences in the light of these changes.
approacnes ano
CHW TRAINING: DEVELOPING INNOVATIVE WAYS TO WORK ON AND AT SCALE
Training iS well recognized as a crucial input into any programme, while the principles of
training and approach to training are broadly accepted, the actual translation o hese
inputs into content, and linked to this, methodologies has till now been and is of
laral-scale^national Ind^?
pr°9ramme specific- With the bating of the NRHM and
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national and state-wide programmes, there is an urgent need to reflect on
Pfot experiences and critically develop ways to improve the design and implementation
asked inclld9er:ammeS‘
°f the imPortant Questions tha? need to be
• Is there a |possibility of coming up with guidelines and processes for development of
content, methodology and the planning of human
- i power?
o What can we adapt based on leornings mom past experiences and in what
learnings from past experiences and
programmes? deVel°P neW n'iethodologies for training CHWs in large-scale
o
o
How can a large-scale programme ensure the creation of high quality and
sensitively contextualized training content?
Y
tn iarge-scale programmes, who are the trainers and how should they be
traTe<\-mentored and supported in their critical roles as
facilitators and participants in processes of health empowerment?
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• Is there potential to come up with methods to make the programme learn as it is
implemented and to incorporate these learnings as we move along?
•• Is
Is there
there aa method by which the different stakeholders can create new paradigms of
engagement and partnership and together focus clearly on facilitating a peoples
movement?
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THIS WORKSHOP
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This workshop is an attempt to initiate a dialogue between the various stakeholders who
are deeply engaged in developing and implementing CHW programmes across India. It
aims to bring together representatives from NGOs, national and state governments,
funding agencies, and researchers to share various experiences as well as re-examine
them from both the specific perspectives of scaled programmes, as well as in the
changing context of the 21st century. In doing so, the workshop attempts to go beyond
the dichotomy of innovation and up-scaling, towards evolving instead a process of
"innovating at scale," in which the creativity and sensitivity of a rich history of
community-based health experiences is combined with the historic imperative and
opportunity to ensure access to health across the vast geographies and social contexts of
India.
We also hope that this dialogue, in the context of the evolving National Rural Health
Mission will provide a space to begin to forge new paradigms of engagement between the
various stakeholders in the field of health.
REFERENCES
1. Training Community Health Workers. Information for action issue paper. UNICEF.
2.
3.
4.
5.
6.
I?.
1983
George Foster. 1982. Applied anthropology and international health: Retrospect
and prospect. Human Organization. Vol. 41, 3, 189-97. As quoted in Banerji D.
1986. Social sciences and health service development in India. Lok Paksh. New
Delhi.
Training Trainers for Development. The CEDPA Training manuals series. Volume 1.
CEDPA. Washington USA.
Staley John 1982. People in development. A trainers manual for groups. SEARCH
Bangalore.
Pachauri Saroj, Reaching India’s Poor: Non-Governmental Approaches to
Community Health, Sage Publications, 1994
Community Health Cell, Community Health Trainers Dialogue - Towards an
Education Policy for Health Sciences, Bangalore, October 1991, mimeographed
report.
Friere Paulo. Pedagogy of the Oppressed. Harmondsworth: Penguin, 1972
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Community Health Worker Training: Linking Pedagogy and
Practice1
Comprehensive Report on a National Workshop
10th to 12th April 2006
Tata Management Training Center, Pune
Dav 1 (April 10, 2006)
Community Health Worker Training- an introduction
Welcome address
Dr. Rakhal Gaitonde started the workshop by extending a warm welcome to everyone
and invited Dr. Antia to deliver the welcome address.
Dr. AntiaHe began by saying that after 58 years of independence we could have achieved a lot
more than we have. Health has been converted into illness or illness care. Medical
profession is responsible for this to a great extent. How can health be separated from
overall development? It cannot be alienated from overall development water, sanitation,
nutrition, and education. We do not have to go somewhere out there to seek for
exemplars. Kerala is a good example of how complete health care can be provided by
spending around 50$ per capita per annum, while even some developed countries spend
around 4600$ in providing health care to only 15% of its population. A close examination
of the case of Kerala, which is so different from other states like Bihar, may provide
answers to many questions?
Medical profession has been dictating the way health is understood. Despite 240
government medical colleges and many more in the. private sector, and 14 lakh doctors,
it is difficult to a get even one doctor for 30000 people. Thus, medical profession has
failed to serve the people.
In the UK, after the Labor government came into power, Beveridge Report was drafted
in order to guide the future of education, health and welfare was prepared. China as a
developmental method started the practice of‘barefoot’ doctors, and erstwhile USSR had
'Felchers' -community based health workers for their people. In India, after the
independence, welfare strategy for health failed to deliver as the struggle was not just
universalizing medicine but curtailing the widespread poverty. The people at grassroots
need the supportive services of medical profession and health system. These supportive
services are important and are not provided by the medical profession. ICSSR and ICMR
reports were the blueprints, which had come out with a policy for decentralized
Gandhian model for health. In 70s various experiment-based projects were started
1 The following document is a comprehensive minutes of the workshop organized in order:
• To share and consolidate innovations and learnings in community health worker training
across programmes over the last three decades.
• To discuss and develop initiatives for mainstreaming these innovations and learnings
towards extending coverage and enhancing quality of community health worker training.
• To initiate dialogue and create networks between various health worker training
programmes, and between civil society groups and the National Rural Health Mission.
1
FOUNDATION FOR RESEARCH 1^
COMMUNITY HEALTH
LIBRARY - PUNE
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namely by Arole, Miraj, Kasar, FRCH etc. They were experiments where the health was
looked beyond illness and enabled people to question the system.
He stated how intelligence and knowledge are two different things. An intelligent plan
may not be very knowledge intensive. Every village has its own set of knowledge base,
which is different from the other. The village community sends us the message: ‘ give us
the knowledge and we will diffuse it to our situation”. There is a need to learn from the
women in villages. Didactic lectures, books and intellect alone will not be able to solve
the problems. We need knowledge that can be diffused to all of them and that suits local
situation.
FRCH passes on information and knowledge to women who percolate it down to other
women in a manner that is relevant and practical. Then they get accreditation of their
knowledge through NIOS (a certificate from National Institute of Open Schooling). He
also stressed that Panchayati raj and Right to Information (RTI) are two tools that are
very useful for people and have been incorporated in the courses (There are 110 dltterent
programmes in NIOS and one of them is on Panchayat Raj & Right to Information). RTI
can be used to find out how much money comes under health to each village. Here is an
extraordinary tool in the hands of people.
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Introductory Key Note’- Historical overview of CHW programmes internationally
After a round of self-introduction, Anant introduced Prof. David Sanders who made his
presentations citing the Present global context, trends in pattern and burden ot
diseases.
Prof. David SandersMany improvements have taken place since 50s but health inequalities have increased.
There are stark global inequities and within that'maternal health shows worst tien s.
Acute respiratory tract infection, diarrhea, malaria, measles, HIV, prenatal problems
are the biggest and perennial causes of child death.
Huge inequities continue to persist not only within countries but also between countries.
He quoted ‘would it be better to be born a Japanese cow on which 2700 $ are spent than
an African citizen on whom a mere 500$ is spent’. Also most health care systems are
technology based rather than need based and they are more selective than
comprehensive.
He showed the ranking of causes of global burden of diseases5 as % DALYS. He stated
that food security and nutrition is not much spoken about though micronutrients are
mentioned Non-communicable diseases are showing frightening emergence even in the
poor people For example even in the developed nation the decrease in mortality rate or
TB is not due to the impact of medicines or health systems but migration m the poor to
urban areas.
There is a rapid urbanization with simultaneous de-industrialization, which is reducing
the employment opportunities for the slum dwellers in cities thereby causing more
poverty and destitution. Current phase of globalization (Trade liberalization) starts fiom
debt crisis. External debt has increased dramatically. Debt is a huge burden on Africa
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and other developing countries. The economies end up recovering and repaying these
debts, which tend to affect the amount they can spend on welfare activities. Private
sector majorly affects the health sector reform. In Africa, water is privatized due to
which a strong lobby is required to avail basic facilities like water etc. Water is
important for food production and sanitation. Food production important for nutrition
and nutrition and sanitation is important for improvement in health. Public health
package does not include water and sanitation.
Community Health Worker Programmes become a way of addressing coverage and
outreach; by activating a support to the people regarding health requirements, to cover
up for the brain drain to urban areas. But CHW can be a success only by being a
functioning part of a health care system, which can improve both her impact on people,
and sustainability of the programme. Within this, the problem of compensation and
conflict between CHW and Nurses is predominant in East Africa. Therefore, it is
important to resolve these internal dynamics. Policy makers need to think of a mix of
financial and non-financial incentives. Government must work with civil societies.
•
Introductory Key note: Historical Overview of CHW programmes in India - focus
on the importance of training
Dr. Ravi NarayanHe recalled all the community health personnel he worked with for two and half
decades. Since people are not just recipients put participants in community health work
programmes, Community building becomes a priority. So the trainings taken for
Community health Workers had significant components of Community building. For
example, in the training camps at Jamkhed, women from various castes were made to
cook together; sleep under blankets, which were stitched to each other; and view each
other’s blood samples under a microscope. These exercises enabled the trainees to
experience a sense of solidarity, similarity and coherence as “human beings ” before
being members of any particular category of societal division.
Amongst the traditional midwives, there is a culture of Affective Trainings i.e., a
training which perpetuated over years as a daughter learnt from her (dai) mother the
practical, emotional, sentimental and skillful aspects of childbirth. Infact traditionally
only a dai’s daughter can become a dai as she has not only received but experienced the
training2.
He traced a genealogy of reports and experiments which have played a directional role
in our health strategies but also'highlighted how some efforts could have played a much
more effective role in the condition of health care in India provided that their
recommendations were taken more seriously. For example
1. Bhore committee talked of village health committee and voluntary health workers
who need sustainable training but it was only given a lip service.
2 We cannot overlook the fact that this practice is not void of the caste practices. It is not just
owing to the fact that a Dai’s daughter goes through affective training that she is an obvious
choice to become a Dai. It is also because she is the daughter of a woman who plays the role of
a mid-wife under the caste-based division of labor therefore becoming eligible for carrying
forward the same role.
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2. In 1970s and 80s, NGOs took up CHW programmes. These included some pioneering
and innovative experiments namely CHWs of Jamkhed, VHWs of Indo-Dutch,
Hyderabad, Lay First Aiders at Adyar, Chennai, Link workers of tea plantations in
South India, Health Aides of RUHSA, MCH workers of CINI, Calcutta, Swasthya Mitras
of BHU at Varanasi, Sanyojaks in Banavasi Seva Ashram at Uttar Pradesh, CHW
course of St. John’s Medical College at Bangalore, Rehbar-e-Sehat of Kashmir
Government (Teacher-workers), CHVs of Sewa Rural at Jhagadia, Tais of Foundation
for Research in Community health
>
>
>
>
>
Here the CHWs were women
They were either volunteers or receiving minimum support
They were married
They belonged to various caste and class representations
Community participation was the key and support from community based groups
was sought
> Innovative training methods were adopted
> Highly mobile field and supervisory staff was employed
Women were encouraged to be part of many local activities and committees
3. On Srivastava Report recommendations many NGO trained CHWs were absorbed
into government programmes as MPWs (male and female), which was further taken up
in the Kartar Singh report. The Janata Experiment (1977) of introducing Community
Health Guides, also known as the Rural Health Scheme was a crucial countrywide CHW
campaign (which focused on CHWs selected by the community, having education up to
class sixth and trained informally in the PHM for 3 months. They were paid a stipend
during training and an honorarium of Rs.50/- per month when they began to work) was
launched in all states except Jammu & Kashmir, Tamil Nadu, Kerala and Karnataka,
but it did suffer from some inherent problems.
4. Under the Janata Experiment, the Manual for Community Health Worker was a
nationally inspired demystification process. This manual could be used to teach about
health to semi-literate populations. However when it was'circulated, the most important
section on Social and Mental health had been deleted.
5. In the National Health Policy, 1983, the CHW component was forgotten. From 1982
to mid 90s no one was talking about community health. The health budget was frozen as
various pay commission s led to an increase in the salary component but the programme
component kept decreasing.
6. In 1995 a new phase started i.e., the Jan Swasthya Rakshak scheme of Madhya
Pradesh; followed by its evaluation and a range of recommendations which suggested a
need for paradigmatic shift in the implementation of community health programmes.
7. 1990s experiments of empowerment like Arogya lyakkam (Tamil Nadu Science
Forum), Arogya Sathi (CEHAT Sathi), and CMSS (Dalli Rajhara Chhattisgarh) showed
this shift ie.,
o
o
o
From alternative health care providers and health extension workers to health
empowerment activists
From project management to process management
From health activities to making people pressurize the existing health services to
make it more responsive and accountable to people’s needs
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8. Recently, the Indian People’s Health Charter of Jana Swasthya Abhiyan - December
2000, the Global People’s Charter for Health of People’s Health Movement - December
2000, the Mitanin Programme of Chhattisgarh - 2002, each one reflecting new ways of
addressing the community health issues. And today we have the National Rural Health
Mission.
ASHA’s can’t be alternatives or extensions; they must be a part of the system and not be
preoccupied as alternative service providers. He said that after 50 years of
independence, NRHM gives us opportunity for a new dialogue; he reminded the house
that GO1 has come to a stage were they are at the verge of a drastic change. However,
we cannot romanticize that the community will take over everything. Community can
take over Primary health care but not the Primary Health Care Center.
National Rural Health Mission: An overview
Dr. D. C. Jain:
He shared the status of health as per the Government of India records and the
improvements vis_a-vis some parameters like control of diseases (tuberculosis, polio,
leprosy, and guinea worm) though a picture of achievements cannot overlook the
overwhelming concerns and deterioration of health standards among the poor. Stark
socio economic differences in IMR, NMR and MMR> critical shortage of human power
(ANMs, doctors, Para medics); huge regional disparity (Kerala has 5 ANM per village
and MP has 1 ANM for 5 villages); unregulated private sector; and no grievance redress
mechanisms to name a few.
He shared that the lack of adequate monitoring mechanisms while formulation of
schemes makes it difficult to ensure results on the ground. The time has come when the
community must participate in a manner that they can confidently hold the government
responsible for all the failures. Community based health workers who are accountable to
the people and make the government accountable is the only way to move forward. He
believed that the CHW program failed because of the word ‘worker’ therefore, now they
are no more called workers but ‘activists’.
Health certainly is a political priority, which is why the lack of (community) health
personnel is being tackled. Also, it is not under'funding but under-utilization, which is
the problem. He explained the major components of the NRHM and how NRHM aims to
fill the gaps.
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The National Rural Health Mission^ an overview
The National Rural Health Mission (NRHM)3 was announced in September 2004 as a part of the Common
Minimum Programme of the Government of India with the following goal "to promote equity, efficiency,
quality and accountability ofpublic health services through community driven approaches, decentralization
and improving local governance"^ The duration of the Mission is seven years (2005-2012) and its focus is on
18 states5 where the challenge of strengthening the weak public health system and improving key health
indicators is the greatest. Taking an ‘omnibus approach’ by integrating existing vertical health
programmes,0 the NRHM seeks to provide effective health care to the rural population, especially the
disadvantaged groups including women and children, by improving access, enabling community ownership
and demand for services, strengthening public health systems for efficient service delivery, enhancing
equity and accountability and promoting decentralisation.7
The key components of the NRHM to achieve these objectives include the following^8
Accredited Social Health Activist (ASHA) Programme: The core component of the NRHM is the
Accredited Social Health Activist (ASHA) Programme, which involves placing a community based
change agent at a 1000 population level, to catalyse a sustainable community-owned process for
behavioural change and to facilitate access to basic health services by the poor. The primary role of
the ASHA is to create awareness on health and its social determinants and mobilise the community
towards local health planning and increased utilisation and accountability of the existing health
services. She would be a promoter of desired health practices and will also provide a minimum
package of curative care as appropriate and feasible for that level and make timely referrals.
Strengthening public health infrastructure: The NRHM recognises that strong public health
systems are imperative for achieving improved health outcomes. The Mission has allocated
additional funds for strengthening the public health service delivery infrastructure, particularly
the sub centres, the PHCs and the CHCs for the provision of primary and first contact curative
care. This would be accompanied by improved management capacity to organise health systems
and services in public health by emphasising evidence based planning and implementation.
Fostering public-private partnerships: The NRHM will support civil society participation to
increase social participation and community empowerment, promoting healthy behaviors at the
community level, and improving intersectoral convergence. This component also includes the
regulation of the private sector to improve equity, transparency and accountability and reduce outof-pocket expenses.
Decentralisation of health planning: One of the core strategies of the NRHM is to empower local
governments to manage, control and be accountable for public health services. It envisions the
setting up of the State Health Mission led by the State Departments of Health and Family Welfare,
the District Health Mission led by the Zila Parishad and the Village Health Plan to be formulated
by the Gram Panchayat. The NRHM has created structures at each of these levels for the planning
and implementation of the initiatives to be undertaken within the Mission.
3
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National Rural Health Mission (2005- 2012), Ministry of Health and Family Welfare, Government of India.
Ibid.
These include: Uttar Pradesh, Uttaranchal, Madhya Pradesh, Chhattisgarh, Bihar, Jharkhand, Orissa, Rajasthan,
Himachal Pradesh, Jammu & Kashmir, Assam, Arunachal Pradesh, Manipur, Nagaland, Meghalaya, Mizoram,
Sikkim and Tripura.
The vertical health programmes converged under the NRHM include the Reproductive and Child Health II project
(RCH II), the National Disease Control Programmes (NDCP) and the Integrated Disease Surveillance Project (IDSP).
National Rural Health Mission (2005- 2012), Ministry of Health and Family Welfare, Government of India.
Ibid.
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Setting the agenda of the Workshop
The participants wanted to know what are the expectations from the workshop to which
Dr. Rakhal responded with the following key pointsit is a significant point in history when NRHM is providing with an opportunity
to re-look at the last 20 to 30 years of community health workers programmes
and their trainings. How can the experiences of small scale (150 villages) be
applied to up scaling? What are the pros and cons of such a task like up scaling
and replicating?
> Based on the learnings that various sectors like funding agencies, government
and NGOs have, can a new paradigm, a new set of possible directions and
probable partnerships be evolved together in order to use situations like NRHM?
> This is not the end of the process but the beginning,’ participants present here
can act as a core group and strategies to work together can be reflected upon.
>
Participants enlisted the following concerns, which they suggested that this workshop
should discuss
>
>
>
>
>
>
>
>
>
The divide between the state and central government, which creates a disparity
at the field level
The under utilization of funds, irresponsible spending and bureaucratic hassles.
How does one ensure transparency and accountability downwards?
NRHM has to achieve many goals by 2012 but does its have certain immediate
achievables? There is a need to draft and share annual outputs and indicators so
that regular monitoring can be made possible.
Can issues of governance and efficiency be talked of and resolved without looking
at the private sector as exemplars?
A sense of ownership amongst people whenever we speak of community-based
programmes needs to be achieved otherwise the interventions of ASHA/ANM
cannot be sustained.
When we speak of the role of ASHA, then the burden of multi-tasking, lack of
support structures and inadequate compensation cannot be overlooked.
Further, HIV-AIDS activities are not clubbed under NRHM, which defeats the
purpose of converging vertical programmes. And if the parallel programmes will
continue how will the impacts of each one be measured.
There were queries as to how the political economy affects the NRHM. Is it
possible to carry forward a health mission without acknowledging the various
globalization forces that may be simultaneously working towards just the
opposite?
NRHM is too broad a topic and trainings are very specific. So, there were
concerns whether NRHM may outshine the need to discuss and debate on
pedagogies and practices of CHW trainings.
7
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Film on Community Health Workers titled Grassroots Realities9
Dr. Parvez Imam-
He shared that during the shooting of the film many CHW said that the availability of
infoi mation helped them learn about things they did not know and gave them a lot of
confidence. All the health care experiments are situated in microcosm and so the
conflicts / struggles are smaller / simpler in nature & hence manageable. But, what will
happen when these conflicts begin to take a larger shape and come face to face with the
macrosystem?
On the other hand there is another important issue of‘economic needs’. The CHWs do
need economic support. But villages themselves may not be able to afford such costs.
And if the government pays the CHWs then how will her accountability towards the
community be ensured?
•
Experience Sharing
2 Community Heath Workers namely Pushpa Tai and Sarubai Salve shared their
experiences of how such a responsibility increases their worldview and confidence but at
the same time life became tough and challenging due to multiple roles and issues of
coordination with ANMs.
The 23'minute film captured what health means to community health workers and where do
the boundaries of health care begin or end for them. It showed how these semi-literate and illliterate women, themselves living in extreme circumstances, are trying to use their newly
found confidence to take the health of their communities back into their hands. The film was
in a mix of Chhattisgarhi, Tamil and Marathi with subtitles in Hindi.
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Day 2 (April 11, 2006)
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Innovation in Training Content and Methodologies in Community Health
Worker Programmes
•
Key Note- Adult learning Principles — How Community Health Workers learn
Dr. BalasubramaniamHe shared his experiences of using technology as a medium for imparting trainings in
the agrarian context. When 100 million agricultural laborer families need to be covered
then one has to think out of the box. However, in India training (where various
innovative models of outreach can be adopted) is the weakest linkage, which is evident
from the underutilization of funds for training. He emphasized on the need to
strengthen only the successful conventional methods and to take alternative trainings
as well as Friere’s ideology more seriously. Trainings have the potential to be learner
centric and induce transformation. There is a requirement to practice horizontal
transfer of knowledge versus vertical transfer of knowledge. He presented how lecture
and reading have much lower retention rate as compared to practical methods. Majority
of the times learning takes place outside the formal set-up. Creating and structuring
opportunities for people to network, communicate, mentor, and learn from each other
can help capture, formalize, and diffuse tacit knowledge. Communities become a
boundary-less container for knowledge and relationships that can be used to increase
individual effectiveness and country’s development. Based on adult learning principles,
he advocated for information-communication technology involving audio-visual media to
aid training Participatory content creation is possible and Participatory and interactive
learning is very high. Tech mode is possible as evident from government supplying
100,000 villages with ICT connectivity, 50,000 villages by Microsoft; 20,000 by ITC and
by Intel; NGOs, Banks and local companies are now provided with this technology7 in
7000 villages.
His presentation followed a short discussion where the usage for ICT for providing
treatment with the aid of telemedicine and for dissemination of information was
debated. While ICT was seen as crucial for sharing knowledge and information, at the
same time, it was argued that this technology requires heavy cost investment. Secondly,
ICT cannot be a substitute for face to face training and the stage at which ICT can be
introduced needs to be clarified. Also, while speaking of ICT, EDUSAT being low cost
cannot be overlooked as it can be used for sharing information particularly in trainings.
In terms of discussing innovations, Aravind Eye Hospital was used as an example where
a system of cross subsidy works. While those who can afford are charged but those who
cannot afford are given free treatment. But here too the cost is not reduced; it is just the
source to recover the cost that is rationalized because the poor are given adequate
subsidy while the rich are expected to pay for the medical services that they may avail.
9
Session L Panel Discussion
Approaches to Training- Focus on content, methodology and human resources for
training chaired by Dr. Ravi Narayan
Dr. Arole, Comprehensive Rural Health Project Jamkhed
He shared the problems faced in the areas where they started their interventions during
the beginning of the 70s. These were owing to hunger and starvation, poor nutrition, low
birth weight, low weight of pregnant and lactating mothers and all these continue to
persist. Such problems could not and cannot be solved through medicines as the causes
and roots of the problems are very different.
He spoke of the communitybased approach that they adopted where the key to address
problems was through prevention, integration and use of appropriate technology. For
this a partnership of the health workers and the health system was sought. Learnings
from the experience> Community Health Worker needs to act as a bridge between the community and
the health system. Therefore selection of a CHW becomes very important as she
must have a stand and respect in the community.
Her
responsibility is to co-ordinate the various service agencies in the
>
community.
> Her role is to demystify health, demand accountability from the health workers,
and educate the community to utilize the system.
> She cannot be a part of the system and hence the system should not be engaged
in selecting or monitoring her or paying her.
For performing the above roles, she needs to have a strong sense of self-esteem, which
can be derived from trainings. Trainings therefore, need to incorporate the various
elements, such that it can address the psychological, social and economic issues. In
trainings at Jamkhed 50% of training time focuses on the individual growth. He gave
the example of Sarubai, who gained such a lot from the trainings that she has been able
to make a qualitative difference to her everyday life. He emphasized on the need to
incorporate sessions on income generation programmes, optimal utilization of resources,
accessing different schemes of poverty alleviation etc. The rest of the 50% of the
trainings should cover technical issues i.e., knowledge and skills to tackle small health
problems. These trainings make them experience the fact that knowledge on health is
not the monopoly of the doctors. It is people’s knowledge.
Ifle detailed out some learnings from the trainings> Practical means to orient the participants were useful as observed in cases
where they were sent to work with the already trained health workers.
> Sessions covered in residential training became very important, as
participants learnt a lot from each other especially at nights when the
sessions could be a lot more informal.
> Participants enjoyed songs, dramas and other folk medium.
> “Experience plays a very crucial role in trainings” was exemplified from the
fact that health workers themselves have now become trainers.
> Ongoing training is very important. The participants in the trainings often
shared that they did not come to learn from the Trainer but to learn from
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each other. (They equated their situation with a group of lamps that remain
lit as long as they are kept together but extinguish when kept apart).
> Trainings should be used to pass on both technical knowhow and inculcate a
sense of social responsibility.
> Trainings can be forums to discuss the lacunae and exploitative tendencies of
the health system
He also shared the pictorial materials of training content. He concluded by stating that
if these health workers are effective there’ll be a change in the health scenario.
However, the new scenario will not be void of problems thereby requiring a new set of
strategies and solutions.
Mr.V.R.Raman,
Chhattisgarh
Mitanin
Programme,
State
Health
Resource
Center,
His presentation was focused on the challenges of training 60000 Mitanin and how that
fits into the context of ASHA under NRHM. He shared the status of health and health
services in Chhattisgarh, the gaps in the supply along with the workload of existing
ANMs, coverage limitations, and weaker linkages with the panchayats. Despite the
given constrains there were a share of opportunities like being a new state, available
space for civil society engagement and scope to experiment. The political environment
called for a popular and massive programme.
Community health workers were not seen in isolation but as a part of the broader health
sector reform. The support and stake of bureaucratic administration, involvement of
funding from European Commission under sector investment programme was a
remarkable arrangement. Further, requirement of funds for drugs was tackled by an
innovative strategy of launching Mukhya Mantri Dawa Peti Yojana (under which
Rupees 5 Crore were mobilized). It was and continues to be not a parallel programme,
but an organic part of the health sector.
He shared the hardships and challenges faced in training the CHWs under this largest
health worker programme of the country one of which v/ere a number of political
uncertainties. Traditionally, Mitanin means “friend for life”. The identity of Mitanins as
friends of people was established and reiterated under this programme. Mitanins had to
be identified, oriented and trained in a set of challenges like unavailability of a cadre of
experienced trainers, training illiterate women who come from varied terrains and
dialects which are very different from one another, tedious interventions of conducting
Training of Trainers as well as updating the skills of existing trainers. If ANMs were to
be involved it would affect their regular function. The trainers were identified from the
communities, at the village level. Also, they are not just trainers but the immediate
support structure for Mitanins). Finally, the issue of monetary compensation to the
Mitanins has been a matter of debate and so far no clear consensus has been sought.
1 Community Development Block has an average of 400 Mitanins. 1 trainer
for 20 Mitanins, 3 coordinators for each block acting as district resource
persons and 1 field coordinator for 5 blocks to give regular inputs, monitoring
and feedback to the State Health Resource Center.
> The trainings take place in 7 rounds spread over 18 months, and each round
has a set of manuals to prescribe to. This includes- determinants of health
>
11
and health services and entitlement; child health issues! Women’s health;
Community based malaria control; Rational and irrational practices!
introduction of Tuberculosis and leprosy control, revision of dawa peti; and
I anchayats interlink ages and coordination. For areas where both Hindi and
Chhattisgarhi were not apt mediums to transfer information, hand made
modules and posters in local dialects were used
> The 12 days camp based training and 30 days on the job training, spread over
18 months is the training strategy in the Programme that has been observed
since the beginning. The first set of seven rounds of training covered 40000
Mitanin and now the programme is proceeding towards the next phase of
training. All Mitanins have completed at least 5 rounds of training. The next
20000 are undergoing the first phase of training.
> The programme is now extended under the NRHM and the Mitanins have
been absorbed as ASHAs.
> Broad roles and responsibilities of Mitanins include: Visiting at the outset of
child birth and deliver six key messages, planning for the expected deliveries,
ANC check up, planning and arranging for referral of complicated cases for
institutional deliveries. There are sets of 75 health messages that the
Mitanins can refer to in their attempts to educate the community. Mitanins
mobilize people to identify their health needs, utilize public health services
and act as interface between the community (at the level of hamlets) and the
systems at the panchayat level. They will be the key animators in executing
the hamlet level actions for the Panchayat plans.
To ensure a better and active involvement of Panchayats, Swasthya
Panchayat Pratiyogita based on 26 indicators was initiated.
> Media was used effectively through a radio programme of 16 episodes along
with supplementary television accompaniments. These were backed by
strategic interventions of advertising the programmes through posters. The
viewership 20000 groups provided with a time-to’time feedback. This,
together with very innovative folk media and theatre was used to mobilise the
community to select their Mitanin, and to -sensitise them about the
Programme and the roles and responsibilities that she will have.
Number of process reviews and participatory evaluation were held in which the
identified gaps were worked upon for the later phases of the programme. These
included- strengthening the training programmes, referral services, civil society protest
mechanism and intersectoral linkages even further. Constant synergy between the
piioiities of the community and the administration to maintain a balance was upheld.
He concluded by saying that when we work on a programme that tries to work with as
well as criticize the health system, our way of protest has to be ‘Silent’ because the
health system cannot digest open criticism.
•
Dr. N. Mistry, Foundation for Research in Comin unity Health, Pune
She stated that it was in the 19th century at the I^eed's conference that Florence
Nightingale mentioned about the use of community health worker for the first time
(which was much before Bhore or Mudaliar Committee reports). Then the ISSSR ICMR
lepoit stated that the community health worker is not a means or a technology to seek
piivate health care but a reflection of a political struggle. FRCH was the secretariat for
this democratically decentralized ICSSRTCMR report. The guidelines of the report
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helped the organization to envisage a structure for the community based health care
services system, which had much learning. The population coverage ranged from 200 to
5000 to 30000 people.
(
The accountability of CHWs was always towards the neighborhood and the panchayat
and not towards the government. She played the role of a neighborhood functionary who
worked as the extended family member. Smaller the unit of coverage more effective
could she be in terms of coverage and commitment. The CHW selected was generally a
married woman who would get accepted in such a responsible position by the
community. If education is identified as an important criterion, then the marginalized
population is generally not represented so this criterion needs to be dealt with more
sensitively and contextually. She shared the experience at Parinche from (Kaldheri)
which is a mountainous terrain. Through much effort 7 to 8 illiterate women were
selected by the organization and when FRCH visited the next time, a completely new set
of women had come. This is because the illiterate women mobilized and brought the
educated/literate women to participate. In Uttaranchal the experience showed that
despite 80% literacy, it was difficult to get educated women to join as CHWs though they
were offered Rs. 3000 monthly remuneration by the panchayats.
She began sharing that the trainings could range from 90 to 120 days and the spirit
with which the trainers worked was derived from the one prevalent in Scandinavian
countries where there is no terminology for teachers. There the teachers are believed to
be learners and facilitators and referred to as “laere”, as they believe in learning,
facilitating and not teaching which precisely is the guiding principle in FRCH.
While practicing these principles in the Mandwa project FRCH had the following
learnings-
> Education is not an absolute requirement in selection.
> Non-formal approaches to trainings are extremely effective
> A system of ongoing communication facilitates social change
Under the Malshiras project it was learnt that there is a need for symphony in training
& service provision because while concentrating on the trees one cannot miss the forest.
Cultural issues, societal norms, equity in distribution cannot be overlooked. But one
must remember that the whole process is gradual and incremental and it cannot be done
in 3 or 4 weeks.
While the earlier trainings were more focused on curative, preventive, promotive aspects
of health and included national health programmes, water, sanitation, immunization,
referral care, veterinary care etc. Now a holistic education is envisioned covering income
generation, public issues, rights and responsibilities, ethics and equity, environment,
ecology, effective communication and community mobilization (UNICEF communication
skills book was used as a reference). The shift is now much broader i.e., from needs to
rights. Trainings aspire to bring about a change in self-image and build a career path for
the health workers. Once the awareness is aroused there is no stopping, as they want
more and more. And as a Resource Center one has to provide for that. Just as skills and
knowledge will build the initial base, it is the actual experience as a health worker that
will add to ones development and confidence.
13
She also shared the stages of learning, which begins with mere exploration of ones self
and surrounding environment; followed by a becoming a participator from a spectator,’
and then becoming a contributor. Lateral linkages among the health workers are
essential for learning.
She enlisted some guidelines for module preparation learnt during the compilation of 4
modules on health and environment, basics of health, health extension activities and
health education. The amygdaline approach“> is used in the four modules. Modules must
include- Positive and negative deviants, Cross cutting themes and Case stories.
Learning does not end with training or communication. It is a stepwise process-’
Communication, assimilation, practice, evaluation, and reflection are steps of constitute
the learning cycle. The role model concept, which is relatively a new concept, can be very
effective.
She shared the success of getting an accreditation from NIOS few years ago which has
helped FRCH training programmes to get some recognition, standardization,
professional space & scope for wider dissemination which may be of help for the NRHM.
She ended with a word of caution i.e., Sift reality from romance.
1. Health workers also have problems like every other human being.
2. If you just focus on the community health workers and not the community, you
have a generation of worker isolation as Paulo Friere rightly said that you have a
focal of local oppression.
•
Dr. Shyam Ashtekar (discussant)
He stated that the government has resources and solutions within its system in order to
meet the training requirements of a large number of community level workers based in
rural areas. This according to him includes the open universities set up in 1988-89 by
the government. There are self-funded universities, which are performing very well in
Bihar, Bengal, Rajasthan and Andhra Pradesh. These can be used for Open and
Distance Learning to train health workers/personnel. Agricultural department has done
some very good work in terms of Open and Distance Learning drawing from extensive
experience. These include using more than one source of instruction, developing
material along with progress; using Multi-layered and Self-instructional learning
material.
Edusat is a low cost dissemination programme. GOI has launched healthsat now, which
many states are using. NRHM should think of using both in a big way. He believed that
for CHWs Open Distance Learning is the natural choice since it is flexible, learner
centric and low cost.
He advocated for getting away from planner centric models to four-perspective models,
which includes the planner, the learner, the trainer/counselor, and the user community^
With this approach the focus of training would be on stimulating the amygdala of the cerebral
cortex. This approach is broader and deeper than a cognitive one because it signals the
emotional quotient of the learner. With this orientation the training would impact the
emotions, perceptions and value system of those involved.
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Unless we move to this balanced perspective, programmes cannot have a contextual
relevance and internal richness of quality.
On the one hand we need to use the old knowledge and incorporate it in new ways of
channelization. On the other hand we need a holistic and creative manner of conducting
trainings is the need of the hour because there are a variety of learner needs calling for
a variety training methodologies. He spoke on the Rings Approach for large scale flexible
Health Worker Programmes. This approach feeds into the need to have core perspective
models so that the community accepts and adopts the new programmes. It suits
heterogeneous groups, allows for multi-tasking and organic changes in the content.
The Rings model is basically a pluralistic approach by design—a post modernist view of
things in community health. A matrix can be made of different themes (subjects) to be
covered under the training at different levels in terms of allocation of time and
resources. The gradation is termed as ring, which is expressed in terms of number of
hours for each theme. This matrix can be restructured/reorganized in the form of
concentric rings, with each column forming a layer of the ring and each theme forming
the spoke of the ring.
In this approach one can choose either the rings or the spokes, partially or completely. It
allows gradual learning by prioritizing and grading of the learning content as ‘Must’
learn, ‘Should’ learn and ‘May’ learn. This is also essential, as community level
initiatives demand multitasking, which makes training complex. It also allows
substitution & revision of the content (lessons) at different levels.
He mentioned of the various changes occurring in the national programmes. Learning
material should keep pace with these changes. Generally materials are revised over 2 to
3 years, but things often change overnight. To cope up with that a multi-author project
where changes can be made without hampering its pace of utility needs to be adopted.
ASHAs who have studied upto the fourth standard can use this.
In case of ASHAs, 5 rings have been made for 5 episodes of training. There is a set of
enlisted themes, which would feature in the rings. Each ring highlights the extent to
which a topic will be covered in one series of training workshops. The topics include
introduction, roles and tasks; determinants of health; water and sanitation,’ nutrition;
human biology; pregnancy, birth and post natal care; child health; contraception;
common medical problems,’ accident and first-aid; National Health Programmes,’
Community,’ Gender,’ PRI and human rights. While a theme may freeze once it is
incorporated in the model, it is within the themes that topics can be altered as per the
requirement.
Panel Discussion (chaired by Dr, Anant Phadke)
Dr. Anant Phadke commented that some of the presentations deviated from the crux of
what they were expected to cover. However, some crucial issues to reflect upon included:
• The reality of remote areas is that no such service system exists. Then how
will the ASHAs play a facilitating role in circumstances where even the bare
minimum does not exist? Therefore some amount of training in curative care
is essential so that ASHA can be a service provider. This aspect according to
him was not clear from any of the presentations made, especially in terms of
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what have been the experiences and major issues of concern when it comes to
meeting the curative demands of the people. He also mentioned that from his
experience, beginning health worker training with medical and technical skill
training is important to acquire credibility in the community, and that in
short periods of time, comprehensive, learner centric training for CHWs is not
possible.
Secondly, many theoretical claims are not supported by practical evidence
like the applicable success of the Ring Approach. The proof that trainings
undertaken by FRCH as well as the ones using IT and EDUSAT can be used
in the context of NRHM (which has a definite time and scale requirement).
Thirdly, all the presenters described how their programmes are being run
whereas what they had to dwell upon were the learnings from these
programmes to suit the upcoming endeavor of NRHM to design training
content and methodology. Also, no relevant training material for the literate,
semi-literate and illiterate workers was displayed or shared to exemplify all
that was being said.
Later Prof Sanders also questioned the viability/ applicability of distance learning
programme with respect to teaching practical skills and sustaining the theoretical up
gradation. Also, ongoing supervision, mentorship and application of the learnings to
practice are great challenges in distance educations programmes. Dr.Shyam Ashtekar
responded that technology has to be supplemented by field-based training. Dr. Pallavi
Patel argued for the importance of training of trainers and the influential role of the
trainers’ attitudes for CHW training to be successful. Prof. Sanders also asked why the
mobilizing, advocacy and challenging roles that CHW have to play were not discussed.
Dr. D. C. Jain expressed his appreciation for all the models used in different areas by
different organizations but a simultaneous concern that how the government can use
the learnings from such experiments. For instance more than 4 lakhs of ASHAs need to
be trained in one or two years. He urged the participants to think about the replication
of the various training approaches at scale in varied contexts within the country, and
asked the presenters about the timelines, costs involved, and the nature/structure of
support structures and human resources required for each of the CHW training
approaches. Even Dr.Pallavi Patel asked for the budgets that these trainings require.
Responding to this, Dr. A role stated that Jamkhed does not get any external funding
and training the health worker never crosses Rupees 3000 to 4000. To Dr. D.C. Jain's
question of timelines for training CHWs, she said that the time taken initially is quite
high, but this comes down with the presence of role models/senior health workers.
Further, Dr. Jain expressed that an attitudinal change is something that is needed at
the higher levels of officials. He shared his concern of how there is a need for dedicated
people at all levels particularly at the district and block level for the trainings to be
facilitated well. Dr. Alok Shukla responded that is no dearth of dedicated people.
Instead of giving programmes and budget to the states, he suggested that the center
must ask the states to come up with a viable project in order to access any funding
available under such programme.
Mr.J.P Mishra highlighted some deficiencies at certain levels in the context of ASHAs.
• Firstly, the selection has been still confined to the government’s discretion
while in Chhattisgarh; selecting Mitanins was seen as a responsibility of the
community. The process in Chhattisgarh began with the involvement of 10 to
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12 NGOs involvement and as the programme was scaled up, there was a
competition between the Medical Officers and the NGOs in terms of outdoing
each other in quality of training but as the basics were right, the results were
going to be feasible irrespective of whoever takes it forward. Mitanin
programme also survived the political administrative changes. Focus of initial
phase of training had nothing to do with medical knowledge. One of the first
outcomes of the programme had been breaking unhealthy/bad cultural
practices like not giving colostrums to the newborn child, not denying water
to the mother, etc.
ASHA programme is not only centrally sponsored but also centrally designed
and that is the problem, whereas the center should be challenging every state
to find its own solution. In fact every state should challenge every district to
find its own solution. NRHM is a very decentralized programme but it is
undermined because the nut bolt of ASHA is at the center. The sooner it is
decentralized to the state level it is better for sustainability.
In certain states like Madhya Pradesh, ASHAs may be viewed with
resentment with Anganwadi workers because of the compensation package.
The most crucial difference between ASHA & Mitanins is the element of
voluntarism. Voluntarism is not sustainable is the underlying assumption but
Mitanin has proved it wrong.
Dr. Sunil Kaul and Dr. Ravi Narayan suggested that the Mitanin programme too
suffered from some deficiencies and before seeing it as an exemplar we must look at
its evaluation report and learn from the recommendations. It is precisely from the
spirit of learning from the evaluations that we can feed into all aspects of a
programme.
Ms. Sarovcr suggested that when we have a set of NGO experiences as well as an
experience like that of SHRC, then perhaps we could address the issue of human
resource by analyzing the two. According to Dr. Sunil Kaul and Dr. Ravi Narayan
there were some unresolved issues and debates like why are we pursuing a mission
mode with specific timelines will lead statea to start the process without well
thought out plans. For example, CHW training started in Assam without
formulation of training modules.or what has been the accepted definition of an
activist etc.
Even Dr. Yogesh Jain argued that it is the role of a CHW's role that would determine
the content and the methodology of the training, and therefore, the principal focus
has to be on the definition of her role.
Dr. Shiv Chandra Mathur talked about the unresolved issues that have lead to a lot
of disillusionment. These include
• The ongoing launching of one programme after another namely, RCH I, RCHII and now NRHM.
• Further the focus of NRHM is on ASHA and the success of ASHAs has been
deduced trainings alone. And in trainings too, Dr Pallavi Patel argued that
there are no mechanism or methodology developed to review the trainers in
any of the approaches mentioned.
• While on the one hand it is a decentralized mission, on the other hand, it is
taking EAG or high focus states instead of district as their focal point.
• Finally, the Central government is aiming to work with a community based
health worker by involving NGOs and is also planning all sorts of inputs
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under the banner of Indian Institute of Public Health Standards. This calls
for a need to coordinate within such different stakeholders and we are not
aware of the strategy adopted by the Central government to do the same.
Dr. Jain responded that the center has conveyed to the states that NRHM has only
formulated broad guidelines as of now. But there is no willingness on the part of the
state to take a proactive stand and adapt the guidehnes to suit their local needs. The
center has prepared the ‘Core Material’, which can be reviewed and changed as per
requirements. Dr. Alok Shukla reacted that Mission should desist from writing training
modules as they can only give proto-types. The states should formulate the actual
content given their unique contexts. He gave example of literacy mission where primers
were written at district levels.
Dr. S. C. Mathur asked why experiments by Dr. Antia and Dr. Arole carried out in 3040,000 populations couldn’t be replicated for the entire district/state. Dr. Antia urged
that we need to have models of convergence only then resources can be used efficiently
and interventions can be sustained. But Dr.Jain added that convergence is possible only
at village levels but it is difficult at central and state levels.
Mr.J.P.Mishra raised the concern whether ASHAs would be the interface between the
community and the system or mere health workers. Dr. Nerges Mistry responded
ASHAs are link workers at the lowest level of hierarchy. Changing mindset at different
levels, especially higher levels are important. Therefore, a mobilisation of the health
system and not only of the community is the need of the hour.
Dr. Rai Arole highlighted that the aim of training is very important, and the fact that
this aim should be to change the mindsets of people, and not to build medical skills in
w omen. He also said that the difference in the performance of government run CHW
programmes at scale versus civil society run programmes in smaller areas arises mainly
due to the lack of motivation of personnel.
Mr. V.R. Raman gave relevant statistics from the Mitanin Programme to highlight the
nature of human resources, timelines and costs involved in implementing CHW training
at scale.
Session II- Presentation of Case Studies
A. Teaching Skills to Community Health Workers
Dr. Shyam Ashtekar- Teaching Clinical Skills to CHWs
His presentation began with a classification of illnesses as minor, medium, acute,
chronic and accidents and the relative ease or complexity of diagnosis and treatment. It
contained various shared matrices that can be used to teach associated symptoms and
their variables for different diseases. He mentioned about single and complex problems,
which make diagnosis difficult and emphasized on the need to keep the training simple
for the benefit of the ASHAs. Then he explained flow charts with interactive IT tools to
make complex diagnostic problems taught simply and use of kiosks to make diagnosis
available. He shared that some Community Health Workers have specific interests and
increasing learning requirements therefore, they need in-depth trainings. This updated
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and in-depth knowledge would give them confidence, retain their interest and build
their credibility in the community. He pointed out that health specificity and clinical
training of CHWs has been neglected.
•
Major Shashi Menon- Behavioural Change Communication (BCC)- A Resource
Approach to Training CHWs
The presentation highlighted that communication is the most important factor that can
bring about change and that communication and health are inextricably linked. The
presentation covered what is behavior and BCC, the steps to BCC, the forces driving the
change on the basis of blocks to BCC, and the various strategies of behavior therapy
that can be effectively used for BCC. Major Menon said that BCC is an interactive
process and not a passive one-way dissemination of information. He pointed out that the
public health system; the community and the family are resources facilitating BCC.
DiscussionThe discussion centered on the idea that the concept of health seen as simple versus it
not being as simple as it is being reiterated.
This is evident from the presentation of Dr. Yogesh Jain, which raised several questions
and concerns. For instance, he questioned the empirical evidence to prove that Village
health workers can manage 85% of health problems. He shared that hunger and
starvation could be addressed locally but there are other complications when it comes to
health. The risk of trivialisation of the health of the poor by focusing only on preventive,
promotive and very basic curative care, rather than secondary and tertiary curative
services could lead to ignorance of another kind. ‘Small places have small problems’ is a
myth and related to our assumption that rural life is very simple. We assume the
simplicity of rural life but very often it does have complicated, diverse and
heterogeneous health needs. Awareness and attitude cannot take care of everything.
According to him diagnostic and curative skills are more important than mobilization
and advocacy skills. Dr. Jain asked pertinent questions such as — Is the treatment by
the CHW appropriate, effective, affordable? Is this CHW strategy like assigning a
“second rate” doctor to the poor? Another important fact that the presentation
highlighted is the complexity of primary health care, that this also needs evidence based
knowledge and constant and complicated research.
Dr. Shiv Chandra Mathur had a slightly different stand. He argued that the activist role
of ASHA is more important than curative role. If behavioural change is not prioritized
then it is difficult to get results on the ground. He pointed out that clinical skills should
be taught to CHWs only after awareness has been created about health. Skill training
also has different stages ranging from acquiring skills and gaining proficiency at the
skill. Therefore, more than managing medical illnesses, the NRHM expects the ASHA to
change the behavior of the community.
However, within the category of behavioural change there were some concerns. Dr. Ravi
Narayan pointed that behavior change cannot be limited to individuals as issues like
stigma require a collective behavioral change. Dr. Narendra Gupta questioned how in a
segmented scenario (as ASHAs would be a heterogeneous group of individuals and the
villages where they will work would be just as fragmented) how could behavioural
change be envisaged?
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DnAbhay Shukla said that it would be impractical to expect the same CHW to do social
mobilization and curative work simultaneously. Also for change and impact there is a
need for large scale mobilization. ASHA alone cannot change the system. According to
Prof.Sanders, it would be difficult for any health system, scheme, programme or worker
do bring about a change or impact until basic hunger and nutrition issues are addressed.
M$_:—Shilpa—Deshpande pointed that there is a need to overcome the dichotomy in
perceiving behaviour and cognition. This dichotomy is reductionist in its approach
towards human behavior. BCC should comprise of cognitive behavioural therapy
techniques than only those of behaviour therapy.
Prof. David Sanders questioned the influence of globalization as ;an important
determinant of health and that both clinical.skills and BCC by CHWs should take this
into account.
Ms. Anuska Kalita said that BCC is only one of the strategies for behaviour change, and
that the focus has to be broadened to include the complex determinants of health
behaviours and highlight the role of communities and health systems in bringing about
behaviour change.
B. CHW Training in Varied Context
•
Dr. Lindsay Barnes- Gender and Social Exclusion in CHW Training
Her presentation stressed on the principle that gender is not a category or an issue that
can be viewed and trained upon in isolation from other issues. It is a theme that cannot
be deduced to skills. It is interlinked with caste and class, attitude and behaviors and
therefore needs to be intertwined with any developmental programme. If it is not viewed
in integration, then Gender blindness, ignorance, discrimination may not just get
perpetuated but also reinforced. Gender awareness and.sensitivity is essential for all
trainers to have especially in scaled programmes. Looking at the dais and doctors
through a gender lens she illustrated how the former are feminized ends of health
system (marginal and poorly compensated) while the doctors are the masculine ends
(highly valued). She questioned why CHWs are women and what all gender stereotypes
is that creating and reinforcing. Finally, she argued that Power and Empowerment
extend beyond the gateways of Training. The CHWs need on site back up and despite
providing that accomplishing a change is very difficult.
•
Dr. Sunil Kaul- Training CHWs in the context of political strife
The presentation shared the experiences of The ANT in training CHWs in a context of
cash starved economy, poor infrastructure, state bankruptcy and poor governance. In
the light of no government or other funds, it was the sense of community feeling and
local contribution that gave shape to their Health programme. In a context where
medical expenses are the largest cause of debt, the CHWs are seen as healthcare
providers and are therefore trained in clinical skills, including diagnosis of illnesses and
prescription of medicines. Trainings covered medical contents and teaching the use of
medicines. The learning materials are in the local language. The greatest challenge is
for the CHWs to compete with quacks and for the organization is monitoring the access
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of the poorest families in the village to healthcare services. He also pointed out the
failures of the program and challenges ahead. Dr. Sunil Kaul was asked if the work of
ANT has brought the MMR down. He replied that their work does not claim to impact
such indicators so early.
•
Dr. Abhay Shukla-' Training CHWs with low literacy levels
His presentation focused on training illiterate health workers in the Swasthya Saathi
Programme, which in 2004 got approved by Shrimati Nathibhai Damodar Thakarsi
(SNDT) Women’s University. The training material was largely pictorial and used
standard symbols to depict concepts of illnesses and other health related constructs.
Training methods involved games, discussions, body puzzles, sharing experiences, role
plays, quizzes, and articulation of each health concept in participants’ own words Even
the Assessment of training outcomes was done with the help of pictorial multiple choice
questions and programmatic monitoring through pictorial monthly recording formats.
Further he shared how Swasthya Saathi is community run and community sustained
programme. There was regular assessment, record keeping and accreditation in the
process.
Discussion-
Dr. Narendra Gupta pointed that a useful addition to the training content and methods
for non-literate CHWs could be anecdotal stories based on the rich oral tradition that
exists in communities. The training of trainers is very important for them to be able to
train CHWs in pictorial material. He also highlighted the importance of locating
training in the larger context - the broader socio-cultural, political, and economic
context, and the need to “make” the context enabling for the functioning of the CHW (for
example, training and sensitising public health functionaries to act as support
structures to the CHWs).
Ms. Arzoo Dutta pointed at the importance of gender sensitisation not just in the
community but also among health systems functionaries and policy makers. The need
for contextualising CHW training in the Northeastern states, without labeling the entire
region as “tribal” is really essential. This will move out of the tendency of homogenising
the unique cultural, political, economic and governance contexts in each of the seven
states.
Dr, Nandita Kapadia questioned how pictorial learning material is very open ended. She
shared her experience of how different groups of people interpret the same pictures
differently.she had also said that -the best form of gender training in her experience at
IHMP is to give women responsibilities for action against discrimination.
Regarding Dr. Abhay Shukla's presentation on training non-literate CHWs, she asked
about the process of standardising the pictures in the Swasthya Saathi Programme, as
in the field areas of IHMP, different communities gave different responses even to
pictures and visuals. Dr. Abhay responded that though formal pre-testing was not done
but learning material was evolved in three stages by actually incorporating the
responses.
Mr, J.P.Mishra argued that NRHM needs to factor the lack of uniformity in its design.
Since communities are not homogeneous and diversity is inherent in a country like
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India, pluralities at the level of policies to incorporate this heterogeneity is the need of
the hour. Different social structures, norms, practices and differences in role allocation
between men and women before we allot the CHW to women. The guidehnes of NRHM
are seen as diktat by the states and the central government needs to check that. In the
light of this argument Dr. Ravi Narayan added that the success of NRHM depends upon
how much space is available for community level prioritization of the expectations from
CHW and how far the states own the mission. For instance, the ASHA needs to be given
a state specific role, identity and name. He had also said that prioritisation of roles to be
played by the CHW by the community rather than outsiders deciding for them. If there
is will to make the NRHM a success in the northeastern states, we need to call the
states by their names and not club them together.
Ms. Laboni Jana had a basic query regarding NRHM, promoting the curative role of
ASHA as this could amount to creation of another new cadre of non- professionally
qualified medical workers (something similar to quacks).
Dr. Lindsay Barnes responded that ASHA would not be a quack, infact she would be
anti-quackery. She added that in order to play an influential role, the sex of CHW
matters. In a scenario where women are undervalued in general, ASHA being from the
same gender may not yield outstanding impact. The sex of the worker does matter and
this has to be thought about in the conceptualization of the programme with deliberate
thought and planning rather than by default and selecting whoever is available. A
gender blind programme design is as dangerous as a gender discriminatory programme
design.
Dr. Sunil Kaul highlighted the uniqueness of the seven northeastern states, supporting
the argument that the Northeastern region should not be homogenised. He also pointed
out that m the context of his region, political strife and instability is the cause and effect
of all the challenges faced by the community.
C. Evaluating Training
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Ms. Seema Deodhar- Evaluation and monitoring of the training process
Her presentation highlighted the various aspects of evaluating the training process and
its outcomes in CHW programmes. Monitoring objectives and indicators of training that
were determined in the pre programmatic planning phase need to use both qualitative
and quantitative methodologies. The documentation of evaluation and monitoring
should feed into the training programme continuously for corrections, contextualisation
and improvement. In evaluating training, feedback from the learner should be an
integral part. The feed back however, is a general response or reaction, but does not give
you what learners have learnt or accomplished. Feedback and response need to be
separated. Response is followed by evaluation followed by assessment. Assessment of
learning should include skills, knowledge and attitudes, as all these three aspects are
equally important to determine the outcome of training. The performance of the learner
depends on various micro and macro factors, and this is an indicator of the larger
programme and the presence of an enabling environment than just training.
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Panel Discussion (Chairperson- Dr. Nandita Kapadia)-
Evaluation of training is a grey area and there are no fixed methodologies for it.
Evaluation needs to incorporate, not just of knowledge but also of field-based skills.
However, before embarking on evaluation, there needs to be clarity on the skills that is
expected from the worker, which are related to her roles and responsibilities. We have to
design tools and see what has worked and what has not. The forces of rusting and
unlearning need to be checked. Therefore, mechanisms for retention and sustainability
of skills and knowledge are required. She also highlighted the importance of separating
programme indicators from training indicators as the former enables to measure impact
on the community while the latter reveals the impact on the CHW/Trainee. Knowledge
about learning principles and theoretical aspects of learning helps to determine the
learning goals, the outcome and process indicators, the methodologies and
duration/content/spacing of training sessions.
Dr. Narendra Gupta suggested that the focus has to be on monitoring and evaluation of
the training rather than the CHWs performance as this process of training, which will
determine her performance. Dr.N.H.Antia argued that eventually the CHW is
accountable to the community and therefore, they are the ones who should evaluate her
performance.
Dr. Abhay Shukla added that the community must get a structured opportunity to
evaluate the organization, as the organization is also accountable to the people.
But Dr. Nerges Mistry argued that the community evaluation cannot be held as the final
word because within them there are groups with vested interests, many groups within
the community would want to maintain status quo in power relationships which if the
CHW is trying to contest would work against her in the community’s evaluation of her
performance.
C. Partnerships for innovations in training CHWs in state programmes
Dr. Alok ShuklaHis presentation highlighted that the partnerships sought under the Mitanin
Programme at all levels. For this there were consultations with government,
professional bodies, NGOs, Panchayats and village level groups. Mobilization formed an
essentia] part of the entire programme. Changes at all the levels were envisaged and
achieved like policy level reforms at the top. Secondly, changes in the position and
legitimacy of health workers evident from the fact that 20000 Mitanins contested village
panchayat elections and 7000 won. These are evidences of systemic change that the
Mitanin Programme brought about. Whatever might be the success or failure he
congratulated the SHRC team for taking a risk, having spent time and effort for this
size of programme. Supply side will remain important & therefore the issue of
governance, infrastructure, cannot be side stepped.
The Mitanin programme was different from either an NGO or a charismatic leader led
movement. It was conceptualized and operationalise as a movement led by the system.
This meant that it would be based within the procedures and processes of the system.
He explained that Dr. Sundararaman had taken the risk of his reputation to undertake
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the initiative of the Mitanin programme. He also focused that the Mitanin programme
or any CHW programme should lie at the heart of a larger Health Sector reform Agenda.
He also pointed out the criticality of ‘ real hard data’ and how the state government
cannot choose to ignore it and its implications.
He highlighted the concept that the ‘ASHA’ should not be viewed as an employee of the
state, and the state cannot provide her a duty chart.
Mr. Biraj PatnaikHe shared some of the challenges of a large-scale partnership based programme. Firstly,
engaging with a heterogeneous civil society with different social perspectives. Here it
was better to focus on processes than individuals. Poor governance and lack of
willingness at various levels of bureaucracy were other issues to constantly tackle.Biraj
pointed to the difficulties of working together with state and civil society groups. He
also stated that as civil society groups represent heterogeneous interests and hence can
be difficult to engage in a large-scale state programme. He defined policy change as a
virus, which permeates the whole system and needs to be addressed and understood
quickly.
He also felt that the strategy followed by some governments of ‘ contracting out’ to
NGOs could lead to difficult situations.
Panel Discussion (Chairperson-Ms. Shilpa Deshpande):
Dr. Peter Berman commented that the models and examples are there but how can the
urgency of a national mission and the compulsions of a programme be dealt with. In a
large scale programme like the NRHM how can mistakes from the previous programmes
be avoided? One of the suggestions was to make systematic and systemic changes,
evolving strategically viable structures of efficiency to ensure better results. Secondly,
ensuie greater flexibility but-that is difficult especially when guidelines are often viewed
like directions.
He also explained that the NRHM needs to be looked at from 2 aspects, i.e.
organisational / institutional and technical aspects or ‘organisational technology’. He.
explained that both of these require evidence and hence can take time to be
operationalised.
Mi. D.K. Saxena added that the state of Jharkhand has created the set guidelines as per
their local needs. For better decentralization and community ownership, they are
facilitating the village health committee, which will further select the Sahiyyas. This
will help them to provide the services to the last house of every village. Jharkhand, the
youngest state has lots of hope from ASHAs/equivalent. They are developing
mechanisms such that both the system and the community respond to her efforts. Also,
partnerships are essential in the success of the programme.
Mr. J.P. Mishra agreed that if the demands were not matched with the supply side, the
programme would not achieve its objectives. Any community health worker programme
is not a mere health initiative but a community empowerment initiative. Since ASHA is
envisaged along the same line of thought, it comes with a lot of hope and expectations.
He shared the learnings and dynamics of the Mitanin programme, especially in scaling
up. He gave the example of the processes of the creation of Mitanin unit costs, which
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was undertaken through a participatory method and also the Nagaland
Communitization act. He spoke about the multi-sectorality of the Scaling initiative.
Community based initiatives might start in one sector but grow into another sector as
argued by the Planning Commission document (9th plan Mid-term evaluation document).
Finally, he shared that charismatic leaders started Mitanin Programme but while
scaling it up there was a transition from individual led movement to system backed
support. And then the struggle got encapsulated in larger structures. He also felt that
demand side mobilization needs to be matched with health sector reforms agenda on the
supply, and they need to keep pace with each other, else it can become problematic.
In the light of charismatic leadership, Dr. Sunil Kaul asked whether we would find
“workaholics” like Dr. Sundararaman. The dedication and uniqueness of such people is
difficult to replicate. But, Dr. Alok Shukla argued that if the willingness and space is
there, then there are enough charismatic and vibrant people to take the task forward.
Questioning the effectiveness of the Mitanin Programme, Dr. Abhay Shukla said that
there is a strange dichotomy between the birds eye-view and worms eye-view and they
do not match. It has a committed team who has managed to achieve certain things
which have not been achieved by many previous programmes. However at the grassroots
there aie large gaps. While NGOs have a different set of output expectations and receive
different kind of support from bureaucracy, a Mitanin Programme has a unique
character. It had a conducive environment to operate in. He also was unclear as to the
kind of partnerships that SHRC had with NGOs and to what extent the commitments
made by each side were met.
Mr. Biraj Patnaik responded as to how different people see the Mitanin differently and
from both the internal and external evaluations done lessons could be learnt. To clarify
further on partnerships, he shared that the government funded the NGOs involved, and
the funds were routed through the district RCH society. Then the State Advisory
Committee was formed to engage in policy making and with other NGOs on designing
modules. Sometimes the commitments were not met due to constrains like pressure
groups operating outside the system.
Dr Alok Shukla added that the need for social processes to be facilitated and consequent
outcomes to be realized is a very long process and the state cannot keep waiting. It has
to make an attempt and try to deliver health care to all. Mr, D.K, Saxena also endorsed
the fact that the unavailability of some structures or the lack of social processes does not
mean that the work should not begin.
Dr. Nandita Kapadia questioned whether it was possible to go to a village and ask
ASHA to empower the community. It seems too abstract. She needs to be given specific
roles along with flexibility and space for any other issue that may come up in her
village.
Dr..Abhay Shukla said that because ASHA is not an employee, it is difficult to give her a
structured duty chart.
Di—Antia urged to use the word confidence instead of the word 'empowerment', He
mentioned that health is just one of the ways to approach people, as it is the most
mystified and when you demystify it people gain confidence.
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Ms. Shilpa Deshpande (chairperson)' There have been civil society & state partnerships,
which have a range of experiences. In some cases partnerships have been contractual
and in some cases they have been on mutual understanding of how do the NGOs present
in the workshop see and perceive their role in the light of such options and accordingly
go forward.
Mr. J.P. Mishra had some concerns with respect to ASHA’s link with incentives, which
works out nearly equal to ANMs salary. If that is the implicit orientation the selection
process may get vitiated.
Ms.Mekhala Krishnamurthy raised the point that just as the government needs to
create a larger sectoral dialogue and involvement in such initiatives, NGOs also need to
self assess, where they are positioned to play a role in such work. They also need to have
clarity on the scope of such work and the role they might be able to play in it.
Dr. Pervez Imam questioned the use of terms like systems and structures, which
according to him were rigid. Secondly he even raised a concern of involving MBAs and
CAs in Community health projects. While Mr. J.P.Mishra clarified that systems and
structures have a crucial role to play in either large-scale or even small-scale projects.
Dr. Sundararaman shared that we need to understand the skills that an MBA or a CA
brings to the table before we dismiss them. Their expertise in Management Information
System, Monitoring and Auditing skills cannot be undermined and need to be utilized.
Dr. Ravi Narayan concluded the day by saying that this workshop is the end of the
beginning and must take on certain issues. Firstly, seriously study all the partnership
and how systems were developed why they failed or how we can protect them? The issue
of partnership, taking place since mid 1990s has shown positive outcomes. In Karnataka
in late 90s, the Civil Society Organizations (CSOs) were invited to chair and be the
secretariat of the task force of Karnataka followed by writing the state health policy &
the Integrated Health Management Programme. The supports by many CSO to the
Rajiv Gandhi Mission in Madhya Pradesh lead to the evolution of schemes like
Swasthya Jeevan Gurantee Yojana & Jan Swashthya Rakshak. Today, there are
examples of the Mitanin programme and the upcoming Sahiyya working group
partnering with NRHM. He also added a few words of caution like not to reduce NRHM
to ASHA & deduce the work of State Health Resource Center to Mitanin Programme.
Learn from Karnataka and Orissa where government and civil societies are partnering
to try & improve the government’s institutional mandate in reaching people. He
suggested not reducing the importance of interventions to individuals. Despite
charismatic individuals, bureaucrats, and technocrats being responsible for initiating
manv innovative ventures, it is the systems that enable any venture to get executed.
Finally there is a need to strike some sort of synergy between the broader scenario of
larger movements of the civil society and larger forces of globalization. There are various
examples of innovations. Large number of materials is available. One should build a set
of accessory resource inventory of grassroots level learning material as a reference
package.
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Day 3 (April 12, 2006)
Training Content & Methodologies for Community Health Workers at Scale
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Key Note- Approaches to achieving scale- Missions and Movements
Dr. T. SundararamanHe began by saying that neither all the big programmes are a failure nor all small-scale
programmes are successful.
Dr. Sundararaman’s key point was that one needs to acknowledge the difference
between scaled CHW programmes and small scale programmes. These have
implications on all aspects of running these programmes and hence these should be
viewed as two distinct entities and not clubbed generically as CHW initiatives. He went
on to highlight the differentiating factors between small scale and large scale
programmes. He explained that small scale programmes tend to be very focused, with
high quality inputs and have tended to focus on curative care also. They also have a very
strong and dynamic leadership factor, which is very critical to their functioning and
eventual success. On the other hand they do tend to underestimate costs, and can get
unsustainable in the long run.
His presentation highlighted the critical factors for the success of small scale
programmes and the cautions, enabling and disenabling factors in running large scale
piogiammes. He also detailed out aspects for operationalising large scale training and a
need to understand that the quality of training (which includes ongoing support,
monitoring, referral support, evaluation) is defiantly impacted at such scale. He
explained that the idiom of opportunity needs to be explored in such large scale
programmes. He also explained that a certain pace within the programme needs to be
maintained, and is critical to political commitment. He also felt that by reaching full
coverage, the programme creates for itself a critical space within a state.
He also explained that though state run programmes have more structured processes, a
certain amount of flexibility needs to be allowed for corrective processes. This also
relates to phasing in a CHW programme iin a state and learning from the first phase for
the future.
He explained that motivation follows a ‘Gaussian curve’ , and this can be applied to the
public health system, or any system involved in a scale up process. 5% of all the
individuals involved in this would have the sensibility, motivation and potential to
work selfless ness, and impact the overall programme.
It is not NGO versus government but designing and implementing a successful
piogramme, ensuring a good quality of referral support and monitoring large scale
intei ventions. As boucault argued that Power is privileging and disprivileging under the
same scenario, therefore, how can power be subverted from within” was a key question
the answer to which could have yielded a successful model of intervention. A model that
could bring about change. He said that there are predictable consequences of actions and
inactions but it is alternative actions that have unpredictable results. If we go on
building exceptions and alternatives then we might get change. In negotiation,
partnership, and peisistence one needs a place to stand and then leverage change. He
concluded with an appeal to persist in working with largcscale state programmes.
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Dr. Abhay Shukla'
He shared the experience of Swasthya Saathi Initiative based on partnership with
Peoples movement. Training inputs were standardized especially the ones for the semi
literate. Village health activities were sustained locally thus a decentralized and costeffective model was developed. Linkages with the public health system especially in
terms of inviting government officials as trainers on topics like how to keep water
sources pollution free. In May 2004 the functionally literate CHWs have been accredited
through a course designed by Saathi-Cehat approved by the SNDT University.
He also explained their work in Madhya Pradesh, which involves working in 40 villages
of Barwani district. Here selection process has been initiated through gram sabhas and
as there is a majority of non-literate health workers, special training curriculum has
been prepared.
Discussion-
Dr. Nerges- She argued that goals of all these rights based approaches shared in the
presentation are largely similar i.e., to build a critical mass, reduce exploitation and
both focus on activating and creating linkages with the public health system. To some
extent both seem to want to integrate with larger socio-economic issues. Sundararaman
suggested this through an enlightened systematization with the focus on human
dynamics. The second approach could be piggy banking on movements, as well as for
integration of the voluntary sector with government led & owned programmes. He
finally showed the role that these learnings would play a crucial role in taking forward
the in ASHA programme in Madhya Pradesh.
Ms. Shalini questioned Dr. Abhay Shukla on his presentation which did not share the
constrains that Saathi-Cehat experienced while working with peoples movements as
Peoples Organizations (PO) have their own flow and way of functioning. While upscaling v/e need to partner with other organizations and for that the NGO has to put in
a lot of efforts in pushing their agenda which may become problematic while working
with a PO which has a different perspective all together. Dr. Abhay Shukla said that
there could be long discussion on the problems of coordinating. Basically, the agenda
was to bring health on to the agenda of people’s organization. This is a complicated
process especially when health is dealt as a service issue. Funded NGOs dealing with
PO, which does not receive any fund, is a complicated. Level of interest of PO in health
is fluctuating. Main initiative was taken by NGOs and when larger issues crop up the
PO also gets involved in mass action and that compensates for the other routine
problems faced.
Prof. David Sanders^ said that the success of community workers programme depends
on the political activeness of the people and availability of technical tools for community
mobilization, without any of which, it is very difficult to sustain itself.
Mr. Raman agreed that sustaining political will is difficult and challenging. Prof
Sanders raised the question of‘how to sustain the political will within which community
health programmes and health initiatives in general could survive? Can participatory
approaches in training start engendering political movements, which then coalesces
with similar activities in other sectors?’ He said that the challenge is to convert political
will into a political wish, which again can be problematic.
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Dr, Sundararaman responded that it would be difficult to replicate processes as they
are unique and context specific. Regarding the political will, which tend to fluctuate,
cannot be seen as constraining and discouraging. If the facifitation is intense enough
then even if the political will reduces some core messages will always have a space in
peoples mind like a woman living in rural house hold can take care of the health of a
child and need not depend on the doctor for everything. Political approaches to training
means a very different style of training and that kind of training may not be replicable
or up scalable as there it involves a special relationship between the trainer and the
trainees, involves context, confidence of the trainee that the trainer has some
commitment and is not merely a technical person.
While Dr.Sundararaman said that health policies and decisions at the level of the
government have been made and it is difficult to ignore them but Dr. Anant Bhan
pointed at the fact that till date India has a hypocritical health policy; determinants of
health based on the pathology; constant undermining of development in real sense of the
term; pharmaceutical corporates patenting policies; a reduction in public health
spending etc. Responding to Dr. Sunderaraman, Dr. Anant Phadke added that in a
retrogressive scenario, how can there be a recommendation to work with the state. But
the way you embrace it or get engaged in it is deeply politically problematic. To engage
is one thing but to embrace it is another stand. And this is also threatening for the
activist/movement perspective. Gain for SHRC is loss for PHM! Finally, he argued that
this workshop has tried to make some contribution in the history of the people’s health
movement in India and this kind of contribution is bound to have its historical (time &
area specific) limitations. By the word movement itself it is clear that it is episodic. Even
if we failed we have made some contribution.
•
Group Discussions on aspects of CHW training at scale
The participants were divided in three groups and each group was asked to discuss,
document and present their reflections in front of the entire house. This intense and
vibrant session had the following learnings'
Group 1- Content, Methodology and Human Resources (Facilitators1 Dr. Sunil Kaul and
Mr. Raman)
What are the essential principles for determining curriculum and pedagogy for
CHW programmes?
The group discussed that the kind of training will depend upon the kind of role
expectations from ASHA. The group enlisted some non-negotiable like the modules
should be generic and flexible for contextualisationi the content should contain topics on
Equity, Gender, Entitlements, Rights and Responsibilities; the categories of‘must knew’
and ‘good to know’, the information on basic medication and borne based medicines;
trainings must be in regional languages and use audio-visual tools.
■
What are the methods, structures and institutions for contextual and effective
implementation at scale and how can monitoring and evaluation be integrated?
The group suggested that the trainings should have an empowerment and confidence
building approach; the nature should be interactive and participatory with use of infield
training and working on-job with existing CHWs. A Cadre of Trainers by conducting
TOTs should be developed. After the initial phase of trainings, preferably the CHWs
■
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aWppt^dATPf:r:ra^SehxeUmplTmo°del coTcZert'e"8
f01i°Wlng & CaSCade
structure which supports health sector along with CHWs autonomo
tT SHRC
recognition by the government; partnership at all IpvaU il l
/
h mandate &
outside the government. Regarding Monitoring and F 1 6 7 a. dynamic Person from
use techniques like peer reviewing.
S
d Evaluatlon’ 11 needs to be inbuilt,
accountabilitylonfdIXcata a arcatcr Z ' T
"“'a1
t''*in"’ES »ith
the trainers at each level. The experienced CHWsran'bo omnted (TOT p'l;ty.a,"0n68t
sx oXnvrr
manage to incorporate and Literate pXZXaX”
bsz
Group 2: Partneroh.ps (Facilitators: Mr. Mishra, Dr. M.stry and Dr. Mathur)
What are the critical learnings from
civil society and government engagement
historically?
The group discussed that a ’
/2ry vuned and contested history of state-civil society
partnerships in the health sector
^workshojXf " 3
6XP™
from the past as illustrated in
ThXXXXXXVaX^^
some places and can he opened up and neXXX
the .pirit ot„lllca, renectlmi
"
the
------ question of partnerships.
■
The group enlisted
Central and
with Government;
partnerships; NGO with NGO; Goverument-NGO
■ These partnerships can be initiated at various levels:
1. MZXgntGXXXnnd“;l,Z fra7'™* ‘-"-Vpcs of partnership);
2.
g-a pXpXfLSXXZXXiX “d
3. State Governments develop state-specific frameworks for engagement.
' opportunifes
™Mit.et°f„PIXXdXnX"
the r’X Of«» >"<-«•
Rut thf
ent on state-specific histones, current contexts and
based °”8tren8tha a“d
■ Framework for Partnership
1. Vision/ advisory level
2.
etP7ent °f t001Sand 'nstruments for implementation
3. Implementationsupport age'ncle's
■■"Planting partners and format,on of resource
4 Design a criteria for partnerships al various levels
O. hollow a transparent selection process and procedure
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Group 3- Support Structures for CHW Programmes (Facilitators: Dr. Sundararaman
and Prof. David Sanders)
What are the ideal contexts and support structures required for effective CHW
programmes?
The state is aware of its inability to provide and now it is opening up for innovative
interventions where NGOs can play a crucial role. If community mobilization and
advocacy are important aspects of the NRHM then here is a context where the civil
society organizations can step in. Though ASHA is viewed as a support worker she too
needs supports like Trainers (who could be from NGOs), Medical practitioners (who
could be upgraded ANMs), ANM, AWW, Panchayat members etc. but until the PHCs do
not work ASHA may not be able to do much. The other support structures for ASHA
include Technical Assistance Agency/Re source Center at the district level; statutory
bodies like Panchayat Health Committee, which ASHA can energize; local institutions
like Village Health Committee, which ASHA can mobilize and organize.
Basically a training and technical structure is what is required at the district and state
level which will provide for facilitation of advocacy and mobilization role.
■
What are the prevailing opportunities and constraints within which the NRHM
is operating?
The opportunities include a vast range of technical skills that various experiences in
public health have generated. People can be mobilized for demanding accountability in a
manner that they do not alienate the system but get the most out of it.
■
■ How can these be effectively influenced and informed?
The attempts for setting up District Programme Management, Public Health
Foundation and Public Health Resource Network can enable an effective use of the
current opportunities.
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11386 Po<>
Concluding Remarks
Dr.Shiv Chandra Mathur pointed towards the concern of ownership and leadership of
the NRHM.
1. The organizational culture of the government needs to be understood. Some kind
of exchange of information between enthusiastic bureaucrats and field level
workers is needed.
2. Need for an ASHA programme needs has to be examined and determined at the
district level.
3. There is no linkage between ANM and ASHA and we need to lean from the Dai
I raining Programme, which failed because of no liaising between the dais and
public health workers that was sought.
4. There should not be isolated structures for ASHA training,
as she needs to be
linked with other public systems and structures.
5. Mission cannot work in a government department. It needs to be an autonomous
unit with linkage with the government.
6. If the center plans, funds and directs all the missions and programmes then why
are the states asked to own them or take them forward. Why can’t the center
make ‘health’ a state subject?
Mi.J.P.Mishra said that health is a state subject and the more focus and ownership
taken at the state level, the wider and deeper would be the D
impact. The quacks in
villages are not mere representations of the private sector but an exhibition of the
Private Practice of Public scenario.
Dr. Sundararaman shared that costing of the CHW programme is a necessity. A
community health worker programme can address issues of social inclusion, nutritional
security and emergency thereby changing the nature of community health work.
If we train people on effort intensive areas with low volume of expenditure then a low
cost high impact activity based programme can be very well developed.
Prof- David .Sanders: Success of ASHA (and NRHM) depends on tthe socio-political
context, technical factors and financial input. While technical factorsa can be planned.
socio political factors are less amenable to manipulation, Key socio-political factors
include community mobilization and political will,.which are: synergistic. Participatory
planning and implementation can facilitate community mobilization. Community-based
workers can catalyze and sustain community mobilization. But Community mobilization
and political will often dissipate as political context changes
Key technical factors include Capacity development for training and ongoing support
and supervision from levels above; participatory approaches to assessment and analysis,
using appropriate technologies and methods; planning with Intersectoral action and
sustainability in mind. Capacity development in two aspects is very essential technical
health and advocacy/mobilization.
He was impressed with the enthusiasm and energy prevalent within the various groups
to aspiie for a hopeful and successful future. The opportunities afforded by current
political conjuncture e.g. NRHM was, according to him, one of the reasons for that.
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National Workshop on
Community Health Worker Training : Linking Pedagogy and Practice
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Reflections and Recommendations
The Workshop
The Foundation for Research in Community Health (FRCH) and the Social Initiatives Group (SIG)> atJCICI
Bank had organised a National Workshop on Community Health Worker 1 raining. Linking Pedag gy
Practice during April 10 - 12, 2006 in Pune.
The workshop represented an effort after almost a decade to bring together a diverse group of individuals
Lhh t atm to initiate sectoral dialogue and action on community health worker (CHW) trammg, and sustain
h th "ugh a network of ’source and research organisations. Located within the current context of the
National Rural Health Mission (NRHM) and its core strategy of introducing a trained com™n'ty
worker - the Accredited Social Health Activist (ASHA) - the workshop a.med to share an conso! date
innovations and learnings in community health worker training across programmes over the last three
decades' discuss and develop initiatives to mainstream these innovations and learnings to extend coverage
«f—-y “
“i»7“-'' ‘ d“tos":xcSHM
between various health worker training programmes, and between civ.l soc.ety groups and the NRHM.
The current context within which the workshop was organised presents a substantial body of past exPer'e"“
and evidence gathered over 30 years of innovations in community health worker programmes, and th
current opportunities presented by the NRHM and its core strategy of the ASHA - a tramed common
based change agent at a 1000 population level, to catalyse a sustainable community-owned process for
behaviouraRhange and to facilitate access to basic health services by the poor In this context the w°rks"0P
wt organised ^address the issue of training in CHW programmes - learning fromMnnovat.ons m CHW
training in various contexts and operationalising these at scale in tne context of the NRHM.
The workshop brought together representatives from the central government and from the stales of
Jharkhand Chhattisgarh Rajasthan and Nagaland; civil society representatives and practitioners from mo
1nan Sf e’nl iffe nt groups and programmes in various parts of the country; academics from interna mna
ancI uni versifies; ^and mldia persons to share experiences of and perspectives on content and
methodology of training community health workers.
The Focus Areas
The workshop focused on training content and methodology innovated in both government and civ.l society
groups in CHW programmes over the last three decades and systems to implement these innovations at scale
by integrating wkh the NRHM. The presentations, discussions and debates focused on important aspects
C W SZ - methodology and human resources; training in varied contexts w.thm ’he county
partner firns ft conceptualising and operationalising community health worker programmes, and support
stttuTes required for the succ^sfui implementation of such programmes. The focus areas of d.scuss.on in
the workshop were the following:
.
Locatinq CHW programmes within the larger context: One of the issues that was highlighted
the freer context of globalisation and the maerosystemic environment of debt and structural
adjustment policies that exacerbate inequities both within and between countries in all dimension, of
development, including health. Professor David Sanders, in his introductory key note address, raced
the international history of CHWs and the emphasis on people's participation in ensuring basic
of communities. It positioned CHW programmes within global economic, social and Pollt'ca'
nrocesses which in turn determine the characteristics and efficiency of these programmes. The
discussions indicated the global debt crisis and the medicahsat.on of health as significant sociaL
economic and political determinants of negative health outcomes, especially for the poor and
vulnerable In this larger context, CHWs have internationally been perceived as agents for realising
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the right to health for the poor.
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Past experiences of CHW programmes: The workshop traced the long history of innovation in
the area of CHW programmes in the country, with civil society organisations having pioneered the
development of successful community health worker models in different geographies. For instance,
as was presented in Dr. Ravi Narayan's address, the health workers of the Comprehensive Rural
Health Care Project in Jamkhed, the Sahyoginis of the Foundation for Research in Community
Health (FRCH) in rural Maharashtra and the health workers of Aarogya lyakkam in Tamil Nadu,
have achieved some success in emphasising an empowerment approach to health and in achieving
desired impact on health outcomes, albeit with limited population and geographical reach. While
civil society groups have shown consistent success of community health worker programmes in
achieving better maternal and child health outcomes, those undertaken by the state at scale have
shown mixed results. Noteworthy among these are the Community Health Volunteer Scheme
initiated in 1978 by the Janata Dal Government, and the Jan Swasthya Rakshak programme launched
by the Government of Madhya Pradesh in 1995. These programmes, however, did not have the
desired impact on health outcomes due to structural gaps in the system, issues in training and lack of
supportive human resource. The disparity in experiences of community health worker programmes
initiated by civil society groups in intensive field areas and by states at scale were traced to three
main factors namely, programme design that involves the conceptualisation of the role and profile of
the community health worker, support structures at the level of the community and linkages with the
health system; lack of state capacity in terms of technical resources to conceptualise and implement
the programme at scale; and lack of civil society participation in designing and implementing these
programmes in order to draw on the experience and technical knowledge of such groups to formulate
informed state policies.
•
The NRHM and future opportunities: The most recent conceptualisation of CHWs at scale has
been the Accredited Social Health Activist (ASHA) Programme, which is a core strategy of the
National Rural Health Mission (NRHM). The NRHM was perceived as a renewed political
commitment of the present government, presenting an opportunity for mainstreaming the
experiences and learnings from civil society innovations. However, the impediments of the past
scaled CHW programmes were identified and the need for change recognised. The workshop
highlighted the issues, debates and queries relating to the perceived lack of autonomy for stales in
decision making and fund utilisation vis-a-vis the central government, the gap that arises due to this
between the conceptualisation and implementation, and the lack of state capacity to independently
undertake these functions. Moreover, the ambiguity in the implementation plan regarding selection,
training, support structures, linkages with the public health system, monitoring and evaluation, and
fund allocation for the ASHA programme was also raised.
Innovations in training content and methodology in CHW programmes: The workshop
highlighted innovations in training community health workers in various programmes from different
parts of the country. The discussions on the training models and systems in the Comprehensive Rural
Health Care Project of Jamkhed; the training methodology and content developed by FRCH; the
innovations in using information-communication technology in CHW training presented by Dr.
Shyam Ashtekar; and the training structures and support systems in the Milanin Programme of
Chhattisgarh contributed to ideas about planning and implementation of CHW programmes at scale.
The process of “training for transformation”, emphasising self discovery and awareness about social
realities, learning from peers and a phased training plan with continuous support, and a flexible
learner-centric approach were the core principles of training in these CHW programmes. Keeping
these non-negotiables in focus, the experiences from the Mitanin Programme highlighted the realities
and challenges of training CH Ws at scale.
CHW training in varied contexts: The workshop discussed issues related to the need for
contextualisation of CHW training to respond to the heterogeneous realities like the relative strength
and ubiquity of public health facilities, the prevalence of non-literacy among CHWs and situations of
political strife and conflict. Experiences of the Action Northeast Trust in implementing CHW
programmes in eco-politically unstable areas of Assam, with a complete absence of health facilities
added to these discussions. The need for contextualised training material and media for non-literate
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workers (for example, the material innovated by Sathi-Cehat in tribal Maharashtra), adapting
material to local practices and beliefs and the use of local dialects were highlighted by experiences
from different programmes in the country. Besides, the roles of the CHW and therefore, the skills
that the training programme builds require to be defined contextually, depending on the health needs
of the community and the available health services. This was exemplified by experiences of different
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programmes in training CHWs on preventive promotive skills with the primary role as a behaviour
change communication agent, versus training in clinical skills for providing basic diagnostic and
curative care. Another major highlight in the workshop was the issue of integrating gender in CHW
programmes. Experiences of Jan Chetna Manch from rural Jharkhand emphasised the need to focus
on gender as an underlying factor in health, and therefore, the necessity to build perspectives on
gender into training programmes for CHWs.
CHW training at scale: The workshop discussed approaches to achieving scale for development
•
programmes through state systems and people’s movements. Experiences of the state level Mitanin
Programme in Chhattisgarh and the people's organisation based Aarogya Sathi programme facilitated
by Sathi-Cehat, in their attempt to sculpt out their own approach by integrating fundamental
innovations in
design and implementation, have the potential to provide learnings for such
programmes at scale. The workshop facilitated focused discussions on various aspects of CHW
training at the scale - content, methodology and human resources; monitoring and evaluation ol
training processes; support structures and partnerships. Also emphasised was the need for
partnership building, capacity building and sharing of resources between the state and civil society in
conceptualising, operationalising and implementing CHW programmes at scale. In this context, the
workshop discussed issues related to ambiguous boundaries between state-civil society engagement
and co-option of civil society by the state. However, drawing from the evidence and experience ot
the varied and contested history of such engagements and partnerships in the health sector, there was
an emerging consensus that political spaces for productive engagement exist in certain situations and
can be opened up and negotiated in others. The issue of partnerships was approached in this context
and spirit of critical reflection on the scope, framework, types and the processes involved in budding
these relationships. Innovative ways of integrating civil society efforts and experiences in the field ot
CHW training with the vision and space provided by the state as articulated in the NRHM were
discussed and hoped to be achieved.
Future Directions
The workshop is the beginning of a sectoral dialogue and indicates various initiatives that can be undertaken
in the future to sustain and forward this effort. Some of the main learnings and recommendations are the
following:
.
Government and civil society partnerships at each level of the decentralised structure of the NRHM
- at the state, district, block and village levels - to facilitate training of the ASHAs, their traineis
trainers and
the other personnel involved in this process.
.
Capacity building and training of government personnel, especially at the district and block levels,
on developing and implementing training for the ASHAs. At the state level, this can involve efforts
such as workshops to orient the State Mission Directors / State Facilitators about the various
innovations and best practices in CHW training in the sector.
.
Integrating learnings from civil society innovations about community mobilisation and CHW
training into the conceptualisation and implementation of, and support to the ASHA programme at
the level of scale.
.
Undertaking review and development of state training modules m a participatory manner by
involving personnel from different levels, as well as seeking feedback from local and sectoral
experts Related efforts have been initiated in Jharkhand for the development of the Sahtyya training
modules The training content which was initially defined by personnel from the state district and
block levels, in collaboration with local civil society groups, is now being reviewed and fmalised in
a state level workshop by sectoral experts from across the country.
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Developing contextualised training content and methodologies, that can sensitively respond to the
unique contextual realities in different geographies across the country. Contextualisation can involve
development of training modules in local languages/dialects; designing content to address local
problems, beliefs and practices; defining the roles and scope of the ASHA to best suit local needs;
and adapting training to suit the profiles of the human resources available in different regions.
•
Building gender sensitivity into training content for the ASHAs, as well as for personnel at all levels
associated with the training system.
•
Developing specific training content for non-literate ASHAs, keeping in mind the high prevalence of
illiteracy in the country, especially among rural women.
•
Consolidating sectoral experiences in CHW training into easily accessible resource material and
undertake its active dissemination to facilitate the ASHA programme.
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Undertaking research on training content, methodology and systems in different contexts to build the
body of sectoral knowledge.
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Community Health Worker: the scope of and hopes from ASHA1
Swati Dogra
The Foundation for Research in Community Health along with the Early Child Health
Team of Social Initiatives Group of ICICI Bank arranged a workshop titled,
"Community Health Worker Training: Linking Pedagogy and Practice" during 10th to
12th April 2006. This exercise was especially crucial in the light of the National Rural
Health Mission2 that focuses on ASHA and aspires to undertake the herculean task to
train four lac community health workers across 18 states in India.
Three sectors including the government, who has launched this mission as well as the
non-government sector along with the funders, were represented in the workshop.
Consequently, there were numerous and often differing perspectives, that reflected the
varying contexts and experiences that each one present in the workshop represented.
This diversity is especially significant in a country as complex as India where there is
simply no ONE way of getting things right. The need is for sharing, consolidating and
learning as a way to effectively move forward.
While the focus was on sharing experiences, the workshop strongly surfaced the
tentativeness with which NGOs and government can work together. The thin line
between partnering with each other versus embracing the others' modus operandi; the
fear of collaboration taking shape of cooption; the apprehension of converging ideas and
experiments at the cost of losing originality of each, were some underlying hiccups that
the workshop raised. But a clear message to build exceptions and find alternatives by
embracing bold and innovative partnerships was seen as a way of looking ahead. These
new sets of relationships need to value the strengths of each partiter along with
understanding their inherent weaknesses.
The following article examines this National workshop, which gathered various camps
of practitioners of public health to reflect on each- other's experiences and evolving
directions for the future. While the event may not have encapsulated the diversity
completely, it certainly is a 'beginning' of inter-sectoral dialogues.
In a nation, where the political environment is going ahead and allowing economic
categories of wealth, accumulation, consumerism and fetishism to become the basis of
development. In a scenario where hunger, malnutrition and abject poverty are barely
getting marginal attention against the food courts, medical tourism and so called
economic boom, the National Rural Health Mission (2005-2012), is seen by many as an
opportune moment.
1 Accredited Social Health Activist (ASHA), is a strategic position created under the NRHM for promoting
access to improved healthcare at household level through a female health worker.
2 National Rural Health Mission (NRHM) is launched in 18 states namely Arunachal Pradesh, Assam,
Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu & Kashmir, Manipur, Mizoram, Mcghaya,
Madhaya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh. Through
this mission, the Ministry of Health and Family Welfare, Government of India aspires to make
architectural correction in the basic health care delivery system by improving the physical and
qualitative access to public health by the marginalized section of our country.
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NRHM indicates a political will to synergize health with nutrition, hygiene, sanitation
and safe drinking water; sees health as a part and parcel of a larger system as well as
focuses on the Public Health Center; it attempts to increase public expenditure on health;
envisions decentralizing management of health programmes, assets and personnel;
aspires to mainstream Indian systems of medicine and make comprehensive primary
health care universally available.
Regarding the NRHM itself, the participants raised various questions and concerns
especially because improving health cannot merely involve bio-medical interventions,
but requires an addressal towards social, economic, political and cultural dimension.
These could be summarized as the following:
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Who owns the NRHM?
Why has a mission mode been chosen?
How can a mission based on the principle of decentralization be centrally
envisaged?
How can decentralization of the mission be ensured?
Why are the State Governments viewing the guidelines given by the Central
Government as a final diktat?
How real and achievable are the goals of this mission?
Does the mission have yearly objectives, outputs and indicators?
Why the HIV-AIDS activities are are not clubbed under NRHM?
How does NRHM intend to converge vertical programmes?
How can the impact of NRHM be measured in the light of other existing health
programmes?
How important are the non-government initiatives to the government?
Who will synthesize learnings from small non-government experiments and
utilize them for NRHM?
How will the aspiration of involving a range of stakeholders and players be
coordinated?
Along with these questions that the workshop brought to the table, there were
discussions on how basics of community health have been understood both by the
conventional and alternate thinking. But it was interesting to note that within the
alternate camp, multiple experiments have given rise to varied perspectives of looking at
health. These models were developed in different states to address needs of precisely
those areas where they were based. The experience and learnings of each programmatic
intervention is crucial because they have provided impetus for policy level changes and
continue to point at the lacunae in the public health systems.
What has been the approach to community health?
Demystification model: It is believed that health is not equal to treating illness. Illness
dramatizes health and medicine mystifies it. This drama and mystification alienates
people from understanding their own mind and body. The medical system has failed to
reach out to the people and therefore, a need to develop systems of localized.
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decentralized and integrated models of health care need to be re-established. Rather
than making patients out of people and then looking for medical solutions to cure them,
the focus on community health needs to be on promotive and preventive systems that
our countTy has a rich heritage of.
However, there were arguments against this simplification model, which is believed to
necessarily homogenize problems of the poor. The risk of trivialising health of the poor
by focusing only on preventive, promotive and very basic curative care, rather than
secondary and tertiary curative services could lead to ignorance of another kind. The
assumption that rural life and people living in villages have simple problems tends to
overlook complicated, diverse and heterogeneous health needs. Science and medicine
have influenced our categories of understanding to such a great extent that complete
dismissal of it is something that seems difficult to achieve.
While both the approaches are interested to reach out to the people's health in an
integrated manner, one sees health as a category within the broader category of health.
The other does not limit health to a functional part of the wider structure but looks at
specialized categories within health itself.
How health programmes view Community Health Workers?
With evolving and changing perspectives in the development sector, community health
worker programmes have taken on the shape of a community empowerment initiative.
Here the activist role of a CHW has gained priority. However there continue to be
constant dialectics between the roles of a CHW. Is he or she going to be a service
provider or a demand generator i.e.. Instead of being a supplying agent, the CHW, will
be an animator who mobilizes people to avail health facilities as their right. Under this
dichotomy some argued that Clinical skills should be taught to CHWs only after their
mobilization and facilitation skills are developed. Therefore, more than managing
medical illnesses, the NRHM should be working towards training the ASHA
(Accredited Social Health Activist) to work on the existing health practices and behavior
of the community.
Within the category of behavioral change, which the CHW is supposed to influence, it is
not individuals but groups, especially the hegemonic ones whose mindset needs to be
changed. Here too there were a series of questions that were raised:
• If the ASHA does not already have an influential position then how would the
dominating practices get shaken?
• How will a ASHA belonging to the non-dominant group influence the dominant
mindset?
• If she is from the dominant group then how will she get acceptance in her own
community if she becomes a representative of the oppressed side?
• If the ASHA is well received then will that indicate that she has succeeded as a
change agent or succeeded as a conformist?
These questions become crucial if the NRHM aims to regularly monitor and evaluate the
impact of ASHA.
But coming back to the role of ASHA as a supply agent versus a demand generator, the
reality of remote areas with minimal service system becomes the point of attention.
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Without enough hospitals and doctors, even if the CHW mobilizes the people,
who will the people go and demand health facilities from?
• What facilitating role can be played under circumstances where the bare
minimum does not exist? .
• Then don't diagnostic and curative skills become as important as the
mobilization and advocacy skills?
Therefore, some amount of capacities in curative care does become essential.
•
But the new roles entrusted to the same CHWs have not over ridden the older roles
thereby creating work load and multiple role expectations which gives rise to another
set of pragmatic issues:
• Is it practical to expect the same CHW to do social mobilization and curative
work simultaneously?
• Is it possible to view social commitment and responsibility in isolation from
economic needs and monetary value?
• If a woman is utilizing her home-based labor time to carry on activities for the
community then for how long will her spirits of voluntarism be the only source
to bank upon?
• How will the compensation to a CHW be calculated? What relation will the
amount have with the amount of compensation paid to the Auxiliary Nurse
Midwife and Anganwadi Worker?
How a Community Health Worker has been trained and oriented?
The various experiences shared by the organizations present in the workshop, enlisted
that trainings that are most conducive to adult learning are the ones using non-didactic
and non-conventional participatory methodologies. Trainers need to be facilitators and
address the multiple learning requirements of participants need to be addressed. There
was a concern that ASHAs will have new and varied requirements to learn and grow.
The career path of ASHAs needs to be looked at from a long-term point of view. On-site
and In-situation back up along with regular lateral'sharing is the key to polish and
improvise on the knowledge and skills. Use of pictorial and non-classroom modes of
trainings have been improvised and must be incorporated in any adult learning
endeavor.
On the one hand it was agreed that, experiential and affective learning enables long term
and deeper impact. On the other hand, it was felt that the use of technology and distance
learning should also be explored. Evaluation of the trainings and trainers was suggested
to be inbuilt in the programme.
Interms of content, trainings conducted in programmes of CHWs have covered a range
of issues and themes. They have been forums to pass on technical know-how and
generate a sense of social responsibility. While innovative, interactive methodology
along with holistic and integrated approach was commonly accepted as the most
effective, there were some debates on the extent to which integration of issues and topics
would be possible. This was an offshoot of the existing dilemmas with respect to the role
of CHWs.
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From curative, preventive and promotive of health to even broader and more
sensitive themes of Community building need to be incorporated in the content
of CHW trainings.
Income generation, public issues, rights and responsibilities, ethics and equity,
environment, ecology, effective communication and community mobilization are
some of the significant topics that CHW trainings should cover.
Through trainings, a set of holistic and integrated approach to development
needs to be instilled.
Even information on national health programmes, water, sanitation,
immunization, referral care, veterinary care as well as discussing lacunae in the
available systems should be added to the content of trainings.
However, many models of focused, on-going and contextual capacity building
interventions have succeeded in programmes,of limited outreach. There were concerns
as to how they could be up scaled. It is a fact that the structure for implementation and
availability of physical and economic support is crucial for performance even more than
the training component. But success of NRHM cannot be reduced to a community health
worker strategy alone.
How can the challenges for ASHA be understood from the above?
The multiple expectations owing to the multiple lacunae in the health delivery system
are envisioned to be addressed through an Accredited Social Health Activist (ASHA)
provided she gets proper orientation and training and has a back up of support available
to her. Without adequate structural strength, it is highly unlikely that the hopes from an
activist model of a Community Health Worker be turned into a reality.
Both her position and role become strategic because she is viewed as a part of the system
as well as an independent entity at the same time. This perception comes from the fact
that if you institutionalize and standardize a role and position then it takes an objective
and mechanical shape, which the NRHM hopes to avoid. So, there is a need of a person
who stems from the system but yet does not suffer from the bureaucratic hassles of it.
Secondly, to ensure an effective performance, she needs to convince and reach out to the
community whom she should be accountable to. ASHA has been envisaged as a
position designed from the top, which needs to be accountable to the bottom and as a
role that facilitating demands and mobilizes supply. The legitimacy of ASHA in the
existing system that is already in place like both the local governance institutions as well
as public health systems will influence her ability to bring about any change.
ASHA has been carved out to be a position and role that can work at the root of the
problem tree and actually influence the shoot. It is also a model that has been allotted
space to maneuver as per the local requirement. It is a part of the mission that
acknowledges and aims to utilize the concepts of decentralization, people's participation
and partnership, in practice. But the success of ASHA depends upon availability of:
•
•
A set of motivated trainers,
An investment in physical infrastructure (availability of efficient PHCs)
5
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•
•
Cooperation of Medical practitioners, Auxiliary
Anganwadi Worker
Support and acceptance from Panchayat members
Nurse
Midwives
and
The other support structures for ASHA include Technical Assistance Agency/Resource
Center at the district level; statutory bodies like Panchayat Health Committee, which
ASHA can energize and; local institurions like Village Health Committee, which ASHA
can mobilize and organize.
But tlie difficulties that ASHA will face due to lack of doctors, the role clash that she
would have with the ANMs, tire lack of mechanisms to coordinate with AWW, the
marginalization of the existing mid-wives and their enriched experience are some key
issues that the mission leaves out. Secondly, the declaration of ASHA being a woman
comes from and feeds into a whole range of gender stereotypes. It was pointed out
during the workshop that if we look at the dais and doctors through a gender lens then
the former are feminized ends of health system (marginal and poorly compensated)
while the doctors are the masculine ends (highly valued). The nature of work that
community health workers have been doing despite being very valuable is not
recognized as an established profession. Selecting women to play roles of such
amorphous nature can therefore be questioned. If women have a marginal say in terms
of control over decisions, how will be able to single handedly bring about a completely
opposite outlook. Perhaps it is essential to look at different social structures, norms,
practices and differences in role allocation between men and women before we allot the
CHW position to women.
NRHM has a formidable task of factoring in some space for diversity as well as evolving
strategically viable structures of efficiency to ensure better results. The workshop
provided a forum to view NRHM as an opportunity to re-look at the last 20 to 30 years
of community health worker programmes (and their trainings) for the purpose of up
scaling and replicating. To learn from them, the government needs a set of central
accessory resource inventory of grassroots level experiences and learning material as a
reference archive for NRHM.
Since community mobilization is seen, as a major component of the mission,
partnerships with civil society organizations who have expertise in facilitating processes
of change, is the need of the hour. A training and technical structure is what is required
at the district and state level which will provide for facilitation of advocacy and
mobilization role. So the Ministry of Health and Family Welfare needs to create space for
meaningful utilization of the various small NGO experiences in NRHM. Simultaneously,
the NGOs should be willing to work in an all-together new mode of partnership with
the government.
today, many of the stakeholders can become a part of the success and failure of the
NRHM. lhe question whether we are ready or not. Is it time for government to make
way for NGOs and for NGOs to step into bigger and wider roles? Can the government
and NGOs jointly take up the responsibility of critiquing the health system from within?
Is it possible for the non-government structures to become such a part of the system that
it would neither ignore nor acquire power but subvert it from within?
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To conclude, the NRHM can play a major role in influencing the health status of our
country provided there is an independent lobby within the NRHM that can constantly
network with practitioners, trainers and researchers towards Resource Pooling. And it is
precisely for this reason that practioners from various stands find it a topic to congregate
for. Within NRHM, the role of a community health worker requires clarity so that it can
actually show the kind of results it is expected to deliver. For the success of ASHA, both
trainings and larger structural back up are extremely crucial. The component of training
can be best taken forward if the existing expertise from the non-conventional
experiences is utilized. Themes of gender, justice and equity cannot be reduced to
modules but crosscut in the overall orientation of the Trainers. While the government
needs to innovate models of participation and partnership, the civil society'
organizations must respond to the pressures of up scaling.
7
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Community Health Workers in India:
Dr. Ravi Narayan
CHC-PHM
CHWS IN INDIA - AN OVERVIEW
Bhorc Committee (194G)
• FRCH and ICICI SIG WORKSHOP
• 10-12 April 2006
‘Formation of village health committees and
voluntary health workers
who need suitable training ."
• TMTC, PUNE
nw,
t KC. JOO*
CHW S IN INDIA - AN OVERVIEW
CHWs of the NCO Sector - I (1970s & 1980s)
Experiments
CHWS IN INDIA - AN OVERVIEW
The CHW’s of the NGO Sector - II (1970s & 1980s)
Overview
• Predominantly women
•
CHWs Jaiiikhed
I
I -Sanyojaks - Banavast Seva
•
VIIWs - Indo-Dutch.
!
| Ashram. Uttar Pradesh
•
Mostly mature, married volunteers
Hyderabad
Lay First Aiders - VHS-
j
•
: • CH W course of St John s
i Medical College, bangalore
•
•
Care to prevent the cooption by village leaders and
representation of all segments
Adyar. Chennai
Link workers • CLWS of tea
i • Rehbar-e-Schat of Kashmir
i Government fTeacher-workersI
•
The participation of the community in identifying CHWs and
•
plantations in South India
; • CHVs - Sewa Rural. Jbasadia
: • Community Health Guides - other
•
The training programme - innovative component* and methods
•
Well trained and highly mobile, livid and supervisory staff
•
Many projects had women on local action • advisory committees
•
Many had local women groups supportive of the process
•
•
•
Health Aide* - RL'I ISA
MCI! worker* C INI.
Calcutta
Swasthy.i Minus BHU.
Varanast
project*
•
Mostly voluntary or link workers with minimum support
their supervision
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CHWS IN INDIA - AN OVERVIEW
CHW’S IN INDIA - AN OVERVIEW
The CHW's of the NGO Sector - III
‘This Is a beautiful hall and the shining chandeliers, aie a treat to
watch. One has to travel thousands of miles to come to see their
beauty The doctors are like these chandeliers, beautiful and
exquisite, but ex|>ensive anti inaccessible..."
"This lamp is inexpensive and simple but unlike the chandeliers it
can transfer its light to another lamp I am like this lamp lighting
the lamp of better health. Workers like me can light another and
another and thus encircle the whole earth. This is Health for All ‘
Muktabal Pol. a Village Health Worker From JAMKHED India.
1*1 Washington. DC. May I 988
Medical Education and Support Manpower
Shrivastava Report (1974)
"What we need therefore, is the creation of large bands of part
time, semi-professional workers from tiie community itself who
would be close to the people, live with litem and tn addition to
promotive and preventive services (including those related to
family planning) will also provide basic medical services needed in
day to day common Illnesses (which account for about eighty
percent of all illnesses)"
These are essentially self employed people and therefore do not
form part of the Government bureaucracy. They could be primary
school teachers, housewives, practitioners of different systems of
medicine and dais..."
<H<
CHWS IN INDIA - AN OVERVIEW
Tiie Janata Experiment (1977)
"nie Janata Government launched the CHW Scheme,
which focussed on CHWs selected by the community,
having 6"' standard education and trained informally
in the PHM for 3 months. They were paid a stipend
during training and an honoraria of Rs.50/- per month
after the training, when they began to work. This
scheme was also called the Rural Health Scheme '
I IK
CHWS IN INDIA
AN OVERVIEW
Rural Health Scheme (GOI) 1977 - 1
Aims & Tasks
"The aim is to provide simple medical aid within the reach of
every citizen by organising a cadre of medical anti paramedical
community health workers, of whom die trained pi actitioiwi s of
the indigenous systems of medicine will be a part
‘The task's expected of the CHW is. immunisation of the ncwlxirin
and young children, distribution of nutrition supplements,
treatment of malaria and collection of blood samples and looking
after elementary curative needs of the community
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CHW S IN INDIA - AN OVERVIEW
CHW’S IN INDIA - AN OVERVIEW
Rural Health Scheme (1977) - 2
Philosophy
• Health work looked after largely by government will
now also rest in the hands of the people
• The CHW will be ol the community', 'accountable to
the community' and the community in turn will
supervise his work
• As expression of community involvement and
participation, the community should supplement the
resources required for the continuation of this work
• Community to completely takeover the programme at
a subsequent time".
The Rural Health Scheme (1977) - 3
Coverage
• 'The Scheme was launched on October 2nd. 1977 in
all PHCs of 28 districts of the country where
unipurpose workers had been reoriented as
multipurpose workers and one PHC in each of the
remaining districts of the country
• The scheme was accepted by all the states and
union territories except Jammu & Kashmir.
Karnataka. Tamil Nadu and Kerala".
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CHW S IN INDIA - AN OVERVIEW
The Rural Health Scheme 1977
Issues of public debate
CHW’S IN INDIA - AN OVERVIEW
4
• I .uv<■< ntiH-nt sitK i-t i<> in providing health care to the lural
iiiasse-. wvkoincd
• Inadetjuate preparation criticised
• Medical profession charged sclieme with proiroting quackery
• Lack uf pilot studies done on leasibility was a weakness
especully Decause heavy investment of public finds required for
miple mentation
• Is it possible to use non Ix^aith workers picked from the
community in a sustainable mannet?
• Du such initiatives make any meaningful alteration in the state
of hvalti- 1.1 the |K*i>pli ’
• Is t.ie approach pi actual' f easible'' Acceptable ’
« ii«
II
The Rural Health Scheme, CHW (1977)
Learning from the Evaluation - 1
Ihc evaluation of CHW Sclwmc
-SOURCE
a i ollalxiiaiivc siuriv by Nlfll-W New Dellii.
INSTITUTIONS
MHI W-Neu IVIhi AIIH K. I’H K.ilkata IIM-AhiiM-<lal>a<1: Ill'S Mumbai, l'"MK
Sew Dellii. Ganilhigram Instiluh* for Rural Hcnllh an.I I .iiiulv I’lntining M.iduiai
SAMPLE
?u I'HCs till si.ilv level officers I It? rbsliii I level nfTu eis I -12 iiieitif.il nffu eis
227 su|wivrseis 225 MI’Ws 2OJ village level worivcis 290 CIIWs. l-Dl .l
riiiiiinuniiv ineinlieis litl-l < ■Miiiuuniiy learteis. 7.1 3IX>s -12 Zill.i I'.o isli.al
nicinlx'is
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CHWS IN INDIA - AN OVERVIEW
CHW'S IN INDIA - AN OVERVIEW
The Rural Health Scheme, CHW (1977)
Learning from the Evaluation - II
The Rural Health Scheme, CHW (1977)
Learning from the Evaluation - III
• Acceptability - Massive sup|
ppOK
• Community enthusiasm for
•r long term financial responsibilities low.
• Objectives, roles and responsibilities of personnel differently
understood by officials at different levels.
• Selection process • Need to involve community proactively
• Selection criteria suggested include age 30+: females preferably: local
residents if possible. Ex-servicemen and dais priority'
• Allopathic dominance to be balanced by involvement ol other systems.
• Trainers training, reading materials for PHCs. supervised field training
with emphasise on prevention and promotion to be strengthened.
•Periodic refresher courses and regular monthly meetings.
• System of procurement and supply of medicines and drugs
should be designed based on methodologies of material
management
• Honoraria - panchayats to be entrusted responsibility
• Recruitment of III Medical Officer in PHC to support training
• Good supervision, periodical orientation and refresher courses
be- orovlded
• Simple monitoring scheme to be developed for concurrent
evaluation
• Training of multi-purpose workers to be linked with CHW
training - because the multipurpose workers would be source of
technical guidance and supervision to the CHWs
CHW S IN INDIA - AN OVERVIEW
CHWS IN INDIA - AN OVERVIEW
ICMR / ICSSR Health for All Report (1981)
National Health Policy (1982)
Community Health volunteers with special skills.
readily available.
who see health as work and not as a job'
"Health volunteers selected by communities
and enjoying their confidence and to whom
certain skills, knowledge and use of technology
could be transferred"
view it as a social function
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CHW S IN INDIA - AN OVERVIEW
The First JSR Evaluation, CHC, 1997
CHW’S IN INDIA - AN OVERVIEW
The Jan Swasthya Rakshak Scheme of
Madhya Pradesh (1995)
Criteria
JSR Scheme
CHW Scheme
Recommendation!
• JSR (unctions ■nd responsibilities
further clarity
• JSR under parKhayat supervision
the C HW Z ion
ci<e<aa«i>
hWaattwl ■ ritrfb
l»r< tfta
• M.tn-4 M.^Klt
•
M» Apt
■ Health project committee In health depanmeni
• More female candidates
• Reduce education limit for women and adivasi randidalrs
• Develop bnkagvs with other sectors
• Use a|>pr<>|>riaie effertive ktcal media
• liaining to lx- strengthened In pioblem identifawon. rnininuiiily
ex|>cncncc and problem solving
• Supportive facilities like hostel to be provided
• Dn'ance learning module and regular reheshei courses
• Re-certification on periodic basis
• Supporiive supervision to be built up
• Independent examination assessing practical skills and knowledge
• Core project team with sup|»rt of peei group ol trainers
<-|« >nr.
< HC M(W.
CHWS IN INDIA - AN OVERVIEW
CHW’S IN INDIA - AN OVERVIEW
The Second JSR Evaluation, CHC, 2001
Rfcommendat ions
• I'.iuM- consult and teifesigii
• Ginun-I Mink la-foie lauiu lung scheme to include li lining ol master tiaiuer
.id'l Mair lrvt*l itifmni.iih>H imi M’limir
• liaiomg of ISK triiiners .11 disiitri and block level
• Oiieniauon of village hc.ilth ■ .ininiiliees and gram salihas to JSR scheme
• SC - SI OUC.s should lie encouiaged and AWWs of ICDS sclv-me
• l ess didactic .md innre puitilem solving approach and paiiici|ial«wy training
• Suengthen medu al supply and pi ar tiers
■ Hu* need Gn oitlc spieail pul.io mfoiillation
• Svslciliasisr linkagrv with government Staff
• |?r\<*l<»|» siiupk* n,|>or<mg s\si.•ms
• rerlitiiral monuoiiiig o( puliln healih systems by grain sablia and village
Ite.iltli ' nnmiiiiees
iiitliilg. inanagcmctM anti at tinn invttht na ni
• lii.'olvi- \UOs in c*|x iimenis
The CHW’s of the NGO Sector (Beyond 1990s)
Experiments for empowerment
•Arogya lyakkam (lanhl Nadu Science Fotutn)
•Atogya Sathi (CEHAT Sathi)
• CM SS Dalli Rajhara Ch ha u isgarh.
Features:
•From alternative health care providers and health extension
workers to health empowerment activists'
•Erum prqjec’ management to process rnanageiiK-iK'
• From Health Action to putting (>eop!e s pressuie to make existing
health services mote responsive and accountable it, [x-ople s
needs
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CHW S IN INDIA - AN OVERVIEW
CHWS IN INDIA - AN OVERVIEW
The Indian People's Health Charter of
Jana Swasthya Abhiyan - December 2000
The Global People’s Charter for Health of
People's Health Movement - December 2000
• ’
A Health Care system which is gender sensitive and
resfxjnsive to tlie people's needs and whose control is vested In
people's hands and not based on market defined concepts of
health care ...‘
• 'Village level healih care based on village health care workers
selected by the community and supported by the gram sabha /
panchayat and the government health seivices which are given
regulatory powers and adequate resource support ...'
• 'Promote, support and engage in actions that encourage
people’s (Xiwer and control in decision making in health al all
levels Including patients and consumer rights
•
Build and strengthen people's organisations to create a basis
for analysis and action
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CHW S IN INDIA - AN OVERVIEW
The Milanin Programme of Chhattisgarh, 2002
Programme Overview
• Concept based on local cultural tools of Mitanin
• Role of Milanins to include liealih education, leadership ol
public health activities and care of common illnesses
• Mitanin to woik in dose association will: ANMs. AVVtVs and
I’Rls
• Block Medical Officer hi tram Mitanins
• 7he first training of six rounds would include building of certain
■innudes, knowledge and skills
• Selection of women as healih worki'i s
• No regular honorarium but voluntarism
• I inking CHW initiative •.vith health sector relorm
■ Building slate ano civil soririv p.iitnerships
CHWS IN INDIA - AN OVERVIEW
The Mitanin Evaluation by CHC - December 2005
Areas of Recommendation
• Cbjectives
• Strategy
• Community Involvement
• Linkages
• Number of Mitatins
• Misuse of Milanins
• Education Level
• Community Mobilization
• Health Education
• Medical Care
• Budget
• Moi al"
• Training
• Monitoring
• Remurvrali.jn
• Suppoi t
• Sustainability
• Visum
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CHW S IN INDIA - AN OVERVIEW
The ASHA Training Programme of the Nalional Kura) Health
Mission ■ 2004
CHWS IN INDIA - AN OVERVIEW
Some Concerns of People's Rural Health Watch of JSA
The ASHA Training Programme of the National
•Activists or appendage
•Lack of adequate regular compensation
•Limited provisions (or first contact care
•RCH focus oxershadowing comprehensive primary health care
•Training to be substantial and adequate
•ASHA not to substitute or replace existing workers including ANM and
Rural Healch Mission • 2004
•A new band of community based functionaries named
as Accredited Social Health Activists (ASHA) who
would be a health activist and mobilize the community
towards local health planning and increase utilization
and accountability of existing health services'.
AWW
•Need for specially developed cadre of local trainers and facilitators
•Adequate budgetary provisions to support all ASHA components
• Mission not to be accompanied by privatization initiatives
• Applying Indian public health standards
• Involving Ayush doctors and providing support.
•Need for community monitoring of ASHA
a
7
Outline of Presentation
Progress in Global Health
COMMUNITY HEALTH WORKERS IN
CONTEXT: GLOBALISATION, HEALTH
SYSTEMS AND PRIMARY HEALTH CARE
David Sanders
School of Public Health
University of the Western Cape
Member of the Global Steering Group of the Peoples Health Movement
'*'»**L*’
WHO Ollehorelinf Ccalre fi* Rneerch irvd Treinifig la Hamaa Resources for Health
• Global trends in burden and pattern of illhealth in the era of Primary Health Care - 1980
to 2004
• Historical evidence for key factors promoting
health
• Impact of globalisation on poverty and health
determinants
• The development and evolution of health
systems and policies, including health sector
'reform*
Life expectancy - increases from 46 years in
1950s to 65 years in 1995
Child deaths - reduced from projected 17.5 to
10.5m per year
•
Substantial control of poliomyelitis, diphtheria,
measles, onchocerciasis, dracunculiasis through
immunisation and disease control programmes
Growing inequalities in child health - within countries
Global health inequities
Growing inequalities in global health
widening {ip In Infant mortality experience
Fiprf): VtJtt -fift
rttn
jwi'i maowr ftMt ifth hrtthUftt
nntrin
• A woman has a nine in ten chance of reaching the
age of 65 years in a high-income OECD country,
IMR
4rrHn«
(Pvrmit)
■ XhMam
• but a four in ten chance in Malawi.
• In Tanzania, every sixth child bom alive will die
before the age of five years,
• while in high income OECD countries, every
167th child dies before the age of five.
I960
19X1
1999
« 4 (WM M aww M Mt
1
regions (WHO 2002)
JLUdUlllg glUUJi Ili>K IdLlUlb cillU
-------- ClassilicaUoU-of moil diseases of the poor In underdeveloped countries_____
contributions
to global burden of disease : % DALYs.
nfmi Kil rjemW
Sutritlnnal
C<wr m« nicable
l«
wasZr him. Minalra *>4 Mixw
me 4«4kincx*
kw Smc jeJ
Errah rt >1 ?ftO?
" Mfr rrta^l »Wnr»
A Historical Perspective
A Historical Perspective
Death rates (per million) In 1848/54 and 1971 in England
and Wales
1848/54
1971
reduction
attribut.
<□ each
category
Communicable
it
C’
H
II
♦1
'»> ii
J;
’■i
at
>'i
Air-bomc
7259
619
40}
Water/food-bornc
3562
35
Other
2144
60
2Lj
13 |
Total
12965
714
74
Non Communicable
8891
4070
26
All diseases
21856
5384
100}
2
Effects of agricultural and industrial revolution
• Rapid urbanisation
• Overcrowding, squalor in towns as infrastructure cannot
cope with influx
• High unemployment, child labour
• Disease, crime and violence is rife (read Charles Dickens)
DEATH
hy <l»» CtMRltMtwft *if <*emm**n
lire*)
Irt Ukke ap hk
wl»( atlier
in
Main reasons for Africa’s (and
Asia’s) Health Crisis
• uf. ffvut
ihr frightful
.Manalrfy k* «hkl< w# are ttr'vaMril'
rr«l«llAMW ef (hr
1a
!• tke 3a|i»ftt
•till • •ch*ul
InhabitanU bate
lite ma«a
ll»>*'<>«ghf»<, <
Cammaw KaAtrt,
ri»r|>liant Katrt fmm i.ni*-
!3
••
t «aAl aw* — aarlraa iteM <•« «Br.i4
•
U e«aa» a —w aaa4.»
• T« tatk I a*
«• Mkaa Ik •••4% •». XWM.*
UaI«»« Milkiaf Ur ■per«IJj 4ane
Increasing poverty and inequality
worsened by inequitable
globalisation,
t» allay
the gracing 4i»e«mrat af th* •r.^Ur,
Janke In Re» nktor. teng^anec
r« ».||
«*.H <vW(Hrn/r
her •perauana wkh the
4*4
Uoifrr.
sau-m rorr’i.t.
Selective PHC and Health sector
''reform", and
lamAr/A. J if**. 1*32.
■fill' » I
A». I i 1 ;
II.
IIIV/AIDS
3
The institutions promoting
economic globalisation
The debt crisis, structural adjustment and
globalisation:
External debt
• World Bank
• A crucial development in the current phase
of globalisation...
• International Monetary Fund (IMF)
• World Trade Organisation (WTO)
l'»
2<i
Debt Service Payments Dwarf
Development Assistance Inflows
Structural Adjustment Programmes:
the main components
Fi». > 4 lAlerM
C fSWo**"*
"
Impact of SAPs on health
Sub sib
• Cuts in public enterprise deficits
■ Ds veiopmanf
Assistance
O Debt service
so
US $ billion, 2002
(StAirte OKuldial from A^jrld Bank World
Indicatori dataltax)
•
Reduction in public sector spending & employment
•
Introduction of cost recovery in health and education
sectors
•
Phased removal of subsidies
"The majority of studies in Africa, whether theoretical or
empirical, are negative towards structural adjustment and
its effects on health outcomes" .
• Devaluation of local currency
• Trade and financial market liberalisation
3'ema-' *nd Sheton. WHO CMH WG6. 2001
4
Roported decrease In Income In urban
I:
i ..
O ’995
• ’996
1 1998
ULJ]
Zimbabwe:
Structural
Adjustment Changes In
300
households
Rtporlad Incraat* In Income In
r
Globalisation is primarily about
trade...
□ l 995
■ 1 995
n I 998
• Globalization, defined as the process of
increasing economic, political, and social
interdependence and global integration which
takes place as capital, traded goods, persons,
concepts, images, ideas, and values diffuse
across state boundaries, is occurring at ever
increasing rates
(llurrdl. 1995, p.447)
JO
115$ tllionsi
Unfair Trade (2)
• In addition industrialized countries apply much higher tariffs
(tariff peaks), sometimes amounting to more than 100 percent,
to the labour-intensive exports that are of special importance
to developing countries. For example, the EU tariff on raw
cocoa exported from Ghana is just 0.5 percent, but the tariff
rises to 30.6 percent on chocolate imported from the same
country (Elliott 2004b). Thus, although 90 percent of cocoa
beans are grown in developing countries, they account for just
four percent of the value of global chocolate production (IMF.
2002).
• Privatization of water and sanitation in many countries over
the past decade has often spawned intense political resistance
because of their predictably negative effects on the poor and
economically insecure (Loftus and McDonald. 2001.
McDonald, 2002; Shaffer. Brenner and Yamin. 2002. Budds
and McGranahan. 2003; Center for Public Integrity. 2003).
279
Total
"m"
49
49
-!36
101
Jarno
United
Sbtej
131
-
Europan
Unbn
• " drawing the poorest countries into the global economy is
the surest way to address their fundamental aspirations"
(G8 Communique. Genoa.
July 22. 2001)
•
BUT... many developing countries have destroyed
domestic economic sectors, such as textiles and clothing in
Zambia (Jeter 2002) and poultry in Ghana (Atarah 2005).
by lowering trade barriers and accepting the resulting social
dislocations as the price of global integration
•
Import liberalization was a key element of structural
adjustment programs; a recent study found that PRSPs may
include “trade-related conditions that are more stringent, in
terms of requiring more, or faster, or deeper liberalization,
than WTO provisions to which the respective country has
agreed”(Brock and McGee 2004)
j?
The result... unequal growth of wealth within countries
Support as a share of
value at productbn (%)
Other
243
Unfair Trade (I)
Northern
agricultural
subsidies:
Japan, the EU
and the US
Source: UNDP
HDR 2005
Trends in income inequality, selected
Latin American & Caribbean countries
xr?.-?::'.
-«-c^
M
fi t
so
40
-
JO
JO
10---------------------------------------0
1936-83
2004
5
The result... unequal growth of wealth between countries
..and unequal distribution of global
GOP |»< cipiln in Or pmresi nrlthe rid»« countiin. 196052 nd 26X0-02
Henry Kissinger:
income
(in coostint 190S USS. simple iww.B'J
□23TO
xxnc —j-
•j
“Thus the process of development begins by widening
the gap between rich and poor in each country ...
tstm - -
What arc developing countries to make of the rhetoric tn
favour of rapid liberalisation when nch countries with full
employment and strong safety nets argue that they need to
impose protection measures to help those of their own
lUTJO
iuiy
XTTJO
cmzens adversely affected by globalisation?
U
The basic challenge is that what is called
globalisation is really another name for the
dominant role of the United States ....”
•WlMVi
M/JO
2G7
•KM 4?
FU'SHHII
. r I.."* .Al
l«.r.w< Mm>"
.WIKU. OMaMH. KOOtel
V»J fXUHr W4i
'(and Worbl Orrter'
Ixciure •< Trinh) tioRcge. Dublin. October 12,
UNDP 1997 n
n
..and growth of poverty
Would it be better to born a Japanese cow
than an African citizen?
Joseph Stiglitz
Poverty in Southern Africa
Chief Economist World Bank. Nobel Prize for Economics 2001
... while I was at the World Bank I saw (Irst hand the devastating
Population living
Population living
below poverty line
below poverty line
1996
2001_______________
Lesotho
49%
49%
Miliwl
60%
65%
Mozambique
69%
69%
Swaziland
41%
66%
Zambla
69%
4-
X6%
;
effect that globalisation can have on developing countries, and
/- i
especially the poor within those countries ...
.
international trade agreements
and the policies that have been
imposed on developing countnes m the process need to be radically
0
500
1000
1500
2000
2500
3000
rethought ...
US dollars
... ninny wrong-hcndcd nctkini were taken, onet that did not zolve
■ Japan annual dairy Aubaidy, par row
the problem, but that (It with the intcreati o( the people In power"
■ EU annual dairy subtidy, par cow
Zimbabwe
61%
75%
O Par capita annual income. sub*3aharan Africa
O Per capita cost of package of essential health mtervenlions
(Source; Cited m UNOCHA, July 2002)
O Per capita annual health expenditure. 63 low Income countries
S69I<3 1 4k»**iJOO" tn] n »mrara Ptngun Book! 2002
u
6
Sub-Saharan African Country per capita
expenditures on health (1997-2000)
The Health System, its
financing and Health Sector
‘Reform’
Historical overview of international
health policies
Recommended expenditure: >S60/capita (Brundtland);
___________________ >S34/eapita (CMH)_________________
Number of countries
Amount of spending
4
>S60
2
11
18
13
S34 - $60
• What preceded PHC?
• Why PHC?
• What is PHC?
• What is Comprehensive Care?
SI2-S34
Data not available of population
<1.5 million
World Bank, World Development Report 2(XM
li
What preceded PHC?
• Maurice King - Medical Care in
Developing Countries
• Djukanovic & Mach - basic health system
with focus on health centres
Categories of auxiliary
Categories
Levels
Curative medicine and paediatrics
Medical assistant
Nursing
Enrolled nurse, puled dresser
.Midwifery
Auxiliary nurse midwife
Health visiting
Assislant health visitor
Env ironmental health
Auistant health inspector and
assistant
7
Evidence base for PHC
Pre Alma Ata:
• Work of McKeown and McKinley
demonstrated importance of socioeconomic
and environmental factors
• China achievements
• CBH projects in several other countries
demonstrated the impact of comprehensive
approach and community level workers
• Newell - “Health by People”
Inequality is unhealthy:
GNP & life expectancy in selected countries
•Principles of the Primary Health Care Approach
•
Universal accessibility and coverage on the basis of need (equity)
•
Comprehensive earc with emphasis on disease prevention and health
promotion
•
Community ind individual involvement and self-reliance
Intersectoral action for health
•
Appropriate technology and cost-cfTcctivcncss in relation to available
resources
1
r
4°°
Lift Expectancy IM2
ir*
Woo
_ -i
soe<
Elements / Programmes of PHC
Common Features of GHALC
Countries
• Political and social commitment to equity
• Education for al! with emphasis on primary
level
• Equitable distribution of public health
measures and PHC and increased
community level coverSgt?*Hea,th at
Cost‘1985
Comment
In order to make P.H.C. universally accessible
to the community as quickly as possible,
maximum community and individual self-reliance
for health development are essential. To attain
such self reliance requires full community
participation in the planning, organisation and
management of P.H.C
The concept of PHC had strong sociopolitical
implications. It explicitly outlined a strategy which
would respond more equitably, appropriately and
effectively to basic health care needs and address the
underlying social, economic and political causes of
poor health.
(p.34, WHO/UNICEF)
8
A Split in the PHC Movement
In 1980s, a focus on cost-effective
technologies and a neglect of social and
environmental determinants and processes led
to substitution of “selective” for
“comprehensive” primary health care (PHC) e.g. UNICEF “Child Survival and
Development Revolution”
'll can be seen that the proper application of
primary health care with have far-reaching
consequences, not only throughout the health
sector but also for other social and economic
sectors at community level. Moreover, it will
greatly influence community organisation in
general. Resistance to such change is only to be
expected’
Alm« Ati Dcclirition. 1978
49
Selective Primary Health Care
"Child Survival and Development
Revolution"
Growth Monitoring
Oral Rehydration Therapy
Breast Feeding
Immunisation
Family Planning
Food Supplements
Female Education
The Health System and its
Human Resources
REHABILITATIVE
CURATIVE
PREVENTIVE
PROMOTIVE
NUTRITION
O.R.T.
EDUCATION
FOR PERSONAL
A FOOD
HYGIENE
WATER
REHABILITATION
NUTRITION
SUPPORT
MEASLES
VACCINATION
Primarily Individually Primarily Population
Foeussed • ; I
Focussed
|
• The WHO definition of health tystemi Includes “all the
activities whose primary purpose Is to promote, restore,
or maintain health:
•
SANITATION
Rehabilitative approach
HOUSEHOLD
FOOD
SECURITY
Curative approach
Preventive approach
Interventions in the household and community and the
outreach (health information and education, etc.) that
supports them;
• Facility-based system and broader public health
interventions, such as food fortification or anti-smoking
campaigns
Promotivc approach
BREAST
FEEDING
SI
• All cateeories of providers: public and private, formal and
informal, for-profit and not-for-profit, allopathic and
indigenous
9
Health sector ‘reform’
Health sector ‘reform’
Includes the following components:
- decentralisation;
- actions to improve the efficiency of national ministries
of health;
- universal delivery of a core set of essential services;
- broadening health financing options;
- working with the private sector, including GPPIs and
- adopting sector wide approaches to aid rational
planning.
Impact of Health Sector Reform on
Health Systems
Quest for efficiency
•
- the
quest
for
efficiency
through
‘rationalisation’ of staff and delivery of a
core set of essential services;
- greater involvement of the private-for-profit
sector; and
- decentralisation.
Health policy is
increasingly
• H.S.R. impacts on public sector health systems
through at least three of its key strategics:
influenced by cost-
effectiveness
approach
•
1993: World Bank
Investing in Health
Report argued for
wider application of
cost-effectiveness
analysis (CEA) to
ensure value for
money in public health
systems.
Camels 1995
Health sector 'reform'
Quest for efficiency
Inappropriate Use of Cost-Effectiveness
Analysis
''[C]ost-cffcctivcncss analyses have shown
improved water supply and sanitation to be costly
ways of improving people’s health. Case
management of diarrhoeal disease is considerably
more cost effective than improvements in sanitation,
and .... encouraging people to wash their hands
and making soap available have reduced the
incidence of diarrhoeal disease by 32% to 43% in
Comnywon on Macroeconomics and Heaitti.?001/0?
different settmvs _____________
MnrtB M <M * MMMn M» lOWM
VAMd
<«
Or
CEA cannot evaluate the effectiveness of
'broader' interventions that may result in
health improvement through numerous direct
and indirect mechanisms
For example, water provision can:
Improve hygiene practice and thus reduce
incidence of diarrhoeal disease
Save women’s time for caring and economic
activity, thus improving household income
and food security
Contribute to increased agricultural
production, thus improving household income
and food security
Health sector 'reform'
Quest for efficiency
Result was to de-emphasize determinants
of health, focus on essential “packages” of
interventions - reminiscent of selective
Public Health packagt^HCClinlcal package:
• Pregnancy-related
• Immunizations
services
• School-based health
services
• Family planning and
nutrition
education
• Family planning and
STD services
• Tuberculosis control,
mainly through drug
therapy
• Programs to reduce
ORrtStW* enth!ttiSsn1ftrt#F tooe&e&s;
determin
a nH renrevnt 'nnhrv Irvoherenr^fl/M ,r. i 11 n »»» ««detenriinants
represent'policy IncoherengtftouS illnCSSCS of
10
Quest for efficiency conl.The move from equity and
comprehensiveness to efficiency and
selectiveness leads to:
• A return to vertical programmes;
• Erosion of intersectoral work and
community health infrastructures
• Fragmentation of health services and
reversal of health gains
..subverting the Mission of Public
Health
• “Ensuring the conditions in which
people can be healthy”
(Institute of Medicine)
Health Care Packages
Health Care Packages
The merit of the package approach is that the
process of priority-setting is explicit. Thus, the
approach encourages public debate about
prioritization and the rationing of health care...
While., essential packages can aid decision
making...confusion has arisen through their
presentation as “products", ready for testing and
implementation.... this “quick fix" claim is
presumptuous and wrong....Although the package
description gives a clear outline of the tasks to be
performed by health workers at each level, there is
no elaboration of how this is to be organized.
Tarimo: Essential Health Service Packages. WHO/ARA/CC'97.7
Tarimo: Essenlial Health Service Packages, WHO/ARA/CC/97.7
Health Care Packages
Cross-sectoral collaboration and ways of
ensuring a consumer voice in the process of
decision-making and implementation have not
received serious attention ....
Tahmo' Essential Health Service Packages. WHO/ARA/CC/97 7
11
Health Care Packages
Finally,
what
happened
to
community
empowerment and participation? In one country
example, community participation is presented as
one of the twelve interventions, rather than an
integrated coherent part of the whole. There does
not appear to have been any community
participation or public involvement in the
determination of package contents, nor any
attempt to assess what people on low-incomes
themselves see as priority concerns.
Tarimo: Essential Health Service Packages. WHO/ARA/CC/97.7
Health Care Packages
The PHC approach is about advocating and
supporting communities to assess their needs,
decide on priorities, implement activities, and
monitor progress. The relative neglect of the
need
for community participation
and
intersectoral action in the construction of
packages
poses an obstacle to the
implementation of primary health care along the
lines envisaged by the Alma-Ata Conference.
Tarimo: Essential Health Service Packages. WHO/ARA/CC/97.7
Health sector 'reform'
Increasing Private Sector
involvement
• HSR usually increases private sector
involvement in health care.
• Private health care as a parallel system
draws on resources of the public health
sector.
• Increased private sector work opportunities
lead to “dual practice” of public sector HR,
resulting in eg. “moonlighting”, competition
for clients and time, internal migration,
pilfering, etc.
Healthy life expectancy (HALE) and government
expenditure on health as per cent of GDP 2000
Health Worker and Mortality
Health systems & personnel
K*U TOO
• Health personnel vital, consume between 60
- 80% of recurrent public health
expenditure (WB, 1994).
• Current health workforce data are
aggregates that mask unequal distribution
between rich and poor African countries
and between rural and urban areas
>■
%
8
90
•
Go*
an
I
\ GO®
M*ekiH»»n kv!
2005
Al. 2004
12
HRH DENSITY BY REGIONS
Health professional migration
from Africa
Jal<Jcl«rea A ftit«
SICtml ttiHn
during a period when a “ban" on active international
recruitment had just come into effect
tn
•no
• Between 1985 and 1995, 60% of Ghana’s
medical graduates left
Chhtl
MUCh Stu
• During the 1990s Zimbabwe lost 840 of
1,200 medical graduates
JPO
ISO
w
*0
Wxktrt (phyikteni. nurtti and mMwMt) p«r 1,000 population
• In 1999, 78% of doctorsjn South Africa’s
rural areas were non-South Africans
- • • • Grana
■
• 2,114 South African nurses left for the UK
Context of current migration trends:
“Pull” : Needs in recipient countries.
Context of current migration trends:
“Push” : HIV/AIDS
• The 27 OECD countries have a workforce of approx. 3
million professionals educated in poor countries
• A dramatically increasing
disease burden due to
H1V/AIDSU in 8 South
Africans HIV positive;
highest infection rate
among young women; I in
5 South African nurses are
HIV positive).
• Upcoming roll-out of
ARV treatment, which
will put a massive
additional workload on
health service staff
• Buchan estimated that the US alone will need I mill.
Nurses over the next ten years.
• The UK currently needs I Ok more doctors and 20k more
nurses to meet needs of new health plan.
• The GATS (General Agreement on Trade in Services) is
likely to aggravate "trade" in health professionals by
increasing the size of the private sector North and South
(GATS Mode3) and easing cross-border movement (GATS
Mode 4).
• “ You feel hopeless that
you cannot do anything
for them, you are fighting
a losing battle
•
BOJW
nwB
Malawi
Kany»
--------- Zamfen
— — BoKaana
Buihan <i it ilVj
w
8
"When thinking about the
situation we are facing at
work we just feel hopeless
and helpless because we
think that al the end o! the
, Lehmann ar«l Zulu, 2004
day it may be you in that
13
International migration—winners
& losers
How much do importing countries gain
from international migration?
• In 1970s, the US government calculated that
it gained US $20,000 for every skilled
worker from a poor country.
• UN Conference on Trade and Development
(UNCTAD):
for each professional aged between 25 and
35 years, USS SI84,000 is saved in training
costs by rich countries
• The loss of approximately 20,000 skilled
All U VI111111 LI 1
.
llk^llltll JtUlUJ U
declining and public health systems
in Africa and many Southern
countries are collapsing as a result
• Increasing poverty and failure to address health
“determinants” rcsultifiy in poorer health status
• Declining per capita health spending reducing
- Health personnel numbers and morale
- Drugs availability
- Transport for outreach & supervision
• Promotion of the private sector through “health
sector reform” and new trade agreements
• HIV/AIDS affecting and infecting health
personnel
global coverage at 75% In 2002
100
90
80
70
60
SO
40
30
20
10
0
!
• ... reversing previous gains in PHC
implementation
IMCI pneumonia case management
(Tanzania)
Cojipragc: child actually receives the intervention
A Case Study of IMCI
Global Immunization 1980-2002, DTP3 coverage
|
E
|
90
80
70
I 40“
IMCI pneumonia case management (Tanzania)
Coverage under actual programme conditions
| Pneumonia mortality averted =
' Intervention efficacy
| Health workers are trained
9%
.. t.,-,
6554T
1807.
■
g
S “
i 20
Source- Jones et al. Lancet 2003. 362: 65-71
II
j Health workers assess child correctly 637.
\
Health workers treat child correfaly 657.
Coverage (mother recognised
40*/.
illness, sought care and comph<
with treatment:
child receives the intervention)
Tugwell framework applied lo multi-country evaluelion data
Source Tugwell. J Chmn Dis. 1985; 38(4) 339-51
14
IMCI pneumonia case management (Tanzania)
Coverage under improved programme conditions
[ Pneumonia mortality averted =
-------------- ------------------------ •
_
■
■
19%
. z- ■ ■
i Intervention efficacy
Health workers are trained
65SV
( 90%
Health workers assess child correctly 90% \
Health workers treat child corres|ly;_ 90% I
Coverage (mother recognised----- ^a0%
illness, sought care and complied i
with treatment:
child receives the intervention)___ I
Source. Tugwell. J Chron Dis. 1985; 38(4):339-51
Why should interventions be delivered
in community settings?
• An analysis of cost effective interventions
for saving newborn lives examined three
different delivery approaches — outreach,
family-community and facility-based
clinical care.
• Outreach and famiiy-community care in
combination at 90% coverage could result
in an 18-37% reduction in mortality even
before facility-based care is strengthened.
Why should interventions be
delivered in community settings?
Why should interventions be
delivered in community settings?
• Many child deaths occur outside health
facilities
• Currently the coverage of many effective
interventions is low — well under 50% in
many cases — and the quality of care is
deficient in many communities.
• Care for neonatal conditions has received
little emphasis in public health programmes,
and only 3-12% of children bom at home in
5 South Asian and Sub-Saharan African
• children from poor families are less likely to
access government health facilities than
those from wealthier families
-poorer families tend to live further
from
such facilities
-even with improved quality of care,
utilisation of such facilities may
remain low
for many reasons — lack of
Definition of Community Health
Workers
‘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’
WHO 1989
Who are Community Health
Workers?
• generic type eg village health workers,
community resource persons, or workers
known by local names.
• more specialised cadres eg community
rehabilitation facilitators, community-based
directly observed therapy short-course
supporters, traditional birth attendants
(TBAs), HIV/AIDS communicators, etc.
• All CHWs perform one or more functions
related to health care delivery, are trained in
15
Which interventions can be
delivered in community settings?
• interventions to promote healthy
behaviours eg hand washing and breast
feeding
• preventive interventions eg insecticidetreated nets for malaria and micronutrients
• more complex tasks eg case management
of childhood illnesses such as malaria,
pneumonia and neonatal sepsis
• active involvement and empowerment of
—thrnunh ^rtivitior nfCHWr
Evidence for impact and cost
effectiveness of community
health workers
• A controlled trial in rural India showed
home-based neonatal care and management
of sepsis can more than halve neonatal
mortality where high 29
• Simultaneous presence of two of seven
clinical signs was 100% sensitive and 92%
specific. Health workers could use these
signs to identify neonates for referral or
Evidence for impact and cost
effectiveness of community
health workers
• .A meta-analysis of community-based trials
of pneumonia case management on
mortality suggested an overall reduction of
24% in neonates, infants, and preschool
children 26.
• A trial in Tigray, Ethiopia, of training local
coordinators to teach mothers to give
nrnmnt home antimaHrinlc chnived a
Evidence for impact and cost
effectiveness of community
health workers
• In Pakistan Lady Health Worker (LHW)
programme performance in recognizing and
treating ARI was weaker than for diarrhoea
management and vaccination counselling,
underscoring need to improve performance
in disease recognition. 31
• Evaluation of a primary care programme in
the Gambia showed greater child morbidity
Evidence for impact and cost
effectiveness of community
A
health workers
• A systematic review ofpneumonia and
malaria management by CHWs identified
seven intervention models i.t.o assessment
of children, system of referral to health
facility (verbal or written) and location of
drug stock.28
• Strongest evidence for mortality reduction
was for community-based pneumonia case
management and active detection. Malariaonly programmes ignore the clinical
similarities between nnrmmnnia and malaria
iLviciuncu iui iiiipaci aim UUSleffectiveness of community
health workers
• A recent systematic review of ‘lay health
workers’ delivery of simple interventions33
was conducted mainly in high-income
countries (35 of 43), but nearly half of them
(15 of 35) in low-income and minority
populations.
• Benefits over usual care were shown for lay
interventions to promote immunisation
uptake in children and adults, and to
improve outcomes for malaria and acute
16
Evidence tor impact and costeffectiveness of community
health workers
• In a recent review of the effects and costs of
expanding immunisation in developing countries,
one of the interventions with the highest impact
on coverage was the use of CHWs36.
• Use of CHWs in periodic outreach programmes
in urban Mexico37, and in the Amazon,
Ecuador38 led to community involvement and
improved services by ensuring that houses were
located precisely, potential recipients were
registered and vaccination days chosen with
parents.
Factors influencing success of
CHW programmes
Health system factors
• CHWs function best in a well-functioning
health system with appropriate management
capacity, functioning referral channels, good
hospital care and reliable supply chains 5. But
they may also be key in poor health systems.
• Interactions between CHW programmes and
formal health services are affected by degree
of involvement of local communities and
health personnel.
Evidence for impact and cost
effectiveness of community
health workers
• CHW-led women’s groups in Nepal provided
education to reduce neonatal and maternal
mortality. The programme achieved substantial
reduction in both neonatal and maternal
mortality rate39 and was very cost-effective. 40.
Factors influencing success of
CHW programmes
Health system factors
• Health professionals often perceive CHWs
as lowly aides 15,50,51 or assistants within
health facilities, overlooking their
community health promoting role. This may
be partly addressed in professional training.
Rivalry may develop between nurses and
CHWs53. Harassment and other constraints
may prevent female health worker
health professionals (doctors and
nurses) and other health workers
• In BangladeinfchtllddZftfettcnding firstlevel government health facilities were fully
assessed, correctly treated or advised re
continued care at home41.
• Lower level workers (family welfare
visitors and nursing aides) performed much
better than higher level workers
(paramedics, physicians, and nurses) in
rational prescription of antibiotics and
provision of appropriate advice to
caregivers.
Factors influencing success of
CHW programmes
Community factors
• Many CHW programmes have emerged and
been sustained in situations of political
transition and popular mobilisation47.
• Mobilised and well-informed communities,
community-based workers and formal health
services have rapidly disseminated child
survival interventions and reduced mortality
eg Nicaragua, Zimbabwe 48.
17
Factors influencing success of
CHW programmes
Community factors
• Mobilisation of specific communities even
without general popular mobilisation can
improve maternal and newborn health. Eg
Nepal community-based participatory
intervention involving local women
improved hygiene behaviours, increased
access to safe delivery through enhanced
care-seeking and improved local transport.
■ I.L
1-
,_1.. on/
.r---------------------- ..-------- :—i ■!-.—
Improving performance of
community health workers
Effective strategies to improve
performance
• An earlier review concluded that CHWs did not
consistently provide services likely to have
substantial impacts on health and that quality
was often poor58.
• a recent review concluded that supportive
supervision leads to benefits and that wellorganised supervisory systems have the
potential to improve motivation and provide
Factors influencing success of
CHW programmes
Political, macroeconomic and international
factors
Factors influencing success of
CHW programmes
Political, macroeconomic and
• Poor accountability of local governments and
politicians, can lead to “reward” appointments eg
LHW programme in Hala, Pakistan 20% were from
different locations than their place of work31
international factors
• Expenditure ceilings and macroeconomic
policies - sufficient ‘fiscal space’ is
necessary to enable governments to finance
health systems.
• Stronger community participation in selection and
monitoring of CHWs could reduce abuse of
appointment systems, although attaining this
depends on general political context45________
• Conversely in China in 60s and 70s surplus
from mllectivf* nrorinrtion funded ‘harpfoot
lllipi u v
Improving performance of community
health workers
Strengthening the management capacity of
• Focussin^FiVAft&f if?^?i&4s^?$Nbrity
problems can be done effectively in lowincome settings, eg Tanzania programme
equips local decision makers with decision
making tools64.
• Improved priority setting by local
management at district level could reduce
iinHcr.S mortality/ ciiKvtnntinlIvz
pciiuiilidiiCt ui cuiiiiiiuiiity
’ health workers
Financial and non-financial incentives
• Most CHW schemes aspire to volunteerism
65.However, most programmes pay their CHWs a
salary or an honorarium.
• Sustained community financing is rare, apart from
China’s “barefoot doctors”.
• Even on a part-time basis, the costs entailed by lost
economic opportunities may be higher than small
honorarium. Other financial incentives include:
small state salary, payments for attending training
sessions68.
18
improving pertormancc ot
community health workers
Financial and non-financial
• Fee-for-service p^Wr^{?s9r^hyments
linked to drug sales may encourage
inappropriate treatment and overuse of
medications. Non-financial approaches eg
further training, flexible hours, may distort
care less.
• Policymakers should consider a mix of
financial and non-financial incentives,
Conclusions
Factors influencing success of CHW programmes
• Socio-political context and technical factors influence success of
community-based programmes and activities
• While technical factors can be planned, socio-political factors are
less amenable to initiation/manipulation
• Key socio-political factors Include community mobilisation and
political will - which are synergistic
• Community mobilisation and political will often dissipate as political
context changes
• Community mobilisation can be facilitated by participatory planning
and implementation
• Community-based workers can catalyse and sustain community
mobilisation
Key technical factors include:
• participatory approaches to assessmentand analysis, using
appropriate technologies and methods
• planning with intersectoral action and sustainability in mind
• implementation using community-based workers to achieve high
coverage
lin
• training and ongoing support and supervision
PEOPLE S HEALTH
MOVEMENT
• PHC successful in certain health care programmes but
social mobilising role and Intersectoral focus
(determinants) neglected
• PHC must be revitalised and In particular community
based actions and CHWs
•
Government heal th departments must work with other
• Accumulating and more rigorous evidence
of effectiveness of CHWs in service
provision
• Much anecdotal and some case study
evidence of CHWs and Promotores de
Salud facilitating access to/organising
around basic needs, although often in a
favourable political context
• Importance of documenting and evaluating
factors- both socio-political and technical -
PEOPLE’S CHARTER FOR
HEALTH
A tool for advocacy:
■ Progress In health undermined by globalisation and
neoliberal economic policies, health sector “reform", the
HRH crisis and (especially In Africa) H1V/AIDS
• Efficacious health interventions exist but have poor
coverage
CHWs: service providers or change
agents?
Health ai a Human Right
The Peoples Health Movement (PHM) is a large
global civil society network of health activists
supportive of the WHO policy of Health for All and
organised to combat the economic and political
causes of deepening inequalities in health
worldwide and revitalise the implementation of
WHO’s strategy of Primary Health Care.
www.phmovement.org
Tickling the broader
determinants of health
Economic Challenges
Social and political challenges
Environmental challenges
War. violence, conflict and
natural disasters
A people-centred health lector
19
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OVERVIEW OF THE
HEALTH SECTOR
si
□
ACHIEVEMENTS
SELECTED HEALTH PARAMETERS
• Remarkable improvement in select health parameters
• Control of diseases
• Eradication of Smallpox in 1977
• Eradication of Guinea worm disease in 2000
• Interruption of polio transmission anticipated by
end 2005
• Leprosy elimination expected by end 2005
• TB cure rate more than global target of 85%
• Improved disaster management and public health
response to outbreaks
1981
55.5
110
152
70
NA
Crude^BirtK Rate^T? v ;
33.9
Crude:bdath;Rate ■ 57 7S 12.5
IbtafFertili^Ratfer-:^- 4.5
Decadal Population Growth (%)
24.66
Life Expectant'.(in years)
Infant Mortality Rate
Onder 5 Mortality Rate
Neonatal Mortality Rate
Maternal Mortality Rate
1991
60.3
80
94
51.1
NA
29.5
9.8
3.6
23.85
2002
63.2
60*
73
40
407
24,8*
8.0
3.0
21.34
Source Sample Registration Survey. 2003; Census of India. 2001 & Compendium of India
Fertility and Mortality Indicators. 1971-97 by Registrar General of India. 1999(' 2003 data)
• Medical Tourism
NATIONAL GOALS & MDG
Current
X FY
Plan
2007
NPP
2010
Socio economic differences
MDG
2015
60-
50
IMR
63
45
<30
27*
NMR
44
26
<20*
<20*
Poorest 20% of
population
(60/1000 live births)
40-
30 '
have more than double
the NMR as compared to
the richest 20%
20T
Institutional
deliveries' >
407
200
clOO
47%
80%
80%
1OO
(26/1000 live births)
10
1
(
*1
c
<
Status
Regional Disparity
CRITICAL SHORTAGES IN INFRASTRUCTURE
State
A»M>k
IMW2
A. •<WU<
142655
23109
26022
6491
Villages per
ANM
Population per
ANM
Births per
ANM
0.22
3723
63.29
3222
Kerala
CRITICAL SHORTAGES IN MANPOWER
Docton at FHC
880
Surnrom
1121
Olxletrlciaiu and Gynect
1074
Multipurpose Worker
(Femaleg ANM
Health Worker (Male)
IltiKh Aitlitanl ( Fcmalr) /
LHV
Tthj- -207.7
' 149.6
11191
Chhatisgarh
5.53
4532
Maharashtra
4.09
5209
107.3
3198
Assam
4.6
4065
111.79
67261
120.1
Phyakiam
1457
Health AiiiitaM (Male)
5137
Jharkhand •(Prov.)
6.49
4165
118.7
I'ediatrkian*
1607
Fharmaciit*
1869
Bihar«(Prov.)
3.76
6191
111.79
Total apecialiata
5335
Lab Technician*
6344
Rajasthan
3.44
Radiographer*
1017
Nuraei / Midwive*
12722
INDIA^.&^
STATUS
3602
5339
114.9
-r
106.72
SYSTEMIC DEFICIENCIES
Citizens’ perception
Lack of Holistic Approach
Limited access to Public Health set up.
Health not a priority.
Doctors & Paramedics not available when
required.
Private sector unregulated & charging too much
Under funded, yet not utilised.
shortage of infrastructure & human resources
Lacks community ownership
weak grievance redressal mechanism
and accountability
Unmet demands
Non integration of Vertical Disease Control
programmes
No community participation
Non responsiveness to Citizens'"»
grievances.__________________________
NRHM - THE VISION
•Architectural correction in health care delivery
NATIONAL RURAL HEALTH
MISSION
•Special focus on 18 states with weak indicators.
•Improve availability of quality health care in rural
areas
•Synergy between health and determinants of good
health
•Mainstream the Indian Systems of Medicine.
•Capacity Building.
•Involve the community in the planning process.
11
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WHAT IS NEW IN NRHM
Improving Health Care Delivery System
Envisages significant step up In expenditure to 2 - 3 % of GDP
Intersectoral convergence with other Health determinants.
Reducing Maternal & Child Mortality
Population Stabilisation
Integration of existing schemes.
Merger of societies at Stele & District level
intersectoral Convergence
Decentralised planning at Village and District level.
Reducing the Disease Burden
Community ownership of Health facilities.
IEC
Fully trained ASHA in each village.
Financing the Mission
Under IPHS, upgradation of CHCs into 24x7 FRUs.
Mainstreaming of AYUSH
ISSUeS & Challenges
Public Private Partnership.
u
Progress & Expected Deliverables
Risk Pooling
OUTCOMES
IMPROVING THE HEALTH CARE DELIVERY SYSTEM
2005 - 2012
a) Institutional Framework of NRHM
•IMR reduced to 30/1000 live births by 2012
b) ASHA
•MMR reduced to 100/100,000 live births by 2012
•TFR reduced to 2.1 by 2012
c) Strengthning Infrastructure
•Malaria Mortality Reduction Rate - 60% upto 2012
d) Human Resource development
•Kala Azar eliminated by 2010
e) Procurement of Drugs & equipments.
f)
•Filaria reduced by 80 % by 2010
Partnership with Non Government Providers
•Dengue Mortality reduced by 50% by 2012
•Leprosy eliminated by December 2005
g) Innovations
is
•TB DOTS series - maintain 85% cure rate
DECENTRALISED PLANNING
•Financial Envelope to be allotted to the districts on normative
basis.
’
CORE STRATEGIES
•Perspective planning as well as annual plan.
’
•Involvemenfof the community and PRIs In developing the
Vi^ea^
•District Plans to converge ipto State Plan.
-
•Capacity of States & Districts to be built for planning and
1,1
3
1
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HUMAN RESOURCES
INFRASTRUCTURE
•Additional Subcentres required. Population norm to be revisited
•All CHCs are to be made operational as First Referral Units'-'9'
(FRUs) providing emergency obstetric and new bpm care. ; if
•50 % of PHCs to be operationalised on 24x7 basis.
States to be encouraged to fill up vacant posts of ANMs / MPW
>.
•1 MMU per District © average cost of Rs.30-40 lakh.
5^^
•Mainstreaming AYUSH in 10% private health facilities.
|
CAPACITY
BUILDING
•Financial Services of
professional including MBAs,
CAs at District and state
•Skilled Mission teams at each
level.
•Comprehensive training for alt
categories
•Training of the PRIs
•Training of ASHA, Mentorinfl
flroup for ASHA.
•One AYUSH doctor being positioned within the PHC.
Likely capacity needs
Developing & Supporting
PUBLIC PRIVATE
PARTNERSHIP
•Guidelines for accreditation of
private health providers.
•Pilots on social franchising,
contracting, DBAs in selected
districts
.
•. Mo&ttw 7 lakh Village Health and Sanitation Committees
• More than 25000 PHC level PRI/HDQRKS Committees
RISK
POOLING
•A Task Group is currently
working on these aspects.
•Pilots in different parts of the
country.
• 600 PWrtct tevel Mission Teams and Resource Groups
Medical Officers into Skilled Birth Attendants.
KEY ACTIVITIES ACCOMPLISHED
Institutional
frame work
Established
KEY
ACTIVITIES
ACCOMPLISHED
■ |g
•Mission Steering Group
•Empowered Programme Committee
•Mission Directorate
•State/District Health Mission
•Advisory Group on Community Action
•Committee on Intersectoral Convergence
•National Programme Coordination Committee
•North East Advisory Committee
•Mentoring group on ASHA set up
•Mission Document
•IPHS
•ASHA
•Training module for ASHA
•State Health Mission / District Health Mission
•Merger of Societies
u
Birth Attendants
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KEY ACTIVITIES ACCOMPLISHED
KEY ACTIVITIES ACCOMPLISHED
f
Kashas;.;- ,
yn^iedfundsto
Sub Centers
___________■ Up gradation /
strengthening
of CHCs / PHCs
■- 'T
-States asked to identify two CHCs per district
for up gradation.
•Rs. 20 lakh foneach CHCas first installment
released.
Survey6 msl,’l,’nent 10 ** released on Facility
.. V V.TV-T^T-r •
Imrnun.sa^on
■■
Increased focus on
finandal f
management
«XPHS Guidelines for. PHCs/Sub Centers being
drafted
"
--------- fi0315 of the Mission and its key components/ strategies_____
strengthening Commumty Health Care through Community Activities
4
Rote of PRIs & Community Action
;
i
2
3
4
• RCH-II launched and under implementation
• Janani Suraksha Yojna launched in all States.
------ Strengthening Public Health Institutions for Health Delivery
5 __ -------------------- Technical Support for the Mission
6 __ —________Exploring New Health Financing Mechanism
7
_________ District Ptenning/Decentraliseo Planning
■
•Pending DCs reduced from Rs. «X35 .
crore in March 2004 to Rs. 3634 crore in
July 2005
New Programs
ITASKCROUPREROKTSI^
2
3
----- 2_____ \ ;
•The unspent balance reduced by Rs.
I 900 crore in the last 6 months.
STATUS OF TASK GROUPS
~
•AD Syringes introduced.
- •Alternate vaccine delivery
•Mobility support to’ Districts/ States for
supervision;
• Sterilization compensation scheme launched by GOI
■TASK GROUPS DELIBERAnONS COMPLETED^g^y
* HMN9rnte^^a?eTecnt Of Neonatal and Childhood Illnesses
undeHloTn
?ateS
be'ng ro,,ed out in al1
under RQi n. Work shops on IMNCI held in 4 States.
Promotion of PPP (mcludmg NGOs) for Public Goals & Regulation of
_____________________ Private Sector
_____________ Strategies for Urban Health Care
* NPwh^rn rlelPNe°nat0,°gy Forum completed training on
Newborn Care in 140 districts in the country.
___________
Financial Norms for NRHM
__________ _________ Medical Education
• Integrated Disease Surveillance Project operationalised.
•
MONITORING
MONITORING
NFHS-II, RHS 2002 to provide Baseline
data for district level.
TOOLS
Mission Control Room,
Facility Survey of Public/Private health
Infrastructure
Triangulated monitoring system under
RCH
external evaluation, social audit,
government reporting.
E-moding.
„
Helpline, web site
LOCUS
MSG members and Jt. Secys in the
MOHFW,
State Nodal officers
Gram Ranch a ya Is/Block
level/District Health Mission.
5
(
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MONITORING
JANANI SURAKSHA YOJANA
Panchxyat,
Rofli Katyan Samiti, External evaluators,
• JSY launched all over the country to promote safe
delivery.
Finance Management Group
Quality Assurance Committees at
State/District level
MONITORS
• Incentive for BPL families of Rs. 1300 for safe delivery
in EAG states, Assam and J & K and Rs. 1000 in all
other states .
Citizens' Charter at Facility level
Hospital Management Society.
ASHA Mentoring Group.
Integrated Disease Surveillance system
Fund release linked to performance
indicators in Moll.
"
• Two private facilities per block being accredited under
the Scheme.
• Assistance also being given for Caesarian section. «
EXPECTED DELIVERABLES DURING
2006—07
.
Ife”- JMILESTONES
&
ACTION PLAN
Selection of 1.5 lakh ASHA and •
training of all the ASHAs
selected during 2005-06
Mission envisages a trained ASHA for
every 1000 population or less in 18
Special Focus States.
Mobile Medical Units (MMU) to be
•
provided to 200 districts
Mobility support to all districts
At least 25,000 Sub-centres to be
strengthened.
At
n
least 700 CHCs
upgraded to FRUs.
to
be
•
Over 75,000 subcentres made functional
duriung 2005-06. All to be made fully
functional Mission period.
•
All 3222 CHCs to be upgraded to FRUs
over Mission period.
Expected Deliverables 2006-07
>.*^7 Remarks .
■Deliverable during 06-07
At least 700 CHCs to be upgraded
to FRUs.
At
•
All 3222 CHCs to be upgraded to FRUs
over Mission period.
•
50% of all PHCs are to be made 24x7
by 2010 and balance over the rest of
the Mission period.
•
All 550 District Hospitals to have RKS.
During 2005-06, 238 District Hospitals
have set up RKS. Balance shall set up
over the next two years.
•
District Health Plans to be made in aH
Districts by 2008
least
500
PHCs
to
be
operationalised on 24x7 basis.
Rogi Kalyan Samitis (RKS) to be set
up in District Hospitals
Preparation of District Health
Action Plan in 300 districts
\
No. of Institutional Deliveries
11.7 million
No of Safe Deliveries
15.6 million
CHALLENGES
6
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CHALLENGES & ISSUES
• Complexity of the sector
(Cross linkages with poverty,
customs)
illiteracy,
social
* Governance issues
• Involvement of states
• Assured availability of incremental Outlays for
Mission period.
THANK YOU
• Shortage of manpower / lack of capacity
• Empowerment of PRIs & community
• Impediments in release of funds
7
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Murphy’i Law on becoming a discoverer
Community Health Worker Training:
Linking Pedagogy and Practice
New Avenues
K.Balasubramanian
Foundation (or Rcicarch in Community Health
e-if
Christopher Columbus was the
best deal maker in history.
He left not knowing where he was
going, and upon arriving, not
knowing where he was.
He returned not knowing where he
had been, and did it all on
SIG
borrowed money and became a
11* April 2006
famous discoverer
Pune
INDIA’S RANKING
1st IN WORLD
Quick! Hide the colour TV!
The anthropologist is coming.
IRRIGATED AREA
CATTLE POPULATION
BUFFALO POPULATION
MILK PRODUCTION
PULSES PRODUCTION
TEA PRODUCTION
brom "The MAD"
JUTE PRODUCTION
INDIA’S RANKING
2nd IN WORLD
Poorest
PADDY PRODUCTION
(CHINA)
WHEAT PRODUCTION
(CHINA)
GROUNDNUT PRODUCTION
(CHINA)
SUGARCANE PRODUCTION
(BRAZIL)
ONION PRODUCTION
(CHINA)
FRUITS PRODUCTION
(CHINA)
VEGETABLE PRODUCTION
(CHINA)
TOBACCO PRODUCTION
(CHINA)
• Major portion of poor people in primary sector
• 60% of the workforce contributes around 20%
of GDP
• Low Productivity, highest cost of prodution
• Globalization and market liberalization moved
in without preparing this sector
• Government extension is supposed to prepare
127 million farm families ( 100 million
agricultural labourers particularly women are
generally forgotten)
11^ A
c0U ND Al lON FOB RESEARCH Ih
COMMUNITY HEALTH
LIBRARY - PUNE
1
Returns to Rural Investment in India
1970- 1993
Returai in Rupee
Per Rupee Spending
How will you reach them in
agricultural sector...
No. of poor reduced
Per Million Rupee
Spending
Agrkullurv R&l)
13.45
84.50
Irrtgution
136
9.7
Roadt
531
123.8
Education
139
41
Power
0.26
3.8
Soil and Wntcr
Conservation
0.96
22.6
Health
0.84
25.5
Anti-poverty
I’ rugranitncs
1.09
17.8
Sourc< IFPRI-World
Training...
Radio
TV
Govt
Dept.
External
• Weakest linkage in India
• To reach 127 million farm families and 100
million agricultural labourers families
Input
supplier
AO
Bank
Credit
Supra
Local
Trader
• Wc have to think out of box
Villager
—'
Villager
Strong Linkage
Local
Villager
Weak Linkage
MSSRE. I99K
Development
• When you extend the canvass of the
community for horizontal transfer of
knowledge and help to develop a
community based knowledge management
• Conventional Training programme for
Vertical Transfer of Knowledge
Impediments in Horizontal
Transfer of Knowledge
• Gender
• Caste
• Class
• Religion
• Age
• Regional
But can be overcome with appropriate mobilization process
2
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Freire criticism still valid
• Conventional education and training: a
banking concept in which the students are
depositories and teachers are depositorsnegating education and knowledge as a
process of inquiry
• Learner-centric, self-determined
transformative learning - Andragogy
Self-Directed, Personal Strategic
Learning
• 70 percent of learning in various sectors taking
place outside formal training
(Peter llcnrchcl)
•
T»c«t knowledge, which is informal knowledge about how things really get
done, is extremely difficult to capture, codify, and deliver through discrete
learning objects and traditional training programs. Communities are a way Io
elicit and share practical know-how that would otherwise remain untapped.
•
Creating and structuring opportunities for people to network, communicate,
mentor, and learn from each other can help capture, formalize, and diffuse tacit
knowledge. Communities become a boundaryless container for knowledge and
relationships that can be used to increase individual effectiveness and
country's development.
Roadmap
for
Capacity Building
Through formal leamingstrengthen natural learning and
facilitate a self- directed
personal-strategic learning
Self- Directed Learning promoting knowledge
management at individual and community level
Generic information
(Value Addition)
Locale - specific knowledge
Capacity building -making every extension official
Facilitator in the local community for adding value
to the information and converting into locale specific knowledge
3
Vertical and Horizontal
Transfer of Knowledge
11 Know} |l don’t Knowj
Adult Learning...
Is community learning;
Lots of self-directed learning with some formal
learning
They
Know
Development
Learning by doing
Zlearn
Mostly based on horizontal transfer of knowledge
and with some vertical transfer of knowledge
Extension consists of “facilitation” as much if not
more than “technology transfer".
They
don’t
Know
Extension ’
;
A
They learn
j Participatory i
I Innovation '•
We learn
Farmers arc not men- but also women- more gender
sensitivity
Building a Learning Community
N«
3
farmers are clients, sponsors and stakeholders, rather
than beneficiaries of agricultural extension.
&
No
Forms of Participation
I
Passive Participal.ion
II
Participation in information giving
III
Participation by consultation
PHASE
Mobil I Tall ion
ACTIVITIHX
SfMTHv rulturnl net ivm ton, • '■nniu'.icnt iXaMion.
undoritf ending unions lh«t Kinknhalckrit.
idrnfifyinif th* nned« for rAfinriiy building from
various Flakrholdi'rx vmu* |M>inlM
OrgNniKrtl ion
ld«*nl<fying th« orgAnixAlton ly|MM, b«lping th*
nxnmunitir « to build organnation* Planning th*
|in»grMmm«* by th* mmmunitj' through their
organ iulion«;
IV
Cttpacily BuilcLng
Inlentolive kiaming. Lnaming by doing. Blinding
of froniior knowlodgo with ImdilionaJ wiadom
Technic*il SupfXMt
Support in trouble
uhoocinfr linkinc tke
iviiniiiunily with
ami otlw-r pntiQrftiiiiiwu*.
focilitotion nnd nupjMWtinc conflict
*r«AolulK>n
nif«*hf«nirtmai
Sysir in Moniwnii'ni
Kn ill >li ngg thi- community to rnMnw^u H*o* n
kllW Ivdg
lg«« iiiMHMgwtiimt NytftiMii on <!*•
of
vrlopm«Mil Itnigriimnivx mrn initmtod .
which
Roling
Technology Mediated
Open and Distance Learning
(Tech MODE)
can play a major role in
reaching large number of
people in less cost.
V
I
J-
Participation for material
incentives
Functional participation
VI
Interactive participation
Interactive
Learning
VII
Self-mobilization/ active
participation
is crucial
Sowir:
Mf ..UN I'oxi* <IVM>.
British Open University
( started in 60s)
ranked
5th above
Oxford University
4
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D«»rrVfc—
br*rbr««MM
I
Firwl
1
U-r k—4A.n— ryer- -tlMl MlWx
W»|» iMnacrws
«r»*rnn Mrvrtee •< • Bwd
Hat Ibr e^aMacr W rraMlr*
Hmt mX iMwarrtef
•rilMIty
Itnir-IB
ImliwIH
r>rB-i
trH-
Mwly
lye*
irwim
•>
thr
lr»r»tae
Ibx^k
Wb^mi
lfer««fh
•M
teal
iMeradM^.
Why Tech MODE
Uw
rawb b
Meer AraMlby, •«
|
•—<!»■»» ■«eenn* lMmr<ba«» Is (rvl Ifanr
mbX
IrrOiBrS
ihrBBck
F"**'.
bbmU
BBd
I
MbBI.i is BayxkraMBB ByMrai bM *IiUb iW
oriel.
Mtb
AetlMIky
—4
■■ee rl *r Imlrwlwv Mrertiand bb4 dnlgiwd
krxer
rverb.
N«
Hw
• Communities respond to audiovisuals
• Contents can be created, used, destroyed
and recreated
j
rral
latetMiMiy bM krsrarr* ■aay
Mt get adi quale wpfM»rl.
SrW-
Vtr, MOb
Itw
r
Very
bfcb
pa>«.V*ilkkr.
• Participatory content creation possible
• Participatory and interactive learning: high.
AraBriltiy. N« rr«l
< erectMl y
tMr
awf
Arttblti)
«<
•«
*4^r|rr
br
with
rral
Ielrr»<rt0< y-ieign rvach
I
Rfa-iUeM
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Health Services - n-Logue’s Online Clinic
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Tech MODE Possible
Community Health
• 100,000 villages with ICT connectivity by
government
• Underrepresented in Mission 2007
• Potential for blended learning
• Content in local languages possible but at
present abysmally low
• Standards for sharability and search on
health in Indian languages ( agrovoc in
agriculture)
• 50,000 villages by Microsoft, 20,000 by
ITC and by Intel
• NGOs, Banks and local companies now in
7000 villages.
• Edusat and other opprotunities.
6
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A Brief Introduction
. ......
•.......
A Critical Overview
IK-
V R Raman & Di Kamlcsh Jain.
SHRC. Chhattisgarh
’« ChHattisgartl, a new state bom on 1« November, 2000,
—^UasJauijched.manyJnitiatives to reform the Health
SeaorJ’A'l^poInt agenda'for reforms was agreed upon
iViby-the government with the civil society groups as a
..Jesuit of regular debates and discourses.
M Mitanin“Programme is the key among these Health Sector
■Reforms as well as its community interface.
m ’Mitanin'/Mitan is a local tribal tradition of bonded
friendship for a life between two. By naming the CHW
’Mitanin', the effort was to reinvent the same spirit for
Health.
« Meant to reach out to the community through about
60000 Hamlet level Mitanins, it is probably the largest
ongoing community health activist programme of the
country now.
Current Status of the Programme
-
Total No. of Selected Mitanins So Far:
60092 in all 146 blocks of the state
. Almost 40000 Completed.? rounds of training - .
and proceeding towards continuation phase of
the programme.
■ Rest about 20000 selected in 65 second phase
blocks have more or less.completed 5 rounds of
training and moving towards next levels.
■ The Remaining training tasks for current
programme under ls‘ Phase are to completed by
the end of May 2006.
■ The Programme has been extended by the state
under ASHA scheme for further 5 years and
continuation trainings are planned.
Chhattisgarh: A Brief Profile
Compulsions behind Mitanin Programme
Health Status & Services Situation
...
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....
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Geographic Divisions and Health Facilities gaps
x Total Districts: 16 (16 DHs- 9 functional)
x Total Blocks: 146 (116 CHCs- 34 functional & 512
PHCs- 327 functional)
Total Gram Panchayats: 9986 (4692 Subcentres1458 functional)
Total Villages: about 19000 (about 17000 AWCs)
x Total Hamlets/habitatlons: more than 70000
x Very low population density and huge areas to
cover for health functionaries, hence many areas7*—
remain uncovered or underserved
Other Issues
* ANMSfWorkload and limitations in expanding the
x Anganwadi centre coverage limited to the nearby
areas only- large number neighborhood
villages/hamlets left out.
x Limited connectivity -Most villages are not
connected by the roads and even unapproachable
in monsoon seasons.
* deHwfry h ^etween peoples perceptions and service
« Weaker linkages of the panchayats with health
system.
Gaps in Health Services Provision
Supply Side
Gaps:
x Infrastructure
x Human
Resource/
Manpower
x Skills, '
capacities and
Motivation
x Drugs, Supplies
. and
Equipments
x Programme
Design
x Referral
arrangements
Community Level
Gaps:
x Inadequate
awareness
x Poor utilisation
of services
« Need for
behavior
changes
x Minimal
community
participation
And the Oppertunities...
x Scopes of a new state
x The political priorities were in need of a popular
and massive programme in health. A possibility of
translating it into a strong community network was
evident.
x The state-civil society engagements were open and
a hope was emerged of setting up and imparting a
pro-poor health reforms agenda
x Community Health worker Programme was not
seen tn isolation, it was part and parcel of a
broader health sector reform.
x Over 3nd above these, a determinant administrator
was there among the key visionaries whose direct
support could last for about 3 years...
Earlier Key Programmes
The Approach to Community Health Workers as
it is attempted in the Milanin Programme
x Community Health Worker- Jamkhed, SEWA Rural,
Mandwa/Parinchay(FRCH), RUHSA,(Vellore),
SEARCH(Ghadchiroli), VGSS; etc.
« Community Health Worker - 1977
* Village Health Guide- 1984
x Link Workers & Depot holders
x JanSwasthya Rakshak- MP-1997
-------------franzidi------------
Compared to earlier efforts
2
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Earlier State run Programmes and Mitanin
Programme- Comparisons
m Largely Male
especially in JSRs and
CHWs
k Only Female
■ More concern on
health - in family
and in society
■ More focus on health
education
■ Less interest in
becoming a quack
The level of operation/coverage
« Usually one for
village
m One for each hamlet
w Better coverage
m Effectively handles
issues of
marginalisation of
some communities
Tendency to quackery
Earlier govt, programmes Mitanin Programme
m Drugs had to be
m Drugs provided by the
prescribed
government
« No referral systems
m Active referral system
k Paved way to irrational x Resisting harmful
treatment (JSR and
curative care and
promoting rational
similar programmes.)
practices has been
made part of the
programme
The Selection Process
Earlier Programmes:
Mitanin Programme:
m Usually by health staff
■ By the village general
meeting;
« Subject to approval of the
village community &
Panchayat:
x both of the above processes
have been sensitized by
meetings conducted by
trained facilitator and
mobilized and mobvated
through specific processes
like kalajatha.
m Or by Panchayats- as
representing the
community-but
panchayats often
represent vested
interests &! health staff,
seek docile help not
partnership-
Curative centeredness
Earlier Programmes
because without catering to
felt need one cannot
mobilize for prevention"
x In NGO CHW programmes
effective curative care
demonstrated but little
preventive or promotive
indicators studied
x In government programmes
like JSR curative care
remained was poor quality;
x No specific plans for
preventive /promotive work
Mitanin Programme
“ curative care supplementarynot central"
x Introduced In training only
after all other preventive and
promotive aspects of the
programme are trained and
deployed and assessed:
x Effective plans for preventive
and promotive care
x Indicators chosen and used
(IMCI, health entitlements
and issues education, local
planning etc)
The Honoraria Issue
Earlier programmes
k Honoraria drives and ensures
participation- in training (for
JSR) and in work ( for CHW).
k Were free to collect user fees
from beneficiaries
Mitanjn Programme:
k No honorariums:
k Livelihood compensation at
Rs 7.5/ training day started
after completion of initial
training and deployment
phase
k Motivation and
regular/quality supportive
supervision has to sustain
the participation
« Social and Economic
empowerment through
various measures
envisaged.
3
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The arguments for and against honoraria
The Debates came up for
Remuneration:
Mitahln’approach eveolved
was based on:
« needs compensation for loss k Only that much work given
of livelihood.
as can be done without loss
of! livelihood
x When everyone else is paid
- why not this volunteer- it « Should be seen as
|
is discriminatory and unfair.
representative ofi community,
I x We cannot secure
-paying her is Inadequate for
1
participation without it
livelihood but makes her
lowest paid employee of
| x We cannot sustain
department
participation without it and
it is difficult to retrain every k Safeguards selection process
from pressures
time there is a drop out.
x Loss of livelihood and actual
costs needs to be
compensated
Training strategy
Earlier State run
Programmes:
m Training a one time
activity- with or without
compensation - period
varies from few days to
few months
x Left for work at the
society just after
training, no follow ups.
Run By NCO or by Government Earlier Programmes:
Monitoring and Support
Earlier Programmes:
Mitanin Programme:
x Detailed budgeted plan
x No specific plans
of support and
x After training, they are
deployment;
on their own with
x a specific area of work is
many (not always)
introduced at the village
ethical informal
level and supported till
arrangements
outcomes begin to be
seen After each
training- on the jobs
training strategy.
« A Monitoring strategy is
in place and regular
troubleshooting is on
Mitanin Programme}
« 12 days of camp based
training and 30 days of on
the Job training and support
per year.
x Camp Training spread over
the year - usually two or
three days at a time
x Training support a
continuous process- the initial
18 month period now
extended to further 5 years
under ASHA
« A team of fulltime volunteer
trainers (20+2 per block) to
provide support
NGO programmes are/were
run parallel to the state.
* Currently NGO programmes
are promoted by Govt and
projected by NGOs as
substitute to state action In
many places
x Government! programmes
are run without any role for
civil society
k
Problems:
x State retreat from
commitments
x NGOs cannot provide
widespread coverage and
systemic solutions
NGOs In the small scale
provide motivated
personalized leadership - but
in large scale they too get
bureaucratized
X Government programmes
failed to generate and
sustain motivation;
seek advantages as
patronage
Mitanin Programme- the basic approach
X It was not parallel or a substitute to the public
hea th systems, but a form of strengthening the
public health systems, by:
Conceptual & Operational Details
-Krcniiw
■ Creating a public consciousness of health services as one
fundamental right
■ Creating public accountability
■ Creating a better understanding of what health and health
care Is.
■ Basing of all health programmes at community.
■ Linking Mitanin programme organically with health sector
reform programmes - MPW training, referral *systems,
disease surveillance, HMIS, standard treatmeimt protocols;
operations research etc.
x The Programme is basically training, training and
more training followed by field level support so as
to sustain the community initiatives
4
Key Objectives of the Programme
The Selection and Training
x Improve awareness of health and health
educationx Improve utilisation of existing public health care
services and advocacy for equitable access and its
effectiveness
x Provide a measure of immediate relief to health
problems of weaker sections of society- curative
and preventive
Organise community .especially women and weaker
sections on health care issues
x Sensitize panchayats and build up its capabilities in
planning and imparting health
« Chosen by the village/hamlet
x Facilitated by a trained facilitator's interaction with
village and the formation of village committees and
women's committees
x The facilitator's training gives them the social and
political insights needed tor such a process.
x Supported by a strong component of rigorous cultural
and social mobilisation: Focused around the kalajathas
x After Selection, Mitanins are trained in various health &
health related issues in 7 rounds: 20 days camp training
spread across 18 months period; Each camp followed by
further field support & functional training of 30 days.
x A continuation Phase of 12 day training per annum has
been approved for those blocks completed 1st set of 7
trainings.
Training Contents
Training Contents contd....
« Round 1: Understanding of Health Health services as
entitlements and Management of Child Health Issues.
■ Follow up: Family level counseling begins. Womens Committees
formed or strengthened
x Round 2: Reinforcement of Child Health Issues and
Introduction of watching and accounting health services
through a tool of Village Health Register.
,
■ Follow up: Village Health Register in place. Health Education
through Cluster meetings starts. Flow of Monitoring forms to
start.
x Round 3: Women's Health
■ Follow up: Meeting
Adoles
---------" counselling
— —•■•-jscence of
girls
begin,
Family
further strengthened, attentL
...ANC,,Delivery,related issues
lion on
and Register complete..
x Round 4: Community Based Malaria Control
■ Follow up: Panchayat Level Initiatives begin especially on Malaria
control, efforts to ensure measures on malaria control and cure.
Expected Active Role of Mitanin as result
of these training
■ Visit on Child birth and delivering essential neonatal care
messages:
k Planning for the expected deliveries and facilitate for proper
ANCs; Prompt referral for complications and Inst, delivery
x Regular Health Education, awareness and Initiatives for health
entitlements through women’s groups: 75 messages
x Identification of malnourished children- refer the severe cases
and counseling for common cases
x Mobilize community for public health services- find out gaps and
help the health worker to fill them
x First level curative care using drug kit-early detection, first
contact care and prompt referral- focus common but killing
diseases on Fever, Coughs & Colds and Diarrhea
x To act as community interfaces for health programmes
x To lead the hamlet level initiatives under Panchayat Health
Planning
x A Monitoring strategy is in p'
---- so as to capture this in various
place
levels right from hamlet, trainer,
ainer. Block, District & State.
» Round 5: Provision of First level contact care and
management of minor ailments.
■ Follow up: Day 1 visit and counseling on common diseases
and birth, provision of 10 essential drugs, referrals.
X
Round 6: Revision of Round 5, Introduction of TB &
Leprosy Control.
■ Mitanin would start to dispense doctor initiated drugs. And
she has been constantly supported to become active so as
to bring the desired programmatic outcomes.
M
Round 7: Panchayat Interlinkages and
Coordination- Swasth Panchayat.
■ Health-centred human develoment index and ranking of
-panchayats according to hamlets health status- Mitanins to
be supported by local structures.
Current Organisational Structure
x About 60000 Mitanins
x 2920 full time trainers @ 20 per b<ock
x 438 District Resource persons @ 3 per block
x Key functionaries of the partner NGOs
x The Govt functionaries: the health dept field staff in
block with BMO as the head
x District Health Department & administration, Nodal
officer and State Level Department Functionaries
x SHRC core team for the programme
(25 Field Coordinators, Publication Unit,
Programme Coordinators, State Programme
Coordinator & Director)
5
Management Organogram
_______
Challenges faced
and redressal approaches initiated
Training Challenges and Strategies that
Addressed them-1
x There was serious Lack! of experienced community health
persons to impart actual training of Mitanins. Earlier concept
was to use ANMs as trainers but looking at the actual training
load and its reflection to their routine function, their role was
limited to one fifth of the training team.A training team of.
volunteer trainers (1 per 20 Mitanins) and District Level
Resource Persons formed to address this. They were pooled
out of. NGOs or active social workers through a process.
x where the trainers weak was the actual technical
understanding and health experience so as to train Mitanins in
various issues. Hence was adopted the manual based camp
training and regular on the job training simultaneously.
x The trainers are regularly supported through DRPs so as to
enhance their capacities and the DRPs by Field coordinators of
SHRC and the FCS by the state technical team available at
SHRC so as to enhance their capacities.
Training Challenges and Strategies that
Addressed them-3
x A 16 episode radio programme and some TV inputs was aired
to supplement the training on various issues. A planned
listening of these was organized ensuring feedbacks from the
womens groups.
x Tools to facilitate health education/action were circulated
widely- both Inhouse preparations and those material
prepared by forerunners.
x Measures for enhancing coordination with ANM and AWWs
inibated through ANM/AWW trainings and AWC level events.
X Technical training and up gradation of trainer skills at all
levels are initiated on a pilot basis.
x Lack of Participation addressed through setting up a unique
competition among Panchayats based on best performance on
26 Mitamn, health services, health outcomes and
determinants related indicators.
Training Challenges and Strategies that
Addressed them-2
« Process reviews and participatory assessments among
Mitanins revealed a number of gaps in the training strategies
and processes, which were addressed through a number of
course correction measures. Also initiated course corrections
as per evaluation findings.
x A large number of Mitanins are illiterates or semi-literates.
The text based modules were found of little use for them
hence the fashion of modules were changed with less text and
more pictures, adopting from CEHAT etc.
x There was an issue of varying local vernaculars and the Hindi
modules were not fitting in- this was addressed by forming
hand made training module versions in local vernaculars like
Halbi, Gondi, Chhattisgarhi, Sadri etc.
x Cluster/Panchayat level sittings of Mitanins initiated so as to
motivate them and to enhance their knowledge and skills.
Training Challenges and Strategies that
Addressed them-4
x Continuing Mobilization initiatives imparted to enhance
Mitanins acceptability at the community level-through
Panchayat meetings, wall writing, I Card/other measures.
Some areas on this are still weak too.
x Health Service Provision Gaps were identified and these were
tried to address through negotiations at various levels.
x Lack! of resources for proper drug kit provision and refills for
Mitanins addressed (further burning issues are still there) through
negotiation of a unique “Mukhyamantri Dawapeti Yojna" worth
Rs 5 cr state budget per annum. The Programme got a state
budget too.
x Systemic issues like inbuilt corruption also affects training
camps in many areas as the health department is directly
conducting training camps In many places- a number of
transparency measures are adopted to 'reduce' this.
6
Persisting Challenges, though partially
addressed...
■ Training Inputs are still weak In some areas, new options
needs to be Invented
k Weak Referral and service linkages, partly because
poor/negatlve supply side responses; rest because of
systemic weaknesses and lacunae.
* Loose of locus on core/pnority issues by department
structures needs to be redressed.
k Intersectoral issues are still to be addressed
m Various issues like right to food, right to health are built up to
an extent al the community level, but the community linkages
and responses vanes from locality to locality
« Issues related to widespread corruption
k The civil society protest and resistance on many issues remain
weak- community action needs to be strengthened.
« A similar to civil war condition in some parts of the state
* A number of political uncertainities
The Critical, but
Additional/Parrellel Inputs
« Silent support to interlinkages with ongoing social
initiatives
x Organisational Processes
x Regular Troubleshooting on various field level and
systemic issues
X Convincing the system on right-based approaches
H Media Interventions
Creative and contributive inputs towards the
administrative priorities of the health department
so as to maintain the department attention to CHW
(this gives you space to propose positive strategies
as well)
Further Training Envisaged....
k Panchayat level Health Planning and Swasth
Panchayat Contests.
* Strengthening the training already imparted
through newer methodologies like audio visuals
etc.
K Working with/for vulnerable social groups- the
disabled, old aged, single women headed families
and other special families..
« The right to food & food security issues
k Household/Home based remedies- The Herbal
systems (AYUSH) Interface
H Imparting various information related to overall
community development
1 hank You all for being with us...
7
EVOLUTION OF HEALTH POLICY IN INDIA
• Bluirv Committee (1946) - Soetul l’liysicinn Concept.
l.tK'al efTort and spirit of self-help
•
Mudliar Committee 11961 > - Building foundu(ion of
preventhe IichBIi work associated "illi inc<liv.il relief.
Mt II hi be ul fore front
• SrivastiiMi Report (1974) - Create bands of para-
Nterf** MiMry
FRCH.
/ Pune
11* Aprt 2006
professiomils from community ilsclf
• l( SSR-ICMR III \ II9KI) - Democratic, decentralized
and participator} people owned health model
COMMUNITY HEALTHCARE SYSTEM
(CHCS)
CHW
CHI
W'lghbiHHlUM'J
tTtr. i
(■ram Panchayat
V).fXX>
- REFLECTION of a political struggle
N«ih^ ttprw
Gr»»ep (trim
i wi s5* • i
I'uiKhayatx
I'copk-'x Ik-allh (jimpk'i "
I'aiKluiyji
190
•
Berman
H SCI IONA RY
Jixi 25u
5 <»x>
- NOT a technology for primary healthcare
REsrossiinunv to
Kill l.ATION
95'S i
» \pprox. rrop««rtM>R <•( l oti I Scoke* C’ntcrcd
■ IU*.pilat-<*un>-Tr«ininc Centre
Otm.Hm ruorliom
Rr^crxc Rvfrrrvl Srr»ke»
IMPLICATION OE A NEIGHBOURHOOD
FUNCTIONARY (1:250)
x
|-unctions as tin Esicndcd l-umily Member
x X ers high ticccssibility / Xccountabiliiy
x Cun underlakc domestic and professional functions
Why Not 1:1(KM) WorkerPopulation Ratio
Z- Village Nut Homogenous Emily
> (Cast - Creed - Socio-economic
Unit*)
r Requirvx Full-time Funclitmury
x < Implicit tons in her puymciil
und lime commitments)
1
LAERE
Lessons from the old ....
Mandwa (70s)
Malsheras (80s)
TEACHER
vs
Experienced potential
Education not absolute requirement
ommunication with
Communicating to
Value of non-formal approaches & PDC promoting social
change
ONCIOUSNCSS
TARGET GRCHJPS/INTERVENTIONS
AISING
Synchrony in communication & service delivery
Don’t miss the forest
Address harmful cultural values, societal norms,
structural inequities
IN fEGRATEI) MULTIPLE FUNCTIONS OF
COMMUNITY WORKER
Human Health: l*rcv<-iiiivr/l*ioiuoli«c mid CurMhr
Approach to Learning
•
•> Pi-obleiii-based learning
' -\l! Xatioii.il Health I’lOgraminci iiicludinf IT1 RCH
lminuni/atx>n
•> Need-based learning
<- Rclcrral* to Exixtine Public / Privtitc Service,
*> Integrated learning
' Uater
Sanitation
Nutninut
\ cterinary (’are
❖ Competency-based learning
Public Information
•> Ethics as an integral part of learning incoriwrate;
•- I'iirticipatioii in Panch.iyati k.ij
' Right !,• liilonitaiii'Mi
f Equitv
income Generation
jiv ironmental / Ecology Education
i. '■£*' 4-4’2
'omniimity Mobilization
>■ \ce<Hinl;t!>lc to her Ciinutiunily □<. UkhiIJ be ir< A.X'M fi AWW
> Effectiveness
> Environmental protection
< Responsibility
>■ Supi'iin ik>i apptti|>tiaiion of lunctioti-. that arc -eo undenaken bv the
(’oniiiiuuiiy
r-Training geared to :
v Change in self image
%• Provision of skills, knowledge and information
<• Sharing and networking
<• Organizational skills
<• Access to economic empowerment
•> Advancement with retention of traditional roots
. 35..'
2
Waler
*atoafkrt>«kc»re
I.'
32XX J'
M Akl
W *U-t
Ma»Mf.1IWWI
U ju-t r.Ulwl.-®
W Jic
•
•
.■.•* . SHCU’
•G*
t JJ. ixJj
F'1^ -‘HF
LESSONS LE/UtN’T
U4.WM exit oarttMonr-i
couxxmox o» umu tirocrrunc
CAOV» > rwMLitK ■ tan
Careful Sclre<U« Criteria A^UlrJ lhr-»«it»> A Cvmiauiiin lUwd I'raicrxA
<• Ounuac Kixhl U orlrr Pnfxiblioa Kalan.
Iltrtrlxplnt: *4 SAUlrei Ma»<rr TrainrrM
<. Freajurnl ><xl Sklllrd Super* hkm
<• I
mid klxtlMUkxkai Supt»ui iRnp«~'r llrahh Sixleuii
<• C»\h t Kiad Krtunr. - IradMieital KreHunrratkv l%i<>rrn* nl
< Mimunllk-x
<* Intevrareet te«m «*l tumlwinlac
v Cruduai ■•kJ I«hrv-rocntal Ke»ln«<turi«z
<■ l alerel IJnlj«tre» : iire<i»K* »r>d \e~«*r1trr
❖ Cnuunaatl* Ouaerahip : InHiatr ~hiU Traininc
<r SusUImuMUi* Fartare >• iw F.UaMiUwd Earit la Pr««-r\x
-f/Tif Hoovi «a(»®n» cany
f®Vorjl«V <r.
Lessons from the new (Parlnche, Ralegan etc)
a •f-a*«
o!
■ doeo cmgn'.t
.rwnxvd tunduvl can navmttxMtfM leftocl on
<y ox ixwerx, ayco to th® extent o<
lt>«s
•
Srtt RtAt 11 Y from ROf.tANCE
•
lnk-j<®1<. fcXPERIENTlAL *.th SKUljXNOWtEDGE
u'--T-<BO0 <W 'ukn <w> wtKh « <un* W»«t 0003
Jiiptojch BfcFORt '<>oduh»k
•
ltx>
•
lLARNinG '
Co<nnujnK.ji<Mi -♦ Avs«'*<ation
-> Rnfiectxin -♦ iiiieimiitza'Hwi
-> Practice* Evaluation
tr»i.i O'ttk'ncn of MtNO -n vxnn O'^wum on
x-rrw. r»ane( ri the urwnxso i» eure»> a tact ot
UnL^MiKed indn-iduai fccv* * Ciecern'ion of worke* «oia!v<i • new
cjrcJt' ol 'oczil orptosstuo
tnr.'M'nen'jii siqnikcana’ Throuqh conic >ou»
being*
process forward THROUGH 1HE lEARNtRS
•
th®
Mo2>f<-S)
uniw»e»«
h«M
a«vw*al®d
s®K-
aA.ir<inet.t
r
ixac'xcc i *xt tfKpenonct) of 6oer<e and art
»
-
teadiHship quaMirn
integrity and ■i.-kpoxsiii^ npOK'-Kh
P;«il Oii>n
4
I
What we did before we were in
YCMOU
The Rings model for
Health worker learning
programmes
♦ We wrote books with many chapters,
with subheads—long narratives, full
themes, 'complete' or 'full' (hold-all)
versions
♦ Printed books and edited them thru
years
A 'new' model for large
scale health worker
programmes for flexi
lea rning
i
Reshuffling was painful, and
caused rifts and divides
♦ We had a PHC group in
Maharashtra—9 members—with
different orientations.
♦ Books were the battleground.
Discarding old work and accepting
new ones was a problem.
♦ Need to have a way of using new
and old work/ideas in a productive
and creative manner.
♦ Single/twin author projects -years of
dedicated work, and projects.
♦ We waited till print edition was
available.
What we did not think
♦ Variety of learner needs/
♦ Various learning abilities
between/within groups
♦ Variety of ways of doing things in
programmes-multiple authors
♦ Frequent changes/updates may be
necessary
♦ Sequencing and grouping of lessons
should be flexible
Lessons from large scale CHW
programmes
♦ We must get away from planner
centric models to four-perspective
models
♦ The 4 perspective model includes the
planner, the learner, the
trainer/counselor, and the user
community.
♦ Unless we move to this balanced
perspective, programmes can not
have a context relevance and
internal richness of quality.
After we joined the
Open University
. •ff
1
I
At YCMOU we realized
The ODL model
♦ The need to be flexi by principle and
by design, not as a convenience.
♦ The original correspondence course model
has now evolved into Open & Distance
Learning (ODL) model which mixes
contact sessions with assignment/ work
center experience.
♦ Self Instruction Material, workbook and
Couenslor Guide are the basic
components.
♦ We now call it a flexi-learning model.
♦ With IT use, we can also harness the
Virtual classroom EDUSAT model. We can
do with fewer trainers.
♦ Use more than one SIM
sources/options, on a common
framework.
♦ Develop material as we progress,
with part of material in hands, and
that too a limited edition.
♦ We decided to make multi-layered
learning material
The student evaluation needs of
ODL
The SIM, WB & CG
♦ Self learning material (SIM), Workbook
(WB) with counselor guidebook (CG) is the
minimum strategy.
♦ The SIM+WB+CG was mainly in book
format. Now it is being reinforced with IT
aids.
♦ For CHWs, the ODL model is the natural
choice since it is flexi, learner centric, and
low cost.
♦ Virtual classroom/IT ad-on tools can
enhance the programme in many ways?
♦ The academic programme does need
student evaluation—individual or
group.
♦ It adds quality, simply by
announcement of evaluation before
the programme.
♦ Evaluation helps us to improve the
programme
9
♦ Programmes without academic
evaluation can degenerate sooner or
later.
.
The learner versus trainer
approach
The varying needs of health
workers
♦ Learners need a say in programmes-if
they are really need-based, problem
based. This is the main plank of adult
learning.
♦ Most of even enlightened and 'good'
programmes are planner-trainer
dominated--the topics, sequence,
language, messages, artwork, are all pre
decided.
♦ W need a shift, esp. in large scale
>
programmes.
♦ It has to be a network based approach3, 0^?
even making learners conFnhrite'and
♦ Different, diverse and even opposing
priorities of learner groups, (for
instance the Kolam tribe needs to
have more children to even survive)
♦ Need assessment necessary before
offering a programme. At least keep
space for local needs.
» J| I
12
2
(
The various situations of health
Different learning levels
training teams
♦ Different ages (25-50) have differing
learning levels. Generally, the older
students are less eager for learning or
unlearning.
♦ varying schooling levels (even non
literate) even in the same district or
blocks.
♦ Development level in each block may be
different, with varying exposure to
ideas/messages/services/goods etc. For
instance Navapur block is developed as
compared to Dhadgaon.
♦ Teams may perceive needs and priorities
differently.
♦ The resources may also be different-for
example home birthing may be necessary
in some blocks while completely
redundant in others.
♦ NGOs may be additional factor in some
blocks.
♦ The time available from doctors/nurses
may be vastly different. Special teams
may not be available.
The needs for updates
The multi-author project approach
♦ Topics need updates-every 2-3
years. Health
approaches/programmes change, so
do technology and solutions. RCH
programme has undergone several
changes in content and context.
NLEP, NTCP, NACP, IMNCI, ICDS are
all changing. The learning material
should keep pace with changes.
♦ There cant be a single author for the
entire set of Learning material-it takes
time, is of less quality, and ignores a
richer possibilities.
♦ That saves time, enhances quality, brings
richness.
♦ But a multi-author project is possible only
on a decided scaffold/framework. It is
easy if we have a plan—goes haywire if we
have none.
IS
14
The must learn-should learn-may
learn- rings
♦ We realized in our dai (TBA)
programme, that 3 books-ANC-NCPNC are better replaced by mustshould-may learn books. It makes
life simple for all the trainers and
learners well.
♦ The rings approach easily can do that
rather than the thematic approach.
The scale is important decider
♦ A small scale NGO programme (20 + )
village can be an intense programme,
customized to local situation and
programme goals. Here we are at the
'best' end or right side of the range of
variables.
♦ A large scale/generic programme requires
broader approach.
♦ In large scale programmes the 'trainers'
and learning environments are not at the
best end, but west-end/left side.
3
Lesson replacement needs
The assignment needs
♦ With time and location, some lessons
need to be replaced, (eg: small
family is good in most places, but in
Kolam tribe big is necessary. Heat
stroke may be replaced with cold
injury in different places).
♦ Health workers hear/see in the
classroom or PHC but 'learn' more in
assignments, after the contact
sessions.
♦ Hence assignments must be neatly
planned. A workbook makes it
possible to record the work.
♦ CHW programmes must alternate
contact phases and assignment
phases for good quality programmes.
♦ There may be less drastic
replacements.
♦ The design must provide for this
flexibility, and not as an
19
20
The matrix vs the narrative
approach
♦ Need to move from long narrative
lessons- to small units laid into a
matrix.
♦ This makes flexibility possible-like it
is easy to replace bricks
♦ It makes learning and training
easier.
The Rings model
21
The matrix to Rings n spokes
♦ Once we make a matrix (see next
slide), we can arrange the sequence
either by columns or rows.
♦ The matrix renders itself for
arrangement in rings
♦ In the ASHA case, we had made five
rings for five episodes, (see slide)
♦ The 'spokes'/sectors are single
themes
--
J"' •
[TKXCS_________________________
iR»>g
' Ring? Ring: Ri>g4 RmgS lol tvs \ sh
|R«>gl|H>ng2
1 t'lroduclon, rotes, tasks
2
2 Bcrig healthy- delerrrmants of ftealth
3 Water-sanitatoo. envronnvrnt
4 lartrlcxi & malnuirttrxi
Know ng oursehres-HrrrMn tx*>gy
Conmjniy. gender. -PW ftghts
Adolescent hea«n •
Cormunication
2
H
3 8]
~58]
2__
8
c
2
2
9 Health services. Govt. P«l Social Mar
To •ness. causes & heahng. «err»x%es
0
2
0
I
4 5
2
2
A'vusiviterbal rredcTw:s
12 Contraceptive Methods '
13 ^evening lbw anted cMdbrth '
14 Hegnancy. Orth, post natal care
IS Gervlal h tec hoot and Hh//A OS
2
22
9
se
‘2
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17 Conrrrxi medcal probterns
2
Health Pioguimgi
J®) Accdents t frit
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(7 5 hrs pei day)
21
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30
30
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27
38
a
-it
26i
5
156
.4 71
20.8
iocb
24
4
The advantages of Rings-approach
z'-"
<
♦ Renders gradual learning
arrangement possible- Must /Should
/May learn
♦ Offers multitasking, which is what
community respects
♦ Complexity can be graded ring by
ring-suits heterogeneous target
groups.
♦ Lessons can be redone/replaced/
substituted at severaLlevel
26
■
The spokes or sectors (themes)
The lesson framework-size and
conversion
style uniformity
♦ It is easy to choose either rings or
spokes, partially or fully. In ASHA
case the first book was Ringl and
next book is 2-3 themes together
(MCH, medical care)
♦ Theme offers some advantage-like
topics are together
♦ But flexibility may be compromised-the theme nearly 'freezes' once it Is
made.
»
♦ The lessons must be of a uniform
size.
♦ Like the leaves of a banyan tree
sapling or a huge tree—have the
same size and plan.
♦ Uniform lesson size and style allows
organic growth and management of
a broad & multi-thematic learning
programme.
Independent lessons-links yes but
Small is beautiful!
repetition needless.
♦ To reap the advantages of Rings
model, we must take care to make
the lessons as independent as
possible. Avoid repetition of
messages, esp differing/divergent
messages
♦ What we need is links to pre and
post topics.
♦ A plan there must be-to offer small
lessons that can finish in 30 minutes
and give a break. The Learning
Objectives-content-KAP, recap,
exercises-- all must be there.
♦ Small lesson size makes focused
learning possible. Avoid multiple
LO/message crowding in the same
lesson,
:
30
5
Bound book vs spiral model
The ASHA context
♦ The flexi approach should be
embodied in a spiral book, rather
than a bound book—at least at the
central-state level. The districts can
make their own bound books.
♦ Spiral book offers flexibility for
corrections /replacement (bound
book is a fait accompli)
♦ The spiral approach makes shift to
either Rings/themes possible.
♦ We used this approach for ASHA.
♦ The Rings model proved robust
enough to withstand drastic change
to thematic from book 2.
♦ Ring 1 can also be replaced by a
book for non-literate ASHAs.
♦ The need for upgrading/add rings or
themes can be met with the matrix
approach quite easiely.
32
3)
Fundamentally pluralistic
♦ The Rings model is basically a
pluralistic approach by design—a
post modernist view of things in
community health
♦ Several possibilities around several
foci (rings need not be concentric),
multiple makers and users, flexible
with locality and time needs.
Deconstruct is the word.
♦ Steers away from whole truths and
grand narratives and diktats. It
provides for participatory approach. J3
IT solutions to syllabus and
IT use in CHW
programmes
The use of IT
learning material,
♦ IT will make it much more effective,
and easy for trainers, provided
computers are available.
♦ PowerPoint shows with clips are the
best and cheapest forms of IT use in
CHW programmes.
♦ Interactive programmes need much
more preparatory work.
♦ Books for take-home can be modeled
as ppts.
♦ IT minimizes 'transmission loss'.
♦ In addition to print material, we now
have IT solutions. CD based lesson
bank can be used directly or in print
format as need be.
♦ This gets rid of centralized printing
and renders distribution economical.
♦ IT offers flexibility and control by
local training teams.
♦ Adds a rich AV component.
3S
X
6
1
What YCMOU is doing
What is YCMOU doing
now?
. 1’
Using rings and IT in several
programmes
♦ The YCMOU school is now using Rings
model in many programmes-Dai, CHW,
Hospital assistant, and later for
Anganwadi sevikas.
♦ Uniform lesson size and plan makes it
possible to share common lessons in other
programmes.
♦ The rings approach makes it possible to
launch programmes as soon as R1 & 2 are
available, and use feedback.
♦ We are even thinking of replacing
centralized printing/storing/distribution . ■
and ask study centers to download and
photocopy as they need.
«
♦ In the primary care programmes-for dais, health workers, Anganwadi
workers—we are now following the
rings model.
♦ All the five ASHA rings with pictures
♦ Power-pts with vi-clips are the basic
stuff and print material is a take
home aid.
♦ Development of a resource-bank of
freely downloadable lessons,“
Appeal for network and resource
banks
♦ Contribute
♦ We will suitably edit and
acknowledge the source
♦ We will put it on ycmou-website
♦ Free access
40
Thanks
School of Health Sciences
YC Maharashtra Open University
Gangapur, Nashik 422222
Ycmouhealth nsk(g)sanchamet.in
Ph 253-2230718, 2231714(ext 3020)
Website: Ycmou-hs
Dr Shyam ashtekar (Director)
Dr Dhruv Mankad (Sr consultant) r.
v A rir- "
7
Proposed Training Strategy
Roles & Responsibilities of ASHA
for
> To create awareness and provide information to
the community on determinants on health
Accredited Social Health Activist
(ASHA)
z To counsel families on maternal and child
health components
z To mobilize the community and facilitate them in
accessing health and health related services
(’Training Division)
Department of Health A: family Welfare
- To assist in development of village health plan
Ministry of Health & FW
Roles & Responsibilities of ASHA
(cont.)
Criteria for Selection of ASHA
z One ASHA per 1000 population
(Areas in tribal.hilly.desert the norms could be relaxed to one ASHA per
habitation, depending on workload)
z To escort/accompany pregnant women & children
for treatment/admission to nearest health facilities
z Primarily a woman resident of the villagemarried/widow/divorced
> To provide medical care for minor ailments
z Preferably in the age group of 25 to 45 years with
formal education up to 8,h class
< To act as Depot Holder for essential provisions
z- To inform about the births, deaths and outbreaks in
the community
z Should have effective communication skills,
leadership qualities and be able to reach out to the
community
< To promote construction of household toilets under
Total Water & Sanitation Campaign
> Preference to disadvantaged population group
Training Strategy for ASHA
Selection Process of ASHA
□
Induction Training - 23 days spread over 12 months
□
v
7 days pre-deployment
v
4 episodes of 4 days each
Periodic Training
l>i\lrict llmllh Sociclv (l)HS|
I
llistrict Nodal Offlcer <I)XQ> / Block Xirdal Odurr (H\<>)
I
- III l'»tili<ar<ir» per blin k
2 days training every alternate month
I
ComnuiniO (a >horl liil of J namo from each tillage)
□
Constitution of level specific Training Team
(STT, DTT and BTT), should include the members from
Department OF Health, PRI.WCD, Rural Development,
NGOs, etc.
□
Identification of Training Venue
□
Development of training plan for each level
Grammliha (111 trlrcl one of (hr Ihree n»mr»|
4
ASHA
1
Adaptation of Training Material for
ASHA
Training strategy for ASHA (cont.)
□ Cascade model of Training
TOT for STT at NIHFW
Training for DTT at SIH&FW
Training for BTT al DTC
❖ Training for ASHA al PHC/ AWTCs /Panchayal, etc.
U Continuing education. & Skill Up gradation
<• Resource Agency/ NGO
-1 Convergence- Joint of ASHA/
ANM
□
Draft training material to be made available by GOI
%•
Training modules (books) based on thematic
approach
v
Facilitator's guide for each book
□
To be reviewed by states locally and adopt as per
their needs within the context of ASHA guidelines
(J
Translation in local language
U
Printing
U
Responsibility: State Nodal Officer
ASHA: Issues for discussion
x Identification of nodal officer at State / District /
Block for ASHA training.
x ASHA - proposed / selected - district-wise
> Selection process
x Constitution of Training Team (STT/DTT/BTT)
x Training material
x Training plan for each level
THANK YOU
x Release for funds for training
2
Clinical training of CHWs
The Basic Plan
Dr Shyam Ashtekar
Categorizing illnesses & health
problems
[
i
(N
<.K<>nris<
OLM.MIMS
II I
K)K A IIU ISIO5 AT THE VIIJ.AGi; IXVEI.
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LXAM.FU3
HOW (YIMMOS
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■ra iffttMUc
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IK*<U OTrfy. .<«■
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a»d w>rwt to*
>»V«al G.vc humc
G«vc U«c
(mu
A
The general symptoms
Some symptoms are 'complexes'
(fever, weakness etc) while others
are for 'spot diagnosis' or single
conditions.
The single conditions
Problems like sore eyes, pus in ear, etc are
easily recognized.
Problems like sore eyes, pus in ear, etc are
easily recognized.
1
Others may desire more clinical
training.
Some CHWs need it simple!
o Some CHWs may want to learn
more—about fever, cough, loose
motions, weakness, or abdominal
pain.
Many CHWs cant take complex and abstract
thinking for clinical decisions. We have
avoided all complexity in ASHA phase!
o This opens up more variables and
learning complexity.
The Diagnostic table
The Diagnostic guide (flow
chart)
The matrix has several uses, but
takes time for learning. It is mainly a
thing to fall-back upon.
The flow chart remains an easy
decision tool, but the CHWs must be
supported to follow the technique
The IT flow charts
With IT programmes, diagnosis can
be available even in kiosks.
— —-—
«•—...
2
The IT flow charts
Immense potential
o With IT programmes, diagnosis can
be available even in kiosks.
o Illustrated flow-charts need to be
developed.
o With interactive tools, the complex
diagnostic problems become simple.
o Evan 'quacks' would benefit and
help their clientele with these tools.
o Good help for consumers.
o Clinical training of CHWs is a
neglected area (we are still in the
denial mode)
o But we are also doing willy mlly it in
IMNCI
o Flow charts can change and simplify
the IMNCI substantially.
And about healing
Thanks
o Healing, an essential function of any
health worker is also being denied—
to the detriment of the programme
itself.
School of Health Sciences
YC Maharashtra Open University
Gangapur, Nashik 422222
Ycmouhealth nsk(g)sancharnet.in
Ph 253-2230718, 2231714(ext 3020)
Website: Ycmou-hs
Dr Shyam ashtekar (Director)
o It is possible train CHWs in 6m-ly
for managing basic health
problems.
o A graded portion of primary care
EDL, AYUSH, non-drug remedies
will be vital to CHW programmes.
3
Behaviour Change
Communication:
A Resource Approach to training
Community Health Workers
Dr M. S. Menon, MD. Major (Retd)AMC.
Director, Kripa Foundation
Cardiologist, S L Raheja Hospital
Prof & HOD (Med), CMPH Med College.
KRIPA FOUNDATION
Battling Substance Abuse and HIV/AIDS
Largest NGO under Ministry of Social Justice and Empowerment
Impact: Through 40 facilities in 11 Indian states
Activities Addiction Awareness. Counselling & Rehabilitation. Employee
Assistance
Help lines, HIV-AIDS Care and Street Children Program
K'ip.4 Pipiccts
Kripa Institute of Training, Kripa Institute of Research, Kripa-AIOS
Regd. off: Kripa foundation 81,'A. Ml Carmel church. Chapel road (W) Mumbai
4000S0
website; www.kripjjfouridation^yrg
I.mail knpadarc^mtnl nct.ui
Helplines Hiv/AIDS 02? ?64?9l58 Substance Abuse 0?? ?640S41i
r ■
FoSn
VISION
A GLOBAL HEALING PRESENCE
GOAL
Empowering those affected by
Chemical Dependency and HIV/AIDS
Knpa Foundation 2006
Mother Teresa at the inauguratYon’oY’tfieVasai Centre: 15 May 1^94
*7
KRIPA
FOUNDATION
(since 1981)
40 facilities.
14 locations.
11 Indian States.
Substance
Abuse and
HIV/AIDS
i related activities
i across India1
Behaviour
....the aggregate of the
responses or reactions or
movements made by an
individual in any situation.
Knpa Foundation 2006
1
Behaviour Change
Behaviour change would refer to
extinguishing maladaptive behaviour
patterns and help people learn new
adaptive ones.
Helping people make behaviour change
involves a series of relatively structured
and predictable steps that can be
adapted to meet the needs of a person
or a problem.
Kupa loundation 2J06
FORCES BLOCKING
BEHAVIOUR CHANGE
•Change program
• New role models (Team
Leaders)
• Insight (old behaviour
seen in new ways)
• Measurement (self and
Local)
• Adjustment with the
environment
•Team support
•Communication framework
reflecting actual client
needs and best practices
•Old role models
• Lack of self-awareness
• Lack of recognition and
reinforcement
• Lack of reflection and
learning
• Lack of self - belief
•Lack of awareness that
'change' begins with me
• Negative/blame culture
• Lack of definitions of
required communication
.behaviours________
Knpa foundation 2006
g9
Communication..^
• Speech and language are only a portion of
communication.
• Other aspects of communication may
enhance or even eclipse the linguistic code.
• These aspects are paralinguistic (text),
nonlinguistic (body language, gesture), and
meta linguistic (slides, sign language).
Kf’CM rounOauon 2006
• Describing the behaviour: specific and
measurability
• Establishing a baseline: frequency and
severity
• Establishing goals
• Developing strategies: behavioural
therapy
• Implementation
• Assessment
• Reinforcement
Knpi PounddUon 2006
CHANGING BEHAVIOUR
FORCES DRIVING
BEHAVIOUR CHANGE
Steps to Behaviour Change
Communication...!
....is the process of exchanging information
and ideas.
An active process, it involves encoding,
transmitting, and decoding intended
messages.
There are many means of communicating
and many different language systems.
Knpa Foundation 2006
:o
Importance of Communication
skills for Community Health
Workers (CHWs)
• Communication and health are
inextricably linked
• Poor communication and impoverished
relational contact can predispose to bad
health
• Effective communication is invariably
the conduit by which health needs are
identified and successful interventions
planned and implemented
Knpa Foundation 2006
2
Need for Understanding Holistic
Health in different Communities
(Urban, Rural)
Modalities in BCC
• Knowledge transfer (Inputs)
Health Goals:
• Therapies
Physical, Mental & Social.
•Non-verbal (e.g IEC material)
Spiritual.
• Therapeutic Duty Assignment
Available Resources:
•Individual and Group
Public Health Systems.
Social & Spiritual Systems.
tfnpi foundation 2006
Knpa »cund*!ion ?006
Behaviour Therapy: Definition
Behaviour Therapy: Use
Behaviour therapy is a form of psychotherapy
which seeks to improve the way a person feels by
changing what they do.
It is commonly used to overcome phobias.
Can be useful in generating "help & health" seeking
behaviour.
Kripj Foundation ?OO6
IS
Areas of CHW Interventions
• Community issues and traditions (stake
holder supported)
- nutritional, environmental
• Family / Social issues (faith / spiritual
leader supported)
- Early marriages, relationships,
codependency
• Individual issues (peer supported)
- personality and psychological (anxiety,
depression, phobia), hygiene practices,
interpersonal stressors, addictions, PTSD,
communication
KnpA Foundation 2006
t:
• Behaviour therapy helps you weaken the
connections between troublesome
situations and your habitual reactions to
them. Reactions such as fear, depression or
rage, and self-defeating or self-damaging
behavior.
• It also teaches you how to calm your mind
and body, so you can feel better, think
more clearly, and make better decisions.
Knpa Foundation 2006
>6
Integration of Behaviour and
Cognitive Therapy(CBT)
Cognitive therapy teaches how certain thinking
patterns are causing symptoms — by giving a
distorted picture of what's going on in life, and
making one feel anxious, depressed or angry for no
good reason, or provoking one into ill-chosen actions.
When combined into CBT, behavior therapy and
cognitive therapy provide you with very powerful
tools for stopping your symptoms and getting your
life on a more satisfying track.
Knp« Fcundat-on 2006
18
3
(
Therapies for Behaviour Change
• Desensitization:
Gradual exposures, reducing fears, phobias, obsessions,
compulsions and anxieties
Generating Competencies
Training Programmes
(new skill, upgrading, professional
level)
Training Methodology
• Shaping:
Gradual change,Successive approximations of desired
behaviours, develop new patterns of behaviour
• Reinforcements:
To enhance learning and solidify gains.E.g.. If you eat your
medicines then you will be allowed extra time to watch TV.
(didactic, field work, own time work,
role plays, games & street theatre)
• Skill training:
Assertiveness training, decision making, problem solving,
communication skills
Accreditation
• Token Economics:
Reward system e.g. School children. Day Treatment
Programs, Hospitals, Prisons etc.
Kfipa »vund4l'O<» 2006
(university, state, national)
Kfipj loundilton 2006
Stake holder participation
Knpa'ouncauon 2006
Group activity
2G
Peer group training
21
Role play and games
4
CHW Cohort Development
IEC based training
• Community needs assessment
• Stake holders/Key informant identification
followed by interactions
• Structured and unstructured observations
• Peer group (potential CHWs identification)
- Rapport building
- Recruitment
- Training
- Testing
• Community rapprochement of external
CHWs
Kr*pj ToundAtion 2006
Monitoring, Evaluation and
Growth
?6
Discuss this scenario for
approaches by a CHW
An anemic rural lady of marriageable
age from a conservative community,
attends the PHC and gives a history of
prior sexual exposures.
• Block, local and institutional levels
• Supervision schedules
• Leadership training
• Skill updating
Discuss a CHWs approach to interacting
with this lady.
Knpa •■oundatian 2006
27
Knpa Foundation 2006
28
5
(
(
Dr Yogesh Jain
85% of the health problems in
a village can be managed by at
the village level
Thoughts
By the village health worker
The fourfold path for judging the
effectiveness of the health worker
based model'.
People in small places have
small problems
And thus require lesser quantity,
quality or level of care
Does the presence of the health worker
improve the access of people to health
care?
Docs it reduce inequity?
Is the treatment appropriate?
Is (he (reatment effective ?
• Choice of drugs
• Can she look after vomiting?
1
(
I
Is the treatment affordable?
■ Shorn of all components of primary
health care, it is a second rate
doctor that you offer to the
“others".
Clinical skills
You take corrimoxazole or lurazolidone /or war child s Kastroenteriiis
and I ni' e Ciproflox
You use cotrimox for your child's pneumonia and / use amoxicillin
iou use MDTor MDT plus for your lepros v and I use dailv rijumpictn
You get treated with DOTS and I take a daily regime
You get < tabs p! Chloroquine for your /<■«•/ and I get my blood checked
and get treated accordingly- take SP or mefloquine
You get GPfor your pyoderma and I will use ora! antibiotic
cough cold
Pneumonia
watary diarrhea
dy wntary
scabies
pyoderma
fungal infections
ear pain
ginglvias
bodyache*
clinical skills
Clinical skills not known
Asthma
vomiting
white discharge
anemia
intestinal helminthiaisis
small wounds
diagnosis of pregnancy
examination of pregnant woman
colicky pain abdomen
dyspepsia
dysmenorrhea
kwtudon
hyp<n»o*iori
b4ta
wuU bite
J»uncttc«
apbtbooc uiceca/ gftoaattlt
cofXlnUng
app«ndicttia
2
diagnostic skills
crwtrt b4«th
■waking in body
>«nMon fw MMlon
p>o«aM
Mnilaleral headache
Mood p<*»u>« check
check h*mog4ob«n
obeliurled labour
•pvtoCTi ameer meklng
Check for meetttia erxl breeef ebaceae
1 COAI> aatbina. CHI)
k>«n(<y meaales
dehydration
roomer he
freer for unde« nufrlfton
< erbunc lee
»wVh| Windreti
rheck tor p-oMpi*
check for
oq*rt alxloman witti pain
Clinical skills not known
piles
leprosy
strangury
prolapse
I
f
What is social exclusion?
Gender and Social Exclusion in
Community Health Worker
Training
Lindsay Barnes
• Discrimination of opportunity and access on
basis of identity
• ‘Gender’ hierarchy cannot be seen in
isolation from other forms of
discrimination: c.g.. castc/community/class
Jan Chctna Manch, Bokaro
April lllh, TMTC, Pune
How to work for social inclusion
• Implies an acceptance of equality for all
• Need to address all forms of discrimination
• Hierarchies of gender / caste/ community/
class are interwoven
So, why to focus on ‘gender’ in
CHW training?
• Within poor communities gender is a cross
cutting division
• Women have specific problems of health
• Women have less access to health care
• Cannot tackle only one form of exclusion in
isolation
• Gender discrimination impacts health and
needs to be addressed in the training
• ‘Gender’ blind training perpetuates /
reinforces discrimination
Steps in addressing ‘gender’ in
CHW training
Things to consider when
selecting a CHW
• Selection of the right people as trainees
• Getting the content of the training right (add
on / weave in?)
• Ensuring the trainers arc aware (the most
difficult bit)
• Empowering women CHWs to provide
services (after the ‘training’ is over)
• Sex of the CHW (Should we only select
women?)
• Attitudes of the trainee (Commitment to
social justice, equality etc)
• Power linkages (Who do they ‘represent’?)
• Aptitude / previous experience
• Education / literacy skills
1
f
f
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‘Doctors’ & ‘Dais’
• Village rich
• Higher caste
• Educated
• Mobile
• High value work
• Brash confidence
• Less experience
• Less ‘knowledge’
• Allopathydrugs
• Well connected
• MALE
• Village poor
Approach & content of training
• Lowest caste
• Not literate
• Limited mobility
• Low value work
• ‘Quiet’ confidence
• Vast experience
• Years of experience
• Hcrbal/massage
• Outside ‘system’
• Positive discrimination in training to ensure
inclusion (men/womcn; high/low caste;
tribal/non-tribal)
• No ‘recipe book’ for ‘gender’
• Need for behavior change (gets personal)
• Skill building to go hand-in-hand with
awareness
• FEMALE
Looking at ill health
Women CHWs and
empowerment
• A middle-aged village woman has acidity
........... need to go beyond antacid...........
• Diet & hunger, fasting
• Awareness, skills & experience not enough
• Low self esteem
• Stress (& violence?)
• Anaemia
• Issues of ‘power’ go beyond ‘training’
• A non-empowered CHW will not be
effective
• Empowennent cannot be ‘trained’
• Access to health care..................................
2
(
(
Swasthya Sathi programmes in collaboration with
People *s organisations
Training of Less Educated /
Non-literate CHWs
Some lessons from the Swasthya Sathi
programme
Anant Phadkc, Abhay Shukla
SATHI-CEHAT
•__L-
Flat No. J & 4 Aman-E Terrace, Plot No. 14(1,
Dahanukar Colony, Kothrud, Pune 411 029
Tel: 020 25452325^5451413
>-\~~p
Entail: cchalpunfa'vtnl.coni
THE GROUND REALITY IS
• 91% of women in rural areas of EAG states do
not have middle level education
Non-literate / functionally literate CHWs would
form a significant proportion of CHWs
‘• This is especially true if
• CHWs are to be women from disadvantaged
communities (adivasi, dalit)
• If remote, backward areas too arc to be fully
covered in any CHW programme including the
<
ASHA programme
YET
• Barring exceptions, very little effort to prepare,
standardize training methodology, training
material for the non-literate CHWs
.-S'
c.
C
e-
-
♦ Knowledge and maturity through life
nv
,nnrinn/'n
nnd
/'uriaritv
experience
and
capacity fnr
for uhctmcf
abstract
thinking
But
■
♦ Problems with reading, writing text
• Less attention span with textual material
even if functionally literate
««♦ Being adults, firm socio-cultural beliefs
’
Special measures needed in training
of non-Uterate CHWs - I
-Xri
4..
y
Specificities of Non-literate /
Functionally Literate CIDVs
A) User friendly approach and setting
• All the training geared around clearly formulated
’learning objectives*
• Eliminating all unnecessary information load;
each bit of new information to be organically
linked to the ‘learning objectives’
♦ Shorter training camps of three to four days’
duration each to suit the convenience of trainees,
especially the women-trainccs
<
Special measures needed in training of
non-literate CIIIVs - Il
' B) Special Training material : pictorial literacy
• Use of specially prepared multicoloured pictorial
manual - each page one main concept
• Use of standard symbols leading to 'pictorial
literacy ’
.St « Key questions approach - set of easily mcmorisable
*
questions for diagnosis
4^' * Physical, three dimensional training aids (e g.rubber
model of uterus, human torso)
• Innovative diagnostic flow charts
1
(
(
■
Special measures needed in training of
non-literate CHWs - III
C) Special Training methods
• Minimise didactic presentation
• Due importance to practicals ( e g. body mapping,
use of paper ‘body puzzle’ ). role plays, games
(diagnostic card games, quiz competition)
• Importance of small group discussions and of each
trainee articulating key points in her own words
• Importance of reiteration, regular revision
• Each key concept to be linked with life experience
<
r.
Assessment, Record
Keeping
♦ Pictorial Multiple Choice Questions
Typical Pictorial
Multiple Choice Question
-S’
'4^
urzw Rinr unrorj-j
n)
'1
Wia 3rTZT ?j 7?T ?T.?ri
(MCQs) to assess the grasping by the
trainee of the knowledge component of
the training (assessment of skills,
attitudes needs a different process)
e @ @
♦ Use of specially prepared pictorial
c
monthly record format
loaitocrl
JUMCim rf vfT^
M<rj WHITH IM-IM TF.
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Typical Diagnostic Flow Chart
oqf?p n tpUR
VT Z1’T-V?<jr-T
rt
___
z-^v
MB
jran vd yir-w-*. ww/-<. <®rr
xfnrt
*?«_____
___
_
Monthly Pictorial Record Format
___
rffni'il.rfl' t»»
•«r«« •r^’ vt
- >fty*rt
• —r
'ST352-
1
. «»< « ««
(«(*<«!
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Approval by SNDT Womens'
University
♦ SATHI training course approved by SNDT
Women’s University since 2004
^S, ♦ Over 100 women CHWs in Maharashtra
and M.P. have appeared and passed the
SNDT approved pictorial MCQ
examination and received certificates
3
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3
itWrtid 10. BOC Gate. HOri^aignon. ASSAM Bunl1@lhcant of(
-
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
®
ISiSlw’r r ■ “awsg
KT ..- .
'
CONTEXT
rar
Poor infrastructure
- 87% villages unelectrified in Assam
-- 90% of villages do not have all-weather road
State bankruptcy affecting salaries for long periods
Poor governance - apathetic response, no action
Militancy, Bandhs, corruption, etc.
Good literacy; acculturation to listen to lectures
Community feeling good in tribals
Low starvation; cash-starved economy
Medical expenses largest cause of debts/landlessnes
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
• Health context in area of work:
About 1 lakh population with 3 ANMs
Direct work in health 28 villages; other 25 villages
1 CHC - 1-2 MOs; 1 PHC - MO 3 times a week
since 2 months
Any immunisation apart from Polio <5%. Some
areas of more than 10000 have NEVER seen
Pulse Polio also
1 insurgent group in work area; now ceasefire
since 6 months
■ Selection Of Villages
need based according to opinion of local advisors,
existing health workers, NGOs etc.
Criterion: distance from health centres, visits of
health workers and distance from Bongaigaon
Even if choice of CHW is per 1000 or so. always
grounded in one village hamlet of whatever size to
ensure accountability to own village.
1
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
c'farifttfr >oviuagf FiofR Jni{ marXohm
\$mhm_{J[a\$moalmj \$moam|Zm’
- (TRAINING VILLAGE HEALTH WORKERS)
■ (g{~Zm§ amBOmo\$moa,
■ bmo_OmZm -gmOmZm m Om|{Z Jm{_{Z
gw~w§\«$m am Omo OmZm'md Jmo-m§ 0|Zm
Om§{gOm| gmjfgZmo JmoZm§ Om'mo & ZmWm'
gaH$ma(Z {_amj-(Oami Wm§Zm-WmZm‘ Xohm\$mhm_gm{b\«$m Om|Zmo _m hmoZmo hmXm| ?
Om|(Z gm~jgo _mZ{g'm gaH$ma(Z ANM
(Auxiliary Nurse and Midwife) Amamo hoeW
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
■
CLEAR EXPECTATIONS FROM BOTH SIDES
• Zm|WmL>m Om|{Z\«$m‘ _m moZJmoZ?
• Om| Zm|Wm§{Z\«$m’ _m bwjj'mo?
• gmgo (g(Z a S>mSQ>ma Amamo amlJ(W JmoZm§
_mlmgo _mZ(a\$moaOm| Q >oqZY&ZmlWm§(Z Jm(_ md
Jodbm§ _ob gbZm^j gmgo \«$mQ> -{\«5V Amamo
Jmoomo JwXw§ (hYOmd gmTZm haY&Jmgj 1000/ (go
amoOm) am§(Z _w(b Om imj {~Wm§L>m No loss, No
profit (hgm-j \$mZzmo hmJmoZY&{-Wm§lmj ho\$mOm~
hmoZmo Amamo (~Wm§(Z Im, m(Z _mdZm (Z
gmo_moYXj XmZ\«$mo_-mo bm|(Z{g, Y
\$moa_mBhaZmo WmlnT _moZgo Health Committee
XmZm§JmjY&hmXmoVZm§ (National) Amamo WHO
(World Health Organisation) (Z JmoZm§Wma
_w{b\$moa(Essential Drugs) (Z List Amd WmZm' JwZ
JmoZm§ _w{b\$moaY&Jm{_{Z\«$m' 100/( goOmj ) am§
lm§Zm haZnT Y&XmZ\«$mo ~mo Q >ogZ (~mogmoago{Z
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
PROCESS of LETTER TO VILLAGE
■ Letter addressed to headman but handed to
ordinary person with explanation of
‘scheme’’ for handing over letter to headman
- avoids cornering of seat.
- Letter gives last date for contacting us ensures village takes one step too!
• Letter outlines need for meeting in our
presence
■ Letter to headman asks for collecting some
training /equipment fee per household to
make CHW accountable to village and
remind her that she is a trustee of the
medicines and other items given for the
village
■ Letter seeks “SMART and trustworthy
women from village; daughters-in law
preferred
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
• Open village meeting
J
to prevent nepotism
z
to build pride of CHW that village ’selected' her
to clarify expectations
✓
to explain in details
to build acountability
v'
to talk of health and politics of drug costs, of
hospitalisation
✓ t
to explain that medicines are not free but shall be paid
✓ Conditions of hosting update meetings with women staying in
individual houses
• Negotiations - as a partnership - duties of self and
expectations from them outlined
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
- PREPARATION OF TRAINING
Containers, Box, all medicines packed and
ready
Guideline in vernacular - Axomiya /Bodo
Body models
Hall etc on hire
One more visit desirable to CHW house to
build relationship with family
40% HOUSFHOI D ATTFNDANCF A Ml 1ST - AT I FAST
2
(
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
■ VILLAGE PHARMACIST MODEL
□
Names of medicines pronounced
□
Handbook of medicines read out and usage
explained and practised - has 20 odd drugs in
vernacular simple language explaining usage,
doses, S/E and precautions
□
Symptom diagnostic chart with Is' 2nd and
3,d choice medicine - Rider: Refer patient if not
improving or worsening in 2 days since
treatment
■ TRAINING
Children allowed to come with father/ nanny
First day light work to allow late comers to
join in
2 types:
3 day basic training (village pharmacist)
7 days training X 3 months (barefoot
doctors); occasional 7-10 day modified
module
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
■Common Symptoms based charts on
• Fever +
■ Pain +
■ Loose motions+
■ Pain Abdomen+
■ Cough+
■ Skin rash+
Leucorrhoea+
Irregular
menses+
Eye /ear
discharge
First Aid
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
, wl j < umpUtnf
rfVER
Wah
I
kihii-r
ln«i ia' "<iia*
\\ t«l> • IwIK
7
<■(ttw
( III OKOQI'INI
. ST
C.OMIUNA'noN
QI I NI Ml
< < >MIUNA HON
( (HRIXfOXA/O
( Il'MOI IOXA< IN
AM()XY< II I IN
I’AHAC I TAMOI
AN’IHIN
mi ii«n i-.N
( IPWOII OX Al I
AMOXYl 11 1 IN
( <>rRIMOXA/(M I
'COUCH
Vxp<Mi> *>4vUmi
•
rlWU .il«Y
M«n«- i!m«« 7 (Myn wmI* i««i
Medicines book use
( OIXIMOXAZIJ
A\1OXV( II I IN
f OTMIMOXA/O
AMOXYI II I IN
Al 111 NDA/OI I
COMMUNITY HEALTH WORKER TRAINING IN THE
6
10
12
IS
NORTHEAST
16 TAB FLUCONAZOLE
TAB ALBENDAZOLE
17 TAB FURAZOLIDONE
CAP/SYP AMOXYCILLIN
18 DROPS EYE/EAR
TAB ANTACID
GENTAMICIN
TAB ASPIRIN
19 TAB IBUPROFEN
20.TAB IRON & FA
LOTION BHC
TAB/SYP CHLOROQUINE 21 POWDER ISABGUL
22 TAB METOCLOPRAMIDE
TAB CHLOROQUINE
23 TAB/ SYP METRONIDAZOLE
TAB CHLORPHENIRAMINE
200/400
TAB CIPROFLOXACIN
24 CREAM MICONAZOLE
25. CREAM NITROFURAZONE
TAB CODEINE
26. TAB OCP (MALA-D)
CONDOM (ZAROOR)
27. POWDER ORS
SYP/TAB COTRIMOXAZOLE
28. TAB/SYP PARACETAMOL
SYP COUGH EXP
29 TAB RANITIDINE
CAP DOXYCYCLINE
30. TAB SALBUTAMOL
31. TAB S-P COMBINATION
TAB DICYCLOMINE
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
■ BAREFOOT DOCTOR TRAINING
□I 400 PAGE manual in Bodo /Axomiya
□I System consolidation of anatomy,
physiology and illness treatment
□I Start with system whose illnesses likely
□
in the training season
Training between April and June maximum need and chance to practise
knowledge
3
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COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
- BAREFOOT TRAINING
□
Each morning topic to build sensitivity to
poor, equity issues and politics of health
□
Manual referred and followed for
sequence for easy recall later
□I Models, computer, AV equipment used
□I Training venue - away from village to
build credibility of training and bring
concentration
- BAREFOOT TRAINING
□ Village encouraged to substitute as
labour lost by health worker while on training
□
Between one phase of training and other,
“home work" that takes the CHW to go
house to house so that it builds up
expectations
□
Meeting by staff in village with manual
and photographs of training to build
credibility
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
• BAREFOOT TRAINING
□ Thermometer and BP instrument provided and training
given to match injection giving capability and hence
status and credibility of existing ‘quack."'
■ Box with Rs 1500 worth generic medicines
given per CHW - price list for CHW and for
patients provided (10-20% margin for CHW
as handling charges to prevent losses of
wrong counting, spillage, expiry etc
■ Model of CHW as volunteer to build
sustainability; home visits not expected
□ Concept of ‘ wrap medicine in a health message'
□ Although no injections taught, empirical identification
of 7 day old fever as Typhoid and allowing
Ciprofloxacin for 14 days, etc. of Fever plus shivering
minus urinary burning as Malaria and to be treated as
such unless proved otherwise
□ Physiology can cure pathology concept fever/cough/pain are friends; look for causes and treat!
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
■ Update training every month or 2 months
■ Simple Records of treatment - name age
gender symptoms, medicines with dose and
money collected
■ Monitoring of how many medicines per
prescription, dosages,
■ How dirty is the booklet/ manual?
■ Records collected every month by field visit
of staff / president of CHW association
■ Revision tests, iterative training periodical
■ Total Rs 2250 per Basic training of CHV plus
monthly meetings for ever
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
■ Periodical Rapid Rural Appraisals through
CHWs
■ Leadership trainings of CHWs
■ Linking CHW to street theatre campaigns on
health, entitlements etc
■ Support like pamphlets for better adherence
to treatment
■ Malaria, others street theatre
• Entitlement advocacy
4
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Children
■
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COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
• ? ?Achievements
Over 80% continue to take medicines and prescribe
28 (of 33 trained) see 8 to 10000 patients a year continued average of 5 rupees pp
70% satisfaction rate amongst treated patients
(informal surveys by TISS/ IRMA students)
Good response in mono-community villages or those
with shared ancestry
Within 6 months, procurement and disbursement of
medicines by President (Depot) and 2 others (sub
depot);
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
■ Clear failures
□I
□I
Health committees
Leadership conversion in non-tribal
villages
Asking people to pay some fee for
services - ready to pay more for medicines
though
□
□I
Drug revolving fund in village box has
dropped;
COMMUNITY HEALTH WORKER TRAINING IN THE
NORTHEAST
■ Challenges
Sustaining interest of CHVs and village - asking for
injections; new medicines; more illnesses
□ Loss of credibility in emergencies as CHV has to rush
to quack'
□ If sustainable, how to show health programme to
□
others?? What is the need for maintaining data?
□
Should we use CHVs for ‘health duties'on regular pay?
For how long? What then? Who pays?
7
(
I
Highlights of the Mitanin Programme
• Chhattisgarh formed in November 2000
CHW Programme
Through Government Efforts
• Programme Started in January 2002 with the
Help of Action Aid India and other Civil
Society Organizations
• Now the programme is in 16 Districts, 146
Blocks, 20,000 villages, and more than 60,000
habitations
Chhattisgarh Experience
Dr AJok Shukla
Biraj Patnaik
Highlights of the Mitanin Programme
• A very Intensive process of community
mobilization
• Facilitation both by Government Employees and
NGOs
• Only Female CHWs
• One CHW per Habitation
• No Honorarium to be paid to CHW
• Separate Consultation with Women/SC/ST
• Ratification by Panchayats
What is needed for a
successful Community Health Worker Programme?
• Commitment of the CHW
• More than 60,000 Mitanins, trained and in
position
• Partnership with all stakeholders
• State Health Resource Center is the main
facilitator
Highlights of the Mitanin Programme
• 6 Rounds of Training Completed
• Mitanin Medicine Kit Distributed
• Policy Reforms successfully completed - Essential Drugs List
- Manpower Policy
- Training Policy
- Integration with Indian Systems
- Public Private Partnerships
• Many Mitanins elected in Panchayat Elections
• Effect of the Programme is already evident in
morbidity statistics
Who are the Stakeholders
How to Bring them together
• Community
• CHW
• Acceptance and active participation of the community
• Government - Central State and Local (PRIs)
• Funding Organizations - both Indian and foreign
• Good quality and effective training
• A functioning and effective Public Health System
• A functioning and effective referral system
• Public Health Professionals
• NGOs- Civil Society Organizations
• Hospitals - both Government and Private
• Doctors, Nurses, Health Workers and other
Paramedical workers
• Government support
1
Overall Goal Of me ProgramniC
Community
CHW
^powerment ofthe Community tajl Her
•K • pad d tw cammumfy
'Seidcled by
Ccnvnurwfy
*Serve« tie Carnmurvfy
Private
Sector
Support
Funding
Agencies
State
Health
Resource
Center
Government
Government
Lessons Learnt - 1
It can not be an unstructured movement
• There are many technical issues involved
in health
• Good health care requires multiple tiers of
increasingly complex health services
• Constant hand holding and support is
needed for the CHW
• Improvement of health can not happen by
a one time campaign - It is a systems
issue
Lessons Learnt - 2
A Central Organization is Needed
• To Negotiate with different Stakeholders
• To Organize Logistics
• To Conduct Operational Research, and
Provide Data to the Government for Policy
Reforms
• To conduct the massive training exercise
• To coordinate between various providers
of basic health and referral services
2
(
Lessons Learnt - 3
Involvement of Government is Essential in a Large Scale
Programme
Lessons Learnt - 4
State-Civil Society Partnership is necessary for success
• Policy reforms are required for systemic
changes
• While State can invest money and bring about
policy changes, civil society can mobilize the
community, and motivate CHWs
• Large Scale investment in social sector
infrastructure is needed e.g. hospital
infrastructure, safe drinking water, sanitation etc.
• Civil Society Organizations can bring about
greater objectivity and accountability in the
programme
• Government Health system must be integrated
with the CHW programme for meaningful results
• State can learn from experiences of civil society
organizations
• Health of People is anyway the responsibility of
the Stale
• It is equally Important to involve professional
bodies of doctors and paramedicals
And bimdiy -
3
Monitoring of Training Process
Evaluation and Monitoring of
Training Process
To collect and analyze set of core training
indicators for
❖Improvising training
❖Assessment of learners and trainers
❖Learning directed to Organizational
goals.
Monitoring Indicators
Continue...
^Attendance
^Dropout
ELearning Assessment
ELearning Objectives and Outcome
3>Gaps in Training
3>List of New Topics suggested by
Learner
^Treatment Record
❖ No of Student attending Non Formal
Education
❖ Information provided
❖ Different kinds of Group formed and activities
Self help Group
Youth Group
Bhajan group
Adolescent group etc
Continue...
Continue...
The Quantitative Information was
supplemented with Qualitative
Information...
Strength:
>Types of patient seeking Treatment
>Type of Information Disseminated
>Proceedings and activities undertaken
in various Groups.
Information was collected by
Documenters regularly.
Limitation:
Information Overload.
1
Evaluation
Levels of Evaluation
>Collect Learners performance in training
and at Community level.
Level I: Feedback
Learner's response to Training Process
Community's response to new functionary
Method: Focus Group Discussion
Individual Interviews
Questionnaire
Frequency: Six monthly
Target: Learner and Community
Evaluator: Internal and External
> Determining the relationship between
training and learning and transfer of
learning at Community level
> Further Intervention
Feedback
Level II- Learning Assessment
Strength:
Assessment:
>Learner's change in attitude
>Training relevant to needs.
>Assess motivation, interest and
participation of learner.
Limitation:
>Does not tell what learner has
accomplished.
>Knowledge gained
>New Skills accomplished
Three components were given equal
weight(33% each)
Learning Assessment
Learning Assessment
Methods Used
> Attitudinal Change : Case studies
Role Play
Observation
> Knowledge:
Written and Oral
exam
>Skills:
Observation ,Role
Play
Frequency: Every Year
Evaluator: Internal and External
Strength: Judgment could be made about
learner's capability for performance.
Limitation: To what degree learning can
be applied in real life situation.
2
Level III Performance
Performance
To assess to what extent student can
apply learning in community or real life
situation.
Performance depends on many factors:
• Family support
• Back up services
• Size of village
• History of Village
• Economic status of village
• Organizational policies
• Party Politics
Method: Observing Informally
Testing in Community
Evaluator: Supervisor who works closely
with student
Level IV - Impact
Impact
What Impact has training is achieved
^Community Level
Organizational level:
Human Resource- Approximately
200 trained women
Service.
Information center.
NIOS Accredit ion
Financial resource: New Project
Resource Center
Evaluator: FRCH, HIVOS, Village Level
. Committees
Learning
Increase Participatory Approach in Evaluation
needed.
Documentation of changes in organizational,
National, International policies is required.
Learning can also occur when teaching gap.
Regular preparation of monitoring report and
its dissemination.
3
(
Approaches to achieving
scale: Missions and
The Godzilla
Postulate
Movements
ZE DOES MATTER
♦ Small Scale Programmes with'NGO
leadership - Flourish.
♦ Large Scale Programmes
organised - Flounder
is it Size or is it
Sector?
The Godzilla Corollary..
e Godzilla Postulate applies to all
programmes requiring community
participation: Literacy; Non formal e
Quality Improvement of School
Watershed Programmes, Agrki
innovations.......
\
♦ Well - perhaps not the self het]
How small is small?
(♦ Usual sizes of small NGO programmes:
■ 30 or 60 villages
■ 50 or 100 villages
■ Seldom below 20...
Programmes have minimum critii
For the group to become estatfi
visibility. Single village prodram
do poorly.. Like each one teach
not work...
is it Size or is it the
NGO character?
The PSM(?!) postulate:
hen Scaling up ‘Government -Led’
Programmes will always do bQtter4han
‘NGO- alone’ programmes.
♦ More bureaucratized. Poorer Systems md
Processes..
♦ Besides...An NGO programme s
politically incorrect.. Retreat of th<ie sl^l
( note PSMs are NGOs that disow ii o^ini
aspire to be called peoples mo\ emehj
So what is lost with
scale..
/j\^otivated Leadership: The Antia Factor..
"Its alright one can do it in Jamkhed or in Mandwabut how can one get an Arole or an Anfia-irreve
place...."
♦ Requirement ... one Antia per
:r ej
eve
villages or at least every 150 ’villa j
Chhattisgarh would requin pb<cx
2000 Antias
♦ The commitment and the cbsts..'>
11 £ c
-UUNOnllUN FOB KtStAHUM I*
COMMUNITY HEALTH
LIBfiARY - PUNE
i
And further lost with
scales are...
And what else goes
uality of Training: the problem of
nsmission loss in the training
cascade..
3. Quality of Trouble-shooting-On
Job Support...
4. Quality of Monitoring... el
weak areas and respondin'
But before we go
on...
^Tne small too is not without its problems..
♦ TOnds to be focused on single items and less diverselike curative care centered ness.
♦ Tend to be evaluated with little relationshifcjo costsco
especially the overheads..
♦ Tend,to be unsustainable without cot derabfe^
foreign funding agency support..
z
♦ Tend to duplicate/parallel govemi
and therefore, in current contex .,.
privatization...( of course without
dynamics of scales..)
ar
Mitanin as Health
Sector Reform..
/ ♦ \he creation of the SHRC.
X«T^e linkage of funds flow of Mitanin programme to developments
ifrall parallel areas of public health system strengthening.( over
14 specific dimensions )
♦ The 39% increase in state budget- the over 50%1qicrease in total
public health expenditure ( but now reached 4% of b^tlay)
♦ The creation of 874 HSCs. 200 PHCs and 16
'.0 CHCs
C
~ doctor
•
------- ,-jhe 4
institutional gaps, the move to 2
PHCs/
doctor CHC. the pressure to make FRUs fuhctIII z>nal.
up of ICDS centers..
/
Long way to go.. But the Mitanin is^he'fla gshit>..
o\tl
Bringing health one step further ohrtheJpolit
c;
"
agenda. In myriad number of w lys.xEg
iys.b
men
incpment
r tffect on the
immunisation on hearing the announc
it
... etc
/s \ Quality of Referral Support in the CHW programme. ( reform in
2^ institutional structures that play higher order roles needed to
^'''complement and later sustain the programme)
A tradition of working with local community that provides links
An ability to persist, learn and correct..
VT
Evaluation: manage able Sample Size and reprei
italive
qualitative inputs.
Need to recogr
lation
'Xjnize that in all above dimensionsyd >en in,
desig r¥^n
- it is not
lot |just multiplying the small to getKie •9
approac
ich also needs change
■■-------- campaig
- r jfKexi ‘fjenc;.. Mlcbel
Evaluation of the literacy
6
r
a
;
Tharakkan, Ramakns
1
0
Ramakrishnan,
P< rornesn Aclu
and....... fina ly RtWavek
Denzil Saldhana and
Referral Support
/ ♦ All small NGO programmes had a very good
^base hospital with a medical team.
♦ But when we scale up the PHC an
have to play this role.
♦ Not a problem, not just an oppoi
of the purpose itself.
♦ Mitanin Programme becomes
health sector reform and sorr
outlast the Mitanin itself!!!!
in
ol
Securing the community
level processes
/♦ m absence of long involvement with local communily( and even
2iQ '■‘•ho speaks for the community?? In NGO programmes we
TreVe a discerning listener .. Whose gaze defines what is
spoken...
♦ But when the dl adminstration gives the appeal.. '&th<
panchayat elite appropnate the voice, or the depamni
functionary does. Who informs the community, who f
the individuals? Who amplifies the voice of the weak?
♦ Hence the need for the trained facilitator- th^
defined process of social mobilisation- sqpgs
through the spint of the programme.
♦ But who selects the prerak?
Principle: An intermediary force is a mus bub
with it a new set of problems
—22'
2
(
I
(
Programme duration
as a variable
Moral Dilemnas..
/♦ We are accountable for the predicatable
^^-r^psequences of our actions.. The consequences of
lack of defined process of facilitation are 100%
predictable - given the relations of powei^embedded'
in existing hierarchies.
♦ But even when we define the nine -st< selej
process and train the prerak - the qp fcbmea'a
predictable - given that we have
>t ch angi id
relationships.
♦ And what about the predictable coi ;equena of Ol
non action- in the unfolding AS 4A pirbgramme..
Pace of the Programme
as a variable..
4* bleed to sustain pace of the programme for
^roth the effect of social mobilisation and to
keep it on the political agenda.
♦ Enough time to allow for a minimum
well defined processes and eno
ih to/Oi
for evolution of structures.. Ai*3
corrections..
But longer duration by itse f is^t
And one needs constant in lovatii
Addressing Transmission
losses in training
cascades..
/^T^ee Key Steps :
♦ High voltage: Capable full time top of
the pyramid: key resource persl
nce/ion
♦ Good conductors: Insistency
systematic use of training</nater
^b(trc
♦ Step up transformers:
evaluation (and on the j ?b ick
/♦ Need to allow for programme structures and
\_^rsonnel to evolve.
♦ Need to allow for people to come in and leave and
others to come in
y♦ And after a structure stabilises one needs
do and
redo many parts of the programme.
And all this needs time and persistence with'
the programme and learning curves...J./
♦ This happens in small programifhesToci - but
bi|t exler/fal
documentation often misses it <s ajmpareq Ip4irst\
person accounts.. But it needs lo beTxiilt ir
Staggering the
Programmes
.
♦ Pilot phase - builds the tools-builds the
^siate leadership- tends to do poorly.
♦ First phase- builds the district teamc----gets the systems in place.
\
♦ Second phase-- reaches ouj/fo fuj^
coverage..
♦ Subsequent phases- re Io rio
aspects, bring in correc idns^J
innovations etc.
\
Emergence of a
training cadre..
/♦ Whether and how --Related to existing human
^"resource availability.
•
Oo w. hav. aixplu. AMM. ...van outud. Ih. gov.cnm.nt .mploymant.
Ilk. In andhra prada.h)
■
Can tb. .listing ANM play this rote?
•
Oo NGOs hav. th. r^ulrad parsons or .xpartisa?
♦ This cadre needed in monitoring and provision of on
training.
♦ But would have low/zero clinical skills
*
♦ All expenence would eventually be le;
limited by the quality of supervision p< ssu
♦ Needs strategy of trainer recruitment; nd
evolution of this workforce.
3
Strategy of
Monitoring
/l\ small NGO programme relies on the review
Monthly Monitoring
Indicators
/♦ blew born visit and six messages
nX'ctmg
But in the large programme ....
♦ Need to put in place a set of defined prooesses^Thecluster meeting, the block trainers review. tt\e district
coordination meeting, the state nodal officers-<ejiew,
the state field coordinators review. /
/\
♦ Need to put in place a large workfi :e
trainers cadre.. The nodal offici hbjra
coordinator.
♦ Need to carefully make a choice of'
Indicators
Evaluation
/♦ Getting sample sizes involves costs and research teams.
'-K^/eeds clear definition of outcomes and its measurability.
♦ Need care in relating processes to outcomes.
♦ Qualitative studies needed to catch enormous diversity
♦ Qualitative studies needs training in qualitative^
methodology, the anthropologists or sociologistXskiUs..
and this is difficult to obtain and even more difficutyXc
standardize.
A
/
• Internal evaluation with in built externalHy
laJHy vwith kfey
processes under qualitative study otic
'
fdis a '\/ay forwar
j.
• Io be wary of experience- need to l^yye gto> mdir g ity*
methodology.
The Power Principle
/ • \eeds to define the determinant of the x - axis location of the
L^syslem- where motivation is on the y- axis
• There are relationships of power embedded in
• KAOwleOge
• InsMutional slructures
• Mind-sels/attitudes
• Programme desgns-
• Not just the key decision - but every single
gfe dr
dete
laden!!
• Relationship to these define the x- axis of
>^motr
• And the leadership needs to be able taqi(uesbo i
relationships in all of these domains > jtO.llhaX/p
leadership
• Need to have the catalyst in place wh > can chj
redefining these determinants, at eve ry level
♦Tzyer 10 to 20 'first day' requests for curative care
♦ Visit in last trimester of pregnancy and the plan for
child-birth.
----------♦ Attendance at the immunisation day.( convixqence
and service facilitation)
X/
♦ Knowing the children al risk and coqn^jllinq^
\
jllinc
♦ DOTS provider role
<
♦ The hamlet level meeting.
f\
Observable. Measurable, verifiable > fr)
sources, aggregatable...
paral
How to get an Antia
everywhere...
Gaussian curve:
biological and most social systems display
a bell shaped ‘ normal’ distribution So too
should motivation..5 to 25 % in any^qroup of a
reasonable size- will potentially have\sj nse
of motivation- to work...................
with self li >8sne*
Whether it be NGOs or qovernrf i€ nt
BEEs
♦ And one needs to have a v s^hxihrou^K
.eaijc^ng'
- an< •r
and finding this 5%. How tc
inhow to adsorb onto the system..
The recipe....
/♦ Get a mix of state and civil society at every level. ^-^nfever one or the other alone.. Carefully define the
institutional mechanisms for this
♦ Let structures/ key persons evolve with oon
reble-----flexibility and innovation..
\
♦ Put in a strong dose of social mobilisation-
-------------------------------.—
------patri;
atria/thy.
questioning
existing
values
-eg
symbols,
♦ Have a catalyst in place to absqiirb the right
and highlight , support and buik' ap^Jlitie
mentor.
♦ Negotiate, negotiate, negotiate-
4
(
I
In conclusion...
The conditions of success are stringent.
♦'Given the relationships - failure would be the
norm.
♦ But given an understanding of the pr^icesses
enough exceptions can be made to d<&k>€ a
new rule.
♦ And Persist. Often you do ndt win )ve
opposition- you just outl ^sNt
♦ But one needs to constiuct^
stand and a way of leverage
Thank you
5
(
....
...
....
Background to collaboration between
health activists and people’s
movements
Swasthya Sathi initiative
ClfW programmes in collaboration with
People’s movements
--■■.ci
-■
.
Abhay Shukla, SATHI CE1IAT
-.‘F. • Recognition by us as health activists that to expect
long term sustained collective initiative around
health related activities alone is usually difficult
’
• Growing realisation among social movements for a
need to combine resisting systemic injustice with
3
developing people-based alternatives in various
spheres of life
V*. Sn Hence the decision by certain Health activists and
People s movements Io systematically collaborate
to develop health initiatives, esp CHW
programmes and health rights initiatives
1
■
Swasthya Sathi programmes - I
Specific features of the SS initiative
• Embedded in existing people's organisations involved
in mobilising toiling people around basic socio
economic issues
• From the outset, a system of financial sustenance by
communities, enabling continuation of the programme;
objective of moving towards Public health system
support
• Health workers with a range of healthcare skills to
meet basic requirements of First Contact Care and to
replace local quacks
• Standardised training inputs for these programmes
(esepcially for less educated / non-literate health
workers) _______________________
Swasthya Sathi programmes - II
• Innovative forms of training with pictorial manuals and
games, focus on functional knowledge and social
attitudes
• Certification of SATHI-CEHAT's health worker course
by SNDT University
• Move for public system support for health worker
programmes in form of Pada Arogya Sathi' scheme
Effort to develop decentralised, community
reliant and more cost-effective model of health
care
s
/
} • Programmes in collaboration with community
organisations since 1996 in four areas of Maharashtra
and MP; over 100 Swasthya Sathis working
• Exclusively women, range from non-literate to high
school, both adivasi and non-adivasi rural areas
Village health activities sustained by local resources
• Locally provide care for minor illnesses, reduce
medical deprivation and exploitation
• Building hamlet health committees for community
health awareness and activities
,!
Why the need for linkage with
the Public health system?
• ,n Princ'ple. public health is a state
responsibility and PHS should give regular
resources for community health activities
-A
• Voluntary or semi-voluntary efforts by CHWs
cannot proceed indefinitely without support
• Organised, regular financial support from
communities is difficult to sustain
• Referral and public health activity linkages
essential
1
i
t
Strcc Arogya Melava
2nd February, 2003 at PHC Saiwan
Pada Swayanisevak programme
under Nav Sanjccvani Yojana
• Mostly males officially selected as health workers
• Appointment only for monsoon season
• One-day training, no training material, no
medicines provided formally
• Tasks limited to chlorination of water, informing
the PHC about disease outbreaks
• Very limited role as a health worker, low
community involvement
Members of SATHI team interacting with PSS scheme from 2000
onwards
Response from Health department
■
.
• Meeting with Additional Director of Health
Services and District Health Officer, Thane
to concretise the project and to ensure
regular supply of medicines; dialogue with
PHC Staff
• Based on suggestion from SATHI team, a
special budget of Rs. 50,000 was allocated
by the Health Dept, to ensure basic drug
supply to trained health workers
• Assurance of cooperation in training,
involvement of District training team
Training Process
• Total 50 women PSS trained in two separate batches
(PHC Saiwan and Kasa)
• 12 days of contact training spread over three training
sessions
• Topics covered in the training - role of health worker,
causes of illnesses, types of organisms, basics of
ix*
human anatomy, about medicines, nutrition /
malnutrition and common illnesses like diarrhoea,
fever, cough, anaemia, pain in abdomen, women's
health etc.
• Involvement of Government officials in some
components of the training like chlorination of wells
2
(
Distribution of SNOT University Certificates by
Secretary. Health Govt, of
or Maharashtra
*
• Curriculum prepared by SATHI-CEHAT for
the training of functionally literate CHWs has
been approved by the SNDT University
• The University conducted examination of the
CHWs with pictorial multiple choice
questions
• All CHWs cleared the exam, most with score
over 70%
• In May 04, certificate distribution at the
hands of Health Secretary, Maharashtra
’+*!
■+l
.1
Efforts to ensure upgraded training
to Pada Swayamsevaks
Intervention in ASHA
programme in Pati, M.P.
• Intervention in case in Mumbai High court on child deaths tn
tribal areas; court orders selection of women as PSS. upgraded
training with help of NGOs
• Govt, of M.P. gives SATHI team responsibility for
monitoring selection of ASHAs in 40 villages of Pati
block of Barwani district
• Selection process through women's group meetings,
hamlet meetings and proposal and approval of names
in Gram Sabhas in Jan. 06
In 27 out of 40 villages, no literate women available
despite efforts to locate such persons
•_ Need for development of special training curriculum
and materials for non-literate ASHAs essential for the
process to proceed further
• Health dept, has initial dialogue with SATHI and YCMOU
representatives on upgraded training
ft®
• A dozen Health NGOs and Community organisations working in
tribal areas of Maharashtra come together in Feb. 05. to
coordinate efforts for upgraded training to Pada Swayamsevaks
"I.
•
Women selected as PSS in nearly 10.000 hamlets in the state in
June 2005
•
However, upgraded training yet to take place despite proposals
and dialogue
■
<
Role of PO in confronting health system
contradicts the collaborative role required for
PHS support: hence two-pronged approach by
PO and NGO
3
F
r
i
l
|K ft a
4
Issues of sustainability and replication
of CHW programmes based in POs
■
Need for initiative and ownership by
‘cornrriuhity + Public resources and support
<
• Local collective resource generation important
as initial boost to programme, but pot possible
on sustained, regular basis
• Neither purely community dependent, nor NGO
dependent, nor Public system dependent model is
satisfactory
• Some form of Public system subsidisation held
as a principle - however practical problems in
eliciting such support
• Need f°r
• Political will from below and above should
reach minimum level of correspondence
- initiation, ownership, active involvement of community
- resources, referral and technical support from PHS
li
Requires Community organisation + minimum political
will from the state; shared change agenda for such
partnership to be forged
4
I. Content, Methodology and
Human Resources
Group Discussions
“Innovation-at-scale”
Groups: 11:15 - 12:45
Presentations: 12:45- 1:30
• What are the essential principles for determining
curriculum and pedagogy for CHW
programmes?
• What are the methods, structures and
institutions for contextual and effective
implementation at scale?
- How can monitoring and evaluation be integrated?
• How can a cadre of trainers/facilitators/
supervisors be developed and supported?
II. Partnerships
• What are the critical learnings from civil
society and government engagement
historically?
• What are the emerging trends and
experiences (SHRC-like institutions)?
• What are the potential roles that civil
society can play in the NRHM
• What would be the minimum
requirements/commitments from each
side?
III. Support Structures for CHW
Programmes
• What are the ideal contexts and support
structures required for effective CHW
programmes?
• What are the prevailing opportunities and
constraints within which the NRHM is
operating?
• How can these be effectively influenced
and informed?
Facilitators
• Group 1: Content, Methodology & Human
Resources
- Raman, Abhay Shukla, Sunil Kaul
• Group 2: Partnerships
- JP Mishra, Nerges Mistry, S C Mathur
• Group 3: Support Structures for CHW
Programmes
- T Sundaraman, David Sanders
1
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Content, Methodology & Human resources
group members
A basic question:
What is the health worker supposed to do?
shd content go beyond the govt, defn of the chw - YES
CHW SHOULD have a curative role beside the preventive & promotive one
Shd have a med box to prescribe from.
1. How to determine the curriculum? & pedagogy
Non neqotiables:
- Generic models of modules
(flexibility for contextualization to community needs practices.)
Content:
- Equity, gender issues, awareness on entitlements & rights.
- regional languages
- must know, good to know, wht u want to know
- basic medicines e..g deworming, malaria, home based meds
Methodology:
- A confidence building approach
thru facilitating learning & constructing knowledge'
- more participatory than didactic
- infield training to be a major component
Supplementing training with
pictorial methods
folk media
role plays + other interactive methods
audio visual media
-apprenticeship : before training they shd work with experienced chws
Human Resource's
- Training of the trainers is crucial
(motivated, local dialect, culturally from the same milieu)
- After the initial phase of trainings, preferably the chws's with field
experience should move on to become trainers
- Communication skills critical
r
structures & institutions:
- Cascade approach
moving up , chw, facilitator, trainer
hamlet -village- block- district- state
- shrc type structure
supporting health sector as well along with chws
- should be autonomous with mandate & recognition by the govt.
- a contd. process of discussion bet ngo / public & govt, before even the inst
& its structure is decided upon.
[this may give each state a locally sensitive (hopefully) the structure ahs to
be autonomous]
- led by a dynamic person from outside the govt.
- PArticipation & partnership bet state & civil society at every level
- quality control by having persons in each team., inbuilt monitoring from
within, the implementor shd not be the monitor
Monitoring & evaluation
- chws monitoring each other / peer review
- inbuilt training
3. How to develop & support a cadre of trainers / facilitators /supervisors?
(The last stage trainer didnt get paid for months b/c phc was empowered to pay
them.)
assess outcome of training
gender & equity training at all level
- phased training
- objective of training - for each module
+ overall CONFIDENCE & ability to take decisions
- experienced chw can train the newer ones
- disc, with a regional person on traditional practices
focus: innovations at scale
gp 1- content methodology & human resources
gp 2- partnerships
gp 3 support structure for chw progs
(
I
(/)
<z>
(D
(0
Past Forward
• We have a very varied and contested history of
state-civil society partnerships in the health
sector
- Rich evidence and experience from the past as
illustrated in this workshop
• However, there is an emerging consensus that
political spaces for productive engagement exist
in some places and can be opened up and
negotiated in others
• It is in this context and in the spirit of critical
reflection, that we have approached the question
of partnerships
The Scope of Partnerships
• The nature of partnerships and the
processes of facilitation are dependent on
state-specific histories, current contexts
and opportunities
• But, there are broad principles
- based on strengths and experience
- shared ownership
- participation
Framework for Partnership
• Vision/ advisory level
• Policy detailing and the development of tools
and instruments for implementation
• Implementation
- network of implementing partners
- resource support agencies
• Require a criteria for partnerships at various
levels
• Require a transparent selection process and
procedure
Types of Partnerships
• Government-Government Partnerships
- Gol-State Government
- State-District
- Inter-department
• Case Study from Rajasthan
• NGO-NGO Networking and Co-ordination
- Chhattisgarh SAC
• Government-NGO Partnerships
Where do we begin the partnership
building process
• Gol
- Create enabling frameworks (prototypes of
partnership)
• Mentoring Group
- Expand the network
- Evolve and operationalise shared principles of
collaboration and state-level facilitation
• State Governments
— Develop state-specific frameworks for engagement
Contexts and support structures
Supporting structure for CHW
programmes
• NRHM is not cast in stone : scope for flexibility
and modification
• ASHA roles: promotive, preventive, curative,
need to balance (community mobilization,
advocacy roles)
- The central government had provided scope for it in
the guidelines
Draw from state level experiences
• Enabling environment and structures is very
important
• Supportive structures and enabling polity
is required at all levels
• Village, block, district, state
• We need a contextual order of public
health expertise at all levels
• Village Lave I
-PRIs: functional Panchayate. health committees.
-Local committees- statutocy. not statutory
Six
t*xoy a*,hc v,,ia9e 'eve,• 008 s‘,uc,ure ma>'have bcen
Block Level
wb'ch •nclude -Trainers/facilitators/supervisors cadre and
LHVs. ANMs. etc
District level
-Technical Assistance /Agency training, technical inputs, advocacy, also focus
on community mobil
xlisation issues
■District level planning - needs a capacity building initiative (i.e.PubKc Health
Resource Network elc . also look at South Afnca s expenence on the same)
Other Key Issues
* State level
“Context: health reforms, enabling environment
-Experiences: SHRC, SWG
- State level Body is needed - technical support,
advocacy al all levels
• Accountability: nature?
-joint review
- Watch committee
• Involvement of people's organizations
- How does one build in space for collective
action for health issues in large scale govt,
run programmes
• Jharkhand VHCS need to be seen as a form of this
1
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Some impressions of CHW workshop.
1.
2.
3.
4.
Impressive degree of energy and experience
Opportunities afforded by current political conjuncture eg NRHM
Opportunities being exploited in new states where ‘space’ exists for policy implementation
ASHA to be introduced in several ? 18 states
■ Success of ASHA (and NRHM) dependent on socio-political context and
technical factors and financing
■ While technical factors can be planned, socio-political factors arc less amenable to
initiation/manipulation
■ Key socio-political factors include community mobilisation and political will which arc synergistic
■
Community mobilisation and political will often dissipate as political context
changes
■ Community mobilisation can be facilitated by participatory planning and
implementation
■ Community-based workers can catalyse and sustain community mobilisation
■ Key technical factors include:
Capacity development for:
■ training and ongoing support and supervision - from levels above
■
participatory approaches to assessment and analysis, using appropriate technologies
and methods
■ planning with intersectoral action and sustainability in mind
5.
Capacity development
■ 2 areas at least - technical health and advocacy/mobilization
Technical
■ Training methods and materials for ASHA as well as for levels above esp in
Public Health (see UWC SOPH slides)
Advocacy
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Community Health Worker Training: Linking Pedagogy and Practice
A National Workshop
April 10 - 12, 2006, Tata Management Training Centre, Pune
<
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i
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Participants
Dr. Abhay Shukla
SATHI -CEHAT, Pune
cehatpu n@ vsn I .com
020-25451413/5438513
Dr. Diane Lynn Spatz
School of Nursing
University of Pennsylvania
spatz@nursing.upenn.edu
Dr. Alok Shukla
Secy., Dept, of School
Education, Govt, of
Chhattisgarh
dr.alokshukla@gmail.com
0942502196
Mr. Suryavanshi
Institute of Health Management,
Pune
Dr. Narendra Gupta
Prayas, Chittorgarh
narendra53 l@rediffmail.com
0164-2215400/2253903,
09414110328
Ms. Niloufcr Randeria
Sir Dorabji Tata Trust, Mumbai
sdtt@tata.com
022-56657176
Dr. Anant Bhan
anantbhan@gmai 1 .com
09371066840
Dr. Dinesh C. Jain
Deputy Commissioner
Child Welfare and Training,
MoHFW Government of India
dcjainfw@yahoo.co.in
011-23062791
Dr. Nandita Kapadia
Institute of Health Management, Pune
ihmp@vsnl.com
02431-221382,221419
Dr. Anant Phadke
SATHI-CEHAT, Pune
cchatpun@vsnl.com
020-25451413/5438513
Dr. D.K. Saxena
Joint Secretary, Department of
Health and Family Welfare,
Jharkhand
Ms. Pallavi Patel
Chetna, Ahmcdabad
chetna@iccnet.net
079-22868856/22866695
Ms. Arzoo Dutta
State Facilitator, National
Rural Health Mission
Nagaland
arzoodutta@yahoo.com
9435019521
Mr. J.P. Mishra
Health & Family Welfare Sector
Programme in India
European Commission Technical
Assistance, New Delhi
mishra@echfwp.com
011-26490204
Dr. Parvez Imam
120 Communications, New Delhi
f20com@yahoo.com
011-26430493
Mr. Bi raj Patnaik
Principal Advisor
Office of the Commissioners
of the Supreme Court,
New Delhi
biraj.patnaik@gmail.com
011-41642147, 09826418554
Prof. David Sanders
University of Western Cape,
Cape Town
sandcrsdav@uwc.ac.za
0044 -2083485797
Ms. Deepanwita
Chattopadhyay
ICICI Knowledge Park
deepanwita.chattopadhyay@
icicibank.com
040-23480022/03
Dr. Dhananjay
Sathi Cell
cehatpun@vsnl.com
Dr. Balasubramaniam
Commonwealth of Learning,
Chennai
kobala2004@yahoo.co.uk
09444376280
Ms. Kaveri Nambissan
walldcn@sanchamet.in
02114-280130
Dr. Lindsay Barnes
Jan Chetna Manch, Bokaro
lindsay_india@yahoo.co.in
09431128882
Ms. Laboni Jana
Child In Need Institute, Kolkatta
laboni@cinindia.org
033-24978206/8192/8641
Ms. Mira Sadgopal
Tathapi Trust
tathapi@vsnl.com
020-2411037/24270659
Dr. Peter Berman
The World Bank, Delhi
pberman@worldbank.org
011-24619491,09871387191
Dr. Raj Arole
Comprehensive Rural Health Project,
Jamkhed
crhp@jamkhed.org
02421-221322, 09423162534
Ms. Sarubai Salve
Jamkhed
Dr. Ravi Narayan
Community Health Cell, Bangalore
ravi@phmovement.org
080-51280009
Ms. Ronita Chattopadhyay
Child in Need Institute, Kolkata
lca@cinindia.org
033-24978206/8192/8641
Maj. Sashi Menon
Kripa Foundation, Mumbai
mamenon@ vsn I .com
022-26778806, 09820068332
1
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Mr. Shiv Chandra Mathur
State Institute of Health &
Family Welfare, Rajasthan
shiv_mathur@hotmail.com
0141-2706534
Dr. Shyam Ashtekar
Y ashwantrao Chavan
Maharashtra Open
University, Nasik
ycmouhealth_nsk@sancharnet.
in
0253-2230718, 09422271544
Dr. Sunil Kaul
The Action Northeast Trust,
Assam
scowl@sify.com
03664-225506, 09435122042
Dr. T. Sundararaman
State Health Resource Center,
Raipur, Chattisgarh
sundararaman.t@gmail.com
0771-2236175, 09827137201
Mr. Vijay Nambissam
wallden@sancharnet.in
Social Initiatives Group
ICICI Bank Limited
ICICI Bank Towers
Bandra-Kurla Complex
Mumbai - 400 051
Dr. N.H. Antia
Dr. Nergis Mistry
Mr. Appasaheb Ghadge
Dr. Bharat
Dr. Dcvraj Chauhan
Ms. Gauri Gokhale
Ms. Necta Rao
Ms. Pushpa Tai
Dr. Rakhal Gaitonde
(subharakhal@gmail .com)
Dr. Sarika
Dr. Subhashree
Ms. Secma Dcodhar
Ms. Shalini
Ms. Vaishali Gaikwad
Ms. Vaishali Sonavvane
Abhijit Visaria
Tel: 022 2653 8084
abhijit.visaria@icicibank.com
Mekhala Krishnamurthy
Tel: 022 2653 7077
mekhala.krishnamurthy@icicibank.co
m
Phone:
020-25887020
020-25881308
Sarovcr Zaidi
Tel: 022 2653 8038
sarover.zaidi@ext.icicibank.com
Dr. V.P. Pandey
Sahiyya Working Group,
Jharkhand
panipandey@yahoo.com
0651-2550730, 09431588909,
Anuska Kalita
Tel: 022 2653 8031
anuska.kalita@icicibank.com
Devanshi Chanchani
Tel: 022 2653 7065
dcvanshi.chanchani@ext.icicibank.com
Email: frchpune@giaspn01 .vsnl.net.in
02114-280130
Dr. Vikram Rajan
The World Bank, Delhi
vrajan@worldbank.org
011-24619491
(
The Foundation for Research in
Community Health
3-4 Trimiti Apartments - B
85, Anand Park
Aundh
Pune-411 007
Ms. Swati Dogra
(swati_dogra@rediffmail.com)
Shilpa Deshpande
Tel: 022 2653 7093
shilpa.deshpande@icicibank.com
Ms. Sathyasree
(sathyasree 1974@yahoo.com)
09835121833
Dr. Yogesh Jain
Jan Swasthya Sahyog, Bilaspur
janswasthys@gmai I .com
07752-270966, 09425530357
Dr. Wiliam McCool
School of Nursing
University of Pennsylvania
mccoolvvf@nursing.upenn.edu
Mr. V.R. Raman
State Health Resource Centre,
Raipur
weareraman@gmail.com
0771-2236175, 09425207375
2
(
(
(
(
(
(
Organizing team
The Foundation for Research in Community Health (FRCH)
Dr. N. H. Antia
Dr. Nerges Mistry
Dr. Rakhal Gaitonde
Dr. Neeta Rao
Ms. Shalini
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Ms. Swati Dogra
Dr. Anant Bhan
The Early Child Health Team of the Social Initiatives Group (SIG),
ICICI Bank
Ms. Mekhala Krishnamurthy
Ms. Sarover Zaidi
Ms. Anuska Kalita
Mr. Abhijit Visaria
-UuiWhiiON FUh HLStAhUh I*
COMMUNITY HEALTH
LIBRARY - PUNF
- Media
11386.pdf
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