Community Health Workers as Influential Health System Actors and not "Just Another Pair Of Hands"

Abstract

<jats:p> <jats:bold>Background:</jats:bold> Over the last 20 years, community health workers (CHWs) have become a mainstay of human resources for health in many low- and middle-income countries (LMICs). A large body of research chronicles CHWs’ experience of their work. In this study we focus on 2 narratives that stand out in the literature. The first is the idea that social, economic and health system contexts intersect to undermine CHWs’ experience of their work, and that a key factor underpinning this experience is that LMIC health systems tend to view CHWs as just an ‘extra pair of hands’ to be called upon to provide ‘technical fixes.’ In this study we show the dynamic and evolving nature of CHW programmes and CHW identities and the need, therefore, for new understandings. <jats:bold>Methods:</jats:bold> A qualitative case study was carried out of the Indian CHW program (CHWs are called accredited social health activists: ASHAs). It aimed to answer the research question: How do ASHAs experience being CHWs, and what shapes their experience and performance? In depth interviews were conducted with 32 purposively selected ASHAs and key informants. Analysis was focused on interpreting and on developing analytical accounts of ASHAs’ experiences of being CHWs; it was iterative and occurred throughout the research. Interviews were transcribed verbatim and transcripts were analysed using a framework approach (with Nvivo 11). <jats:bold>Results:</jats:bold> CHWs resent being treated as just another pair of hands at the beck and call of formal health workers. The experience of being a CHW is evolving, and many are accumulating substantial social capital over time – emerging as influential social actors in the communities they serve. CHWs are covertly and overtly acting to subvert the structural forces that undermine their performance and work experience. <jats:bold>Conclusion:</jats:bold> CHWs have the potential to be influential actors in the communities they serve and in frontline health services. Health systems and health researchers need to be cognizant of and consciously engage with this emerging global social dynamic around CHWs. Such an approach can help guide the development of optimal strategies to support CHWs to fulfil their role in achieving health and social development goals.</jats:p>

Evaluation of a training program for soft skill education and financial literacy to community health workers in India: a quasi-experimental study

“…Finally, in highlighting the socio-demographic attributes of the change patterns observed, our ndings demonstrate that ASHAs elder in age but with experience ≤ 12 years have increased probability of acquiring soft skills and change in perceptions related to practice at personal, community and workplace levels. This clearly a rmed the observation in the previous studies that health worker's performance is often related to increasing age and experiences regarding relations and power [13,24]. Greater probability of increased nancial literacy and self-con dence scores among ASHAs with more than 12 years of experience may re ect the need and outcome of savings in the last 10-12 years.…”

“…Furthermore, one-third of the participants in the present study had more than 12 years of experience. The increasing years of experience not only bring to ASHAs an increased social capital and networking within the health system but increased skills and performance in delivering outcomes [13]. Started in 2005, the ASHA program is still evolving in India and has been viewed from different lenses.…”

“…The empowering views of the program are improved respect and dignity to health workers in the community, and the disempowering lens nds a lack of support and political contradictions from the health systems [13].…”

“…Female health workers experience unequal gender relations with the community and other health cadres and need to exercise agency to deftly balance the demands and supply of essential services in the community [13]. The training on gender dynamics and relations help community health workers to navigate and negotiate the di culties and dilemmas at all levels, personal, community, and workplace.…”

“…Factor 1 was characterized by high factor loadings for change in perceptions of out of 86 (93.0%) ASHAs would like to participate again in training and also recommended this training to others. The median (IQR) score of the scale of perceptions regarding the change in practices related to gender issues, soft skills, and savings at the personal level was 12 (6)(7)(8)(9)(10)(11)(12)(13)(14)(15). Similarly, the median (IQR) scores of the scale of perceptions regarding change at community and workplace level were 11 (5)(6)(7)(8)(9)(10)(11)(12)(13)(14) and 9 (5-11), respectively.…”