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

Sumit Kane,Mukta Gadgil,Barbara McPake,Anjali Radkar

doi:10.34172/ijhpm.2020.58

Abstract

Background: 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. Methods: 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). Results: 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. Conclusion: 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.

Highlights

In 1990 Gill Walt, in the title of her book on community health workers (CHWs), wondered whether CHWs had become “just another pair of hands.”[1]
Using the Indian health system as a case study, we show how CHWs in many instances are emerging as powerful social actors with influence in the communities they serve and in frontline health services
Schneider,[24] in her recent synthesis, argues that it is “necessary to ensure that CHWs do not become lowly players at the bottom of a health worker hierarchy, drawn into health facilities as an ‘extra pair of hands.’” Schneider expresses concern that “CHWs risk being drawn into health facilities as menial workers, especially if they are answerable to facilitybased providers.”[24]

Summary

Introduction

In 1990 Gill Walt, in the title of her book on community health workers (CHWs), wondered whether CHWs had become “just another pair of hands.”[1]. In these comprehensive accounts of the many ways in which context shapes CHWs’ performance and lived experience, a key narrative, in many ways reminiscent of Walt’s title, stands out. Schneider,[24] in her recent synthesis, argues that it is “necessary to ensure that CHWs do not become lowly players at the bottom of a health worker hierarchy, drawn into health facilities as an ‘extra pair of hands.’” Schneider expresses concern that “CHWs risk being drawn into health facilities as menial workers, especially if they are answerable to facilitybased providers.”[24]

Methods

Results

Discussion

Conclusion