CHWs (137) Selection of CHWs for pre-service training (17) CHWs with low literacy (2)

9 July, 2019

Dear All,

Charles Dewah, Marion Subah, Rebecca Furth and a few others have echoed my thoughts about educational qualifications, certification and other aspects of WHO guidelines to formalise the CHWs becoming a part of the mainstream.

I was among those inspired by the work of Aroles and Bangs in rural and tribal areas of India when I was beginning my work in the community to look at Early Childcare and development of children with special needs in the urban slum community. In essence I was trying out something similar, except that the focus was on childhood disability.

Today, after a few years in such settings (resource constrained urban settlements), these are a few of my observations :

1. Communities are not homogeneous. Neither is the nature of community health needs.

2. The factors that influence health in the community are several.

- Often, the determinants at play are not very different from those propounded by Dahlgren-Whitehead. [*1 see note below]

(Pediatricians may also relate to the Bronfenbrenner model of Child Development [*2])

3. CHWs, even when residing in the community, have a limited understanding of health care when not a part of the system and require training, a continued guidance and hand holding support in special projects because of their low levels of literacy.

4. The level of native intelligence is high, they learn quickly on the job, are self-motivated to perform with small incentives (which include acknowledgement of their contribution and respect for their work), in addition to a decent remuneration.

It would be a pity to lose the traditional health workers such as the dais or traditional birth attendants (TBA) on the grounds of education level or not having a recognised certificate. Many of them demonstrate a commitment to community service and possess good interpersonal skills. There is a strong need to have modular training to retain them in the System.

5. Changes over time in the world around the CHWs are not to be ignored.

The younger generation of CHWs do care about certification and career prospects.

They adapt to technology well and can perform better under technology-guided supervision. However, they are quick to make career moves in quest of better financial prospects and this results often in poor experiential learning as well as loss to the community.

Acceptance by target Community also takes a while and a public service ethos can be developed only if there are senior professionals working alongside or mentoring the junior cadres.

Personally, I believe that on-the-job training adds value to the work, irrespective of the curriculum of pre-service training.

6. CHWs may be seen as Community Health aides who are a part of the health team in the Primary care setting and not as replacing other health professionals in the Health Centre. While being valuable human resources for health in all Developing countries, they must not be seen as alternative health work force substituting for the Nurses, therapists, and doctors. They must be empowered with skills and knowledge to bridge the divide between marginalized, hard- to- reach Communities and inaccessible Health Centres. Hence, the training should be appropriate to the tasks under consideration and certification should also reflect the scope of the training.

Lastly, the time is ripe for us to now explore how global health Communities and local CHW communities can work together to better understand the needs and priorities for Primary Health care in the context of Universal Health Coverage. This may mean prioritising prevention, health promotion, rehabilitation and palliative care as prime areas for CHWs, while encouraging them to play assistive roles for diagnostic and curative services as per the demands in the particular setting.

Thank you.

Best regards,


HIFA profile: Sunanda Kolli Reddy is a Developmental Paediatrician from New Delhi,India, with a special interest in Early Child Care and Development of children with neurodevelopmental problems in underserved communities. She is actively involved in health promotion, community-based research, care provider training for promoting abilities of children with special needs, through the various programmes of Centre for Applied Research and Education on Neurodevelopmental Impairments and Disability-related Health Initiatives (CARENIDHI), which she heads ( Her work in the community settings to widen the disability-in-development model of CBR encompasses the wider determinants of health and human capabilities and issues which impact the lives of the poor. She combines her experience in developmental paediatrics with the core work of CARENIDHI's grassroots convergence programmes in partnership with groups working in the area of Implementation research and policy. She is a member of the HIFA working group on Community Health Workers.

write2sunanda AT

[*Note from HIFA moderator (Neil PW):

1. The Dahlgren-Whitehead rainbow model of socialdeterminants is described here:

2. The Bronfenbrenner model of Child Development is described here: