CHWs (34) What are your thoughts on the Guideline? (16)

9 June, 2019

Dear Neil and HIFA colleagues,

Just managed to catch up on the interesting discussions of the week today and realised we are moving on to the next part of the discussion. If I am not too late to contribute to the thread [*see note below], I would like to share a few thoughts that occurred to me as I went through the vibrant discussion on HIFA and CHIFA.

a) One significant area to work on during the revision of the guidelines on Health policy and system support to CHWs would be on the modality of integration of the CHW group into the Health systems of countries.

- A prerequisite for integration would be that CHWs must be remunerated commensurate with their work in the community in a well delineated linkage to the Health Centres whose personnel will likely provide the guidance and supervisory support that can help them perform better.

My personal view based on the observations regarding the different cadres supposed to work at primary and secondary levels is that in the absence of guidelines, there is already too much of fragmentation of care even amongst the uniformed staff for primary care within the Government funded primary care. Those familiar with work in India know that Health is a state subject - with provincial or district health administration having directives from the state Government- , so when it comes to National programmes or Centre prioritised work such as Maternal and Child health, there is some confusion between the responsibilities and accountabilility of the different members involved (Auxilliary Nurse Midwives vis-a-vis ASHA Workers, our equivalent of accredited CHWs).

b) I came across a viewpoint on CHIFA (Massimo) that the existing health workers within the System can be promoted to do much of what is expected of the CHWs, if only Governments cared to have in place some quality standards and good remuneration policy. While we all agree on the existing Primary care health staff to have better support including remuneration - a prerequisite to even expect quality performance within the public Health System - , WHO's policy guidelines must not be seen as supplanting the current system but as strengthening the areas where we see gaps, if not gaping lacunae. Dr. Joseph Ana's response yesterday well encapsulated the context and rationale for working towards optimising the CHW program. I can perhaps add one point now - something I was keeping for discussion in the following week but may be in context here - and that concerns a distinct feature that must differentiate a CHW from all other uniformed personnel: He or She must belong to the community settings in the neighborhood of the Primary Healthcare facility i.e. be a resident of the catchment areas or the geographical vicinity of the centres serving the target population.

c) Would integration of CHWs within the Health System be better if they were a salaried group within Primary Health Centres linked to the District Healthcare Facility providing specialist services and training? Depends on how well organised the Health System is in terms of levels of Care and administrative support for UHC.

There were a couple of expert comments related to the lack of a sustainable career pathway for Home care workers and Nursing aides (who often have some informal on-the-job training). I think so too. Again ,a case for formal training (mentored by the Senior Nursing staff of PHCs?) with certification after a short period of training can make them - and the people they serve - feel secure.

d)Lastly, to the part I feel strongly about:

- I am fully in agreement with Dr.Barzegar's recommendation that there be a mid-level technical person with experience in CBR to guide and supervise CHWs for Disability-related work or rehabilitation in resource constrained settings.

- The pre-service training can include some orientation to all the areas in which CHWs within the current health systems play an important role and in addition, have a disability-specific module for her to work with a holistic approach that addresses prevention, Health promotion, caregiving, referral support and long-term rehabilitation in the framework of Community based inclusive development.

I also feel that a broad set of core competencies (recommendation 3 of the guidelines) can ensure their integration into the team operating at Primary Health care level. Important if the common thread that runs through the discussion is to ensure UHC. Just as with doctors, who have a broad understanding of different areas they study during MB,BS., with expertise that stands them well for primary Healthcare, but may still require additional studies for unimodal specialisation for secondary / tertiary care settings, so also for CBR (which to my mind is a specialised area even though it does not get recognised as such because one is not getting linked to a level higher in heirarchy.).

I would like to remind all here that we are speaking of CBR workers as a cadre of CHWs strengthening services within the System rather than be the ones taking care of all (not a context of where there is no doctor).

Thanks and regards,



Dr. Sunanda K. Reddy

Chairperson (Honorary), CARENIDHI

Adjunct Faculty, SACDIR, IIPH Hyderabad

Phone: +91-9818621980, +91-9560302666

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 (NPW): Thank you for your rich contribution, Sunanda. Contributions on any aspect of CHWs at any time are welcome.]