CHWs (4) Community Health Workers as Influential Health System Actors

21 July, 2020

(With thanks to Health Systems Global CHW TWG)

CITATION: Community Health Workers as Influential Health System Actors and not “Just Another Pair Of Hands”

Sumit Kane, Anjali Radkar, Mukta Gadgil, Barbara McPake

Internationnal Journal of Health Policy and Management



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.

'We show that far from being powerless and weak as the literature tends to portray them, CHWs have the potential to emerge as powerful social actors with influence in the communities they serve and

in the frontline health services. We argue that health policy-makers should take a more nuanced view of CHWs and engage with them as influential actors in their own right.'

COMMENT (Neil PW): It is clear that 'CHWs have the potential to be influential actors in the communities they serve'. I would add that some of them have the potential to be influential actors nationally and internationally. Previous global discussions on HIFA have been enriched by contributions from CHWs in many countries. One of HIFA's priorities is to increase the number of CHWs on our forums, because we really need to hear their voice. If you know a CHW who can write in English, French, Portuguese or Spanish, please point them to

Best wishes, Neil

Coordinator, WHO-HIFA Collaboration: Empowering Community Health Workers (CHWs) to accelerate progress towards Universal Health Coverage

HIFA Project on Community Health Workers

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - ), a global community with more than 20,000 members in 180 countries, interacting on six global forums in four languages in collaboration with WHO. Twitter: @hifa_org FB: