Community mental health workers in rural India

13 January, 2020

The announcement below is forwarded from the Health Systems Research India Initiative

We have discussed previously on HIFA about the whether there is a case for all CHWs to have a core curriculum of training, whether some CHWs might be trained exclusively in some specialised tasks, and if so what they should be called. The emerging consensus answers to these questions appear to be no, yes, and "they should not be called 'specialist CHWs'". This paper underlines the role of CHWs who are trained exclusively and specifically in mental health skills, and describes them as "dedicated" CHWs...

[HSRII:1411] A time motion study of community mental health workers in rural India BMC Health Services Research,December 2019, 19:878

A time motion study of community mental health workers in rural India

BMC Health Services Research, December 2019, 19:878

Vijaya Chebolu et al


Community Health Workers (CHWs) are critical to providing healthcare services in countries such as India which face a severe shortage of skilled healthcare personnel especially in rural areas. The aim of this study is to understand the work flow of CHWs in a rural Community Mental Health Project (CMHP) in India and identify inefficiencies which impede their service delivery. This will aid in formulating a targeted policy approach, improving efficiency and supporting appropriate work allocation as the roles and responsibilities of the CHWs evolve.


A continuous observation Time Motion study was conducted on Community Health Workers selected through purposive sampling. The CHWs were observed for the duration of an entire working day (9 am - 3 pm) for 5 days each, staggered during a period of 1 month. The 14 different activities performed by the CHWs were identified and the time duration was recorded. Activities were then classified as value added, non-value added but necessary and non-value-added to determine their time allocation.


Home visits occupied the CHWs for the maximum number of hours followed by Documentation, and Traveling. Documentation, Administrative work and Review of work process are the non-value-added but necessary activities which consumed a significant proportion of their time. The CHWs spent approximately 40% of their time on value added, 58.5% of their time on non-value added but necessary and 1.5% of their time on non-value added activities. The CHWs worked for 0.7 h beyond the stipulated time daily.


The CHW’s are “dedicated” mental health workers as opposed to being “generalists” and their activities involve a significant investment of their time due to the specialized nature of the services offered such as counselling, screening and home visits. The CHWs are stretched beyond their standard work hours. Non-value added but necessary activities consumed a significant proportion of their time at the expense of value-added activities. Work flow redesign and implementation of Health Management Information Systems (HMIS) can mitigate inefficiencies.


Comment (Neil PW): The full text includes the conclusion: 'Therefore, segregation of the “generalist” and “dedicated” health worker is necessary and a single tier “generalist” cadre of workers may not be able to address the requirements arising due to varied healthcare challenges.' This makes sense. The paper doesn't discuss about terminology, ie whether "dedicated CHW" is preferable to "specialist CHW". Joseph Ana and others have suggested we shoudl notuse the term 'specialist CHW' because this would be unacceptable to many higher-level cadres. But I believe there is a case for using the term, not least because it is consistent with our use of the same term for other cadres: "specialist doctors", "specialist nurses", "specialist midwives", "specialist pharmacist", so why not "specialist CHWs"? All that this term means is that the CHWs have specific training in one area of health care. If we scramble for other terms such as "dedicated", we add to the confusion.

Best wishes, Neil

Coordinator, HIFA Project on Community Health Workers - Supported by the World Health Organization

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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 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org FB: