Assessment of mid-level health workers supports integration in health and wellness centres to deliver primary health care services
WHO recognizes primary health care (PHC) as the most cost effective and equitable means to achieving universal health coverage (UHC). In India, the National Health Policy 2017 and the on-going operationalization of Ayushman Bharat - Health and Wellness Centers aims to bring comprehensive PHC closer to India’s 1.3 billion population. Fundamental to the success of this initiative is the addition of a cadre of mid-level health care workers in the form of community health officers to lead the PHC team. To date, over 115 000 health and wellness centres are functional and nearly 90 000 community health officers have been added to the health workforce. The WHO Country Office in India provides technical and implementation support in select states and aspirational districts towards achieving the Ministry of Health and Family Welfare’s goal of 150 000 functional health and wellness centres by the end of 2022. A recent WHO-led assessment of the role and performance of community health officers in health and wellness centres in two states in India indicates that community health officers make a noticeable addition to the public sector’s capacity to manage the noncommunicable disease (NCD) burden, as well as address common ailments, and thereby represent a primary care response to the epidemiological transition in India. The results of the assessment informed recommendations to further strengthen the contribution of community health officers to deliver primary health care services.
How did India do it, and how did the WHO Secretariat support India?
WHO technically and financially supported studies in the states of Assam and Chhattisgarh, which account for a cumulative population of 60 million people, to assess the role and performance of mid-level health care workers within primary care settings and identify opportunities to further enhance their contribution in health and wellness centres.
The studies used mixed methods. The quantitative component included data from health and wellness centres to evaluate service utilization patterns. The qualitative methods captured information from in-depth interviews, focus group discussions, and community surveys to assess the range and quality of health care services provided by the community health officers in health and wellness centres.
According to the 2018 UHC Technical brief on mid-level health workers, mid-level health workers are those who have received shorter training than physicians but perform many of the same tasks as physicians. The mid-level health care workers’ role in Assam and Chhattisgarh is provided by two cadres of community health officers: 1) nursing graduates trained in a new six-month bridge program; and 2) a pre-existing cadre of diploma clinicians who have undergone a three-year training program in modern medicine.
Given the scope of services and functions managed by community health officers, it was critical to assess their performance, including community perception. Assessment results were favorable and led to important recommendations to further strengthen the contribution of community health officers. Community health officers provide services during pregnancy and childbirth, neonatal and infant health care, in addition to diabetes and hypertension screening, monitoring, and continuum of care. Concurrently, they are also involved in management and referral of trauma and emergency cases and conduct minor surgical procedures. During the COVID-19 pandemic, most mid-level health care workers were involved in contact tracing and community surveillance to identify, isolate, and manage suspected cases.
In Assam, there is high community acceptance of community health officers, and most respondents (61%) agreed that the range of health services improved after such providers have been posted at health and wellness centres. In many instances, the survey participants preferred seeking health services at health and wellness centres than visiting higher level centres because of ease of access and shorter waiting times. In Chhattisgarh, community health officers scored well on provision of hypertension, diabetes, and malaria services and their scores for these diseases were close to that of medical assistants and medical officers. Around 80% of prescriptions written by community health officers for hypertension and diabetes were found to be correct. However, there were gaps identified for other disease conditions, such as diarrhea, vulvo-vaginal candidiasis and pre-eclampsia (mean score <50%). This demonstrated that community health officers performed better on diseases for which algorithm-based protocols were available.
Diseases commonly understood as lifestyle related were found to be common among the poor and chronic ailments figure significantly in the health care needs as perceived by communities, including in tribal and rural areas. Health and wellness centres have made a noticeable addition to public sector capacity to manage the NCD burden, as well as address common ailments, and thereby represent a primary care response to the epidemiological transition in India. How mid-level health care workers perform has a huge bearing on PHC and some of the important lessons and recommendations for improving their performance, including a) scaling up regular trainings and mentoring; b) developing standard treatment protocols for non-physician cadres; c) improving infrastructure and availability of drugs and diagnostic facilities; d) strengthening referral systems and use of technology for continuum of care; and e) clear career pathways.
Community health officers play a pivotal role in augmenting the capacity of health and wellness centres for screening and management of NCDs, in addition to reproductive, maternal and child health services. Assam and Chhattisgarh have shown a clear commitment to advance PHC with dedicated community health officers at health and wellness centres although implementation challenges exist. WHO-supported operational research enables these states to strengthen PHC delivery through refining implementation approaches to supply and demand. On one hand, it is equipping health and wellness centres to complement the functioning of community health officers and the PHC team; on the other hand, it is increasing demand and greater utilization of primary care services by improving awareness in the community about the range of health services rendered at health and wellness centres.
Photo Credit: © WHO India/Kumar Gaurav
Photo Caption: COVID-19 vaccination in a health and wellness centre.
Photo Credit: © WHO India/Kumar Gaurav
Photo Caption: NCD screening in a health and wellness centre.