Introduction:
The strengthening of the public healthcare system gets the utmost importance, with every government prioritizing Universal Health Coverage (UHC). The Community Health Workers (CHWs) play a crucial role in the public health care system by facilitating and attending the health needs of the community. The UHC ensures that all people obtain the health services they need without suffering from any financial hardship while paying for them.(1) UHC requires a reliable, efficient, well-regulated health system supported by essential medicines and technologies and a well-trained and motivated workforce of sufficient capacity.(2) With 65.97 percent of the rural population in India, (3) ensuring affordable, accessible, and quality healthcare services in rural India have raised challenges such as limited healthcare infrastructures and deliverables, lack of human resources, and disproportionate burden on the grassroots health workers with limited skills.
The National Sample Survey (2011-12) reported the distribution of qualified health workers towards urban areas in India. The density of trained health workers was 22.7 per 10,000 populations in urban areas as compared to 3 per 10,000 populations in rural areas. Besides, there is a wide variation in the density of health workers across states, especially the northeastern and north-central states, which has a lower frequency of qualified health workers compared to the national average.(4) Rural India, as of March 31, 2017, has a shortfall of 10,112 female health workers at primary health centers, 11,712 female health assistants, 61,000 female health workers, and Auxiliary Nurse Midwives (ANMs) at sub-centers’.(5) Furthermore, geographical complexities such as hilly terrain, remote areas with few connectivity, conflict-prone areas, and areas close to international borders add more the shortfall of health workers in the healthcare system.
Community Health Workers in India
The government of India established the National Rural Health Mission (NRHM) in 2005 to overcome the menacing effect of disparities in healthcare services in rural India. NRHM laid the creation of Community Health Workers (CHWs), recognized to be an integral part of the health workforce as an Accredited Social Health Activist (ASHA). ASHA was created to reduce maternal and child mortality rates by connecting with the rural population directly. The shortage of workforce in rural India is slightly considered to be compensated by the presence of the CHWs, playing a pivotal role in increasing the availability of and access to primary health care services in difficult or peripheral areas. ASHA, in India, is considered to be an efficient entity in bridging the growing health disparities.
The primary responsibilities of ASHA in the healthcare system are to educate and promote health and wellbeing among the rural communities through collaborating with ANMs and the Anganwadi workers (AWW). (6) The Activist is envisaged with three primary function: 'link worker,' 'service extension worker' and 'health activists in the community who creates awareness on health and its social determinants and mobilize the community towards local health planning and increased utilization and accountability of the existing health services' (6-7). Under NRHM, ASHA is expected to reach a population of 1000 in a rural village, assisting the AWWs and ANMs in delivering the healthcare service. ASHA facilitates the functions of reproductive healthcare, institutional deliveries, vaccination, and immunization of children. ASHA, at the same time, takes care of the cash assistance promoting institutional deliveries under Janani Suraksha Yojana (JSY). (8) The activists are selected based on the gender and resident of the community served, age, and level of education. An activist has to be a female, with formal education up to class 8th, from 25-40 years old and should be a resident of the community served. However, selection criteria are usually not met. (9) The national guidelines stated the basic training module for ASHAs: 23 days of training programs in the first year, and subsequently, 12 days of training every year after that. (7) The training programs equip the activists with the essential introduction to healthy food, water safety, birth attendant, pregnancy registration, information on JSY, and other maternal and child related healthcare services. The kit is provided to the health activists that include oral contraceptive pills, condoms, some life-saving drugs such as cotrimoxazole and chloroquine. (7) Evidence from the existing studies suggest that preventable maternal and newborn deaths can be averted through simple, evidence-based intervention such as community health workers, and its increasing engagement is critical to universal access to healthcare provision. (6, 10-13)
There have been limited studies on the working conditions and challenges of health workers in the steep geographical terrain. Existing literature lacks scholarly intervention on the functioning of health workers in the peripheral region of India. This work is a snippet from a cross-sectional study conducted in the Indo-Bangladesh borderland region of Assam provides a limited scope for generalization on the challenges and experiences of ASHAs engaged in the peripheral regions. ASHAs in the peripheral region encounter several barriers because of the nature of the geographical location, as well as political and social context. Therefore, this study aimed to assess the functioning of CHWs and identify the challenges and barriers they face while delivering the services to the communities in the borderland region of India. Throughout the study, CHWs are referred to as ASHAs, as recognized by the NRHM, India.
Methods
Study design and Setting
The study was conducted in three districts of Assam, namely Karimganj, Dhubri, and South Salmara, adjacent to the Indo-Bangladesh border in the north-eastern region of India. The state of Assam is crucial to the northeastern region of India. The nature of borderland in Assam adversely affects the socio-economic condition, literacy, and health and wellbeing of individuals residing close to the border. Bangladesh border practically has no natural obstacles, border villages are densely populated, and cultivation carried out till the last inch of the borderline. The region to the borderline is densely populated, primarily are landless laborers. The World Bank report on Assam stated that 43 to 60 percent of the population is below the poverty line in the districts sharing international borderline: Dhubri, South Salmara and Karimganj. (3)
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Figure 1 Data Collection Sites (Shaded grey) |
Study Population
All women from the age group of 15-49, gave birth in the last one year or was pregnant during the time of data collection period, residing in the villages, that is 0 to 15 km. from the borderline in Karimganj, Dhubri and South Salmara were eligible for inclusion in the study. To explore and analyze the challenges and barriers associated with the ASHAs, any health workers engaged in the studied area were included for the study.
Sample Size and Assumptions
The health activists (n=16) were selected randomly from the three districts, and unstructured interviews were conducted. The interviews were generally for 20 to 25 minutes, focusing mostly on the working conditions, challenges, and contact with community members. Pseudonyms are used while reporting the qualitative findings.
Further, based on data extracted from NRHM, the researcher has identified the households that have pregnancy cases or women given birth in the last year. The NRHM dataset reported 26757 women fulfilling the criteria. The study has randomly selected 355 women that fit the criteria. The representational cases were attained by using the Cochran formula (a statistical formula)
of sampling design, where N= population size, p= percentage, or proportion picking a choice, e= sampling error, and z= number of standard deviations a given portion is away from the mean. The assumptions were: confidence level at 95 % = 1.96, sampling error = 0.05, taking the proportion of 45 % = 0.45. A simple random sampling method was used for selecting households of women in the three districts, as represented in Table 1.
| Table 1: District-wise distribution of Religion and Level of Education |
| District |
The religion of Household and Level of Education |
|
Hindu |
Muslim |
Total |
Primary |
Secondary |
Higher |
No Education |
Primary |
Secondary |
Higher |
No Education |
Dhubri |
7 |
18 |
21 |
12 |
12 |
17 |
5 |
19 |
111 |
South Salmara |
5 |
16 |
19 |
19 |
13 |
22 |
7 |
18 |
119 |
Karimganj |
8 |
19 |
22 |
8 |
16 |
19 |
6 |
27 |
125 |
Total |
20 |
53 |
62 |
39 |
41 |
58 |
18 |
64 |
355 |
Data Collection Tool and Technique
The qualitative data collected from the health activists were recorded, and later translated and transcribed. The data was collected during May, June, and July 2019. A pre-tested questionnaire of the National Family and Health Survey – 4 (NFHS – 4) was used to attain information from 355 women in the studied area. The questionnaire was translated into the local Bengali language.
Qualitative data analysis
The thematic framework approach was used in data analysis by identifying recurring and emerging themes. These themes served the dual purpose of promoting communities’ utilization of healthcare services. The qualitative analysis of the functioning of health workers was be substantiated by the quantitative analysis of health workers' services towards community utilization of primary healthcare services.
Quantitative data analysis
The study developed a series of a table describing the sample characteristics that include socioeconomic and demographic characteristics, and utilization of services. Utilization of service includes access to healthcare facilities in case of any sort of illness, registration of pregnancy cases, opting for institutional delivery, financial assistance, and arrangement of transport to the hospital.
Findings
The sample characteristics of the studied population are presented in Table 2, and Table 3 represents the engagement of the health workers with the communities.
| Table 2: Sample Characteristics |
|
Wealth Index |
Lowest |
Second |
Mid |
Fourth |
Highest |
n |
% |
n |
% |
n |
% |
n |
% |
n |
% |
Education Qualification |
No Education |
45 |
64.29 |
15 |
21.43 |
10 |
13.33 |
0 |
0 |
0 |
0 |
Primary |
5 |
7.14 |
30 |
42.86 |
20 |
26.67 |
20 |
30.77 |
15 |
23.08 |
Secondary |
20 |
28.57 |
25 |
35.71 |
35 |
46.67 |
40 |
61.54 |
25 |
38.46 |
Higher |
0 |
0 |
0 |
0 |
10 |
13.33 |
5 |
7.69 |
25 |
38.46 |
Housing Condition |
Unhealthy |
35 |
63.64 |
10 |
15.38 |
10 |
15.38 |
5 |
7.69 |
0 |
0 |
Second |
15 |
27.27 |
30 |
46.15 |
20 |
30.77 |
0 |
0 |
0 |
0 |
Mid |
5 |
9.09 |
20 |
30.77 |
5 |
7.69 |
20 |
30.77 |
10 |
15.38 |
Fourth |
0 |
0 |
5 |
7.69 |
15 |
23.08 |
25 |
38.46 |
20 |
30.77 |
Healthy |
0 |
0 |
0 |
0 |
15 |
23.08 |
15 |
23.08 |
35 |
53.85 |
Engagement with the community includes attending and assisting in case of any illness, registering pregnancy cases, educating and informing the benefits of institutional delivery, assisting with documentation of financial resources, and arranging transportation facilities during the time of pregnancy.
| Table 3: Engagement of Health Workers for Communities health need |
| Domain |
Determinants |
N |
% |
Healthcare Facility |
Private |
51 |
14.4 |
ASHA |
12 |
3.4 |
AWW |
9 |
2.5 |
Sub-centers |
4 |
1.1 |
Primary Health Centres |
176 |
49.6 |
Municipal Hospital |
14 |
3.9 |
Urban Hospital |
14 |
3.9 |
Community Health Centres |
75 |
21.1 |
Pregnancy Cases Registered |
ANM |
15 |
4.2 |
ASHA |
314 |
88.5 |
AWW |
26 |
7.3 |
Place of Delivery |
Home |
96 |
27.04 |
Municipal Hospital |
6 |
1.69 |
Urban Health Centre |
42 |
11.83 |
Community Health Centre |
66 |
18.59 |
Primary Health Centre |
109 |
30.7 |
Sub-Centre |
5 |
1.41 |
Private |
31 |
8.73 |
Source of Financial Assistance |
JSY |
177 |
68.34 |
Other State Government Initiatives |
82 |
31.66 |
Transport to Hospital |
Doctor |
40 |
15.44 |
ANM |
5 |
1.93 |
AWW |
16 |
6.18 |
ASHA |
58 |
22.39 |
Relatives |
140 |
54.05 |
The qualitative finding of the study is thematically defined and substantiated by data from the survey in the two-way tabular format. The interviews broadly focused on three main domains: (i) functioning of ASHAs in the problematic areas, (ii) Challenges and barriers in the functioning of ASHAs, and (iii) factors affecting the functioning of ASHAs.
The themes that emerged out of the domain explain ASHAs as a facilitator and grass-root health workers. They are responsible for educating the communities for a healthy lifestyle, from nutrition to cleanliness, to tackle any unforeseen health crisis. Being a local to the community, the influence they have over the community can help the health system to intervene deep into the health behavior of the community members.
I [ASHA] generally try to educate the community about menstrual hygiene, using the sanitary pad and having nutritional food during pregnancy (ASHA, Karimganj).
People in my area, are very rigid in adopting a new method that government introduce, which are far better than our traditional form, be it in hygiene or case of pregnancy (ASHA, Dhubri)
The health workers act as a link between skilled healthcare providers and the community by time to time, updating the health status of the community. The Lady Health Visitor (LHV) coordinates between different stakeholders.
We [ASHA] look after the people here in the village, LHV comes and take account of the status, reports it to the ANM and Doctors at nearby PHC. Language is an issue here because the village communities speak Sylheti, but most of the doctors that are posted here are from different language speaking communities like Assamese, Hindi, etc. so we have to coordinate with the patient and doctors sometimes [ASHA, South Salmara].
In discussion with the ASHAs, they revealed the dependency of the community for all minor to major ailments. ASHAs being the first point of contact is called for duty in case of any emergency in the village.
There was an incident last year, a woman with pregnancy complication needed immediate assistance. My friend [another ASHA] called me because she is newly recruited and has less experience. I attended it, but the case was complicated, and it was Sunday, so there was no skilled doctor available in nearby PHC or SC. I, along with her family, took her to the Mankachar town. No emergency service like the ambulance was provided, even though we called thrice [ASHA, South Salmara].
Further, deliberating the conversation, ASHAs reported that they arrange for the financial assistance for the patient. From attending patients during pregnancy, arranging financial assistance to attending community member’s health during any emergency, ASHAs remain as foot soldiers for the rural healthcare system. The challenges and barriers that ASHAs face during delivery of services and factors affecting the services are: incentive pattern, inadequate supply of resources, and geographical locations. The findings are elaborately explained with the community data in the discussion section of the study.
Discussion
The functioning of ASHAs in Borderline areas
ASHAs as facilitators and grass-root health workers
The data analysis reveals that the roles of ASHAs include health promotion, disease prevention, treatment of primary medical conditions, and collection of health data. The workers are engaged in activities both with the health facilities such as Primary Health Centres (PHCs) and sub-centers (SCs), and the community they belong to. ASHAs work as a facilitator to promote a healthy lifestyle, from informing the necessity of cleanliness and usage of improved drinking and toilet facilities. This form of educating the community will help prevent epidemic and enhance to fight the endemic in any particular community. The ASHAs are expected to encourage access to healthcare services in the community members and mobilize the community for engaging in several healthcare programs. The role of ASHAs is also to concern about facilitating the community where to access care when needed. The literature stated this role of CHWs as ‘Patient Navigator’(14, 15), help the community members to interpret health information and related schemes. The role of ASHAs necessitates for providing logistical support for patient care, such as registering pregnancy, antenatal care, and postnatal care, keeping track post-pregnancy for vaccination.
Moreover, it is also the responsibility of the ASHAs to report back to the healthcare facilities they are attached to. The ASHAs also have an additional role in providing treatment for primary clinical conditions and minor ailments such as diarrhea or fever. The functioning of ASHAs is active in all the spheres of providing the community with every trivial deliverable necessary for a community good health and wellbeing.
Engaging ASHAs as health care facilitators at the grassroots level has been observed significantly positive outcomes in reducing maternal and child mortality rates. It has been observed that ASHAs maintains elaborative and extensive records of the pregnancy cases and childbirth, which directly needs to be reported to the ICDS centers. The health workers follow up cases, encourage to go for a regular check-up (antenatal and postnatal), escorts women during pregnancy. Many a time, health workers, take a step ahead by arranging communication, connecting with doctors, if the attendant of the patients is not qualified enough to understand the communication with the doctors. The health workers play a vital role, particularly in the problematic areas, where the socio-economic conditions and level of education, is relatively lower than other privileged geographic areas.
The ASHAs, many a time, work as trained primary medical service providers. They are provided with necessary medical kit and blood pressure instruments to monitor the health of the community. The community usually considers them to the first point of contact for any kind of illness or health complications. Doctors and the ANMs believe that the ASHAs are very useful in providing healthcare services deep into the community, through timeliness and cost-effectiveness of healthcare services. The healthcare providers believe that despite the difficulties in terms of terrain, poor socio-economic condition, and illiteracy, the efforts ASHAs put is highly commendable.
Meanwhile, another crucial concerns raised by the health care service providers working in the peripheral PHCs and SCs is language as a significant hindrance in communicating with the local community members, as, most of the community members speak Sylheti languages (different from the usual Bengali or Assamese dialect, mostly influenced by the regional language of Bangladesh). It is generally expected from the ASHAs to act as a moderator in communication between the patient and healthcare providers. The absence of communication between the doctors and patients or communication through mediators can sometimes confuse concerning treatment. Therefore, it is observed that the language proficiency of the ASHAs is a mandatory aspect that should be undertaken by the concerned authority while training the workers.
Lastly, the healthcare service providers and members from the communities highlighted the importance of ASHAs, as this reduces the work pressure of the healthcare providers. On the other hand, communities felt that ASHAs are cost-effective as they can avail of various healthcare services at home, which additionally is time-efficient.
ASHAs as the First point of contact for the community:
The analysis of the investigation of the involvement of the ASHAs directly with the community are based on seven broad areas: community seeking treatment for minor ailments, pregnancy registration, and antenatal care, assisting and arrangement for transportation to the hospitals during delivery, assisting child vaccination, information on government policies and schemes, linking bridge between the healthcare providers, and frequency of visit by the ASHAs.
The analysis revealed that in case of any ailment, out of 355 respondents, 5.9 percent of respondents prefer to visit the ASHAs and Anganwadi workers for treatment. This data has a contradictory standpoint from what it gathers from the observation and discussion with the ASHAs and healthcare providers. It can, however, be interpreted in two ways: either the ASHAs are not well-equipped, or the members of the community believe ASHAs are not qualified enough even to treat a minor ailment. From discussion and observation, it can be concluded that most of the ASHAs do not qualify the minimum eligibility criteria, and any training provided to them by the healthcare system goes in vain. At the same time, it is also the reluctance of many ASHAs to take the extra load of treating the patient because most of them are underpaid.
It is being observed that ASHAs manually maintain the record of pregnancy cases in their community. 88.5 percent of the pregnancy registration is done under the ASHAs (Table-03); however, many workers felt that it gets tedious to maintain the record that leads to loss of information of any particular case. The ANMs in the Sub-Centers rely on the data provided by the ASHAs for procuring emergency medical services from the PHCs. This manual record-keeping sometimes causes a problem for the community members and the ASHAs as well.
In the case of antenatal care, 87.62 percent of the women in the three districts are provided either by the ANM, LHV, or ASHA workers. In the peripheral region, during the pregnancy period, it is difficult for women to travel, because of poor transportation and lack of all-weather roads. So, getting antenatal care in a convenient environment is what most households desire. At the same time, the cost of antenatal care gets higher, with people moving towards urban or primary healthcare centers.
One of the primary roles of ASHAs is also to encourage or institutional delivery and follow all the medical procedures required during the phase of pregnancy. Out of 355 respondents, 72.95 percent of the population opted for institutional delivery, where 8.73 percent of the respondents undertook private care (Table-03). It is encouraging to observe that people opting for institutional delivery would marginally reduce the risk the maternal mortality. Moreover, the ASHAs felt that with their presence and motivation, the direct result of people opting in relatively risk-free delivery. At the same time, another determinant for the increase in institutional delivery is the financial aid provided by the government.
Janani Suraksha Yojana (JSY) and other state government initiatives also led to a rise in risk-free pregnancy delivery. In the borderline area, 68.34 percent of the respondents receive financial assistance from JSY initiative (Table-03).
ASHAs many times out of their compassion towards the community members, move one step ahead for helping the community with arranging transport for the pregnancy delivery. ASHAs mentioned that most of the male members of the household panic during the labor pain, and fail to make a suitable decision. The members immediately dial-up to the ASHAs for help. Although ASHAs are trained for a medical emergency during the pregnancy phase, they come out for help, make arrangements for transportation within their capacity. 22.39 percent of the respondent's transport to the hospitals is arranged by the ASHAs, where 54.05 percent of transport arrangements are done by the members of the family (Table-03). Besides, the ASHAs looks after the child healthcare provisions, from vaccination to overall illness. The vaccination card is distributed to the parents by the health workers, with every detail of vaccination. 83.33 percent of the respondents have undertaken all the vaccination at ICDS centers that were assisted by the ASHAs.
Factors influencing the functioning of ASHAs
The remuneration and incentive structure seemingly is a significant determinant that affects the functioning of ASHAs. The ASHAs are dependent on the JSY scheme that helps to fetch the compensation and incentives, as the regular remuneration is relatively less. ASHAs consider pregnancy to be the primary source of income as JSY guarantee more considerable incentive for the workers for referral and assisting women for institutional delivery. The ASHAs receive Rs.600 for every successful institutional delivery, which is considered to be very less for the labor they put into the work. This incentive pattern narrows the ASHAs activities only towards activities that are more incentivized than the other, which fails to perform effectively in non-incentivized activities such as encouraging the community for a healthy lifestyle, child care. It is also reported from their discussion that irregular and inconsistency in payment of incentives adversely affect the functioning of the workers. Apart from the job as a Health worker, the workers are engaged in other agricultural activities, so support the family. The less regular salary, no regular incentive structure negatively affects their personal and family life, which directly affects the functioning. Female workers are discouraged from working by the families as they can hardly contribute to the family income.
The ASHAs in remote areas face difficulties with the unavailability of resources, both infrastructure and human resources. The workers in the remote areas of Assam felt the need for a continuous and adequate supply of necessary equipment in their medical kit such as drugs, ORS, condoms, delivery kit for smooth functioning. Many a time, due to the absence of skilled nurses in the village, the health workers act as doctors and are in higher demand. With the limited supply of resources, health workers usually have to turn down patients and refer them to the nearest hospitals.
The geographical location pose hindrance on the functioning of the workers. The health workers expressed that during the monsoon season, the community member, along with the workers, faces severe difficulties. Villages are not connected with all-weather roads, causing communication failure. It is also being observed that villages having well-connected roads and proper transport facilities usually do not face difficulties in availing government services. Due to the geographical terrain, the health workers and community members' access and affordability of healthcare services are challenged.
The functioning of ASHAs was established by the indicator variables extracted from the survey and in-depth interview: contact with the community, frequency of meeting the patients, assisting patients’ pre-pregnancy and post-pregnancy, engaging with the Integrated Child Development Programme (ICDS) for vaccination and immunization, and assisting in preventive, curative and promotion role of Public Health department. The cross-sectional study recognizes the work of ASHA through attending sick patients, assisting with the abortion, arranging transport for health facility for delivery, assist children for vaccination, and contacting the community.
Conclusion
Strengthening the healthcare system is the utmost priority for achieving UHC in India, as the recent WHO's integrated action framework entitled 'Leave no one behind.' Community Health Workers are vital to the healthcare system in India; therefore, the focus on reinforcing rural health workers will help achieve the goals of UHC.
The issues of rural healthcare are entirely different from the urban counterparts. The multiple roles that ASHAs play are identified with multiple challenges that need a more substantial policy intervention for smoother functioning. The literature and data simultaneously portray the positive contribution of the health workers in fighting maternal and child mortality, as well as morbidity. The incentive structure of the workers and their performance has a strong association, which is discussed in the earlier studies. The incentive structure, on the other hand, makes the worker ineffective in non-incentivized activities. The programs and policies for enhancing CHWs require a strong understanding of the local context and realities on the ground. The government intervention for strengthening the health system should be focused on improving the working condition of health workers.
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