Community Processes
One of the better places to begin understanding this issue is a visit to the NHSRC website pages on Community Processes. NHSRC from its very inception had one of its major divisions dedicated to this agenda and their rich publications over the years is a good documentation of how this aspect of NRHM was rolled out. There are two web-pages, one related to Community Health Workers viz the ASHA programme and the other to the other forms of community engagement.
However, these are programme details. There is very little theory available there. But without a theoretical basis this would hardly have been possible. Though NRHM fully recognized community engagement as one of the main directions of health systems strengthening, there was poor clarity on how exactly this would be achieved. This was also true of most of the reform measures under NRHM. A major role in filling this gap was played by the Public Health Resource Network, a civil society organization established initially to take the learnings from the Chhattisgarh forward. Then with the coming of the NRHM the focus of the organization shifted to supporting the effort at district health planning and implementation through the creation of a 15-volume set of guidebooks. The power of ideas is immense and many of the ideas there became a part of the NRHM mainstream. (The current RTH website is in one way, only a continuation of that same spirit ).
One of the most impactful of the PHRN volumes was Volume 7, the guidebook for Community Processes. The PHRN volume on Community Processes has seven chapters: The first chapter is on the role of panchayati Raj Institutions. The second chapter is on Village Health Committees and Community Based Organizations. The third chapter is Village Plan based local action on health. The fourth is on involving NGOs or civil society and the next on peoples movements and the campaign for health rights and Public Participation in facility Management. Altogether it is the most comprehensive treatment of this topic. Written at the outset of the NRHM and widely disseminated through training programmes both of officers and of civil society activists, almost every strategy in this became part of the NRHM mainstream.
On the community health workers we present the following resources, organized chronologically.
All the articles of the first decade (2002 to 2012) are making the case for a community health worker programme- and how it can be taken to scale. In the second decade it was more a question of how to improve both programme outcomes and the terms of employment.
We begin with an almost unknown article by NH Antia and Nergis Mistry, which makes the Case for a CHW. We then present Mitanin Analytic Documentation- August 2004 – the first evaluation of the Mitanin programme. This is an internal evaluation. There have since been over 5 external evaluations- but we share this here because this evaluation was what guided the SHRC in shaping the programme. We then have two important efforts at theorizing the programme. One was Harsh Manders article on: “People’s Health in People’s Hands? A Review of Debates and Experiences of Community Health in India.” The other was by Mekhala Krishnamurthy and Sarover Zaidi on “Community Health Workers, Essential Elements and Enabling Environments.” (2005). Looking at the programme from another angle we have Sulakshana Nandi writing on ” Right to Health Action by Mitanins in Koriya District.” (2006) and Sundararaman writing on “Universalisation of ICDS and Community Health Worker Programmes: Lessons from Chhattisgarh”( 2006) The important point we make by presenting this set of articles is that it is not only practice, we also had to build our own theory to take this forward. These are relatively unknown articles and though we occasionally tried we could seldom get it published, at least not as we wanted it to read. Peer reviews and collaborators would change the narrative.
The environment became much more enabling by year 2007. There was growing international recognition for the role of CHWs. One important endorsement and support was a paper published by Andy Haines, then director of London School of Tropical Medicine and David Sanders, Peoples Health Movement and others in Lancet,2007 on “Achieving child survival goals: potential contribution of community health workers”. This same issue also gave a full page to the Mitanin programme in an article called “Community health-workers: scaling up programmes” thus giving visibility and credibility to the work ongoing in Chhattisgarh. There was also an important review of Community based health workers in Africa-again by Sanders and Lehman, 2004, that also added support to the concept.
With the coming of NRHM, the Community Health Worker programme rapidly scaled up nation-wide as the ASHA programme. By now , as compared to only five years earlier it was established that CHWs make a difference and that it is feasible for government to run programmes on scale. But there was heavy contestation on what her role should be- that of a link worker and last mile in service delivery, that of a primary care provider herself who also provides clinical care, or that of an activist. A major realist evaluation covering 8 states was carried out to address this issue. The Report on Evaluation of Functionality and Effectiveness of ASHA programme across 8 states; and its Executive Summary was actively disseminated and widely discussed within the policy community to build a better shared understanding of the issue. A brief record of a conference presentation in BMC proceedings: Determinants of functionality and effectiveness of community health workers: results from evaluation of ASHA program in eight Indian states is the only peer reviewed publication that this could be accorded. But nevertheless it remains one of the documents most often referred to in all publications that follows
In the next decade (2012 to 2022) there is a huge increase in the number of publications, reports, evaluations and presentations on the community health worker programme. The questions asked were different and so were the aspects covered. We will provide a sample of these presentations soon. Currently we provide only one work “Community health workers and accountability: reflections from an international “think-in”, and this gives the reader an example of the new questions that were being asked of CHWs
As of now we have not included any papers on the other dimensions of community processes.
We however share early Guidelines for Village Health and Sanitation Committees.
We also share one article “ Discourses around stigma and denial” published in EPW which is an exploration of community perceptions and dynamics during the covid 19 pandemic. We intend to develop a section on behaviour change communication also.
On the role of Local Governments, we share one paper: Who’s In Charge Of Social Determinants Of Health? Understanding The Office Of The Municipal Health Officer In Urban Areas. We will be developing this section further.