Over-Reliance on frontline health workers in India

INTRODUCTION

The public health system in India has witnessed major changes over the last few decades in response to the ever-increasing healthcare demands and disease burden. NHPs have been frequently revised to align them with the changing health care needs and priorities and sustainable development goals (SDGs) for 2030, alongside the introduction of novel digital health initiatives under the Ayushman Bharat Digital Mission. The basic unit of public healthcare transitioned from sub-centres to Health and Wellness Centres and, since 2023, to Ayushman Arogya Mandirs.^1-3

Ever since the launch of the National Health Mission (NHM) in 2005, the frontline workers such as Auxiliary Nurse Midwives (ANMs) and Accredited Social Health Activists (ASHAs) have played a pivotal role in delivering the maternal and child health services. According to the revised Indian Public Health Standards (IPHS) guidelines (2022), one ANM is allotted per sub-centre for a population ranging between five to eight thousand. The public health transition has placed greater responsibilities on frontline health workers without significant redistribution of their roles. Their initial role of maternal and child health care has been diversified to all national programs that include- communicable diseases (Malaria, leprosy, tuberculosis, infectious disease outbreaks); with the ANMs being responsible for supervisory postnatal care visits, while ASHAs requiring to conduct at least six postnatal home visits.⁴ The various roles include- creating awareness, counselling for various conditions like birth preparedness, breastfeeding and complementary feeding, immunization, contraception etc.; mobilize community to access healthcare services, physically accompanying the pregnant women and children during delivery or any other major treatments; conduct active screening for major NCDs like diabetes and hypertension. Apart from the preventive and promotive services, the ANMs provide primary medical care for common illnesses such as diarrhoea, fevers, first aid for minor injuries and neonatal sepsis. Their role also extends to the gram panchayats, where they contribute to the Village Health and Sanitation Committee by promoting construction of household toilets under the Total Sanitation Campaign. The health workers like ANM and ASHA are also expected to play a pivotal role in cancer screening. ASHAs, ANMs and Anganwadi Workers (AWWs) coordinate immunization, nutrition support and sanitation programs while also assisting in outpatient care during emergencies. Under the Integrated Child Development Services (ICDS) program, they provide nutritional supplementation, treat diseases and refer high-risk cases.⁴ As a final step, they need to extensively document their work, by both manual means and digital record-keeping.⁵ For example, the ANMs in the state of Andhra Pradesh are expected to maintain at least twenty-eight registers and twenty-three mobile apps under different programs (Table 1). In the same state, ANMs recruited through the secretariat at the local administration (‘Sachivalayam’), are often directed to works that are unrelated to health. For example, distribution of pensions under various social schemes or surveys (Like household geotagging) that are not directly related to health services. Thus, ANMs are also foresee having a challenge in prioritization between the works assigned by the medical officer and those assigned by the local administration. A recent notable addition is to secure a national quality assurance standards (NQAS) accreditation by the sub-centres to ensure quality services through these facilities. Such a huge workload on the frontline health workers is expected to divert their focus away from a precise core healthcare delivery. Despite the value of these responsibilities, many workers have not received adequate training, in turn directly affecting the delivery of critical services.⁶

The significant contribution of these health workers in the Indian public health system is often unuttered. A national-level study highlighted that maternal engagement with frontline health workers had significantly improved maternal and child health outcomes, particularly in the low-income groups.⁷ A time and motion study in South India revealed that additional program responsibilities have not been matched by a revision of ANMs’ roles, leading to inefficiencies and administrative overload.⁸ A training assessment in Jharkhand found gaps in ANMs’ knowledge of family planning services, highlighting the need for structured skill-based learning.^8,9 Similarly, case studies in Pune and Mangalore reported that frontline workers are increasingly engaged in data collection rather than direct healthcare services, necessitating skill-based training programs.¹⁰

CONCLUSION

Thus, the village health workers’, particularly the ANMs’ roles and responsibilities are largely increasing with the growing number of programs, as these programs are largely implemented by them. The ANMs are getting overburdened, with various program implementation relying heavily on their efforts. It must be remembered that the data generated at the village and sub-centre level from the various programs are unquestionably important for policy decisions and resource allocation. A critical exploration to options in task shifting is thereby suggested at the earliest to promote a timely efficient public health delivery system in the country.

REFERENCES

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