Over the last few weeks, I had a chance to meet a few inspiring non-profits, academic institutes and hospital systems in various part of India. All of these teams are either working on using technology tools for data collection and analysis, adopting digital tools, digitizing their work processes, or a combination of any of these tasks.
What stood out for me was the reliance of many, if not most, of these projects on the availability of community-based field force; many of these community health workers were the ASHA workers and in a few cases people with similar background and expertise. At a couple of community centers, I was able to interact with some of the ASHA workers, their equivalents and discuss about their work. These discussions raised many questions in my mind and led me to a rabbithole of how digital is reaching community globally and in India. This article tries to tease out some of those thoughts.
Why and What of Community Health
The World Health Organization (WHO) outlines two approaches to expand and ensure access to essential health services by optimizing the use of the existing healthcare workforce: task shifting and task sharing. Task shifting allows for the shifting of tasks from highly qualified healthcare workers to other workers with less training and less qualifications.
As Karen Leban and colleagues explain in their interesting paper, ‘Community Health Workers, by definition, are embedded in, drawn from, or at least work in the community. They are therefore in a good position to promote health in ways that reflect the political, environmental, social, and cultural realities of the community, partly through facilitation of broader community participation. While the interface position provides CHWs a good platform to improve community health, a major challenge in large-scale CHW programmes is that CHWs need to establish and maintain beneficial relationships with the actors in the national health system (requiring integration) as well as with actors in the community system (requiring embedment in the community). CHWs are accountable to both sides’
Considering their importance, using community health models is one of the most important priorities globally, and the World Health Organization puts this in their ‘Global strategy on digital health 2020–2025'-
(To) develop approaches to the management of health at the population level through digital health applications that move health and well-being from reactive-care models to active community-based models, and reduce the burden of data collection from front-line workers by reorienting reporting-based tools into service delivery tools;
India, ASHA workers and Public Health
India’s Accredited Social Health Activist (ASHA) programme was launched by the National Rural Health Mission (NRHM) (now known as the National Health Mission (NHM)) in 2005, in line with its policy of community engagement to ensure people’s participation in health. One ASHA is responsible for conducting health promotion activities for 1000 people in a village.
ASHAs are recruited from the community based on leadership and communication skills and have at minimum an tenth grade education. This education requirement is relaxed in areas where women are unqualified. Women between 25 and 45 years are preferred. The responsibilities of ASHAs include functioning as a “health care facilitator, service provider, and health activist”.
According to Indian Government’s Rural Health Statistics for the year 2019–2020, for 833 million Indians who live in rural areas, there are just 810 district hospitals, 155 404 sub-health centres, 24 918 public health centres, and 5183 community health centres to serve them. ASHAs especially play an important role by task shifting and task sharing.
India’s success in reducing maternal and infant mortality and its steps towards detailed antenatal care and institutional deliveries (reduction in maternal mortality rate from 556/100000 deliveries in 1990s to 103 in 2017–19 period)is largely attributed to the 90,000 strong ASHA network and their diligence within their communities to tackle this huge issue.
Overburdened CHWs and Digitization
As Bagnoli and colleagues report, CHWs are facing an ever-expanding list of activities. In 1978, the World Health Organization’s Alma Ata Declaration named CHWs as a cornerstone of comprehensive primary health care. CHW guidelines developed by WHO in 1987 listed 23 activities and tasks that CHWs may be responsible for. The consensus today is that no one person can perform all the activities laid out in the declaration. And yet, the role of CHWs continues to grow.
In 2018, WHO guidelines to optimize CHW programs were released, describing eight primary health care services that CHWs could support. This does not mean CHWs are doing less.
ASHA workers are not considered as full time workers, and receive completely performance based incentive payments, without any fixed income. They themselves do not possess any medical insurance and there have been reports of them suffering from health issues themselves.
CHWs equipped with digital tools are a valuable lifeline between health facilities and communities in need of care. As the only form of organized health care for millions of people in low- and middle-income countries, prepared and equipped CHWs have become even more critical with the spread of COVID-19.
Going Digital is not a Silver Bullet
It is evident from these points that CHWs can act as important resources especially in low-resource settings and their work can be effectively augmented by digital support. However simply digitizing existing processes may not have the desired impact. Asif Akram from ‘Living Goods’, Caitlin Augustin at ‘DataKind’ and Jeanne Koepsell from ‘Save the Children’ mention some of the challenges-
- A lack of interoperability between reporting systems and an abundance of siloed technology solutions within the health system.
- Challenges in data confidence and building a workforce with appropriate skills to utilize and interpret data collected.
- A knowledge and collaboration gap still exists between those creating digital health technologies and those adopting, implementing, and utilizing these tools.
Feroz and colleagues point out similar issues-Challenges still exist in building the capacity of CHWs to use digital tools and interpret data collected. The lack of digital skills among CHWs is not unique to the health system in LMICs. CHWs encounter unique challenges when adopting and using digital health solutions for health service delivery. These include lack of CHWs training on new digital tools, weak technical support, issues of internet connectivity, and other administrative related challenges.
The scene is quite similar in India. Because of their reach and spread in the communities all over India, digital health projects are all being designed to cater to ASHAs as a primary delivery mechanism. While this thought process is generally a good design principle, the implementation and monitoring of involving ASHAs is fragmented, short-term and ignorant of the other existing issues with the ASHA model. Some common themes I observed with current digital health project landscape using ASHA workers are-
- Deploying faulty/suboptimal digital equipment
- Multiple repetitive data entry/review interfaces
- Inability to access data,
- Lack of ongoing support and funding beyond a short-term proof-of-concept project.
- Fragmented approach to projects, not involving rest of the health system
These challenges have further worsened ASHA workers’ motivations in adopting digital technologies in their work.
What should come next?
Bagnoli and colleagues offer some interesting tips for organizations who intend to use CHWs in their digital health projects-
- Don’t collect data that you don’t need
- The goal of digital systems should be to replace paper systems altogether
- Acknowledge that increasing responsibility should be met with appropriate support
- Invest in the usability of digital tools
There are two examples of global initiatives which are working on some of these challenges-
- Digital Square: Digital Square is a digital health marketplace (or ‘square’) where supply and demand come together to accelerate health equity. We connect health leaders with the resources necessary for digital transformation. Digital Square is housed at PATH, and supported by USAID, the Bill & Melinda Gates Foundation, and a consortium of other donors. One of the most interesting aspect of their work is to Promote the development, adoption, and reuse of digital health global goods, and helps increase their availability, adaptability, and maturity.
- Living Goods: Living Goods is a non-profit working to enable government partners to improve health outcomes nationally, by ensuring CHWs can reach their full potential. aim to digitally empower thousands of government community health workers (CHWs) to provide accurate care and prompt follow-ups by using a smartphone app that details every patient contact, enables real-time performance management of health workers in outlying villages, and detects early outbreaks.
Both Digital Square and Living Goods have interesting case studies about using digital health approach in an integrated, user-centric approach for CHWs, which can act as role-model for helping community health’s digitization approach.