India’s frontline health workers help stave off global crisis

UTTAR PRADESH, India — Sonam Kumari was petrified when she conducted her first solo birth. She had assisted in several deliveries, but never done one by herself.

Her eyes light up as she recounts that day. “I was trembling when I delivered the first child," she said in her make-shift clinic on a muddy side street in a remote village in the state of Jarkhand. "I couldn’t believe I had done it. I cried, I screamed out: 'I did it, I did it!' The next day I gave out sweets to the entire village.”

That was months ago, after Kumari completed an initial week-long training with Intrahealth International, a US nonprofit, to give community health workers the skills to assist women during childbirth. Since then, Kumari has delivered more than a hundred babies, each one free of complications.

As a frontline health worker, someone from the local community trained to provide immediate health services, Kumari is not a doctor or a nurse. But she is arguably doing something they can't in her village: helping the poorest of the poor gain access to health care.

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Frontline health workers have been around for a while. In the 1950s, for example, the Chinese government pioneered a “barefoot” doctors initiative to help disadvantaged and rural populations. But experts say they are now, more than ever, in a position to stave off a looming global health crisis.

Today, people who experience nearly a quarter of all global disease are treated by only 3 percent of the world's health workers, according to the World Health Organization (WHO). Most of these patients are among the world's 3.5 billion rural poor.

Trained health professionals are rare in these vulnerable areas, and the practitioners that do exist are often lured to richer countries, like the US, which import legions of nurses from the developing world. WHO estimates that there is a global deficit of about 2.4 million doctors, nurses and midwives.

Frontline health workers help bridge the gap.

Intrahealth staff say they have trained more than 15,000 community health workers in Uttar Pradesh, home to 200 million. They also work in the neighboring state of Jharkhand.

Intrahealth isn't the only NGO advocating this approach, but what makes the program different is the depth of the training and the fact that each health worker gets a mentor that is a doctor or another skilled health worker. Ongoing relationships with their mentors allow Intrahealth's frontline health workers to constantly update their skills, and regular group visits to a central health facility allow them to draw support from one another.

Dr. Anupama Shandilya, a district program officer in Uttar Pradesh, has been an enthuiastic supporter of the program and says she has noticed a dramatic improvement in health indicators since the USAID-funded Intrahealth program was established three years ago. The number of malnourished children has dropped 25 percent, she says.

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Health care in India can use all the help it can get. The sprawling health-care system in the world's largest democracy is notoriously inconsistent in the quality of care it provides.

Economists Abhijit Banerjee and Esther Duflo, co-authors of the book, "Poor Economics: A Radical Rethinking of the Way to Fight Global Poverty," found that a low quality of care at Indian health facilities has deterred many rural poor from going to government hospitals. “Government health centers are often closed when they are supposed to be open. Furthermore, even when government doctors and nurses are around, they do not treat their patients particularly well,” they wrote.

Instead, many poor prefer private clinics run by practitioners who aren't necessarily qualified. Moreover, poor Indian families almost exclusively reach out for health care during crises, as opposed to before a crisis hits when preventative care could make a difference.

Introducing concepts like preventative care is where frontline health workers can potentially be the most effective, says Tina Rosenberg, a New York Times journalist who covers global health issues.

Frontline health workers can serve as a connector between the past and the present, she says, helping communities warm up to foreign concepts in modern medicine while simultaneously preserving what is most effective about traditional approaches.

“There are many traditional beliefs and practices that are extremely harmful — for example, the idea that pregnant women should eat very little, that babies should not receive breast milk until they are a few days old, or that the proper way to deal with a cobra bite is to go to the temple. Having a village woman use and advocate more modern practices, and seeing the example of success is the most effective way to change these beliefs,” she wrote by email.

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Of course, while clearly playing a vital role, frontline health workers are far from a panacea.

Kate Mitchell, who has done research on frontline health workers and currently works with the Harvard School of Public Health, warns that they can only be successful if part of a larger, functioning health system.

“Often times, community health workers serve less as a direct service provider and more as a link between the community and the health system," said Mitchell. "This role is also critical, especially when it comes to pregnancy and childbirth in settings where most women deliver at home without a skilled birth attendant.”

Experts agree that long-term support for the programs is crucial if they are to become sustainable operations.

Dr. Shandilya says that in her district sustainability is likely two to three years away, and she isn't overly optimistic that they will continue to get the support they need. She blames a lack of political will and shrinking budgets across the board.

Funding is an issue, even in rosier economic times. Unlike many disease eradication targets, that are more easily measurable, the benefits of supporting community health workers is harder to quantify.

Rosenburg, the journalist, says it takes time for the programs to fully take root. "Time, of course, means there must be a structure supporting them, and that's not always the case," she says. "You can't just train a woman once and then leave her on her own.”