Task Force 6: Accelerating SDGs—Exploring New Pathways to the 2030 Agenda
Frontline health workers are the backbone of a resilient health system. This was evidenced during the COVID-19 pandemic where they were at the forefront of managing the pandemic despite the severe risk it posed to their health. The Antara Foundation’s experience working with frontline health workers in rural India reveals that investing in health workers is imperative as they are central to last-mile service delivery and ensure comprehensive healthcare. This policy brief calls for investing in frontline health workers to build resilient health systems that can deal with complex health challenges.
1. The Challenge
Frontline health workers refer to individuals who provide health services directly to the community. They are the first and often the only point of contact to the health care system[1] for millions of vulnerable people, especially those living in remote and hard-to-reach areas.
There is a growing body of evidence that shows the role health workers play in improving health outcomes. Consequently, there has been a steady investment in health workers globally. Evidence from Indonesia and Rwanda suggests that investing in health workers can ensure increased reach.[2]
During the COVID-19 pandemic, frontline health workers were engaged around the clock, to support their communities. They responded with great agility and tenacity to ensure that health services on-ground kept pace as the pandemic progressed. In developing countries where frontline health workers bear a large share of the health system’s burdens, the dependence on them was even greater. A rapid community survey conducted in May 2020 by The Antara Foundation (TAF) showed that nutritional services provided by frontline health workers remained uninterrupted for 55 percent of all respondents.
In India, the public health system led all prevention, management and resilience efforts during the pandemic. The Auxiliary Nurse Midwife (ANM), Accredited Social Health Activist (ASHA), and Anganwadi Worker (AWW)—together called the AAA—were central to the relief effort and ensured that routine health services were not hindered in the process. The AAA collaborated across various activities to prevent, manage and treat COVID-19 cases in rural India.
During health emergencies, the dependence on health workers increases exponentially. An analysis of previous outbreaks, like severe acute respiratory syndrome (SARS) and the Ebola virus, provides concrete evidence of the increasing challenges and pressures faced by frontline health workers.[3] Often, these crises magnify pre-existing fractures within the system. Thus, repeated lessons from different health emergencies show a need to invest in the frontline workers’ capacities. Some of the significant challenges faced by them include:
- Absence of adequate skills: Lack of suitable training and support for frontline health workers is a significant hurdle for service delivery. During the pandemic, we observed multiple context-specific cases that highlighted the need for targeted training and support.
- Unclear role definition: COVID-19 has proven to be an extremely dynamic health emergency, with the situation, guidelines for care and clinical practices changing daily. In such an environment, frontline health workers seldom had clarity about their role or the extent of care they were required to provide.[4] This caused many discrepancies in the initiatives run by community health workers (CHWs).[5] In a rapid assessment conducted by TAF during the pandemic, 87–97 percent AAAs identified awareness generation among community members as a core responsibility. However, only about 40 percent identified contact-tracing and reporting cases to authorities as part of their job role and about 30 percent knew that identifying high-risk cases is part of their role, despite frontline health workers being the primary cadres responsible for identification and reporting.
- Lack of adequate compensation: Women constitute 90 percent of frontline health care. They are often underpaid for their services and labour, particularly in healthcare.[6] A study on AWWs in Bihar, India, found that salary was the primary motivator for these frontline health workers, and delayed salary is a major cause of job dissatisfaction.[7] A recent World Health Organization (WHO) analysis of 104 countries showed that, overall, a gender pay gap of 28 percent exists among the health workforce.[8]
- Poor collaboration: Studies show around 70 percent of unfavourable outcomes in healthcare settings have been due to poor collaboration among health workers.[9] Health workers from different departments, programmes and states often work in silos with minimal communication. Poor collaboration may result in inefficient planning, delay in decision-making and fragmented service delivery. TAF’s analysis of government data shows that poor collaboration results in data variance between cadres who provide services to the same beneficiaries. In September 2020, TAF began its efforts towards greater convergence in Madhya Pradesh’s Chhindwara district. At the start of the programme, there was a variance of 21 percent in the number of pregnant women registered between the two departments providing health and nutrition services, respectively, to these women. This resulted in about 3,000 women being excluded from receiving nutritional services annually.
- Mental health challenges: There is strong evidence to substantiate how quality care is compromised because of increased medical errors and suboptimal patient care practices by burnt-out frontline health workers. Work-related burnout also results in poor professional behaviour, higher absenteeism, low organisational commitment and greater patient dissatisfaction.[10] Evidence from a systematic review showed that 30.4 percent of healthcare workers in direct contact with patients infected with the SARS virus exhibited symptoms of emotional exhaustion.[11]
- Focus on data entry instead of data use: Evidence suggests that approximately 56 percent of a frontline health worker’s time is lost in accessing and updating beneficiaries’ records instead of providing holistic healthcare.[12] Investing in building data skills among frontline health workers can enable them to take better decisions and, thus, improve public health outcomes.
2. The G20’s Role
Universal health coverage (UHC) in the G20 countries hinges on well-functioning health systems. With less than a decade left to achieve the Sustainable Development Goals (SDGs), efforts towards global health preparedness must be expedited to ensure that the health system is run by a well-trained and capable workforce when future public health threats emerge.
The declaration by the WHO to designate 2021 as the ‘Year of Health and Care Workers’ reaffirmed the significance of frontline health workers in enhancing the resilience of healthcare systems.
The G20 has made significant efforts to improve the status of frontline health workers. For instance, China has invested in protecting the working conditions of health workers, and France has promoted continuous professional development for health workers. Countries like Germany, Italy, South Korea and Saudi Arabia have revamped training and capacity building of health workers.[13] But there is significant scope to deploy systematic efforts to ensure better health outcomes.
3. Recommendations to the G20
We recommend seven solutions to strengthen health worker systems across the G20 countries (see Figure 1).
Figure 1: Strengthening Health Worker Systems
Investing in capacity building of frontline health workers
The WHO guideline on strategies for human resources in health indicates the need for dedicated training for the health workforce.[14] Empirical evidence also affirms the need for continuous practical training to ensure quality service provision.[15] However, ad-hoc training continues globally.[16] There is a need to contextualise the capacity building of workers, regularly track the outcomes and implement high-impact training mechanisms.[17] Contextual factors related to the community have been found to influence community health worker performance and impact service provision.[18] Countries can leverage core-competency–based training that focuses on technical knowledge and also build interpersonal and communication skills to bridge the cultural gap between the community and the health system.[19]
TAF’s experience in maternal and child health also demonstrates the need to emphasise good quality training. In our intervention districts, knowledge scores of frontline health workers have increased by approximately 30 percent through focused training and on-field handholding efforts.[a] In our context, capacity building has shown maximum improvement in health worker performance when it is continuous, contextualised to the needs of the health worker and emphasises practical skill development. Further, evidence from our work shows that 93 percent of respondents rated training much higher when they incorporated all three elements. All these efforts would allow for streamlined avenues for continuously upskilling frontline health workers. We encourage the G20 to systematically invest in:
- Systems for on-the-job training of frontline health workers
- Setting up of specialised training centres to upskill frontline health workers both on the technical front and using core-competency–based methods
- Building partnerships with civil society organisations and private training centres to leverage them for capacity building of frontline health workers
Ensuring job clarity and avoiding duplication
Community health workers should clearly understand their roles to ensure quality healthcare provision. This is a prerequisite to avoid conflict that can stem from the duplicity of work.[20] Standard operating procedures, adequate guidance and training on roles and responsibilities can help solve this. Frontline health workers must have a clear understanding of their essential, non-essential and additional activities[21] to ensure clarity regarding their roles and expectations. We recommend investments in building job clarity by clearly defining the roles of each cadre within national health policies and responsibility allocation as per defined roles.
Improving work conditions and incentives
Overall working conditions of frontline workers are critical to ensure better impact.[22] Evidence shows that community health workers’ productivity is affected by their work environment. We recommend that the G20 invests in creating a positive work environment by focusing on adequate workload, supportive supervision, sufficient equipment and respect.[23] A study on the impact of performance-based incentives showed that community health workers who received financial incentives to detect TB cases showed a 33.2 percent increase in the number of cases detected.[24] However, it is essential to note that purely incentive-based structures are often disrupted during periods of crises. In India, ASHA workers, who primarily receive incentive-based income, were employed in critical COVID-19 outreach work during the pandemic. This meant they could not carry out their routine work for which they would have received incentives, leading to income uncertainty.[25] A minimum compensation structure should be ensured, supported by international organisations like the International Labour Organisation and the WHO.[26] Additionally, appropriate incentives should be layered on top of the minimum compensation as needed, to further motivate and recognise the valuable contributions of frontline health workers. Therefore, we recommend that the G20 focus on creating an enabling work environment and streamlining community health workers’ remuneration so that they have fair compensation and greater economic security in line with minimum wage requirements.[27]
Focusing on frontline health workers’ mental health
Healthcare providers are exposed to events daily that contribute to psychological distress.[28] There is a need to alleviate stress, teach self-care strategies and implement organisational measures to support their mental health and well-being.[29] We recommend to the G20 three initiatives[30] to help with the same:
- Governments should provide trained mental health support, including in-house psychologists and outreach programmes, for frontline health workers in high-pressure environments.
- It is crucial to train supervisors to effectively manage frontline health workers under their charge in a supportive manner.
- Frontline health workers should be supported by providing them with amenities that improve their work experience and alleviate some of their daily concerns, such as transportation or accommodation.
Establishing a framework for integration between multiple cadres
Similar to India’s multi-cadre community health workers structure of ASHAs, AWWs and ANMs, Indonesia has multiple kadres responsible for different health needs,[31] as does Brazil with community health agents and auxiliary nurses.[32] Integration between different cadres of the health system helps them build an ecosystem of accountability and ensures comprehensive care. TAF’s flagship intervention, the AAA platform, is a microplanning platform that helps different frontline health worker cadres in Madhya Pradesh,[b] India, plan and deliver Reproductive, Maternal, Newborn Child plus Adolescent Health (RMNCHN+A) services across the continuum of care in a collaborative manner. This intervention resulted in a 43 percent increase in early registration of pregnant women and a 7 percent increase in the identification of high-risk pregnancies in Chhindwara, Madhya Pradesh, since December 2020. Integration across cadres promotes increased interaction, better role definition and understanding, and ensures knowledge transfers through peer learning. This facilitates better service delivery to the community across the continuum of care. We recommend such innovations that encourage collaborative microplanning and information sharing to the G20 to facilitate interaction and collaboration between different health cadres.
Including frontline health workers in decision making
Health workers are closest to the problems that policymakers try to solve. They have detailed insights and real-life experiences that can help guide efficient and effective policy development. Practising inclusivity in decision making and including feedback from healthcare workers is critical. It helps create successful guidelines and processes that support better health outcomes and beneficiary experiences.[33] Frontline health workers are often required to solve problems independently, making them prime candidates to facilitate better decision making.[34]
There is a need to create platforms like the Frontline Health Workers Coalition and the Human Resources for Health 2030 Program so that frontline health workers can participate and get involved in local and global decision making.[35] The Bihar government, in collaboration with CARE, a not-for-profit organisation, designed a mobile application for frontline workers to support them in decision making to enable a more holistic healthcare ecosystem and has observed great initial results.[36]
Enabling a data-oriented and tech-enabled approach
Frontline health workers also collect and report large volumes of health data critical to the health system’s functioning.[37] Historically, they have been responsible for collecting data on various healthcare priorities of the government, while their supervisors are responsible for using this information to make decisions.[38] Governments often rely on health worker data to run their health information system. But there is little focus on empowering frontline workers to utilise this data to plan their work better and prioritise service delivery. Studies around M-health solutions have shown that when frontline workers use data to deliver services, there is better communication and decreased costs.[39] The G20 needs to focus on including tech-enabled solutions that simplify data collection and enable frontline health workers to use data to drastically improve service quality. Considering the expanding responsibilities of frontline health workers in delivering vital primary health services, we call for strategic solutions that streamline data collection, optimise cost-effectiveness, reduce information aggregation time, simplify monitoring and surveillance processes, and enhance transparency.
These recommendations aim to provide direction to different countries within the G20 on areas requiring investment for faster UHC achievement. Health workers form the pillars of health systems globally. Systematic and large-scale investments are, thus, imperative. Global empirical evidence supports such measures to improve working conditions for health workers as they are likely to ensure better health outcomes.
Attribution: Chandrika Bahadur et al., “Investing in Frontline Health Workers for a Resilient Health System,” T20 Policy Brief, July 2023.
[a] TAF Monitoring Data for Chhindwara and Betul of baseline and midline assessments were taken one-year apart.
[b] Eight districts in Madhya Pradesh—Chhindwara, Betul, Seoni, Gwalior, Morena, Barwani, Khargone, Damoh.
Endnotes
[1] Tracy Geoghegan, “Frontline Health Workers: The Best Way to Save Lives, Accelerate Progress on Global Health, and Help Advance U.S. Interests,” Frontline Health Workers Coalition, January 2012, https://www.hrhresourcecenter.org/node/3925.html.
[2] USAID and MCHIP, “Case Studies of Large-Scale Community Health Worker Programs: Examples from Afghanistan, Bangladesh, Brazil, Ethiopia, Niger, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe,” USAID and MCHIP, January 2017, https://mcsprogram.org/resource/case-studies-large-scale-community-health-worker-programs-2/.
[3] Jo Billings et al., “Experiences of Frontline Healthcare Workers and Their Views about Support during COVID-19 and Previous Pandemics: A Systematic Review and Qualitative Meta-Synthesis,” BMC Health Services Research 21, no. 1, September 2021, https://doi.org/10.1186/s12913-021-06917-z.
[4] Karen Willis et al., “‘Covid Just Amplified the Cracks of the System’: Working as a Frontline Health Worker during the COVID-19 Pandemic,” International Journal of Environmental Research and Public Health 18, no. 19 (September 28, 2021): 10178, https://doi.org/10.3390/ijerph181910178.
[5] Jan-Walter De Neve et al., “Harmonization of Community Health Worker Programs for HIV: A Four-Country Qualitative Study in Southern Africa,” PLOS Medicine 14, no. 8, August 2017, e1002374, https://doi.org/10.1371/journal.pmed.1002374.
[6] Leah Rodriguez, “6 Reasons We Need to Value Women’s Unpaid Work in Health Systems,” Global Citizen, July 7, 2022, https://www.globalcitizen.org/en/content/women-unpaid-healthcare-global-facts-covid-19/.
[7] Aparna John, Tom Newton-Lewis, and Shuchi Srinivasan, “Means, Motives and Opportunity: Determinants of Community Health Worker Performance,” BMJ Global Health 4, no. 5, October 1, 2019, e001790, https://doi.org/10.1136/bmjgh-2019-001790.
[8] Mathieu Boniol et al., “Gender Equity in the Health Workforce: Analysis of 104 Countries,” World Health Organization, January 1, 2019, https://apps.who.int/iris/bitstream/handle/10665/311314/WHO-HIS-HWF-Gender-WP1-2019.1-eng.pdf.
[9] Tulipoka N. Soko, Diana L. Jere, and Lynda Law Wilson, “Healthcare Workers’ Perceptions on Collaborative Capacity at a Referral Hospital in Malawi,” Health Sa Gesondheid 26, no. 0, July 30, 2021, https://doi.org/10.4102/hsag.v26i0.1561.
[10] Lene E. Søvold et al., “Prioritizing the Mental Health and Well-Being of Healthcare Workers: An Urgent Global Public Health Priority,” Frontiers in Public Health 9, May 7, 2021, https://doi.org/10.3389/fpubh.2021.679397.
[11] Emanuele Preti et al., “The Psychological Impact of Epidemic and Pandemic Outbreaks on Healthcare Workers: Rapid Review of the Evidence,” Current Psychiatry Reports 22, no. 8, July 10, 2020, https://doi.org/10.1007/s11920-020-01166-z.
[12] DataKind, “How Data Empowers Health Workers—and Powers Health Systems,” May 6, 2021, https://www.datakind.org/blogs/how-data-empowers-health-workers-and-powers-health-systems.
[13] G20 Health, “Briefing paper on “Coordinated and Collaborative Response”,” September 2021, https://www.salute.gov.it/imgs/C_17_pagineAree_5459_11_file.pdf.
[14] World Health Organization, Global Strategy on Human Resources for Health: Workforce 2030 (Geneva: World Health Organisation, 2016), https://apps.who.int/iris/handle/10665/250368.
[15] World Health Organization, Working for Health and Growth: Investing in the Health Workforce, Geneva, WHO , 2016, https://www.who.int/publications/i/item/9789241511308.
[16] Kristine M. Gebbie, and Bernard J. Turnock, “The Public Health Workforce, 2006: New Challenges,” Health Affairs 25, no. 4, July 1, 2006, 923–33, https://doi.org/10.1377/hlthaff.25.4.923.
[17] Kara Decorby-Watson et al., “Effectiveness of Capacity Building Interventions Relevant to Public Health Practice: A Systematic Review,” BMC Public Health 18, no. 1, June 1, 2018, https://doi.org/10.1186/s12889-018-5591-6
[18] Maryse Kok et al., “How Does Context Influence Performance of Community Health Workers in Low- and Middle-Income Countries? Evidence from the Literature,” Health Research Policy and Systems 13, no. 1, March 7, 2015, https://doi.org/10.1186/s12961-015-0001-3
[19] American Public Health Association, “Lessons Learned From a Community–Academic Initiative: The Development of a Core Competency–Based Training for Community–Academic Initiative Community Health Workers,” American Journal of Public Health, n.d., https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2011.300429
[20] Olivia Ly et al., “Exploring Role Clarity in Interorganizational Spread and Scale-up Initiatives: The ‘INSPIRED’ COPD Collaborative,” BMC Health Services Research 18, no. 1, September 3, 2018, https://doi.org/10.1186/s12913-018-3474-2
[21] Soumyadeep Bhaumik et al., “Community Health Workers for Pandemic Response: A Rapid Evidence Synthesis,” BMJ Global Health 5, no. 6, June 1, 2020, e002769, https://doi.org/10.1136/bmjgh-2020-002769
[22] Organisation for Economic Co-operation and Development, Ready for the Next Crisis? Investing in Health System Resilience, OECD Health Policy Studies, OECD, 2023, https://doi.org/10.1787/1e53cf80-en.
[23] Wanda Jaskiewicz and Kate Tulenko, “Increasing Community Health Worker Productivity and Effectiveness: A Review of the Influence of the Work Environment,” Human Resources for Health 10, no. 1, September 27, 2012, https://doi.org/10.1186/1478-4491-10-38.
[24] Thomas Gadsden et al.,“Performance-Based Incentives and Community Health Workers’ Outputs, a Systematic Review,” Bulletin of the World Health Organization 99, no. 11, November 1, 2021, 805–18, https://doi.org/10.2471/blt.20.285218.
[25] Priya Nanda et al., “From the Frontlines to Centre Stage: Resilience of Frontline Health Workers in the Context of COVID-19,” Sexual and Reproductive Health Matters 28, no. 1 (January 1, 2020): 1837413, https://doi.org/10.1080/26410397.2020.1837413.
[26] World Health Organization, “Protecting, Safeguarding and Investing in the Health and Care Workforce,” WHO, 2021, https://apps.who.int/gb/ebwha/pdf_files/WHA74/A74_ACONF6-en.pdf.
[27] Mathieu Despard et al., “Financial Well-Being of Frontline Healthcare Workers: The Importance of Employer Benefits” (Washington University in St. Louis, 2022), https://doi.org/10.7936/64M8-V455.
[28] Editorial, “India @ 75: Investing in a Healthy Workforce for a Healthy Future,” The Lancet Regional Health 3 (August 1, 2022): 100049, https://doi.org/10.1016/j.lansea.2022.100049
[29] Billings et al., “Experiences of Frontline Healthcare Workers,”14.
[30] Gemma Williams et al., “ How are Countries Supporting their health workers during COVID-19?” 26 (2),no.2 (2020),https://apps.who.int/iris/bitstream/handle/10665/336298/Eurohealth-26-2-58-62-eng.pdf
[31] Katharine Shelley, Novia Afdhila, and Jon Rohde, “Indonesia’s Community Health Workers (Kaders)l,” CHW Central, April 20, 2018, https://chwcentral.org/indonesias-community-health-workers-kadersl/
[32] Perry et al., “Case Studies of Large-Scale Community Health Worker Programs,”18-24.
[33] Holly Sims et al., “Frontline Healthcare Workers Experiences and Challenges with In-Person and Remote Work during the COVID-19 Pandemic: A Qualitative Study,” Frontiers in Public Health 10 (September 20, 2022), https://doi.org/10.3389/fpubh.2022.983414
[34] Markus Hinterleitner and Stefan Wittwer, “Serving Quarreling Masters: Frontline Workers and Policy Implementation under Pressure,” Governance 36, no. 3 (July 2023): 759–78, https://doi.org/10.1111/gove.12692.
[35] Crystal Lander, “Opinion: We Must Involve Front-Line Health Workers in Health Workforce Policy,” Devex, April 7, 2021, https://www.devex.com/news/opinion-we-must-involve-front-line-health-workers-in-health-workforce-policy-99549
[36] Manoj Gopalakrishna, “Opinion: 3 Ways to Support Health Care Workers and Strong Health Systems,” Devex, September 23, 2020, https://www.devex.com/news/opinion-3-ways-to-support-health-care-workers-and-strong-health-systems-98084
[37] Tisha Mitsunaga et al., “Utilizing Community Health Worker Data for Program Management and Evaluation: Systems for Data Quality Assessments and Baseline Results from Rwanda,” Social Science & Medicine 85 (May 1, 2013): 87–92, https://doi.org/10.1016/j.socscimed.2013.02.033
[38] C.F. Otieno et al., “Reliability of Community Health Worker Collected Data for Planning and Policy in a Peri-Urban Area of Kisumu, Kenya,” Journal of Community Health 37, no. 1 (February 1, 2012): 48–53, https://doi.org/10.1007/s10900-011-9414-2.
[39] Thomas J. Betjeman, Samara Soghoian, and Mark Foran, “M-Health in Sub-Saharan Africa,” International Journal of Telemedicine and Applications 2013 (January 1, 2013): 1–7, https://doi.org/10.1155/2013/482324.
