CHALLENGES OF CHNs

Geographical barriers, bad weather, and inconvenient transportation have resulted in delays and
challenges in providing mobile health services.
If the organizational leaders support CHNs effectively, they get autonomy in their work, which
gives them an opportunity to perform their work successfully.
Unsupportive community relationship

Poverty, floating population, poor health literacy, language barriers, and insufficient stakeholder
interest are factors responsible for the unsupportive relationship with the community.

Likewise, people move from one area to another for better job opportunities and deter public health
workers from providing targeted services.
Moreover, poor health literacy also contributed to poor community participation in
public health services.
Another barrier related to the public is the poor interest of local stakeholders and
community volunteers for health. One respondent expressed her hardship when the local
ward/village administrator did not collaborate in implementing community health services
Undereducation in professional practice

The highest professional education of participants in this study was bachelor’ s degree in nursing,
and they did not receive specialized training in CHN practices when they transferred to public
settings from clinical settings. Some nurses uncovered inconveniences in engaging in their initial
period in the community.

The majority of the problems arising from the health system itself, such as insufficient resources
and weak collaboration among various categories of health workers, could not be overcome by the
CHNs themselves.

On the other hand, the absence of standard education criteria at the entry-level to the
public health system made CHNs feel inadequate in providing health services to the public. They
were satisfied when they gained an opportunity to attend refresher courses and on-the-job trainings
at the local level, despite national and international training being limited to some of them.
As a consequence of inaccessibility to advance education in CHN practices, CHNs
could not be involved in the policy development process through the use of evidence-based public
health practices. In contrast, insufficient human resources reinforced them to expand their
workability to supervise and monitor volunteer health workers and expand the population catchment
area.
the professional education of nursing personnel in community settings should be
upgraded to promote effectiveness in providing public health services toward UHC.
To meet the PHC demands, some important facilitating factors are the roles of the
nursing graduates completed from baccalaureate and master’ s programs that focus on health
promotion, disease prevention, diagnosis and management of chronic illnesses, and population
health

Although health system factors could be solved, population factors such as poverty and poor
health literacy pose persistent barriers to UHC.

Extreme poverty is a principal barrier to achieving the benefits of universal access to

The poor interest of local administrators extends the work burden of CHNs and frontiers.

The collaboration between health systems and local communities for frontline workers should be
strengthened for UHC.

strengthening the social accountability of the public is important for their own health, especially for
local stakeholders.
 Five “A's” for our consideration:

1. Awareness or the lack of it: How aware is the Indian population about important issues
regarding their own health? Studies on awareness are many and diverse, but lacunae in
awareness appear to cut across the lifespan in our country. Adequate knowledge regarding
breastfeeding practice was found in only one-third of the antenatal mothers in two studies

The answers may lie in low educational status, poor functional literacy, low accent on education
within the healthcare system, and low priority for health in the population, among others.

The message is clear – we must strive to raise awareness in those whom we work with and must
encourage the younger generation to believe in the power of education for behavior change.

2. Access or the lack of it: Access (to healthcare) is defined by the Oxford dictionary as “The
right or opportunity to use or benefit from (healthcare)”

A 2002 paper speaks of access being a complex concept and speaks of aspects of availability,
supply, and utilization of healthcare services as being factors in determining access. Barriers to
access in the financial, organizational, social, and cultural domains can limit the utilization of
services, even in places where they are “available.

Physical reach is one of the basic determinants of access, defined as “ the ability to enter a
healthcare facility within 5 km from the place of residence or work”

Using this definition, a study in India in 2012 found that in rural areas, only 37% of people were
able to access IP facilities within a 5 km distance, and 68% were able to access out-patient
facilities[14] Krishna and Ananthapur, in their 2012 paper, postulate that in general, the more
rustic (rural) one's existence – the further one lives from towns – the greater are the odds of
disease, malnourishment, weakness, and premature death.[15]

Even if a healthcare facility is physically accessible, what is the quality of care that it offers? Is
that care continuously available? While the National (Rural) Health Mission has done much to
 improve the infrastructure in the Indian Government healthcare system, a 2012 study of six states
in India revealed that many of the primary health centers (PHCs) lacked basic infrastructural
facilities such as beds, wards, toilets, drinking water facility, clean labor rooms for delivery, and
regular electricity.

As thinkers in the disciplines of community medicine and public health, we must encourage
discussion on the determinants of access to healthcare. We should identify and analyze possible
barriers to access in the financial, geographic, social, and system-related domains, and do our
best to get our students and peers thinking about the problem of access to good quality
healthcare.

3. Absence or the humanpower crisis in healthcare: Any discussion on healthcare delivery

A 2011 study estimated that India has roughly 20 health workers per 10,000 population, with
allopathic doctors comprising 31% of the workforce, nurses and midwives 30%, pharmacists
11%, AYUSH practitioners 9%, and others 9%.This workforce is not distributed optimally, with
most preferring to work in areas where infrastructure and facilities for family life and growth are
higher. In general, the poorer areas of Northern and Central India have lower densities of health
workers compared to the Southern states.

While the private sector accounts for most of the health expenditures in the country, the state-run
health sector still is the only option for much of the rural and peri-urban areas of the country. The
lack of a qualified person at the point of delivery when a person has traveled a fair distance to
reach is a big discouragement to the health-seeking behavior of the population. According to the
rural health statistics of the Government of India (2015), about 10.4% of the sanctioned posts of
auxiliary nurse midwives are vacant, which rises to 40.7% of the posts of male health workers.
Twenty-seven percentage of doctor posts at PHCs were vacant, which is more than a quarter of
the sanctioned posts.[18]
 Considering that the private sector is the major player in healthcare service delivery, there have
been many programs aiming to harness private expertise to provide public healthcare services.
The latest is the new nationwide scheme proposed which accredits private providers to deliver
services reimbursable by the Government. In an ideal world, this should result in the
improvement of coverage levels, but does it represent a transfer of responsibility and an
acknowledgment of the deficiencies of the public health system?

As trainers and educators in public health, how are we equipping our trainees to deliver a health
service in the manner required, at the place where it is needed and at the time when it is
essential? It is time for a policy on health human power to be articulated, which must outline
measures to ensure that the last Indian is taken care of by a sensitive, trained, and competent
healthcare worker.

4. Affordability or the cost of healthcare: Quite simply, how costly is healthcare in India, and
more importantly, how many can afford the cost of healthcare?

It is common knowledge that the private sector is the dominant player in the healthcare arena in
India. Almost 75% of healthcare expenditure comes from the pockets of households, and
catastrophic healthcare cost is an important cause of impoverishment.[19] Added to the problem
is the lack of regulation in the private sector and the consequent variation in quality and costs of
services.

The public sector offers healthcare at low or no cost but is perceived as being unreliable, of
indifferent quality and generally is not the first choice, unless one cannot afford private care.

Locally, a consciousness of cost needs to be built into the healthcare sector, from the smallest to
the highest level. Wasteful expenditure, options which demand high spending, unnecessary use
of tests, and procedures should be avoided. The average medical student is not exposed to issues
of cost of care during the course. Exposing young minds to issues of economics of healthcare
will hopefully bring in a realization of the enormity of the situation, and the need to address it in
whatever way possible.
5. Accountability or the lack of it: Being accountable has been defined as the procedures and
processes by which one party justifies and takes responsibility for its activities.

In the healthcare profession, it may be argued that we are responsible for a variety of people and
constituencies. We are responsible to our clients primarily in delivering the service that is their
due. Our employers presume that the standard of service that is expected will be delivered.
Our peers and colleagues expect a code of conduct from us that will enable the profession to
grow in harmony. Our family and friends have their own expectations of us, while our
government and country have an expectation of us that we will contribute to the general good. A
spiritual or religious dimension may also be considered, where we are accountable to the
principles of our faith.

Communication is a key skill to be inculcated among the young professionals who will be the
leaders of the profession tomorrow. As leaders in community medicine and public health, we
may be the best placed to put this high up in the list of skills to be imparted. A good
communicator is better placed to deal with the pressures of the relationships with client,
employer, peer, colleague, family, friend, and government.

The five as presented above present challenges to the health of the public in our glorious country.
As we get ready to face a future which is full of possibility and uncertainty in equal measure, let
us recognize these and other challenges and prepare to meet them, remembering that the fight
against ill health is the fight against all that is harmful to humanity.