Investments in public health: The centrality of frontline health workers

The ability of the health sector to deliver is contingent on motivation of the frontline worker, say Anuja Jayaraman, director (research) and Nikhat Shaikh, consultant, SNEHA Mumbai. While motivation of health workers is crucial to ensure low attrition, they stress that appreciation of their efforts cannot be a one day event

Investing in people is as important as investing in physical infrastructure. The efforts of skilled health personnel and community health workers, in the fight against COVID-19, have been recognised and celebrated all over the world. A few years ago, World Health Organisation recommended that countries have a mix of community-based and mid-level health workers to deliver primary healthcare. This is irrespective of the COVID pandemic. For instance, in the US, recent discussions have revolved around making medics and counselors as the first responders instead of the cops as is the current practice.

A fact that is consistently observed across countries is the positive correlation between density of health workers in a region and probability of survival for mothers, infants, and children. The density of health workers varies across the developed and developing countries. India has less than 25 health personnel (doctors and nurses) per 10,000 persons. This is lower by at least a factor 7 compared to developed countries.

Frontline workers act as an essential bridge between communities and public health systems. They play a pivotal role in conducting detailed community surveillance, identifying and referring those displaying COVID-19 symptoms. Given the nature of the pandemic, they are at risk, will definitely experience work pressure and mental health challenges due to worries about infection, safety of their families, endless working hours and being away from families while posted in quarantine or isolation ward.  Worldwide, there is a realisation that COVID will take a toll on the health workers and there will be indeed long term effects. The ability of the health sector to deliver is contingent on motivation of the frontline worker. Low attrition of health workers is linked to the sustainability of community-based health programs. Motivation of workers is crucial to ensure low attrition.

Studies from many countries have established that what motivates workers include the desire to share knowledge with their community; ability to see improvements in the community’s health; appreciation, recognition, and respect from their community. On the flip side, lack of adequate monetary compensation, acts a dampener. In recent years, in India, anganwadi workers have sought job security, regularisation and adequate compensation.

We at SNEHA, Mumbai, a non-profit organisation that works with women, children and public health and safety systems, sought to understand what motivates frontline workers. While the study was conducted before COVID-19 many of the insights can inform the discussions today.

We found that for the health system to deliver, one needs motivated individuals involved with organisations that care about the cause and socio-cultural level motivation is equally important. The health worker is self-motivated in anticipation of personal growth, development of skills on-the-job, and opportunity to use information communication technologies in daily work.They are altruistic and interested in working with vulnerable communities. For some the personal objective is to break the cycle of ignorance and poverty with education and empowerment. The workers seek mentoring, counseling on how to handle difficult cases, like to be empowered and supported during personal crises.

The Union Cabinet approved an ordinance in April 2020 to amend the Epidemic Disease Act, 1897 to protect healthcare workers against violence during epidemics. Passing legislation to protect medics and health workers from abuse is important and one aspect of the story.

The other challenge is getting access and being accepted by the community when the public health system is ineffective. If the clinics and hospitals are not well stocked it is like sending the worker to war without any equipment. This not only diminishes the capacity to perform optimally but also risks losing credibility among community members.

Within the community there is initial resistance and this takes time to overcome. Eventually communities respond by helping in identification of potential beneficiaries and mediate with households refusing to seek help or cooperate.

Positive feedback from other stakeholders including police and municipal health facilities acts as a reinforcement. It is indeed a hard day’s work! So appreciation of the efforts of health workers cannot be a one day event.

The time is also opportune for investing in the next generation of healthcare workers and this will have two benefits. One, it should be possible to shift primary care services to lower level health workers and this can address certain gaps and crowding of the tertiary hospitals for basic services. Second, in addition to creating jobs today, investing in healthcare has long term economic benefits.