Presentation made at the All India People's medical and health education conference organised in February 2015 by the All India People's Science Network by Tanya Seshadri & Prashanth N S

1. Building the
frontline health workers
Strengthening the role and training of health
workers as a health science education challenge
Tanya Seshadri1 & Prashanth N S2
1 Malki Initiative, Biligirirangan Hills, Chamarajanagar district, Karnataka
2 Institute of Public Health, Bangalore

2. 20th century medical technologies
Melissa Cory Medical Media & National WWII museum

3. http://www.sambradd.com/gathering-wisdom-visuals-for-a-healthy-future/

4. “By the beginning of the 21st century, however, all is not
well. Glaring gaps and inequities in health persist both
within and between countries, underscoring our collective
failure to share the dramatic health advances equitably. At
the same time, fresh health challenges loom. New
infectious, environmental, and behavioral risks, at a time of
rapid demographic and epidemiological transitions,
threaten health security of all. Health systems worldwide
are struggling to keep up, as they become more complex
and costly, placing additional demands on health workers…
Frenk, J., Chen, L., Bhutta, Z. et. al. (2010). Health professionals
for a new century: transforming education to strengthen health
systems in an interdependent world. The Lancet, 376(9756),
1923–1958. doi:10.1016/S0140-6736(10)61854-5

5. Professional education has not kept pace with these challenges, largely because of
fragmented, outdated, and static curricula that produce ill-equipped graduates. The
problems are systemic:
• mismatch of competencies to patient and population needs;
• poor teamwork;
• persistent gender stratification of professional status;
• narrow technical focus without broader contextual understanding;
• episodic encounters rather than continuous care;
• predominant hospital orientation at the expense of primary care;
• quantitative and qualitative imbalances in the professional labour market;
• and weak leadership to improve health-system performance.
Laudable efforts to address these deficiencies have mostly floundered, partly
because of the so-called tribalism of the professions—ie, the tendency of the
various professions to act in isolation from or even in competition with each other.
Frenk, J., Chen, L., Bhutta, Z. et. al. (2010). Health professionals
for a new century: transforming education to strengthen health
systems in an interdependent world. The Lancet, 376(9756),
1923–1958. doi:10.1016/S0140-6736(10)61854-5

6. Improving equity and quality in healthcare of the population
requires a deeper appreciation of these inequities and a
relatively slower planning and management of our health
services to build a responsive and people-centered health
system.

7. It is in this context that the nature of healthcare teams, their
capacity and their performance becomes relevant.

9. Doctor-centredness
• Healthcare teams in India are pre-dominantly doctor-
centred in clinical (hospital) or public health (districts and
taluka) settings.
• In the government health services, doctors with several
years of experience in clinical settings are routinely
entrusted with management responsibility for small to
large hospitals and districts.
• Doctors are automatically assumed to be able to
undertake public health management (of districts and
talukas) without efforts at building their public health
management capacity.

10. Neglect of “other” health
worker professions
• At the same time, other health workers such as
pharmacists, nursing staff, physiotherapists,
counsellors/social workers and the recently introduced
block/district programme managers have relatively
limited managerial roles.
• Even where these cadres maintain a high degree of
interest in these roles, their influence (either through
legitimate powers vested to them or through informal
organisation-specific socio-cultural norms) on healthcare
teams and their management is comparatively
insignificant.

11. Doctor-centredness affects
patient-centredness of care
• The social and cultural distance between most rural
Indian patients and doctors is already high for early
career doctors, most of them having come from the
relatively better-off geographical areas and social
groups.
• Healthcare teams do not benefit from the richness of
perspectives that comes from many of these cadres,
thus also impacting the socio-cultural aspect of the
quality of care and patient-centredness of care that these
cadres are likely to have contributed to.

12. “Other” health worker
cadres & career pathways
This distance (between doctors and health workers) only
increases with time, as the career pathways for doctors is
relatively better off, when compared to the other cadres,
both within government services and in the private sector.

13. • Given this scenario, clarifying and advancing the interest
and influence of non-medical health workers within
healthcare teams (both government and private) as well
as clarifying their career pathways holds a strong
potential in improving the equity of care and making care
more patient-centred.

14. “promote interprofessional and transprofessional education
that breaks down professional silos while enhancing
collaborative and non-hierarchical relationships in effective
teams”
Frenk, J., Chen, L., Bhutta, Z. et. al. (2010). Health professionals
for a new century: transforming education to strengthen health
systems in an interdependent world. The Lancet, 376(9756),
1923–1958. doi:10.1016/S0140-6736(10)61854-5

15. Implications for our health
science education system
• Qualifications and education: need for structuring and
streamlining health worker entry requirements through
better training courses (more than a ‘fill-in-the-blank’
course). Consider diploma like courses.
• Defining career pathways: need for creating clearer
career pathways for health workers – male and female;

16. Frenk, J., Chen, L., Bhutta, Z. et. al. (2010). Health professionals
for a new century: transforming education to strengthen health
systems in an interdependent world. The Lancet, 376(9756),
1923–1958. doi:10.1016/S0140-6736(10)61854-5

17. Frenk, J., Chen, L., Bhutta, Z. et. al. (2010). Health professionals
for a new century: transforming education to strengthen health
systems in an interdependent world. The Lancet, 376(9756),
1923–1958. doi:10.1016/S0140-6736(10)61854-5

18. Health worker ‘lability’
• Bridge courses between community health workers/ASHA-like
volunteer along with work experience become nurses/midwives.
• Similarly, after certain number of years of experience and perhaps a
bridge course, become senior supervisory staff.
• Possible links to professional courses like pharma/lab
tech/nursing/dentist/medicine or maybe BBM/MBA (to become block or
district manager).
• Possible link to MSW, public administration, public health nutrition, etc.
• Consider new categories like – diploma in public health work in
community, bachelor in community health nursing, bachelor in
community health work.
• Since all ANMs women even in remote villages – why not use this as
opportunity to bring these women working in health sector one step
forward into roles of social work, public administration, programme
managers, professional nursing and even medicine

19. Health worker motivation
• Improving health worker motivation: dignity & recognition as
qualified person, scope to be able to further oneself by good
work and training (both well-performing and poorly performing
health workers at the same level even after many years of
service)
• Improving health worker exchange and networking platforms:
Newsletters, local journals that cater to experience sharing
and recognition of work - case studies, innovations (cf.
Arogyavani of GoK/KSHSRC), CME-type discussions at
district, state and national level for health workers – where
their story and experience is central and cross learning
encouraged.