The National Village Health Guide Scheme in India: lessons four decades later for community health worker programs today and tomorrow

Abstract

BackgroundBased in part on the success of India’s early community health worker (CHW) programs, the Government of India launched in 1977 a national CHW scheme—the Village Health Guides (VHGs)—to provide preventive, promotive, and basic curative care to rural populations. Although this program had promising origins in smaller demonstration projects, it failed to deliver the hoped-for impact at scale and was abandoned. Based on extensive evidence and experience, the World Health Organization and the World Health Assembly have strongly endorsed the value of national CHW programs and their integration into national health systems. Surprisingly, given the scale and importance of the VHG program and its pioneering nature as a national CHW program, little has been published describing this experience. This article is the second in a series that focuses on critical issues that face the effectiveness of large-scale CHW programs.Case presentationSeveral systemic factors emerge as main contributors to the failure of the VHG Scheme, namely, a lack of support from the formal health sector, an overly hasty implementation of the scheme, and poor communication between the government and health centers about the role of the VHGs. The remuneration structure and the VHG selection process were at the root of the program’s shortcomings at the implementation level.ConclusionNational CHW schemes are an increasingly important tool for achieving universal health coverage and ending maternal and child deaths by 2030. Although the VHG Scheme was initiated over 40 years ago, the lessons described in this case highlight important considerations to help both current and future large-scale CHW programs avoid the same pitfalls.

Community health workers at the dawn of a new era: 4. Programme financing

“…The 2018 WHO guidelines for CHW programmes [ 47 ] emphasize that CHW programmes “require long-term, dedicated financing: attempts to set up and run a large-scale CHW initiative on a shoestring budget is likely to yield disappointing outcomes.” The national Village Health Guides programme of India, launched rapidly in 1977 with inadequate financing and eventually abandoned, is a case in point [ 48 ]. And the WHO guidelines for CHW programmes emphasize the need for fair and just remuneration of CHWs [ 47 , 49 ], which unfortunately is not present in most programmes.…”

Health for the People: Past, Current, and Future Contributions of National Community Health Worker Programs to Achieving Global Health Goals

“…Despite nearly a century of experience, we continue to struggle with how to define, deploy, and support such health workers. Almost 30 years ago, in his introduction to a series of case studies of national CHW programs, Stephen Frankel wrote 36 :…”

“…As a result, many programs were inadequately supported and experienced high attrition. 36 By the late 1980s, the pendulum had swung away from CHW programs. Two seminal books— The Community Health Worker: Effective Programs for Developing Countries 37 and Community Health Workers in National Programs 38 —cast a sharp critical eye, drawing lessons from large-scale CHW programs implemented over the preceding decade.…”

Healthcare Delivery Systems in Rural Areas

“…India: The concept of Community Health Worker (C.H.W.) was introduced under the "National Village Health Guide Scheme" much before the idea of primary Healthcare (through the Alma Ata declaration at Kazakhstan in 1978) was proposed [15]. However, lack of affiliation to a formal health system, poorly defined job responsibilities, and poor financial remuneration plagued the Village Health Guide scheme's success.…”