Changing roles of grass-root level health workers in Kerala, India

Objective: Multipurpose health workers (MPWs) are envisioned as key personnel in the delivery of primary health care. We evaluated their role and participation in implementing different national health programmes in Kerala, India. Design: Cross-sectional, community-based survey. Participants: We selected three out of the 14 districts in Kerala. Three-hundred and twenty-six MPWs (95 male and 231 female) from 44 randomly selected primary health centres from the three districts were questioned using a structured pre-tested questionnaire that sought information regarding the provision of health services by the MPWs to eligible beneficiaries in the community. We randomly selected 90 subcentres (30 from each district) and 750 households using a cluster sampling technique, and conducted household surveys to compare the actual delivery of services at the doorstep with that reported by the MPWs. Work sampling of MPWs was also performed to examine the fieldwork time spent by them on implementing individual national health programmes. These data were supplemented with focus group discussions and personal interviews of MPWs and household members. Results: MPWs consistently ‘over-reported’ their performance when self-reported information was compared with that obtained from household surveys. Male MPWs concentrated on the National Malaria Eradication Programme and health education while female workers focused on the family welfare and immunization programmes. Key national health programmes (such as for tuberculosis and acute respiratory infection) were neglected by all MPWs. MPWs were aware of health problems of the elderly, but were not adequately trained nor officially expected to deliver any services in these fields. Conclusions: Grass-root level workers apportion more time to select national health programmes to the detriment of other health programmes, thereby negating their multipurpose role. Our study emphasizes the need for interventions to derive ‘multipurpose benefits’ from the MPWs.