1 Introduction

 India has, on average, one doctor for approximately 854 people [1], which surpasses the World Health Organization's (WHO) recommended standard of 1:1000. While the improvement in availability of doctors is a mark of India’s commitment to a strengthened health system, their distribution across the country is rather skewed. According to a WHO report (2016), 60% of the country’s 2-million strong health workforce caters to urban India, even though around 65% of the country’s population is rural [2, 3]. The skewed distribution of health professionals toward urban hubs creates a vacuum of qualified health providers in remote rural regions, leaving them underserved and medically disadvantaged [4]. With limited viable options in sight, people from such geographies are often pushed to rely on informal or unqualified healthcare providers [5, 6]. Such healthcare providers are heterogenous in composition encompassing varied untrained practitioners such as traditional healers, pharma graduates, drug compounders, and unaccredited village doctors, as well as degreed practitioners trained in alternative medicines (AYUSH doctors) practicing allopathic medicine without formal training. These informal healthcare providers irrespective of their qualification and training are widely prevalent among rural communities and often found to be only source of healthcare and allopathic prescriptions [5,6,7].

The widespread community acceptance of untrained and/or informal practitioners is rooted in their perceived ability to provide affordable, accessible, and effective treatment [5, 8]. Here, the metric of effective treatment is considered as quick and inexpensive recovery, one of the key reasons behind untrained practitioners’ heavy reliance on allopathic medicines [6]. As described by George and Iyer’s study on informal healthcare providers in Karnataka, social pressures and unrealistic patient expectations towards instant cures fosters unauthorized and irrational drug prescriptions, eventually exposing the community to serious health risks.

Given the failure of regulation of non-degree, untrained and informal practitioners and the overall shortage of qualified healthcare workforce in rural regions, the Government of India (GoI) introduced a new cadre of mid-level health providers (MLHP) at the sub-health centre (SHC) level. The MLHP, also known as Community Health Officers (CHOs), were non-physician clinicians with a shorter duration of medical training, performing basic clinical functions at the primary healthcare level. This was viewed as a cost-effective and immediate solution to the much larger systemic problem of healthcare human resource shortage. Moreover, CHO’s positioning as the first point of contact between the community and the public health system leveraged them as a key gatekeeper, ensuring appropriate referrals and reducing workload at secondary and tertiary facilities. While the purposes and functions of introducing the new cadre are well delineated in several guidelines and policy documents, there is a need to explore the roll-out of this new cadre in real settings and present a critique as meaningful feedback to the policy.

This study analyses the real-world functioning of CHOs in India, focusing on their role and limitations in providing basic clinical care at sub-health centers (SHCs). It explores the gap between policy intentions and ground realities faced by CHOs, particularly regarding their authority to prescribe medicines.

1.1 Role of CHOs: current policy landscape

In 2018, the Indian government introduced Ayushman Bharat – Health and Wellness Centres (AB-HWC) as a platform to deliver Comprehensive Primary Health Care (CPHC). These AB-HWCs were envisaged to deliver an expanded range of services including screening and management of non-communicable diseases (NCDs), mental health, ENT, dental care, geriatric and palliative, and trauma and emergency care. The AB-HWCs were designed to improve population coverage and mitigate risk factors. AB-HWC’s transformation was particularly pronounced at the SHC level because of their proximity to the community – SHC have a population coverage of approximately 3000–5000 compared to Primary Health Centre’s 30,000.

CHOs were positioned as the leader of the primary healthcare team at the lowest level of the healthcare system, the SHC-HWC, recognizing the shortage of trained healthcare workforce at the community level (Fig. 1). This new cadre of healthcare providers consisted of Ayurvedic practitioners, BSc. in community health or Nurse (GNM or BSc.) and such other relevant qualification trained specifically to deliver primary health care services to the people and ensure continuum of care. The cadre was developed to ensure and improve clinical management and care coordination at the primary level. With their proximity to the community, CHOs were expected to improve health service utilisation at the primary care level and ensure continuity of care through regular follow-up.

Fig. 1
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Positioning of CHOs at district level

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The Ayushman Bharat – CPHC Operational Guidelines [9] served as the overarching guideline for AB-HWC operations and the primary policy governing the roles and responsibilities of CHOs. According to these guidelines, a CHO is responsible for providing basic clinical care, chronic case management, and maintaining a continuum of care. The guidelines outline their role in case management for chronic illness based on diagnosis and treatment plans made by the Medical Officer (MO) who shall initiate the treatment. Such coordination with MO is facilitated through the teleconsultation platform of the Government of India called e-sanjeevni. Rolled out under the ambit of the National Health Mission (NHM) on a hub and spoke model, e-sanjeevni was initiated as an intervention to curb the non-availability of doctors and specialists on ground and to reduce patient burden in district and tertiary care facilities [10]. For HWCs, e-sanjeevni’s doctor-to-doctor teleconsultation service was an opportunity to support CHOs and thereby SHCs with skilled doctors in remote rural regions, helping them with early diagnosis, treatment initiation, and maintaining a continuum of care.

While early and correct diagnosis is important to be facilitated by MO, treatment initiation is not the end goal. CHOs are also expected to provide clinical care in the form of treatment adherence, counselling, and support throughout the patient journey, as specified in the standard treatment guidelines for the newly introduced expanded range of services. For this, CPHC guidelines allow CHOs to provide medicines at the SHC-HWC as per the provisions of Schedule K, item 23 of the Drugs and Cosmetics Rules 1945. Schedule K drugs are those medicines that do not require the presence of a licensed dealer for their distribution and sale [11]. These include basic over-the-counter medicines, contraceptives, and vitamins. Moreover, Schedule K, item 23, also permits Multipurpose workers (MPWs), Auxiliary Nurse and Midwife (ANMs) and Anganwadi workers (AWWs) to provide the same set of medicines falling under it, thereby suggesting that all drugs under this schedule can be provided by ANMs and CHOs alike.

In addition to these rules, the MoHFW also initiated the Free Drugs Service Initiative (FDSI) [12] as a response to high Out of Pocket Expenditure (OOPE) and lack access to essential medicine [13]. FDSI ensured access to a set of essential drugs at each public health facility, free of cost. With the upgradation of SHC/PHC to HWCs, the demand for medicines also increased. For instance, SHC-HWC has a list of 105 essential medicines ranging from antibiotics to anti-allergic drugs, contraceptives, and medicines used in diabetes, thyroid, and hypertension. The list of 105 essential medicines covered not only over-the-counter (OTC) medicines (Schedule K) but also those belonging to Schedules H, H1, and X. However, not all medicines can be prescribed at the SHC-HWC level because the authority to prescribe medicines only lies with a registered medical practitioner [11]. Therefore, despite the availability of medicines at SHC-HWC, CHO’s prescribing authority is restricted, thereby hindering their ability to meet community needs.While the roles and responsibilities of CHOs are defined in the CPHC guidelines, their actions on ground are shaped by several factors including the pre-existing policy frameworks. Ideally any reforms, such as introduction of CHOs, should be in alignment with the existing policies to avoid contradictions and ambiguity in implementation. In the same vein, any ambiguity or contradictions in the authority and capacity of CHOs to carry out their functions can impact the service delivery and utilisation at the SHC-HWC, thereby affecting the overall primary healthcare ecosystem. This study further explores various challenges around CHO’s positioning as a new cadre in the health system.

2 Methods

2.1 Study design

The study used a exploratory design in which CHOs and MOs were selected from their respective SHC-HWC and PHC-HWC after stratifying AB-HWCs based on geographic zones. A qualitative approach was used to gather in-depth information about the experience of CHOs at AB-HWC. In-depth interviews were conducted to gain insights on current drug provisioning and prescription practice at these centres. Health worker’s perspective on CHO’s role at SHC-HWCs and their capacity to perform routine tasks were also explored.

2.2 Participants

To ensure a representative sample, the country was geographically divided into five zones (Table 1). From each zone, two states were chosen by simple random sampling—2 SHC-HWC and 1 PHC-HWC were randomly selected from each state. The study involved three type of respondents—CHOs, MOs, and State Nodal Officer (SNOs) (Table 2). The CHOs chosen were those working in the SHC-HWC for at least 1 year.

Table 1 Geographical distribution and selection of healthcare facilities in different zones and states
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Table 2 Distribution of respondents for in-depth interview in the study
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2.3 Data collection and analysis

Data collection surveys were conducted between September and October 2021. A semi-structured interview guide was prepared for CHOs and MOs at AB-HWCs and pilot tested. A separate interview guide for key stakeholder perspective from CPHC SNOs was prepared. The interviews were conducted digitally with all the participants following all the protocols of qualitative interviewing. Interviews with CHOs lasted about 30–35 min, with the MOs 25 min, and with SNOs for about 15 min. Participation in all interviews was voluntary and confidential, based on informed consent. The audio recording was also done with the participants with due consent. In the cases where permission was not given for audio recording, field notes were used. All audio interviews and notes were translated from Hindi to English before analysis. Data analysis was done manually using MS Excel for thematic analysis.

2.4 Ethical considerations

As per the National Ethical Guidelines for Biomedical and Health Research involving Human Participants, 2017 (Reference: Sect. 4.8.1, page no.36) of Indian Council of Medical Research, Government of India the study did not require ethical approval. Researchers strictly followed survey ethics and ensured privacy and integrity of the study participants, in line with the Declaration of Helsinki. Informed consent was obtained from each participant for voluntary participation in the study and interviews were electronically recorded only after acquiring the consent of the respondents. A complete confidentiality of data was ensured in storing, handling and analysis.

2.5 Findings

The sample of 20 CHOs were selected pan-India comprised a heterogenous mix of ayurvedic practitioners, homeopaths, rural health practitioners (RHPs), B.Sc. and GNM nurses. While each cadre had their own specific experience as a CHO, in our analysis few common themes emerged in alignment with geographic locations and educational background. Major themes identified in the analysis are presented subsequently in two sections. The first part highlights the challenges faced by CHOs in meeting the expectation outlined in the CPHC guidelines. It explores the ideas of agency, internal team support and availability of basic facilities like medicines that impede their ability to carry out routine function. In the second part we delve into the CHOs actions and experiences while wading through the various challenges in their functioning at SHC-HWCs. This part also explores the internal and external expectations placed on the CHOs to provide basic clinical care to the population.

3 Challenges in providing basic clinical care to community

3.1 CHO’s lack of agency

Agency related concerns emerged as a common theme amongst CHOs. Many CHOs felt that they did not have the authority to carry out the tasks they were meant to fulfil. In most cases, CHOs felt that their education and skills were disregarded, and their work reduced to menial tasks. One CHO described their dissatisfaction, stating, “We are basically data entry operators.” The dissatisfaction also arose from the way e-sanjeevni program was rolled out and the associated misplaced incentives. To maximise teleconsultation usage, most state administrations set consultation targets to ensure that CHOs utilised the services routinely. While some states like Maharashtra and Haryana had daily targets, others like Odisha and Assam had weekly ones. Mostly, CHOs felt forced to make such calls even though the case didn’t demand it, simply because they had a daily/weekly target to be achieved.

“I have been given a target by the SNO. CHOs are supposed to do 5 teleconsultation cases per day. If we do so, we will get an incentive of Rs 1000/month. But I don’t think it is right. If there is a need to do teleconsultation, we will. Now, I have to try and make 5 calls a day, even if the case doesn’t demand it.”

Mandating targets for teleconsultation took away CHO’s agency to make clinical decisions and fostered feelings of discontent. They often felt their knowledge and ability to handle cases was demeaned. This observation was particularly prominent in CHOs who were Ayurvedic practitioners or belonged to the RHP cadre of Assam.

“We are doing honest work, if there is any need for it (teleconsultation) we will do it. I don’t have an issue with e-sanjeevni but putting targets on our head demeans our skills and work.”

“We are trained practitioners. Handling such basic cases is not beyond our understanding. We understand what we can treat and what we cannot.”

Agency related concerns were most prominent in issues pertaining to their ability to prescribe medicines. As per the CPHC guidelines [9], CHOs were meant to provide basic clinical treatment, primary care, and even cater to trauma and emergency cases.However, as per law, they were limited to providing Schedule K medicines, which constrained their capacity.

“What is the point of sitting with an almirah full of medicines but not having the ability to prescribe. I am not saying we should be able to prescribe all medicines, but at least some drugs for basic needs. There is no point calling the doctor for small, small cases. Drugs like cetirizine, antibiotics, basic painkillers for first aid should be allowed”

3.2 Complex team dynamics

CHOs were introduced at the SHC as the leader of the primary care team, essentially replacing ANMs as the head of the sub-centre. Introduction of a new cadre in the team hierarchy leads to tension within team dynamics. Coordination issues amongst ANMs and ASHAs were a common concern amongst CHOs. They claimed they were viewed as “outsiders”, as ANMs had far better reach and connect with the community.

“The ANMs have been here so long they have better connect with the community and the ASHAs. I am seen as an outsider.”

The lack of support from the team was a significant cause for discontent and low morale for the CHOs. They described their relationship with the ANM as, “… it (relationship) is not well. She (ANM) cannot digest that I am the team lead now and not her. She hardly agrees with me. It is a big problem.” Such challenges caused constraints on the CHOs ability to carry out their role of maintaining continuity of care and providing primary health.

Another contributing factor here were the CPHC guidelines, basis which CHOs could provide medicines as per an existing prescription, an e-prescription generated through e-sanjeevni, or drugs belonging to Schedule K. Many CHOs believed this placed them on equal footing with the ANMs or the pharmacist, who can also provide medicines on the basis of valid prescriptions. Given the outcomes expected of an SHC-HWC and a CHO in turn, they felt that reducing their capacity to give medicines to an ANM’s level defeats the purpose of having a new cadre in the first place. Moreover, it also contradicts their role as the leader of the primary healthcare team at the SHC-HWC by undermining their authority in front of the ANM.

“If we are sitting at the centre, we should have some authority. If the MPHW and ANM can give medicines like Amoxicillin, why can’t we? It further demeans our position in front of them.”

3.3 Unavailability of medicines

Medicine availability also appeared to be a common issue amongst CHOs. Most CHOs found the available medicines at the centre to be inadequate in meeting the needs of the people. While the FDSI’s 105 EDL was flexible and subject to state government’s discretion based on internal context, CHO’s stated that they didn’t even have 50% of the medicines mentioned in the list. The lack of essential medicines was flagged as a significant constraint in their ability to provide primary clinical care at the AB-HWCs. Many CHOs claimed that limitations in the supply for basic medicines—antibiotics, antifungals, pediatric doses—hindered their capacity to maintain a continuum of care in the community.

“Calcium tablets are often in shortage. Insulin also gets stocked out. Such basic routine medicine that are important for elderly.”

“I don’t think the medicines are adequate in meeting the needs of the patient. Patients come here expecting treatment. We don’t even have basics like levocetirizine, cough syrups, or diclo gel.”

“We face serious supply issues. I have to go on my scooter to the nearest CHC, which is about 20 kms away, to restock my supply.”

4 CHO and drug prescriptions: contradictory conditions

Of the ten states considered for this study, only CHOs from Maharashtra were allowed to prescribe medicines. These CHOs were primarily Ayurvedic Doctors and permitted to prescribe medicines available in the Essential Drug List (EDL) of the SHC-HWC. Some CHOs in Assam were also allowed to prescribe medicines at the SHC. These were mainly of the Rural Health Practitioner (RHP) cadre. Nurses placed as CHOs were not permitted to prescribe. The medicines prescribed at the SHC were strictly those in the EDL. While they had instructions not to prescribe medicines at the SHC-HWC, all CHOs provided drugs like antihistamines, antibiotics, and antifungals to the people. Ideally, these drugs belong to Schedule H and require a medical doctor’s prescription. The guidelines also support the same in that the CHOs can only dispense such drugs and not prescribe them independently. But the CHOs feel that “Drugs like cetirizine, amoxicillin, basic painkillers for first aid should be allowed. There is no point calling the doctor or doing a teleconsultation for basic cases.”

Ultimately, restrictions on prescription exist by law, but medicines are given out regardless due to the expectation placed on CHOs to provide basic clinical care.

4.1 CHO: close to community, far off from expectations

The distance between SHC and PHC/CHC was a significant factor leading to CHOs providing medicines. Of the 20 CHOs interviewed, the average distance between their SHC and the respective PHC/CHC was about 8 km. The distance ranged as high as 15–20 km in some states like Odisha, and Maharashtra. A CHO from Nagaland with an SHC-PHC distance of 10 km said that it takes about 500 Rs to commute to the PHC from their locality. The cost and time intensive journey to reach PHCs highlighted their inaccessibility and the importance of having a robust sub-centre level HWC operation. This was especially important for vulnerable and marginalized communities who cannot access means of transport and are thus dissuaded from availing healthcare.

“Patients come here for all sorts of issues like gastritis, first aid injuries, delivery, dressing. They can't go the PHC as it is very far. There is no transport, and even if there is, it is very expensive. We have so many elderlies in the communities, there are women with small babies too. It is very difficult for them to reach PHC and we can’t expect them to go there just to get routine medicines. That is why we try our best to do as much as we can at this centre.”

Community expectations were found to be a key driver leading to CHO’s felt need to provide medicines at SHC-HWC. Patients considered medicines to be synonymous to healthcare. The belief stretched to an extent that they viewed medicines as a sign of effective treatment. Many CHOs obliged to people’s expectations in providing medicines to build trust with them. They stated that if medicines weren’t available at SHCs, people will lose faith and eventually stop coming.

“People come here to get their problems solved. They want medicines for their ailments, if we don’t give medicines, they think we are not doing our job and stop coming to the centre.”

“They (patients) often pressurize us into giving medicines. They sometimes demand of medicines that are not even available in the EDL.”

Moreover, in the absence of public health doctors in remote regions, CHOs were viewed as doctors in the community, driving patient expectations higher. CHOs felt a deep sense of responsibility towards the community and were willing to go the extra mile to cater to their needs. Building trust within the community was central to CHO’s endeavour to successfully establish themselves in the centre. As a result, they often felt obligated to comply to patient expectations to foster trust and retain footfall.

“This sub-centre is equivalent to a hospital to the people living here. We have to give basic medicines, otherwise they think we haven’t treated them.”

“Patients see us as doctors. They don't know or care what a CHO is. They come here to get treated and that is what we do. They have faith in us, and we must return it by helping them to the best of our ability.”

5 Discussion

CHOs or MLHPs were meant to improve health outcomes in the community by undertaking basic diagnosis and treatment. The practice of using MLHPs or non-physician clinicians as an alternative to the shortage of medical doctors has been adopted by many countries. Global evidence on MLHPs suggests that they perform several clinical functions—diagnosis, basic clinical care, health promotion—as well as physicians and have emerged as leading source of primary care [14,15,16]. Although, unlike CHOs, MLHPs worldwide function in an environment that supports their agency, and their actions are regulated well within a robust legal framework. Studies show that MLHPs are allowed limited prescriptive authority from a pre-defined formulary which improves patient care in underserviced regions and ensures effective resource utilisation [16,17,18,19]. Enhancing their role to include provisioning of medicines may prove crucial to improvements in the quality and accessibility of healthcare at the primary level [16, 17, 20, 21].

Similarly in India, to address the shortage of MBBS doctors in rural subcentres, MLHPs like nurse-practitioners or AYUSH physicians can be effectively utilized after undergoing standardised training in community medicine [22]. Studies [14, 23] show that patients' perception of the care received from non-physician clinicians placed in rural primary health centers of India was similar in levels of satisfaction and trust to clinical physicians, AYUSH physicians and Registered Medical Assistant (RMA)s. This suggests that patients were equally satisfied, with the quality of care they received from MBBS doctors compared to others in primary care setting. These findings reinforce the idea of utilising MLHPs as a viable alternative to doctor shortage in rural remote regions. However, for MLHPs, or CHOs in this case, to be successful, they need to be well-embedded in the healthcare system.

In the case of CHOs, evidence from the ground indicates that the public healthcare ecosystem doesn’t completely support their functioning yet. Despite new program initiatives like FDSI and e-sanjeevni to support their function and improve SHC utilization, barriers to provide healthcare continue to persist. The challenges stem from improper implementation of programs, misplaced incentives, lack of support both internally within the team, and from institutions and policy landscape. For instance, Sect. 32 of the National Medical Commission (NMC) Act 2019 allows limited prescription rights to a non-MBBS mid-level medical practitioner termed ‘Community Health Provider’ [24]. According to this Act, a Community Health Provider may prescribe primary and preventive care medicines independently. However, the Act is unclear regarding the qualification of said Community Health Provider and doesn’t define primary and preventive care medicines.

Ambiguity regarding the authority and capacity of CHOs in prescribing medicines can hamper the access and utilisation of health services at the primary healthcare level. This is especially true in a country like India where medicines are often considered synonymous to healthcare. Our findings suggest that social expectations for prompt treatment may have, at times, compelled Community Health Officers (CHOs) to provide medicines at SHC-HWCs, despite existing policy restrictions. The findings are in line with studies done on healthcare providers in rural India [5, 6], wherein the demand for cheap and quick recovery leads to prescription of allopathic medicines by non-degree health practitioners. The absence of clear protocols and robust regulation in the prescription and dispensation of medicines can not only affect a CHO’s ability to maintain a continuum of care but also contribute to the irrational use of drugs. Such concerns create barriers for CHOs to leverage their position as an MLHP successfully and subsequently impacts the overall performance of SHCs in delivering comprehensive primary healthcare. Therefore, there is a need to clarify the scope of practice and the range of medicines that a CHO can prescribe to achieve universal health coverage through AB-HWC.

6 Conclusion

Recognizing and addressing the challenges faced by CHOs in their role as MLHPs is crucial for achieving equitable healthcare outcomes and achieving universal health coverage in rural and underserved areas. Currently there is a mismatch in the rights accorded to CHO’s and community’s expectations from them.. Limitations on their authority to prescribe select medicines, a lack of agency, and inadequate team support hinders their effectiveness at the SHC. This creates a gap between policy intentions and the realities faced by CHOs on ground. Bridging this gap requires a comprehensive approach involving policy change, capacity-building initiatives and supportive measures to maximize the impact of CHOs in delivering comprehensive primary healthcare services. The reforms however must not undermine the existing system of clinical practices and authorities of healthcare providers. Our recommendation is to expand existing authority and rights of CHOs and saving them from becoming just another cadre burdening supply side of the Indian healthcare delivery system.