Describe the health team and the concept of the multipurpose worker.

The Health Team and Multipurpose Workers

• The members at village and sub-centre level — the ASHA; the anganwadi worker; the trained DAI; the multipurpose worker female (ANM) and male; and the community health officer
• At PHC level — the medical officer; health assistants male and female (formerly the health supervisor and lady health visitor); pharmacist; laboratory technician; and staff nurse
• The multipurpose worker scheme was recommended by the KARTAR SINGH committee (1973), and its reasoning is what the topic is really about
• The problem it addressed — before it, each vertical programme had its own field worker: a malaria surveillance worker, a smallpox vaccinator, a family planning worker, a trachoma worker and an ANM
• The consequences of that arrangement were — duplication of travel and of contact with the same households; a worker fully occupied when their programme was active and idle when it was not; confusion for the villager about who did what; waste of the expensive commodity, which is the worker’S time rather than their training; and separate supervisory chains for each
• The solution — convert the single-purpose workers into multipurpose workers, each responsible for all health activities in a defined population of about 5,000
• The advantages — one worker visits the household and addresses everything; better use of time; a continuing relationship with families rather than an episodic contact; a single supervisory line; and the ability to use every contact for every purpose
• The difficulties that emerged in practice, which a complete answer includes — overload, since the tasks of five workers were given to one; dilution of specialist skill, particularly in malaria surveillance; inadequate retraining during conversion; continuing demands from vertical programme managers who each want their own reports; and weak supervision
• The malaria surveillance point is the specific criticism — blood smear collection fell after conversion, because a worker with twenty tasks does the ones that are supervised and reported
• The supervisory norm — one health assistant supervises six multipurpose workers, that is, the workers of six sub-centres
• The ANM (Auxiliary Nurse Midwife) is the pivot of the rural system
• Her functions — antenatal, intranatal and postnatal care; conducting deliveries or referring them; immunisation; family planning; newborn and child care; nutrition; treatment of minor ailments; control of communicable disease including blood smears and DOTS; maintenance of records and the eligible couple register; and organising the village health and nutrition day
• The principles of effective team functioning — clearly defined roles with no gaps and no unnecessary overlap; shared goals understood by all; communication and joint review; supportive rather than punitive supervision; mutual respect, without which task-sharing is resisted; and appropriate delegation
• Supportive supervision deserves emphasis — supervision that observes, teaches and solves problems raises performance, while supervision that only inspects and reprimands produces falsified records and concealed difficulty
• The concept of task-shifting is the modern extension of the same idea — moving specific tasks to workers with shorter training, so that scarce skilled staff are used only for what only they can do
• Its Indian examples — the ASHA giving DOTS and doing newborn visits; the ANM performing immunisation and antenatal care; the community health officer managing non-communicable disease at sub-centre level; and nurse-led screening
• Task-shifting requires adequate training, clear protocols, reliable supplies, supervision and a functioning referral route — without these it becomes dumping of work rather than sharing of it
• Five workers once visited the same household, which is the duplication the multipurpose scheme was created to end
• The scarce commodity is the worker time, not their training, which is the argument for combining roles
• Overload followed when five tasks became one job, which is the honest criticism of the scheme
• Blood smear collection fell after conversion, since a worker with twenty tasks does the supervised ones
• Supervision that only inspects produces false records, while supervision that teaches raises performance
• One health assistant supervises six workers, that is the workers of six sub-centres
• Kartar Singh recommended the scheme in 1973, which is the date and committee to attach to it
• Task-shifting without support is dumping, and needs training, protocols, supplies, supervision and referral
• The ANM is the pivot of the rural system, and her range of functions should be listed rather than summarised
• One worker gives a continuing relationship with families, rather than the episodic contact of a campaign
• Vertical managers still demand separate reports, which reimposes the fragmentation the scheme was meant to remove
• Mutual respect makes task-sharing possible, since delegation is resisted where it is felt as demotion
• The community health officer extends the idea, placing a mid-level provider where no doctor will go