The Alma Atta Declaration in 1978, recognised that key to the community health is the provision of primary health care and this realization has led to the utilisation of community health workers (CHWs) for achieving this goal (WHO, 1978). CHWs work in the community, selected by and answerable to the community for whom they work. They receive briefer training than the health care professionals and are supported by the health system (Frankel and Doggett 1992). They help the doctors and nurses in activities such as health promotion and serve as “helping hands” (Scott and Shanker 2010; Walt and Gilson 1990). In low and middle income countries (LAMICs), they play a key role in delivering services in the health system to the poor and underserved populations and thus bridge the human resource and financial gaps (WHO, 2007). The roles, responsibilities, training and incentives for the CHWs vary across the world according to the programs in which they are involved.
India’s flagship program in health, National Rural Health Mission (NRHM) launched in 2005 initiated the Accredited Social Health Activist (ASHA) Programme with the aim of community participation in the health system. ASHAs are female community health workers and they form one of the world’s largest community health force (Liu et al. 2011). Each ASHA caters to one thousand people and they serve as the link between the government health care services and the community, mitigating the cultural and social barriers and enhancing the community participation (Lipekho et al. 2015). They receive service and performance-based incentives for performing their primary duties such as referral and escort services for institutional deliveries and facilitating immunisation (Wang et al. 2012). However, utilizing services of ASHA workers for mental health was not existent. This has started to change. Apart from the above example, there are a couple of reports of their role in psychiatric case-finding (Reddy et al. 2014; Ibrahim et al. 2020). The authors believe that unlike the other non-communicable diseases like Hypertension and Diabetes (Abdel-All et al. 2019), ASHAs can easily fit into the mental health system and the mental health work can easily be integrated into their routine without any extra burden. For example, quick screening, counselling and referral to treatment centres and other social welfare agencies can easily be achieved. Efforts in the past were less successful for non-communicable diseases because the tasks involved certain medical procedures such as measuring blood pressure and blood glucose levels which are considered difficult by the CHWs.
As part of the DMHP, the CHWs like ASHAs can be trained in identification, referral and delivering simple psychosocial interventions. They also can play a role in overcoming barriers for acceptability of mental health services in the community such as stigma, myths, and lack of awareness (Rasaily et al. 2017). Such training is happening in states such as Karnataka where almost 40,000 ASHA workers have been trained in the field of mental health. The training includes recognition of mental health disorders such as schizophrenia, depression, anxiety and alcohol use disorders, basic counselling, and referral to the treatment centres (Armstrong et al. 2011; Kallivayalil 2018).
Research projects in the communities have shown that lay health workers can effectively be used in task shifting for depressive disorders. This has been shown to be cost-effective (Buttorff et al. 2012). The Ministry of Health and Family Welfare, Govt. of India has made provision for two CHWs per Primary Health Centre (PHCs) dedicated to deliver mental health services (Policy Group 2012). The Ayushman Bharat Initiative through the establishment of Health and wellness centres (HWCs) also proposes that the health services (including dispensing medicines) should be delivered by non-physician health workers, mid-level health providers, Multipurpose and ASHA workers (Mishra 2012). ASHAs have a respected position in their local communities and can be effectively integrated into the existing health systems. Communities will respond better if ASHAs engage them with regard to mental health (Mishra 2012). ASHA programme provides an opportunity to improve the mental health services through supporting communities to access treatments, reducing the pressure on the health system, bringing in-depth knowledge about the villages, and facilitating the community participation in the health programmes. However, some of the challenges still remain like (1) not to overburden ASHAs, (2) not to diminish the quality of care of services they currently provide as they take on new tasks, (3) to determine whether to recruit new cadre or to work with existing cadres of ASHAs. Table 2 shows some of the recommendations to overcome these challenges.
Table 2 Recommendations to improve ASHA workers role in mental health services Finally, we need more studies to test the effectiveness of CHWs in detection and as well as referral of people with mental health issues. CHW programmes must be adequately resourced and should have strong monitoring, evaluation, and quality assurance systems in order to be effective so that they can continually improve and help in bridging the treatment gap and reducing the burden of mental illness.