Community Health Workers: Understanding Roles and Responsibilities
A comprehensive guide to community-based healthcare personnel in India
- Introduction to Community Health Workers
- District Public Health Nurse (DPHN)
- Health Visitor (HV)
- Public Health Nurse (PHN)
- Multi-Purpose Health Worker – Female (MPHW-F)
- Multi-Purpose Health Worker – Male (MPHW-M)
- Anganwadi Worker (AWW)
- Accredited Social Health Activist (ASHA)
- Best Practices and Updates
- Hierarchical Relationship
- Conclusion
Community Health Workers providing essential healthcare services in rural India
Introduction to Community Health Workers
Community health workers form the backbone of India’s public healthcare system, especially in rural and underserved areas. They serve as the vital bridge between communities and the formal health system, ensuring healthcare access for all citizens. India’s community health workforce consists of several cadres of workers, each with distinct roles, responsibilities, and hierarchical relationships.
This comprehensive guide explores the roles, responsibilities, and relationships between the various community health workers in India, including District Public Health Nurses (DPHNs), Health Visitors (HVs), Public Health Nurses (PHNs), Multi-Purpose Health Workers (MPHWs), Anganwadi Workers (AWWs), and Accredited Social Health Activists (ASHAs).
District Public Health Nurse (DPHN)
Definition
A District Public Health Nurse (DPHN) is a senior nursing professional who supervises public health nursing and midwifery staff at the district level. The position was created around 1962 to guide, supervise, and monitor the performance of public health nursing personnel in the district.
Key Responsibilities
- Supervise and monitor activities of public health nursing staff across the district
- Evaluate population health trends and analyze health data for the district
- Plan and implement public health nursing programs
- Conduct performance evaluations of nursing staff
- Coordinate training programs for nursing staff
- Ensure quality standards in maternal and child healthcare services
- Liaise between nursing staff and district health administration
- Monitor implementation of national health programs
- Support epidemic investigation and control measures
- Maintain records and prepare reports on nursing activities
Workplace Settings
DPHNs are typically stationed at the District Health Office or Chief Medical Officer’s (CMO) office. They work primarily in administrative roles with periodic field visits to different health facilities within the district.
Memory Aid: “DISTRICT”
D – Direct supervision of nurses
I – Implementation monitoring
S – System planning
T – Training coordination
R – Records management
I – Integration of health programs
C – Coordination of nursing activities
T – Trend analysis of health data
Health Visitor (HV)
Definition
A Health Visitor is a qualified healthcare professional who provides community-based health services with a focus on maternal and child health, disease prevention, and health promotion. Health Visitors act as a vital link between families and healthcare systems.
Key Responsibilities
- Conduct home visits to assess family health needs
- Provide antenatal and postnatal care to mothers
- Monitor child growth, development, and immunization status
- Provide health education to families and community groups
- Supervise and guide Auxiliary Nurse Midwives (ANMs)
- Identify and refer cases requiring specialized medical attention
- Support tuberculosis control programs and other disease control initiatives
- Maintain health records and prepare reports
- Coordinate with other health workers for comprehensive care
- Promote family planning and reproductive health services
Workplace Settings
Health Visitors work from Primary Health Centers (PHCs) and Community Health Centers (CHCs), spending significant time in community settings making home visits and conducting outreach activities.
Memory Aid: “VISITOR”
V – Vigilant monitoring of maternal and child health
I – Immunization tracking
S – Supervision of ANMs
I – Information and education
T – Treatment referrals
O – Outreach activities
R – Record keeping and reporting
Public Health Nurse (PHN)
Definition
Public Health Nurses are registered nurses who specialize in community health and focus on improving population health through preventative, promotive, curative, and rehabilitative healthcare. They work across all sectors of the community with a public health perspective.
Key Responsibilities
- Plan and implement community health programs
- Provide health education to communities
- Train and guide other health workers including ANMs and ASHAs
- Monitor and evaluate community health programs
- Conduct health needs assessments
- Provide technical support for maternal and child health services
- Assist in disease surveillance and outbreak investigations
- Supervise immunization programs
- Maintain public health records and prepare reports
- Coordinate with different health agencies and stakeholders
Workplace Settings
PHNs typically work at Community Health Centers (CHCs), Primary Health Centers (PHCs), and District Health Offices. They may also work in schools, occupational health settings, and other community institutions.
Memory Aid: “PUBLIC HEALTH”
P – Population-focused care
U – Universal health promotion
B – Building health capacity
L – Liaison with healthcare facilities
I – Immunization program supervision
C – Community health education
H – Health assessments
E – Evaluation of programs
A – Administration of health services
L – Linking communities to resources
T – Training health workers
H – Health promotion and disease prevention
Multi-Purpose Health Worker – Female (MPHW-F/ANM)
Definition
Multi-Purpose Health Worker – Female, also known as Auxiliary Nurse Midwife (ANM), is a frontline health worker who provides basic healthcare services at the subcentre level. They focus primarily on maternal and child health services but have a broad range of responsibilities.
Key Responsibilities
- Provide antenatal, intranatal, and postnatal care
- Conduct normal deliveries in peripheral areas
- Implement immunization programs for children and pregnant women
- Provide family planning services and counseling
- Maintain health records and registers
- Coordinate with AWWs and ASHAs for community outreach
- Conduct home visits for maternal and child health follow-up
- Provide first aid and basic treatment for common ailments
- Refer complicated cases to higher healthcare facilities
- Participate in disease surveillance activities
- Distribute contraceptives and essential medications
- Conduct field testing for diseases like malaria
Workplace Settings
MPHW-F/ANMs are primarily based at Health Sub-Centers, covering a population of 5,000-6,000 (3,000 in hilly or tribal areas). They divide their time between the sub-center facility and community outreach work.
Memory Aid: “FEMALE ANM”
F – Family planning services
E – Essential maternal care
M – Maternal health monitoring
A – Antenatal care
L – Linking with higher facilities
E – Emergency first aid
A – Assisting deliveries
N – Neonatal care
M – Management of immunization
Multi-Purpose Health Worker – Male (MPHW-M)
Definition
Multi-Purpose Health Worker – Male is a frontline health worker who focuses primarily on disease control programs, environmental sanitation, and general healthcare. They complement the work of female MPHWs to ensure comprehensive health coverage.
Key Responsibilities
- Implement communicable disease control programs (malaria, TB, etc.)
- Conduct disease surveillance activities
- Collect blood smears for malaria detection
- Monitor water quality and promote safe drinking water
- Conduct environmental sanitation activities
- Support immunization programs
- Educate communities on disease prevention
- Maintain health records related to disease control
- Identify and refer cases for further treatment
- Distribute contraceptives and promote family planning among males
- Support in managing public health emergencies
- Coordinate with village health committees
Workplace Settings
MPHW-M workers are also based at Health Sub-Centers and cover the same population as their female counterparts. They spend significant time conducting field visits for disease surveillance and environmental health activities.
Memory Aid: “MALE MPHW”
M – Malaria surveillance
A – Awareness on disease prevention
L – Liaison with community leaders
E – Environmental sanitation
M – Management of disease outbreaks
P – Promotion of safe water
H – Health education for men
W – Water quality testing
Anganwadi Worker (AWW)
Definition
Anganwadi Workers are community-based voluntary frontline workers under the Integrated Child Development Services (ICDS) program. They focus primarily on nutrition, early childhood care, and education, serving as the first point of contact for health-related matters in villages.
Key Responsibilities
- Provide supplementary nutrition to children below 6 years
- Distribute nutrition to pregnant and lactating mothers
- Conduct growth monitoring of children
- Provide non-formal pre-school education to children aged 3-6 years
- Maintain records of beneficiaries
- Provide health and nutrition education
- Assist ANMs in immunization sessions
- Identify and refer malnourished children
- Function as depot holder for RCH Kits/contraceptives
- Mobilize community for health programs
- Implement Nutrition Programme for Adolescent Girls (NPAG)
- Coordinate with ASHA workers for comprehensive care
Workplace Settings
AWWs work from Anganwadi Centers that typically serve a population of 1,000 in general areas and 700 in tribal areas. They split their time between center-based activities and home visits.
Memory Aid: “ANGANWADI”
A – Assessing growth of children
N – Nutrition supplementation
G – Growth monitoring
A – Adolescent education
N – Non-formal education
W – Women’s health education
A – Assisting immunization
D – Distributing supplements
I – Identifying at-risk children
Accredited Social Health Activist (ASHA)
Definition
ASHA workers are community health activists introduced under the National Rural Health Mission (NRHM). They are selected from the community and serve as the first point of contact between the community and the public health system.
Key Responsibilities
- Create awareness on health determinants (nutrition, sanitation, etc.)
- Counsel women on birth preparedness and safe delivery
- Accompany pregnant women and children to health facilities
- Provide primary medical care for minor ailments
- Promote construction of household toilets
- Mobilize community for health campaigns
- Act as depot holder for essential health supplies
- Maintain village health register
- Promote breastfeeding and complementary feeding
- Facilitate immunization sessions
- Conduct home visits for newborn care
- Promote family planning methods
- Prevent RTIs/STIs through awareness
- Inform about nutrition and health services available
Workplace Settings
ASHA workers are community-based and typically cover a population of about 1,000 in their own villages. They conduct home visits and community meetings, and accompany patients to health facilities.
Memory Aid: “ASHA HELPS”
A – Awareness creation
S – Supporting pregnant women
H – Health promotion
A – Accompanying patients
H – Home visits
E – Education on health
L – Liaison between community and health system
P – Primary care for minor ailments
S – Supplying essential medications
Best Practices and Updates in Community Health
1. Digital Health Records Integration
Recent updates in India’s public health system include the integration of digital health records for community health workers. ASHA and ANM workers are now being equipped with tablets and smartphones to maintain electronic records, improving data accuracy and enabling real-time monitoring of health indicators. This digital transformation helps track maternal and child health more efficiently and facilitates better coordination between different levels of healthcare providers.
2. Task-Shifting and Capacity Building
There is an increasing focus on task-shifting and capacity building among community health workers to address the shortage of healthcare professionals in rural areas. MPHWs and ASHAs are receiving enhanced training to manage non-communicable diseases like diabetes and hypertension at the community level, expanding their traditional role beyond maternal and child health. This approach aims to provide more comprehensive primary healthcare closer to communities.
3. Integrated Service Delivery Model
The latest approach emphasizes an integrated service delivery model where different community health workers coordinate closely to provide comprehensive care. Rather than working in silos, ASHA, AWW, and ANM workers (often referred to as the “Triple A” approach) now conduct joint household visits, share information, and collectively address community health needs. This collaboration enhances efficiency and ensures a holistic approach to community health management.
Hierarchical Relationship Between Community Health Workers
Understanding the hierarchical relationship between various community health workers is essential for nursing students to comprehend the reporting structure and supervision patterns in India’s public health system.
| Level | Position | Reports To | Supervises |
|---|---|---|---|
| District | District Public Health Nurse (DPHN) | Chief Medical Officer (CMO) | PHNs and Health Visitors |
| Block | Public Health Nurse (PHN) | DPHN and Block Medical Officer | Health Visitors and ANMs/MPHWs |
| PHC | Health Visitor (HV) | PHN and Medical Officer In-charge | ANMs/MPHWs (Female & Male) |
| Sub-center | MPHW-F (ANM) & MPHW-M | Health Visitor | ASHAs and coordinates with AWWs |
| Village | ASHA Worker | ANM/MPHW-F | None (Collaborates with AWW) |
| Village | Anganwadi Worker (AWW) | ICDS Supervisor/CDPO | None (Collaborates with ASHA) |
Important Note:
While ASHA workers and AWWs work at the same level (village), they have different reporting structures. ASHAs report to the health department through ANMs, while AWWs report to the Women and Child Development Department through ICDS supervisors. However, they collaborate closely for service delivery.
Key Differences Between Community Health Workers
- Scope: DPHN operates at district level; PHN at block level
- Function: DPHN primarily administrative; PHN combines administrative and clinical
- Responsibility: DPHN focuses on program monitoring; PHN on implementation
- Qualification: HV requires higher qualification than ANM
- Role: HV supervisory; ANM primarily service delivery
- Coverage: HV covers multiple sub-centers; ANM covers one sub-center
- Focus: Female – maternal and child health; Male – disease control
- Activities: Female – reproductive health; Male – environmental health
- Primary Services: Female – ANC, PNC; Male – disease surveillance
- Department: ASHA – Health; AWW – Women & Child Development
- Primary Focus: ASHA – healthcare linkage; AWW – nutrition and education
- Facility: ASHA – home-based; AWW – center-based with outreach
Conclusion
Community health workers form the essential foundation of India’s public health system, particularly in rural and underserved areas. Each cadre of worker—from DPHNs at the district level to ASHAs and AWWs at the village level—plays a unique and complementary role in ensuring comprehensive healthcare delivery.
Understanding the specific responsibilities, hierarchical relationships, and coordination mechanisms between these workers is crucial for nursing students and healthcare professionals. The effective functioning of this multilayered system depends on clear communication, appropriate task allocation, and collaborative efforts between all levels of community health workers.
As India’s healthcare needs evolve with changing disease patterns and population demographics, the roles of community health workers continue to adapt. The integration of digital tools, enhanced training, and collaborative approaches are strengthening the capacity of these workers to deliver quality healthcare services at the community level.
For nursing students, gaining in-depth knowledge about these various roles provides essential context for their future practice, whether they work within the public health system or interact with it in other healthcare settings. This understanding will help them appreciate the complex network of healthcare delivery and their potential place within this system.