How a Technical Agency Helped Scale Up a Community Health Worker Program: An Exploratory Study in Chhattisgarh State,...

-India's goal of universal health coverage underscores the need for scale in community action for health. Among the few successes in community programs is Chhattisgarh's Mitanin Program, designed and maintained at the scale of the entire state (covering almost 20 million). Evaluations of scaled-up interventions typically examine population health outcomes, placing less emphasis on how programs succeed or fail. To address this knowledge gap, we undertook a qualitative research study to explore the role of the State Health Resource Centre (SHRC), a state technical agency, in scaling up Chhattisgarh's Mitanin health worker program over a ten-year period commencing in 2002. We undertook observation, policy documentary review, in-depth interviews, and focus group discussions with policy/program developers, facilitators and trainers, community health workers, and representatives of civil society. Data analysis followed an inductive approach of qualitative data analysis and data were thematically organized in the form of folk theories including interlinked contexts, mechanisms, and outcomes reflecting the experience of the SHRC in scaling up community action for health in the state. The first folk theory links the enabling context of the formation of a new state with mechanisms of pluralistic and multistakeholder governance of the SHRC and avoidance of overt political patronage of the program, contributing to the sustainability of the program through multiple administrative and political transitions. The second folk theory elaborates how equity-focused mechanisms such as linking the program to locally important, intersectoral agendas for marginalized communities and attentiveness to career trajectories of female frontline workers created space for these workers to organize and demand livelihood rights against a broader context where the indigenous tribal minority and women are widely excluded from the social and political mainstream. These exploratory findings illustrate how the pluralistic governance structure of the SHRC, coupled with a set of unique contextual strategies, contributed to the longevity of the program and professional growth and opportunities for female community health workers, with lessons for other low- and middle-income country decision makers.