'Trust and teamwork matter': community health workers' experiences in integrated service delivery in India

Glob Public Health. 2014;9(8):960-74. doi: 10.1080/17441692.2014.934877. Epub 2014 Jul 15.


A comprehensive and integrated approach to strengthen primary health care has been the major thrust of the National Rural Health Mission (NRHM) that was launched in 2005 to revamp India's rural public health system. Though the logic of horizontal and integrated health care to strengthen health systems has long been acknowledged at policy level, empirical evidence on how such integration operates is rare. Based on recent (2011-2012) ethnographic fieldwork in Odisha, India, this article discusses community health workers' experiences in integrated service delivery through village-level outreach sessions within the NRHM. It shows that for health workers, the notion of integration goes well beyond a technical lens of mixing different health services. Crucially, they perceive 'teamwork' and 'building trust with the community' (beyond trust in health services) to be critical components of their practice. However, the comprehensive NRHM primary health care ideology - which the health workers espouse - is in constant tension with the exigencies of narrow indicators of health system performance. Our ethnography shows how monitoring mechanisms, the institutionalised privileging of statistical evidence over field-based knowledge and the highly hierarchical health bureaucratic structure that rests on top-down communications mitigate efforts towards sustainable health system integration.

Keywords: India; community health workers; integration; teamwork; trust.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anthropology, Cultural
  • Attitude of Health Personnel*
  • Community Health Workers / economics
  • Community Health Workers / organization & administration
  • Community Health Workers / standards*
  • Community-Institutional Relations / standards
  • Community-Institutional Relations / trends
  • Delivery of Health Care, Integrated / organization & administration*
  • Female
  • Humans
  • Interviews as Topic
  • Male
  • Motivation
  • Patient Care Team / organization & administration*
  • Pharmaceutical Preparations / supply & distribution
  • Primary Health Care / organization & administration*
  • Professional-Patient Relations
  • Rural Health Services / organization & administration
  • Trust
  • Workforce


  • Pharmaceutical Preparations

Grants and funding

Funding: This research has been funded by the Norwegian Research Council's Global Health and Vaccination Research programme (GLOBVAC) as part of a larger research project [grant number 196382] on Health systems strengthening within vaccination programmes: an ethnographic study.