Table 1 Factors contributing to the failure of the Village Health Guide Scheme

Hasty planning and scale-up

The rapid expansion of the scheme left little room for adaptation or iterative learning. Thus, the problems identified in early evaluations of the scheme were not sufficiently addressed.

Poor communication

Communication between the central government and the local communities about the scheme was limited. As a result, there was much confusion among communities and PHC centers surrounding the VHGs and the role they were meant to fulfill.

Distorted selection process

The Scheme’s planners intended for communities to select and supervise their own VHGs. However, this task was often guided by only a select group of community leaders and later by district-level officials (after patterns of political patronage became apparent). Furthermore, despite recommendations that there be an equal number of male and female workers, almost all the VHGs selected were male.

Lack of support from the health system

PHC centers were poorly poised to train and supervise a CHW cadre

Suboptimal supervision

In the theoretical outline of the scheme, VHGs were meant to be supervised by the community. In practice, however, this task was often delegated to the local PHC centers, deemphasizing the community-centered goals of the VHG program.

Lack of adequate logistical support

VHGs were often without needed supplies and medicines

Issues related to remuneration

Although the compensation that VHGs received was relatively small, it substantially altered the perception of their work. VHGs were regarded as government workers rather than community advocates and educators. In addition, the honorarium became unsustainable for the central government to fund in later years of the program.