Chapter I
Roles and responsibilities of MLHP
Contents:
 Introduction
 Taking stock of current experience with middle level provider
 Improving access
 Preserving quality
 Education of MLHP’s, role and responsibilities
 Regulation and management
Learning Objectives
Understand the concept of MLHP and enumerate the roles and responsibilities of MLHP
Introdution
Health care burden of developing countries is rapidly increasing day by day. Most of the
population belongs to below poverty line and are unable to avail health care services. Health
facilities of developing countries are inadequate to meet the demands of vast population.
To get over with health issues the country requires health care professionals and healthcare
facilities for providing required healthcare support. On the other hand shortage of trained health
care professionals also directly creates extra burden on the government.
In India, the government is working towards easy access of healthcare services for all. The
community health officer is the new step by Indian government which comes under mid-level
healthcare providers. Mid-level health care providers are new emerging workforce in healthcare
sector.
Need for MLHP
 Studies reported around 11.5% households in rural areas and about only 4% in urban
areas, are not receiving any form of OPD care at sub-centre, primary health centre and
CHC level. This indicates the low utilization of primary health care for minor ailments or
it may be because of inefficient health-care services or unavailability of healthcare
providers.
 In order to expand access to comprehensive primary health care (CPHC), government of
India has launched Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (PMJAY) in
Sept, 2018. PMJAY is a centrally sponsored scheme. Under this scheme - health and
wellness centres (HWCs), sub health centres (SHCs), and primary health centres (PHCs)
are being strengthened as health and wellness centres (HWCs).
 The services in HWCs will be provided through a mid-level health care provider
(MLHP)/community health officer (CHO) placed at a HWCs and medical officer at PHC
(rural/urban). The MLHP/CHO will undergo a certificate in community health through
IGNOU or public university
 Community health officers are health care workers with training less than that of a
physician but greater than that of more ordinary nurses and other medical assistants. India
is a second most populous nation in the world and also a developing country. As per
WHO, by 2024 the projected population would be 1,447,560,463.
 With this growing population, India is in a great demand of doctors and nurses. At
present India has a shortage of an estimated 600,000 doctors despite of more than 529
government and private medical colleges having an annual intake of 70,978 students.
 community health officer will bridge the gap between population and sub-centre, primary
health centre and community health centre.
 CHO’s are permitted to serve the community independently to diagnose, manage and
treat minor ailments and impairments and also engage in preventive Expended Service
Delivery. Continuum of Care – Tele-health/ Referral.
 Their expanding roles are more helpful for low- and middle-income countries, as a
strategy to overcome the shortage of health care workforce challenges and improve
access to essential health care services.
 So, the MLHP or CHO or mid-level practioner (MLP) or community health provider
(CHP) are sounds the same and ultimately it means the majority of nurses will be in this
role.
Definition
Mid-level health providers (MLPs) are health workers trained at a higher education institution
for at least 2-3 years. They are authorized to work autonomously to diagnose, manage and treat
illness, disease and impairments, as well as engage in preventive and promotive care.
They are increasingly being used to render services autonomously, particularly in rural and
remote areas to make up for the gaps in health workers with higher qualifications.
Mid-level health providers; a promising resource to achieve the health Millennium Development
Goals
MLHP is a health provider: According to WHO, Mid Level Health Provider is :
a. Who is trained, authorized and regulated to work autonomously,
b. Who receives pre-service training at a higher education institution for at least 2-3 years, and
c. Whose scope of practice includes (but is not restricted to) being able to diagnose, manage and
treat illness, disease and impairments (including perform surgery, where appropriately trained),
prescribe medicines, as well as engage in preventive and promotive care.
Concept of MLHP
Many countries are facing critical shortages of health workers, in particular in rural areas, which
hinder the provision of essential health services.
According to the UN Secretary General Global Strategy for Women’s and Children’s health, up
to 3.5 million additional health workers are needed in 49 low-income countries in order to
achieve the health Millennium Development Goals targets.
The concept of mid-level health providers started 100 years ago in many countries and showed a
remarkable change in their health indicators. Since last 10 years, the growth of health
professionals is in rise with its new emerging roles.
Mid-level health care providers are new emerging workforce in healthcare sector. India is
alarming country for disease burden and to cover the huge gap in providing health care facilities,
it requires the mid-level health care providers at different settings of the country. In order to
provide quality primary health care In 2019, a new Mid-level Health Care Provider role was
introduced in India, also known as Community Health Officer/ Community Health Provider. The
role was intended for support the health and wellness centres in community.
In many settings, however, finding the resources to train and employ new health workers is
problematic.
Mid-level practitioners, also called assistant practice clinicians and non-physician
practitioner, are trained health care providers who have a defined scope of practice. This means
that they are trained and legally permitted to provide healthcare in fewer situations
than physicians and some other health professionals, but more than other health professionals.
Mid-level providers are cost-effective in primary care settings, where they can relieve physicians
of the necessity of providing routine care.
Community health officers play a role to bridge the gap between community people and health
care facilities. The services provided by them improve the quality of life in community and also
empowers the community health care settings
Acc to World Health Organization,
What do we mean by quality of care?
Quality of care should:
●
Fit the needs of the patient;
●
Cause no harm to the patient;
●
Be right for the patient (correct diagnosis and treatment, i.e. evidence based);
●
Be given without unnecessary delays;
●
Include only the necessary medical tests and procedures for the specific diagnosis and
treatment;
●
Be fair and not affected by gender, religion, language, age or income.
● Mid-level providers are health workers with 2-3 years of post- secondary school
healthcare training who undertake tasks usually carried out by doctors and nurses, such as
clinical or diagnostic functions.
● They are increasingly being used to render services autonomously, particularly in rural
and remote areas to make up for the gaps in health workers with higher qualifications.
● Experience demonstrates that, where these mid-level providers are adequately trained,
supported and supervised, they can deliver essential health services including maternal
and child health, HIV and other priority conditions with similar quality standards as
physicians, and often for a fraction of the cost.
● Mid-level health workers should therefore be included as part of the general planning and
management of the health system, and equally benefit from support, supervision,
regulation, quality control, and opportunities for professional development and career
progression.
● Their role has been progressively expanding and receiving attention, in particular in lowand middle income countries, as a strategy to overcome health workforce challenges and
improve access to essential health services.
● Finally, there is a clear need for establishing procedures and systems that can integrate
core HR management functions, such as accreditation, regulation, professional
development and career progression for MLP, in the planning and management of the
health system.
MLHP In India
In 2019, a new mid level health care provider role was introduced in India, known as
Community Health Officer (CHO). The role was intended to support the Health and Wellness
Centres in community level in India.
Govt of India has Integrated Middle-Level Health Provider (MLHP) in Basic B.Sc Nursing and
Post Basic B.Sc Nursing Curriculum in Feb 2019.
The total number of hours to incorporate in the existing Community Health Nursing subject is
around 75 hours (theory + practical). It will be feasible to accommodate in the 195 hours already
allocated in the B.Sc Nursing Syllabus (internship period) & P.B.B.Sc.(N) in CHN.
The following areas to be incorporated in the Community Health Nursing subject of B.Sc
Nursing Syllabus and also in Post Basic B.Sc Nursing:1. Roles and responsibilities of Mid-Level Healthcare Providers (MLHP)
2. New national health programmes
3. AYUSHMÄN BHARAT- The up gradation of sub-centers into of health and wellness centers,
Concept of Comprehensive primary health care and key elements of CPI-IC, Service delivery
and continuum of care and Roles of Mid-level health care providers(MLHP)
4. Diagnosing and treatment skills essential at sub-centre level using Standard treatment
protocols as per national health programmes
5. Introduction to Rashtriya Bal Sureksha Karyakaram (RBSK)
6. .Social mobilization skills
7. Drug dispensing
8. Programme management including supervision and monitoring
9. Investigation of an outbreak
10. Behavior change communication and soft skills
11 Integrated Disease Surveillance Project (IDSP)
12. Mother and Child Tracking System (MCT S)
13. Chikungunya
14. Organization of labour room
15. Safe child birth checklist
16. Postpartum visits by health workers
17. Family planning 2020
18. National family planning programmes
19. Food Borne diseases
Following topics to be reviewed by MLHP: Health planning and health care delivery system in India (IPHS guidelines)
 Health Management Information System(HMIS)
 Electronic Medical Records(EMR)
 Micro birth planning
 Adolescent counseling
 Sources of vital statistics
 Financial Management, Accounts and Computing at Sub - Centre Mental health act, drug
de-addiction programmes
 Time trends in disease occurrence in epidemiology
 Infant and young child feeding and counseling
 Nutrition across life cycle and update on national nutritional programmes Use of
Equipment
 Throat problems and febrile seizure in children
 Transportation of baby and common accidents and mishaps 111 labour room
Counselling-GATHER Approach
 Update biomedical waste management by specifying biomedical waste management rules
2016
 Suturing of superficial wounds
 Postpartum Intra Uterine Contraceptive Device (PPIUCD)
 All the national health programmes on Communicable, non communicable
Training & Selection of MLHP
The current Nursing curriculum will enable the student to work as MLHP to attain a set of
competencies. Also for candidates who had not studied MLHP in their curriculum, can be trained
in a six month, IGNOU accredited “Certificate programme in Community Health’’ to build
competencies in public health primary care theory, skill and experiential learning.
Selection process of candidates for MLHP will be based on state wise competitive exams or
contract basis based on academic score to recruit competent and motivated candidatesPreferentially local selection.
Career progression pathways for MLHPs in public health functions to be charted at least up to
district level to synergize with public health cadre.
Roles and responsibilities of MLHP
CHO roles and responsibilities are purely population oriented in public health.
They are expected to provide specific service delivery, leadership, supervision, management and
take pro-active role in all the activities at community level, organize various health program and
activity in health promotion according the need
These roles of CHO help to bridge the gap between health care facilities and population seeking
health care.
Roles are:
 Health care services
 Administrative and supervision services
 Other services
Non
Commu
nicable
diseases
Maternal
health care
Care in Illness
and minor
ailments
Eye &
ENT
Care
Neonate and
infant health
care
Roles &
Responsibilities
of Mid Level
Health Provider/
CHO
Mental
Health
Services
Communicable
& Non
Communicable
diseases
Child &
adolescent
health care
Reproductive
health care
Emergency
Services
Oral
Health
Geriatric
&
Palliative
Care
Health care services
 Maternal health care: Prenatal care like antenatal checkup, screening for high risk,
immunization and supplementation, child birth, postnatal care and if require referral to
higher center.
 Neonate and infant health care: Management of high-risk newborn, screening of
congenital anomalies, IMNCI services, immunization.
 Childhood and adolescent health care: Adolescent health counselling, identification of
drug abuse, detection of any deficiency, nutritional supplement and referral services.
 Reproductive health care: Family planning, prevention and management of STI,
identification of gynecological problems and referral services.
 Communicable diseases: Diagnosis and treatment of vector or water borne diseases,
provision of DOTs and DPMR (disability prevention and medical rehabilitation) services
for leprosy along with referral services.
 Illness and minor ailments: Identification and management of fever, respiratory infection,
diarrhea, cholera, skin rashes, pain, typhoid, etc.
 Non-communicable diseases: Screening, prevention, control and management along with
follow up and maintenance of treatment modalities.
 Eye and ENT: Screening along with primary care of ophthalmic and ENT problem and
referral services of any emergency.
 Oral health: Regular checkup and screening of oral health.
 Geriatric and palliative care: Health camp organization routine checkup.
 Emergency services: Burn, injury, trauma along with first aid management.
 Mental health care: Screening and counseling along with referral services.
Administrative and supervision services
 Administrative services: Guidance to other co-health workers and maintain inventory,
report submission.
 Supervision: Supervision of national health program, ASHA, home visits, health
promotion activities.
 Care pathway: Provide specific care according to standard treatment guidelines.
 Case coordinator and manager: Provide communication to higher authority regarding
specific case, coordinate in care and management of care.
 Disaster and outbreak of disease: Local response to disease outbreak and early
management of disaster.
 Fund management: Support the team for entitling the fund for various projects and
program.
 Data management: Record population data with various health indicator and
communicate it.
 Environmental role: Education to community, speak about safe water, sanitation, disposal
of waste, pollution control and identify environmental hazards and control.
Other skills
 Communication skills, interpersonal relationship skills, transcultural competence,
assessment skills, training capability, professionalism, advocacy, education and
facilitation.
Conclusion
 Since we have shortage of doctors and specialists, the shift in role to mid-level health
care provider will relieve the overburdened doctors and specialists, at least in rural health
setting
 Mid-level health care provider has the limited license only in primary and preventive
healthcare to practice medicine at mid-level, who qualify the criteria as may be specified
by regulations which will have an overwhelming representation of doctors.
 This initiative by government of India will help to provide easy and affordable health
care services to the population which also plays an important role for universal health
coverage in India.
REFERENCES
1. World Health Organization, Global Health Workforce Alliance. The Kampala Declaration and
Agenda for Global Action. Geneva: WHO; 2008.
2. International Labour Organization. The International Standard Classification of Occupations
(ISCO-88). Geneva: ILO; 2004.
3. World Health Organization, Western Pacific Region. Mid-level and nurse practitioners in the
Pacific: models and issues. Manila: WHO/WPRO; 2001
4. Desai S et al. Int J Community Med Public Health. 2020 Apr;7(4):1610-1617