Leadership Where It Matters Most: Lessons from India’s Frontline Health Workforce

CC BY-NC 4.0

By Jasmine Maringmei

When we picture leadership in health systems, we often imagine senior officials or hospital executives making decisions in conference rooms. Yet across India’s rural landscape, leadership is lived every day in small Sub-Health Centres where Community Health Officers (CHOs), Auxiliary Nurse Midwives (ANMs), multipurpose workers (MPWs), and Accredited Social Health Activists (ASHAs) sustain the foundations of care. These workers play a significant role in primary care delivery in rural and underserved areas. Despite this, the training and support they receive remain dominated by a narrow definition of capacity-building, centered almost exclusively on technical or “hard” skills.  

While such skills are critical for clinical competence, the ability to communicate, collaborate, and lead within teams and communities is equally essential. Yet these “soft skills” are rarely prioritized in health professional education or practice, often considered intuitive or secondary.

Field experiences across India increasingly demonstrate that focusing on technical skills without relational competencies limits the impact of even the most well-designed reforms. 

Through my experiences with over a decade of fieldwork in India, from Himachal Pradesh to the Andaman and Nicobar Islands, I have observed persistent gaps in teamwork and coordination. Frontline workers stationed in the same facility often barely knew one another, interacting only at monthly review meetings. This lack of engagement produces operational silos, blurred roles, and fractured accountability. It leaves workers feeling disempowered, demotivated, and isolated. Traditional training rarely creates space to build trust, leadership, or peer support, all of which directly influence service quality. 

One place where this has been demonstrated was in the Ayushman Bharat system. Launched in 2018, this national public health program signaled a major structural shift in India’s health system. Through the establishment of Health and Wellness Centres designed to deliver comprehensive primary health care, the system expanded its scope to include chronic disease management, mental health, geriatric care, palliative care, and preventive health promotion. This transformation requires stronger collaboration than ever before.  

Despite this need, India still lacks a structured mentorship ecosystem for frontline health workers. Supervision is often transactional, driven primarily by the completion of checklist goals rather than promoting skill-building.

In addition, supervisors rarely receive continued training themselves. When mentorship initiatives do exist, they are often one-time interventions with little follow-up. Without reflective spaces, workers have limited opportunities to clarify misconceptions, manage conflicts, or build leadership skills. Supervision also varies widely across districts, from highly engaged officers to more distant oversight. Deeply rooted hierarchies may limit open dialogue. Without consistent guidance, frontline workers may struggle with motivation, confidence, and burnout, issues that affect both personal well-being and patient outcomes. 

In this context, the SATHI mentoring program in Bhavnagar district, Gujarat, provides an innovative approach to strengthening leadership and teamwork. The institution’s involved in designing and implementing SATHI were the Indian Institute of Public Health, Gandhinagar (IIPHG), Bhavnagar Government Nursing College, the Bhavnagar Chief District Health Office, the State Health System Resource Center, Gujarat, All India Institute of Medical Sciences, Delhi (AIIMS-D), and the Johns Hopkins Bloomberg School of Public Health. The pilot program focuses on improving team dynamics and service delivery across 12 service areas at Sub-Health Centres. The recently concluded SATHI pilot uses a year-long mentoring structure. Each Sub-Health Centre is assigned two mentors, typically an AYUSH Medical Officer and a nursing tutor, who conduct two in-person sessions per month. Sessions run for 1.5 to 2 hours and are supported by monthly online expert discussions. 

The curriculum is structured yet participatory. Sessions begin with recap reflections, fostering shared ownership. Content integrates theory with practice, identifying leadership styles, addressing conflict, or dividing tasks equitably. WhatsApp-based homework encourages participants to reflect on leadership traits, practice communication techniques, and identify role models who inspire them. Experiential activities anchor the learning: role-plays, case scenarios, group tasks such as constructing structures with cotton, thread, and incense sticks, and affirmation exercises. These activities promote trust-building, camaraderie, and collaborative problem-solving. Participants receive small stipends to support attendance, and mentors receive logistical support and session-based compensation. Sessions have been held in Gujarati and local dialects, grounding them in the local context.  

During interactions with the mentors and Sub-Health Centres teams in the eleventh month of the intervention, several reflections were shared regarding the perceived value of the program. The most striking change is cultural. Participants described shifting from “I do my work” to “We work as a team.” Workers who previously performed their tasks silently and individually began sharing workload, discussing cases, and checking in with colleagues. Stage fright decreased. Comfort with digital tools improved. Longstanding tensions, particularly between CHOs and ANMs, and ANMs and ASHAs, began to soften. One CHO shared, “Earlier we worked side by side but never really talked. Now we understand each other’s roles better.” Several participants also described improvements in patient care. As one explained, “I didn’t use to listen properly before. This program helped me become an active listener… I understand my patients better now.” 

Mentors reported parallel benefits, including greater patience, improved stress management, and a shift toward collaborative rather than hierarchical leadership. The safe, reflective spaces created during sessions enabled workers to share frustrations and seek solutions together, strengthening peer-to-peer support networks across Sub-Health Centres. 

Building on these positive outcomes, the Indian Institute of Public Health Shillong has worked with the Department of Health and Family Welfare, Government of Meghalaya to adapt a similar program called SATHI for the West Garo Hills District in the state of Meghalaya. Because a direct transplant would be ineffective, the model has been contextualized by translating material into local languages, aligning with district priorities, scheduling sessions around immunization days and field visits, and integrating local case studies. In Meghalaya, the approach will also strengthen team functioning at both PHCs and SHCs through structured coaching relationships led by PHC Medical Officers and Supervisory Cadres, such as Public Health Nurses and Community Health Organizers. Modules, based on adult learning principles, will focus on understanding team purpose, teamwork, roles and responsibilities, team performance, and essential clinical skills. 

Long-term sustainability will depend on anchoring the program within district institutions. While the pilot focuses on SHCs, the broader vision includes phased statewide expansion. Yet, critical questions remain. Will mentoring continue without travel allowances or logistical support? Can a culture of collaborative leadership be sustained once external facilitation ends?

These concerns point to a larger challenge: leadership development must be recognized as foundational to primary care strengthening, not an optional enhancement. 

India’s frontline workers are at the center of the country’s primary care transformation. As the health system demands more complex chronic disease management, preventive care, digital health navigation, and community engagement, frontline workers must be equipped not only with clinical tools but also with the skills to lead, collaborate, and adapt. The SATHI experience shows the transformative potential of structured mentorship at the lowest tiers of the health system. When frontline workers are supported to reflect, communicate, and lead together, they deliver better care and help build a more resilient, equitable system. 

Jasmine Maringmei, MPhil

is a tribal youth belonging to the Rongmei Naga community from Manipur, Northeast India. She is a Policy Analyst for the Indian Institute of Public Health Shillong - Public Health Foundation of India (PHFI), supporting the India Primary Healthcare Support Initiative (IPSI) project in West Garo Hills District in Meghalaya. She is a Atlantic Fellows for Health Equity Senior Fellow. The opinions expressed here are her own.