This study identified misunderstandings of the RHM role and the structural limitations that reduce their effectiveness. These two components underpin and influence the extent to which the programme is recognised and accepted at the health system, community and individual level. Gender further influences how the community experiences and recognises the work of RHMs.
1. Understanding of the role
1.1 The RHM role: “their visibility is not clear”
Confusion over the exact role of RHMs was widespread among all study participants, including MoH representatives. Some common understandings of the focus on sanitation and hygiene emerged, yet numerous additional responsibilities were identified ranging from looking after sick people to “giving pills”. The historical development of the RHM programme was noted as a reason for this confusion at community level, with many comparisons made between the original and current role. Regarding HIV/TB work, little was mentioned without probing. Historical inclusion of home-based care for HIV was occasionally stated, with challenges on disclosure and promoting condom use often cited. Older community members were more likely to know RHMs personally. Observation showed RHMs focus on older community members in household visits, with the exception of babies.
1.2 Expectations: “when you are going to check on a sick person, bring a hoe”
There is an expectation for RHMs to work past their MoH endorsed role. Additional tasks included distribution of food parcels, collection of money, and washing dead bodies. Such tasks affect RHM relationships with community members, the latter perceiving RHM bias in choosing ‘favourite’ households for distribution of food. Expectations were identified at community, clinic and governmental level, with some RHMs being asked to clean clinics.
Community members expressed an understanding and expectation for RHMs to provide more than health education and clinic referrals:
“When my wife was sick, [the RHM] used to come to my home, even when she was weeding she could come and assist her, the role of the RHM stayed in my heart as a big thing.” (Male community member)
Various reasons for poor recognition emerged, including that RHMs no longer provide first aid material (historically distributed). One RHM emphasised that community members complain:
“A person will come when you are teaching and tell you they have a headache, you do not have paracetamol, so when you are teaching, they will not listen because there is nothing that you have helped them with.” (Female RHM)
During IDIs, RHMs were positive about reception from community members, only discussing these challenges more openly in the group discussion. Community expectations and confusion over what health education entails, leads to assumptions of RHMs doing work for community members, e.g. building a latrine after education on sanitation and hygiene. One RHM explained this, including the influence community leaders have on community expectations:
“The way [community leaders] say it, it sounds like we are supposed to do it for the people. The people will also think that a RHM is someone that has nothing to do.” (Female RHM)
2. Organisational structure of the RHM programme
Several aspects related to the organisation of the RHM programme, emerged from the data. It was identified that RHMs could absorb new activities and deliver health programmes more effectively with appropriate training and materials provided. The MoH and NGOs do not consistently provide RHMs with sufficient training, materials and support needed to perform required tasks.
Comparing RHMs with Active Case Finders (ACF) of the TB programme, a KI explained the success:
“Ask anything to an ACF right now they give you… the knowledge the ACF has it is more than what the RHM has. Because we trained them.” (KI, MoH)
Following initial training, RHMs reported that they felt neglected. Accessing formal programme support structures was a common challenge. In particular, a lack of supervision was mentioned, with several RHMs explaining that they needed more supervision to have their work validated or corrected.
The large number of RHMs and the ratio to supervisors was highlighted by MoH KIs as a limitation in the programme structure.
“… For the RHM programme manager to manage 5,000 people, that's a very big group of people.” (KI, MoH)
The RHM programme falls under the MoH. A MoH KI admitted to not knowing what the RHM job currently is.
“I'm not sure, honestly I just have to be honest, I'm not sure” (KI, MoH)
Participants reported a lack of collaboration between national and regional levels, with current MoH structures hindering RHM performance and programming.
“They are so many that their data should have an impact in the country. But from what I've seen, it seems the national level has to come up with a system…” (KI, MoH)
Lack of organisational structure was also seen in the absence of clarity on HIV/TB activities. KIs and MSF staff explain how other CHW groups like the ACFs were given TB specific tasks and relevant training, leaving the RHM role unclear in terms of HIV/TB. The position of the RHM programme within the broader MoH system was clearer at the peak of the HIV crisis, compared to the current low prioritisation of the programme:
“We were working together but it was then, when HIV was a problem, we had good relationship because we wanted to see them taking care of the sick…” (KI, MoH)
Insufficient stipends, termed “soap money”, was commonly cited as a challenge and often affected the RHMs’ ability to present themselves as professionals in the community. Irony in terming it a ‘salary’ was acknowledged. MoH informants discussed how this could affect motivation, with the need to cover transport costs leaving some at a loss each month. RHMs considered insufficient stipends as a lack of ‘consideration’ for them and their work:
“We are wondering if the [government] may consider us and give us a bit of something so that even as I go along the mountains, it may feel easy to walk if there is money making me happy” (RHM)
“Unfortunately my sneakers are worn out. You wouldn't want to arrive to people dressed like that, you need to dress better” (Female RHM)
3.1 Self-recognition: “It’s something in the heart, you just get happy that you have done the visit” (RHM)
Many RHMs portrayed their work as significant, explaining it as an ‘act of service’. Numerous RHMs invoked religious language when describing their work, often involving elements of benevolence. Responding to socio-economic challenges, the majority of RHMs discussed sharing their own food with community members under their care, and paying for transport to clinics.
Contrasting with this however, RHMs saw limitations in their efficacy. For HIV, they emphasised that ‘nothing’ can be done but to motivate people to go to the clinic where doctors could provide substantial help.
“The stories [health promotion], they already know, we have already told them, only we have nothing helpful …” (Female RHM)
3.2 Visibility and respect for RHMs: “We have them, but we do not see them”
There is consensus that no ‘one’ type of RHM exists, with commitment to work schedule, skill and knowledge varying among the group. For RHMs to be successful, community members felt RHMs needed to work every day. On average, RHMs are tasked with 15-20 households to visit each month. However, some households were never visited by their RHM.
Support from community leadership was seen as vital for the success and ease of RHM work. Many RHMs felt unsupported by community leaders, with some leaders seeing RHMs as “earning for free.” There are not always opportunities to conduct health education at community meetings. A community leader said he was unable to remark on how well RHMs are working, and that he did not have their phone numbers. Challenges including the old age of RHMs and low education levels, especially regarding updated MoH criteria, were common.
“These days we are living in times where people are educated, it seems even the RHMs could be people who are at a level of the people … Today I feel like the RHMs should be upgraded, able to look at things that are written down.” (Community leader)
4. The experience and influence of gender
Gender emerged as a fundamental component in both the content of RHM health education, and the acceptability of interacting with the group. Poor male health seeking behaviour compared to women was often identified as problematic. The programme was regularly perceived by community members as dealing with “women issues.”
Engaging men was explained as a big challenge, with several examples of men rarely prioritising interactions with RHMs, as they are too busy with other tasks - “men do not like to sit and listen.” Instead they instruct their wives to meet with RHMs. Gender was seen as potentially influencing the ease and acceptability of discussing certain topics, both for RHMs sensitising community members on specific health issues, and for members of the community to raise their individual health needs with RHMs. Community leaders echoed this widespread opinion, explaining that female RHMs are appropriate to speak to women, and that men would accept information better from male RHMs.
“…obviously the man will think that the female RHM could go and tell his wife that your husband has had this, whereas if it is a man he could easily understand.” (Community leader)
“It is difficult to take my issue and share it with somebody’s wife [RHM].” (Male community member)
In contrast, higher level MoH participants did not consider gender as a limiting factor on the acceptability of health messaging in the community.
“I do not think there is difficulty in talking to each other for whichever gender when it comes to seeking health related information.” (MoH nurse)
“I think any gender of RHMs can work.” (KI, MoH)
In addition to gender influencing whether RHMs can discuss certain topics, one RHM highlighted the difficulty of changing behaviour in topics related to gender (e.g. condom use) by comparing to her personal life.
“With HIV, I think not using condoms [is the biggest problem] … I usually talk about that to people as an RHM, but I am failing to do that inside my own house. Even with my own husband, it is difficult for us [women] to use a condom … (Female RHM)