FGDs involved a total of 62 community health workers (32 males, 30 female) who were divided into 6 groups of 10–12 participants. IDIs were conducted with 17 district stakeholders including health providers (4 health assistants, 3 facility health workers) 4 community development officers, and community leaders (3 elected community leaders, 3 Health Unit Management Committee Chairpersons). The mean age of all participants was 42.6 years (SD 10.5). Other social demographic characteristics are shown in Table 1.
Participant sociodemographic characteristics
Highest Education Level
Enablers and barriers to CHW sustainability identified by study participants were grouped under four categories. Here, categories are presented together with details of sustainability-related factors within each category.
1) Health System Effectiveness
Participants reported that a number of health system factors affected the sustainability of CHW programming. Staffing and supply shortages were seen to negatively affect CHW activity level and impact post intervention:
Availability of Supplies, Medicines and Services: CHWs described feeling dispirited when they had done a good job creating demand, yet when patients they mobilized to seek care attended facilities, medical supplies and medicines were lacking:
…when you tell someone ‘take your child for immunization’ she will simply tell you that ‘whenever she goes there [health facility] she does not find any drugs’…the woman loses morale instead and comes back. (CHW, FGD).
… [People] do not get what they are expecting when they reach [the health facility]. She leaves [home] sick knowing that she will get treated because she is a poor woman with no money and when she reaches there [health facility], the health work tells her… ‘I have written for you… go and buy drugs… there are no drugs here’. (CHW, FGD).
Additionally, community members seeking care were reported to sometimes be requested payment by health providers before receiving services, this was discouraging to CHWs:
Health services are there but sometimes the common person who goes to access [antenatal care] may not afford to pay the charges. … Because when she gets [to health facility], they will ask her for some money... It becomes a challenge for women when they go to deliver from health facility… (CHW, FGD).
Payment requested of clients was seen by participants as a barrier; failure to get adequate or reasonable services when encouraged or sensitized to do so by a CHW were seen to decrease the potential impact of the CHW referral and demotivate CHWs because the impact of their hard work is reduced; participants suggested that where service expectations are not met, communities may begin to lose trust and no longer follow CHW advice.
Availability of facility health providers: Participants linked sustainability of the CHW network with facility health providers who were available to attend to women and children. Some community members complained that they continued to face shortages, tardiness or absence of health workers when they arrived at health facilities. This was seen to compromise sustainability of the community intervention and may discourage to CHWs who refer patients.
… there are always few health workers who do not keep time…the facility is supposed open by 8:00am…you find them [health care providers] beginning work at 11:00am. (CHW, FGD)
2) CHW Program Factors
A number of CHW program factors were identified by participants as key influencers of CHW sustainability.
CHW Selection and Training: The all community process used in the intervention to select CHWs and subsequent training was reported by community members as an enabler to their longevity and service. Study participants expressed confidence that CHWs, who were part of the community and selected by the community itself, would remain. They expressed that the skills and knowledge that CHWs had gained during training had continued to be shared with neighbors after the intervention ended.
[The project] left when it had trained [CHWs]; even when [the project] ended, the CHWs continued working because they had experience through what they were taught. Because even if [the project] ended, the CHWs are in the village and they provide advice when they see a sick child or pregnant woman in the village. (CHW, FGD)
CHW Recognition and Incentives: Participants explained that for CHW activities to be sustained, CHWs required community recognition. Where CHWs were not perceived as important or legitimate, or where understanding of their volunteerism was lacking, motivation and morale were negatively affected. During the intervention, some small non-financial incentives (i.e. T-shirts and soap) were provided. Some respondents especially community health workers felt these small, non-financial incentives maintained CHW motivation.
Provision of incentives like t-shirts during the training motivated the CHWs… (Health Unit Management Committee Chairperson, IDI).
CHW Supervision: Provision of ongoing support to CHWs by facility-based supervisors was seen as critical for maintaining CHWs and community-based programming; the health facility staff who supervise CHWs built trust and were seen to facilitate long-term CHW network success.
CHW Refresher Training: Interval training to review key topics and introduce new skills and knowledge is known locally as ‘refresher training’. Refresher training was seen by participants as a promotor for CHW momentum and ongoing motivation. Upon the project ending, decreased opportunities for training was seen as a threat to sustainability.
Refresher trainings were meant to refresh them [CHWs) and since the time they were trained…they have never got any other training. So, think of that. A person who is totally illiterate, does not know how to read and write, if you do not make a refresher training, he or she forgets everything. Even filling the register becomes a problem…they have totally forgotten because other organizations which come they do not train them, that’s the most painful part of it. (Health Assistant, IDI).
3) Community Attitudes and Beliefs
Respondents noted that to maximize and sustain CHW network health impacts community understanding of the CHW role and responsibility was critical. While some communities were early adopters, others communities increasingly engaged only when ‘incentivized’; certain communities continued to hold deeply rooted community beliefs and attitudes that conflict with CHW messaging.
Community Engagement: Solid engagement by implementers of broad community at the start of the interventions was seen as key in supporting CHWs roles in the community post-intervention. Initial intervention sensitization about potential benefit and roles of CHWs increased uptake of health promotion messaging by the community members.
Sometimes, a programme can be introduced in a certain community but there is no awareness and there is no mobilisation. People do not know that the programme is going to help them, people do not know their responsibility in that programme, the role they are supposed to play and the role implementers. For programmes [health related] to work, people should know their role, as the beneficiaries and the implementers know their role. So when people [community members] are missing that knowledge of course they cannot accept such a programme. (Health worker, IDI).
Some community members seemed only interested in engaging with CHWs where they were provided with an incentive (known locally as ‘facilitation’).
People in our community thought we were being paid salary not working as volunteers…it became a challenge; you mobilize ten people only two will come if you are lucky. They want to be “facilitated”, when for us [we] have received nothing… (CHW, FGD)
Community Beliefs: Persistent and traditional beliefs contradicting CHW health promotion messaging continue to challenge uptake of messaging and practice change encouraged by CHWs and others at the community level, limiting health impact for certain populations.
Talking about family planning is a challenge. Community members say that when one uses family planning pills for a long time, they affect their performance [sexual performance]. That is what people say and we are not technical persons to give the right information. (Community Development Officer, IDI).
Among the community members, the problem we find, they have what we call preconceived opinions…they think when they go to health facilities they will find young midwives delivering them…they have trust in the old women, traditional birth attendants (Health Assistant, IDI).
4) Stakeholder Engagement
Integration of the CHW network and its supporting structures within existing government structures was described to be a key factor for sustainability, especially the extent of integration and alignment with government programs and priorities.
Alignment with District Priorities and Programs: District involvement in CHW programming was reported as an enabler of sustainability. Respondents described that long-term government support had been enhanced through active district leadership and involvement during the implementation phase. The prioritization of MNCH by the district had been accompanied by increased resources allocated to MNCH services, integration of CHW activities within district health programs, support for CHW supervisors, and improved supply chain management for medical supplies and drugs all which enabled continued CHW momentum.
District health officers and other health leaders have helped in the way of integration of [MNCH] programs. For example, in case of other meetings they get involved in and they discuss about the same interventions like immunization. They are the ones who know and bring the challenges of health interventions to the technical planning committee meetings and others such that they are funded. So they lobby for these interventions. (Community Development Officer, IDI)
Local Government Involvement: Participants linked sustainable CHW effectiveness over time with the level of local government leader support. A CHW describes his/her CHW team experiencing resistance when not well-supported by elected community leaders:
… Instead of moving together as a team in what we were doing to develop our area, some [local leaders] thought we are paid salary. Others thought we are taking away their responsibilities, so instead of [the project] growing stronger, they started opposing us. You know local leaders have a lot of influence, if he/she does not support you, you may not do much on the ground. For example, instead of them advising fellow men to go with their wives for antenatal, they are not there, they are not advising fellow men on having toilets at their homes, they are not there to advise men who refuse to build kitchens and renovate their homes. For us we advise; we are not law enforcers. (CHW, FGD).
CHWs complained that since extra allowances were not available within the intervention for government officials, some were hesitant to participate in community-based health activities, jeopardizing impact:
Sometimes when you go to the [elected official] …he will say “your community programs with no allowances waste our time” …some [local leaders] will not be interested and will not help at all. (CHW, FGD).