Our findings show that CHW programmes were influenced by a variety of factors which were programme related, while others were contextual and health systems related. The programmes used different types of CHWs, and their tasks were mainly in health education and promotion, treatment of some diseases in the children under five, distribution of drugs for NTDs, and facilitating referrals.
The selection of the most suitable community members to become CHWs is vital to the quality and acceptability of health services provided [19, 20]. Similar to the experience in South Sudan, several studies in other settings have established that CHWs are selected based on community membership, social acceptance, gender, knowledge of the culture and languages, personality, past experience, and the level of education [21–23]. The literacy level in South Sudan is a serious obstacle to the recruitment of CHWs since less than 35% of men and 19.2% of women is literate [24]. Working with communities during the selection process is vital because it ensures that the members understand and accept the work of the CHWs [25, 26]. Although the communities led the selection process, we found instances where the selection criteria [14] were not followed. There was also a preference for married women over men and young women over young men since they are deemed to stably reside in the communities. Brown and colleagues, however, advised not to use either age or marital status as selection criteria [20, 25], and it is generally advisable to have a mix of female and male CHWs, depending on the health topics and cultural norms [25, 27, 28].
Our findings reveal differences in the duration of training sessions for CHWs on similar topics across the counties due to lack of funds and standardised training modules. Elsewhere, studies uncovered variations in the content, quality, length, and training methodologies between CHW programmes [25, 27, 28]. Researchers have reported cases where CHWs received training sessions that were insufficient and of poor quality [23, 28, 29]. Instead, training sessions should be competency-based, to allow the participants to gain the necessary technical and social skills, and the training materials should be in a language understood by the CHWs, preferably with pictographic illustrations [25].
We found that refresher training sessions were only occasionally offered and did not all make use of standardised training material. A study from Uganda concluded that regular refresher training sessions for CHWs managing multiple infectious diseases were needed since the initial training sessions were not sufficient to ensure CHW performance [30]. Moreover, international guidelines and experiences elsewhere stipulate that training sessions need to be gender sensitive and responsive since women and men might have different literacy levels and often operate under different social expectations [25, 28]. Some CHW programmes (e.g. for home health promoters and traditional birth attendants) did not have official training curricula. The quality of training, e.g., for CHWs to understand their roles, the services they will offer, and how to provide them, is a critical factor in the success of any CHW programme and requires adequate investment [25, 31].
This study found that the supervision of the CHWs was carried out by supervisors from the community, the health system, and the supporting NGOs. The health facilities and CHDs provided minimal supervision to the CHWs, for example in the iCCM programme. This was partly because health workers perceived supervision of the CHWs as additional work that needs to be incentivised. Similar to our findings, a study done in Guinea, Liberia, and Sierra Leone identified weak links between CHWs and the formal health system as deterrents to effective implementation of community health programmes [32]. Some studies found that during the conflict, the use of community members as CHW supervisors was crucial in increasing the resilience of the iCCM programme [16, 33].
NGOs played an important role in supervising CHWs in the areas where they operated. Supervision should provide opportunities for learning, problem-solving, (community) feedback, and quality assurance. Supervision is an opportunity to assess and strengthen the knowledge and skills of CHWs, thereby improving the quality of service delivery [25, 27, 29, 31, 34, 35]. However, there was inadequate supervision exemplified by infrequent visits due to insecurity, and lack of means of transport. Studies have reported that during conflicts, and where there is insecurity, the frequency of supervision reduces or even stops [16, 36, 37]. A study in Guinea, Liberia, and Sierra Leone also found weak supervision of CHW activities [32]. Additionally, in Rwanda, the infrequent supervisory visits compromised the quality of community health programmes [23].
We found that CHWs received material and financial incentives to facilitate their work, yet incentives were not harmonised across the programmes. Studies have revealed that CHWs are usually given small financial incentives such as honorarium, travel allowance, or other irregular payments but are also motivated by non-financial incentives such as social recognition and prestige, an opportunity to gain knowledge and access to medicines that can benefit their families [27, 28, 38]. Whether CHWs should work as volunteers or should be paid a salary is often under debate [27]. WHO recommends that CHWs should be remunerated based on their task descriptions [25]. Without proper compensation of CHWs, the community health programmes may face high attrition [25, 27, 28, 39].
Our findings show that CHWs’ performance in South Sudan is generally assessed based on the activities conducted and the reports submitted. Generally, a lack of performance management frameworks was found. Performance appraisal of the health workforce is fraught with challenges, however, there is a consensus that the ultimate goal should be to improve motivation and performance of workers for better health outcomes [40, 41]. A recent study proposed a framework for CHW performance measurement and some of the domains include; CHW incentives, supervision and performance appraisal, data use, data reporting, service delivery, quality of services, CHW absenteeism and attrition, community use of services, experience of services, referrals, and trust [42]. Closely linked to supervision is the quality of reported data.
Our findings show that the CHWs were reporting on their activities, but the quality of data was regarded as poor.
We found that, despite variation, communities were involved in situation analysis, planning, selection of CHWs, and supervision of community health activities. There is growing consensus that programmes that seek to promote empowerment should involve participation of community members, to offer opportunities for gaining knowledge and skills, confidence, experiences and ability to detect and solve problems [43–47]. Community participation provides people with a sense that members can solve their problems through careful reflection and collective actions [25, 47, 48]. In Ghana, community leaders, trained volunteers and other community members supported health education activities to facilitate skilled birth attendance and contributed land, construction materials, and labour for building health centres [49]. Our findings revealed that in some locations, the BHCs did not exist or were dormant. Given their importance in the BHI strategy, there is need to form or reactivate the committees to ensure ownership and sustainability. Hence, strengthening local governance structures (e.g., the BHCs) and processes, with attention to appropriate representation and inclusion, should be part of the investment in CHW programmes [50].
This study highlights a need for a collaborative relationship between the CHWs and facility staff to ensure accountability, coverage and quality of care. For example in Mozambique, coordination and communication between the CHWs and the formal health workers enhanced accountability towards the community and the health system [51] and in Uganda, improved communication between CHWs and clinicians through m-health improved the quality of care [52].
Our findings reaffirm that CHW programmes are funded by donors and implemented through NGOs. Kozuki and colleagues reported that there was no funding for iCCM from the national budget. Therefore, once donor funding ceased, the organisation and the structures were left hanging [33]. A study done in Mayendit county in 2017, however, found that when the local authorities have active and responsible roles in the programmes, community engagement is more sustainable [2]. Our findings reaffirm that CHW programmes were fragmented and lacked a standardised regulatory framework. There was inadequate coordination among the community health programmes in the country. Erismann et al., found similar weaknesses in South Sudan and Haiti and recommended establishing and strengthening coordination mechanisms to avoid creating inequalities that might lead to tension and deterioration in social cohesion [2]. Lehmann and others [50] have suggested that harmonising and integrating donor support is an essential building block to the functionality of any CHW programme. Hence, BHI in South Sudan was established to ensure co-ordination and harmonisation of CHW programmes.
Our findings are commensurate with the observation in other fragile and conflict-affected settings where NGOs often create parallel supply chains to ensure the consistent supply of drugs to the NGO supported facilities [16, 53]. Yet, our findings also show inadequate facilities for the storage of medical commodities in the health facilities and at county level. There were also reports of drug misuse leading to stock-outs. The shortage of medical commodities, which are mainly supplied by NGOs, can have consequences beyond the immediate supply, such as a reduction in the trust of CHWs by community members and a decline in utilisation of the services [13, 39, 47]. In Guinea, Liberia, and Sierra Leone during the Ebola outbreak, the supply chain, restriction on movement of the NGO staff due to hostilities, community resistance, and closure of some health facilities hampered service delivery [32]. Other studies in Afghanistan and South Sudan reported that severe weather conditions and insecurity along the roads, poor management, and high distribution costs led to stock-outs of the medical commodities [29, 33, 36].
We identified some contextual factors that affected the previous community programmes and might impact the BHI, such as insecurity, the economy, community, and gender-related issues. Conflicts in Unity and Western Equatoria states led to suspension and even termination of some of the CHW programmes. Some studies from South Sudan demonstrated that in parts of Unity State where there was a conflict, the internally displaced CBDs continued to provide the services to displaced persons and their host communities [2, 33]. In some counties, where weather and security challenges were anticipated, the NGOs and supervisors prepositioned the drugs to last them for longer periods without replenishment. This ensured availability of the drugs and other medical commodities during the crises [33, 36, 54].
While this study did not show a direct relationship between the effects of economic crisis and motivation, the CHWs were reported to prefer financial incentives above material incentives to provide for their families. There were instances in this study where some communities were reported to prefer female CHWs compared to their male counterparts. However, the low level of literacy, especially among women [24], puts them at a disadvantage of being selected as a CHW. Despite the conflicts in the country, the government has made political commitments by introducing the BHI strategy to improve access to healthcare [13, 14]. This, however, remains hampered by a lack of (public) funds and legislative framework to support CHWs who have no formal public health certification.
The insights from our findings give rise to several policy recommendations. There is a need for the MoH to take a leading role in coordination to ensure ownership and sustainability of the CHW programme. This can be done through policy dialogues, information sharing, participatory decision-making, and resource mobilisation. It is also essential for policymakers to design an incentive structure that will not create a financial burden to the government and the communities. To ensure a strong and functional CHW programme, there is a need for a collaborative relationship between the CHWs and the health facility staff. This will facilitate supervision, enhance accountability, supply of medical commodities and referral of clients. Supervision should be frequent, regular and use standard supervision guidelines with clearly defined objectives to reinforce knowledge, skills, competencies, and motivation. Lastly, a minimum quality of training can be assured through using set guidelines and/or curricula based on the context and education level of the CHWs and the type of work they are expected to perform.
Study Limitations
This study was subject to several limitations. Participant’s bias may have occurred since the participants were either policymakers or programme implementers, which could have resulted in them being less critical about the programmes they were responsible for. The study, however, made a conscious effort to cross-validate and triangulate information from stakeholders with different interests in the matter. The study was carried out at the onset of BHI implementation; thus, some aspects of the strategy may not have been clear to both the participants and the researchers and certain policy details may have shifted.
The community activities presented in the HPF reports were only those under the programme contractual obligations. The study did not capture the views of CHWs or community members directly, and, therefore, cannot be taken to represent their experiences. As the BHI is being scaled up, future research should include CHWs to learn from their experiences. This includes due attention to the power context in which both Boma health workers and citizens operate, influencing CHWs’ ability to deliver services and the citizen’s ability to access them.