Factors Impacting Sustainability of Community Health Worker Programming in rural Uganda: A Qualitative Study

Abstract

Background Despite significant global progress towards decreased child mortality over the past decades, over 5 million children died before reaching their fifth birthday in 2018. Additionally, the number of women dying during pregnancy and childbirth was 295, 000 in 2017. Majority of these deaths occurred in sub Saharan Africa yet these deaths are preventable with known interventions. A huge global investment has been made in initiating community health work (CHW) programs which play a critical role in health promotion with increasing scale up in sub Saharan Africa. The government of Uganda continues to identify maternal, newborn and child health (MNCH) programming as a priority and national policies continue to encourage community-based approaches for health promotion through the Village Health Team approach to reduce maternal and child mortality. However, sustaining of CHWs programs remains a challenge and less is known about if and how these CHW networks can be maintained. Methods A sustainability-focused qualitative evaluation was conducted five years following a district-wide comprehensive MNCH intervention that involved selection and training of a large CHW network (n =2626) in 2 rural districts in southwest Uganda. Focus Group discussions (FGDs) and in-depth interviews (IDIs) were conducted to gain insights into the factors affecting CHW program sustainability. Interviews were digitally recorded then translated and transcribed directly into English. Data was managed using NVivo software (version 12, QSR International, Burlington Mass.). Thematic content analysis was done to identify themes relevant to sustainability. Results Enablers and barriers to CHW sustainability identified by study participants included health system effectiveness (availability of supplies, medicines and services and availability of facility health providers), community health worker program factors (CHW selection and training, CHW recognition and incentives, CHW supervision and CHW refresher trainings), community attitudes and beliefs, and stakeholder engagement (alignment with district priorities and programs and local government involvement). Conclusion Effectiveness of health systems and human resources were major factors in sustainability for this community health intervention. Sustainability could be strengthened through increased community member involvement during implementation and improved support for general health system effective functioning.