How should community health workers in fragile contexts be supported: qualitative evidence from Sierra Leone, Liberia and Democratic Republic of Congo

Abstract

Background: Community health workers (CHWs) are critical players in fragile settings, where staff shortages are particularly acute, health indicators are poor and progress towards Universal Health Coverage is slow. Like other health workers, CHWs need support to contribute effectively to health programmes and promote health equity. Yet the evidence base of what kind of support works best is weak. We present evidence from three fragile settings-Sierra Leone, Liberia and Democratic Republic of Congo on managing CHWs, and synthesise recommendations for best approaches to support this critical cadre. Methods: We used a qualitative study design to explore how CHWs are managed, the challenges they face and potential solutions. We conducted interviews with decision makers and managers (n = 37), life history interviews with CHWs (n = 15) and reviewed policy documents. Results: Fragility disrupts education of community members so that they may not have the literacy levels required for the CHW role. This has implications for the selection, role, training and performance of CHWs. Policy preferences about selection need discussion at the community level, so that they reflect community realities. CHWs' scope of work is varied and may change over time, requiring ongoing training. The modular, local and mix of practical and classroom training approach worked well, helping to address gender and literacy challenges and developing a supportive cohort of CHWs. A package of supervision, community support, regular provision of supplies, performance rewards and regular remuneration is vital to retention and performance of CHWs. But there are challenges with supervision, scarcity of supplies, inadequate community recognition and unfulfilled promises about allowances. Clear communication about incentives with facility staff and communities is required as is their timely delivery.

Community Health Workers' Experiences in Strengthening the Uptake of Childhood Immunization and Malaria Prevention Services in Urban Sierra Leone

“…Motivating factors described by the CHWs in our assessment largely overlap with those from previous studies ( 31 – 35 ). A study carried out in Tanzania found that dedication to public service, desire for health knowledge, personal pride, and positive reception by community members served as sources of CHW motivation ( 32 ).…”

“…Previous research suggests that CHWs in LMICs tend to be inundated with many tasks ( 22 , 33 , 38 ), which reinforces the results of our assessment. In addition to multiple responsibilities, research from Sierra Leone, Liberia, and the Democratic Republic of Congo suggests that CHWs sometimes take on second jobs because financial incentives they receive are limited, and this may result in CHWs being not fully committed to their healthcare duties ( 31 , 39 ). Unfulfilled stipend disbursements demotivated CHWs in our assessment, which is also a persistent challenge in other settings ( 33 , 40 , 41 ).…”

Community health workers at the dawn of a new era: 9. CHWs’ relationships with the health system and communities

“…Policy preferences for CHW selection need to reflect community realities. For example, in fragile settings such as in Liberia and the Democratic Republic of the Congo, it was challenging to find candidates who were literate, though the policy included literacy as a requirement [ 83 ]. In Sierra Leone and Liberia, the policies state a preference for female CHWs.…”

“…In Sierra Leone and Liberia, the policies state a preference for female CHWs. However, in Sierra Leone there were more male candidates due to hesitancy on the part of women to apply (due to cultural norms), while in the Democratic Republic of the Congo there were more female CHW candidates because of the many active women’s associations there [ 83 ].…”

Does Inter-Border Conflict Influence the Views of Task Sharing Among Community Health Volunteers in Nigeria? a Qualitative Study

“…This broad, analytical transactional framework is based on existing models Kok et al, 2015;Palazuelos et al, 2013) and ndings that have been used by others to validate the framework to support improvement of healthcare services through policy development (Dieleman et al, 2011;Kok et al, 2015;. These frameworks can also be employed in fragile and con ict affected contexts, although the evidence base related to their application is weak (Raven et al, 2020a).…”