Abstract
BackgroundThe performance of community health workers (CHWs) in Swaziland has not yet been studied despite the existence of a large national CHW program in the country. This qualitative formative research study aimed to inform the design of future interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, we aimed to determine what potential changes to their program CHWs and CHW program managers perceive as likely leading to improved performance of the CHW cadre.MethodsThe CHW cadres studied were the rural health motivators, mothers-to-mothers (M2M) mentors, HIV expert clients, and a community outreach team for HIV. We conducted semi-structured, face-to-face qualitative interviews with all (15) CHW program managers and a purposive sample of 54 CHWs. Interview transcripts were analyzed using conventional content analysis to identify categories of changes to the program that participants perceived would result in improved CHW performance.ResultsAcross the four cadres, participants perceived the following four changes to likely lead to improved CHW performance: (i) increased monetary compensation of CHWs, (ii) a more reliable supply of equipment and consumables, (iii) additional training, and (iv) an expansion of CHW responsibilities to cover a wider array of the community’s healthcare needs. The supervision of CHWs and opportunities for career progression were rarely viewed as requiring improvement to increase CHW performance.ConclusionsWhile this study is unable to provide evidence on whether the suggested changes would indeed lead to improved CHW performance, these views should nonetheless inform program reforms in Swaziland because CHWs and CHW program managers are familiar with the day-to-day operations of the program and the needs of the target population. In addition, program reforms that agree with their views would likely experience a higher degree of buy-in from these frontline health workers.
Highlights
The performance of community health workers (CHWs) in Swaziland has not yet been studied despite the existence of a large national CHW program in the country
This study focused on four CHW cadres in Swaziland: rural health motivator (RHM), mothers-to-mothers (M2M) mentors, HIV expert clients, and a community outreach team for HIV
Analyzing the data from the semi-structured qualitative interviews with the 54 CHWs and 15 CHW program managers, we found that CHWs and program managers viewed the following four factors as needing improvement to increase CHW performance: (i) higher monetary compensation, (ii) a more reliable supply of equipment and consumables, (iii) additional training, and (iv) extending CHW responsibilities to allow them to attend to a wider variety of healthcare needs
Summary
The performance of community health workers (CHWs) in Swaziland has not yet been studied despite the existence of a large national CHW program in the country. This qualitative formative research study aimed to inform the design of future interventions intended to increase the performance of CHW programs in Swaziland. Faced with a vast shortage in physicians and nurses [1], task-shifting to less well-trained health worker cadres has been promoted to increase access to healthcare in many low- and middle-income countries [2,3,4]. Large-scale, national CHW program, called the rural health motivator (RHM) program, which has been in existence since 1976 [7, 8]. The following key research priority in the 2006 World Health Report regarding CHWs has not yet been fully answered: “Improving performance, incentive systems and remuneration – what level and method of remuneration and types of non-financial incentives maximize cost-effectiveness but are sustainable? What are the other effective approaches to improving performance?” [2]
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