Governance of community health worker programs in a decentralized health system: a qualitative study in the Philippines

Background

Sustainable Development Goal (SDG) 3 commits to promoting wellbeing “for all, at all ages” by the year 2030, with SDG 3.8 specifically committing to universal health coverage (UHC) [1]. This emphasis on universal health coverage has strengthened national and international commitments to the equitable delivery of primary health care services, especially in low-resource settings, and has renewed interest in community health worker programs as a means of implementing UHC [2]. Community health worker (CHW) programs, in which community members are trained in basic health care delivery to provide care to their local communities, have been identified as a key intervention for achieving UHC [2,3,4,5]. Depending on the program, CHWs may be responsible for a wide range of tasks (e.g., maternal and childhood health, nutrition, immunizations) or for individual disease-specific interventions (e.g., anti-malaria campaigns, tuberculosis testing) [6]. In low- and middle-income countries (LMICs) where governments are increasingly adopting decentralized health care policies, CHWs are often the first point of contact with health systems for many individuals [6, 7]. Thus, these programs serve as an intermediary between health systems and communities, with the intention of extending the reach of health care providers, enhancing access and equity of health services, and improving individual and community level health outcomes (e.g., [4, 6, 8,9,10,11,12]).

Despite this optimism for CHW programs and their potential contributions to achieving UHC, there are several factors that may negatively influence the governance of these programs.Footnote1 In many LMICs, local, regional, and national politics and policies have been found to impact the effectiveness of CHW programs [9, 13]. For example, the existence of legislation regarding CHWs can support the rights of CHWs (e.g., payment, working conditions) and enhance the sustainability of programs [9]. Conversely, political and local support can be weak, with limited human and fiscal resources allocated for programs, minimal training and supervision provided to CHWs, and inconsistent monitoring of programmatic outcomes [11, 14,15,16]. Additionally, operating at the intersection of formal health systems and communities necessitates the involvement of multiple actors, but relationships between these actors are not always coordinated or strategic [12, 17, 18]. These relationships, which are influenced by factors such as a community’s socioeconomic status, the level of community participation, and the power of community leaders, can complicate program governance [6, 12, 15].

Sociocultural and individual-level factors also influence the governance of CHW programs. Individuals have diverse backgrounds and motivations for becoming and remaining CHWs, which are based on socio-economic, political, and pro-social incentives (e.g., civic and religious ideals of service and care) [19,20,21]. For example, existing research has explored the role of gender and household socio-economic status within CHW programs [9, 11, 21, 22]. These factors can also influence CHW training, retention, and remuneration [6, 14, 16]. Although existing literature has explored these sociocultural and individual-level factors, as well as the broader governance challenges of CHW programs, few studies have examined the intersection of these factors and their potential influence on the contributions of CHW programs to achieving UHC within LMICs.