This paper describes CHW experiences of training, resource provision and supervision in two arms of a cRCT. Participants described several shortfalls in the government-implemented CHW programme in the study area in these domains. Our findings show that the intervention package provided through this study temporarily (during the intervention) mitigated some of these shortfalls and CHWs reported higher job satisfaction and motivation as a result of the added training, support and supervision.
Our findings suggest that CHWs in the standard government system are operating in isolation and with little support. These findings are concerning considering the recommendation of a supportive system that is required for successful implementation [2, 35]. On the other hand, CHWs receiving supervision and other resources as a part of the cRCT reported that it has had significant positive impact on their motivation and ability to carry out their work effectively. These findings are important for understanding the building blocks of a functional supervision system and how these building blocks can be improved to create a more effective CHW program.
Large scale CHW programs face many challenges [36], and often - once scaled - the effectiveness partly falls away [37]. The focus in many studies is on informational content, messages, dosage and there is a need to better understand the nature of supervision provided, what resources are available, what training is conducted – and how these elements are experienced by CHWs themselves. Given the struggles of the CHWs in the control arm of this study, it appears that important building blocks are neglected or absent. This has been the case in many national CHW programs [37, 38]. The intervention in this study has somewhat mitigated these challenges and lessons learnt from it could be useful for other CHW programs.
From our interviews, it is clear that initial buy-in and engagement for the training that was conducted as part of the cRCT was low. It appears that CHW were required to perform tasks that they did not fully understand or believe in and were not supported to perform their duties. It is encouraging, however, that after the training a new understanding of the value and potential of the intervention was created, seemingly leading to improved confidence, self-efficacy and motivation for CHWs.
It is clear that training plays a major role in CHW program success. The additional training provided in this study improved CHWs knowledge and confidence and there appears to be scope for more research on both the quality of CHW training and on the need for ongoing in-the-field and other trainings [7]. Furthermore, our findings suggest that training needs to be paired with access to equipment, transport and supervision to be fully effective. CHWs in both arms of the cRCT report how the added training made a major difference in their knowledge and motivation. But knowledge without accountability and essential equipment limited the ability of CHWs in the control arm to fully make use of their skills. The added resources (equipment and transport) provided to the intervention CHWs substantially improved their ability to perform their job, which in turn improved their motivation. It is concerning that such an important building block of the CHW program is so neglected in the current system [39]. This needs to be addressed. It is possible that limited access to equipment and resources is linked to financial constraints [40], or a lack of political will or coordination [39].
CHWs in this study report major differences in the way supervision was conducted in the two arms of the trial. Findings suggest that the frequency and approach of the supervision for control CHWs was poor, echoing current evidence [14]. Intervention CHWs report an earlier lack of supervision, whereas during the study they felt more supported. The supervision approach that the CHWs did experience previously appeared to have been more fault-finding/punitive than supportive, which is reported both by CHWs in this study and others [41–45] as being demotivating. There should be a stronger focus on supervisor training [44] and on supervision strategies in designing and implementing CHW programs [13]. Given that both CHWs and supervisors in the intervention arm experience the relationship between them as a main contributing to factor to successful supervision, it is deeply concerning that supervisor posts in the control arm are either not filled, or filled by a supervisor not based in the intervention area and that none of the control CHWs were ever accompanied in the field by their supervisors. This raises the question of whether health facility supervisors [professional nurses] actually are best suited for providing supervision to CHWs. They often work in overburden health facilities with little or no time for additional activities and are usually bound to their facilities [13, 46].
CHW confidence and motivation increased through improved knowledge, skills and support [47, 48] leading to better service delivery and through that, increased program credibility and community uptake. Supervision in the intervention arm of this study and others [52], appears to enhance program credibility in the community, which facilitates program acceptance. Further, the knowledge gained through Philani trainings emerged as a facilitator for community acceptance. Prior to the implementation of the Philani system, CHWs only worked with notebooks, and they describe that as they now have scales, some medication and folders – they are taken more seriously by the community and thus find it easier to gain acceptance, resonating with current literature describing how equipment enhances program credibility [42].
When planning new CHW programs, it is important to keep in mind that these building blocks work together to create a functional system in which the CHW can work effectively. Unless sufficient resources for training, supervision, equipment, and logistic support such as transport, are available – a CHW program may be inefficient. Intervention CHWs report feeling that they have more to offer the community now as they are better trained, have got access to equipment, and are being supported by supervisors. Given the importance of supervisor skills and the relationship-building required for successful supervision, more attention should be given to supervisor training. Involving all stakeholders, including CHWs and supervisors should be considered when designing CHW programs [46], and supervision strategies. Equally important to note is that it took more than 18 months for this intervention to settle, an important finding especially in light of many CHW research programs that are limited in timescale.
Our findings highlight which CHW program domains that are important for CHWs themselves and indicate that adequate resources be allocated to training, supervision, equipment and logistical support such as transport when designing a CHW program. CHWs in the control arm were more motivated after receiving additional training but experienced many challenges in putting their knowledge to use as resources and supervision was missing. The intervention in this study seem to have mitigated some of these challenges by providing additional training, equipment, transport and supportive, in-the-field supervision. In a low resource setting like the rural Eastern Cape, CHWs deliver a valuable service to their communities and need to be supported through a functional supervision system, especially in the light of an emerging focus on CHW rights and needs [48]. Our findings show that the package delivered through the Philani model can improve CHW motivation and work performance, which in turn improves community uptake and health outcomes.
Limitations
It is important to note the limitations of this study. Firstly, the CHWs interviewed in this sub-study were from a relatively small pool of Department of Health-employed CHWs taking part in a larger cRCT. This may have caused concerns about confidentially and furthermore it may have had an impact on the level of honesty in the interviews, particularly with critical feedback. We do not believe this was the case in this study, as various measures were put in place to ensure confidentiality, as described, and the feedback of DoH support was quite critical. Furthermore, the interviewer was not previously known to the CHWs and was completely independent of the EC DoH, which we believe was an advantage. Secondly, we did not have the capacity to conduct individual interviews with the full sample, and chose to randomly select CHWs for individual interviews. Some CHWs started as CHWs later than others, which may have affected their experiences. Thirdly, the first author has been involved in the Philani program, with both intervention and evaluation, which may have influenced how the data was viewed. This potential risk was mitigated by having an external interviewer conduct the interviews and having a second researcher analyse sections of the data.