I was interested to see this paper in the open access journal Human Resources for Health. It draws attention to the importance of the process for selection of CHWs: ‘Though there is consensus that local communities should be involved in the selection of CHWs, questions have remained on how that selection should be structured.

A review of studies on CHW programmes noted that authors state that CHW were “selected by the community” without showing how this was done. This is problematic if large-scale programmes involving volunteer CHWs are to be sustained in communities. The question that needs to be constantly asked is what is the best way to draw volunteers from a community, without relying on financial incentives?’ Indeed, this suggests a wider question: How to attract and retain CHWs, with or without financial incentives, in a way that maintains and indeed strengthens current links and trust between the CHWs and the communities they serve.

It seems to me that one of the biggest challenges facing scale-up of CHWs and their integration into the formal health system will be: How to integrate CHWs while maintaining their trust, accountability and sense of ownership to and by the communities they serve. I look forward to hear your views.

CITATION: Selection and performance of village health teams (VHTs) in Uganda: lessons from the natural helper model of health promotion

Emmanuei Benon Turinawe, Jude T. Rwemisisi, Laban K. Musinguzi, Marije de Groot, Denis Muhangi, Daniel H. de Vries, David K. Mafigiri, and Robert Pool

Human Resources for Health  (2015) 13:73

http://www.human-resources-health.com/content/pdf/s12960-015-0074-7.pdf

ABSTRACT

Background: Community health worker (CHW) programmes have received much attention since the 1978 Declaration of Alma-Ata, with many initiatives established in developing countries. However, CHW programmes often suffer high attrition once the initial enthusiasm of volunteers wanes. In 2002, Uganda began implementing a national CHW programme called the village health teams (VHTs), but their performance has been poor in many communities. It is argued that poor community involvement in the selection of the CHWs affects their embeddedness in communities and success. The question of how selection can be implemented creatively to sustain CHW programmes has not been sufficiently explored. In this paper, our aim was to examine the process of the introduction of the VHT strategy in one rural community, including the selection of VHT members and how these processes may have influenced their work in relation to the ideals of the natural helper model of health promotion.

Methods: As part of a broader research project, an ethnographic study was carried out in Luwero district. Data collection involved participant observation, 12 focus group discussions (FGDs), 14 in-depth interviews with community members and members of the VHTs and four key informant interviews. Interviews and FGD were recorded, transcribed and coded in NVivo. Emerging themes were further explored and developed using text query searches. Interpretations were confirmed by comparison with findings of other team members.

Results: The VHT selection process created distrust, damaging the programme’s legitimacy. While the Luwero community initially had high expectations of the programme, local leaders selected VHTs in a way that sidelined the majority of the community’s members. Community members questioned the credentials of those who were selected, not seeing the VHTs as those to whom they would go to for help and support. Resentment grew, and as a result, the ways in which the VHTs operated alienated them further from the community. Without the support of the community, the VHTs soon lost morale and stopped their work.

Conclusion: As the natural helper model recommends, in order for CHW programmes to gain and maintain community support, it is necessary to utilize naturally existing informal helping networks by drawing on volunteers already trusted by the people being served. That way, the community will be more inclined to trust the advice of volunteers and offer them support in return, increasing the likelihood of the sustainability of their service in the community.

SELECTED EXTRACTS:

‘The natural helper model (NHM) is based on a simple premise: within every community, an informal helping network already exists. People with problems naturally seek out other people they trust, and interactions are often spontaneous [31]. The NHM taps into and uses this already existing network to disseminate accurate information on health and other social services to the community; since many people are linked to different helping networks simultaneously [32], the dissemination of health messages can be reinforced.’

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