Table 2 Programme design and cross-cutting factors influencing HSAs’ relationships with the community and health sector
Programme design elements influencing relationships | Cross-cutting factors influencing relationships | ||
|---|---|---|---|
Trust | Communication and dialogue | Expectations | |
HSAs’ relationships with the community | |||
Nature of HSAs’ position and role | Honesty, familiarity, good attitudes, reliability, respect and time spent in the community enhanced community trust, and if not present, hampered community trust in HSAs | When HSAs were either from or resided in the communities, this supported opportunities for ongoing communication and dialogue Increasing amount of facility-based tasks or prioritization of agricultural work undermined communication and dialogue between HSAs and communities | |
Support from the community | Support from traditional leaders enhanced HSAs’ credibility, which enhanced community trust in HSAs Mistrust from volunteers towards HSAs about financial incentives hampered community trust in HSAs | Support from traditional leaders facilitated communication and dialogue between HSAs and community members, for example during community meetings | Volunteer support helped HSAs in managing community expectations, improving HSAs’ relationships with the community Expectations of volunteers that could not be met, regarding financial and other incentives, training and supplies, hampered HSAs’ relationships with the community and health sector |
Community monitoring and accountability structures | Within some programmes, e.g. iCCM, a formal system was in place to support and monitor drug distribution through the VHC, in others this was absent or mediated by traditional leaders. This study revealed no further information on underlying factors influencing HSAs’ relationships with the community. | ||
HSAs’ relationships with the health sector | |||
Support from other health workers, managers and NGOs | Disrespect from other health workers led to HSA and community mistrust towards the health sector Support from other health workers enhanced credibility and community trust towards HSAs Perceived lack of management support and favouritism regarding supplies led to mistrust from HSAs towards management | Disrespect from other health workers hindered communication between other health workers and HSAs | HSAs’ expectations with respect to supplies, bicycles, and housing issues were not met (particularly in rural areas) |
Training | Perceived favouritism regarding training led to mistrust from HSAs towards management | HSAs’ training expectations were not met – particularly in rural and hard to reach areas | |
Supervision | Lack of care and insight of supervisors into HSAs’ situation led to mistrust of HSAs towards supervisors | Supervision with a negative approach and without feedback hindered communication between HSAs and supervisors/management | |
Referral | Lack of feedback after referral hindered communication between HSAs and the health sector | ||
Monitoring and accountability structures | Monitoring and accountability structures from the side of the health sector were programme specific and irregularly conducted because of resource constraints. The study revealed no further information on underlying factors influencing HSAs’ relationships with the health sector. | ||