In this study, we investigated the responsibilities, motivations and challenges that CHMCs face in the implementation of the CHPS initiative in Ghana and how these challenges impact on volunteerism.
Concerning the responsibilities played by CHMCs, we intended to ascertain whether CHMCs were aware of their responsibilities in the implementation of CHPS in their various zones and whether they were carrying out those responsibilities. We found that the CHMC members were aware of their role(s) in the CHPS initiative and played four key responsibilities in their various zones: providing support to the CHO through resource mobilisation, home visiting, conducting a health needs assessment, monitoring logistics availability and ensuring the wellbeing of CHO, assisting the CHOs in the planning of CHPS activities, ensuring that they were aware of the activities undertaking by their respective CHOs; and helping in the amicable resolution of conflicts between the CHO and community members.
The responsibilities performed by the CHMCs in the System Learning Districts for the effective functioning of their respective CHPS compounds were in line with the requirements of the CHMC per the community health volunteers training manual developed by the [8]. Again, the roles and responsibilities of the CHMCs in the two System Learning Districts were similar to the roles of community health committees in some African countries such as Zimbabwe. In the case of Zimbabwe, the role of community health committees include; identification of priority health problems within communities, planning how to help communities raise their resources, organising and managing community input and advocating for the availability of resources for community health activities and inputs [26].
As an essential component of their responsibilities, discussants were always aware of the various services rendered by their respective CHOs. Home visits, educational talks (in communities and schools), disease control programmes, home deliveries, treatment of minor ailments and conduction of child welfare clinics (CWC) were some of the activities that were known to be conducted by CHOs in the various CHPs zones by the CHMCs. To the discussants, being aware of the various activities of the CHO did not only serve as an indicator of their performance but also served as a measure to keep their respective CHOs on their toes to deliver on their mandate. The finding was in line with the expectations of the CHMC, who are expected to perform an oversight responsibility [8]. Also, further studies support this finding [27].
We found that the CHMC was always involved in the planning and undertaking of health activities in their respective zones. Some of the activities the CHMC planned in unison with the CHOS include; how to run the health facility, development of action plan, planning on the treatment of neglected tropical diseases, and how to keep the CHPS compound tidy. Working together with people (teamwork) to improve the health status of the community is a skill that every CHO is supposed to acquire under the CHPS initiative [8]. As such, they are supposed to involve the CHMC in the planning of their activities. This element has been affirmed by research [28]. Hence, the involvement of the CHMCs in planning activities of the CHO is likely to improve the health outcomes of the communities. Even though discussants did not receive any form of recognition from their community members, they went ahead to carry out their duties to the best of their abilities. It could be argued that the opportunity to contribute to the improvement of individual and communal health outcomes through the strengthening of the CHPS initiative is a strong driving force to get community health committees to effectively do their work. Thus, the CHMCs in the two System Learning Districts were effectively carrying out their expected responsibilities in line with the training manual of the [2] despite a lack of recognition for volunteers.
Although CHMCs constitute an integral part of the successful implementation of the CHPS initiative, membership is purely voluntary. As such, one must have a strong motivation to serve on such a committee, taking into consideration the challenges that are associated with community health volunteerism. Three main reasons (provision of leadership to improve community health needs, opportunity to upgrade personal skills and the moral obligation of the affluent in society to give back to their communities), grouped into three thematic areas (the value function, the understanding function and the protective function respectively) under the functional approach of volunteerism [14] were the main reasons why members obliged to serve on their respective CHMCs. In other words, both intrinsic and extrinsic motivation [29] played a role in driving discussants to become community health volunteerism in our two System Learning Districts.
The value function was found to be an important contributor to volunteerism in the two System Learning Districts. Some CHMC members were of the view that they owed it to their communities to volunteer and provide the much-needed leadership to help properly steer the affairs of their respective CHPS facilities to maximise their performance and improve the health status of their communities thereby reducing the burden of existing health disparities in the country. This, they said, could be achieved through the conduction of proper community health needs assessment guided by effective leadership. Hence, some CHMC members believed that their presence on their respective CHMCs would enrich the performance of the committees to enable effective primary healthcare delivery in their zones by maximising the performance of their various CHPS compounds. Thus, they were concerned for the welfare of their communities and therefore decided to contribute to societal development. This assertion has been supported by studies conducted in the USA [30] and the United Kingdom [31].
The understanding function was also found to be another motivating variable for some CHMC members to volunteer on their respective CHMCs. Members were ready to work as volunteers to help improve the health outcomes of their respective communities by agreeing to serve on their respective CHMCs. CHMCs who were traditional birth attendants were of the view that being on their respective CHMC would enable them to improve on their knowledge on skilled delivery and thereby serve their communities better. To them, better understanding and skills in deliver will help improve delivery outcomes in their various communities even if they received no financial reward for the work they do. Studies conducted in Malaysia [32] and elsewhere in the world [33] reported similar findings where people volunteer to upgrade their skills. Furthermore, studies have found that while volunteers may not wish to receive some form of incentive for their work, most volunteers are more likely to give off their time when they perceive they are upgrading their knowledge, skills and understanding through volunteerism [34]. It could, therefore, be argued that volunteerism, it could lead to skills development becomes more attractive to prospective volunteers. The aspect of volunteerism in the CHPS initiative should, therefore, be made attractive by incorporating skills development training programmes for volunteers in their field of expertise to motivate them to give off their best.
Furthermore, the protective function, borne out of the feeling of guilt, motivated some discussants to serve on their various CHMCs. The financial and social standing of some community members pushed them to commit and work with their respective CHOs as a way of giving back to their communities. For such group of volunteers, they felt fortunate enough to have reached their current social standing and thus felt guilty to refuse to serve their people as volunteers to help improve communal health outcomes when they were better placed to do so. They, therefore, had a moral duty to play by giving back to their communities and found no better way than to volunteer to join their respective CHMCs. In short, they felt guilty for being socially and economically advantaged over other community members and had to do the needful by volunteering as CHMC members to help uplift their communities. This finding was supported by similar studies conducted elsewhere in the world [35, 36].
Concerning the challenges that CHMCs faced in the discharge of their duties, several issues were raised. These ranged from financial, logistical and telecommunication, lack recognition and support from community members, to lack of motivation and lack of frequent skill development training programmes for CHMCs who doubled as TBAs in their respective communities. These challenges were also found to have a negative influence on the performance of CHMCs as they were demotivated as a result. The Population Council and the Ghana Health Service [8] posited that community health volunteers, including CHMC members, are to be motivated by their respective communities to keep up with their voluntary work. Thus, they need constant encouragement, support and recognition from their communities. Hence, the lack of remuneration and support for community health volunteers, as found in this study, conflicts with such recommendation. Evidence suggests that projects that offer minimal economic incentives to community health volunteers tend to limit their focus and their performance while those that offer some form of incentives maximise the potential of such workers [37, 38]. The lack of motivation was therefore found to demotivate community health volunteers since they felt neglected. Efforts should, therefore, be made to find ways of remunerating community health volunteers to encourage them to give off their best if successful implementation and sustenance of the CHPS initiative is to be achieved.
Logistical and technological challenges such as the unreliable supply of proper working gear, lack of bicycles and tricycles as poor telecommunication network also served as a demotivation for some CHMC members and hampered their work. Studies have shown that lack of these supplies to volunteer health workers diminishes the effectiveness and seriousness they attach to their work [33, 39]. The lack of supply of basic logistics such as raincoat and bicycles has therefore led apathy and bitterness on the part of some CHMC members, thereby affecting their maximal cooperation and operations as community volunteers which is likely to impact on the running of their respective CHPS compounds for communal benefit. The lack of telecommunication services in some of the communities also hampered the work of CHMC members. As members are drawn from different communities and villages in the CHPS zone to form the CHMC, some members hail from communities where there is weak or no telecommunication signal at all, thus making telephonic calls difficult. This affected the organization and attendance of meetings of the CHMC. Moreover, valuable time is lost in situations where there is the need to report emergency cases to the CHO or when referrals need to be made as key stakeholders such as ambulance drivers, become unreachable due to poor telecommunication network. Participants were therefore handicapped and demoralized to effectively perform their duties as volunteers. Meanwhile, it has been found that to effectively mobilise communities for positive health outcomes, there is need for an effective communication network in these rural communities [40, 41], hence, efforts should be made to improve on logistical and telecommunication challenges facing communities under the various CHPS zones in Ghana.
Moreover, as part of the community health volunteers training manual, various suggestions were made as to the need to recognize and motivate community health volunteers by the Ghana Health Service. To this end, communities are expected to assist CHMC members on their farms or businesses, or provide them with foodstuffs as well as pay their transportation costs to training programmes and other meetings. Also, communities are expected to provide logistics such as working gear, bicycles and motorcycles as well as money to cover maintenance cost [8]. Unfortunately, we established that communities no longer offer these motivational and supportive services to community health volunteers, including the CHMC. The lack of recognition, therefore, served as a demotivation to CHMC volunteers and thus hampered their work.
The last challenge, as stipulated by discussants, especially those who also served as TBAs, was their disappointment in the lack of periodic refresher courses on their skills. The importance of training courses as a source of motivation, capacity building and performance for volunteers has been scientifically established [42]. Hence, failure to provide such an incentive which is of utmost importance to people who play a crucial role in communal delivery outcomes served as a demotivation to CHMCs, especially TBAs and thus, negatively affected their output as effective community health volunteers.