Kok et al.

Human Resources for Health (2015) 13:80

DOI 10.1186/s12960-015-0077-4

RESEARCH Open Access

A qualitative assessment of health extension

workers’ relationships with the community
and health sector in Ethiopia: opportunities for
enhancing maternal health performance
Maryse C. Kok1,2*, Aschenaki Z. Kea3, Daniel G. Datiko3,4, Jacqueline E.W. Broerse2, Marjolein Dieleman1,
Miriam Taegtmeyer4 and Olivia Tulloch4

Abstract
Background: Health extension workers (HEWs) in Ethiopia have a unique position, connecting communities to
the health sector. This intermediary position requires strong interpersonal relationships with actors in both the
community and health sector, in order to enhance HEW performance. This study aimed to understand how
relationships between HEWs, the community and health sector were shaped, in order to inform policy on
optimizing HEW performance in providing maternal health services.
Methods: We conducted a qualitative study in six districts in the Sidama zone, which included focus group discussions
(FGDs) with HEWs, women and men from the community and semi-structured interviews with HEWs; key informants
working in programme management, health service delivery and supervision of HEWs; mothers; and traditional birth
attendants. Respondents were asked about facilitators and barriers regarding HEWs’ relationships with the community
and health sector. Interviews and FGDs were recorded, transcribed, translated, coded and thematically analysed.
Results: HEWs were selected by their communities, which enhanced trust and engagement between them.
Relationships were facilitated by programme design elements related to support, referral, supervision, training, monitoring
and accountability. Trust, communication and dialogue and expectations influenced the strength of relationships. From
the community side, the health development army supported HEWs in liaising with community members. From the
health sector side, top-down supervision and inadequate training possibilities hampered relationships and demotivated
HEWs. Health professionals, administrators, HEWs and communities occasionally met to monitor HEW and programme
performance. Expectations from the community and health sector regarding HEWs’ tasks sometimes differed, negatively
affecting motivation and satisfaction of HEWs.
Conclusion: HEWs’ relationships with the community and health sector can be constrained as a result of inadequate
support systems, lack of trust, communication and dialogue and differing expectations. Clearly defined roles at all levels
and standardized support, monitoring and accountability, referral, supervision and training, which are executed regularly
with clear communication lines, could improve dialogue and trust between HEWs and actors from the community and
health sector. This is important to increase HEW performance and maximize the value of HEWs’ unique position.
Keywords: Health extension workers, Community health workers, Maternal health, Ethiopia, Performance, Community
involvement, Trust

* Correspondence: [email protected]
1
Royal Tropical Institute, P.O. Box 95001, 1090 HA Amsterdam, The
Netherlands
2
VU University Amsterdam, Athena Institute for Research on Innovation and
Communication in Health and Life Sciences, De Boelelaan 1081, 1081 HV,
Amsterdam, The Netherlands
Full list of author information is available at the end of the article

© 2015 Kok et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Kok et al. Human Resources for Health (2015) 13:80 Page 2 of 12

Background
In 2004, the Government of Ethiopia introduced the Woreda Health Office

Health Extension Programme (HEP), a free primary health

care package with four components: disease prevention
Health Centre
and control, family health, hygiene and environmental
sanitation, and health education and communication. A
female cadre of salaried community health workers Health posts: 2 HEWs per 5,000 population
(CHWs) called health extension workers (HEWs) was
introduced nationally. HEWs are secondary school
graduates and receive a 1-year training in basic health Development Group: 25-30 households
service delivery1. They are selected from the communities
that they serve and are supposed to work at the health post
level for 25% of their time and in the community for the Health Development Army: One-to-five networks
remaining 75% [1–4]. Over 38 000 HEWs are employed in
Ethiopia, contributing to a significant increase in health Figure 1 Overview of HEWs’ intermediary position between the
service coverage in recent years [2]. community and health sector.
A clearly defined hierarchy links the health sector and
HEWs to the community. The woreda (district) health
office has general oversight of the health system. One seems much lower [3], and their knowledge and per-
health centre is, on average, linked to five health posts and formance in maternal health-related tasks is poor [6].
together they form the primary health care unit. A health Ethiopia’s maternal mortality ratio remains high: 676
post serves a population of about 5000 and is staffed deaths per 100 000 live births and only 10% of women
by two HEWs who are technically and administratively deliver with a skilled birth attendant [7]. HEWs only
accountable to health centres [2]. Health professionals conduct 1.6% of all assisted deliveries in the country
from the health centres supervise HEWs, and the [8]. There have been calls for improved performance of
HEWs refer clients in need of higher level health care HEWs on maternal health-related tasks [2–4,6].
to health centres or hospitals [5]. HEWs are account- Evidence from CHW programmes worldwide has identi-
able to the administration of the kebele (lowest admin- fied several factors, related to programme design, that can
istrative unit), who in turn are responsible for giving influence CHW performance. These include CHW task
support to the HEWs [5]. definition, human resource management (including
HEWs are linked to the community through a network training, supervision and incentives for CHWs), quality
of community volunteers, who are members of the health assurance processes, resources and logistics and CHWs’
development army (HDA). The HDA was introduced in links with the community and health sector [9,10]. Health
2012, officially replacing other community-based workers systems are social institutions in which different actors are
such as health promoters and traditional birth attendants linked with each other in chains of relationships [11].
(TBAs). It is based on gradual training of model families Strong interpersonal relationships between CHWs and
by HEWs. Model families become leaders of a group of clients (henceforth referred to as the community) on one
five families known as the “one-to-five network”, who in side and CHWs and health professionals and supervisors
turn form a “development group” of 25 to 30 households (henceforth referred to as the health sector) on the other
within a village. “Graduation” to a model family occurs side are needed to ensure good CHW performance
after training in all components of the HEP and proven [12–16]3. It has been found that CHWs’ relationships
implementation at the household level. All members of with the community are strong when CHWs have been
the HDA are supposed to support HEWs in the imple- selected from and by their community and CHWs’
mentation of the HEP [2,5]. An overview of HEWs’ inter- relationships with the health sector are strong when
mediary position between the community and health there is respect for the roles of CHWs from health profes-
sector is presented in Figure 1. sionals [9,10]. The importance of CHWs’ relationships for
A number of the HEWs’ tasks are related to maternal performance is accentuated by the nature of their work
health. These include provision of antenatal care, clean (CHWs as facilitators of community agency) and their
and safe deliveries2, postnatal care, family planning, intermediary position between the community and the rest
immunization and nutritional advice. HEWs have con- of the health system. However, in-depth evidence is lacking
tributed substantially to the improvement in women’s on which factors hinder or facilitate relationships. We con-
utilization of family planning, antenatal care and HIV ducted qualitative research in southern Ethiopia to identify
testing [3]. However, their contribution to advocating facilitators of and barriers to interpersonal relationships
for skilled delivery and conducting postnatal check-up between HEWs and actors in the community and health
Kok et al. Human Resources for Health (2015) 13:80 Page 3 of 12

sector and, where possible, their impact on HEW perform- asked about all different actors with whom they interacted
ance in maternal health. and whether relationships were strong or weak and
why and how they facilitated or hindered their work.
Methods I nformation about performance of HEWs was self-
A qualitative study, using 14 focus group discussions reported and defined at two levels: the HEW level
(FGDs) and 44 semi-structured interviews, was con- (this included self-esteem, motivation, attitudes, com-
ducted in 2013 in the Sidama zone of the South Nation petencies, guideline adherence, job satisfaction and
Nationalities and Peoples Region of Ethiopia. We used capacity to facilitate community agency as characteris-
qualitative methods in order to obtain in-depth insight tics of performance) and end-user level (this included
into how relationships between HEWs and the community utilization of services, health-seeking behaviour, adop-
and health sector were shaped and, where possible, what tion of practices promoting health and community
made them facilitate or hinder HEW performance. The empowerment as characteristics of performance) [9].
participants included HEWs, TBAs, health professionals Study participants gave informed oral or written con-
and community members (Table 1). Participants were sent. Daily debriefing sessions with all data collectors
drawn from six woredas selected for a larger study, on the were held to discuss key findings, identify saturation
basis of diversity in maternal health performance and dis- of themes and refine lines of inquiry. All interviews
tance from the zonal capital. Study respondents were pur- and FGDs were digitally recorded, transcribed and
posefully sampled to represent different ages and job translated into English. A sample of transcripts was
experience and were identified with help of health centre randomly checked against the recordings by one re-
and woreda health office staff. searcher (AK).
Data were collected by four local health systems The transcripts were independently read in pairs by
researchers, who received a 1-week training in qualitative four researchers to identify key themes and develop a
data collection for the purpose of the study. Semi-struc- coding framework. This process used open coding with
tured topic guides were developed in English, trans- regard to factors influencing relationships [17], com-
lated into Amharic and Sidamigna language and back- bined with a pre-defined framework of factors that could
translated for consistency. The topic guides were influence performance [9]. Transcripts were coded using
piloted in an area that was not included in the study, NVivo (v.10) software, emerging themes were discussed
and adaptations to questions were made. The FGDs and the coding refined. The coded transcripts were
and interviews included questions on demographic infor- further analysed and summarized in narratives for each
mation, expected and performed tasks, career, experiences theme and sub-theme. Study findings were presented,
relating to maternal health, training, supervision, monitor- discussed and validated with the regional and woreda
ing and evaluation and referral. The questions focused on health offices in a stakeholder meeting.
barriers and facilitators with regard to these issues, includ- The study was approved by the Royal Tropical Institute
ing effects on HEW performance. Regarding relationships Ethical Review Committee in Amsterdam and the South
with the community and health sector, respondents were Nation Nationalities and Peoples Region Health Bureau
Table 1 Overview of focus group discussions and interviews
Method Participants No. per district No. of districts Total no. of respondents (total number of FGDs)
Focus group HEWs 1 6 57 (6)
discussions (FGDs)
Women in community 1 6 55 (6)
Men in community 0 or 1 2 19 (2)
Total 131 (14)
Semi-structured HEWs 2 6 12
interviews
Mothers 2 6 12
Traditional birth attendants (TBAs) 1 6 6
Kebele administrators 0 or 1 3 3
Health centre heads or delivery 1 6 6
case team leaders
HEP coordinators 0 or 1 3 3
Regional HEP coordinator NA NA 1
Zonal HEP coordinator NA NA 1
Total 44
Kok et al. Human Resources for Health (2015) 13:80 Page 4 of 12

Research and Technology Transfer Core Process of South Support for HEW activities from the community
Ethiopia. Support from kebele and other leaders Support from
the community was demonstrated in various ways. Some
Results HEWs reported that kebele administrators supported
Interpersonal relationships between HEWs and actors in them in conducting home visits and maternal health
the community and health sector were influenced by sev- education sessions. Kebeles are expected to facilitate
eral factors. First, programme design elements influencing pregnant women’s forums during which HEWs talk
HEWs’ relationships with the community are presented, with all pregnant women in the kebele. HEWs and HEP
followed by those influencing HEWs’ relationships with administrators reported that these group discussions
the health sector. Cross-cutting factors categorized as trust, facilitated women supporting each other and assisted
communication and dialogue, and expectations (as sum- HEWs in conveying their antenatal health messages.
marized in Table 2), are presented throughout. These
cross-cutting factors emerged as important influencers of “We have the pregnant women’s forum with tea and
relationships, within all identified programme design coffee to discuss maternal health with them. This is not
elements. Quotations are used to illustrate main themes. considered by other health offices, but we have taken the
time in the forums to increase their participation and to
HEWs’ relationships with the community
discuss maternal health so that we help them and
HEWs’ relationships with the community were facilitated support them financially…” (HEW, FGD)
by the following: the nature of HEWs’ position and role in
the community, support from the community (including Other HEWs reported a lack of support from the kebele
support regarding referral) and community-driven moni- level, partly as a result of lack of per diems for activities
toring and accountability mechanisms. related to health as compared to agriculture or education.
This lack of support resulted in constrained communica-
tion and dialogue between HEWs and the community and
The nature of HEWs’ position and role
lower motivation and job satisfaction, because of lower
Many respondents reported that the attributes shared
community attendance to health activities and meetings.
by HEWs in the community assured a “natural link”
between them and the community. Good relationships
“…the kebele administration helped us after much
were reported to result from HEWs being selected
negotiation and begging. Otherwise they wouldn’t
from the community they are supposed to serve and
support us on their own initiative…” (HEW, interview)
continuing to reside in that community. Community
members reported that HEWs being female was im- Some HEWs reported that besides kebele administrators,
portant to them, as they prefer to discuss maternal they involved religious leaders and elders to support their
health issues amongst women. HEWs’ position as com- work regarding maternal health advocacy and communi-
munity members themselves appeared to safeguard cation with the community.
trust in and respect for the HEW from the community
side and a good attitude towards the community and
Support from the health development army It was
enhanced self-esteem from the HEW side.
widely recognized that HDA leaders had been supporting
HEWs in identification and referral of pregnant women,
“First I trust God and then the HEW. She calls an
conducting postnatal care follow-up, mobilization of com-
ambulance when she finds a problem. We tell the
munities for immunization campaigns and health education
HEW our problems. They are always with us.”
in the community.
(Mother, interview)
“We teach the women in our community. We, the
“…they [the clients] are our mothers as well, and we
leaders of the one-to-five network, give our advice to
are serving our own community. Their children are
convince pregnant mothers. When their labour starts we
our children, and the community is my community.”
call to the HEW to inform and conduct the delivery.”
(HEW, interview)
(Woman, FGD)
In one woreda, a male respondent reported that when
the selection system is not followed and HEWs do not Most HEWs were positive about the role and func-
come from the kebele they need to serve, their relation- tionality of the HDA, as it helped them with referral and
ships with the community are constrained as a result of advocacy tasks or had an impact on the community’s
lack of trust from the community side, leading to poor understanding of maternal health. Despite positive contri-
performance. butions by the HDA, the structure was inactive in some
Kok et al. Human Resources for Health (2015) 13:80 Page 5 of 12

Table 2 Programme design and cross-cutting factors influencing HEWs’ relationships with the community and health sector
Programme Cross-cutting factors influencing relationships
design elements
Trust Communication and dialogue Expectations
facilitating
relationships
HEWs’ relationships with the community
Nature of HEWs being selected from the HEWs residing in their community of
HEWs’ position community that they will serve generally service facilitated ongoing
and role enhanced community trust in HEWs, communication and dialogue with
partly facilitated by good attitudes and community members
high self-esteem of HEWs as a result of
serving their own community
If HEWs served a community which they
were not originating from, community
trust in them could be hampered
Support for Some HEWs were supported by TBAs, as Support from kebele administration, Community expectations regarding TBA
HEW activities both community and HEWs trusted the religious leaders and HDA leaders involvement were not always in line with
from the competencies of TBAs in child birth and facilitated communication and dialogue the policy, and this created dilemmas,
community related tasks above those of HEWs between HEWs and community which could hamper HEWs’ relationships
members, assisting HEWs in community with community and TBAs
mobilization, health education,
identification of clients and referral; if this
support was not present, communication
and dialogue with community was
hampered
In some areas, support from TBAs to
HEWs was ceased, because of lack of
communication between HEWs and TBAs
if TBAs were still conducting deliveries,
which is not allowed by government
Community Quarterly facility or public forums,
monitoring and political gatherings, kebele cabinets,
accountability pregnant women’s forums and
structures community-based review meetings were
structures that facilitated communication
and dialogue between HEWs and the
community, including feedback on
performance
HEWs’ relationships with the health sector
Referral Improper handling of referral cases Lack of referral forms and feedback after Community expectations with regard to
hampered trust from HEWs and referral hindered communication payment of transport and higher level
community in the health sector between HEWs and the health sector care did sometimes not match with the
reality, hampering trusting relationships
between HEWs (who made the referral)
and community
Supervision Supervision with a fault-finding approach
and without feedback, partly as a result of
lack of resources and training of supervisors,
hindered communication between HEWs
and supervisors/management
Training HEWs’ expectations regarding trainings
and career advancement were not met,
hampering relationships between HEWs
and health sector
Monitoring and Irregular held monitoring and evaluation
accountability meetings hampered communication
structures between HEWs and the health sector
Support from Regular support from health professionals Sometimes, expectations from the
other health at health centre level enhanced HEWs’ management level about tasks of HEWs
professionals competencies and made them feel part of interfered with HEWs’ work
a team
Kok et al. Human Resources for Health (2015) 13:80 Page 6 of 12

areas and some respondents reported that the voluntary HEWs and weakened their potential as intermediaries
nature of HDA work could constrain their potential. between communities and the rest of the health system.

Community-driven monitoring and accountability mechanisms

Support from traditional birth attendants The HEP
The study identified several structures facilitating commu-
currently promotes skilled delivery in health facilities, but
nity monitoring and accountability. The performance of
HEWs are nevertheless supposed to be trained in con-
health centres was evaluated by the community during
ducting “safe and clean” deliveries in health posts. How-
facility or public forums, held on a quarterly basis. At the
ever, most health posts were found not to have provided
health post level, HEWs were monitored by the kebele
delivery services in recent years, because of lack of skills,
administration and sometimes by the leaders of the HDA.
experience or confidence of HEWs, lack of materials and
Many HEWs mentioned that they collected reports from
equipment, the traditional habit of home delivery with a
the leaders of the HDA and incorporated them as part of
TBA or bypassing of the health post by seeking delivery
their activities. Most HEWs stated that they had been con-
services at the higher level right away. One HEW raised
ducting regular meetings with the HDA leaders, exchanging
the issue of expectations of community members exceeding
feedback on their work and receiving reports of activities
her capability, which led to demotivation.
performed by the HDA. This assisted HEWs to adjust
maternal health education to the needs of the community.
“They [the community] would like to give birth at the
health post, but we tell them that training is done turn
“We meet every month with the leaders of the
by turn and it will take some time to start the service at
one-to-five network. We discuss our work, what
the health post … We are not giving the services which
is going on in the community; they also bring their
we are supposed to give.” (HEW, interview)
report and discuss it.” (HEW, interview)
There is a national policy prohibiting TBAs to assist
Other meetings used for discussing performance were
delivery; rather, they should focus on referral of women
shengo (political gatherings), the pregnant women’s forums
for skilled delivery. TBAs were, however, still found to
and kebele cabinets. Some HEWs reported that they evalu-
conduct deliveries. The community, and sometimes also
ate the quality of the service they provide in the community
the HEW, trusted and preferred the TBAs conducting
during joint meetings with the woreda health office, kebele
deliveries. This was related to good communication and
administration and community representatives. In this way,
dialogue (teamwork) between HEWs and TBAs but also
the monitoring and accountability structure is both related
lack of self-confidence, skills and competencies of HEWs
to the community and the health sector and there is
in conducting deliveries, which until recently they were
enhanced communication and dialogue between all levels.
expected to perform as part of the HEP.
“Sometimes the community with the kebele
“…we call the TBAs to assist labour due to the skill
administration gather and evaluate our performance…
gap and [low] confidence we have. …TBAs have
The kebele officials and the community give a witness
stopped attending deliveries now, but because of a
about their satisfaction.” (HEW, interview)
lack of skills we attend the deliveries with their help.
We fear attending deliveries. …We call them and they
HEWs’ relationships with the health sector
help us.” (HEW, interview)
HEWs’ relationships with the health sector were influenced
by the following: referral, supervision, training, monitoring
“People say ‘the known devil is better than the
and accountability systems and support from other health
unknown God’, and the people believe in them
professionals.
[TBAs]. We also communicate with the TBA, because
the TBA is more popular than me in the kebeles, so I
Referral
use her to contact women.” (HEW, FGD)
There is an established referral system between HEWs,
Some TBAs reported difficult relationships with the health centres and hospitals, and all HEWs reported that
HEWs as a result of TBAs conducting deliveries against they refer maternal cases when the situation is beyond their
the policy. They were excluded from activities managed by capacity. Referral was constrained by miscommunication
HEWs and were not invited for meetings. In other com- between the health sector, HEWs and communities. Some
munities, the TBAs’ role was indeed restricted to referral. HEWs used referral forms; however, most reported absence
The tension between what communities and HEWs often of referral forms at their health post. As a result, a HEP
preferred (TBA involvement) and what policy directed coordinator at the zonal level indicated that the referral
(TBAs restricted to referral role) created dilemmas for record-keeping system was poor. Feedback from the
Kok et al. Human Resources for Health (2015) 13:80 Page 7 of 12

referred facility to the HEW was variable. Some HEWs functioning well. A lack of communication skills and
reported improper handling of referral cases in the knowledge related to the HEP among the HEWs’ supervi-
health centre. sors was one of the weak points mentioned by some par-
ticipants in the study that would limit the scope of
“The basic thing we have to consider is a woman supervisors to build the capacity of HEWs.
should not die giving birth. Sometimes even death can
happen in a health centre. I knew a woman died …, “Health professionals know the science very well but
because the health centre didn’t refer her to the are not familiar with the health extension packages…
hospital as early as possible.” (HEW, FGD) The nurses who are more clinically competent
are expected to give support to HEWs who
Lack of transport or requests for payments regarding know the packages very well: this is not logical.”
transport for clients, requests for payments at the health (Woreda HEP coordinator, interview)
centre level (which should be free) and fees for clients at
the hospital level were reported. These constraints in the It was also mentioned that the health professionals who
referral system further hindered HEWs’ relationships supported the HEWs were sometimes disrespectful or un-
with the health sector and, because of this, their trusting friendly to HEWs, leading to constrained communication,
relationship with the community. In some cases, HEWs mistrust and demotivation. The majority of the HEWs
got the blame of constraints that community members interviewed mentioned that they did not receive written
faced at the health centre or hospital level, as they were feedback after the supervision, which was confirmed by a
the ones referring the clients there. respondent from one of the health centres. Few HEWs
reported to receive feedback based on command post
evaluation formats.
Supervision
Supervision from the side of the health sector was
Training
mostly reported to be in place, although not always
Many HEWs reported disappointment with the limited
regularly implemented, sometimes caused by transpor-
possibilities for trainings. Refresher trainings on maternal
tation problems. Some HEWs were satisfied; however,
health were reported to lack practical elements on delivery.
many complained about a fault-finding attitude of
Official trainings for upgrading were also a source of disap-
supervisors, an overemphasis on checking of records
pointment for many HEWs. The selection process was not
and registers and a lack of supportive and problem-
clear, the entrance exams considered too difficult and pro-
solving approaches. Quotes from HEWs clearly show
motion after attending the training was not guaranteed.
that adequate supportive supervision could increase
their motivation and credibility.
“Even if we get education opportunity and make
improvements in our level, there is no difference to
“If the woreda supervisors come and see our work, we
me. Because the HEW who upgrades her status will
will be happy. We need encouragement from the
again be assigned in the [same] kebele, no transfer is
woreda officials. We will be encouraged by the
given to her, just as if she had not joined the school.”
appreciation for our good work, but our morale
(HEW, FGD)
will be affected if our good work is ignored.”
(HEW, interview)
On-the-job training from the health centre was supposed
to take place once a week, but often, HEWs reported that
“What makes us not work hard is, when the woreda
this was not happening.
health office comes for supervision, they leave our
strong parts and take very minor things and
Monitoring and accountability towards the health sector
discourage us due to those things.” (HEW, FGD)
The coordinator of the HEP at the regional level reported
The responsibility for the direct supervision of that the performance of HEWs was assessed during super-
HEWs recently changed from the woreda health office vision and regular meetings.
to the health centre, with a group of health profes-
sionals, each assigned to supervise and support one We meet and contact HEWs directly when we
of the five health posts in the catchment area, form- provide supportive supervision at health post level,
ing the command post. They are expected to provide when we provide refresher trainings. During these
feedback to the woreda level. The majority of HEWs times we conduct discussions on health work
who participated in the interviews and FGDs stated performance and build their capacity…” (Regional
that this recently introduced system was not yet HEP coordinator, interview)
Kok et al. Human Resources for Health (2015) 13:80 Page 8 of 12

However, from the perspective of HEWs, these supervi- many times with people about these things. If we are
sion meetings were not always held or conducted in a not involved in these activities, they cut our salary.”
supportive way. HEWs’ work is based on monthly plans. (HEW, interview)
Reports, containing information from the health manage-
ment information system and data collection from various Discussion
programmes, were supposed to be sent from the health HEWs have a unique intermediary position between the
post to health centre and from there towards the woreda community and health sector, which gives them the ability
health office. HEWs were supposed to have weekly meet- to act as brokers and facilitators of dialogue and trust
ings with the command post, monthly meetings with the [18,19]. To be able to perform optimally, HEWs require
health centre and quarterly meetings with the woreda strong interpersonal relationships with actors in the com-
health office to discuss these reports, but HEWs and health munity and health sector. Programme design elements
centre staff reported that meetings were irregular. related to support and accountability either facilitated or
hindered relationships between HEWs and the community
Support from other health professionals and managers or health sector. Trust, communication and dialogue and
HEWs had regular contact with health professionals at expectations (of actors in the community, health sector
the health centre level, which was important to enhance and HEWs themselves) were cross-cutting factors influen-
their competencies and made them feel part of a team. cing relationships. The quality of relationships was, in
Many HEWs and health centre respondents reported some cases, reported to influence HEW performance at
good relationships between HEWs and health profes- the individual level, in particular motivation. An overview
sionals, who supported HEWs on special occasions or of factors influencing relationships between HEWs and
regarding specific services. the community and health sector, and thus influencing
HEW performance, is presented in Figure 2.
“They help us very well during the vaccination
mobilization period.” (HEW, FGD) Tensions of HEWs’ intermediary position
The natural position and role of HEWs in their kebele safe-
“To link health posts with health centres, starting from guards trust, credibility and respect towards the HEW and
last year, all staff from health centres provide support to their engagement with that community, which can enhance
health posts once or twice per week, to identify gaps and HEW performance [13,14,20,21]. However, HEWs are
to deliver services together with HEWs, especially during selected by the health sector and must meet the standards
antenatal care services to run HIV tests since HEWs of the sector. There are sometimes differing expectations
cannot do this…” (Woreda HEP coordinator, interview) from the community and health sector regarding roles and
tasks of HEWs, for example, regarding HEWs’ role in child-
Some HEWs reported competing programmes and birth or involvement in political matters, leading to tension
expectations from the upper level, intervening with their (when HEWs feel they cannot meet expectations [22]), high
planned activities. workload and demotivation. Clearly demarcated roles and
tasks of HEWs which are communicated with all levels
“We may plan to accomplish certain activities, but using job descriptions, government directives and explana-
from the woreda health office we will be told to do tions in joint meetings where community and health sector
other things… When we plan to teach mothers or representatives are present could prevent this. This should
want to have community conversations, the woreda be taken into account in current debates, in which HEWs
health office may tell us to do other activities like are increasingly expected to advocate referral to skilled
vaccination campaigns.” (HEW, FGD) deliveries in health centres or hospitals rather than
assisting “clean and safe” deliveries (conducting deliveries
Not only were HEWs expected to conduct health- themselves) in the community.
related tasks beyond those scheduled according to their HEWs’ position as intermediaries enables support
work plan, some respondents also reported HEWs’ from both the community and health sector towards
involvement in other sectors and politics, requested by the HEW, which could enhance HEW performance
administrators. This disturbed their regular work, led to [9]. Community support generally relied on voluntary
high workload and in certain cases to mistrust from the systems, while the formal community structure (the
community towards the HEW. kebele administration) seemed to lack leadership when
it comes to supporting health services. Reinforcement
“Sometimes we are involved in the activities coming of the support from the kebele administration towards
from women affairs and the education sector. We are the HEP is recommended to increase HEWs’ credibil-
also involved in political matters. We are quarrelling ity, ability to initiate communication and dialogue
Kok et al. Human Resources for Health (2015) 13:80 Page 9 of 12

Relationships with community Relationships with healthsector

Trust Trust
HEW performance
Communication & dialogue Communication & dialogue
self-esteem,
Expectations Expectations
motivation, attitude,
competencies,
adherence,
satisfaction, capacity Programme design
HEWs’ position and role community agency
Referral
Programme design
Supervision
Support (incl.
Training
referral)
Monitoring &
Monitoring &
accountability
accountability
Support

Figure 2 Factors influencing relationships between HEWs and the community and health sector and the influence on HEW performance.

with communities and motivation. Support from TBAs to improve performance in Rwanda [26]. Refresher
was reported as well, although this sometimes pre- training could establish relationships with other health
sented problems for HEWs, because relationships be- workers or enhance trust from other health workers
tween HEWs and TBAs did not always correspond with a because of the upgraded knowledge of HEWs. However,
TBA’s new roles as directed by the government. Relation- HEWs were generally dissatisfied with their opportunities
ships between HEWs and TBAs were directed to be fo- for receiving trainings. Clear selection processes for training
cused on referral, and the collaboration between HEWs attendees [24,27] and clear prospects of possibilities for
and TBAs in conducting deliveries can thus be seen as an upgrading after training are needed to keep HEWs mo-
unintended effect of their relationship. Thus, HEWs were tivated and prevent attrition [13,28]. Visible supervision
not always working in line with the health system’s stan- and training of HEWs by the health sector is important
dards as a result of tensions emerging from their inter- to enhance credibility of and trust in HEWs, as found
mediary position. HEWs sometimes felt they should in other settings [29–32].
support well-respected TBAs who were still conducting de-
liveries, thereby accommodating views of the community Relationships between HEWs, community and health sector
to maintain trust and keep good relationships with the enhancing performance
community. Community support to HEWs in Ethiopia has been
HEWs’ linkage with the health sector through referral demonstrated by voluntary CHWs4, churches, mosques
was identified but was not always strong, because of com- and community associations [12,33]. The new HDA
munication problems and sometimes a lack of trust of structure presents an opportunity for further strength-
communities and HEWs regarding the costs and quality of ening HEWs’ relationships with the community side, in
higher level services. Improvements regarding handling that it provides actual support towards HEWs’ tasks,
of referred cases, payments and feedback could improve monitoring of HEWs’ performance and accountability.
performance. The HEW supervision system had recently Dysfunctional or inactive community structures have
changed which led to unclear roles and insufficiently been reported to negatively influence CHWs’ embed-
trained supervisors. Supervision meetings with top-down ment in and communication with the community and
communication or a fault-finding nature can hinder the CHW performance in other settings [24]. Other studies
trust of health workers in the health sector and hamper have shown the effectiveness of community monitoring in
their performance [23,24] and their relationships with promoting the performance of professional health workers
the community [25]. HEW supervisors are predomin- [34] and CHWs [35,36]. However, more research is
antly engaged in clinical activities, making training on needed on the exact mechanisms of how this can improve
supportive approaches to supervision, preventive and the performance of CHWs [37]. HEWs felt that relation-
community health necessary to capacitate them in supervi- ships with religious leaders and elders were important to
sion of HEWs. Furthermore, supervision time should be enhance their performance. This facilitating relationship
officially allocated, as health centre staff can be overloaded has also been observed in other studies [12,38,39]. HEWs
with other work. Possibilities for peer-based approaches and HDA leaders are all female; this was found to be posi-
in addition to the current supervision system could be tively valued by the community, because of the cultural
considered, as CHW peer support groups were found suitability of handling reproductive health issues by
Kok et al. Human Resources for Health (2015) 13:80 Page 10 of 12

women. This has been found in other settings as well [40– health sector were derived from this broader research,
42]. However, more research would be needed to estab- and thus, some in-depth questions probing on those
lish if the gender of HEWs could negatively influence relationships were not asked. However, we think that
their relationships with traditional leaders, husbands the data presented in this article are representative for
of pregnant women and other male community mem- the six districts included in the study, as interpersonal
bers and so hinder HEW performance in maternal relationships emerged as one of the most important
health. influencers of HEW performance in the data set. Sec-
The command post as the monitoring and accountability ondly, as in any qualitative study, one must contend
system at the side of the health sector seemed to be with social desirability bias. We tried to avoid this by
functional in some areas and needs further scale-up. in-depth probing and conducting the interviews and
Evaluation meetings with community and health sector FGDs in neutral environments. Thirdly, the outcomes
representatives were held in some areas. This could be a of this study cannot easily be generalized to other
vehicle for improved communication and accountability settings. However, by including respondents from dif-
towards both sides and needs further expansion and ferent settings and by triangulation via different types
investigation. of respondents and data collection processes, the
findings do present useful insights for other settings.
Health systems as social institutions Lastly, the study focused on relationships between
Health systems are social institutions with chains of HEWs and the community and health sector. Relationships
relationships between different actors. Optimal perform- among HEWs and between HEWs and other community-
ance depends on the strength and nature of relationships based workers were not fully assessed, although they could
between all actors [11]. We explored the relationships be- influence HEW performance, as presented in other studies
tween health professionals and HEW supervisors, HEWs from Ethiopia [44–46]. Furthermore, relationships are also
and their communities. The influence of relationships on influenced by more personal characteristics of HEWs.
HEW performance was reciprocal: HEW performance
could also influence trust, communication and dialogue Conclusion
and expectations (Figure 2). For example, HEWs’ lack This study provides in-depth information on which factors
of competence in childbirth could negatively affect the hinder or facilitate relationships between HEWs, the com-
trust of the community in the HEW and thereby ham- munity and health sector, which can inform other CHW
per relationships between the community and HEWs. programmes aiming for enhanced CHW performance.
When we see health systems as social institutions, the We found several programme design elements that could
ways of bringing about change in health systems go beyond facilitate interpersonal relationships of HEWs with actors
altering written rules and distributing resources and extend from the community and health sector, especially related
to effectively managing relationships between different ac- to support of and accountability to both sides. Within those
tors [43]. HEWs’ relationships with the health sector could programme design elements, trust, communication and
be strengthened by human resource management practices dialogue and expectations were influencing the strength of
and approaches that focus on building trust and improving relationships. Clearly defined roles and responsibilities
dialogue within the workplace, such as problem-solving at all levels and standardized support, monitoring and
supervision and culturally appropriate communication accountability, referral, supervision and training could
[11,23,25]. Improved relationships between HEWs and improve communication, dialogue and trust between
the health sector could positively influence their relation- HEWs and actors from the community and health
ships with the community through improved trust and sector. This is important to maximize the value of
motivation, which could further positively influence HEW HEWs’ unique intermediary position and ultimately
performance. In addition, programme designs that facilitate improve HEW performance, not only in maternal
community support and monitoring and accountability health but regarding their roles and tasks in all com-
could further improve trust, communication and dialogue ponents of the HEP.
between HEWs and the community and manage ex-
pectations at all levels, which in turn could enhance Endnotes
1
HEW performance. Our study is based on the following definition of
CHWs: “health workers performing functions related
Study limitations to health care delivery; who have received a limited
This study is limited by several factors. Firstly, the study training focused on activities they need to carry out in
was part of a broader research project that included all the context of the intervention(s) they implement; and
factors that could influence HEW performance. Issues have received no formal professional or paraprofes-
related to HEWs’ relationships with the community and sional certificate or tertiary education degree” [47].
Kok et al. Human Resources for Health (2015) 13:80 Page 11 of 12

Therefore, HEWs are seen as CHWs. However, com- Can: Success Stories from a Dynamic Continent. Edited by Chuhan-Pole P,
pared to CHWs in other countries, HEWs may be seen Angwafo M. Washington D.C., USA: The World Bank. 2011:433-43
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the health post level. They cannot be referred to as skilled 7. CSA. Ethiopia demographic and health survey 2011. Addis Ababa, Ethiopia
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4
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Abbreviations health worker “logic model”: towards a theory of enhanced performance in
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Competing interests a qualitative study. Working paper no. 2. Addis Ababa, Ethiopia: The Last
The authors declare that they have no competing interests. Ten Kilometers Project, JSI Research & Training Institute, Inc; 2011.
13. Glenton C, Colvin Christopher J, Carlsen B, Swartz A, Lewin S, Noyes J, et al.
Author’s contributions Barriers and facilitators to the implementation of lay health worker programmes
MK, AK, DD, MT and OT contributed towards the study design. MK and AK to improve access to maternal and child health: qualitative evidence synthesis.
were involved in data collection; data analysis was conducted by MK, AK, DD Cochrane Database Syst Rev. 2013;10, CD010414.
and OT. MK drafted the manuscript with substantial input from JB and MD, 14. ERT1. Final report of evidence review team 1. Which community support
and all authors critically reviewed and contributed towards the manuscript. activities improve the performance of community health workers? pp. [52]
All authors read and approved the final manuscript. p.: U.S. Government Evidence Summit: Community and Formal Health System
Support for Enhanced Community Health Worker Performance; 2012:[52] p.
Acknowledgements 15. ERT2. Final report of evidence review team 2. Which formal health system
The study presented in this paper is part of the REACHOUT programme. This support activities improve the performance of community health workers?
programme has received funding from the European Union Seventh Framework pp. [27] p.: U.S. Government Evidence Summit: Community and Formal
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