Collaboration between community-based health workers and health facilities in a region of The Gambia: a qualitative study

Abstract

Collaboration between community-based health workers and health facilities is important for patient care and for addressing the health needs of communities. This study aimed to explore the extent and nature of the interactions between health workers posted at health facilities and those based within communities in a selected setting of the North Bank East Region, The Gambia, in order to inform design of a malaria control trial in the region and contribute to global research on strengthening community health worker programs and their connection to the health system. We conducted a qualitative study in the North Bank East region of The Gambia, which included 24 semi-structured interviews with Village Health Workers (VHWs), Community Health Nurses (CHNs), and health facility nurses. Respondents were asked about roles and responsibilities, referral, follow-up, supervision, trainings, and support, monitoring and accountability, and challenges to their work. Interviews were audio-recorded, transcribed, coded, and analyzed thematically. A number of factors were found to be important in influencing the collaboration between community-based health workers and health facilities. Community-based CHNs serve an intermediary role and provide support to both the VHWs and the health facilities; however, we found a significant disconnect between VHWs and health facilities that was not sufficiently bridged by the CHNs. This disconnect may be partly a result of limited opportunities for VHWs and health facility staff to interact; a gap that is further reinforced by undervaluation of the VHW’s role and contribution in the health system. External pressures and funding mechanisms limit local and regional agency, which our findings suggest is an underlying factor that de-incentivizes collaboration beyond what is needed to fulfill tasks relate to specific indicators. The results of this study suggest the need for interventions – such as the trial this study was a part of – and the regional/national health system more generally, to find ways of integrating, and strengthening referral and feedback systems, between VHWs and health facilities. This would result in increased opportunities for all health facility staff to interact, greater local and regional agency to make decisions and, ultimately, stronger health systems that are better able to provide care.