Health systems strengthening in rural Zimbabwe: Identifying strategies to improve Community Health Worker performance

Background: The recruitment, training and retention of Community Health Workers (CHWs) remains important towards delivery of essential health services in low-income countries. CHW motivation and satisfaction are key to job performance, but selecting and implementing appropriate intervention strategies to sustain motivation requires understanding the community, CHWs and their work context. Objectives: In this study, we sought to (1) characterize CHWs, perceptions of their work and work context as part of a health systems strengthening intervention in rural Zimbabwe, and (2) identify strategies to improve work motivation and satisfaction.  Methods: In the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial, trained CHWs deliver household-level educational messages to participants. In a survey that utilized Likert-type questions to assess work resources, motivation and supervisory aspects, 325 CHWs responded. Factor analyses were performed to reduce data and descriptive analyses were performed to present proportions responding positively (e.g. agree and strongly agree) to Likert questions.  Findings: On items within factors representing intrinsic motivation; “motivating and support” supervision; and “informing, consulting & respect” supervision, the majority of CHWs, 89%, 86%, and 77% respectively, responded positively. While 59% reported receiving peer support, 46% reported satisfaction with their allowance and 40% reported experiencing work resource shortages. Conclusions: CHWs were intrinsically motivated and reported experiencing a supportive supervisory environment. However, reported dissatisfaction with monetary allowances and shortages of work resources suggest potential intervention points to improve CHW performance outcomes, and will inform the design of a multiple incentive package for CHWs in rural Zimbabwe.