Community health workers in health systems strengthening: a qualitative evaluation from rural Haiti

BACKGROUND: Haiti is among the countries facing serious shortages in human resources for healthcare. In rural Haiti, the need for daily, long-term adherence to medication for HIV and TB was initially the driving factor for recruitment of community health workers (CHW) during scale-up of HIV services. Their role became broader over time. This qualitative study evaluated the role of CHW in the health system as a whole in both HIV and non-HIV-related services in rural Haiti and investigated the challenges and facilitating factors for their work. METHODS: We used qualitative methods including focus group discussions and group interviews in four sites in rural Haiti. Data from 462 CHW were analysed for themes and content according to standard ethnographic methods. RESULTS: CHW contributed to a wide range of primary health services and non-HIV-related activities. Recognition from the community, status, satisfaction of contributing to the well-being of others and remuneration were facilitating factors to performing their work. Challenges included insufficient materials to cope with the obstacles on the ground, lack of diagnostic and treatment roles in their activities, high work load, and desire for ongoing training and a higher salary. CONCLUSION: CHW initially hired for HIV care represent an important part of the health system in rural Haiti in both HIV-related and primary healthcare services. CHW programmes have important potential for building capacity in the health workforce and thereby contributing to strengthening of the health system as a whole. Attention must be paid to adequate remuneration, training and provision of materials.