Towards a sustainable approach: understanding the factors shaping a micro-entrepreneurship approach for community health workers in rural Uganda

Community Health Workers (CHWs) play a role in improving access to healthcare in rural areas. Rapid scale-up of CHW programs is essential for addressing global health workforce shortages and achieving universal health coverage. However, many CHW programs remain underfunded and face persistent challenges, including unreliable access to essential supplies, insufficient remuneration, and limited supervision, contributing to high attrition and reduced effectiveness. Innovative and sustainable approaches are needed to better support and sustain CHW programs. This study explores a CHW+ approach that combines pragmatic micro-entrepreneurship, a sustainable supply chain, and telehealth support. The model is implemented by a not-for-profit organization (NGO) using a revolving fund to facilitate access to health commodities. Within this hybrid approach, CHWs remain embedded in the public health system while supplementing their income through sale of essential health products. To gain insight into the factors influencing the functioning of the CHW+ model in rural Uganda, we conducted a mixed-methods study combining interviews with 31 key-informants and descriptive analysis of order volume, frequency and persistence of 1003 CHWs+ in four districts. The functioning of the CHW+ model was shaped by five domains: demand for CHW+ services, national and district policies, community influences, organizational dynamics, and individual CHW+ characteristics. Demand for CHW+ services is influenced by public health system shortages, presence of NGOs, proximity to health facilities, and competition from private outlets. CHWs+ are particularly valuable in areas with frequent stock-outs of government supplies but face challenges where NGOs provide free medicines. Economic conditions, population density, and local market dynamics further influence their performance, alongside national policies and local leadership. Individual factors such as financial skills and alternative income sources also shape CHW+ success. The functioning of the CHW+ model varied across districts; some sustained success due to strong demand and local support, while others saw an initial surge followed by decline, often due to leadership changes or NGO interventions. Our findings highlight the specific conditions under which a pragmatic micro-entrepreneurship approach can support CHWs, emphasizing the need for context-sensitive implementation and ongoing monitoring to maintain a sustained contribution to community health.