Lived experiences of long-serving (>15 years) community health workers in South Western Uganda: a phenomenological study

Background Community health workers (CHWs) are central to primary health care in Uganda, yet most serve as unpaid volunteers and attrition is a recurring concern. Little is known about why some CHWs persist for more than 15 years. We explored the motivations, challenges and coping strategies of long-serving CHWs in Mbarara, Rubirizi and Rwampara districts, South Western Uganda. Methods We conducted a qualitative phenomenological study using in-depth interviews with 36 CHWs and 18 parish CHW coordinators who were selected and trained by Healthy Child Uganda between February 2004 and January 2008 and had served for more than 15 years. 36 village CHWs, selected by simple random sampling, and 18 parish CHW coordinators, selected purposively. Interviews were audio-recorded and transcribed, and analysed using inductive and deductive thematic analysis following Braun and Clarke. Themes were organized across the individual, interpersonal, community and organizational levels of a socio-ecological framework. Results Motivation arose from professional growth (social recognition, confidence in public speaking, transferable skills and the uniform as a marker of identity), community respect, trust and an advisory role, friendships among CHWs, the satisfaction of protecting community health, and modest financial and material incentives. Challenges included inadequate refresher training; health and safety risks among ageing CHWs; community resistance; conflict between CHW duties and family or farming roles; lack of transport, funds and equipment; uncooperative or corrupt local leaders; absence of an organizational structure; and declining supportive supervision. CHWs coped through faith, passion and commitment, expectations of future recognition or pay, savings and credit groups, peer and family support, subsistence farming and small businesses. Conclusions Persistence beyond 15 years rests largely on intrinsic and social rewards and on coping strategies that CHWs finance themselves, rather than on health system support. Regular refresher training, supportive supervision, predictable transport support, protective equipment, a clear organizational structure and formal recognition are needed to retain this ageing and experienced workforce.