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Health interventions introduced as part of donor-funded projects need careful planning if they are to survive when donor funding ends. In northeast Nigeria, the Gombe State Primary Health Care Development Agency and implementing partners recognized this when introducing a Village Health Worker (VHW) Scheme in 2016. VHWs are a new cadre of community health worker, providing maternal, newborn and child health-related messages, basic healthcare and making referrals to health facilities. This paper presents a qualitative study focussing on the VHW Scheme’s sustainability and, hence, contributes to the body of literature on sustaining donor-funded interventions as well as presenting lessons aimed at decision-makers seeking to introduce similar schemes in other Nigerian states and in other low- and middle-income settings. In 2017 and 2018, we conducted 37 semi-structured interviews and 23 focus group discussions with intervention stakeholders and community members. Based on respondents’ accounts, six key actions emerged as essential in promoting the VHW Scheme’s sustainability: government ownership and transition of responsibilities, adapting the scheme for sustainability, motivating VHWs, institutionalizing the scheme within the health system, managing financial uncertainties and fostering community ownership and acceptance. Our study suggests that for a community health worker intervention to be sustainable, reflection and adaption, government and community ownership and a phased transition of responsibilities are crucial.
Initially the scheme was implemented in 57 of Gombe’s 114 Wards to test and refine it before subsequent scale-up throughout the state. The Agency planned to recruit approximately 1200 VHWs across these wards, serving an estimated population of 1 628 481 (Nigeria, 2006). VHW selection criteria were they were women, aged between 18 and 49 years, preferably married and literate in English. VHWs were expected to work in their own communities, and their role involved delivering maternal, newborn and child healthcare messages; encouraging improved health and healthcare seeking behaviours; undertaking basic healthcare provision, such as treating pregnant women for anaemia and referring women to health facilities, thereby promoting healthcare uptake. They received 4 weeks’ training, a small stipend, a uniform and various job aids. VHWs were directly supervised by Community Health Extension Workers (CHEWs) who provided a link between primary health facilities and the communities they served. CHEWs, a cadre that is specific to Nigeria, are trained for 3 years and deliver basic health services in primary healthcare clinics and in the community. In addition, the work of VHWs was reviewed and discussed by Ward Development Committees (WDCs), a community management structure introduced in Nigeria to oversee the delivery of health and development services, and to represent their communities. An ‘adaptive management process’ was adopted whereby stakeholders periodically reflected on progress and, when necessary, adapted the intervention’s design to operate more effectively. The process involved three phases (Figure 1). In collaboration with the Agency, the ‘set-up phase’ involved the nongovernmental implementer recruiting and training VHWs, and agreeing a phased transition whereby the Agency would take responsibility of implementation and finances. During the ‘consolidation phase’, VHWs received further training, the scheme became fully operational, and the transition began where the Agency’s funding contribution increased incrementally. Finally, the ‘mature phase’ involved the full handover of implementation and financing responsibilities from the nongovernmental implementer to the Agency. Village Health Worker Scheme’s implementation phases and data collection rounds We embraced a health policy and systems research approach using qualitative methods. The health policy and systems research approach was appropriate to our aim as the focus is on understanding the influence of policy processes including policy and programme development and implementation, and on intervention outputs rather than measuring outcomes and impacts (Gilson, 2012). We conducted three rounds of in-depth interviews and focus group discussions in 2017 and 2018, which allowed us to trace the scheme’s development over time. Our data collection points aligned with the scheme’s implementation phases (Figure 1). During the ‘set-up phase’, our interviews and focus group discussions explored how sustainability featured in the scheme’s planning and set-up. In the ‘consolidation phase’, we focussed on adaptations aiming to improve the scheme’s sustainability. We conducted a final round of interviews and focus group discussions during the ‘mature phase’, where we asked respondents to reflect on the transition process and the handover of responsibilities to the Agency. After each round, we presented emerging findings to the Agency, the nongovernmental implementer and the donor in the form of oral presentations and research briefs. Hence, the researchers acted as ‘critical friends’, which enhanced our access to research participants and meant our findings could benefit the scheme as it developed (Coghlan and Brydon-Miller, 2014). Nevertheless, this may also have impacted on the data we collected, and our ability to fully capture more negative and critical aspects of the scheme. Our focus was on identifying and better understanding the key actions promoting the scheme’s sustainability. Our interviews and focus group discussions were informed by the literature on sustainability, specifically Hirschhorn et al. (2013); Larson et al. (2014); Torpey et al. (2010); WHO and ExpandNet (2010). Specifically, we explored the following themes: Data collection focused on two of Gombe’s 11 Local Government Areas (LGAs), Kaltungo and Nafada, purposively selected as those with the highest and lowest facility deliveries, giving us insights into contrasting health system contexts. Within each LGA, we selected the ward with the best VHW performance, based on monitoring data from the scheme’s first 6 months, because our focus was on identifying the actions promoting the scheme’s sustainability, rather than challenges or failures. Interviews and focus group discussions were conducted with stakeholder groups and beneficiary communities that had experienced the scheme (Figure 2 and Table 1). The focus group discussions, which were moderated by experienced researchers, involved between six and twelve participants, and focussed on intervention design, health worker motivation and social sustainability. Our respondents represented all of the major stakeholder organizations at different levels of the health system involved in the implementation of the scheme. Individuals within those organizations were purposively selected based on their direct involvement and therefore detailed knowledge of the scheme. All VHWs were women. Most CHEWs were women, although two were men. Stakeholders and WDC members were both women and men. In each LGA, we approached community and religious leaders to help us to recruit willing community participants within those areas. Those leaders endorsed our work and encouraged community members to participate but did not influence which community members we invited to be part of our focus group discussions. Refreshments were given to participating VHWs and communities, and community members were each given a bar of soap. Stakeholder groups at different levels of the health system Number of interviews and focus group discussions Informed by our framework, we created a topic guide to explore key themes with our interviewees and focus group discussion respondents, while being attentive to emerging themes. Hence, our approach was both deductive and inductive (Pope and Mays, 2000). We created versions of the topic guide for each stakeholder group, with questions tailored for each round of interviews and focus group discussions. A team of Gombe-based researchers experienced in qualitative interviewing and focus group discussions assisted with the data collection. They were orientated about the study’s purpose, the topic guide and requirements relating to research ethics; they also helped to refine and modify the topic guide. Interviews and focus group discussions were conducted in English or Hausa, based on participants’ preferences. While in the field, emerging themes for follow-up in future interviews and focus group discussions were discussed during daily debriefings. The recordings were transcribed, and where necessary, translated into English. For each round of data collection, the researchers conducted initial analysis by structuring interview and focus group discussion transcripts according to the major themes within our framework. We deliberately ensured the themes within the framework were broad, and hence, the data collection process was open to emerging themes, rather than confined to rigid categories. Hence, we took a primarily deductive approach while drawing out issues emerging within each theme within our framework. Thematic analysis was then formally conducted by the first author after each round using NVivo 11 to code all of the transcripts. We adopted different approaches to enhance the reliability and validity of our findings (Seale, 2017). We conducted reliability checks of a sample of sound recordings against corresponding transcripts. During daily debriefings, the research team including the first author discussed emerging findings to help triangulate them. The first author also shared and discussed all emerging findings based on NVivo coding with the research team in order to reach a shared interpretation. Reporting emerging findings to stakeholders allowed us to refocus the study after each round of data collection and strengthen the validity of our findings through member checking. In practice, these stakeholders agreed with our findings, and hence, no changes were made on this basis. Before every interview and focus group discussion, each participant was informed about the study and gave written or recorded consent (Hausa or English), including whether we could use sound recorders and include quotations in our outputs. We explained that participants could withdraw from the study at any time. Each day, recordings, field notes, transcripts and consent forms were stored securely on password protected computers. Ethical approval was granted by the authors’ institutes.
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