Table 1

Key factors influencing CHW accountability ecosystems

ThemeSubthemeInfluence on accountability ecosystem
Local political contextType of political regimeIn political and bureaucratic systems that are characterised by informality, CHW recruitment and placement may be vulnerable to patronage, undercutting accountability for the equitable delivery of services.
Less centralised regimes may prioritise community ownership, supporting downwards accountability and programme sustainability; the inverse is also true, in centralised regimes, CHWs may function as a mechanism for community accountability to the state.
Regimes that prioritise upwards accountability can interfere in selection or placement of CHWs, leading to coercive programmes and community mistrust.
Electoral cycleThe imperative to support healthcare as a voting issue can lead to politicians’ concrete support of CHWs.
Interactions with other community-based structuresFormal linkages to VHCs/similar local structuresCreating formal linkages with VHCs and similar, and/or making CHWs formally accountable to representative political structures can improve downward accountability.
Democratic deficitEngagement with local structures that feature a democratic deficit can reproduce processes of exclusions that shape ill health.
Treatment of CHWs by the health systemQuantum and approach to remunerationRemuneration risks shifting CHW accountability toward the health hierarchy and away from the community, but lack of adequate, regular remuneration undermines CHW morale and commitment to job duties.
Activity-based incentives can lead to ‘behavioural distortions’ that weaken commitment or attention to community priorities.
Mode and focus of supervisionPunitive supervision, absent supervision or supervision for government (vs community) priorities promotes upward, and undermines downward accountability.
Strong supervisory and programmatic support of female CHWs helps address/overcome gender norms that may otherwise limit their mobility and autonomy.
Resourcing and service delivery contextProvision of job enablers (medical kits, etc) can enhance community perceptions of CHWs’ position in the health system, and trust in CHWs’ ability to do their job.
Quality of care at facilities to which CHWs refer people shapes community trust in CHWs and willingness to follow CHW advice.
Relationships with other health providersRespect/disrespect shown to CHWs by other health providers influences community trust and willingness to follow CHW advice; social status (incl. gender) and other power differentials play a role.
Community perceptions of CHWsCHW qualificationsLack of education or certification can undercut community belief that CHWs are capable of responding effectively to community needs.
Well trained, qualified, and enabled CHWs can build trust in responsiveness of health system to community needs.
CHW embeddednessAcceptance may be greater when CHWs come from the communities they serve, but this can be complicated by caste, gender and other identities.
Attention given to community prioritiesAttention to government (vs community) priorities may undermine downward accountability.
In settings where trust in government is low, the extent to which CHWs are perceived as being aligned with government may shape community perceptions of CHW motivation and action.
CHW professional associations/unionisationImproved CHW job conditionsCollective action can result in better/more regular salary and other benefits that strengthen CHW motivation and performance.
Better salary and professionalisation could cause communities to question CHWs’ understanding of and commitment to community priorities.
Opportunities for lobbyingCollective membership can enable CHWs to effectively lobby for better governmental consideration of community health priorities.
  • CHW, community health worker; VHC, Village Health Committees.