Overall perceptions on CHWs’ performance

The work of CHWs is unanimously considered by all health professionals who were interviewed, including nurses and doctors, as an essential component of the primary health care strategy. In their views, CHWs represent a key linkage between the community and the health units and a strategic source of information for team work. The majority of them, however, recognized that their overall performance is often weak, with implications on team work and the community. Few doctors complained that some community members, for example, do not even know who are their CHWs and end up attending the Unit for inappropriate reasons. All informants unanimously acknowledged that most of the barriers that justify CHWs’ inefficiencies are systemic.

CHWs themselves perceived the quality of their performance as frequently sub-standard and admitted that their motivation was not always strong and firm. CHWs unanimously complained that their work is more driven by the need to comply with the quantity rather than the quality of their performances. They argued that their performance cannot be standardized, as it is highly contextual and subjective, and that the organization of their work, the prioritization of tasks and the harmonization of all activities requested is hard to be achieved in daily practice. Many of them experienced frequently the inability to comply with planning their daily goals.

This situation was also strongly perceived during ethnographic work. For example, during home visits, the plan for providing support to a certain amount of patients per

day, was frequently hampered by requests of people met on the street, or within a household that presented a variety of problems. It gets hard for them, then, to dismiss requests and follow on with their planned schedule. Similarly, CHWs’ individual planning, when available, was modified by the need to satisfy other requests coming from the nurse and other entities (health managers, external technical groups).

CHWs feel to act “naturalmente” (na hora, within the moment), without rigid plans, supervision and support. They reported there was no time to discuss and reflect on the work, to prioritize and better structure their activities.

These views were also shared by the majority of nurses and doctors who acknowledged the inability of CHWs to organize, prioritize and standardize their work, which decrease the efficient use of their time and the quality of service delivery. Accordingly to them, CHWs’ work is not based on risk assessment, but on their personal motivation. For example, education groups with patients are only conducted when there is at least one CHW who is taking the leadership and organizes other CHWs. Additionally, they may show resistances to the introduction and use of tools and job aids that could facilitate their work, as their methods are more artisanal and spontaneous. Ethnographic observations clearly revealed the informality that moulds CHWs tools and professional identity.

As discussed with all informants and observed during field sessions, it is really common that nurses and doctors have no control over CHWs’ actions, schedule and activities. On the other side, as argued by many participants, CHWs’ attempts to be independent in their work organization get frustrated as they feel lack of autonomy and appropriate skills. CHWs also may feel insecure in performing their actions, and they attempt to balance these gaps by relying heavily on their personal experience and knowledge, rather than on a more objective and structured basis.

Doctors and nurses described how CHWs alone are not always able to recognize risk factors. Sometimes they refer problems to the team with delay, due to their inability to promptly perceive hazards. One doctor reported the effects of these delays in referring newborns to the Unit, and the consequent impossibility to perform all the required screening tests.

On their side, CHWs complained about a gradual deviation from their original mission, which turns out now as more oriented on papers and bureaucracy, rather than on

contact and interactions with people of their communities. According to them, the number of visits delivered to each family decreased, together with their duration and ability to follow up more closely difficult cases. Also, time to organize events that could foster community engagement decreased. CHWs perceived that their role had been gradually moved to health care rather than the health promotion, as envisioned under the official definition of their role. Ethnographic observations have emphasized the lack of attention for health promotion during home visits and within health units, especially when comparing practices between the intervention group of CHWs, who had a recent refresh of their promotional potential, and the control one.

These opinions were backed by nurses and doctors who explained how CHWs tend to adapt their performance more on a biomedical model of health than on a more comprehensive vision and that their reports to the team about specific patients were increasingly focussing on disease specific issues rather than broader social determinants. They confirmed that CHWs’ role in health promotion and education tends to be weak and, with respect to mothers and children, CHWs often limit their actions to measure height and weight of babies and check immunization status. When mothers attend the Unit, then nurses are often obliged to provide the kind of advice that should have been provided by CHWs.