The relative influence of the community and the health system on work performance: A case study of community health workers in Colombia

A central component of the primary health care approach in developing countries has been the development and utilization of community-based health workers (CHWs) within the national health system. While the use of these front line workers has the potential to positively influence health behavior and health status in rural communities, there continues to be challenges to effective implementation of CHW programs. Reports of high turnover rates, absenteeism, poor quality of work, and low morale among CHWs have often been associated with weak organizational and managerial capacity of government health systems. However, no systematic research has examined the contribution of work-related factors to CHW job performance. The research reported in this paper examines the relative influence of reward and feedback factors associated with the community compared to those associated with the health system on the performance of CHWs. The data are drawn from a broader study of health promoters (CHWs) conducted in two departments (provinces) in Colombia in 1986. The research was based on a theoretical model of worker performance that focuses on job related sources of rewards and feedback. A survey research design was employed to obtain information from a random sample of rural health promoters (N = 179) and their auxiliary nurse supervisors about CHW performance and contributing factors. The findings indicate that feedback and rewards from the community have a greater influence on work performance (defined as degree of perceived goal attainment on job tasks) than do those stemming from the health system. Work performance was shown to be more strongly associated with feedback factors such as the perceived value community members place on HP activities and direct observations of health improvement, than with the supervisory feedback. Work performance was also more strongly associated with the perceived reward of having influence in the community than with rewards associated with the health system, working with other HPs, written commendation and salary. These results suggest that the CHW may have stronger links to, and dependency on, the community for rewards, feedback and motivation to perform than has generally been acknowledged. The authors suggest a health system participation model that would focus management support on the worker-community interface rather than the worker-health service interface. It is argued that if the national health system were to consciously promote and strengthen the relationship between the CHW and her community, this would positively affect performance of CHWs.