Ethics declaration

The study was approved by the National Ethics Committee for Health Research reference: 318, 24^th December 2021, and Oxford Tropical Research Ethics Committee (OxTREC) approval reference: 535–21, 24^th August 2021. All respondents gave written informed consent to participate in the interviews and to be audio-recorded. Respondents were informed that they had no obligations to participate and that there would be no consequences for them should they decide not to participate. They were also informed that their decision to participate would be kept confidential. Participants were compensated for their time (5 USD) and travel expenses (up to 10 USD).

Study design

This study was part of two multi-country research programmes across Southeast Asia that aimed to better understand health concerns and health needs in remote and rural communities and to conduct various assessments, reviews and implementation trials of scalable, high-impact interventions. These included an assessment of VMW programmes across the Asia-Pacific funded through the Regional Artemisinin-resistance Initiative 3 Elimination (RAI3E) by the Global Fund to Fight AIDS, Tuberculosis and Malaria [10–12], and a feasibility study of non-malarial febrile illness management at community level through the South and Southeast Asian Community-based Trials Network (SEACTN) funded by the Wellcome Trust [13]. This article presents findings from a qualitative study, which included in-depth interviews (IDIs) and focus group discussions (FGDs) with stakeholders in the communities receiving and providing the malaria services and those involved in planning or implementing VMW service provision in Cambodia to elicit their views and perspectives about current challenges, opportunities, and prospects for future programme development.

Study context

Pursat Province is located in western Cambodia, along the border with Thailand, in an area characterised by the densely forested Cardamom mountains and wildlife sanctuaries (Fig 1). Kravanh is 1 of 5 districts in Pursat province and includes 7 communes and 55 villages. According to reports from the Ministry of Health, Kravanh had >40 malaria cases per 1,000 population and an annual blood examination rate of over 20% in 2019. Since then, the number of cases has reduced significantly. From January to March 2024, 176 malaria cases (162 P. vivax and 2 P. falciparum) were reported nationally and only one P. vivax case was identified in Kravanh district [14]. Our study was conducted in 6 malaria endemic communes located at variable distances from health facilities among which, 4 reported confirmed malaria cases in 2019 and 2020 [15].

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Fig 1. Study provinces and locations of study villages in Cambodia.

The map was created using QGIS software version 3.26 (Buenos Aires) and contains a basemap from OpenStreetMap (https://www.openstreetmap.org/#map=6/54.91/-3.43), which is made available under the Open Database License (https://www.openstreetmap.org/copyright). National and provincial administrative boundaries were from Global Administrative Areas version 3.6 (https://gadm.org/download_country.html). Locations of the study sites and district referral hospital were collected on KoboToolbox.

https://doi.org/10.1371/journal.pgph.0003962.g001

In addition to primary care centres and the Phnom Kravanh Operational District (OD), a variety of community-based programmes are active in this area, managed by local non-governmental organisations (NGOs) and international organizations (IOs) such as the consulting firm University Research Co (URC) [16, 17] and other organisations implementing the U.S. President’s Malaria Initiative [18]. The VMW programme is managed by the CNM in collaboration with the provincial health departments (PHDs), ODs and health centres. According to the guidelines, VMWs must receive annual training and supervision from ODs and health centre staff on malaria diagnosis and case management, counselling and health education, and case reporting for disease surveillance. Regarding treatment, VMWs are required to follow the protocol on directly observed therapy. P. falciparum patients should be taking artemisinin-based combination therapy on days 1 and 2, ideally in the presence of VMWs, but when this is not possible, the VMWs should visit the patient on day 3 to confirm that the treatment was completed. For P. vivax cases, VMWs should conduct a follow-up visit on day 3, 7, and 14 to monitor the patients’ treatment adherence and observe any side effects of primaquine treatment. Mobile malaria workers (MMWs) are tasked with active malaria case detection among mobile and migrant populations, and additional activities such as chemoprevention among forest workers [19]. VMWs/MMWs receive monthly stipends and financial incentives, including incentives to perform specific activities such as outreach and case investigations, although the incentive structure and level vary widely depending on the implementing organisation [20]. All VMWs/MMWs are required to participate in monthly meetings with supervisors to discuss their work, deliver reports and replenish supplies. At the time of the study, there were 71 active VMWs and 16 MMWs in Kravanh District, according to the list in the operational district, covering a population of 50,763 according to the 2019 national census [21]. Nationwide, as indicated by the latest CNM report in 2020 [19], there were 5,968 VMWs active in 2,984 villages (with > 5 malaria cases per 1000 population) and 637 MMWs.

In addition to VMWs, these villages are also served by Village Health Support Groups (VHSG)—a community-based network of volunteers overseen by the Ministry of Health, who work closely with health centres to promote health education and facilitate access to health facilities. The head of the VHSG is elected by the community, and appoints other members, typically with a ratio of 1 volunteer for every 10–50 households. A comparative table of governance, functions, and implementation of VMWs, MMWs and VHSG is provided in Table 1.

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Table 1. Comparative table of governance, functions, and implementation of community-based health services in Cambodia.

https://doi.org/10.1371/journal.pgph.0003962.t001

Study participants and sampling

For the IDIs, participants were selected to capture the diversity of perspectives of those involved in community-based health care in Cambodia. Following a preliminary stakeholder mapping, based on the review of documents and consultations, summarised in Table 1, we approached and invited to interview representatives of different categories, including: planners and managers of the VMW programme, working in the CNM and other central departments of the Ministry of Health; implementers at the national and sub-national levels, employed in the Ministry of Health or NGOs; and international stakeholders from WHO, research organisations and other agencies involved in programme implementation. In the communities, we aimed to interview VMWs and adult community members, selecting at least one VMW in each of the six communes.

Programme managers and international stakeholders were approached using the professional network of researchers involved in this project, and others were recruited by snowball sampling. In the communities, the first author (LHO) randomly approached residents at their homes, walking through the villages without following a predetermined sampling frame. A group of community members, some of whom participated in the interviews, were later invited to join a focus group discussion.

Data collection

Interviews were conducted in-person at participants’ homes, in communal spaces, workplaces or online. FGDs were conducted in-person at a public venue in their village or nearby health centre. Semi-structured topic guides for the IDIs and FGDs were developed based on previous studies of community health [22, 23]. They were designed to encourage discussion of priorities in the communities as well as the implementation of community care, including governance, financing and the relation with the wider health system (S1 Appendix) [24]. The topic guides were pilot tested with the initial respondents and reviewed for correct translation and clarity. Interviews across all categories of stakeholders and FGDs focused on (1) perceptions about malaria, other health concerns, and access to services in remote and rural communities; and (2) views and experiences about the implementation of the VMW programme. In interviews with programme managers and international stakeholders (3) prospects for the development of community-based care in Cambodia were also examined, considering governance, priorities and financing. The interview guides were iteratively reviewed throughout the data collection period in light of emerging findings.

Most participants were interviewed in Khmer by LHO although some online interviews with planners and implementers were conducted in English and involved MJ and ML. The sample size for the interviews with community members was determined by data saturation. Data collection was completed between March 15th and May 2nd, 2022. The IDIs and FGDs lasted typically between 20–50 minutes and 40–60 minutes respectively, with no participant withdrawals.

Data processing and analysis

Recorded interviews and FGDs were transcribed, translated into English and imported into NVivo version 12 (QSR International), for qualitative thematic analysis. The analysis aimed to identify themes around the key domains of our investigation defined above, although the coding process was flexible to allow the researcher to identify emerging themes. The consolidated criteria for reporting qualitative research (COREQ) were consulted to ensure comprehensive reporting of qualitative data from interviews and focus groups conducted in this study [25].

Malaria and other health concerns

Fever, gastrointestinal illnesses, and other health issues

Febrile illnesses, such as dengue and flu, were often cited as health issues for children, whereas adults more commonly reported stomach pain, diarrhoea, vomiting, and indigestion. Many described experiencing illnesses from insect or other animal bites, including snake bites. Concerns regarding hygiene and sanitation also emerged, as well as heavy alcohol and energy drink consumption, indicated by VMWs as the most common cause of diarrhoea, vomiting, and stomach-related illnesses in adult males. Female respondents described that they were informed about their contraceptive choices and many reported having had injections, intrauterine devices, and/or birth control pills from health centres and local NGOs.

When prompted, community members did not perceive themselves at risk of COVID-19 and most had received vaccination. One technical officer at an international organisation summarised the health concerns in remote rural communities as follows:

“The most pressing health needs in remote communities in Cambodia… I would say… they are water-borne diseases, skin rashes, digestive problems… they are not debilitating but still a problem also because people tend not to go to the health centre for these problems. Antenatal care is also an issue… if something goes wrong, [pregnant women] cannot spend the whole day to reach the health centre. Other problems are snake bites, which result in limb losses and deaths, and also occupational accidents in farming activities and other work” (Technical officer at international organisation, Phnom Penh, IDI)

Health services for the communities

In Kravanh, residents could access a variety of health services, depending on their location, socio-economic status and preferences. Respondents of Por ethnicity mentioned that traditional healers were still popular in their villages but were less common than in the past. In all villages, VHSGs, VMWs and other volunteers supported by international organisations offered general health education or specialised services for malaria, tuberculosis, maternal health, and nutrition, linking local communities with the public health sector.

The local public health centres and the district hospital provided basic medical services, including maternal care, vaccinations, and treatment for common illnesses. Poor community members explained they were eligible for various forms of subsidised assistance, including free health care. Pregnant women, mothers and children under two years of age were entitled, under a social assistance scheme for the population with low socioeconomic status, to cash transfers to attend counselling visits and check‐ups at the health centres and hospitals:

“When my daughter gave birth at the district hospital, the hospital didn’t charge anything because we have a poor identification card (Poor 1 card) and we get 200,000 Riels (50 USD) and also 5,000 Riel (1.25USD) a day.” (Village 2, female community member, FGD)

Despite these opportunities, distance, travel times, and associated costs were often described as significant barriers to accessing care at public health facilities:

“The majority of the community members are poor. For example, if someone falls ill at night, our only means of transportation is motorcycle. If there is no motorcycle for some families, this is a big challenge. Our community is far from a health facility and the road condition is not good.” (Village 1, male community member, FGD)

Community pharmacies and private clinics were often a preferred care option, delivering more personalized services and sometimes better-equipped facilities, though they were described as costly and not accessible to all:

“It is difficult sometimes to get treatment from the health centre after showing the poor identification card (a social assistance scheme) since there are not enough staff for consultation, drugs and equipment at the facility. So I went to a private clinic and I paid a lot” (Village 1, female community member, IDI)

The VMW programme: Views, experiences and challenges

All interviewed VMWs engaged in agriculture as the main source of income. Many of them were appointed as VMWs because they were involved in other roles in the communities (such as a village chief, deputy chief or a member of the village committee) while others were selected by village authorities:

“The village chief told me many times about this VMW position: ‘if you can join, you can help the community and control the spread of the disease’… I talked to my family and accepted the position.” (Village 4, female VMW, IDI)

Following recruitment, VMWs received malaria training from various providers, including the Kravanh health centre, the provincial and district hospitals, and international organisations. Their work schedule was flexible, mainly involving door-to-door visits in their catchment area, management of suspected malaria cases, and attendance at monthly meetings in the health centre. MMWs were tasked with active case detection in forest areas and additional activities such as chemoprevention among forest workers. In addition to the malaria programme, some were involved in other community health programmes supported by the World Health Organization (WHO), Food and Agriculture Organization (FAO), and other international organisations. Most VMWs were also active in the VHSGs, assisting health centres in vaccination and health information programmes. In these multiple roles, they were seen as a focal point for immediate care in the communities.

The interviewed VMWs were generally happy about their work with the malaria programme, willing to undertake new roles, and took pride in helping their communities while some complained that social status and hierarchies could undermine acceptance by community members, especially when VMWs were perceived to be poorer than their clients. The contribution of VMWs to malaria control was recognised in the FGDs and individual interviews although financing was often cited as a significant challenge to programme implementation. For VMWs, sources of income included their monthly allowance (which was reported to be around 20 USD), irregular incentives for participation in health or rural development activities, and informal business activities, such as the sale of medicines. For example, one VMW who was also involved in a reproductive health programme explained how she would make profit selling contraceptive pills to villagers. Yet most VMWs complained about scarce remuneration and some reported that incentives had reduced recently due to the winding down of malaria projects. This was often cited as a major challenge to programme implementation, resulting in limited availability of VMWs, often busy with other income-generating activities:

“I tried to seek help from the VMW, but he was always busy… he is a farmer and has other businesses too…The VMW comes to our house often, sometimes once every four or five days… When he comes to our house, he always explains and provides health information. And he says that if anyone in the household has any diseases or our child is old enough for vaccination, we should see a doctor as soon as possible…. But he is busy with other jobs, so he cannot visit us often…his supervisors should provide him with a daily wage and refund travel costs. Sometimes they [VMWs] do not have the money to buy food, do not eat enough and have no motorbikes. This affects the quality of health services provided by VMWs” (Village 1, female community member, IDI)

Prospects for the development of community care

There was a consensus among domestic and international stakeholders that VMWs remain a critical health system asset to support malaria control and elimination. Programme managers and international stakeholders stressed that VMWs should continue malaria services, including active surveillance and case management in low-endemic areas targeted for elimination:

“VMWs are still really important for elimination to conduct surveillance and monitor the situation to prevent the parasite reintroduction… and VMWs living in remote areas are really important to find new cases” (Respondent from an international organisation, Phnom Penh, IDI)

Concurrently, there was wide agreement in the communities that VMWs should provide a more comprehensive package of services, including treatment for common illnesses, monitoring of blood pressure and blood sugar levels and relief of general symptoms, such as headache, fever, and stomach pain through medication.

“If there is no more malaria disease, the VMWs should provide more services like for non-communicable disease, medicine for fever, flu, and other diseases that need basic treatment, so we don’t need to go to the district hospital or clinic. We can be relieved and cured. There are no health posts or health centres in our area… some families don’t have motorcycles, it’s hard for them to reach health facilities on time” (Village 5, male community member, FGD)

“We really need extra health services in our community as soon as possible. We are happy with the services that the workers have provided so far. They are fast learners and they should get training for other services in the future” (Village 3, male community member, FGD)

Similarly, programme managers and international stakeholders often stressed that VMW services should be expanded to ensure continued uptake and relevance. Suggestions for add-on activities included adoption of new tests for dengue and chikungunya, and the prevention and monitoring of non-communicable diseases, with careful consideration of eligibility and training, alignment with national health policy on primary care and non-communicable diseases (NCDs), and recognition that expansion of VMWs should not divert resources away from local health centres.

“I think dengue and chikungunya can definitely be [within] the remit of VMWs like any diagnosis that doesn’t require a medical or nursing background… a diagnosis that is based on either a binary yes/no diagnostic test or you need to refer to the health centre. This is definitely something that the VMWs could do well… a lot of them are very quick in picking up technologies although we have a range of ages and a range of abilities so we should reassess the suitability of VMWs depending on the technology. Some of the older VMWs may not be suitable” (Respondent from an international organisation, Phnom Penh, IDI)

“We could do a pilot in one province. We will start redesigning the health centre to include chronic care services. This implies building the workforce and strengthening the public health functions. And Village Malaria Workers–which one day will be called Village Health Workers–will also support NCD intervention and chronic care, at the community level” (Respondent from an international organisation, Phnom Penh, IDI)

“I would want to make sure that we don’t need to rely too heavily on community health workers as a system to improve health in Cambodia… I wouldn’t want to substitute improving and investing in health facilities with reliance on VMWs… VMWs should be more of a support to this… VMWs can do many things like blood pressure monitoring. But I wouldn’t want them to substitute what trained health care professionals can do” (Respondent from an international organisation, Phnom Penh, IDI)

Although there was optimism about these opportunities, concerns were raised about the availability of financial support for new roles and activities that extend beyond the remit of existing donors and funding schemes.

“Another important part is that Global Fund funding at this level won’t last forever so the VMWs need to be integrated in the wider health system at some point and financed more by their own ministries of health” (Consultant, Bangkok, IDI)

“I think it is also dependent on what the donors propose like if Global Fund says we really think we would like to keep the village malaria worker network transformed into a community health worker network, that would be a strong incentive for governments to go along with that” (Researcher, Bangkok, IDI)

When discussing prospects for domestic funding, provincial health managers considered scaling down certain programme components, such as shifting from monthly to quarterly meetings with VMWs in the health centres, while leveraging local resources for additional support. A senior health manager mentioned ongoing discussions between the Ministry of Health and the Ministry of Interior regarding the potential involvement of communes, which could allocate part of their budgets to community-based health services. Funding from communes was seen as an opportunity to advance administrative decentralization and enhance local ownership of these services. It was also suggested that VMWs could be upgraded into multi-purpose healthcare workers in the short to medium term, and eventually integrated into the existing community health structures–particularly the VHSGs–to provide a single point of care in the communities, as outlined in 2021 roadmap document issued by CNM [26].

"To ensure the sustainability of community-based services, we plan to collaborate with the commune councils, as each commune has an annual budget. We try to highlight the benefits of investing in health services for their communities. Commune councils could allocate part of their budgets toward the health sector in their respective areas. To achieve this initiative, we must work closely with the Ministry of Interior." (Programme manager, Phnom Penh, IDI)

“In the mid-term review of the malaria strategy, we discussed low malaria transmission and how the community network can be sustainable. We have a roadmap to integrate village malaria workers in the communes by 2025 into the health system not only for malaria but also for other health diseases” (Programme manager, Phnom Penh, IDI)

Strengths and limitations

This study enhances understanding of the various community-based malaria workers in Cambodia’s health system and their roles in malaria control and elimination, contributing to concurrent studies across the research projects in Cambodia [10, 39, 40] and in the region [36, 41]. We interviewed key stakeholders at different health system levels, and were able to reach VMWs with diverse experiences and involvement in health programmes in the communities. We conducted team debriefs to discuss the findings and assess their validity, and stakeholder meetings to share and triangulate the preliminary findings with selected participants. Some limitations must be noted. These include limited generalizability due to the context-specific nature of the findings, and potential sample size and selection biases, which may not capture the full diversity of experiences within the programme. The study involved interactions among Cambodian and non-Cambodian researchers with different backgrounds, disciplinary expertise, and appointments. However, we cannot rule out that subjective biases of leading authors may have influenced the interpretation of data. Additionally, reliance on self-reported data introduces risks of recall and social desirability biases, also considering that the research team had established relationships with local stakeholders due to involvement in other research projects [42]. Last but not least, the study was conducted when COVID-19 control measures were still in place, resulting in limited availability of participants and limitations to field work.