1.1. Background of the study

Community health workers (CHWs) are pivotal to augmenting primary care service capacities in low and middle-income countries [1]. In settings like the Philippines, integrating CHWs into healthcare provider networks has been a strategic response to address service demands amid increasing workforce shortages [2]. CHWs have been a salient feature of the healthcare system in the Philippines for decades, with each CHW responsible for the welfare of residents in their assigned communities. As of 2020, an estimated 241,282 CHWs were reported to be in active service [3]. Locally referred to as Barangay Health Workers, named after the barangay—the smallest administrative unit in the Philippines, CHWs have become embedded in the delivery of primary care services since the program’s inception.

The recognition of lay health workers in national healthcare frameworks gained momentum following the Alma Ata Declaration of 1979. In response, the Philippines established primary care as a national priority and subsequently launched its CHW program in 1981 [4,5]. Existing literature suggests that CHWs assume a minor role in barangay health centers as their ability to participate in direct service provision is contingent on whether midwives or nurses are present to supervise them [6,7]. Nevertheless, the role of CHWs extends beyond healthcare facilities. Their duties include providing culturally appropriate medical advice, facilitating referrals, and mediating between patients and providers [8]. Although increasingly recognized for these bridging functions, the full range of CHW responsibilities is still largely dependent on local leadership [1,4,9]. Amidst fragmentation in health governance and policy, a comprehensive description that captures the full scope of CHW work becomes all the more elusive.

Signaled by the passage of Republic Act No. 7160 or the Local Government Code of 1991, national entities delegated a considerable portion of healthcare decision-making authority to local government units (LGUs) like the municipality or the barangay [10]. Under this set-up, LGUs take charge of operating the primary, secondary and tertiary levels of care. The primary level focuses on patients in the community setting while the latter levels take place in hospitals [4]. CHWs operate on the primary level. They collaborate with other members of the healthcare provider network in health promotion and disease prevention efforts. Despite this standardized set-up, systems devolution has contributed to the variability and expanded breadth of CHWs’ responsibilities [4]. Decisions on the procurement of medical equipment, health budget allocation, and the onboarding of health personnel were principally determined by these localized units. Within a decentralized framework, the recruitment of CHWs, the honorarium set aside for them, and the specific duties assigned to CHWs are all under the purview of their respective LGUs [6]. While devolution aimed to bolster system responsiveness, actualizing this goal still hinges on the commitment of the incumbent leadership at the local level. This precariously positions CHWs against a potentially dynamic political landscape, as their employment and the resources they have access to are predicated on the priorities of the LGU [1].

CHWs have been operational in barangay health centers longer than their counterparts in other countries [6,11]. However, the only legislative measure safeguarding their rights and welfare was enacted through the BHWs’ Benefits and Incentives Act of 1995. This act aimed to protect CHWs’ right to self-organize and mandated LGUs to provide a form of subsistence allowance [12]. In late 2022, House Bill No. 6557 or the Magna Carta for Barangay Health Workers subsequently received unanimous approval in its conclusive third reading [13]. The passage of the Magna Carta marked a significant step towards ensuring CHWs receive workplace protections, which include health benefits, retirement cash incentives, and hazard pay. With the passage of the Philippines’ Universal Healthcare Law of 2019, LGUs are slated to receive capitated funds from the Philippine Health Insurance Corporation to support primary care services [14]. If these funds are implemented with system-strengthening interventions as intended, augmented organizational support can alleviate the burden on CHWs to address resource scarcity on an individual level. On ground realities, however, are far from these goals. Full implementation of these laws have stalled due to varying health priorities among LGUs, the lack of monitoring systems to ensure adherence [4], and inadequate awareness among CHWs themselves [15]. Moreover, protections specifying the permissible scope of work for CHWs are lacking, the grounds for lawful termination are ambiguous, and compensatory practices are largely discretionary [1].

The inadequate attention to CHWs in legislation is symptomatic of the institutional undervaluation of their role in improving community health outcomes. A nationally representative survey reported that over 50% of health visits from the country’s poorest wealth quintile were made to community health centers [16]. In underserved areas, these facilities were primarily staffed by CHWs who lacked medical supplies [6] and training to support increasing service demands. CHWs are often the first and sometimes the only point of healthcare contact for many of these community frontlines. Despite their involvement in augmenting service capacities, existing research on the roles they assume and the barriers and enablers that influence their role performance remains limited. Therefore, examining the multi-level factors that influence role performance is crucial in ensuring policies respond to the experiences of CHWs in the field.

1.2. Study objectives

The present study aims to achieve two objectives: (1) To describe the roles assumed by CHWs in a rural and remote municipality in the Philippines; and (2) To identify the multi-level barriers and enablers CHWs perceive as influencing the performance of these assumed roles.

2.1. Research gap

CHWs have been the backbone of the Philippine healthcare system for over four decades. Despite the passage of policies aimed at improving workplace protections and financial support, CHWs continue to encounter persistent challenges in carrying out their roles. These challenges are further shaped by the decentralized structure of the healthcare system, making them highly context-specific. This presents a critical research gap. Exploring the enablers and barriers to CHW role performance through their lived experiences offers valuable, grounded insights into the realities of service delivery in devolved settings. Such understanding is essential for informing policies that are responsive to realities at the grassroots level. Focus group discussions (FGDs) were conducted to capture nuanced perspectives. This method enables rich, in-depth exploration of shared experiences within their local contexts.

2.2. Conceptual framework

Using the socioecological model adopted from Bronfenbrenner’s ecological systems theory of development, this study examines the factors that enable or inhibit CHW role performance across various spheres of influence [15,16]. The model asserts that individual, interpersonal, organizational, and policy-level factors influence human experience or, in this case, role performance [17,18]. Our framework adopts Gjerde & Ladegard’s conceptualizations [19], defining ‘roles’ as the spectrum of behaviors and responsibilities incumbent upon individuals within an organization. To examine factors influencing role performance, we have integrated insights from Mhlongo et al., [20] who characterize barriers as elements that adversely impact CHWs’ ability to perform their roles, and enablers as factors that facilitate this performance. Fig 1 presents the framework and working definitions used in this study [19,20].

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Fig 1. Adaptation of Bronfenbrenner’s socioecological model and definitions of roles, barriers, and enablers.

https://doi.org/10.1371/journal.pgph.0004965.g001

Despite the paucity of studies exploring CHW experiences in the Philippines, existing research has leaned on analytical frameworks like Campbell and Cornish’s triad of social contexts [1,4] or Bronfenbrenner’s multi-level approach [6]. The present analysis gravitated towards the latter to avoid predetermining more specific thematic categories and to clarify the level at which interventions should be directed. Community and policy-level factors were collapsed into a single umbrella category for parsimony.

2.3. Study setting

This study presents a secondary analysis of focus group data obtained by the Philippine Primary Care Studies (PPCS) program. PPCS is a publicly-funded program aimed at strengthening primary care systems through universal health coverage and building workforce capacities [21]. The parent study, from which our data originated, focused on exploring the use of a clinical decision support tool within a cadre of CHWs. The parent study for this analysis was conducted in two rural and remote municipalities in the Philippine provinces located in Central and Southern Luzon, respectively. Given the politically sensitive narratives presented in this study, the researchers opted to anonymize the specific municipalities and barangay units from which participants were recruited.

According to the 2020 National Census, the rural site in Central Luzon supports an estimated total population of 853,373 people across 11 municipalities and one city [20,21]. In comparison, the remote site in Southern Luzon is, over 360 miles from the Philippines’ National Capital Region, a Pacific-facing peninsula home to an estimated population of 828,655 people across 14 municipalities and one city [22]. The province of our remote site features a mountainous landscape and is particularly prone to typhoons, owing to its position along the Pacific typhoon belt [21,23,24]. CHWs in both provinces have been the backbone for supporting essential primary care services and public health initiatives.

2.4. Sampling and data collection

Recruitment for the parent study began on June 11, 2023 and concluded on July 7, 2023. Six focus group discussions (N = 6) with approximately five to eight participants were conducted at each site. CHWs were purposively recruited to reflect various lengths of service in their field. Three tenure categories were used to diversify participant recruitment, broadly defined as short tenure for those with less than three years of experience, medium tenure for individuals who had been in their roles between three to six years, and long tenure for those with over six years of experience as a CHW. These tenure cutoffs were aligned with the general quartile distribution of the years in service of CHWs in rural and remote areas, which were last measured by the PPCS program in 2022.

Inclusion criteria for recruitment encompassed CHWs currently employed by each municipality, individuals 18 years and above, and those with prior exposure to the clinical decision support tool piloted by the parent study. The inclusion of CHWs with prior exposure to UpToDate was crucial for the usability study undertaken by the parent study. This approach ensured that participants were already familiar with or had experience using the application, enabling them to discuss their perceptions of the tool. CHWs who had retired before data collection commenced were excluded from recruitment. A combined total of 34 individuals were recruited and participated across both sites.

A multi-lingual team of researchers conducted all focus group discussions. Focus groups were facilitated in English and Filipino in the rural site and English and Bikolano, a local language spoken in the remote site. Participants in these settings used each of these language pairs interchangeably as part of their vernacular. Focus group sessions lasted between 60–90 minutes and were audio-recorded by researchers of the parent study. While the parent study did not provide any financial incentives, participants were reimbursed for transportation costs and received groceries as a token of appreciation. Both verbal and written informed consent were obtained from participants before each focus group session.

2.5. Focus group discussion guide and compatibility

The parent study adopted a semi-structured focus group discussion guide to assess the compatibility of UpToDate in supporting CHW workflows [25]. Pilot testing for the adapted study instrument was conducted by the parent study in the same two sites and an additional urban site in April 2021. In addition to investigating user perceptions of UpToDate, this adapted facilitator’s guide included questions that delved into CHWs’ roles and capacity-building needs. FGDs for the parent program touched upon the experiences of CHWs and the factors influencing their performance within their local health units in-depth. For example, the CHWs were asked about the scope of their daily responsibilities, the command hierarchies within their practice, and the various types of resources or support available to them. The facilitator’s guide also had prompts exploring perceived barriers and enablers of effective role performance among CHWs (see S1 Appendix). A mixed inductive/deductive approach was used to investigate this subset of the FGD data for secondary analysis. Since participants recruited for the present study included English, Filipino, and Bikolano speakers, the interview guide was translated by the facilitators into the language/s spoken by the participants.

2.6. Data management

Three research assistants from the parent study transcribed each interview verbatim before translating it into English. All personally identifiable information, such as names, specific barangay assignments, or identifiable participant attributes were appropriately redacted during transcription. Subsequently, each participant was assigned an unlinkable case ID before initiating secondary analysis. Anonymized data was accessed by analysts for research purposes on September 1, 2023. The secondary analysis described in this paper was conducted by a social scientist and a medical doctor with prior exposure working in each of the settings described in Section 2.2. Neither analyst was directly involved in collecting or transcribing focus group data under the parent study. Furthermore, all names presented in this study are pseudonyms and bear no relation or resemblance to the actual names of the participants.

2.7. Data analysis

All verbatim transcripts from the six focus groups were uploaded into NVivo 14.0 for analysis. The present study used a mixed deductive and inductive approach to develop the codebook and organize the data into themes. Deductive codes involved an a priori interest in the roles assumed by CHWs and the factors that either impeded or facilitated their role performance. In this study, we employed open and axial coding for our qualitative data analysis. Open coding involved segmenting narrative data into thematic components, while axial coding focused on identifying relationships between these components and organizing them into broader categories.

Inductive codes were elicited by randomly drawing two transcripts and having two researchers independently identify emergent codes (open coding). To do this, the secondary data analysis team reviewed the untranslated transcripts and their corresponding English translations while coding.

After open coding, both analysts convened to develop a preliminary codebook wherein codes were either collapsed or expanded. CHW roles, as organized in existing literature [9], formed a part of the axial codes used to categorize CHW responsibilities derived from open coding (deductive). These deductive codes specifically focused on detailing the various bridging functions of CHWs (see Section 3.2). Additional axial codes were inductively added to further categorize CHW roles that were not captured by the deductive codes but were represented during the open coding phase. Inductively added axial codes emphasized CHWs’ function as direct service providers and experts in the community. Codes relating to the barriers and enablers of role performance were primarily inductively derived and thematically structured using the adapted socioecological model (see Fig 1).

The coding framework was then applied to all other transcripts, with revisions discussed through analytic memos and iteratively incorporated throughout data analysis. To maximize internal consistency, 50% of the transcripts were double-coded by a second analyst using the established codebook. A summary table of the organized themes, working descriptions of each, and illustrative quotations were presented to the larger transdisciplinary research team involved in the study. This team included mathematicians, clinical epidemiologists, health administrators, medical doctors, social scientists, and site staff. Feedback from these internal presentations was incorporated to refine interpretations and policy recommendations.

2.8. Ethics clearance

Ethics approval for the parent study was obtained from the University of the Philippines Manila Research Ethics Board (UPMREB – 2015-489-01). Ethics approval is renewed for all PPCS study activities across all pilot sites. Since none of the researchers involved in this secondary analysis had access to personally identifiable information obtained by the parent study, the Johns Hopkins School of Public Health Internal Review Board (IRB) determined the present analysis exempt from IRB review.

3.1. Demographic profile

Table 1 describes the socio-demographic characteristics of participants across the six focus group discussions. Of the participants, 15 were recruited from the rural site and 19 were from the remote site. Except for one short-tenure CHW, all focus group participants were female. Participants were between 28 and 75 years old at the time of recruitment. Due to the recruitment methods used by the parent study, participants’ average years in service varied and ranged from 10 months to 31 years. Furthermore, most participants were married (82%), received secondary education or less (79%), and had no other form of employment or independent source of income apart from community health work (68%).

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Table 1. Socio-demographic distribution of focus group participants.

https://doi.org/10.1371/journal.pgph.0004965.t001

3.2. Roles and responsibilities of community health workers

Emergent themes underscored the multi-faceted nature of the roles and responsibilities undertaken by CHWs within their practice. These roles were identified through the analysis of participant accounts. Our findings reveal the intricate web of roles that CHWs effectively assume, namely: 1) community expert; 2) direct service provider, 3) service extender, 4) knowledge broker, and 5) social change agent. Table 2 provides an overview of these various roles assumed by CHWs and the corresponding responsibilities associated with each role.

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Table 2. Overview of roles assumed and responsibilities performed by CHWs on the field.

https://doi.org/10.1371/journal.pgph.0004965.t002

CHWs have multifaceted and synergistic roles in augmenting community health outcomes. They are knowledgeable about their communities’ health needs and adept at navigating local social networks. LGUs leverage this expertise for public health surveillance and ongoing health status monitoring of patients. CHWs’ understanding of their communities complements their role as knowledge brokers, bridging the gap between communities and the healthcare system. They not only comprehend local contexts but also actively facilitate information and resource exchange within their networks. Additionally, CHWs act as social change agents and address various social health determinants in their practice. These tasks include advocating for mothers to participate in livelihood programs, monitoring for intimate partner violence, and helping community members access social welfare benefits. Cathy, a short-term CHW, describes their role as social change agents:

“Couples can have disagreements due to a woman’s pregnancy. In several instances, these conflicts have led to domestic violence. Since some CHWs are also tasked to monitor cases of domestic violence, we try to de-escalate these tensions and support counselors to the extent we can.”

The role of CHWs as direct service providers, however, is relatively narrow. Their duties are primarily limited to blood pressure monitoring and administering first aid if other providers are unavailable. While a few CHWs recalled instances when they suggested diagnoses to patients, most exercised caution due to their fear of potentially providing inaccurate interpretations of medical conditions. This cautious approach led them to refer patients to the supervising midwives or the primary care physicians stationed at the central health unit. Gina, a long-tenure CHW, described:

“When mothers message me on Facebook about their child’s symptoms, I consult UpToDate [a digital clinical decision-support tool] to find what can be done to improve the child’s condition. However, I stick to providing light advice. I’m afraid to interpret complex health information, as I could easily make mistakes and potentially harm the patient.”

Despite their limited clinical responsibilities, CHWs serve as health service extenders by aiding patients in accessing care, distributing medicines, and providing logistical support for public health initiatives. The distinction between CHW responsibilities inside and outside facilities is minimal, except for facility cleaning and maintenance. However, the presence of CHWs in barangay health centers exemplifies their role in extending services from the central health unit to more peripheral service areas. While these satellite centers often lack sufficient medical supplies for most care functions and CHWs are not trained to diagnose, their presence in these facilities ensures that patients can reliably reach individuals who can connect them to other providers within the healthcare provider network if needed.

3.3. Barriers and enablers to role performance

3.3.1. Overview.

Using the socio-ecological model to examine the barriers and enablers experienced by CHWs in the field, this study reveals that role performance among CHWs is shaped as much by their individual capabilities as by their evolving social relations, organizational environments, and the broader community contexts in which they operate. Table 3 provides a general overview of the barriers and enablers influencing CHW role performance described by participants in focus group discussions.

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Table 3. Overview of barriers and enablers organized according to the socioecological model (SEM).

https://doi.org/10.1371/journal.pgph.0004965.t003

4.1. Community health workers at the fulcrum of health communication

The objectives of this study were twofold: 1) to explore the roles and responsibilities of CHWs; and 2) to identify the perceived barriers and enablers they encounter in performing their roles. Insights gathered from focus group discussions in remote and rural areas of the Philippines highlighted the extensive responsibilities shouldered by CHWs. CHWs assumed clinical and non-clinical roles within their practice – ranging from direct service provision, navigating patients through healthcare processes, to intervening on the social factors that influence health outcomes. Barriers to role performance included limited technological literacy, low self-efficacy in clinical decision-making, workplace tensions, patient resistance, inadequate supplies, unclear role delineation, and political instability. Conversely, enablers encompassed strategies such as diskarte, proficiency in emotional labor, cultural competence, strong interpersonal relationships, organizational support through clinical decision aids and training opportunities, and community support via social media and engaged local governance.

Echoing previous findings, this study underscored the indispensable function of CHWs in facilitating the bidirectional flow of information between patients and the healthcare system [1,9]. Their mediating role is especially evident when relational hierarchies exist between patients and providers or between community members and local government officials. CHWs bridge patient-provider communication given their ability to translate complex health information in a language and register accessible to patients. Conversely, CHWs were able to advocate for the needs of community members given their proximity to both healthcare providers and government officials alike.

CHWs’ embeddedness in community and healthcare provider networks supports their bridging functions and positions them at the fulcrum of health communication. The physical proximity and relational embeddedness of CHWs to the community intimated an in-depth understanding of local beliefs, practices, and behavior patterns. Conversely, the liminality of the CHW position—straddling the line between community member and healthcare professional—afforded CHWs access to information otherwise inaccessible to community members. Through effective training and support, CHWs have the potential to optimize human healthcare resource allocation and maximize local capacities in underserved settings.

The explicit boundaries of CHW responsibilities were ambiguous and described by participants as overextending the scope of health service delivery. For example, disseminating social service benefits and mobilizing disaster evacuation efforts also depended on CHW involvement. Fragmentation in the command chain and the absence of a formal job description contributed to such role ambiguity [31]. Overlapping oversight from multiple supervisory bodies and the lack of standardized workplace protocols meant that CHWs often handled an assortment of seemingly unrelated tasks. Within the data, this was corroborated by accounts where participants felt unable to refuse ad hoc tasks or felt overwhelmed by the concurrent tasks assigned to them by the midwife, the CHW federation, and local officials.

4.2. The precarity of community health work

CHWs were implicitly tasked with navigating the complexities of shifting medical environments, divergent political and societal expectations, and resource constraints faced when performing their roles. Material exigencies and the lack of organizational and policy-level support heightened the precarity of their positions. Although expected to assume multiple roles within the healthcare system, a significant fraction of their tasks were neither formally accounted for nor compensated. CHW remuneration hinged on locally appropriated health budgets [6] and the efficiency of local administrators in managing bureaucratic procedures [19]. When health budgets were sidelined or onboarding was delayed, CHWs expectedly experienced compensation issues. This resulted in CHWs receiving no payment, reduced payment, or enduring delays that could span a few months to over five years. In one of the more severe cases noted in this study, changes in local leadership reportedly led to the abrupt dismissal of an entire cadre of CHWs due to their perceived affiliations with the previous administration. However extreme this may seem, parallel accounts have been documented in past research examining the same phenomenon of interest [1,4].

The lack of workplace protections typically afforded to other healthcare roles heightened the precarity of CHW work, as previous literature suggests [6,32]. Beyond timely remuneration, study participants were neither formally entitled to standardized employment benefits nor did they receive severance pay or retirement benefits. Previous research has consistently shown the profound impact of non-financial incentives on CHWs’ professional motivation. Access to training and a driving sense of purpose for the job propelled CHWs to remain in service even in the absence of remuneration [32,33]. However, the unpredictability of remuneration made CHW work untenable as a primary income source. In most instances, participants had to depend on their partners or other family members to support their daily needs.

The absence of firm entry requirements within the profession has disproportionately driven economically insecure women to engage in community health work [32]. This trend can largely be attributed to the scarcity of viable employment options available for individuals with limited education and the child-rearing obligations borne by many of the women interviewed. In environments rife with poverty, the potential for the exploitation of these women is of grave concern. Societal norms reinforce the expectation for women to assume caring roles both domestically and professionally. Furthermore, the appeal of CHW programs to individuals who might otherwise struggle to find employment has, historically, been leveraged to justify unpaid labor [32–34]. The pervasive issues that underlie community health work were best exemplified in the Philippines’ Department of Health pocket handbook for CHWs, which demanded from CHWs unwavering “perseverance [when performing their roles] despite difficulties, setbacks and lack of financial support” [35]. This has situated CHWs in a precarious position where their labor is institutionally undervalued, yet a deep commitment and altruistic ‘love’ for their work is expected in return.

4.3. Overcoming situational limitations through diskarte and social capital

A systematic review of the accessibility of essential medicines in low-middle-income countries indicated that, on average, CHWs were confronted with difficulties in fulfilling supply-side demands about one-third of the time [36]. These findings aligned with local literature on CHW experience, wherein workforce shortages and the unavailability of medical supplies have impeded health service delivery [6,33]. In the present study, managing the burden of resource scarcity was often shifted onto individual and interpersonal capacities in the field. Demands unmet on an organizational or community level were predominantly addressed by CHWs through their own diskarte or self-devised strategy.

Social capital emerged as a critical enabler for CHW role performance amidst situational limitations. Following Bourdieu, social capital can be defined as the sum of “actual or potential resources which are linked to [the] possession of a durable network of more or less institutionalized relationships of mutual acquaintance and recognition” [37]. Social capital underpinned CHWs’ ability to effectively mobilize resources, assist in public health surveillance efforts, and mediate between patients and the health system. Previous research similarly suggested that the effectiveness of CHWs in the field is largely affected by the social capital they cultivate with community members. A cross-sectional study conducted during the COVID-19 pandemic reported that CHWs with stronger community ties were more likely to participate in pandemic response activities [38].

Within the present study, the role of social capital was even more apparent when considering its interplay with diskarte. Where diskarte reflects an individual’s ability to navigate and overcome resource constraints, network embeddedness cultivated through social capital enhances this ability. Examples such as pooling donations from fellow CHWs to address the lack of medical supplies or deciding to create Facebook group chats to connect with patients in remote areas were some ways social capital factored into participants’ diskarte. Their profound understanding of local resources and networks can potentially improve the effectiveness of program interventions if these strategies were accounted for. Although the conceptual relationship between diskarte and social capital remains underexplored, this study underscored the potential of exploring this milieu in future research and policy. Productively scaling out diskarte could involve broadening CHW participation in health decision-making and program design. Specifically, this could involve initiating regular sensemaking workshops with CHWs to obtain feedback to appraise and evaluate existing public health policy on both local and national levels.