‘Of’ the community but not ‘of’ the health system: Translating community health workers’ knowledge into credible advice in Aceh, Indonesia

Abstract

Community health workers (CHWs)—or ‘cadres’ as they are known in Indonesia—are intermediaries between the health system and the community, providing maternal and child health services at a village level. However, systemic and contextual factors inhibit CHWs from realising their potential impact. Training is essential for improving CHW performance; however, there is a need to understand whether and how this affects the care communities receive. This paper explores how communities in Aceh Province, Indonesia, receive care from cadres and the extent to which training interventions of CHWs influence this care. Semi-structured interviews were conducted remotely with 10 cadres in two districts in Aceh between June and July 2021, and five focus group discussions were conducted face-to-face with 21 caregivers of young children in one district in September 2021. Data were iteratively and thematically analysed throughout data collection. Cadres were seen as ‘of’ the community but not ‘of’ the health system. Cadres found training valuable. However, training did not adequately address the contextual challenges cadres face. From the caregivers’ perspective, cadres’ enhanced knowledge did not translate into credible guidance. Their proximity to the community and perceived distance from the health system undermined caregiver perceptions of cadres’ credibility. Infrastructural limitations of Posyandu inhibited CHW’s perceived ability to perform their roles effectively. To maximise the potential of their role, there must be more investment in enhancing the credibility of cadres within their communities—and programmatic factors such as training must better account for and adapt to the local context.