Abstract
The mixed methods research aimed to 1) study, analyze, and draw lessons about the potential and participation of village health volunteers (VHVs) in community health management; 2) examine the relationship between factors, potential, and participation of VHVs in community health management; and 3) develop policy recommendations for enhancing the potential and participation of VHVs in community health management after the transfer of sub-district health promoting hospitals to provincial administrative organizations. The sample was selected using purposive sampling from 20 sub-district health promoting hospitals (SHPHs) across 10 provinces, covering 4 regions where the operations of the SHPHs were transferred and registered under the Provincial Administrative Organizations (PAOs). The research was conducted from February 2023 to January 2024. Data were collected using questionnaires from a sample of 482 VHVs and 480 community members. Additionally, focus group discussions and interviews were conducted with representatives of VHVs, community members, administrators, and individuals responsible for or involved in operations at the health region, provincial, district, and local levels. The total sample size was 1,530 people. Quantitative data were analyzed using descriptive statistics (frequencies, percentages, means, medians), and KR 20 was used to analyze knowledge scores. Relationships and differences between factors, potential, and participation of VHVs in community health management were analyzed using the Wilcoxon signed-rank test, Chi-square, and Fisher's exact test. Multiple logistic regression was employed to analyze factors associated with VHVs' ability in community health management. For qualitative data from in-depth interviews and focus groups, content analysis was used to synthesize key conclusions. The research results showed that out of the 482 VHV samples, the majority were females (81.95%), aged between 50-59 years old, with 39.21% having completed lower secondary education. The average duration as a VHV was 16.38 ± 9.64 years (with 34.85% having more than 20 years of experience), and 87.34% had prior training experience. As for the 476 community member samples, the majority were females (63.75%), with 40.21% having completed primary education, and 27.71% working as farmers. The potential of VHVs comprises knowledge, attitudes, and behavioral skills in community health management across 5 aspects: health planning, leadership and budget management, health promotion activities and disease prevention/control in the community, evaluation of community health management, and information technology for community health management. The results revealed that the majority of VHVs scored high in knowledge (96.89%). Both VHVs and community members held highly positive attitudes towards VHVs' roles in community health management, with mean scores of 4.37 (SD=0.49) and 4.20 (SD=0.49) respectively. Moreover, both groups perceived VHVs to possess strong behavioral skills in practicing community health management, with mean scores of 4.31 (SD=0.50) for VHVs and 4.28 (SD=0.60) for community members. There was a noticeable difference in VHVs' opinions regarding their potential for community health management before and after the transfer of SHPHs to PAOs. A decrease in perception was observed across all aspects after the transfer. Statistically significant differences were found in health promotion activities and disease prevention/control in the community (p-value = 0.019), mirroring community members' opinions (p-value = 0.015). Both VHVs and community members rated VHVs' participation in community health management as high (mean 4.27, SD=0.57 and mean 4.11, SD=0.58). However, the overall level after the transfer was significantly lower than before (p < 0.038). Regarding VHVs' ability in community health management, both groups rated it as high (mean 4.17, SD=0.58 and mean 4.08, SD=0.61), with the highest mean for monitoring and evaluation (mean 4.30, SD=0.66 and mean 4.22, SD=0.69), and the lowest for self-health management ability (mean 4.12, SD=0.69 and mean 4.00, SD=0.71 Factors associated with the high ability of VHVs in community health management, as analyzed using multiple logistic regression, included: 1) VHVs' potential in terms of behavioral skills in community health management practices 2) VHVs' participation in community health management 3) Age group of VHVs 4) Duration as a VHV and 5) Occupation. All five factors showed a significant relationship with VHVs' high ability in community health management (p<0.001). To enhance VHVs' long-term potential, they should develop competencies to overcome personal factor limitations. Skill development and promoting participation in community health management are recommended. Policy Recommendation for the Transition Period: 1) The Decentralization Committee should develop a clear strategic plan to enhance the roles of community networks. 2) The Ministry of Public Health, specifically through the Department of Health Service Support, should define the roles and responsibilities of agencies concerning the development of VHVs in the new context following SHPH transfers. This effort should include supporting District Health Offices in transitioning roles to offer academic training and support for VHVs. Additionally, the Ministry of Public Health should review criteria, qualifications, selection methods, termination processes, and upgrade VHV standards. 3) The Central and Provincial Committees should collaborate to establish clear curricula and standards for VHVs. Consider designating District Health Offices as "Village Health Volunteer Training and Development Offices" to provide support for VHVs. It's essential to promote integration between the Ministries of Public Health and Interior to harness the potential of community networks. 4) The Ministry of Interior, in collaboration with PAOs, should create systems and mechanisms for public health administration. This includes establishing new structural relationships between VHVs and PAO executives. Additionally, leveraging Provincial and District Health Boards to facilitate collaboration with health partners and district health teams will drive efficient, continuous local health systems with clear direction. This approach should emphasize VHVs' public health roles according to established standards. 5)The Ministries of Interior and Public Health should collaboratively develop fundamental public health information systems and establish relevant reporting mechanisms for VHV performance. These systems should be integrated with the Ministry of Public Health's information system to effectively utilize data for service delivery, human resource management, and resource allocation within a unified, non-duplicative database
