A realist perspective on optimizing community health workers' roles and functions to deliver integrated...

Community Health Workers (CHWs) play a crucial role to support health care delivery in underserved communities. Although the value of CHWs' contributions is widely recognised, there is limited evidence on the mechanisms that enable CHWs to deliver people-centred care. Using a realist evaluation approach guided by WHO's Integrated People-Centred Health Services (IPCHS) framework, the study focused on how different contexts and mechanisms interact to align with the IPCHS strategies to shape CHWs' capacity to deliver people-centred care. This realist qualitative study was conducted in five rural communities in KwaZulu-Natal, South Africa. Data was collected through structured observations of CHWs' interactions with households; interviews with CHWs, service users, household decision makers, outreach team leaders (CHWs' supervisors), and clinic operational managers. Data was further corroborated through three focus group discussions with CHWs. Using thematic analysis and realist evaluation methods, we identified Context-Mechanism-Outcome (CMO) configurations influencing CHWs' delivery of people-centred care, followed by refinement of the programme theory and development of middle-range theories. The study identified meta-mechanisms (trust, legitimacy, and motivation) that operate across all domains of the IPCHS framework and underpin the ability of CHWs to engage communities, coordinate care, and deliver integrated, people-centred services. These meta-mechanisms are triggered within enabling conditions, notably formalized supervision, CHW integration into the formal health system, and intersectoral collaboration. However, governance gaps such as precarious employment, inadequate remuneration, poor resourcing, lack of data feedback loops, and insufficient institutional recognition of CHWs' intersectoral role undermines these interactions, resulting in the poor delivery of IPCHS. The study contributes to policy discussions by providing middle-range theories that explain how, why, and when CHW-led people-centred interventions fail or succeed. Critical findings include the need for a dynamic Integrated, Mechanism-Sensitive Model of the IPCHS and governance reforms that include structured workforce integration for adequate resourcing and intersectoral action.