Among the 20 CHW who participated in this study, 11 are between 31 and 40 years of age, and 9 are between 41 and 50 years of age. The majority of CHW participants (n=14) have completed primary school, and the remaining six have completed secondary school. Majority of CHW have experience ranging from 11 to 15 years (n=12). Supervisors of CHWs at the level of health centers and at hospital level hold bachelor's degrees. The summarized demographic characteristics of CHWs are depicted in table 1. 

The study purposely interviewed participants to elicit the facilitators and barriers CHWs experience during the delivery of maternal and child health services at the community level. The categories were generated from the data findings emerging from participants responses, then grouped logically into major themes (Table 2).

Participants shared their experiences of working as CHW. During the interview of one-on-one and focus group discussion participants narrated factors that motivate them to give the maternal and child health services to their community. The supervisors of CHWs at health center and at district hospital levels also gave their perception regarding the factors that facilitate CHWs to deliver maternal and child health service to the community. The following factors emerged as categories that facilitate the CHWs to deliver maternal and child health services to their communities: liking their work, trust by the community, respect from the community, the willingness to help, desire to gain knowledge, being human, and sacrifice for wellness of community.

Community health workers and their supervisors at health center and district hospital revealed that CHW like their work. Community health workers who participated in this study indicated the love of their work and they are happy to serve their community. One CHW said that “Being a community health worker is about saving lives and loving the population. For me, being a community health worker was a choice based on my love for the community and the importance to this profession to my community. The choice of being a community health worker is open to everyone”.

Participants also revealed the trust their community has to them as major factor that pushes them to continue working as community health workers. One participant said “We are trusted by the people. We are always open to hearing complaints from the public. In addition to giving them what we have, we are also trained to do for them the things that may be of benefit to them. In terms of their health, for example, family planning issues, they are free to say what they think. They trust us and tell us everything.”

Participants demonstrated that community health workers are motivated to accomplish their job because the respect community attribute to this service. A participant said that “they respect us too much. If they see a CHW, they ask him the problems they could ask from the health care professional. When you reach to their respective homes, they take care for you. Even if it is not all of them, I cannot say that many people they respect us because CHW service we deliver.”

Through the one-to-one and focus group interview, participants of this study revealed a strong willingness to serve as CHW. During elections, CHW volunteer to serve by delivering maternal and child health service despite difficulties involved with the task. A participant highlighted that “this program is important because as you care to a mother, you are also caring a child. This service may decrease the neonates who die during delivery. So, I like this volunteerism work due to its incredible role because for reducing maternal and child mortality”.

Participants in this study demonstrated that the knowledge they gain when they become CHW is important to them and the entire community. A participant indicated that “to be a community health worker is good .It helps you to get more knowledge because you attend various trainings. Then I become a CHW it benefited me a lot, it helped me to know many things that I couldn’t have known if I wouldn’t had the opportunity to become a CHW.” Another participant said that “as a community health worker, I gained skills of how to maintain hygiene and importance of hygiene in life”.

Participants in this study indicated the importance of having the human personality in delivery maternal and child health services. Regarding this personality the supervisor of CHWs said that “for me they accomplish well their responsibilities of focusing on care of maternal and child health. This requires having humanity characters by which you should be able to sacrifice for others. For example, a woman may have a plan to come today on 14th July for family planning issues where at the same day a CHW has a plan for going in farming activities. She may reach at his/her home for that care at an hour that she/he is in preparations to go to his/her farm. It is a humanity which may encourage this person to first provide him a service and then go to his/her activities.”

Sacrifice to serve the community was also an important factor that pushes community health workers to give the health service to mothers and their children. A participant said that “this work requires the sacrifice for others and always focusing on the reason we have been selected by our community. Although, we do not have a known salary we are not demotivated because of the sacrifice to keep serving our community and we know clearly that we are the health care volunteers. So, it is better to keep working courageously.”

Community health workers revealed the importance of earning some amount during the delivery of this service as a motivation to continue serving. A participant said that “there is a PBF that our government give to us, when a CHW accompanies a mother for delivery, she is counted as your client and get from her a PBF of 200 Rwf. It means for a month if you take 20 pregnant women it means that you may get from them 4000 Rwf. Even if she is your client and come to deliver to health center without your presence, she stays counted as your client. This helps us to get money. In general, the community health workers are happy as we are not working for nothing. It should be better if we get it through our mobile money account directly.”

Participants in this study indicated that the work of community health workers has various barriers. Participants mentioned the following as barriers of serving as a community health worker; working many hours, lack of equipment, lack of knowledge, unsatisfactory salary, heavy workload, lack of working space, lack of facilitation for communication, poor attitude by some community members, family conflicts, lack of specified working time, and believes.

Participants indicated the challenges of working for many hours when giving the service of maternal and child health service. Their work does not have specified time, at time they work in night hours. A participant said that “we even work at nighttime as the people are free to come whenever it is needed”.

Participants also indicated a barrier of accessing the equipment they use for their work of serving as community health workers. They indicated challenge of accessing equipment like old telephone, they do not have rainy coat, boats, the files for keeping their documents, and some medication they use for managing health conditions. Participants also indicated that the rapid SMS they were using to report health related cases is no longer working. A participant reported that “before, they used to give us the boots, now it has stopped. They used to give us the rainy clothes, it has stopped. What I may say in short is that they may give us the materials to be used to accomplish our tasks and if possible, give a bicycle to help us in moving from a place to a place.”

Community health workers who participated in this study revealed how the law payment they get as barrier to them. A participant said that “for changes, our government may increase the amount pay per each client. For example, if now for a pregnant mother who is going to deliver, they pay us 200 Rwf, they should increase it to 1000 Rwf as the things are too expensive nowadays”. Another participant highlighted that “my advice is that this PBF given should be increased, it is too small. Frankly speaking, it should be increased and should be better if it is given regularly each month”.

Participants indicated a heavy workload as barrier they meet during implementation of maternal and child health services. Participants indicated that sometimes local authorities give them extra duties that they were not elected for. In this regard a participant said that “some time they request to counting the families with unproper toilets, counting those who have been bitten by snakes, to be present in all programs related to a growth of children, to count all children who has a school dropout, to encourage people to join EJO HEZA program, and counting the families who has not paid their community-based health insurances. This increases the workload to us”. Similarly, another participant indicated that “there are many services we ought to provide that are not part of our responsibilities as the community health workers. We help them to encourage people to have hygiene and proper hygiene. We encourage people to get the community-based health insurances, counting the school dropped out students in your villages”.

Participants indicated the working space as a barrier to them. A participant said that “to care for our clients in our family houses is a barrier because of lack of privacy and confidentiality. We provide health services when our children are watching”. Another participant said “I have a small house and I do not have enough space to put health material I use and when a patient comes at home I do not have a space where I can sit her comfortably. So, government should build us good houses”.

Participants also indicated communication as a challenge. A participant said that “Airtimes for calling at the health center is a problem, if we are calling for help or calling the supervisor of CHWs when we need him/him it is a problem”. Another participant said “The other barrier is that before, we had been given a free way of communication between us, the community health worker. But now, it is not possible. I mean that the way of using CUG is not possible for all of us. CUG is the way health workers communicate to each other but this service is not working in some areas. This is a barrier in communication and in reporting”.

Participants also highlighted the barrier of some community members with poor attitude regarding the work of community health workers. “Some may disrespect you simply because they believe that the community health worker cannot provide any medical advice and that he should only address their health problems with medical staff.” Another participant said “There may be a time when the perception of people is totally different from what you have been expecting, including the perception of people in the majority.”

Participants indicated the lack of a known time for working as a barrier. A participant indicated that “the barriers are the inability of some people to respect time when you have planned it, they do not respect an appointment, they come at any time”.

Personal believes was also identified as barrier to the work of a community health worker. A participant indicated that "It may be difficult to visit someone with mental health problems, or to deliver a family planning campaign to a home where family planning is viewed as a sin. While you may see it as necessary for that family, they may not want to even understand the family planning program. Besides teaching them the importance of the program, there's nothing else you can do for them. Then you let them decide for themselves. Others say their churches do not accept family planning programs."

The purpose of this study was to explore barriers and facilitators, community health workers face during the provision of maternal and child health care services. Data collection used a one-on-one interview on 20 community health workers, four supervisors of community health workers at health center level, and at district hospital level.

Participants shared their experiences of working as community health workers. During the interview of one-on-one and focus group discussion participants narrated factors that motivate them to give the maternal and child health services to their community. The supervisors of community health workers at health center and at district hospital levels also gave their perception regarding the factors that facilitate community health workers to deliver maternal and child health service to the community. The following factors emerged as categories that facilitate the community health workers to deliver maternal and child health services to their communities: liking their work, trust by the community, respect from the community, the willingness to help, desire to gain knowledge, being human, and sacrifice for wellness of community. On another hand, participants in this study indicated that the work of community health workers has various barriers. Participants mentioned the following as barriers of serving as a community health worker; working many hours, lack of equipment, lack of knowledge, unsatisfactory salary, heavy workload, lack of working space, lack of facilitation for communication, poor attitude by some community members, family conflicts, lack of specified working time, and believes.

The findings from this study align with previous findings about the community health facilitators conducted by 1423 which showed that community health workers were highly respected by the beneficiaries because they were closely involved with the community. Similar to the previous studies conducted in Rwanda 24, community health workers were motivated by community respect, in addition to Rwanda's community performance-based financing. Similarly, a study that was conducted in Eastern Uganda by 11 indicated that community health workers were motivated by a community appreciation, being called doctors, monetary incentives, and material incentives. Respect and monetary incentives were key factors that motivated community health workers to continue delivering maternal and child health services. In this study, participants revealed that the small money given to them when they report a pregnant woman at a health service is very important to them, and they are happy about it.

In this study community health workers revealed the trust and respect as motivating factors for them to continue delivering maternal and child health services. A participant in this study said We are trusted by the people. We are always open to hearing complaints from the public. In addition to giving them what we have, we are also trained to do for them the things that may be of benefit to them. In terms of their health, for example, family planning issues, they are free to say what they think. They trust us and tell us everything. The study by Lutwama and colleagues 6 also, emphasized the importance of trust and respect towards the community health workers in motivating them to keep the job.

On the other hand, participants in this study demonstrated challenges of working as community health workers. They revealed the lack of material, lack of privacy, and unsatisfactory allowance. A participant indicated that the first barrier is the shortage of materials like those to be used in rainy season. For example, there are time by which you may be requested to visit a patient while your t-shirt or shoes are too old. When you go there with those old clothes and equipment, they may consider you as being dirty. A study conducted by 1925 support this finding and indicate that community health workers use their resources for providing maternal and child health services. This study warned that such situation could jeopardize the delivery of maternal and child health services if it is not addressed. In this study, participants indicated the possibilities of communicating health care services using their airtime. They also indicate the serving for a long time. When such situations are not handled appropriately, they can result into poor services of maternal and child health services by community health workers.