In this section, we summarise the lived experiences of community members who volunteer as BHWs in our urban and rural study locations. We also describe the salient themes from these accounts that relate to factors that influenced their initial motivation to volunteer and that determine their continuing involvement.
Becoming a BHW: the role of socio-political positioning and technical knowledge
The social relationships and political positioning of BHWs played an important role in their pathway to participation in the local health system (i.e. recruitment, appointment, and continuing inclusion). Recruitment was largely dependent on having these socio-political connections rather than on having the right skills or technical knowledge to deliver health services. The barangay captain, the leader of the village administration, holds the power to appoint BHWs, and with no formal guidelines to follow, appointments are arbitrary. Some BHWs recalled that they or their peers were appointed by the captain as a result of personal or political relationships, or following a recommendation from other barangay officials, including current BHWs or health staff. Some of the reasons cited for these endorsements included a history of active involvement in barangay activities, such as programmes on feeding, family planning, and fitness. For example,
Amy (1 year in service) shared:
I volunteered myself and I said to [the barangay councillor] that if he wins, [allot me a position]. I’ve been applying since before, but I was not given the opportunity. I only volunteer. When he won a seat, I finally got a position at the [health] centre. [The councillor] is my husband’s buddy.
Importantly, however, there need not be any reason for the endorsement other than the prospective BHW’s need for a job, as
Ellen (2 years in service) recalled:
My livelihood then was to wash and iron clothes and take to care of children. But when I had a grandchild I could no longer do those tasks, so I asked the barangay treasurer (who happens to be my co-godmother) for any available jobs in the barangay. She told me that they can make me a BHW, so I suddenly became one.
Ellen’s example points to the informality of the application process to become a BHW, something supported by most respondents’ accounts. Cea (11 years in service) recalled that she was interviewed by the local doctor and simply asked (not assessed) about her capacity to work in health centre: “I was interviewed and she asked, ‘Can you do community area activities? Can you do duties in the health centre? Can you do all of this?’” Skills and professional qualification, while useful, are largely secondary to personal connections.
Given that barangay captains are elected every 3 years and their power to appoint (or remove) BHWs, one’s position may not be secure when administrations change. Many BHWs recalled instances when they or their former peers were dismissed because they were not allied politically with the newly elected captain’s party.
Luisa (5 years in service) shared that she was dismissed because her religious values did not permit her to vote; while
Catherine (6 years in service) recalled that she was dismissed unexpectedly at an earlier point in her career:
We thought that they would not remove anyone, including BHW positions. I was confident. I did not even vote and had no involvement in the political system. After the election on July 1, I went to the barangay office and my name was not included on the list of BHWs.
While a connection to barangay officials appears to be a common route to becoming a BHW, involvement with the wrong politician or non-involvement in politics can also be liability, underscoring the political nature of the position. However, several examples of more merit-based appointments were noted, such as where applicants had previously volunteered for other community activities or programmes (e.g. in the barangay day care centre) or assisted existing BHWs.
In general, the activities performed by BHWs involved two roles: serving as frontline health centre staff and acting as community health mobilisers. However, the balance of activities depended on the priorities of the health centre manager to which the BHW was assigned. BHWs were commonly involved in various health centre programmes, including immunisation, maternal care, family planning and hypertension management. Their weekly schedules varied from barangay to barangay, but they typically spent the whole day in health centres 2–3 times a week.
As frontline staff at local health centres, BHWs are often the first point of contact for patients. They welcome patients and perform a range of specific tasks, including admitting and interviewing patients and recording patient information and/or vital signs (e.g. blood pressure), before being seen by a doctor or nurse, if available. BHWs confirmed that their role did not involve diagnosing or prescribing.
As community health mobilisers, BHWs serve as a bridge between the community and their local health centre, promoting health and engagement with existing services, often working house-to-house. They particularly encourage uptake of programmes such as child feeding and NCD prevention and screening at health centres. While they are not allowed to dispense medicines, administer vaccines, or provide direct patient care, they play a supportive role, which includes assisting midwives, blood pressure monitoring, and talking to and motivating patients to adopt appropriate health behaviours.
Gina (38 years in service) shared:
We encourage them. This is our job: to encourage them that we have a health centre and to seek help if they feel something.
BHWs also assist patients in the community with self-management of their chronic conditions. For instance, they measure the blood pressure of those with hypertension at both the health centre and during house-to-house visits, take the opportunity to remind patients of upcoming follow-up appointments, advise them if medicines are available at the health centre for prescription refills, and educate community members.
Ruby (22 years in service) shared:
I remind them that they should not be confident if they don’t feel anything [symptoms]. We don’t know if we have hypertension.
BHWs’ role as community health mobilisers also includes a public health surveillance component, following up on non-adherence and surveying prevailing health conditions in the community.
April (8 years in service) described:
If we are not in the health centre, we visit our assigned area. We ask who is pregnant. We ask who is sick. We ask who has tuberculosis. We also do lectures on tuberculosis.
Denden (10 years in service) also described:
We visit them. We knock on their doors and ask why they don’t visit the centre. We remind them to finish the programme. If they give us a chance, we explain the need to continue the programme. It’s like the patient and I are a tandem.
BHWs’ local knowledge and position in the community are useful assets in their role as health mediators, helping them to identify health needs and engage with community members to link them to services
. Maria (2 years in service) talked about using her local knowledge and position in the community to achieve this:
We know for example in our community who has tuberculosis. We always research them, so that we encourage them to undergo treatment. During immunisation, we notify parents to bring their child to the health centre.
BHWs also mentioned that they are often approached by patients before they have reached the health centre, which suggests that they enjoy a high level of trust among community members as intermediaries of the health system. Lili (11 years in service) told us about being contacted often by patients asking for medicines and using this opportunity to remind then about the importance of engaging with services to “consult the doctor before taking medicine. It’s just not about taking medicine.”
Contracting arrangements and compensation
BHWs are considered part-time, volunteer workers and not government employees. Hence, they do not receive a regular salary. However, BHWs from rural areas reported being given honoraria and allowances of PhP 1150 (USD24) each month; in urban communities honoraria were also paid but their size, and that of any other allowances, varied depending on whether they were contracted by city or barangay administrations, with the latter having smaller budgets. Although urban BHWs all perform similar duties and report to local health centres, the financial incentives, in the form of honoraria to acknowledge their voluntary contributions and allowances to cover the incidental costs of carrying out their assignments (e.g. transport), varied by location. For barangay-funded BHWs, the combined lump sum was reported as PhP 2300 (USD 50) per month distributed in cash by barangay offices, and PhP 3000 (USD 60) for city-funded BHWs paid through a designated local bank. In addition to honoraria and allowances, city-funded BHWs are provided with PhilHealth membership, the national social health insurance programme.
Other non-monetary incentives that BHWs reported receiving included free medicines from the health centre, free health services, and groceries at Christmas from local or barangay administrations. Since the honoraria received by both rural and urban BHWs is insufficient to support themselves and their families, most respondents reported also having part-time jobs, mostly in the service industry, alongside their BHW duties.
Beyond economic empowerment: social positioning and common good
We now describe how relational dimensions of BHWs’ work play an important role in their initial motivations and in sustaining participation over time. Interviewees described a range of motivations for volunteering as BHWs, with the desire to serve the community and improve its health as the most frequently mentioned factor.
Gina (38 years in service) described this motivation to contribute to the common good of the community:
I observed the lack of health [knowledge] in our barangay. Parents are not aware of what to do for their child’s fever. They only cover them with [wet towels]. It's just like a cold. I want to know why, why they lack attention and knowledge.
Sisa (1 year in service) cited similar motivation and particularly wanted to improve health-seeking behaviour of the community: “I want the community to be aware that if they are sick, they should consult a doctor. I advise them to go to the doctor.” Jhoanne (4 years in service) derived pleasure from serving the community: “I’m happy to serve my fellow community members. You will be happy if you do it with you heart. You will learn a lot [from being a BHW].”
Supporting the community required some BHWs to contribute their own money, for example to purchase medicines for patients who could not afford them, and to cover costs to travel to their assigned areas.
April (8 years in service) described the honorarium and allowances provided as insufficient to shoulder such expenses:
During our areas of assignment, it’s our own-pocket expenses. It’s fortunate if the barangay can provide a transportation service. What if none? We will walk and of course, we will eat and drink. Not all households can provide drinks. Our PhP 3000 honorarium [and allowance] is really not enough.
Gina (38 years in service), said that it was inevitable that she would use her own funds:
I visited a patient and he had no food. I gave my own money. I also arrived when he was sick. He had no money for medicine and I gave him money. I accompanied a patient to the hospital. It’s my own pocket expense.
Mell (5 years in service) described how a provincial governor promised to increase the financial incentives given to BHWs.
Our governor’s term is about to end, but he promised that we, the BHWs, will become counterparts of nurses, doctors and midwives. We need salary. We need honorarium.
Although some BHWs reported struggling financially as a consequence of the low honorarium and allowances, they still expressed contentment with what they were doing. The opportunity to serve the community gave them a sense of fulfilment, through the relational aspects of their involvement in the programme. Their relationships with other BHWs, patients, and the wider community, as well as the new knowledge they gained, compensated for the relative lack of financial and non-financial incentives.
Denden (10 years in service) expressed that it was not about how high her compensation was:
If feels good to help. Sometimes [patients] comfortably share their stories. That’s the best part. After they are treated, they go again to you and say thank you. That’s the best part to us. A simple thank you means a lot and it makes us smile. It’s not about how high is our compensation. If you enjoy your work, it’s the best feeling. It’s feels good to give service to the community.
Enhancing one’s social position, particularly through establishing new relationships in the community, gaining respect, and acquiring technical knowledge, played an important role in sustaining participation. Amy (1 year in service) echoed: “Patients trust us. One of my neighbours visited my house and asked if I can take her blood pressure or when I will next be on duty. [I feel] they trust me. They wait for me to be on duty.”
Cherry (12 years in service) shared that she gained respect (‘
respeto’) from being a BHW:
Interviewer: What do you feel being a BHW? Are you happy?
Cherry: “I’m happy that they address me as ‘Ma’am’. If I was not a BHW, they would not address me as ‘Ma’am’. I’m happy with that. They respect me. I gain respect.”
Many BHWs spoke of the opportunities to travel outside of their localities, develop camaraderie with fellow BHWs, and acquire health knowledge as rewards in themselves, pointing to the role conferring a multiplicity of benefits. As
Lili (11 years in service) said:
Being a BHW is difficult, but fun, because you are able to visit places you don't get to visit for seminars, out of town activities, and the like. And then of course the ‘bonding’ here in the health centre. It’s also fun because we learn a lot.
This camaraderie also appeared to be developed and reinforced through the model of BHW training, which was similar in both urban and rural study locations. New recruits typically shadowed more experienced BHWs and other health workers to familiarise themselves with health centre workflows. This was followed by brief training on basic procedures, such as blood pressure monitoring and first-aid. BHWs gained further knowledge and skills through participating in occasional activities organised by national and/or local government agencies, including workshops on immunisation, tuberculosis management and monitoring, and basic life support, among others. While BHWs found such activities useful, many claimed that the most valuable sources of knowledge and skills came from their interactions with experienced BHWs and from their own experiences on the job.
Finally, since the BHWs interviewed were typically mothers and wives, they also found the additional income and, as mentioned above, the opportunity to gain health knowledge and skills as attractive incentives. As
Sisa (1 year in service) recalled:
I’m a mother and for my children, it’s good that I have [health] knowledge. I have no husband and I mainly guide my children. I need [health] knowledge in case of emergency. I can use what [I learn] as a BHW and apply it to my family.