As the Alma-Ata Declaration advocates, primary health care (PHC) is vital to achieving universal health coverage (UHC) [1]. However, inadequate resourcing and equipping of health systems, coupled with endemic shortages of healthcare workers, hamper essential healthcare services. African and Asian countries reportedly have a healthcare worker shortfall of over 4 million [2].

Countries were recommended to tap into the potential of Community Health Workers (CHWs) to bridge gaps in healthcare [3]. CHWs are lay healthcare workers selected by their local communities and receive standardised training outside the conventional medical curriculum, which helps them deliver HC services [4]. In Zimbabwe, CHWs are known as Village Health Workers (VHWs) and assist in providing PHC services in their local communities, including health promotion and education, diagnostic and treatment of minor health ailments, community-based disease surveillance, maternal and child health, and referral of complicated conditions to health facilities [5].

Globally, CHWs help foster collective, community-driven, collaborative approaches and promote local accountability [6]. Their role continues to evolve across different health systems, with tasks shifting and now dominating to include curative care and case management with professional nurses [7]. In high-income countries, their role has changed towards managing non-communicable diseases such as hypertension and diabetes [8]. However, in low-income countries, these are used to control infectious diseases. On the other hand, the double disease burden has compelled emerging economies such as Bangladesh, Brazil, Iran, Rwanda, and South Africa to have CHWs address both communicable and non-communicable diseases, after achieving satisfactory outcomes in maternal and child health and controlling TB and malaria [4, 6].

Community health workers in some African countries continue to face challenges in service delivery [7]. An unsustainable workload has contributed to CHWs' burnout [9]. A study in Tanzania revealed that one village had 289 households, which were covered by one CHW who was not even provided with a means of transportation. In some settings, CHWs are not paid any salaries/allowances, and subsidise community health activities with out-of-pocket funding [10]. In Malawi, poor quality of service delivery by CHWs has been reported as a result of inadequate training opportunities, while in Nigeria, they have been affected by a lack of equipment, which hinders the translation of theory to practice [11].

Globally, some innovative programs were applied to enhance community health programs. These include community engagement, fostering partnerships with local communities, and technology integration [12]. Based on continuous feedback mechanisms and evaluation, such programs should be designed to adapt to the ever-changing community health needs [12]. Such models were found to be successful in countries like Bangladesh, Brazil, Cuba, and Rwanda [13]. They had sustainability mechanisms for scaling up to the broader population through ongoing funding, community support, and policy integration, leveraging technology for real-time data transmission, telemedicine, and remote consultations [14].

The poor performance of the Zimbabwean economy has pushed many nurses and doctors to migrate to developed countries, notably the United Kingdom and Australia [15]. In 2015, the country had eight healthcare workers per 10,000 people, falling short of the World Health Organisation (WHO) standard of 23 per 10,000 [5, 16]. The shortage of health service providers, particularly nurses, has compelled the Zimbabwean health system to rely on VHWs to complement the existing staff in delivering Primary Health Care (PHC) services.

In the early 1980s, Zimbabwe sought to provide PHC services equitably among the populace as part of its egalitarian reforms. It trained many VHWs to deliver community health services with varying degrees of effectiveness [17]. The economic recession of the early 2000s has contributed to poor health outcomes, with the Infant Mortality Rate increasing from 53 to 56 per 1,000 live births between 1992 and 2016 [18]. The maternal mortality rate remains high at 443 per 100,000, exceeding the expected Sustainable Development Goal (SDG) target of 70 per 100,000 [19]. Beitbridge district, by its geographic location as the busiest inland port city and being along the transport corridor in the SADC region, has three-quarters of the Matabeleland South Province’s 21% HIV/ AIDS prevalence, which is co-morbid with TB [20-22]. To revitalise the VHW Program, the VHW Strengthening Plan of 2017 was developed but never operationalised due to role ambiguity, service duplication, and limited coordination [16]. This study seeks to quantitatively explore the VHWs' roles and challenges, and strategies that could be implemented to improve primary healthcare service delivery [16].

The study has revealed that more women are involved in community health services than their male counterparts. Perhaps this could be due to the voluntary nature of the work, as revealed by respondents in the first qualitative phase of this research, who demonstrated inadequate financial allowances [16]. Social constructs such as culture and stigma may have influenced male involvement in community health voluntary activities, as this gender is often perceived as the primary caregivers for their families; hence, they might not be willing to engage in these activities [32]. Studies in Mudzi and Mutoko Districts, Zimbabwe [5], and in the Democratic Republic of Congo (DRC) have also revealed lower participation by women in community health activities [33]. Women seem to be generally considered better healthcare providers than men, as was revealed during the Ebola outbreaks, when Sierra Leone and Liberia enacted policies to promote more women's participation in community health services [33].

The majority of VHWs were found to have secondary education. Whilst there seems to be no policy in Zimbabwe regarding minimum formal education requirements, studies have revealed that potential VHWs are recruited on their ability to read and write [5]. Other countries like Ethiopia, India, and Pakistan require VHWs to have attained at least the 8^th grade of formal education [34]. VHWS needs to be literate to cope with the ever-changing dynamics of community health services and adapt to task-shifting.

Health education seems to be the most practised role, followed by disease surveillance and child growth monitoring. Health education is central to the delivery of primary health care (PHC) by village health workers (VHWs). This is mainly carried out during household visits by urban and rural cadres to deliver health promotional messages on preventing and controlling endemic conditions, aiming to reach a target of 100 people per month [35]. This finding was consistent with a study in The Gambia. VHWs are also expected to conduct weekly visits to hold ‘health talks’ with residents on preventing and controlling endemic diarrhoea and malaria [36]. Since health education does not require many material resources, perhaps VHWs consider it the most straightforward role. Health education is the cornerstone of health service delivery as it promotes individual well-being and community and population health.

Community-based disease surveillance (CBS) is also highly practised by the VHWs. It was reported in the first stage of this sequential mixed methods research that Beitbridge was affected by a cholera outbreak in 2023 and has endemic conditions such as malaria and tuberculosis (TB). Our earlier findings from in-depth interactions with health service providers and VHWs revealed a heavy reliance on these cadres to carry out passive case finding for malaria, TB, and, more recently, COVID-19 during contact tracing. These cadres report the unusual occurrence of infirmities in their communities through ‘signals’ to the nurses in charge of their local clinics for further investigations [5]. Considering the health worker shortages in Zimbabwe and the reliance on VHWs for public health surveillance, this calls for improved capacity building of VHWs in public health surveillance. This observation was also validated by the relatively high ranking of additional training requirements as one of the strategies to improve VHW effectiveness. A scoping review of 25 low- and middle-income countries (LMICs) by Alhassan and Wills revealed the significant impact of continuous training on CBS in controlling communicable diseases, such as malaria, TB, Ebola, and COVID-19 [37].

This study revealed that VHWS occasionally diagnose and treat minor ailments and immunise against some child-killer diseases. As mentioned in the findings stage of this exploratory sequential mixed-methods research, VHWs face challenges such as a lack of timely replenishment of medical and equipment supplies. These findings can substantiate earlier findings from the qualitative component of this research, which showed that VHWs often had depleted therapeutic stocks in their medical kits. Gore et al. [5] reported that VHWs in Zimbabwe faced challenges due to the inconsistent supply of medicines like paracetamol, coartem, and malaria rapid diagnostic test (RDT) kits.

The inadequacy of resources has been cited as a challenge faced by VHWs, which could hinder their effectiveness and efficiency in service delivery. This validated our prior findings, which mentioned that two or three VHWs staying in different villages share specific basic equipment, such as baby weighing scales and mid-upper-arm circumference (MUAC) measuring tapes used in child growth monitoring. The proportion of the health service delivery against the national fiscus budget in Zimbabwe has always been less than 10%, making overall health financing a challenge [4], and this falls short of the Abuja Declaration of 2001, which had set a minimum of 15% of the total national budget for the improvement of the health delivery system [38]. Most Southern African Development Community (SADC) countries serving South Africa have struggled to meet this target, mainly relying on external donor funding [39]. On the contrary, Brazil's Unified Health System has contributed to improved community health outcomes related to MCH, as over 98% of the required resources are channelled towards basic healthcare to attain universal health coverage [8].

The study has shown that most rural VHWs have larger geographical areas to cover and frequently have to walk over 5 km to access remote areas, as their bicycles are often deemed obsolete due to a lack of routine maintenance. These findings were also consistent with a systematic literature review by Astale et al. [7] on the challenges faced by CHWs in LMICs, who reported that a lack of transport had contributed to the perceived high workload, which hinders the efficiency of service delivery.

It was also reported that VHWs received US$42 per quarter, which they considered inadequate. They typically received it several months after the end of the quarter, which could be contributing to their waning motivation. These assertions were consistent with findings by Gore et al. [5] and Kambarami et al. [35] in Zimbabwe, who reported high attrition rates and a lack of enthusiasm, hindering the program's progress. Perhaps as a consequence of this, VHWs are highly recommended for providing adequate resources to support the effective delivery of PHC services.

Most respondents highly recommended using mobile health (mHealth) as a potential strategy to enhance primary health care (PHC) service delivery by village health workers (VHWs). While only a handful of these cadres reported having been issued mobile health technology gadgets, they seem to appreciate the need to catch up with advancements in mobile health technology. A scoping review by Early et al. [40] revealed an increasing number of health systems globally incorporating mHealth technologies and applications, with no exception for LMICs [40]. Whilst acknowledging the potentially disruptive nature of digital technology, the World Health Organisation maintained that these technologies could improve the skills and knowledge of Community Health Workers (CHWs) through data capture, storage, and exchange, as well as remote monitoring, virtual diagnosis, and facilitating a continuum of care throughout the healthcare system. Mobile health tools are now being explored worldwide to enhance the VHW's ability to effectively diagnose specific ailments, communicate and share electronic resources, and improve community health surveillance, geospatial mapping, and real-time reporting [41]. In India, the incorporation of the ReMind mHealth into the maternal and child health program helped to reduce maternal and neonatal deaths by over 300 and nearly 150,000 (respectively). The program contributed to women's empowerment, as mHealth tools facilitated effective engagement with Community Health Workers (CHWs) to identify maternal and child health (MCH) danger signs and manage them before conditions deteriorated [40]. In Malawi, an application known as cStock enables Health Surveillance Assistants (HSAs) to maintain optimal stocking levels. They interact with an ICT dashboard at the district level through an enquiry via a short message service (SMS) to receive updates on when to replenish their medical stocks [42]. On the other hand, a study in Kampala, Uganda, identified high training costs, skill deficiencies, and limitations in infrastructure and data security as potential barriers to the successful implementation of mHealth technologies for VHWs [43].

The integration of community health into the healthcare delivery system could improve the provision of essential health services by VHWs. Perhaps this was suggested to improve the working conditions for the VHWs, who are often regarded as volunteers despite the evolution of their roles and the shifting of tasks. In Zimbabwe and other sub-Saharan African countries, there is high staff attrition, and having VHWs integrated into the healthcare system could help bridge the human resources gap, ensure the program's sustainability, and improve knowledge and skills on best practices [44] Mupara et al. [45] made the point that community health integration entails their incorporation into healthy public policies and the six building blocks of the WHO’s framework on health systems. The Unified Health System of Brazil integrated CHWs, enabling improved working conditions, boosting a sense of identity within the healthcare system, and providing supportive supervision and enhanced mentorship, contributing to improved community health outcomes [46].

This study was conducted in the Beitbridge district of Zimbabwe and could have implications for generalisation across the country. Furthermore, the self-reported data could also introduce some bias.

Village Health Workers in Beitbridge are predominantly female and appear to be literate. These complement the healthcare system through frequently conducting health education, community-based disease surveillance, and monitoring of infant growth rates. There is a high perception among the VHWs that they are inadequately resourced, with limited knowledge and skills, which could be contributing to the role of diagnosing and curing of minor ailments, practised the least, leading to more frequent referrals to health facilities. The VHWs felt they were given inadequate allowances, which could hinder their motivation. Given their contribution to community health, VHWs strongly prefer integration into the health system and the use of mobile health technology to enhance service delivery effectiveness and efficiency.