Primary health care (PHC) remains the foundation for achieving universal health coverage and improving population health outcomes globally. The Alma-Ata Declaration of 1978 recognized PHC as the cornerstone for achieving “Health for All” and emphasized the importance of community participation in health service delivery [1]. This commitment was reaffirmed in the 2018 Declaration of Astana, which described PHC as a whole-of-society approach to improving health and well-being through accessible, integrated, and people-centered services [2].

Community Health Workers (CHWs) have become essential actors in strengthening PHC systems, particularly in low- and middle-income countries experiencing shortages of trained health personnel. CHWs operate at the interface between communities and the formal health system and are uniquely positioned to improve access to healthcare, promote disease prevention, provide health education, support referrals, and facilitate community engagement [3]. Evidence from different settings demonstrates that CHWs contribute to improving maternal and child health, immunization uptake, malaria control, treatment adherence, and disease surveillance [4]-[6]. Historical community-based programs, such as the Jamkhed Comprehensive Rural Health Project, have also demonstrated that locally embedded health workers can strengthen PHC delivery and enhance community participation in health systems [7].

Despite the growing recognition of CHWs, their effectiveness depends substantially on the extent to which they are integrated into national health systems. Integration involves formal institutional recognition, appropriate governance, sustainable financing, standardized training, supportive supervision, reliable logistics, functional reporting systems, and effective coordination with the wider health system [8][9]. However, CHW programs in many resource-constrained settings continue to operate within fragmented systems characterized by inadequate supervision, irregular remuneration, weak supply chains, poor reporting mechanisms, and limited policy support [10].

The need for effective CHW integration becomes even more critical in fragile and conflict-affected settings. Millions of people live in environments where conflict weakens health systems and severely disrupts access to essential healthcare [11]. Conflict may destroy health infrastructure, displace populations and healthcare workers, interrupt medical supply chains, weaken governance structures, and reduce the availability and utilization of essential health services [12]. In these settings, CHWs often become frontline and trusted responders who maintain continuity of care when health facilities are inaccessible or dysfunctional. Evidence from conflict and post-conflict settings indicates that CHWs contribute to disease surveillance, community sensitization, referral services, outbreak response, maternal and child health services, and the continuation of essential healthcare when facility-based systems are disrupted [12][13]. Nevertheless, CHWs working in fragile settings commonly face insecurity, inadequate logistics, interrupted supervision, delayed remuneration, excessive workloads, psychosocial stress, and weak institutional support [12][13].

In Cameroon, community-based health strategies evolved from Community-Directed Treatment with Ivermectin for onchocerciasis control to broader Community-Directed Interventions addressing malaria, tuberculosis, HIV/AIDS, maternal and child health, immunization, health education, and disease surveillance [14]. The Government of Cameroon further recognizes the role of CHWs through the National Community Health Strategy 2021-2025, which aims to strengthen community participation and improve access to PHC services [15].

The need for effective community-based healthcare is particularly pronounced in Cameroon’s South-West Region, where the ongoing socio-political crisis has disrupted health service delivery. The conflict has contributed to population displacement, insecurity, reduced functionality of health facilities, declining utilization of essential services, and difficulties accessing healthcare [16]. Under these circumstances, CHWs have become increasingly important in maintaining continuity of care, supporting disease surveillance, conducting health education, facilitating referrals, and connecting communities with the formal health system. Despite their growing importance, empirical evidence regarding the extent to which CHWs are integrated into PHC systems in conflict-affected areas of Cameroon remains limited.

Although CHWs have been widely studied in relation to specific programs, including maternal and child health, malaria control, immunization, and infectious disease management, less attention has been paid to their overall integration into PHC systems in conflict-affected settings. In Cameroon, few studies have comprehensively examined the institutional dimensions of CHW integration, including governance, supervision, logistics, financing, reporting systems, and community participation, using a mixed-methods approach. This knowledge gap limits evidence-based policymaking for strengthening community health systems in fragile contexts.

This study, therefore, aimed to assess the integration of Community Health Workers into the primary health care system in the conflict-affected Tiko Health District of Cameroon using a mixed-methods approach. Specifically, the study examined community awareness and utilization of CHW services, assessed the contribution of CHWs to PHC delivery, and identified key barriers and facilitators influencing their effective integration into the health system. The findings are expected to inform policies and interventions to strengthen CHW integration and improve PHC delivery in conflict-affected and other resource-constrained settings.

This study examined the integration of Community Health Workers (CHWs) into the primary health care (PHC) system in the conflict-affected Tiko Health District of Cameroon using a mixed-methods approach. The findings indicate high community awareness, positive perceptions, and strong trust in CHWs, together with substantial contributions to PHC delivery. However, institutional challenges, including financing, supervision, policy implementation, and workforce recognition, continue to constrain sustainable integration. Residence, educational level, and conflict context were independently associated with perceived CHW integration.

The high level of awareness, positive perceptions, and trust reported by both household heads and CHWs demonstrates that CHWs have become an accepted and credible component of PHC in the Tiko Health District. This acceptance is likely linked to Cameroon’s community-based recruitment strategy, which promotes community ownership, cultural competence, accountability, and stronger relationships between CHWs and the populations they serve. Community participation in the selection and supervision of CHWs has consistently been associated with improved program effectiveness, greater utilization of health services, and enhanced sustainability, as trusted CHWs are more likely to influence health-seeking behavior and the acceptance of preventive interventions [3][8][19]. Similar findings have been reported in Ethiopia and Uganda, where community ownership strengthened CHW performance and increased public confidence in community health programs [20]. Collectively, these findings suggest that community trust remains a fundamental determinant of successful CHW integration within PHC systems.

Trust assumes even greater importance within the context of the ongoing socio-political crisis affecting Cameroon’s South-West Region. Armed conflict frequently disrupts healthcare through insecurity, displacement of health personnel, interruption of supply chains, and reduced access to health facilities. Under these circumstances, CHWs often become the most accessible providers of basic healthcare because they remain embedded within affected communities. Their proximity enables them to continue health education, disease surveillance, referral services, and maternal and child health interventions despite significant disruption to routine facility-based services. Similar experiences have been documented in humanitarian settings across Sierra Leone, Liberia, South Sudan, and the Democratic Republic of Congo, where CHWs maintained continuity of essential healthcare during conflict and disease outbreaks [12][13]. Likewise, during the COVID-19 pandemic, CHWs strengthened community surveillance, promoted infection-prevention measures, addressed misinformation, and ensured the continuity of essential health services despite unprecedented pressure on health systems [21][22]. These findings reinforce World Health Organization recommendations that CHWs should be recognized as integral components of resilient primary health care systems and incorporated into national emergency preparedness and response strategies [23].

The findings further demonstrate that CHWs play a central role in delivering comprehensive PHC services. Respondents consistently identified community sensitization, disease surveillance, maternal and child health services, immunization support, and distribution of essential health commodities as core CHW responsibilities. These findings reflect the global transition from disease-specific community programs towards integrated PHC models that address multiple health priorities simultaneously. Consistent with previous studies, well-supported CHW programs improve maternal and newborn health, increase immunization coverage, strengthen malaria prevention, enhance treatment adherence, and expand access to essential healthcare among underserved populations [9][24]. In resource-limited settings, CHWs also help bridge shortages of skilled health personnel by extending preventive, promotive, and selected curative services beyond health facilities, thereby improving equity in healthcare delivery [24].

The substantial involvement of CHWs in disease surveillance is particularly important because early detection and reporting of disease outbreaks remain fundamental to effective public health systems. Their close interaction with households enables timely identification of unusual health events, prompt referral of suspected cases, and dissemination of accurate health information. Similar contributions were observed during the Ebola outbreaks in West Africa and the COVID-19 pandemic, where CHWs strengthened surveillance systems, promoted community engagement, countered misinformation, and maintained continuity of essential health services [21][22][25]. These experiences demonstrate that CHWs contribute not only to routine PHC delivery but also to national health security, emergency preparedness, and health system resilience.

An interesting finding was that CHWs reported greater involvement in maternal and child health services than household heads. This discrepancy is likely attributable to differences in respondents’ understanding of CHW responsibilities rather than actual differences in service delivery. While CHWs are familiar with the full scope of their responsibilities, community members may primarily associate them with visible activities such as health education and the distribution of health commodities, overlooking household-based services, including antenatal follow-up, immunization support, growth monitoring, and the referral of pregnant women. Similar discrepancies between provider and community perceptions have been reported elsewhere, highlighting the need for continued community engagement to improve public understanding of the comprehensive role of CHWs within integrated PHC systems [26].

While these findings demonstrate that CHWs are well accepted and play an indispensable role in PHC delivery, sustainable community health programs depend not only on operational performance but also on the extent to which CHWs are institutionally integrated into the broader health system. This distinction is critical because effective service delivery alone cannot ensure long-term program sustainability without adequate governance, financing, supervision, and policy support.

Although respondents perceived CHWs to be well integrated into routine PHC activities, the findings suggest that operational integration has not yet translated into full institutional integration. Operational integration refers to the active participation of CHWs in delivering essential health services, whereas institutional integration requires formal recognition within the health system through supportive policies, sustainable financing, standardized training, effective supervision, career development opportunities, and integration into national health information systems [8][23]. Experiences from Ethiopia, Rwanda, and Brazil demonstrate that stronger institutionalization of CHWs improves program sustainability, accountability, and coordination between community- and facility-based health services [20][24]. The present findings therefore suggest that, although Cameroon has made substantial progress in integrating CHWs into PHC delivery, greater investment in institutional support is required to maximize their long-term contribution to the health system.

Despite these encouraging findings, several systemic barriers continue to hinder the full institutional integration and long-term sustainability of CHW programs [3][8][24]. Financial constraints emerged as the most important barrier to CHW integration, highlighting the limitations of programs that rely predominantly on volunteerism. Although commitment to community service remains an important source of motivation, inadequate financial and non-financial incentives reduce job satisfaction, increase attrition, and threaten program sustainability [9][24]. Respondents also identified inadequate refresher training, irregular supervision, and limited awareness of policies governing CHW activities as important constraints. Similar barriers have been reported across sub-Saharan Africa, where inconsistent remuneration, weak supervision, and fragmented governance continue to undermine CHW performance despite their recognized contribution to PHC [3][24]. Rather than viewing CHW remuneration solely as a program cost, governments should recognize it as an investment in health system strengthening because adequate support improves retention, accountability, productivity, and continuity of care. Likewise, regular refresher training and supportive supervision are essential for maintaining technical competence, improving adherence to national guidelines, and ensuring quality service delivery [23][27].

Conversely, community trust, supportive PHC structures, continuous capacity building, digital health technologies, and collaboration with development partners were identified as important facilitators of CHW integration. These factors strengthen program performance by improving communication, supervision, accountability, and utilization of health services. Digital reporting systems are particularly valuable because they facilitate real-time disease surveillance, strengthen communication between CHWs and health facilities, improve data quality, and support program monitoring [28]. Similarly, partnerships between governments and development organizations provide technical assistance, training, logistics, and financial resources that strengthen community health programs, particularly in fragile settings where domestic resources remain limited [23]. However, sustained program success will require a gradual transition from donor-supported initiatives towards stronger government ownership and sustainable domestic financing.

An important finding of this study is CHWs’ contribution to maintaining continuity of essential health services during the ongoing socio-political crisis. Respondents acknowledged that Community-Directed Interventions enabled the continued delivery of health education, disease surveillance, maternal and child health services, and patient referrals despite insecurity and disruptions to routine healthcare. These findings illustrate the resilience of community-based health systems and are consistent with evidence from conflict-affected settings where CHWs sustained essential healthcare while supporting outbreak preparedness and humanitarian response [12][13][21]. The present findings therefore reinforce growing international recognition that CHWs should be incorporated into national emergency preparedness and health security strategies rather than being viewed solely as providers of routine community health services.

The multivariable analysis demonstrated that residence, educational level, and conflict context independently influenced perceptions of CHW integration. Higher perceived integration among urban respondents may reflect stronger health infrastructure, better supervision, improved logistics, and closer collaboration between CHWs and formal health services than is often achievable in rural communities [20][28]. Respondents with lower educational attainment were also more likely to perceive greater CHW integration, possibly because they rely more heavily on community-based health services than individuals with greater access to alternative healthcare sources [20]. Most importantly, the strong association between conflict and CHW integration highlights the adaptability of community-based health systems during humanitarian crises. Rather than weakening community health programs, prolonged insecurity appears to have increased community reliance on CHWs as trusted and accessible providers of essential healthcare, a finding that is consistent with reports from other fragile and conflict-affected settings [12][13][23].

These findings have important implications for health policy and practice in Cameroon. Strengthening CHW integration will require formal institutional recognition, sustainable financing, competency-based training, supportive supervision, reliable supply chains, career development pathways, and integration into routine health information systems. Such reforms should be accompanied by robust monitoring and evaluation systems to assess CHW performance, quality of care, and community satisfaction, thereby informing evidence-based policy decisions. Collectively, these investments would improve CHW motivation, retention, accountability, and service quality while strengthening PHC resilience and accelerating progress towards Universal Health Coverage and the Sustainable Development Goals [8][9][23].

This study has several limitations. The cross-sectional design precludes causal inference, while reliance on self-reported information may have introduced recall and social desirability bias. Selection bias cannot be completely ruled out because participation depended on respondents’ availability and willingness. In addition, the study was conducted in a single health district, which may limit the generalizability of the findings to other regions of Cameroon or similar conflict-affected settings. Nevertheless, the mixed-methods design, inclusion of household heads, CHWs, and key informants, and triangulation of quantitative and qualitative findings strengthen the credibility and comprehensiveness of the study.

Community Health Workers remain indispensable to primary health care delivery in the Tiko Health District, particularly amid the ongoing socio-political crisis. Their high level of community acceptance, broad contribution to essential health services, and strong operational integration underscore their importance in strengthening community health systems and improving equitable access to care. However, persistent challenges related to financing, supervision, policy implementation, and institutional recognition continue to constrain their full potential. Strengthening institutional support through sustainable financing, continuous capacity building, effective supervision, and integration of CHWs into national health workforce and information systems will enhance program sustainability, improve health system resilience, and contribute to achieving Universal Health Coverage in Cameroon and similar resource-constrained settings. Future longitudinal and implementation studies are warranted to evaluate the long-term impact of strategies to strengthen CHW integration and improve health outcomes in conflict-affected communities.

Conceptualization: SA, MUA; Study design: SA, MUA; Methodology: SA, CN, MA, MUA; Investigation: SA; Data collection: SA; Data curation: SA; Formal analysis: SA, CN MUA; Data interpretation: SA, CN, MA, MUA; Validation: CN, MA, MUA; Supervision: MA, MUA; Project administration: MUA; Writing of original draft: SA; Review and editing: CN, MA, MUA; Resources: MUA; Overall oversight/guarantor: MUA; Final approval of the manuscript: SA, CN, MA, and MUA.