'Government don't know me and if I stop, they won't know': A qualitative study on the lived experiences of volunteer health workers in the Nigerian health system and their implications for the sustainable development goals.

Background: Volunteer health workers play an important, but poorly understood role in the Nigerian health system. We report a study of their lived experiences, enabling us to understand their motivations, the nature of their work, and their relationships with formally employed health workers in Primary Healthcare Centres (PHCs) in Nigeria, the role of institutional incentives, and the implications for attaining the health-related sustainable development goals (SDGs) targets.

Methods: The study used ethnographic observation of PHCs in Enugu State, supplemented with in-depth interviews with volunteers, formally employed health workers and health managers. The analysis employed a combination of narrative and reflexive thematic approaches.

Findings: The lived experiences of most volunteers unfold in four stages as they move into and out of their volunteering status. The first stage signifies hope, arising from the ease with which they are accepted and integrated into the PHC space. The anger stage emerges when volunteers confront the marked disparity in their treatment compared to formal staff, despite their substantial contributions to healthcare. Then, the bargaining stage sets in, where they strive for recognition and respect by pursuing formal employment and advocating for fair treatment and improved stipends. A positive response, such as improved stipends, can reignite hope among volunteers. If not, most volunteers transition to the acceptance stage - the acknowledgement that their status may never be formalised, prompting many to lose hope and disengage.

Conclusion: There should be a clear policy on recruitment, compensation, and protection of volunteers in the health systems, to enhance the contribution they can make to the achievement of the health-related SDG targets.