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Community health worker (CHW) performance is influenced by the way in which management arrangements are configured vis-a-vis the community and health services. While low-/middle-income contexts are changing, the literature provides few examples of country efforts to strategically modify management arrangements to support evolving CHW roles (e.g. chronic disease care) and operating environments (e.g. urbanization). This paper aims to understand the performance implications of changing from community-based to health centre-based management, on Ethiopia's Urban Health Extension Professionals (UHEPs), and the tensions/trade-offs associated with the respective arrangements. We conducted semi-structured interviews/focus groups to gather perspectives and preferences from those involved with the transition (13 managers/administrators, 5 facility-based health workers and 20 UHEPs). Using qualitative content analysis, we deductively coded data to four programme elements impacted by changed management arrangements and known to affect CHW performance (work scope; community legitimacy; supervision/oversight/ownership and facility linkages) and inductively identified tensions/trade-offs. Community-based management was associated with wider work scope, stronger ownership/regular monitoring, weak technical support and weak health centre linkages, with opposite patterns observed for health centre-led management. Practical trade-offs included: heavy UHEP involvement in political/administrative activities under Kebele-based management; resistance to working with UHEPs by facility-based workers and health centre capacity constraints in managing UHEPs. Whereas the Ministry of Health/UHEPs favoured the health centre-led management to capitalize on UHEPs' technical skills, Kebele officials were vested in managing UHEPs and argued for community interests over UHEPs' professional interests; health facility managers/administrators held divided opinions. Management arrangements influence the

Globally, health worker shortages continue to plague developing countries. Community health workers are increasingly being promoted to extend primary health care to underserved populations. Since 2004, Healthy Child Uganda (HCU) has trained volunteer community health workers in child health promotion in rural southwest Uganda. This study analyses the retention and motivation of volunteer community health workers trained by HCU. It presents retention rates over a 5-year period and provides insight into volunteer motivation. The findings are based on a 2010 retrospective review of the community health worker registry and the results of a survey on selection and motivation. The survey was comprised of qualitative and quantitative questions and verbally administered to a convenience sample of project participants. Between February 2004 and July 2009, HCU trained 404 community health workers (69% female) in 175 villages. Volunteers had an average age of 36.7 years, 4.9 children and some primary school education. Ninety-six per cent of volunteer community health workers were retained after 1 year (389/404), 91% after 2 years (386/404) and 86% after 5 years (101/117). Of the 54 'dropouts', main reasons cited for discontinuation included 'too busy' (12), moved (11), business/employment (8), death (6) and separation/divorce (6). Of 58 questionnaire respondents, most (87%) reported having been selected at an inclusive community meeting. Pair-wise ranking was used to assess the importance of seven 'motivational factors' among respondents. Those highest ranked were 'improved child health', 'education/training' and 'being asked for advice/assistance by peers', while the modest 'transport allowance' ranked lowest. Our findings suggest that in our rural, African setting, volunteer community health workers can be retained over the medium term. Community health worker programmes should invest in community involvement in selection, quality training, supportive supervision and incenti