Reciprocal innovation to improve access to primary healthcare in Belgium: adaptation and development of a community health worker intervention

Widening health inequities in Belgium highlight the need for proactive, outreach-oriented primary care models. Large-scale community health worker programmes in low- and middle-income countries have demonstrated effectiveness in bridging healthcare access gaps and are increasingly recognised as potential reciprocal innovations for high-income countries. However, little is known about how such models can be successfully transferred across contexts, as these processes are rarely reported in sufficient detail, limiting replication and cumulative learning. This study addresses these gaps by detailing the development of the Community Health Workers for Primary Healthcare Access (COMPASS) intervention—a CHW-based model adapted from Brazil and South Africa for the Belgian health system. The COMPASS intervention was developed through a multi-phase, iterative process informed by the ADAPT guidance (Moore et al., 2021) and the Six Steps in Quality Intervention Development (6SQuID) (Wight et al., 2016). Three phases structured the process: (i) problem identification and exploration of potential solutions through qualitative fieldwork in Belgium and South Africa as well as field visits to Brazil and the UK; (ii) participatory adaptation and intervention design via co-creation workshops with stakeholders in Belgium; and (iii) pilot testing to refine the model and prepare for evaluation. Phase 1 fieldwork in Antwerp identified key access barriers in Belgium; complementary fieldwork in South Africa, and field visits to Brazil and the UK, highlighted mechanisms through which CHWs address such barriers: mechanisms included sustained, structured, and culturally sensitive support embedded in both communities and the health system. Phase 2 co-creation workshops determined which elements of the Brazilian and South African CHW models could be retained as core components and which required adaptation to align with Belgian primary care structures and local needs. Phase 3 pilot testing confirmed feasibility and led to final refinements, resulting in a COMPASS intervention that is both contextually appropriate and ready for evaluation. By providing a detailed account of the COMPASS intervention’s adaptation and development, this study illustrates how established frameworks can be applied in practice to guide the design and transferability of complex health interventions. It offers practical guidance for adapting health service innovations across contexts in a transparent, systematic and context-sensitive manner.