Contextual factors affecting the integration of community health workers into the health system in Limpopo Province, South Africa

Abstract

Background Community health workers (CHWs) are an essential cadre in the health systems of many low- and middle-income countries. These workers provide a wide variety of services and are key to ongoing processes of task shifting within human immunodeficiency virus programmes in particular. Ward-based outreach teams (WBOTs) are South Africa’s latest iteration of the CHW programme and have been introduced as part of the National Department of Health’s Primary Health Care Re-engineering programme. Methods In order to assess the perceived effectiveness of the WBOTs in supporting the ongoing rollout of antiretroviral therapy, tuberculosis care and patient support, we conducted a qualitative investigation focusing on the perceived successes and challenges of the programme among CHWs, community leaders, healthcare workers and community members in the Mopani district, Limpopo province, South Africa. Results The CHW programme operates across these contexts, each associated with its own set of challenges and opportunities. Conclusions While these challenges may be interrelated, a contextual analysis provides a useful means of understanding the programme’s implementation as part of ongoing decision-making processes.

Barriers to the Implementation of the Ward-Based Outreach Team Program in Mpumalanga Province: Results From Process Evaluation

“…OTLs in other studies reported being unable to support CHWs adequately as a result of their excessively high workloads. 27 The evaluation established that the supervision of outreach teams was inconsistent and inadequate and compromised the ability of CHWs to perform their duties. 23 , 28 , 29 OTLs’ planned house visits with the CHWs were hampered by the lack of transport, which affected the actual supervision session with the CHWs.…”

“…Whereas they are expected to visit 5 households per day, they do much more despite the lack of resources, the poor training, the difficult working conditions, and the suboptimal supervision. 22 , 27 , 31 , 36 CHWs spend a lot of time walking from 1 house to another, and they are affected by the sun or the rain, as they lack protective clothing. 37 In addition to their outreach activities, they conduct campaigns, assist in immunization, and deliver pre-packed medicines for chronic clients.…”

“…Inadequate remuneration for CHWs is reported in other studies. 27 , 29 The irregular payment of the stipend has a huge impact on the quality of the outreach services. In addition, the CHWs’ morale, self-confidence, and credibility in the community were negatively affected by their lack of uniforms, which hinders the performance of their outreach duties.…”

“…Moreover, the CHWs use their own funds to pay for transport to reach households they cannot access on foot. 27 , 37 Since the taxi fare is at their own cost, the lack of a stipend affects the implementation of the WBOTs, as the CHWs are unable to meet the minimum required number of allocated households. The lack of dedicated workspaces in clinics for the outreach teams to do administrative work puts a damper on their morale because they have to work under the trees to compile their weekly and monthly reports.…”

“…In other studies, the fear of being stigmatized was raised by some participants as a barrier against the implementation of the outreach program. 27 , 37 …”