Exploring the roles and factors influencing community health workers’ performance in managing and referring severe acute malnutrition cases in two subdistricts in South Africa

Abstract

As primary providers of preventive and curative community case management services in low- and middle-income countries (LMICs), community health workers (CHWs) have emerged as a formalised part of the health system (HS). However, discourses on their practices as formalised cadres of the HS are limited. Therefore, we examined their role in care, referral (to clinics) and rehabilitation of severe acute malnutrition (SAM) cases. Focusing on SAM was essential since it is a global public health problem associated with 30% of all South Africa's (SA's) child deaths in 2015. Guided by a policy analysis framework, a qualitative case study was conducted in two rural subdistricts of North West province. From April to August 2016, data collected from CHW's training manuals and guideline reviews, 20 patient record reviews and 15 in-depth interviews with four CHW leaders and 11 CHWs. Using thematic content analysis which was guided by the Walt and Gilson policy triangle, data was manually analysed to derive emerging themes on case management and administrative structures. The study found that although CHWs were responsible for identifying, referring, and rehabilitating SAM cases, they neglected curative roles of stabilisation before referral and treatment of uncomplicated cases. Such limitations resulted from restrictive CHW policies, inadequate training, lack of supportive supervision and essential resources. Concurrently, the CHW program was based on weak operational and administrative structures which challenged CHWs practices. Poor curative components and weak operational structures in this context compromised the use of CHWs in LMICs to strengthen primary healthcare. If CHWs are to contribute to Sustainable Development Goal (SDG) 3 by reducing SAM mortality, strategies on community management of acute malnutrition coupled with thorough training, supportive supervision, firm operational structures, adequate resources and providers' motivation should be adopted by governments.

Health policy triangle framework: Narrative review of the recent literature

“…Two studies examined alcohol-related policies [ 35 , 68 ] where one study scrutinised illegal drug policies [ 37 ]. Three studies explored nutrition: two focusing on malnutrition management and prevention in UMICs [ 56 , 62 ] and one reviewing school food policy development and implementation in the Philippines [ 74 ]. Interestingly, all three mental health policy analysis studies included in this review focused on the topic of child, and mostly, adolescent mental health policy [ 45 , 63 , 75 ].…”

Assessment of growth monitoring among children younger than 5 years at early childhood development centres in Nelson Mandela Bay, South Africa

“…The full assessment should include mid‐upperarm circumference (MUAC) measurement, plotting and interpreting weight for height, an examination of oedema, a clinical examination for Integrated Management of Childhood Illnesses (IMCI) danger signs and an appetite test [ 6 ]. However, CHWs lack adequate training, require better supervision and essential resources, and are sometimes inhibited from performing stabilisation care before referral due to restrictive policies [ 7 ]. As a result, in most areas in South Africa, screening by CHWs only include measurement and interpretation of MUAC and to assess for the presence of oedema, followed by referral to the nearest primary health care centre.…”

Factors influencing the implementation of severe acute malnutrition guidelines within the healthcare referral systems of rural subdistricts in North West Province, South Africa

“…To achieve SDG 3.2, efforts to reduce preventable deaths of under-five children, SSA should strive to identify and address bottlenecks to the successful implementation of SAM management guidelines [5,26]. In previous studies, the limitations of managing SAM at the SA community level have been identified [27] and the comprehensiveness of SA's SAM guidelines has been appraised [28]. To enhance the narrative, this study explored the complexity of implementing SAM guidelines by focusing on the diagnosis, management, and referral of underfive children within the rural subdistrict's referral system and the factors influencing these practices.…”