Integrating community health workers into the formal health system to improve performance: a qualitative study on the role of on-site supervision in the South African programme

Abstract

ObjectivesTo explore the role of on-site supervision in community health worker (CHW) programmes and CHW integration into the health system. We compared the functioning of CHW teams reporting to a clinic-based nurse with teams supervised by a community-based nurse. We also consider whether a junior nurse can provide adequate supervision, given the shortage of senior nurses.DesignA case study approach to study six CHW teams with different configurations of supervision and location. We used a range of qualitative methods: observation of CHW and their supervisors (126 days), focus group discussions (12) and interviews (117).SettingSouth Africa where a national CHW programme is being implemented with on-site supervision.ParticipantsCHWs, their supervisors, clinic managers and staff, district managers, key informants from the community and CHW clients.ResultsEffective supervisors supported CHWs through household visits, on-the-job training, debriefing, reviewing CHWs’ daily logs and assistance with compiling reports. CHWs led by senior nurses were motivated and performed a greater range of tasks; junior nurses in these teams could better fulfil their role. Clinic-based teams with senior supervisors were better integrated and more able to ensure continuity of care. In contrast, teams with only junior supervisors, or based in the community, had less engagement with clinic staff, and were less able to ensure necessary care for patients, resulting in lower levels of trust from clients.ConclusionSenior supervisors raised CHW skills, and successfully negotiated a place for CHWs in the health system. Collaboration with clinic staff reduced CHWs’ marginalisation and increased motivation. Despite being clinic-based, teams without senior supervisors had lower skill levels and were less integrated into the health system.

The supervisory relationships of community health workers in primary health care: social network analysis of ward-based outreach teams in Ngaka Modiri Molema District, South Africa

“…On the whole, PHC facility staff and middle managers at subdistrict and district levels did not have much of a role in supporting and overseeing the work of the WBOTs. This resonates with previously documented problematic relationships between CHWs and the PHC system, poor organisational support in PHC facilities and a prevalent perception of not being respected 1 16 22 23 27. While the immediate supervisor of the CHWs is the TL, the PHC facility managers and staff have a pivotal role in supporting, overseeing and integrating the work of the WBOTs.…”

“…Yet the evidence from this study shows that approached holistically, supportive supervision involves a wide range of actors and relationships within a system 9. There is considerable evidence, from both the NW and elsewhere, that CHWs/WBOTs are often treated as outsiders by actors in the PHC system and perceive themselves as exploited and unacknowledged by the broader system 16 22–25. On the other hand, respondents were almost unanimous on the importance of the WBOT programme for communities.…”

“…In light of this, many of the actors in the PHC system could be better mobilised to directly and indirectly, play a supportive role to the WBOTs. This support would ensure that WBOTs’ resourcing, monitoring and support are integrated into processes at all levels of the district health system, thus improving their integration into the formal health system and performance outcomes 16 22 27. The study findings suggest key gaps in this wider supervisory cascade.…”

“…Second, the centrality of TLs needs to be recognised, and their numbers and mandates protected to ensure they focus on the WBOT programme. TLs are critical actors and provide regular support to CHWs, and as found in other studies, support and supervision from professional staff motivates CHWs 22 28. Given their centrality as actors, the dire shortage of TLs (ratio of 1 TL to 6 teams in the district), increasingly with dual community and other roles, poses a major threat to the WBOT programme.…”

Resource requirements for community-based care in rural, deep-rural and peri-urban communities in South Africa: A comparative analysis in 2 South African provinces

“…Another study aiming to profile current CHWs based in KZN [20] identified poor communication between them and facility-based nurses in the referral of clients, leading to poor job satisfaction among CHWs and an understanding of ongoing health services provided to clients. A study [21] to explore the role of on-site supervision of CHWs in South Africa found that those supervised by senior nurses were more motivated and performed a greater range of tasks, and those that were clinic-based were better integrated in the health system and therefore more able to ensure continuity of care. In contrast, teams supervised by junior supervisors, or based in the community, had less engagement with clinic staff, and were less able to ensure necessary care for patients, resulting in lower levels of trust from clients.…”