Sub-national perspectives on the implementation of a national community health worker programme in Gauteng Province, South Africa

Abstract

IntroductionIn 2011, in line with principles for Universal Health Coverage, South Africa formalised community health workers (CHWs) into the national health system in order to strengthen primary healthcare. The national policy proposed that teams of CHWs, called Ward-based Primary Healthcare Outreach Teams (WBPHCOTs), supervised by a professional nurse were implemented. This paper explores WBPHCOTs’ and managers’ perspectives on the implementation of the CHW programme in one district in South Africa at the early stages of implementation guided by the Implementation Stages Framework.MethodsWe conducted a qualitative study consisting of five focus group discussions and 14 in-depth interviews with CHWs, team leaders and managers. A content analysis of data was conducted.ResultsThere were significant weaknesses in early implementation resulting from a vague national policy and a rushed implementation plan. During the installation stage, adaptations were made to address gaps including the appointment of subdistrict managers and enrolled nurses as team leaders. Staff preparation of CHWs and team leaders to perform their roles was inadequate. To compensate, team members supported each another and assisted with technical skills where they could. Structural issues, such as CHWs receiving a stipend rather than being employed, were an ongoing implementation challenge. Another challenge was that facility managers were employed by the local government authority while the CHW programme was perceived to be a provincial programme.ConclusionThe implementation of complex programmes requires a shared vision held by all stakeholders. Adaptations occur at different implementation stages, which require a feedback mechanism to inform the implementation in other settings. The CHW programme represented a policy advance but lacked detail with respect to human resources, budget, supervision, training and sustainability, which made it a difficult furrow to plough. This study points to how progressive reform remains fraught without due attention to the minutiae of practice.

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

“…Similarly, evaluations of the WBOTs conducted in other provinces of South Africa found that no specific budget was set aside for the WBOTs. 11 , 20 - 23 …”

“… 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. In addition, the expectation that the OTLs work in clinics as well as in the community outreach program short-changes the WBOT program and leaves the CHWs under-supervised.…”

“…The participants highlighted that despite extensive community consultation not all households were open to the program. Munshi et al 23 attribute resistance to the uptake of the WBOTs to a lack of awareness about the outreach teams in the community. Race, religion, and middle class status were barriers against the uptake of the program in this evaluation, as in others.…”

“…Similarly, evaluations of the WBOTs conducted in other provinces of South Africa found that no specific budget was set aside for the WBOTs. 11,[20][21][22][23] The lack of an adequate budget resulted in shortages of equipment, supplies, transport and human resources, and acted as a barrier against the successful implementation of the WBOTs. 20 In many instances, the outreach teams were not able to conclude the services provided to the households due to a lack of resources.…”

An innovative model for management of cardiovascular disease risk factors in the low resource setting of Cambodia

“…For screening, suggested approaches involve Community Healthcare Workers or a similar cadre. However, these have not been widely rolled out in real-world settings ( Ndou et al , 2013 ; Tang et al , 2014 ; Munshi et al , 2019 ). Many suggested approaches for treatment in LMICs developed in recent years include the diagonal approaches of integrating existing infectious disease services to manage long-term conditions.…”