"They are our eyes outside there in the community": Implementing enhanced training, management and monitoring of South Africa’s ward-based primary healthcare outreach teams

Abstract

Introduction In 2018, South Africa’s National Department of Health provided additional resources for ward-based primary healthcare outreach teams (OT) with support from the U.S. President’s Emergency Plan for AIDS Relief. The intervention package included a new training curriculum, enhanced staffing, revised management and supervisory structures, and more intensive monitoring and evaluation (M&E). The goal was to strengthen OT and their impact on both primary healthcare and HIV-specific services. We conducted a process evaluation of this intervention package during its second year and examined implementation successes and challenges. Methods We conducted a mixed-methods evaluation at 20 purposively selected facilities in Bojanala and City of Tshwane districts, including surveys with 222 community health workers (CHWs) and outreach team leaders (OTLs); key informant interviews and online surveys with 28 policy and program stakeholders; 70 in-depth interviews with health facility staff; 20 focus group discussions with 194 CHWs; 20 structured health facility assessments; directly-observed time-motion studies; and review of program documents. Results Most participants highlighted the hiring and training of CHWs and OTLs as a key implementation success because this had partially alleviated staffing shortages and helped clarify CHWs’ and OTLs’ responsibilities and supervisory structures. The new monitoring tools were welcomed for their potential to improve data collection and program tracking. However, participants highlighted many program challenges: short-lived gains in CHWs’ knowledge and skills due to lack of ongoing training and mentoring; insufficient integration of OT into health facility management structures; persistent shortages of equipment, supplies, transportation, and workspace for CHWs; and insufficient remuneration for staff. Conclusion Strengthening and expanding CHW programs, such as OT, requires intensive support and continuous investments. To sustain improvements in training, supervision, and job satisfaction, CHWs must be equipped with needed resources, provided with ongoing supportive supervision, and strengthened by optimized program management, monitoring and processes.

Barriers to and enablers of quality improvement in primary health care in low- and middle-income countries: A systematic review

“…An example of this came from a convergent mixed methods process evaluation of continuous quality improvement in South Africa [ 69 ] where health workers were discouraged by layers of managerial approval. In such cases across multiple PHC contexts, QI tasks were perceived to be time consuming—reducing health workers’ confidence in the QI initiative—and abandoned [ 45 , 48 , 49 , 52 , 54 , 58 , 59 , 62 , 67 , 69 , 71 – 75 , 81 , 83 – 85 , 90 ].…”

“…QI implementation is enabled when health workers and managers perceive an intervention to be effective e.g., by observing the desired outcomes for patients and successful acquisition of new skills [ 41 , 44 , 62 , 67 , 72 , 74 , 75 , 81 ]. A relative advantage accrues when implementers view a new QI initiative as better than current practice and when the intervention is designed to foster collaboration among a diverse team of workers, and even PHC clients.…”

Human resource time commitments and associated costs of Community Caregiver outreach team operations in South Africa

“…Each CCG team is assigned a municipal ward where they provide health services to the community such as HIV, tuberculosis (TB), maternal and child health, and chronic condition care through household visits, typically working in pairs of 2–3 individual CCGs [ 3 ]. However, there are challenges in operating community-oriented care programs such as CCGs, both in South Africa and elsewhere in Sub-Saharan Africa [ 6 , 7 ]. In South Africa, CCG coverage is unevenly distributed, with complete coverage in only half of the country’s 4,277 wards [ 8 ].…”

“…In March 2017, there were 3,275 CCGs teams-representing only 42% of the estimated 7,800 teams required to provide comprehensive national care [4]. And, while CCGs do ease access to care in communities, they have limited understanding of certain interventions, can overemphasize care for certain diseases and strategies, have high workloads, and can experience pushback from communities based on stigma and perception [7,[9][10][11].…”

“…Community-based care interventions like CCGs are only implementable with an appropriate understanding of resource requirements [7,[9][10][11]. Ideally, these programs aim to maximize the number of successful visits on a per day basis, since the number of households covered by each CHW is based on distance and travel time between households, demographic structure, and burden of disease [4].…”