Which primary care model? A qualitative analysis of ward-based outreach teams in South Africa

Abstract

Globally, models of extending universal health coverage through primary care are influenced by country-specific systems of health care and disease management. In 2015 a rapid assessment of the ward-based outreach component of primary care reengineering was commissioned to understand implementation and rollout challenges.AimThis article aims to describe middle- and lower-level managers’ understanding of ward-based outreach teams (WBOTs) and the problems of authority, jurisdiction and practical functioning that arise from the way the model is constructed and has been operationalised.SettingData are drawn from a rapid assessment of National Health Insurance (NHI) pilot sites in seven provinces.MethodsThe study used a modified version of CASCADE. Peer-review teams of public health researchers and district/sub-district managers collected data in two sites per province between March and July 2015.ResultsRespondents unequivocally support the strategy to extend primary health care services to people in their homes and communities both because it is responsive to the family context of individual health and because it reaches marginal people. They, however, identify critical issues that arise from basing WBOTs in facilities, including unspecific team leadership, inadequate supervision, poorly constituted teams, limited community reach and serious infrastructural and material under-provision.ConclusionMany of the shortcomings of a facility-based extension model can be addressed by an independently resourced, geographic, community-based model of fully constituted teams that are clinically and organisationally supported in an integrated district health system. However, a community-oriented primary care approach will still have to grapple with overarching framework problems.

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

“…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 practice, TLs reported to a number of actors, especially where a shortage of professional nurses required them to oversee several teams across PHC facilities. This created confusion on supervisory lines into the PHC system, a situation which can impact on the functioning of WBOTs 23 27…”

An Analysis of the Services Provided by Municipal Ward Based Primary Health Care Outreach Teams in an Urban District in South Africa: A Key Contribution Towards Universal Access to Care.

“…[20] Much of the existing research on WBPHCOT programmes in SA, explored processes and barriers to implementation. [21][22][23][24] Current health service indicators that inform routine monitoring for WBPHCOTs largely document input and process indicators such as numbers of teams, compliance, supervision coverage and households registered. [25] There is little published local evidence on the outputs of WBPHCOT (the what) in households in South Africa.…”

Moving to a strong(er) community health system: analysing the role of community health volunteers in the new national community health strategy in Malawi

“…As reported in earlier Malawian studies,12 35 36 there are genuine concerns over HSAs’ roles, which expanded over time against unmatched training support, and the expectation that they can deliver both community-based and facility-based activities as part of their job description. Experience from South Africa’s ward-based outreach team model suggests that while primary healthcare staff are expected to assume more community-based responsibilities, including leadership and clinical supervision to non-health professional team members, in reality, they tend to prioritise facility-based care given workload demands 47. The expansion of CHBC programmes in Malawi to include patients with other chronic conditions (besides HIV)14 has to a large extent been unsupported by capacity building in these areas.…”