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BackgroundSimilar to other countries in the region, South Africa is currently reorienting a loosely structured and highly diverse community care system that evolved around HIV and TB, into a formalized, comprehensive and integrated primary health care outreach programme, based on community health workers (CHWs). While the difficulties of establishing national CHW programmes are well described, the reshaping of disease specific and care oriented community services, based outside the formal health system, poses particular challenges. This paper is an in-depth case study of the challenges of implementing reforms to community based services (CBS) in one province of South Africa.MethodsA multi-method situation appraisal of CBS in the Western Cape Province was conducted over eight months in close collaboration with provincial stakeholders. The appraisal mapped the roles and service delivery, human resource, financing and governance arrangements of an extensive non-governmental organisation (NGO) contracted and CHW based service delivery infrastructure that emerged over 15–20 years in this province. It also gathered the perspectives of a wide range of actors – including communities, users, NGOs, PHC providers and managers - on the current state and future visions of CBS.ResultsWhile there was wide support for new approaches to CBS, there are a number of challenges to achieving this. Although largely government funded, the community based delivery platform remains marginal to the formal public primary health care (PHC) and district health systems. CHW roles evolved from a system of home based care and are limited in scope. There is a high turnover of cadres, and support systems (supervision, monitoring, financing, training), coordination between CHWs, NGOs and PHC facilities, and sub-district capacity for planning and management of CBS are all poorly developed.ConclusionsReorienting community based services that have their origins in care responses to HIV and TB presents an inter-related set of resource mobilisation, system design and governance challenges. These include not only formalising community based teams themselves, but also the forging of new roles, relationships and mind-sets within the primary health care system, and creating greater capacity for contracting and engaging a plural set of actors - government, NGO and community - at district and sub-district level.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-1109-4) contains supplementary material, which is available to authorized users.

Cape Town is currently one of the hotspots for COVID-19 on the African continent. The Metropolitan Health Services have re-organised their primary health care (PHC) services to tackle the epidemic with a community-orientated primary care perspective. Two key goals have guided the re-organisation, the need to maintain social distancing and reduce risk to people using the services and the need to prepare for an influx of people with COVID-19. Facilities were re-organised to have ‘screening and streaming’ at the entrance and patients were separated into hot and cold streams. Both streams had ‘see and treat’ stations for the rapid treatment of minor ailments. Patients in separate streams were then managed further. If patients with chronic conditions were stable, they were provided with home delivery of medication by community health workers. Community health workers also engaged in community-based screening and testing. Initial evaluation of PHC preparedness was generally good. However, a number of key issues were identified. Additional infrastructure was required in some facilities to keep the streams separate with the onset of winter. Managers had to actively address the anxiety and fears of the primary care workforce. Attention also needed to be given to the prevention and treatment of non-COVID conditions as utilisation of these services decreased. The epidemic exposed intersectoral and intrasectoral fault lines, particularly access to social services at a time when they were most needed. Community screening and testing had to be refocused due to limited laboratory capacity and a lengthening turnaround time.

Evaluation of rehabilitation programmes is essentialin order to monitor its effectiveness and relevance. There is howevera need to consider policies when conducting evaluation researchin rehabilitation. The aim of this paper is to present the theoreticaland legislative underpinnings of rehabilitation in South Africa.A narrative review of national and international disability legislationand empirical research in context of rehabilitation was conducted.The findings of this review reveals that as a fluid construct, thediscourse of rehabilitation has been underpinned by the changingtheoretical and socio-political understandings of disability. This inturn has influenced various international and national health anddisability policies and legislations that oversee the implementation ofrehabilitation practice. Despite this, there has been little evaluationof public health rehabilitation services in context of these policies and legislations in South Africa. The fluidity of rehabilitationneed to be considered when conducting evaluation research in rehabilitation.