Community health worker models in South Africa: a qualitative study on policy implementation of the 2018/19 revised framework

Abstract

South Africa has a long history of community health workers (CHWs). It has been a journey that has required balancing constrained resources and competing priorities. CHWs form a bridge between communities and healthcare service provision within health facilities and act as the cornerstone of South Africa’s Ward-Based Primary Healthcare Outreach Teams. This study aimed to document the CHW policy implementation landscape across six provinces in South Africa and explore the reasons for local adaptation of CHW models and to identify potential barriers and facilitators to implementation of the revised framework to help guide and inform future planning. We conducted a qualitative study among a sample of Department of Health Managers at the National, Provincial and District level, healthcare providers, implementing partners [including non-governmental organizations (NGOs) who worked with CHWs] and CHWs themselves. Data were collected between April 2018 and December 2018. We conducted 65 in-depth interviews (IDIs) with healthcare providers, managers and experts familiar with CHW work and nine focus group discussions (FGDs) with 101 CHWs. We present (i) current models of CHW policy implementation across South Africa, (ii) facilitators, (iii) barriers to CHW programme implementation and (iv) respondents’ recommendations on how the CHW programme can be improved. We chronicled the differences in NGO involvement, the common facilitators of purpose and passion in the CHWs’ work and the multitude of barriers and resource limitations CHWs must work under. We found that models of implementation vary greatly and that adaptability is an important aspect of successful implementation under resource constraints. Our findings largely aligned to existing research but included an evaluation of districts/provinces that had not previously been explored together. CHWs continue to promote health and link their communities to healthcare facilities, in spite of lack of permanent employment, limited resources, such as uniforms, and low wages.

Exploring effort–reward imbalance and professional quality of life among health workers in Cape Town, South Africa: a mixed-methods study

“…The other key pillar of the government’s ‘Re-engineering PHC’ scheme envisions the creating of a larger cadre of more generalised CHWs. Other studies suggest that, in recent years, CHW roles have already significantly expanded to encompass an increasingly comprehensive range of health promotion, prevention and treatment tasks [ 27 , 61 ]. The planned reorientation away from predominantly curative and disease-specific roles might help to streamline and systematise the training of and support provided to CHWs.…”

“…As one of a range of studies conducted in the context of the larger ASSET research project, recruitment for this study was restricted to groups of health workers associated with PHC facilities that were part of the ASSET pre-implementation phase or those linked to intervention sites. Not least since there remain great variations in the ways CHW programs are implemented across South Africa [ 27 ], this may mean that results are not generalisable to other healthcare facilities beyond Cape Town. A small sample size also meant that we may have been underpowered to show associations between key variables.…”

“…This includes consolidating CHW roles and employing them directly, rather than through government-funded non-profit organisation (NPO) subcontractors, as well as turning CHWs into more generalised health workers with responsibilities for a growing range of health promotion, prevention and treatment interventions [ 23 , 25 ]. However, this has also raised concerns not just about the practicability of reorienting existing community-based care structures, but also about a growing disjuncture between the government’s emphasis on the importance of community-based care—and the often-precarious working conditions faced by CHWs, who are typically employed on low-paid, short-term contracts with limited support and opportunities for career progression [ 23 , 26 , 27 ].…”

Deploying a Fotonovela to Combat Methamphetamine Abuse among South Africans with Varying Levels of Health Literacy

“…To answer RQ2, the target group comprised of professional nurses and community health workers who deal with the problem of MA use in affected communities. Community health workers, supported by other health professionals such as doctors and nurses, form a bridge between communities and healthcare service provision within health facilities in South Africa [ 37 ] (pp. 1–2).…”

Skills2Care: An innovative, cooperative learning programme for community health workers in South Africa

“…Several recent systematic reviews have indicated that training and continuous training for CHWs are important if their work is to remain relevant and up-to-date. 1 , 2 , 3 , 6 Murphy et al 6 have pointed to the lack of opportunities for professional development for CHWs, which training seeks to address. 7 The systematic reviews also indicated that training is necessary to improve CHWs’ motivation, and increase community confidence in their services.…”