Piloting a roving nurse mentor into community-based health programmes to capacitate community health workers: Findings from a realist evaluation in South Africa

Abstract

Background Many low- and middle- income countries (LMICs) are repositioning community health workers (CHW) programmes to provide promotive and preventive services and referrals to the formal health service. However, the CHW low literacy levels, insufficient supervision and fragmented programmes result in the under-performance of the programmes in many settings. In this paper, we report on the realist evaluation of an intervention to explain mechanisms that led to a change in CHW care and household coverage in a semi-rural area of South Africa. Methods Using a case study approach, we conducted in-depth interviews, focus group discussions and observations to document the experiences of CHWs, their supervisors, clients, facility staff and community representatives prior to the intervention, during, and after a 6 month post-intervention gap to assess how the benefits were generated and sustained. Results The nurse mentor (senior nurse) intervention operated in a complex and dynamic environment with resource shortages, conflicts between CHWs and facility staff, and a disruptive CHW labour union. Over 15 months, the mentor was able to overcome these issues and (1) create learning platforms for the CHWs and their supervisors to learn and practice new skills relating to priority activities, (2) address their fears of failing and (3) establish operational systems to address inefficiencies in the CHWs’ activities, resulting in improved service provision and household coverage. An increase in the CHWs’ stipend to the minimum wage improved their motivation, and their direct employment by the Department of Health led to their formal integration into the health care team working at their ‘home’ facility. However, given the volatile communities in which the teams operated, and the communities focus on demanding government housing, the nurse mentor was not able to establish a collaboration with the community structures. Conclusions A roving nurse mentor overseeing several CHW teams within a district healthcare system is a feasible option, particularly in a context where there is a shortage of qualified supervisors. However, the long term sustainability of the effects of intervention is dependent on CHWs’ formal employment by the Department of Health.