Household coverage, quality and costs of care provided by community health worker teams and the determining factors: findings from a mixed methods study in South Africa

ObjectiveCommunity health workers (CHWs) are undertaking more complex tasks as part of the move towards universal health coverage in South Africa. CHW programmes can improve access to care for vulnerable communities, but many such programmes struggle with insufficient supervision. In this paper, we assess coverage (proportion of households visited by a CHW in the past year and month), quality of care and costs of the service provided by CHW teams with differing configurations of supervisors, some based in formal clinics and some in community health posts.ParticipantsCHW, their supervisors, clinic staff, CHW clients.MethodsWe used mixed methods (a random household survey, focus group discussions, interviews and observations of the CHW at work) to examine the performance of six CHW teams in vulnerable communities in Sedibeng, South Africa.ResultsA CHW had visited 17% of households in the last year, and we estimated they were conducting one to two visits per day. At household registration visits, the CHW asked half of the questions required. Respondents remembered 20%–25% of the health messages that CHW delivered from a visit in the last month, and half of the respondents took the action recommended by the CHW. Training, supervision and motivation of the CHW, and collaboration with other clinic staff, were better with a senior nurse supervisor. We estimated that if CHW carried out four visits a day, coverage would increase to 30%–90% of households, suggesting that some teams need more CHW, as well as better supervision.ConclusionHousehold coverage was low, and the service was limited. Support from the local facility was key to providing a quality service, and a senior supervisor facilitated this collaboration. Greater investment in numbers of CHW, supervisors, training and equipment is required for the potential benefits of the programme to be delivered.

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Sub-national perspectives on the implementation of a national community health worker programme in Gauteng Province, South Africa

BMJ Global Health ◽

10.1136/bmjgh-2019-001564 ◽

2019 ◽

Vol 4 (Suppl 10) ◽

pp. e001564 ◽

Cited By ~ 1

Author(s):

Shehnaz Munshi ◽

Nicola J Christofides ◽

John Eyles

Keyword(s):

South Africa ◽

Community Health ◽

Primary Healthcare ◽

Health Workers ◽

National Policy ◽

National Health System ◽

Shared Vision ◽

Health Coverage ◽

Team Leaders ◽

Implementation Stages

IntroductionIn 2011, in line with principles for Universal Health Coverage, South Africa formalised community health workers (CHWs) into the national health system in order to strengthen primary healthcare. The national policy proposed that teams of CHWs, called Ward-based Primary Healthcare Outreach Teams (WBPHCOTs), supervised by a professional nurse were implemented. This paper explores WBPHCOTs’ and managers’ perspectives on the implementation of the CHW programme in one district in South Africa at the early stages of implementation guided by the Implementation Stages Framework.MethodsWe conducted a qualitative study consisting of five focus group discussions and 14 in-depth interviews with CHWs, team leaders and managers. A content analysis of data was conducted.ResultsThere were significant weaknesses in early implementation resulting from a vague national policy and a rushed implementation plan. During the installation stage, adaptations were made to address gaps including the appointment of subdistrict managers and enrolled nurses as team leaders. Staff preparation of CHWs and team leaders to perform their roles was inadequate. To compensate, team members supported each another and assisted with technical skills where they could. Structural issues, such as CHWs receiving a stipend rather than being employed, were an ongoing implementation challenge. Another challenge was that facility managers were employed by the local government authority while the CHW programme was perceived to be a provincial programme.ConclusionThe implementation of complex programmes requires a shared vision held by all stakeholders. Adaptations occur at different implementation stages, which require a feedback mechanism to inform the implementation in other settings. The CHW programme represented a policy advance but lacked detail with respect to human resources, budget, supervision, training and sustainability, which made it a difficult furrow to plough. This study points to how progressive reform remains fraught without due attention to the minutiae of practice.

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Sustaining the National Health Insurance Scheme in South Africa: The Roles and Challenges of Community Health Workers

The Open Public Health Journal ◽

10.2174/1874944501811010494 ◽

2018 ◽

Vol 11 (1) ◽

pp. 494-506 ◽

Cited By ~ 2

Author(s):

Takalani G. Tshitangano ◽

Foluke C. Olaniyi

Keyword(s):

South Africa ◽

Health Insurance ◽

Community Health ◽

Community Health Workers ◽

National Health Insurance ◽

National Health ◽

Universal Health Coverage ◽

Health Workers ◽

Health Coverage ◽

Universal Health

Background:The provision of universal health coverage is acknowledged as a priority goal for healthcare systems globally. In South Africa, the National Health Insurance system has been endorsed as a funding model for the provision of universal health coverage for South Africans. Community Health Workers have contributed to better universal health coverage outcomes in many countries. A study in India revealed that coverage of health care practices is positively correlated with the knowledge level of Community Health Workers. In South Africa, there is a difference in the duration of training of Community Health Workers in different provinces, especially in Vhembe District.Objective:This study aimed to assess Community Health Workers’ knowledge regarding their roles and describe their challenges within the context of National Health Insurance.Methods:Qualitative design was used to collect data from 33 participants who formed five focus groups comprising six to eight members each. Ethical principles of research such as permission, informed consent, voluntary participation and anonymity were observed. Data was analysed using thematic data analysis technique guided by Tesch open coding method.Results:The findings revealed that Community Health Workers lack adequate knowledge regarding the roles they are expected to play within Ward Based Outreach teams. Some of the challenges they face include transportation to clients’ homes and poor reception in households.Conclusion:A review of the South African Qualification Authority health promoter unit standards is recommended coupled with the mentorship of Community Health Workers by retired nurses to help them understand their roles better.

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‘Do you trust those data?’—a mixed-methods study assessing the quality of data reported by community health workers in Kenya and Malawi

Health Policy and Planning ◽

10.1093/heapol/czz163 ◽

2020 ◽

Vol 35 (3) ◽

pp. 334-345 ◽

Cited By ~ 1

Author(s):

Regeru Njoroge Regeru ◽

Kingsley Chikaphupha ◽

Meghan Bruce Kumar ◽

Lilian Otiso ◽

Miriam Taegtmeyer

Keyword(s):

Mixed Methods ◽

Data Quality ◽

Community Health ◽

Health Workers ◽

Calculated Data ◽

Mixed Methods Study ◽

Quality Data ◽

Growth Monitoring ◽

Health Coverage ◽

Quality Of Data

Abstract High-quality data are essential to monitor and evaluate community health worker (CHW) programmes in low- and middle-income countries striving towards universal health coverage. This mixed-methods study was conducted in two purposively selected districts in Kenya (where volunteers collect data) and two in Malawi (where health surveillance assistants are a paid cadre). We calculated data verification ratios to quantify reporting consistency for selected health indicators over 3 months across 339 registers and 72 summary reports. These indicators are related to antenatal care, skilled delivery, immunization, growth monitoring and nutrition in Kenya; new cases, danger signs, drug stock-outs and under-five mortality in Malawi. We used qualitative methods to explore perceptions of data quality with 52 CHWs in Kenya, 83 CHWs in Malawi and 36 key informants. We analysed these data using a framework approach assisted by NVivo11. We found that only 15% of data were reported consistently between CHWs and their supervisors in both contexts. We found remarkable similarities in our qualitative data in Kenya and Malawi. Barriers to data quality mirrored those previously reported elsewhere including unavailability of data collection and reporting tools; inadequate training and supervision; lack of quality control mechanisms; and inadequate register completion. In addition, we found that CHWs experienced tensions at the interface between the formal health system and the communities they served, mediated by the social and cultural expectations of their role. These issues affected data quality in both contexts with reports of difficulties in negotiating gender norms leading to skipping sensitive questions when completing registers; fabrication of data; lack of trust in the data; and limited use of data for decision-making. While routine systems need strengthening, these more nuanced issues also need addressing. This is backed up by our finding of the high value placed on supportive supervision as an enabler of data quality.

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Interplaying role of healthcare activist and homemaker: a mixed-methods exploration of the workload of community health workers (Accredited Social Health Activists) in India

Human Resources for Health ◽

10.1186/s12960-020-00546-z ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Anand Kawade ◽

◽

Manisha Gore ◽

Pallavi Lele ◽

Uddhavi Chavan ◽

...

Keyword(s):

Mixed Methods ◽

Health System ◽

Community Health ◽

Community Health Workers ◽

Health Workers ◽

Social Health ◽

Health Coverage ◽

Nurse Midwife ◽

Auxiliary Nurse

Abstract Background Globally, community health workers (CHWs) are integral contributors to many health systems. In India, Accredited Social Health Activists (ASHAs) have been deployed since 2005. Engaged in multiple health care activities, they are a key link between the health system and population. ASHAs are expected to participate in new health programmes prompting interest in their current workload from the perspective of the health system, community and their family. Methods This mixed-methods design study was conducted in rural and tribal Primary Health Centers (PHCs), in Pune district, Western Maharashtra, India. All ASHAs affiliated with these PHCs were invited to participate in the quantitative study, those agreeing to contribute in-depth interviews (IDI) were enrolled in an additional qualitative study. Key informants’ interviews were conducted with the Auxiliary Nurse Midwife (ANM), Block Facilitators (BFF) and Medical Officers (MO) of the same PHCs. Quantitative data were analysed using descriptive statistics. Qualitative data were analysed thematically. Results We recruited 67 ASHAs from the two PHCs. ASHAs worked up to 20 h/week in their village of residence, serving populations of approximately 800–1200, embracing an increasing range of activities, despite a workload that contributed to feelings of being rushed and tiredness. They juggled household work, other paid jobs and their ASHA activities. Practical problems with travel added to time involved, especially in tribal areas where transport is lacking. Their sense of benefiting the community coupled with respect and recognition gained in village brought happiness and job satisfaction. They were willing to take on new tasks. ASHAs perceived themselves as ‘voluntary community health workers’ rather than as ‘health activists”. Conclusions ASHAs were struggling to balance their significant ASHA work and domestic tasks. They were proud of their role as CHWs and willing to take on new activities. Strategies to recruit, train, skills enhancement, incentivise, and retain ASHAs, need to be prioritised. Evolving attitudes to the advantages/disadvantages of current voluntary status and role of ASHAs need to be understood and addressed if ASHAs are to be remain a key component in achieving universal health coverage in India.

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Post-trial perceptions of a symptom-based TB screening intervention in South Africa: implementation insights and future directions for TB preventive healthcare services

BMC Nursing ◽

10.1186/s12912-021-00544-z ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

Nicole Salazar-Austin ◽

Minja Milovanovic ◽

Nora S. West ◽

Molefi Tladi ◽

Grace Link Barnes ◽

...

Keyword(s):

South Africa ◽

Community Health ◽

Community Health Workers ◽

Health Workers ◽

Implementation Strategies ◽

Healthcare Services ◽

Preventive Therapy ◽

Provider Perceptions ◽

Symptom Screening ◽

Study Implementation

Abstract Background Tuberculosis is a top-10 cause of under-5 mortality, despite policies promoting tuberculosis preventive therapy (TPT). We previously conducted a cluster randomized trial to evaluate the effectiveness of symptom-based versus tuberculin skin-based screening on child TPT uptake. Symptom-based screening did not improve TPT uptake and nearly two-thirds of child contacts were not identified or not linked to care. Here we qualitatively explored healthcare provider perceptions of factors that impacted TPT uptake among child contacts. Methods Sixteen in-depth interviews were conducted with key informants including healthcare providers and administrators who participated in the trial in Matlosana, South Africa. The participants’ experience with symptom-based screening, study implementation strategies, and ongoing challenges with child contact identification and linkage to care were explored. Interviews were systematically coded and thematic content analysis was conducted. Results Participants’ had mixed opinions about symptom-based screening and high acceptability of the study implementation strategies. A key barrier to optimizing child contact screening and evaluation was the supervision and training of community health workers. Conclusions Symptom screening is a simple and effective strategy to evaluate child contacts, but additional pediatric training is needed to provide comfort with decision making. New clinic-based child contact files were highly valued by providers who continued to use them after trial completion. Future interventions to improve child contact management will need to address how to best utilize community health workers in identifying and linking child contacts to care. Trial registration The results presented here were from research related to NCT03074799, retrospectively registered on 9 March 2017.

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An innovative approach to improve the detection and treatment of risk factors in poor urban settings: a feasibility study in Argentina

BMC Public Health ◽

10.1186/s12889-021-10569-3 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Poggio Rosana ◽

Goodarz Danaei ◽

Laura Gutierrez ◽

Ana Cavallo ◽

María Victoria Lopez ◽

...

Keyword(s):

Public Health ◽

Risk Factors ◽

Primary Care ◽

Community Health ◽

Community Health Workers ◽

Feasibility Study ◽

Health Workers ◽

Health Coverage ◽

Cvd Risk Factors ◽

Cvd Risk

Abstract Background The effective management of cardiovascular (CVD) prevention among the population with exclusive public health coverage in Argentina is low since less than 30% of the individuals with predicted 10-year CVD risk ≥10% attend a clinical visit for CVD risk factors control in the primary care clinics (PCCs). Methods We conducted a non-controlled feasibility study using a mixed methods approach to evaluate acceptability, adoption and fidelity of a multi-component intervention implemented in the public healthcare system. The eligibility criteria were having exclusive public health coverage, age ≥ 40 years, residence in the PCC’s catchment area and 10-year CVD risk ≥10%. The multi-component intervention addressed (1) system barriers through task shifting among the PCC’s staff, protected medical appointments slots and a new CVD form and (2) Provider barriers through training for primary care physicians and CHW and individual barriers through a home-based intervention delivered by community health workers (CHWs). Results A total of 185 participants were included in the study. Of the total number of eligible participants, 82.2% attended at least one clinical visit for risk factor control. Physicians intensified drug treatment in 77% of participants with BP ≥140/90 mmHg and 79.5% of participants with diabetes, increased the proportion of participants treated according to GCP from 21 to 32.6% in hypertensive participants, 7.4 to 33.3% in high CVD risk and 1.4 to 8.7% in very high CVD risk groups. Mean systolic and diastolic blood pressure were lower at the end of follow up (156.9 to 145.4 mmHg and 92.9 to 88.9 mmHg, respectively) and control of hypertension (BP < 140/90 mmHg) increased from 20.3 to 35.5%. Conclusion The proposed CHWs-led intervention was feasible and well accepted to improve the detection and treatment of risk factors in the poor population with exclusive public health coverage and with moderate or high CVD risk at the primary care setting in Argentina. Task sharing activities with CHWs did not only stimulate teamwork among PCC staff, but it also improved quality of care. This study showed that community health workers could have a more active role in the detection and clinical management of CVD risk factors in low-income communities.

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

Health Policy and Planning ◽

10.1093/heapol/czaa172 ◽

2020 ◽

Author(s):

Joshua P Murphy ◽

Aneesa Moolla ◽

Sharon Kgowedi ◽

Constance Mongwenyana ◽

Sithabile Mngadi ◽

...

Keyword(s):

South Africa ◽

Qualitative Study ◽

Policy Implementation ◽

Community Health ◽

Resource Constraints ◽

Health Workers ◽

Healthcare Providers ◽

Successful Implementation ◽

Programme Implementation ◽

Healthcare Facilities

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.

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Fidelity of HIV programme implementation by community health workers in rural Mopani district, South Africa: a community survey

BMC Public Health ◽

10.1186/s12889-018-5927-2 ◽

2018 ◽

Vol 18 (1) ◽

Cited By ~ 3

Author(s):

Nireshni Naidoo ◽

Jean P. Railton ◽

Sellina N. Khosa ◽

Nthabiseng Matlakala ◽

Gert Marincowitz ◽

...

Keyword(s):

South Africa ◽

Community Health ◽

Community Health Workers ◽

Health Workers ◽

Community Survey ◽

Programme Implementation

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Compensation Models for Community Health Workers: Comparison of Legal Frameworks across Five Countries

10.21203/rs.3.rs-36222/v1 ◽

2020 ◽

Author(s):

Madeleine Ballard ◽

Carey Westgate ◽

Rebecca Alban ◽

Nandini Choudhury ◽

Rehan Adamjee ◽

...

Keyword(s):

South Africa ◽

Public Sector ◽

Community Health ◽

Community Health Workers ◽

Health Workers ◽

Legal Framework ◽

Law Firms ◽

Advantages And Disadvantages ◽

Compensation Mechanisms ◽

Legal Frameworks

Abstract Background Despite the life-saving work they perform, community health workers (CHWs) have long been subject to global debate about their remuneration. There is now, however, an emerging consensus that CHWs should be paid. As the discussion evolves from whether to financially remunerate CHWs to how to do so, there is an urgent need to better understand the types of CHW payment models and their implications. Methods This study examines the legal framework on CHW compensation in five countries: Brazil, Ghana, Nigeria, Rwanda, and South Africa. In order to map the characteristics of each approach, a standardized questionnaire was developed and targeted at local law firms. The questionnaire covered legal structures and requirements for compensation of CHWs, CHW compensation mechanisms, CHW legal protections and benefits, and alignment of national CHW policies with global guidelines. Results The five countries profiled represent possible archetypes for CHW compensation: Brazil (public), Ghana (volunteer-based), Nigeria (private), Rwanda (cooperatives with performance based incentives) and South Africa (hybrid public/private). Advantages and disadvantages of each model with respect to (i) CHWs, in terms of financial protection, and (ii) the public sector, in terms of ease of implementation, are outlined. Conclusions While a strong legal framework does not necessarily translate into high-quality implementation, it is the first necessary step. While certain approaches to CHW compensation - particularly public-sector or hybrid models with public sector wage floors - best institutionalize recommended CHW protections, political will and long-term financing often remain obstacles. Removing ecosystem barriers - such as multilateral and bilateral restrictions on the payment of salaries - can help governments institutionalize CHW payment.

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