The effect of a roving nurse mentor on household coverage and quality of care provided by community health worker teams in South Africa: a longitudinal study with a before, after and 6 months post design

Mobilisation towards formal employment in the healthcare system: A qualitative study of community health workers in South Africa

In low and middle-income countries, community health workers (CHWs) play a critical role in delivering primary healthcare (PHC) services. However, they often receive low stipends, function without resources and have little bargaining power with which to demand better working conditions. Using a qualitative case study methodology, we studied CHWs' conditions of employment, their struggle for recognition as health workers, and their activities to establish labour representation in South Africa. Seven CHW teams located in semi-urban and rural areas of Gauteng and Mpumalanga Provinces were studied. We conducted 43 in-depth interviews, 10 focus groups and 6 observations to gather data from CHWs and their representatives, supervisors and PHC facility staff. The data was analysed using thematic analysis method. In the rural and semi-urban sites, the CHWs were poorly resourced and received meagre remuneration, their employment outsourced, without employment benefits and protection. As a result of these challenges, the CHWs in the semi-urban sites established a task team to represent them. They held meetings and caused disruptions in the health facilities. After numerous unsuccessful attempts to negotiate for improved conditions of employment, the CHWs joined a labour union in order to participate in the local Bargaining Council. Though they were not successful in getting the government to provide permanent employment, the union negotiated an increase in their stipend. After the study ended, during the height of COVID-19 in 2020, when the need for motivated and effective CHWs became more apparent to decision makers, the semi-urban-based teams received permanent employment with a better remuneration. The task team and their protests raised awareness of the plight of the CHWs, and joining a formal union enabled them to negotiate a modest salary increase. However, it was the emergency created by the world-wide COVID-19 pandemic that forced decision-makers to acknowledge their reliance on this community-based cadre.

Community health workers' quality of comprehensive care: a cross-sectional observational study across three districts in South Africa

Background

Community healthcare worker (CHW) training programs are becoming increasingly comprehensive (an expanded range of diseases). However, the CHWs that the program relies on have limited training. Since CHWs' activities occur largely during household visits, which often go unsupervised and unassessed, long-term, ongoing assessment is needed to identify gaps in CHW competency, and improve any such gaps. We observed CHWs during household visits and gave scores according to the proportion of health messages/activities provided for the health conditions encountered in households. We aimed to determine (1) messages/activities scores derived from the proportion of health messages given in the households by CHWs who provide comprehensive care in South Africa, and (2) the associated factors.

Methods

In three districts (from two provinces), we trained five fieldworkers to score the messages provided by, and activities of, 34 CHWs that we randomly selected during 376 household visits in 2018 and 2020 using a cross-sectional study designs. Multilevel models were fitted to identify factors associated with the messages/activities scores, adjusted for the clustering of observations within CHWs. The models were adjusted for fieldworkers and study facilities (n = 5, respectively) as fixed effects. CHW-related (age, education level, and phase of CHW training attended/passed) and household-related factors (household size [number of persons per household], number of conditions per household, and number of persons with a condition [hypertension, diabetes, HIV, tuberculosis TB, and cough]) were investigated.

Results

In the final model, messages/activities scores increased with each extra 5-min increase in visit duration. Messages/activities scores were lower for households with either children/babies, hypertension, diabetes, a large household size, numerous household conditions, and members with either TB or cough. Increasing household size and number of conditions, also lower the score. The messages/activities scores were not associated with any CHW characteristics, including education and training.

Conclusion

This study identifies important factors related to the messages provided by and the activities of CHWs across CHW teams. Increasing efforts are needed to ensure that CHWs who provide comprehensive care are supported given the wider range of conditions for which they provide messages/activities, especially in households with hypertension, diabetes, TB/cough, and children or babies.