"They are our eyes outside there in the community": Implementing enhanced training, management and monitoring of South Africa’s ward-based primary healthcare outreach teams

Barriers to and enablers of quality improvement in primary health care in low- and middle-income countries: A systematic review

The quality of health care remains generally poor across primary health care settings, especially in low- and middle-income countries where tertiary care tends to take up much of the limited resources despite primary health care being the first (and often the only) point of contact with the health system for nearly 80 per cent of people in these countries. Evidence is needed on barriers and enablers of quality improvement initiatives. This systematic review sought to answer the question: What are the enablers of and barriers to quality improvement in primary health care in low- and middle-income countries? It adopted an integrative review approach with narrative evidence synthesis, which combined qualitative and mixed methods research studies systematically. Using a customized geographic search filter for LMICs developed by the Cochrane Collaboration, Scopus, Academic Search Ultimate, MEDLINE, CINAHL, PSYCHINFO, EMBASE, ProQuest Dissertations and Overton.io (a new database for LMIC literature) were searched in January and February 2023, as were selected websites and journals. 7,077 reports were retrieved. After removing duplicates, reviewers independently screened titles, abstracts and full texts, performed quality appraisal and data extraction, followed by analysis and synthesis. 50 reports from 47 studies were included, covering 52 LMIC settings. Six themes related to barriers and enablers of quality improvement were identified and organized using the model for understanding success in quality (MUSIQ) and the consolidated framework for implementation research (CFIR). These were: microsystem of quality improvement, intervention attributes, implementing organization and team, health systems support and capacity, external environment and structural factors, and execution. Decision makers, practitioners, funders, implementers, and other stakeholders can use the evidence from this systematic review to minimize barriers and amplify enablers to better the chances that quality improvement initiatives will be successful in resource-limited settings. PROSPERO registration: CRD42023395166.

Human resource time commitments and associated costs of Community Caregiver outreach team operations in South Africa

INTRODUCTION

In South Africa, Community Caregivers (CCGs) visit households to provide basic healthcare services including those for tuberculosis and HIV. However, CCG workloads, costs, and time burden are largely unknown. Our objective was to assess the workloads and operational costs for CCG teams operating in different settings in South Africa.

METHODS

Between March and October 2018, we collected standardized self-reported activity time forms from 11 CCG pairs working at two public health clinics in Ekurhuleni district, South Africa. CCG workloads were assessed based on activity unit times, per-household visit time, and mean daily number of successful household visits. Using activity-based times and CCG operating cost data, we assessed CCG annual and per-household visit costs (USD 2019) from the health system perspective.

RESULTS

CCGs in clinic 1 (peri-urban, 7 CCG pairs) and 2 (urban, informal settlement; 4 CCG pairs) served an area of 3.1 km2 and 0.6 km2 with 8,035 and 5,200 registered households, respectively. CCG pairs spent a median 236 minutes per day conducting field activities at clinic 1 versus 235 minutes at clinic 2. CCG pairs at clinic 1 spent 49.5% of this time at households (versus traveling), compared to 35.0% at clinic 2. On average, CCG pairs successfully visited 9.5 vs 6.7 households per day for clinics 1 and 2, respectively. At clinic 1, 2.7% of household visits were unsuccessful, versus 28.5% at clinic 2. Total annual operating costs were higher in clinic 1 ($71,780 vs $49,097) but cost per successful visit was lower ($3.58) than clinic 2 ($5.85).

CONCLUSIONS

CCG home visits were more frequent, successful, and less costly in clinic 1, which served a larger and more formalized settlement. The variability in workload and cost observed across pairs and clinics suggests that circumstantial factors and CCG needs must be carefully assessed for optimized CCG outreach operations.