Outreach services to improve access to health care in South Africa: lessons from three community health worker programmes

Implementing active surveillance for TB: A descriptive survey of healthcare workers in the Eastern Cape, South Africa

BACKGROUND

 South Africa is a tuberculosis (TB) high-burden country. In the Eastern Cape (EC), community health worker (CHW) teams implement active surveillance for TB to curb spread in disadvantaged communities. However, achieving the goals of the End-TB strategy require coordinated efforts that implement policy and strengthen health systems.

AIM

 This survey described views of healthcare workers (HCWs) in primary care facilities on factors that influence implementation of active surveillance for TB.

SETTING

 This survey was conducted across two districts, among healthcare workers working in TB rooms at primary health facilities.

METHOD

 A cross-sectional survey of HCW in the EC.

RESULTS

 The survey included 37 clinics in the OR Tambo Health District (ORTHD) and 44 clinics in the Nelson Mandela Bay Health District (NMBHD). Routine screening at primary care facilities (88.2%) and contact tracing initiatives (80.8%) were the common modes of TB screening. Tuberculosis screening services in the community were only provided by CHWs in 67.3% of instances. Although CHWs were adequately trained and motivated; the lack of transport, limited availability of outreach team leaders (OTLs) and poor security limited implementation of TB screening services in the community. Comparison between both districts revealed TB screening was limited by lack of transport in the rural district and poor security in the urban context. Community engagement provided a platform for improving acceptability.

CONCLUSION

 Community-based TB screening was limited. Inadequate coordination of services between stakeholders in the community has limited reach. Further research should describe that coordinating resource allocation and community empowerment could improve the implementation of active surveillance for TB.Contribution: This study highlights the views of TB room HCWs who believe the opportunity for community-level TB screening is improved with effective leadership and community engagement for acceptability of these services.

An overview and visual analysis of research on government regulation in healthcare

Objective

During the period of COVID-19, government regulation (GR) played an important role in healthcare. This study examines the current research situation of GR in healthcare, discusses the research hotspots, the most productive authors and countries, and the most common journals, and analyzes the changes in GR in healthcare before and after the outbreak of COVID-19.

Methods

This study followed PRISMA guidelines to collect literature on GR in healthcare. And the VOSviewer software was used to perform a quantitative analysis of these documents to obtain a visual map, including year, country, institution, journal, author, and research topic.

Results

A total of 1,830 papers that involved 976 academic journals, 3,178 institutions, and 133 countries were identified from 1985 to 2023. The United States was the country with the highest production (n = 613), followed by the United Kingdom (n = 289). The institution with the largest number of publications was the University of London in the UK (n = 103); In the author collaboration network, the biggest cluster is Bomhoff M, Bouwman R, Friele R, et al. The top five journals in terms of the number of articles were BMC Health Services Research (n = 70), Plos One (n = 35), Health Policy (n = 33), Social Science & Medicine (n = 29), Health Policy and Planning (n = 29), and Frontiers in Public Health (n = 27). The existing literature mainly focused on "health policy," "public health," "China," "mental health," "India," "qualitative research," "legislation," and "governance," et al. Since 2020, research on "COVID-19" has also become a priority in the domain of healthcare.

Conclusion

This study reveals the overall performance of the literature on GR published in healthcare. Healthcare needs GR, especially in response to the COVID-19 epidemic, which has played an irreplaceable role. The outbreak of COVID-19 not only tested the health systems of various countries, but also changed GR in healthcare. With the end of COVID-19, whether these changes will end remains to be further studied.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Primary healthcare delivery models in African conflict-affected settings: a systematic review

BACKGROUND

In conflict-affected settings, access to primary healthcare for displaced populations is constrained by multiple challenges. These include geographical, cultural, communication, logistical and financial barriers, as well as risks posed to health workers and the population by insecurity. Different models of care are used to provide primary healthcare to affected communities. However, there is a paucity of evidence on how these models are selected and implemented by organisations working in conflict and displacement-affected settings. Our aim was to explore the different primary healthcare delivery models used in conflict-affected settings to understand gaps in existing healthcare delivery models.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The review protocol was registered with the International Prospective Register of Systematic Reviews. We searched six databases for manuscripts published from January 1992 to December 2020. Publications were included if they reported primary healthcare models of care in conflict-affected settings of Africa. Data was analyzed descriptively and thematically using tables, charts and text.

RESULTS

Forty-eight primary research articles were included for analysis from which thirty-three were rated as "high" quality. The results showed that the models of care in place in these conflict-affected settings include health facility-based, community-based, mobile clinics, outreach and home visits. Primary healthcare for internally displaced persons and refugees is provided by a wide range of actors including national and international organisations. A range of services is offered, most commonly nutrition, mental health and sexual/reproductive health. Some organisations offer vertical (stand-alone) services, while others use an integrated service delivery model. Multiple cadres of healthcare workers provide services, frequently lay healthcare workers such as Community Health Workers.

CONCLUSION

Understanding the different modalities of primary healthcare delivery in conflict-affected settings is important to identify existing practices and gaps in service delivery. Service delivery using community health workers in conflict-affected settings is a low-cost primary care delivery strategy that may help optimize contributions of existing personnel through task shifting.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Realising radical potential: building community power in primary health care through Participatory Action Research

BACKGROUND

While community participation is an established pro-equity approach in Primary Health Care (PHC), it can take many forms, and the central category of power is under-theorised. The objectives were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance to support participation as a sustainable PHC component.

METHODS

Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by community stakeholders, who generated new data and evidence with researchers. Dialogue was then initiated between communities and the authorities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical, local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks.

RESULTS

Co-constructing evidence among community stakeholders in safe spaces for dialogue and cooperative action-learning built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptations. The process was subsequently scaled across the sub-district.

CONCLUSIONS

Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process, creating spaces where people could produce and use evidence to make decisions. Impacts were seen in demand for implementation outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts, and (3) developing and sustaining authentic learning spaces.

Governance of community health worker programs in a decentralized health system: a qualitative study in the Philippines

Background

Community health worker (CHW) programs are an important resource in the implementation of universal health coverage (UHC) in many low- and middle-income countries (LMICs). However, in countries with decentralized health systems like the Philippines, the quality and effectiveness of CHW programs may differ across settings due to variations in resource allocation and local politics. In the context of health system decentralization and the push toward UHC in the Philippines, the objective of this study was to explore how the experiences of CHWs across different settings were shaped by the governance and administration of CHW programs.

Methods

We conducted 85 semi-structured interviews with CHWs (n = 74) and CHW administrators (n = 11) in six cities across two provinces (Negros Occidental and Negros Oriental) in the Philippines. Thematic analysis was used to analyze the qualitative data with specific attention to how the experiences of participants differed within and across geographic settings.

Results

Health system decentralization contributed to a number of variations across settings including differences in the quality of human resources and the amount of financial resources allocated to CHW programs. In addition, the quality and provider of CHW training differed across settings, with implications for the capacity of CHWs to address specific health needs in their community. Local politics influenced the governance of CHW programs, with CHWs often feeling pressure to align themselves politically with local leaders in order to maintain their employment.

Conclusions

The functioning of CHW programs can be challenged by health system decentralization through the uneven operationalization of national health priorities at the local level. Building capacity within local governments to adequately resource CHWs and CHW programs will enhance the potential of these programs to act as a bridge between the local health needs of communities and the public health system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06452-x.

Significant inefficiency in running community health systems: The case of health posts in Southwest Ethiopia

Background

Although much has been documented about the performance of the health extension program, there is a lack of information on how efficiently the program is running. Furthermore, the rising cost of health services and the absence of competition among publicly owned health facilities demands strong follow up of efficiency. Therefore, this study aimed to assess the technical efficiency of the health posts and determinants in Southwestern Ethiopia.

Methods and materials

We used data for one Ethiopian fiscal year (from July 2016 to June 2017) to estimate the technical efficiency of health posts. A total of 66 health posts were included in the analysis. We employed a two-stage data envelopment analysis to estimate technical efficiency. At the first stage, technical efficiency scores were calculated using data envelopment analysis program version 2.1. Predictors of technical efficiency were then identified at the second stage using Tobit regression, with STATA version 14.

Results

The findings revealed that 21.2% were technically efficient with a mean technical efficiency score of 0.6 (± 0.3), indicating that health posts could increase their service volume by 36% with no change made to the inputs they received. On the other hand, health posts had an average scale efficiency score of 0.8 (± 0.2) implying that the facilities have the potential to increase service volume by 16% with the existing resources. The regression model has indicated average waiting time for service has negatively affected technical efficiency.

Conclusion

More than three-quarters of health posts were found inefficient. The technical efficiency score of more than one-third of the health posts is even less than 50%. Community mobilization to enhance the uptake of health services at the health posts coupled with a possible reallocation of resources in less efficient health posts is a possible approach to improve the efficiency of the program.

An analysis of the services provided by community health workers within an urban district in South Africa: a key contribution towards universal access to care

INTRODUCTION

Community health worker teams are potential game-changers in ensuring access to care in vulnerable communities. Who are they? What do they actually do? Can they help South Africa realize universal health coverage? As the proactive arm of the health services, community health workers teams provide household and community education, early screening, tracing and referrals for a range of health and social services. There is little local or global evidence on the household services provided by such teams, beyond specific disease-oriented activities such as for HIV and TB. This paper seeks to address this gap.

METHODS

Descriptive secondary data analysis of community health worker team activities in the Ekurhuleni health district, South Africa covering approximately 280,000 households with 1 million people.

RESULTS

Study findings illustrated that community health workers in these teams provided early screening and referrals for pregnant women and children under five. They distributed condoms and chronic medication to homes. They screened and referred for hypertension, diabetes mellitus, HIV and TB. The teams also undertook defaulter and contact tracing, the majority of which was for HIV and TB clients. Psychosocial support provided was in the form of access to social grants, access to child and gender-based violence protection services, food parcels and other services.

CONCLUSION

Community health workers form the core of these teams and perform several health and psychosocial services in households and poor communities in South Africa, in addition to general health education. The teams studied provided a range of activities across many health conditions (mother and child related, HIV and TB, non-communicable diseases), as well as social services. These teams provided comprehensive care in a large-scale urban setting and can improve access to care.

Understanding perceived access barriers to contraception through an African feminist lens: a qualitative study in Uganda

BACKGROUND

There are many barriers that impact a woman's access to contraception in rural sub-Saharan Africa, such as financial constraints, supply shortages, stigma, and misconceptions. Through and African Feminist lens, this study examines how these perceived barriers intersect with each other, and how they negatively impact women's access to family planning and their perceived value of contraceptives in Luweero, Uganda.

METHODS

This qualitative study analyzed data collected from healthcare workers at one private clinic and one public clinic that offer family planning services in four focus group discussions in Luweero, Central Region, Uganda. Two focus group discussions were held in each clinic. Eligible participants spoke English, were at least 18 years of age, and had at least 3 years of experience as a healthcare worker in Luweero. Among the participants were nurses, midwives, family planning counsellors, and village health workers, both male and female. Coded transcripts were analyzed using a reflexive methodology through an African Feminist lens.

RESULTS

Most of the responses indicated that financial constraints experienced either by the clinic or the women significantly impact access to family planning. Certain social barriers were discussed, and the participants explained that barriers such as stigma, misconceptions, lack of knowledge, religiosity and cultural values impact women's motivation or ability to access contraceptive methods. Side effects also have a significant role to play in women's ability or motivation to navigate through these perceived social barriers.

CONCLUSIONS

Participants determined that increased funding for transportation for village health teams, consistent funding for free contraception, and expanded sensitization efforts that particularly target men would be some of the most impactful methods they can adapt to address some of these barriers.

The roles, responsibilities and perceptions of community health workers and ward-based primary health care outreach teams: a scoping review

BACKGROUND

Community health workers play important roles in rural primary health care settings. They work within ward-based primary health care outreach teams yet their roles are not always clearly defined and operationalized. There is thus a need to explore perceptions about the roles and responsibilities of community health workers.

OBJECTIVE

To investigate the roles, responsibilities and effectiveness of community health workers working within ward-based primary health care outreach teams.

METHOD

A scoping review of the published peer reviewed literature on community health workers working in ward-based primary health care outreach teams within low and middle-income countries was conducted. The following five electronic databases were searched: EBSCOhost, Google Scholar, Science Direct, EMBASE, PubMed, and Clinical key. Out of 69,969 identified articles, 31 met the inclusion criteria. The majority of the studies were from South Africa.

RESULTS

Both positive and negative perceptions were reported. Suggestions for improvements were also put forward. Positive factors included: ongoing training and up skilling; collaboration and trust building with other health care workers; mentoring and supervision; motivation and recognition, and incentives and remuneration. Negative factors covered: inadequate mentorship and poor supervision; role conflict; lack of support; poor remuneration; inadequate manpower; poor knowledge, and insufficient training. The review identified the following as the roles and responsibilities of community health workers: conducting home visits; identifying vulnerable community groups; promoting health and wellness; increasing access to health care; contact tracing; delivering health education; giving counselling and psychosocial support, and providing preventive health services.

CONCLUSION

The information available for community health workers in terms of their roles, responsibilities and effectiveness is inadequate, considering their roles and responsibilities in ward-based primary health care outreach teams. This lack of information constitutes barriers to effective service delivery, a common situation among this group of community health workers.

How Can One Strengthen a Tiered Healthcare System through Health System Reform? Lessons Learnt from Beijing, China

How one can reshape the current healthcare sector into a tiered healthcare system with clarified division of functions between primary care facilities and hospitals, and improve the utilization of primary care, is a worldwide problem, especially for the low and middle-income countries (LMICs). This paper aimed to evaluate the impact of the Beijing Reform on healthcare-seeking behavior and tried to explain the mechanism of the change of patient flow. In this before and after study, we evaluated the changes of outpatient visits and inpatient visits among different levels of health facilities. Using the monitored and statistical data of 373 healthcare institutions 1-year before and 1-year after the Beijing Reform, interrupted time series analysis was applied to evaluate the impact of the reform on healthcare-seeking behavior. Semi-structured interviews were used to further explore the mechanisms of the changes. One year after the reform, the flow of outpatients changed from tertiary hospitals to community health centers with an 11.90% decrease of outpatients in tertiary hospitals compared to a 15.01% increase in primary healthcare facilities. The number of ambulatory care visits in primary healthcare (PHC) showed a significant upward trend (P < 0.10), and the reform had a significant impact on the average number of ambulatory care visits per institution in Beijing's tertiary hospitals (p < 0.10). We concluded that the Beijing Reform has attracted a substantial number of ambulatory care visits from hospitals to primary healthcare facilities in the short-term. Comprehensive reform policies were necessary to align incentives among relative stakeholders, which was a critical lesson for other provinces in China and other LMICs.

Implementing active surveillance for TB-The views of managers in a resource limited setting, South Africa

BACKGROUND

The achievement of the World Health Organization's END TB goals will depend on the successful implementation of strategies for early diagnosis and retention of patients on effective therapy until cure. An estimated 150,000 cases are missed annually in South Africa. It is necessary to look at means for identifying these missed cases. This requires the implementation of active surveillance for TB, a policy adopted by the National Department of Health.

AIM

To explore the views of managers of the TB program on the implementation of active surveillance for TB in the resource constrained setting of the Eastern Cape, South Africa.

METHODS

A descriptive, explorative, thematically analysed qualitative study based on 10 semi-structured interviews of managers of the TB program. Interviews were transcribed verbatim and analysed using the framework method and Atlas-ti.

RESULTS

Active case finding of people attending health facilities was the dominant approach, although screening by community health workers (CHWs) was available. Both government and non-government organisations employed CHWs to screen door to door and sometimes as part of campaigns or community events. Some CHWs focused only on contact tracing or people that were non-adherent to TB treatment. Challenges for CHWs included poor coordination and duplication of services, failure to investigate those identified in the community, lack of transport and supportive supervision as well as security issues. Successes included expanding coverage by government CHW teams, innovations to improve screening, strategies to improve CHW capability and attention to social determinants.

CONCLUSION

A multifaceted facility- and community-based approach was seen as ideal for active surveillance. More resources should be targeted at strengthening teams of CHWs, for whom this would be part of a comprehensive and integrated service in a community-orientated primary care framework, and community engagement to strengthen community level interventions.

Understanding efficiency and the effect of pay-for-performance across health facilities in Tanzania

BACKGROUND

Ensuring efficient use and allocation of limited resources is crucial to achieving the UHC goal. Performance-based financing that provides financial incentives for health providers reaching predefined targets would be expected to enhance technical efficiency across facilities by promoting an output-oriented payment system. However, there is no study which has systematically assessed efficiency scores across facilities before and after the introduction of pay-for-performance (P4P). This paper seeks to fill this knowledge gap.

METHODS

We used data of P4P evaluation related to healthcare inputs (staff, equipment, medicines) and outputs (outpatient consultations and institutional deliveries) from 75 health facilities implementing P4P in Pwani region, and 75 from comparison districts in Tanzania. We measured technical efficiency using Data Envelopment Analysis and obtained efficiency scores across facilities before and after P4P scheme. We analysed which factors influence technical efficiency by regressing the efficiency scores over a number of contextual factors. We also tested the impact of P4P on efficiency through a difference-in-differences regression analysis.

RESULTS

The overall technical efficiency scores ranged between 0.40 and 0.65 for hospitals and health centres, and around 0.20 for dispensaries. Only 21% of hospitals and health centres were efficient when outpatient consultations and deliveries were considered as output, and <3% out of all facilities were efficient when outpatient consultations only were considered as outputs. Higher efficiency scores were significantly associated with the level of care (hospital and health centre) and wealthier catchment populations. Despite no evidence of P4P effect on efficiency on average, P4P might have improved efficiency marginally among public facilities.

CONCLUSION

Most facilities were not operating at their full capacity indicating potential for improving resource usage. A better understanding of the production process at the facility level and of how different healthcare financing reforms affects efficiency is needed. Effective reforms should improve inputs, outputs but also efficiency.

Peer Mentorship via Mobile Phones for Newly Diagnosed HIV-Positive Youths in Clinic Care in Khayelitsha, South Africa: Mixed Methods Study

BACKGROUND

Youths in South Africa are poor utilizers of HIV health services. Medecins Sans Frontieres has been piloting youth-adapted services at a youth clinic in Khayelitsha, including a peer virtual mentorship program over mobile phones, piloted from March 2015 to May 2016.

OBJECTIVE

The objective of this study was to evaluate the effect of the peer mentorship program on youth engagement with HIV services and explore the acceptability of the program to both mentors and mentees.

METHODS

Antiretroviral initiation, retention in care (RIC), and viral load suppression were compared between youths engaged in the virtual mentorship program and two matched controls. In-depth interviews were also conducted for 5 mentors and 5 mentees to explore acceptability and impact of the program.

RESULTS

A total of 40 youths were recruited into the virtual mentorship program over the study period. Of these, data were obtained for 35 and 2 matched controls were randomly sampled for each. There was no difference in baseline demographics (eg, age, gender, and CD4 count). Mentees had increased antiretroviral initiation (28/35, 80% vs 30/70, 42% in matched controls) and viral load completion (28/35, 80% vs 32/70, 45%); however, no differences were found in viral load suppression or RIC at 6 or 12 months. Mentors reported being motivated to participate in the program because of previous personal struggles with HIV and a desire to help their peers. Mentees reported fears of disclosure and lack of acceptance of their status as barrier to accessing services, but they felt free to talk to their mentors, valued the mentorship program, and indicated a preference for phone calls.

CONCLUSIONS

Peer mentorship in youths is acceptable to both mentors and mentees and appears to increase linkage to care and viral load completion rates.

Realities and experiences of community health volunteers as agents for behaviour change: evidence from an informal urban settlement in Kisumu, Kenya

BACKGROUND

Community health workers play an important role in health service delivery and are increasingly involved in behaviour change interventions, including for hygiene-related behaviour change. However, their role and capacity to deliver behaviour change interventions, particularly in high-density urban settlements, remain under-researched. This study examines the behaviour change-related activities of community health volunteers (CHVs)-community health workers affiliated with the Kenyan Ministry of Health-in a peri-urban settlement in Kenya, in order to assess their capabilities, opportunities to work effectively, and sources of motivation.

METHODS

This mixed-methods study included a census of 16 CHVs who work in the study area. All CHVs participated in structured observations of their daily duties, structured questionnaires, in-depth interviews, and two focus group discussions. Structured data were analysed descriptively. Thematic content analysis was followed for qualitative data. Results were synthesized and interpreted using the capability, opportunity, motivation for behaviour change framework, COM-B.

RESULTS

In addition to their responsibilities with the Ministry of Health, CHVs partnered with a range of non-governmental organizations engaged in health and development programming, often receiving small stipends from these organizations. CHVs reported employing a limited number of behaviour change techniques when interacting with community members at the household level. Capability: While supervision and support from the MOH was robust, CHV training was inconsistent and inadequate with regard to behaviour change and CHVs often lacked material resources necessary for their work. Opportunity: CHVs spent very little time with the households in their allocated catchment area. The number of households contacted per day was insufficient to reach all assigned households within a given month as required and the brief time spent with households limited the quality of engagement.

MOTIVATION

Lack of compensation was noted as a demotivating factor for CHVs. This was compounded by the challenging social environment and CHVs' low motivation to encourage behaviour change in local communities.

CONCLUSIONS

In a complex urban environment, CHVs faced challenges that limited their capacity to be involved in behaviour change interventions. More resources, better coordination, and additional training in modern behaviour change approaches are needed to ensure their optimal performance in implementing health programmes.

Detection, referral and control of diabetes and hypertension in the rural Eastern Cape Province of South Africa by community health outreach workers in the rural primary healthcare project: Health in Every Hut

BACKGROUND

 Non-communicable diseases, mainly cardiovascular diseases, diabetes, cancer and chronic respiratory diseases, are responsible for approximately 63% of all deaths occurring worldwide in any given year. The majority of these deaths have occurred in low- and middle-income countries (LMICs). The latest World Health Organization (WHO) report shows that the increase in diabetes is also most pronounced in the LMICs. The South African Labour and Development Research Unit estimated a 9% prevalence within the adult population in 2016. In the Eastern Cape Province, hypertensive heart disease has become the second most common cause of death, followed by diabetes, the third most common cause of death.Aim and setting: The aim of this study was to report on the follow-up of patients in the community with known hypertension or diabetes or who were deemed at-risk (as identified during a prior community-wide survey).

METHODS

 Data were collected via a household primary health screening, monitoring and follow-up process, which included taking anthropometric measurements, blood pressure (BP) and blood glucose and referring to clinics for further testing and treatment where necessary.

RESULTS

 Of the 1885 participants followed up by the community health outreach workers, 1702 were known to be hypertensive and 183 were deemed at-risk [of these, only 24 (13.2%) had normal or high normal systolic BP readings]. There were 341 participants with diabetes and 34 at-risk of diabetes [of these, 28 (82%) had levels of 11 mmol/l or higher at follow-up]. There was a significant improvement in BP and glucose control over repeated visits.

CONCLUSION

 In this rural area of the Eastern Cape, South Africa, the follow-up of patients with hypertension or diabetes as well as those individuals at-risk adds value to hypertension and glucose control.

Exploring the care provided to mothers and children by community health workers in South Africa: missed opportunities to provide comprehensive care

BACKGROUND

Community health workers (CHWs) provide maternal and child health services to communities in many low and middle-income countries, including South Africa (SA). CHWs can improve access to important health interventions for isolated and vulnerable communities. In this study we explored the performance of CHWs providing maternal and child health services at household level and the quality of the CHW-mother interaction.

METHODS

A qualitative study design was employed using observations and in-depth interviews to explore the content of household interactions, and experiences and perceptions of mothers and CHWs. Fifteen CHWs and 30 mothers/pregnant women were purposively selected in three rural districts of KwaZulu-Natal, SA. CHW household visits to mothers were observed and field notes taken, followed by in-depth interviews with mothers and CHWs. Observations and interviews were audio-recorded. We performed thematic analysis on transcribed discussions, and content analysis on observational data.

RESULTS

CHWs provided appropriate and correct health information but there were important gaps in the content provided. Mothers expressed satisfaction with CHW visits and appreciation that CHWs understood their life experiences and therefore provided advice and support that was relevant and accessible. CHWs expressed concern that they did not have the knowledge required to undertake all activities in the household, and requested training and support from supervisors during household visits.

CONCLUSIONS

Key building blocks for a successful CHW programme are in place to provide services for mothers and children in households but further training and supervision is required if the gaps in CHW knowledge and skills are to be filled.

Community health worker perspectives on a new primary health care initiative in the Eastern Cape of South Africa

BACKGROUND

In 2010, South Africa's National Department of Health launched a national primary health care (PHC) initiative to strengthen health promotion, disease prevention, and early disease detection. The strategy, called Re-engineering Primary Health Care (rPHC), aims to provide a preventive and health-promoting community-based PHC model. A key component of rPHC is the use of community-based outreach teams staffed by generalist community health workers (CHWs).

METHODS

We conducted focus group discussions and surveys on the knowledge and attitudes of 91 CHWs working on community-based rPHC teams in the King Sabata Dalindyebo (KSD) sub-district of Eastern Cape Province.

RESULTS

The CHWs we studied enjoyed their work and found it meaningful, as they saw themselves as agents of change. They also perceived weaknesses in the implementation of outreach team oversight, and desired field-based training and more supervision in the community.

CONCLUSIONS

There is a need to provide CHWs with basic resources like equipment, supplies and transport to improve their acceptability and credibility to the communities they serve.

Who bears the cost of 'informal mhealth'? Health-workers' mobile phone practices and associated political-moral economies of care in Ghana and Malawi

Africa's recent communications 'revolution' has generated optimism that using mobile phones for health (mhealth) can help bridge healthcare gaps, particularly for rural, hard-to-reach populations. However, while scale-up of mhealth pilots remains limited, health-workers across the continent possess mobile phones. This article draws on interviews from Ghana and Malawi to ask whether/how health-workers are using their phones informally and with what consequences. Health-workers were found to use personal mobile phones for a wide range of purposes: obtaining help in emergencies; communicating with patients/colleagues; facilitating community-based care, patient monitoring and medication adherence; obtaining clinical advice/information and managing logistics. However, the costs were being borne by the health-workers themselves, particularly by those at the lower echelons, in rural communities, often on minimal stipends/salaries, who are required to 'care' even at substantial personal cost. Although there is significant potential for 'informal mhealth' to improve (rural) healthcare, there is a risk that the associated moral and political economies of care will reinforce existing socioeconomic and geographic inequalities.

From Community Health Workers to Community Health Systems: Time to Widen the Horizon?

-Community health workers (CHWs) have reemerged as significant cadres in low- and middle-income countries and are now seen as an integral part of achieving the goal of universal health coverage (UHC). In international guidance and support, the emphasis is increasingly shifting from a focus on the outcomes of CHW-based interventions to the systems requirements for implementing and sustaining CHW programs at scale. A major challenge is that CHW programs interface with both the formal health system (requiring integration) and community systems (requiring embedding) in context-specific and complex ways. Collectively, these elements and relationships can be seen as constituting a unique sub-system of the overall health system, referred to by some as the community health system. The community health system is key to the performance of CHW programs, and we argue for a more holistic focus on this system in policy and practice. We further propose a definition and spell out the main actors and attributes of the community health system and conclude that in international debates on UHC, much can be gained from recognizing the community health system as a definable sphere in its own right.

"It is always HIV/AIDS and TB": Home-based carers' perspectives on epilepsy in Cape Town, South Africa

The study highlights the complex cultural religious factors affecting epilepsy and a need for integrated home-based care services. Two focus group discussions exploring home-based carers’ (HBCs) perspectives on epilepsy were conducted using a semi-structured focus group interview guide, which was based on Kleinman's explanatory model framework. The audio-recorded data were transcribed verbatim, and a thematic analysis was done. The three main themes were epilepsy names and metaphors, religious beliefs about the cause and treatment of epilepsy, and HBCs’ perceived roles and strategies for engaging in epilepsy care. Findings provide some insights for research, policy, and practice.

Linkages between public and non-government sectors in healthcare: A case study from Uttar Pradesh, India

Effective utilisation of collaborative non-governmental organisation (NGO)-public health system linkages in pluralistic health systems of developing countries can substantially improve equity and quality of services. This study explores level and types of linkages between public health sector and NGOs in Uttar Pradesh (UP), an underprivileged state of India, using a social science model for the first time. It also identifies gaps and challenges for effective linkage. Two NGOs were selected as case studies. Data collection included semi-structured in-depth interviews with senior staff and review of records and reporting formats. Formal linkages of NGOs with the public health system related to registration, participation in district level meetings, workforce linkages and sharing information on government-supported programmes. Challenges included limited data sharing, participation in planning and limited monitoring of regulatory compliances. Linkage between public health system and NGOs in UP was moderate, marked by frequent interaction and some reciprocity in information and resource flows, but weak participation in policy and planning. The type of linkage could be described as 'complementarity', entailing information and resource sharing but not joint action. Stronger linkage is required for sustained and systematic collaboration, with joint planning, implementation and evaluation.

HIV Prevention in Resource Limited Settings: A Case Study of Challenges and Opportunities for Implementation

BACKGROUND

Sub-Saharan Africa has the highest global prevalence of HIV, and the prevention of transmission between HIV-seropositive and -serodiscordant sexual partners is a critical component of HIV prevention efforts. Behavioral interventions that have demonstrated efficacy in reducing risk behaviors associated with HIV transmission and infection and have been translated, or adapted, to a variety of settings.

PURPOSE

This manuscript examined implementation of behavioral interventions within resource limited health care delivery settings, and their adoption and integration within service programs to achieve sustainability.

METHODS

The CDC/Partner Program, an evidence-based risk reduction intervention, was implemented in Community Health Centers (CHCs) in Zambia using a staged technology transfer process, the Training the Trainers Model. Provincial workshops and training workshops on the provision of the intervention were used to establish a cadre of trainers to provide on-site intervention facilitators capable of ultimately providing coverage to over 300 CHCs.

RESULTS

CHC staff provided the intervention to clinic attendees in four provinces over 4 years while also training new facilitators. The implementation process addressed multi-level issues within the context of training, consultants, decision making, administration, and evaluation as well as practical considerations surrounding travel, training, staff compensation and ongoing quality assurance.

CONCLUSIONS

The majority of challenges to implementation and maintenance were addressed and resolved, with the exception of structural limitations related to restricted resources for personnel and funding. Strengths of the program included its collaborative structure, active program leadership, commitment and support at the provincial level, the use of task shifting by existing clinic staff, the train the trainer model and ongoing quality control. Enhanced infrastructure is needed in for future implementation, such as training centers within each province, certified expert coaches and annual workshops and system changes to ensure available staff.

How supportive supervision influences immunization session site practices: a quasi-experimental study in Odisha, India

BACKGROUND

Routine immunization (RI) is a key child survival intervention. Ensuring acceptable standards of RI service delivery is critical for optimal outcomes. Accumulated evidences suggest that 'supportive supervision' improves the quality of health care services in general. During 2009-2010, the Government of Odisha and UNICEF jointly piloted this strategy in four districts to improve RI program outcomes. The present study aims to assess the effect of this strategy on improvement of skills and practices at immunization session sites.

DESIGN

A quasi-experimental 'post-test only' study design was adopted to compare the opinion and practices of frontline health workers and their supervisors in four intervention districts (IDs) with two control districts (CDs). Altogether, we interviewed 111 supervisor-supervisee (health worker) pairs using semi-structured interview schedules and case vignettes. We also directly observed health workers' practices during immunization sessions at 111 sites. Data were analyzed with SPSS version 16.0.

RESULTS

The mean knowledge score of supervisors in CDs was significantly higher than in intervention groups. Variegated responses were obtained on case vignettes. The control group performed better in solving certain hypothetically asked problems, whereas the intervention group scored better in others. Health workers in IDs gave a lower rating to their respective supervisors' knowledge, skill, and frequency of supervision. Logistics and vaccine availability were better in CDs.

CONCLUSION

Notwithstanding other limitations, supportive supervision may not have independent effects on improving the quality of immunization services. Addressing systemic issues, such as the availability of essential logistics, supply chain management, timely indenting, and financial resources, could complement the supportive supervision strategy in improving immunization service delivery.

Reactions of community members regarding community health workers' activities as a measure of the impact of a training program in Amazonas, Brazil

Objectives: The aim of this study was to evaluate the impact of community health worker (CHW) training on recognition and satisfaction regarding the performance of CHWs among members of the community in Amazonas, Brazil, which is a resource-poor area underserved with regard to medical health-care accessibility.

Methods: Baseline and endline surveys concerning recognition and satisfaction with respect to CHW performance among members of the community were conducted by interview using a questionnaire before and after implementation of a program to strengthen community health projects in Manicoré, Amazonas, Brazil. One of the components of the project was CHW refresher training, which focused on facilitating adequate use of health-care services and providing primary health care, including health guidance. The baseline survey was performed in February 2004 at the beginning of the project, and the endline survey was performed in February 2006 at the end of the project. There were 82 and 120 CHWs working in Manicoré at the times of the baseline and endline surveys, respectively. Statistical analysis was performed to determine the significance of changes in experience with CHW activities, expected functions of CHWs, and satisfaction regarding the performance of CHWs between the baseline and endline surveys. In addition, qualitative analysis was conducted to evaluate the acceptability, feasibility, and sustainability of CHW refresher training.

Results: Overall recognition and level of satisfaction regarding CHW performance among members of the community were improved from the baseline to the endline survey, regardless of type of residential area, such as town and/or remote area. Members of the community came to not expect CHWs to “provide strong medicine” (P < 0.001) and “provide injections” (P < 0.001), and came to appreciate “go to hospital with a sick person” (P = 0.031) as a function and role of CHWs.

Conclusions: The results of the present study indicated that steady approaches to motivate and support CHWs in resource-limited settings could improve performance of CHWs and satisfaction of people in the community regarding the activities of CHWs to sustain their health.

Head Start's impact is contingent on alternative type of care in comparison group

Using data (n = 3,790 with 2,119 in the 3-year-old cohort and 1,671 in the 4-year-old cohort) from 353 Head Start centers in the Head Start Impact Study, the only large-scale randomized experiment in Head Start history, this article examined the impact of Head Start on children's cognitive and parent-reported social-behavioral outcomes through first grade contingent on the child care arrangements used by children who were randomly assigned to the control group (i.e., parental care, relative/non-relative care, another Head Start program, or other center-based care). A principal score matching approach was adopted to identify children assigned to Head Start who were similar to children in the control group with a specific care arrangement. Overall, the results showed that the effects of Head Start varied substantially contingent on the alternative child care arrangements. Compared with children in parental care and relative/non-relative care, Head Start participants generally had better cognitive and parent-reported behavioral development, with some benefits of Head Start persisting through first grade; in contrast, few differences were found between Head Start and other center-based care. The results have implications regarding the children for whom Head Start is most beneficial as well as how well Head Start compares with other center-based programs.

Implementation of HIV prevention interventions in resource limited settings: the partner project

Evidence-based HIV prevention interventions have been translated to a variety of contexts across sub-Saharan Africa. Non-specialized community health center (CHC) staff members have been successfully engaged to deliver the interventions, which can be integrated into pre-existing HIV service programs in community-based health care delivery sites. This manuscript describes the process of implementing the Partner Project, a couples HIV risk reduction intervention, and examines the ability of CHC staff to achieve risk reduction outcomes comparable to those of the highly-trained research staff. The Partner Project was implemented within the HIV Counseling and Testing program in 6 urban community health clinics in Lusaka, Zambia. One hundred ninety-seven HIV-seroconcordant and -discordant couples were sequentially enrolled to the control group or to receive the intervention from partner research or CHC staff members. Couple members completed assessments on condom use, alcohol use, and intimate partner violence (IPV) at baseline, 6, and 12 months follow-up. Sexual barrier use outcomes achieved by the CHC staff were comparable to or better than those achieved by the Partner Project research staff, and both were superior to the control group. A reduction in IPV was observed for the entire sample, although no change in alcohol use was observed. Implementation of HIV prevention interventions at the community level should take advantage of existing resources available within the CHC staff. This is especially relevant in resource limited settings as consideration of the financial and clinical requirements of intervention programs is essential to the achievement of successful program implementation.

Translation and sustainability of an HIV prevention intervention in Lusaka, Zambia

The scale-up of HIV treatment programs in sub-Saharan Africa necessitates creative solutions that do not further burden the health system to meet global initiatives in prevention and care. This study assessed the work environment and impact of providing a behavioral risk reduction intervention in six community health centers (CHCs) in Lusaka, Zambia; opportunities and challenges to long-term program sustainability were identified. CHC staff participants (n = 82) were assessed on perceived clinic burden, job satisfaction, and burnout before and after implementation of the intervention. High levels of clinic burden were identified; however, no increase in perceived clinic burden or staff burnout was associated with providing the intervention. The intervention was sustained at the majority of CHCs and also adopted at additional clinics. Behavioral interventions can be successfully implemented and maintained in resource-poor settings. Creative strategies to overcome structural and economic challenges should be applied to enhance translation research.

Supervising community health workers in low-income countries--a review of impact and implementation issues

Background

Community health workers (CHWs) are an increasingly important component of health systems and programs. Despite the recognized role of supervision in ensuring CHWs are effective, supervision is often weak and under-supported. Little is known about what constitutes adequate supervision and how different supervision strategies influence performance, motivation, and retention.

Objective

To determine the impact of supervision strategies used in low- and middle-income countries and discuss implementation and feasibility issues with a focus on CHWs.

Design

A search of peer-reviewed, English language articles evaluating health provider supervision strategies was conducted through November 2013. Included articles evaluated the impact of supervision in low- or middle-income countries using a controlled, pre-/post- or observational design. Implementation and feasibility literature included both peer-reviewed and gray literature.

Results

A total of 22 impact papers were identified. Papers were from a range of low- and middle-income countries addressing the supervision of a variety of health care providers. We classified interventions as testing supervision frequency, the supportive/facilitative supervision package, supervision mode (peer, group, and community), tools (self-assessment and checklists), focus (quality assurance/problem solving), and training. Outcomes included coverage, performance, and perception of quality but were not uniform across studies. Evidence suggests that improving supervision quality has a greater impact than increasing frequency of supervision alone. Supportive supervision packages, community monitoring, and quality improvement/problem-solving approaches show the most promise; however, evaluation of all strategies was weak.

Conclusion

Few supervision strategies have been rigorously tested and data on CHW supervision is particularly sparse. This review highlights the diversity of supervision approaches that policy makers have to choose from and, while choices should be context specific, our findings suggest that high-quality supervision that focuses on supportive approaches, community monitoring, and/or quality assurance/problem solving may be most effective.

Development of non-profit organisations providing health and social services in rural South Africa: a three-year longitudinal study

Introduction

In an effort to increase understanding of formation of the community and home-based care economy in South Africa, we investigated the origin and development of non-profit organisations (NPOs) providing home- and community-based care for health and social services in a remote rural area of South Africa.

Methods

Over a three-year period (2010-12), we identified and tracked all NPOs providing health care and social services in Bushbuckridge sub-district through the use of local government records, snowballing techniques, and attendance at NPO networking meetings—recording both existing and new NPOs. NPO founders and managers were interviewed in face-to-face in-depth interviews, and their organisational records were reviewed.

Results

Forty-seven NPOs were formed prior to the study period, and 14 during the study period – six in 2010, six in 2011 and two in 2012, while four ceased operation, representing a 22% growth in the number of NPOs during the study period. Histories of NPOs showed a steady rise in the NPO formation over a 20-year period, from one (1991-1995) to 12 (1996-2000), 16 (2001-2005) and 24 (2006-2010) new organisations formed in each period. Furthermore, the histories of formation revealed three predominant milestones – loose association, formal formation and finally registration. Just over one quarter (28%) of NPOs emerged from a long-standing community based programme of ‘care groups’ of women. Founders of NPOs were mostly women (62%), with either a religious motivation or a nursing background, but occasionally had an entrepreneurial profile.

Conclusion

We observed rapid growth of the NPO sector providing community based health and social services. Women dominated the rural NPO sector, which is being seen as creating occupation and employment opportunities. The implications of this growth in the NPO sector providing community based health and social services needs to be further explored and suggests the need for greater coordination and possibly regulation.

"She is my teacher and if it was not for her I would be dead": exploration of rural South African community health workers' information, education and communication activities

Community health workers (CHWs) are important resources in health systems affected by the HIV/AIDS pandemic. International guidelines on task-shifting recommend that CHWs can provide diverse HIV services, ranging from HIV prevention to counselling patients for lifelong antiretroviral therapy. There is, however, little evidence on the experiences with CHW delivery of these services in Africa. This qualitative study included 102 interviews that explored experiences with information, education and communication (IEC) activities provided by CHWs within rural South Africa. Semi-structured interviews were conducted with CHWs (n = 17), their clients (n = 33) and the primary caregivers of these clients (n = 30), allowing for data source triangulation. Twenty-two follow-up interviews explored emergent themes from preliminary interviews. Despite limited formal education and training, CHWs in this study were significant providers of IEC, including provision of generic health talks and HIV-specific information and facilitation to support clients' entry and maintenance in the formal health system. They often incorporated local knowledge and understanding of illness in their communication. CHWs in this study were able to bridge the lifeworlds of the community and the formal services to expedite access and adherence to local clinics and other services. As mediators between the two worlds, CHWs reinterpreted health information to make it comprehensible in their communities. With growing formalisation of CHW programmes in South Africa and elsewhere, CHWs' important role in health service access, health promotion and health maintenance must be recognised and supported in order to maximise impact.

Outreach services to improve access to health care in South Africa: lessons from three community health worker programmes

Introduction

In South Africa, there are renewed efforts to strengthen primary health care and community health worker (CHW) programmes. This article examines three South African CHW programmes, a small local non-governmental organisation (NGO), a local satellite of a national NGO, and a government-initiated service, that provide a range of services from home-based care, childcare, and health promotion to assist clients in overcoming poverty-related barriers to health care.

Methods

The comparative case studies, located in Eastern Cape and Gauteng, were investigated using qualitative methods. Thematic analysis was used to identify factors that constrain and enable outreach services to improve access to care.

Results

The local satellite (of a national NGO), successful in addressing multi-dimensional barriers to care, provided CHWs with continuous training focused on the social determinants of ill-health, regular context-related supervision, and resources such as travel and cell-phone allowances. These workers engaged with, and linked their clients to, agencies in a wide range of sectors. Relationships with participatory structures at community level stimulated coordinated responses from service providers. In contrast, an absence of these elements curtailed the ability of CHWs in the small NGO and government-initiated service to provide effective outreach services or to improve access to care.

Conclusion

Significant investment in resources, training, and support can enable CHWs to address barriers to care by negotiating with poorly functioning government services and community participation structures.