Scaling community-based services in Gauteng, South Africa: A comparison of three workforce-planning scenarios

Exploring the promise and reality of ward-based primary healthcare outreach teams conducting TB household contact tracing in three districts of South Africa

Background

Tuberculosis (TB) household contact tracing is a form of targeted active case-finding for which community health workers (‘outreach teams’) in South Africa are primarily responsible for its implementation. We conducted an exploratory qualitative study to understand the role of outreach teams in delivering TB household contact tracing.

Methods

The study took place in three districts of South Africa between May 2016 and February 2017. We conducted 78 in-depth interviews (IDI) (comprising 35 key stakeholders, 31 TB index patients and 12 HHCs) and five focus group discussions (FGD) (40 outreach team members in four FGDs and 12 community stakeholders in one FGD).

Results

Outreach teams contributed positively by working across health-related programmes, providing home-based care and assisting with tracing of persons lost to TB care. However, outreach teams had a limited focus on TB household contact tracing activities, likely due to the broad scope of their work and insufficient programmatic support. Outreach teams often confused TB household contact tracing activities with finding persons lost to TB care. The community also had some reservations on the role of outreach teams conducting TB household contact tracing activities.

Conclusions

Creating awareness among outreach workers and clinic personnel about the importance of and activities related to TB household contact tracing would be required to strengthen the delivery of TB household contact tracing through the community-based primary health care teams. We need better monitoring and evaluation systems, stronger integration within a realistic scope of work, adequate training on TB household contact tracing and TB infection prevention control measures. Involving the community and educating them on the role of outreach teams could improve acceptance of future activities. These timely results and lessons learned should inform contact tracing approaches in the context of COVID-19.

Modelling cost benefit of community-oriented primary care in rural South Africa

Background

Globally, rural populations have poorer health and considerably lower levels of access to healthcare compared with urban populations. Although the drive to ensure universal coverage through community healthcare worker programmes has shown significant results elsewhere, their value has yet to be realised in South Africa.

Aim

The aim of this study was to determine the potential impact, cost-effectiveness and benefit-to-cost ratio (BCR) of information and communications technology (ICT)-enabled community-oriented primary care (COPC) for rural and remote populations.

Setting

The Waterberg district of Limpopo province in South Africa is a rural mining area. The majority of 745 000 population are poor and in poor health.

Methods

The modelling considers condition-specific effectiveness, population age and characteristics, health-determined service demand, and costs of delivery and resources.

Results

Modelling showed 122 teams can deliver a full ICT-enabled COPC service package to 630 565 eligible people. Annually, at scale, it could yield 35 877 unadjusted life years saved and 994 deaths avoided at an average per capita service cost of R170.37, and R2668 per life year saved. There could be net annual savings of R120 million (R63.4m for Waterberg district) from reduced clinic (110.7m) and hospital outpatient (23 646) attendance and admissions. The service would inject R51.6m into community health worker (CHW) households and approximately R492m into district poverty reduction and economic growth.

Conclusion

With a BCR of 3.4, ICT-enabled COPC is an affordable systemic investment in universal, pro-poor, integrated healthcare and makes community-based healthcare delivery particularly compelling in rural and remote areas.

The use and value of maps in Community-Oriented Primary Care: Does process matter?

Background

Maps are important tools in healthcare delivery. In Community-Oriented Primary Care (COPC), they are expected to be used to plan services and resources for defined geographical areas, delineate team practice areas, allocate healthcare workers to households and support service delivery and performance management.

Aim

This is a study of the use and value of maps and mapmaking in the delivery of healthcare services through Ward-Based Outreach Teams (WBOTs).

Setting

This study was conducted between 2014 and 2016 in Mamelodi (South Africa), an urban settlement selected to begin the City of Tshwane’s WBOT implementation programme in 2013.

Methods

This study is based on three qualitative participatory mapmaking projects with WBOT healthcare professionals and workers. Data generated through mapmaking, focused group discussions, individual semi-structured interviews, reflective writing and feedback workshops were analysed thematically.

Results

Through mapmaking and discussions about the maps, healthcare providers took ownership of the maps they were creating or viewing, added their own information onto the maps, voiced issues about their practice, generated new knowledge and shared ideas and solutions for challenges. These processes expanded the use and value of maps beyond assisting participants to gain insights into the context, people and organisations of their places of work.

Conclusion

Maps become creative learning tools that can be used in emergent ways to solve healthcare service and other problems when they are actively generated and engaged through facilitated discussion and reflection. This allows WBOTs to see maps as dynamic canvasses that they can use to improve service delivery.