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

A systematic review of the types, workload, and supervision mechanism of community health workers: lessons learned for Indonesia

BACKGROUND

Community health workers (CHWs) have demonstrated capability to improve various health indicators, however, many programmes require support in meeting their objectives due to subpar performance and a high rate of CHW attrition. This systematic review investigated the types of CHWs, their workloads, and supervision practices that contribute to their performance in different countries.

METHODS

The search was carried out in November 2022 in Medline, Embase, and Neliti for studies published in Indonesian or English between 1986 and 2022 that reported public health services delivered by CHWs who live and serve the community where they live but are not considered health professionals. The findings were synthesised using a thematic analysis to assess key factors influencing the performance of CHWs.

RESULTS

Sixty eligible articles were included in this review. CHWs were responsible for more than two diseases (n = 35) and up to fifteen, with more than eighteen activities. Their roles covered the human life cycle, from preparation for pregnancy, care for newborns, health for children, adolescents, and productive age to elderly individuals. They were also involved in improving environmental health, community empowerment, and other social issues hindering access to health services. They carried out promotive, preventive, and curative interventions. The CHW-population ratio varied from eight to tens of thousands of people. Some CHWs did not have a clear supervision system. Challenges that were often faced by CHWs included inappropriate incentives, inadequate facilities, insufficient mentoring, and supervision, many roles, and a broad catchment area. Many studies revealed that CHWs felt overburdened and stressed. They needed help to balance their significant work and domestic tasks.

CONCLUSIONS

Effective planning that considered the scope of work of CHWs in proportion to their responsibilities and the provision of necessary facilities were crucial factors in improving the performance of CHWs. Supportive supervision and peer-supervision methods are promising, however, any CHW supervision required a detailed protocol. This systematic review emphasised the opportunity for CHW management system improvement in Indonesia.

Community health workers' experiences of supervision by nurses at clinics in Limpopo Province

Background

Supervision of community health workers (CHWs) is considered, among others, a strategy to achieve universal healthcare globally. In South Africa, it is incorporated in the ward-based primary healthcare (PHC) outreach teams' policy and strategy, a national health insurance policy component. Supervision of CHWs by nurses in the policy is considered a measure to facilitate PHC service provision to communities. However, CHWs experienced varying levels of supervision from nurses and other workers globally and in South Africa.

Aim

This study explored and described the experiences of CHWs about supervision received from nurses at PHC facilities in Limpopo Province.

Setting

Participants were drawn from seven PHC facilities in Polokwane and Lepelle-Nkumpi subdistricts of the Capricorn District.

Methods

A qualitative exploratory-descriptive and contextual study design was employed. Participants were selected utilising a purposive sampling method. Semi-structured interviews were conducted to collect data. Data were analysed according to themes and their associated categories. Measures to ensure rigour and ethical principles were applied.

Results

Two main themes emerged: positive supervision experienced by CHWs and supervision challenges experienced by CHWs.

Conclusion

The varying experiences of CHWs about supervision from nurses emerged and reflected the need for functioning supervision mechanisms.

Contribution

The experiences of CHWs indicated inconsistent delivery of supervision by nurses in PHC facilities. The findings highlighted the need for effective supervision measures that are vital for the success of the CHW supervision programme.

Making progress in early-career publishing: evolutions of the women's publication mentorship programme

Mentorship is vital for early-career researchers, especially women from low- and middle-income countries seeking to publish their work. This paper explores the evolution of the Women's Publication Mentorship Programme, a collaborative initiative pioneered by the Alliance for Health Policy and Systems Research, further strengthened through the partnership of Health Systems Global, and Health Policy and Planning. Over a span of five years and encompassing three cohorts, the program supported 45 early-career researchers from 24 countries, resulting in insightful papers on equity-oriented health system topics. Beyond the direct outcomes of strengthening the writing skills of first-time women authors and facilitating paper publications, the Programme has also influenced Health System Global's strategic approach and conceptual framework for systemic capacity strengthening in health policy and systems research. It has also played a pivotal role in addressing the longstanding gender imbalance in global health authorship. Amid these achievements, our program consistently evolved, drawing from lessons of the past cohort. Challenges, such as the need for extended paper development timelines, addressing language barriers, and strengthening methodological rigor in initial manuscripts, were met with solutions. Insights and experiences from previous participants translated into tangible results, notably elevating the quality of journal supplement publications. This commentary explores key lessons from the second cohort's journey and its evolving nature. It also highlights persistent challenges and provides practical recommendations for organizations to enhance their mentorship programs, ultimately fostering the career growth of early-career researchers in health policy and systems research.

Conceptualising the Factors Influencing Community Health Workers’ Preparedness for ICT Implementation: A Systematised Scoping Review

Background: Globally, community health workers (CHW) are increasingly viewed as an integral part of the health system as opposed to simply being an extension of it. Given this view, most low- or middle-income countries (LMICs) have refocused their efforts on reorganising CHW initiatives to maximise their impact. The ongoing endeavours to augment the practice of community health workers using technological solutions are characterised by as many challenges as opportunities. In low- and middle-income countries, including South Africa, information and communication technology (ICT) has become a promising development in the enhancement of the equitable coverage of health services by community health workers. However, there has not been a wide-scale implementation and adoption of ICT; most technology initiatives fail to scale up during the implementation stage, which is attributable to human and context-related factors. Although there has been an effort to develop solutions to address ICT infrastructure and technical barriers, conceptualising an evidence-based understanding of the contextual and user-related factors that influence the efficacy of technology adoption by CHWs within their multidimensional system remains critical. Objective: The purpose of the study is to conceptualise the social factors to consider when implementing a bespoke ICT solution suited to the specific demands of CHWs in primary healthcare in developing contexts, with a particular focus on the South African context. Methodology: The methodology involves synthesizing, extracting, and consolidating the findings of a systematised scoping review into concepts and factors. The review adapts Arksey and O’Malley’s scoping review approach to the study and incorporates 59 relevant articles. Results: Although the knowledge base on CHWs is extensive, there is a considerable gap in addressing structural challenges within the community system, which contributes significantly to the overall performance of CHW programs. Factors promoting policy adaptations, common practice within the health system, CHW competencies, a community’s development in terms of knowledge and economic advancement, safety and security, the environment, and the socio-cultural context all play a significant role in facilitating or impeding the success of health interventions from the individual to the national level. Conclusions: Within several practical limitations, the study shows that despite the efforts of various developing countries to promote technology adoption, the barriers to ICT adoption outweigh the benefits gained in developing countries. The paper argues that addressing these challenges before and during implementation is critical. The authors conclude with some essential concerns about assisting CHWs towards realising the desired health outcomes through ICT.

The contribution of family physicians to district health services in South Africa: A national position paper by the South African Academy of Family Physicians

The purpose of this position paper by the South African Academy of Family Physicians (SAAFPs) is to inform decision making on human resources for health policy in South Africa and the placement of family physicians (FPs) in the district health system. National policies have been marred by misunderstanding of the roles and contribution of FPs; and there is unhelpful variability in how FPs are positioned in the health services between provinces. In the private sector, medical aid schemes have discriminated against FPs by failing to remunerate them as specialists and to recognise their scope of practice.

Supportive supervision from a roving nurse mentor in a community health worker programme: a process evaluation in South Africa

BACKGROUND

Many low and middle- income countries (LMICs) are repositioning community health worker (CHW) programmes to provide a more comprehensive range of promotive and preventive services and referrals to the formal health service. However, insufficient supervision, fragmented programmes, and the low literacy levels of CHWs often result in the under-performance of the programmes. We evaluate the impact of a roving nurse mentor working with CHW teams proving supportive supervision in a semi-rural area of South Africa.

METHODS

We conducted a longitudinal process evaluation, using in-depth interviews, focus groups and observations prior to the intervention, during the intervention, and 6 months post-intervention to assess how the effects of the intervention were generated and sustained. Our participants were CHWs, their supervisors, clients and facility staff members and community representatives.

RESULTS

The nurse mentor operated in an environment of resource shortages, conflicts between CHWs and facility staff, and an active CHW labour union. Over 15 months, the mentor was able to (1) support and train CHWs and their supervisors to gain and practice new skills, (2) address their fears of failing and (3) establish operational systems to address inefficiencies in the CHWs' activities, resulting in improved service provision. Towards the end of the intervention the direct employment of the CHWs by the Department of Health and an increase in their stipend added to their motivation and integration into the local primary care clinic team. However, given the communities' focus on accessing government housing, rather than better healthcare, and volatile nature of the communities, the nurse mentor was not able to establish a collaboration with local structures.

CONCLUSIONS

A roving nurse mentor overseeing several CHW teams within a district healthcare system is a feasible option, particularly in a context where there is a shortage of qualified supervisors to support CHWs activities. A roving nurse mentor can contribute to the knowledge and skills development of the CHWs and enhance the capacity of junior supervisors. However, the long-term sustainability of the effects of intervention is dependent on CHWs' formal employment by the Department of Health.

An innovative model for management of cardiovascular disease risk factors in the low resource setting of Cambodia

Non-communicable diseases are increasing in developing countries and control of diabetes and hypertension is needed to reduce rates of the leading causes of morbidity and mortality, stroke and ischaemic heart disease. We evaluated a programme in Cambodia, financed by a revolving drug fund, which utilizes Peer Educators to manage diabetes and hypertension in the community. We assessed clinical outcomes and retention in the programme. For all people enrolled in the programme between 2007 and 2016, the average change in blood pressure (BP) and percentage with controlled hypertension (BP < 140/<90 mmHg) or diabetes (fasting blood glucose (BG) < 7mg/dl, post-prandial BG < 130 mg/dl, or HBA1C < 7%) was calculated every 6 months from enrolment.  Attrition rate in the nth year of enrolment was calculated; associations with loss to follow-up were explored using cox regression. A total of 9139 patients enrolled between January 2007 and March 2016. For all people with hypertension, mean change in systolic and diastolic BP within the first year was −15.1 mmHg (SD 23.6, P < 0.0001) and −8.6 mmHg (SD 14.0, P < 0.0001), respectively. BP control was 50.5% at year 1, peaking at 70.6% at 5.5 years. 41.3% of people with diabetes achieved blood sugar control at 6 months and 44.4% at 6.5 years.  An average of 2.3 years [SD 1.9] was spent in programme. Attrition rate within year 1 of enrolment ranged from 29.8% to 61.5% with average of 44.1% [SD 10.3] across 2008–15. Patients with hypertension were more likely to leave the program compared to those with diabetes and males more likely than females. The programme shows a substantial and sustained rate of diabetes and hypertension control for those who remain in the program and could be a model for implementation in other low middle-income settings, however, further work is needed to improve patient retention.

Barriers to the Implementation of the Ward-Based Outreach Team Program in Mpumalanga Province: Results From Process Evaluation

Background:

South Africa adopted the ward-based outreach team (WBOT) program as one aspect of the three-stream approach to primary health care (PHC) re-engineering. PHC re-engineering seeks to modify the hospicentric and curative approach into a more preventive and promotive approach to improve health outcomes. There has not been an evaluation of the implementation of the WBOTs in Nkangala District since its inception in 2012.

Methods:

A process evaluation approach using qualitative methods was used to examine and describe the contextual, organizational, health provider, and program-related barriers considered to affect the implementation of the WBOTs 3 sub-districts in one of the health districts in Mpumalanga Province, South Africa. The framework for this evaluation was informed by the logic model framework developed by the Center for Disease Control as well as the 3 domains of evaluation recommended by the Medical Research Council Guidance on process evaluation. Data were collected through in-depth interviews with multiple data sources directly involved in the implementation of the WBOTs. A thematic analysis was done using NVivo 11.

Results:

The key critical barriers identified by the evaluation include the inadequate provision of resources, the lack of supervision, the heavy workload for outreach teams, the inadequate and irregular payment of stipends, threats to the safety of the CHWs, and the cultural beliefs and practices of the communities who are to receive the services. The lack of adequate financial resources was the main challenge, and will continue to pose a risk to the successful implementation of the WBOTs.

Conclusions:

Although the barriers are being reported as separate contextual factors, the internal and external contexts are interdependent, interact with one each other, and should not be considered in isolation. The need to improve stakeholder engagement on the WBOT program underscores the importance of the external context in the successful implementation of WBOTs.