Background
Low and middle income countries (LMICs) often have a patchwork of community health worker (CHW) programmes, sometimes led by non-government organizations (NGOs), reaching some communities but not others, focused on specific disease (e.g. HIV/AIDS) or population groups (e.g. child health) [
1,
2]. The international calls for universal health care have led some countries to attempt to achieve wider population reach with their CHW programmes [
3,
4]. Many LMICs are exploring ways to utilize CHW programmes to respond to wider range of conditions, including non-communicable and infectious diseases [
3] and increasing CHWs’ roles in promotive and preventative care [
5]. The importance of the CHWs’ role has been given greater prominence and urgency during the COVID-19 pandemic, with CHWs expected to educate the public and to identify possible COVID cases [
6‐
8]. The shift to more comprehensive programmes, in terms of population coverage and health conditions, requires greater supervision to manage, train, mentor and monitor CHWs and to facilitate links with the healthcare system and community structures [
9].
South Africa has a long history of CHW programmes starting in the 1940s [
10]. Since democracy, CHW programmes, despite considerable fragmentation, have played an important role in extending healthcare services to needy populations [
11]. With recent reforms of primary health care services, South Africa is establishing a nationwide CHW programme, covering a more comprehensive range of health conditions than in the past [
9,
12,
13]. The CHW programme is known locally as the ward-based outreach team (WBOT) programme [
14,
15]). Each WBOT is meant to comprise a team of at least 6 CHWs, a nurse (outreach team supervisor), environmental officer and health promoter. The outreach team supervisor role is to provide field supervision to the CHWs during household visits, ensure they [CHWs] have the resources that they require (e.g. stationary) to fulfil their duties, and help establish team relationship with community structures. Each WBOT, operating within a facility’s catchment area, provides promotive and preventive services to households. CHWs, who were previously working for NGOs contracted by the South African Department of Health (DoH) became members of WBOTs. While the DoH required CHWs to have passed their final school examination in order to be transferred to the new programme, this requirement wasn’t always implemented. As a result, the majority of the CHWs recruited into the new programme had low literacy levels. Similar to other contexts, South Africa has a limited number of health professionals available to be the outreach team leaders who oversee the CHWs, and many CHW teams are functioning without adequate supervision and remain poorly integrated into the healthcare systems [
9,
16,
17].
CHWs joining these new teams undertake training on identification of the need for antenatal and post-natal care, monitoring immunization and adherence to long-term medication, screening for malnutrition, TB, gender-based violence, making referrals to health and social services, and following up on patients who need to visit the clinic. The training is delivered in two phases, the first with a written examination (level 1), the second with a practical assessment in the field (level 2) [
14]. In Sedibeng District, where this study took place, the CHWs also delivered long term medication each month to elderly or disabled patients.
In this paper we report on a longitudinal qualitative process evaluation, describing the impact of a roving nurse mentor. We describe if and how she built the capacity of the CHW teams and their supervisors, their relationships with both the local health system and community structures, their impact, and whether and how the effect was sustained once the nurse mentor left. We explored the iterative interaction between the context the intervention and the moderating factors that lead to a change. While we will report on the changes in quantitative outcomes elsewhere, it is important to mention here that the intervention led to an increase in the proportion of households who received a visit in the last year from 20 to 30%. Moreover, the CHWs provided care to a greater range of people and performed a greater range of more complex tasks. For further papers on the situational analysis see [
9,
18], and tool development see [
13].
Findings
Training and resources
Prior to the intervention, both supervisors had been in their posts for 4 months. They had completed 2-year nursing qualification and 2–3 years post-training work experience but had not worked with CHWs before. One of the supervisors (Team 2) originated from outside the province and sometimes appeared uneasy supervising the CHWs, as the majority of the CHWs were local women and older than her. The supervisor in Team 1 was from the district, assertive and managed a relatively younger group of CHWs (Table
3).
Table 3
CHW team members characteristics
Supervisor |
No. of enrolled nurses | 1 | 1 |
Age (years) | 36 | 31 |
Mean years as nurse | 5 | 2 |
Years in programme | 0.3 | 0.3 |
CHW |
No. of CHWs per team | 14 | 20 |
Mean age in years (range) | 42 (23–58) | 33 (23–54) |
Mean years (range) as CHW | 10 (3–9) | 6 (5–17) |
No. of CHWs who have finished high school education | 25% | 33% |
No. of CHWs who have passed phase 1 training | 2 | 1 |
No. of CHWs who have passed Phase 2 training | 0 | 0 |
Prior to the intervention, the CHWs’ length of service ranged between 2 and 4 years. Many of the CHWs had not completed their final school leaving qualification (Table
3). Only a few of the CHWs had completed Level 1 CHW training, and none had completed the Levels 2 or 3 CHW training. Further details on the characteristics of the CHWs are provided elsewhere [
18].
During data collection prior to the intervention, the CHW teams were provided with equipment bags (one bag per pair of CHW), containing blood pressure and glucose machines, weight scales, bandages and umbrellas. In one team, the CHWs had not received training on how to use the manual blood pressure machines provided. By the time of the intervention, much of the equipment was faulty. The CHWs shared the remaining working equipment; despite informing the district office, the faulty equipment was not replaced or repaired. The Team 2 CHWs held their work planning meetings in the facility meeting room, however the room was often used by nurses, and then the CHWs had to move outside the facility. CHW commented: “When they [nurses] like they don’t even tell you that they have a meeting; they just enter the room… you just know that you have to go outside” (Interview, CHW4, Team 2). Team 1 CHWs, based in a smaller facility, had no room to use, and met their supervisors outside.
Prior to the intervention, according to interviews with CHW team members, CHWs needed to make copies of their various forms that they use during household visits (e.g., household registration and referral forms). However, according to the team supervisors, the photocopy machines were often broken or out of ink. Staff had to contribute their own funds to purchase ink, which many of the CHWs could not afford, and so didn’t make copies. The supervisors had to travel to the sub-district office (30kms away) to make copies. (During the intervention, the nurse mentor occasionally provided copies of stationary so the CHWs were able to undertake their work). CHWs had to use their own funds to purchase a notebook and pen to record daily activities; many used loose pieces of papers to record the details of visits. Due to space constraints within the two facilities, the CHWs kept completed client forms at home. This practice had a negative impact on the CHWs’ work, as the forms were rarely brought back to the clinic and were not used to reporting CHW activities.
Conditions of employment and unionisation
At the beginning of the study, the CHWs were a contracted labour force managed by a private administrative payroll company. They received a stipend of R2 500 (143 USD) per month. The facility staff members expressed dismissive attitudes towards the CHWs. A CHW commented: “The facility manager tells us that we are not part of the clinic [because they were contracted to the payroll company] so there’s nothing she can do for us’ (Interview, CHW8, Team 1). The CHWs felt belittled: “The peer educators, HIV/AIDS counsellor we all go together to sign the same contract, but they are treated as if they are more educated than us, they call us street maids” (CHW-FGD, Team 2).
A task team was established by the CHWs to demand improved conditions of employment. The task team consisted of CHWs, lay counsellors and health promoters from the district. Only a few CHWs from our study sites participated in the task team meetings, as they were held in the district town and transport was expensive. A greater number of the CHWs participated in protests, which were often 1 day ‘stay-aways’; one militant CHW threatened to report CHWs to the task team if they went to work. Clinic staff often asked the supervisors and CHWs to do facility-based work when they should be in the community; the CHWs were told by the task team to stop activities in the facilities, including those activities that were part of the CHW programme (e.g., assisting nurses to retrieve CHW patient files and practicing taking blood pressure measurements in the vital signs room). They were also told not to work when the supervisors were not present, or if it was raining.
Towards the end of the intervention, the CHWs were formally employed by the Provincial Department of Health (PDoH) in June 2018. Their monthly stipend was increased to the minimum wage of R3 500 (200 USD). The increment encouraged the CHWs: “It has motivated me to work harder than before” (Interview, CHW, Team 2). Some CHWs used the increment to invest in the education of their children: “I am now able to save for my child secondary school education. I have been saving R1 000 every month, so when she passes matric I am able to pay for her college fees” (Interview, CHW5, Team 2).
The following sections focus on the findings from the four focal areas of the nurse mentor intervention – household registration, medication delivery, patient follow-up, and community engagement.
Chronic medication delivery
Discussion
In our study, we examined the role of a roving nurse mentor in building the capacity of two CHW teams led by junior nurses in two primary health facilities in a semi-rural area of South Africa. Initially, with many of the CHWs not having finished their schooling, the mentor’s involvement evoked fear in some CHWs, resulting in them being obstructive, or not fully participating in capacity-building activities. The mentor had to strike a balance between pushing the CHWs to try to learn and adopting a gentler approach that didn’t alienate them. Over time the nurse mentor was able to get this balance right and the CHWs and their supervisors improved their skills and confidence. Other studies in LMIC settings have similarly found many CHWs may not have finished their school education and stressed the importance of providing a supportive environment to help them overcome their fears of failing again, so enabling them to reach their potential [
26,
27].
The nurse mentor negotiated with the staff to establish three new operational systems to assist the CHWs: the book for recording the patients’ medication delivery dates; working in the vital signs room to practice taking BP measurements; and the use of a list and three visits only to patients who needed to be traced. These systems led to an improvement in CHW performance, although the CHWs were still hampered by the lack of equipment and limited space and the dismissive attitude of junior facility staff. The CHWs needed a dedicated senior person to work out what systems were required, negotiate with facility staff to establish them, and to navigate problems when they arose. The change to being employed by the DoH meant the facility managers took greater responsibility for the CHW team and were able to build on the improvements established by the nurse mentor and the programme became more integrated into the facility. It is unlikely that facility managers, with their workload, would have been able to bring the CHWs’ skills and confidence up to the necessary level without the nurse mentor.
Difficult relationships between CHWs and other healthcare staff members have been documented in other studies. In a study of CHWs and professional nurses’ relationships in South Africa [
28], the CHWs reported finding it uncomfortable working with professional nurses, as the nurses often failed to recognize CHWs as members of the health team. Other studies have found some clinicians tend to undermine and marginalize the CHWs role [
28,
29]. Systematic review evidence suggests that health workers’ negative attitudes towards CHWs affect their performance [
30]. A study in Malawi found clinicians who were reluctant to give drugs to health surveillance assistants hindered the health surveillance assistants role and performance in the community [
31]. Similarly, Payne et al argued the stalemate between clinicians and CHWs is largely due to differences in training (curative and non-curative) [
32]. In our study, we found that a senior nurse, who serves as a point of authority within the CHW teams, and champions the role of CHWs, can be a critical resource in establishing operational systems, and addressing conflicts between CHWs and clinic staff. Similarly, a study in rural north west South Africa, found team leaders were the source of support for CHWs as the facility managers often struggled to provide supervision support due to unmanageable workloads in the facilities [
33].
World Health Organization (WHO) recommendations and evidence from several countries suggests that community members tend to utilize services if the health programme is embedded in the community structures [
34‐
37]. For example, in Rwanda village leaders and community security officers had a crucial role in ensuring mothers and pregnant women were aware of the maternal and child services available to them at health facility and community level [
38]. In Malawi, volunteers, who belonged to a wide range of community-based committees, supported the health surveillance assistants in completion of their daily tasks and made effort to inform them of problems that required their attention in the community [
36]. The communities where we undertook our study had community forums but at the time of the study these focused on the community’s pressing concerns of lack of housing rather than the delivery of healthcare services.
The WHO Global Strategy on Human Resources for Health emphasizes the need to align CHW initiatives and programmes to broader national health workforce policies [
39] if CHWs effectiveness is to be realized [
34]. Many CHW labour groupings have focused on securing permanent employment, decent wages and recognition of CHWs as contributing members of healthcare system [
40‐
42]. Our findings show that paying CHWs and integrating them into the healthcare system was important for improved and sustained CHWs motivation and performance. The WHO guidelines do not adequately acknowledge the chronic shortage of health workers in LMICs to oversee CHW programmes [
9,
30,
35]. Our study provides evidence for the success of a CHW supervision configuration that is potentially suitable for contexts with a health worker shortage. A roving, experienced nurse mentor can be responsible for several CHW programmes in a district healthcare system, contribute to the knowledge and skills development of the CHWs, and enhance the capacity of junior supervisors. However, the long-term success of this approach is dependent on fair remuneration and the integration that results from formal employment of CHWs.
This study contributes to understanding how to address the challenges inherent in many CHW programmes of insufficient supervision, poor health systems integration and poor relations with local communities. During our study, the CHW team and facility staff may have changed their normal routines and behaviors during observations. However, our extensive data collection meant the research team became a familiar presence over the course of the study. The intervention study was undertaken with only two CHW teams so we do not know if the intervention would work if the mentor took on more teams.
Conclusion
In a resource constrained setting like South Africa, where there is a shortage of health workers to oversee the implementation of CHW programmes, a roving nurse mentor working with more than one CHW team can successfully improve CHWs skills and confidence, the supervisory ability of the CHW team leader, set up appropriate organizational systems, improve the working relationships between the CHW team and health facility staff. However, the long term success of CHW programmes is dependent on formal employment and better integration of CHWs into healthcare systems.
Acknowledgements
The authors would like to thank the following individuals for their invaluable contribution: the fieldworkers, CHWs and their supervisors, health facility staff members and community representatives. The support of the Sedibeng Health District management, in particular the former district director Mrs. Salamina Hlahane and community-based services coordinator Mrs. Bridget Lefhoedi is highly appreciated. The authors would also like to thank these organisations for their generous support: Department of Health Sedibeng District, Gauteng Department of Health and the UK Medical Research Council (MRC).
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