Background
There is a growing embrace of community health workers (CHWs) and task shifting to junior professionals as a response to human resource shortages in primary health care. A key difficulty is how to integrate them into health systems to provide comprehensive people-centred primary health care [
1‐
3]. The South African government has been striving to deliver improved public primary health care service for all since 1994, with infrastructural initiatives based on a new district health system. However services remain fragmented, with most doctors and nurses located in the private sector, resulting in poor health outcomes [
4]. This is a function of the apartheid past as well as failures in current health leadership-management in South Africa [
5].
National Health Insurance (NHI) in South Africa is an attempt to address this public-private inequity, mostly by funding changes [
5,
6]. NHI includes service delivery reform, termed primary health care (PHC) re-engineering, as a shift towards more prevention. There are three streams in PHC re-engineering: municipal ward-based PHC outreach teams, school health teams, and district-based clinical specialist teams (to support maternal and child health outcomes mostly) [
4,
6]. CHWs have been described by government officials as poorly coordinated, inadequately trained and supervised, randomly distributed in verticalised programmes and struggling with links between the community and fixed clinics [
7]. PHC outreach teams are an attempt to change CHWs deployment to a more integrated, team-based approach responsible for defined populations and strengthening interactions between services and service users [
8].
The PHC outreach team consists of a professional nurse (a senior nurse trained over three years), supported by a health promoter and environmental health officer, leading a team of six CHWs within the geographic area of a municipal ward, as the unit of election of councillors to local government. Each CHW takes care of 250 families. The PHC outreach team is supposed to work with another professional nurse and an enrolled nurse (a junior nurse trained over 2 years) at the clinic to provide comprehensive care to this population, from health promotion to treatment of minor ailments [
8]. CHWs are to have a standardised scope of work; clearly defined roles, responsibilities and job description; certified training; specified qualification requirements; employment mechanisms; training and supervision packages; and remuneration and condition of service [
4]. The CHWs do mostly household profiling, screening, and health education, with supervision by their professional nurse team leader. The CHWs refer problem patients to their supervising professional nurse and/or the clinic nurses and then do community-based follow-up of these patients with health education and home-based care. There may be more than one team per ward, depending on the population.
Johannesburg is one of five health districts/municipal districts in Gauteng Province, which is one of the nine provinces in South Africa. Johannesburg is home to 4.4 million people [
9]. Most smaller clinics are managed by local government/municipal managers (known as the City of Johannesburg (CoJ)), whilst the fewer larger community health centres (CHC) are managed by managers appointed by provincial government for the health district (known as Johannesburg Metro). Johannesburg Metro is the principal manager of the health district and CoJ is deemed an agent, in terms of the National Health Act of 2003. Each has a set of programme managers overseeing all verticalised services, e.g. non-communicable diseases or HIV-TB for Johannesburg. There had been various efforts in Johannesburg since 2009 on developing community-oriented primary care (COPC); however, there has been little public examination of the challenges in implementing PHC Outreach Teams, as a stream of PHC re-engineering.
The aim of this study was to understand the views of district health managers in Johannesburg on the implementation of PHC outreach teams.
Discussion
It is significant that managers in Johannesburg see PHC re-engineering, with its preventive approach and re-orientation from specialised to generalist CHWs, as a step in the right direction. It underlines government intent towards a more integrated horizontal approach [
7] and its value in PHC [
11].
However, managers in Johannesburg quickly pointed out implementation challenges of leadership-management, citing poor planning, poor integration and poor communication. Middle managers suggested that PHC outreach teams be central to the district’s re-arrangement and functioning. They asked the question: ‘we talk about re-engineering, can we re-engineer a system that is broken?’ and questioned the ethics of overwhelming service delivery. Kautzky and Tollman [
12] feel that there needs to be an intense effort to salvage the currently over-bureaucratized and rigid primary care service. PHC reform needs a redefinition of strategic and organisational planning of the district health system in South Africa [
13]; otherwise, patients will continue to get lost in the system because of lack of integration, as government points out [
8]. Conceptualizations of integration appear poor. A salient view is that people-centredness should be the organising focus of integrated PHC [
14]. However, the tendency is for managers, especially senior district managers, to organise and integrate around themselves and the bureaucratic structures they create.
This was evident with managers cautioning about the impact on current services with the current culture of ‘pushing queues’. They thought that clinic staff would see this as extra work and resist changes. Sub-district managers say that facility and operational managers are unable to see the big picture [
15]. The shortages of equipment, supplies and transport seemed to reflect a currently dysfunctional service that needed ‘financial re-engineering’ rather than a lack of resources. South Africa already spends the second highest percentage of government expenditure on health in Africa [
16]. These challenges of lack of leadership, integration and service take up in PHC Outreach teams are not unique to Johannesburg [
17].
Current command and control approaches are seen as flawed with a bottom-up approach suggested as critical [
18]. Managers in Johannesburg recommended that management and planning should be decentralised to facility managers. Decision space is required for managers [
19]. A service interface empowered as close to the community is likely to be patient-, person- and people-centred [
12]. Decentralisation is an important call in Africa [
20,
21] and South Africa [
22]. There is a need for a complex adaptive systems thinking approach. There needs to pro-active management, local service improvement priorities and population accountability [
23]. Managerialism in the public service can demobilise communities, rendering community participation very patronising [
24]. Familiarity with the community by all providers improves community engagement and service integration [
25] but also risked the invasion of privacy and confidentiality. Managers shared this sentiment. They were also worried about patient autonomy with the PHC outreach teams.
Managers considered human resource challenges as a serious challenge, with most of their focus on CHWs. They saw the service profoundly shifting to make the CHWs the first point of contact with the formal health system and addressing the current verticalised programmatic fragmentation of care. This seems aligned with national intent [
8,
26] and good practice internationally [
27‐
29]. CHWs understand contexts and social situations from which their patients come and manage a myriad of social challenges within families and communities, congruent with international evidence of promising benefits [
30].
Managers’ in Johannesburg wanted the formalisation of CHWs, especially in respect of incentives. This is an important consideration in a systematic review of design factors influencing performance of CHWs in low- and middle-income countries [
1]. Managers felt that the CHW workload was very heavy and their working conditions difficult, citing the lack of space, stationery and equipment. This is not unique to South Africa [
31] and influences CHWs productivity [
32]. CHWs deployment requires a strengthening of the existing health system and an enabling environment for CHWs [
29,
33]. Managers shared sentiments in line with international calls for better recruitment, standardisation and performance management [
33,
34].
Managers felt the need for more formalised CHW training, with the amount of complexity being thrust on CHWs without the ability to cope. This concern is evident in other programmes in Africa [
35], with community criticism of CHWs competence jeopardising the programme [
36]. Managers in Johannesburg felt that the training focus should be local and more than just a ten-day course.
CHWs are politically powerful being ‘agents of the state’ being very present in the community and potentially holding the key to access of health services. On the other hand, their employment may render them as bureaucratic extensions of a dysfunctional health service, where their role as advocates for social change is replaced by a predominantly technical community management function [
37,
38]. Politicians see CHWs as a panacea to all their problems and there is a danger that the CHW programme will take on more than it can deliver [
26,
29].
Formalising CHWs would require significant budget but costs could be modest [
27,
39]. Managers questioned the ethics of holding CHWs in a state of precarity: exposed to risks, poorly supported, poorly and often irregularly paid. This lack of care for the carer is symptomatic of the entire public service [
40] and creates the impression that CHWs are readily disposable.
Government has premised the PHC outreach team on professional nurses as team leaders [
17]. Participants saw this requirement as unrealistic and suggested using enrolled nurses instead. Managers in Johannesburg questioned the use of school and district nurses and the choice of inexperienced nurses as new team leaders. Managers suggested that teams be linked to a PHC Nurse based at the clinic, seeing referred patients and able to see patients comprehensively. However, such teamwork is confounded by their concern about the culture of quotas and long teas amongst staff. A major reason for dissatisfaction with health services is the non-responsiveness of the nursing profession and the non-caring attitude of health care personnel [
18,
41]. Change management, dealing with resistance, appears a key hurdle on which implementation of PHC Re-engineering appears to be stumbling [
42,
43]. Task shifting can be useful but overburdening lowly-paid health workers with very complex tasks can be counterproductive, whatever the short-term cost benefits may appear. Integration with task shifting needs local clinical leadership to manage the staff-skills mix [
44]. Task shifting is more than substitution and delegation. It includes supervision, enhancement, mentoring and innovation [
45]. Managers in Johannesburg felt that the capacity of facility managers was limited and needed changing. Clinic managers are struggling with the same problems as general staff: poor practice environment, workload, professional support, training, pay, standards of care and security [
46]. Whether leadership training is enough to address the current culture is moot. The relegation by managers of doctors to clinical curative work and the poor use of clinical associates is of concern [
47‐
50]
There are limitations to this study. It obtains views of only one health district in Gauteng. Some key members of management are noted as missing. The research team involvement in previous work on PHC outreach teams may have biased results. Further such research is required in other districts. The study was done in 2013 and may be dated.