The roles, responsibilities and perceptions of community health workers and ward-based primary health care outreach teams (WBPHCOTs) in South Africa: a scoping review protocol

Community health workers had their origins in China in the 1920s and were precursors to the “barefoot doctor” programme which was a movement in the 1950s [1‐3]. Community health workers have been defined as “a diverse group of health workers whose common characteristic is their work outside of health facilities directly with people in their homes, neighbourhoods, communities and other non-clinical spaces where health and disease are produced”. In the 1960s, community health worker programmes emerged in Indonesia, India, Tanzania and Venezuela [3].

Just over a decade later, an international conference on primary health care (PHC) was held at Alma Ata where a Declaration of Health for All by the year 2000 was made. The Alma Ata Declaration of 1978 articulated the urgent need for all governments, health and development workers and the communities, to protect and promote the health of all the people of the world [4]. Primary health care was identified as the key intervention in attaining the Alma Ata Declaration. The community health workers’ role in providing PHC was highlighted in the Declaration [5]. These categories of staff need to be suitably trained to work as a health team in order to respond to the identified and expressed health needs of the community. Community health worker programmes in low-, middle- and high-income countries proved to be successful in the 1980s in countries like Brazil (community health agents), Bangladesh (family welfare assistants) and Nepal (female community health volunteer programme) [3].

During the 1990s, the World Health Organization promoted task-shifting to counteract the overstretched health care system [6]. Pakistan launched their large-scale, community-based lady health worker programme in 1992, followed by Ugandan community health worker (CHW) programme (village health teams) [7, 8]. In 2004, Ethiopia embarked on a training programme of their health extension workers [3, 9], while in 2005, India introduced her CHW programme which is now the largest in the world (accredited social health activists) [3]. Although CHWs have different names in different countries (home-based carers, community caregiver), their roles overlap. For example, in low-income countries, CHWs are instrumental in reducing childhood malnutrition, improving maternal and child health, increasing access to family planning and controlling the spread of HIV, malaria and TB infections [3].

In middle-income countries, CHWs form important health team members and are critical for PHC provision including health promotion [8, 10, 11]. Therefore, this study review will include research articles from low and middle incomes with South Africa in mind. Evidence shows that in the USA, CHWs can contribute to the management of hypertension, diabetes and HIV and screening for cancer and can control the risks of cardiovascular diseases [3, 12, 13].

Community health workers have been widely used in low- and middle-income countries to scale up HIV care. In rural Haiti, CHWs have served to bridge gaps in access to care which arise from lack of communication in terms of patient follow-up and long distances which patients travel to address health problems [14]. Such cadres have been involved in directly observed administration of tuberculosis medicines since the mid-1980s in Haiti [14]. A comparative assessment done on the integration of community home-based care programmes within national primary health care revitalisation strategies in Ethiopia, Malawi, South Africa and Zambia highlights some common strengths across the four countries. Community home-based care programmes in these countries, in which service delivery cuts across health and non-health domains and begins to extend beyond one priority disease, bring a vital resource to the primary health care revitalisation agenda. Furthermore, they support the establishment of primary care networks which are capable of addressing the health and social care demands of patients with chronic conditions [15]. South Africa has implemented CHW programmes for decades; however, the country failed to include them in the post-apartheid health system [16]. The CHW programme in South Africa dates back to as early as 1940, with the establishment of the Pholela Health Centre by two medical doctors, Sydney and Emily Kark [17].

The Centre’s task was to promote curative and preventive services [17]. During this era, the first five community health workers operated from the centre and each was responsible for 4000–5000 people. Communicable disease control and community health education were their main tasks [17]. The model being used for CHW (community health worker) programmes in South Africa has its roots in the Pholela Health Centre community-oriented primary health (COPC) model. Lately, South Africa is including CHWs as important members of community-based health programmes using Brazil’s model, in which CHWs form the foundation of the health care system.

In 2010, South Africa’s National Department of Health (NDoH) 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, aims to support a preventive and health-promoting community-based PHC model by using community-based outreach teams (known in South Africa as ward-based primary health care outreach teams or WBPHCOTs). The WBPHCOTs are staffed by CHWs under the supervision of facility-based nurses. These teams provide health education, promote healthy behaviours, assess community health needs, manage minor health problems and support linkages to health services and health facilities [18]. The recommendation is that ward-based primary health care outreach teams should comprise a professional nurse who is the outreach team leader, a health promotion officer, an environmental health officer and six CHWs [19]. A gap remains between policy and implementation, especially in rural districts which needs to be addressed [20]. In South Africa, the WBPHCOTs have been established, registered and have been reporting their activities through the District Health Information System (DHIS) since January 2012; however, the concern is that WBPHCOTs are not functioning optimally, while still constituting a large part of the KwaZulu-Natal Department of Health’s budget. In this study, the researcher will explore roles and responsibilities of community health workers in WBPHCOTs. In addition, the aim of South Africa’s health care system is to strengthen health services and improve accessibility to the community through primary health care re-engineering. This programme comprises the nurses and the community health workers. Although the promise of WBPHCOTs is improving community health, several factors are undermining its success. Key among these challenges are as follows: varying perceptions of the CHW roles, lack of knowledge and skills and lack of stakeholders and community support [21‐24].

A scoping review of peer-reviewed and grey literature on the role and responsibilities of community health workers’ perceptions of ward-based primary health care outreach teams will be conducted. The review will include a quality assessment. This review will be guided by Arksey and O’Malley’s scoping review framework (Arksey and O’Malley, 2005) which stipulates the following steps:

This scoping review will evaluate the documented evidence that suggests the roles and responsibilities of ward-based primary health care outreach teams. The review will also highlight factors enabling or hampering the effectiveness of ward-based primary health care outreach teams. The rigorous and systematic nature of this review will ensure that it captures all relevant information on ward-based primary health care outreach teams. This review will explore areas where the WBPHCOTs are not functioning well and make recommendations for improvement, as well as identify areas where they are functioning well and suggest ways of replicating these. Results from this scoping review will be useful to inform programme implementers of the impact made by these teams on health and health care in the country.