What is the most effective model for deployment of community health workers in under-served communities in South Africa? The Bathlokomedi project
To achieve universal health coverage we need affordable access to health care for under-served communities. There are too few professional health workers in low and middle income countries so supervised task shifting is needed. Community health worker (CHW) programmes (CHWs are lay people with minimal training who visit households to case find and support adherence to treatment) have been shown to improve access to care, but there is insufficient evidence on how to best operationalise these at scale. South Africa has recently launched a national CHW programme alongside their professional nurse led primary care clinics. This study aims to explore the functionality of different models of provision.
Three CHW team models were studied in a poor area of South Africa: 1) primary care clinic based with dedicated professional nurse leader and enrolled nurse (2 years training); 2) primary care clinic based with dedicated enrolled nurse leader; 3) health post (a portable structure with no electricity but close to the served community) based with professional nurse leader and enrolled nurse.We undertook comparative case analysis of two examples of each model. Data includes interviews with 19 nurses, 74 patients seen by a CHW and referred to the clinic/post and, 24 community representatives; focus groups with all CHW teams; observation of 37 nurse days; 91 CHW days including visits to 528 households. A cross sectional survey of 1320 households in CHW served communities to assess health care need and receipt of CHW services is underway.
Comparative case analysis suggests differences between models include: quality of supervision, on the job training, mentoring and feedback given to CHWs and enrolled nurses; effectiveness of processes for referral to clinic, planning of CHW activities and, support for CHWs going to new or remote households; level of experience of enrolled nurses and their engagement with CHWs. Common barriers to effective working include lack of transport, airtime and supplies (e.g. forms) and no uniforms.The survey is nearing completion and results will be presented.
Currently a well-functioning CHW team is a) integrated with a primary care clinic; b) led by an experienced professional nurse who has minimal other clinic based commitments and has skills in supervising and training enrolled nurses and CHWs, managing teams, negotiating with clinic colleagues and assessing patients in primary care; c) has effective processes for planning, data recording and retrieving; d) has necessary resources for their work. Survey results will reveal whether the different models have different capacities to meet community health needs.The South African CHW programme is in evolution. There are more available enrolled nurses than professional nurses. With attention to on the job training and mentoring of enrolled nurses and CHWs, are enrolled nurses able to successfully lead CHW teams?