Some, however, said they could discern a work schedule. They said that on certain days WBOTs would come to conduct follow-up on previously seen cases, and on other days they would deliver chronic medication for stable patients, administer vitamin A and also provide health education. WBOTs also specifically visited the elderly people on certain days, while on other days they focused on child health-related issues.
In terms of time spent per visit, most respondents mentioned that the duration of the visit depended on the nature or the purpose of their visit to the particular household and that generally they spent at least 30 minutes at their homes. Respondents said that WBOTs play an important role in reducing out-of-pocket expenses and improving their access to services.
They said that the areas serviced by WBOTs are vast and clinics are far from communities. They further said that in the past they were unable to go to the clinic to collect medicine when they did not have money for transport. However, since the introduction of WBOTs, they reported that they no longer needed to go as often, and that they went only when they were referred by the WBOT or when it was necessary. The presence of WBOTs in communities brought some sense of relief to people, as they presented them with an opportunity to learn and ask about things they did not know or understand before the introduction of the teams.
Respondents actively encouraged fellow community members to use their services. As one put it:. My other brother passed on in November. He was looking for assistance and I told him to contact them, because people are not the same, there is a person that makes you understand things and put your mind at ease. The current package of care for WBOTs was regarded as insufficient for community needs. With the exception of pre-packed prescriptions for known stable chronic patients, WBOTs did not supply medications.
Participants felt that some of the basic PHC services, such as child vaccinations and deworming, should be shifted to the WBOTs to reduce referrals to the clinic. Referrals were perceived to occur largely because WBOTs offered limited services and could not handle complicated cases. While WBOTs seem to provide patients with referral letters some report that, at times, these were not given. Respondents also gave WBOTs feedback on referrals and their facility visits. Among study participants, there were some who had not had contact with WBOTs, mainly because they were close to a health facility.
Some also reported difficulty accessing WBOT services when they needed them, either because there were too few teams to service the need and they came only after long intervals or because the healthcare professionals attached to them were unavailable when needed.
So those are our problems. The study reveals that WBOTs are regarded as a valuable resource that provides people with much needed access to healthcare in remote and rural communities.
In particular, the functions and activities of the WBOTs were regarded as bringing services closer to people, mostly through the provision of health education, by delivering chronic medication for clinically stable patients and by making referrals to clinics and follow-ups after clinic visits. Clinic access was especially effective when people were provided with letters of referral. Services provided by WBOTs showed potential to help reduce unnecessary clinic visits as well as related costs of transport to healthcare facilities.
The introduction of WBOTs has lightened the burden associated with seeking healthcare as they now incur less costs, and benefit from availability of community-based healthcare and managed referral pathways.
Research on HIV or AIDS and tuberculosis TB treatment adherence has shown that the leading cause of loss to follow-up and treatment default among antiretroviral and TB patients is because of out-of-pocket expenses, particularly patient inability to pay for the transport costs for clinic visits. Community health workers, who are also members of the WBOTs, have been shown to bridge the gap in service delivery, help strengthen the link between the community and healthcare system, 14 ensure better patient retention and treatment adherence, and therefore contribute to improvement in prioritised health outcomes.
Reliability of WBOTs could be enhanced by explicit and consistent scheduling of visits, a more accessible and responsive system in cases where the need to contact team members arise, and the expansion of the package of services provided.
WBOTs need to provide a comprehensive primary care package of services in communities, as done in other developing countries that offer similar services. This may be a result of perceptions if the package of services is not well-discussed or conveyed and can lead to client dissatisfaction and strained relationships. Service packages delivered by community health workers are known to be crafted individually for each household, and needs for each client is central to the process of negotiating care.
These household follow-ups are similar to what the FHT does, where they are responsible for a permanent and systematic follow-up of a given number of families residing in a circumscribed area, and for establishing ties of commitment and shared responsibility. In analysing perceptions of WBOTs, people understand and value the services WBOTs are providing, as they have increased access to their healthcare and reduced out-of-pocket expenses.
In this way, they make an important contribution to national government efforts to provide healthcare for all. The reach of WBOTs and the current package of service provided by them are limited, however, and are a cause of some dissatisfaction that needs to be addressed.
The recommendations below are presented based on the finding and conclusion of the study:. The current package of care should be expanded to include performance of procedures such as child vaccination, deworming and handling of complicated cases.
Increasing the number of teams per ward should be advocated for in order for the team to visit households frequently. The study is a qualitative study based on perceived experiences of purposively selected individuals in a defined community in rural KwaZulu-Natal.
It is limited in scope and scale, providing insights into a particular aspect of primary care re-engineering at one point in time. The findings are indicative and not necessarily generalisable. The authors declare that they have no financial or personal relationship that may have influenced them in writing this article. Both authors read and approved the final article. The perceived role of ward-based primary healthcare outreach teams in rural KwaZulu-Natal, South Africa.
National Center for Biotechnology Information , U. Published online May Landiwe S. Khuzwayo 1 and Mosa Moshabela 2. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Corresponding author: Landiwe Khuzwayo, moc. Received Nov 19; Accepted Feb 2. These challenges, combined with the fact that CHWs are equipped with limited skills and often work in remote and isolated areas, point to the need for supervision systems that not only monitor performance but also provide moral and other forms of support [ 4 , 5 , 6 ].
Reviews examining effective designs for CHW programmes have consistently found that the quality of supervision of CHWs affects the performance of programmes [ 7 , 8 , 9 , 10 , 11 , 12 , 13 ]. Good supervision of CHWs, amongst other benefits, has the potential to improve and strengthen the relationships or interactions of CHWs with other health workers in the health system, resulting in improved trust and performance [ 20 , 21 ].
Despite its importance, the literature provides little evidence of what a good supervision system for CHWs entails [ 1 , 22 , 23 ]. Supervision is a key component of human resource management and amongst a number of important strategies to improve health worker performance and health outcomes [ 6 , 24 ].
Various definitions of health worker supervision are offered in the literature. Sennun et al. This definition views supervision principally as a monitoring process that ensures compliance with standards and quality of care. It differs from definitions that explicitly consider supervision as not only a performance management and administrative tool, but also as a mechanism of personal and developmental support to health workers.
The management function is concerned with ensuring compliance with organisational standards and policies, the developmental function seeks to improve knowledge and skills to perform, and the support function addresses morale, motivation and job satisfaction.
They argue that improving health outcomes production and resource development people cannot be addressed independently, but are rather complementary and equally important. Community health workers are not a new phenomenon in South Africa.
Over the years, CHWs have played a significant role in the health sector in a wide variety of areas such as maternal and child health, HIV, TB and other chronic conditions [ 29 , 30 , 31 , 32 ].
The RPHC strategy recommended, amongst a number of reforms, the Ward-based PHC outreach team strategy to strengthen health prevention and promotion, identify individuals and families at high risk and build links between households and health care facilities. The WBOT strategy represents the latest and most significant in a line of policy initiatives over the last decade to shape the community-based sector.
The team is attached to a facility, operates within a municipal ward and provides promotive and preventive services to individuals at household level. Training for CHWs is standardised with official tools outlining the functions of the team leaders, CHWs, facility managers and other managers at the district, province and national levels.
National guidelines, policy and training documents were developed for the WBOT strategy, specifying roles and functions for both CHWs and OTLs [ 37 , 38 ], which were to be implemented at provincial and district level. This article describes the extent to which the national policy and training documents related to WBOTs in South Africa provide guidance on supervision processes; how these documents conceptualise supervision; and how they balance the production and people components of supervision.
The article then explores how those involved in implementing the WBOT strategy perceive the current supervision practice versus prescribed policy and training documents. This study aims to contribute towards understanding of the design of supervision strategies, and their alignment with the implementation of support and supervision processes in CHW programmes.
The study was based in two districts of the North West Province, an early adopter of the programme. The province started implementation immediately after the NDoH announced the programme in , with pilot teams in all 19 sub-districts across the province by By December , A descriptive qualitative study of policy and practices related to supervision of WBOTs in two districts of the North West Province was conducted.
To explore practices, focus group discussions were held with facility managers, team leaders and community health workers involved in the immediate supervision system of WBOTs in two districts of the North West Province. Focus group discussions were conducted in one sub-district in each district. From each sub-district, one older and one recently established outreach team and their associated PHC facility managers were purposefully sampled. The four ward-based outreach teams were purposefully sampled, in consultation with sub-district managers, as being typical examples of functioning WBOTs established in the earlier and later phases of the programme, and for their knowledge and experience, and therefore, potential as information rich cases.
The document review was conducted on all NDOH policy and training documents, which contained any text relating to supervision or support of the WBOT programme. The remaining documents were obtained from the provincial office responsible for overseeing the programme. The district confirmed that they used most of them as reference documents. The documents include a set of guidelines issued in the inception stages of the programme , three guides for CHWs , team leaders , and middle to top managers , respectively, and a recent policy framework The documents are listed in Table 1 in chronological order of publication.
All the text related to supervision and support for CHWs and the WBOTs was extracted from the documents and entered into an excel spreadsheet.
The text was organised along the three domains of supportive supervision management, development, support that emerged from the literature.
Within each of the three domains, themes and sub-themes and the specific elements were inductively coded based on the material in the documents.
Both authors agreed on the framework for the analysis and read the documents. The first author TA did the coding, which was then discussed and validated with the second author HS. A semi-structured interview guide with open-ended questions on the supervision of WBOTs was used to conduct focus group discussions FGDs with a total of 40 respondents Table 2.
Respondents were provided with information sheets to familiarise themselves with the research topic and given an opportunity to ask questions. They gave written consent to participate in the study and were made aware of their right to withdraw from the study at any time. FGDs were conducted with the three categories—facility managers, team leaders and CHWs—as separate groups to avoid power relations arising from professional status and hierarchies inhibiting participation.
A semi-structured FGD guide loosely structured the discussion, allowing for probing for more information and seeking clarification where necessary. All the interviews were conducted in English, including the CHWs, all of whom have at least secondary level schooling and attend training programmes in English. Analysis of FGDs was done using the thematic content analysis approach [ 40 ]. The researchers read all the transcripts to familiarise themselves with the text, then identified codes, categorised the codes and developed themes and sub-themes that emerged from the text based on the three basic functions of supervision management, development and support.
The researchers then analysed the strengths, weaknesses, gaps and alignment between the official positions on supervision from the document review with practices from the interviews. The trustworthiness of the study was thus enhanced by these well-established local relationships, shaping the depth and quality of FGDs, and the ability to draw on wider contextual and tacit knowledge in the analysis.
The Toolkit is the first document that was distributed at the beginning of the programme and is widely used as a reference guide for implementation. However, this document remains in draft format and is yet to be revised or issued as a final document. The Policy document is the most recent and most significant of the documents, but lists supervision functions in very summary terms.
Table 3 summarises the official guidance on supervision by document source and theme—management, development and support. Management was further categorised into sub-themes of line authority, performance management and provision of resources. These summary judgements were based on the full text extracted from the documents that talks to supervision provided in Additional file 1. The line authority sub-theme includes the following functions as captured from the documents: the recruitment of team leaders, ideal candidates for team leader positions, CHWs supervisor and team leader supervisor.
According to the documents, districts and sub-districts appoint team leaders and facility managers supervise and participate in the recruitment of team leaders. There is consensus across documents that team leaders are to supervise CHWs and oversee activities of the team and that CHWs report to the facility manager through their team leaders. The performance evaluation sub-theme functions include how to monitor, record and report on performance, and the designation of responsibility for these functions to facility managers and team leaders.
As with the line responsibilities, these functions are addressed in all the documents, bar the CHW Manual, which only mentions that the team leaders manage the performance of team members with no further details. The resources sub-theme includes the provision and management of basic resources and availability of physical space for storage of records and team meetings.
Basic resources for service delivery include transport, stipends, basic clinical supplies and stationery for recording keeping and reporting. The Policy document states that the provincial Department of Health will fund the programme and make available resources for the teams and that it is the responsibility of the facility and sub-district managers to supply and manage these resources.
It further mentions that the department will ensure availability of space for WBOTs through the Ideal Clinic programme, a national clinic accreditation programme. The remaining documents refer to resources in either passing or not at all.
In none of the documents is there a specific list of items to be supplied. The development theme relates to the level of guidance provided in the documents on capacity building for WBOTs members and their supervisors. There is formal training for CHWs and orientation for team leaders, facility managers and middle managers to support the programme.
This capacity building is to be achieved through induction, skills development, clinical guidance and technical support in the form of in-service trainings and workshops. However, this is not categorised by format, frequency and content. The CHW Manual identifies the health promoter as a source of technical support on health promotion but also provides no further details.
The Policy document simply mentions that the department will confirm the training content and method to build the required capacity for CHWs and the development and maintenance of a capacity building system at district level. In general, basic training is well established, but further development post in-service is only superficially acknowledged.
Except for the Team Leader Guide, the documents provide some guidance on how supervisors need to support WBOT members, but do so in very limited terms. In sum, the documents reviewed provide considerable detail on the management functions of supervision, but much less on development and support, the two other crucial pillars of supportive supervision.
All the documents acknowledge the need for supervision and outline basic reporting lines. Neither the Toolkit nor the Policy spells out a comprehensive approach to supervision, support and line authority functions. Rather, decision-making is delegated to sub-national levels. The training documents, on the other hand, provide considerably more detail on the procedures and style of supervisory relationships.
Both the Team Leader Guide and the Management Guide were piloted in the North West Province and distributed through workshops at the beginning of the programme, and the team leaders who were in pilot WBOTs at the time were oriented on the contents. However, the induction workshops were subsequently discontinued and the Team Leader Guide document was then distributed as part of the team leader package, where its status remains semi-official. While the documents reviewed refer to supervision in various places, currently, there is no standalone, overarching and coherent framework or document for the supervision of CHWs and WBOTs.
Moreover, most of the documentation, which exists, although widely available and referenced, has uncertain status. In establishing the line authority function of WBOTs, the North West, as other provinces, struggled to attract professional nurses as team leaders to rural areas where most of the WBOTs are based. As a result, the province sought to recruit professional nurses from facilities and retired nurses to work as team leaders. Team leaders were recruited in a variety of ways, most commonly volunteering to take on the role.
I heard over the radio that there was an advertisement… So I went to the district office to find out about that … it was confirmed and then we had to do some applications and … we were called for an interview. In most areas, facility managers were tasked with supervising the outreach teams. The facility managers were also not involved in the recruitment of team leaders. As indicated, performance evaluation forms to enable team leader to monitor and review the performance of CHWs were developed and distributed during the inception phases of the programme in the North-West.
There was no formal performance review system for team leaders and WBOTs as a whole. This was compounded by the fact that CHWs and retired nurses as team leaders were contracted on a short-term basis with no performance agreement. As a result, facilities felt they had no control over the functions of team leaders and WBOTs, even if informal monitoring took place.
Some facilities also reported holding meetings with the WBOTs to update each other on achievements and challenges within the communities. At the beginning of the programme, the department provided the majority of the CHWs with kit bags as part of their phase 1 training.
These bags had basic supplies such as bandages, gloves, and condoms. The districts instructed facilities to replenish the supplies of WBOTs reporting to them on an ongoing basis. However, CHWs indicated that the supplies were limited and not provided regularly. Some facility managers made mention that they provided resources such as gloves and nappies to outreach teams.
All teams indicated that they did not have space to work and had to improvise with solutions to do their work and keep records safe. There is shortage of transport in the province, and in instances where wards are vast, households are hard to reach on foot. Trainers include maternal and child programme coordinators, team leaders and professional nurses, who are not necessarily team leaders.
Team leaders are encouraged to attend CHWs trainings to familiarise themselves with the curriculum and observe how CHWs perform in the training. In some instances, team leaders are also trainers. As indicated earlier, in the inception phases of the programme, the department provided a non-compulsory 5-day orientation workshop for team leaders in the province.
However, team leaders recruited beyond the pilot phase were not offered these workshops. Team leaders regarded it as their responsibility to provide CHWs with in-service training to improve clinical and technical skills and appeared motivated to improve the capacity of CHWs. Team leaders were also reported to have good relations with CHWs. Outreach teams interacted with facility staff, but WBOT members generally felt that facility managers did not understand the role of the teams.
Facility managers were described as putting pressure on teams to assist in the facilities. A fundamental challenge that limits the effectiveness of WBOTs in South Africa is their poor integration into local health systems, which in turn undermines the role of CHWs in community healthcare.
A study in Uganda, for example, found that creating a bidirectional feedback loop by holding monthly meetings and using data collected timeously improved CHW activities and ensured that the continuum of services from community to facility is maintained. In addition, support from community leaders and social workers as well as community acceptance plays an important role in the success of the CHW programme.
Evaluating the interaction of CHWs and the community from a cultural and gender perspective is therefore imperative; for example, male community members may resist interaction with female CHWs. When making these decisions to introduce male CHWs into the programme, it is imperative to adopt an approach that is conducive to developing supportive relationships between CHWs and community members that improve health-seeking behaviour.
Minimal, inconsistent or irregular payment of stipends remains a critical challenge in maintaining CHWs interest and involvement in community-based programmes. For example, a lack of comfortable footwear and umbrellas to protect CHWs from harsh weather elements may prohibit them from conducting household visits. The fact the CHWs have not been provided with official uniforms or name tags may also present a problem with regard to identification and authority of the CHWs in the community and health systems.
Funding constraints also mean that CHWs often lack resources to travel to households, meetings and training sessions. Hermann et al. Moreover, the use of mobile technology should be considered to assist CHWs with their tasks and to improve communication. Studies show that the use of mobile technology by CHWs to collect field-based health data, receive reminders and alerts, facilitate health education and conduct person-to-person communication improved quality of care, service efficiency and programme monitoring.
They are therefore expected to have adequate knowledge to do their work. However, sustaining and updating knowledge through continual training is a challenge.
Phase two training is currently underway, which will address knowledge gaps. This, in turn, can arouse a feeling of stigmatisation in community members which may result in individuals refusing to talk to CHWs, providing incorrect contact information, pretending to be someone else when visited by CHWs and asking to change the location of CHW visits. For example, there has been a report of CHWs specifically providing ART adherence support, trying to conceal their identities when visiting households by refraining from wearing uniforms given to them by their NGOs and pretending to be selling various commodities.
This may enable individuals to feel more comfortable to provide accurate medical information to their CHWs and details regarding treatment options can be shared with them by CHWs.
This will also enable individuals to build relationships with external sources of support such as CHWs and PHC facilities in order to obtain healthcare advice and treatment. The policy may include ethical guidelines governing their roles, such as the requirement of registration with health bodies currently not required , ethics training and the legal framework in which the CHWs operate. This may improve CHWs credibility in the community.
We have presented several examples of successful CHW initiatives. CHW efforts can lead to improved health outcomes by improving community access to PHC in terms of health education, patient linkage to and retention in care.
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