Moving towards universal health coverage (UHC) requires an affordable service platform that enables under-served, vulnerable communities to access care. Vulnerable people often fail to access care, feel unsupported so that they miss appointments, or fail to adhere to treatment schedules. An accessible and affordable service platform requires sufficient numbers of appropriately trained health workers to provide comprehensive primary health care.
Supervised shifting of tasks from expensive, trained staff to others who can perform tasks requiring less specialized knowledge, is one approach to address this need. Programmes that train and deploy community health workers (CHWs; lay people with minimal training), are well placed to support people from vulnerable communities to negotiate access to facility-based care. Research has shown that CHW programmes are successful if there is good programme design and management, integration with the health system, and the programme is designed to be able to meet the community’s needs.
However, there is insufficient evidence on how to put these characteristics into practice. Policy makers and service providers want to know:
how many CHWs are needed and at what cost
what constitutes a manageable workload and travelling distances
is it more effective to have two cadres (one responsible for comprehensive preventative and promotive care and another for the physical care of house-bound patients) to allow the health system to draw on the services of people with lower education levels who are able to provide physical care.
Effective integration into the health system requires a national training programme that ensures integration of the CHW scope of work, supervision, referral networks and supply chain into the hierarchy of the health system. Without this integration, continuity of care is unlikely to be effective, and nurses may resist working with CHWs.
Decision makers ask:
Whether CHWs should operate from a clinic at some distance from the community they serve, or a basic health post located within the community?
Does reporting to a clinic-based nurse facilitate the CHW team’s access to medication & supplies, as well as allow engagement with clinic staff about patients who have been referred?
Does the benefit of having a health post as a base in the community, with a full-time nurse who can do home visits, outweigh these advantages?
With limited numbers of nurses able to supervise CHWs, what strategies might ensure efficient use of these trained individuals?
Could a nurse supervise several teams, if each team had a senior CHW as an immediate supervisor?
South Africa is currently shifting from multiple NGO-led, donor-funded CHW programmes to a national government programme, and is intending to scale up teams of CHWs to provide comprehensive, integrated, community-based care.
In this study CHP will develop a CHW service model based on the key elements of the South African CHW policy, local circumstances and constraints with particular reference to affordability, and an understanding of the literature on barriers and facilitators. To understand the local circumstances, we will evaluate current programmes that are structured in different ways in the Sedibeng Health District (South Africa). We will then review additional international literature where necessary, and seek the opinions of international and national experts, in order to develop several potential models. This will be followed by a consensus-building workshop with local stakeholders in order to select the most appropriate model for implementation. We will implement and evaluate (using a before-and-after design) this model in two pilot sites.
The findings of the study will provide practical lessons for implementing a CHW programme at scale in South Africa and similar settings in other low and middle income countries. Click here to read a brochure about this study.