Bridging the Gap Between National Policy and District Implementation Plans for Integrated Community Health Care Worker Programmes to Strengthen the Health System – Ekurhuleni District, Gauteng, South Africa.

A conversation with: Thoko Maboe

Health care system strengthening is a fundamental aspect towards a well-functioning health system that enables universal health coverage without incurring financial hardships to the individual. Globally there is consensus about the positive impact that the strategy could have in the achievement of the Sustainable Development Goals. In South Africa, the National policy provides guidance on how the Ward-based Community Care Worker programme should be organised and implemented. There are challenges at the implementation level due to the dynamic organisation and the variety of stakeholders rendering services which has an impact on the health system. These services are rendered in different platforms that require a coherent approach by different government departments and non – Government organisations.

The community also presents at health care facilities with all kinds of problems, some lying outside the scope of the health service but having a direct impact on the overall result to be achieved by the health services. District Health Plans are also informed by the demand from the community as well as the burden of disease in the community. The implementation of the CHCW programme is thus constrained by vertical and weak coordination within the District stakeholders.

Ward based outreach team National model Department of Health South Africa.

The teams are responsible for a defined number of households and render integrated services led by a registered nurse based in the local health facility. Currently the CHCWs role extends beyond HIV/TB to include maternal and child health, chronic and non communicable diseases.

Political leadership initiatives Ntirisano project – Gauteng Province.

The Ntirisano project was launched in Gauteng Province by the Premier Mr. D. Makhura on the 11^th September 2014. The project is aimed at strengthening the collaboration between all stakeholders for service delivery and to ensure that people are served where they live to address inefficiencies in resource allocation and duplication of services. The project was launched in partnership with various government departments, field workers from different government departments, NGOs, and Community Health Care workers. The project has been implemented in all Gauteng Districts.

The Ntirisano model is aligned with the social services model which is (Richardson and Patana: 2012) based on individual service providers or a group of integrated service providers which determines the circumstances and needs of the service users. The outer circle represents the connection and integration between service providers. Through the case worker (case management) families can communicate with housing services, legal services, health services and social services. Integration in this model is described as collaboration and cooperation among service providers to maximise better outcomes for service users.

District Integrated Implementation plans for HIV /AIDS and TB.

The District has adopted the 90.90.90 strategy which is monitored on a monthly basis. My experience as a member of this team is that there is a need to strengthen the outreach services for the District to reach the set targets. As one of the task team members indicated “We need to take the primary health services out to the community. There is no way that we can reach these targets by focusing only in the health facilities”.

But then what drives and constrains progress in Ekurhuleni District?

Decentralisation

There is consensus among all stakeholders about an integrated compressive approach to Community outreach services and initiatives have already taken place in different government organisations and political heads. However, the direction between National and Local policy direction is not clear to implementers.

Resources

CHCWs are from different stakeholders with non-standardised conditions of service resulting in duplication, overlap and poor coverage of services. Improvement of conditions of service, supervision and skills development are constrained by limited resources. Pooling of resources from all stakeholders could improve the resources available.

Training, Supervision and support.

The professional nurse model of supervision is costly and difficult to implement. Alternative models of supervision i.e. peer and community by all stakeholders can improve the supervision levels and the quality of services. Integrated training on key performance indicators and burden of disease by all stakeholders is important.