A conversation with: Lucia D’Ambruoso, Rhian Twine, Denny Mabetha, Jennifer Hove, Maria van der Merwe, Kathleen Kahn, Stephen Tollman, Sophie Witter
COVID-19 and CHWs in South Africa
South Africa had timely and decisive action in response to COVID-19. Most significant was the lockdown, delaying spread and preventing surge. Community-based public health has been a major focus: 28,000 CHWs were deployed across the country for community screening and door-to-door testing and contract-tracing. CHWs are a key part of South Africa’s COVID-19 response. There are approximately 70,000 CHWs in the country employed by over 3,000 non-governmental organisations (NGOs). As part of commitments to National Health Insurance (NHI), Ward-Based Primary Healthcare Outreach Teams (WBPHCOTs) were introduced in 2011 as part of a significant primary health care (PHC) revival connecting people with services.
Despite significant government efforts to formalise and integrate CHWs into the public health system, however, multiple obstacles exist. Implementation of WBPHCOTs has been slow and uneven and there is low coverage. By 2017, only 42% of the required teams had been established, with many inadequately staffed. There is also relatively low awareness of the expanded CHW roles and functions in communities. Moreover, despite recognition of the potential for WBPHCOTs to promote local action on the social determinants of health, these roles are not well-defined, valued or supported.
South Africa’s COVID-19 response has in large part relied on community-based preventative approaches. Multiple, competing challenges related to the lifting of restrictions, variants of the virus and vaccine preparedness necessitate new forms of cooperative, real-time health systems and policy learning. And, as vaccines become available, delivery at community level will become urgent, with CHWs playing key roles. There is therefore a clear need to support CHWs to connect with communities and to rapidly generate evidence on local needs and situations as part of efforts supporting systems to continuously and collaboratively learn to improve.
The VAPAR (Verbal Autopsy with Participatory Action Research) programme aims to improve the evidence base on the health of disadvantaged populations, and promote utilisation of this evidence in the health system. The process combines verbal autopsy (VA), a method to determine levels and causes of death in settings where deaths go unrecorded, and participatory action research (PAR), a process through which different stakeholders organise evidence for action. To date, we have focused on community-nominated priorities of alcohol and drug abuse, and lack of clean, safe water eliciting community knowledge, quantifying associated burdens of disease, and supporting actors from communities, government and non-governmental agencies to build dialogue, and develop action responding to the issues identified.
The process has built relationships among otherwise disconnected stakeholders. Community stakeholders report that the authorities have started to pay attention to the community voice since VAPAR started and, although changes cannot be directly linked to VAPAR, that service provision has improved in the community. Community stakeholders also report that the processes of raising and framing local issues, and building dialogue with the authorities on feasible, local action to address the issues identified builds strategic, analytical and public-speaking skills and confidence in safe spaces, and shared awareness of local priorities.
We have established conducive working relationships with the provincial department of health (DoH), aligning to DoH priorities, and embedding into routine PHC planning and review. Government stakeholders report finding the process appropriate and relevant to promoting community participation in the health system and a complementary model for community participation in PHC. They are also enthusiastic about opportunities to learn about and engage with other departments to support policy and strategy implementation, and to hear the community voice directly.
The programme’s location in the MRC/Wits-Agincourt Unit’s Health and socio-demographic surveillance system (HDSS) brings additional data to bear on community-nominated priorities. Situating the programme in the HDSS supports the development of spaces and processes to enable engagement, exchange and alignment of external research to national and sub-national priorities facilitating accountability of researchers to local contexts and uptake of research output.
During 2020, we adapted the programme in consultation with local communities and health officials to make practical contributions in the context of the COVID-19 pandemic. We initiated dialogue between community stakeholders involved in the process and CHWs and through this process developed three overarching aims:
- Contribute to the development of capacities supporting CHWs and district health system stakeholders to conduct rapid research on local health issues with participatory methods;
- Facilitate use of evidence in routine PHC planning and review, providing timely data on burden of disease, the human experience of that burden, and on feasible local action;
- Further develop multisectoral engagement supporting community responses addressing social determinants.
Recognition of the need for community mobilisation by CHWs is not accompanied by understandings of how to operationalise the concept in practice. CHWs can contribute significantly to population health improvements, but need support to realise this potential. This need is acute in the context of a dynamic and complex public health crisis. The research will support CHWs to connect routinely with community groups and support rapid generation of evidence on local issues. Understanding the operational contexts and challenges of CHWs will also contribute to the evidence base on implementation of policy and strategy for CHWs.
Important synergies exist in institutional collaboration. We intend to gain insights into the needs of communities while simultaneously navigating system opportunities and challenges. Embedding research into health policy and systems supports situated understandings of organizations supporting new co-produced solutions, and multisectoral action to improve health outcomes. In addition to policy and strategic frameworks on WBPHCOTs, the work contributes towards attainment of the objectives in the Medium Term Strategic Framework and NDP Implementation Plan 2019-2024, onto which the Mpumalanga DoH strategic plan 2020-2024 is anchored, and the district health plan (DHP) and provincial annual performance plan (APP) in terms of enhanced learnership and governance to improve quality of care and to improve quality of service in public health facilities and CHW competencies in community mobilisation.
More generally, supporting the ability to generate and use data for learning is strategically important in all settings, and there is increasing recognition of the need for real-time adaptive learning in the coronavirus response. We have adapted our process to support CHWs to connect with communities, generating and taking evidence to those who organise and provide health and other public services, and working at different levels to understand and enable change. Fundamentally, the process contributes to collective response based in solidarity and shared rights and responsibilities for health and enabling constructive dialogue to build relationships critical for enabling shared responsibilities.