By: Helen Schneider, Emmanuelle Daviaud, Donnela Besada, Sarah Rhode, and David Sanders
South African Community Health Workers collaborate on interdisciplinary health teams to provide health prevention and promotion services for chronic health conditions. Each worker receives twelve months of training to provide primarily home-based care. Country-wide implementation of the South African program has been slow to implement, and no formal impact evaluations have been conducted to date.
In 2011 South Africa adopted the Ward-Based Primary Health Care Outreach Team (WBPHCOT) Strategy. Outreach Teams are made up of generalist Community Health Workers (CHWs), who are supported by nurses as Outreach Team Leaders and linked (for referral, support, and oversight) to local Primary Health Care (PHC) facilities. These Outreach Teams build upon a pre-existing NGO-based community care and support system that emerged as a response to HIV/AIDS in South Africa.
By early 2017, 42% of the estimated required total of 7,800 teams were reporting activity data through the District Health Information System. A Policy Framework and Strategy was launched in December 2017, and an investment case for the policy has been completed. However, additional resources have yet to be allocated for roll out of the strategy. This and other constraints have led to slow and uneven implementation of the WBPHCOT strategy nationally.
The Policy Framework proposes a generalist CHW whose role encompasses prevention and promotion, adherence support for chronic lifelong conditions, early identification of ill-health through screening and referral, and basic therapeutic, rehabilitative and palliative care. The WBPHCOTs are to work in close cooperation with facility-based health workers, other government departments, NGOs, community structures and the private sector. The major focus is households, with some additional activities in schools and other community venues for childhood development activities.
A standardized and accredited curriculum for a comprehensive CHW cadre has been approved nationally and is being implemented through a decentralized training infrastructure. The training consists of a series of classroom-based and practical trainings that total 12 months in length.
WBPHCOTs are supervised by Outreach Team Leaders, who are higher-level (professional) or mid-level nurses specifically appointed or seconded from local PHC facilities. Teams refer clients and report to designated PHC facilities, which are also supposed to provide supplies and space for the Outreach Teams. There are challenges in the relationship between the communities and the facility teams.
Incentives and remuneration
Remuneration levels for these generalist CHWS are in the range of US$ 150-290 per month, below the lowest rungs of the public sector employment regime and in many instances, below the national minimum wage.
There is widespread support for the reorganization of the community-based health sector, and specifically for the WBPHCOT Strategy. There has been one national process evaluation of the strategy but so far there has been no national impact evaluation.