Developing a district level supportive supervision framework for community health workers through co-production in South Africa

Tumelo Assegaai,Vera Scott,Helen Schneider

doi:10.1186/s12913-021-06350-2

Abstract

BackgroundOne of the key challenges of community health worker (CHW) programmes across the globe is inadequate supervision. Evidence on effective approaches to CHW supervision is limited and intervention research has up to now focused primarily on outcomes and less on intervention development processes. This paper reports on participatory and iterative research on the supervision of CHWs, conducted in several phases and culminating in a co-produced district level supportive supervision framework for Ward Based Outreach Teams in a South African district.MethodsDrawing on a conceptual framework of domains of co-production, the paper reflects on the implications of the research process adopted for participants, generation of research knowledge and recommendations for practice, as well as lessons for research on the supervision of CHWs.ResultsThrough the research process, participants reflected and engaged meaningfully, honestly and productively across hierarchies, and were able to forge new, dialogic relationships. The iterative, back forth feedback, involving a core group of participants across phases, enabled additions and validations, and informed further data collection. The culmination of the process was consensus on the key issues facing the programme and the generation of a set of recommendations for a local, context-specific framework of supportive supervision. The process of engagement, relationships built and consensus forged proved to be more significant than the framework itself.ConclusionThe co-production approach can enable local impact of research findings by providing a bottom-up collaborative platform of active participation, iterative feedback, knowledge generation and mutual learning that can complement guidance and frameworks from above. Although time consuming and not without its limitations, this approach to research has much to offer in advancing understanding of CHW supervision.

Highlights

South Africa, like many other low and middle income countries, has adopted community health worker (CHW) programmes in the face of high chronic communicable and non-communicable disease burdens and human resources for health shortages [1, 2]
Supportive supervision is considered among the key priorities for CHW programmes, and is required to nurture the skills, knowledge, confidence, and motivation of community cadres [9,10,11,12]
Interventions, guidelines and reports on supervision of CHWs are typically designed or developed using an evidence-based approach, as reflected in the 2018 World Health Organization (WHO) guideline on health policy and system support to optimize community health worker programmes [14]

Summary

Introduction

South Africa, like many other low and middle income countries, has adopted community health worker (CHW) programmes in the face of high chronic communicable and non-communicable disease burdens and human resources for health shortages [1, 2]. The country is in the process of institutionalising universal health coverage, with the inclusion of CHWs as a component of Primary Health Care (PHC) [3, 4]. Despite their promise, community health worker programmes across the globe have experienced challenges that include limited training and resources, low trust with other primary health care workers and inadequate supervision [5,6,7,8]. One of the key challenges of community health worker (CHW) programmes across the globe is inadequate supervision. This paper reports on participatory and iterative research on the supervision of CHWs, conducted in several phases and culminating in a coproduced district level supportive supervision framework for Ward Based Outreach Teams in a South African district

Results

Discussion

Conclusion