Abstract

BackgroundNational community health worker (CHW) programmes are returning to favour as an integral part of primary health care systems, often on the back of pre-existing community based initiatives. There are significant challenges to the integration and support of such programmes, and they require coordination and stewardship at all levels of the health system. This paper explores the leadership and governance tasks of large-scale CHW programmes at sub-national level, through the case of national reforms to South Africa’s community based sector, referred to as the Ward Based Outreach Team (WBOT) strategy.MethodsA cross case analysis of leadership and governance roles, drawing on three case studies of adoption and implementation of the WBOTs strategy at provincial level (Western Cape, North West and Gauteng) was conducted. The primary case studies mapped system components and assessed implementation processes and contexts. They involved teams of researchers and over 200 interviews with stakeholders from senior to frontline, document reviews and analyses of routine data. The secondary, cross case analysis specifically focused on the issues and challenges facing, and strategies adopted by provincial and district policy makers and managers, as they engaged with the new national mandate. From this key sub-national leadership and governance roles were formulated.ResultsFour key roles are identified and discussed:Negotiating a fit between national mandates and provincial and district histories and strategies of community based servicesDefining new organisational and accountability relationships between CHWs, local health services, communities and NGOsRevising and developing new aligned and integrated planning, human resource, financing and information systemsLeading change by building new collective visions, mobilising political, including budgetary, support and designing implementation strategies.ConclusionsThis analysis, from real-life systems, adds to understanding of the processes involved in developing CHW programmes at scale, and specifically the negotiated and multilevel nature of leadership and governance in such programmes, spanning analytic, managerial, technical and political roles.

Highlights

  • Community health workers (CHWs) have a long and varied history in health systems, recently regaining attention [1]

  • Schneider and Nxumalo International Journal for Equity in Health (2017) 16:72 (Continued from previous page). This analysis, from real-life systems, adds to understanding of the processes involved in developing CHW programmes at scale, and the negotiated and multilevel nature of leadership and governance in such programmes, spanning analytic, managerial, technical and political roles

  • Drawing on notions of CHW programme leadership and governance as distributed in health systems and as more than the constitutive dimensions [16], this paper provides an empirical case study of reforms to the community based health sector in South Africa

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Summary

Introduction

Community health workers (CHWs) have a long and varied history in health systems, recently regaining attention [1]. South Africa still has very high levels of avoidable mortality caused by burdens of both communicable and non-communicable disease, as well as injury and violence Much of this burden is preventable, and there is an urgent need to strengthen the preventive and promotive responses of the PHC system. In a “Discussion Document” [20] the Task Team outlined a set of proposals for the establishment of “Ward Based Outreach Teams” of CHWs, led by professional nurses (referred to as “Outreach Team Leader”), linked closely with other community based providers (e.g. environmental health officers), and local PHC facilities They would be assigned to electoral wards, responsible for a defined number of households and accountable to the local health facility. The roles of teams were to be comprehensive: extending beyond HIV/TB to include maternal-child health and chronic non-communicable diseases; with preventive and promotive, in addition to care orientations, and mobilising cross-sectoral collaboration on the social determinants of health

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