Sub-national perspectives on the implementation of a national community health worker programme in Gauteng Province, South Africa

Abstract

Key messages What is already known? ► There are often implementation challenges on the ground when new top-down policies are implemented ; the community health worker (CHW) programme implemented in South Africa as part of health sector reform was no different. New programmes need to be integrated in the health system and embedded in the communities they serve. What are the new findings? ► Gaps in the fit between the programme and the organisation of the health system create implementation challenges. ► Applying the Implementation Stages Framework highlighted how gaps in the exploration stage affected implementation of the CHW programme during the installation phase. ► The Implementation Stages Framework recognises that there is movement back and forth between the stages but did not account for the adaptations that occurred on the ground to compensate for gaps and challenges in implementation. ► A thoughtful and capable manager at the district level facilitated the implementation of the new programme , but was insufficient to overcome structural and microlevel challenges. What do the new findings imply? ► A mechanism needs to be established so that adaptations on the ground can be shared with other districts and settings where a programme is being implemented. ► Our study shows that detailed planning for implementation of new policies is critical if programmes are to result in successful sustainable systemic change in community health systems. AbsTrACT Introduction In 2011, in line with principles for Universal Health Coverage, South Africa formalised community health workers (CHWs) into the national health system in order to strengthen primary healthcare. The national policy proposed that teams of CHWs, called Ward-based Primary Healthcare Outreach Teams (WBPHCOTs), supervised by a professional nurse were implemented. This paper explores WBPHCOTs' and managers' perspectives on the implementation of the CHW programme in one district in South Africa at the early stages of implementation guided by the Implementation Stages Framework. Methods We conducted a qualitative study consisting of five focus group discussions and 14 in-depth interviews with CHWs, team leaders and managers. A content analysis of data was conducted. results There were significant weaknesses in early implementation resulting from a vague national policy and a rushed implementation plan. During the installation stage, adaptations were made to address gaps including the appointment of subdistrict managers and enrolled nurses as team leaders. Staff preparation of CHWs and team leaders to perform their roles was inadequate. To compensate, team members supported each another and assisted with technical skills where they could. Structural issues, such as CHWs receiving a stipend rather than being employed, were an ongoing implementation challenge. Another challenge was that facility managers were employed by the local government authority while the CHW programme was perceived to be a provincial programme. Conclusion The implementation of complex programmes requires a shared vision held by all stakeholders. Adaptations occur at different implementation stages, which require a feedback mechanism to inform the implementation in other settings. The CHW programme represented a policy advance but lacked detail with respect to human resources, budget, supervision, training and sustainability, which made it a difficult furrow to plough. This study points to how progressive reform remains fraught without due attention to the minutiae of practice.