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Strengthening Primary Healthcare in South Africa Through Multi-Stakeholder Collaboration and Effort

A CHW Think Tank led by South Africa’s National Department of Health is seeking to address critical gaps facing CHW policy implementation and to support community levelservice delivery improvements.
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South Africa’s history of implementing community health worker (CHW) programs dates back as far as the 1940s, with the introduction of Pholela Community Oriented Primary Care in the country’s KwaZulu-Natal province. In the 1990s, the increased burden of HIV, AIDS and tuberculosis led to the rise of large-scale community-based healthcare services provided by non-governmental and community-based organizations. This happened in collaboration with government, driven under the fundamental principle of community involvement and intersectoral collaboration in the delivery of health services.

However, poor coordination of non-governmental and community-based organizations on one side and government on the other, coupled with discrepancies in CHW models offered by these organizations, resulted in a siloed approach in the provision of community-based services and fragmented CHW programs. Challenging working conditions, vertical scopes of work and interrupted renumeration led to dissatisfaction among CHWs, ongoing labour protests and a need for concerted interventions.

Recognizing the vital role CHWs play in the delivery of healthcare globally and in South Africa, the Johnson & Johnson Center for Health Worker Innovation (the Center) is seeking to ensure that this critical cadre is adequately supported in contributing to visible improvements in access to care, management of the high burden of disease, and supporting the well-being of vulnerable groups within the healthcare system.

A formal structure to support successful policy implementation

“The implementation of WBPHCOTs represents an important milestone in an ongoing effort to transform healthcare in the country and ensure that primary healthcare is strengthened."
– Ramphelane Morewane, Chief Director, District Health Services in the National Department of Health

In 2011, South Africa adopted the Ward-Based Primary Health Care Outreach Teams (WBPHCOTs) strategy consisting of generalist CHWs supported by nurse team leaders and are connected to local primary healthcare facilities which was subsequently approved by South Africa’s National Health Council. However, the formalization of WBPHCOTs through the policy provisions alone will not strengthen community healthcare. There is also a need for other interventions such as increased supportive supervision, enhanced capacity development, and improved monitoring and evaluation across the board.

To this end, the Center, with support from Johnson & Johnson Foundation, is collaborating with South Africa’s National Department of Health and multiple stakeholders to establish a formal “CHW Think Tank” structure, with Health Systems Trust (HST) serving as the Secretariat. In addition to Department of Health, both at a national and provincial level, the Think Tank comprises broad representation, including governmental organizations, non-profit organizations, civil society organizations involved in CHW work, academia, developmental partners and funders, all of which are appointed by the Director General for Health.

The primary aim of this diverse collaboration is to provide technical guidance and support in the review of the WBPHCOTs policy framework and strategy to strengthen implementation thereof and propose recommendations for consideration in the next policy update.

Leveraging the power of co-creation

“The implementation of this policy framework and strategy will bring healthcare closer to vulnerable communities, families and individuals, especially in the rural areas of South Africa, thus building on our national culture of caring.”
– Dr. M.J. Phaahla, South African Minister of Health

This work began in 2020 with a two-day CHW co-creation workshop convened by the National Department of Health and HST. Objectives of the workshop included assessing the gaps between the current status of CHWs versus global best practice and the current status of CHWs in relation to the South African policy context, and identifying the critical policy and implementation gaps and challenges facing CHWs in providing healthcare services.

The workshop created a platform for critical thinking and enabled robust discussion to inform targeted ways to support CHWs and the implementation of the Policy and Framework Strategy for WBPHCOTs. It also laid a foundation for identifying and prioritizing five initial key policy interventions to be addressed by the formalized CHW Think Tank. These include accreditation of CHW training, supported training of CHWs and Outreach Team Leaders (OTLs), supporting the policy review process, evaluating the implementation of a mobile health application, and strengthening monitoring and evaluation of the CHW program.

Although COVID-19 delayed progress, two important interventions focused on training and development of CHWs and the policy review process are now underway as part of year one of execution.

“Through our involvement in the CHW Think Tank, we are reminded of the incomparable impact of a multi-stakeholder approach and what we can achieve when we work together to achieve a common vision,” says Laura Nel, Director for Global Community Impact. “We have seen first-hand how this approach can eliminate duplication of effort, spark more robust debate, provide a platform to leverage best practice and build improved trust and co-operation between all stakeholders. We are proud to work alongside the National Department of Health, which has demonstrated strong leadership as the custodian of this critical work. Together, we remain committed to building and strengthening a primary care health workforce made up of capable, confident CHWs and nurses (OTLs) so that they can provide quality care to the communities they serve.”