Implementing comprehensive, integrated, community-based health care for vulnerable communities in South Africa: An evidence-informed model

Lead Research Organisation: University of the Witwatersrand
Department Name: School of Public Health


In low and middle income countries across the world many poor communities have little access to health care. Providing health care is a challenge as the available national resources for health care is limited. People in these communities suffer from infectious diseases such as TB and HIV and from long term health conditions such as diabetes and high blood pressure. In poor communities many people with these conditions do not know they have them. Even if aware of their health condition, people may be unable to access the right treatment. Community Health Workers (CHWs) are local people trained to visit households in their community to identify people who are unwell, help them gain access to health care and support them in treatment. Existing CHW programmes have been successful in tackling infectious disease, as well as improving maternal and child health, but programmes usually focus on a limited range of health problems and do not cater for people with multiple problems. This project will design and evaluate a comprehensive integrated CHW programme that aims to identify and support the treatment of all types of ill health experienced in poor communities.

Research has demonstrated that CHW programmes are successful if there is good programme design, management, integration with the health system, and a good 'fit' with the community. However, there is insufficient evidence on how to operationalise these attributes for a successful comprehensive, integrated CHW service. Policy makers and service providers want to know how many CHWs are needed and at what cost, how are they best supervised, what is the best balance in terms of training, scope of work and household coverage, and how can they remain responsive to their community yet integrated with the health system? We aim to identify the key features of an evidence-informed CHW service model and the lessons for scale up.

South Africa is a middle income country with poor communities who have limited access to health care. The national Government is committed to strengthening primary care through the provision of community-based care by CHWs for these communities. The project will be undertaken in Sedibeng District, Gauteng Province of South Africa. Our collaborator, the District manager, is currently piloting three designs of comprehensive, integrated CHW programme, with different CHW-to-household ratios and different levels of access to supervision for the CHWs. Our objectives are to:
1) observe and interview existing CHW teams to understand how they work, and undertake a community survey to assess coverage,
2) using what we learn, in consultation with local, provincial and national stakeholders and international experts, to design an evidence informed CHW model then,
3) implement the model in two communities,
4) assess the impact by undertaking a survey of the community before and 15 months after implementation, as well as observation and interviews, and
5) to inform policy, implementation and practice.

The project results will inform the national roll out of these programmes by the South Africa Department of Health. By providing sufficient detail about the intervention, its context and evaluation, we expect governments internationally to be able to assess the applicability of the evidence-informed CHW model for their contexts and any adaptations needed. This will inform the use of resources for the provision of health care for poor communities, and the channeling of donor resources from high income country governments and other donor organisations, to maximise health benefit for poor communities.

Technical Summary

Low and middle income countries (LMICs) aim for universal health coverage (UHC) but there is a shortage of resources and qualified personnel. Community Health Workers (CHWs) take on tasks to release nurse time, e.g. household screening. Evidence indicates infectious disease specific CHW programmes are effective in vulnerable communities. But for UHC, comprehensive CHW programmes are needed to tackle the rising prevalence of non-communicable disease. There is little evidence on how to achieve this.

We will identify the features of an evidence-informed CHW service model, and lessons for scale up. The study will be in South Africa where: policy is to establish comprehensive CHW services; innovative service models exist in Sedibeng District; policy makers have requested the research.

An observation study will describe, cost and compare six CHW programmes (two sites each of three different innovative models) to identify what facilitates or impedes success. Data collection: household survey (n=352/model) for health care indicators (e.g. antenatal clinic attendance, vitamin A to under 5s), observation of CHW household visits, interviews with health service and community key informants, CHWs and householders. Analysis will elicit: coverage; costs; affordability; causal links between service model, operationalization, context and effect.

The service model development will be informed by the observation study, three scoping literature reviews, opinions of international experts, and local stakeholders in a consensus workshop using Nominal Group Technique.

We will implement the resulting evidence informed CHW service model for 15 months (where there is no existing CHW programme) and evaluate its impact with survey and process evaluation, using similar data collection to the observation study. Analysis will indicate: impact; how impact is achieved or not; and, costs to health service.

Results will be used by policy makers in South Africa and other LMICs

Planned Impact

The economic and societal impacts from the proposed study are likely to be extensive and wide-ranging. Firstly, a practical, evidence-informed CHW service model will be provided for South African policy makers and practitioners at national, provincial and district level that when scaled up will enable the provision of comprehensive, integrated, community-based care for vulnerable communities. Having drawn on the 'ground-level' experience in Sedibeng, this model will have considered a wide range of implementation challenges. It will be adaptable to suit the varying population densities in rural and urban settings, the human resources constraints in the South African health system, and will include strategies that are likely to facilitate integration of the CHW programme into the health system. Further, consideration of affordability of the model will enhance the financial sustainability of the South African public health sector.

Moreover, by piloting the evidence-informed model, we will generate new knowledge as to which strategies contribute towards to (un)successful implementation and why, as well as system barriers and to how to remove such barriers. This knowledge will, if used, enhance the effectiveness of the South African health services. Furthermore, the collaborative approaches used in the model development workshop and consensus process will provide practitioners with experience of contributing positively to the research process and its role in policy development from the outset, and so strengthen their confidence to engage actively with researchers.

If shown to be effective, the CHW service model will improve health and well-being of communities in the study site during the study, and, if rolled out, other communities in South Africa. The findings of the study will also contribute to international knowledge in this field, and may influence health policy (and so its beneficiaries) in other low and middle income countries. Lastly, researchers and research users (Department of Health, involved from project design to end stages) will enhance their research capacity, knowledge and skills through participation in the project.

The beneficiaries of the research, specific to the project, will be
1. Individual policy makers, managers, and practitioners at facility, district, provincial and national level in South Africa;
2. Organisations such as health clinics, district and provincial departments of health;
3. Individuals living in vulnerable communities who struggle to access care;
4. Researchers and research users who participate in or engage with the project.

Likely time scales of impact differ according to beneficiary. Researchers and research users participating in the project will benefit from the beginning of the project, as well relevant organisations through their ongoing participation in project implementation. Individuals who live in the two pilot sites are likely to benefit directly through the establishment of the intervention. Decision makers (whether policy makers, managers or practitioners) will benefit as the project proceeds through involvement in the stakeholder workshops, and particularly when the finding are available. More distant decision makers are likely to benefit when the findings become widely available through policy briefs, presentations and finally journal articles.
Description Information on both costs and coverage of the district CHW programme
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Participation in a advisory committee
Description Developing a selection tool for Community Health Workers in sub-Saharan Africa
Amount £144,033 (GBP)
Funding ID MR/R000999/1 
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 11/2017 
End 12/2018
Description NIHR Global Health Research Unit
Amount £5,686,768 (GBP)
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 06/2017 
End 05/2022
Description National Research Fund PhD Bursary
Amount R 255,000 (ZAR)
Organisation Norwich Research Park 
Sector Private
Country United Kingdom
Start 01/2018 
End 12/2020
Description Postdoctoral Research Abroad Program (PRAP)
Amount $40,000 (USD)
Organisation Ministry of Science and Technology, Taiwan 
Sector Public
Country Taiwan, Province of China
Start 10/2016 
End 10/2017
Description Pre-PhD internship
Amount R 123,300 (ZAR)
Organisation University of the Witwatersrand 
Department Centre for Health Policy
Sector Academic/University
Country South Africa
Start 02/2017 
End 01/2018
Description SARCHi Health Systems and Policy Research
Amount R 175,000 (ZAR)
Organisation Imperial College London 
Department Centre for Health Policy
Sector Academic/University
Country United Kingdom
Start 01/2018 
End 03/2019
Title Tool assess the quality of care provided by community health workers (QoCAT) 
Description The tool is used by fieldworkers (lay people with some training) when observing community health workers conducting household visits in the community. The tool allows the fieldworker to record the types of conditions that the CHW provided a service for, what health messages they provided, what actions they took and what plans were made. It was developing in South Africa. 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2018 
Provided To Others? No  
Impact There has been a recent expansion of community health worker programmes in many low and middle income countries. Given the importance of their work, investment in these programmes, and the training programmes that have been development, there is a need to assess the quality of the service that CHW provide. As the majority of their work is conducted in households in the community, that is where the assessment should take place. It is costly to have a clinically trained person observing the CHW, and there is the associated ethical issue of whether the person with more clinical expertise should intervene. Hence we developed a tool that can be used by lay people with some training. 
Description Batlhokomedi website 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact The Batlhokomedi Study was provided with a dedicated page in the Centre for Health Policy's website. This page describes the study and provides an opportunity for visitors to download the Research Brief.
Year(s) Of Engagement Activity 2016
Description District meeting 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact We presented our initial research findings to district and sub-district managers to a) determine whether our findings matched their experience; b) discuss the implications of our findings; c) plan for the intervention phase of the study
Year(s) Of Engagement Activity 2017
Description Inception Meeting 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact 9 policy makers joined 7 members of the study team for a study inception meeting hosted at the Centre for Health Policy. This provided policy makers an opportunity to learn about the study, engage with study goals and methodology, and provide input and guidance regarding the development of detailed study implementation plans. The meeting resulted in the formation of a Provincial Advisory Committee, which will continue to provide input and guidance to the study team, and play a role in ensuring the broad dissemination of findings to relevant audiences.
Year(s) Of Engagement Activity 2016
Description Presentation at the Society for Academic Primary Care Annual Scientific Meeting UK 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Presentation to stimulate discussion about the project
Year(s) Of Engagement Activity 2017
Description Provincial meeting 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact We presented our findings to provincial managers and official, and solicited contributions from other districts about their experiences. We also discussed the intervention phase of the research
Year(s) Of Engagement Activity 2017