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

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.

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

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.