Exploring the municipal ward based primary health care outreach teams implementation in the context of primary health care re-engineering in Gauteng
Background In order to achieve the Millennium Development Goals, South Africa embarked on a strategy in 2011 to re-engineer its Primary Health care (PHC) system. This included the creation of Ward-based Outreach Teams (WBOTs). Each team comprises six community health workers (CHWs) led by a professional nurse linked to a clinic. The national guidelines prescribe that each municipal ward should have at least one WBOT to improve access to health care and strengthen the decentralised district health system. Implementation of the WBOT policy has varied across the country. Methodology This qualitative study explored WBOT staff and manager views on initial WBOT implementation in the Ekurhuleni health district. Research methods included five focus group discussions with CHWs; 14 in-depth interviews with team leaders and managers; and ethnographic observations. Using the framework analysis approach, data were coded based on themes relevant to the National Implementation Research Network’s (NIRN) Implementation Drivers’ Framework, including: competency, leadership and organizational drivers of the initial implementation processes. The context in which implementation occurred was also an important theme, as derived from the NIRN formula for successful implementation. Results There were significant weaknesses underscoring the current implementation of WBOTs in the district. The experiences of WBOT staff and managers illustrate that competence to perform the ideal roles was compromised by poor staff selection, inadequate training and limited coaching. CHWs complained of precarious working conditions, payment delays and uncertainty of employment contracts. Within the community context, CHWs experienced both positive and negative attitudes from the community and clinic staff from inter alia: traditional beliefs; stigma; and, the perception that CHWs were increasing clinic workloads. Despite this, CHWs valued their expanded role, including the ability to refer to services beyond the clinic such a social services, police and home affairs, and felt motivated by the impact of their work in the communities they serve. Weak organisational processes, compounded by poor planning, budgeting and rushed implementation, resulted in problems with procurement of resources. The lack of support for robust data management led to poor data verification, quality and use for decision-making. Communication challenges revealed leadership deficiencies at the national and implementation levels. This led to confusion about the ownership of the programme and poor integration of WBOT into the service delivery package in traditional clinic settings. Conflicting departmental mandates (between provincial and municipal departments), fragmented leadership and accountability, all lack of insight into the policy objectives and a disabling and ill-prepared context, constrained efforts of WBOTs at the local level. This also affected the embeddedness and acceptance of the programme in clinics and the community, impacting on implementation fidelity. Conclusion Sustainable systemic change requires clear, detailed planning guidelines, defined leadership structures, budgetary commitments, and continuous communication strategies. Furthermore, successful change is dependent on the on-going commitment to human resources development and capacity building, including investment in supervision, quality training, organisational support and competent staff. This study highlights the critical importance of organisational readiness that includes health systems and actor readiness when implementing policies across decentralised systems. Furthermore, adaptation to local contexts must be heeded in policy processes. This study further illustrates that in order to re-engineer PHC, to achieve the vision and values set out by the Alma Ata Declaration, and, to strengthen outreach services across relevant sectors, participation of all relevant actors in the implementation process.
A Research Report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of: Master of Public Health (MPH) School of Public Health Faculty of Health Sciences University of the Witwatersrand 19 June 2017