Sub-national perspectives on the implementation of a national community health worker programme in Gauteng Province, South Africa
Sub-national perspectives on the implementation of a national community health worker programme in Gauteng Province, South Africa
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DOI：
10.1136/bmjgh-2019-001564
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发表时间：
2019-11-01
影响因子：
8.1
通讯作者：
Eyles, John
中科院分区：
文献类型：
--
作者：
Munshi, Shehnaz;Christofides, Nicola J.;Eyles, John
简介 2011年，根据全民健康覆盖的原则，南非将社区卫生工作者（CHW）正式纳入国家卫生系统，以加强初级卫生保健。国家政策建议建立由专业护士监督的社区卫生工作者团队，称为基于病房的初级卫生保健外展团队（WBPHCOT）。本文在实施阶段框架的指导下，探讨了 WBPHCOT 和管理者对南非一个地区 CHW 计划实施早期阶段的看法。 方法 我们进行了一项定性研究，包括 5 次焦点小组讨论以及对 CHW、团队领导和管理者的 14 次深度访谈。对数据进行内容分析。结果由于国家政策模糊、实施方案仓促，早期实施存在明显缺陷。在安装阶段，针对差距进行了调整，包括任命街道经理和注册护士作为团队领导。社区卫生工作者和团队负责人履行其职责的工作人员准备不足。作为补偿，团队成员互相支持，并尽可能提供技术技能方面的协助。结构性问题，例如社区卫生工作者领取津贴而不是就业，是持续存在的实施挑战。另一个挑战是设施经理受雇于当地政府机构，而社区卫生工作者计划被视为省级计划。 结论 复杂计划的实施需要所有利益相关者拥有共同的愿景。适应发生在不同的实施阶段，这需要反馈机制来为其他环境中的实施提供信息。 CHW 计划代表了一项政策进步，但缺乏人力资源、预算、监督、培训和可持续性方面的细节，这使得该计划难以耕耘。这项研究指出，如果没有适当关注实践的细节，渐进式改革仍然充满挑战。
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.