The challenges of reshaping disease specific and care oriented community based services towards comprehensive goals: a situation appraisal in the Western Cape Province, South Africa
The challenges of reshaping disease specific and care oriented community based services towards comprehensive goals: a situation appraisal in the Western Cape Province, South Africa
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DOI：
10.1186/s12913-015-1109-4
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发表时间：
2015-09-30
影响因子：
2.8
通讯作者：
Qukula, Tobeka
中科院分区：
文献类型：
--
作者：
Schneider, Helen;Schaay, Nikki;Qukula, Tobeka
背景：与该地区其他国家类似，南非目前正在将围绕艾滋病毒和结核病发展起来的结构松散、高度多样化的社区保健系统重新定位为以社区卫生工作者（CHWs）为基础的正式、全面和综合初级卫生保健外展计划。虽然已经很好地描述了建立国家卫生保健规划的困难，但重塑基于正式卫生系统之外的特定疾病和面向护理的社区服务，构成了特别的挑战。本文对南非一个省实施社区服务（CBS）改革所面临的挑战进行了深入的案例研究。方法：与省级利益相关者密切合作，对西开普省的哥伦比亚广播公司进行了为期八个月的多方法情况评估。评估绘制了一个广泛的非政府组织（NGO）的角色和服务提供、人力资源、融资和治理安排，承包和CHW为基础的服务提供基础设施，在该省出现了15-20年。它还收集了广泛的行动者——包括社区、用户、非政府组织、初级保健提供者和管理人员——对哥伦比亚广播公司的现状和未来愿景的看法。结果：虽然对CBS的新方法得到了广泛支持，但实现这一目标仍面临许多挑战。虽然主要由政府资助，但基于社区的交付平台仍然处于正规公共初级卫生保健（PHC）和地区卫生系统的边缘。CHW的角色是从家庭护理系统演变而来的，范围有限。干部的流失率很高，支持系统（监督、监测、融资、培训）、保健科、非政府组织和初级保健设施之间的协调以及分区规划和管理CBS的能力都不发达。结论：重新定位源于艾滋病毒和结核病护理响应的社区服务，带来了一系列相互关联的资源调动、系统设计和治理挑战。这不仅包括使以社区为基础的团队本身正规化，而且还包括在初级卫生保健系统内形成新的角色、关系和思维方式，并在区和分区一级建立更大的能力，以便与政府、非政府组织和社区等多种行为体签订合同并使其参与。
Background: Similar to other countries in the region, South Africa is currently reorienting a loosely structured and highly diverse community care system that evolved around HIV and TB, into a formalized, comprehensive and integrated primary health care outreach programme, based on community health workers (CHWs). While the difficulties of establishing national CHW programmes are well described, the reshaping of disease specific and care oriented community services, based outside the formal health system, poses particular challenges. This paper is an in-depth case study of the challenges of implementing reforms to community based services (CBS) in one province of South Africa.Methods: A multi-method situation appraisal of CBS in the Western Cape Province was conducted over eight months in close collaboration with provincial stakeholders. The appraisal mapped the roles and service delivery, human resource, financing and governance arrangements of an extensive non-governmental organisation (NGO) contracted and CHW based service delivery infrastructure that emerged over 15-20 years in this province. It also gathered the perspectives of a wide range of actors - including communities, users, NGOs, PHC providers and managers - on the current state and future visions of CBS.Results: While there was wide support for new approaches to CBS, there are a number of challenges to achieving this. Although largely government funded, the community based delivery platform remains marginal to the formal public primary health care (PHC) and district health systems. CHW roles evolved from a system of home based care and are limited in scope. There is a high turnover of cadres, and support systems (supervision, monitoring, financing, training), coordination between CHWs, NGOs and PHC facilities, and sub-district capacity for planning and management of CBS are all poorly developed.Conclusions: Reorienting community based services that have their origins in care responses to HIV and TB presents an inter-related set of resource mobilisation, system design and governance challenges. These include not only formalising community based teams themselves, but also the forging of new roles, relationships and mind-sets within the primary health care system, and creating greater capacity for contracting and engaging a plural set of actors - government, NGO and community - at district and sub-district level.