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

在世界各地的低收入和中等收入国家，许多贫困社区几乎无法获得医疗保健。提供保健服务是一项挑战，因为可用于保健服务的国家资源有限。这些社区的人们患有结核病和艾滋病毒等传染病，并患有糖尿病和高血压等长期健康状况。在贫困社区，许多患有这些疾病的人并不知道自己患有这些疾病。即使知道自己的健康状况，人们也可能无法获得正确的治疗。社区卫生工作者（CHW）是经过培训的当地人，可以访问社区的家庭，以确定谁是不舒服的人，帮助他们获得医疗保健，并支持他们接受治疗。现有的保健和福利方案在应对传染病以及改善妇幼保健方面取得了成功，但方案通常侧重于有限的健康问题，不照顾有多种问题的人。该项目将设计和评估一个全面的综合社区卫生福利方案，该方案旨在确定和支持治疗贫困社区经历的所有类型的健康不良，研究表明，如果有良好的方案设计、管理、与卫生系统的整合以及与社区的良好“配合”，社区卫生福利方案是成功的。然而，没有足够的证据表明如何操作这些属性成功的全面，综合CHW服务。政策制定者和服务提供者想知道需要多少社区卫生工作者，费用是多少，如何对他们进行最好的监督，在培训、工作范围和家庭覆盖面方面的最佳平衡是什么，以及他们如何能够在与卫生系统相结合的同时对社区作出反应？我们的目标是确定一个循证的CHW服务模式的主要特点和经验教训，以扩大。南非是一个中等收入国家，贫困社区谁拥有有限的医疗保健。国家政府致力于通过社区保健工作者为这些社区提供基于社区的保健来加强初级保健。该项目将在南非豪登省Sedibeng区进行。我们的合作者，地区经理，目前正在试验三种全面的综合社区卫生工作方案的设计，不同的社区卫生工作者与家庭的比例和不同程度的社区卫生工作者的监督。我们的目标是：1）观察和采访现有的CHW团队，以了解他们是如何工作的，并进行社区调查，以评估覆盖率，2）使用我们学到的，与地方，省和国家利益相关者和国际专家协商，设计一个证据知情的CHW模型，然后，3）在两个社区实施该模型，4）通过在实施前和实施后15个月对社区进行调查以及观察和访谈来评估影响，以及5）为政策提供信息，项目成果将为南非卫生部在全国推广这些方案提供信息。通过提供有关干预措施、其背景和评估的足够详细信息，我们希望国际上的政府能够评估循证CHW模型在其背景下的适用性以及所需的任何调整。这将为贫困社区提供卫生保健资源的使用提供信息，并引导高收入国家政府和其他捐助组织的捐助资源，以最大限度地提高贫困社区的健康效益。

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.