Community-orientated primary health care: Exploring the interface between community health worker programmes, the health system and communities in South Africa

“

TL;DR

This qualitative case study of seven community health worker (CHW) teams in South Africa found that while programmes attempted to follow community-orientated primary care (COPC) principles, their effectiveness was limited by insufficient training, supervision, and funding, as well as community disinterest due to pressing socioeconomic needs like housing. Multidisciplinary support improved CHW skills, but integration into the health system and sustainable resources remained major challenges. The findings highlight that for CHW programmes to succeed, governments must provide adequate funding for training, supervision, supplies, and remuneration.

Full summary

4,902 CHARS

**Background** Community health workers (CHWs) are increasingly deployed in low- and middle-income countries to extend primary health care to underserved populations. Community-orientated primary care (COPC) is an approach that integrates public health and primary care, emphasizing a defined community, multidisciplinary care, evidence-based practice, comprehensive services, integration into the health system, and community participation. South Africa introduced a nationwide CHW programme (ward-based outreach teams, WBOTs) in 2011, building on earlier NGO-led initiatives. This study examined whether CHW programmes in four districts (Sedibeng, Johannesburg, Tshwane, Ehlanzeni) were implemented in accordance with COPC principles 7–8 years after the national rollout.

**Methods** A descriptive case study using multiple qualitative methods was conducted across seven CHW teams in semi-urban and rural areas of Gauteng and Mpumalanga provinces. Data were collected from September 2016 to April 2019. Methods included nine focus group discussions with CHWs (approximately 10 participants each, all women), 98 observations of CHWs during household visits, 17 semi-structured interviews with facility managers, outreach team leaders (OTLs), and community representatives, and 16 key informant interviews with family medicine practitioners, programme coordinators, nurses, and academics. Data were analyzed using inductive thematic analysis and framework analysis, with themes grouped under COPC principles.

**Key Results** - **Defined community and use of evidence**: In Tshwane, Sedibeng, and Johannesburg, teams conducted community diagnoses and household mapping. Tshwane used tablets with a mobile app for data collection, but funding shortages meant lost or damaged tablets were not replaced, forcing a return to paper records. In other districts, paper data were stored at CHW homes and not used to inform care. A key informant in Sedibeng noted, “WBOT asks you questions regarding your needs, but only God knows for what, because I haven’t seen anyone acting on the collected data.” - **Service integration**: Urban sites had catchment areas close to health facilities, enabling supervision. In rural Ehlanzeni, CHWs reported to the facility only on Fridays due to distance, reducing supervision access. One team had no supervisor for a prolonged period (“we have not had a supervisor since October last year”). Supervisors in rural sites lacked transport to accompany CHWs. Relationships with facility staff varied: in some sites, supervisors negotiated for equipment and support; in others, CHWs were called degrading names like “mamoroto” (someone who works with urine). Back-referral forms from nurses were often incomplete, hindering follow-up care. - **Comprehensive and multidisciplinary care**: In urban sites, CHWs received expert advice from multidisciplinary teams (doctors, dieticians, nurses) during weekly meetings. For example, in Tshwane, “the multidisciplinary team consisting of a dietician, doctors, nurses and so forth attended the meeting. They reviewed the difficult cases and advised the CHWs accordingly.” However, CHWs often lacked sufficient knowledge and skills; a key informant stated, “you cannot expect people who are at that level of training, who are not managed properly and without team leaders to function well.” Unmet health needs (e.g., suspected cervical cancer, cataract cases) were identified but could not be addressed due to distant tertiary hospitals and patient transport costs. - **Community participation**: Programme leaders consulted local political and traditional leaders, school managers, and NGOs. In Tshwane, a ward councillor helped secure a health post. In Sedibeng, community leaders built a shelter for patients queuing. However, many residents were more concerned about housing, water, and employment than health services. Protests over service delivery disrupted CHW work; in Sedibeng, a health post was burned down during protests over electricity cuts. CHWs also faced stigma from their previous HIV/TB roles, with some households refusing visits.

**Clinical Implications** The study demonstrates that COPC-informed CHW programmes can improve chronic care management and case detection (e.g., TB, hypertension, child malnutrition in Sedibeng), but their effectiveness is severely constrained by inadequate training, supervision, and sustainable funding. Multidisciplinary support enhances CHW competence, but without integration into the health system and community structures, programmes remain fragile. Governments must allocate sufficient resources for training, supervision, supplies, and remuneration to overcome barriers. The findings underscore that CHW programmes cannot succeed in isolation from broader socioeconomic issues; addressing community priorities like housing and water is essential for meaningful engagement.