There is widespread recognition of the contribution of CHWs through provision of preventative, promotive and curative services to the progressive realisation of UHC [40]. Despite recognition, in practice, CHWs face systemic barriers and biases, which significantly undermines potential. There is a clear need to support CHWs to connect with communities, and in health facilities, as part of a whole-of-society approach [41]. In this study, CHWs reported a range of inter-related capacity problems: inadequate training, low and no pay, precarious employment, hazardous working conditions, unmanageable workloads, poor career progression, critical equipment shortages, and unstable organizational capacity.
Training was a major issue. CHWs trained by WBPHCOTs had an ‘advantage’ in clinic settings, while untrained and unemployed CHWs struggled to adapt and be recognised. In terms of authority, there were reports of embedded biases: discrimination, lack of respect, lack of role clarity and limited opportunities for communication and trust-building. While arguably the best-performing domain, accountability mechanisms were fragile. Together, these issues severely restricted CHWs’ decision space.
The literature confirms and contextualises these findings. There are low levels of integration of CHWs in the formal PHC system, implementation has been slow and uneven, and there is low coverage [17][42]. There is a lack of national leadership and financial support, poor governance, low employment status and pay, political interference, inadequate supervision, and support, particularly in terms of links to facilities, compounded by roles that are poorly defined and supported [17][42]. As of 2020, Mpumalanga DoH has established 235 out of 560 (42%) WBPHCOTs. Nevertheless, the provincial strategic plan 2020-24 aims to absorb all 6,119 CHWs currently funded by CBOs into government contracts [43].
The study assessed a training intervention to support the functionality of CHWs. Initial outcomes suggest a modest but defined improvement in decision space for CHWs. The analysis demonstrated positive impacts in terms of capacity and authority: provision of vital training resources, greater role clarity, and in improved public speaking and analytical skills. It also contributed to promoting accountability: building trust and communication with communities, in the health system and quality relationships between CHWs. The intervention contributed to widening decision space and thus served as an implementation support strategy for PHC re-engineering.
The analysis highlighted contextual and systems constraints. Challenges such as a fair, living wage, stable employment, career progression, workloads, and logistical support were harder for the intervention to address. These are critical issues that require urgent attention. Through the PAR process, issues surfaced were referred to higher levels, and by virtue of the alliances and relationships built, the positioning and probability of remedial action was optimised. Scaled application establishing and sustaining platforms for dialogue, learning and action is now being rolled out beyond the study setting, replicating, and refining the model in the rural province.
While the evidence-base is limited, WHO guidance on optimising CHW programmes sets out the need for core competencies in communication and community engagement and mobilisation [44]. Recommended modalities of training include those that are: theoretical and practical, with priority on supervised practical experience; face-to-face and e-learning, with priority on face-to-face; training in or near the community; in appropriate languages; positive training environments; and inter-professional approaches. There is recognition of the need for evidence on certification or contracting and career ladders, as well as contextualized, realistic HPSR understandings of what works, how, with whom, to what extent and within specific health systems contexts and circumstances [44].
This study was, in part, organised to contribute to gaps identified by Roman et al on understanding and supporting the extent to which authorities have meaningful power for local decision-making [37]. The analysis suggests that synergy across the components is vital in enabling or constraining CHW decision space. In this analysis, accountability mechanisms are present but need to be coupled with improved organisational recognition and, critically, improved resources in a range of areas. Interventions that attempt to impact these core components are relevant for overall health system performance (Fig. 1). Financial, human, administrative, technical, and organizational resources are required to ensure success, scale-up and sustainability and, ultimately, improved local decision-making in the health sector [37][45][46].
The analysis also contributes to the literature on decentralization and its role in health systems improvement. As Roman et al point out, there will be little change where decision space is unavailable [37]. Decentralization has the potential to improve the South African health system experiencing epidemiological transition, with entrenched health inequalities, and an evolving situation in relation to PHC re-engineering, and COVID-19. Widening CHW decision space in this context has the potential to reap great dividends [47]. Decentralization however exists to different degrees and in varying extents across different settings [46][48][49][50].
The analysis suggests that mutually supportive, bottom-up approaches are likely to support PHC reforms and COVID responses, consolidating and harmonising strengths at different levels of the system. ‘Post-COVID’, further challenges play out related to the continued widening and deepening of health inequalities [51], the global human resources for health crisis [52], and the ascendant double burden of infectious and non-communicable disease in LMICs [28][53]. These affirm the need for new forms of real-time health systems and policy learning combining insights from implementation experience with policy and planning [54][55].
Methodological reflections
The analysis was based on a small sample, albeit representative of the surveillance area, and reasonably representative of the province. Positive response bias among respondents may have also been a risk. This was mitigated by triangulating multiple data sources. Deepening the small evaluative evidence base on participatory learning interventions is a priority in future. Decision space is an approach to understand how decentralised health systems operate. It has not been applied in great depth to CHW roles and functions, however, enabled evaluation of a short-term training intervention. In terms of reflexivity and positionality, researchers observed and empathized with female CHWs, in their bid to provide for their families and expectations of resilience.
The analysis supported increased understanding of health workers in lower levels of the system, their difficulties and bureaucratic challenges faced with regards to decentralization. Capacity building of actors in the health system is warranted in this regard. Otherwise, the HDSS institutional base was a major factor conferring legitimacy on the learning platform and process owing to the long-established presence of and trust relationships with rural communities and the district health system. As stable public health observatories, HDSSs occupy strategically important positions to broker data-driven decision-making between people and services.