In our study, we examined the role of a roving nurse mentor in building the capacity of two CHW teams led by junior nurses in two primary health facilities in a semi-rural area of South Africa. Initially, with many of the CHW not having finished their schooling, the mentor’s involvement evoked fear in some CHWs, resulting in them being obstructive, or not fully participating in the capacity-building activities. The mentor had to strike a balance between pushing the CHW to try to learn, despite not having positive educational experiences, and adopting a gentler approach that didn’t alienate them; over time the nurse mentor was able to get this balance right, and so improving the CHWs’, and their supervisors’, skills and so building their confidence. In LMIC settings, CHW often may not have finished their school education, and so it is important to provide a supportive environment to overcome their fears of failing again, and so enabling them to achieve their potential (25, 26).
The nurse mentor negotiated with the facility staff to establish three new operational systems to assist the CHW: the book for recording the patients’ delivery dates; working in the vital signs room to practice taking BP measurements; and the list and three visits only to patients who needed to be traced. These systems led to an improvement in the CHW performance, although they were still hampered by the lack of equipment, limited space and the dismissive attitude of junior staff. The CHW needed a dedicated senior person to work out what systems were required and to establish them, and to navigate problems when they arose. Once the nurse mentor left, it was difficult to maintain these systems as negotiation with staff was hampered by existing social hierarchies. However, once the CHW were more integrated into the clinic due to their change in employment status, the facility managers took greater responsibility for the CHW team.
Doherty and Coetzee investigated CHWs and professional nurses’ relationships in South Africa (27). The CHWs reported to be uncomfortable to work with the professional nurses, as they [nurses] often failed to recognise them as members of the health team. Similarly, Payne et al argued the stalemate between clinicians and CHWs is largely due to differences in training (curative and non-curative) (28). Other studies have found some clinicians tend to undermine and marginalize the CHW role (27, 29). Systematic review evidence suggests that health workers negative attitudes towards CHWs affect their performance (30). A study in Malawi found clinicians who were reluctant to give drugs to Health Surveillance Assistants (HSA) to have hindered their role and performance in the community (31). In our study, we found that a senior nurse, who serves as point of authority within the CHW teams, and champions the role of the CHW, is a critical resource in establishing operational systems, and addressing emerging conflicts between CHWs and clinic staff. Once the CHW were employed by the DoH, and so fully integrated into the health system, the facility managers built on what the nurse mentor had achieved; it is unlikely with their workload as a facility managers, that they would have been able to bring the CHWs’ skills and confidence up to the necessary level without the nurse mentor.
International evidence suggests that community members tend to utilise services if the health programme is embedded in the community structures (32–35). For example, Tuyisenge, Crooks and Berry studied the CHW provision of maternal health care services in Rwanda. In this context, village leaders and community security officers assumed the crucial role of ensuring mothers and pregnant women were aware of the maternal and child services available to them at health facility and community level (36). Similarly, Kok et al, explored the relationships between Health Surveillance Assistants (HAS), health system and community and implication for HAS performance in Malawi (34). Volunteers, who belonged to a wide range of community-based committees, also supported the HSAs in completion of their daily tasks and made effort to inform the HSAs of problems that required their attention in the community. Our study found community forums with the potential to collaborate with the CHW programme but these forums were focused on the lack of housing rather than healthcare services. Due to the volatile political situation in the communities, it appeared that the intervention period of only 15-month was too short to establish collaborations with community structures, as well as build relationships in the clinic.
Globally, CHW labour groupings have focused on securing permanent employment, decent wages and recognition of CHWs as contributing members of healthcare system (37–39). Similarly in South Africa, the CHWs are demanding better wages from the government; in Gauteng Province, their persistence resulted in their monthly stipends being increased from R2 500 (143 USD) to R3 500 (200 USD) and being formally employed by the DoH. It appears the CHWs’ protests drew attention to their contribution. Our findings show that paying the CHWs a minimum wage and effectively integrating them into the healthcare system, is critical to CHW motivation and performance. During the COVID-19 pandemic the CHWs in Gauteng Province have been permanently employed by the PDoH, with an increase in salary to R7 500 (491 USD).
The WHO Global Strategy on Human Resources for Health emphasizes the need to align CHW initiatives and programmes to broader national health workforce policies (40); this includes strengthening CHW selection, training and supervision, if CHW effectiveness is to be realised (32). Although the WHO guidelines highlight areas of CHW programmes that need to be looked into, the guidelines however do not adequately acknowledge the chronic shortage of health workers in LMICs, to oversee the CHW programmes (9, 30, 33). Our study provides evidence of a unique CHW supervision configuration, which can be considered for other contexts that continue to experience health worker shortage. Through our 15 months intervention, we demonstrated that a roving, experienced nurse mentor can be responsible for several CHW programmes in a district healthcare system, contribute to the knowledge and skills development of the CHWs, and enhance the capacity of junior supervisors. However, the long term success of this approach is dependent on fair remuneration and the integration that results from employment of CHW by the DoH.
The limitations of the study were, firstly, that the CHWs, their supervisors and facility staff may have changed their normal routines and behaviors during observations (the hawthorne effect). To mitigate this, we observed the same pair of CHWs for at least 3 days; over this time, and the course of the four-year study, we found reverted to their normal behaviours. Secondly, the intervention study was undertaken with two CHW teams, and so this limited our ability to judge how many teams a roving mentor could support. Additionally, intervening in only two CHW teams limits the generalizability of the findings, however, the two facilities and CHW teams were typical of many teams situated in semi-rural parts of South Africa. The study demonstrates some strengths. As far as we know, this is one of the few studies that piloted an intervention to address challenges inherent in many CHW programmes (i.e. insufficient supervision, poor health systems integration and poor relations with local communities). The outcomes imply that with careful consideration of differing contexts, a similar intervention may be useful elsewhere. Furthermore, the use of realist evaluation methodology to understand how local context influenced the actors’ interaction with the intervention (mechanisms) proved to be critical in understanding the dynamics process involved in building CHW capacity in a resource constrained environment.