This study shows the extensive outputs of CHWs and their contributions towards reducing the quadruple burden of disease in the Ekurhuleni district.
Developing countries must consider the role of CHW teams in achieving universal health coverage. Much of the existing research on WBPHCOT programmes in SA explored processes and barriers to implementation.[22-25] Current health service indicators that inform routine monitoring for WBPHCOTs largely document input and process indicators such as numbers of teams, compliance, supervision coverage and households registered. There is little published local evidence on the outputs of WBPHCOT efforts in households in SA.
Ekurhuleni has had high child malnutrition rates compared to other districts in the province, leading to greater emphasis of maternal and child health activities by CHWs. Discussions with OTLs suggest that CHWs did find fewer such children, and routine district indicators showed that between 2011-12, when CHWs were first introduced and 2018-19, the severe acute malnutrition rate in Ekurhuleni halved, with most of this decline occurring in the latter three years when the district had the most number of teams. Further research is needed to explore team effectiveness.
Most of the 1108 CHWs have supported their households for three years or longer, providing early screening, referrals, access to birth certificates, social grants and food parcels. This role of CHWs aligns with findings documented in several countries.
Over the duration of this study period, the numbers of CHWs remained relatively unchanged, however, early antenatal screening still improved in Ekurhuleni; from OTL feedback this was possibly due to gradual improvements in CHW performance. Supervision and support are factors that may have helped, even when there is limited funding and CHWs. Globally, CHWs have demonstrated their impact on improving early antenatal care in poor communities.  The increased pregnancy screening, especially in early pregnancy and the identification of unhealthy children in households supported by WBPHCOTs over the study period demonstrates their vital contributions to MCH in Ekurhuleni.
Most CHW screening activities used to be on TB & HIV; these services continued, with fewer clients with TB symptoms being found in CHW households, possibly due to the early TB screening, referrals and treatment. Since 2011-12 a wider range of health conditions are part of the WBPHCOT household screening activities in Ekurhuleni as compared to the past. Infectious diseases and NCDs are commonly seen in both urban and rural areas  related to the growing aging population and the quadruple burden of disease in the country. Given these demographic changes, the role of CHWs in early household screening, referrals and treatment support of hypertension, diabetes and cervical cancer becomes crucial. They can increase early chronic disease diagnosis, improve chronic disease control and reduce complications over time.
Early and appropriate referrals to primary health care services is an important part of access to care. CHWs can make appropriate neonatal or pregnancy referrals.[30,31] Through better education about immunizations and identification of defaulters, over time there were less children to refer, improving child immunization in CHW supported households.
In addition to screening, clients that require care must be referred to PHC clinics. In our study, those with NCDs and requiring immunization had the highest reporting rates to clinics. CHWs are better able to explain to clients reasons for referral, promoting the client to report to the next level of care CHWs influence the health seeking behaviour of mothers and child caregivers, resulting in good reporting to clinics, and contribute to overall district performance on immunization. Evidence of this in Ekurhuleni is that 60-80% of clients referred by CHWs reported to the clinic, facilitating access to care.
Once CHW referred clients report to clinics, they are seen by a clinician. As clients reported to clinics, the health service responded through further investigations, or diagnosis and/or management of conditions. OTLs engaged clinicians on their clients’ behalf, checked the daily number of CHW referrals with those who reported to the clinic and accessed care. Clients referred for pregnancy and immunization had good linkage to care in Ekurhuleni over the years, partly due to fewer numbers and increased clinic staff acceptance of the role CHWs played in early screening and referrals. There was reasonable linkage to care for those with STIs and possible cervical cancer. OTLs played a vital role in enabling access to care. However, not as many NCD, TB and HIV clients were linked to care, possibly due to larger numbers, inferring that the capacity of the health service to respond to CHW referrals was an ongoing challenge.
Physical tracing of defaulter clients in an urban setting in South Africa, is not without its challenges, especially for HIV and TB defaulters. With a large migrant population in urban settings, there are challenges in getting the correct contact details of clients. This problem is reiterated in studies conducted in Kenya and other parts of South Africa. In Ekurhuleni some patients deliberately provide false contact details, while others seemingly move around frequently for jobs and other reasons. This is particularly so for HIV defaulters, as shown in Fig. 11, where only 50-60% of defaulting clients were successfully traced. South Africa has one of the largest anti-retroviral programmes in the world and is struggling to achieve the 90-90-90 targets for initiation of anti-retroviral treatment and retention in care. Although CHWs contributed in finding defaulting HIV clients in Ekurhuleni, to improve this further, there is a need to record accurate patient information when accessing care the first time, updating information regularly and/or getting details of a second contact known to the client. Another factor is stigma around an HIV diagnosis with many patients not disclosing their status to their partners. Many defaulters were also in households not allocated to CHWs and of those they successfully traced, a good proportion did report to clinics. This implied good CHW communication skills. Greater household support and contact with CHW teams has the potential to reduce stigma and defaulters in the long-term.
A large proportion of defaulters who reported to clinics were put back on treatment/care; this positive finding was possibly due to a combination of clinics initiating tracing, awareness by clinic staff of returning patients and less clinical work-up needed. CHWs consistent and improved performance may have also contributed to the improved return to care.
CHWs have the opportunity to provide wider support on the psycho-social determinants of health in these communities, though this was not easily quantified. Where households could be directed to get a birth certificate for a child or an identity document for an elderly person, it meant access to financial support through various welfare grants in South Africa. Accessing these grants would mean access to food, money for medicines, schooling and other essentials. Even though South Africa emphasized a primary health care approach in health policies from 1994; PHC delivery was more curative and clinician driven, with less emphasis on psycho-social services. In discussions with CHW teams they emphasized what they believed is their critical contribution to addressing psycho-social challenges, however no data is collected to support this. Provision of social support reinforces the credibility of CHWs in households leading to improved household relationships.  The mechanisms by which CHWs influence heath behaviour change over time, possibly through this social support, are part of the puzzle of understanding their role, Fig. 14. Future research should explore this aspect further.
Over the years, Ekurhuleni clinics have realized the value of CHW teams as the foot soldiers of the health service within the community. This perception translates to believing that they are the solution to most community related challenges affecting the health system. While the results of this study did not explore nor indicate this, evidence shows that overloading CHWs with too many activities can make them inefficient in their daily tasks. Current workloads with simple tasks and messages across health conditions are reasonable for optimized performance.
There was some reduction in performance of team activities during 2018-19. This is likely to have been caused by two issues. The district was a pilot site for a national standardized training program. Secondly, CHWs were agitating to be made permanent staff. Both these affected household visits in that year. In April 2020, the CHWs in Ekurhuleni were made permanent with salaries, benefits and job security; so performance is expected to improve in subsequent years.
Limitations of this study include that we did not explore quality or retention in care. And although we did not also compare with other districts, South Africa publishes an annual district health barometer each year, which showed that Ekurhuleni had improved in many areas of maternal, child health, TB and HIV.