This study assessed, from the perspectives of recipient CHWs, a training intervention to support professional functionality and local decision-making capability in contexts of decentralising PHC and a public health emergency. The pre–post evaluation surfaced multiple systems constraints that, together, significantly restricted CHW decision space; disconnecting people and services and reversing PHC policy goals. The systemic norms and biases constraining CHW decision space also transmitted clear signals to CHWs about their low value and worth to the system, and did so at a time when CHWs displayed extraordinary resilience and commitment in face of COVID-19.

In terms of capacity and resourcing, there was inadequate training, low and no pay, precarious employment, hazardous working conditions, unmanageable workloads, poor career progression, and critical equipment shortages. Training was a major issue. WBPHCOTs-trained CHWs had some advantage in clinic settings, while untrained and unemployed CHWs struggled to adapt and be recognised. In terms of authority, CHWs experienced discrimination and disrespect as they shifted to support clinics in COVID responses. There was poor role clarity and limited opportunities for communication and trust-building. While supervision structures were generally clear and relationships with communities overall good, accountability mechanisms were fragile.

The intervention contributed to CHW decision space in different ways and through different mechanisms. There were modest, defined improvements in roles (authority) and resources (capacity). Provision of vital training was well-received, as were capabilities for dialogue, which drove greater role clarity. Supportive learning spaces helped CHWs develop analytical, facilitation and public speaking skills, which built individual and collective agency. Public speaking skills were especially valued.

The intervention also improved connections (accountability). CHWs narrated the ‘triple-gain’ of building shared mindsets, trust and communication with communities, the health system, and through quality peer-to-peer relationships. CHWs reported that the principles of democratic involvement and respectful dialogue unlocked learning for them, as well as enabling peer learning and strategic alliance building. The platform closed at least some of the distance between CHWs and higher level systems actors. While employment, careers, pay and conditions were harder for the intervention to address, the intervention was a means to refer systems and structural issues to higher levels, and, by virtue of new strategies alliances and relationships, better positioned for systems response.

While encouraging, initial impacts should be considered relative to operational contexts and challenges. Low levels of CHW integration remain in the formal PHC system. WBPHCOT implementation has been slow and uneven, and there is low coverage [16, 52]. 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, and roles are poorly defined [16, 52]. As of 2020, the provincial DoH has established less than half of the planned WBPHCOTs (235 out of 560 [42%]). While more progress is needed, new policy commitments are driving integration. The provincial strategic plan 2020–24, aims to absorb all 6119 CHWs currently funded by CBOs into government contracts [53].

Overall, professional labour shortages for CHWs and PHC are extensive [54]. In 2021, the DoH reported recruiting an additional 985 CHWs across the country, bringing the total to 48,443 [55]. The following year, however, there was no increase in recruitment owing to COVID and budget constraints [56]. Moreover, the health promotion and prevention focus in PHC Re-engineering overlooks the need for CHW-led curative care, e.g., for malaria and childhood pneumonia, diarrhoea and acute malnutrition [57]. It has been estimated that South Africa would need closer to 400,000 CHWs to redress this balance [57]. South Africa’s disease profile is one of multiple, transitioning burdens of socially patterned illness and disease [40]. Expanded CHW training needs to be integrative: of chronic health conditions as well as their social determinants [58].

Fundamentally, the evaluation underscored that CHWs need to integrate with both communities and services. This necessitates skills and competencies to navigate varied relationships in a sustained, strategic manner [59]. Acknowledging a limited evidence-base, WHO guidance sets out the need for core CHW competencies in communication, and community engagement and mobilisation [60]. Recommended training modalities include: theoretical and practical, with priority on 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 [60]. There is recognition of the need for evidence on certification or contracting and career progression, as well as contextualised, realistic HPSR understandings of what works, how, with whom, to what extent and within specific health systems contexts and circumstances [60, 61].

The study contributes to these gaps, as well as gaps identified by Roman et al. on understanding and supporting the extent of power for local decision-making as part of decentralising health reforms [33]. A limited number of studies explore interactions between accountability mechanisms, resources and organisational capacity and how this influences available decision space. Understanding these functions and how the components interact has the potential to improve the feasibility of functional organisations for CHWs, and improve policy implementation. Synergy across the components was vital in enabling or constraining CHW decision space. In this analysis, accountability mechanisms were present but need to be coupled with improved organisational recognition and, critically, improved resources in a range of areas (Fig. 3). Financial, human, administrative, technical, and organisational resources are required to ensure success, scale-up and sustainability and, ultimately, improved local decision-making in the health sector [62, 63].

Fig. 3
figure 3

Dimensions of increasing decision space

Decentralisation is a response to disinvestment, human resources crises and structural disadvantage in public institutions in LMICs. The depth and extent of which exist across the health system; in how people and their professional roles are subjectively perceived and organisationally valued, and how they are materially resourced. In theory, decentralisation has the potential to support the South African health system to deal with protracted epidemiological transition, entrenched health inequalities, and an evolving situation in relation to PHC re-engineering, and COVID-19 [64]. In practice, HPSR approaches expanding everyday leadership and resilience [65], such as and including widening CHW decision space, have the potential to realise policy goals of close-to-people care. The analysis suggests that mutually supportive, bottom-up approaches can support PHC reforms by consolidating and harmonising strengths at different levels of the system. Structural challenges should not be overlooked. As Roman et al. point out, there will be little change, where decision space is unavailable [33]. There is an immediate and fundamental need to shift CHW temporary contracts to permanent government positions with higher salaries, pensions, leave and sick pay, to improve working conditions and resourcing, and for whole systems improvements in the organisational valuing of the cadre [29, 30].

Methodological reflections

Decision space is an approach to understand how decentralised health systems operate. The framework has not been applied in great depth to CHW roles and functions. The framework structured the evaluation and supported increased understanding of health workers in lower levels of the system, their difficulties and bureaucratic challenges faced. Our approach incorporated different lenses on community health systems encompassing health systems ‘building blocks’, social relations in complex systems, and front-line standpoints [66]. Future work should expand critical analyses on decentralisation and addressing the organisational valuing of the cadre.

Otherwise, the analysis was based on a small sample drawn from the surveillance area, which is reasonably representative of the district and province. This study was concerned solely with CHW perspectives. This was owing to their marginalisation in the system, their being the primary recipients of the training, and in response to calls from the WHO for more research on different training styles, CHWs as active change agents, and elevating CHW voices [5]. Acknowledging the training as inherently mutual, the analysis complements other studies, evaluations and learning from the perspectives of community and health systems stakeholders [38, 43, 44]. Extending and integrating evaluative evidence base on participatory learning interventions is a priority in future.

In terms of the process, stability, predictability, and trustworthiness were important features of the platform during the global public health emergency in 2020/21. The HDSS institutional base conferred legitimacy on the team and platform owing to its established presence and trusted relationships with rural communities and the district health system over 30 years [41]. The research team University and DoH staff, with data collection and analysis led by South African and Ghanian clinical researchers in Universities. As CHW’s experiences were documented, we empathised with female colleagues, in their bid to provide for their families and communities, and in terms of the expectations from resilience and commitment in the face of multiple systems constraints and new threats from a global pandemic.

Codesign was critical. Strategic partnerships between CHWs and health system are important to overcome weakness in CHW programmes [67]. The process was codesigned to be of practical relevance to health systems actors and every design decision was made to provide and expand utility to end-users needs and preferences to support uptake. Formalising, sustaining and embedding the process take time and space with multi-sectoral colleagues adapting methods for use in districts. Continued cooperative working is key as the model is adapted for inclusion into routine health systems functions.

Most CHWs have now returned to ‘usual’ work patterns, with some facilities retaining a 50:50 split between the clinic and community (personal communication, 31 January 2023). ‘Post-COVID’, further challenges play out related to widening and deepening of inequalities [68], human resources for health crises [69], and multiple, intersecting burdens of disease and chronic illness [40, 70]. These affirm the need for new forms of real-time health systems and policy learning, that are inclusive and embrace diverse forms of evidence and learning, combining insights from implementation experience with policy and planning [71]. Our study demonstrates that building meaningful partnerships between CHWs, communities and policy-makers is possible and has the potential to confront and transform the underlying structures of health inequalities.


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