Browsing by Author "Assegaai, Tumelo"

Now showing 1 - 7 of 7
  • Thumbnail Image
    Item
    Developing a district level supportive supervision framework for community health workers through co-production in South Africa
    (BMC, 2021) Assegaai, Tumelo; Schneider, Helen; Scott, Vera
    One of the key challenges of community health worker (CHW) programmes across the globe is inadequate supervision. Evidence on effective approaches to CHW supervision is limited and intervention research has up to now focused primarily on outcomes and less on intervention development processes. This paper reports on participatory and iterative research on the supervision of CHWs, conducted in several phases and culminating in a coproduced district level supportive supervision framework for Ward Based Outreach Teams in a South African district.: Drawing on a conceptual framework of domains of co-production, the paper reflects on the implications of the research process adopted for participants, generation of research knowledge and recommendations for practice, as well as lessons for research on the supervision of CHWs.
  • Thumbnail Image
    Item
    Factors associated with workplace and interpersonal trust in the supervisory system of a community health worker programme in a rural South African district
    (Kerman University of Medical Sciences, 2022) Assegaai, Tumelo; Schneider, Helen
    Key to effective supportive supervision, and ultimately performance of community health workers (CHWs), is the nature of relationships in the formal health system at the coal face of programmes. The central character and defining feature of effective relationships, in turn, is the ability to engender trust. This study describes factors associated with workplace and interpersonal trust, the relationship between the two sets of trust factors and how this shaped perceived performance of CHWs in ward-based outreach teams (WBOTs) in a rural South African district. : In the context of a wider study of supportive supervision of CHWs, factors recognised to be associated with trust in the literature were studied qualitatively in Ngaka Modiri Molema district, North West Province. Focus group discussions (FGDs) and individual interviews were conducted by the first author with CHWs (23), team leaders (12), facility managers (10) and middle managers (5). Interviews were recorded, translated and transcribed. Perceptions of trust factors associated with workplace and interpersonal trust were analysed thematically.
  • Thumbnail Image
    Item
    National guidance and district-level practices in the supervision of community health workers in South Africa: A qualitative study
    (Human Resources for Health, 2019) Assegaai, Tumelo; Schneider, Helen
    Background: Supportive supervision is considered critical to community health worker programme performance, but there is relatively little understanding of how it can be sustainably done at scale. Supportive supervision is a holistic concept that encompasses three key functions: management (ensuring performance), education (promoting development) and support (responding to needs and problems). Drawing on the experiences of the ward-based outreach team (WBOT) strategy, South Africa's national community health worker (CHW) programme, this paper explores and describes approaches to supportive supervision in policy and programme guidelines and how these are implemented in supervision practices in the North West Province, an early adopter of the WBOT strategy. Outreach teams typically consist of six CHWs plus a nurse outreach team leader (OTL). Methods: A qualitative, descriptive study that combined a document review of national policy and guidelines with key informant interviews in two districts of the North West Province was conducted. An overall WBOT policy statement and four guidelines on aspects of the strategy, spanning the period 2011-2017, were reviewed for statements on the three core facets of supervision outlined above. Eight focus group discussions, involving facility managers, team leaders and community health workers (total 40 respondents), purposively selected from four sub-districts in two districts, assessed local-level supervision practices. Alignment across policy and guidance documents and between policy/guidance and practice was examined. Findings: While all the official policy documents and guidelines reviewed acknowledged the need for supervision and support, these elements were inadequately developed and poorly aligned, both in terms of scope and in providing firm guidance on the supervision of WBOTs. The practices of supervision entailed a variety of reporting lines, while development and support processes were informal and often lacking, and teams poorly resourced. There was internal cohesion and support within teams amongst CHWs and between CHWs and OTLs. However, primary health care clinic managers, who were supposed to supervise the WBOTs, struggled to fulfil this role amidst the high workloads in facilities, and relationships between WBOTs and facility staff often remained strained. Conclusion: This study identified weaknesses in both the design and implementation of the supervision system of WBOTs. The lack of explicit, coherent and holistic guidance in policy and the failure to address constraints to supervision at local level undermine the performance and sustainability of the WBOT strategy in South Africa.
  • Thumbnail Image
    Item
    Supervision and trust in community health worker programmes at scale: Developing a district level supportive supervision framework for ward-based outreach teams in North West Province, South Africa
    (University of Western Cape, 2021) Assegaai, Tumelo; Schneider, Helen
    National community health worker (CHW) programmes are to an increasing extent being implemented in health systems globally, mirrored in South Africa in the ward-based outreach team (WBOT) strategy. In many countries, including South Africa, a major challenge impacting the performance and sustainability of scaled-up CHW programmes is ensuring adequate support from and supervision by the local health system. Supervisory systems, where they exist, are usually corrective and hierarchical in nature, and implementation remains poor. In the South African context, the absence of any guidance on CHW supportive supervision has led to varied practices across the country. Improved approaches to supportive supervision are considered critical for CHW programme performance. However, there is relatively little understanding of how this can be done sustainably at scale, and effective CHW supervisory models remain elusive. Research to date has mostly positioned supervision as a technical process rather than a set of relationships, with the former testing specific interventions rather than developing holistic approaches attuned to local contexts.
  • Thumbnail Image
    Item
    Supervision and trust in community health worker programmes at scale: developing a district level supportive supervision framework for ward-based outreach teams in North West Province, South Africa
    (University of the Western Cape, 2021) Assegaai, Tumelo; Schneider, Helen
    Introduction: National community health worker (CHW) programmes are to an increasing extent being implemented in health systems globally, mirrored in South Africa in the ward-based outreach team (WBOT) strategy. In many countries, including South Africa, a major challenge impacting the performance and sustainability of scaled-up CHW programmes is ensuring adequate support from and supervision by the local health system. Supervisory systems, where they exist, are usually corrective and hierarchical in nature, and implementation remains poor. In the South African context, the absence of any guidance on CHW supportive supervision has led to varied practices across the country. Improved approaches to supportive supervision are considered critical for CHW programme performance. However, there is relatively little understanding of how this can be done sustainably at scale, and effective CHW supervisory models remain elusive. Research to date has mostly positioned supervision as a technical process rather than a set of relationships, with the former testing specific interventions rather than developing holistic approaches attuned to local contexts. This doctoral study was exploratory in nature, seeking to generate an in-depth and contextualised understanding of the supervision phenomenon in one specific district in the North West Province (NWP) in South Africa. Using co-production methodology in an iterative approach, the study culminated in the formulation of a supportive supervision framework with CHWs and other frontline actors. Methods: The study was based on a holistic conceptual framework of supportive supervision, which was viewed as comprising three core functions ‒ accountability, development and support ‒ embedded in a complex and multi-level system of resources, people and relationships. To address the study objectives, the research used a mix of qualitative and quantitative methods. Three studies were conducted in a phased process: study 1 comprised a qualitative description of policy and practices in two districts related to the supervision of WBOTs; study 2 identified the main actors and mapped the supervisory system of WBOTs in the district, using social network analysis (SNA); and study 3 involved a qualitative exploration of workplace and interpersonal trust factors in the district and the supervisory system of WBOTs in the district. These three studies provided inputs for a workshop aimed at developing recommendations for a district-level, WBOT supportive supervisory framework. Four published papers reporting on the research conducted are presented in this thesis. It should be noted that the research was conducted during a turbulent political and administrative period in the NWP, when the WBOT programme changed from being a flagship programme for the country to one in crisis. This shifting context needs to be borne in mind when the findings are viewed and interpreted. Results: The study identified weaknesses in both the design and implementation of the supervisory system of WBOTs, with the absence of clear guidance resulting in WBOTs and PHC facilities performing their roles in an ad hoc manner, defined within local contexts. The study documented evidence of high internal cohesion within WBOTs and (where present) with their immediate outreach team leaders (OTLs). However, the relationships between WBOTs and the rest of the primary health care (PHC) and district health system were characterised by considerable mistrust – both towards other workers and the system as a whole. This occurred against a backdrop of increasing OTL vacancies, and the perceived abandonment of WBOT training and development systems and career opportunities. These findings are not dissimilar to those reported previously on the WBOT programme in South Africa and in programmes in other low-resource settings. Nevertheless, through its in-depth, exploratory and participatory approaches, this study provides additional insights into the phenomenon of supportive supervision. Firstly, in conceptualising supportive supervision as a set of ‘bundled’ practices within complex local health systems, the findings reflected the complexity of everyday realities and lived experiences. Secondly, through the embedded nature of the research and the phased data-collection process, the study was able to observe the impact of wider health system contexts and crises on the coalface functioning of the WBOT programme. Thirdly, the study emphasised how supportive supervision depends on healthy relational dynamics and trust relationships, and, finally, how a co-production approach can translate broad guidance, experience and theoretical understanding into meaningful, local practice owned by all the actors involved. Ultimately, the process of engagement, building relationships and forging consensus proved to be more significant than the supportive supervision framework itself. Conclusion: The lack of explicit, coherent and holistic guidance in developing CHW supportive supervision guidance and the failure to address supervision constraints at a local level undermine the performance and sustainability of CHW programmes. Effective supportive supervisory systems require bottom-up collaborative platforms characterised by active participation, sharing of local tacit knowledge and mutual learning. Supervisory systems also need to be designed in ways that promote relationships and generate trust between CHW programmes, other actors and the health system.
  • Thumbnail Image
    Item
    The supervisory relationships of community health workers in primary health care: social network analysis of ward-based outreach teams in Ngaka Modiri Molema District, South Africa
    (BMJ Global Health, 2019) Assegaai, Tumelo; Schneider, Helen
    Introduction Supportive supervision remains a key challenge to the sustainability of community health worker (CHW) programmes globally. The aim of the study was to identify critical actors and patterns of relationships in the supervision of ward-based outreach teams (WBOT) in a rural South African district. Methods A cross-sectional study of social and professional relationships of WBOTs with other primary health care (PHC) system actors was conducted using a social network analysis (SNA) approach. A structured questionnaire was distributed to CHWs (37), WBOT team leaders (3), PHC facility managers (5) and PHC local area managers (2) (total n=47) assessing interaction patterns of supportive supervision, namely management, development and support. Results The supportive supervision system pivoted around team leaders, who were nurse cadres and who ensured internal cohesion and support among WBOT members. The network patterns also showed the extent of peer support between CHWs in WBOTs. PHC facility staff and middle managers in the subdistrict did not appear to play active roles in the supervision of CHWs and their team leaders. However, there were exceptions, with WBOTs drawing on sympathetic cadres identified among the PHC facility staff for support. Conclusion Supportive supervision of CHWs can be thought of as a system of horizontal and vertical relationships that go beyond just one supervisor-supervisee interaction. In this study, supervisory relationships within teams functioned better than those between teams and the rest of the PHC system. Understanding these relationships is key to designing effective supportive supervision in CHW programmes. SNA can be a valuable approach in identifying the relationships to be strengthened. © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions.
  • Thumbnail Image
    Item
    The supervisory relationships of community health workers in primary health care: Social network analysis of ward-based outreach teams in Ngaka Modiri Molema District, South Africa
    (BMJ Global Health, 2019) Assegaai, Tumelo; Schneider, Helen
    Introduction Supportive supervision remains a key challenge to the sustainability of community health worker (CHW) programmes globally. The aim of the study was to identify critical actors and patterns of relationships in the supervision of ward-based outreach teams (WBOT) in a rural South African district. Methods A cross-sectional study of social and professional relationships of WBOTs with other primary health care (PHC) system actors was conducted using a social network analysis (SNA) approach. A structured questionnaire was distributed to CHWs (37), WBOT team leaders (3), PHC facility managers (5) and PHC local area managers (2) (total n=47) assessing interaction patterns of supportive supervision, namely management, development and support. results The supportive supervision system pivoted around team leaders, who were nurse cadres and who ensured internal cohesion and support among WBOT members. The network patterns also showed the extent of peer support between CHWs in WBOTs. PHC facility staff and middle managers in the subdistrict did not appear to play active roles in the supervision of CHWs and their team leaders. However, there were exceptions, with WBOTs drawing on sympathetic cadres identified among the PHC facility staff for support. Conclusion Supportive supervision of CHWs can be thought of as a system of horizontal and vertical relationships that go beyond just one supervisor– supervisee interaction. In this study, supervisory relationships within teams functioned better than those between teams and the rest of the PHC system. Understanding these relationships is key to designing effective supportive supervision in CHW programmes. SNA can be a valuable approach in identifying the relationships to be strengthened.