Leadership and governance of community health worker programmes at scale: a cross case analysis of provincial implementation in South Africa
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Date
2017
Authors
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Journal ISSN
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Publisher
BMC
Abstract
BACKGROUND: National community health worker (CHW) programmes are returning to favour as an integral part of
primary health care systems, often on the back of pre-existing community based initiatives. There are significant
challenges to the integration and support of such programmes, and they require coordination and stewardship
at all levels of the health system. This paper explores the leadership and governance tasks of large-scale CHW
programmes at sub-national level, through the case of national reforms to South Africa’s community based sector,
referred to as the Ward Based Outreach Team (WBOT) strategy.
METHODS: A cross case analysis of leadership and governance roles, drawing on three case studies of adoption and
implementation of the WBOTs strategy at provincial level (Western Cape, North West and Gauteng) was conducted.
The primary case studies mapped system components and assessed implementation processes and contexts. They
involved teams of researchers and over 200 interviews with stakeholders from senior to frontline, document reviews
and analyses of routine data. The secondary, cross case analysis specifically focused on the issues and challenges
facing, and strategies adopted by provincial and district policy makers and managers, as they engaged with the
new national mandate. From this key sub-national leadership and governance roles were formulated.
RESULTS: Four key roles are identified and discussed:
1. Negotiating a fit between national mandates and provincial and district histories and strategies of community
based services
2. Defining new organisational and accountability relationships between CHWs, local health services,
communities and NGOs
3. Revising and developing new aligned and integrated planning, human resource, financing and information
systems
4. Leading change by building new collective visions, mobilising political, including budgetary, support and
designing implementation strategies.
CONCLUSION: This analysis, from real-life systems, adds to understanding of the processes involved in developing
CHW programmes at scale, and specifically the negotiated and multilevel nature of leadership and governance in
such programmes, spanning analytic, managerial, technical and political roles.
Description
Keywords
Community systems, Community health workers, Community health system strengthening, National CHW programmes, Governance, Leadership, Stewardship, Strategic management
Citation
Schneider, H. & Nxumalo, N. (2017). Leadership and governance of community health worker programmes at scale: a cross case analysis of provincial implementation in South Africa. International Journal for Equity in Health, 16: 72