Questions/Answers

Please provide a brief summary of the initiative including the problems/challenges it addressed and the solutions that the initiative introduced (300 words maximum) The South African primary healthcare system is under strain due to the high burden of disease. People were presenting at clinics with chronic illnesses instead of at the onset of the illness. The Western Cape (WC) Department of Health (DoH) in the Eden District in partnership with the National Health Insurance (NHI) trained Community Care Workers (CCW) to conduct home visits and inform communities about the need to take care of their health. In 2011, the WC DoH implemented phase 1 of 3 phases in collaboration with the national DoH. Pilot sites were chosen in the under-served communities across the country. In the WC, the rural sub-district of Oudsthoorn specifically the town of Bridgeton was chosen for the development of an appropriate rural model for community care workers in preparation for the full implementation of the NHI in the future. The focus was to develop a CCW model for rural settings, that promotes community health and the prevention of illnesses before it presented at the clinics. The existing model was reactive and not proactive in nature. The Family and Marriage Society of South Africa (FAMSA-NGO) was appointed as the service provider, while training was provided to 20 Community Wellness Workers (CWWs). They were called CWW to differentiate them from the CCWs that was also working in the area. The CWWs created awareness in their community about the basics of good health-care, advised residents about the services at the local clinics, screened for specific indicator illnesses and encouraged adherence/ willingness with prescribed medication, immunization, and family planning, etc. Field Workers were trained to conduct mini-census to gather community data that would assist the NHI to analyze the burden of disease and to determine the impact of proactive primary healthcare.

Eden Health District was chosen as one of the National Health Insurance Pilot sites in South Africa to strengthen the performance of the public health system. Of concern was the optimal usage of Home and Community Based-Care Services (HCBC) within disadvantaged communities. Three Universities conducted a policy review to evaluate the Community-Based services, highlighting a range of constraints in the HCBC system. Several recommendations were made in changing the delivery of HCBC Services. Some suggestions were made regarding the search for an ideal Community Health Worker model. This included the on-going debate by health policy makers on effective means to expand health care coverage to communities to promote health, prevent illnesses, the treatment and care of the ill, and the rehabilitation of individuals after an illness. The objectives of the initiative were to develop and test a rural model for CCWs taking into account the recommendations of the CHBC policy review, with a view of strengthening the performance of the public health system, covering a range of Comprehensive Health Services. This model is a paradigm shift from a reactive to a pro-active approach by Community Care Workers, with the emphasis on wellness and patient self-management.

The envisaged model, in search for the ideal community health worker, is based on the assumption by health policy makers on effective means to expand health care coverage to communities for the promotion of health, the prevention of illness; the treatment and care of the ill and rehabilitation of individuals. The “population coverage approach” for the re-engineering of Primary Health Care for the NHI enhances the focus on community outreach within a CBS platform, where Community Health Workers play an essential role. The focus will be on a Comprehensive package of Care, including infectious diseases, women’s health, infant child and adolescent health, men’s health, mental health, chronic disease management, and clinical care and intervention. The package of care is in-line with the health needs and main Burden of disease as determined in the local rural community.

The envisaged model, in search for the ideal community health worker, is based on the assumption by health policy makers on effective means to expand health care coverage to communities for the promotion of health, the prevention of illness; the treatment and care of the ill and rehabilitation of individuals. The “population coverage approach” for the re-engineering of Primary Health Care for the NHI enhances the focus on community outreach within a CBS platform, where Community Health Workers play an essential role. The focus will be on a Comprehensive package of Care, including infectious diseases, women’s health, infant child and adolescent health, men’s health, mental health, chronic disease management, and clinical care and intervention. The package of care is in-line with the health needs and main Burden of disease as determined in the local rural community.

The package of care addresses the health needs of different groups of the population in line with the Community needs that have been assessed using a standardized tool. This includes: • the need for Family Planning, • TB screening • Need for HIV testing, and • Chronic Disease Management: o Hypertension, o Diabetes, o Asthma and o Mental health. It addresses the needs of unborn babies, newborn babies, adolescents, mothers and men based on Burden of Disease of rural communities

Though progress has been made, it must be seen as a continuous process with work in action: • Within the pilot site, the number of clients that accepted HCT showed a marked increase. This also translated into increases in adjacent health facilities • Increase of 7.3% in immunizations among children younger than 1 year • 68.4% increase in children, less than 5 years, with diarrhoea that visited the clinic. Early identification of sick children for treatment could possibly impact positively on child mortality rate. • The sharp increase in the number of pneumonia cases, for children younger than 5 years. Though it might seem to be alarming, the CHW interventions (Screening, referrals and treatment of sick children) with early identification and referral of sick children could impact positively on the mortality rate of children less than 5 years. • Improved ANC booking rate: < 20 weeks, suggesting some impact by the screening of CHWs. All pregnant women found in households by CHWs who had not booked at the clinic were motivated and referred to the health facilities. • The same positive trend applies to Cervical Cancer Screening where the coverage rate also improved.

• This rural model is an exceptional model that shifted the emphasis of CHWs from a reactive to a pro-active approach and screening with door-to-door coverage, with a shift to wellness and patient self-management. It has never been implemented elsewhere in the rural areas of the Western Cape. • It has shown that these HCBC services can assist the Primary Health Care Facilities in achieving their health outcomes and also releasing some PHC staff from certain duties that can be performed by trained Community Health Workers. • Standardized procedures have been developed, such as screening and referral systems, as well as data management. Of much importance is the range of lessons learnt during the development and testing phases of the project, incorporating aspects such as the Interface between the Community-Based Services platform and Primary Health Care facilities, accurate and reliable data-management processes, etc. • An interactive approach was used, with continuous monitoring and evaluation of processes and interventions implemented. Qualitative and Quantitative assessment processes were used to determine progress with the development and implementation of the new rural model. • This project differentiates itself from similar projects in other provinces as suitable training modules, with appropriate Community Health Worker booklets and patient leaflets were developed

This innovation is original, based on the outcomes of the HCBC policy review that was undertaken in the Eden District: • The CHW booklets and client leaflets that were developed, specifically for CHWs and taking into account the main burden of diseases. Training and refresher courses have been developed in line with the above. The training course has been accredited on a Level 1. • The training for the CHW was appropriate and linked to the needs of the Department of Health. • Appropriate referral and back-referral tools have been developed. • Effective data-management tools have been developed.

Financial: The National Department of Health funded the project since 2012. o For the 2012/2013 financial year, R 1.84 million was set aside. o For the 2013/2014 financial year, R100000 was set aside for the Policy Review. o For the 2014/2015 financial year, R 1.2 million was set aside for the development of the model. o For the 2015/2016 financial year, R 1.2 million was set aside for the testing of the model. o For the 2016/2017 financial year, R1.25 million was set aside for the roll-out of the model. In addition, the Eden Health District Office contributing R 600000 and the Oudtshoorn Sub-district Management contributed 200000 to the development, testing and roll-out of the rural model. Human resources: An NPO nurse and 20 CHWs were appointed via an NPO, as well as project managers for developing and testing the model, and a project manager for the interface management role during the roll-out phase. Supporting materials: A range of printed materials was used by the CHWs: This included training course material for CHWs; CHW Booklets and Client Leaflets of Chronic Conditions, and Woman’s and Child Health; Household registration and assessment forms; Household surveys; Screening tools; Referral tools and Data management tools.

Yes

The project and rural CWW model that has been developed in Oudtshoorn is highly replicable, with standardized: • CHW and Supervisor Job descriptions and procedures, • Household assessment, • Client screening tools, • Client referral tools • Data-management tools • Household survey. It could be replicated elsewhere in disadvantaged rural areas with health needs. This model can be rolled out to any community irrespective of population size, within disadvantaged rural communities. The model is currently being rolled-out throughout the rural areas of the Western Cape, with the emphasis on CHW training. An accredited level 1 Training course has been developed and about 800 CHWs have been trained. It has in a relatively short period shown that it does correlated with some improvement on the health services of local communities in the five rural districts of the Western Cape.

The project funding from National Department of Health ended 31 March 2017. However, the project has been accepted as the rural model for Community Based Services platform in the Western Cape Province and has been funded by the Western Cape Provincial Department of Health, as part of it normal ongoing health activities. The model has been rolled out in all the rural districts in the Western Cape. The main challenge is to obtain continued buy-in from all key-stakeholders, with positive outcomes on select Health Indicators. The model developed was firstly based on Institutional sustainability, where the relevant institutions (e.g. Health clinics and NPOs) will be able to be self-sustainable in future. Set procedures and management tools have been developed that are sustainable. Institutions have or can in future be capacitated to deliver such services to impoverished communities. The role out and sustainability of the project does not rely on any additional funding. The existing usage of funds and staff employed could be used (with some staff re-orientation) to sustain the project. From a household and community perspective the model has proven that the community is positive towards the new rural model and that they feel that it impacted on them. Expectations of the community must be managed by proper community communication from the health department to ensure sustainability of community buy-in. The project has shown that the project has impacted on some aspects of self-management. This model focuses on the empowerment of rural communities, to take actions and responsibility for their own health.

The model developed is believed to be durable in time. It is expected that the impact of the project on rural communities will only be seen over an extended number of years. Improving health knowledge within rural communities, their attitudes, lifestyle, and resultant behavioral changes cannot be done overnight. The model has been developed that all role-players re-orientate health services from a reactive to a pro-active approach. As already stated, the project and the resultant model have been thoroughly documented. Standardized procedures (e.g. client screening and referral pathways) and tools and documents have been compiled that can be used in future. The model is based on basic core aspects of Comprehensive health service provision that covers unborn babies, children, men and women. It is envisaged that the project will need to be run over a couple of years in rural communities to obtain maximum health outcomes. The focus is on the training and capacitation of Community Health Workers, and the correct application of tools and procedures. Buy-in from all stakeholders is essential for the long-term sustainability of the model and durability thereof.

Yes

• Continuous M&E of CHW activities A combination of Daily, Weekly and Monthly CHW tally sheets, together with CHW referral and PHC facility back-referral forms were used to quantify outputs of the CHWs and clinics. This data gave reliable statistics on the number of screenings performed, the number of referrals made, the number of clients that actually visited the clinic, and appropriateness of referrals made by CHWs • Independent Household Surveys: These surveys were undertaken to determine how the community experience the initiative; how they experienced the CHWs; what services have been rendered by the CHWs; satisfaction with CHW services. It also focused on CHW referral processes and outcomes of clinic visits. These surveys also determined expectations of the community, and the perceived impact on them in terms of understanding their illness better, improved treatment adherence levels, impact on lifestyle, health and quality of Life. • Health indicators On the PHC platform data was gathered on a range of health indicators (PHC Headcount, TB, HCT, Cervical Cancer screening, etc.)

• Continuous M&E of activities During the project’s development phase 41 141 client visits took place, while 1 854 referrals to the clinics were made (that is 4.5% of all client-visits). Approximately 21.7% of all referred clients attended the local clinic. A high percentage of CHW referrals were deemed appropriate (87.7%) by health professionals. During the testing phase 50 785 people were screened, of which 3 641 were referred to the clinic (7.1% of all screenings). In total 47% of all referred people attended the clinic. High appropriateness levels of referrals have been obtained. • Independent Household Surveys: Survey among clients (693 households) of CWWs indicated positive opinions towards the project and its implementation. They expressed positive sentiments towards the CWWs, and services used at clinics. Most importantly interventions have impacted positively on their understanding of illnesses, adherence levels, responsibility for their health, changing lifestyles, improvement in health and Quality of Life. • Survey among CWWs A CWW survey indicated that they were satisfied with their new roles and responsibilities, working activities, and general relationships. Some negativity was expressed on their stipend and relationship between the CWWs and the clinic. • Health indicators Positive trends have been observed in terms of PHC Headcount, TB, HCT, etc.

Impact was determined by the increase of PHC headcount, and a range of objective health outcomes as obtained from the official Western Cape Primary Health Care Information System. • TB statistics: o Number of TB cases o New smear positive PTB (Pulmonary tuberculosis) • Total Number of clients accepted HIV Counselling and Testing (including antenatal clients) • Cervical Cancer screening (Women attending the health clinic for cervical cancer screening) • PHC Headcount (Number of people attending health facility)

Various stakeholders have been engaged with in designing, implementing and evaluating the project: The initiative formed part of the NHI Pilot Project and was funded by the National Department of Health. The NDoH was continuously engaged with during the entire project, providing business and operational plans with monthly, quarterly and annual performance reviews. Design phase: Academics from local universities (Universities of Cape Town, Stellenbosch, and the Western Cape) conducted a policy review on the Home and Community Based Services platform. A Project Manager from the private sector assisted in developing the framework for the initiative and with the testing thereof Academics from the University of Cape Town and training experts from private companies assisted with the development of CHW Booklets and Patient leaflets on Chronic Diseases, Women’s and Child Health. Implementation phase: A Project Manager from the private sector assisted developing and testing the model, while another manager (also from the Private Sector) assisted with interface management during the roll-out phase of the project. A private company was appointed to develop a level 1 Accredited CHW course. FAMSA Karoo, a local Non-profit organization, was contracted to appoint a supervisor and 20 CHWs during the development and testing phases of the project. Other stakeholders included Sub-district management and staff working at PHC facilities that provided a range of health services (including management oversight) to the clients of CHWs The community living in Oudtshoorn and other Western Cape rural districts were engaged with on an ongoing base, being the main recipients of the Health Services rendered by the CHWs and PHC facilities. They were engaged during the household registration process, household assessment, health screening and referral processes. Evaluation phase: Private companies appointed local community fieldworkers to conduct annual household surveys

The following key lessons have been learnt: • The ability to manage the change in work orientation, from a reactive to a proactive approach, among the NPOs and CHWs as well as to establish healthy work and communication relations between Community-Based Services and the Primary Health Care platforms. This can be overcome by effective interface management between the Primary Health Care and Non-Profit platforms through ongoing communication with continuous feedback on outcomes. • Day to day supervision of the CHWs by the NPO must be in place to ensure the delivery of needed outputs by CHWs and the quality thereof, and by sorting out problem cases within the community. • Systems must be in place to ensure that data-management contributes to the success of the project by providing timeous and accurate data on the work outputs of the CHWs and the PHC facilities. This includes the accurate recording, capturing, analysis of household data with effective Monitoring and Evaluation feedback sessions to all relevant stakeholders • Enhancing knowledge levels of CHWs and supervisors empowering CHWs through continuous training and refresher courses on select health topics • Buy-in from stakeholders on all managerial and operational levels, with shared vision and passion for the project