Expanding Community Health Worker decision space: impacts of a Participatory Action Research training intervention in a rural South African district (preprint)

BACKGROUND While recognised in policy and strategy, in practice, Community Health Workers (CHWs) in South Africa experience many challenges. Since the COVID-19 pandemic, CHW roles have expanded, shifting from communities to clinics. The objective was to assess a community-based training intervention to support functionality and local decision-making of CHWs in rural South Africa, aiding CHWs to undertake new, expanded roles during the COVID-19 pandemic.  METHODS: CHWs from three rural villages were recruited and trained in rapid Participatory Action Research (PAR) methods via a series of workshops with community stakeholders. Training was designed to support CHWs to convene community groups, raise and/or respond to health concerns, understand concerns from different perspectives, and facilitate and monitor action in communities, health, and other public services. Narrative data from in-depth interviews with CHWs before and after the intervention were thematically analysed using the decision space framework to examine functionality in devolved decision-making.  RESULTS: CHWs reported experiencing multiple, intersecting challenges: lack of financial, logistical and health systems support, poor role clarity, precarious employment, low and no pay, unstable organizational capacity, and fragile accountability mechanisms. CHWs had considerable commitment and resilience in the face of COVID-19 in terms of increased workloads, increased risk of infection and death, low job security and poor remuneration. The training intervention addressed some resourcing issues, increased management capacity, gave CHWs greater role clarity, improved community mobilisation skills and forged new community and facility-based relationships and alliances. Through regular spaces and processes for cooperative learning and collective action, the intervention supported CHWs to rework their agency in more empowered ways with communities, clinic staff and health managers, and among peers. The training thus served as an implementation support strategy for primary healthcare (PHC).  CONCLUSION: The analysis revealed fundamental issues of recognition of CHWs as a permanent, central feature in PHC. The training intervention was positively impactful in widening decision space for CHWs, supporting functionality and agency for local decision-making. The intervention has been recommended for scale-up by the local health authority. Further support for and analysis of how to sustain expansion of CHW decision space is warranted.

Realising radical potential: building community power in primary health care through Participatory Action Research (preprint)

BACKGROUND: While community participation is an established pro-equity approach in Primary Health Care (PHC), in practice it can take many forms, and the central category of power is under-theorised. The objectives of this paper were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance.  METHODS: Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of collective evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by rural community stakeholders, who generated new data and evidence with researchers. Dialogue and learning were developed between the authorities and communities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical and local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks.  RESULTS: Co-constructing evidence among community stakeholders in ‘safe spaces’ for dialogue and cooperative action built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptions. The process was subsequently scaled across the sub-district.  CONCLUSIONS: Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process creating spaces where people could create and use evidence to make decisions. Impacts were seen in demand for implementation in outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts and (3) developing and sustaining authentic learning spaces.

‘Voice needs teeth to have bite’! Expanding community-led multisectoral action-learning to address alcohol and drug abuse in rural South Africa (preprint)

ABSTRACT There is limited operational understanding of multisectoral action in health inclusive of communities as active change agents. The objectives were to: (a) develop community-led action-learning, advancing multisectoral responses for local public health problems; and (b) derive transferrable learning. Participants representing communities, government departments and non-governmental organisations in a rural district in South Africa co-designed the process. Participants identified and problematised local health concerns, coproduced and collectively analysed data, developed and implemented local action, and reflected on and refined the process. Project data were analysed to understand how to expand community-led action across sectors. Community actors identified alcohol and other drug (AOD) abuse as a major problem locally, and generated evidence depicting a self-sustaining problem, destructive of communities and disproportionately affecting children and young people. Community and government actors then developed action plans to rebuild community control over AOD harms. Implementation underscored community commitment, but also revealed organisational challenges and highlighted the importance of coordination with government reforms. While the action plan was only partially achieved, new relationships and collective capabilities were built, and the process was recommended for integration into district health planning and review. We created spaces engaging otherwise disconnected stakeholders to build dialogue, evidence, and action. Engagement needed time, space, and a sensitive, inclusive approach. Regular engagement helped develop collaborative mindsets. Credible, actionable information supported engagement. Collectively reflecting on and adapting the process supported aligning to local systems priorities and enabled uptake. The process made gains raising community ‘voice’ and initiating dialogue with the authorities, giving the voice ‘teeth’. Achieving ‘bite’, however, requires longer-term engagement, formal and sustained connections to the system. Sustaining in highly fluid contexts and connecting to higher levels are likely to be challenging. Regular learning spaces can support development of collaborative mindsets in organisational contexts aligning community voice with state capacity to respond.