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

ABSTRACT

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.