Integrating community health workers into the formal health system to improve performance: a qualitative study on the role of on-site supervision in the South African programme.

Objectives: To explore the role of on-site supervision in community health worker (CHW) programmes and CHW integration into the health system. We compared the functioning of CHW teams reporting to a clinic-based nurse with teams supervised by a community-based nurse. We also consider whether a junior nurse can provide adequate supervision, given the shortage of senior nurses.

Design: A case study approach to study six CHW teams with different configurations of supervision and location. We used a range of qualitative methods: observation of CHW and their supervisors (126 days), focus group discussions (12) and interviews (117).

Setting: South Africa where a national CHW programme is being implemented with on-site supervision.

Participants: CHWs, their supervisors, clinic managers and staff, district managers, key informants from the community and CHW clients.

Results: Effective supervisors supported CHWs through household visits, on-the-job training, debriefing, reviewing CHWs' daily logs and assistance with compiling reports. CHWs led by senior nurses were motivated and performed a greater range of tasks; junior nurses in these teams could better fulfil their role. Clinic-based teams with senior supervisors were better integrated and more able to ensure continuity of care. In contrast, teams with only junior supervisors, or based in the community, had less engagement with clinic staff, and were less able to ensure necessary care for patients, resulting in lower levels of trust from clients.

Conclusion: Senior supervisors raised CHW skills, and successfully negotiated a place for CHWs in the health system. Collaboration with clinic staff reduced CHWs' marginalisation and increased motivation. Despite being clinic-based, teams without senior supervisors had lower skill levels and were less integrated into the health system.