Re-Engineering Primary Health Care: A Formative Process Evaluation of rPHC Implementation in King Sabata Dalindyebo sub-District in the Eastern Cape Province of South Africa
Creators: name: Rabkin, Miriam
name: Mutiti, Anthony
name: Mwansa, Judith
name: Macheka, Tonderayi
name: Austin-Evelyn, Katherine
name: El-Sadr, Wafaa Mahmoud
Publisher: name: Columbia University
Year: 2015
Subjects: Outcome assessment (Medical care)
Medical care--Evaluation
Health services administration
Medical care
Public health

description: In 2010, the Department of Health of South Africa launched a “Re-engineering Primary Health Care” (rPHC) initiative, aiming to shift the focus of primary health care to a health-promoting community-based model. At the heart of the program are ward-based primary health care outreach teams, comprised of generalist community health workers (CHWs) supervised by facility-based nurses. With the support of the Eastern Cape Department of Health (ECDOH), ICAP at Columbia University conducted a formative process evaluation to describe the implementation of ward-based rPHC activities in one sub-district between January 2012 and December 2013. King Sabato Dalyindebo (KSD) sub-district of OR Tambo District was selected by ECDOH as the evaluation location. The process evaluation used both qualitative and quantitative methods, including in-depth interviews with implementers and nurses, focus group discussions with CHWs and community members, structured surveys of knowledge and satisfaction completed by nurses and CHWs, and review of existing DOH data on training and service delivery. Key findings included: 1. Ward-based outreach teams were launched by December 2013. By the end of 2013, KSD sub-district had trained, staffed and launched ward-based outreach teams in all 35 wards, with more than 100 CHWs engaged in community-level activities. 2. Outreach, counseling, and adherence support services were being delivered to communities. CHW encouraged community members to seek facility-level health care services, and assisted in the identification and referral of HIV and tuberculosis (TB) defaulters, linking these patients back to treatment. 3. The outreach teams have added value, but their performance has not been rigorously evaluated. Although implementers and nurses indicated that investments in CHW training had improved the capacity of outreach teams, quality had yet to be assessed. Community members were deeply appreciative of CHW outreach services, but noted some concerns about confidentiality. Lower-than-expected CHW test scores on the evaluation surveys suggest that retention of knowledge may be a challenge. CHWs reported low levels of field-based supervision and minimal feedback or performance reviews, and fewer than half the CHWs rated their own team’s work as good or excellent. 4. Household profiling data have yet to be utilized to guide programming. Although a very large amount of household “profiling” data had been collected, implementers and DOH noted concerns about data quality. In addition, information about the prevalence and distribution of illness had not been aggregated or analyzed by the sub-district or District DOH, and there were substantial backlogs in the aggregation of descriptive data about rPHC activities (e.g., number and type of visits) and entry into the Demographic and Health Information System (DHIS). This prevented DOH from using the data to inform policy or guide programs. In summary, the rPHC program has tremendous potential to link communities with prevention, care and treatment services. The process evaluation highlighted achievements and challenges, as well as areas where intensified support could have substantive impact.