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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
  1. Yu-hwei Tseng1,
  2. Frances Griffiths1,2,
  3. Julia de Kadt1,
  4. Nonhlanhla Nxumalo1,
  5. Teurai Rwafa1,
  6. Hlologelo Malatji1,
  7. Jane Goudge1
  1. 1 Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
  2. 2 Warwick Medical School, University of Warwick, Coventry, UK
  1. Correspondence to Dr Jane Goudge; Jane.goudge{at}


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.

  • human resource management
  • organisation of health services
  • qualitative research
  • public health
  • health policy

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  • Contributors YHT analysed and interpreted data, wrote and revised the manuscript with JG, and approved the final manuscript as submitted. FG and JG conceptualised and designed the study, analysed data, critically revised the manuscript and approved the final manuscript as submitted. JdK carried out data collection process, managed data, analysed data, critically revised the manuscript and approved the final manuscript as submitted. NN analysed data, revised the manuscript and approved the final manuscript as submitted. TR and HM analysed data and approved the final manuscript as submitted.

  • Funding MRC-UK under Health Systems Research Initiative (MR/N015908/1). Taiwan Ministry of Science and Technology (105-2917-I-564-006).

  • Competing interests None declared.

  • Ethics approval The study protocol and instruments were approved by the University of the Witwatersrand’s Human Research Ethics Committee (Medical) (M160354), the Gauteng Provincial Health Research Committee in South Africa and the Biomedical and Scientific Research Ethics Committee (BSREC) at Warwick University (REGO-2016–1825), UK.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement A sample of site-specific summary is available in appendix.

  • Patient consent for publication Obtained.

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