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Table 2 Key leadership and governance themes identified in case studies of WBOTs implementation

From: Leadership and governance of community health worker programmes at scale: a cross case analysis of provincial implementation in South Africa

Broad L&G function Province
North West Western Cape Gauteng
Policy formulation/adoption Long standing and widespread support for the district health system and PHC led to ready acceptance and early adoption of the policy A well-established and reasonably governed system of NGO contracting for community based care perceived as different to national WBOTs strategy and led to minimal initial adoption, but later formulation of a comprehensive strategy District based nodes of innovation, led by family physicians and following unique local designs (“health posts”), led to a complex negotiated process of accommodation and adaptation of the WBOTs policy at local level
Reallocation of roles and responsibilities In all three provinces the reorientation of community based services implied new roles, relationships and mindsets amongst all role players in the community based, PHC and district health systems - local health facilities and managers had to play new oversight and coordination roles and be willing to allocate resources (staff, space) in support of teams - new relationships had to be developed with communities and community structures - the roles of the NGO sector had to be redefined - (sub)-district systems had to play a stronger priority setting, planning and monitoring role
Development of new systems In all three provinces, community based services have existed on the margins of the health system, with poorly developed and integrated human resource, financing and information systems. Greater expectations of performance of the community based sector have demanded changes in these systems: - payment of CHW stipends shifted from NGOs to government payroll systems to ensure regular payment (in two provinces) - improved support and supervision from professionals - new curricula and training processes instituted for standardised and comprehensive roles - new M&E systems developed that are aligned with new roles and integrated into the routine district health information systems, and piloting the use of mHealth However: - Financing is still largely from special budget sources (such as HIV/AIDS and TB conditional grants), received from national government, and only partially integrated into core provincial resource allocation mechanisms - Remuneration, conditions of service and career pathing for CHWs have not been adequately addressed - Recruitment and funding of Outreach Team Leaders a key factor in future sustainability
Leading and managing change Rapid adoption of the strategy followed a common collective vision about WBOTs that led to strong leadership of the process at district and sub-district levels. This was accompanied by deliberate scale up processes: planning, piloting, community “dialogues”, implementation support structures, including feedback and accountability At the time of the case study, the province was still in policy formulation stage. In subsequent months there was an incremental process of negotiating new roles and modes of delivery with NGO partners, and developing new training and M&E systems. Piloting of comprehensive roles planned at district level (in the NHI pilot site). Changes happened prior to new policy. The leadership role of family physicians in partnership with DHS management was key, and led to the development of a unique district model. Involved extensive local alliance building (including mobilising local financial resources for implementation)
All provinces face the challenge of generating political, including budgetary commitment, and developing the case for greater investment and resources for WBOTs