Globally, models of extending universal health coverage through primary care are
influenced by country-specific systems of health care and disease management. In 2015 a rapid
assessment of the ward-based outreach component of primary care reengineering was
commissioned to understand implementation and rollout challenges.
AIM : This article aims to describe middle- and lower-level managers’ understanding of
ward-based outreach teams (WBOTs) and the problems of authority, jurisdiction and
practical functioning that arise from the way the model is constructed and has been
SETTING : Data are drawn from a rapid assessment of National Health Insurance (NHI) pilot
sites in seven provinces.
METHODS : The study used a modified version of CASCADE. Peer-review teams of public
health researchers and district/sub-district managers collected data in two sites per province
between March and July 2015.
RESULTS : Respondents unequivocally support the strategy to extend primary health care
services to people in their homes and communities both because it is responsive to the family
context of individual health and because it reaches marginal people. They, however, identify
critical issues that arise from basing WBOTs in facilities, including unspecific team leadership,
inadequate supervision, poorly constituted teams, limited community reach and serious
infrastructural and material under-provision.
CONCLUSION : Many of the shortcomings of a facility-based extension model can be addressed
by an independently resourced, geographic, community-based model of fully constituted
teams that are clinically and organisationally supported in an integrated district health system.
However, a community-oriented primary care approach will still have to grapple with overarching framework problems.