Background: In South Africa, the re-engineering of primary health care (PHC) includes establishing PHC teams, also called ward-based outreach teams (WBOTs), which consist of community health workers (CHWs) who perform health promotion, disease prevention and disease management in households in defined areas. The need to train CHWs properly has been recognised and various training programmes currently exist. A qualification developed by the Department of Higher Education and Training (DHET) to educate potential CHWs is the National Certificate (Vocational) Primary Health programme. Registered on NQF Levels 2, 3 and 4, subjects include Community Oriented Primary Care, Public Health, Human Body and Mind, South African Health Systems, English, Mathematics, and Life Orientation. It has been offered since 2013 on a full-time basis over three years at various Technical and Vocational Education and Training (TVET) Colleges across South Africa. In 2014 the Department of Family Medicine at the University of Pretoria entered into a partnership with the City of Tshwane and Gert Sibande TVET College to present the NC(V) Primary Health curriculum to a cohort of existing CHWs on a part-time basis over four years.
Aim and objectives: This research aimed to evaluate the NC(V) Primary Health qualification to determine whether it is adequate, appropriate, effective, and relevant training for CHWs in PHC teams in South Africa. The objectives of the research were 1) to evaluate the NC(V) Primary Health programme; 2) to determine how the NC(V) Primary Health programme contributed regarding PHC provided to individuals and families in defined geographical areas, curriculated qualifications and human resource development, and individual learning, employment and personal aspirations; 3) to document lessons learnt from the implementation of the NC(V) Primary Health qualification nationwide; and 4) to make recommendations regarding CHW training for South African ward-based outreach teams.
Methodology: The pragmatic evaluation used qualitative methods to gain information from participants in three provinces, from both the full-time and part-time offerings. There were 65 participants in the research, including TVET college managers, NC(V) Primary Health lecturers, curriculum experts, a government consultant, a PHC team leader, NC(V) Primary Health students, and existing CHWs doing the programme part-time. Thirteen in-depth interviews, seven focus groups, five written lecturer reflections, nine written student reflections, and various fieldwork notes were used as sources of data. Thematic analysis of data was performed, and relevant theoretical frameworks were used to make sense of the data. Various policy and curriculum documents were also analysed.
The NC(V) Primary Health programme was well-structured to produce workers with the required competencies in primary health. Students’ understanding and application of theory and practice contributed to growth in critical thinking and development of agency. Participants expressed deep commitment to and belief in the programme. Although the full-time programme did not have sufficient fieldwork learning opportunities, a unique strength was the interprofessional nature of teaching and students benefitted from exposure to various health professionals. Improving English, mathematics and computer skills were also advantageous. Hope at the possibility of second chances and a better future was evident, and some students were able to access further educational opportunities. The programme was regarded by participants as transformative, empowering and, thus, of value to communities. However, frustration and disappointment were apparent from those who had experienced criticism of their participation in the programme or when their learning and contribution was not valued in PHC teams. Disappointment and despondency were palpable among participants regarding the unfolding uncertainty about the future of the programme, and also their own futures.
Conclusion: This study contributes to the ongoing discourse around the education and training of CHWs in South Africa. Careful, respectful and thoughtful regard must be given to the training as people’s lives – individuals, families, and communities – are deeply and directly affected by the training and associated vocational prospects (or lack thereof). CHW education and training programmes should be based on the community oriented primary care (COPC) approach and consider the capabilities of CHWs in context. Novel partnerships and interprofessional contributions will optimise education and training and produce well-rounded and competent CHWs. Structuring of programmes should be in line with the NQF to facilitate career progression and pathways. These findings are in line with policy recommendations from the recently published WHO ‘Guideline on health policy and system support to optimize community health worker programmes’. CHWs should not be underestimated and their voices need to be heard, especially in terms of their contributions and valuable work, their learning needs, and as advocates for the communities they serve.
Keywords: NC(V) Primary Health, Community Health Worker, Education and Training, Primary health care re-engineering, Ward-based primary health care outreach teams