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Task shifting to improve the provision of integrated chronic care: realist evaluation of a lay health worker intervention in rural South Africa
  1. Felix Limbani1,
  2. Margaret Thorogood1,2,
  3. Francesc Xavier Gómez-Olivé3,
  4. Chodziwadziwa Kabudula3,
  5. Jane Goudge1
  1. 1 Centre for Health Policy, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
  2. 2 Division of Health Sciences, University of Warwick, Coventry, UK
  3. 3 MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
  1. Correspondence to Dr Felix Limbani; limbanif{at}yahoo.co.uk

Abstract

Introduction Task shifting is a potential solution to the shortage of healthcare personnel in low/middle-income countries, but contextual factors often dilute its effectiveness. We report on a task shifting intervention using lay health workers to support clinic staff in providing chronic disease care in rural South Africa, where the HIV epidemic and an ageing population have increased demand for care.

Methods We conducted a realist evaluation in a cluster randomised controlled trial. We conducted observations in clinics, focus group discussions, in-depth interviews and patient exit interviews, and wrote weekly diaries to collect data.

Results All clinic managers had to cope with an increasing but variable patient load and unplanned staff shortages, insufficient space, poorly functioning equipment and erratic supply of drugs. These conditions inevitably generated tension among staff. Lay health workers relieved the staff of some of their tasks and improved care for patients, but in some cases the presence of the lay health worker generated conflict with other staff. Where managers were able to respond to the changing circumstances, and to contain tension among staff, facilities were better able to meet patient needs. This required facility managers to be flexible, consultative and willing to act on suggestions, sometimes from junior staff and patients. While all facilities experienced an erratic supply of drugs and poorly maintained equipment, facilities where there was effective management, teamwork and sufficient space had better chronic care processes and a higher proportion of patients attending on their appointed day.

Conclusion Lay health workers can be valuable members of a clinic team, and an important resource for managing increasing patient demand in primary healthcare. Task shifting will only be effective if clinic managers respond to the constantly changing system and contain conflict between staff. Strengthening facility-level management and leadership skills is a priority.

Trial registration number ISRCTN12128227.

  • task shifting
  • lay health worker
  • South Africa
  • realist evaluation
  • chronic care

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Footnotes

  • Handling editor Seye Abimbola

  • Contributors FL was responsible for the research implementation and data collection, analysis and interpretation of data, and drafting and revising the manuscript. MT conceptualised the study, had overall oversight of the research and contributed to the drafting of the manuscript. FXGO and CK supported collection, analysis and interpretation of data and contributed to the drafting of the manuscript. JG conceptualised the study, had overall oversight of the research and analysis and provided the editorial support in the drafting and finalisation of the paper. All authors read and approved the final manuscript.

  • Funding This research was conducted with financial support from Medical Research Council of the UK (MRC UK) under the Global Alliance for Chronic Diseases programme (grant reference MR/JO16020/1).

  • Disclaimer The authors declare that the funders did not have a role in the design of the study and collection, analysis and interpretation of data and in writing the manuscript.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The process evaluation was granted ethics clearance from the Committee for Research on Human Subjects (Medical), University of the Witwatersrand (certificate number M140619) and Mpumalanga Province Research and Ethics Committee. Ethical clearance for the trial was also obtained from the Committee for Research on Human Subjects (Medical), University of the Witwatersrand (certificate number M130964), Mpumalanga Province Research and Ethics Committee and Biomedical Research Ethics Committee, University of Warwick, UK (certificate number REGO-2013-562).

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

  • Data sharing statement The data sets generated during and/or analysed during the current study are not publicly available because qualitative data, although anonymised, can inadvertently reveal the identity of participants, particularly key informants, but are available from the corresponding author on reasonable request.

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