School of Public Health & SAMRC/UWC Health Services to Systems Unit, University of the Western Cape, Robert Sobukwe Road, Bellville, Cape Town, 7535, South Africa.
Centre for Health Policy/MRC Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
Int J Equity Health. 2017 Sep 15;16(1):72. doi: 10.1186/s12939-017-0565-3.
BACKGROUND: National community health worker (CHW) programmes are returning to favour as an integral part of primary health care systems, often on the back of pre-existing community based initiatives. There are significant challenges to the integration and support of such programmes, and they require coordination and stewardship at all levels of the health system. This paper explores the leadership and governance tasks of large-scale CHW programmes at sub-national level, through the case of national reforms to South Africa's community based sector, referred to as the Ward Based Outreach Team (WBOT) strategy. METHODS: A cross case analysis of leadership and governance roles, drawing on three case studies of adoption and implementation of the WBOTs strategy at provincial level (Western Cape, North West and Gauteng) was conducted. The primary case studies mapped system components and assessed implementation processes and contexts. They involved teams of researchers and over 200 interviews with stakeholders from senior to frontline, document reviews and analyses of routine data. The secondary, cross case analysis specifically focused on the issues and challenges facing, and strategies adopted by provincial and district policy makers and managers, as they engaged with the new national mandate. From this key sub-national leadership and governance roles were formulated. RESULTS: Four key roles are identified and discussed: 1. Negotiating a fit between national mandates and provincial and district histories and strategies of community based services 2. Defining new organisational and accountability relationships between CHWs, local health services, communities and NGOs 3. Revising and developing new aligned and integrated planning, human resource, financing and information systems 4. Leading change by building new collective visions, mobilising political, including budgetary, support and designing implementation strategies. CONCLUSIONS: This analysis, from real-life systems, adds to understanding of the processes involved in developing CHW programmes at scale, and specifically the negotiated and multilevel nature of leadership and governance in such programmes, spanning analytic, managerial, technical and political roles.
背景：国家社区卫生工作者（CHW）计划作为基层医疗保健系统的一个组成部分重新受到重视，通常是在基于社区的现有倡议的基础上。这些计划在整合和支持方面存在重大挑战，需要在卫生系统的各个层面进行协调和管理。本文通过南非社区部门的国家改革案例，即基于病房的外展团队（WBOT）战略，探讨了次国家级大规模 CHW 计划的领导和治理任务。
方法：通过对省级采用和实施 WBOTs 战略的三个案例研究（西开普省、西北省和豪登省）进行跨案例分析，分析领导和治理角色。主要案例研究绘制了系统组件，并评估了实施过程和背景。它们涉及研究团队和 200 多次与来自高层到一线的利益相关者的访谈、文件审查以及常规数据的分析。二次、跨案例分析专门关注省级和地区政策制定者和管理者在应对新的国家任务时所面临的问题和挑战，以及他们所采用的策略。由此制定了关键的次国家级领导和治理角色。
结果：确定并讨论了四个关键角色：1. 在国家任务与省级和地区历史以及基于社区的服务战略之间进行协商；2. 定义 CHW、地方卫生服务、社区和非政府组织之间的新组织和问责关系；3. 修订和开发新的一致和综合的规划、人力资源、融资和信息系统；4. 通过建立新的集体愿景、动员政治支持（包括预算）以及设计实施策略来引领变革。
结论：这项来自真实系统的分析增加了对大规模发展 CHW 计划所涉及的过程的理解，特别是在这些计划中领导和治理的协商和多层次性质，涵盖了分析、管理、技术和政治角色。
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