Buthelezi Usangiphile E, van Rensburg André J, Moshabela Mosa, Bucibo Sanah, Radebe Noxolisa, Luvuno Zamasomi, Kathree Tasneem, Bhana Arvin, Petersen Inge
Centre for Research in Health Systems, University of KwaZulu Natal, Durban, South Africa.
School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
PLOS Glob Public Health. 2025 Sep 3;5(9):e0004926. doi: 10.1371/journal.pgph.0004926. eCollection 2025.
Community Health Workers (CHWs) play a crucial role to support health care delivery in underserved communities. Although the value of CHWs' contributions is widely recognised, there is limited evidence on the mechanisms that enable CHWs to deliver people-centred care. Using a realist evaluation approach guided by WHO's Integrated People-Centred Health Services (IPCHS) framework, the study focused on how different contexts and mechanisms interact to align with the IPCHS strategies to shape CHWs' capacity to deliver people-centred care. This realist qualitative study was conducted in five rural communities in KwaZulu-Natal, South Africa. Data was collected through structured observations of CHWs' interactions with households; interviews with CHWs, service users, household decision makers, outreach team leaders (CHWs' supervisors), and clinic operational managers. Data was further corroborated through three focus group discussions with CHWs. Using thematic analysis and realist evaluation methods, we identified Context-Mechanism-Outcome (CMO) configurations influencing CHWs' delivery of people-centred care, followed by refinement of the programme theory and development of middle-range theories. The study identified meta-mechanisms (trust, legitimacy, and motivation) that operate across all domains of the IPCHS framework and underpin the ability of CHWs to engage communities, coordinate care, and deliver integrated, people-centred services. These meta-mechanisms are triggered within enabling conditions, notably formalized supervision, CHW integration into the formal health system, and intersectoral collaboration. However, governance gaps such as precarious employment, inadequate remuneration, poor resourcing, lack of data feedback loops, and insufficient institutional recognition of CHWs' intersectoral role undermines these interactions, resulting in the poor delivery of IPCHS. The study contributes to policy discussions by providing middle-range theories that explain how, why, and when CHW-led people-centred interventions fail or succeed. Critical findings include the need for a dynamic Integrated, Mechanism-Sensitive Model of the IPCHS and governance reforms that include structured workforce integration for adequate resourcing and intersectoral action.
社区卫生工作者在为服务欠缺社区提供医疗服务方面发挥着关键作用。尽管社区卫生工作者的贡献价值得到广泛认可，但关于促使他们提供以人为本医疗服务的机制的证据却很有限。本研究采用由世界卫生组织的以人为本综合卫生服务（IPCHS）框架指导的现实主义评估方法，聚焦于不同背景和机制如何相互作用，以与IPCHS战略保持一致，从而塑造社区卫生工作者提供以人为本医疗服务的能力。这项现实主义定性研究在南非夸祖鲁 - 纳塔尔省的五个农村社区开展。数据通过对社区卫生工作者与家庭互动的结构化观察、对社区卫生工作者、服务使用者、家庭决策者、外展团队负责人（社区卫生工作者的上级）以及诊所运营经理的访谈收集。通过与社区卫生工作者进行三次焦点小组讨论，进一步证实了数据。运用主题分析和现实主义评估方法，我们确定了影响社区卫生工作者提供以人为本医疗服务的背景 - 机制 - 结果（CMO）配置，随后完善了项目理论并发展了中程理论。该研究确定了跨IPCHS框架所有领域运作的元机制（信任、合法性和动机），这些机制支撑着社区卫生工作者参与社区、协调护理以及提供综合、以人为本服务的能力。这些元机制在有利条件下被触发，特别是正式的监督、社区卫生工作者融入正式卫生系统以及部门间协作。然而，治理差距，如不稳定的就业、薪酬不足、资源匮乏、缺乏数据反馈循环以及机构对社区卫生工作者部门间角色的认可不足，破坏了这些互动，导致IPCHS的实施效果不佳。该研究通过提供中程理论，解释了由社区卫生工作者主导的以人为本干预措施失败或成功的方式、原因和时机，为政策讨论做出了贡献。关键发现包括需要一个动态的IPCHS综合、机制敏感模型以及治理改革，其中包括为充足资源配置和部门间行动进行结构化的劳动力整合。
