title: Insights of health district managers on the implementation of primary health care outreach teams in Johannesburg, South Africa: a descriptive study with focus group discussions.
abstract: Primary health care (PHC) outreach teams are part of a policy of PHC re-engineering in South Africa. It attempts to move the deployment of community health workers (CHWs) from vertical programmes into an integrated generalised team-based approach to care for defined populations in municipal wards. There has little evaluation of PHC outreach teams. Managers' insights are anecdotal.
  
  
  
  This is descriptive qualitative study with focus group discussions with health district managers of Johannesburg, the largest city in South Africa. This was conducted in a sequence of three meetings with questions around implementation, human resources, and integrated PHC teamwork. There was a thematic content analysis of validated transcripts using the framework method.
  
  
  
  There were two major themes: leadership-management challenges and human resource challenges. Whilst there was some positive sentiment, leadership-management challenges loomed large: poor leadership and planning with an under-resourced centralised approach, poor communications both within the service and with community, concerns with its impact on current services and resistance to change, and poor integration, both with other streams of PHC re-engineering and current district programmes. Discussion by managers on human resources was mostly on the plight of CHWs and calls for formalisation of CHWs functioning and training and nurse challenges with inappropriate planning and deployment of the team structure, with brief mention of the extended team.
  
  
  
  Whilst there is positive sentiment towards intent of the PHC outreach team, programme managers in Johannesburg were critical of management of the programme in their health district. Whilst the objective of PHC reform is people-centred health care, its implementation struggles with a centralising tendency amongst managers in the health service in South Africa. Managers in Johannesburg advocated for decentralisation. The implementation of PHC outreach teams is also limited by difficulties with formalisation and training of CHWs and appropriate task shifting to nurses. Change management is required to create true integrate PHC teamwork. Policy review requires addressing these issues.
authors.affiliation: Department of Family Medicine, University of Witwatersrand, Johannesburg, South Africa.
authors.forename: Shabir
authors.initials: S
authors.lastname: Moosa
authors.affiliation: Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium.
authors.forename: Anselme
authors.initials: A
authors.lastname: Derese
authors.affiliation: Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium. Wim.Peersman@UGent.be.|Knowledge Centre Brussels Integrated Care, Erasmus University College Brussels, Brussels, Belgium. Wim.Peersman@UGent.be.
authors.forename: Wim
authors.identifier: 0000-0002-4276-7408
authors.initials: W
authors.lastname: Peersman
mesh_terms: D001291:Attitude of Health Personnel; D002391:Catchment Area, Health; D002947:Cities; D003142:Communication; D003150:Community Health Workers; D003695:Delivery of Health Care / Q000458:organization & administration*; D017144:Focus Groups; D006295:Health Resources; D006297:Health Services Accessibility; D006801:Humans; D007857:Leadership; D009726:Nurses; D010348:Patient Care Team; D010559:Personnel Management; D011320:Primary Health Care / Q000458:organization & administration*; D036301:Qualitative Research; D012111:Residence Characteristics; D013019:South Africa; D014937:Work
keywords: Africa; Community healthcare workers; Human resources; Outreach teams; Policy; Primary health care