Barriers to the Implementation of the Ward-Based Outreach Team Program in Mpumalanga Province: Results From Process Evaluation

BACKGROUND: South Africa adopted the ward-based outreach team (WBOT) program as one aspect of the three-stream approach to primary health care (PHC) re-engineering. PHC re-engineering seeks to modify the hospicentric and curative approach into a more preventive and promotive approach to improve health outcomes. There has not been an evaluation of the implementation of the WBOTs in Nkangala District since its inception in 2012. METHODS: A process evaluation approach using qualitative methods was used to examine and describe the contextual, organizational, health provider, and program-related barriers considered to affect the implementation of the WBOTs 3 sub-districts in one of the health districts in Mpumalanga Province, South Africa. The framework for this evaluation was informed by the logic model framework developed by the Center for Disease Control as well as the 3 domains of evaluation recommended by the Medical Research Council Guidance on process evaluation. Data were collected through in-depth interviews with multiple data sources directly involved in the implementation of the WBOTs. A thematic analysis was done using NVivo 11. RESULTS: The key critical barriers identified by the evaluation include the inadequate provision of resources, the lack of supervision, the heavy workload for outreach teams, the inadequate and irregular payment of stipends, threats to the safety of the CHWs, and the cultural beliefs and practices of the communities who are to receive the services. The lack of adequate financial resources was the main challenge, and will continue to pose a risk to the successful implementation of the WBOTs. CONCLUSIONS: Although the barriers are being reported as separate contextual factors, the internal and external contexts are interdependent, interact with one each other, and should not be considered in isolation. The need to improve stakeholder engagement on the WBOT program underscores the importance of the external context in the successful implementation of WBOTs.