Expanding Community Health Worker decision space: learning from a Participatory Action Research training intervention in a rural South African district.

BACKGROUND: While integral to decentralising health reforms, Community Health Workers (CHWs) in South Africa experience many challenges. During COVID-19, CHW roles changed rapidly, shifting from communities to clinics. In the contexts of new roles and re-engineered primary healthcare (PHC), the objectives were to: (a) implement a training intervention to support local decision-making capability of CHWs; and (b) assess learning and impacts from the perspectives of CHWs. METHODS: CHWs from three rural villages (n = 9) were trained in rapid Participatory Action Research (PAR) with peers and community stakeholders (n = 33). Training equipped CHWs with tools and techniques to convene community groups, raise and/or respond to local health concerns, understand concerns from different perspectives, and facilitate action in communities and public services. CHWs' perspectives before and after the intervention were gained through semi-structured interviews. Data were collected and analysed using the decision space framework to understand local actors' power to affect devolved decision-making. RESULTS: CHWs demonstrated significant resilience and commitment in the face of COVID-19. They experienced multiple, intersecting challenges including: limited financial, logistical and health systems support, poor role clarity, precarious employment, low and no pay, unstable organisational capacity, fragile accountability mechanisms and belittling treatment in clinics. Together, these restricted decision space and were seen to reflect a low valuing of the cadre in the system. CHWs saw the training as a welcome opportunity to assert themselves as a recognised cadre. Regular, spaces for dialogue and mutual learning supported CHWs to gain tools and skills to rework their agency in more empowered ways. The training improved management capacity, capabilities for dialogue, which expanded role clarity, and strengthened community mobilisation, facilitation and analysis skills. Development of public speaking skills was especially valued. CHWs reported an overall 'tripe-benefit' from the training: community-acceptance; peer support; and dialogue with and recognition by the system. The training intervention was recommended for scale-up by the health authority as an implementation support strategy for PHC. CONCLUSIONS: Lack of recognition of CHWs is coupled with limited opportunities for communication and trust-building. The training supported CHWs to find and amplify their voices in strategic partnerships, and helped build functionality for local decision-making.

Assessing the impact of antimicrobial stewardship implementation at a district hospital in Ghana using a health partnership model.

Background: Antimicrobial stewardship (AMS) is imperative in addressing the menace of antimicrobial resistance (AMR) in health systems. Commonwealth Partnerships for Antimicrobial Stewardship uses a health partnership model to establish AMS in Commonwealth countries. The Hospital of Kwame Nkrumah University of Science and Technology in partnership with Ulster University, Northern Ireland, undertook an AMS project from November 2021 to May 2022. We report on implementation of the AMS, its impact on antibiotic use and infections management at the University Hospital; Kumasi, Ghana. Methods: The Global-Point Prevalence Survey (PPS) protocol was used to assess antibiotics use at the hospital at baseline, midpoint and end of the project. Feedback on each PPS was given to the hospital to inform practice, behavioural change and improve antibiotic use. Results: Antibiotic use reduced from 65% at baseline to 59.7% at the end of the project. The rate of healthcare-associated infections also reduced from 17.5% at baseline to 6.5%. Use of antibiotics from the WHO Access group was 40% at baseline but increased to 50% at the endpoint. Watch antibiotics reduced from 60% to 50% from baseline. Culture and susceptibility requests increased from baseline of 111 total requests to 330 requests in the intervention period to inform antimicrobial therapy. Conclusion: The model AMS instituted improved antibiotic use and quality of antimicrobial therapy within the study period. Continuous staff education and training in AMS, and use of standard tools for assessment and application of local data to inform infections management will ensure sustenance and improvement in the gains made.