How Community Health Workers Can Better Support People-Centred Care in South Africa

What is it about?

Community Health Workers (CHWs) are often the first link between people in rural or underserved areas and the health system. They visit households, provide health education, support families living with chronic conditions, and connect people to clinics and social services. While their importance is widely recognised, CHWs often face challenges that make it difficult for them to do their jobs effectively. This study looked at how CHWs in five communities in KwaZulu-Natal, South Africa, work with households, clinics, and government programmes. Using a realist evaluation approach, the researchers asked: What helps CHWs deliver people-centred care? And what holds them back? The study found that CHWs are most effective when they build trust, are seen as legitimate health workers, and remain motivated. These qualities—called “meta-mechanisms”—help CHWs connect with families, coordinate care, and advocate for patients. But these strengths can only be realised if the right conditions are in place: reliable supervision, secure jobs, proper resources, and collaboration across sectors like health, social development, and local government. Unfortunately, many CHWs face insecure contracts, low pay, poor recognition, and limited support. Communities sometimes misunderstand their role or expect them to provide material support, like food parcels, which they cannot always deliver. This can lead to frustration, burnout, and loss of trust. The research highlights the need for better governance, clearer role definitions, fairer working conditions, and stronger intersectoral coordination. When CHWs are properly supported and valued, they can play a powerful role in making healthcare more accessible, responsive, and centred on people’s real needs.

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Why is it important?

1. Health Equity Community Health Workers (CHWs) bring healthcare closer to people in rural and underserved areas. Without them, many families—especially those facing poverty, stigma, or chronic illness—would struggle to access care. Supporting CHWs strengthens equity by ensuring everyone can get care, not only those who can reach hospitals and clinics. 2. Trust and Connection The study showed that trust, motivation, and legitimacy are the foundations of CHW effectiveness . When communities trust CHWs, they are more likely to open up about health problems, follow treatment, and seek care earlier. Without this trust, people delay care, which leads to worse outcomes. 3. System Integration CHWs don’t just provide care—they link households to clinics, social services, and local governance. This makes them key “connectors” in integrated, people-centred care. If they are unsupported, health and social systems remain fragmented, and patients fall through the cracks. 4. Policy and Governance Impact The research highlights that precarious employment, low pay, and weak supervision undermine CHWs’ ability to work effectively . Improving contracts, recognition, and support structures is not just about fairness—it directly improves health outcomes, programme sustainability, and system efficiency. 5. Global Relevance South Africa’s challenges are shared across many countries. By generating middle-range theories (explanations of how and why CHWs succeed or fail), this research provides insights that can be applied in other settings working towards Universal Health Coverage and the Sustainable Development Goals.

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