Empoderando a los agentes comunitarios de salud como líderes locales y nacionales en la lucha contra la tuberculosis en Sudáfrica mediante la investigación acción participativa: perspectivas del proyecto UseMyVoice
Barra lateral del artículo
Contenido principal del artículo
Resumen
Si bien los agentes comunitarios de salud (ACS) tienen importantes contribuciones que ofrecer al sistema de salud sudafricano y a la respuesta frente a la tuberculosis (TB), su experiencia ha sido insuficientemente valorada en los procesos de mejora de la calidad y formulación de políticas. Alcanzar plenamente los beneficios de los ACS requiere sistemas comunitarios de salud que respondan a sus necesidades; sin embargo, persisten importantes vacíos en nuestro conocimiento sobre cómo lograrlo.
En este artículo de Lecciones y Experiencias, describimos nuestras experiencias y reflexiones sobre la aplicación de un enfoque de investigación acción participativa (IAP) para empoderar a los ACS en un contexto rural y desatendido como líderes en la respuesta sudafricana contra la TB. Mediante dos ciclos de acción-reflexión, esta iniciativa de la sociedad civil visibilizó las perspectivas de los ACS sobre la atención local de la TB, generó espacios de colaboración mediante el diálogo, desarrolló conjuntamente acciones innovadoras para responder a las brechas identificadas y fortaleció la capacidad de los ACS para participar en acciones colectivas de incidencia política dirigidas a fortalecer su papel en la respuesta nacional.
Los ACS identificaron el estigma relacionado con la TB como un desafío local insuficientemente abordado y señalaron la capacitación inadecuada, los riesgos ocupacionales y la remuneración injusta como obstáculos clave para su efectividad. Las producciones de teatro comunitario y las campañas de incidencia multifacéticas ayudaron a crear condiciones que condujeron a cambios en los servicios de su clínica local, en la política provincial de empleo de ACS y en el apoyo de responsables nacionales de formulación de políticas.
Identificamos lecciones clave y recomendaciones sobre cuatro desafíos comunes de la investigación participativa que pueden orientar futuras aplicaciones de la IAP para el empoderamiento de los ACS. Primero, el tiempo y las discusiones reflexivas promovieron la confianza. Segundo, apoyamos el desarrollo de un poder emancipador mediante el fortalecimiento de capacidades, la construcción de redes, el desarrollo de materiales accesibles sobre políticas para ACS y el aprovechamiento del impulso de acciones de corto plazo hacia acciones de mayor impacto. Tercero, cuestionamos definiciones limitadas de escalabilidad que priorizan la replicación de los resultados del trabajo de los ACS sin procesos que transformen las relaciones de poder. Cuarto, las barreras a la participación de los ACS (por ejemplo, idioma y tecnología), exacerbadas por la pandemia de COVID-19, hicieron necesarias múltiples opciones de participación.
Este trabajo demuestra cómo la IAP puede llevar a acciones innovadoras para abordar barreras locales en la atención y desafíos nacionales relacionados con la fuerza laboral, mediante el fortalecimiento de relaciones, la participación reflexiva, las dimensiones emancipadoras del poder, la resistencia a normas extractivas y la adaptación a los desafíos.
Descargas
Detalles del artículo
Esta obra está bajo una licencia internacional Creative Commons Atribución 4.0.
Authors of content published in JCSH retain the copyright to their works.
Citas
Murphy JP, Moolla A, Kgowedi S, Mongwenyana C, Mngadi S, Ngcobo N, et al. Community health worker models in South Africa: a qualitative study on policy implementation of the 2018/19 revised framework. Health Policy Plan. 2020 Dec 27;36(4):384–96. doi:10.1093/heapol/czaa172
Department of Health. Policy Framework and Strategy for Ward-Based Primary Healthcare Outreach Team (WBPHCOT) 2018/19 - 2023/24. Pretoria: National Department of Health; 2018.
Ajudua FI, Mash RJ. Implementing active surveillance for tuberculosis: The experiences of healthcare workers at four sites in two provinces in South Africa. South Afr Fam Pract. 2022 Jul 26;64(1):5514. doi:10.4102/safp.v64i1.5514
Daviaud E, Besada D, Budlender D, Kerber K. Investment Case for Community Health Workers In South Africa What costs and what benefits For the health sector, for the economy and For society? South Africa Medical Research Council; 2018 May.
Thomas LS, Jordaan J, Pillay Y, Buch E. Contributions of a community health worker program in improving district health system performance in South Africa, using routine health service variables in a quasi-experimental study design. BMC Health Serv Res. 2025 Aug 19;25:1105. doi:10.1186/s12913-025-12772-z
VAPAR. CHWs Position and Role: Realising community health systems solidarity for comprehensive PHC [Internet]. Verbal Autopsy with Participatory Action Research (VAPAR) Mpumalanga health policy and systems learning platform; 2022 Jul [cited 2025 May 27]. p. 5. (Verbal Autopsy with Participatory Action Research (VAPAR) Expanding the knowledge base through partnerships for action on health equity). Available from: https://www.vapar.org/_files/ugd/532615_d86ff0e81d354a74831a3762e4ca259d.pdf.
Ahmed S, Chase LE, Wagnild J, Akhter N, Sturridge S, Clarke A, et al. Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice. Int J Equity Health. 2022 Apr 11;21(1):49. doi:10.1186/s12939-021-01615-y
Mabetha D, Ojewola T, van der Merwe M, Mabika R, Goosen G, Sigudla J, et al. Realising radical potential: building community power in primary health care through Participatory Action Research. Int J Equity Health. 2023 May 17;22(1):94. doi:10.1186/s12939-023-01894-7
Dam TA, Forse RJ, Tran PMT, Vo LNQ, Codlin AJ, Nguyen LP, et al. What makes community health worker models for tuberculosis active case finding work? A cross-sectional study of TB REACH projects to identify success factors for increasing case notifications. Hum Resour Health. 2022 Mar 12;20(1):25. doi:10.1186/s12960-022-00708-1
Astale T, Abebe T, Mitike G. Workload and emerging challenges of community health workers in low- and middle-income countries: A mixed-methods systematic review. PLOS ONE. 2023 Mar 13;18(3):e0282717. doi:10.1371/journal.pone.0282717
WHO. Health Policy and System Support to Optimize Community Health Worker Programmes for HIV, TB and Malaria Services: An Evidence Guide. 1st ed. Geneva: World Health Organization; 2021. 1 p.
D’Ambruoso L, Abruquah NA, Mabetha D, Van Der Merwe M, Goosen G, Sigudla J, et al. Expanding Community Health Worker decision space: learning from a Participatory Action Research training intervention in a rural South African district. Hum Resour Health. 2023 Aug 18;21(1):66. doi:10.1186/s12960-023-00853-1
World Health Organization. What do we know about community health workers? A systematic review of existing reviews-eng. Geneva: World Health Organization; 2020. (Human Resources for Health Observer Series). Report no.: 19.
Community Health Impact Coalition. CHW Advocates are seizing power. Community Health Impact Coalition [Internet]. [cited 2026 Jan 5]. Available from: https://joinchic.org/resources/chw-advocates/.
Odhiambo S, Ballard M, Pyne B, Harrison K. Stanford Social Innovation revuew [Internet]. [cited 2025 Oct 5]. From Unpaid to Unstoppable: The Rise of the Professional Community Health Worker Movement (SSIR). Available from: https://ssir.org/articles/entry/movement-to-professionalize-community-health-workers.
Malatji H, Griffiths F, Goudge J. Mobilisation towards formal employment in the healthcare system: A qualitative study of community health workers in South Africa. PLOS Glob Public Health. 2024 Mar 20;4(3):e0002226. doi:10.1371/journal.pgph.0002226
Community Health Impact Coalition. The Case for CHWs: Champions of the Health System. Community Health Impact Coalition [Internet]. [cited 2026 Jan 5]. Available from: https://joinchic.org/resources/the-case-for-chws-champions-of-the-health-system/.
Cornish F, Breton N, Moreno-Tabarez U, Delgado J, Rua M, de-Graft Aikins A, et al. Participatory action research. Nat Rev Methods Primer. 2023 Apr 27;3(1):1–14. doi:10.1038/s43586-023-00214-1
Pinto RM, da Silva SB, Penido C, Spector AY. International Participatory Research Framework: triangulating procedures to build health research capacity in Brazil. Health Promot Int. 2012 Dec;27(4):435–44. doi:10.1093/heapro/dar090
South African National AIDS Council. National Strategic Plan for HIV, TB, and STIs 2023-2028. Republic of South Africa; 2023 Mar.
South African National Department of Health. National TB Recovery Plan 4.0 April 2025 – March 2026. 2025.
Sinha B, Chowdhury R, Sankar MJ, Martines J, Taneja S, Mazumder S, et al. Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis. Acta Paediatr Oslo Nor 1992. 2015 Dec;104(467):114–34. doi:10.1111/apa.13127
Atif M, Javaid S, Farooqui M, Sarwar MR. Rights and Responsibilities of Tuberculosis Patients, and the Global Fund: A Qualitative Study. PLOS ONE. 2016 Mar 21;11(3):e0151321. doi:10.1371/journal.pone.0151321
Cramm JM, Finkenflügel HJM, Møller V, Nieboer AP. TB treatment initiation and adherence in a South African community influenced more by perceptions than by knowledge of tuberculosis. BMC Public Health. 2010 Feb 17;10:72. doi:10.1186/1471-2458-10-72
van der Westhuizen HM, Giddy J, Coetzee R, Makanda G, Tisile P, Galloway M, et al. Strengthening accountability for tuberculosis policy implementation in South Africa: perspectives from policymakers, civil society, and communities. BMC Glob Public Health. 2024 Jul 17;2(1):48. doi:10.1186/s44263-024-00077-y
Schenck C. Reuters [Internet]. 2023 [cited 2026 Jan 5]. South Africans blame city as cholera cases rise | Reuters. Available from: https://www.reuters.com/world/africa/south-africans-blame-city-cholera-cases-rise-2023-05-22/.
Baum F, MacDougall C, Smith D. Participatory action research. J Epidemiol Community Health. 2006 Oct;60(10):854–7. doi:10.1136/jech.2004.028662
Gosin MN, Dustman PA, Drapeau AE, Harthun ML. Participatory Action Research: creating an effective prevention curriculum for adolescents in the Southwestern US. Health Educ Res. 2003 Jun;18(3):363–79. doi:10.1093/her/cyf026
Baum FE. Power and glory: applying participatory action research in public health. Gac Sanit. 2016 Nov 1;30(6):405–7. doi:10.1016/j.gaceta.2016.05.014
Foster I, Galloway M, Human W, Anthony M, Myburgh H, Vanqa N, et al. Analysing interventions designed to reduce tuberculosis-related stigma: A scoping review. PLOS Glob Public Health. 2022 Oct 19;2(10):e0000989. doi:10.1371/journal.pgph.0000989
Gaiha SM, Salisbury TT, Usmani S, Koschorke M, Raman U, Petticrew M. Effectiveness of arts interventions to reduce mental-health-related stigma among youth: a systematic review and meta-analysis. BMC Psychiatry. 2021 Jul 22;21(1):364. doi:10.1186/s12888-021-03350-8
Human W, Nathavitharana RR, Van Der Westhuizen HM, Galloway M, Schoeman I, Muedi P, et al. Opinion: Could community health workers be the answer to reducing Tuberculosis stigma? Spotlight [Internet]. 2021 Jul 9 [cited 2026 May 12]. Available from: https://www.spotlightnsp.co.za/2021/07/09/opinion-could-community-health-workers-be-the-answer-to-reducing-tuberculosis-stigma/.
John SF, Mubangizi BC. ‘Lives over profits! Bread not bullets!’: A people’s coalition for good governance in South Africa’s state of disaster. J Civ Soc. 2023 Jan 2;19(1):76–93. doi:10.1080/17448689.2023.2206151
Egid BR, Roura M, Aktar B, Quach JA, Chumo I, Dias S, et al. ‘You want to deal with power while riding on power’: global perspectives on power in participatory health research and co-production approaches. BMJ Glob Health. 2021 Nov 1;6(11):e006978. doi:10.1136/bmjgh-2021-006978
Grant J, Nelson G, MItchell T. Negotiating the Challenges of Participatory Action Research: Relationships, Power, Participation, Change and Credibility. In: Reason P, Bradbury H, editors. The Sage handbook of action research: participative inquiry and practice. 2nd ed. London ; Thousand Oaks, Calif: SAGE Publications; 2008.
Abimbola S. The uses of knowledge in global health. BMJ Glob Health. 2021 Apr 5;6(4):e005802. doi:10.1136/bmjgh-2021-005802
Jupp D, Ali SI, Barahona C. Measuring empowerment? Ask them: quantifying qualitative outcomes from people’s own analysis: insights for results-based management from the experience of a social movement in Bangladesh. Stockholm: Sida; 2010. 99 p.
Popay J, Whitehead M, Ponsford R, Egan M, Mead R. Power, control, communities and health inequalities I: theories, concepts and analytical frameworks. Health Promot Int. 2021 Oct 13;36(5):1253–63. doi:10.1093/heapro/daaa133
Freudenberg N, Tsui E. Evidence, Power, and Policy Change in Community-Based Participatory Research. Am J Public Health. 2014 Jan;104(1):11–4. doi:10.2105/AJPH.2013.301471
Heller JC, Givens ML, Johnson SP, Kindig DA. Keeping It Political and Powerful: Defining the Structural Determinants of Health. Milbank Q. 2024;102(2):351–66. doi:10.1111/1468-0009.12695
Gaventa J, Cornwall A. Power and Knowledge. In: Reason P, Bradbury H, editors. The Sage handbook of action research: participative inquiry and practice. 2nd ed. London ; Thousand Oaks, Calif: SAGE Publications; 2008.
Jemal A. Transformative consciousness of health inequities: Oppression is a virus and critical consciousness is the antidote. J Hum Rights Soc Work. 2018 Dec;3(4):202–15. doi:10.1007/s41134-018-0061-8
Tseng Y hwei, Griffiths F, de Kadt J, Nxumalo N, Rwafa T, Malatji H, et al. Integrating community health workers into the formal health system to improve performance: a qualitative study on the role of on-site supervision in the South African programme. BMJ Open. 2019 Feb 27;9(2):e022186. doi:10.1136/bmjopen-2018-022186
Hu M, Stoecker R. Using Participatory Action Research as a Liberatory Tool in Nonprofit Organizations. Public Integr. 2024 Nov;26(6):662–73. doi:10.1080/10999922.2023.2227387
Abimbola S. The Foreign Gaze: Essays on Global Health. IRD Editions; 2024.
Adams V. Introduction. In: Metrics: What Counts in Global Health [Internet]. Duke University Press; 2016 [cited 2024 Feb 23]. Available from: https://read.dukeupress.edu/books/book/78/chapter/100616/Introduction.
TB Screening And Testing Standard Operating Procedure [Internet]. Pretoria, South Africa: Department of Health, Republic of South Africa; 2022 [cited 2026 Feb 1]. Available from: https://www.nicd.ac.za/wp-content/uploads/2023/10/TB-SCREENING-AND-TESTING-SOP-2022.pdf.