The South African health care system is faced with a quadruple burden of disease (Pillay-Van Wyk et al. 2016). The quadruple burden of disease includes HIV, AIDS, TB, noncommunicable diseases (NCDs), violence and injuries and diseases related to maternal and child health (Basu 2018; Maredza et al. 2016; Modjadji & Madiba 2019). Although many survive the above-mentioned conditions and diseases, some of these diseases may result in limitations in functioning and disability, increasing the need for rehabilitation, which is the key health strategy to address compromised functioning and quality of life for these individuals (World Health Organization [WHO] 2017). Access to rehabilitation services remains a challenge for many persons with disabilities (Hanass-Hancock, Myezwa & Carpenter 2015; Vergunst et al. 2015; Visagie & Swartz 2016), especially those who come from vulnerable communities and have limited financial and health service resources (Gamiet & Rowe 2019). Community-based rehabilitation with transdisciplinary teamwork is important for the improvement of quality management of the needs of vulnerable people in the community (Vyt 2008).

The South African Government initiated the National Health Insurance (NHI) Plan, which was expected to revolutionise health care delivery in the country (Naidoo 2012). The NHI’s focus is to ensure access to health care by subsidising those who cannot afford health care services (South African Government 2022). The adoption of the NHI plan is in line with the implementation of the primary health care (PHC) approach based on the Alma Ata declaration (WHO 1978). Primary health care is a people-centred approach that includes health promotion, disease prevention, treatment, rehabilitation and palliative care dealing with the physical, mental and social well-being of a person throughout their lifetime (WHO 2022). Through PHC and the NHI, all South Africans will receive equal treatment based on their health needs and not based on their socio-economic status (South African Government 2022).

At the centre of the NHI is the plan to strengthen and improve PHC by establishing and implementing ward-based outreach teams (WBOTs) (Khuzwayo & Moshabela 2017), which consist of community health workers (CHWs) with a range of different backgrounds (educational, experiential and training) and competencies resulting in a cadre of workers with varied skill levels, literacy levels and capacities (Vyt 2008). The WBOTs are supported by nurse team leaders and are linked to local PHC facilities (via referral, support and oversight) (Schneider et al. 2018). The WBOTs at a PHC level assist patients to adhere to medication and the management of chronic conditions (Naidoo et al. 2018; Schneider et al. 2018). However, there is evidence showing that the WBOTs lack the skills to address the needs of people with disabilities (Austin-Evelyn et al. 2017; Sherry 2015). Physiotherapy, an important part of rehabilitation for people with disabilities, forms an integral part of services offered at a PHC level (Maleka, Franzsen & Stewart 2008). The problem is that the training and scope of practice of CHWs who form part of the WBOTs have not focused on the social determinants of health or the development of skills required for community mobilisation (Schneider et al. 2018). Working with physiotherapists as part of a community rehabilitation team can empower the WBOTs with basic skills in rehabilitation care in the community. Thus, the aim of our study was to explore the integration of physiotherapists as members of WBOTs.

In our qualitative, exploratory study conducted in Tshwane, focus group discussions (FGDs) were used to explore the views of CHWs on the integration of a physiotherapist in WBOTs. This design was considered to be appropriate because the potential inclusion of a physiotherapist will impact on how the WBOTs will function, hence the need to explore the views of the CHWs who have been functioning without this inclusion. Our study should provide in-depth information to help to understand the views of the participants on this issue (Gundumogula 2020).

The City of Tshwane is divided into seven regions and has a total of 124 health facilities, comprising clinics, community health centres, district and regional hospitals, central or tertiary hospitals and other hospital groups (private hospital facilities). The settings for our study were 10 PHC facilities of Region 2, Tshwane District. Region 2 is in the northern part of the city, and the borders of the region are the Sinoville-Montana areas in the south, the Temba-Hammanskraal areas in the north, the N1 Highway in the east and the Onderstepoort-Soutpan Road in the west. The townships Stinkwater and Hammanskraal are included in Region 2, which also houses both vast and small agricultural holdings (Cooperative Governance and Traditional Affairs [COGTA] 2020). Region 2 has an estimated population figure of 339 175 people and 115 882 households (Statistics South Africa 2011).

Our study population included CHWs from the Tshwane district, Region 2. There were 31 WBOTs consisting of about 320 CHWs (Tshwane District WBOT presentation 2016). Each WBOT consisted of a team leader and 6–20 CHWs. The team members of the WBOT were recruited by firstly having a formal meeting with each team, explaining the aims and method of our study. The team members who were willing to participate were encouraged to list their names with the team leader, and the first 11 CHWs were chosen. All CHWs who voluntarily consented to participate and who were actively part of a WBOT working in the community were included. CHWs who were still undergoing training, not working actively in the community, not part of a WBOT or who refused to participate were excluded.

Data show that WBOTs experience challenges when managing patients with limited function who need physiotherapeutic services. The WBOTs said that they felt incompetent regarding the quality of care they offered to the community because of their limited rehabilitation knowledge and skills, and they lacked the resources to perform home-based duties as expected. The CHWs felt disrespected in the community.

Our study explored the views of CHWs on the integration of physiotherapists into WBOTs and found that caring for patients with chronic conditions and disabilities is challenging for the WBOTs. The WBOTs felt insecure and helpless when dealing with patients in the community. They expressed limited health knowledge and limited rehabilitation skills. The limited rehabilitation skills amongst the WBOTs was also noted by Khuzwayo and Moshabela (2017) and Tsolekile et al. (2014). Ward-based outreach teams were of the opinion that their interventions were limited and not always beneficial to those who needed them. WBOTs complained of walking long distances daily, which made them tired by the time they arrived at patients’ homes. These findings are similar to Austin-Evelyn et al. (2017), who found that there was a lack of transport, equipment and limited medical supplies amongst WBOTs. The CHWs who are part of the WBOTs faced negative perceptions in the community, and this was also noted by White, Govender and Lister (2017).

There is poor access to physiotherapy services. Patients need physiotherapy intervention in their homes or at their local clinics, as they could not afford the costs associated with travelling to clinics or hospitals further away. They were referred to the only clinic, clinic X, which had a limited number of physiotherapists. Patients were often given another appointment when they went to clinic X for the first time, as it was not their appointment date. This often delayed their treatment sessions or made patients miss their treatment, as they did not have the money for transport for the next appointment date. This is similar to Vergunst et al. (2015) stating that people with disabilities have limited access to health care because of financial issues and transportation difficulties in reaching health care facilities. Eide et al. (2015) in a study in four African countries confirmed that patients with disabilities face more barriers in accessing health care services and that the socio-economic status of the individuals was the strongest predictor of accessibility to such facilities. The CHWs felt that integrating a physiotherapist as a member of the WBOTs could benefit the health of patients because of the limitations they currently experienced in accessing physiotherapy services on time, that is, lack of money and transport, the poor referral system and the limited number of physiotherapists at clinic X.

The participants reported that the integration of a physiotherapist in WBOTs would improve their confidence, as they would be educated by the physiotherapist on how to handle patients and continue to practise the skills learned. Visagie and Swartz (2016) were of the opinion that one-on-one therapy is not the solution to the rehabilitation needs of persons with disabilities in remote, rural settings, recommending that the rehabilitation in a rural setting should be supported with a transdisciplinary team, family members, CHWs and peer mentors. The benefits of this community-based rehabilitation approach would include cost-effectiveness, less intrusion in family units, holistic service delivery and greater opportunities for service deliverers, such as CHWs on the WBOTs being able to enhance their knowledge and skills (Visagie & Swartz 2016), where skills would be shared and interventions provided across professional boundaries (King et al. 2009; Sims, Hewitt & Harris 2015).

The authors agree with the CHWs on the WBOTs who also indicated that patients would then receive regular services, which would improve their physical outcomes because of more focused interventions provided by the transdisciplinary team. They would be able to get physiotherapy-related services at home and thereby decrease the waiting periods at clinic X, leading to a quicker provision of health services (Hanass-Hancock et al. 2015). The inclusion of a physiotherapist as a member of the WBOTs would play an important role in ensuring universal health coverage for the population of South Africa (Tiwarii, Nedii & Chikte 2020), as per adoption of the NHI plan (South African Government 2022).

Our study should be repeated in other health regions, which could have wider recommendations if the same findings are repeated. Our study may influence the training of the WBOTs to include basic physiotherapy techniques in their study curriculum so that they have basic rehabilitation skills to be able to manage patients with disabilities. If broadened to include other study sites, our results may influence health policy to include rehabilitation into primary health care.

The main disadvantage of the qualitative approach of our study is that the findings cannot be extended to wider populations with the same degree of certainty that quantitative analyses can.

Although WBOTs are doing beneficial work in their communities by providing a range of services, they lack physiotherapy services, which disadvantage the community and people with disabilities specifically. In South Africa, the South African Constitution and the ratification of the United Nations Convention on the Rights of Persons with Disabilities (Sherry 2015) support the right to health for people with disabilities. It is thus concluded that policymakers consider the inclusion of a physiotherapist in the WBOTs in the National Department of Health.