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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
Yu-hwei Tseng1,
Frances Griffiths1,2,
Julia de Kadt1,
Nonhlanhla Nxumalo1,
Teurai Rwafa1,
Hlologelo Malatji1,
Jane Goudge1
1 Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
2 Warwick Medical School, University of Warwick, Coventry, UK
Correspondence to Dr Jane Goudge; Jane.goudge{at}gmail.com
Objectives To explore the role of on-site supervision in community health worker (CHW) programmes and CHW integration into the health system. We compared the functioning of CHW teams reporting to a clinic-based nurse with teams supervised by a community-based nurse. We also consider whether a junior nurse can provide adequate supervision, given the shortage of senior nurses.
Design A case study approach to study six CHW teams with different configurations of supervision and location. We used a range of qualitative methods: observation of CHW and their supervisors (126 days), focus group discussions (12) and interviews (117).
Setting South Africa where a national CHW programme is being implemented with on-site supervision.
Participants CHWs, their supervisors, clinic managers and staff, district managers, key informants from the community and CHW clients.
Results Effective supervisors supported CHWs through household visits, on-the-job training, debriefing, reviewing CHWs' daily logs and assistance with compiling reports. CHWs led by senior nurses were motivated and performed a greater range of tasks; junior nurses in these teams could better fulfil their role. Clinic-based teams with senior supervisors were better integrated and more able to ensure continuity of care. In contrast, teams with only junior supervisors, or based in the community, had less engagement with clinic staff, and were less able to ensure necessary care for patients, resulting in lower levels of trust from clients.
Conclusion Senior supervisors raised CHW skills, and successfully negotiated a place for CHWs in the health system. Collaboration with clinic staff reduced CHWs' marginalisation and increased motivation. Despite being clinic-based, teams without senior supervisors had lower skill levels and were less integrated into the health system.
organisation of health services
To the best of our knowledge, this is the first study to examine the role of different levels of supervision and location of the community health worker (CHW) team on the team's motivation, performance and integration into the health system.
The case study approach allowed us to purposively select teams based on their supervision/location configurations, and to compare and contrast their functioning to understand what worked, and what did not.
We employed multiple qualitative methods, including participant observation, interview and focus group discussion, to collect a substantial amount of data, enabling triangulation across data sources and sites.
Limitations to the study include the observer effect (Hawthorne effect) during data collection, subjective rather than objective evaluations of CHW performance and data collection limited to a single health district.
Community health workers (CHWs) play an important role in improving healthcare coverage and access in low-income and middle-income countries (LMICs).1–3 However, optimising the contribution of CHWs continues to be a global challenge. CHWs, with no professional qualification, perform primary healthcare (PHC)-related functions in the community.1 4 They work on the periphery of the health system and often in underserved communities where needs are immense and multifaceted. For this reason, CHWs require frequent and supportive supervision that supplements their training and connects them with the health system.3 5 6 Recent reviews suggest that adequate supervision, and integration into the health system, are essential components to programme effectiveness.5 7–9
Effective integration of CHW programmes into the health system requires government financing, national level planning, training and CHW scope of work, supervision, referral networks and supply chains to be connected to and incorporated into similar processes provided for other cadres.9 Without integration, there is unlikely to be a smooth patient pathway from CHW to clinic, limiting the effectiveness of CHWs. There is a growing literature on supervision, with some evidence that supportive supervision improves motivation and performance.10–14 However, much of this evidence is from non-governmental organisation (NGO) programmes (which are less integrated into the health system), or from programmes in which the CHWs' work is focused on a specific disease (eg, HIV) or population (eg, pregnant women). With the goal of universal access to comprehensive, integrated care, it is important to understand the type and level of supervision that will enable CHWs to provide the full range of required tasks, as well as facilitate integration into the health system.12–15
Given the double burden of non-communicable and infectious diseases in LMICs, governments such as South Africa's are seeking to shift CHW initiatives from focusing on a single disease or population group to a more comprehensive approach.16 South Africa is implementing a national CHW programme (ward-based outreach teams [WBOTs]) as part of efforts to strengthen primary healthcare.17 The intention is to provide full-time on-site supervisors whose responsibility is to manage, train, mentor and monitor CHWs and to facilitate links with the health system and the community. However, given the shortage of healthcare workers, as in other LMIC settings, there is a limited number of nurses available to supervise CHWs. In this study, we ask whether CHW teams should be linked to a clinic, and report to a clinic-based nurse who may facilitate referrals, access to supplies and CHWs' integration into the health system. Or should CHWs be based in the community in which they are working, with a dedicated nurse who does not have the additional demands of clinic duties? We also ask whether a junior (enrolled) nurse is able to provide adequate supervision, given the shortage of senior (professional) nurses. By asking these questions, we examine supervision practices, the team's integration into the health system and their effect on CHW motivation and performance.
In the initial observation phase (September 2016–February 2017) of a 3-year intervention study in Sedibeng Health District, Gauteng Province, we used a case study approach to examine the operation of CHW teams with different configurations of supervisors and locations: (1) clinic-based teams supervised by a senior nurse (professional nurse [PN]) and a junior nurse (enrolled nurse [EN]); (2) community (health post)-based teams supervised by a PN and an EN and (3) clinic-based teams supervised by an EN only. We studied six teams (two of each of the three configurations), each team and their supervisors being a single case study.
In some South African provinces, CHWs, previously employed by NGOs, have been absorbed into a government WBOT programme in an attempt to shift from a patchwork of condition-specific services to a comprehensive programme with a national scope.15 18 The CHWs' role is predominantly health promotion, prevention and screening. Standardised CHW training covers identification of the need for antenatal and postnatal care, monitoring immunisation of under 5s, adherence among patients with chronic diseases, screening for malnutrition, tuberculosis (TB), gender-based violence and making referrals to health, social and other services. WBOT teams are meant to comprise a PN, six or more CHWs, one health promoter and one environmental officer,17 although realities on the ground often do not allow this.
We selected Sedibeng Health District as our study site due to the variation in supervision structures and location of its CHW teams. The district is relatively affluent by South African standards, although over 20% of its residents fall below the food poverty line. Outside the urban areas, disadvantaged communities with inadequate shelter, food insecurity and high disease burdens have limited access to services such as clinics, transport, water and electricity.
Sedibeng District has established 16 health posts to provide community-orientated care, different from the disease-focused care provided by 28 primary healthcare clinics.19 A health post consists of one or two temporary structures (providing 3–6 rooms), often operating without electricity and with irregular water supply. It is managed by one or two PNs, who obtain medication and other resources via a 'mother' clinic. The nurses supervise the CHW team, and provide basic services such as chronic medication, immunisation and treating minor ailments. Some health posts are placed at some distance from a clinic, in order to improve access to basic services.
At the time of the study, there were 39 CHW teams (each with between 6 and 20 CHWs) in 37 of the district's 72 wards (the smallest geopolitical area). Sixteen of the teams were based at health posts and the remaining 23 were clinic-based. In addition to the services outlined in the national training programme (see above), the CHWs delivered medication to elderly or disabled chronically ill patients.
Selection of CHW teams for study
The research team consulted with district officials, categorising the CHW teams into three types. We selected two teams of each type with the requirement that each pair of teams needed to be as similar as possible (important characteristics included urban or rural location, the size of the teams and the type of community they served). (We needed to pool the data from the two teams to generate a sufficient sample for the analysis of the coverage data, reported elsewhere.) The key characteristics and description of catchment areas of each team are shown in table 1. The two health post teams were closest to the community, while the rural teams had the largest geographical area to cover.
Supervision configurations of CHW teams and their catchment areas
Eight fieldworkers received 2 weeks of training, covering research methods and ethics, study tools, extensive role-play and observation practice, as well as an overview of training that CHWs receive. Between September 2016 and February 2017, the field team collected interview and observation data on each team's activities, resources, engagement with the clinic and community, successes and challenges as well as client and key informant views of the performance of the teams. (Further details of CHW performance using more objective indicators, such as coverage and the quality of care, will be reported elsewhere.) Data collection method and types of data are summarised in table 2.
Data collection method, participants and data collected
Fieldworkers observed CHWs and their supervisors throughout the workday, and wrote detailed daily field notes guided by a template. After each day spent in the field, the fieldworkers spent a day in the office typing up field notes in full. Each CHW or supervisor was observed for 3–5 consecutive days (interrupted by the office days) to allow for reduction in the Hawthorne effect. Participants were randomly selected, although changes were sometimes required due to CHWs taking leave or being absent. Participants responded well to observation, and relaxed substantially during the course of the first day of observation, although there is some evidence that the CHWs conducted more household visits early on in the observations.
All available CHWs participated in the focus group discussions (FGDs), and all supervisors and facility managers (except one) were interviewed. Community representatives were purposively sampled. Key informant interviews were recorded and transcribed. Finally, 74 household members, who received referral advice from CHWs during observed home visits, were interviewed a month later, to understand their experience of the CHW service, and whether referral advice was acted on. Interviews were conducted in participant's home, in the participant's choice of language(s) and recorded with a digital recorder. Field workers used the recording to draft a summary of the interview in English.
Taking a case study approach, we drew data from the various sources to develop an explanatory description of each team, and then drew comparisons across teams. This process involved several steps. First, we extracted data from each interview or day's observation into a template, either by summarising descriptions of events, or extracting raw data such as useful quotations. This increased our familiarity with the data and allowed us to reduce its volume significantly. Multiple team members extracted data from the same sources, compared extracted data and modified extraction strategies until we were confident about inter-extractor reliability.
Second, the authors presented a brief summary of each site in a 1-day workshop. Through this collective process we identified themes that revealed the similarities and differences across the sites, such as weekly and daily pattern of activities, resources available, record keeping, managing patient referrals to the clinic, engagement with clinic staff, relationship between CHWs and supervisors, relationship with patients, local NGOs and key community stakeholders. We then generated a template into which we collated site-specific data under these themes, producing a summary for each site (see online supplementary appendix).
In preparing the manuscript, we continued to revisit the raw and summarised data to confirm descriptions of the context, enrich the content, provide clarity and check emergent ideas. The multiple data sources, as well as events documented by multiple field workers, allowed triangulation that increased the validity of our findings.
All participants gave informed consent. When accompanying CHWs into the community, fieldworkers obtained verbal consent from household members, prior to entering any household. There were few refusals.
Patients were not involved other than as respondents. Feedback has been given to provincial, district and facility management, as well as CHW supervisors and CHWs in the intervention sites in various forms, including facility level workshops.
CHW conditions of work across districts
The lack of integration led to work conditions that were demotivating for CHWs. They were not formally employed by the government, but were an outsourced workforce, managed by a private payroll company and paid a minimal stipend for 6 hours work a day. They struggled to contact the private payroll company responsible for monitoring attendance and paying stipends. An electronic system requiring CHWs to clock in/out at the clinic limited their ability to reach outlying areas as they needed to travel between the clinic and these areas on foot. Two months prior to the start of our fieldwork, CHWs had been on strike over their conditions of employment. Moreover, opportunities for career development into nursing were limited, particularly for those without a high school diploma.
CHW work was hampered by insufficient provision of logistical support due to the lack of integration. They often worked without necessary resources, including equipment, stationery, uniform, name badges or funds for transport or communication. For example, a team of 20 CHWs shared one or two blood pressure machines borrowed from the facility. When equipment, such as a glucometer, was provided, the associated consumables such as glucose strips were often not replenished. Notebooks used by CHWs to record daily activities were purchased out of their own stipend. The general lack of resources compromised CHWs' work and generated resentment.
While teams based in health posts had some dedicated space, clinic-based teams did not have sufficient space to meet, complete paper work or store their files; often files were kept at home. Supervisors did try to address these deficiencies, and some of the endeavours appeared to be morale boosting. CHWs reported that when one supervisor negotiated with the facility manager to use a meeting room for CHW meetings, it immediately increased their job satisfaction.
Before she (PN) came, we were like orphans, we had no space inside the clinic. We were doing everything outside. She came with a lot of changes around here…PN had played an important role in our lives…I even enjoy my work now. (CHW-FGD, 1A)
The supervisors
The supervisors in our study sites were either senior (ie, PN) or junior (ie, EN) nurses. A PN, with a 4-year degree in nursing, is able to diagnose patients, prescribe treatment and dispense medication. Importantly, the PN supervisors in the study site were trained in primary healthcare and community nursing, and had attended various other courses on TB, HIV, diabetes and hypertension, integrated management of childhood illnesses (IMCI), nursing management and leadership. Many were rehired retirees (Rehired retirees were used for three reasons. First, due to the shortage of professional nurses in the system, drawing in those who had retired increased the supply. Second, they had a wealth of experience in community nursing, which younger nurses often did not. Third, they were given an increment on top of their pension, rather than a full salary, and so cost the district less than a formally employed PN.), who had >30 years of experience as a nurse before they joined the programme (table 3). ENs have completed a 2-year course and can provide nursing care under supervision of a PN. All ENs except one (site 3B) received 1-week induction training on the WBOT programme before joining. Some of the EN supervisors in the site had also attended courses on early childhood development, TB, prevention of mother to child transmission and the expanded immunisation programme. Most of the ENs were younger and less experienced in community work than the CHWs they supervised. The PN supervisors reported to the facility manager, as did the EN supervisors, if there was no PN supervisor in the team.
Supervision of CHW—who, what and when
Supervisor activities
Formal and informal (on-the-job) training
In four of the six sites, 90%~100% of the CHWs had completed the first phase of the national training programme, but only three sites (all with PN supervisors) had a significant number of CHWs who had passed the second phase of training (table 3). Both phases require a written test, followed by a practical assessment conducted by the supervisor during household visits; success in this assessment requires a competent supervisor, and comprehensive and ongoing training. One PN placed considerable emphasis on training. 'When PN came, she checked who had done what course and organised training for those who needed it' (CHW-FGD, 1A). This PN also used daily morning meetings as training sessions, 'our PN is teaching us … every day in the morning' (CHW-FGD, 1A). Given the volume of information that CHWs were required to retain, these regular sessions were important. This PN involved the two ENs in the training: 'Sister teaches us like nobody's business' (EN, 1A), enabling the ENs to take up the supervisory role.
In contrast, in the EN-only sites, supervisors were unable to arrange formal training for the CHWs, in part due to their rural location at some distance from the district training centre, and because the ENs were not sufficiently skilled to carry out the practical assessment. With little experience themselves, they were also unable to provide on-the-job training.
Supervised home visits
ENs routinely accompanied different pairs of CHWs on home visits several days a week. Some ENs demonstrated sensitivity in correcting CHWs' practice. "When I can see this one didn't do it right, I keep quiet in the house, but immediately after we step outside as we are walking I do on-the-spot training" (EN, 1B). Other ENs working without a PN supervisor, seemed uninvolved during the home visits. Despite one EN spending 4 days a week out in the community, the CHWs did not acknowledge her as a supervisor, "When we get there she's doing the same job that I normally do when I am alone" (CHW-FGD, 3A). Consequently, her CHWs did not report problems they encountered to her, such as patients with suspected TB, as they had little trust in her problem-solving capability.
Regular debriefing
One health post-based PN/EN team (2A) held daily debriefing sessions, at which CHWs described the households visited, problems encountered and actions taken. The sessions strengthened CHWs' knowledge base and problem-solving abilities, and provided a platform for collective supervision, enabling the CHWs to learn from each other's experience.
One team (1A) held debriefings in conjunction with other activities, such as in-service training or medication preparation, which diluted the effects of debriefing. In other teams, feedback was said to happen once a month, but we were unable to validate this, and difficulties with recall of events for a whole month would likely limit the utility of this approach. Those teams that had no place to meet inside the facility tended not to discuss serious matters for reasons of confidentiality. "Sometimes we stand outside to hold meetings… patients and the security personnel will be listening to what we are discussing" (CHW-FGD, 3A).
The CHWs used notebooks to document their daily activities. Through reviewing these notes, experienced supervisors could discuss the visits with the CHWs, ask questions and provide support, as observed in teams 1A, 1B and 2B. In every team there were CHWs that took poor notes, but this was better contained by supervisors willing to spend time reviewing records, and discussing problems with the relevant CHWs. It sent a clear message that documentation of activities was central to the work.
Assistance in compiling reports
PNs of two teams (1A and 2B) required CHWs to compile their statistics every Friday, as doing it on a weekly basis (rather than monthly) reduced recall error and thus enhanced quality. One PN verified the weekly report of each CHW against their notebooks, correcting mistakes and making sure that the CHWs understood the meaning of each data category and how notes were translated into figures. This practice strengthened the ability of CHWs to record their work, and trained them to be accountable for what they did. To make sure that CHWs reported faithfully, another supervisor would make unsolicited household visits, "Sometimes I would just go out, and when they talk about households, I would say, oh that one who lives in that shack? And they would say, 'Sister you went there?' I would say, Yes, it is necessary" (SN, 2B). In contrast, EN supervisors without senior support, tended to simply accept whatever reports the CHWs handed over, with no discussion or interrogation of the statistics produced.
Clinic duties
There was an understanding between district officials and facility staff that clinic-based supervisors were to spend 70% of their time on CHW duties, and assist clinic staff in the remaining 30% of their time, particularly if the clinic was short staffed. District officials regularly restated this 'rule', as they were concerned about supervisors neglecting their CHW duties. We did observe EN supervisors, who did not have PN supervisors, spending substantial amount of time in the clinic, but this was because they felt unable to contribute to CHW activities. However, one EN with PN supervisor said:
if I am not busy I help with vital signs stations… it is not part of my job but I do it anyway … I refer my patients and the nurses see them. So there is teamwork. The support system is great so I never felt pressure to leave my WBOT duties. (EN interviews, 1B)
Remember, (patients) in this family planning (unit of the clinic), are also the children of the mothers and the fathers that we deliver the medication at home. So, we're working hand in hand…even if they (clinic staff) ask, are you finished what you were doing? If you don't mind, can you please help me to take a blood pressure on this patient? Then I will do. (EN interview, 1A)
The consequences of supervision
Motivation, job satisfaction and engagement
Job satisfaction, professional confidence and motivation were more evident in teams with effective supervision. One CHW commented that since the PN arrived: "we started to feel that we are now CHWs and human beings" (CHW-FGD, 1A). Two ENs supervised and mentored by PNs, explained: "At first it was challenging for me leaving the hospital and working in the community… maybe I'm not a nurse anymore, but now I feel more useful. The community is aware of us … they are coming to us. People are taking treatment now. I think there is lesser tracing on ARV patients, most defaulters you will find are TB. Our stats are going up" (EN, 1B). "I'm a street nurse…but you know what, when I reach the households, this is very enjoyable" (EN, 1A). When CHWs were on strike over issues with their contract in 2016, some CHWs at the clinic-based PN/EN site (1B) continued working, not wanting to let their patients down or damage their relationship with supervisors and the facility. Their supervisor interpreted their actions: "they see that you, as their leader, are supporting them and trying to understand where they come from, especially with this employer thing being mixed up. That is why I am saying, hence, they refused to go on strike today" (EN, 1B).
However, in the absence of supportive supervision, insufficient training constrained CHWs ability to assist patients, and as a result, demotivated them. Their frustrations over their working conditions were unresolved, and sometimes unacknowledged by their immediate supervisors. Some CHWs decided to work fewer hours a day as a passive protest, in addition to participating in the collectively organised strikes.
CHWs with engaged and skilled supervisors carried out a fuller range of activities, and used their discretion to make decisions. For example: "A patient had an elevated blood glucose level. However, it was too late for the patient to go to the clinic, so rather than writing a referral letter, she visited the patient again with glucometer after work, by which time the glucose level had dropped by 50%. The next morning, she went for a third time and found that sugar level had returned to normal" (Observation notes, 1A). This CHW, from a clinic-based PN/EN team, was able to interpret the glucometer readings, and rechecked the patient to avoid making an unnecessary referral.
The dedication of some CHWs to their work is evident in the following client interview: "If you send a message to a CHW, it does not matter what time it is, or what the problem is, they will come and help you. Whatever problem you have, you can talk to them, and you are not worried that they will be talking about your problem around the area. I like the work they do very much" (Patient-BT, 2A). In the EN-only model where supervision was the weakest and support from facility staff was negligible, CHW activities were minimal, with CHWs often only delivering medication to the elderly. One CHW highlighted how a colleague's poor performance impacted on the collective reputation of the team, 'It's not good if the patient comes here and when one of the clinic staff checks the card finds out the medication delivery is long overdue. It affects all of us in the eyes of the clinic staff and the PN' (CHW-FGD, 1A).
Collaboration between CHWs and facility staff
Located at a distance from the main clinics, health post teams received little supervisory support from clinic staff. Other than supplying medication, there was little managerial oversight by the clinic. "I am not directly supervising them except for sometimes when they are there. You can only supervise something that you can see. With the CHW team it is just via the phone and then it ends there" (Facility Manager, 2A). In the health post located in a community without a clinic, the PN spent a considerable amount of time seeing patients, and so neglected her CHW supervision responsibilities. Furthermore, the distance between the health post and the clinic hampered efforts to ensure CHWs' patients accessed to care at the clinic.
The saddest part is when the patient comes to the clinic and the file is not there, the doctor does not see the patient, and the patient is getting upset with us. Every time when we go to the clinic, we have to look for the files, the clerks do not assist us and we don't even find those files. (Observation notes from conversation with CHW, 2A)
In clinic-based team, without a senior supervisor to assist, management of files was also a problem:
Sometimes you find the admin clerk is in a bad mood, she speaks to us in a bad way in front of the patients, 'I am not going to give you the file. You have to go back to the patient to tell the patient to come to the clinic to collect it'. You report to the sister, she will tell you that she has been warning (the admin clerk) for several times but she does not listen. (CHW-FGD, 3A)
CHWs reported that other facility staff expressed a dismissive attitude towards them:
the peer educators, HIV/AIDS counsellor we all go together to sign the same contract but they are treated as if they are more educated than us, they call us street maids (CHW-FGD, 3B)
When asked why they were not allowed to work inside the facility, the CHWs responded: 'the manager tells us that we are not part of the clinic, so there's nothing she can do for us' (field notes, 3A). The denial of sharing space exacerbated the CHWs' sense of marginalisation and exclusion.
However, in clinic-based teams, with the support of senior supervisors, and the resulting growth in skills and confidence, CHWs had been able to establish better relationships with clinic staff. In turn, clinic staff, seeing the CHWs' greater motivation and effort, were more likely to treat the CHWs with respect. There were several benefits to this resulting collaboration. First, communication and coordination was better. Working together, the facility manager and PN were able to confirm whether, once defaulters had been traced by CHWs, they returned to the clinic. 'We engage with facility manager, she helps with problems that we have…. we include her in everything' (EN, 1B). Clinic staff willingly accepted referrals from CHWs, and included the CHWs in training sessions: 'Sister X is not (in the CHW team), but she is very helpful. She attended severe malnutrition training and she called all the CHWs and did a presentation for everybody' (EN, 1B).
Second, in one clinic, the contribution of CHWs had become indispensable: 'If they (CHWs) were not there, it means you will be over worked, the clinic will always be full, to be honest. There is good communication between us' (Facility Manager, 1A).
The third benefit was the empowerment of CHWs, who learnt to negotiate with other less willing staff: "I have a patient who doesn't want to come to the clinic and I don't want my patient to default on her HIV treatment. I said to the sister 'my patient is working at the farms so please pack medication for her. I'll ask her to come next month'. The sister scolded me because the patient did not come on her last appointment. So I begged the sister and promised to bring the patient myself. Then it was sorted, the patient got her medication and she came to the clinic with me" (CHW-FGD, 1B).
Negotiating acceptance and building the community's trust
All CHW teams depended on the supervisor to liaise with key community members: "We established good relations with the ward councillor so whenever there was a problem I would call her" (PN, 2B). The presence of the senior supervisor increased CHWs' credibility in the community: "If CHWs found that I am not well, they report to the PN, and the PN would come and see me. I have noticed that when I follow the PN's advice, my health improves. We are alive today because of them" (Patient-BT, 2A).
Box 1 describes visits to two different households conducted on the same day by the same CHW, for which she received very different support from the facility.
Support from the clinic facilitates community health worker (CHW) performance and client trust
Case 1: Patient defaults as nurse insists on waiting for test results
The patient, a woman on antiretroviral (ARV) drugs with a spinal cord problem, had moved recently. She was no longer able to collect ARVs and go for physio appointment at the clinic near her previous home as she had no money for transport. She asked for a referral to a closer clinic. The nurse refused as ARV patients tended to move clinics, so patient stole the file.
The CHW took her file to the closer clinic to ask if she could collect medication for the patient. The CHW was told that a new file had to be opened and the patient had to wait for CD4 results to come back. As a result, when we interviewed her, the woman had been defaulting for the past 3 weeks.
In the interview the patient said the CHW had not followed up on her requests for food parcels as they had no food, for a physio appointment, or for her husband to be tested for HIV. "The CHW doesn't follow-up on me to see how I am doing; the only thing that she is good at is making empty promises" (Patient-AA, 3A).
Case 2: Social worker responds to CHW request
The patient was a woman whose child was knocked down and killed by a car in front of her and her children. The family were traumatised. CHW wrote a referral letter to a social worker. The patient went to the social worker and then started attending a support group. CHW also arranged for the social worker to see her husband and children at home.
Patient said she trusted CHW because 'she is kind, open and she knows how to speak to people even if you are in a difficult situation. She does not gossip about her patients on the street' (Patient-Z, 3A).
Inadequate and unpredictable support from the clinic profoundly influenced the CHW's ability to provide care for her clients, and in turn, the degree of trust between client and CHW.
Table 4 summarises the key effects of location and the level of supervision on CHW performance.
Impact of supervision and location on the determinants of CHW performance
In this paper, we explored the effect of three different supervision and location configurations on CHW motivation and performance. We have demonstrated that experienced supervisors employed a range of strategies to train, motivate and monitor CHWs, to improve the quality of their work. In turn, CHWs were treated with greater respect by the clinic staff, making space for collaboration and support that benefited both parties. Being a near-equal of the facility manager, a PN supervisor was in a position to bridge the divide between the CHWs and clinic staff. When one of the PNs obtained a place for the CHWs inside the facility, she secured a position—physical and symbolic—for them in the health system. She drew in other staff to participate in the supervision of CHWs, further strengthening their legitimacy. Clinic staff provided advice and ensured that CHWs' patients accessed the care that they needed. CHWs traced the defaulting patients for the clinics and so improved the clinic's performance. The senior supervisor, a shared resource to both the CHWs and the clinic, was able to effectively integrate the CHWs into the health system.
In contrast, the teams in health posts found it difficult to build relationships with the clinic, particularly if the health post was at some distance from the clinic and the PN was busy with patient consultations. The EN-headed teams lacked adequate training and supervision, and consequently the CHWs' performance was minimal. With little evidence of the CHWs' contribution, the social distance between the CHWs and clinic staff remained substantial. Given her junior position, the EN was not able to facilitate collaboration with the clinic to reduce this distance. Hence, despite being based in the clinic, the EN-led CHW teams were not effectively integrated into the health system.
Our study has several limitations. First, despite fieldworkers asking CHWs to carry out their duties as normal, during observation many CHWs appeared to make extra effort to reach a greater number of households. We followed the same CHWs for 3–5 days to mitigate this, and the number of household visits did fall overtime, as the CHWs became used to the presence of an observer. Second, our data on CHW performance were based on what we learnt from our respondents rather than on an objective measure of performance. Third, while we selected study sites to ensure that the different supervisory configurations were included, we do not know to what extent the included CHW teams are representative of others in the same district. The study demonstrates noteworthy strengths. As far as we know, this is the first study to examine the effect of different levels of on-site supervisors as well as the location on CHW performance in a government programme. The case study approach allowed us to purposively select teams based on their different supervision/location configurations, and to compare and contrast their functioning in order to understand what worked, and what did not.
CHW supervision is often no more than periodic interactions by facility staff or officials who may not understand the context and role of CHWs. This can result in bureaucratic inspection and fault-finding, rather than problem solving and support.6 7 20 For example, in the Ethiopian national programme, supervisors make irregular visits from either the local health centre or district office.21 In our study, the presence of an appropriately skilled and qualified on-site supervisor enabled ongoing supportive engagement, rather than a distant supervisor who had fit supervisory visits into a busy schedule. Evidence from a rapid assessment of the South African WBOT programme in five provinces suggested that the existing facility-based staff were unable to provide effective supervision as they were already overstretched, working in under-resourced and underperforming clinics.15 The authors concluded that CHW teams should be based in stand-alone health posts with a nurse supervisor, rather than within a clinic. Our data suggest it would be more advantageous for the nurse supervisor and the CHWs to be based at a clinic, with clear rules about how much time the supervisor can spend on clinic activities.
In the Ethiopian programme, CHWs based in health posts also struggled to make referrals and experienced dismissive attitudes from clinical staff; while where there was more regular contact, the CHWs felt valued and part of the team.21 Studies in Uganda, Bangladesh and Bolivia have reported that contact with a higher level of the health system gave CHWs credibility with their clients.22–24 Similar to our findings, in Mozambique supervision increased the participation of CHWs in the intervention facilities.13
Training and supervision of supervisors is a more neglected subject than that of CHWs.9 25 26 This issue is beyond the scope of this paper, but in the second phase of our 3-year study, we are evaluating the effect on performance of a PN supervisor in building the capacity of the EN supervisors.
Globally, there are ongoing efforts to scale-up CHW programmes as a means to strengthen health systems and accelerate universal health coverage. These include the call for 1 million CHWs in sub-Saharan Africa,27 making CHWs available everywhere on the African continent,28 new funding commitments from the private sector,29 as well as the recent WHO guideline on health policy and system support to optimise CHW programmes.30
The new WHO guideline states that "planners should adopt 'whole-of-system' approaches, taking into account health system capacities and framing the CHW role vis-à-vis other health workers in order to appropriately integrate the CHW into the health system".30 The guideline also indicates that while there is benefit of supportive supervision, there is a lack of granular evidence. Our study provides rich evidence on the range of supervision strategies, how the effectiveness of these varies by the level of supervisor and whether the team has its base in a facility or not. Taking a whole-system perspective has enabled us to draw conclusions about the barriers and facilitators to integrating the CHW into the system. Here we offer recommendations based on the experience of well-functioning teams to complement current global efforts (table 5).
Programme design features and supervisory strategies that worked
With high expectations of CHW programmes in improving access to care in South Africa and other similar settings, full-time, on-site supervision can make an important contribution in enabling CHWs to provide comprehensive, promotive and preventative care. In the context of an overstretched health system, senior supervision located within a clinic can enable the development of a collaboration between the clinic and CHWs, reducing the CHWs' marginalisation, and enabling their potential contribution to improving health outcomes to be realised.
The authors would like to thank the following individuals for their invaluable contribution: the field workers, the respondents, the CHW teams, Mrs Salamina Hlahane, district manager at Sedibeng and Mrs Bridget Lefhoedi, community-based services coordinator. Input from Professors Margaret Thorogood, David Sanders and Emmanuelle Daviaud throughout the study has been highly appreciated. The authors would also like to thank these organisations for their generous support: Department of Health Sedibeng District, Gauteng Department of Health, the UK Medical Research Council (MRC) and Taiwan Ministry of Science and Technology.
Perry HB ,
Zulliger R ,
Rogers MM
. Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness. Annu Rev Public Health 2014;35:399–421.doi:10.1146/annurev-publhealth-032013-182354
Datiko DG ,
Yassin MA ,
Theobald SJ , et al
. Health extension workers improve tuberculosis case finding and treatment outcome in Ethiopia: a large-scale implementation study. BMJ Glob Health 2017;2:e000390.doi:10.1136/bmjgh-2017-000390
Lehmann U ,
Sanders D
. Community health workers: what do we know about them. The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. Geneva: World Health Organization, 2007:1–42.
van Ginneken N ,
Lewin S ,
Berridge V
. The emergence of community health worker programmes in the late apartheid era in South Africa: An historical analysis. Soc Sci Med 2010;71:1110–8.doi:10.1016/j.socscimed.2010.06.009
Barnett ML ,
Gonzalez A ,
Miranda J , et al
. Mobilizing Community Health Workers to Address Mental Health Disparities for Underserved Populations: A Systematic Review. Adm Policy Ment Health 2018;45:1–17.doi:10.1007/s10488-017-0815-0
Hill Z ,
Dumbaugh M ,
Benton L , et al
. Supervising community health workers in low-income countries-a review of impact and implementation issues. Glob Health Action 2014;7:24085.doi:10.3402/gha.v7.24085
Glenton C ,
Colvin CJ ,
Carlsen B , et al
. Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis. Cochrane Database Syst Rev 2013;10:CD010414.doi:10.1002/14651858.CD010414.pub2
Kok MC ,
Kane SS ,
Tulloch O , et al
. How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature. Health Res Policy Syst 2015;13:1–13.doi:10.1186/s12961-015-0001-3
Pallas SW ,
Minhas D ,
Pérez-Escamilla R , et al
. Community health workers in low- and middle-income countries: what do we know about scaling up and sustainability?. Am J Public Health 2013;103:e74–e82.doi:10.2105/AJPH.2012.301102
Dieleman M ,
Taegtmeyer M , et al
. Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review. Health Policy Plan 2015;30:1207–27.doi:10.1093/heapol/czu126
Bosch-Capblanch X ,
Liaqat S ,
Garner P
. Managerial supervision to improve primary health care in low- and middle-income countries. Cochrane Database Syst Rev 2011:9.doi:10.1002/14651858.CD006413.pub2
Rabbani F ,
Shipton L ,
Aftab W , et al
. Inspiring health worker motivation with supportive supervision: a survey of lady health supervisor motivating factors in rural Pakistan. BMC Health Serv Res 2016;16:397.doi:10.1186/s12913-016-1641-x
Madede T ,
Sidat M ,
McAuliffe E , et al
. The impact of a supportive supervision intervention on health workers in Niassa, Mozambique: a cluster-controlled trial. Hum Resour Health 2017;15:58.doi:10.1186/s12960-017-0213-4
Ameha A ,
Karim AM ,
Erbo A , et al
. Effectiveness of supportive supervision on the consistency of inter-grated comunity cases management skills of the health extension workers in 113 districts of Ethiopia. Ethiop Med J 2013;52:65–71.
Marcus TS ,
Hugo J ,
Jinabhai CC
. Which primary care model? A qualitative analysis of ward-based outreach teams in South Africa. Afr J Prim Health Care Fam Med 2017;9:1–8.doi:10.4102/phcfm.v9i1.1252
Schneider H ,
Schaay N ,
Dudley L , et al
. The challenges of reshaping disease specific and care oriented community based services towards comprehensive goals: a situation appraisal in the Western Cape Province, South Africa. BMC Health Serv Res 2015;15:436.doi:10.1186/s12913-015-1109-4
Department of Health, South Africa. Provincial guidelines for the implementation of the three streams of PHC Re-engineering. http://www.jphcf.co.za/wp-content/uploads/2014/06/GUIDELINES-FOR-THE-IMPLEMENTATION-OF-THE-THREE-STREAMS-OF-PHC-4-Sept-2.pdf (accessed 23 Jan 2017).
Trafford Z ,
Swartz A ,
Colvin CJ
. "Contract to Volunteer": South African Community Health Worker Mobilization for Better Labor Protection. New Solut 2018;27:648–66.doi:10.1177/1048291117739529
Nxumalo N ,
Choonara S
. A rapid assessment of ward-based PHC outreach teams in Gauteng Sedibeng district–emfuleni sub-district. Johannesburg: Centre for Health Policy, University of the Witwatersrand, 2014.
Roberton T ,
Applegate J ,
Lefevre AE , et al
. Initial experiences and innovations in supervising community health workers for maternal, newborn, and child health in Morogoro region, Tanzania. Hum Resour Health 2015;13:19.doi:10.1186/s12960-015-0010-x
Kea AZ ,
Datiko DG , et al
. A qualitative assessment of health extension workers' relationships with the community and health sector in Ethiopia: opportunities for enhancing maternal health performance. Hum Resour Health 2015;13:80.doi:10.1186/s12960-015-0077-4
Bartos A ,
Tenorio A ,
Saunero R , et al
; Extending the duration of exclusive breastfeeding in El Alto, Bolivia through a community-based approach and the provision of health services. Geneva, Switserland: Child Health and Nutrition Research Initiative, 2009.
Nankunda J ,
Tumwine JK ,
Soltvedt A , et al
. Community based peer counsellors for support of exclusive breastfeeding: experiences from rural Uganda. Int Breastfeed J 2006;1:19.doi:10.1186/1746-4358-1-19
Haider R ,
Ashworth A ,
Kabir I , et al
. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial [see commments]. Lancet 2000;356:1643–7.doi:10.1016/S0140-6736(00)03159-7
Daniels K ,
Nor B ,
Jackson D , et al
. Supervision of community peer counsellors for infant feeding in South Africa: an exploratory qualitative study. Hum Resour Health 2010;8:6.doi:10.1186/1478-4491-8-6
Rowe AK ,
Onikpo F ,
Lama M , et al
. The rise and fall of supervision in a project designed to strengthen supervision of Integrated Management of Childhood Illness in Benin. Health Policy Plan 2010;25:125–34.doi:10.1093/heapol/czp054
Singh P ,
Sachs JD
. 1 million community health workers in sub-Saharan Africa by 2015. Lancet 2013;382:363–5.doi:10.1016/S0140-6736(12)62002-9
The Lancet Global Health. Community health workers: emerging from the shadows?. Lancet Glob Health 2017;5:e467.doi:10.1016/S2214-109X(17)30152-3
Winters N ,
O'Donovan J ,
Geniets A
. A new era for community health in countries of low and middle income?. Lancet Glob Health 2018;6:e489–e490.doi:10.1016/S2214-109X(18)30072-X
World Health Organization. WHO guideline on health policy and system support to optimize community health worker programmes. http://apps.who.int/iris/bitstream/handle/10665/275474/9789241550369-eng.pdf?ua=1 (accessed 13 Dec 2018).
Contributors YHT analysed and interpreted data, wrote and revised the manuscript with JG, and approved the final manuscript as submitted. FG and JG conceptualised and designed the study, analysed data, critically revised the manuscript and approved the final manuscript as submitted. JdK carried out data collection process, managed data, analysed data, critically revised the manuscript and approved the final manuscript as submitted. NN analysed data, revised the manuscript and approved the final manuscript as submitted. TR and HM analysed data and approved the final manuscript as submitted.
Funding MRC-UK under Health Systems Research Initiative (MR/N015908/1). Taiwan Ministry of Science and Technology (105-2917-I-564-006).
Ethics approval The study protocol and instruments were approved by the University of the Witwatersrand's Human Research Ethics Committee (Medical) (M160354), the Gauteng Provincial Health Research Committee in South Africa and the Biomedical and Scientific Research Ethics Committee (BSREC) at Warwick University (REGO-2016–1825), UK.
Data sharing statement A sample of site-specific summary is available in appendix.
Patient consent for publication Obtained.


ArtLifting Co-Founder and Chief Happiness Spreader Liz Powers wrote this blog post for The Huffington Post on July 22, 2015.
I have worked with non-profits for 8 years and with homeless individuals for the past 9. During that time, I did a lot of reflecting. I thought about how frustrating it was to feel stifled - how I wanted to make an enormous impact. And move fast.
My job used to be running art groups in homeless shelters. Having to wait a year to hear back regarding grant proposals made moving fast impossible. More importantly, however, I thought about all of my friends in non-profits - how they were doing amazing work, but also how much of the work that they did not generate revenue. I didn't want to compete with them for grants.
I recognize that many non-profits generate revenue in order to survive and grow. But countless non-profits do not have the ability to generate revenue due to the cause they are championing. For example, homeless shelters that support domestic violence victims need to rely on grants.
I find it useful to think about the funding for non-profits with the help of an analogy: all foundation money and other grants are essentially a single pot of money. There are innumerable, worthy non-profits competing for a scoop from that single pot of money - 1.5 million non-profits in the U.S. alone, to be exact. I didn't want to compete against my friends at non-profits for a share of the pot of gold. Anything I received meant my friends would get precisely that much less. One cause's success is effectively another's obstacle.
I didn't want to rely on grant money to grow. I wanted to grow the pot of money.
There are countless talented homeless and disabled artists who need a marketplace to share their work with the community. I needed to solve this problem. Not just in Boston where I'm from, but nationally. And fast. I know so many individuals who can benefit from a marketplace now. Not 5 years from now.
That's why I decided, well aware of the potential for "vilification," to create a for-profit social enterprise - one that would be financially sustainable and scalable. And so we made ArtLifting a Delaware public benefit corporation, a new legal entity that combines high-growth business with a legally binding social mission. So far, it has proven to be the perfect fit. We have a double bottom line: to maximize both impact and financial growth.
At the risk of sounding like someone who is justifying her decision, however, I'd like to share with you the thought-process that led me to choose a for-profit model. For many reasons, I encourage others to realize that there is no need to apologize for using a for-profit entity to support a good cause.
Firstly, if our mission is to benefit both current and future artists, it is imperative that ArtLifting is financially sustainable. As someone who works and sympathizes with homeless and disabled individuals, I understand how easy it can be to want to seek short-term solutions to immediate problems. However, after nearly a decade of working with these individuals, I have come to understand the importance of - yes, it's cheesy - dreaming bigger: seeking long-term solutions to big picture problems. And in order to do that, I learned that I needed to think about revenue generation whenever and wherever possible.
I want to maximize our artists' opportunity to earn their own income. Before we existed, many of the artists we work with had no outlet. The ones that did, were lucky if they could make $20 selling their originals on a street corner. We need to treat these artists with the respect that they deserve. Since we launched just a year a half ago, five of our artists have already gained housing. Original artworks have already sold for as much as $1700. Artists earn endless amounts of money since we sell prints as well as products. Being a benefit corporation is the perfect solution for us.
In considering scalability, we looked to other art companies for inspiration. Part of our value proposition to artists is that we treat them professionally. This isn't charity. Artists earn 55% of the profit from each sale and invest $0 to initiate the sales. ArtLifting artists have the chance to earn their proceeds as professionals. Artist Allen Chamberland explains: "I want to be treated as a regular artist. I know that if you go into a regular gallery they take 50%. I realize that any business has expenses that need to be covered. I don't expect this to be done for free, especially for the scale that it is at now."
We want to treat our artists with dignity. They don't want a hand out - they want to earn their own income. As we've heard from many of our artists, the power to earn generates hope. We view ourselves merely as the vehicle that connects them with the countless customers who love their work.
Social enterprises not only grow the pot of money, but also have the potential to give back to nonprofits. I still remember the helplessness I felt when I was running art groups - many women at the shelters were creating new art and in need of supplies immediately. I could do little else, however, but wait a year to hear back from foundations regarding their sparse grants - I dug through recycling centers to pull together supplies for the season; I posted on craigslist and biked around to strangers' homes to get donations. Often, donated paints were hardened and brushes stiffened. When ArtLifting grows into a large business, we will have the ability to donate high-quality art supplies to art programs across the country. I can't wait.
If you see a need in your community, I recommend that you first take time to reflect on the wealth of potential solutions. Can it generate revenue? If so, go for it. The next question is whether a non-profit or for-profit social enterprise the best fit? Remember that the most meaningful solution is often one that is financially sustainable and scalable. Don't shy away from a for-profit entity for fear of "selling out." A for-profit social enterprise is an investment - it offers the opportunity to grow fast and give back.
I am a disabled artist with a very low income and I have artist friends who are even worse off than me, both financially and disability-wise. When I first heard of your organization it sounded like a good deal for the artists but the more I look into it the more upset I became. Something is very wrong with what you are doing.
I understand why you have set up a company instead of a non-profit and why are charging a commission to the artists but the percentage they receive 55% is disgraceful, insulting and dishonest. Saying how wonderful it is that you have discovered their great talent and works of art or that you are giving them opportunities and income by managing the selling their work doesn't change the fact that you are are not repaying them in proportion to the part they play in your operation. You can justify it all you want but you should not be charging them that much.
If you were REALLY doing right by them, a lot more people would be off the streets by now.
Sure Galleries take half, but Galleries are not dealing with homeless, destitute, disabled people. Most galleries are not also making endless prints and products out of the work of their artists. Let's face it, you are getting much more out of the deal than the artists are. You pride your selves on giving people recognition and self respect by doing them this "favor" of setting up a "Gallery" for them to be in. But in fact, your whole presentation puts the artists in a kind of pitiable light. The art gets short shrift as well. The artwork is not even presented professionally- can't find any mention of medium or process for the pieces. It's all about on-line shopping and products.
Clearly you are taking advantage of the artists desperation, their disabilities and certainly their lack of sophistication and expertise. They are like sitting ducks and you have totally taken advantage of them. I would never enter into such an arrangement and I would dissuade others from doing so as well. Personally I think you should be investigated.
I hope you will immediately lower your commission to a more reasonable amount for these circumstances and I would also recommend that you include some of the artists as employees in your operation.
It's a great idea – too bad you didn't really follow through.


text:
Ten artykuł dotyczy sezonu 1970 Rajdowych Samochodowych Mistrzostw Polski.

Kalendarz

Uwagi
,

Klasyfikacje Rajdowych Samochodowych Mistrzostw Polski 1970
 Puchar Motoru

Punkty w Pucharze "Motoru" przyznawano za 6 pierwszych miejsc według klucza: 8-6-4-3-2-1. Do końcowej punktacji zaliczano zawodnikom 3 najlepsze wyniki. Warunkiem sklasyfikowania był udział w co najmniej dwóch eliminacjach.
W przypadku uzyskania przez kilku zawodników równej ilości punktów w klasyfikacji rocznej o kolejności decydowała:
1) większa ilość lepszych miejsc
2) większa ilość lepszych miejsc w bezpośrednich spotkaniach
3) w razie dalszej równości - ex aequo

W Pucharze "Motoru" klasyfikowane były załogi startujące samochodami polskiej produkcji.

 Punktacja RSMP:

Punkty w RSMP przyznawano za 6 pierwszych miejsc według klucza: 8-6-4-3-2-1. Do końcowej punktacji zaliczano zawodnikom 3 najlepsze wyniki. Warunkiem sklasyfikowania był udział w co najmniej dwóch eliminacjach.
W przypadku uzyskania przez kilku zawodników równej ilości punktów w klasyfikacji rocznej o kolejności decydowała:
1) większa ilość lepszych miejsc
2) większa ilość lepszych miejsc w bezpośrednich spotkaniach
3) w razie dalszej równości - ex aequo

Podział samochodów startujących w rajdach zgodnie z regulaminami FIA:
 Grupa I - Seryjne samochody turystyczne. Produkowane w ilości co najmniej 5000 egzemplarzy w ciągu 12 miesięcy. Prawie całkowity zakaz przeróbek mających na celu poprawienie osiągów samochodu. Jeżeli pojemność silnika przekraczała 700 cm3, samochód tej grupy musiał mieć co najmniej 4 miejsca.
 Grupa II - Specjalne samochody turystyczne. Wyprodukowane musiały być w ilości co najmniej 1000 egzemplarzy w ciągu 12 miesięcy. Dozwolony duży zakres przeróbek poprawiających osiągi pojazdu. Tak jak w grupie I, jeżeli pojemność silnika przekraczała 700 cm3, samochód tej grupy musiał mieć co najmniej 4 miejsca.
 Grupa III - Seryjne samochody GT produkowane w ilości co najmniej 1000 sztuk w roku. Pojazdy co najmniej dwumiejscowe. Ograniczenia przeróbek i modyfikacji takie same jak w grupie I.
 Grupa IV - Specjalne samochody GT. Warunkiem homologacji było wyprodukowanie co najmniej 500 egzemplarzy w ciągu 12 miesięcy. Dozwolone przeróbki takie jak w grupie II.

Grupy podzielone były na klasy w zależności od pojemności skokowej silnika:
 klasa 1 - do 600 cm3
 klasa 2 - do 850 cm3
 klasa 3 - do 1000 cm3
 klasa 4 - do 1300 cm3
 klasa 5 - do 1600 cm3
 klasa 6 powyżej 1600 cm3
Samochody grupy IV nie mogły zdobywać punktów do RSMP.

Klasa 6

Klasa 5

Klasa 4

Klasa 3

Klasa 2

Klasa 1

Przypisy

redpajama_set_name: RedPajamaWikipedia


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In the event of a dispute you shall not withhold payment. We will investigate any dispute and issue refunds where relevant. TBI reserves the right to terminate/suspend any service if payment schedules are not being followed.
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TBI reserves the right to cancel the service at any time. Fees are charged on a Pre-pay basis and are non-refundable. In addition, some accounts incur set-up fees; these charges are also non-refundable. In this event, customers will be entitled only to a pro-rata refund based upon the remaining period of contract. In case cancellation is initiated by the customer, the customer will be charged our standard hourly charge in addition to any other applicable charge.
If a customer contravenes TBI terms of service, a refund will not be issued in the event of cancellation.All Hosting is subject to a 12 month contract. If you do not cancel your agreement 30 days before the end of the current year, then you are liable for another 12 months charge.
Any customer withdrawing payments via Bank or Credit card [a "chargeback"] may be subject to a punitive fee of R300.00, should TBI deem this charge back to be unfair. TBI also reserves its rights to defend such charge backs and recover the original monies from the card issuer.
The domain name is registered in your own name and contact details. You should be aware that the domain name is registered through a registrar and as such you shall agree to fully abide by the terms and conditions set out by the third party for such services.
You agree to take all legal responsibility for use of third party domain name and hosting services and supply truthful details to the third party services.
You agree that the information submitted for registration of domain names is then available to the general public via the registrars Whois system. However, Clients who are using their website for non-trading purposes may ask the third party registrar for their contact information not to be included in the registrars Whois system.
You are liable to pay TBI for any domain name registrations including but not limited to further domain name registration fees, domain name transfer charges, yearly domain name renewals, hosting charges, yearly hosting renewals, hosting upgrades, extra disk space, bandwidth and any other related or hidden charges levied by a third party that TBI are not aware.
TBI will make every effort to renew your domain names on your behalf. In case it is not renewed, TBI cannot be held responsible for non-renewal of your domains and as a customer you should check to see if your domain names have been renewed annually. You agree to pay the domain name and hosting fees and all renewal fees as soon as demanded by TBI. In the event of non-payment, TBI may take ownership of your domain name.
TBI reserves the right to advise you as such and send a separate quotation to you and to request payment for any further alterations.
By entering in to an agreement (verbal or written) for SEO, you will pay TBI for the contract period set and the hours allocated to do the job.
In case of any delay in payments, TBI reserves the right to suspend the service and not work on the site. However, you shall be charged for the hours allocated. This will affect your results in the search engine. However, TBI, at its discretion may decide to reallocate these missed hours, if possible.
Unless mutually agreed, this agreement shall last for a period of 6 Months. Either you or TBI may terminate this Agreement by giving to the other party 30 days written notice of its intention to do so.
You understand that Search Engines are independent companies who select the rank sites using their own criteria. We will optimize your pages to enable them to appear on the regional listings/search engines; however TBI cannot guarantee appearance and position on search engines. While you must follow TBI's recommendations for optimizing its website for Search Engine Listing in order to maximize its chances of increasing its Search Engine exposure you acknowledge that TBI does not and cannot guarantee that Customer's website ranking will be improved in any Search Engine listing. To enable TBI to optimize your websites you must provide FTP login details for the website and you acknowledge that the TBI cannot undertake any optimization until such FTP login details have been provided.
TBI's list of the most important Search Engines includes those Search Engines that TBI considers to be the most important with regard to popularity, language, content, location, coverage or any other criteria that TBI using its expertise considers suitable.
TBI and the Customer will choose a suitable set of words to search for in the Search Engines. This will be used as a test phrase to assess how your website is ranking in Search Engines.
A person who is not a party to this Agreement has no right under The Contracts [Rights of Third Parties] Act 1999 ["The Act"] to enforce any terms of this Agreement or the Terms but this provision does not affect any right or remedy of any third party which exists or is available apart from under the Act.
TBI may also pay third parties for links or advertisements; the cost of this will either be deducted from your available hours or added to your bill.
TBI will allocate on a monthly basis the time allowed in your contract to do Search Engine Optimization and you will responsible to pay us for that time and any additional hours if requested by you.
You agree that the information that you have given us or give to us in the future is correct and is in no way misleading, offensive or against any Country's Law. You will maintain secrecy of your pass words and will be solely responsible for any unauthorized access to your account by any person.
You hereby acknowledge and agree that TBI may terminate its services or involvement with you, at any stage or at any time during the introductory and/or negotiation and/or facilitation process, by giving you written notice thereof, without TBI having to provide you with any specific explanation or reason, or without TBI having any legal or financial obligation or liability towards you of whatsoever nature.
This Agreement may be terminated at any time if: (a) your website contains any material which is illegal, pornographic, radically abusive or is likely to cause offence or to damage TBI reputation; (b) you commit any material breach of this agreement; (c) you enter into liquidation whether compulsory or voluntary, as a receiver or administrator appointed, enter into any arrangement with your creditors or cease or threaten to cease to trade; (d) you stop paying TBI.
However, we will give you seven days to meet any such obligation before terminating our Agreement.
We reserve the right to suspend all or any of the services that we have given to you, including those that have been already paid for should any of these terms not be met.
The price that we charge you for our services is stated in your contract. You will pay to us all the charges on their due dates. Payment will either be in advance or by invoice. We reserve the right to make that decision. You can and may request additional services at any time after your Agreement has started. If we agree to provide you with these services you will pay the additional services that they incur.We will charge you for any administration costs and loss of work that have occurred for any payment not being met for whatever reason or that has not been honoured by your bank or any method of payment that has been made by you to us.
The charge for these defaults for non-payment and indeed any default of payment regardless of what it is or how it has been caused will be 100% of all outstanding order values. Should this debt have to be recovered in the Court additional charges including all legal and recovery costs will be charged to you. As a director or owner of your business you also give us your personal guarantee that all monies owed to us if your business is unable to meet them will be paid by you.
All services are rendered ensuring its quality. We generally take upfront and subsequent payments. If at any time in the service rendering process, you are not satisfied with the quality of work, you may bring it to our attention. We will investigate and decide about the refund. In general, we will not refund payments on time spent/services rendered, since TBI's charges are based on the hours of work spent on the project. If a customer contravenes TBI terms of service, a refund will not be issued in the event of cancellation.
Refunds are only possible if we are unable to render the services to you. The refund will be based on the hours that you have paid for but not used. No refunds will be given for hours spent on research, development, design and administration.
You are not entitled to a refund of any of our services if you: Decide to discontinue the use of our services Find our charges to be higher compared to others and you can't afford the services; Choose the wrong specifications for the service; Knew about the particular fault prior to purchase; and/or Were responsible for causing the fault.
You represent to TBI and unconditionally guarantee that any elements of text, graphics, photos, designs, trademarks, or other artwork furnished to TBI for inclusion in Webpages are owned by you, or that you havepermission from the rightful owner to use each of these elements, and will hold harmless, protect, and defend TBI and its subcontractors from any claim or suit arising from the use of such elements furnished by you.
Unless explicitly specified, it is assumed that: TBI will hold all copyright to the site it designs unless otherwise stated in writing; It will remain the sole intellectual property of TBI; TBI will own the intellectual property rights in any service given to you. You will have no resell rights. If you require copies of your site, you will be charged by the hour for any admin costs that are incurred including postage and packaging. TBI will not be responsible for any Copyright infringement or Domain name infringement against any law in any land brought on by your website.
TBI respects privacy of its clients. TBI will not monitor, edit, or disclose any personal information about your accounts, including hosted content, without your prior consent, unless TBI has a good faith belief that such action is necessary to: (a) comply with legal process or other legal requirements of any relevant authority; (b) protect and defend the rights or property of TBI; (c) enforce the terms of a Task Order, this Agreement or these Terms and Conditions; or (d) protect the interests of users of TBI's Hosting Services. You acknowledge and agree that your IP address is transmitted and recorded with each message sent from the Hosting Service.
In this Agreement, "Confidential Information" shall mean any and all technical or business information, including third party information, furnished in connection with this Agreement, in whatever tangible form or medium, or disclosed by you to TBI (including, but not limited to, product/service specifications, prototypes, computer files and programs, models, drawings, marketing plans, financial data and personnel statistics). Notwithstanding the termination, expiration or cancellation of this Agreement TBI agrees to treat such Confidential Information as confidential for a period of ONE year from the date of receipt of same unless otherwise agreed to in writing by you.
You will keep the details of the Agreement and any such information which you may learn about TBI, our business technology and our clientele, strictly confidential and agreed not to disclose it to any third party. Upon termination, cancellation or expiration of this Agreement for any reason or upon request of the disclosing party, all Confidential Information, together with any copies of same as may be authorized herein, shall be returned.
You agree that if TBI suffers any loss or there is a failure from your end to meet any of these obligations, you agree to pay us directly and immediately for any proven losses that may occur.
The obligations imposed in this Article shall not apply to any information that: (a) is known to the public (through no act or omission of TBI in violation of this Agreement); (b) is lawfully acquired by TBI from an independent source having no obligation to maintain the confidentiality of such information; (c) was known to TBI prior to its disclosure under this Agreement; (d) was independently developed by the TBI; or (e) is required to be disclosed by governmental or judicial order.
The requirements of use and confidentiality set forth herein shall survive the expiration, termination or cancellation of this Agreement.
The entire risk as to the quality and performance of the WebPages and website is with you.
only that the same arises as a result of the negligence of the TBI, its employees, agents or authorized representatives.
We will not be liable to make any payment to you including the return of deposits either in part or full for any delay or failure to meet any of our obligations under this or any other agreement made to you by either verbal, written or electronic means.
This includes [but is not limited to] any events that are beyond our control such as our computers, technology in general, telecommunication TBI equipment including satellite and internet suppliers.
We are liable to you to cover the contract and services provided to you as long as none of the other points in this contract are broken by you.
You agree to use all Company services and facilities at your own risk and agree to defend, indemnify, save and hold TBI harmless from any and all demands, liabilities, losses, costs and claims, including reasonable Attorney's fees asserted against TBI, its agents, its customers, officers and employees, that may arise or result from any services provided or performed or agreed to be performed or any product sold by you, your agent, employees or assigns. You agree to defend, indemnify and hold harmless TBI against liabilities arising out of: (a) any injury to person or property caused by any products sold or otherwise distributed in connection with TBI server; (b) any material supplied by you infringing or allegedly infringing on the proprietary rights of a third party; (c) copyright infringement; (d) any defective products sold to customers from TBI server and (e) claims arising from omission to inform or implement the updates needed for the site.
You agree that this indemnification extends to all aspects of the work completed by TBI, including but not limited to website content and choice of domain name.
TBI makes no warranties with regard to the site and its contents. TBI cannot guarantee the functionality or operations of their website or that it will be uninterrupted or error free, nor does it warrant that the contents are current, accurate or complete.
TBI is not responsible for any content published on your website that infringes any law, copyright or compliance. Customer is solely responsible for the security, confidentiality and integrity of all the content and messages received, transmitted through or stored on the web/server hosting service.
TBI will not be responsible for any damages or losses your business may suffer. TBI makes no warranties of any kind, express or implied for services we provide. TBI does not back up your data/website and while every attempt would be made in the unlikely event of any corruption or hardware failure. TBI disclaims any warranty or merchantability or fitness for a particular purpose. This includes loss of data resulting from delays, non-deliveries, wrong delivery, and any and all services interruptions caused by TBI and its employees. TBI reserves the right to revise its policies at any time.
TBI hands over files on request, once full payment has been made. However, the intellectual rights are the property of TBI unless stated otherwise at the time of contract. On handover of files from Company to you, you shall assume entire responsibility in ensuring that all files are functioning correctly before use. While every effort is made to make sure files are error free, TBI cannot guarantee that the display or functionality of the web design or the website will be uninterrupted or error free. If, after handover of files, errors are found in code TBI has created and the standard development platform, domain name set-up and hosting set-up are the same as when work began, then TBI can correct these errors for you free of charge for a period of 3 months, after acceptance of the work. After the 3-month period, TBI reserves the right to quote separately for any work involved in correcting an error.
If, after handover of files, errors are found in code TBI has created and the standard development platform, or the domain name set-up or hosting set-up have been changed, TBI can correct errors and reserves the right to quote separately for any additional work needed as a result of changes to the browser software, domain name set-up or hosting set-up.
TBI may from time to time recommend to you that updates are needed to your site, including but not limited to new legislation compliance, software compatibility and web standards. TBI reserves the right to quote for any updates as separate work. You agree that TBI is not liable for any failure to inform or implement these updates to their site.
You agree that TBI is not liable for any failure to carry out services for reasons beyond its control, including but not limited to acts of God, telecommunication problems, software failure, hardware failure, third party interference, Government, emergency on a major scale or any social disturbance of extreme nature such as industrial strike, riot, terrorism and war or any act or omission of any third party services.
You agree that TBI is not liable for any bugs, performance issues or failure of third party software as they are open-source softwares distributed under the GPL ("GNU General Public License") and are maintained and developed by a community of thousands of users and Companies. Any bugs, performance issues or failure with the software will be directed to the respective Development community.
We will not be liable to return any art work to you or any other material that you supply to us for the purpose of providing our services to you.
To maintain the quality of our service to our clients we reserve the right to change these terms and conditions and the nature of our services, which we have agreed to provide to you by giving you at least 28 days written notice. This notice will appear on our website.
You may not transfer any of your rights or obligations under this Agreement to anyone else without our prior or written agreement.
If you wish to write to us, please send your letter to our main office by means of a recorded method. Any other method apart from email with proof of sending will be classed as unsent. These terms and conditions together with the order schedule, work sheets and any additional attachments form the whole of our agreement. They apply in place of any terms and statement made to you by any TBI representative.
All notices must be in writing. Notices to TBI must be addressed to 4 Vlier Place, Bloubosrand, Randburg, 2188 or such other address as is advised by TBI. Notices to the Customer will be considered validly given if addressed to your address as shown in the agreement or such other address as is advised by you to TBI in writing.
In the event that any provision of the Terms shall, in whole or in part, be determined to be invalid, unenforceable or void for any reason, such determination shall affect only the portion of such provision determined to be invalid, unenforceable or void, and shall not affect in any way the remainder of such provision or any other provision of the Terms. No waiver of any rights TBI has under this Agreement shall be deemed from any failure by TBI to enforce any part of this Agreement.
This Agreement and Terms shall be governed by and subject to the laws of South Africa without regard to its rules concerning conflicts of law. The parties hereto irrevocably consent that all disputes which may arise out of or in connection with this Agreement or the Terms shall be subject to the exclusive jurisdiction of the courts of South Africa.
The Digital Creative Agency - Based in Gauteng, South Africa. If it's marketing or anything visually stimulating you require, we have you covered!


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Thanks to its central location, this hotel offers numerous possibilities if you want to visit the Lys region, the Flemish Ardennes, Ghent, Bruges and Kortrijk. It boasts five halls that can be used for receptions, parties and seminars. The hotel rooms are equipped with a phone, a seat, TV with a movie channel, a terrace and a bathroom that has a bath, a shower and a toilet. Every morning you get to enjoy a delicious lavish breakfast buffet.


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The Singer Featherweight sewing machine was available for sale between 1933 and 1964. It has quickly become one of the most popular sewing machines in the world. The popularity of these sewing machines has helped reveal a wealth of information about its many variations and production history. Many of those who have used this machine are now Singer Featherweight collectors.
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Sewing machine bag – Annick Han
This sewing machine is surrounded by myths. While many believe that the Singer Featherweight was available in all colors, the truth is that this machine was only produced in beige / tan, white / green and black color. There were no blue, red or yellow machines. Most collectors have repainted their machines and added new decals. A limited number of machines had a removable bed extension for free arm sewing.
If you search for information about Singer Featherweight on the Internet, you see that many users and collectors are trying to determine the manufacturing date of their machines. The truth is that it is not possible to correctly specify the year of manufacture for your sewing machine, but only the date when large series of serial numbers were released to different factories. These machines have been manufactured in large quantities at Kilbowie, Scotland and Elizabethport, New Jersey. There were more than 1,055,326 featherweight machines manufactured between 1848 and 1959.
The popular 222 freearm was not available for sale in the United States. The company believed that this model would be too expensive to have a clear market. Another myth says that the belt on white / green machines breaks at some point. The truth is, this part makes it a lighter and quieter machine. Many still believe that there were remarkable differences between the Singer Featherweight sewing machines depending on the factory where they were manufactured. In fact, there was no different quality between the factories. Both plants used identical manufacturing equipment.
There are many sources of information about Singer Featherweight sewing machines on the Internet. Books have been written about this small but powerful machine. An incredible amount of history has grown up around Featherweights, so it's important to separate the truth from the myth. Although most users claim that this machine is very portable, it is actually a full-size, durable machine that needs maintenance to perform its best. Keep it good and it will continue to sew. Although it only makes a straight stitch, the featherweight has a wide range of features and decorative accessories.
Determining Antique Singer Sewing Machine Value For many, the ancient Singer sewing machine value is mostly or partly sentimental. The machine they own usually belonged to a family member and was sent down through the generations as a legacy. However, this does not mean that the ancient Singer Machine value is purely in the sentimental or in the family tree. Many collectors are looking for ancient Singer sewing machines for their rarity, for their beauty and for the pure craftsmanship that went into their creation.Singer began manufacturing sewing machines back in 1851, later in 1856, they offered the first home use model, which was the cost prohibitive for most consumers at that time. Most people who bought a Singer model in the 1850s did it on a payment plan, about the same as a credit card today.These previous models were fitted and equipped with a pedal, while the later models contained locking stitches (patented by Singer 1859) and two pedals. The machine that started a home-run revolution was so popular, it even had its own "action figures" control and miniature sewing machines made of cast iron.Over the next few decades, Singer focused on creating more affordable models for home use through mass production, giving the original beauties behind. In the early 1900s, cupboards were created and even flip-top sewing machines, followed by various changes that lead to today's plastic models.The original models from the middle to the end of the 19th century can be valued in the high thousands depending on their condition, model, original addition, the housing and of course the market and the pool of potential buyers. While the condition is a factor, the antique Singer sewing machine value is more based on the production year and type of machine.Factors that can be considered when determining the value of your antique singer's machine include.
Facts Featherweight machine Myths Sewing Singer	2019-04-24

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