5: How many CHWs do we need?
The ideal number of CHWs depends on a number of factors, including the population served (decisions to be taken in this regard will include whether rural and/or urban households are served, and whether household income is taken into account); the chosen ratio of CHWs to individuals or households; the distance and means of transport between households; the role to be performed by the CHWs (including whether the CHWs will have obligations inside health facilities and also at people’s homes), among others.
Also relevant is the existence of a formal primary healthcare service infrastructure. In some countries in which CHW programmes have been successful, CHWs are the primary healthcare system. This is not the case in South Africa.
The WBPHCOT Policy provides that one team will serve an average population of 6,000 individuals, or 1,500 households, per annum and gives the following factors for the number of CHWs and HBCs per WBPHCOT: population density; geographic location; burden of disease in catchment population, and distance from PHC facility. Due to the significant variation in each of these factors, there is no ‛best practice’. However, the WBPHCOT Policy suggests that a standard WBPHCOT will include six CHWs, meaning that each CHW is allocated to 250 households or 1,000 individuals, assuming that CHWs work alone.
The proposed standard ratio of CHWs to population is significantly lower than that in other successful programmes. Locally, in KwaZulu-Natal, one CHW serves 50 or 80 households, depending on poverty levels. In Thailand, only 8-15 households are served by one CHW and in Brazil the ratio is 1:150 households. In Rwanda, one CHW is appointed to 255 people. Having assessed the CHW programmes in Brazil, Nepal, Bangladesh and Rwanda, the Investment Case suggests that accepted practice validates the ratio of 1:150 households.
The total number of CHWs required depends on the ratio chosen and the total population coverage desired. Michel Sidibé, Executive Director of UNAIDS, in his plenary speech at the 2016 International AIDS Conference in Durban, proposed a total of 200,000 CHWs by 2020. This would provide for a ratio of one CHW to 265 people, if the whole population was covered. The National Development Plan has a more ambitious target of 700,000 CHWs by 2030 to serve an estimated future population of 60 million, meaning a ratio of one CHW to every 85 people, which would be one of the highest CHW-to-population ratios in the world.
At this point, there is no evidence to suggest that a standard ratio of one CHW per 250 households would be effective, given the range of tasks allocated to CHWs, and the need in many communities for CHWs to team up and visit households in pairs in the interests of safety. This doesn’t account for the large proportion of South Africa’s population that live in sparsely populated rural areas in which CHWs would have to travel long distances between households. In such areas, the ratio would need to be dramatically different.
The ratio proposed by Michel Sidibé (1:265) is unlikely to be financially attainable at this stage but may be a target to aim for. We argue that the Brazilian ratio of 1:150 households or 600 people, as supported in the Investment Case, is based on evidence and is therefore the most appropriate ratio for the South African setting. The ratio would need to be amended to suit local conditions.
The question that then arises is the population that should be covered. This is more a matter of priority than of excluding some populations permanently from coverage. The Investment Case proposes allocating WBPHCOTs to all wards where 60 percent of the population is below the upper bound poverty line. This would amount to coverage of 36.1 million people. At a ratio of 1 CHW to 600 people, this would require 60,166 CHWs or 10,027 standard WBPHCOTs, a huge increase from the 2,335 WBPHCOTs currently in existence. It is a good place to start.
Previous: 4: What should CHWs do?
 Draft Municipal Ward Based Primary Health Care Outreach Team (WBPHCOT) Policy Framework and Strategy April, 2015, p25.
 Rural Health Advocacy Project Position on Community Health Workers. Accessible at: www.rhap.org.za/category/community-health-workers/.
 T Doherty et al ‛Ending preventable child deaths in South Africa: What role can ward-based outreach teams play?’ SAMJ July 2016, Vol 106, No 7, p673.
 Draft Investment Case for Ward-Based Primary Health Care Outreach Teams, p46.