6: How should CHWs be employed?

6: How should CHWs be employed?

Issues around the employment of CHWs are some of the most highly contested in discussions of CHWs in South Africa. For years, CHWs have been calling for employment by the Department of Health, the standardisation of payments, training and role clarification, and for an increase in their salaries.

CHW programmes around the world deal with the payment and employment of CHWs differently. There is a mix of NGO-driven programmes and those that are centralised and operate out of a Department of Health. What is clear is the need for CHWs to be embedded both in the community and in the healthcare system. Where CHWs are employed by NGOs, embeddedness in the healthcare system tends to be more difficult. Equally, programme consistency cannot be ensured. Embeddedness in communities can be ensured, regardless of employer, by ensuring that CHWs are from the communities that they serve and that the community is involved in recruitment.[1] There are limitations to this manner of recruitment however, as CHWs operating in their own communities may find it difficult to discuss the health problems of their neighbours and those neighbours may be less willing to provide such information to the CHW.[2]

Employment by the state makes supervision, management and the development of a standard programme easier. It is also in line with South African government policy to insource where possible, including the resolution in the 53rd ANC National Congress in 2012 to insource those providing critical services in the Department of Health.[3]

The WBPHCOT policy envisages employment by the Department of Health or by NGOs (where they exist) and seconding of CHWs to Departments of Health.[4] It is unclear whether NGOs would be amenable to a secondment arrangement. National Treasury has, in meetings with CHWs, expressed its preference for NGO employment as such employment is less expensive for the state (in that it does not need to pay public sector salaries, including benefits) and does not add to the already substantial state wage bill.

Given the vital importance of proper integration into the healthcare system and the need for the creation of decent jobs in South Africa, we cannot continue to rely on the employment of CHWs through NGOs and the payment of extremely low stipends. If we value the work of CHWs and consider it indispensable to the move towards a preventative health system, as we purport to, CHWs must be employed by the state and receive the associated benefits. While this will be more expensive, it also offers the social and economic benefits described earlier. The Investment Case pins the cost of employment of CHWs on Level 1, notch 1 at R67,806 per CHW per annum. This is the level we should be pursuing.

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[1] U Lehman and D Sanders ‛Community Health Workers: What do we know about them?’ WHO Evidence and Information for Policy, Department of Human Resources for Health; Geneva, January 2007, p18.

[2] Interview with Kirsten Thomson, Associate Researcher at Wits Reproductive Health and HIV Institute.

[3] http://www.anc.org.za/docs/res/2013/resolutions53r.pdf.

[4] Draft Municipal Ward Based Primary Health Care Outreach Team (WBPHCOT) Policy Framework and Strategy April, 2015, p27.