The barefoot soldiers of a public health care system that doesn’t seem to care

By Nomatter Ndebele

For the past 17 years, 55-year old Doris Ntuli has worked as a community caregiver (CCG) in the community of Sweetwaters, in Pietermaritzburg, Durban. In that time Ntuli has only received a pay increase of R300 (US$20). Her total monthly income is R1500 (US$95).

That one increase was all she’s ever been given. Other than that she and her colleagues work without support or resources in a hostile environment and one which provides little help to the people of the communities they serve.

In 2001, the KwaZulu-Natal province launched Operation Sukuma Sakhe, a social health care model that offers an integrated approach to both social and health-care services. The model puts one community caregiver (or community health worker, as it is generally known in South Africa) in charge of 60 households in order to oversee their health as well as their socio-economic wellbeing.

Care givers report to a “war room” with representatives from various social development departments including Home Affairs, Agriculture, Human Settlements, Health and Social Development. Here they are expected to report any issues affecting their allocated households to the relevant departments, who are then required to intervene, either by going back to the specific household or sending whatever is needed back with CCG.

What should be a strict and formal process however, hardly ever happens. On some days, department representatives don’t show up, and care givers say that not once have they received responses to cases written up in the report books in their absence.

This is one of the reasons CCGs, who are a vital part of the primary health care system, have lost credibility in the community. They never seem to deliver on their promises.

Seven years ago, for instance, on one of her rounds, Doris came across a quadriplegic blind man, who was living in an outside room and fending for himself. Although his family lived with him, they did very little to take care of the man. Doris told the family that she would report the matter and ensure that a wheel chair was delivered to the man.

“For seven years, I went back and forth to that war room to report the matter, but I received no help. I eventually stopped going back to the house because I was so ashamed,” says Doris.

The man died before any assistance came.

For two years now, Doris has left reports at the war room, detailing a case of an improperly sealed sewerage access point.

“It’s not safe. It’s just a big dark hole and if a child falls into that pit, they will be gone.”

To this day, the sewage access point remains open and no one from the war room has responded in any way. Doris admits that she is close to giving up on the matter. Clearly, nobody cares.

Although CCGs are employed as an extra hand for the departments of health and social services, they are met with much resistance. Nurses in the local clinics look down on them, viewing them as uneducated and providing very little support for the work they do.

Over the past six years, civil society has pushed for the government to recognise community health workers as legitimate aides of the public health care system, and calling for them to be formally employed and given the support they need to do their jobs.

Simanga Sithebe, a representative from Sinani, an organisation that works closely with CCGs in eThekwini, says that one of the biggest issues CCGs face is a lack of resources. They have no travel allowance and are not compensated for any expenses.

“They often pay out of pocket to provide patients with money for trips to the hospital or clinic,” said Sithebe.

CCGs are also forced to work with few or no materials. Often, Doris will get a bag of nappies and nothing else – no gloves, no TB masks – but she is expected to do her rounds regardless.

“The nurses tell me that they only have enough stock for themselves, and that we haven’t been budgeted for,” said Doris.

“Even people who clean the streets have a uniform. They have boots, but I walk up and down this community everyday in my sandals until they break,” she adds.

Sithebe explained that dysfunctional administrative processes have an impact on the work of these community health workers. The renewal of contracts is not a well-managed process and CCGs can wait for up to two months to find out whether their contracts will be renewed.

Despite the fact that CCGs are contracted by the KwaZulu-Natal Department of Health on one- or two-year contracts, they receive no benefits at all.

“If I die tomorrow, these children you see here won’t even have 20c to their name” says Ntuli.

For years, the CCGs in Durban have been promised better opportunities, but very few have materialised. When Doris started, she was told that she could be eligible for nursing training. This hasn’t happened, and in the 17 years that she has worked, only two other CCGs she knows have received training.

Doris, and many other CCGs in Durban have tried to have their grievances heard. Their peaceful marches and heartfelt pleas have gone unnoticed.

“I am supposedly working for the department, but not once have I seen a representative come and address our issues. For years they have ignored us,” said Doris.

At the beginning of May this year CCGs in Sweetwaters decided to take drastic action.

Doris joined a group of CCGs who staged a shut down at the local clinic. The group arrived early in the morning and locked the gates of the clinic, denying patients and staff access. It was only after this act of civil disobedience, that the CCGs were promised a response.

Their drastic action was a means to an end, but she and others knew that it will quite likely further strain relations between themselves and staff at the facility.

“We have never had a good working relationship with the sister at the clinic, and after this, I know things will be even worse. But what could we do?”

In spite of all these problems, Operation Sukuma Sakhe is hailed as one of the best primary care health care approaches and is supposed to act as the model on which all other provinces will base their systems.

There is a lot of work to be done in terms of supporting the people who drive the operation. For many people in far-flung rural areas, CCGs are their only line of connection to the public health care system and to social services.

It is not enough to theoretically empower CCGs without providing necessary resources for them to carry out their work.