Community health workers (CHWs), who are predominantly women have struggled to be formally integrated into the health service delivery system, and they are disgruntled.

By Ntsiki Mpulo

Motsoaledi on the role of community healthcare workers:

Community health workers (CHWs), who are predominantly women have struggled to be formally integrated into the health service delivery system, and they are disgruntled. Thousands of workers have taken to the streets in various provinces for their right to employment and equal treatment under the law and in the interim poor people face being without one of the most direct lines of healthcare.

Gauteng based workers staged a night vigil outside the Department of Health in May 2016, demanding that the Minister address their grievances. In the Free State, 94 CHWs were found guilty of contravening the Gatherings Act. They had gathered to hold a peaceful night vigil outside the MEC for Health’s office in 2014 after he had summarily dismissed 3800 of them without warning.

In an interview with Spotlight, South African Health Minister Dr Aaron Motsoaledi acknowledged the need for CHWs but said that there was an oversupply of workers who may not have the skills needed to serve the needs of the communities.

“In the NHI whitepaper we said the heartbeat of the health care system is going to be the primary healthcare system,” he said “Nurses are the backbone and community health workers are game changers.”

The calculations on which the minister has based the requirement for South Africa are those proposed in the National Health Insurance plan which states that each ward in the country should have an average of 10 community health workers to administer primary healthcare effectively. As there are 4000 wards in the country this equates to 40 000 CHWs. In South Africa, there are currently an estimated 70 000. “Unfortunately, we have a complex unplanned situation. It is part of our unfortunate past,” says Motsoaledi. “Many people believe the AIDS denialism era is gone but we are still experiencing its consequences.”

The minister explains that many community health workers began volunteering during the height of the HIV/AIDS epidemic. “Most of them came in as home based workers because people were dying and people had to act,” he says. “They were employed by churches, NGOs, philanthropic organisations and the Department of Social Development and even the Department of Health but it was unplanned and chaotic.”

In the much lauded Brazilian primary healthcare programme community health workers (CHWs), recruited from the local community, are each responsible for up to 750 people (approximately 100-150 households) in each micro area.  Current estimates put the number of CHWs in Brazil at just over 250 000. If each of the 40 000 envisaged CHWs in South Africa is responsible for 750 people (as is the case in Brazil), 30 million people will be covered. 70,000 CHWs will cover 52.5 million people.

The Minister insists that CHWs’ require sufficient training in order to discharge their duty to the communities they serve.  “The work of primary healthcare is not just about volunteering, it’s also about selection. We don’t want a primary healthcare worker who will walk into a house and talk about HIV but can’t offer other services or advice,” says Motsoaledi. “When asked about diabetes or high blood pressure they can’t help. We need our community health workers to be able to help on all levels of primary healthcare.”

He says that his department has already trained some 10 000 CHWs and cited SukhumaSakhe, a service delivery model piloted by the KwaZulu-Natal premier’s office through which CHWs were employed, as a model which may be replicated across other provinces. He suggests that the programme has already borne significant benefits for the province. “When the programme was introduced in 2011, KwaZulu-Natal had the highest prevalence of mother to child transmission, now the province has the lowest.”

The SukhumaSakhe programme was conceptualised to comprise representatives from various departments in the municipalities which would gather information about the state of service delivery in the province through meeting with community representatives on a regular basis. A “war room” to which CHWs and other community representatives could report issues was set up – this was to include health issues like drug stock-outs,   A Spotlight team interviewed CHWs in the province, who reported that this model is not as successful as purported.  Some CHWs have complained that when cases are reported to the authorities, they are not investigated and that municipal representatives on the task team do not attend feedback meetings.

The minister acknowledges that nurses and community health workers are often at loggerheads. “Nurses don’t see CHWs as part of the system because of the sporadic nature of their interactions. They see them as nuisances.”

However the Minister expects that a solution to the issue is imminent.  He says that he has asked the directors general and heads of departments in each of the provinces to map out a permanent solution.

“The solution will not be a blanket one, which is what they are asking for. If we want to destroy the primary healthcare system, we’ll just close our eyes and put people into it because they are there rather than assessing the needs of the community and applying the appropriate skills,” says Motsoaledi