Health workers as change agents and patient advocates

 By Karessa Govender, Rural Health Advocacy Project

I wear two hats, the first is that of a member of a civil society organization, the Rural Health Advocacy Project (RHAP) and the second hat is that of a healthcare worker who served in the public sector for seven years. My thoughts on health workers as patient advocates stems from my experiences in both spaces – the public sector and civil society.

I find that the term “advocacy” has been shrouded in negativity. To the ordinary health worker in the public health system – the process of advocacy either appears too technical, something that is reserved for a few loud mouths or at its worst, stirs up connotations of radicalism and violent protests. These examples paint a limited picture of what advocacy is and thus it is no surprise that the typical healthcare worker distances themselves from it.

Our state health workers are precariously positioned between satisfying the needs of their patients and also having to appease their employer – the Department of Health. It is not an easy space for young health professionals to navigate having recently graduated within the pristine walls of tertiary institutions. This does not in any way negate the responsibility of health workers in advocating but rather to emphasize the challenging South African health system in which health workers find themselves. The recent health crisis in the North West is only a snapshot of what is happening in our greater public health system. Health workers from the most urban province, Gauteng, will echo similar sentiments to those practicing in the most rural province, the Eastern Cape. And whilst our leaders debate on whether there is in fact a health crisis – it’s the health users and health workers on the ground that bear the brunt.

Demystifying advocacy for the health worker

During our advocacy training with health workers in the public health system, we routinely ask: should the health worker be responsible for advocating for patients? They resoundingly respond in the affirmative – that yes, it is the role of healthcare workers to advocate for their patients. And yet, when we probe them further on whether they do in fact advocate for their patients – we often receive lukewarm responses. Their reasons for inaction range from ‘I’m too busy’, ‘I don’t know how to’, ‘the system has always been this way – nothing will change’, ‘I fear victimization.’

All of these reasons stem from the way we frame advocacy – the negative framing of advocacy has left health workers ill equipped and defeated. We need to change the way we understand and approach advocacy – we need to reframe advocacy as a core competence and responsibility of all health professionals. Being able to effectively advocate should be as routine as drawing blood for a nurse or doctor.

Before we continue to ignore the elephant in the room, we should ask, what exactly is advocacy?

‘Blending science, ethics and politics, advocacy is self-initiated, evidence based, strategic action that health professionals can take to help transform systems and improve the environments and policies which shape their patients’ behaviours and choices, and ultimately their health.’ (World Health Communication Association, 2010)

A definition coined by Kevin Teasdale, that resonates closely to me is ‘advocacy is about power. It means influencing those who have power on behalf of those who do not (Teasdale, 1998). ‘We will further unpack the concept of power shortly.

What are the barriers to health worker advocacy?

For us to completely understand the role of health workers as change agents and patient advocates, it is necessary for us to be aware of the barriers to advocacy. I will present these barriers firstly from the barriers inherent in health workers and secondly, barriers that are systemic and make it challenging for health workers to advocate.

To put it bluntly, South African health workers feel powerless. As communities we place health professionals on pedestals. And yet this contrasts starkly with the powerlessness that health workers truly feel. During our advocacy training, health workers consistently tell us they feel powerless to tackle health system issues. It must be emphasized that it is not just junior staff that feel this way but even those in senior positions such as clinical mangers and hospital CEOs. This pervasive feeling of being a cog in a chugging system threatens agency. If we view health users as the primary victims of the public health system, we must acknowledge that our health workers are the secondary victims.

Health workers may feel powerless because of a number of reasons:

• they tried to advocate previously and were unsuccessful,
• they lack the knowledge and practical skills to advocate within their settings
• they are genuinely overwhelmed by the complexities of the public health system.

Health workers cite the lack of knowledge and skills required to advocate as a significant barrier for not advocating. We have found severe gaps in health worker knowledge on:

• internal and external reporting mechanisms,
• the awareness of reporting and regulatory bodies
• and the rights of the health worker if they do indeed decide to whistle-blow.

Universities have a significant role to play here in mainstreaming advocacy within the curriculum. Our locally trained health professionals are known the world over for their exceptional clinical skills and yet drop the ball repeatedly when dealing with real life challenges within the local health system. Our health workers must be as advocacy competent as they are clinically competent – because it is indeed the inability to manage health systems crises and not individual patient challenges that is at the core of many of our health workers leaving public service for greener pastures. Universities cannot just equip health workers on how to perform clinical procedures without preparing them for the challenges these environments pose to young health professionals. Health science training to date has focused on ideal health systems and this further disempowers young health professionals and turns them into adversaries to the public health system rather than allies.

Rural Health Advocacy Project is strongly advocating for the mainstreaming of advocacy within undergraduate health science curricula. UKZN is doing innovative work, spearheading the incorporation of advocacy into the health sciences through a manual developed by RHAP, Advocacy for Health: An Educators Guide to Incorporating Advocacy into the Health Sciences Curriculum. This manual is also being implemented in other universities across the country.

Despite living in the country with one of the best constitutions in the world and a country that, historically, has been vocal about human rights injustices, our current public health system is not kind to its own speaking up. Health workers have voiced to us a genuine fear of speaking up in the likelihood of victimization. The recent incident of Tower Hospital in the Eastern Cape attests to this. Earlier this year, a psychiatrist blew the whistle on poor management and living conditions of mentally ill patients within the facility. Reports indicate that he was forced to resign. Rather than his complaints being investigated – the doctor himself has become the object of scrutiny by the Eastern Cape Department of Health. It is not only deplorable but counterproductive for the health system to treat those that speak out on human rights injustices in this manner. It also sets a precedent for health workers going forward – if whistleblowers are going to be chastised for their efforts – what incentives do health workers have for speaking out?

What are the essential skills of an effective health worker advocate?

It is important to also look at the skills health workers require to advocate:

1. Agency – we know with Life Esidimeni, that despite a few health workers, one professional body and a group of occupational therapy students speaking up, there were many that saw the shop sinking and did nothing to address the issue. My personal experience in the public health system shows that the major difference between those who try to improve things in the system and those that do not is agency. The belief that your presence and skills can and will have some impact. In a time of chronic hopelessness that is pervasive in our country – a sense of hope and agency are the core drivers of change.
2. Agency requires an investment in the system. Health workers must ‘own’ the spaces they occupy. Health workers must be invested in the systems they work in and not just outsiders who clock in very morning and out every afternoon. We must acknowledge the public health system was never sold as a long-term career option for health workers. At most, young health professionals are told to ‘do some time in government’ because of the valuable clinical experience they are likely to receive and then move on to better things. Health workers who are invested in the system are resilient enough to play the long game of advocacy – knowing very well that issues cannot be resolved overnight.
3. Agency feeds off knowledge. Health workers must have a comprehensive understanding of the contexts in which they serve. A doctor who recently attended our advocacy workshop remarked: ‘I try to do my best clinically with my patients just to make up for everything else that is out of my control.’ Her intention was that her impeccable clinical skills would make up for the numerous gaps and challenges in the system. But this is not ideal – we cannot expect health workers to be responsive to the challenges of the health system without them having a good understanding of the systems they work in. They must know the communities they work in – the health needs of these communities, the socio-economic challenges, the referral pathways and very importantly the barriers these communities face when accessing health services. I have noticed that health workers who are hospital based often have a very limited understanding of the communities they work in. The PHC approach strongly advocates for reaching communities where they are and making the availability of health services as close as possible to communities. As health workers, we need to shift our focus of interventions from the singular patient to the health of the community as a whole.
4. Health workers must have a good understanding of the resources and channels available to them to advocate: resources within the hospital such as reporting channels and forums that exist for complaint management. There is a tendency for health workers to complain amongst themselves and yet we fail to formally report complaints using the relevant channels. When internal reporting fails, health workers must be aware of the external resources available – The Health Ombud housed within the OHSC, the South African Human Rights Commission and advocacy organisations. It is shocking to see the high number of health workers we have trained who have not heard of organisations such as TAC or SECTION27, let alone the regulatory bodies they can use when complaints have not been resolved at a facility level.
5. Resilience and grit to persevere. This reminds me of a pair of doctors who chose to work in a hospital in the rural Eastern Cape. They committed to spending a minimum of 10 years at this facility. They made the staff aware of this when they arrived at the hospital. They were aware that health systems change does not take place overnight. In a medical fraternity that favours specialization and city living – their decision was not a popular one. We must create a culture of health workers who are ground breakers – whom rather than pursuing the socially accepted standard of what a successful health worker is, choose to build services where there are none. This little rural hospital is now lauded as one of the go-to institutions for health workers who wish to work in rural.
6. Healthcare workers need to develop the skill of engaging others. Health workers become extremely frustrated with system issues that directly affect patient rights and access to services – and therefore it makes sense for health workers to engage patients and communities when advocating.
7. The ability to mobilise among ourselves and form alliances. Professional bodies come into play here – the South African Society of Psychiatrists (SASOP) is a good example of a professional body that is not afraid to get its hands dirty and proactively respond to the health system crisis. They were closely involved in alerting authorities on Life Esidimeni. They were also able to identify a gap in advocacy knowledge amongst their members and we are now in partnership with SASOP to provide advocacy training to their members. For the health workers here today, who are your professional bodies – are you engaging them? Are they responsive to the current health system crisis?

What does good health worker driven advocacy look like?

One of the biggest health challenges our country has faced to date has been HIV/AIDS. This crisis directly pitted patients and health workers against the state. At the time, the state refused to administer Nevirapine to pregnant HIV+ mothers. Eventually national department of health succumbed to the pressure of civil society, individuals affected with the illness and health workers by ensuring the drug was routinely prescribed to all pregnant women who are HIV+.

How was this work of advocacy successful where so many others fail?

1. The ability to carefully select an issue amongst other competing issues. At the time, millions were infected or affected by HIV.
2. The health workers who were a part of advocating, had expert knowledge on the issue. Professor Haroon Salojee, who was closely involved, is a paediatrician.
3. Meaningful collaboration between the health workers who identified the gap in service delivery, the communities that were affected by the illness and civil society. Prof Saloojee was pivotal in spearheading this issue however the success of this case lies in his ability to engage communities and civil society. This shows that collective participation is much more successful than when health workers act alone.
4. Resilience and grit. The road to achieving the final goal of HAART for all pregnant HIV+ mothers was long. Health workers must understand that advocacy is often a marathon and not a sprint and must be prepared for the disappointments and frustrations along the way.

Unfortunately, it is only high level advocacy like the one I’ve mentioned that gets reported on. But there are cases of ‘low level’ advocacy that are also happening everyday within our institutions, unnoticed and unreported.

A call to action

1. The focus of my piece has been predominantly on the role of the health worker as a patient advocate however the true custodians of the health system are communities. As communities, we cannot place the responsibility to advocate solely on health workers.
2. There is a strong need for communities to OWN their health rights and take back the power of the right to health from the department of health and health workers. For this to happen, communities must be empowered with knowledge and skills – knowledge of their health rights and how THEY can advocate for themselves using health workers as allies. As communities are we are of the channels and bodies we can use and report to? The Office of the Health Standards Compliance is one such body – use it!
3. Communities must find ways of having their voice heard. Representation on hospital boards and clinic committees is one such way. Communities must also create their own platforms – imbizos allow for the identification of pertinent issues. There is power in numbers – the collection of these case studies can be used as evidence to the health authorities.

The reform of the health system will depend on joint collaboration from all stakeholders – communities – health workers – and civil society organisations. The realization of a long and healthy life for all will depend on the strength of these individual stakeholders and their ability to strategically work together.

Works Cited

Association, W. H. (2010, May 11). Promoting Health: Advocacy Guide for Health Professionals .

Teasdale, K. (1998). Advocacy in Healthcare . Blackwell: Oxford.