COVID-19: Community Healthcare Workers are crucial to SA’s response
The Department of Health has announced that it will rely on community healthcare workers (CHWs) to assist with tracking and tracing potential COVID-19 cases but has not provided assurances about how it will protect these workers during the process and beyond.
On Monday 13 April, Professor Salim Abdool Karim, the chair of the Ministerial Advisory Committee on COVID-19 outlined the government’s plans to increase tracing and testing in communities as part of the aggressive strategy to curb the spread of the virus in the country.
Karim and Minister of Health Dr Zweli Mkhize have acknowledged the importance of expanding screening and testing where people live, focusing first on high density and high-risk areas. To this end, there will be more than 28 000 (CHWs) going house-to-house in vulnerable communities to screen and test people.
Reliance on CHWs to provide health care services is not new and in the same way that their interventions are central to the tuberculosis (TB) and HIV responses, CHWs are going to be critical to South Africa’s response to COVID-19. Part of this is because they are already embedded in communities and are able to assist in tracing those who are at risk of contracting the virus. They will also continue to be instrumental in tracing and monitoring even after the lockdown has ended.
While this bold and decisive action is timely and necessary, it is unclear how government intends to protect CHWs amidst reported shortages of personal protective equipment (PPE).
CHWs across the country stand ready to assist with efforts to ensure that the virus is contained but they are deeply concerned about their safety. A telephonic survey of CHWs in Gauteng, KwaZulu-Natal and the Western Cape in the week in which the President announced the lock down revealed worrying inconsistencies in information communicated regarding training, the availability of PPE for CHWs and standard operating procedures across and between provinces.
The provision of personal protective equipment
CHWs are expected to conduct house-to-house visits to assist with tracing and therefore risk of exposure as they may encounter infectious individuals (some of whom may be asymptomatic). If they are exposed, there is also a risk of cross-contamination across the households that they visit and to their families.
Ensuring that CHWs are equipped with the appropriate PPE and carefully trained on its optimal use is therefore critical. To date the department of health, as far as we are aware, has issued no guidance specifically to CHWs regarding the kinds of protective equipment they will be provided. Whenever the Health Minister briefed the public and recently also MPs during a parliamentary briefing, he used the word health care workers who will be provided with PPEs. In his assurances he has not publicly referred to CHWs as a distinct group. Mkhize has advocated for the use of masks for the public including those made of cloth, but CHWs will require medical masks according to advice from the World Health Organisation.
Standardisation of operations and protocols across and within provinces
The responsibility of mobilising and training CHWs has been left to provinces. Yet, the South African Constitution emphasises cooperative governance. While provinces are responsible for health services, there are also critical and related national and local government responsibilities. There is an urgent need for national coordination to ensure that there is consistent information and application of protocols and operations.
It is also not clear if the 28 000 CHWs that will be doing the testing and screening are being drawn from the existing cohort of CHWs who form part of the Ward Based Primary Healthcare Outreach Teams (WBPHCOT), or whether a new team is specifically being recruited for this purpose. This is important for two reasons:
1. If the 28 000 are CHWs who are already in the system and performing various tasks including tracing of HIV or TB treatment defaulters, what plans have been put in place to ensure continuity of those services? This must be done in a manner that does not burden other CHWs; and
2. If 28 000 CHWs have been specially recruited and trained for the COVID-19 response, how are they going to be integrated into the system and what support systems have been provided to primary health care facilities so that they have the capacity to supervise the WBPHCOT programme and the COVID-response teams?
To date, there is no standardised protocol for the mobilising of CHWs and their training in relation to the tasks allocated to CHWs during the COVID-19 response. In one province, CHWs have been told to remain at home and not conduct their ordinary work, while in another, they are expected to report to the facility and take direction from facility managers who have not been briefed. In other instances, CHWs are expected to assist with tracing people who may have been exposed to the virus without training and without protective gear.
The Health Minister must issue a directive to provincial health departments with standardised protocols for operations in relation to CHWs. These should include CHWs not to enter homes without appropriate protective gear. CHWs should not be required to perform tasks that will expose them to danger.
While some provinces have taken steps to absorb CHWs into provincial Departments of Health, this is not the case for all provinces. In the Western Cape, for example, CHWs continue to be employed through non-governmental organisations (NGOs). It is not clear what the procedures are for such CHWs to be mobilised for the COVID-19 response and what the role of the NGOs will be.
Urgent steps must be taken to ensure that CHWs employed through registered NGOs are afforded the same protection as those given to government employed CHWs. This should include the assurance that should they contract the virus they will be able to receive compensation through the Compensation for Occupational Injuries and Diseases Act (COIDA). The Minister must issue a directive to all health departments regarding the registration of CHWs for COIDA.
The protection of CHWs against criminal elements
The majority of CHWs are women. They face significant danger in the course of their work. Government must prioritise the safety of CHWs. The army has been deployed to assist the police to maintain law and order during this period. In some instances, CHWs may need security support when they venture into particularly densely populated areas and in areas where they will potentially be vulnerable to sexual violence and other criminal behaviour.
In addition, CHWs are at risk of being stigmatised by community members who are hostile towards people with COVID-19 infection. In the past week, CHWs deployed to conduct COVID-19 screenings in Nkomazi in Mpumalanga were attacked and harassed by distrustful community members. In response, the Municipality had to “[s]wiftly intervene with police and reiterated our message through the community radio. There’s no such thing as health workers will infect people when they conduct screenings. These people are trained to assist the community. There’s only a questionnaire that will determine that one should go for testing”.
This shows that an extensive and ongoing education campaign in communities will be crucial to protect CHWs so that they are able to conduct their duties.
The work of CHWs is stressful under normal circumstances. In light of the heightened risks the pandemic poses, they will be under even more emotional and physical stress. It is thus also imperative that CHWS are provided with psycho-social support during this period and beyond.
As a crucial component of the health care system, and indeed to the COVID-19 response, CHWs must have access to the same support and protection as is being provided to other health care providers. While this demand for the protection, training and equipping of CHWs is being made within the context of the COVID-19 pandemic, it also highlights pre-existing issues with the conditions under which CHWs work. These include not having security of employment as they are continuously hired on fixed term contracts and receiving a meagre stipend (recently increased to R3 500 month through a bargaining council agreement, after years of fighting for standardised remuneration).
CHWs have also long complained about the lack of support from health facilities with which they work, lack of uniformity of their training, and lack of uniformity regarding job scope.
The bigger question is therefore what is the government going to do about improving CHWs conditions of employment?
*Mpulo is the Head of Communications at SECTION27. Mafuma is a legal researcher in SECTION27’s Health Rights Programme.