North West doctors release open letter calling for end to closure of health services

Over 70 North West doctors have released an open letter expressing their concern over the impact the ongoing labour action is having on the delivery of health services. Although they support the grievances of the protestors, the doctors said that as “care givers, we have been silent for too long. We have taken an oath to “do no harm” and in our silence, we have contributed to harm. This cannot go on as we are concerned about methods used which include closure of health care facilities that affect the health of our society.”

Read the full letter here: Letter of Concern Health Crisis NWP (iii).

SA’s new AIDS plan falls short on community health workers

By Sasha Stevenson

South Africa’s new National Strategic Plan (NSP) on HIV, TB and STIs will be launched on March 24. It presents a unique opportunity to start correcting the rudderless management of community health workers (CHWS) in the South African public healthcare system in recent years. (For in-depth background on CHWs, see Spotlight’s recent special investigation.)

The draft of the new NSP states: “HIV, TB and STI prevention, treatment and care is labour intensive and requires diverse cadres of human resources from multiple sectors.” And, “Community health workers need to be formalized as a cadre, appropriately trained and supported, and fully integrated into the health system.”

These are promising statements on human resources for health in general, and community health workers in particular, being key enablers for NSP 2017-2022. The question, however, is how far the new NSP goes in advancing the discussion around and demand for the development and integration of community health workers as a vital cadre of health care worker for the implementation of the NSP and strengthening of the health care system. The answer, unfortunately, is not far enough.

Focus on prevention

The new NSP puts prevention at its centre. In doing so it supports the new ‘test and treat’ policy which is aimed at reducing HIV-related morbidity and mortality and significantly reducing TB incidence and TB mortality. It envisages a comprehensive multi-sectoral prevention programme focused on high incidence hot spots in the hope of changing individual risky sexual behaviour. It sets ambitious targets and lays out detailed indicators.

Disease prevention, health promotion, and linkage to care are at the core of CHW programmes the world over. Health behaviour and social welfare promotion, preventive health care service and commodity distribution, diagnosing and management of common illnesses, assistance during birth, and community organising are all traditional CHW functions.

Despite the broad statements made, and despite what would appear to be the natural alliance between the needs of the new NSP and the need of the health system more broadly for the employment and integration of CHWs, the NSP is low on detail and does not get into any hard numbers in relation to CHWs.

Important targets missing

The NSP 2017-2022 should set targets for the number of CHWs employed or WBPHCOTs developed. It should set targets on CHW capacitation for TB case detection and for preventing loss to follow up for HIV and TB patients. It does none of this.

Goal 2 of the NSP expressed the need for guidelines on the role of, and tools for the use of, CHWs in HIV testing and counselling, linkage to care, and initiation on ART. The implementation and expansion of “community and peer-led programming” is aimed for under Goal 3, without acknowledgement of the direct role of CHWs in such programming. Clinics will open for longer hours – undoubtedly positive – but it is not clear that CHWs will be appropriately supported in the ongoing provision of home based care.

At a time when CHW policy has stalled; when posts for other health care workers are being frozen; but when there is a renewed focus on HIV and TB and the need to treat 5.5 million people, the incorporation of a properly trained, managed and integrated CHW cadre into the HIV and TB programme is vital. Unfortunately, it looks as if the drafters of the latest NSP are missing this opportunity.

The work of a nurse

By Mary-Jane Matsolo

‛There is a huge difference between a clinic nurse and a government hospital nurse. Clinic nurses usually do referrals, unlike us, we have to deal with it all – drips, oxygen tanks, two to four injections required to treat a patient with meningitis. We do all of it, from documenting how many patients we’ve seen, to arranging medicines to give to the patients, and monitoring and taking their vitals before doctors do their rounds in hospitals. That’s if a patient doesn’t come in that needs serious medical attention, which is also the work of a nurse – to resuscitate the patient, which could take anything from two to three hours,’ explains Sister Elinor Mpulo (name changed) .

A public hospital nurse’s day starts in the early hours, at 7 am, and usually doesn’t end until the late

hours of the evening. A double shift is also required in a 40-hour-week. The functions mentioned above should be completed before the doctors do their rounds at 8 am; whatever hasn’t been completed before has to be done after the doctors have left. Many days, come 12h00, a nurse hasn’t even had a tea break.

‘The conditions we work under strip away a nurse’s calling’

The TAC visited the Far East Rand Hospital in Springs after pictures of substandard conditions were sent in by field workers in the area. The images showed patients sleeping on the floor, beds with patients sleeping in passages, patients sleeping in bathrooms with non-functioning flushing toilets, and visible unprotected electrical wiring coming out of the walls.

We went to the hospital with the intention of questioning the CEO. He was not on the premises, and so we visited the wards to see the conditions for ourselves. What we saw, confirmed the evidence in the pictures.

Hoping to get information from patients about their experiences at the hospital, we found that a majority of them were mental health patients and unable to give us any substantial input. We asked to see to the nurse in charge of the ward who, unlike many in her position who are reluctant to open up about conditions they work under for fear of losing their jobs, or to protect the department, was willing to speak to us.

Sister Mpulo, who began nursing when she was 18 and who will soon retire at the age of 55, has seen it all. She spoke to us from the heart, listing the challenges at the hospital and with the entire system. She explained that the main reason behind the overcrowding at the hospital, resulting in some patients having to sleep on the floor and patient beds being moved into the bathroom area, is due to renovations that have been ongoing since 2014. Many patients that come through casualty are told the wards are full and there is a shortage of beds. They are given an option of being given medication and to go home, or to sleep on mattresses on the floor. If they agree to stay, they are made to sign a consent form, to cover the hospital. Up to 62 patients are squeezed into a ward with the capacity to take 31-46 people. Sometimes, the hospital closes admissions to regulate bed capacity.

Patients, regardless of their illness, and including mental health and TB patients, share wards. Some

A nurse walks down a Gauteng hospital passage way with a child in this file photo.
A nurse walks down a Gauteng hospital passage way with a child in this file photo.

TB patients waiting for test results don’t know their status when admitted, putting other patients and nurses at risk of contracting TB. Even the hospital’s TB wards, Sister Mpulo says, are overcrowded, with little to no ventilation. The only way nurses can protect themselves from being infected with TB is to wear their TB masks, something they are reluctant to do because they usually come in one size, are uncomfortable and, when temperatures are hot, it’s very hard to breath while working with them on.

Furthermore, the wards don’t have enough oxygen points, and there are not enough drip stands. All these conditions make the nurses’ work very difficult, and the people that suffer the most are the patients, says a visibly exhausted Mpulo.

When new doctors are employed, they know nothing about the patients and it’s up to the nurses to bring doctors up to speed on the patients’ records and to ensure that everything runs smoothly so the doctor doesn’t make a mistake.

‛We become burned out and our concentration levels are low. At least, in the last two months, the department has employed some nurses and doctors, which is good. We can only do so much – many nurses take sick leave before they reach a state of burnout. A nurse at a clinic is required to see one to eight patients but at a hospital level we see anything from 12-20 patients a day. The conditions we work under strip away a nurse’s calling,’ she says.

 

Getting the system to work

By Ufrieda Ho

Staff shortages remain a massive challenge for the public health service.

The Gauteng Department of Health earlier this year released information in response to questions

Patients are left in hospital corridors for long periods.
Patients are left in hospital corridors for long periods.

from the Democratic Alliance. The Department reported that state hospitals need 1,151 Grade 1 medical officers, 110 medical registrars, 78 community service medical officers, 160 Grade 1 medical specialists, and 58 intern medical officers. There are 17 clinical unit and department head vacancies and a dire shortage of nurses. The report noted 1,184 vacancies for Grade 1 nursing assistants, 1,340 Grade 1 professional nurses, 141 speciality nurses and 88 primary health clinical nurses.

 

The pressure of getting doctors and nurses into the system is complicated by the lure of private

sector salaries and employment conditions. This year, the system has come under additional significant strain as student protests rock the higher education institutions. If interns and qualified doctors are prevented from entering the system it will severely compromise the service offered at the province’s academic teaching hospitals.

In October, however, the Gauteng Department of Health announced that it had seen a ‛net gain of 2,227 nurses by the end of August, and 1029 medical professionals’. Earlier in the year, the Department also announced that 25 Cuban doctors would start working in the province. The Cuban doctors will focus on maternal, infant and child care. Infant mortality and maternal deaths remain a priority even in the country’s economically dominant province. Meanwhile, currently, there are 400 South African medical students being trained in Cuba as part of government’s initiative to plug the gap of doctors in South African public health care.

In June, the MEC for Health, Qedani Mahlangu, said a new double-storey paediatric unit at Chris Hani Baragwanath hospital should be completed next year. The unit will cater for children under the age of 10 and the target is to treat 3,000 inpatients and 2,000 outpatients a month at this facility.

The Gauteng Department for Emergency Medical Services budget has increased to R1,2 billion for

No sign of improving, a sign flippantly tells patients that their long waiting times means “they’re not dying”
No sign of improving, a sign flippantly tells patients that their long waiting times means “they’re not dying”

the current financial year. This amount will go towards the procurement of an additional 150 ambulances, 25 primary response vehicles, 11 rescue vehicles and five mobile emergency communications and command vehicles.

The provincial government has shown some positive initiatives, though the long term test lies in ensuring that good projects and recruitment drives are sustainable, adaptive and have the commitment of properly trained staff, to make them effective.

According to Mahlangu’s 2016-17 budget speech, recent successes include the Stock Visibility System (SVS). This is a phone app-driven system that allows nurses and staff to scan medicine barcodes to track stock levels of ARVs, TB medicines and vaccines, to be entered into a stock levels database. By the middle of this year 110 clinic should have been connected to the SVS system, with a roll out to all primary health clinics to be completed by the last quarter of this year, the Department reported.

The Gauteng provincial government’s own scorecard of its districts, meanwhile, identifies Tshwane as the best performing district in the country this year, with Laudium and Calcot Dhlephu clinics rated as Gauteng’s top clinics.

Furthermore, the Department said some of their facilities improved their national core standards rating, with Steve Biko Academic Hospital scoring 96 percent, Kalafong Hospital 81 percent and Mamelodi Hospital 73 percent. Declines in performance were noted at Charlotte Maxeke and George Mukhari Hospitals.

Community health workers: A Spotlight in-depth feature

The role of community health workers in the South African public healthcare system has been

A community health care worker cleans an elderly woman during her visits around the community of Sweet Waters in KwaZulu-Natal. She resorts to using bread bags in the absence of gloves.
A community health care worker cleans an elderly woman during her visits around the community of Sweet Waters in KwaZulu-Natal. She resorts to using bread bags in the absence of gloves.

unclear and controversial. How many do we need? What exactly should their role be? Who should employ them? What should they be paid? Is there good evidence to inform policy? Sasha Stevenson of SECTION27 lead Spotlight’s in-depth investigation into these pressing questions.

The structure of our health system and the nature of our healthcare workforce are unsuited to the goals that we have set ourselves: universal health coverage; an ‘end to AIDS’; and the reduction in non-communicable diseases through preventative and health promotion services. These goals can’t be reached in a hospital-centric health system with unsupervised, NGO-employed and underpaid community health workers (CHWs) serving as the only community-based services in the absence of capacitated and reliable clinic and hospital outreach programmes.

For some time, the national and provincial departments of health have been discussing and partly implementing a CHW programme. There have been multiple policy documents and there has been some action from provincial departments but we remain a long way from establishing a standardised CHW programme, let alone one that is capable of meeting the objectives of the health system, the National Strategic Plan (NSP), and the population.

2: Why do we need CHWs?
3: History of CHWs in South Africa
4: What should CHWs do?
5: How many CHWs do we need?
6: How should CHWs be employed?
7: How much will the CHW programme cost?

 

Judgement reserved in Bophelo House 94 appeal

By Nomatter Ndebele

A full bench of the Bloemfontein High Court today reserved judgement in the appeal of the so-called Bophelo House 94. In July 2014 the Bophelo House 94, a group of mostly elderly women, were arrested during a peaceful night vigil outside of the headquarters of the Free State Department of Health (Bophelo House). The women were protesting their dismissal as community healthcare workers (CHWs) earlier in 2014 and problems in the provincial healthcare system. In October 2015 the Bloemfontein Magistrate’s Court found the Bophelo House 94 guilty of having taken part in a ‘prohibited gathering’.

Advocate Rudolf Mastenbroek, arguing for the Bophelo House 94, told the court that it was not a crime for the CHWs to have attended a gathering for which no notice was given and that the gathering had not been ‘prohibited’. As in previous court appearances, he argued that criminally persecuting people for attending gatherings was an infringement of their fundamental right to protest.

In response, State Advocate Gideon Mashamaite argued that the CHW’s were liable for criminal persecution for attending a night vigil for which no notice was given. He argued that the gathering was prohibited since no notice was given. He further argued that failure to provide notice of demonstrations would prevent law enforcers from doing their job of assessing whether or not a gathering should be prohibited.

The Judges seemed unconvinced by the state’s arguments, asking more than once that the state show how the gathering in question was prohibited. Judge President Mahube Molemela said “How  can we criminalize hundreds of people for attending a gathering, because the convener failed to give notice?”

Executive Director of SECTION27 Mark Heywood said that although court proceedings had gone well, there was still a long road to go. “For the arrested CHW’s the struggle is not over,” he said. “They remain dismissed in a province that desperately need CHW’s.”

When court adjourned, the convicted community Health Care Workers erupted in song, singing “Asinavalo, sisebenza kanzima” –(We have no fear, we work hard).

Earlier in the day the Right2Know Campaign released a statement of solidarity with the Bophelo House 94. They said that “it is deeply concerning that the worker’s democratic right to protest was violated in this way. R2K has noted with concern that the right to protest appears to be under threat in South Africa with police becoming more aggressive towards protesters and officials increasingly intolerant.”

The state’s representatives at court  declined to comment for this article.

Note: Spotlight is published by the Treatment Action Campaign and SECTION27, both of which are involved in this case.

New Emergency, New urgency

By Nomatter Ndebele

Following a 10 000-strong activist march on the first day of the International AIDS conference in Durban, the Treatment Action Campaign and SECTION27 hosted a press conference to outline the strategy of the activist groups beyond the conference.

SECTION27 executive director Mark Heywood said: “The Minister of Health said yesterday that his department is already working on our demands for a comprehensive plan to provide all people living with HIV in South Africa with treatment. We welcome this. But this is an easy commitment to make. We will only believe it when we see that commitment translating into real change.”

He also called for a more focused campaign to “turn off the tap on new infections”. While great strides have been made in the country, there are still high levels of new infections each day, particularly amongst adolescents and young women. Heywood said it was important to ensure that young children in schools have access to condoms, as well as HIV tests, together with comprehensive sexual education literacy to empower young people to make better and more informed decisions, which will have a direct influence on lowering the rate of new infections.

Stonewalled

Although there is still a lot of work to be done to ensure treatment for all, the activist group continues to be stonewalled by a lack of funding. The budget for the TAC, dropped by 14 million rand this year alone. Putting the group under great pressure. “Cars run on petrol, and we are the petrol, but we need money,” said Heywood. The TAC, will be calling on funders and sponsors to continue to support NGOs in order for lives to be saved.

Alongside funding issues, the Treatment Action Campaign addressed the plight of Community Health Care Workers. They asked for them to be at the forefront of the struggle for treatment for all. Executive director of UNAIDS, Michel Sidibe made a call for one million health care workers and 200 000 in South Africa. “For 10 years we have been fighting to get this issue heard,” said Violet Kaseke Paralegal at SECTION27.

Although Community Health Care Workers serve as the backbone of the Public Health Care System, they are forced to do so with minimal resources. Many health care workers, work without the basics like gloves and masks which often leads to them dying after contracting communicable diseases from the patients they treat.

“For the Treatment Action Campaign and SECTION27, this conference cannot be business as usual,” said Heywood. “We are looking for more than just commitment and rhetoric. They are looking for change, not just at AIDS 2016, but beyond that too.”

Related articles:

The next International AIDS Conference needs to be “an earthquake”

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

So many have forgotten

By Vuyiseka Dubula

I was just months away from knowing my own HIV status when, in the year 2000, the people took over the streets of Durban marking a revolution to come. Although I was not present in Durban for that year’s AIDS conference – I was already connected to the struggle.

This year I will be attending the 2016 AIDS conference. As I reflect on the last decade and a half, I wonder that if Durban was a person, what would I tell her?

I would tell Durban that after we left you we continued on a difficult path, one which many of us never thought would happen post-apartheid. I remember the year 2004, for which I have no reason to remind myself or you, but I will; because so many have forgotten what it used to be like to march next to someone and then in a few months they are bedridden and dying.

Twelve years ago Francoise Louis, an Médecins Sans Frontières (Doctor without Borders) doctor, called me Ntombi yam, not her “patient”, and I called her Magogo, not “doctor”. Then, this family grew as other comrades and brothers such as Gilles Van Cutsem, Eric Goemaere and Shaheed Mathee became my lifetime comrades and doctors. Today, I am seen by my nurses sister Nompumelelo Mantangana and sister Lindiwe Kotelana. We have become family. I didn’t know any of these hard working health activists before April 2001.

I remember Kebareng Moeketsi, Mandisa Magugwana, Zoliswa Magwentshu, Nomfundo Somana, Queen Qhiza, Vuyani Jacobs, Johanna Ncala, Mike Matyeni, Ronald Low, Jason Wassenaar and many of my comrades. I wish they were here to reflect with me.

I remember Edward Mabunda, who danced and sang in our national march called “Save our Lives” in 2003, not knowing he won’t be around like me to write a reflection to you in 2016. After the treatment march, we had to nurse comrade Nkosinathi, our branch organiser. His ill-health made me confront and visualise my own death. The deterioration in his health made me realise that death was no longer a distant matter, but that it was at my doorstep. I felt rage from fear of death and I felt anger at the moral bankruptcy of our government. Nkosinathi always had a smile. If only our leaders were not so busy with ideological debates, comrade Nko would be writing this reflection with me.

The pills I take twice a day are a reminder of how leaders can sell their people out – how they can commit genocide and go unpunished. It is a reminder of how building poor people’s power is the only weapon we have against the abuse of political power. The pills are a beautiful memory as well as a painful one.

One would have thought that we learn from the past not to repeat our mistakes. Yet, much as the lives of people living with HIV were disregarded under Mbeki’s leadership, poor people’s lives are still disregarded. the daily war on women’s bodies is still not being taken seriously by our leaders. The Marikana Massacre is only the tip of an iceberg. Between Durban 2000 and Durban 2016 our politics have become that of control, domination and NGO institutionalisation.

But, even as I reflect about my journey and my current life within the geographical and spatial segregations of Cape Town I take pride in still taking the same pills Francoise gave me on the 14th June 2004 (AZT, 3TC and NVP). These pills were fought for with blood and life. For 12 years my viral load has been undetectable. The progress is undeniable. Even so, I feel dislocated at times. My mental health is not seen by the healthcare system to be as important as my viral load. Too often I see old comrades who have been on treatment for years, relapsing.

As much as my life and the country has changed in the last 16 years, much has remained the same or gotten worse. I am still expected by the health system to fetch my treatment every two to three months – and if you go too late you are classified as a defaulter. I am lucky to have a village of support from Nombasa Krune Dumile, Sis Mpumi, Norute Nobola, Yandisa Dubula, Fanelwa Gwashu, Mandla Majola, and Lindiwe Kotelana – somehow someone is always there to pick up my medication.

Every night my nine-year-old daughter Nina reminds me that “ndikuphathele amanzi mama” (should I bring you water mom or have you taken your pills?). My three-year-old son Azania also feels compelled to help me with swallowing them by asking “mama khandiqhekezele ndiyakucela” (can you please give me a piece)? There are days when I take the six pills without even thinking what they are for – because HIV is not always present in my thoughts.

Twelve years ago I could name many people who lived openly with HIV – not because they wanted attention, but because people like me needed to know we are not alone. Today we hardly know – it’s the same old faces who are now in their late thirties or fourties. We barely talk openly. We are not visible enough to those who just learnt their status.

The world of HIV is moving very fast – we are now talking about controlling the epidemic and ending AIDS by 2030. But I wonder. Our public healthcare system remains the same – it is weak and falling apart. How will we end AIDS? Where is the long promised National Health Insurance? If the space for civil society and funding for civil society is shrinking, who will control AIDS? If NGO’s and social movements are not building from below who will end AIDS? If corruption becomes normalised who will hold those looting from the state accountable?

This is no longer Mbeki’s or apartheid’s fault but the fault of our current government. They too must account for their own misdeeds. Honest introspection, debate and action is urgently needed. I hope this will happen in Durban.

This year, I celebrate 15 years of knowing that the HIV test I took in 2001 was not a crazy idea – thanks to Nomandla Yako’s counselling and treatment literacy education that changed my life when I first walked into Ubuntu clinic. Without that strong initial contact I would have been a lost soul. Finding comfort and power in my comrades, sisters and brothers arms Nomfundo Dubula, Nonkosi Khumalo, Sipho Mthathi, Linda Mafu, Rukia Cornelius, Zackie Achmat, Mark Heywood, Noloyiso Ntamehlo and many more. Finding and joining the Treatment Action Campaign was the best thing I have ever done. The people I have walked this journey with will always hold the highest place in the revolution house. They know who they are. I thank you all.   

 

Vuyiseka Dubula is the former General Secretary of the Treatment Action Campaign and a member of the Board.

 

Fighting for the right to care

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.

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

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

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).

Tireless: Doris Ntuli
Tireless: Doris Ntuli

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.