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.
Issues around the employment of CHWs are some of the most highly contested in discussions of CHWs in South Africa. For years, CHWs have been calling for employment by the Department of Health, the standardisation of payments, training and role clarification, and for an increase in their salaries.
CHW programmes around the world deal with the payment and employment of CHWs differently. There is a mix of NGO-driven programmes and those that are centralised and operate out of a Department of Health. What is clear is the need for CHWs to be embedded both in the community and in the healthcare system. Where CHWs are employed by NGOs, embeddedness in the healthcare system tends to be more difficult. Equally, programme consistency cannot be ensured. Embeddedness in communities can be ensured, regardless of employer, by ensuring that CHWs are from the communities that they serve and that the community is involved in recruitment. There are limitations to this manner of recruitment however, as CHWs operating in their own communities may find it difficult to discuss the health problems of their neighbours and those neighbours may be less willing to provide such information to the CHW.
Employment by the state makes supervision, management and the development of a standard programme easier. It is also in line with South African government policy to insource where possible, including the resolution in the 53rd ANC National Congress in 2012 to insource those providing critical services in the Department of Health.
The WBPHCOT policy envisages employment by the Department of Health or by NGOs (where they exist) and seconding of CHWs to Departments of Health. It is unclear whether NGOs would be amenable to a secondment arrangement. National Treasury has, in meetings with CHWs, expressed its preference for NGO employment as such employment is less expensive for the state (in that it does not need to pay public sector salaries, including benefits) and does not add to the already substantial state wage bill.
Given the vital importance of proper integration into the healthcare system and the need for the creation of decent jobs in South Africa, we cannot continue to rely on the employment of CHWs through NGOs and the payment of extremely low stipends. If we value the work of CHWs and consider it indispensable to the move towards a preventative health system, as we purport to, CHWs must be employed by the state and receive the associated benefits. While this will be more expensive, it also offers the social and economic benefits described earlier. The Investment Case pins the cost of employment of CHWs on Level 1, notch 1 at R67,806 per CHW per annum. This is the level we should be pursuing.
The central goal of the new NSP is prevention. In focusing on prevention, 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.
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 healthcare service and commodity distribution, diagnosis and management of common illnesses, assistance during birth, and community organisation are all traditional CHW functions.
CHWs have long been recognised to be an important part of a primary healthcare system. They have the potential to bring the community closer to health services, and health services closer to the community, and to play a vital role in preventative and other health services that do not require professional and in-facility care.
The efficacy of CHWs depends on the effectiveness of the healthcare system as a whole. They are not a panacea for a weak system and cannot replace facility-based healthcare services. What they can do is offer certain services to otherwise underserved communities, and provide preventative and health promotion services that are not otherwise adequately available within the health system. Evidence suggests that CHWs can bridge the gap between the community and the healthcare system and can facilitate patient re-entry into healthcare services after a negative experience.
The factors holding us back in our HIV programme are many and varied. Medicine stock-outs continue to be a serious health system weakness, with the 2015 Stop Stock-Outs survey finding that one in three health facilities experienced a stock-out of ARVs or TB medication in the three months prior to the survey call. And behaviour-change interventions have not resulted in the reduction of risky sexual behaviour as intended. But well-trained and capacitated CHWs can help us to reach ‛smaller’ goals: making sure that people who access treatment keep taking it; tracing people with TB or who are close to people with TB and ensuring that they have access to, and take, treatment. They can offer information to help reduce risky sexual behaviour. These interventions are the core business of CHWs. We will not be able to meet NSP targets without them and thus the development of a strong CHW cadre should be seen as a fundamental component of the NSP.
Linked to but separate from the NSP, are numerous and compelling arguments for investment in a CHW programme. In ‛Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations’ Dahn and others report on the findings of a high-level panel that looked into the case for investment in a CHW programme, summarising the findings in the following four pillars:
Investment in CHWs is a requirement to achieving critical health objectives.
Investing in CHWs results in a positive economic return.
Scale up of CHWs can lead to cost savings in other parts of the health system.
Investment in CHW systems yields further societal benefits.
Looking at each of these pillars in more detail, the case for investment in a CHW programme in South Africa is clear.
Achieving critical health objectives
The provision of universal health coverage is impossible when people have to travel to access health services with healthcare professionals whose training is expensive and lengthy. In a review of studies on CHW programmes in eight countries, including three in Sub-Saharan Africa, it was found that the services offered by CHWs helped in the decline of maternal and child mortality rates and assisted in decreasing the burden and costs of TB and malaria. Without health promotion and disease prevention services, best provided by CHWs, the burden on the healthcare system from HIV, TB, non-communicable diseases (NCD), among others, will continue to rise in a manner that is not sustainable. As described below, CHWs can play an important role in HIV, TB and NCD interventions through promoting and assisting with adherence; directly observing treatment; leading and/or facilitating support groups; encouraging health-seeking behaviour; and doing basic screening, among other services. There is no other cadre of healthcare worker that can perform this vital role.
The return on investment
The economic burden of a population that is not healthy is clear. Poor health in early life can hinder cognitive development and worsen educational outcomes. Unhealthy employees stay away from work or go to work but are unproductive. This puts significant strain on the economy. On the other hand, there is an appreciable economic benefit to having a healthy population. The Lancet Commission on Investing in Health reported that around one quarter of economic growth between 2000 and 2011 in low- and middle-income countries resulted from the value of improvements to health. The return on investment in health was estimated to be nine to one. The investment in an effective CHW programme, therefore, has the potential to offer both health and economic benefits for South Africa.
Cost-savings elsewhere in the health system
CHWs can provide care that traditionally has been carried out by professionally-trained medical staff, at higher cost, in facilities or in community settings. There is good evidence globally that CHWs can provide effective services at a lower cost. The treatment and management of chronic diseases and TB, maternal health interventions and neonatal care, for example, can all be offered by CHWs. South Africa has already seen the benefits of ‛task shifting’ with the adoption of nurse initiated and managed antiretroviral therapy (ART). Shifting appropriate tasks to CHWs frees up nurse and doctor time that can then be used for tasks more suited to their skills. With the significant challenges presented by understaffing, and long waiting times at health facilities, this is an important benefit from investment in a CHW programme in South Africa.
Further societal benefits
Investment in health has benefits that go beyond improving the health status of individuals and strengthening the economy; the health sector is a job generator. In a sample of 123 countries, women were found to make up 67 percent of employees in health and social sectors, compared to 41 percent of total employees. A CHW programme can lead to employment of women, of young people, and of people in rural areas with few employment opportunities otherwise. Access to care closer to home also saves significant transport costs that have to be absorbed by poor households (up to R600 one way in rural Eastern Cape). In South Africa, while access to healthcare services in the public sector is free of charge, ancillary burdens fall on households. These burdens are unmanageable in a population where 26.7 percent of the population is unemployed and 36.3 percent of the population has stopped looking for work. A well-designed CHW programme can address these issues.
There is not nearly enough research in South Africa on the case for investment in CHWs. In light of research conducted elsewhere, the economic and social benefits of a well-designed and comprehensive CHW programme in South Africa are clear. Here, we seek to lay out what such a programme should look like.
 L Crigler et al ‛Developing and Strengthening Community Health Worker Programmes at Scale: A reference guide for program managers and policy makers’ USAID and MCHIP, 2013, p6-2.[number sequence is odd – plse check]
 G McCord et al ‛Deployment of community health workers across sub-Saharan Africa: financial considerations and operational assumptions’ Bulletin of the WHO 2012;91:244-253B.
 U Lehman and D Sanders ‛Community Health Workers: What do we know about them?’ WHO Evidence and Information for Policy, Department of Human Resources for Health; Geneva, January 2007, v.
 Rural Health Advocacy Project Position on Community Health Workers. Accessible at: www.rhap.org.za/category/community-health-workers/.
 R Zulliger et al ‛‟She is my teacher and if it was not for her I would be dead”: Exploration of rural South African community health workers’ information, education and communication activities’ AIDS Care-Psychological and Socio-Medical Aspects of AIDS, 2014 26(5), p 626-632.
 B Dahn et al ‛Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations’ Accessible at: http://www.chwcentral.org/strengthening-primary-healthcare-through-community-health-workers-investment-case-and-financing.
 B Dahn et al “Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations” Accessible at: http://www.chwcentral.org/strengthening-primary-healthcare-through-community-health-workers-investment-case-and-financing, p5.
 “Working for Health and Growth: Investing in the health workforce” Report of the High-level Commission on Health Employment and Economic Growth, p19.
 D Jameson et al “Global health 2035: a world converging within a generation” Lancet 2013 Dec 7; 382(9908): 1898-955.
 B Dahn et al “Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations” Accessible at: http://www.chwcentral.org/strengthening-primary-healthcare-through-community-health-workers-investment-case-and-financing, p7.
 ‛Working for Health and Growth: Investing in the health workforce’ Report of the High-level Commission on Health Employment and Economic Growth, p25.