Community healthcare workers (CHWs) can be the glue that connects our healthcare system to communities. They are critical to health promotion, disease prevention, early diagnosis and referral, and helping people to stay on treatment and stay healthy.

What is more, an effective CHW programme – where CHWS are empowered and treated with respect – is entirely possible. It does not require any mental acrobatics to imagine a system where more CHWs are employed under decent conditions. All that’s required for a better functioning CHW programme is political commitment from those in power and good and inclusive governance in provincial health departments.

Policy framework

One positive is that, to some extent at least, the critically important role of CHWs has already been recognised in various national policies.

The Policy Framework and strategy document for Ward Based Primary Health Care Outreach Teams (WBPHCOTs), finalised in 2018, defines a Community Health Worker as “any worker who is selected, trained and works in the community … They are the first line of support between the community and various health and social development services. They empower community members to make informed choices about their health and psychosocial wellbeing and provide ongoing care and support to individuals and families who are vulnerable due to chronic illness and indigent living circumstances.”

The National Development Plan (NDP) 2030 states that households must have access to a well-trained community health worker. The plan describes the important role that CHWs can and should play within the WBPHCOT in addressing the social determinants of health through health education and prompt referral to health and other services. The NDP proposes that if CHWs are to be supported to fulfil these expectations and to become fully recognised members of multidisciplinary effective primary healthcare teams, their employment conditions, education and training, support and supervision and issues such as transport, must be improved uniformly across all provinces.

Against this policy and strategy framework, and the NDP 2030, other authors, in previous publications including Spotlight, have written on the current state of health services in the Eastern Cape and the state of implementation or limited implementation of the WBPHCOTs, as well as the various roles and history of CHWs over time.

Challenges faced by communities and CHWs

As part of a recent online course run by the People’s Health Movement South Africa (PHM-SA) on Comprehensive Primary Health Care, Social Determinants of Health, advocacy and activism and running campaigns, CHWs conducted a community needs and asset assessment in a few areas of the Eastern Cape where they work. This included rural areas such as Tsolo, Ngqeleni, Butterworth, Port St Johns and urban centres of Mthatha and Port Elizabeth (KwaZakele and KwaNobuhle).

Since CHWs live in the same communities they serve, they experience the same social, economic and environmental living conditions.

Although there are differences between deep rural areas, small towns and cities, access to clean water and adequate sanitation was a big issue for all. In the deep rural areas water is mostly accessed from rivers and unprotected springs that communities share with animals. In small towns and some parts of the cities, taps run dry for long periods of time.

In the rural areas hospitals and clinics are often far from homes, which discourages people from going to clinics and is one reason for treatment interruptions. Roads are often bad and in Ngqeleni the bridge to Canzibe hospital has been broken for a number of years. In the rainy season people cannot reach the hospital due to floods. Transport is expensive, especially when most community members rely solely on social grants. Some do not even manage to access grants, as they have no birth certificates or IDs. This makes it difficult for CHWs to persuade people to go to the clinic unless they are seriously ill. In the smaller towns and cities clinics are closer and people can walk there – but even here there were many reports of medical stockouts, shortages of staff and equipment, long waiting times, and poor staff attitudes in some facilities.

Despite these challenges, CHWs also noted some positives. Some health services work well with CHWs and NGOs. In some areas traditional practitioners have a good working relationship with the services and refer people to the clinic as needed. Some services run campaigns with CHWs and NGOs. They also have good screening and testing services for TB and HIV, non-communicable diseases, Pap smears and child and maternal services.

These accounts are corroborated by formal research and reports from other CHWs in the Eastern Cape over the past five years.

Ways to transform the CHW programme in the Eastern Cape

For years, CHWs in the province have made repeated calls to assist them in ensuring better health outcomes in their communities. These calls include the following:

1. Transparent and appropriate recruitment and employment policies

We need a more transparent recruitment process that ensures CHWs come from the area in which they live. Ideally, members of the community should be part of the selection process.

As CHWs retire, die or leave for other reasons, new CHWs must be recruited promptly.

All CHWS must be employed by the provincial Department of Health and training must be standardised. At present there is no standardisation as some CHWs work for the Department of Health and others for NGOs, the Department of Social Development, and some are employed through the government’s Extended Public Works Programme. All do health education in the community, but some focus on child and maternal health, others on care for the elderly and particularly delivering their medication from the clinic, psychosocial support for youth, nutrition, organising various support groups, and all promote healthy lifestyles by promote exercising, gardening and refer as necessary to the clinic.

Having different employers means differences in salary, education and scope of practice, although they are doing much the same work. Not all CHWs earn the meagre stipend of R3,500 per month implemented only by the department of health. Others generally get paid less. All CHWs should be employed permanently by the Department of Health with all the usual benefits. Once employed permanently by the department, CHWs feel other health workers will recognise and respect them. 

2. More CHWs must be employed in the province.

There are approximately 4,129 CHWs in the Eastern Cape. The province needs at least 7,757 CHWs based on the national department’s standard of one CHW per 1,500 people.

The present ratio of CHW per population needs to be revisited based on research in other low and middle-income countries. In Rwanda, for example, there is one CHW for every 300 people. In Brazil, the ratio is one per 800 people and in Thailand one per 93 people. Here in South Africa we have one CHW servicing 1,500 people with some flexibility for context. So, for effective outcomes and taking local contexts into account, more CHWs are needed.

In the rural Eastern Cape, where distances between households and services are great, more CHWs might be needed than in denser urban areas. Therefore, as their scope of work increases as intended in the WBPHCOT policy document, and the NDP, in remote rural areas a higher ratio of CHW to population should be considered by taking into account the burden of disease and distance from health services.

3. CHWs should be given all the tools they need to stay safe.

Issues around transport should be addressed by exploring transport options CHWs could use that are appropriate for medication deliveries. One option worth exploring is petrol motorised bicycles.

CHWs also need protective gear for the weather and protective equipment (PPE) against diseases such as TB and Covid-19.

To improve access to health services, it is also crucial that the government fixes infrastructure such as roads and bridges where needed, as well as  health facility buildings.

4. CHWs need supportive workplaces and involvement in and with broader community structures.

Establishing workers’ committees at clinics that include all workers, from doctors to cleaners, can help improve health outcomes. These committees should meet regularly and provide a safe space for all health workers to debrief, air grievances and sort out any tensions between staff.

CHWs should have a dedicated space (in health facilities) to meet and do their administrative work, and they must have regular supervision.

Last, CHWs need the support of an intersectoral body that includes  various community structures, as health outcomes depend on other sectors and community participation. The greatest need is for CHWS to be involved in structures dealing with water and sanitation, food security, social grants and income generation.

Most importantly, CHWs should be involved in all the processes to achieve these improvements.

Ultimately, we need a people-centred and caring primary health care led health system with adequate numbers of CHWs as the frontline health workers. We need CHWs who are well recognised by government, health services and the community; who are well trained, and appropriately compensated. There is no other way or alternative if we want to make primary healthcare work.

*This article is part of Spotlight’s ‘Reimagining health in the Eastern Cape’ series – in which activists, healthcare workers, policy-makers and others are asked to reflect on how access to healthcare in the province can be improved. DM/MC

*Melanie Alperstein serves on the steering committee of the People’s Health Movement South Africa and Tinashe Njanji is the national co-ordinator.

*This article was produced for Spotlight – health journalism in the public interest. Sign up for our newsletter.