Underpaid and unprotected: The case for supporting community health workers

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A health worker screens for Covid-19 in Attridgeville in April 2020. Picture: Gallo Images/Alet Pretorius
A health worker screens for Covid-19 in Attridgeville in April 2020. Picture: Gallo Images/Alet Pretorius


In July 2020, Community Health Workers staged a protest outside the offices of the Eastern Cape health department in Bhisho, calling for their enlistment as full-time employees in the department of health. Subsequently, the Eastern Cape MEC for Health, Sindiswa Gomba, stated that their full-time employment was “not a straightforward issue for the province”.

Health workers asking for representation on the Nelson Mandela Health forum, which serves as one of the oversight bodies for primary healthcare in Bhisho, were told that they could not be included because they were employed to assist the province with its Covid-19 coronavirus response. The irony of exclusion based on their temporary employment, while there is ongoing active debate at the national level about their permanent employment, was not lost on these workers, desperately seeking to add their voices to discussions on policy and programmes.

Noluthando Mhlongo from KwaZulu-Natal is among some health workers that work with the C-19 people’s coalition. Mhlongo asked: “How can we be relied on to screen and test communities for Covid-19, yet not be allowed to share our perspectives from the frontline at health forums?”

TB Proof is also a member of the C-19 coalition.

For the health of about 300 000 South Africans living outside of a two-hour range of a public hospital, these community health workers provide an essential service. Employing them drastically expands a country’s healthcare workforce, making healthcare more accessible. Furthermore, their employment increases vaccination uptake, improves tuberculosis (TB) outcomes and decreases child morbidity and mortality.

Community health workers play a critical role in the government’s response to the Covid-19 crisis in South Africa. To contain the virus, South Africa’s health department has employed large-scale screening, testing and tracing using clinics, community healthcare centres and mobile testing units.

Read: New mothers are living in hospital hell

All these strategies rely on them

Chair of the ministerial advisory group on Covid-19, Professor Salim Abdool Karim, described these health workers as South Africa’s “secret weapon against Covid-19”.

Yet, their requests for consultation on their scope of work, remuneration and protective equipment remain unanswered despite multiple advocacy letters addressed to the minister of health, Dr Zweli Mkhize, demonstrating government’s lack of political commitment to support them.

In a statement released in April, the health minster promised that healthcare workers would be deployed with “appropriate personal protective equipment”. However, this has not always transpired.

It is time to enact changes that provide meaningful support to them and grant them a seat at the table

These health workers face unacceptably dangerous working conditions that put them at risk of Covid-19 and lack the basic employment conditions for them to be provided with compensation should they fall ill. Early data from the pandemic shows that there has been a steep increase in Covid-19 infections among health workers across the continent.

Data from India suggests that the use of face shields in addition to surgical masks, hand sanitiser, gloves and shoe covers, can reduce the risk of Covid-19 infections in community health workers. Yet, no guidelines have been published advising recommended personal protective equipment for them. Although the increased risk of TB has long been documented, there is a specific lack of consensus about their need for N95 respirators, despite being expected to take the risk of obtaining sputum cultures from people who may have TB, in addition to providing Covid-19 related care.

“When it comes to N95 respirators, we are unprotected,” said Boniwe Plaatjie, a community health care worker from the Northern Cape. This has dangerous consequences for these workers, who are risking their lives to care for underserved communities. Furthermore, failure to prepare and protect them shows a flagrant and unacceptable disregard for the lives of those on the frontline, and it undermines the importance of the public health messages they are tasked to deliver.

Read: Covid-19: What life is like in Khayelitsha after the surge

Despite their integral role in South Africa’s health system, there is a long history of community health care workers being denied access to contribute to discussions that determine the scope and payment of their work.

For instance, the Ward Based Primary Healthcare Outreach Teams policy (initially drafted in 2011 and finally released in 2018) was developed to facilitate the provision of integrated primary healthcare at the household level and community outreach services.

South Africa’s swift initial response to the Covid-19 pandemic instils hope that the country can make radical decisions to address its health problems

In the foreword to the policy framework and strategy document released in December 2017, former minister of health, Aaron Motsoaledi, wrote that “community health care workers form the bridge between communities and healthcare service provision within health facilities”. The then director-general for health, Dr Precious Matsoso, wrote in her foreword that “community health care workers organised into ward based primary healthcare outreach teams will play a pivotal role in improving access to primary healthcare for vulnerable communities”.

Yet to date, no implementation plan for the ward based primary healthcare outreach teams policy has been released, nor have these workers been consulted on its development or content.

Read: ‘We want the public to know government wants us to work without PPE’ – striking Bara healthcare workers

Now, with Covid-19, community health care workers are struggling to balance their new tasks within their prior broad scope of work that remains undefined.

“The lack of representation in discussions about implementation of primary health care is a major impediment to South Africa’s goal of rolling out universal health coverage,” said Gale Mookroof, a community health care worker from the Northern Cape.

It has been estimated that if South Africa invests in 41 000 more of these workers, 34 800 lives will be saved in the next decade. However, before the programme is expanded, we must ensure that national and provincial health departments allow them to be represented when policy is made and implemented.

South Africa’s swift initial response to the Covid-19 pandemic instils hope that the country can make radical decisions to address its health problems. For the ongoing repercussions of the Covid-19 pandemic to be tackled effectively, the contribution of community health care worker to the pandemic response and to a universal health coverage agenda needs to be adequately recognised. Their salaries should reflect the effort and risks they have shouldered alone for too long.

It is time to enact changes that provide meaningful support to them and grant them a seat at the table.

*The authors are all members and/or board members of TB Proof, a leading TB advocacy organisation in South Africa.

*This article was first published in Spotlight – health journalism in the public interest.


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