Community healthcare workers can be the glue that connects our healthcare system to communities. They are critical to health promotion, disease prevention, early diagnosis and referral, as well as helping people stay healthy and on their treatment programmes.
An effective programme – where workers are empowered and treated with respect – is entirely possible. It does not require mental acrobatics to imagine a system where more community healthcare workers are employed under decent conditions. All a better functioning programme needs is political commitment from those in power, and good and inclusive governance in provincial health departments.
One positive is that, to some extent, the critically important role of community healthcare workers has already been recognised in various national policies.
The policy framework and strategy document for ward-based primary healthcare outreach teams, which was finalised in 2018, defines a community healthcare worker as “any worker who is selected, trained and works in the community”. It adds: “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
Government’swebsite states that households must have access to a well-trained community health worker. The NDP describes the important role that these workers can and should play within the ward-based primary healthcare outreach teams in addressing the social determinants of health through education and prompt referral to health and other services.
The NDP proposes that if community healthcare workers are to be supported in fulfilling these expectations and becoming fully recognised members of multidisciplinary effective primary healthcare teams, their employment conditions, education and training, support and supervision, as well as 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 ward-based primary healthcare outreach teams, as well as the various roles and history of community healthcare workers over time.
Challenges faced by communities
As part of a recent online course run by the People’s Health Movement SA on comprehensive primary healthcare, social determinants of health, advocacy, activism and running campaigns, community healthcare workers 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 the urban centres of Mthatha and Port Elizabeth (KwaZakele and KwaNobuhle).
Since they 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.
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 the fast-flowing river.
Transport is expensive, especially as most community members rely solely on social grants. Some do not even manage to access grants because they have no birth certificates or IDs. This makes it difficult for community healthcare workers 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 – yet there were still many reports of medical stock-outs, shortages of staff and equipment, long waiting times and poor staff attitudes in some facilities.
Despite these challenges, community healthcare workers also noted some positives. Some health services work well with these workers and NGOs. In certain areas, traditional practitioners have a good working relationship with the services and refer people to the clinic as needed. Some services run campaigns with them. They also have good screening and testing services for TB and HIV, noncommunicable diseases, pap smears, and child and maternal services.
These accounts are corroborated by formal research and reports from other community healthcare workers in the Eastern Cape over the past five years.
Transforming the community healthcare worker programme in the Eastern Cape
For years, these workers in the province have made repeated calls for assistance in ensuring better health outcomes in their communities.
1. A more transparent recruitment process is needed that ensures that community healthcare workers come from the area they live in. Ideally, members of the community should be part of the selection process.
As they retire, pass away or leave for other reasons, new community healthcare workers must be recruited promptly.
All community healthcare workers must be employed by the provincial department of health, and training must be standardised. At present, there is no standardisation as some healthcare workers are employed by the department of health and others by NGOs, the department of social development or 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 (particularly delivering their medication from the clinic), psychosocial support for young people, nutrition and organising various support groups. However, they all promote healthy lifestyles by exercising, gardening and referring patients as necessary to the clinic.
Having different employers means differences in salary, education and scope of practice, although the workers are all doing much the same work. Not all community healthcare workers earn the meagre stipend of R3 500 per month implemented only by the department of health. Others generally get paid less. All of them should be employed permanently by the department of health with all the usual benefits. Only then will they feel that other healthcare workers recognise and respect them.
2. More community healthcare workers must be employed in the province. There are approximately 4 129 community healthcare workers in the Eastern Cape. The province needs at least 7 757, based on the national department’s standard of one per 1 500 people.
The present ratio of community healthcare workers per population needs to be revisited based on research in other low- and middle-income countries. In Rwanda, for example, there is one for every 300 people. In Brazil, the ratio is one per 800 people, and in Thailand it is one per 93 people. In South Africa, we have one healthcare worker servicing 1 500 people, with some flexibility for context. So, for effective outcomes and taking local contexts into account, more community healthcare workers are needed.
In the rural Eastern Cape, where distances between households and services are large, more community healthcare workers may be needed than in denser urban areas.
3. They should be given all the tools they need to stay safe. Issues regarding transportation should be addressed by exploring what transport community healthcare workers could use that is appropriate for medication deliveries. One option worth exploring is petrol-powered motorised bicycles.
They also need protective gear for the weather and protective personal equipment against diseases such as TB and Covid-19.
To improve access to health services, it is also crucial that government fixes infrastructure such as roads and bridges, where needed, including health facility buildings.
4. There must be 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 tensions between staff.
Community healthcare workers should have a dedicated space (in health facilities) to meet and do their administrative work. They must also have regular supervision.
Lastly, they 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 them to be involved in structures dealing with water and sanitation, food security, social grants and income generation.
Most importantly, they should be involved in all the processes to achieve these improvements.
Ultimately, we need a people-centred and caring primary healthcare-led health system with adequate numbers of community healthcare workers as frontline health workers. We need community healthcare workers who are well recognised by government, health services and the community, and who are well trained and appropriately compensated. There is no other way of making 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.
*Melanie Alperstein serves on the steering committee of the People’s Health Movement SA and Tinashe Njanji is the national coordinator.
*This article was produced for Spotlight – health journalism in the public interest.