he Covid-19 pandemic has helped to renew respect for community health workers (CHWs) both among other health workers and the communities they serve, public health experts say. But they warn this won’t be enough to put the country’s community health worker programme, which has faced barriers for years, on a more sound footing, as workers across the country prepare for a nationwide strike. 

Workers demand that they be made permanent employees of provincial health departments — with higher salaries, as well as medical aid and pension benefits — instead of being outsourced to nonprofits organisations that pay them stipends, or working under temporary provincial health department contracts. 

Reports of community health workers planning to down tools were already prevalent during higher levels of lockdown in June and again in September, but the National Education, Health and Allied Workers’ Union (Nehawu) has now started balloting its members across the country in preparation for industrial action.

“In most provinces, CHWs have one-year contracts with provincial health departments and are paid a stipend but also don’t have benefits,” says Lungiswa Tsolekile, a senior lecturer at the school of public health at the University of the Western Cape (UWC). 

In countries like South Africa that have a serious lack of doctors and nurses, community health workers are used to address the crippling health worker shortage through “task shifting” – transferring some of the easier but time-consuming tasks of professional health workers, such as following up on HIV or tuberculosis (TB) patients to ensure they take their medication correctly.

South Africa has about 55 000 community health workers, according to a register published in the 2017 District Health Barometer. 

Community health workers have played a crucial role during the Covid-19 pandemic. When the coronavirus outbreak took hold in the country in March, tens of thousands of community health workers were dispatched to hand out educational materials, screen people for Covid-19 and trace the contacts of people who tested positive for the new coronavirus, SARS-CoV-2. 

Nehawu spokesperson Khaya Xaba argues: “It’s important that the department of health does good by these workers. During the peak of the coronavirus outbreak, they were the ones of the frontlines doing mass screenings and risking their lives.”

But so far, the increased focus on community health workers during the pandemic hasn’t catalysed the changes in the government’s approach to this cadre that civil society was hoping for, says Sasha Stevenson, head of health at the legal advocacy group Section 27. 

“We were hoping that proper compensation and integration into the health system would come, but that hasn’t happened. And what we know is that the CHWs remain fundamental to any kind of primary health care-based system. That’s what the National Health Insurance (NHI) scheme [that aims to give all South Africans access to the same level of healthcare regardless of their income] is supposed to be. So fixing those things is really urgent.”

How effective are SA’s community health workers? 

The success of South Africa’s NHI, which, according to the NHI Bill should be implemented in full by 2026 — will depend heavily on the effectiveness of community health workers. 

The Bill has been approved by cabinet, but still has to be debated in parliament. 

The  document  stipulates that contracting units for primary healthcare, which will consist of public clinics and community health centres in an area, should be created. The contracting units will be linked to teams of community health workers, which will comprise six community health workers and a nurse as the team leader. The teams would go to people’s homes to provide preventative health information, promote healthy lifestyle choices and provide palliative and rehabilitation care, according to the department of health’s Policy Framework and Strategy for Ward-Based Primary Healthcare Outreach Teams.

How well those units work, will — to a large extent  — depend on how efficiently the country’s community health worker system operates. 

“The NHI is not just about the clinical aspects of care that is provided in the facilities,” says Lindiwe Madikizela-Hlongwa, director of community services in the national department of health. “It’s also about prevention that should be provided in communities. That’s where the community health workers will play a significant role.”

But South Africa’s community health worker system has been plagued by problems for years. Research published in 2013 showed the country’s community health workers had almost no positive effect on South Africa’s health indicators. This is in stark contrast to countries such as Ethiopia and Brazil, where such programmes have led to dramatic drops in the number of deaths of children of five years and younger, and mothers during pregnancy, birth or shortly thereafter. 

A healthy community health worker programme could save two million lives within the next decade, according to a 2018 investment case modelling study conducted by the South African Medical Research Council. That includes their potential interventions in HIV, TB, hypertension, diabetes, and mother and child health. 

But these successes rely on a well-resourced platform, in which workers are well trained, remunerated and supervised, the research emphasises — issues that have long gone unresolved. 

And without the money and the political will to bolster the primary healthcare projects that will form the basis of universal health coverage under the NHI, experts say, these problems will simply not go away...