Home care: Community healthworker Nonqaba Melani weighs a child in Khayelitsha, assisted by Chuleza Nangu. Melani is a ‘Mentor Mother’ who looks after the health of mothers and children. (Jacques Smit)

Community healthworkers shafted by SA's policy shambles

Mia Malan
The community healthworker system is in chaos, leaving vulnerable communities at risk.

If you're one of the health department's new "ward-based" community healthworkers, who all undergo the same training, have the same job title and work the same hours, your monthly stipend will be R1 000 in Mpumalanga, R1 500 in the Northwest and R2 263 in Gauteng.

In the Eastern Cape, Gauteng, Northwest and KwaZulu-Natal, you'll be paid directly by the provincial health department, which would eliminate "dry seasons" or payment interruptions because you will have been uploaded on to the department's automatic payroll.

But in the Free State, Limpopo and the Northern Cape, you'll be employed and paid by a nonprofit organisation contracted by the local government. If the provincial health department pays the nonprofit organisation late or not at all, you'll be paid late, too, or even lose your salary (see graphic).

If you happen to be one of the thousands of "single-purpose" community healthworkers in South Africa who focus on one health issue only – for instance, HIV counsellors or TB tracers (who track tuberculosis patients who have defaulted on their treatment) – and you currently work for a nonprofit organisation outside the "ward-based" system, you're likely to be retrained as a "ward-based" community healthworker, which will enable you to address all health issues in your community.

But this is only if you live in Kwazulu-Natal, Limpopo, Mpumalanga and Northwest. If you're based in the Eastern Cape, Free State or Gauteng, it's possible that you will lose your job.

And, if you're from the Western Cape, you won't fall under the "ward-based" system, in which six community healthworkers are allocated to each municipal or electoral ward, because the province has chosen to follow an entirely different system.

  • Why Free State community healthworkers are losing their jobs: read this

No policy
"This is exactly what happens in the absence of a policy: you leave every province to do whatever it wants," says Pranitha Pillay from the Rural Health Advocacy Project, a partnership between the University of Witwatersrand, Section27 and the Rural Doctors' Association of Southern Africa. "How can that be a national strategy?"

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

Such "lay" workers, who are trained using a combination of short, in-service and slightly more formal courses, generally live in the communities they serve. They do home visits during which they compile inventories of vulnerable groups, such as pregnant women and children under five in their neighbourhoods, keep track of people's general health concerns and link them to health facilities when needed.

Since 1994, according to a 2013 study in the journal, Health Policy and Planning, South Africa's community healthworker programmes haven't had much of a positive impact. In stark contrast, in countries such as Ethiopia and Brazil 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.

Researchers attribute this to the fact that our programmes are unco-ordinated, unregulated and unstructured, with none formally forming part of the country's public health system.

Also, rather than being trained "comprehensively" to deal with general prevention and care, most of our 72 000 healthworkers have focused on "single health issues", such as HIV or TB. Their training ranges vastly from between two weeks to four years, according to a 2011 health department document. 

Graziela dos Santos (25), a community health worker in Brazil, checks up on one of her patients. The favelas are served by teams of community workers who are the doctors' eyes and ears

Lessons from Brazil
After a visit to Brazil's community health programmes in 2010, Health Minister Aaron Motsoaledi decided to correct this situation. On his return he announced that he was going to create community healthworker programmes similar to those in Brazil – programmes that would hopefully have the same kind of positive impact on health indicators such as maternal and child mortality.

This would mean that community healthworker programmes would be standardised, would form part of the public healthcare system and workers would be comprehensively trained, as opposed to each dealing with different "specialised" health issues.

Motsoaledi announced his new strategy with the release of a discussion paper, "Re-engineering Primary Healthcare in South Africa," in November 2010. It recommended that each municipal or electoral ward be assigned at least one primary healthcare outreach team consisting of six community healthcare workers, led by a professional nurse.

Three and a half years later, the minister's strategy is being implemented, but with a serious impediment: there is no national policy, despite health activists having lobbied for this for years. The result is chaos, with each province implementing the strategy differently.

Policy shambles 
According to Pillay, in the absence of a formal policy, the health department risks "sabotaging" its own programme and undermining its "primary health strategy".

"There is a failure of leadership to articulate how provinces are supposed to make the community healthworkers strategy happen, where the money is going to come from and how we will properly support the right number of workers with a decent scope of work," Pillay says. "If we don't say anything about it, we breathe life into the failure of leadership."

One of the main recommendations of Motsoaledi's strategy document is that community healthworkers should be paid significantly more and that their remuneration should be standardised. If "community healthworkers are to play a meaningful role in revitalising primary healthcare … there needs to be …. an immediate and tangible improvement in salaries and conditions of service," the document stipulates.

According to Helen Schneider, who heads the University of the Western Cape's public health department, and who helped to produce the 2010 document, the average domestic worker earns more than community healthworkers. "I would say we need to double their stipend," she says.

The strategy document calculates workers' remuneration at a package of R75 000 (R6 250 a month, including benefits) if they become full-time government staff members, amounting to an overall cost of R3.2-billion a year. If nonprofits were to manage and pay the workers the cost would be reduced to an annual package of about R30 000, but the strategy document does not recommend the nonprofit route.

In practice, not a single "ward-based" community healthworker receives a salary close to either of the government or nonprofit packages, and all provinces pay different stipends. 

"[B]roken promises"
A 2013 study authored by Schneider and her colleagues, which evaluated the implementation of "ward-based" teams in pilot wards of North West Province in 2011, found that community healthworkers were utterly disappointed by "broken promises".

"They were promised that they will get R3 000 a month by national people. This was communicated in front of all the team leaders and everybody that was present," one team leader told the study's authors. "Suddenly the new contract says R1 500."

Schneider says the small stipends are the result of the community healthworker strategy being an "unfunded mandate" at this point in time.

The document also recommends that workers should be appointed and paid by local government, rather than by nonprofit organisations, to eliminate periods during which they don't get paid because of late payments to nonprofits. It would also result in similar work benefits, as opposed to workers all receiving different benefits from nonprofit organisations with different policies.

But only four provinces are following the recommendation to pay their workers directly and, even in cases where it is happening, work benefits have not been standardised. 

Financial constraints 
Says Pillay: "Without funding, provinces get to do what they want with this strategy. Unless you allocate money, provinces will say, 'we don't have money and national hasn't given us extra money to implement this strategy. We can only do what we can afford.'"

Although while the strategy document recommends that "ward-based" workers should be recruited from the "existing pool" of "single-purpose" workers, only four provinces are doing that, leaving the remaining community healthworkers feeling "abused, demoralised and insecure", according to Mark Heywood of Section27.

In the Free State 2 200 healthworkers lost their jobs in June. When they protested about their dismissals in front of the Free State health department's headquarters in July, they were arrested on charges of taking part in an "illegal gathering".

The health department's deputy director for primary healthcare, Jeanette Hunter, told Bhekisisa in July that a draft policy would be distributed at a meeting with civil society in the first week of August. But the meeting never happened, and the draft policy has not been released.

"It's extremely problematic that we're not talking about finalising a policy by the end of 2014. We started lobbying for this policy in 2008," Heywood says. "Why is Aaron Motsoaledi not sorting this out? It's his responsibility.


How many households should a healthworker serve? 

The health department's 2010 primary healthcare strategy document and a consequent 2011 "implementation toolkit" differ on the number of "ward-based" community healthworkers South Africa needs to revitalise its primary healthcare system. The workers are called "ward-based" because they're expected to work in municipal or electoral wards as part of primary healthcare outreach teams: each ward will have at least one team of six community healthcare workers led by a professional nurse. 

According to the 2010 document, the country needs 41 440 community health workers, each of whom will serve 250 households (each household consists of average of four people). But the 2011 document's "training and orientation plan" calculates the need at only 33 000 workers, each to be responsible for 270 households. 

Health activists say both these numbers are far too low. "Given our very high burden of disease in South Africa, 250 to 270 households will mean that many members of households will go without care and may not even be able to be visited," says David Sanders from the People's Health Movement pressure group. "Acute illnesses, particularly among children, are quite likely to be missed, especially in rural areas, where homes are spread over vast areas."

What's more, says Prinitha Pillay from the Rural Health Advocacy project, "we don't know what '250 or 270' households means. Is it one visit a month to each household or one a year? We just don't know." In comparison, Brazil community healthworkers are each assigned 150 households and are expected to visit each home at least once a month. 

According to Pillay, "village health communicators" in Thailand are responsible for as few as eight to 15 homes. In KwaZulu-Natal, where "ward-based" community healthworkers have been working since the early 2000s as part of a separate provincial programme, each worker looks after only 60 households, according to Gcina Radebe from the local department's primary healthcare directorate. 

Another challenge is that South Africa does not have enough professional nurses to lead the 6 907 (according to the 2010 document) or 5 842 (according to the 2011 document) primary healthcare outreach teams. In KwaZulu-Natal a shortage of professional nurses has led to the department announcing that it would use staff nurses (with two years of training, rather than the four years of training required for professional nurses) as team leaders in the remote northern district of Umkhanyakude.

In the Western Cape, which does not follow the "ward-based" system, but funds nonprofit organisations to manage "home- and community-based care teams", a ratio of one professional nurse to 15 community healthworkers is used, according to the Western Cape Health MEC's spokesperson Helen Rossouw.

"The national norm of 1:6 is currently not affordable and none of the provinces have been able to put this norm in place. The Western Cape is planning towards a ratio of 1:10 for 2030," Rossouw says.


Mentor Mothers: Caring for the smallest children

For the past eight years, Nonqaba Melani (51) has been knocking on thousands of doors in Khayelitsha, Cape Town. “I never say no to any request for help. I am well known now and respected in the community. They know me and see what I do,” she says. 

During her visits she is armed with a backpack containing a scale, a measuring tape and growth charts on which she plots the weight and height of every child under six. 

Melani is called a Mentor Mother – a name for a community healthworker whose main focus is the health of mothers and children. She works for a nonprofit organisation, Philani, funded by the Western Cape health department to provide “home- and community-based services”. 

There are 120 Mentor Mothers in the province, serving 5 975 families.

Globally, research has shown that the work of community healthworkers can lead to significant drops in maternal and under-five mortality rates. 

Melani does about seven to eight home visits a day. If a child is malnourished, she will visit the mother at least once a week. As the child improves, she will talk to the mom every two to four weeks. 

The help she offers could be anything from advice on how and what to feed the child, guidance on hygiene and referrals to government clinics to assistance with applying for a child support grant. 

Melani has also been trained to deal with other conditions when necessary, such as taking care of bedridden patients who might live in the same house as young children. 

“Here in Khayelitsha we have many problems in the same house. There could be a malnourished child, tuberculosis, HIV and cancer in the same house,” says Nokwanele Mbewu, Philani’s senior programme manager. 

“That means we have to train our workers comprehensively, otherwise we will end up with a different worker visiting the family for each issue.” 

A 2013 study published in the medical journal Aids has shown that, in communities where Mentor Mothers work, HIV-infected mothers have babies with far healthier “height-for-age measurements” than those moms who don’t have access to Mentor Mothers. 

Such moms are also more likely to use treatment that can prevent their babies from contracting HIV during birth or breastfeeding. 

Both HIV-positive and -negative moms served by Mentor Mothers have been shown to be more likely to breastfeed exclusively for six months (research has shown that this practice has significant health benefits for babies) and they use condoms more consistently during sex.

Melani lives in the community that she serves and is responsible for about 500 households where she has to identify underweight children and make sure those requiring help get it.

The number of households she serves is double the suggested ratio of the national health department for its new “ward-based” community health worker programme, which would make each worker be responsible for 250 households.

Although health activists argue that 250 households a worker is far too many, Philani’s medical director Ingrid Le Roux says that it’s “unrealistic” in South Africa to expect anything less “as it will hugely impact on available budgets”. 

Melani received six weeks of training before she was appointed as a Mentor Mother. She earns about R1 500 a month and receives a monthly cellphone allowance of R30. 

She receives “hands-on” supervision. According to Le Roux, “every 36 Mentor Mothers are supervised by a co-ordinator in the form of a professional nurse”. The professional nurse oversees three assistant co-ordinators, who in turn supervise 10 to 12 Mentor Mothers. 

“No one supervises from the office. Our nursing sisters are out in the community every day and would work with one assistant co-ordinator and four community health workers a week,” Le Roux says. 

But, even though Mentor Mothers are supervised by professional nurses, which studies have shown is crucial to their success, a ratio of one nurse to 36 community health workers is six times that of the 1:6 as suggested by a 2011 “implementation toolkit” of the national health department. 

“That is a lot of support, I cannot see that we can have that system in this country,” Le Roux says. “We simply don’t have enough nurses for this. We need to find our own system.”

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community healthcareAaron MotsoalediNational Health DepartmentSection27Rural Doctors Association of South Africa