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The ups and downs of community healthcare

Often medical help comes too late for people in rural areas but community health workers could change this.


There is a little bit of Latin hidden in many healthcare users’ government clinic cards: the letters, TCA PRN, or “To come again pro re nata

Pro re nata is Latin for “as the circumstance arises”. Most patients have no idea what the Latin means, but this opaque scribble is what predicates much of many peoples’ interactions with the healthcare system. The major problem is what “the circumstance” means to those concerned.

In an ideal world, “the circumstance” is when a woman plans to fall pregnant and wants to ensure the best chance for a safe, healthy pregnancy.

It is when a caregiver brings a child for their scheduled vaccinations and growth monitoring or for a skin test because an uncle who lives with them recently tested positive for tuberculosis (TB).Unfortunately, “the circumstance” in many tragic cases is when a once-healthy schoolteacher has finally been reduced to an emaciated shadow of her former self by HIV. It is when a homeless man, who has been unable to travel to his clinic for his TB medication, has begun to cough up blood.

It is when a starving child who has been living off flour mixed with water, instead of breast milk, is too weak to cry.

In public health, this is known as a “downstream” intervention. Because of enormous demands on the healthcare system, most energy is spent caring for those closest to dying. These cases require enormous efforts from trained healthcare professionals to avert death, and even this is not always possible.

But there are more and more places where “upstream” healthcare is being offered. A while back, I had the opportunity to get a glimpse of what healthcare and “the circumstance” may become if community health workers are deployed. In this particular case, upstream meant uphill (and downhill) in rural Eastern Cape.

A few dozen metres from Zithulele Hospital, a provincial government hospital near Mqanduli, stands a small cluster of buildings. They’re all freshly painted and at odds with their informal surroundings and bent-wire fences.

A preschool on the left stands out with its mural of happy, doe-eyed creatures, smiling out into the morning. This is Philani, home of the  Mentor Mothers programme. My host, Ncedisa Paul, turns from a whiteboard and greets me.

Philani is one of the many nongovernmental organisations in South Africa that runs a community health worker programme. Most of South Africa’s estimated 72 000 community health workers are employed by NGOs, according to the Centre for Health Policy at the University of the Witwatersrand.

Philani’s head office is in Cape Town, Paul explains. In the villages surrounding Zithulele Hospital, Philani focuses on mothers, children under six, orphans and vulnerable children.

The organisation trains mothers to become community healthcare workers. In the community, these women help to educate others on issues such as child health and HIV.

After every group of mothers complete training, Philani representatives speak to the local chiefs to ensure that the women are allowed into the community and that their work is understood and embraced.

The work is challenging. “People do not want to [take their children] for immunisations,” says Paul. “Clinics are too far away and when they are told that there is no stock, they do not want to go again tomorrow.

“People will go from clinic to clinic, trying to hear that they’re not HIV positive — because they don’t want to accept that,” she continues.

In the next room Paul shows me the Mentor Mothers training manual. It is a detailed tome that all trainees systematically work through. This reflects a larger area of uncertainty concerning community health workers: What is and what should be their scope of practice? Many feel that they should engage with health in its broadest sense but numerous organisations have opted for a specialised approach for efficiency.

The result is that community health workers are trained in different ways and the curricula span from a few weeks to a few years. It has resulted in unco-ordinated efforts with varying levels of effectiveness.

Mentor Mothers has a functional referral system. Patients are referred to clinics or the hospital for further investigation of a wide array of complaints. The organisation’s community health workers are also trained to use a system known as IMCI, or Integrated Management for Childhood Illnesses, which allows people with little training to effectively detect many serious ailments in children.

I join a young woman who has been assigned as a mentor mother to a large number of nearby families. Nwabisa Mnqanqeni, a mother of three, has agreed to take me along on her day’s home visits.

A community health worker survey, quoted in a 2007 health department document, found that most health workers were women without employment or a matric qualification.

Community health worker programmes often provide some of the few employment and training opportunities in poor communities. Mnqanqeni was identified and recruited into the programme. She now receives a small monthly sum. Depending on the organisation that employs a healthcare worker, this monthly pay can be called a salary, stipend or incentive.

Like most community health workers, we stride into the cool morning air on foot, climbing hill after hill. Mnqanqeni carries an orange backpack filled with a bathroom scale, some books and a record of all the individuals assigned to her stewardship.

We stop at a blue rondavel. “Nqonqo,” says Mnqanqeni, and we enter. The room is filled with activity. There are six children, three adults and eight chickens. The children wander around, warily staring at the intruders.

“Here is a pregnant woman and a child who is not growing well,” explains Mnqanqeni. We page through their clinic cards. The 18-month-old is gaining weight, but only just — a fact only discernible by using a growth chart. This could be a sign of inadequate nutrition or of a hidden problem sapping the child’s energy. A referral letter is quickly penned and a plan to follow up is made.

The expectant mother climbs on to the scale. She’s been losing weight, but is otherwise well. Mnqanqeni is not too alarmed because the woman was recently seen at the clinic and she has made a note for her to go again during the week.

Mnqanqeni completes her notes and makes a mark in her ledger. She surveys the room again, checking that everyone in the house has been tended to recently.

Inside the next house, a rectangular, unplastered brick building, three children stand washing themselves in a sun-bleached, pink basin. A solitary bed in the corner is being used as a couch during the day. The boy is suspicious of the bathroom scale we assembled on the floor, nervously clutching his mother behind him.

Mnqanqeni weighs him, checks his vaccinations and makes some notes in her book. She and the mother agree that he should visit the clinic as soon as possible.

We move on to the next home, further down the hill. Two curious, yet aggressive dogs guard the perimeter and encircle our small posse, emitting low growls. Mnqanqeni nervously tucks her hands into her sleeves and I am not sure how ready I should be to give a kick or a shout. Luckily the dogs’ owner is at hand and they slink off.

We enter this home and the same routine ensues: the mother drags a howling tot on to the scale. She is weighed and found wanting. She has lost weight. A family member has just been diagnosed with TB. Mnqanqeni writes a note to the local clinic.

The exposure of community health workers to TB and other occupational health risks has generated much controversy: Are these workers protected and guaranteed compensation by the legal system or are they to fend for themselves when they make the transition to patient as a result of their work? There is no conclusive answer.

There is much uncertainty on what direction community health worker programmes will take but the University of the Western Cape’s Uta Lehmann and David Sanders concluded, writing for the World Health Organisation in 2007, that “particularly in poor countries, community health worker programmes are not cheap or easy, but remain a good investment, since the alternative in reality is no care at all for the poor living in geographically peripheral areas”.

Towards the end of the afternoon, we begin to make our way back to the Philani house, with the day’s work completed.

From any vantage near the hospital, facing the east, one can see the ocean underlining the horizon. Green-brown hills dotted with rondavels and smallholdings, many animated by the amblings of people and animals, fill the remainder of the vista.

Knowing that community health workers are steadily combing this landscape, with the potential to radically alter the meaning of the little bit of Latin we use to invite people to our clinics and hospitals, we may see pro re nata acquiring an increasingly upstream meaning.

One sincerely hopes the prescription chart for all South Africans, especially those in rural areas, may one day read: “One community health worker visit, as frequently as necessary.”

Koot Kotze is a medical intern at an Eastern Cape hospital. Parts of this article are based on his experiences during a late 2014 visit to Philani Hospital. He writes a monthly column for Bhekisisa.

Koot Kotze is a medical doctor and researcher from South Africa, currently based at the Department of Primary Care Health Sciences at the University of Oxford.