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‘They fail us, year in and year out’: Why community health workers are ditching unions

  • Community health workers in South Africa say they’re disillusioned with trade unions in the country. 
  • Barring those who work in Gauteng, most of these health workers earn about R4 000 a month, but have no benefits such as pension or medical aid.
  • A 2018 agreement about CHW contracts has been extended until 2025. Workers say that unions and the health department are simply pushing back their dreams of ever becoming insourced employees.

Community health workers (CHWs) say they’ve “lost all faith” in trade unions as their fight for contracts that include pension and medical aid benefits nears a decade. 

Gauteng is the only province where these health workers get the same protection as other permanently employed government staff, such as nurses. In 2020, CHWs in Gauteng were classified as level two public servants, so they’re eligible for pension and medical aid benefits and they earn between R9 000 and R11 000.

Elsewhere in the country, CHWs have one-year contracts with the provincial health departments or they work for (and are paid by) nonprofits who have deals with the state. As there’s no limit to how many times the contract can get renewed, these workers often stay in their roles for years on end. But at age 60 they have to stop — and then leave without any compensation for their long service. 

CHWs get a payout of about R4 000 a month, as part of a 2022 agreement struck between three unions and the government’s bargaining council for the health and social development sectors, which was set up to help broker deals or resolve disputes between workers (or their unions) and the state. The 2022 deal is the third extension of one that was first set out in 2018.  

Margaret Gale Mookroof, 41, a CHW with 16 years of experience, says many of her colleagues have left their unions. Though these bodies had managed, for example, to change the workers’ status from volunteers to formal employees in KwaZulu-Natal in 2014 and helped to cement the original 2018 deal, many of these workers feel disillusioned by the agreement having been extended yet again, to 2025, rather than unions fighting for their services to be insourced by the government. Being recognised as permanent employees — with a pension and medical aid — will help to give them financial stability, they say. 

Mookroof says: “They’re failing us, year in and year out.”

Johannes Dyasi,* 57, agrees. In the Northern Cape, where he works, unions only pay attention to the CHWs when it suits them he says — like when they need to bolster numbers in protests for the issues of permanent health staff. 

In South Africa, trade unions have historically been a powerful ally for labourers, fighting for more than just workers’ rights. However, despite over 13-million workers still being registered as union members in the country, researchers have found that many perceive the organisations’ leadership to be corrupt and out of touch with what their people want. 

Dyasi agrees, saying that CHWs in particular get no benefit from membership and that there’s been no change to their employment conditions in years. 

“We don’t have activists anymore, only betrayers taking advantage of vulnerable workers to reach the top.”

Unions’ point of view

But union bosses don’t agree.

CHWs normally belong to one of four labour organisations (or their affiliates): The National Education, Health and Allied Workers Union (Nehawu); The Public Servants Association of South Africa (PSA); The Health and Other Services Personnel Trade Union of South Africa (Hospersa); or the National Union of Public Service and Allied Workers (Nupsaw). 

According to Solly Malema, Nupsaw general secretary, Nupsaw was “instrumental” in the 2014 deal that got the KwaZulu-Natal health department to recognise CHWs as contract employees, who are eligible for standard benefits, instead of volunteers

That case, he says, set the groundwork for getting CHWs registered on the government’s salary system instead of their being employed by NGOs, and so strengthened their negotiation power to get the 2018 collective agreement signed. 

Malema says they will continue to fight in the Western Cape, where community workers are still employed by NGOs, because ”they’re behaving like a federal state”.

Asked about Nupsaw’s rejection of a proposed investigation by the labour department into the wages and employment conditions of CHWs, Malema explains that having a set minimum wage for CHWs will block any chance of their becoming insourced.

He continues: “CHWs are public servants, and they must enjoy all the same benefits as public servants [like in Gauteng]. That’s the route we want to go, not this minimum wage process.”

More work for little pay

In countries like South Africa, which has a serious lack of doctors and nurses, CHWs help carry the load through “task shifting”, which means they take on some of the easier but time-consuming jobs of professional health workers (such as following up on HIV or tuberculosis patients to make sure they take their medication correctly).

South Africa has just over 54 000 CHWs and, ideally, each one should be able to reach 150–250 households per year, depending on the area they serve.  

Despite an already high workload, their list of duties has expanded since 2011, when the health department planned for CHWs to look after people’s primary healthcare needs throughout their lives — from antenatal to palliative care and everything in between, such as preventing lifestyle diseases, for example diabetes, and helping people to recover from strokes or heart attacks. Contributing to community support groups, wellness programmes and activities at early childhood development centres are also part of their job

South Africa’s planned National Health Insurance (NHI) scheme will rely heavily on well-trained CHW teams to deliver primary healthcare services. 

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Through the NHI, the government will attempt to give all South Africans and documented immigrants and refugees access to the same basic health services for free. 

The NHI Bill is currently being considered by the National Assembly. 

But while CHWs are written into the future of South Africa’s health system, the workers themselves don’t have much to look forward to. 

Mercy Ngwenya,* 55, for example, will have to retire from her job in five years’ time. CHWs can only work for the state until the month of their 60th birthday, says Tebogo Lekgethwane, the North West health department spokesperson.

She’s been a CHW in the Western Cape for more than two decades, yet she’s never held a position with any benefits. Ngwenya worries about what her life will be like then, since her time as a public servant is running out.

“When I retire, I will have nothing,” she says. 

In the Northern Cape, Dyasi hopes the government’s old-age grant (which pays out at most R1 980 a month) will be enough to support him and his family.  

“There’s no dignified tomorrow.”

A future unsure

There is no talk of employing CHWs permanently in the Western Cape until the national health department comes up with a plan that outlines CHWs’ responsibilities and pay, says Mark van der Heever, a spokesperson for the province’s health department. 

In October 2022, the national health department received extra funds to spend on personnel after the taxman collected more money than expected. 

However, Finance Minister Enoch Godongwana warned that a lot of the state’s extra spending would depend on the outcome of a fight over the public sector wage bill. 

Unions’ demands for a 10% wage increase were rejected and the government instead agreed to a 3% increase and a monthly allowance of between R458 and R1 695, depending on an employee’s salary level, which will run until the end of March

In the North West, Joyce Maseko,* 37, doesn’t think anything will change by the time she retires. “They’ll just give [us] forms to claim money from the UIF [Unemployment Insurance Fund].”

In her province, the health department isn’t planning to insource CHWs either, because “provinces have been told not to make any changes to how they’re employing CHWs [until the National Health Council decides on it], according to Lekgethwane. 

For the moment, the national health department is treading water, saying they’re waiting for the outcome of their labour colleagues’ proposed look into CHWs’ employment conditions

And in the meantime, most CHWs will just keep doing their jobs — at great personal risk. 

Says Dyasi: “Many of our colleagues died during the COVID pandemic, but to those at the top, it’s just like a fly dropped dead. But we are the foot soldiers. We are the ones sent out to the streets and houses, not knowing what danger lies ahead.”

*Three of the four CHWs Bhekisisa spoke to for this article requested anonymity out of fear that they would lose their jobs. Their identities are known to the Centre.

Nicole Ludolph is a health journalist at Bhekisisa.