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The National Health Insurance (NHI), for which membership will be compulsory, is a funding scheme that aims to address healthcare inequity in South Africa. The scheme will do this by creating a fund that the government will use to buy healthcare services at set fees from accredited public and private health providers. The NHI Act was signed into law on 15 May 2024 but before it will come into effect, Parliament will need to enact further legislation (including ones providing for its funding).

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Community health workers – could COVID finally unlock their role in the NHI?

In the absence of action from the health department, South Africa’s community health workers are once again having to fight for their rights.

The COVID-19 pandemic has helped 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 that pay them stipends or working under temporary provincial health department contracts. 

Reports of CHWs 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 their 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,” explains Lungiswa Tsolekile, a senior lecturer at the University of the Western Cape’s school of public health. 

In countries like South Africa that have a serious lack of doctors and nurses, CHWs 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 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. 

CHWs 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 CHWs were sent into communities to hand out educational materials, screen people for COVID-19 and trace the contacts of those people who tested positive for the new coronavirus, SARS-CoV-2. 

Nehawu’s 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 CHWs during the pandemic hasn’t catalyzed 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, Section27. 

“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 healthcare-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 South Africa’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, or CUPs, that will consist of public clinics and community health centres in an area, should be created. The CUPs will be linked to teams of community healthcare workers, which will consist of 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 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,” explains  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 CHW system has been plagued by problems for years. Research published in 2013 showed the country’s CHWs had almost no positive impact 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 2-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.

Is the CHW programme working better than before?  

A 2013 study in the journal Health Policy and Planning found that South Africa’s community health worker programme had no impact on issues such as maternal and child health between 1994 and 2013. 

The bad results are largely attributed to inconsistent training, a lack of recognition from the health system and the fact that most workers were trained only to help with specific health issues relating to HIV and TB. 

But those gaps were supposed to be filled when South Africa adopted a ward-based primary healthcare outreach team strategy in 2011 and a policy framework which sets out how to train community healthcare workers in 2017. 

Under these policies, workers would now be trained to be generalists, who look out for people’s health throughout their life, explains Bob Mash, head of the department of family and emergency medicine at Stellenbosch University.

That includes everything from palliative care to disease prevention, for example advocating that people exercise healthy food choices, helping patients recover from strokes or attend antenatal care. Contributions to community support groups, wellness programmes and activities at early childhood development centres are also part of their expanded role. 

Implementation has, however, been “slow and uneven, and coverage is still relatively low”, write authors for the 2018 South African Health Review.

As a result, it’s not clear that South Africa’s community health worker project is doing any better than before, says Emanuelle Daviaud, a health economist at the South African Medical Research Council (SAMRC).

In 2016, researchers observed six community health worker teams (consisting of six workers each) across three different sites of Gauteng’s Sedibeng health district for a year. They wanted to evaluate how effective their work was, so they conducted surveys of community members’ experiences of CHWs, focus group discussions with the workers and interviews with facility managers and supervisors. The research was published in the British Medical Journal in August. 

Their findings? CHWs visited only 17% of 150 to 250 households they were mandated to oversee. This amounted to one or two households per day. Moreover, the households the workers did visit, didn’t see much benefit. 

Workers asked community members only half of the questions they were supposed to and people only remembered about a quarter of the health messages that the CHWs conveyed. More crucially, only half of the community members surveyed took the community health workers’ advice— many people simply didn’t take the CHWs seriously. 

The problem, as previous research has confirmed, is supportive supervision, Daviaud says. 

Community health worker teams supervised by professional nurses fared far better than those headed by enrolled nurses. In South Africa, professional nurses study for four years and can diagnose patients and prescribe certain treatments, while enrolled nurses train for two years and provide nursing care under supervision, explains Daviaud. 

In one striking example, Daviuad says, community health workers went on strike, leaving the supervisors to go out into people’s houses — as a result, referral rates to the clinic shot up. 

She says because South Africa has so few professional nurses, enrolled nurses were pulled in to help with the supervision of CHWs. Enrolled nurses should be able to fill these gaps: “It could be that the community health workers need more training or that the supervisors don’t go out with their teams enough.

“If I were in charge of the country’s CHW project,” Daviaud concludes, “I’d focus on the training of supervisors.”

Will the supervision lessons we’ve learned from COVID unlock community health workers’ NHI power? 

When the coronavirus outbreak took hold in South Africa in March, community health workers’ jobs had to change. Usually, workers would go into the households they look after to monitor who’s living there, whether anybody is pregnant and needs antenatal care or to screen people for symptoms of tuberculosis (TB), for example.

But that stopped with COVID-19, when CHWs’ attention was switched to handing out educational documents about the novel coronavirus and conducting COVID-19 screening, contact tracing and test referrals, explains Uta Lehmann, director of the school of public health at the University of the Western Cape (UWC).

Although CHWs’ work was touted by senior politicians as a key part of South Africa’s COVID-19 response, some experts argue it’s doubtful a programme that has been struggling for so many years could have had a significant impact during the pandemic. 

But the health department’s Lindiwe Hlongwa-Madikizela disagrees. She says the benefits of well trained and competent CHWs, coupled with good supervision, was showcased during the early months of the country’s COVID outbreak.

The difference was that every team of community health workers now had a professional or enrolled nurse as a team leader, including those who previously did not have one — in the same way that the NHI Bill requires teams to be constructed. The nurses were assigned to go with CHWs into communities to screen and, where necessary, collect samples for SARS-CoV-2 tests. People were therefore getting services in the comfort of their homes or communities.  

Ian Sanne, the CEO of the nonprofit, Right To Care, helped to co-ordinate community health workers during COVID-19. The workers were employed by nonprofits funded by the President’s Emergency Plan for Aids Relief, Pepfar and the United States Agency for International Development (Usaid).

The project worked with 12 000 CHWs employed by nonprofits and another 20 000 employed by provincial health departments. 

“We scrambled to put in place a door-to-door screening programme which was successful in reaching large numbers of households,” he says. With the data CHWs collected, it was possible to get a clearer view of what case numbers were, since they identified as yet undiagnosed cases of COVID-19.”

COVID showed us the benefits of using community health workers to deliver medication to patients’ homes 

In the Western Cape, CHWs were given the task of delivering patients’ chronic medication to people’s homes during COVID — medication for which they would normally queue at pharmacies and clinics. This service was running on a small scale before lockdown for people who couldn’t attend support clubs for chronic conditions. In March, it was scaled up to the whole of Cape Town, according to Lungiswa Tsolekile, a senior lecturer at the University of the Western Cape’s school of public health. 

The school’s head, Uta Lehmann, says the provincial health department project — which is implemented by nonprofits — may have helped boost respect for community health workers in the community and mended some of fraught relationships between facilities and the nonprofits which employ workers in the province. Lehmann interviewed five nonprofits about their experience of the pandemic. 

Delivering chronic medication is a task community health workers have said they’re up for for ages, but facilities and pharmacists have been resistant, arguing that this job should be done by trained, skilled health workers. 

Community health workers act as links between clinics and communities and receive on-the-job training, but they usually have no clinical qualifications — the educational requirement to become such a worker varies between provinces but the Policy Framework and and Strategy for Ward-Based Primary Healthcare Outreach Teams stipulates prospective CHWs should have a matric certificate. 

In the Western Cape there are no particular requirements, although workers are expected to have training in home-based care, Tsolekile says. 

Pharmacists argue that when chemists dispense medicine to patients, they also have a responsibility to find out how they’re feeling and to educate people about how to take the drugs, and that community health workers aren’t qualified to interpret such feedback. 

But COVID provided a way around such arguments, Lehmann explains: “Suddenly [using community health workers to deliver medicine] was possible because we needed to keep old and sick people out of facilities to limit their exposure to the virus.” 

But Tsolekile says community health workers are currently only delivering packages to people. 

The packages are sealed and each comes with a label listing the medication inside so there’s little need to worry, says Daviaud. What’s more, the patients who qualify for this service are stable and already know how to take their medications. 

Workers delivered about 10 packs of medication a day and ended up visiting far more households than they usually would. And all the extra work paid off, Lehmann says. “It improved the relationship between community health workers and the community itself. Very importantly, it improved the relationship between the nonprofits, community healthcare workers and facilities.”

‘We are suffering’:  Western Cape CHWs fight for better pay

Community health workers in the Western Cape are not employed by the provincial health department. Instead, nonprofits receive funding from the  health department to deliver and report on a set package of services that CHWs need to deliver, which can include home visits, referrals for antenatal care and support for TB patients. Since they’re not employed directly by the government, the workers don’t get any of the benefits other government health workers have, such as medical aid or pension, Tsolekile explains.  

This arrangement saves the province money because the government doesn’t need to pay for benefits. Also, since nonprofits only pay CHWs stipends, they can recruit more staff with the funding they receive, a 2017 Stellenbosch University master’s thesis by Jonathan Lucas, found.  The thesis reveals that the closest comparable public servant to a community health worker — a health promoter — makes about double what outsourced CHWs do in a year excluding benefits.  

CHWs in the province will down their tools for a week from 9 November accompanied by the Treatment Action Campaign (TAC), says Simo Sithandathu, provincial manager for the TAC in the Western Cape.

Among their demands are better pay and better safety, explains Sithandathu. The department has promised to organise security for workers, who say they are vulnerable to muggings and attacks while they work.

But the provincial health department spokesperson, Mark van der Heever, says security is part of the service level agreements the department signs with nonprofits and that CHWs should consult their supervisors for assistance with security.  

Van der Heever says the province has no plans to stop outsourcing community health worker services to nonprofits. 

But Lucas argues that a funding model, where all CHWs are outsourced to nonprofits, may not be sustainable from a legal point of view. Under the Labour Relations Amendment Act, outsourced employees who earn under a certain threshold and have worked for the contractor for more than three months are considered to be employees of the employer who is outsourcing the service, in this case the health department. 

Moreover, the South African Labour Court previously ruled in favour of community health workers based on the Act in a Gauteng case in which a similar type of outsourcing to the Western Cape’s model was disputed. 

In June, the Gauteng health department announced that the province’s 8 500 community health workers would be made level two public servants, which means they would be paid about R8 500 per month and receive benefits, including pension and medical aid, according to salary scales from the department of public service and administration. But, according to a statement by acting Health MEC Jacob Mamobolo, this process had not yet been finalised by the end of September. 

Since the CHWs were integrated into the health department’s system in Gauteng, things have been much easier, says Zoleka Mbotshelwa, former chair of the Gauteng Community Health Care Forum, and she’s experienced more respect from community members and other health workers. 

She says: “People now treat me like I’m a nurse.”

It’s a double-edged sword, Lucas writes, since the Western Cape cannot afford to pay for benefits for all the CHWs and only taking in a few will leave coverage gaps for large parts of the province. Most managers interviewed for the research agreed that the province must nonetheless move to be compliant with the Amendment Act. 

And, argues Daviaud, a well funded CHW programme in some areas may be better than a “spreading the jam thin” and running an underfunded project. 

But Van der Heever says the payment of CHWs in the province is in line with the Public Health and Social Development Sectoral Bargaining Council (PHSDSBC) 2018 resolution which stipulates workers should be paid R 3 500 per month but the document doesn’t mention benefits. 

Will anything change for community health workers? 

The policies and research to back a well-functioning community health worker platform are already there, but what’s always been missing is a champion in the national health department, says Helen Schneider, a health systems and policy researcher at the University of the Western Cape’s department of public health. 

The newfound recognition for community health workers could be an opportunity to valorise the country’s community health worker project, especially since community health workers are “tied up with South Africa’s NHI future”, she argues. The ward-based teams will form the basis of healthcare under the scheme. 

But it will take more than just the respect community healthcare workers have earned during the COVID-19 pandemic, Schneider says. 

What is needed is support from the health department to roll out the plans that have already been drawn up, Schneider says, as well as a “substantial” investment in primary healthcare systems and adequate supervision and support around them.  

“Community health workers need to be integrated into the health system – that means they need employment status benefits and better payment. While many people have said CHWs are the future of healthcare in South Africa, it’s unclear to me how these questions are going to be resolved.”

Years of inaction means the health department must now also contend with the bottom-up pressure from CHWs themselves in the form of a looming strike, Schneider explains.  

Not far from Scheider’s office in Bellville in the Western Cape, Cynthia Tikwayo, a Western Cape community health worker, is at home, preparing to go out into the community to work. 

“Although employing CHWs through nonprofits works for the government, it does very little for community health workers themselves,” she says. And since COVID-19, CHWs have more on their plates, but their pay hasn’t increased.  

“I was lying in my house with COVID-19. Nobody cared. All [the department and the nonprofits] want is their stats.”

Workers in the Western Cape have been stuck in a never-ending loop when they attempt to negotiate better pay and benefits, Tikwayo says. “We try to call a meeting with the nongovernmental organisations (NGOS) but they never came to us. When we go to the health department, they say they pay the NGOs.

Tikwayo says she and her colleagues have been waiting for three years for a visit from the Western Cape Health MEC, Nomafrench Mbombo, to discuss their options.

Van der Heever, however, points out that community health workers didn’t indicate that they still want to meet with Mbombo in their latest memorandum of demands.  

But Tikwayo maintains: “Nomafrench Mbombo you promised to come and visit us. But you never came.”

Joan van Dyk was a health journalist, senior health journalist and news editor at Bhekisisa between 2017 and 2023.