In this article Bongani Bunyonyo* highlights the problems facing community health workers, also known as home based care workers.
Community health Workers in South africa
Though there are no officially confirmed statistics, it is estimated that there could be anything upward of 500 000 community health workers active in the South African health care sector. Community Health Workers are regarded as volunteers, and the payment they receive is called a stipend as opposed to a wage. Many are expected to report for duty regularly, and are subject to discilplinary procedures. Since they are regarded as volunteers, it is taken for granted by government, NGOs and community based organisations that they are not covered by labour legislation like the Basic Conditions of Employment Act. They deny that these workers are covered by labour laws, hence they refer to them as volunteers and not employees.
Experiences of Community health Workers
There is a perception among Community Health Workers, the majority of whom are women, that their contribution fundamentally lacks recognition in the eyes of health care authorities, other health care workers and communities. They regard themselves as an undervalued, flexible and exploited labour force without labour rights or benefits.
Some of the problems experienced by community health workers are:
- Low levels of pay, ranging from R500 to R1500 per month
- Sometimes workers are not paid for months, referred to as Dry Season
- Workers using their own funds to purchase food for patients
- The mainly women workers are exposed to risks such as rape and robbery because of the high crime levels in the townships and informal set- tlements in which they work
- No provision of protective clothing like gloves, masks, etc. This leads to exposure to illnesses of their patients
- Lack of provision of uniforms
- Absence of career paths and employment oppor- tunities in clinics where they work
- Lack of provision of accredited training
- Lack of counselling and support services to help the workers cope with the demands of their work
The real employer is widely perceived to be the government. The NGOs and CBOs employing them are regarded as insignificant players who are merely a conduit for payment of stipends. Community Health Workers report to and are accountable to clinic staff. Professional nurses in the clinics exercise considerable control over the activities of CHWs, their working hours and degree of integration or marginalization in facility teams.
Professional nurses also work to demarcate and maintain their territory as professionals. They resist suggestions that CHWs should wear uniform. They see this as interference in their professional career, and do not want to be put on a par with CHWs. Though at times they are supportive of the work of CHWs, the nurses are at the same time very protective of their careers. They also closely monitor how the community relates to the CHWs. They even take offence when community members visit a clinic and refer to CHWs as nurse or sister.
Origins of Community health Workers
The concept of Community Health Workers is not a new phenomenon. It has evolved over a number of decades as an attempt to provide adequate health services in different countries. Community Health Workers were promoted and became part of many developing health systems globally. The concept of CHWs has been experimented with in different contexts. There is therefore a range of variations internationally in the types of Community Health Workers and the forms of service they provide.
In South Africa, CHWs have been in existence since the 1970s. Initially, these programmes were of a generalised nature. Over time, there was a shift to more specific programmes. Many of the programmes were shifted towards Maternity Child Care, or disease intervention,such as for TB and malaria treatment.
Neo-liberalism and volunteerism
The ANC, after the 1994 elections, identified CHWs as critical in the implementation of primary health care, the corner stone of its health care policy. This fitted in perfectly with its neo-liberal GEAR policy. Like all other neo-liberal policies, the GEAR was designed to facilitate the greater flow of wealth from the poor to the wealthy. One way in which governments do this is to cut the amount of money it spends on social services to the working class. In this way it is better able to cut taxes to the wealthy and subsidise the profits of the rich in a range of other ways. The introduction of GEAR policies on health, as part of the broader macro economic policy of the government, resulted in fundamental restructuring of the health service. The effects of GEAR in the health sector resulted in the closure of hospitals, understaffing, inadequate expenditure on equipment, closure of some nursing colleges and promotion of private health care. The state shifted the responsibility of providing primary heath care to NGOs and onto the communities directly, including the phenomenon of volunteer CHWs and home based care workers. Most community members rely on government clinics and hospitals to access basic health care. They cannot afford private health provision. They constitute the majority and rely on the government to provide basic health care. This is a mirror image of how the state has shifted some of its other responsibilities such as cleaning the townships onto local communities, also through the volunteerism model. The rapid expansion in the HIV/Aids funding also made a significant impact on the large scale deployment of CHWs. Community Health Workers in South Africa emerged as part of the broader government response to the HIV/Aids epidemic. The government sees home and community based care as an integral part of caring for people with HIV/Aids and other chronic illnesses. Volunteerism in the health sector influenced the discourse on community caregivers and at the same time provided a model for organising volunteers emerging in other sectors. The state brought all volunteers in different sectors under the Expanded Public Works Programmes (EPWP) in 2003.
The EPWP is part of the state strategy to alleviate poverty and create jobs. The evolution of CHWs became an integral part of the general economic and social platforms of the government. The government does not provide this service, but funds NGOs and CBOs to provide home and community care. The programmes are also funded by international donors for NGOs and CBOs to conduct home and community health care activities for communities. The programme heavily relies on Community Health Workers who perform the function of providing primary health care to communities. Community Health Workers are predominently female, with few protections and benefits, yet they are extremely vulnerable and highly exploited.
Attempts at Organising
Community Health Workers have started organising themselves. The workers in the clinics in Thembisa, Ivory Park, Kathorus, Braam Fischer approached the General Industries Workers Union of South Africa (GIWUSA) to assist them in organising. The caregivers wanted the union to assist them in dealing with problems they are encountering when performing their duties. The workers in Alexander township have subsequently also expressed interest in the organising initiative. Khanya College has also been assisting with the organising effort. There is some uneveness amongst the workers. Most of the workers are young and do not have organisational experience. Also, because of the nature of their work, it is very difficult to have meetings where all the workers are available in a particular facility. They report for work in the morning and leave after 10h00 to visit their patients.
Some workers do not want to associate themselves with any organising initiatives. They fear victimisation by their project managers. The challenge in organising these workers is that although they are based in one facility, they are employed by different NGOs or CBOs. Their working conditions differ, depending on the NGOs or CBOs that employ them. This encourages a situation where workers focus on their own NGO or CBO, making them more inward looking. While the efforts by the CHWs to organise is new, this narrow consciousness among many of them has to be broken if significant inroads in organising these workers are to be made. The organisers have to maintain a good relationship with the managers of NGOs and CBOs so that they can have access to the workers before they visit their patients in the mornings. From experience, it is difficult to have general meetings on weekends since this is the only time the CHWs have for their own household responsibilities, given that the vast majority of the workers are women.
It is also difficult to organise meetings after work. Health workers are not staying in the same place and travelling in the evening exposes them to the possibility of rape, robbery, etc. It was mentioned earlier that the majority of these workers are women, and are extremely vulnerable in the crime ridden townships and informal settlements. These are the areas where their patients live. The security of health workers is not guaranteed even during the day when they visit patients. The challenges are to examine more closely the nature of community health workers, their working conditions, how restructuring in the health sector is unfolding and what the implications are for the future of community health work. Also, locating community health workers within the broader state volunteerism strategy will assist in developing organising strategies that are appropriate for these workers. These organising strategies could hold important lessons for organising other volunteers, such as patrollers and cleaners.