98 community care workers representing over 50 organisations with the Community Care Workers Forum, the Wellness Foundation and the People’s Health Movement of South Africa met to reaffirm the importance of community care workers in South Africa’s health system and to expose the terrible working conditions that many community care workers are experiencing.
On 25 May 2013 in a Public Health Forum in Cape Town, a community care worker (CCW) shared her story of how she contracted XDR TB while attending to a dying patient in a shack in Khayelitsha. Sharing her journey of illness, stigma, painful recovery and commitment to her duty of care speaks volumes about the plight of communitycare workers in South Africa. Thousands of these workers, the vast majority women, work in the homes of the poorest of the poor bringing basic wound care, TB and HIV treatment, empathy, care and rehabilitation to those in desperate need. CCWs often work without protective face masks, gloves and other basic materials. These heartbreaking stories of community care workers using plastic bags for gloves, homemade clothes for dressings, risking physical harm make a mockery of our health system, government and society.
It is well established internationally that community care workers are the foundation of successful primary health care systems. Research and experience from a growing number of countries show rapid improvements in child health when good household coverage is attained through the use of community-level workers who are supported by clinics and health centres and are equipped with basic skills to identify, prevent and treat common conditions.
The number of tasks a CCW can reasonably perform depends upon the ratio of CCWs to households, the duration and quality of their training, and the extent and quality of their supervision. In Thailand and Rwanda, a high CCW-to-household ratio ensures that all households, including the poorest with the most vulnerable children, are visited regularly and health problems are detected early. Such a high ratio of CCWs to households has been attained by having both full-time and part-time CCWs with ratios of 1:10 to 1:20. In Thailand, for example, high coverage is achieved by instituting a ‘two-tier’ system where there is one full-time CCW for every 300-500 households, who then supervises 10 part-time CCWs who have more limited training. Such high coverage of households has been shown to have a dramatic impact on health outcomes, especially of young children. The ratio currently proposed in South Africa of one CHW to 270 households is extremely unlikely to have such an effect given South Africa’s very high burden of disease, and the large percentage of people requiring time-consuming home care.
If South Africa were to adopt such a ‘two-tier’ approach this would require a total of at least 500, 000 community-based workers, the majority of them part-time. In addition to rendering health care more accessible and equitable, such a system would create jobs, and indirectly improve health by reducing the prevalence and depth of poverty.
In South Africa, there is currently no standardisedtraining or employment of community care workers. Despite this, thousands of community care workers are working in vulnerable communities helping to address the need caused by South Africa’s burden of disease and the failure of ourailing health system. We know that many CCWs work as volunteers, others for a stipend from NGO’s, a few through health departments. Where wages are paid, they range from R800 – R2000 per month. Payment is often erratic and dependent on the current budget of the employing organization, and most CCWs are employed through temporary annual contracts which may or may not be renewed. Because the work of community care workers is not formally recognized , they have no associated benefits and almost no occupation health and safety training. Yet as we have heard from this particular community care worker’s story, contracting communicable infections such as TB is a real and potentially life threatening problem.
In addition to the potential risk of contracting communicable diseases, community care workers are exposed to tremendous personal risk when conducting their work. Violent muggings, sexual assault andexposure to the domestic and community violence endemic to many South African communities is a reality for community care workers. They often walk from houseto house alone when they are called upon for help and have no protection and often little support from local health facilities.
The National Health Insurance Green Paper places Re-engineering of Primary Health Care at the heart of the plans for a new health system. Planned Community Outreach Teams will implement the primary health care policy, employing thousands of community health workers to cover all South African households. Given the centrality of this government policy, it is inexplicable that the current conditions of training and work of community care workers have not been improved. Community care workers are also specifically mentioned in the National Development Plan with proposed ratios to households of both full time and part time CCWs. The crisis of unemployment alone should be an impetus to formalise community care work into paid, formal, decent employment which could potentially create 500 000 new jobs for work that desperately needs to be done.
CCWsrepresent an important health resource with enormous potential for providing and extending key but simple health interventions to vulnerable and underserved populations as well as acting as advocates for their communities and helping them organise for improved social and environmental conditions. In a country with an enormous burden of disease, very poor health indicators, a crisis of unemployment and a plan to transform our health system into one based on the principles of primary health care, community care workers should be at the centre of our programmes and not at the periphery. The districts where the National Health Insurance is being piloted are an opportunity to explore how to integrate CCWs into the formal health system. Yet in most of these, there is no consultation of community care workers or involvement of community care workers in the pilot schemes. Most community care workers at this meeting lacked even basic information about the NHI.
It is our position that community care work should be decent work. CCWs need standardised training, appropriate health professions accreditation and a living wage. As for all workers in South Africa, community care workers should be protected by our labour and occupational health laws to ensure a safe and healthy work environment. Their work should be coordinated and supported by the Department of Health whose responsibility it should be toensure decent employment contracts and adequate distribution of equipment such as gloves and masks. The continued devaluing of the role of community care workers is a direct and real threat to the successful implementation of the NHI proposal and specifically the plan to re-engineer primary health care. We cannot build a healthy nation by exploiting and abusing our front line carers.
Apart from providing an essential health service through home based care, CCWs can play a central role in transforming the health of their communities as agents of change. This requires a shift in thinking about the meaning of community participation in health. Instead of being the lowest paid lackeys of a dysfunctional health system, they would be liberators, freeing people from the scourge of ill health.
In view of the above, the Community Care Workers Forum, the Wellness Foundation and the South Africa call on government, specifically the National Parliamentary Portfolio Committee on Health and the National Minister of Health to call an urgent consultation with community care workers and their organised structures to immediately redress the most blatant and dangerous employment practices they experience. This consultation must address the standardisation of appropriate training and accreditation, role and remuneration of these vital workers in our health system. In addition, there needs to be a broader discussion about how to facilitate full community participation to ensure health for allin South Africa.