we are serious about Universal Health Care, we need to match the commitment
shown by community health workers (CHWs). Not only must their contribution to
the pandemic response be adequately recognised, but CHWs deserve a say in health
policymaking and implementation that affects them, the authors argue.
In July 2020, Community Health Workers
(CHWs) staged a protest outside the offices of the Eastern Cape Health
Department in Bhisho, calling for their enlistment as full-time employees in the
Department of Health. Subsequently, the Eastern Cape MEC for Health, Sindiswa
Gomba, stated that the full-time employment of CHWs was ‘not a straightforward
issue for the province’.
CHWs asking for representation on the Nelson Mandela
Health forum, which serves as one of the oversight bodies for primary
healthcare in Bhisho, were told that they could not be included because they
were employed to assist the province with its Covid-19 response.
The irony of
exclusion based on their temporary employment, while there is ongoing active
debate at the national level about their permanent employment, was not lost on
these CHWs desperately seeking to add their voices to discussions on policy and
Noluthando Mhlongo, a CHW from KwaZulu-Natal who is
among some CHWs that work with the C-19 people’s coalition asked, “How can we
be relied on to screen and test communities for Covid-19, yet not be allowed to
share our perspectives from the frontline at health forums?” TB Proof is also a
member of the C-19 coalition.
For the health of approximately 300 000 South Africans living outside of a two-hour
range of a public hospital, CHWs provide an essential service. Employing CHWs
drastically expands a country’s healthcare workforce, making healthcare more
accessible. Furthermore, CHW employment increases vaccination
uptake, improves tuberculosis (TB) outcomes and decreases child morbidity and
CHWs play a critical role in the government’s response
to the Covid-19 crisis in South Africa.
To contain the virus, South Africa’s
National Health Department has employed large-scale screening, testing and
tracing using clinics, community healthcare centers and mobile testing units.
All these strategies rely on CHWs.
Chair of the Ministerial Advisory Group on Covid-19, Prof.
Salim Abdool Karim, described CHWs as South Africa’s
‘secret weapon against COVID-19’. Yet, CHWs’ requests for
consultation on their scope of work, remuneration and protective equipment
remain unanswered despite multiple advocacy letters addressed to the Minister of
Health, Dr Zweli Mkhize, demonstrating government’s lack of political
commitment to support CHWs.
In an April 2020 statement, the Health Minster promised
that healthcare workers would be deployed with “appropriate personal protective
equipment”. However, this has not always transpired.
CHWs face unacceptably dangerous working conditions
that put them at risk of COVID-19 and lack the basic employment conditions for
them to be provided with compensation should they fall ill.
Early data from the
pandemic shows that there has been a steep increase in
Covid-19 infections among health workers across the African continent. Data from
India suggests that the use of face shields in addition to surgical masks, hand
sanitiser, gloves and shoe covers, can reduce the risk of COVID-19 infections
in CHWs. Yet, no guidelines have been published advising recommended personal
protective equipment (PPE) for CHWs. Although the increased risk of TB in CHWs
has long been documented, there is a specific lack of consensus about their
need for N95 respirators, despite being expected to take the risk of obtaining
sputum cultures from people who may have TB, in addition to providing Covid-19
“When it comes to N95 respirators, we are unprotected,”
said Boniwe Plaatjie, a CHW from the Northern Cape. This has dangerous
consequences for CHWs who are risking their lives to care for underserved
communities. Furthermore, failure to prepare and protect CHWs shows a flagrant
and unacceptable disregard for the lives of those on the front-line, and it
undermines the importance of the public health messages they are tasked to
Despite their integral role in South Africa’s health
system, there is a long history of CHWs being denied access to contribute to
discussions that determine the scope and payment of their work. For instance,
the Ward Based Primary Healthcare Outreach Teams (WPHCOT) policy (initially
drafted in 2011 and finally released in 2018) was developed to facilitate the
provision of integrated primary healthcare at the household level and community
In the foreword to the policy framework and
strategy document released in December 2017, former Minister of Health, Aaron
Motsoaledi, wrote that “CHWs form the bridge between communities and healthcare
service provision within health facilities”. The then Director General for
Health, Dr Precious Matsoso, wrote in her foreword that “CHWs organised into
WBPHCOTs will play a pivotal role in improving access to primary healthcare for
vulnerable communities”. Yet to date, no implementation plan
for the WBPHCOT policy has been released, nor has CHWs been consulted on its
development or content.
Now, with Covid-19, CHWs are struggling to balance
their new tasks within their prior broad scope of work that remains undefined.
“The lack of CHW representation in discussions about implementation of primary
health care is a major impediment to South Africa’s goal of rolling out
Universal Health Coverage,” said Gale Mookroof, a CHW from the Northern Cape.
It has been estimated that if South Africa invests in 41,000 more CHWs, 34,800
will be saved in the next decade. However, before the program is expanded, we
must ensure that national and provincial health departments allow CHWs to be
represented when policy is made and implemented.
South Africa’s swift initial response to the Covid-19
pandemic instils hope that the country can make radical decisions to address
its health problems. For the ongoing repercussions of the COVID-19 pandemic to
be tackled effectively, the contribution of CHWs to the pandemic response and
to a universal health coverage agenda needs to be adequately recognised.
salaries should reflect the effort and risks they have shouldered alone for too
long. It is time to enact changes that provide meaningful support to CHWs and
grant them a seat at the table.
-The authors are all members and/or board members of TB
Proof, a leading TB advocacy organisation in South Africa.
article was first published in Spotlight– health journalism in the public
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