Ill residents may suffer most after the axing of Free State community health workers.
“Slaughterhouse! Stop the killing and give us back our jobs so we can save lives!” are the rhythmic chants from 500 protesters, mostly women, echoing through the early winter morning hours in downtown Bloemfontein.
Twelve police vehicles with flashing blue lights are following them. Rush-hour traffic has come to a standstill.
It’s biting cold.
Many of the picketing women are middle-aged and are wearing white-and-purple T-shirts emblazoned with the words “HIV Positive”. Others are dressed in tracksuits with blankets wrapped around their waists.
Until April, they were community health workers. Then, they say, Free State health MEC Benny Malakoane sent them letters informing them that their services were no longer needed.
A man with a megaphone clenches his fist and thrusts it into the air. “Amandla!” he screams. “We’re here to fight for the health of our people. Viva, community health workers, viva!”
“Awethu!” the crowd responds.
The procession reaches its destination: Bophelo House in Maitland Street, the headquarters of the Free State health department.
Two weeks ago police arrested 127 of the protesters and held them in custody for 36 hours because they had toyi-toyied “without government permission” throughout the night in front of the building, demanding reinstatement.
“Benny! Benny Malakoane!” the man on the megaphone shouts. “We know you are in there! You can come out now. Come and try and arrest us again and see what happens this time.”
“The first patient I helped to trace was Johannes Diphoko,” explains Mpho Molapo (34) in the sitting room of his aunt’s RDP house. “It was in February 2007 and Johannes had tuberculosis [TB]. He was supposed to take his pills for six months, but in the second month of his treatment he disappeared. The nurses didn’t have time to look for him.”
Molapo lives in the small community of Soutpan, about 30km outside Bloemfontein, where the only form of public healthcare for more than 5 000 people is a three-roomed clinic, Ikgomotseng. The sign in front of the clinic advertises everything from immunisations, rehabilitation, mental and youth health services to the treatment of chronic and infectious diseases.
But the reality is far removed from the information on the board.
Added stress on nurses
Officially, there are three nurses employed at Ikgomotseng. But for the past two weeks only one has reported for work. “It’s stress,” says the sole nurse on duty, asking not to be named.
Next to the nurse on a chair is a box overflowing with medicine bottles, plasters and substances “for injection purposes”, she says.
“This is illegal,” the nurse says while pointing to the box. “Most of this medication is supposed to be locked away in a pharmacy. But we haven’t had a pharmacy assistant since May and our clerk died in 2003 and was never replaced. And now the 14 community health workers we had have also been taken away. We have no idea why.”
The workers focused on different conditions: some did HIV testing, some followed up on diabetes and hypertension patients and others were home-based care workers.
Molapo was a community health worker called a “TB tracer”. It was his job to “trace” TB patients when they defaulted on treatment, and once he’s found them, to ensure that they took their medication.
He found Johannes Diphoko lying on a bed in his father’s house in Soutpan. “He struggled to breathe and couldn’t walk, so I fetched a wheelchair from the clinic and pushed him there,” Molapo says. “I needed to get him back on treatment.”
Protecting the community
Diphoko’s health wasn’t Molapo’s only concern; he needed to protect the rest of the community. If a person with TB is left untreated, he or she will infect on average between 10 to 15 other people with the bacterium, according to the World Health Organisation. And Soutpan, the Health Systems Trust’s 2013 district health barometer says, has a TB disease rate well above both the provincial and the national average.
When patients like Diphoko do not complete their treatment, they can develop drug-resistant forms of TB that can take much longer to treat than ordinary TB and for which the treatment, according to a study in the medical journal Tropical Medicine and International Health last year, is about 40% more expensive.
Currently, the health department spends more than half its budget on treating drug-resistant forms of TB.
Molapo therefore spent the next nine months visiting Diphoko at his house “every single week morning” to personally ensure that Diphoko was taking his pills, until he was cured.
By the end of February 2007, Molapo had traced 40 TB patients who had been defaulting on their treatment. Some were working on nearby farms and were hesitant to ask for time off work to collect their medication; others were elderly people who didn’t have the physical strength to walk to the clinic.
“I called the farmers and asked them to bring their workers, and the old people’s drugs I delivered at their homes,” Molapo says.
No more work
But last month he stopped working because a Free State health department letter informed him that his services had been terminated.
“Just like that, after all these years of work to help the government. I couldn’t believe it,” Molapo says. “It’s like the work we have been doing was worth nothing. Like we never existed.”
There’s a long line of patients waiting for the nurse on duty at the Ikgomotseng clinic. She wants to help them all, but is despondent. “Look at my stats,” she says, taking out a blue register book in which the names of the patients she sees are noted. “In June we helped only half the number of patients we normally do.”
Before June, community health workers filled in as clinic receptionists, and helped to open files for patients and to sort out medicine in the pharmacy. They also weighed patients and screened them for HIV and TB.
“It’s policy at this clinic that we have to test all patients for TB. From last month we no longer do, because we simply don’t have the time. The system is falling apart,” says the nurse.
Now the first serious cracks have begun to emerge. One of the clinic’s patients with ordinary TB has developed drug-resistant TB. “He didn’t turn up to collect his monthly treatment, but I had no one to send to go and look for him,” she explains. “Now we sit with the results. His mother told me she found him in Brandfort at a family member’s house and took him to the clinic. The sister phoned me this week to let me know he’s developed a worse form of TB and will now need to be hospitalised.”
Outside the clinic, in one of Soutpan’s endless grey lines of RDP houses, Thandiwe Moleko is equally disheartened. Molapo has been visiting her daily since February and helping her to take her TB treatment.
“I get confused, because the nurses don’t always give me all the drugs I need when the clinic runs out of stock. This month I had to go alone to collect my drugs and got different sizes [milligrams] of the pills. I have no idea how to take them and I don’t have Mpho to show me. I’m not sure I’ll get cured now. Maybe I’ll get that other, really bad TB. I’m scared …”
Passing the buck?
According to HIV lobby group the Treatment Action Campaign (TAC), 3 800 Free State community health workers were served with notices that terminated their services in April.
But Free State health department spokesperson Mondli Mvambi said this week that this was a “lie … Only 2 200 community health workers were affected and the letter they received wasn’t intended for them; it was addressed to the nongovernmental organisations (NGOs) that employed them with the government funds their organisations received until the termination of their contracts.
“It’s presumptuous to want to frame the MEC. Instead of handling the issue themselves with the health workers, the organisations passed the buck to the workers themselves by forwarding them the letter [and] getting the TAC involved,” Mvambi insists.
He maintains that the money the Free State government has been “investing in the NGOs [to run the programme on behalf of the provincial health department] has not been worth the output. This was discovered by MEC Malakoane when he walked around in the health facilities. These community health workers are not properly trained and their work is not properly monitored. We need to ensure decent work for decent payment.”
Community health workers received a monthly stipend of R1 400.
Mvambi says the department will issue new tenders for community health worker contracts to NGOs next month, but the department has not yet established how many community health workers it will be able to afford.
He says the province is also in the process of training “ward-based community health workers” who will receive “more extensive training” and work with teams of doctors and nurses in municipal wards. These workers will report directly to the provincial health department.
Around the world, studies have shown that community health workers in developing countries with doctor shortages can drastically improve maternal and child mortality rates, and also the uptake of and adherence to treatment.
In Ethiopia, analysts largely ascribe a 67% drop in under-five mortality rates between 1990 and 2012 to the country’s community health worker programme, which was launched in 2004. And Brazil’s two-thirds reduction in under-five mortality in the past two decades is often directly credited to the country’s massive community health worker programme.
South Africa, however, does not have a formal community health worker policy. “The health minister [Aaron Motsoaledi] is on the record since 2009 [as] saying he wants to follow the Brazilian model and formalise community health workers. But after all these years, we still don’t have a policy,” says Mark Heywood from the social justice organisation Section27. “These workers feel abused, demoralised and insecure.”
According to the national health department’s deputy director general for primary healthcare, Jeannette Hunter, “interested parties” will discuss a draft community health worker policy in August. She intends to have it finalised by November.
Back in Soutpan, Molapo has no idea what will become of him. “Where will these jobs be advertised and who will advertise them?
“Why is no one telling us about them?”
He and his colleagues have vowed to continue their vigils and protests every Wednesday night between now and September 1, when the community health workers who were arrested during the previous protest will appear in court.
Molapo fetches a handwritten list of his former patients from a bookshelf.
“Are we really worth nothing to Benny Malakoane?” he asks. “It’s like we never added value to his department. Who does he think he is?”
This is the first in a two-part series on community health workers. Next week’s article will focus on their impact on Brazil’s public healthcare system.