/ 4 September 2014

Analysis: Why policy is failing community health workers

Until May this year, Mieta Maine (41) coped well with the two chronic ­conditions afflicting her: diabetes and high blood pressure.

Obtaining her medication from her local clinic in Soutpan, a small village about 30km from Bloemfontein, wasn’t without problems, though. It would take her an entire day of queuing at the Ikgomotseng clinic to get her monthly supplies. Often the facility would run out of stock, which meant she would return home empty-handed.

But then she had Kindu Maroosele, a community health worker, to help her. Maroosele knew all the nurses personally and would contact them to find out when new stock would arrive, and would fetch the medication on Maine’s behalf and deliver it to her house.

Maine’s problem was time. She has something very few people in Soutpan have: a job. She works for the local municipality’s bucket removal service. Every weekday, she travels with a truck to remove the full buckets from toilets and replace them with clean ones.

“Having a job means I can’t disappear from work [for] more than one day per month to fetch medication. My bosses complain when I do that,” Maine says. “Kindu really helped me. I never missed a dosage and stayed healthy.”

Maroosele would also make sure Maine took her medication correctly and would visit her four times a week to see that she hadn’t missed a dose.

The health worker is a drug-adherence counsellor and had six patients who depended on her for their treatment. The rest of her time she spent at the Ikgomotseng clinic, helping the nurses to “organise” patient files and medicines.

Contracts terminated
But in June, Maroosele, along with 2 200 other Free State community health workers lost their jobs, after the provincial health department informed the nonprofit organisations they were working for that their funding would not be renewed.

This week, 130 of the health workers appeared in the Bloemfontein regional court on charges of protesting illegally. In July, police arrested them at an all-night vigil in front of the provincial headquarters, Bophelo House, in downtown Bloemfontein. They were picketing over what they termed their “unfair dismissal”.

On Monday, they pleaded not guilty and the case has been postponed to October 2 for a full hearing.

Meanwhile, Maine is struggling. She has missed two months of hypertension medication because the clinic had no stock in June and July on the days when she went to collect it. As a result, she has been absent from work frequently due to “sky-high” blood pressure and the consequently devastating effect on her diabetes.

“I’m the breadwinner in the house and help to look after my sister and her children. If I lose my job or die, nine people will suffer,” Maine says.

While the court was in session, Maroosele was sitting quietly in her RDP house in Soutpan. She couldn’t afford to attend and be among the 1 000 health activists who gathered outside the court building because she no longer receives her R1 400 monthly stipend.

Twelve years of community health experience was sitting at home doing nothing.

Kindu Maroosele was laid off after the Free State health department cut off funding to nonprofits. (Delwyn Verasamy)

‘Barefoot doctors’
China calls them “barefoot doctors”, Ethiopia refers to them as “health extension workers” and Pakistan brands them “lady health workers”. But they all have one thing in common: they’re lay workers who have received in-service training, and in some cases slightly more formal training to deal with basic health problems in their communities.

Globally, research has shown that community health workers going from home to home in poorer communities can have significant positive impacts, particularly on reducing maternal mortality rates and the number of children dying before their fifth birthday.

In Ethiopia, for instance, the United Nations International Child­ren’s Emergency Fund reports that the country has halved its under-five mortality rate over the past decade, mainly as a result of 38 000 health extension workers who are employed by the government and placed in communities where doctors and nurses are scarce. Among other things, these workers help mothers with breastfeeding, see that their babies get vaccinated and help them to implement basic healthcare measures such as good hygiene in their homes.

And in Brazil, where the government reports that community health workers cover more than half of the country’s massive population, United Nations Development Programme (UNDP) figures show that, between 1990 and 2011, there was a two-thirds drop in the death rates of children under five and 50% fewer mothers dying during pregnancy, birth or shortly thereafter.

SA lagging behind
Fast forward to South Africa. According to health department figures, the country experienced a dramatic growth in the number of community health workers, from 5 600 in the mid-1990s to 72 839 in 2011.

But UNDP figures show that our maternal mortality rate almost doubled between 1998 and 2010: from 150 per 100 000 live births to 269. The under-five child mortality rate showed only a marginal improvement: from 59 per 1 000 live births in 1998 to 53 per 1 000 in 2010.

Why is it, then, that community health workers such as Maroosele have not had a positive impact on South Africa’s health indicators? Mostly because our community health programmes are “diverse, unstructured and unregulated”, a 2013 study published in the journal Global Health Action found.

The authors discovered that community health worker programmes with good outcomes, such as those in Brazil, are different in two important ways to South Africa’s: they’re far more structured and formal.

A 2011 health department document, with guidelines for the implementation of primary healthcare, says that our community health worker programmes are “randomly distributed with poor coverage”, are funded through nongovernmental organisations with “inadequate accountability” and are rarely linked to formal health facilities.

Inadequate training
But, more importantly, South Africa’s community health workers have not been trained properly in many disciplines and tend to concentrate on single health issues. Maroosele has, for instance, been trained in drug adherence counselling but not in how to deal with infants or nursing mothers.

At the Ikgomotseng clinic, there were 14 community health workers until May. Some traced tuberculosis patients who defaulted on treatment, others were HIV counsellors; some recruited men to undergo medical male circumcision, which can reduce their chances of contracting HIV, and some were home-based carers. Other counsellors, such as Maroosele, dealt with noncommunicable chronic conditions such as diabetes and hypertension.

In Brazil, Ethiopia and Pakistan, community health workers are trained comprehensively and can deal with more or less all conditions. But Brazil and Ethiopia have also formally adopted community health workers as part of their public health system and the government pays them directly.

But most of our provincial health depart­ments have, until recently, avoided employing community health workers and have allocated funds to nonprofit organisations to employ the workers on their behalf – mainly because it’s cheaper and less labour-intensive, experts say.

Community health workers in the Free State, who often help sick and working patients get their chronic medication, were laid off in April. (Delwyn Verasamy)

Primary health care vision 
In 2010, Health Minister Aaron Motsoaledi visited Brazil and returned “with a vision for the re-engineering of primary health care” based on the Brazilian model, according to the provincial guidelines document.

A discussion document followed and in 2011 the health department produced an “implementation toolkit” on how to train and appoint “ward-based” primary healthcare outreach teams. Comprehensively trained community healthcare workers, managed and appointed by the government, were an essential part of that plan.

The document recommended that there should be at least one primary healthcare outreach team per municipal ward (there are 4 277 wards). Each team would consist of six community health workers led by a professional nurse and assisted by a health promotion and environmental officer, who would be spread among several teams.

People involved in public healthcare were excited, timelines were produced, budget modelling exercises were done and the subsequent National Health Insurance green paper, which was published in late 2011, strongly acknowledged the role of comprehensively trained community healthcare workers in the implementation of the scheme.

But suddenly everything juddered to a halt. The national policy every­one thought would follow never materialised.

In July, the national department’s deputy director general for primary healthcare, Jeanette Hunter, told Bhekisisa that a draft policy would be circulated in the first week in August at a meeting with all role players, including civil society.

The meeting never happened.

“Three-and-a-half years later, there’s still no document we can comment on,” says Prinitha Pillay of the Rural Health Advocacy Project, a partnership between the University of the Witwatersrand’s Centre for Rural Health, the Rural Doctors’ Association of Southern Africa and the social justice organisation Section27.

“We keep on asking for it, to give us something we can comment on, but we’re not getting it. And, if I understand right, it’s not close to coming out.”

No policy to protect workers
It was the lack of a community healthcare worker policy which made it possible for Maroosele and her colleagues to be fired without recourse, because a policy would include regulations the Free State health department would be obliged to follow.

Without a national policy in place, the provincial departments have started to recruit, train and appoint ward-based community health workers, but all in different ways.

Although the 2011 toolkit document explicitly states that ward-based community health workers should be recruited “from among the existing [pool] of community health workers funded by the department of health”, such as Maroosele, who would then be retrained, exactly the opposite has happened in the Free State.

The idea was to get these “single-purpose” or “limited-purpose” workers like Maroosele, at least for the first phase of recruitment, to become comprehensively trained and employ them as ward-based community health workers.

But the Free State health department spokesperson, Mondli Mvambi, says “there is no automatic guarantee that those people [the 2 200 community healthcare workers who lost their jobs] will be getting jobs”.

Mvambi cites his department’s finances and the “nongovernmental organisations not performing sufficiently” as the reasons for why the organisations lost their contracts.

It is not the only department that is following that route. According to the Gauteng and Eastern Cape health departments’ spokespeople, they also don’t necessarily recruit ward-based community health workers from the respective provinces’ existing pools of community health workers.

“We can’t have this fancy strategy, based on the Brazilian model, that’s supposed to decrease all maternal and child mortality rates and then not know what is going to happen to the ‘single-purpose’ community health workers that are there now,” Pillay said. “What will happen to the 72 000 that existed in 2011?”

In Soutpan, there is not a single community healthcare worker left at the Ikgomotseng clinic. The nurse on duty has a huge box of random medicines next to her because she doesn’t have a pharmacy assistant to organise the clinic’s medicines.

“I haven’t heard anything about this ward-based community health workers,” she says, searching for Panado in the box. “All I know is that all our community health workers are gone and no one has told me who will replace them.”

She stops fiddling and looks up. “Maybe the minister has studied the budget and thought: ‘Eish! I can’t afford these billions of rands.'”

No uniformity in how provinces deal with ward-based carers

There are huge discrepancies among provinces in what “ward-based” community health workers are paid, who pays them, the kind of work benefits they get and how many households they need to cover. 

The health department’s 2011 “provincial guideline for the implementation of the three streams of primary healthcare ­re-engineering” states that nongovernmental organisations need to be informed that “their roles are changing and that over the next two years [from 2011 to 2013], they will cease to be funded to employ community health workers as this will be done by the department of health”. 

Yet in 2014, a year after the proposed deadline, only four of the eight provinces implementing the ­ward-based system – Gauteng, KwaZulu-Natal, the Eastern Cape and North West – pay their workers directly; all the other provinces have contracted nonprofit organisations to do so. Moreover, provinces have different viewpoints about whether “single-purpose” workers employed by NGOs, such as home-based care workers, should continue to do work that “ward-based” community health workers may not have the time for, such as taking care of patients at home. 

According to Helen Schneider, who was a member of Health Minister Aaron Motsoaledi’s 2010 primary healthcare task team that compiled a discussion document for the re-engineering of primary healthcare, these differences have arisen not only because there is no national policy, but also because South Africa’s community health worker strategy is an “unfunded mandate at this point in time”. 

“There has been no ring-fenced funding sources for this ­programme in the same way that there is for clinical specialist and school health teams.” With an unfunded mandate, Schneider, who heads up the University of the Western Cape’s public health department, says that “provinces do what they can and interpret and apply as they see fit”. 

Next week, Bhekisisa will focus on what civil society and academics think South Africa’s community health worker policy should look like and the different ways in which provinces treat community health workers.