RHAP Position on Community Health Workers – Caring for Rural Populations through Sufficient and Supported Community Health Workers
Within the framework of the PHC re-engineering are 4 streams, one of which is the ward based outreach teams. Within these teams the Community Health Workers (CHWs) are foreseen to be an integral part and whose primary focus would be population based surveillance, health prevention and promotion. RHAP recognises the efforts to improve access to prevention and promotion of health care services as essential components of the PHC approach. However, the increased attention to prevention and promotion does not eliminate the needs nor the rights of underserved and poor communities to access care and treatment at decentralised levels.
RHAP’s concerns with the developments around the CHW Programme:
- The lack of a CHW policy and commiserate resources for implementation
- Uncertainty about the scope of CHWs including the apparent lack of consideration and resource allocation of other health care services traditionally provided by community health workers such as clinic-based counselling and decentralised care at household level
- Lack of rurality considerations and
- Need for fair working conditions for all CHW categories that play a role in the delivery of Primary Health Care
- RHAP is concerned about the delay from the 2011 audit report of CHWs and the launch of the PHC re-engineering strategy to an actual policy that provides detailed guidance on how it will be achieved (considering the current fragmented and different provincial CHW plans) and a policy that clearly delineates roles and scope of CHWs.
- The CHW policy must not be narrowed down to ward-based CHWs only whose primary role is to provide prevention and promotion services, but it must include other PHC services and the policy needs to prioritise individuals and communities who are vulnerable, out of reach and underserved.
- An over-emphasis on prevention and population based outcomes, and lack of strategy for step-down care, runs the risk of undermining and jeapordising not only the PHC strategy’s purpose but in fact the overhaul of the entire health system which aims to improve health outcomes, access and achieve equity.
- There is a lack of clarity on how provinces are meant to realise the CHW policy in terms of extra budget allocation and in addition if extra resources will be considered for rural areas (extra transport allowances etc.
Definition and Scope of Community Health Workers
The Definiton and Scope of Community Health Workers must include care and treatment over and above prevention and promotion.
Poor follow-up and continuity of care, partly owing to difficulty of access and/or poor referral systems negates the benefit of any intervention, be it the many outpatient examples, or the fewer but very costly admissions (especially if surgery is involved). Follow-up and aftercare must happen in the community (preferably at patients’ home) rather than the facility as much as possible, owing to the difficulties with access to the facilities, particularly for ill patients. If not, such important facility efficiency indicators such as average length of stay (ALOS), cost per patient day equivalent and bed utilisation rate (BUR) change to unacceptable levels.
Step-down care is explicitly not part of the scope of practice of the ward-based CHW category as it focusses on prevention and health promotion. To date home based care appears to have been understood by government and other stakeholders as “grannies cooking for sick people”. There must be a move away from the traditional view of an homebased carer as an individual who assists with activities and organization of domestic living (cleaning, collections, general assistance) for which few skills are required, to a necessary help for poorly capacitated individuals at home i.e decentralised individual based care and a bed in the community. This community bed is desparately needed to meet the need of, e.g.:
- physical incapacitation at home ( acute and chronic)
- mental health/illness support and
- palliative care
We are concerned that there will either be over task shifting if the above is amalgamated into the WBOT CHWs role without necessary protection, increase of numbers and commiserate working conditions OR that physical incapacitation at home ( acute and chronic), mental health/illness support and palliative care will be neglected altogether.
The crucial link between home and facility is illustrated in the management of mental illness. This is best managed by understanding the functionality of a patient over time. The Home Carer (under supervision of the nurse) provides this more time-intensive interaction with the family at the home, observing the patient during repeated visits, so allowing for a seamless and informed referral between home and facility when required.
Crucial areas of follow-up care such as post-surgery, home rehabilitation or treatment of pressure sores means that a bed-ridden patient can be discharged from hospital and cared for by his/her family in bed at home, and will on occasion only come in to hospital for respite care. Without this the hospital-based health care worker may have no choice but to keep the patient in hospital. This “community bed” provides significant cost savings to the hospital too.
RHAP is concerned that the numbers envisaged in the PHC document of approximately 40000 does not really account for the broader scope needed; and that many more CHWs are needed in rural area where distance are a real factor.
Rurality factor of distance and burden of disease is not accounted for in the household:CHW ratio. The current national ratio of 1:250 households across the board is not appropriate. KZN currently have different ratios applied 1 to 50 households for poorest wards and 1 to 80 in the more affluent urban wards. International examples show much higher ratios: in Village Health Communicators in Thailand are each responsible for only 8-15 households. In Brazil it is 1 to 150 households, whilst even locally KZN Province uses different rural and urban ratios. In rural communities, for their widespread distribution, difficult topography and composition (higher elderly and children and ill patient returning home for care) require a similar lower number of households per CHW. An adjusted ratio of rural areas and more resources for rural workers is needed as well as an evidence-based model of what would constitute an ideal ratio.
We question what has informed the 1 to 250 households in SA, as the ratio communicated in various DoH drafts and presentations and what was the average number of members used for a household? On what basis does the DOH believe that SA needs less CHWs to address our country’s need with its high burden of disease compared to current international trends?
Transport cost of visiting (rural) households needs to be considered with extra resource allocation for rural ward based teams
Fair working conditions
We believe that the critical role played by WBOT CHWs, HBCs and other categories of CHWs in the Health System and their challenging working conditions, demand fair pay, proper training and supervision. They must be recognised through their formal adoption into the health system, rather than being treated as a by-product.
- We see that a longer term contract i.e. not temporary employment, long term security, similar across provinces, with benefits e.g. pension, sick leave, access to occupational health and safety benefits, are some critical elements needed.
- Recognition that these are not unskilled workers so should be compensated commensurately and thus it should be beyond the minimum wage.
- Clarity on who is expected to employ them i.e. DoH vs NGOs vs CBOs needs to be specified and be consistent across the country to avoid fragmentation
- Some other (not exhaustive) points of fair working conditions are included below that we support:
ü Community Health Care Workers should be provided with appropriate Personal Protective Equipment such as latex free gloves and masks
ü CHW should be supplied with enough materials such as bandages, soaps, disinfectants for cleaning wounds and medication to support the work they are doing.
ü Health and safety training and rights awareness should be provided for CHWs
ü CHWs should be registered under the Compensation of Injury and Diseases Act because they are at risk of being injured or infected in the work they are doing.
ü Access to HIV/AIDS /TB Post Exposure Prophylaxis and ongoing counselling should be in place for CHWs.
ü Proper employment contracts with clear conditions of employment and job descriptions
ü Formal training should be integrated into the jobs of CHWs and their skills should be formally recognised.
ü A proper system should be established for managing the work of CHWs within health care system. This should include debriefing, support groups, counselling and other forms of psycho-social support.
Finally, in a country plagued by high unemployment levels, millions of households living near the poverty line, and the many associated social ills, the CHW programme should be championed as a National Government priority, providing an opportunity to create jobs while improving health. It is surprising indeed that there is no multi-departmental support to finance and roll-out this initiative on a large scale.
Download the RHAP CHW Position Statement
The 4 streams are 1) ward based outreach teams 2) district clinical specialist teams 3) integrated school health policy and 4) GPs contracting into the NHI sites.