Community Health Workers and the Response to HIV/AIDS in South Africa: Tensions and Prospects

Centre for Health Policy, School of Public Health, University of Witwatersrand, PO Box 1038, Johannesburg 2000, South Africa.
Health Policy and Planning (Impact Factor: 3.47). 06/2008; 23(3):179-87. DOI: 10.1093/heapol/czn006
Source: PubMed


After a decline in enthusiasm for national community health worker (CHW) programmes in the 1980s, these have re-emerged globally, particularly in the context of HIV. This paper examines the case of South Africa, where there has been rapid growth of a range of lay workers (home-based carers, lay counsellors, DOT supporters etc.) principally in response to an expansion in budgets and programmes for HIV, most recently the rollout of antiretroviral therapy (ART). In 2004, the term community health worker was introduced as the umbrella concept for all the community/lay workers in the health sector, and a national CHW Policy Framework was adopted. We summarize the key features of the emerging national CHW programme in South Africa, which include amongst others, their integration into a national public works programme and the use of non-governmental organizations as intermediaries. We then report on experiences in one Province, Free State. Over a period of 2 years (2004--06), we made serial visits on three occasions to the first 16 primary health care facilities in this Province providing comprehensive HIV services, including ART. At each of these visits, we did inventories of CHW numbers and training, and on two occasions conducted facility-based group interviews with CHWs (involving a total of 231 and 182 participants, respectively). We also interviewed clinic nurses tasked with supervising CHWs. From this evaluation we concluded that there is a significant CHW presence in the South African health system. This infrastructure, however, shares many of the managerial challenges (stability, recognition, volunteer vs. worker, relationships with professionals) associated with previous national CHW programmes, and we discuss prospects for sustainability in the light of the new policy context.

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    • "Attrition is a major challenge confronting community-based care programmes and could be a consequence of the challenges that caregivers experience while working in these programmes (Akintola, 2011; Nkonki et al., 2011). Community caregivers confront many challenges, including the physical and psychological burden associated with providing care (Akintola, 2006; Akintola et al., 2013), lack of recognition by the formal health care system (Schneider et al., 2008), poverty among home care patients resulting in lack of money for food and transportation to health facilities, lack of basic protective equipment and materials necessary for infection control, and lack of remuneration or opportunities for employment (Akintola, 2006; Akintola & Hangulu, 2014). "
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    ABSTRACT: This paper examines employment and skills training for community caregivers within the expanded public works programme in South Africa. The paper argues that, as currently conceptualised, the skills and learnership programmes for community caregivers fail to take full advantage of the prevailing labour market realities. Therefore, the paper argues for strategic reconceptualisation of the programme to include learnerships for community caregivers that impart more mid-level to higher-level skills to meet current and future labour market demands particularly in primary health care. This, it is argued, will address the scarcity of skills in the health sector of the economy. Furthermore, the proposed programme will simultaneously have positive impacts on unemployment, the primary health care system and the socio-economic well-being of community caregivers.
    No preview · Article · May 2015 · Development Southern Africa
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    • "The formalisation of some aspects of carework by the government also resulted in the creation of new categories of CHWs (e.g. HIV treatment supporters) as well as new models for state payment of CHWs via NGO mediators (Schneider et al., 2008). In the process, though CHW work became somewhat more formalised, it also remained highly fragmented and poorly regulated. "
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    ABSTRACT: Khayelitsha, an economically marginal peri-urban settlement in Cape Town, is home to a number of ‘flagship’ public health interventions aimed at HIV/ AIDS and TB. Alongside these high-profile, foreign donor-driven treatment and care programmes are a plethora of NGOs that provide a wide range of community-based carework. Some of these organisations are large, well funded and well connected globally, while others are run by a few unem- ployed women responding to care needs in their neighbourhoods. This article explores the ways that community health workers (CHWs) who work for these organisations understand and speak about their involvement in carework as volunteers, employees or managers of community-based care organisations. Many CHWs framed their work through discourses of gender, religion or culture (‘African-ness’). They also described forms of material or economic benefits of providing carework, but many were concerned that these might be seen as existing in tension with more socially accepted, altruistic motivations for care. We explore here how CHWs narrate and understand their roles and motivations as carers and members of a resource-constrained community. Keywords: community health worker; South Africa; motivation; ethnography; ubuntu; care
    Full-text · Article · Jul 2014 · Critical Public Health
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    • "However, addressing these challenges many not necessarily require putting all categories of community-based health workers on the government payroll. Considering the difficulties in paying CHA incentives and the role of non-financial incentives in promoting work motivations, we agree with Schneider [33] that relatively loose processes surrounding the selection and deployment of community-based health workers and voluntary forms of participation may potentially be advantageous. Improving non-monetary incentives such as providing them with materials that identify them as community-based health workers (badges, t-shirts, and so on), frequent refresher training, supportive supervision [53] and closer links to CHAs, could motivate this group of health workers to collaborate more effectively with CHAs. "
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    ABSTRACT: Background In order to address the challenges facing the community-based health workforce in Zambia, the Ministry of Health implemented the national community health assistant strategy in 2010. The strategy aims to address the challenges by creating a new group of workers called community health assistants (CHAs) and integrating them into the health system. The first group started working in August 2012. The objective of this paper is to document their motivation to become a CHA, their experiences of working in a rural district, and how these experiences affected their motivation to work. Methods A phenomenological approach was used to examine CHAs’ experiences. Data collected through in-depth interviews with 12 CHAs in Kapiri Mposhi district and observations were analysed using a thematic analysis approach. Results Personal characteristics such as previous experience and knowledge, passion to serve the community and a desire to improve skills motivated people to become CHAs. Health systems characteristics such as an inclusive work culture in some health posts motivated CHAs to work. Conversely, a non-inclusive work culture created a social structure which constrained CHAs’ ability to learn, to be innovative and to effectively conduct their duties. Further, limited supervision, misconceptions about CHA roles, poor prioritisation of CHA tasks by some supervisors, as well as non- and irregular payment of incentives also adversely affected CHAs’ ability to work effectively. In addition, negative feedback from some colleagues at the health posts affected CHA’s self-confidence and professional outlook. In the community, respect and support provided to CHAs by community members instilled a sense of recognition, appreciation and belonging in CHAs which inspired them to work. On the other hand, limited drug supplies and support from other community-based health workers due to their exclusion from the government payroll inhibited CHAs’ ability to deliver services. Conclusions Programmes aimed at integrating community-based health workers into health systems should adequately consider multiple incentives, effective management, supervision and support from the district. These should be tailored towards enhancing the individual, health system and community characteristics that positively impact work motivation at the local level if such programmes are to effectively contribute towards improved primary healthcare.
    Full-text · Article · May 2014 · Human Resources for Health
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