The need to promote a client-centered response by protecting the rights of healthcare workers in the region: The plight of community care givers and health care workers in South Africa ARASA 2014 Annual Partnership Forum (APF) Violet Kaseke SECTION27

Introduction There is no longer any question of whether CHWs can be a key agent in improving health: the question is how their potential can be realized (Kahssay et al 1998).

Who are Community Health Workers? + Currently it is estimated that there are CHWs in the country. + The umbrella term “CHW” embraces a variety of community health aides: Home based carers, Care givers, lay counsellors, adherence counsellors, TB DOT supporters. + CHWs are: + Peers from the communities they serve + Conduct a range of activities and roles + Some are paid, some are unpaid.

What makes this cadre of health professionals effective? + CHWs have access to the population they serve + The unique relationship they have with clients provides social support that is critical to self management + The trusting relationship with clients lays the foundation for good self management

The broad policy framework + National Guideline on Home-based care/Community-based Care, December National Human Resources for Health Planning Framework Draft Community Care worker Management Policy Framework 2009

The role of CHWs in implementing health care services + CHW have been directly incorporated to various governmental plans such as: + The National Strategic Plan on HIV, STIs and TB, (NSP), + Tuberculosis Strategic Plan for South Africa, 2007 – 2011 (TBSP) and the HR Framework + Challenges to achieving the targets and objectives of the NSP: + Insufficient number of well trained and well resourced CHWs capable of facilitating HIV, TB and PMTCT programmes

How effective are CHWs in achieving the MDGs? CHWs at the core of the HIV response + CHWs have been integral in the fight against HIV/AIDS + Initially home-based care programs were used to support primary care givers of people living with HIV/AIDS (PLWHA) to facilitate dignified deaths, to educate community members and to provide counselling and general assistance, among other tasks. CHW services have now evolved into more comprehensive care. + CHWs fill critical gaps in ART services by enhancing universal access to HIV counselling and testing. + Provision of home-base care in communities by CHWs is also a mechanism for reducing stigma and facilitating access to care for individuals living with HIV. + CHWs can be used to assist in preparing patients for beginning treatment by carrying out home visits and educating them about the treatment process and about HIV. + Assist with adherence to treatment.

What are the challenges faced by CHWs? + Non-formalization of employment – lack of benefits such as Medical Aid, pension, UIF, Provident Fund + Irregular payments of CHWs by the DoH and through the NGOs + Inadequate monthly income received by CHWs – CHWs in South Africa are paid R R Disparities in pay rates across different provinces + Rampant discrimination against CHWs by other health care workers, particularly by permanent nursing staff + The lack of occupational health present a high risk of CHWs contracting communicable diseases + Inadequate training programmes + Limited or no psychological support for CHWs + Lack of career paths for CHWs to advance within the health or related sectors

Challenges with NPOs + Currently the NPOs s are funded by the DoH to employ CHWs. + There are some deep routed problems which include: + Poor working conditions + Exploitation of CHWs + Misappropriation of funds + Ghost workers + Lack of coordination – different provinces dealing with CHWs in a haphazard manner, resulting on poor service delivery + No effort has been put into monitoring, supervising and supporting the CHWs and NPOs s. + Currently there are no rules and procedures to be followed by NPOs

Should CHWs be employed by the State? One of the solutions to the challenges raised is to standardize the conditions of employment for CHWs. + Firstly by classifying them as employees. CHWs satisfy the definition of an employee under section 213 of the LRA and section 1 of the BCEA. + The state has the capacity and the resources to employ all CHWs- this is the most effective way to ensure that their employment is standardized. + Currently CHWs are deprived of their rights under labour law and other rights violations, which effectively reduce them to a cheap and exploited labor force, this would not be the case if they were to be employed by the state.

Rights of CHWs constantly overlooked + The right to fair labour practices, section 23 of the Constitution + The right to equality, section 9 of the Constitution: this is the basis for protecting workers against unfair discrimination +The right to human dignity section 10 of the Constitution : promoting mutual respect between employer and employee + The most important of these laws are the Labour Relations Act (LRA) and the Basic Conditions of Employment Act (BCEA). These laws deal with a range of issues from hours of work, annual leave, sick leave, notice pay (under the BCEA) to rights to challenge unfair labour practices and unfair dismissals and negotiate and strike over better working conditions (under the LRA).

What is the National Department of Health saying about this? + DoH states that it is unable to employ all CHWs. Initially the DoH proposed to employ CHWs, however this is no longer their position. Main concerns + Budget constraints + Too much logistics in employing CHWs. + Alternative solution- Primary Health Care Re-engineering Guidelines?

Challenges with the PHC Re-Engineering Strategy - Ward Based Primary Health Care Outreach Teams (WBPHCOT) +Narrow definition which excludes other cadres of CHWs such as Home-based care giver and HIV Counsellors + Roles and competencies of CHWs: + the competencies expected of CHWs against the proposed minimum entry requirements for selection into the PHC teams +Selection criteria for CHWs who want to be part of the WBPHCOT + minimum requirements +CHW to household ratio - The proposed ratio is 1 CHW to 250 households. The concern is that this is not feasible given the rural factors of distance and burden of disease, including quality of service.

SECTION27’s efforts so far + Submissions: + Policy Framework for Home and Community Based Care and Support Programme in September 2008) + The Community Care Giver Policy Framework in June 2009) + These submissions emphasized the need for better managerial systems and support to CHWs as well as access to training and appropriate career pathways. + Constant engagements with NDoH and ECDoH + Formation of task team comprising of SECTION27, Rural Health Project, Treatment Action Campaign, Gauteng CHW Task Team and the National Department of Health + Consultations with CHWs in the Eastern Cape, Gauteng, Mpumalanga, Limpopo

Recommendations + The Department be required to integrate CHWs fully into its system, and that all benefits that are available to permanent staff should be extended to CHWs; + Implementation of CHW policies

In conclusion + The State has a constitutional obligation to provide an urgent solution to the problem at issue as CHWs continue to be exploited on a daily basis and health services are being compromised as a result of this.

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