Frontline Community Health Workers kept in the dark

Photo: SACLA Facebook group.

In a country that has the biggest divide between public and private healthcare, community careworkers are not recognized as employees and do not enjoy labour rights and the protection of SA’s labour laws.
In a gloomy room in a cinder block RDP house so cramped there is barely enough space to move his wheelchair, Masixole Sosikela, 29, looks as if he is part of the furniture.
Sosikela lost the use of his legs in a car accident three years ago and has since been confined to the small house he shares with his mother and young brother. With his mother at work and his brother at school, he spends his days alone in the house in BM Section, Greenpoint, Khayelitsha. His only daytime visitor is home community health worker, Nikezwa Bara, who comes to see him three times a week. She spends about an hour with him, washing and dressing his bedsores, emptying his catheter and changing his linen. Bara also prepares him something to eat in the kitchen and wheels him outside to enjoy a bit of sunshine.
Bara is one of 106 community health workers (CHWs) in Khayelitsha who offer essential health and social services to over 1,000 patients who are bed-ridden or chronically or terminally ill. For these patients, the CHWs are a lifeline of care and company.

Khayelitsha, Cape Town, Western Cape, South Africa

Unknowingly working as EPWP workers

Contracted on a six-monthly basis by the South African Christian Leadership Assembly (SACLA), a health NPO, Bara has been offering essential services to the sick, aged and disabled in the largely informal settlement of Greenpoint in Khayelitsha for six years, receiving R1,700 a month for 22.5 hours of work a week. What Bara doesn’t know, is that according to the provincial department of health, her employment is part of an Expanded Public Workers Programme (EPWP) implemented by various NPOs in the health sector.

Likewise, nine other community healthcare workers who are contracted to various health NPOs, said they had no idea that they were working within an EPWP. But according to provincial health department spokesperson Monique Johnstone, all 3,253 CHWs who were working in the Western Cape as of August 2016, are employed under the EPWP, and not informing employees of this fact was in violation of the ministerial sectoral determination governing the EPWP. Contracts seen between CHWs and SACLA, as well as NPO Afrika-Tikkun, make no mention of the EPWP.

However, one health NPO, listed as a health department implementing agency – which wanted to vet their response before going to press –stated that the 54 CHW working under their organisation are not part of the EPWP, although “most of them” had the opportunity to attend training courses offered by the EPWP.

Skills training offered

To this end, Johnstone stated R10,3m is budgeted in the current financial year for the provision of skills training to EPWP employees “to ensure that beneficiaries (i.e. CHWs) gain skills while they work on EPWP projects with the aim of enhancing their employment opportunities in social sector programmes upon exit from the EPWP projects”.

But Bara, and all other careworkers interviewed, say while they have received training in primary health and auxillary nursing, the training was not accredited and thus does not enhance their employment prospects.

Although a contract between Afrika-Tikkun and one of their CHWs that was made available to Workers’ World makes no mention of the EPWP, Afrika-Tikkun’s media liaison, Catherine van Schoor, said that their 92 CHWs are in the EPWP and receive “lots of training” provided by “fully qualified and accredited trainers”.

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Disparities in payment amounts are also evident. While Johnstone said provision is made for CHWs to be paid R1,886 per month for a 22.5-hour work week, the contracts in Workers’ World’s possession stipulate payments of R1,745 per month, a difference of R141, or R1,692 over the one-year period of the contract.

Lack of safety equipment

At a meeting with nine CHWs who work for SACLA, St Luke’s, Philani and Afrika Tikkun, only those working for Philani and Afrika Tikkun said that they are provided with masks and gloves for working with those suffering from infectious diseases such as TB and HIV+ patients.

The CHWs working for SACLA said that they receive one pair of surgical gloves per week, which they believe they are expected to wash and reuse, and are provided with an apron. No masks are provided. The CHWs working for St Luke’s said that they receive no safety equipment whatsoever, although St Luke’s claims CHWs are provided with masks, gloves and aprons.

Given that CHWs have to visit patients who are often living in poverty-stricken and dangerous areas, the one safety initiative taken by NPOs is to ensure that they work in pairs.

While this provides some measure of safety, working conditions are tough and CHWs are continually faced with unexpected and challenging situations.

Threats to community careworkers’ safety

When she set out to do her rounds on 22 September, Bara received the address of a new patient from the Sister in charge at SACLA. Accompanied by this reporter, her usual colleague had taken the opportunity to attend a healthcare meeting. Bara had to trudge through the streets and alleyways of Greenpoint informal settlement looking for the house, putting herself in danger of being mugged or attacked in the high-crime area. Local residents she spoke to said they didn’t know where to find the house, nor did they know the name of the patient she was looking for. Using her own airtime, she tried to call the patient’s cellphone but it went straight to voicemail.

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When she did eventually locate the home, she discovered the patient had TB and was HIV positive, conditions she was not made aware of when receiving her assignment.

Bara also had to see another patient in Greenpoint who had been sick and housebound since she suffered a stroke three years ago. Although the woman has twin sons, Bara says they don’t take care of their mother as they are involved in criminal activities. As a result, Bara had to wash her, change the linen, help her with her exercises and ensure she takes her medication.

Exploitation and poverty wages

When Bara completed her duties, she had worked an hour beyond what she gets paid for, and needed to travel a further 45 minutes before getting home and taking care of her own family.

Like almost all the CHWs interviewed, Bara dreams of becoming a professional nurse but has no money to further her studies. Earning less than R2,000 a month to be on the frontline of community care leaves her with no savings at the end of the month as she is the breadwinner in her household.

Proper accredited training within the EPWP would go some way to helping her, and other CHWs, achieve their dreams of contributing more fully to public healthcare and allowing new CHWs to enter the workplace.

Responses from SACLA were not forthcoming before going to print, while Philani stated they would not be able to answer questions as their media spokesperson was out of the country.

A new union, the National Union of Careworkers of South Africa (NUCWOSA), is due to officially launch in November and will take up these issues raised by CHWs.

NUCWOSA provincial coordinator, Ayanda Nabe, said the union was established specifically for community care workers, home-based carers and counselors. Nabe said the government was using CHWs as cheap labour in the healthcare system and CHWs deserved proper employee status and a living wage.

She said 7,000 members had signed up across the country so far.

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