Barring those people hurrying by to get out of the heavy rain, the usually busy Sulani Street, home to the Khayelitsha Site B Community Health Clinic, was devoid of pedestrians on the cold morning of 24 November. In front of the clinic, though, community health workers danced and sang protest songs in the rain, like their colleagues in vulnerable communities across Cape Town.
Under the banner of the National Union of Public Service and Allied Workers, hundreds of community health workers marched in protest to the provincial legislature the next day. They demanded to be incorporated into the Western Cape Department of Health, and provided with adequate personal protective equipment and a Covid-19 danger allowance.
Cynthia Tikwayo, 47, lives in Site B and has been a community health worker for 10 years. When she began working, her patients were primarily people with HIV and tuberculosis (TB). Her job entailed visiting them and encouraging them to take their medication. “I told patients about my [situation], that I was sick, I got divorced, I was depressed, but look at me now. So why do you just give up?” she said. Helping people in her community had a profound effect on Tikwayo. “[It] became a part of my life. That’s why I am a [community health worker].”
Over the course of her career, her responsibilities have multiplied and her working hours doubled from four to eight a day. But her salary only increased from R2 100 in 2018 to R3 500 in 2019.
“R3 500 is nothing for what we are doing. We have children, we have houses, we have got many things we want to do,” said Tikwayo, who lives with her son and her two nieces, both of whom depend on her financially.
After a decade with the same organisation, she is still employed on an annual contract that gets renewed each year. “I can’t even go to the bank for a loan. They will say that I just have a one-year contract. After 10 years, if I leave tomorrow, I will get nothing. It’s painful,” said Tikwayo.
Vital but underpaid
Community health workers like Tikwayo find themselves in a paradoxical situation. The work they do is important and fulfilling, yet their salaries are inadequate and their conditions of employment are precarious.
These workers perform a number of tasks, including home-based care, adherence support for antiretroviral and TB treatment, screening for HIV, TB and sexually transmitted infections, health promotion, monitoring of pregnant women, weighing and reporting on the vital statistics of newborn babies, and wound-dressing in clinics. They work in the communities in which they live.
Despite the seeming informality of their roles, they form an integral part of community-based healthcare services. Western Cape health department spokesperson Maret Lesch says they “form part of teams that are supervised by professional nurses. Those teams are part of a broader national programme of ward-based outreach teams.”
The policy framework and strategy for ward-based primary healthcare outreach teams, published in 2018, describes community health workers as “the bridge between communities and healthcare service provision within health facilities”. It says they “play a pivotal role in improving access to primary healthcare for vulnerable communities”.
In addition to improving access to healthcare, they also proved invaluable in the provincial health department’s response to Covid-19. When it was clear that South Africa would not be spared the pandemic, townships were quickly identified as potential hotspots owing to residents’ socioeconomic circumstances, lack of access to nutritional food, and the lack of water and sanitation. Some of the strategies that were put in place to try to contain the spread of the coronavirus relied heavily on community health workers.
To slow the spread effectively, people who had been infected needed to be identified and isolated from other residents. Community health workers were deployed to do door-to-door screenings and refer those who qualified to the nearest testing station.
Clinics were also identified as potential high-risk areas for those with chronic diseases. In an effort to move non-essential services such as the collection of medication away from clinics, community health workers began delivering chronic medication to patients’ homes. This intervention dramatically reduced the amount of people at clinics on a daily basis.
In the Western Cape, there were 3 790 community health workers employed by non-profit organisations (NPOs) that had been awarded contracts by the health department, figures for June 2020 show. An additional 511 were hired in the Cape Town metro as part of the Covid-19 response. According to Lesch, this practice of outsourcing began in 2004, when community health workers were used in the department’s response to HIV.
Ignoring the pleas of community health workers to be insourced, Lesch says there are no plans to absorb them into the department, and “in the absence of a national community health worker resource plan we will continue to contract with NPOs for the provision of community services”.
In addition to their lack of permanent work, community health workers say that the conditions of their employment prevent them from having any say in their jobs. “We are not part of their decision-making. They just tell us what they have decided. So we cannot oppose it because we do not know where their decisions are coming from,” said Kanyisa Bunyonyo, one such health worker. “We don’t have a say in the NPOs and we don’t have a say in the Department of Health. They always take decisions on our behalf.”
While the consequences of those decisions may prove to be good for the communities they serve, they are not always good for the health workers.
Initially during the Covid-19 pandemic, doing door-to-door screening and medication deliveries was “scary because the people were chasing us away”, Tikwayo said. It was also frustrating as they now had to walk long distances and often had trouble locating the people to whom they were supposed to deliver the medication.
Working on the front lines also came without a danger allowance. “They sent us into the communities to get corona,” Tikwayo said to her fellow workers at the provincial legislature during their picket.
Lack of support
Tikwayo tested positive for Covid-19 on 6 July, but she is thankful to have recovered within a month. She was booked off work for 14 days and stayed home, struggling to breathe. It persisted and she was booked off for another 10 days. In all the time that she was at home, Tikwayo did not receive a phone call or message from anyone at her NPO or the department.
“I was scared, and it was very difficult for me because I had shortness of breath. No one from the NPO or the Department of Health called me to see how I was. All the NPO wanted was a certificate to say that I had Covid-19 and that I wasn’t sitting at home.”
Tikwayo’s experiences are shared by other community health workers, as was evidenced by their vocal reactions to the impassioned speeches made by her and fellow organiser Ntombethemba Maduna. Having seen their Gauteng counterparts being absorbed into the provincial health department at a salary of R8 500 a month, the community health workers are angry at the Western Cape government’s resistance.
Reading a memorandum in front of the crowd, Maduna said: “We reiterate that there is no rational nor legal basis for the continued exclusion of community health workers from permanent staff establishments in the Department of Health, as the work they are performing is permanent in nature.”
While the protesters had hoped to hand over their list of grievances to Nomafrench Mbombo, the member of the executive council for health in the Western Cape, or Alan Winde, the premier, they were disappointed to be met by head of department Douglas Newman-Valentine instead. It was a move they felt indicated that the department does not take them seriously.
Reflecting on the pickets and march, however, Maduna said: “I feel very happy. Especially when I see the community health workers united and showing the Department of Health that we are still here. This is the start of the road. We will show the Department of Health that this will not end. We will continue and continue until our demands are met.”
In the meantime, the workers will continue doing their important work, making their contribution to the delivery of healthcare in their communities. “It’s difficult to work with these organisations,” said Tikwayo, “but we don’t have a choice. We have to put food on the table.”