The emergence of community health worker programmes in the late apartheid era in South Africa: An historical analysis

Abstract

There is re-emerging interest in community health workers (CHWs) as part of wider policies regarding task-shifting within human resources for health. This paper examines the history of CHW programmes established in South Africa in the later apartheid years (1970s–1994) – a time of innovative initiatives. After 1994, the new democratic government embraced primary healthcare (PHC), however CHW initiatives were not included in their health plan and most of these programmes subsequently collapsed. Since then a wide array of disease-focused CHW projects have emerged, particularly within HIV care.Thirteen oral history interviews and eight witness seminars were conducted in South Africa in April 2008 with founders and CHWs from these earlier programmes. These data were triangulated with written primary sources and analysed using thematic content analysis. The study suggests that 1970s–1990s CHW programmes were seen as innovative, responsive, comprehensive and empowering for staff and communities, a focus which respondents felt was lost within current programmes. The growth of these earlier projects was underpinned by the struggle against apartheid. Respondents felt that the more technical focus of current CHW programmes under-utilise a valuable human resource which previously had a much wider social and health impact. These prior experiences and lessons learned could usefully inform policy-making frameworks for CHWs in South Africa today.

Community Health Workers in Low-, Middle-, and High-Income Countries: An Overview of Their History, Recent Evolution, and Current Effectiveness

“…The manner of selection and training, payment and incentives, career advancement opportunities, and supervision also vary broadly (25,44,88). Recent estimates have suggested that as many as 85,000-200,000 CHWs function in various roles in the United States (25,36,132). In other countries around the world, a conservative estimate is that there are more than 5 million CHWs, including 2.3 million in India alone (Figure 1).…”

‘It’s in our veins’: caring natures and material motivations of community health workers in contexts of economic marginalisation

“…Health system reform immediately after apartheid was mostly technicist and disease oriented and CHWs were left out of public health policy and strategy (Coovadia, Jewkes, Barron, Sanders, & McIntyre, 2009;van Ginneken et al, 2010).…”

“…The first is the recognition that HIV-related funding may have diverted vital resources away from other necessary health-related interventions, and a consequent drying up of 'HIV money' among many South African NGOs relatively accustomed to plentiful funding. The second is a shift towards channelling donor funding through the state (van Ginneken et al, 2010) and growing international trust in South Africa's political leadership to effectively use global public health funding.…”

Towards Promotion of Community rewards to Volunteer Community Health Workers? Lessons from Experiences of Village Health Teams in Luwero, Uganda

“…embraces a variety of selected community based health aids, who are given basic short-term training to work in their communities (Lewin et al, 2010). It is widely acknowledged that CHWs must respond to local societal and cultural norms and customs to safeguard community acceptance and ownership of them (Lehmann & Sanders, 2007a).…”

“…While it was initially expected that CHW programmes would appeal to mass voluntarism, in practice many programmes have financially rewarded CHWs, even hiring them as salaried assistants (Bloom & Standing, 2001;Hongoro & McPake, 2004). However, such financial incentives lead to high attrition (Kironde & Klaasen, 2002;van Ginneken, Lewin, & Berridge, 2010), especially since they often consist of small token allowances (Eng & Parker, 2002;Hadi, 2003).…”