Community health workers and the response to HIV/AIDS in South Africa: tensions and prospects

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.