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H S T
by:
M a r c h 19 9 7
Bupendra Makan, Max Bachmann
AN ECONOMIC ANALYSIS OF COMMUNITY HEALTH WORKER PROGRAMMES IN THE WESTERN CAPE PROVINCE
Supported and Co-ordinated by the Health Systems Trust
AN ECONOMIC ANALYSIS OF COMMUNITY HEALTH WORKER PROGRAMMES IN THE WESTERN CAPE PROVINCE
CHWs in Training
By Bupendra Makan & Max Bachmann MARCH 1997
SUPPORTED AND CO-ORDINATED BY THE
H S T HEALTH SYSTEMS TRUST
ISBN No 8 1-919743-07-3
Designed and printed by Kwik Kopy Printing, Durban
FOREWORD The participants of a research project conducted during 1996 commissioned this report. The broader research project is documented under the Health Economics Unit Working Paper series, titled “An Economic Evaluation of Community Health Worker Programmes: Western Cape Province Case Studies” (Makan and McMurchy 1996). Both the initial project and this national report were funded by grants from the Health Systems Trust. The accuracy of the information presented as well as any opinions expressed remain the responsibility of the organisation and/or individuals commissioned to undertake the study.
AUTHORS Bupendra Makan and Max Bachmann
CONTRIBUTORS TO THE REPORT Health Economics Unit Di McIntyre & Dale McMurchy NPPHCN Elise Levendal, Mizana Matiwana & Peter Long Western Cape CHW Programmes SACLA Health Project (Gavin Derbyshire, Di Hawitson & George Moore) Health Care Trust (Bridget Lloyd & Whitey Jacobs) Mamre CHW Programme (Mercia Arendse) Zibonele CHW Programme (Johannah Kelkelame) Rural Foundation (Jenny Bader) NPPHCN Training Centre (Cheryl-Anne Shiskin-Cox) & The Health Systems Trust Natasha Palmer
ACKNOWLEDGEMENTS Sincere thanks are due to all representatives and CHWs of the community-based health worker programmes (CBHWPs), non-governmental organisations (NGOs), concerned individuals and other interest groups for their input, guidance and sharing of knowledge and experiences. The names of all those who participated either directly or indirectly on the broader project appear at the back of this document. Their contribution was extremely valuable and we hope that both reports will provide assurance that the work of CHWs is recognised. Special thanks go to the communities who were involved in the household surveys. Hopefully now that there is more information available, there can be a “speedy resolution to the deployment and training of CHWs”. The Health Care Trust and the SACLA Health Project provided the pictures for this report.
i
TABLE OF CONTENTS Foreword, Authors, Contributors to the Report and Acknowledgements List of Tables and Figures List of Abbreviations List of Appendices Executive Summary Recommendations
i iii iii iii iv v
CHAPTER 1: INTRODUCTION
1
1.1 1.2 1.3
1 1 1
Background An Economic Evaluation of CHW Programmes Literature Review of CHW Effectiveness and Cost Studies
CHAPTER 2: THE HISTORY, ROLE AND FUNCTION OF COMMUNITY HEALTH WORKERS
3
CHAPTER 3: COMMUNITY HEALTH WORKERS IN SOUTH AFRICA
5
3.1 3.1.1 3.2 3.3 3.4 3.5
5 5 6 6 7 7
Contextualising the South African Policy Debate on CHWs The SA Department of Health’s Policy on CHWs The Non-governmental Organisation Responses and Lobby The Department of Health’s and NGOs Response to the CHW Crisis The Western Cape Provincial Policy Regarding CHWs The Current Position on CHWs
CHAPTER 4: EVALUATION OF COMMUNITY HEALTH WORKER PROGRAMMES IN THE WESTERN CAPE PROVINCE
4.1 4.1.1 4.1.2 4.1.2.1 4.1.2.2 4.1.2.3 4.1.2.4 4.1.2.5 4.2 4.2.1 4.2.2 4.2.3 4.2.4 4.2.5 4.3 4.3.1 4.3.2 4.3.3
Community Survey of CHW Activities, Roles and Functions Methods of the Community Survey Results of the Community Survey Socio-economic Information on Communities and Areas Served by CHWs CHWs Activities Attitude to CHWs Willingness to Pay for Services of CHWs Performance and Effectiveness of CHWs Cost Analysis of CHW Programmes CHW Programme Recurrent Costs CHW Programme Capital Costs CHW Programme Total Costs CHW Programme Supervision Costs NPPHCN Training Centre Total Costs Results of the Cost Analysis CHW Programme Costs and Activities NPPHCN - Training Centre Costs and Activities Analysis of CHW Programme Costs and Activities
8
8 8 10 10 10 10 11 11 11 11 11 12 12 12 12 12 13 13
CHAPTER 5: DISCUSSION AND RECOMMENDATIONS
15
5.1 5.2 5.2.1 5.2.2 5.2.3 5.2.4
Discussion Recommendations Context for considering CHW programmes in the South African Health Care System Recommendations to Policy-Makers at National, Provincial and District Level Recommendations to CHW programmes Recommendations for further research into CHW activities
15 16 16 16 17 18
Bibliography Appendices
19 22
ii
LIST OF TABLES AND FIGURES Figure 1: Table 1: Table 2: Table 3: Table 4: Table 5: Table Table Table Table
6: 7: 8: 9:
A Systems Approach for CHW Advocacy of Oral Rehydration Solution Therapy Tasks Expected of CHWs in the WHO Inter-regional Study of eleven Countries NPPHCN Directory of CHWs in South Africa - 1994 CHW Programme Descriptive Profiles CHW Programme Areas Covered by the Community Survey Percentage of respondents with “good” knowledge of health topics, comparing those who had and had not had contact with a CHW in the last six months CHW Programmes Total Costs and Numbers of Patient Contacts for 1994/95 Capital and Recurrent Costs as % Total Expenditure for 1994/95 Allocation (%) of Programme Costs to Different Activities in three CHW Programmes Average Costs per unit of CHW Activity and Supervision Costs as Percentage of Total Costs
LIST OF ABBREVIATIONS ANC CASE CBHWP CBOs CHWs CRIC CRWs DHS DoH HCT HEU HIV / AIDS HST IDT MCHWP MOU MRC NGOs NPPHCN NPPHCN-TC ORS PAWC PHC RDP RF SA SACLA SAHSSO SANCO SHAWCO TB UNICEF VHW WC WHO WWWs WCRSC ZCHWP
African National Congress Community Agency for Social Enquiry Community-based health worker programmes Community-based Organisations Community health workers Careers Resource and Information Centre Community Rehabilitation Workers District Health Systems Department of Health Health Care Trust Health Economics Unit Human Immunity-deficient Virus / Acquired Immune Deficiency Syndrome Health Systems Trust Independent Development Trust Mamre Community Health Worker Programme Mid-wives Obstetrics Unit Medical Research Council Non-governmental organisations National Progressive Primary Health Care Network National Progressive Primary Health Care Network - Training Centre Oral Rehydration Solution Provincial Administration Western Cape Primary Health Care Reconstruction and Development Programme Rural Foundation South Africa South African Christian Leadership Assembly South African Health and Social Services Organisation South African National Civics Organisation Students Health and Welfare Committee Tuberculosis United Nations Children’s Fund Village Health Worker Western Cape World Health Organisation Women’s Wellness Workers Western Cape Regional Services Council Zibonele Community Health Worker Programme
Appendix 1: Appendix 2: Appendix 3:
List of Contributors to the Study A Systems Approach for CHW Advocacy Family Planning. Recommendations of the Conference on “Assessing the Feasibility of Greater State Support to CBHWPs”
LIST OF APPENDICES
iii
Child Health Day activity
EXECUTIVE SUMMARY The role and functioning of Community Health Worker (CHW) programmes in South Africa’s health system requires clearer definition and evaluation. This report seeks to inform this process by providing information for CHW programmes, the national and provincial policy-makers and district level health managers involved in the debate. It provides information about CHW programmes in the Western Cape province and presents an innovative evaluation methodology. Information was obtained predominantly from CHW programme records, interviews, community surveys and selected literature reviews. The data was collected under the supervision of the Health Economics Unit (HEU) (based at the University of Cape Town) in collaboration with participant CHW programmes. Data collection was based on the “systems approach”, namely the inputs, processes, outputs, impact costs and performance factors of CHW programmes. This study describes five CHW programmes and one CHW training centre operating in the Western Cape province. These programmes jointly account for an estimated 49% of the total CHW programme expenditure in the province (an estimated R11,7 million for 1994/95). Research included household surveys in the areas served by programmes, which provided demographic health profiles and information on the health knowledge of communities served by CHW programmes and detailed cost analyses of each programme. It helped answer questions about what CHWs do, which communities they serve, how programmes differ and what their service costs are. The study found that CHWs deliver essential Primary Health Care (PHC) services, particularly in marginalised communities. All the CHW programmes were operating in rural or peri-urban areas, which were characterised by severe poverty and inadequate services. A high percentage (81% - 98%) of the population in the areas served had seen a CHW in the past year. At least 88% of all respondents knew the CHW in their area. The diseases treated by CHWs closely match the illnesses most commonly reported by communities living in their areas. The majority of respondents (82% - 93%) were in favour of CHW activities in their communities. Despite the recent introduction of free health care for children less than 6 years of age and pregnant women, between 67% and 93% of respondents were willing to pay up to R5 per contact for CHWs services. A key finding was that the curative and preventive roles of CHWs are integrally linked, with CHWs using curative visits as a platform for providing health education. The percentage of children with “Road to Health cards” and immunisation coverage in the areas served by CHWs was recorded to be high (between 76% and 93% of children surveyed). Those who had seen CHWs as compared to those who had not seen a CHW, were generally more likely to have good knowledge about oral rehydration solution (ORS) therapy, burn treatment, and tuberculosis (TB). These findings suggest that CHWs may have imparted the knowledge effectively, but it is also possible that more knowledgeable patients could have sought CHW contact. The cost analysis of CHW programmes revealed that the average cost for initial training at the National Progressive Primary Health Care Network Training Centre (NPPHCN-TC) was approximately R17, 000 per CHW during 1994 and R10, 000 during 1995. The decrease in costs between 1994 and 1995 is associated with economies of scale. The average salary of full-time CHWs in four of the programmes was R1, 350 per month for 1994/95 (R16, 200 per annum). In the fifth programme, which is largely part-time and farm-based, CHWs received average monthly salaries of R269 (R3, 230 per annum).
iv
The average costs for CHW activities varied between programmes. Costs were similar in different peri-urban programmes, but higher in the rural programme areas. The average cost per visit to a generalist CHW ranged from R11 to R35. For the three peri-urban CHW programmes, the average cost per home visit was R26, R28, and R27 respectively. Specialist visits (e.g. those for TB supervision), were more expensive than generalist visits. Visits for TB treatment in two CHW programmes ranged from R27 to R82. Generally, the cost of a visit to a CHW was about half that of a home visit. Average costs of visits to CHWs were as high, if not higher, in the programme employing part-time CHWs than in other programmes employing full-time CHWs. As a broad indicator and measure of efficiency, CHW costs can be compared to costs of other health services. However, this comparison does not take into account differences in disease severity and professional training. The costs per visit to a CHW and per home visit were similar to the estimated costs of visits to public sector clinics. The Health Expenditure Review (1995) estimate that for 1992/93 the average cost of a clinic visit is R30, and an outpatient visit at a community hospital is R55 (McIntyre et al 1995). Rispel et al (1996) estimates a visit to a periurban clinic (Upington) to cost R22. The cost per visit to a CHW calculated in this study (ranging from R11 - R35 per visit to a CHW). It is noted that when accounting for inflation to the 1992/93 public sector costs (as referenced from the McIntyre et al study), and comparing it to the costs of CHW contacts for 1994/95, it is evident that the CHW costs are lower. Therefore, CHWs might indeed provide an affordable PHC service, although the services are not absolutely comparable to clinics. The true efficiency of the programmes depends, however, on whether they are effective in preventing serious illness through health promotion, early diagnosis and treatment and, where necessary, referral. CHWs should be seen as complementary to the formal services and not as cheap substitutes. The particular strengths of CHWs (e.g. accessibility, acceptability, and cultural sensitivity) as well as their limitations (e.g. ability to diagnose and treat serious illnesses) should be considered. Costs of CHW supervision and support were proportionately greater in small programmes than in larger programmes. Programmes started more recently tend to have higher costs than those operating for several years do. These findings suggest that there may be economies of scale, which would justify support for expansion of medium to large-scale programmes. Alternatively, starting new programmes is likely to involve higher costs. A wide range in average costs and remuneration between programmes suggests that less efficient programmes can learn from more efficient ones. Home visiting and supervising in small projects are relatively costly activities. The comparison between CHWs and facility-based care is a useful one, but in most cases not representative of a real choice. This study has shown that CHWs provide essential information and treatment of common illnesses to people in areas where there is limited access to other health services. Further questions raised by this study relate to: how effectively CHWs deliver their services, taking into account their health education, curative and preventive activities? How CHWs are monitored and evaluated considering the priorities for primary care development? Given the dependence on donor funding, whether the consideration of “volunteer” type programmes, which would incur substantial recurrent cost savings (e.g. current remuneration costs of CHWs) is a more viable option? The sustainability of CHW programmes largely depends on whether health authorities and donor organisations agree to finance their maintenance and expansion. This in turn is dependent on the ability of CHW programmes to show effectiveness, achievements and affordability.
RECOMMENDATIONS Several key themes related to transforming South Africa’s health care system suggest that community-based interventions such as CHW programmes will continue and have an important role to play. The adoption of the PHC approach with its emphasis on community participation, and affordable, preventive and promotive care, are the central features of this process. Other related themes pertinent to the South African situation are: • the development of a District Health System (DHC); • the decentralisation of health care delivery; • the scarcity of health care resources; and • the continued pressure on CHW programmes with regard to external donor funding. All aspects of the CHW debate are not limited solely to the issue of economic analysis of CHW programmes. The international literature review contributed significantly to informing the context of the recommendations. Similarly, some important points arose from the review of the policy environment associated with CHWs in South Africa. These served to contextualise the background for the more specific recommendations emanating from the economic analysis covered in this report.
v
The recommendations of this report are divided according to the stakeholder categories to whom they are most relevant. These relate to: Recommendations to policy-makers at National, Provincial and District Level: • Develop a coherent government policy on the role, function and financing of CHW programmes in order to inform provincial planning. • Strengthen collaborative links between community-based and CHW programmes and formal health services (noting supervision and referral links) and informal health care providers (e.g. traditional healers, traditional birth attendants, etc.). • Pursue mechanisms for provincial support to CHW programmes noting the provision of financial subsidies, facilities and equipment, as well as assistance with CHW training and supervision. • The need to consider/investigate “volunteer” type CHW programmes and support via the district health authorities. • Clarify the role of CHW programmes. • Card “volunteer” type programmes within the DHS. • Consolidate and disseminate a basic core-curriculum for the training of CHWs and community volunteers. • Recognise that the training of formal health care workers needs to be sensitised to the PHC approach and the role and functioning of CHWs. Recommendations to CHW programmes: • Incorporate cost and performance measures into management and routine monitoring and evaluation (with an emphasis on improving record systems, evaluating programmes in relation to clearly defined objectives and criteria etc.). • Increased collaboration between CHW programmes focused on the sharing of information (targeted at developing more effective and efficient systems) and for sectorial lobbying (e.g. provincial consortia of CHW programmes). • CHW programmes should retain their independent and NGO status in order to maintain community accountability and participation structures. • Ensure that CHW training is responsive to the specific health needs of the community. Recommendations for further research into CHW activities: In examining the role, function and costs of CHW programmes, there remains a need for research to measure the efficiency and effectiveness of their activities. Core research areas relate to: • Determining an appropriate size and structure for CHW programmes. Models presented by Lomax and Mametja (1995) and in this provincial case study could facilitate such a process. Such research could then inform decisions as to whether existing programmes should be transformed, extended or additional programmes developed. • The cost and effectiveness of specialist CHW programmes in comparison to generalist programmes should be further evaluated. • “Volunteer” type (part-time and unpaid) CHWs and programmes, especially in terms of acceptability of the notion to NGOs and communities and it’s operationalisation, needs to be investigated. • Alternative models of developing CHW programmes and alternative sources of funding for CHW programmes need investigation.
CHW Children’s day immunisation check ups
vi
CHAPTER 1 INTRODUCTION 1.1
Background
The role, performance and cost effectiveness of CHWs and their place within a transformed South African health care system have been the subject of ongoing debate in recent years. CHWs are widely seen as a vital part of the PHC approach, and as important partners in health care delivery, especially in peri-urban and rural areas where there is poor access to state and local authority health services. However, some health professionals see CHWs as non-priority personnel and question their role and impact on health and development. This view is strengthened by a lack of evidence on the effectiveness of community-based health interventions by CHWs. It is further compounded by limited knowledge of who CHWs serve, what they do and what their services cost. In 1996, the South African Department of Health (DoH), in a national policy directive, left the question of funding and support for CHW programmes to the discretion of the nine provincial health departments (DoH 1996). While some provinces, KwaZulu-Natal and the Eastern Cape, have already begun to consider NGOs within the functioning of a District Health System (DHS), little direct mention has been made of CHW programmes themselves. However, ongoing uncertainty at the national level is beginning to take its toll in the form of reduced funding possibilities for CHW programmes. The present policy vacuum suggests the need for relevant information about the nature and functioning of CHW programmes. Such information can be used as a basis for the development of greater state support if this is shown to be appropriate within the context of DHS development.
1.2
An Economic Evaluation of CHW Programmes
The aim of this study was to evaluate and analyse the nature, performance and costs of a sample of peri-urban and rural based CHW programmes operating in the Western Cape province. The objectives of the study were to provide an overview of the history, role and function of CHWs with an emphasis on the South African experience, describe and compare the CHW programmes in terms of the socio-economic status, health and health care utilisation of populations served, the nature of the programmes’ work, and to evaluate and compare costs with output indicators (noting total and average costs). Programmes were analysed using a systems framework, as summarised in Figure 1. The example used to illustrate the systems framework is the process associated with oral rehydration solution (ORS) therapy (see Appendix 2 for a further example in relation to family planning activities of CHWs). Valid measures of inputs, processes and outputs were defined, and impacts were indirectly inferred from community surveys. This summarised report focuses on the first three stages of the systems framework, with an emphasis on the cost considerations (see Figure 1). Measures of impact and outcome attributable to CHW programmes were also addressed, however, they are not dealt with in this report (see Makan and McMurchy 1996). The latter area of impact and outcomes (i.e. changes in health status) are not introduced given the considerable methodological debate surrounding their measurement (Berman et al 1987 and Walt 1988b). Figure 1: A Systems Approach for CHW Advocacy of Oral Rehydration Solution (ORS) Therapy: 1
2
3
4
5
INPUT e.g. trained CHW and ORS packets
PROCESS e.g. CHWs diagnose, educate and prescribe ORS
OUTPUT e.g. ORS packet given to child
IMPACT e.g. Increased knowledge and behavioural influences about ORS
OUTCOME e.g. dehydration and death of children avoided
TOTAL COST
COST
COST PER OUTPUT UNIT
COST PER IMPACT
EFFECTIVENESS AND COST EFFECTIVENESS
Source: PHC Manual for Trainers, 1995, Rossi, 1979, and Berman et al, 1987.
1.3
Literature Review of CHW Effectiveness and Cost Studies
The effect of CHW programmes has been analysed in several previous studies. Three South African studies conducted in the former Ciskei, Western Cape and KwaZulu-Natal compared populations before and after the introduction of CHW programmes, and showed improvements in knowledge of ORS, breast-feeding, possession of “Road to Health” cards, immunisation coverage, supervision of births and/or infant and child mortality
1
(Kuhn et al 1990, Matthews et al 1991, Lomax and Mametja 1995). A fourth study found that people living in KwaZulu-Natal health wards covered by CHW programmes had better health knowledge than people in wards without programmes (Lomax and Mametja 1995). These studies illustrate the difficulties of impact and outcome comparisons. Other factors, such as the activities of state health services may have changed over time, or may have been different between wards, and this may contribute to observed differences in health status or knowledge of the communities served. The ideal way to exclude the effects of other factors would be to allocate randomly different communities to receive, or not to receive, new CHW programmes while controlling for other factors. Changes in health status or knowledge could then be compared between served and unserved communities. However, randomisation is unlikely to be feasible on a large scale (Walt 1988b). An alternative method would be to compare changes over time in otherwise similar communities with and without new CHW programmes, but without randomisation. This method is as yet untried, due to its potentially high resource requirements in terms of time and costs (Walt 1988b). A third method, used in this study, was to compare people who had and had not been served by CHWs and to adjust statistically for differences between them. The main limitation of this method is that it is only possible to make statistical adjustments for those factors that are accurately measured. Results obtained must be treated with caution and therefore cannot be claimed to prove effectiveness (See Makan and McMurchy 1996). The costing methodology, the key focus of this report, is shown to be less problematic and serves to provide a useful baseline assessment of CHW resource utilisation (See input, process, output stages of system approach in Figure 1). Sigwaza et al (1994) conducted an evaluation of the performance, impact and costs of the Valley Trust CHW Programme in KwaZulu-Natal. The results provided positive feedback on the programme in terms of achievement of it’s objectives, coverage, and the CHWs education roles. It also identified weaknesses in CHW programmes record and referral systems. In terms of impact, the study showed that 75% of respondents were in support of the programme and that there was a relatively good knowledge about the roles of the CHWs. Importantly, the study presented a crude cost per CHW of R615 CHW checking blood pressure per month for services rendered during the 1993/94 period (Sigwaza et al, 1994). However, the costing methodology did not account for capital, training costs and donated funds. Their recommendations indicated the need for further analysis of the effects of CHWs, and stressed the importance of comparing costs between programmes. Internationally, there are limited economic evaluation studies on CHW programmes. To date, a methodology focused on costs and effectiveness has been pursued in only one study (Berman et al 1987). This report integrates the methodology developed in the Berman et al (1987) study to contribute to understanding not only the nature of CHW programmes, but also their costs.
2
CHAPTER 2 THE HISTORY, ROLE AND FUNCTION OF COMMUNITY HEALTH WORKERS It is widely recognised that the historical roots of health care are deeply embedded in community initiatives, and that facility-based care is a fairly recent development dating to the 19th century, and coinciding with biomedical advances in health (Walt, 1988a; Starr, 1988). These developments have in turn focused on individuals rather than on the community or a public health approach. Support for CHW programmes can therefore be seen as a reassertion of the importance of community linkages to the bio-medical health care system. The history of CHW programmes can be traced to two key origins (Frankel 1992). The first is an acceptance of the relative failure of facility-based services or a response to the lack of trained personnel, in poor and rural communities, to provide adequate and appropriate services for the majority of health problems at a reasonable cost. The second, is the recognition that health interventions need to be comprehensive and include preventive, promotive, curative, rehabilitative and palliative measures. It is argued that CHWs can effectively provide these services (Walt 1988b, Sidal 1972). Internationally, there has been a clear link between CHWs, PHC, and DHS development (Berman et al 1987 and Walt 1988a). It is evident from international experience, that the PHC approach together with CHW programmes has been the basis of DHS development, especially in developing countries. The Alma-Ata conference held in 1978, described the PHC approach as the mechanism for achieving the World Health Organisation (WHO) goal of “Health for All”. CHWs were understood to serve as integral agents for the achievement of this goal. The term CHW, which came into wide usage in the 1980s, encompasses a variety of types of health workers. These have included CHW reference to family welfare educators, health promoters, health volunteers, village health workers, as well as barefoot doctors, feldshers, and auxiliary nurses. In some communities where CHWs specialise in areas such as rehabilitation, mental health, and women’s health, they may called accordingly. Whilst the diversity of names reflects the variety of tasks and functions performed by CHWs, they all refer “to an indigenous attempt to meet local health needs” (Walt 1988a). The WHO definition is “CHWs are members of the community where they work; should be selected by the communities; should be answerable to the communities for their activities; should be supported by the health system but not necessarily as a part of its organisation; and have a shorter training than professional workers” (WHO 1987). Berman et al (1987) in defining CHWs1 noted that they are “...volunteers or who may receive a salary ... who are generally not civil servants of professional employees of the ministry of health”. This is an important differentiating point of various CHW programmes in the international context. It has been shown that the relationship CHWs have with their funders will to some extent impact on and determine their role and function (Berman et al 1987, Walt 1988b). For example, CHWs who are employed from within the DoH may be given a different role to perform than if the CHWs were funded by their local communities to act as their representative in health matters. Similarly, CHWs who are funded from within NGOs may have to function within the agenda set by the NGO and not by the community or DoH. An international survey of CHW programmes conducted by the WHO showed that some CHW functions are shared by most countries, while others are less consistent between countries (See Table 1 over).
1 Berman et al (1987) defined CHWs as “local inhabitants given limited amount of training to provide specific basic health and nutrition services to the members of their communities. They are expected to remain in their home village or neighbourhood and usually work part-time as health workers”.
3
Table 1:
Tasks expected of CHWs in the WHO Inter-regional Study of Eleven Countries: Designated tasks in all 11 countries (*): • First aid, treat accidents and simple illness • Dispense basic drugs • Pre- and post-natal advice and motivation • Child-care advice and motivation • Nutrition motivation and demonstration • Immunisation motivation and assistance during clinic • Environmental sanitation, personal hygiene and motivation • Referral of difficult cases to the health centre or hospital • Maintain records and reports • Participate in meetings Designated tasks in 10 out of 11 countries: • Family Planning motivation • Communicable disease screening, referral, prevention, and motivation • Communicable disease follow-up, motivation of confirmed cases • Visit homes on a regular basis Designated tasks in 8 out of 11 countries: • Nutrition action • Collect vital statistics • Perform tasks outside the health sector Designated tasks in fewer than 8 countries: • Communicable disease action (7 countries) • Family Planning Distribute supplies (6 countries) • Assist health centre clinic activities (5 countries) • Immunisation - give shots (3 countries) • Perform school health activities regularly (3 countries) • Deliver babies (2 countries)
Source: Berman et al 1987, Walt 1988a & b and Lomax and Mametja (1995). Note: * These task align with the Alma Ata Declaration which defined the role of the CHW as performing services at the community level within the parameters identified as the elements of PHC (WHO 1978)
The extent to which CHWs should provide curative care has been widely debated. For some, any emphasis on curative care will merely transform CHWs into the lowest tier of health service personnel. They become perceived as an inferior type of primary level nurse in the community. For this reason, some health workers have stressed that CHWs should not be seen as a level in the tier of health personnel, but rather as a complementary cadre of health worker which works alongside formal bio-medical primary level health workers (i.e. those located at clinics and community health centres) (Frankel 1992). In commenting on implementation Walt (1994) referred to an example from Botswana. The introduction of CHWs as a way of expanding primary health services, was perceived by some clinic nurses as a useful way of getting “an extra pair of hands” rather than “improving outreach services to the community” (Walt 1994). This issue highlights the importance of gaining a clear understanding of, and agreement on, objectives of the role and function of CHWs. In certain instances, generalist CHWs are provided with additional training in “specialist areas”. These specialist CHWs are trained to meet specific community needs, and may function as community-based rehabilitation workers (CBRWs), environmental health officers, women’s wellness workers (WWWs), HIV/AIDS educators or even dedicated malaria workers. This practice has gained tremendous support internationally. Key factors for the effective functioning of CHW programmes include the adherence to appropriate criteria for selecting and training CHWs (Lomax and Mametja 1995) and adequately defined monitoring and supervision activities (Makan and McMurchy 1996, Chetty 1993). Sanders (1985) indicated that the accountability of CHWs/ VHWs is crucially linked to the selection process set by the community and not the medical professionals. The relationship is further strengthened by the fact that CHWs/FHWs while working part-time as health workers are partly subsidised by their community in either cash or kind (Sanders 1985). Of consequence the methods of selection and payment help to ensure control over the CHW by the community. The experience of developing countries where NGOs, dominated by medical professionals, through whom funding is channelled, assume accountability above the community, there are inevitably problems in the sustainability of programmes (Walt 1988b and Sanders 1985). In summary, this chapter has outlined the key roles and functions of CHWs and illustrates that in situations where monitoring and supervision processes are poorly co-ordinated, payment is provided from external and state sources, that CHW programmes are likely to experience problems. This was particularly relevant in reviews of large-scale and government programmes (Walt 1988a, World Bank 1995) and poses key lessons for South African programmes.
4
CHAPTER 3 COMMUNITY HEALTH WORKERS IN SOUTH AFRICA There were an estimated 7,047 CHWs deployed across South Africa in 1994/95 (NPPHCN 1995). Approximately 19% of these were trainee CHWs, and the large majority of CHWs were operative in the KwaZulu-Natal, former Northern Transvaal, and Free State areas (Table 2). Table 2: NPPHCN Directory of CHWs in South Africa - 1994 Area *:
Full-time CHWs
Trainee CHWs
Total
%
232
26
258
3.6
Eastern Cape
177
18
195
2.7
Transkei
189
0
189
2.7
Western Cape
322
95
417
5.9
51
0
51
0.8 32.8
Border
Eastern Transvaal KwaZulu Natal
** 2,111
197
2,308
Northern Transvaal
1,269
1,014
2,283
32.4
Free State
1,093
9
1,102
15.6
Transvaal - PWV Total
243 81 %
5,687
19 %
1
244
3.5
1,360
100% 7,047
100.0
Source: NPPHCN CHW Directory 1995 and HEU validation *
- According to the pre-1994 South African provincial boundaries
** - Part-time CHWs operating in KwaZulu-Natal province
3.1.
Contextualising the South African Policy Debate on CHWs
Various surveys have been conducted recently to gauge public opinion on health issues in South Africa. According to the results of a survey conducted by the Community Agency for Social Enquiry (CASE) in 1995, 65% of total respondents (namely 71% of Africans, 68% of so-called Coloureds, 59% of Indians, and 30% of Whites) indicated support for the introduction of trained CHWs into their communities. More specifically, a large majority of respondents recognized that CHWs would serve to improve health services. In general, proportionately more people living in rural areas (74%) were likely to favour CHWs, than those in formal (58%) or informal urban areas (59%) (Hirschowitz and Orkin, 1995). Health workers in rural areas (operating in KwaZulu Natal) have also indicated consistent and vocal support to CHW programmes (McCoy et al, 1994). 3.1.1 The SA Department of Health’s Policy on CHWs The issue of CHWs has been debated extensively in South Africa. This sub-section highlights government policymakers’ thinking about CHWs since 1990, and contextualises the key positions within the debate. At a CHW forum workshop on CHWs in 1990, the former Director General of Health, Dr C. Slabbert, reviewed the experience of CHW programmes in South Africa. Despite reference to various limitations, he called for a more focused approach to the range of issues confronting CHW programmes. The DoH’s position at the time referred to the “firm belief that in our PHC programme we need the CHW. The successful implementation of CHW programmes demands avoiding the pitfalls encountered by other countries ... the basic goal of the forum is to lay a solid foundation on which all health authorities can build their CHW and PHC Programmes” (DoH, CHW Forum, 1990). In 1994, the African National Congress (ANC) initially presented strong support for CHWs in its draft policy documents on health sector transformation. CHWs were seen as “... an important part of PHC ... in expanding and improving health services, provided they have effective support structures and referral systems and they receive ongoing training. They can also be catalysts for community development, mobilising people around issues like the need for clean water, sanitation, waste disposal, safe playgrounds and so on, and they can play an important role in empowering people with knowledge and involvement in health issues. They should be integrated into health services and paid, like other workers according to their level of training and skills by the community or by the government. Career structures and pathways for promotion within the systems should be open for them so that their contribution can be recognised” (ANC second draft Health Plan, 1994). However, this position had been significantly watered down by the time of the publication of the final health plan. Only one reference to CHWs appeared: “local CHW programmes will be encouraged, provided that they are integrated into local health services, but no national programme will be launched at this point” (ANC Health Plan, 1994).
5
However, the Reconstruction and Development Programme (RDP), in attempting to contextualise the importance of meeting the basic needs of all the people of South Africa, stressed: • community involvement in planning, management, delivery, monitoring, and evaluation of health services; • providing core teams for every community health centre and clinic, which will require incentives to attract staff to under-serviced (especially rural) areas and increased training of CHWs and environmental health officers; • empowering people and communities; • addressing the curative biases in the health budget; and • transforming fragmented health care delivery into a unified health system with a focus on PHC. (Government of National Unity, RDP White Paper, 1994) Lastly the RDP made specific mention that “the system must encourage the training, use and support of CHWs as cost effective or alternative personnel”. Despite popular opinion and an increased lobby for CHWs, the official government policy released in 1996 made no definitive statement on CHWs. This lack of clear support to CHWs contributed to further uncertainty around the sustainability of CHW programmes in South Africa. The above references to CHWs from policy submissions and government, forms the backdrop for examining the current position of NGOs and the DoH regarding the role, function and deployment of CHWs.
3.2
The Non-governmental Organisation Responses and Lobby
In response to the lack of a clear policy position on CHWs, the NPPHCN and its affiliates argued that the RDP priorities fell directly within the ambit of CHW programme activities. It was indicated that the contribution of CHW programmes toward the RDP warranted serious consideration, but despite this overlap in intent and priorities, no direct government funding was forthcoming to CHW programmes. To address the ongoing lack of clarity concerning CHWs, health sector NGOs held a national summit in June 1994. The key objective was to assess the feasibility of greater state support to community-based health worker programmes (CBHWPs) and increased national co-ordination of CHW programmes. The conference issued recommendations on training, curriculum, accreditation, and re-orientation of professional health care personnel. In addition, the conference strongly favoured the consideration of CHWs within the context of a DHS (See Appendix 3: Recommendations of the Conference on “Assessing the Feasibility of Greater State Support to CBHWPs”). In October 1994, the NPPHCN submitted a memorandum to the Minister of Health, in which concern was raised about the final draft of the ANC’s Health Plan and government policy with respect to CHWs. It was felt that the lack of policy would destroy the notion of community ownership and community-supported organisations and in turn damage the trust that has been built-up by NGOs and CBOs within the communities. It was also pointed out that the issue had seriously contributed to the funding crisis confronting CHW programmes. Many programmes operated in communities where CHWs were the only source of health care available, were on the brink of closure.
3.3
The Department of Health’s and NGOs Responses to the CHW Crisis
The government’s cautious response to the CHW issue is probably best captured by the Minister of Health, Dr N. Zuma, at a National Assembly budget vote speech in October 1994, where the following statement was made: “A human resource question for S.A. that is not resolved is the employment of CHWs in the health care system. The question often asked is whether the DoH plans to absorb these workers into the health care system. The Human Resource Committee, in its deliberations, is examining the role of CHWs in service delivery. As you may know CHWs have played a role in service delivery at local level and have been paid from donations of funds from international sources. Since their services are community-specific, the local authorities, and possibly the provincial MEC’s can decide on policy regarding their absorption into local health services. Before the National Health Ministry can take a policy decision on this matter we will have to know the financial implications on the health care system. Since this is a local matter, therefore input from local authorities and provincial MEC’s and taking into account the findings of the Human Resource Committee will be crucial in determining the fate of CHWs. ... I believe that CHWs have a valuable role to play at local level. They may be employed by local authorities or local NGOs...” (Minister Zuma, October 1994). In the 1995 directory of CHW programmes, the NPPHCN reiterated its concern of the funding crisis and uncertainty of foreign donors with respect to CHW programmes. It was observed that: “CHW programmes should be the responsibility of local government so as to enhance accountability to local communities ... which does not absolve national government from adopting a clear policy principle to guide local government” (NPPHCN, 1995). This sentiment can be traced back to the NPPHCN / SAHSSO Health Policy Conference held in 1992, where the future of CHWs was debated within a “paradox of policy” context (Lund, 1993).
6
3.4
The Western Cape Provincial Policy Regarding CHWs
The Western Cape Provincial Health Plan (1995) reflected the position of health care stakeholders in the province concerning CHWs by the following statement: “Given the underdevelopment of the lower levels of service, a priority will be to increase the numbers of primary and community level workers, especially clinical nurse practitioners, workers in health promotion, environmental health, nutrition, rehabilitation etc. and CHWs drawn from disadvantaged communities. Many of these “auxiliaries” or assistants should be placed at clinics and community health centres and supported by the appropriate professional cadres in the district” (Provincial Administration Western Cape 1995). The position highlights the consideration of the redistribution and reorientation of health personnel in districts so that they can function as comprehensive workers in communities where the health burden is heaviest and service provision is usually poorest. Similarly, when considering the DHS, there is specific mention of CHWs in its “ideal mix of personnel” where CHWs are envisaged at the community, satellite clinic, clinic, and community health centre levels. The recommendation is that, “CHWs should be generalist, and that the “specialisation” of CHWs should be avoided. Lastly, the training of CHWs, along with other personnel is identified as a priority area and is envisaged as a function of the district health office.
3.5
The Current Position on CHWs
Despite the vigorous debate on the role and functions of CHWs in the 1990s, considerable confusion remains on the official policy of how CHWs are to be deployed within the South African health care system. As a result, CHW programmes continue to be surrounded by uncertainty which increasingly impacts on their operations and future sustainability. The DoH’s most recent policy statement on CHWs was contained in the official policy document titled “Restructuring the National Health System for Universal Primary Health Care”, which stated that: “It is recognised that CHWs may be able to make an important contribution to the health of communities in some instances, and to provide a link between the formal health services and communities. Furthermore, ... this category of health worker should not be incorporated into the formal health services. This obviously does not preclude NGOs / CBOs and other organisations from continuing with CHW programmes” (DoH 1996). From the policy debate outlined above, there is a further need for clarification on the potential of CHW programmes to contribute in the following areas, namely: • to provide basic and comprehensive health services (as outlined in the RDP); • to foster community involvement and participation; and • to enhance DHS development (in relation to local authorities’ health service functioning) within the broader integrated health system. The relationship which should exist between CHW programmes and district and provincial government is also still in need of clarification. In response, the National Assembly Portfolio Committee on Health in its report on the Health Budget vote, CHW counselling a mother recommended that there “needs to be a speedy resolution to the question of the training and deployment of CHWs” (National Assembly Portfolio Committee on Health, 1996). In order to contextualise the above debate it is necessary to examine what is happening in reality (albeit a provincial setting). The following chapters of this report outline the issues concerning the role, function and performance of CHWs, the communities served and their perceptions and experiences, and the cost of services. This information will hopefully feed into the debate and allow for rational decisions to be made on the future of CHWs.
7
CHAPTER 4 EVALUATION OF COMMUNITY HEALTH WORKER PROGRAMMES IN THE WESTERN CAPE PROVINCE It was estimated in 1994 that the Western Cape province had 24 community-based health programmes plus 10 health committees that employed a total of 687 part-time and full-time CHWs (Makan and McMurchy 1996).2 For this study, five programmes, employing 301 CHWs, were selected for analysis. They were the South African Christian Leadership Association’s (SACLA) peri-urban and rural programmes, the Health Care Trust (HCT), Rural Foundation (RF), Mamre CHW Programme (MCHWP) and the Zibonele CHW programme (ZCHWP). The selection included a range of rural and peri-urban programmes, which employed CHWs on a full-time or part-time basis. In addition, the selection included a range of generalist and specialist type programmes, for example the Mamre programme which provides chronic care and youth directed health education services only. Other CHW programmes included both generalist and specialist activities (e.g. the ZCHWP’s Women’s Wellness division). The study included the following: • a survey comprising of 1,517 household questionnaires, based on a random sample of populations served by three of the programmes; • a cost analysis of each CHW programme for the 1994/95 financial year; • an analysis of the activities and costs of National Progressive Primary Health Care Network Training Centre (NPPHCN-TC), which provides training for many of the CHW programmes in the province.
4.1 The • • •
Community Survey of CHW Activities, Roles and Functions specific objectives of the community survey were to: determine the coverage, utilisation and community perceptions of the CHW programmes; describe the health knowledge and health profiles of the communities served by the CHW programmes; and examine the relationship between CHW activity and community health knowledge and practices.
4.1.1 Methods of the Community Survey The population studied consisted of all households in the residential areas covered by three CHW programmes (including the SACLA, HCT, and RFCHW Programmes).3 The total estimated population sizes in the study areas of these three CHW programme areas was 226,185, residing in an estimated 45,080 households. Tables 3 and 4 provide an outline of the CHW programmes and their respective residential areas of operation, the estimated population served, the number of CHWs per area and the average population per CHW.
2
The Makan and McMurchy study conducted in 1996 estimated 687 CHWs to be operative in the Western Cape Province for 1994. This differs from the 417 recorded in the NPPHCN directory (NPPHCN) 1995). Differences are likely given definitional issues linked to CBHWs (see Makan and McMurchy 1996).
3
The information collected for the Zibonele survey was not included in this report because the Zibonele questionnaire was substantially modified to fit in with another survey for the Women’s Wellness Workers component of the programme (Moodley 1995). Similarly, the Mamre CHW programme was not included in this study’s community survey given that an intensive survey had been conducted in 1996 (Weinberg and Louw 1994, Louw and Katzennelbogen 1994).
8
Table 3: CHW programme Descriptive Profiles CHW programme
Programme link to CHW characteristic: Representivity & operationalised principles of PHC
Areas of Operation: • Peri-urban • Rural
Health care providers in the areas served by the CHW programme: Health service availability
CHW Programme Size: i.e. • small scale, medium or large • number of CHWs
Year of Commencement
SACLA Health Programme
Yes
Peri-urban & Rural 6 areas served in total
Varied-SACLA clinics, Local Authority Clinics, mid-wives obstetrics unit, and Community Health Centres
Medium scale 79 CHWs 11 CRWs -----------------90 Total
1980
HCT CHW Programme
Yes
Peri-urban 2 areas served
LimitedPart-time Local Authority Clinic
Small scale 11/15 CHWs
1992
Mamre CHW Programme
Yes
Peri-urban Rural 1 area served
Limitedonly a Local Authority Clinic
Small scale 4 CHWs
1992
Rural Foundation CHW Programme
Yes
Rural
Limited and variedsome areas covered by WCRSC Mobile clinics and connection to district surgeons
Medium Scale 189 FHWs and/or CHWs
1986
LimitedClinic and Day Hospital
Small Scale 15 CHWs
1992
14 areas served
Zibonele CHW Programme
Yes
Peri-urban 1 area
Source: CHW project records, 1994/95 Note: CRWs: Community rehabilitation workers and FHWs: farm health workers
Table 4: CHW programme Areas Covered by the Community Survey CHW Programme
Areas of Operation
SACLA Health Programme - peri-urban
• Site B • Site C • New Crossroads • Browns Farm • KTC
SACLA Health Programme - rural
• • • •
HCT CHW Programme
Estimated population served & (Areas served):
Number of CHWs for areas surveyed:
Ratio - Average population per CHW:
190,000 (6)
52
3,654:1
17,500 (4)
8
2,188:1
• Browns Farm • Samora Machel
10,000 (1)
15
667:1
Rural Foundation CHW Programme
• Devon Valley • Klein Drakenstein • Stellenbosch • Goudini • Tulbach • Wolseley • Elgin • Caledon • Riebeeck Kasteel
8,685 (9)
105
83:1
Zibonele CHW Programme
• Griffiths Mxenge
9,000 (1)
15
600:1
Montagu Ashton Ashbury Zolani
Source: CHW project records, 1994/95
Due to political and logistical problems at the time of conducting the community surveys, several areas were excluded. Four of the thirteen RF areas were excluded because of limited time and local seasonal farm work activities that the CHWs were involved in. One of the two HCT areas was excluded because of the recent commencement of operations in 1995. One of six SACLA areas was excluded because of local community problems.
9
Within each area covered by each programme, a random sample of households was selected, using systematic sampling with random starting points. The sampling unit was a household, with one person (normally the main caregiver) in each household providing information on all the people in the household. Each area was divided into quadrants, and within each quadrant starting points were randomly selected on maps. From each point, households were systematically selected, with sampling intervals depending on the size of population served and sample size requirements. Sampling intervals ranged between 20 and 160 households in peri-urban areas and between 2 and 9 in rural areas. Where an appropriate respondent was not available, households were visited a second time. If after the second visit no respondent was present, a neighbouring household was used. The total sample comprised 1,517 households of which responses were obtained for 1,492 (98.5%). The questionnaire included demographic details, health status, health care use of each household member, respondents’ perceptions of health and social problems, health knowledge, perception of the role of CHWs, knowledge of primary care facilities, and health service preferences. The questionnaire was initially written in English, then translated into Afrikaans and Xhosa, and then translated back into English to ensure valid translation. The questionnaire was piloted in one area. Interviews were conducted by 40 CHWs from the CHW programmes. Interviewers were selected according to literacy, numeracy and previous experience as interviewers. The interviewers were allocated to areas other than those in which they normally operated. Training was provided and the need for interviewer objectivity was stressed. Nevertheless, it is possible that respondents’ comments on CHWs may have been influenced by the fact that the interviewers were CHWs, and there may have also been bias on the part of the CHW interviewers. The repeatability of the questionnaires was assessed by re-administering certain questions to 5% of respondents.
4.1.2 Results of the Community Survey 4.1.2.1 Socio-economic Information on Communities and Areas Served by CHWs The survey showed that the populations served were deprived according to several measures, with marked urban and rural differences: • all rural residents lived in brick housing; • most peri-urban residents lived in shacks; • 9% of respondents had no schooling, with higher percentages in rural areas; and • between 29% and 40% of urban adults and 1% and 6% of rural adults were unemployed.4 Moreover, between 12% and 16% of residents were aged under 6 years and only 2-6% were aged over 60 years.
4.1.2.2 CHWs Activities CHWs were most likely to treat the commonest reported illnesses. The most common adult illnesses were, in order of frequency, fevers and colds, cough, backache, pains, headaches, and high blood pressure. In children, the commonest illnesses were cough, diarrhoea, fever and colds, skin diseases, tuberculosis and worms. These survey findings corresponded with the records of CHW work which found that the commonest illnesses treated were, in order of frequency, worms, fever, burns, cough, diarrhoea and vomiting, and pains. These conditions are arguably appropriate for CHW treatment, both because of their frequency, and because inexpensive, effective, safe medications exist. 4.1.2.3 Attitude to CHWs At least 93% of respondents in each area were aware of CHWs and local CHW programmes. When asked whether they would use a CHW as a first point of health care contact for specific problems such as coughs, cuts or rashes, between 30% and 85% said that they would, but with proportions varying widely between programmes and types of illness. Between 81% and 98% of respondents had contact with local CHWs in the last year, and between 74% and 86% had had contact in the previous six months. Asked whom they would choose to speak to about a confidential or “secret” problem, only between 28% and 30% would choose a CHW. In the SACLA rural programme, a social worker (26%) or fellow church member (20%) was more likely to be consulted than a CHW (3%). Between 76% and 93% of children surveyed had up to date “Road to Health Cards”, meaning that they had received all of the immunisations necessary for their respective age. When asked which activities CHWs should perform, most respondents’ expectation was in keeping with the services provided. A third said CHWs should help the sick and injured, 61% said they should also provide health education with or without other functions, and 2% said they should provide education only.
4
The low unemployment recorded for the rural areas need to be understood as related to seasonal employment and importantly that the survey period coincided with the harvesting season (see Makan and McMurchy 1996).
10
4.1.2.4 Willingness to Pay for Services of CHWs On average, 83% (between 67% and 93%) of respondents said that they would be prepared to pay up to R5 to see a CHW. Eleven percent (1% - 28%) said that they would not be prepared to pay at all, with the highest percentage in the poor peri-urban HCT area. This issue excluded consideration of community members “ability to pay” and the effect of free health care service provision. 4.1.2.5 Performance and Effectiveness of CHWs A key function of CHWs was to provide education about preparation of ORS, burns and TB. In order to estimate whether CHWs had been effective in imparting this knowledge, the knowledge of those who had had CHW contact in the last year was compared to the knowledge of those who had not had such contact.5 Table 5 shows that in all programme areas, respondents who had seen a CHW in the last year were more likely to have “good” knowledge of ORS, burns treatment, and tuberculosis prevention. This association remained significant even when education level and employment status were controlled statistically. For other types of knowledge examined, there was no consistent advantage to those who had CHW contact. These findings suggest that CHW contact leads to greater knowledge of ORS, burns and TB prevention. This is plausible as these topics are part of CHW programme objectives and CHW training. However the causal effect could work in the opposite direction, as it is possible that people with greater health knowledge would be more likely to seek CHW contact. The effectiveness of health education cannot be accurately determined by a cross-sectional study, and would require a randomised controlled trial or controlled before-after comparison. Table 5: Percentage of respondents with “good” knowledge of health topics, comparing those who had and had not had contact with a CHW in the last six months SACLA peri-urban CHW No contact contact Number ORS constituents and proportions
SACLA rural CHW contact
No contact
Rural Foundation CHW No contact contact
433
48
296
69
442
52
69%
48%
35%
1%
47%
18%
Burns treatment
91%
82%
72%
59%
77%
46%
TB prevention
96%
82%
86%
70%
63%
53%
TB symptoms and signs
99%
93%
58%
69%
86%
69%
HIV transmission
45%
44%
58%
69%
64%
100%
HIV & AIDS protection
66%
56%
49%
62%
67%
46%
Frequency of reported condom use
49%
49%
32%
39%
11%
5%
Source: Makan and McMurchy, HEU Working Paper No. 25, 1996
4.2
Cost Analysis of CHW Programmes
Costs of all five CHW programmes were compared for the 1994/95 financial year. The analysis included a review of total, capital and recurrent costs, and average costs per CHW and per unit of activity. Costs were stepped down where appropriate, with an emphasis on estimating average costs per type of activity. The costs of the NPPHCN Training Centre were also analysed. Programme costs were expressed in terms of recurrent costs (which are incurred in months within a year), and capital costs (which accrue over more than one year). Capital costs were annualised to account for different periods of depreciation. HCT costs were averaged over 1994/95 and 1995/96 because expenditure varied widely between the two financial years. Cost information for all CHW programmes was obtained from audited financial statements. 4.2.1 CHW Programme Recurrent Costs Recurrent costs included medical supplies, remuneration, accounting, advertising, electricity, maintenance, stationery, telephones, travel and workshop overheads. The value of professional time spent on programmes but not directly remunerated, for example, for support provided to one programme by university staff, was included. 4.2.2 CHW Programme Capital Costs Capital costs were annualised assuming different life spans of different capital items, as follows: buildings (30 years), CHW training (15 years), furniture (10 years), vehicles (5 years) and computers (2 years). Because a single head office supported both SACLA programmes, head office costs were allocated to the urban and rural programmes in proportion to the numbers of CHWs.
5
The HCT area was excluded from this analysis, as only 2% had not had CHW contact in the last year.
11
4.2.3 CHW Programme Total Costs CHW programme total costs were allocated to each type of programme output or activity in proportion to the amount of time spent by CHWs on each type of activity. For three programmes, time allocation was determined by each CHW in each programme over three weeks during November and December 1994, using an activity log record charts. This method enabled the allocation of total programme costs according to various CHW activities (e.g. home visits, meetings, in-service training etc.). For the other two programmes, “time spent on CHW related activities” was obtained from routinely collected activity records. 4.2.4 CHW Programme Supervision Costs Supervision costs were defined as all costs of head office activity, in-service training, and inputs by external and support staff of universities and other NGOs. 4.2.5 NPPHCN Training Centre Total Costs Training centre total costs were obtained from audited annual financial statements for 1994/95, and were allocated to four different types of training output in proportion to the numbers of trainees attending each type of training, and the duration of the respective courses. Training centre costs per CHW trained were divided by 15, to reflect the assumption that the average CHW would use their training for 15 years. These annualised training costs were regarded as the true training cost regardless of what fees were actually paid to the Training centre by the programmes.
4.3
Results of the Cost Analysis
4.3.1 CHW Programme Costs and Activities Table 6 highlights the varying scale of costs and activities of the different programmes. The combined cost of the five CHW programmes (R4,9 million) and the NPPHCN-TC for 1994/95 was 49% (an estimated R5,7 million) of the total Western Cape CBHWP expenditure of R11,7 million (see Makan and McMurchy 1996). SACLA periurban (47%) and RF programme (22%) are much larger than any of the other CHW programmes, whether expressed as expenditure, numbers of CHWs or number of patient contacts. The crude average cost per CHW across generalist CHW programmes ranges from R5,673 at the RF programme to R39,469 for the SACLA rural programme. For the specialist type activities provided by the Mamre CHW programme the crude average cost per CHW was estimated at R64,667. Table 6: CHW Programmes Total costs and Numbers of Patient Contacts for 1994/95
Total Annual Expenditure (R) Number of CHW’s Average monthly salary (R)
SACLA peri-urban
SACLA rural
HCT *
Rural Foundation
Zibonele
2,311,222
315,751
505,052 *
1,072,194
438,759
258,666
71
8
13 *
189
15
4
269
1,300
1,300
5,673 **
29,251
64,667
1,600
1,600
1,100 *
Average crude cost per CHW per year (R)
32,552
39,469
38,850 *
Number of patient visits to CHWs
96,430
4 ,992
5,925 *
32,034
N/A
Number of Home Visits
27,338
1,907
5,916 *
N/A
13,014
Number of TB visits
10,131
N/A
743 *
N/A
N/A
Mamre (1994)
5,977 (youth meetings) 1,657 (chronic) N/A
Note: * For the HCT CHW programme information is presented in terms of the average for 1994 and 1995. ** RF programmes CHWs are part-time, accounting for the low crude cost per CHW per year. N/A - Not Applicable
All CHWs were full time except for the RF programme, which employed part-time CHWs (or Farm Health Workers (FHW)) at a lower average cost. For the other CHW programmes (SACLA, HCT, Mamre, and Zibonele) CHWs were paid an average salary of R1,350 per month for 1994/95. For its part-time CHWs, the RF programme had an estimated average monthly salary of R269 (R3,230 per CHW per annum). RF’s CHWs are given a nominal honorarium for their work as CHWs in addition to their normal farm wage. The honorarium for these CHWs ranged from R50 to R280 per month. The crude cost per CHW for each of the programmes assessed in this study, except for the RF programme, was higher than that calculated for the Valley Trust CHWs (R7,380) (Sigwaza et al, 1994). However, the Valley Trust costing was not a full economic costing and did not include capital and hidden costs (e.g. subsidies and donations).
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4.3.2 NPPHCN - Training Centre Costs and Activities The average cost of initial training incurred by the NPPHCN-TC was estimated at approximately R17,000 per CHW for 1994 and R10,000 for 1995. However, the fees charged are significantly less than these real costs, for example, basic CHW training in 1994 was provided at a fee of R600 per CHW (Makan and McMurchy 1996 and NPPHCN-TC 1995). This shows that the CHW training of CHW programmes are subsidised by the NPPHCN-TC in terms of training costs. (Note: The RF programme undertakes its own internal initial and ongoing training). In addition, the decrease in training costs per CHW incurred by the NPPHCN-TC between 1994 and 1995 is largely due to a change in the number of trainees in the various training categories. There was an increase in basic CHW training, coupled with a sharp decrease in ongoing training, and a suspension of the health committee training (NPPHCN-TC 1995). When compared with the costs of training a “specialist” rehabilitation worker at the Valley Trust CHW programme (Sigwaza et aI, 1994), the NPPHCN-TC costs are substantially lower. The cost of training a rehabilitation worker at Valley Trust was estimated to be R27,336 excluding allowances. 4.3.3 Analysis of CHW Programme Costs and Activities Table 7 below, shows that the largest individual contributions to programme recurrent costs was the combined salaries of CHWs, co-ordinators and support staff, followed by medical supplies. Annualised capital costs ranged from 5% to 12% of total costs. If CHW training costs were annualised over fewer than 15 years, then the annual training cost estimates would be proportionately higher, and therefore the annualised capital costs higher. Table 7: Capital and Recurrent Costs as % Total Expenditure for 1994/95 SACLA peri-urban
SACLA rural
HCT *
Recurrent Costs
93
88
90
Salaries as a % of Recurrent Costs
Rural Foundation
Zibonele
Mamre (1994)
AVERAGE
94
92
89
91
57
51
47
57
77
52
57
Medical supply costs as a % of Recurrent Costs
8
9
17
**
5
5
9
Other Recurrent Costs (i.e. administration, travel, ongoing training, etc.)
35
40
36
43
18
43
34
7
12
10
5
8
11
9
100
100
100
100
100
100
100
Capital Costs Total Costs
Note: * Information is presented in terms of the average for 1994 and 1995. ** Medical supplies information for the Rural Foundation programme was not dis-aggregated.
Table 8 below illustrates the results of an in-depth time-log analysis of the SACLA peri-urban and rural programmes, and HCT CHW programme, as applied to the total costs. The analysis performed was used to illustrate how to divide out programme costs according to the central activities that CHWs are engaged in. Table 8: Allocation (%) of Programme Costs to Different Activities in three CHW Programmes Programme Activities
SACLA peri-urban
SACLA rural
HCT 16
Visits to CHWs
38
50
CHW Home visits
25
35
9
CHW TB home visits
10
N/A
26
CHW Workshop and meetings
19
11
26
8
4
23
100
100
100
CHW Community education Total %
When total programme costs were allocated to different CHW activities, average costs per activity were determined, as shown in Table 9. Table 9: Average costs per unit of CHW activity in Rands and supervision costs as a percentage of total costs Programme
SACLA peri-urban
SACLA rural
HCT
Rural Foundation
Zibonele
Mamre
Average Cost of Visits to CHWs
R11
R35
R18
R33
R100
R22 (per Youth Contact)
Average Costs of Home Visits
R26
R65
R28
N/A
R27
R78 (per Chronic Care Patient)
Average Cost of TB home visits Supervision costs as % Total Cost
R27 17%
N/A 24%
R82 44%
N/A 40%
N/A N/A
N/A 41
41% Note: N/A or shaded areas indicate where CHW programmes not engaged in type of activity or where information had not been sufficiently dis-aggregated.
13
A patient visit to a CHW was generally less costly than a CHW home visit. CHWs average costs were less costly in the peri-urban areas than in rural areas. This is likely to be because CHWs have further to travel in rural areas, and support to rural CHWs may be more expensive given that the head office (as with the SACLA CHW programme) is located in the peri-urban area. Generally, the cost of a visit to a CHW was about half that of a home visit. Home-visits are more comprehensive; they cover household health assessments, health education and any basic curative requirements. Specialist visits, like those for TB supervision, were more expensive than generalist visits. The average cost of a home visit was similar across CHW programmes in the peri-urban areas. For three CHW programmes, namely SACLA peri-urban, HCT and Zibonele, the average cost per home visit is calculated at R26, R28, and R27 respectively. The rural programmes of SACLA and the RF CHW programmes appear to be more expensive than the peri-urban programmes, perhaps reflecting the greater time necessary for travelling to patients’ homes. When comparing costs between programmes, it is important to consider the size of CHW programmes and the duration of operation. The longer the programme has been in existence, the more effective the CHWs and managerial staff seem to be in conducting their activities. The larger programmes with more CHWs (e.g. SACLA and the RF) have lower average costs per visit than those with fewer CHWs (e.g. HCT). The crude cost per CHW is also lower in larger programmes (e.g. particularly low in the case of the RF programme SACLA). Administrative and supervision costs of the larger programme SACLA CHW are a smaller proportion of the cost per CHW contact than for other programmes. In other words, the larger programmes were able to spread their administrative and overhead costs over a greater number of CHWs and CHW visits. It should be noted that the combined peri-urban and rural supervision costs of the SACLA programme is 41%. This may suggest that extending CHW programmes may lead to greater efficiency. However, increasing scale may pose dangers in terms of managerial capacity, commitment, affordability, and accountability to local communities. The most costly interventions were HCT TB visits (R82 per TB patient home visit) and the Mamre chronic care workers’ activities (R78 per patient visit). As indicated above, the Mamre programme’s chronic care workers’ activities are highly specialised and often very time consuming. This indicates that comparison between specialist programmes is more difficult due to differences in the types of intervention. For the HCT, with reference to the TB programme and the high average cost of TB home visits, the central issue were associated with the recent commencement of the programme. The start-up or sunk costs included high consultation expenses, high drug costs, food and nutrition costs for TB clients, as well as costs linked to intensive initial training for the specialist CHW activity. In addition, it is noted that the Zibonele CHW programme’s average cost of visits to CHWs, estimated at R100, is exceptionally high. This is due to visits only occurring at the clinic of the programme, where there exists a high CHW to patient ratio. There was also a relatively low attendance at the time of this review. Although for the Rural Foundation the crude cost per CHW is comparatively low, its average cost per visit is higher than the peri-urban CHW programmes and similar to the SACLA rural programme. This is because these CHWs do fewer visits annually than the other CHWs and that they serve as CHWs part-time (in conjunction with their other farm duties). If the RF CHW programme were able to increase the number of contacts annually, their average costs could decrease reflecting greater effectiveness. Lastly, in reflecting on the R5,7 million total expenditure for 1994/95, of the combined selected CHW programmes and training centre it is important to consider the sources of funding. The large majority of funds, an estimated 75%, are sourced from donor funds (either directly from foreign aid agencies (e.g. Kaiser Family Foundation, Kellogs Foundation etc.) and SA funding bodies (e.g. Kagiso Trust, IDT etc.). The remaining funds are sourced from internal donors (e.g. local authorities, private sector, private donations etc.).
14
CHAPTER 5 DISCUSSION AND RECOMMENDATIONS 5.1
Discussion
This study demonstrates why the costs of CHW programmes are important to consider. It shows that the extension of CHW programmes to underserved communities in the province would require a considerable expansion of the current funding sources. This study provides insights into the functions and costs of a broad range of programmes and should serve to inform decisions on the magnitude of additional funding required and whether expanded funding is justifiable. CHW programmes provide basic treatment, counselling and health education to large numbers of people in deprived and poorly serviced communities. This study shows that the average costs for CHW activities varied between programmes and areas of operation. The average cost per visit to a generalist CHW ranged from R11 to R35. Cost of home visits were similar in different peri-urban programmes (ranging from R26 to R28) and higher in rural areas (R65). These costs of CHW activities are within an interesting margin to primary care services, such as public sector clinics. The Health Expenditure Review estimated that for 1992/93 the average cost of a clinic visit6 was R30 and an outpatient visit at a community hospital was R55 (McIntyre et al 1995). In a subsequent detailed study of PHC services in South Africa entitled “Confronting Need and Affordability”, various health service sites were costed for 1992/93. The average cost per visit (based on total cost divided by the total number of consultations) was calculated at R22 for a curative care visit to a clinic (e.g. Upington - peri-urban), R29 for a rural health facility visit at Agincourt, and R45 per visit at Alexander Health Clinic (Rispel, Price and Cabral; 1996). It should be noted that when accounting for inflation to the 1992/93 public sector costs, to this studies cost of CHW contacts for 1994/ 95, it is evident that the latter costs are marginally lower. Therefore, this study has shown that CHWs “may” provide an “affordable” first level contact within a PHC service. However, as indicated, costs and cost effectiveness comparisons to state run clinics may be difficult. These comparisons do not take into account differences in disease severity, professional training and skills of health personnel and the quality of care provided by these types of complementary health services. In fact these limitations have confronted researchers attempts to find a true cost-effectiveness comparison for CHW programmes. The issue of remuneration of salaried CHWs versus “volunteer” and unpaid CHWs, is a key factor that needs further consideration and debate. It has been argued that the benefits associated with “volunteer” type CHW programmes include recurrent cost savings and the recruitment of a more committed and motivated CHW (Walt 1988a and Berman et al 1987). One option of this “volunteer” approach would necessitate for the state to provide training and supervision/administration costs to CHW programmes. Donor and other sources of finances could then be directed to infrastructural and co-ordination expenditure. Possible drawbacks of this approach would be the faster turnover and attrition of CHWs, increased training costs for CHW programmes, and the political unacceptability of using “volunteer” CHWs. Analyses of the effectiveness of both CHW programmes and clinics are necessary to enable any real comparison. However, for programmes the central issues relate to: (i) whether they provide health education which is effective in preventing disease, (ii) whether their intervention in the early treatment and diagnosis of patients prevents more serious disease from developing, and (iii) whether CHWs prevent the unnecessary use of more costly services. These issues were beyond the scope of this study and should form the basis of subsequent more detailed effectiveness studies. It is concluded that CHWs are complementary to other PHC or clinic based services and have favourable cost structures which should necessitates that they are not merely seen as cheap substitutes. The particular strengths of CHWs (e.g. appropriate area deployment, accessibility, acceptability to communities served, and responsiveness to cultural sensitivity) as well as their limitations (e.g. ability to diagnose and treat serious illnesses) should be appreciated. The Berman et al (1987) study in examining the tasks performed, the quality of care, coverage and equity, cost efficiency and health impact, concluded that the coverage and equity of CHW programmes were better than that of clinic-based services and provided at lower costs. In addition, the authors noted the need for follow-up on issues related to quality of care and level of impact, given the tendency of programmes to slip into curative care. The recommendations from Berman et al study (1987), a monumental research project, was that CHW programmes have the capacity to provide low cost, equitable, and accessible health care, but to do so they need more commitment in terms of resources for support, supervision and appropriate training. These findings are similarly relevant to this provincial study. 6 The Health Expenditure Review calculated cost per visit for clinics included costs directly attributable to clinics but not other costs for preventive programmes and administrative support (McIntyre et al 1995).
15
The issue of sustainability of the Western Cape CHW programmes, and indeed for South Africa, as highlighted in this report, needs to be examined in relation to the large dependence on foreign donor funds. This dependence has serious and inherent limitations. These have been highlighted in the African and international experience (see World Bank 1995). More importantly, when reflecting on the definition of CHWs and the issues of accountability and “who pays”, there are numerous reasons why programmes need to explore alternative models of developing CHW programmes and alternative funding sources. Key questions regarding whether the benefits of CHWs justify the costs, essentially relate to their effectiveness, their activities in the communities to whom they are accountable and whether their objectives are priorities for the health service. This study has provided baseline programme and activity costs with which such issues of effectiveness, affordability and comparability can be further addressed and debated. The sustainability of CHW programmes in terms of costs, performance and accountability, needs to urgently be brought into focus. The options at this stage are either to go for the part-time “volunteer” type programmes (the least costly option) or full-time professionalised CHW programmes (the most costly model). These options have been singled out within the Lomax and Mametja (1995) report, in which part-time and voluntary CHWs were seen as agents, who receive initial training and are deployed to serve the communities and health service (e.g. by providing health information).7 On the other hand, the full-time and paid CHW option is considered within the structure of district health authorities (through whom finances will flow) and to whom CHWs would be accountable.
5.2
Recommendations
It is important to note that the following recommendations are based, not only on this report, but also from the more detailed analysis contained in the Health Economics Unit working paper “An Economic Evaluation of CHW Programmes: Western Cape Province Case Studies” (Makan and McMurchy, 1996). In addition, the local and international literature review contributed significantly to informing the context of the recommendations. Some important points arise from the review of the policy environment associated with CHWs in South Africa. They contextualise the background for the more specific recommendations emanating from the economic comparative analysis of costs and consequences of a sample of CHW programmes operating in the Western Cape province covered in this report. 5.2.1
Context for considering CHW programmes in the South African health care system
In the analysis of the South African policy environment, there are several areas that support the integration of CHW programmes into formal health care delivery. Local health inequities, poor access and inadequate service provision, have contributed to the rise of community-based health care interventions. Within the transforming health sector in South Africa, there is clearly a case for the role and functioning of community-based models to be recognised and further developed. International case studies also point to this and stress the importance of considering the limitations and strengths of community-based models. The background to considering community-based and CHW programmes in South Africa are characterised by: • the adoption of the PHC approach (recognising the principles of providing health care which is equitable, participatory, pr eventive and promotive; appropriate, and using a multi-sectoral approach); • the development of a DHS; • the decentralisation of health care delivery; • the scarcity of health care resources; and • the continued pressure on programmes with regard to external donor funding. All these issues feed into specific recommendations raised below. These are divided according to the stakeholder categories to whom they are most relevant. In certain instances, these may overlap and are not mutually exclusive. 5.2.2
Recommendations to policy-makers at National, Provincial and District Level
National / Provincial Level •
A coherent government policy on the role and function of CHW programmes in the SA health system must be developed in order to inform provincial and district planning.
•
A collaborative relationship between community-based and CHW programmes and formal health services needs to be supported and strengthened (noting supervision and referral links).
•
Mechanisms for provincial support to CHW programmes should be investigated. This could include provision of financial subsidies, facilities and equipment, as well as assistance with training and supervision.
7
The indirect costs of providing the CHWs will then be transferred back to the CHW and/or community. The Lomax and Mametja report (1995) note that the communities are in fact poor and low wage earners, which would impact on the perceived benefits and affect the sustainability of the programme.
16
These mechanisms could be implemented on a pilot basis initially, as has been the case with the recent integration of the Mamre project into the Atlantis district health sub-structure. Resource requirements for such support must be made explicit, and be taken into account in provincial allocations to districts health authorities. •
“Volunteer type CHW programmes with state funding for training and supervision is another potential mechanism of support which needs consideration.
•
There is a need to consolidate and disseminate a basic core-curriculum for the training of CHWs and community volunteers, into which the differing health needs of different communities served by particular CHW programmes can be integrated. Provincial and district stakeholders should be involved in this process of curriculum development and training.
•
In pursuit of enhanced service delivery and collaboration, the training of formal health care workers needs to be sensitised to the PHC approach and the role and functioning of CHWs.
District Level •
CHW programmes must be recognised as providing an important PHC service for under-served communities. They should be clearly incorporated in the situation analysis and plans of the district health authorities.
•
The role of CHW programmes within the DHS must be clearly defined. This could include traditional CHW activities such as health education and promotion, treatment of minor ailments, supervision of TB patients, rehabilitation services, basic curative care and developmental activities. It could also be expanded to include activities such as the collection of basic health information data.
•
Strengthen collaboration arrangements to the district health authorities and other health care providers (e.g. traditional healers, traditional birth attendants, etc.)
5.2.3
Recommendations to CHW programmes
•
CHW programme record systems need to be developed to include consideration of workloads (e.g. accurate recording of home visits), time and activity management, outputs, patient case mix and referrals.
•
CHW programmes need regular monitoring and evaluation, requiring the formulation of explicit objectives against which to be evaluated (e.g. quality care). Performance measures and indicators need to clearly reflect the achievements of interventions in relation to programme objectives.
•
The incorporation of cost considerations into the management and design of CHW programmes is vital. Total costs, average costs and costs per activity must be calculated as these directly impact upon efficiency, effectiveness and sustainability.
•
CHW programmes should share information with one another. Programmes should evaluate their costs and effectiveness relative to other similar programmes. They can learn from the experience of other programmes that have developed more effective and efficient organisational structures and mechanisms. For example, if a programme has a higher average cost per visit, further evaluation may reveal a significantly higher supervisor to CHW ratio.
•
Provincial consortia of CHW programmes should be established. These should integrate core microactivities (e.g. sharing of information on training, CHW activities, record systems, core curriculum, areas served etc.) and co-ordinate macro-level activities (e.g. funding mechanisms, lobbying strategies). In addition, such consortia should be involved in clarifying the role of CHWs, developing a programme for performance monitoring and evaluation, and exploring methods for enhancing CHW capacity.
•
It is important that community-based and CHW programmes retain their NGO status. This is pertinent in order to allow programmes to maintain their community accountability and participation structures.
•
CHW training should be responsive to the specific health needs of the community (e.g. AIDS/HIV education, traditional birth attendants etc.).
17
5.2.4 Recommendations for further research into CHW activities Whilst this study has examined the role and function of CHW programmes, and in particular analysed the costs of programmes, there remains a need for research to measure the efficiency (for example, the benefits of economies of scale) and effectiveness of their activities. Research needs to be carried out to determine: •
the appropriate size and structure for CHW programmes. Models presented by Lomax and Mametja (1995) and in this provincial case study could facilitate such a process. Such research could then inform decisions as to whether existing programmes should be extended or additional programmes developed.
•
The cost and effectiveness of specialist CHW programmes in comparison to generalist programmes should be further evaluated.
•
“Volunteer” type CHW programmes, in terms of the acceptability of the notion to NGOs and communities and its operationalisation, needs to be considered.
•
alternative models of developing CHW programmes and sources of funding for CHW programmes.
This study provides important information for ongoing and improved management of the CHW projects concerned. It also provides information on CHW role, function, performance and costs, which together need to be considered for a possible model for comprehensive PHC services in SA. Information is a valuable resource and tool. With reliable and valid information, decision-makers have a basis to make informed decisions, and can thus depend less on intuitive and political decisions (Vundule 1996). The information generated by this analysis, and the further evaluation called for, are crucial to proper planning, monitoring and evaluation of programmes and service provision.
18
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L Lankester T; (1992); Setting up Community Health Programmes - A Practical Manual for use in Developing Countries; Macmillan. Lomax K and Mametja D (Editors); (1995); Assessing the Feasibility of Greater State Support to Community-based Health Programmes; Health Systems Trust; Durban. Louw J and Katzennellenbogen J; (1994); The Mamre Community Health Worker Programme: An Evaluation of the Youth Worker’s Work; Department of Psychology; University of Cape Town and the Medical Research Council; Cape Town. Lund F; (1993); Paradox and Policy: Some Lessons From CHW Projects; Critical Health; Number 42; Johannesburg. M Mathews C, Van der Walt H, Hewitson D; (1991) Evaluation of the SACLA Health Project; Centre for Epidemiological Research in Southern Africa, Medical Research Council, Cape Town. Makan and McMurchy; (1996) An Economic Evaluation of Community Health Worker Programmes; Western Cape Province Studies; Health Economics Unit Working Paper No. 26, University of Cape Town; Cape Town Mamre CHW Programme, (1994 and 1995), Internal records and interviews, Cape Town. Matthews C, Hewitson D, van der Walt (1991); Evaluation of SACLA Health Project; Centre for Epidemiological Research in South Africa; Medical Research Council and SACLA Health Project; Cape Town. Mathews C, Van Der Walt H, Barron P. A. (1994); A Shotgun Marriage - Community Health Workers and Government Health Services. South African Medical Journal; October 1994; No 84 : pages 659 - 663. McCoy D, Couper I, Fredlund V, Reid S, Ross A; (1994); Promote the Community Health Worker; letter to the Editor; South African Medical Journal; South Africa. McIntyre D, Bloom G, Doherty J and Brijlal P; (1995); Health Expenditure and Finance in South Africa; Health Systems Trust and the World Bank, Durban; South Africa. Mills A and Gilson L; (1988); Health Economics for Developing Countries - A Survival Kit, Evaluation and Planning Centre for Health Care; London School of Hygiene and Tropical Medicine; United Kingdom. Mohammed H and Bachmann M; (1993); Brown Farm Community Health Survey; Department of Community Health - University of Cape Town and the Western Cape Regional Services Council, Cape Town. Moodley J and Makan B; (1995); Costing the Zibonele CHW Programme - 1994/95; Unpublished Report, Health Economics Unit; University of Cape Town. Moodley J; (1995); An Evaluation of the Zibonele Women’s Wellness Workers Project; thesis submission to the Diploma in Health Management (Economics and Financial Planning); Department of Community Health - University of Cape Town. Unpublished report. Moodley J, Pick W, Bradshaw D and Cooper D; (1996); The Infant and Under five Mortality Rate of Griffiths Mxenge. Health Systems Research Series, Working Paper No 12; University of Cape Town. N Naidoo D.P; (1995); An Evaluation of Health Care Resources for the Treatment of Diarrhoea in Children in Khayelitsha; Dissertation submitted to the Post-graduate Diploma in Health Management (Economics and Financing), Department of Community Health; University of Cape Town. National Assembly Portfolio Committee on Health Portfolio; (1996); Foreword by Tshabalala M; Report on the Health Budget Vote, Cape Town. NPPHCN; (1993); The Rock, “Health Workers : CHWs in Perspective”; Johannesburg. NPPHCN; (1994 October) Memorandum to the Western Cape Provincial Minister of Health: E. Rasool; Cape Town. NPPHCN; (1995); Community Health Worker Directory, Johannesburg. NPPHCN-TC, (1994 and 1995), Internal records and interviews, Cape Town. O Ofusu-Ammah V; (1983); National Experience in the use of CHWs : A Review of current issues and Problems; Offset Publications 71, WHO, Geneva. P PAWC; (1995); Western Cape Strategic Health Plan; Cape Town. Philpot S, Pillay S, and Voce A; (1995); WITS / Tintswalo Community Rehabilitation Worker Training Programme - Evaluation Report; Centre for Health and Social Studies; University of Natal; Durban.
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R Ramprasad V; (1985); Critique of an Experience; Report of the Study on the CHW programmes funded by Oxfam (India) Trust, Bangalore. Rifkin S; Mueller F and Bichmann W; (1988); Primary Health Care : on Measuring Participation; Social Science and Medicine; Volume 26; pages 931-940. Rispel L, Price M and Cabral J; (1996); Confronting Need and Affordability : Guidelines for Primary Health Care in South Africa; Centre for Health Policy, Department of Community Health; University of the Witwatersrand. Rossi P. H, Freeman H. E, Wright S. R; (1979); Evaluation - A Systematic Approach; Sage Publications, United Kingdom. Rural Foundation CHW Programme, (1994 and 1995); Internal records and interviews, Cape Town. S SACLA CHW Programme, (1994 and 1995); Internal records and interviews, Cape Town. Sayed R; (1995); Sampling Methods and Practice - course handouts; Department of Community Health; University of Cape Town.
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Sidel V. M; (1972); Barefoot Doctors of the People’s Republic of China; New England Journal of Medicine; 286; pages 1291-1300. Sigwaza T, Jinabhai N, Mametja D, Mbhele N, Ntansi D, Ntuli N, Philpott H, Pillay S, Ross S; (1994); An Evaluation of the Valley Trust Community Health Worker Programme; Centre for Health and Social Studies, University of Natal; Durban. Smith P. G. and Morrow R. H (Editors); (1991); Methods for Field Trials of Interventions against Tropical Diseases - A Toolbox, United Nations Development Programme / World Bank / WHO Special Programmes for Research and Training in Tropical Diseases; Oxford University Press; New York Starr P; (1988); The Social Transformation of American Medicine : The Rise of a Sovereign Profession and the Industry; Basic Books; New York.
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APPENDICES
CHWs of Health Care Trust at Brown’s Farm
APPENDIX 1: LIST OF CONTRIBUTORS AND PARTICIPANTS Project co-ordinator and principal researcher: Project Members:
Bupendra Makan Di McIntyre, Kamy Chetty, Max Bachmann, Bupendra Makan, Dumo Baqwa and Dale McMurchy
Collaborating CHW Programmes:
SACLA Health Project (Di Hewitson, Gavin Derbyshire, George More) Health Care Trust (Bridgit Lloyd, Mzonke Jacobs, Spectorine Mtshofeni) Mamre CHW Programme (Mercia Arendse, Johanna Johannes, Hilda Adams, Gavin Collins, and Margeret Hoffman) Zibonele CHW Programme (Johannah Kelkelame, Kuku Jacobs, Linda Mgqamqo, Di Cooper) Rural Foundation (Jenny Bader and Maira Kelly) NPPHCN Training Centre (Vanessa Davids, Nomvuyo Dayile, Cheryl-Anne Shiskin-Cox)
Other Departments and Organisations consulted:
National Progressive Primary Health Care Network (Elise Levendal and Mizana Matiwana), Department of Community Health UCT (Jennifer Moodley, Rauf Sayed, Leslie London, Hassan Mohammed, Maylene Shung King, Margeret Hoffman, Di Cooper, Rodney Ehrlich) Medical Research Council (Merrick Zwarenstein) Public Health Programme - University of the Western Cape (Arthur Heywood), Independent Development Trust (Marina Clarke)
Selected Chapters Reviewed and Edited by:
Max Bachmann - Bristol University (formerly at the Department of Community Health, UCT) Di McIntyre - Health Economics Unit, Jane Edwards and Peter Barron - Health Systems Trust, Peter Long - NPPHCN, Gavin Derbyshire - SACLA Health Project, David McCoy - Child Health Unit: UCT, Lucy Gilson - Centre for Health Policy, University of Witwatersrand
Data Collection and Coding:
Ronita Fisher, Tanya Jacobs, Bruce Kadalie, Godfrey Lemphane, Abigail Julie, Lisa Jones
Data Entry and Validation:
Mrs Van Niekerk and Mrs Jaftas - ITS, UCT
Data Analysis and Interpretation:
Dale McMurchy, Bupendra Makan, Rauf Sayed and Jane Edwards
CHW Programme Members: CHWs and Community Survey Team: CHW Co-ordinators:
SACLA: Anna Genu, Nosapho Matabata, Nosolomzi Rienie Jansen, Priscilla Steenkamp, Bettie Fluks, Melany Hartman, Anne Swanepoel, Sara Tasan, Navakuye
22
Sijeku, Thandi Tengenu, Winnie Nkosi, Nonathi Ntwana, Maria Hoffman, Bawuti Mqayi, Eunice Memani, Nomsa Sondlo, Priscilla Maqolo, Eunice May, Thandi Xanywa, Nombulelo Mnukwa, Dahlia Cona, Nokwakha Femela, Nofemeli, Nomampondomise Mjuleni, Nokwakha Nikelo, Prudence Nogavu, Christina Mhlabeni, Monica Duda, Jeanette Maselana, Iris Dyantyi, Nomonde Stafans, Margaret Mapipa Health Car e Trust: Liziwe Mpe, Nomboniso Koncoshe, Nozi Diko, Nofoto Mhlalasa, Miriam Spondo Rural Foundation: Alta Paulse, Juline Frieslaar, Angela Joorst, Denise Johnson, Caroline van Wyk, Jackie Hansen, Debbie Bell, Jenny Bader, Maire Kelly, Eleanor Fourie
APPENDIX 2: A SYSTEMS APPROACH FOR CHW ADVOCACY FAMILY PLANNING : 1 INPUT • •
•
Trained Health Workers Contraceptive supplies (pills, IUDs, condoms) Examining Table
TOTAL COST
2 PROCESS •
• •
Taking Reproductive History Physical Examination Patient education/ teaching
3 OUTPUT • • • •
COST
Number of Patients: examined fitted with IUD instructed in family planning objectives, benefits and methods COST PER OUTPUT UNIT
4 IMPACT Patients: can name three methods of contraception are in favour of spacing pregnancies choose a contraceptive method and use it correctly COST PER IMPACT
5 OUTCOME Increased interval between children
EFFECTIVENESS AND COST EFFECTIVENESS
Source: PHC Manual for Trainers, 1995, Rossi, 1979, Berman et al 1987 Note: * where in comparative terms efficiency is defined as the lowest cost per unit and greatest output.
23
APPENDIX 3: RECOMMENDATIONS OF THE CONFERENCE ON “ASSESSING THE FEASIBILITY OF GREATER STATE SUPPORT TO COMMUNITY BASED HEALTH PROGRAMMES” Date Venue
: 14 June 1994 : Glenmore Pastoral Centre, Durban
Phased CBHWP model be considered for implementation by the national government. In the fist phase financial, political, structural, and other support should be given by the government to existing programmes in order to strengthen them. Progress to the second phase should be subject to the completion of evaluations to measure their effectiveness. The evaluations should be used to decide whether or not such programmes should be expanded. Details regarding how and where to utilise CHWs, their roles, mechanisms for support, etc. Should be worked out in consultation with interest parties at provincial and district levels. Government support be extended to the development of a national core curriculum together with the formation of an “accreditation committee” as a way of consolidating the curriculum and examine recognition, accreditation and career paths. Training of CHWs should be carried out at local training centres because it is more cost effective and will ensure community involvement. Provincial training centres should be venues to train CHW facilitators and supervisors and serve as a CBHWP resource centre. Training of community and local government committees in preventive and promotive health as well as the management and supervision of CHWs is vital to the success of the programmes. In order to promote understanding and support it is proposed that health personnel be re-orientated through training to understand the principles of PHC and the role and functions of CHWs. It is essential that mechanisms to support CBHWPs be built into the district-based health system of health care. CBHWP representatives should serve on District Management Committees thus ensuring linkages and commitment from other sectors in carrying out projects. These committees should access funds to pay CHWs and as such ensure CHWs’ accountability to these committees. Key role players of CBHWPs should be included in discussions presently under way to plan and implement districtbased health models in order to secure a place for CBHPs in the future health system. A task group should be set up to : • identify which CBHWPs currently operating should be included in phase one; compile a set of criteria to identify completion of the first phase model; • explore how CBHWPs capacities can be strengthened through state support; • determine what mechanisms must be in place to support CBHWPs effectively; • determine the extent of state involvement. Source: Lomax and Mametja 1995
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