It’s a bright spring day with a light breeze carrying at times the fishy odours of a working harbour and at others the salt-fresh clean of the ocean. Across the bay winds the curves of Cape Town’s famous Chapman’s Peak drive. With views like that, this surely be must some of the most valuable real estate on earth, but you wouldn’t think so if you turned your eyes mountain-ward and towards the community of Hangberg, established in the 1950s as part of the Group Areas Act. Like many of Apartheid’s engineered communities, where real communities were torn apart, categorised arbitrarily and rehoused in bland concrete blocks, Hangberg suffers the ills that have been visited on subsequent generations. Unemployment is usual, substance use and gangsterism rife, and violence against women and children endemic. The proximity to the harbour means that many of Hangberg’s residents have generation-deep connections with the sea, working in fish factories, or employed as contractors to retrieve wrecks or dredge the harbour. There are much disputed fishing rights and a thriving poaching community which supplies some of Cape Town’s best “kreef” or lobster. We are spending the morning with the “blue ladies” of Hangberg, a group of six Community Health Workers (CHWs) employed by a local NGO (www.tbhivcare.org ). The “blue ladies” spend their days navigating the streets and slopes of Hangberg, taking medicines and care to those who can’t manage the brief but steep commute to the local clinic which features prominently on the single tarred road in and out of this community.
The reason for our visit is simple. We want to see how our first attempt to create a truly comprehensive training package for CHWs is faring. We are practising the new vogue, agile development, borrowed from the IT world, but not as yet sufficiently underpinned by the meticulous and rigorous process evaluation we have come to recognise as essential in the creation of health systems interventions. We are late to the training of CHWs, in part because many others were doing so but mainly because we struggled to clarify the scope of what was required of these people, mostly women. Not so much clarify, as comprehend. It didn’t matter whether the ask was from South Africa, Malawi or Bangladesh, the policy documents thrust in our hands in the hope that we could translate them into something tangible and useful, detailed an array of responsibilities that only a corporation of health workers, communication specialists, engineers or perhaps a team of comic super-heroes could deliver. From recognising and treating children critically ill with pneumonia or dehydrated from diarrhoea, to screening for everything from tuberculosis, pregnancy, to hypertension and mental illness, to securing safe water sources and peppered with terms like “community mobilisation”, they read like critiques for everything that multiple government sectors are failing to deliver. It is simultaneously a bold vision for engagement between communities and health services and task-dumping on a grand scale.
But recent years have seen a tempering of expectations, and after sustained pressure we have at last made a start. Our brief from the Western Cape Government was to design a comprehensive, co-ordinated set of materials for CHWs to use in households through to step-by-step training materials for those mandated to train CHWs.
Back in Hangberg we are late, as we had thought we were setting out from a clinic on the other side of the valley, but the women nonetheless greet us warmly. Usually they work in pairs, with clearly defined households to visit generally a street or two away from their own homes. But this morning we plan to go together. Visitors are rare and they are keen to show us what they do. First we make a quick pit stop at the local hall opposite, from where an off-site medication delivery system operates every Wednesday morning on one side of the hall while the “Elderly Club” meets on the other. The set-up is simple enough. A trestle table covered in a bright red tablecloth with white trim, cardboard boxes filled with pre-packaged medications manned by one CHW. Patients walk in, hand in their card, with a barcode that identifies their medication, receive their parcel and a reminder of their next clinic visit. The whole process takes less than a minute. “I couldn’t get my meds this quickly at my private pharmacy” I quip, much to the amusement and satisfaction of the CHWs. They collect medications for those clients whose mobility is restricted and we set off, climbing the slope that leads to the blocks of cement flats and the sprawl of wooden structures that reach high into the mountains behind.
Our first stop is at the home of an elderly women who suffers from chronic venous insufficiency, and who is chair-bound for most of the day. At my insistence, I ask that the CHW check that we may be invited in and talk with her. We visit eight homes that day, and not one of the residents say no to these strangers, despite the fact that the visit is unannounced and many are still busy with morning activities. Chantel tells me she brings this woman her meds, and massages her feet twice a week. The home is typical of so many lower-income homes in South Africa. The floor is concrete, a large cabinet dominates the room on which are displayed some ornaments and a series of photographs that document the progress of grandchildren through school, a right denied to so many older South Africans because of Apartheid. The home is pristine, and her daughter is bustling in the small kitchen washing the breakfast dishes. The tenderness and care between the older woman and Chantel are evident. Chantel addresses her as “Auntie”, a term of respect in these communities. I enquire about what they discuss while she massages her feet. “Health issues” she responds, but I sense that there is also a catch-up on family goings-on and community gossip. The nature of the relationship is evident in a few brief minutes: this is not only about the delivery of medication, but the healing power of touch and the mitigation of the social isolation faced by many people whose mobility is limited and economic means almost non-existent. This is person-centred care at its most holistic and best. It is a pattern that we would see repeated in every household we visited that morning.
We bid Auntie farewell, Chantel reassures her she will be back as usual the following morning for her massage, and we head upwards, winding our way through alleys and past makeshift wash-lines replete with this morning’s washing from which comes the distinctive smell of “Omo”, a local washing powder whose traction in lower economic households is built on the fact that it works best in cold water. Hot water remains a luxury that few households enjoy. The streets are busy, filled mainly with men, unemployed and at a loose end. We pass the community’s poachers, the most junior of whom are repairing old kreef nets, the neon purple of the new nylon in stark contrast to the aged ochre of the rest of the nets passed from one generation to the next. The group’s leader requests that the CHWS replenish their supply of condoms, a mischievous smile breaking across his and some of the others’ faces. I’m impressed. By the frankness of such an open request, by the commitment to safer sex, and by the trust and respect that is so clearly a pre-condition of such an open exchange. This is trust that is well-earned through mornings of hard work, a culture of inclusiveness and reservation of judgment. The act of bearing witness to the hard lives that most people in their communities endure is in itself an act of healing and reconciliation.
We continue our visits picking our ways through alleys, and up old tires filled with sand that serve as steps. We see an octogenarian who is well-cared for by her family, and one who is not. We see older women who are chair-bound, by arthritis, COPD and cardiovascular disease. One is talking to her grandchild, nine month’s old, pulled up to her chair in his stroller while his mother attends to domestic duties. “I’ve raised nine grandchildren from this chair”, she says. There are no toys in sight, only her expressive face and endless chitchat that will provide this child with robust foundations for his future language and social development.
We finish the morning by visiting one of the CHWs who is at home recuperating after a below-knee amputation for complications from diabetes. “I looked after people in wheelchairs. I never thought that one day I would be in one of my own.” Her family and tribe of blue ladies have rallied around her and ensured she has been able to access all she needs to recover as quickly and fully as possible. But it’s evident that this is a large loss, and that she misses her work and the meaning it gives her.
As we sit around talking, I ask the blue ladies what about the PACK training was different, if anything. Emmarentia, who has been quiet all morning, is the first to volunteer “It teaches us how to go into a household, how to introduce ourselves, be professionals. When we go into the house we go with confidence because we know what we are going to say.” Household assessments form a major part of the CHWs’ responsibilities although we haven’t completed any today. I find it hard to believe that there are households that these women have not been into, and people they do not know. But there are, and the training and revised stationery that they are required to complete has given them the confidence to enter them. A key objective of the household assessment is to generate demand for services. A simple pamphlet detailing what communities can expect of their CHWs and pointing them to local services has been already been reprinted many times, welcomed and widely distributed, in some communities by household members who have declared that this is a task too large for one person and offered to help. “That clinic is full now” says Anna. “People know what services they can get there now.”
“So do you think this has changed the way the community sees you?” I ask.
The CHWs laugh, adding that the community sees them as nurses now, that when they talk they can see they know what they are talking about. “They even come knocking in the night, when a baby is being born.” CHWs extend health services out into the streets, into homes and beyond clinic hours. Many, and certainly all six of the women with whom we have spent that morning, display high standards of professionalism. It’s time their commitment was rewarded not only by the gratitude of their community but by a living wage and recognition for the service and healing they provide. As for us, it’s time to crack on and complete the comprehensive training package they need.
Names of the Community Health Workers have been changed to protect their privacy.
About the author:
Lara Fairall is a doctor by training, a scientist by choice and Head of the University of Cape Town’s Knowledge Translation Unit who have developed the Practical Approach to Care Kit to strengthen to quality of primary healthcare in LMICs.
Since August 2015 the KTU and BMJ have been engaged in a non-profit strategic partnership to provide continuous evidence updates for PACK, expand PACK related supported services to countries and organisations as requested, and where appropriate license PACK content. The KTU and BMJ co-fund core positions, including a PACK Global Development Director, and receive no profits from the partnership. PACK receives no funding from the pharmaceutical industry. This paper forms part of a Collection on PACK sponsored by the BMJ to profile the contribution of PACK across several countries towards the realisation of comprehensive primary health care as envisaged in the Declaration of Alma Ata, during its 40th anniversary .