Reversing Re-Engineering: The Failure of the Community Health Worker Program in the Free State Province, South Africa

There is a tremendous array of proof as to the benefits that the deployment of community health workers (CHW) potentially hold. Evidence-based improvements in multi-faceted health outcomes are often found in the literature. Ironically, some countries with much lower per capita spending on health, are witnessing substantially more concrete outcomes than compared to a relatively affluent country like South Africa. This is noteworthy given the South African state’s intention to create a large cadre of standardized CHWs as essential components of the Ward Outreach Team initiative under the Primary Health Care re-engineering process that is tentatively emerging in South Africa. One of the most troubling absences in the extensive range of knowledge related to CHW and their activities, is the fact that little evidence is available to direct and forewarn as to the management of CHW programs at scale, under the auspices of the existing health system. Equally worrying in the case of South Africa’s move towards a universal CHW program are the associated challenges of re-orientating a range of eclectic community-based services that literally sprung up overnight to respond to disease specific requirements notably related to HIV and AIDS and to TB, to the creation of a standardized and regulated CHW program. CHW are supposedly a response to more inclusive, participatory, equitable and relevant responses related to health care needs in a world where inequalities (especially in relation to health) are constantly soaring. However, the history of community-based health care activities, as can be witnessed by the 2014 incident in the Free State province by the peremptory dismissal of a group of CHWs, is replete with the duplication of errors and falling prey to the pitfalls of the past.