As South Africa moves towards universal healthcare, health policy experts warn that the country has grossly underestimated the number of health workers it will need to ensure access to health services for everyone.
Although the policy is still being formulated, the proposed move to institute a national health insurance (NHI) programme will be accompanied by a re-engineering of primary healthcare services.
South Africa’s bid to improve access to quality healthcare is based on the Brazilian primary healthcare model. The re-engineering it will require is expected to place a greater emphasis on population-based health and outcomes, and seek to decentralize health services.
As part of the project, school health programmes will be strengthened and specialist teams, including gynaecologists, paediatricians and advanced midwives, will be assigned to each of South Africa's 52 health districts. This is expected to address the country's stubbornly high rates of infant, child and maternal mortality.
Districts are divided into wards, which will also roll out ward-based primary healthcare outreach teams of community healthcare workers (CHWs). Each worker is expected to be responsible for 250 households, or about 1,000 people, according to draft discussion papers.
However, David Sanders, professor and founding director of the School of Public Health at South Africa's University of the Western Cape, says this ratio is far too large to chart the kind of success seen in Rwanda.
"We have a big research project in Umlazi (a township outside Durban, South Africa) where CHWs are told about every single birth at Prince Mshiyeni Memorial Hospital and are required to follow up with mothers for an antenatal visit within 48 hours, and they can't do it," Sanders told IRIN/PlusNews. "How is one health worker going to cover 250 households? [It's] impossible."
CHW in South Africa under-utilized
Between 2007 and 2011, Rwanda doubled its number of healthcare workers, and even though almost 60 percent of these healthcare workers were among lower level cadres, the country was able to chart a decline in general mortality as a result, Sanders said.
Rwanda now has more community health workers than South Africa but only one-fifth of its population, nevertheless South Africa's community healthcare workers are under-utilized. "Community health workers are not playing a role in curative treatment, they rather just advise patients," said Sanders, speaking at the People's Health Assembly, held this week in Cape Town. "In South Africa, they are not even allowed to prescribe deworming medication, which can be bought over counter."
In a country with an HIV prevalence of about 18 percent, CHWs are also prohibited from performing the heel pricks necessary for dried bloodspot infant HIV testing, he pointed out. Decentralizing this function could multiply the number of HIV-positive babies diagnosed and treated.
With an unemployment rate that the Congress of South African Trade Unions estimates is as high as 40 percent, the government has implemented infrastructure projects to create jobs. Sanders argues that if the country invested in training more CHWs, it could create employment and improve health indicators.
"If we had part-time community health workers, [with] each worker covering 25 households - not 250 - they could do that on a part-time basis and receive a part-time wage," he said. "We could create 400,000 or 500,000 jobs and get the health coverage we need."