By The People

The Maoist cultural revolution introduced the concept of a barefoot doctor – a rural paramedic permanently deployed in far-flung villages. These embedded health-workers would live within and under the same conditions as their client communities – copying the Chinese peasant farmers’ Spartan aversion to footwear (which, apart from being an urban luxury had a ruinous effect on the paddy).

In South Africa, increased pressure on the public health system, coupled with the urgency of the HIV phenomenon has led to renewed interest in this model. Two recent studies, by Nina Hunter of the University of Kwazulu/Natal and Irwin Friedman of the Seed Trust, have highlighted experiences in the South African experience of barefoot medicine.

South Africa’s first brush with barefoot medicine came in the 1980’s. Friedman’s study implicates the change of regime in 1994 with the collapse of this network. Citing a reluctance of the new government to fund a national lay caregiver network, Irwing notes that the networks “were replaced mainly by numerous small [community based organisation] projects fielding a disconcerting array of ‘volunteers’ and single-purpose workers that have less coherence and insecure funding.”

Since then, there has been a formalisation of funding, training and other support for better resourced programmes. The expanded public works programme presents a further fillip, with the health department having indicated an intention to include caregiver networks as part of it’s sector-contribution to the public works programme.

A second phase followed a decade later with the Cuban deployment of the mid-nineties, in terms of which a team of Cuban doctors was spread across state facilities in under-resourced (largely rural) clinics and hospitals across the country. This project was marked by some successes, but as it happened entirely in terms of a government-to-government agreement, lacked a critical component of private initiative. The South African government has been aware of this limitation, and on the back of it’s volunteerist project of 2002/3 sought to encourage and help initiate the establishment of broader community-based networks.

The government regards the rise of community caregivers as an important component in the broader deployment of community development workers. At an address in the Northwest three years ago, president Mbeki described how these cadres “should be able to assist the people to tackle a whole variety of questions, including those relating to health, welfare, agricultural development, economic activity, education and training and safety and security”. This raises the prospect of improved cooperation between the state-sponsored health infrastructure (both the national and provincial departments) and private caregiver initiatives. The trick is to optimise the dovetail.

Much of the content of community caregiving is driven by the requirements of HIV-related care. This is not surprising, given the scale and character of the pandemic In Friedman’s estimation, currently there are close to 9000 groups, involving more than 19000 volunteers, receiving state funding. The provincial health department in Kwazulu province has allocated R15.7m for community care in the 2004/5 financial year. This allocation is expected to grow, given the scale of HIV infection in that province. A successful programme may see replication in other provinces, where similarly robust attempt at reducing the reliance on state-care are still lacking. These networks face formidable challenges including uncertainty in the training qualification framework and integration with related organsiations in and out of the government’s social services architecture.

Nina Hunter’s study found evidence of a switch away from public reliance on state health infrastructure. Over the five-year period from 1999 to 2004 the client satisfaction figures for public health services declined. At the start of the period, 41% of respondents indicated unhappiness with the levels of service at hospital and clinics. This rose to 68% by the end of the period. The corresponding figures for clients satisfied with the service were 50% and 24% respectively. In contrast, the dissatisfaction figures for community caregiver service were 82% and and 29%. The respective satisfaction figures were 11% and 40%.

The attitudinal shift indicated in these figures is explained by an increased understanding about the role of community-based care. As Hunter indicates “Some family caregivers describe the condition of ill people as not improving when they are in hospital. Medical managers believe that nursing care is what is needed for terminally ill patients, whose condition will ultimately not improve. However, a shortage of nurses is a key problem in providing this care, as are hospital resources. Family caregivers express a need for professional care, but medical managers express a need for support at the community-level in caring for terminally ill people.”. This, a coordinated effort in which state resources are focused on short-term (including emergency) treatment, and away from hospice-like functions is likely to lead to an optimal arrangement for the public/private distribution of healthcare. And as the shift in perceptions persists, communities are likelier to reduce their reliance on the state for end-to-end provision of health care. At the same time, the state should follow through by honouring its commitment to support independent caregiver networks.

Hunter cites cost and stigma as significant barriers to the integration of state and caregiver efforts. Cost arises because community caregivers are provided with treatment prescriptions which they cannot afford to execute. This leads to ineffective improvisation or – worse yet – a breakdown in collaborative effort. Stigma is a problem as it prevents patients from presenting at clinics, on account of the publicity garnered from spending hours waiting in a public, earmarked queue. This leads to an over-reliance on homecare, which not only pressures limited caregiver resources, but puts those resources to uses to which they’re not optimally suited.

The prescriptions in both the Friedman and Hunter studies provide budgetary and logistical constraints for entities establishing independent caregiver organs. Firstly, an allocation must be made for paying a stipend to the caregivers. This could range from R1000 to R1800 per month, depending on where the caregivers are located. In Hunter’s analysis, this compares favourably with minimum wages in other sectors. A maximum of 250 households has been suggested to facilitate effective monitoring and limit the erosion of quality. Empirical evidence uncovered by Hunter is that rural caregivers earn 40% less than their urban counterparts. As the caregiver network assumes responsibility for a broader range of interventions, training becomes important. Friedman emphasises issues to be addressed in the development of uniform training standards for community caregivers. This includes mentoring and stakeholder engagement, in order to assure quality control and smoothed cooperation. In addition, training should be based on registered standards, with a preference for training in the regions where the workers are to be deployed.

A comprehensive guide to possible community intervention is provided by Friedman. The range includes:

* Generic community health workers.
* Home-based caregivers.
* Treatment supervisors.
* Farm and village health workers.
* Family planning advisors.
* Traditional birth attendants.
* Home nurses.
* Nutrition advisors.
* Water and sanitation workers.
* Community disability workers.
* HIV/AIDS communicators/counsellors.
* Paramedics.

Hunter mentions the gender-related aspects of community care. These are not explicitly addressed in policy directives, with possibly ruinous effects on the implementation of programmes. She quotes studies that indicate “that there has been a continued and dramatic feminisation of the labour market that has occurred in South Africa over the second half of the 1990s. The increase in employment among women has been largely due to the increase in self-employment in the informal economy, which is associated with lower earnings and insecure working conditions (ibid). While government has encouraged women to participate in the labour market, this economic approach is not in line with government’s policy of welfare retrenchment. No guidance is given on how women are meant to provide both unpaid care and work at the same time.” This increases the need for caregivers to exchange their experiences.

If the prescriptions for increased caregiver support are to be implemented, then several private sector initiatives should be implemented. On the issue of training, a pre-emptive curriculum and resource development will speed the unification of training standards, and introduce efficiencies in training. Technologies to facilitate the transfer of skills and experience should be put in place. Higher up the cost and complexity chain, Friedman calls for GIS networks to track the deployment of personnel. These may be developed and sponsored privately. At the same time, specific attention should be paid to the programme in Kwazulu province, which will continue to provide lessons for the cooperative implementation of these programmes. Friedman points to structural issues, such as the need for specialisation within the caregiver networks. The idea is that an overarching layer of generalist structures will coordinate and monitor the specialists. Since there will always be a requirement for integration with skilled professionals, the ranks of the medical community (palliative nurses, professional counsellors and the like) should be canvassed for volunteers to assist in defining the collaborative scope. And finally, government should be lobbied coherently and continuously, to maximise the chance of benefiting from it’s stated commitment to the programme.