Should the state hire community health workers permanently?

Most community health workers (CHWs) in South Africa, except those in Gauteng, earn a stipend of about R4,000 per month, without benefits like pension or medical aid, and without the security of a permanent pay cheque. 

They’ve been fighting for better working conditions for almost a decade — with their main goal being to get on the government’s payroll, as their colleagues in Gauteng are, who are classified as level 2 public servants.

At this level, an employee such as a CHW can earn between R9,000 and R10,500, and have benefits like a housing allowance, pension and medical aid.

The government, though, wants to set up a “sectoral determination” for CHWs instead, whereby the basic conditions of employment for workers in a particular field would be standardised. In the case of CHWs, this would include a set minimum wage, possibly a travel allowance when they have to work outside of their usual communities, and suitable housing for those having to work in remote areas, on farms or at mines.

Currently, CHWs are contract workers who are employed for 12 months at a time, either by provincial governments or nonprofit organisations. (Gauteng is the only exception: here they are permanent government employees.) Though their salaries have been standardised across the country since 2018 following a bargaining council agreement, they don’t have long-term job security and many end up with nothing after years of work.

To make sure that CHWs have fair working conditions, the National Minimum Wage Commission, which has to advise the government on things like what fair pay would be for workers in South Africa and what their working conditions must be, started looking into how CHWs are employed. 

The commission is sifting through responses from the public after the initial announcement in December that the labour department is looking into sectoral determination for CHWs. 

The department’s spokesperson, Teboho Thejane, says they are still reviewing the submissions and can’t give any comment on the outcome of the investigation yet. 

“We’re looking at finalising the process in June,” he says. By then they would have gathered information on how CHWs are usually employed and worked through all the public responses. They will then put together a report for the minister of labour, who will check whether all the requirements for a sectoral determination have been considered in the report and make a final decision on whether the plan will go ahead. 

“It’s a laborious process,” says Thejane. 

Union bosses, though, say setting up a sectoral determination is a way for the government to wiggle out of incorporating CHWs into their formal workforce, as was agreed to in negotiations with labour organisations in 2018.

Solly Malema, spokesperson for the National Union of Public Service & Allied Workers, says that if CHWs are placed under a sectoral determination, the department will continue employing them as contract workers. 

“They are health workers and should be employed permanently. We really can’t afford for a sectoral determination to be established.”

But will making CHWs permanent government workers change how health services get to the people who need them most? 

Unions say workers must come first 

In 2018, unions struck a bargain with the government to standardise CHW salaries. This deal, says Nicholas Crisp, who is spearheading the government’s plans for establishing a National Health Insurance (NHI) scheme, had honourable intentions. 

“But it’s impractical,” he says.

Rolling out the NHI will rely heavily on well-trained CHW teams to deliver primary health-care services, especially in areas where people struggle to get to clinics or hospitals.

Crisp says it’s the right call to ensure that CHWs are protected and that there must be rules that determine the work they do depending on their education and experience — which is something that’s being considered as part of the sectoral determination. However, pushing for permanent government employment will limit the kind of work CHWs can do, he says. 

CHWs are employed by provincial governments and nonprofit organisations and are usually from the communities where they work. They are important to help care for people with HIV, TB, and sexually transmitted infections, as well as those with chronic conditions like high blood pressure and diabetes. CHWs teach these patients about their illnesses, deliver their medication and help them take their medication on time.

If CHWs are employed only by the department of health, “what about those employed on farms and mines, or local governments?” he asks. 

“Are we now going to prevent them [anyone outside of the government] from employing CHWs as well and from having a CHW dispensation?” asks Crisp. “Are there going to be two different kinds of CHWs? It doesn’t make sense.” 

Unions did not respond to Bhekisisa’s questions on Crisp’s view. 

Has sectoral determination worked before? 

In the Western Cape and Mpumalanga, some or all of the money for paying CWHs comes from the department of public works’s expanded public works programme (EPWP) instead of from national or provincial health budgets. This programme, which is meant as a stepping stone to help unemployed people earn an income and learn new skills, also funds other contract workers such as security guards and admin assistants at public schools.

In May 2012, the then minister of labour, Mildred Oliphant, passed a ministerial determination for EPWP workers. Though the process for establishing a ministerial determination is different from that of a sectoral determination, the result of both is a list of standardised working conditions that would protect workers from exploitation.

For example, the EPWP ministerial determination sets out working hours, mealtimes workers are entitled to, conditions for maternity leave and other employment standards. It also says that employers have to explain the conditions of employment to their workers, such as payment, training and expected work hours and duties.

Security guards employed by the programme, for instance, are allowed to earn extra money by working 55 hours a week and up to 11 hours a day, instead of the standard work week of 40 hours and a daily limit of eight hours. 

Having a set list of conditions, says Crisp, is a real-life example of how a sectoral determination can protect CHWs from having to do work outside of their scope and help manage how they are employed in nongovernment settings. 

Yet in Gauteng, the same province where CHWs are insourced, EPWP workers deployed to the provincial health department have protested against being replaced when recruitment for a new intake of workers started on 1 April. EPWP work is one of the ways the government tries to stem unemployment, yet workers would have been left without jobs once their contracts ended. 

After the demonstrations contracts were extended by 12 months and their union said they’ll continue to negotiate for permanent employment. 

Steady jobs, better lives

Mandy Witbooi*, who’s been a CHW in Gauteng since 2009, is one of 8,532 workers who were permanently employed by the province between 2020 and 2021. Before this, she used to work irregular hours for little pay and had no benefits.

She says that her duties did not change much, which are set out in a “scope of practice” and were explained during training once they became permanently employed. 

But her lifestyle is better. As a level 2 public servant, she now earns about R10,000, works regular eight-hour shifts (instead of not having set hours before) and gets benefits such as medical aid and a housing subsidy.

“Our workload is also lighter than when we were with the NGOs,” she says, because they received training that made their duties clearer and they don’t have to take on overflow jobs (from nurses) now.

For Witbooi, becoming an insourced, permanent employee was the result of a long fight. 

She’s much happier now.

“We used to be paid R3,500 and didn’t always get our money when we worked through NGOs. We fought and fought and held placards, and now we’re getting a better salary and benefits.” 

* Not her real name

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter