Vulnerable and poor communities in many low- and middle-income countries still face many barriers to health care, including stretched services. The health of people in poor communities is further compromised by a lack of access to transport, clean water and sanitation and nutrition. This means that they require services that can respond to a complex mix of challenges.

One way to mitigate these problems is through the use of community health workers. In sub-Saharan Africa and particularly South Africa, community health workers fulfil a significant role in improving access to health care for poor communities. They create a link between the health system and communities. They also have the potential to improve access to sectors other than health, creating avenues to services such as social welfare and housing.

In South Africa, there are more than 65,000 community health workers who provide a wide range of care-related services in poor communities. They provide a wide range of care related services, which can include:

• Providing health information;

• Conducting health promotion activities and awareness about diseases;

• Identifying and attending to minor ailments and referring chronic conditions for treatment;

• Connecting communities to resources and services; and

• Conducting defined activities in areas such as treatment and counselling support for TB and HIV, malaria, rehabilitation, hypertension and diabetes.

Although research shows how effectively community health workers can contribute to the improvement of health care provision, many of these programmes have failed in the past. This failure comes from the expectation that they act as a single solution to a complex set of problems, including weak health systems.

It also stems from the misconception that they are a cheap alternative to providing services to underserviced communities.

The pros and the cons

Community health workers face a myriad of challenges. These hinder their potential to provide outreach services.

Our research compared three programmes in two provinces – the Eastern Cape, which is South Africa’s second-poorest province, and Gauteng, which remains the least poor.

In Gauteng, community health workers were unable to respond to complex household needs. Examples include being unable to link patients to social services for social grants because they lack formal documents such as birth certificates or identity documents. These often require problem-solving skills beyond health-sector specific problems which the health workers did not have because of their limited training and supervision.

Another problem was that they encountered the same struggles as their patients because they lived in the same communities. For example, they did not have money to take transport to referred services such as hospitals. They were therefore unable to travel with patients to negotiate access to services. This problem is compounded by community health workers receiving limited support from the organisations they worked for.

Despite the Eastern Cape being one of the most under-resourced provinces in the country, there were several well-functioning aspects of the community health worker programme which could be implemented elsewhere. These included:

• Community health workers received training that involved sectors other than health such as the police and social welfare services. This helped shape their roles which in turn enabled them to provide broader services beyond health.

• Ongoing training, including on-site, peer-to-peer and group training.

• Mentoring aimed at improving knowledge and to assist with problem-solving skills. This proved useful given that working in communities with limited resources requires innovative interventions.

• Money for travel expenses which enabled community health workers to accompany clients to access services such as distant hospitals or registering for a social grant.

• Mobile phone vouchers: these helped the community health workers keep in contact with supervisors. This proved helpful when negotiations with government authorities proved to be difficult and a call to the supervisor helped break the deadlock.

• Equally important was the relationship between community health workers and ward councillors: community health workers were able to draw on ward committees as well as their existing social networks to assist households.

But community health workers across both provinces faced a common challenge – a lack of co-ordination within and between departments at all levels.

Success factors

Community health worker programmes can only be successful if there are several changes in the system that govern them. This includes increasing efforts to formally incorporate them into the health workforce in ways that recognise their unique needs.

Institutional support such as ongoing training and supervision needs to be provided. Practical resources which are often overlooked, such as transport and improved mechanisms for community participation that encourages accountability, also need to be taken into consideration.

A multi-sectoral approach that transcends health-specific interventions is also key.

Nonhlanhla Nxumalo received funding from the Global Health Research Initiative (GHRI), a collaborative research funding partnership of the Canadian Institutes of Health Research, the Canadian International Development Agency, Health Canada, the International Development Research Centre, and the Public Health Agency of Canada. Supplementary funding was contributed by the African Doctoral Dissertation Research Fellowship, Carnegie Corporation New York (Carnegie Cooperation Transformation Programme at Wits), and the National Research Foundation South Africa.