In South Africa, locals with basic training are becoming increasingly central to the provision of healthcare and drugs. What are the benefits and risks?
Over the last decade, policies towards HIV/AIDS across sub-Saharan Africa have steadily moved away from prevention and towards the provision of anti-retroviral therapy (ART).
In South Africa, drug roll-out has more than doubled and the country is currently on track to reach its target of supplying ART to 2.5 million people by 2014. According to UNAIDS, the nation still has the largest global population living with HIV at 5.3 million, but HIV-infection rates have dropped by 41% since 2001.
At the forefront of this drive to provide ART have been local communities. Community-based provision has been seen as a "magic bullet" for delivering frontline HIV/AIDS care by many, but there are risks involved and it is crucial that local initiatives are not seen as a wholesale replacement for concerted and more formal state healthcare efforts.
Community Health Work: a retro solution to anti-retroviral delivery?
Using Community Health Workers (CHWs) is nothing new. CHW schemes flourished during the 1980s, coinciding with apartheid and Structural Adjustment policies. Many community schemes campaigning for better healthcare inspired social change and were championed as "innovative, responsive, comprehensive and empowering".
However, in 1994, the new democratic government returned to a national plan of primary healthcare which effectively scrapped CHWs. The then incoming Minister of Health, Nkosazana Dlamini-Zuma, denounced CHWs as representing "second-rate care".
But then in the 2000s, with South Africa struggling to face the burden of care associated with HIV/AIDS, and with limited alternatives, CHWs began to re-emerge. Initially this largely focused on providing homecare for patients dying of AIDS. However, new legislation and increased funding for ART programmes has since shifted their role from palliative care to delivering frontline treatment.
Spreading the burden: from clinics to 'clubs'
Through the 2000s, health clinics managed to increase provision of ART but many also became overburdened and the proportion of patients following up with treatment decreased.
In response, more decentralised non-clinic approaches were developed. These community-based schemes were initiated to offer a pragmatic solution to shortages of medical professionals, which represented a "critical bottleneck" in efforts to prevent and treat HIV, and increase retention of care rates.
CHWs are essentially local people who are given basic training to operate within their own area. While it takes six years to train a doctor, a community worker can be trained within several weeks and is much cheaper.
CHWs also have the advantage of being more closely embedded at the local level. This has led to considerable improvements in terms of patients continuing with their treatment as problems associated with clinics - such as transport costs and long waiting times - are bypassed.
Research by Médecins Sans Frontières (MSF) who set up Community Adherence Clubs in the township of Khayelitsha found that participating in local clubs "reduced loss to follow-up by two thirds and nearly halved the proportion with virologic rebound or breaks in monitoring compared with patients who remained in clinic-based care". Furthermore, MSF found retention in care rose to 97% for patients enrolled in adherence clubs, compared to 85% for those in clinical-based care.
Given these initial successes, and the affordability of these schemes, it was not surprising that South Africa's '2012 Primary Healthcare Re-Engineering Framework' explicitly placed Community Health Workers (CHWs) at the core of delivering life-saving ART in "resource-limited settings".
Whilst there are some clear advantages to community level engagement, however, CHWs have also drawn certain criticisms. Though the diversity of approaches makes generalisations impossible, common themes are brought out.
Firstly, some critics have commented that narrowing the role of CHWs to focus exclusively on treatment may come at the expense of situated projects aimed at instigating social change. However, Gilles Van Cutsem, Medical Coordinator and Acting-Head of Mission for MSF in South Africa and Lesotho, told Think Africa Press that MSF's experience in Khayelitsha shows the opposite. In Khayelitsha, he argued, drug adherence clubs act as "hubs of expertise".
The supportive networks that develop in these environments help educate people about their treatment, eventually promising to put sufferers in a position to hold the health sector accountable. Connections between community health work and emerging activism are particularly prominent in South Africa, where the civil society links made through the Treatment Action Campaign were vital in initially securing drug access.
Secondly, there are concerns regarding the level of training CHWs receive. As care becomes increasingly local, it is essential that community workers are trained to detect early symptoms of TB or ART toxicity. Equally, inadequate or inappropriate training may mean that health workers fail to understand the local community structure in terms of the sexual and gender divisions.
Critics have further suggested that the quality of care decreases as health workers are increasingly overburdened and underpaid. Care quality may also decrease as pressure to boost the quantity of provision grows.
The health of a nation
While conspicuous increases in drug roll-out across South Africa give cause for optimism, it remains to be seen whether shifting emphasis onto the community can deliver universal ART access.
A decade ago, Thabo Mbeki's AIDS denialism misguided the South African population and "muddied the waters" of the AIDS response. Renewed encouragement on bottom-up community action may open up new channels along which knowledge can be disseminated, and individuals can be empowered to seek both preventative and palliative measures to confront HIV/AIDS.
It is, however, essential that these community measures do not become a substitute for state action. Whilst CHWs have historically been volunteers, the 2012 Re-Engineering Framework marks an attempt to coordinate on-the-ground efforts with formal channels of state funding.
Whilst the work of NGOs must be lauded, moving health away from the formal to the local must not simply represent a cynical national budget saving strategy. Equally, the state must compensate areas which have long suffered from chronic healthcare deficits.
There is still a need to link community networks to a formal referral system for those patients requiring urgent medical assistance, and this renewed focus on HIV/AIDS care must not come at the expense of other health priorities.