South Africa


Their perseverance has paid off: In the midst of the pandemic, community health workers have won a major victory in their fight for recognition and rights. By Usche Merk

The corona pandemic has hit South Africa hard, but by no means everyone and everywhere to the same extent: in the townships, the Covid-19 mortality rate is twice as high as in affluent neighbourhoods. One antibody study has found that black South Africans are five times more impacted by infections than white South Africans. Another study shows that poor black women have suffered the worst socio-economic and health impacts from the pandemic, whilst simultaneously bearing the brunt of the additional childcare, nursing and the struggle to survive, as well as suffering increasing patriarchal and sexualised violence.

But the pandemic has also made something visible that otherwise stays hidden in South Africa: It was and is primarily the female community health workers who ensure that people in marginalised neighbourhoods can at least rudimentarily protect themselves against Covid-19, that diseases like HIV, tuberculosis or diabetes continue to be treated and that shelters remain accessible to people facing sexualised violence. Thus, community health workers (CHW) - for the most part black women living in poverty themselves who are often single mothers – are the bedrock of the health system. Women, whose own lives are often marked by illness, violence and hardship, do the care work at home and in the neighbourhood, whilst simultaneously providing basic health care. Even during the hard lockdown and in the midst of high infection rates, they have served as “frontline soldiers” in the government pandemic response, organising information and education, contact tracing and care of the sick. Yet all the while, their rights and safety have been disregarded. Without preparation, without sufficient masks and other protective equipment, the Department of Health sent them to the “front”, without proper payment or occupational health protection.

Rights that should go without saying

Almost ten years ago, women started to organise against rightlessness. They challenged exploitation and invisibility and now – in the thick of the pandemic – they have secured a first, impressive victory: In July 2020, the Gauteng Province Department of Health (around the metropolises of Johannesburg and Pretoria) announced that the almost 8,500 community health workers in the province would be offered permanent jobs. This did not come voluntarily; the Department’s had ultimately being forced by a 2018 labour court decision the women had fought for that ruled that people who have been regularly working five days a week on behalf of the Department for years cannot be considered volunteers and fobbed off with one short-term contract after the other. It took another two years and a dramatic pandemic before the decision was finally implemented. But it has fundamentally changed the lives of female health workers in Gauteng. Their salaries have more than doubled and for the first time they themselves are now covered in the event of illness, too. Furthermore, they are now entitled to leave and training days, paid maternity leave and other workers’ rights - rights that should go without saying.

“This struggle has not been easy,” the Gauteng CHW Forum representatives write in their newsletter, “we won through dedication and sacrifice. Some of our comrades are still not contracted, some passed on before they could see this milestone and many were victims of abuse and unfair treatment from the Department of Health and were dismissed.” And, they go on, this struggle will continue until those dismissed in the course of this process are reinstated and the more than 50,000 female health workers in other provinces are also given contracts. “Our victory comes in the midst of the pandemic and therefore in a situation of great danger. But it will be an empty victory if we fail to defend community health workers and our communities against Covid.”

The invisible parts of this success

What does it mean when marginalised women, who live far apart and usually have a large family to provide for alone, join forces to wage a political struggle that no one wants to hear about? And what does it mean for medico to support a process like this? In a touching book written by the founders of the Gauteng CHW Forum with the support of medico’s partner organisation Khanya College, women tell of their lives and how they became community health workers. These are brutal stories about the lives of poor, black women caught between apartheid, exploitation and patriarchal violence. Experiences of injustice, the serious AIDS illness of close relatives, but also the lack of other ways to earn a living led them to become health workers, work that is a source of pride for many despite all the difficulties. “Sometimes it is very tough, but we are respected in the community because we are really there for them,” writes an older colleague.

Individual stories became a shared experience. On the street corner, under a tree, in the car park outside the clinic, sometimes on long walks, afraid of clinic managers, jealous men or husbands and worried about the children waiting at home, they shared. A process began, a process to change things together. Staff from NGOs like Khanya College listened to the women and supported them with phone cards, information and travel money. They arranged training on self-organisation, health policy and workers’ rights. The community health workers started travelling from clinic to clinic by public minibus and on foot, talking to their colleagues there and convincing them to form committees themselves and join a common forum. “Each member is an organiser. 'Each one teach one', we say, because we all don’t have much time,” says one founder of the CHW Forum in Gauteng.

Gradually, the women learned to organise processes of democratic decision-making and representation, deal with internal conflicts, organise protest actions, stand up to arrogant officials and brutal police, or to deal with trade unions that were eager to gain members but not willing to do anything to support them. Organising a community-grounded and participant-led social movement is a slow, arduous process, but one marked by compassion and solidarity. Their specific situation as women means it is never just about their professional care work, but also always about personal and communal care, that the committees, workshops and protest campaigns are also times of caring for each other.

A network reaching all the way to Frankfurt

These processes have been supported for years by a network of different medico partner organisations - Khanya College, Sophiatown Community Psychological Services, Section 27, Sinani, People’s Health Movement and Wellness Foundation. For them, solidarity is more than the professional implementation of the mandate to organise training, political and legal advice, networking and public relations. It means always considering the perspectives and needs of others; listening when women are desperate or furious because they are being treated badly, because their protests are being crushed instead of heard; creating safe spaces for them to address their own issues and find their own voices, while finding practical solutions when more phone cards are needed or legal aid has to be organised.

The NGO colleagues also help each other out when necessary because everyday life in South Africa, especially during a pandemic, is exhausting. Struggles for care work also have to take into consideration the “wounded carer”. And for medico, too, solidarity with this struggle means accepting and being open to the multi-layered dynamics of a network of NGOs and self-organisation structures, an intense and unpredictable process that often does not fit into the logic of co-funded projects planned over multiple years. Applying nonetheless for money from the Federal Ministry for Economic Cooperation and Development (BMZ) to be able to provide the partner organisations with the necessary funds, but at the same time supporting the process in a way that reflects the needs of the social and political struggle and does not fail due to rigid donor requirements – this, even on the part of the BMZ, calls for contact persons with smart ideas and a sense of solidarity. And it also calls for mutual support in the medico team, too, when it is all too much for one team member or the figures and reports are enough to make another team member despair. So the success achieved by the health workers in Gauteng is a collective one to which many wonderful women, but also some men, were contributing. The joy is a shared one.

An inspiration for further struggles

The key experience for the health workers is an old South African insight from the struggle against Apartheid: demands will not be met by carefully convincing those in power of the ethical and moral correctness of your position. “They will only be met because of the combined energy, strength and courage of our collective action – our collective struggle to shift power – to break with the logic of this unjust society and build a new one,” explains a People’s Health Movement (PHM) activist. Inspired by the success of their colleagues in Gauteng, the health workers in the Eastern Cape Province also wrote a letter to the Health MEC there demanding permanent jobs. When this went unanswered, they went to the Department of Health and demanded a meeting. But the Department sent the police, who chased the women away with rubber bullets at night. Their determination has been all the stronger ever since. With the Gauteng precedent behind them, they want to take court action to ensure decent working conditions in all provinces. And they want to strengthen their self-organisations. Meanwhile they now have broad support upon which to build - large civil society networks have protested against the police crackdown and called for solidarity.

Over the course of the pandemic, new and strong alliances between civil society actors have emerged. Right at the beginning with the help of the medico partner network and the People’s Health Movement, over 300 NGOs joined together to form the “C19 People’s Coalition” and thus a strong voice in the fight for justice in the control measures of the pandemic. Both the struggles of the community health workers and the Covid-19 crisis have shown the opportunities, but also the necessities for a grassroots health movement that fights for a health system with equal access to prevention and care: a movement that holds those in charge accountable and stands up against neoliberal politics that cut the health budget in the middle of the pandemic.

The health workers and the NGO network have agreed to continue working together. Their first aim: a bottom-up people’s vaccination campaign. Their vision: a nationwide grassroots health movement that breaks with the logic of economic, political, gender and global inequality. medico will continue to support this process in solidarity, whose relevance points out far beyond South Africa.

Published: 12. May 2021

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