An Under-Appreciated Occupation: Community Care Workers and Their Employment Conditions

Community care workers (CCWs) perform a vital service in the health care system. The work that they do provides substantial cost savings to the health care system (National Institute for Occupational Safety and Health [NIOSH], 2010: 1) and governments rely on their work, which can be unpaid, to sustain public health services (Community Care Workers Forum, 2010: 1). Despite the important role that community health care has within the primary health care (PHC) system, the occupation is not well recognised and seldom has fringe benefits. Salaries remain low and CCWs experience poor working conditions with numerous hazards to their health and safety. This essay investigates two main issues: how socially useful the work is that CCWs do and whether CCWs have to struggle to do their work, given that their workplace is the community. To answer these questions, we begin by analysing CCWs’ contribution to the health sector, then describe the work that they do and examine the difficulties that they face in their employment conditions, including an analysis of how social determinants of health affect their work, and we conclude by considering what future scenarios lie ahead.

CCWs, also known as ‘home-based carers’, provide health care services in households, and play an increasingly important role in the trend towards a PHC-dominated health care system (World Health Organization [WHO], 2007: 1). In 1978, an international conference at Alma-Ata affirmed that PHC is key to achieving developmental goals (WHO, 1978: 1). Since the late 20^th century this affirmation has resulted in a restructuring of health care systems, such as ‘task-shifting’ responsibilities downwards to less qualified occupations in order to improve service delivery (Lund & Budlender, 2009: 23). In particular, this translates into extra responsibilities being placed on CCWs. In South Africa, the National Health Insurance scheme provides a fresh opportunity to campaign for a strengthened PHC system supported by community-level workers (ibid.). On the one hand, research shows rapid health improvements where CCWs visit households regularly (Sanders & Reynolds, 2011). However, on the other hand, this needs to be well-resourced and appropriate training given, in order to prevent extra risks being placed on CCWs, or care responsibilities being placed on unskilled health care volunteers or unpaid care-givers (Lund, 2010: 505).

With this understanding of the role that CCWs play in the health care system, let us now look closer at the nature of the occupation itself. CCWs offer services in people’s homes other than their own, such as helping with activities in daily living (bathing, eating and getting out of bed); delivering medical services, such as administering medication; changing dressings; or giving massages and palliative care (NIOSH, 2010: 1). As we have seen, their work is necessary and beneficial for health outcomes, yet, in South Africa, their salaries remain disproportionately small and unregulated, and they have minimal access to health insurance or pension schemes (Lund, 2010: 500). Furthermore, CCWs are exposed to many health and safety risks due to the nature of their job and the environment that they work in. For example, they are often assigned to HIV/AIDS or TB programmes (Sanders & Reynolds, 2011), so are at greater risk of contracting these diseases (a biological hazard). Many CCWs work in communities where there is violence, or in households with domestic violence, which can lead to stress (a psycho-social hazard) or injury. Other hazards include ergonomic hazards (such as lifting people and bending over), physical hazards (such as negotiating street traffic or aggressive animals) and environmental hazards (such as pollution, in low-income communities). With a “precarious” employment status (Lund, 2010: 503) and an income between R500 and R1 500 per month (Samson, 2008, as cited in Lund, 2010: 501), it is perhaps surprising that CCWs are numerous. Research has shown that CCWs’ motivation work comes from the desire to care for others (The Industrial Health Resource Group [IHRG], 2012: 5), and also the hope that it will lead to better employment prospects (Lund, 2010: 504).

Another set of factors that impact the work of CCWs is the social determinants of health. The social determinants of health directly impact the work that CCWs do because they are at the front line of PHC, leading them to deal with unhealthy socio-economic, cultural and environmental conditions, living and working conditions, social and community influences and individual lifestyle factors (Bradshaw, 2008: 53-60). For example, inequality in society, or having a low socio-economic position, is associated will poor health (Bradshaw, 2008: 53). The material wellbeing of clients can also make it difficult to provide care, such as when there is no electricity to cook food (Orner, 2006: 237). Traditional environmental concerns are sanitation and clean water. Modern environmental concerns include industrial pollutants and climate change (Bradshaw, 2008: 54). Food security is a constraint on living conditions, while nutrition and feeding programmes support care work (Lund, 2010: 507). Housing subsidies also determine the living conditions of clients (ibid.). Individual lifestyle factors that impact on health include unsafe sex, alcohol use, tobacco use, lack of physical exercise and unhealthy diets (Bradshaw, 2008: 60). In South Africa, these social determinants of health are exacerbated by a so-called ‘quadruple burden of disease’ due to high rates of poverty, non-communicable disease, violence-related injuries and HIV/AIDS.

To summarize, we have seen that CCWs struggle to do the work they do because of their terms of employment and because of their working conditions. To explore this directly from the CCWs’ point of view, let us analyse a statement made by an anonymous group of care workers, working for an NGO in Cape Town:

“Some people think that we are lucky to have work. The truth is that we are subsidising the government. We are doing the work the government is supposed to do, doing it for wages which are too low. The unemployed are doing it for free. Yes, we are all there, doing that important work. We are giving care. Of course this makes us proud. But still we say: it is not easy to go and face this every day.”

(IHRG, 2012: 5)

This statement shows us that this group feels exploited, that they are unfairly given a burden that the government is meant to shoulder. They say that the work they do is difficult to “face … every day” (ibid.). This feeling is reflected in a study on unpaid caregivers of people living with AIDS, which found that the caregivers struggled emotionally (Orner, 2006: 238). For example, the carers dealt with stigmatization, poverty, poor infrastructure, a lack of affordable transport and an overburden of duties – simultaneously caring for many different clients and still fulfilling the role of a carer in their own households. The precarious terms of employment and a lack of freedom to unionize is reflected in the first group’s decision to remain anonymous (IHRG, 2012: 4).

Although the first group feels exploited, their comment shows us, as with other examples, that CCWs feel that their work is important. CCWs care for others even when the work is unpaid, out of a sense of responsibility and love towards their clients (Orner, 2006: 239). They are motivated to do their job, although they do not feel as if it is enough to solve all the social and health-related problems that they see (IHRG, 2012: 4-5).

In conclusion, we have seen that CCWs work is vitally important, yet their terms of employment are exploitative and employment conditions are unhealthy. The work that they do strengthens the PHC system and reduces the financial and physical burden on the health care sector. Health and safety hazards are a key concern, and CCWs are exposed to social determinants of ill health more than the average person. CCWs struggle against resource scarcity and with emotional burdens, but they continue to do their work out of a sense of pride in helping those who are in need.

[1 302 words]

October 2014

References

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