The community health worker programme as a response to HIV/AIDS in South Africa : a case study on oNompilo in KwaZulu-Natal

For more than a decade, South Africa has been confronted with two major developments challenging every aspect of its society: the far-reaching political and social transformation processes after the end of apartheid and the rapidly-spreading HIV/AIDS epidemic. Health system transformation towards a more equitable distribution of resources and an improved access to health care became major governmental goals after 1994. However, the impact of the HIV/AIDS epidemic has left South Africa's public health sector struggling to provide appropriate services. The need to look for alternative strategies returned Community Health Workers (CHWs) onto the national health-policy agenda in late 2003, increasing the need for understanding details of existing programmes and their potential to address the devastating epidemic. KwaZulu-Natal's (KZN) CHW programme has been identified as the most advanced model and became the blueprint for the national rollout. Thus it was timely and useful to contextualise the actual CHW programme structures as they emerge in KZN and to examine their potential in addressing the complex drivers and impact of the HIV/AIDS epidemic. First, on the basis of an intensive literature review and in-depth interviews an agreed model of KZN's CHW governance structure was developed. Second, the research has identified CHW managers' current understandings of the actual and expected roles CHWs can play in communities strongly affected by HIV/AIDS and unveiled their views on key factors facilitating or hindering their success in fulfilling these roles. Results indicate that CHWs offer a valuable addition to the overburdened health sector by extending prevention and care services into marginalised communities. However, successful local implementation strongly depends on the existence of effective management and supervision structures and adequate resources. Here, greater awareness of the complex processes characterising the KZN programme may give the opportunity better to deal with arising management issues and improve CHW effectiveness.