Support needed for decent care labour in South Africa’s health system*

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Khwezi Mabasa
Senior Researcher at Mapungubwe Institute for Strategic Reflection (MISTRA) | + posts

Khwezi Mabasa is Senior Researcher MISTRA and SALB Board Member.

The burden of care work and social reproduction falls on women, says Khwezi Mabasa, but despite the critical role women play, the way they are treated by the state is reinforcing inequality across class, race and gender.

Covid-19 has highlighted several structural fault lines in the contemporary neo-liberal social order. It has shown the limitations of systemic inequalities across different human development areas, especially in the political economy. Several stakeholder representatives are discussing how Covid-19 impacted different sectors in the economy, with a specific focus on employment and business closures. This is understandable in a country with the highest unemployment and inequality figures, which deepen long-standing race, class, gender, and spatial development disparities.

Yet, the mainstream political economy debate underestimates one crucial factor: the importance of care work and social reproduction in essential human development areas like childcare, health, and social work.  Neo-liberal policy prescripts and the limited focus on workplace or shopfloor labour limit society’s support for care labour across society. I want to specifically point to several key shortcomings in the national health system, and the care labour required to achieve equal access to quality healthcare as stated in the Freedom Charter and Constitution.

Firstly, the persistent skewed health worker and patient ratio that exists in our public hospitals and clinics. Several accounts from health workers’ experiences during the pandemic highlight the negative impacts of staff shortages and vacancies on issues such as employee burn out. This structural human resource challenge started in the early 2000s, pre-dating Covid-19 . It can be traced back to the public health budget cuts in the areas of human resource and health training institutes like nursing colleges.

Equally the quality and effectiveness of non-clinical support staff work (such as porters, security, cleaners etc.) has been negatively affected by outsourcing these functions to private companies. Several trade unions organising in the public health sector raise these issues sharply in their public health policy advocacy and engagement with employers.

Covid-19 highlights the outcomes of ignoring these genuine working condition grievances, which can only be resolved through changing social and macro-economic policies that currently cause budget cuts in public health.

A second, and closely related issue, is the minimal progress in expanding the size and quality of primary health care in communities. The proposed National Health Insurance (NHI) policy identifies Community Healthcare Workers (CHW) as the main policy implementers and drivers of an effective redesigned primary health care system. Yet, their employment status in our health system is largely atypical and exploitative. Health sector trade unions still advocate for CHWs to be integrated into the public health system as direct government employees. But the government maintains its historical policy stance on this matter, which basically states that costs of public employment will be too high if CHWs are fully integrated as health workers in standard employment.

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CHWs picket to make authorities aware of their grievances (Pic: Mkhuseli Sizani)

The result is low pay, no access to benefits, and limited employment security for CHWs. Gauteng’s provincial health department absorbed 8 794 CHWs into formal employment last year. However, this is not sufficient because the country has 70 000 CHWs in total, and this figure amounts to half of what is required to effectively service all wards. The recent budget cuts and challenges arising from employing CHWs in atypical employment explain the primary health care failures before and during the Covid-19 pandemic. Research proves that CHWs play a crucial role in alleviating community-based health challenges created by pandemics like Covid-19 or Ebola. South Africa’s NHI vision anchored around primary health care will inevitably fail if there is no decent work in the sector. Macro-economic and social policy frameworks need to be reformed so they create the decent health care work required for NHI.

Lastly, society needs to address the long-standing structural inequalities between private and public health care in South Africa. Different civil society groups and trade unions highlight how the disparities lead to unequal access to health care. The clearest signs of this inequality can be seen in health service quality, infrastructure, working conditions, human resource numbers and health costs.

In addition, health system inequalities are closely related to the broader class, race, and gender disparities in South Africa. All these inequalities within SA’s health system place an extra burden on care labour outside the workplace. This includes the unpaid care work undertaken by women who look after the elderly and sick in their own households or communities. The ILO states that ‘women perform 76.2 per cent of the total amount of unpaid care work, 3.2 times more time than men’. Working class advocacy for decent health care work must accommodate the demands and experiences of women informal care workers in communities.

* The article is based on Mabasa’s public health policy advocacy and training while he served COSATU.

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