Lay health workers and HIV programmes: implications for health systems

Abstract

One of the consequences of massive investment in antiretroviral access and other AIDS programmes has been the rapid emergence of large numbers of lay workers in the health systems of developing countries. In South Africa, government estimates are 65,000, mostly HIV/TB care-related lay workers contribute their labour in the public health sector, outnumbering the main front-line primary health care providers and professional nurses. The phenomenon has grown organically and incrementally, playing a wide variety of care-giving, support and advocacy roles. Using South Africa as a case, this paper discusses the different forms, traditions and contradictory orientations taken by lay health work and the system-wide effects of a large lay worker presence. As pressures to regularise and formalise the status of lay health workers grow, important questions are raised as to their place in health systems, and more broadly what they represent as a new intermediary layer between state and citizen. It argues for a research agenda that seeks to better characterise types of lay involvement in the health system, particularly in an era of antiretroviral therapy, and which takes a wider perspective on the meanings of this recent re-emergence of an old concept in health systems heavily affected by HIV/AIDS.

Keywords:

• lay health workers
• home-based care
• health systems
• HIV

Notes

1. Lewin et al. (2005) define lay workers as “any health worker carrying out functions related to health care delivery; trained in some way in the context of the intervention; and having no formal professional or paraprofessional certificated or degreed tertiary education.” The use of the term “lay health worker” in this paper is deliberate and is used to denote their structural position as the opposite of “professional” health workers.

2. This situation is somewhat different to that of Latin America and Asia where generalist CHW programmes remain important components of country health systems (Rohde et al., 2008).

3. DOTS stands for “directly observed therapy, short course”, the World Health Organization's model of TB care, implemented in South Africa from the mid-1990s.