HOW OUR UNSUNG HEROES CAN REDUCE STUNTING
South Africa’s community health workers (CHWs) share the same lived experience as the people they serve. They are part of their communities, key figures of influence and mobilisation. They bring primary healthcare to those who struggle to access it and enable the formal health service to be more responsive to community needs. They are not only the eyes and ears of communities; they are connectors – linking people to the formal health system through home visits. CHWs are also well-placed to address the drivers of stunting, but they are often under-resourced and unrecognised.
This learning brief looks at how Grow Great, Philani and One To One Africa (OTOA) are supporting CHWs with the training and equipment they need to prioritise maternal and child health and reduce malnutrition.
The care and nutrition that mothers and children receive during the first 1 000 days of a child's life play a crucial role in shaping their growth and learning trajectory. But South Africa is facing a malnutrition crisis, with recent figures revealing one in four has limited access to food.1 Malnutrition is one of the major drivers of stunting – a (largely preventable) condition where young children are too short for their age and do not reach their full growth potential due to chronic nutritional deprivation, often made worse by repeated infections. The country has a persistently high stunting rate, with more than a quarter of children under five years of age affected.2
Countries such as Peru and Brazil, which struggle with similar resource constraints to South Africa, have successfully reduced stunting. In just eight years, from 2008 to 2016, Peru cut its stunting rate from 28% to 13%; between 1974 and 2007, Brazil reduced stunting in children under five years of age from 37.1% to 7.1%.3 There was no single recipe to reduce stunting; each country used its own contextappropriate strategy; however, community health workers (CHWs) played a central role in both of these success stories.
SUPPORTING ACCESS TO PRIMARY HEALTHCARE
In South Africa’s primary healthcare system, the current ratio is 0.31% of doctors per 1 000 patients, far below the World Health Organisation's recommendation of one doctor for every 1 000 patients.4 The South African ratio translates to one doctor often being responsible for more than 3 000 patients, with a severe shortage of doctors in rural areas and the public sector.
CHWs form part of a powerful network that enables the formal health service to make sense of, and respond to, community health issues despite these shortages. They are also connectors – linking communities to primary health services through home visits, so patients can avoid joining long queues at clinics or paying expensive transport costs.
“We’ve seen that in countries where stunting rates have dropped, CHWs were empowered, trained and upskilled to spot children showing early signs of growth faltering. These countries credit much of their success to the impact CHWs have had on maternal and child health outcomes.”
- Nicola Stofberg, Grow Great deputy executive director
1 Statistics South Africa. 2025. General Household Survey 2024. Pretoria: Stats SA. Available at: https://www.statssa.gov.za/publications/P0318/P03182024.pdf
2 Mbali, N. 2023. Childhood stunting and malnutrition are critical health challenges for SA. Daily Maverick, 26 July. Available at: https://tinyurl.com/4vwhkk7j
3 Kathuria, A.K., Arur, A. and Kariko, E. n.d. Success stories with reducing stunting: Lessons for PNG. Washington, D.C.: World Bank. Available at: https://tinyurl.com/2ses8b9a
In South Africa there are about 45 000 CHWs.5 They are mostly female, and each supports roughly 250 households. They offer health education, conduct screenings for early detection of diseases or complications, provide support for adherence and make referrals for health, nutrition and complex social issues including substance abuse, gender-based violence (GBV) and chronic poverty.6 CHWs work in teams led by an outreach team leader (an enrolled or professional nurse) and are linked to primary healthcare clinics. They are well-positioned to identify when children are not growing as they should because
5 Jooste, S., Ramlagan, S., Magobo, R., Shean, Y., Sewpaul, R., Dukhi, N., Cloete, A., Petersen, Z., Mabaso, M., Davids, A., Maseko, G., Ginyana, T., Molopa, L., Vondo, N., Parker, S., Zuma, K. and Moyo, S. 2023. A national skills audit of community health workers and outreach team leaders employed by the National Department of Health 2023. Pretoria: Human Sciences Research Council.
6 Thomas, L.S., Buch, E., Pillay, Y. et al. 2021. Effectiveness of a large-scale, sustained and comprehensive community health worker program in improving population health: The experience of an urban health district in South Africa. Human Resources for Health, 19:153. Available at: https://doi.org/10.1186/s12960-021-00696-8
PREVENTATIVE SCREENING AND HEALTH PROMOTION
UNDER DIFFICULT CONDITIONS
CHWs have walked a long and difficult road in South Africa, acting as conduits for the primary healthcare system and reaching people where the state presence is weak. They played a significant role in addressing the HIV and TB epidemics and remain a first point of contact for healthcare at community level. While CHWs are not clinical professionals, they are recognised healthcare providers whose scope of work is largely preventative. Trained to deliver screening and health promotion services, they also support chronic disease management, maternal and child health, palliative care and basic preventative care – but they do not diagnose illnesses. CHWs are typically contracted by provincial governments or employed through non-governmental organisations (NGOs).
CHWs face a variety of obstacles in their work, including that they often operate in high-crime areas, work with limited resources, and receive inadequate training, support and remuneration. Many CHWs are not provided with the basic equipment necessary to perform growth monitoring of children at home. For instance, they currently lack basic scales for measuring weight. Instead, they are given coloured measuring tapes to assess mid-upper arm circumference (MUAC), which can help identify children with acute malnutrition. While this method remains valuable, better early detection and intervention methods are needed.
In rural parts of the Eastern Cape, Limpopo and Mpumalanga, clinics and caregivers are often difficult to reach because of the long distances between them. Most CHWs rely on public transport or walk to carry out their work. CHWs also face mental health pressures, as they often serve in multiple caregiving roles within vulnerable and impoverished communities. They must balance this demanding work with their own responsibilities as daughters, wives, mothers and grandmothers. Despite these challenges, CHWs continue to serve their communities, but their impact could be far greater with stronger support, training and resources.
“If we truly value our CHWs and if they had the time to deliver quality education, adequate screening and prevention for maternal and childcare, we would see the system become less burdened over time. CHWs are leaders within their communities, and efforts to uplift them will enable preventative measures to be carried out at the community level by other trusted figures, such as religious and traditional leaders.”
– Dr Tevarus Naicker, DGMT innovation director
DGMT believes that to improve the future of South Africa’s children, it is crucial for CHWs to be properly trained in maternal and child health and nutrition, as well as the building blocks of early childhood development (ECD).
This learning brief features three NGO-run programmes that demonstrate how care can be delivered, with a key focus on maternal and child health and nutrition. The interventions focus on identifying and supporting pregnant women and infants during the first 1 000 days, a period that has the most profound long-term influence on both health outcomes and socio-economic development.
GROW GREAT: HALVING STUNTING BY 2030
Grow Great is a national campaign that began in 2018 with one goal: to halve childhood stunting by 2030. At the time, stunting (the result of chronic malnutrition in early life) was often considered a normal condition, and thus rarely spoken about, even as it held millions of children back. To promote understanding of the condition, Grow Great launched its national awareness campaign and mobilised South Africans to reduce stunting. “Too many children were falling behind before they even had a chance to begin,” says Grow Great’s deputy executive director Nicola Stofberg. “We set out to change that. Today, Grow Great works across clinics, households and communities to make stunting visible, urgent and solvable – and to build a future in which every child can grow to their full potential.”
Grow Great Champions (GGC) is an initiative of the campaign that equips CHWs to become champions for children, particularly in preventing stunting. The programme aims to build a national network of motivated CHWs who advocate for child well-being at the community level. It provides CHWs with resources, training, mentorship, and a community of practice, meaning they are better able to support families and improve maternal and child health and nutrition outcomes. Grow Great enters into formal partnerships with the Department of Health to train CHWs.
GROW GREAT RUNS FOUR CORE TRAINING SESSIONS:
Onboarding of team leaders, with a focus on the first 1 000 days, which is aligned with the pillars in the national Side By Side7 campaign, growth monitoring and supervision of CHWs.
As part of their core work, CHWs screen for vulnerable children and mothers, specifically identifying children at risk of stunting. They conduct growth monitoring using appropriate tools and provide tailored advice on proper nutrition and essential care practices to support healthy growth and development. Through regular home visits and health promotion, CHWs play a critical role in empowering caregivers to prevent stunting and ensuring timely referrals when needed.
As part of their broader training, GGCs are trained on the Road to Health Book, which includes important guidelines such as LovePlayTalk. These guidelines are demonstrated by GGCs in homes; parents and adults in the family are encouraged to interact with their baby by talking and reading to them, and through interactive play. By demonstrating these interactions, the GGC builds trust with the caregivers, which opens the door to providing additional support and information about the child’s health, growth and development.
GGC was launched in mid-2018 and to date over 3 800 GGCs across Limpopo, Gauteng, the Free State, Mpumalanga, the Western Cape and the Northern Cape have collectively growth monitored over 270 000 children under the age of two. They have also supported over 48 277 pregnant women to care for themselves and their baby, attend antenatal clinic visits and identify and refer at-risk behaviour (such as drinking). Among the mothers reached, Grow Great is seeing a higher uptake in exclusive breastfeeding compared to the national average.8 7 Side-by-Side is a campaign of the National Department of
Onboarding of CHWs, focusing on the first 1 000 days and growth monitoring.
One-day growth monitoring training for CHWs, with the focus again on growth monitoring skills (particularly weight, length and MUAC measurements).
Refresher training, an annual one-day training for both team leaders and CHWs.
“CHWs are an incredibly powerful way to deliver complex health information at different points in a child’s journey. When a mom is pregnant and not attending her antenatal clinic visits, a CHW can encourage her and connect her to the healthcare she needs. This helps ensure her baby is growing well in utero and that she’s taking her antenatal vitamins, reducing the risk of low birth weight, which is a strong predictor of stunting.”
- Amanda Edwards, Grow Great M&E specialist
PHILANI MENTOR MOTHERS: BRINGING HEALTHCARE HOME
The Philani Maternal, Child Health and Nutrition Trust is an initiative established by Dr Ingrid Le Roux, a Swedish doctor whose vision has transformed the lives of numerous mothers and children. In 2002, an extension to the project, the mentor mother programme, began operating in informal settlements surrounding Cape Town, where the clinic-based nutrition rehabilitation programme had struggled to reach children facing severe malnutrition.
Philani only engages with a community when invited to do so, and with the support of local structures in the recruitment process. The initiative begins by identifying women who, despite living in poverty, have raised healthy children – these women are known as 'positive deviants'.9 The programme aims to build on the existing skills of these women, encouraging them to share their coping strategies and knowledge with others in their community.
Philani's training unit provides a thorough six-week introductory course (four weeks in class, two in the field) in maternal and child health and nutrition for newly recruited mentor mother candidates. The training also includes basic ECD training (practical and easy ways to stimulate your child in the home, education about development milestones, etc.). Once employed, mentor mothers receive the necessary equipment and ongoing practical training in the field from coordinators who collaborate closely with them.
9 Griehsel, M. and Stanford, M. 2013. Philani Mentor Mother Programme. Giant Film Production. Available at: https://www.philani.org.za/wp-content/uploads/2014/08/Mentor-Mother_D9-2.pdf
The programme focuses on bringing a supportive and informative primary healthcare intervention into the homes of families. Mentor mothers guide moms through the rehabilitation of their underweight children, support pregnant mothers to improve birth outcomes, help decrease the number of children born with a low birth weight, assist in the prevention of mother-to-child HIV transmission, and improve the quality of life of people with chronic illnesses.
Philani focuses on two main strategies to deal with malnutrition from a preventative standpoint: antenatal support and home-based growth monitoring. It also includes a brief alcohol harm reduction intervention offered to any community member who screens as being at high risk for alcohol misuse, including but not limited to pregnant women. In recent evaluations conducted in the Eastern Cape, the rate of low birth weight among babies born to women supported by Philani was approximately 9%, compared to the national rate of approximately 13%.
In addition:
Women visited by mentor mothers are more likely to attend antenatal care, breastfeed exclusively and avoid harmful practices, improving health outcomes and demonstrating the importance of companionship.10
Mentor-supported mothers show significantly lower depression scores. 11, 12
The model strengthens primary healthcare by linking households to clinics and services – identifying risks, treating malnutrition, supporting treatment adherence, and improving access to grants.13
In the Western Cape, there is a formalised partnership whereby the mentor mothers programme is funded through the Western Cape DoH as part of their community-based service. In the Eastern Cape, although Philani has occasions to work with the provincial DoH, mentor mothers are employed directly by Philani.
In 2025, Philani has 290 mentor mothers:
245 operating in the Western Cape in Khayelitsha, Crossroads and Mfuleni.
45 operating in the Eastern Cape across the Zithulele and Coffee Bay regions of the OR Tambo District.
10 Stansert Katzen, L., Tomlinson, M. et al. 2020. Home visits by community health workers in rural South Africa have a limited, but important impact on maternal and child health in the first two years of life. BMC Health Services Research, 20:594.
11 Stansert Katzen, L., le Roux, K.W. et al. 2021. Community health worker home visiting in deeply rural South Africa: 12-month outcomes. Global Public Health, 16(11):1757–1770.
12 Tomlinson, M., Rotheram-Borus, M.J. et al. 2016. Thirty-six-month outcomes of a generalist paraprofessional perinatal home visiting intervention in South Africa on maternal health and child health and development. Prevention Science, 17(8):937–948.
13 le Roux, K., le Roux, I. et al. 2014. The role of community health workers in the re-engineering of primary health care in rural Eastern Cape. South African Family Practice.
“The primary healthcare system is not quite in touch with what's happening on the ground in communities. Our model is really trying to address that through door-to-door, visits, bringing knowledge to where the person is, and figuring out what they need. Maternal and child health, in our opinion, is just not a priority at the grassroots level; the way interventions are structured from our health system doesn't really have a strong implementation plan for that.”
– Dr Ingrid Froneman, Philani deputy director
ONE TO ONE AFRICA: FIGHTING MATERNAL AND
NEONATAL MORTALITY
In 2016 One to One Africa (OTOA) started work in the rural Eastern Cape aimed at addressing the unacceptably high rate of maternal and neonatal mortality. OTOA follows a similar model to Philani, recruiting women from local villages to become mentor mothers in the OR Tambo District, specifically in the Nyandeni sub-district.
OTOA runs an eight-week training programme (six weeks in class, two in the field) for the mentor mothers. The training includes peer mentoring, learning the ins and outs of home visits, screening for TB and HIV, reproductive health education, antenatal care, postnatal care, infant feeding and nutrition. OTOA provides qualified mentor mothers, affectionately known as Nomakhaya (isiXhosa for “home-carers”), with the necessary equipment and resources. In 2019, the programme was expanded to support 27 government CHWs across 10 facilities in Libode, Lusikisiki, and Port St Johns, providing them with training, equipment, uniforms and ongoing supportive supervision.
To promote access to healthy, nutritious food for children, OTOA implements a comprehensive nutrition intervention that includes prenatal vitamins for pregnant women, the distribution of seedlings to support household food gardens, multiple micronutrient supplementation (MMS), and fortified porridge for young children.
In 2022, OTOA launched the expanded Enable programme, which introduced new components in addition to existing mentor mother activities:
Five ECD mentor mothers are now providing structured play, educational activities, and parenting sessions to 600 caregivers and their children in the community.
OTOA trained 10 mentor brothers or Abakhuluwa (isiXhosa for “elder brothers”), who engage men to help challenge harmful masculinities, discrimination and inequality. These mentor brothers encourage men to become more actively involved in their partners' health, address gender-based violence and promote responsible parenting.
In light of the 31% adolescent pregnancy rate within the programme, OTOA also recruited and trained six youth champions to empower girls, build resilience, and offer essential HIV and sexual health information and referrals to adolescents and young mothers.
A dedicated social worker employed by OTOA collaborates with the Departments of Home Affairs and Social Development, as well as the South African Social Security Agency (SASSA), to facilitate timely birth registrations, identity document applications, and access to social grants, while also addressing child protection cases.
In 2024 there were 30 OTOA-trained mentor mothers supporting 3 697 pregnant women and new mothers. In addition:
of malnourished children were fully rehabilitated within six months. of children had up-to-date immunisations. of babies with a low birth weight were rehabilitated.
“When you consider that their presence alone has helped virtually eliminate maternal and neonatal mortality, and significantly reduce malnutrition, it’s clear that Nomakhayas are making a profound impact. While they aren’t highly trained, the outcomes of their work suggest they have the knowledge needed to drive meaningful change.”
- Gqibelo Dandala, OTOA executive director
There is no doubt that CHWs are a critical workforce able to address the drivers of stunting in homes, and that they bring tangible benefits to their communities.
PRIMARY BENEFITS OF SUPPORTED CHW INTERVENTIONS
PATIENTS RELATE TO MENTOR MOTHERS
Mentor mothers are neighbours, relatives and friends of the people they serve, and they are already familiar with their daily struggles, community dynamics, language and culture. They have a deep understanding of the health challenges that communities face, and are able to build up relationships of trust and support. Philani’s Dr Froneman explains: “Quite unique to the model of being a mentor mother is this idea of connection. Our health systems are large, with patients just being numbers in a big system, and poverty really breeds this feeling of isolation and disconnect. Mentor mothers provide connection, they provide care, they say: ‘I know you; I care about what happens to you.’”
Dr Emma Chademana, OTOA programme director, points out that many of the Nomakhaya team members themselves live with a chronic illness. They are comfortable talking about their own health with caregivers, and provide examples of how someone who lives with a chronic condition can still be healthy.
EARLY INTERVENTIONS
CHWs connect vulnerable people to the support and care that they need, providing blood and glucose screening as well as specific maternal support in situ related to:
Antenatal care: CHWs provide information on preventing stunting, exclusive breastfeeding, nutrition guidelines, hypertension, HIV status, mental health and antenatal supplements, and encourage antenatal clinic visits.
Postnatal care: They rehabilitate low birth weight babies, offer lactation support, encourage postnatal clinic visits, and provide information on child nutrition, the introduction of solids, immunisations, and accessing the Child Support Grant (CSG).
“I think the gold dust about mentor mothers is the ‘why’. They provide information in a digestible manner to our clients, helping them understand why it's important to do what is being advised. Why is it important to focus on nutrition? Because it affects the health of your child. When you know better, you do better. Mentor mothers are the carriers of that knowledge, and they answer the big ‘why’. Once people click onto the ‘why’, they start taking action for themselves.”
- Gqibelo Dandala, OTOA executive director
PROVIDE CONTEXT-SPECIFIC SUPPORT
CHWs play a significant role in educating women about the benefits of exclusive breastfeeding, and they play an equally important role in supporting those moms who do not. “The CHW will know the individual context and if the mom is not breastfeeding, there is no judgement. She can help to educate the mom about the correct use of formula, that diluting formula foods is not ideal and that mixed feeding is not ideal,” says Dr Tevarus Naicker, DGMT innovation director.
A VALUABLE RESOURCE
CHWs are a valuable resource for their communities – helping caregivers prioritise their health by providing accessible healthcare knowledge. They also share their insight into the community with the primary healthcare system. For example, when accompanying someone to the clinic, a CHW might say: “This client has a two-year-old and a six-year-old at home, so their immunisation schedules should be checked.” A CHW’s knowledge of the whole family can improve the health of that family and, over time, benefit the wider community.
“As a mentor mother, I'm passionate about empowering fellow mothers with practical knowledge to care for their children. We visit homes, sharing tips on nutritious feeding, breastfeeding, and utilising local resources like home gardens. Our goal is to make healthy practices accessible and affordable, showing that good nutrition doesn't have to be expensive. We're making a tangible difference in our community, even if it's not always immediately recognised.”
- Andisiwe, OTOA mentor mother
THEY CAN INFLUENCE MOMS TO REACH MILESTONES
CHWs sit both inside and outside the system and, by addressing maternal and child health and nutrition through the first 1 000 days, can influence mothers' decision-making at critical stages. They can also help mothers navigate the unfamiliar primary health care system, which can be far from where they live. A CHW can oversee all the key milestones that need to be reached in order to ensure that, by the age of two, a child is well nourished and ready to thrive.
As these three programmes have shown, public understanding of the importance of the first 1 000 days, and the link between maternal and neonatal health and stunting, has expanded in recent years. There are several key lessons to share about how to achieve maximum impact.
KEY LESSONS
1 PUT MATERNAL AND CHILD HEALTH ON THE MAP
“Since
Grow Great trained us, communities accept and understand us in a way they didn’t before. We now have equipment like scales and MUAC tapes, and we help mothers access nearby services at minimal cost. The support we provide, especially to pregnant women, allows us to identify those facing challenges, record their cases and refer them to the clinic in time. This reduces the maternal mortality rate.”
– Kholofelo Mmola, GGC from Mopani, Limpopo.
Historically, a significant portion of funding from the National Department of Health (NDoH) has been earmarked for HIV and TB interventions. NGOs that have the support of provincial governments in maternal care have learned to demonstrate why the first 1 000 days is so important and how this can be incorporated into existing HIV/TB-focused policy, while ensuring that CHWs have the necessary support to navigate the multiple aspects of their service delivery.
2
CHWS MUST BE PROPERLY EQUIPPED
In impoverished communities, CHWs are often the first to respond to a crisis, but the last to receive any equipment. If the government wishes to address the malnutrition crisis and reduce mortality, it must empower CHWs with the tools to growth monitor children early. Providing CHWs with a basic mechanical scale, along with training to recognise at-risk children, could easily offset the investment needed for the equipment. Successful programmes like those mentioned here have demonstrated the effectiveness of using scales to monitor children's growth in their homes.
As Grow Great’s Stofberg points out, “If we can get one thing right in our country it should be that every CHW has a scale and is able to growth monitor a child.”
WHAT’S IN THE BACKPACK OF GROW
GREAT CHAMPIONS?
Digital scale
Mid-Upper Arm Circumference (MUAC) tape
Measuring tape
Pregnancy tests
Client folders and growth charts
First 1 000 Days guide (their training manual)
Basic stationery (pen, pencil, ruler, eraser and sharpener)
Guide to the Road to Health Book
A branded scarf
“The scale is truly a special item for us. It helps the CHWs negotiate their way into homes and provide an immediate service (weight measurement), which paves the way to building trust and relationships between service provider and client.”
– Dr Thato Mosidi, GGC strategic lead
The mother might explain that it was her husband’s way of caring for the child. In other cases, Nomakhayas might find a pregnant, HIV-positive woman on treatment – while her partner is not.
“Culturally, Nomakhayas cannot engage with husbands or partners directly about these issues,” explains OTOA’s Dr Chademana. “We realised we needed to support them as caregivers, and we actually needed another man to speak to them about this.” The mentor brother programme was launched as a way of engaging male partners in the maternal and child health programme. It also aims to address the rise of GBV and tackle harmful norms and cultural practices.
DATA CAN HELP DEMONSTRATE IMPACT
MENTOR BROTHERS SUPPORT MEN AND TACKLE HARMFUL NORMS
Initially OTOA Nomakhayas supported the infant and mom during home visits, but a gap was identified in support for male partners. For example, a mom might agree to exclusively breastfeed, but when the Nomakhaya returned, she would find a two-month-old baby drinking formula.
The District Health Information System (DHIS) collects data at the clinic level, but the work done by CHWs is often not captured in the system. Thus, all the work, effort, time and impact of CHWs goes unseen by the health system. In Gauteng, however, GGCs have been able to share information from the Grow Great database, and it is recognised by the health department.
All three NGOs in this brief are using a digital app that helps CHWs track clients and also provides real-time data. The app is designed to work offline when CHWs are out of range, and sync back to the main server when connected. The hope is that the data collected via this app will be integrated into the health system so that CHW impact can be seen. This can help make the case for why CHWs should be better funded by the NDoH. 4
CHIME: MUSIC FOR MOMS’ MENTAL HEALTH
OTOA uses an app to screen for depression and other mental health concerns, revealing a rise in such issues. In partnership with the Perinatal Mental Health Project at the University of Cape Town, they introduced CHIME (Community Health Improvement through Musical Engagement), a musical intervention that empowers Nomakhayas to support their clients through song. Research shows this approach is therapeutic and can help reduce certain mental health challenges. Nomakhayas have produced albums of songs, each carrying a health message on topics such as depression, diabetes, high blood pressure and accepting an HIV diagnosis.
early antenatal care, keeping immunisations up to date, and the importance of Vitamin A and deworming. As Amanda Edwards, Grow Great’s M&E specialist, stresses, these interventions are all evidence-based approaches to tackling stunting, but there’s no single solution. “All of these things are linked. One cannot say: ‘We’ll make sure all our moms are exclusively breastfeeding and, bam, we’ve cured stunting.’ It’s about providing a comprehensive intervention to the women who need it most, at the most critical phase, to address as many of the underlying causes as possible,” she explains.
Public understanding of what stunting is, why it's an important issue, and what can be done about it has improved, but it is still not widely recognised as a crucial factor in child well-being. More education is needed. CHWs can help by highlighting the wide-ranging impacts of stunting. Its effects are long-term: children who are stunted are more likely to face chronic illness, become overweight, struggle to find work, and add to the burden on the health system.
AGENTS OF CHANGE
Many CHWs have little education – some passed matric, others did not – and their employment opportunities are limited. By being part of the supported programmes examined above, they are empowered in two significant ways. Firstly, they are given an income; many feel this “gives them a voice” in their own household. Secondly, their personal status in the community is elevated when they become a Nomakhaya. Many are active in community structures, such as child health or water and sanitation committees, because they’re recognised as credible voices. At community events, people expect to see a Nomakhaya present, as they’re regarded as local leaders.
By attending local meetings, mentor mothers deepen their understanding of the local context and become aware of the priorities of the communities they serve. At the same time, they are trying to advocate for better health outcomes and empower the communities from within. “In those committees, in those meetings, we are trying to infuse the sense of agency for people’s health as well,” explains OTOA’s Dr Chademana.
5 6
NO SILVER BULLET FOR STUNTING
CHWs promote exclusive breastfeeding for the first six months and encourage dietary diversity thereafter to ensure children are well nourished. They also share information on
CONNECT MOMS TO THE CHILD SUPPORT GRANT (CSG)
A criticism sometimes levelled at Grow Great is that the campaign addresses malnutrition, but doesn't hand out food. Grow Great believes that simply handing out food parcels is not going to solve the malnutrition crisis. But a CHW can connect women with local resources that will give them access to food. Grow Great’s Edwards explains: “A really great success for us is connecting our most vulnerable women to the CSG. This involves getting them to the Department of Social Development (DSD), helping them fill out the paperwork and getting birth registration documents so that they're able to access the social support they need to buy necessary resources, such as food for the house.”
DGMT is advocating for the proposed Maternal Support Grant (MSG) as another way for moms to access affordable nutritious food.14
RECOGNITION IS IMPORTANT
CHWs often feel disconnected from the primary health system, but are still expected to make referrals to clinics. When the health system is unresponsive, CHWs can feel vulnerable and lose motivation to continue making referrals. For example, a nurse might say: “Who are you to tell me this child has symptoms of TB? You are not a clinician.” According to Grow Great’s Stofberg, this kind of response can undermine a CHW’s confidence in her ability to make a difference.
Equipping CHWs to do their jobs properly is a motivating factor. However, providing them with recognition within a formalised programme also helps them feel like valued members of a community that contributes to important work. It is equally important to recognise the impact that team leaders and operational managers have on the success of a group of CHWs; they can influence different layers of the health system and help them see the impact of their work. That’s why Grow Great celebrates CHW Day annually.
MENTOR MOTHERS ARE THE EYES AND EARS OF THE COMMUNITY
When entering a new community, mentor mothers are essential for understanding the lay of the land. For example, Philani has recently begun supporting Mfuleni, opposite Khayelitsha on the N2 highway, where the programme began. It’s a completely different environment. Philani has been deliberate in training new CHWs to ask: “Does this apply in your community?” Mentor mothers are the eyes and ears of the community, and Philani relies on their feedback. “Philani is there to serve the community. It's not about what we think is right. It's about what they need,” says Dr Froneman.
WHAT'S NEXT?
Government adoption and recognition are essential for CHWs to do their jobs well. To be effective, their training and resourcing must be integrated into the health system – but this won’t happen without departmental buy-in. Sensitising the health system to CHWs’ capabilities, the roles they can play, and the funding required to support them is critical.
The Western Cape government has acknowledged that CHWs are an important resource and is helping to fund Philani mentor mothers. Grow Great has been making headway in Gauteng; instead of the organisation delivering interventions and training, it helps the province roll out the model with Grow Great as its technical support partner. In the Eastern Cape, OTOA occasionally partners with government. However, neither NGO is in a position to scale its programme to the rest of the country. This risks creating fragmented systems that run in parallel. One solution is to build on the existing CHW network, offering a more comprehensive healthcare package in which baseline training in maternal and child health and nutrition is compulsory.
One powerful force missing in the CHW space is a collaborative coalition of NGOs doing similar work. Competition for funding, geographic reach or partnerships with the health department may stand in the way. There’s an opportunity to create a formal structure that brings these organisations together, allowing them to share experience, amplify influence and strengthen support for CHWs. “I think our voices will be more strongly heard by the department if we're calling for the same thing, to improve government’s approach to CHWs,” concludes Grow Great’s Stofberg.
This is the learning experience of:
Learning Brief written by Daniella Horwitz and edited by Rahima Essop, with contributions from Grow Great, Philani, One to One Africa and DGMT.