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• Carry out basic assessments of communities, households groups and individuals.
• Provide basic health education and referrals for a wide range of services.
• Support and assist in navigating the health and social services system.

  Rationale:
  The National Health Council has mandated an improvement in the health outcomes and for this to occur significant steps need to be taken in the restructuring of the health system. This is one of the 10 points in the five year Health Sector 10 Point Plan, noted as ‘overhauling the healthcare system’. It is also the fourth pillar of the Negotiated Service Delivery Agreement as ‘strengthening the effectiveness of the health system’. This qualification will form an integral part of this strategy. It will form the basis for the appointment requirements of the Community Health Workers that will be employed by the various government departments (currently an estimated number of approximately 70 000 people).

  The caveat for the South African model should be built on the ward system that has been implemented in KwaZulu-Natal. Each ward should have one or more Primary Health Care (PHC) outreach teams. These teams are composed of a professional nurse, environmental health and health promotion practitioners as well as 4-5 community health workers who are expected to serve a population of approximately 7 660 people.

  The model contains three streams:

• Award based PHC outreach team for each electoral ward.
• Strengthening school health services.
• District based clinical specialist teams with an initial focus on improving maternal and child health.

  Evidence from many countries suggests that provision of home and community based health services and their links with the fixed PHC facilities in particular are critical to achieve good health outcomes, especially child health outcomes (Sepulveda et al, 2006). The role of community health workers in many countries has contributed to better health outcomes (WHO 2007).

  The roles of Community Health Workers (CHW) (as part of the PHC outreach teams) will include:

• Conducting community, household and individual health assessments and identifying health needs and risks (actual and potential) and facilitating the family or an individual to seek the appropriate health service.
• Promoting the health of the households and the individuals within these households.
• Referring persons for further assessment and testing after performing simple basic screening.
• Providing limited, simple health interventions in a household (e.g. basic first aid, oral rehydration and any other basic intervention that she or he is trained to provide).
• Providing psychosocial support and managing interventions such as treatment defaulter tracing and adherence support.

  Given the key role that CHWs will play, they should, over time be directly managed by the Department of Health.
  Ideally each ward within the district should be covered with a PHC outreach team. There are 4,277 electoral wards in South Africa. The population sizes of wards are variable so to the geography and density of each ward. Urban wards are highly populated with high density whilst rural wards are sparsely populated and often with poor infrastructure. This means that ward populations may range from less than 1000 in some wards to more than 20 000 in others.
  This qualification will capacitate the Community Health Workers to fulfil their role in this revised structure.

RPL for entry requirements to access the qualification: Accredited providers and approved workplaces may recognise prior learning against the relevant access requirements.

Entry Requirements:
NQF Level 1 or equivalent competences in Mathematical Literacy and Communications.

Knowledge Subjects:

• Public and Community health support, NQF Level 3, 22 Credits.
• Family and Community Services, NQF Level 3, 10 Credits.
• Basics of Community Health, NQF Level 3, 8 Credits.
  Total Credits for Knowledge Subjects: 40.

  Practical Skills Modules:

• Mobilise community to address community health issues, NQF Level 3, 4 Credits.
• Identify the service needs and ease of access to health and social services, NQF Level 3, 4 Credits.
• Promote healthy life styles and mental wellbeing, NQF Level 3, 6 Credits.
• Promote HIV prevention including HIV testing, condom use, partner reduction, circumcision, STI treatment, NQF Level 3, 4 Credits.
• Provide information on prevention of accidents and incidents in homes, NQF Level 2, 4 Credits.
• Record and report on information provided to individuals, households and communities, NQF Level 3, 4 Credits.
• Promote and provide support for maternal and women’s health, NQF Level 2, 14 Credits.
• Promote child health, NQF Level 4, 4 Credits.
• Support community members with psychosocial problems, NQF Level 4, 3 Credits.
• Provide an integrated approach to support treatment adherence, NQF Level 3, 4 Credits.
• Identify and treat a select number of minor ailments, NQF Level 2, 8 Credits.
• Provide basic support to people who are unable to care for themselves, NQF Level 2, 4 Credits.
  Total Credits for Practical Skills Modules: 63.

  Work Experience Modules:

• Operation and dynamics of communities, NQF Level 4, 6 Credits.
• Household registration and assessment processes, NQF Level 3, 14 Credits.
• Health promotion processes, NQF Level 3, 6 Credits.
• Formal health provision processes, NQF Level 2, 12 Credits.
• Emotional and social wellness support processes, NQF Level 3, 6 Credits.
• Household treatment processes of minor ailments, NQF Level 3, 16 Credits.
  Total Credits for Work Experience Modules: 60.

• The key geographic features which impact the functioning of the community are identified and analysed on the map.
• The physical infrastructure in the area is identified and how this supports or limits the effective functioning of the community is indicated.
• The overall services in the community are identified and described.
• For a specific ward the actual households are drawn and described.
• The governance (Including traditional), NGO and civil society structures in the community (Formal and informal) are identified and described.
• The status of the key social determinants of health in the community is identified.
• The involvement of industry in the community is identified.
• Various scenarios, community interactions, examples of situations where stigma impacts negatively on the human dignity of community members are related.

  Associated Assessment Criteria for Exit Level Outcome 2:

• The registration and profiling templates are correctly completed, using the details given, of a range of households.
• The screening tools for communicable and non-communicable health problems are used.
• At least 80% of a given range of non-communicable and chronic health problems as well as indicating the early warning signs of these problems are indicated and how these problems can be prevented is explained.
• The appropriate support needed at a community and household level, for persons living with non-communicable and chronic health problems is identified.

  Associated Assessment Criteria for Exit Level Outcome 3:

• The real health conditions of the households and the potential impacts of the community situations on the health of people are identified and described.
• The actual health information needs of the various households are identified.
• The appropriate communication material to meet the information needs is identified.
• The best methods of conveying the required health messages are identified and described.
• A health promotion discussion with individuals is conducted.
• Presentations to small groups are made regarding health related issues.
• Information and basic counselling on substance abuse is provided.
• Actual counselling sessions are observed and the emotional states of people during counselling are identified.
• The appropriate responses of a counsellor to the various emotional states are identified.

  Associated Assessment Criteria for Exit Level Outcome 4:

• The various mental health problems are classified and the key issues of the mental health problems that need to be dealt with are identified.
• The role of the Community Health Worker regarding the identified mental health problems is described.
• The additional professional services that these individuals may require are identified and how to access these services is described.
• The measures to be taken regarding emergencies involving people with serious mental and substance use problems (suicide and violence) are described.

  Associated Assessment Criteria for Exit Level Outcome 5:

• Provided with descriptions of a range of signs and symptoms that a woman and /or a man can present, the condition associated with the signs and symptoms is identified.
• Provided with a description of health problems, the appropriate services persons with the specified health and social problems will require are identified.
• All the definitions used in describing wellness, mental health and life style choices are explained and the relevance of these terms and definitions to the work of the Community Health Worker is outlined.
• A list of typical health screening activities is categorised, who should participate in the screening activities is indicated, why this is important is explained and what the role of the Community Health to support the effective use of the various screening processes is outlined.

  Integrated Assessment:
  An external integrated summative assessment, conducted through the relevant QCTO Assessment Quality partner is required for the issuing of this qualification. The external integrated summative assessment will focus on the Exit Level Outcomes and Associated Assessment Criteria.
  The external assessment will be conducted through a written examination of plus minus two hours where both theory and practical skills are assessed. The assessments will take place at decentralised assessment sites with registered invigilators and standard assessment question papers.

Over recent years Brazil implemented a programme to formally educate these community based health workers. Thus, Brazil has taken the lead in demonstrating significant gains in population health outcomes when they integrated CHW into the Family Health Programme. Lessons from Brazil indicated that a systematic approach towards integrating CHWS into formal health structures is required.

In many countries community health worker programmes have failed in the past because of unrealistic expectations, poor planning and an underestimation of the effort and input required to make them work. This has unnecessarily undermined and damaged the credibility of the CHW concept. According to the World Health Organisation, CHW programmes remain vulnerable unless they are driven, owned by and firmly embedded in communities and it enjoys a good and well integrated relationship with the formal health structures.

Evidence also reveals that CHW programmes thrive in mobilised communities but struggle where they are given the responsibility of galvanising and mobilising communities. For CHWs to be able to make an effective contribution they need to be carefully selected, appropriately trained and most importantly they require adequate and continuous support. The WHO has identified that the length, depth, organisation of, responsibility for and approaches to training vary dramatically across programmes. There is a general agreement that training should be competence and practice-based and aligned closely to the CHWs working context. The qualification constructed in this curriculum is fully based on the anticipated work of the CHW in South Africa.

Training materials and activities should be specifically developed for CHWs rather than using training packages developed for facility-based health workers. But while the literature reflects a great diversity of approaches, location, organisation and length of training, there is a general agreement that continuing or having refresher training is as important as initial training. A number of studies have also found that if regular refresher training is not available, acquired skills and knowledge are quickly lost.

There are some more formal learning programmes and certificate courses in the USA. These courses are relatively short courses aimed at dealing with some of the technical elements of the requirements of the work of a Community Health Worker. For example:

• University of Hawaii Maui College offers a 17 Credit certificate of competence for aimed at preparing individuals to work as unlicensed members of the health and social service care teams to provide care for individuals in community based settings. This course introduces theoretical and practical clinical skills necessary for providing basic health care assistance and screening services. The courses that make up this certificate include:
  > CHW 150: Community Health Workers (4 Credits).
  > CHW 155: Community Health Worker Externship (3 Credits).
  > PHARM 103: Introduction to Pharmacology (1 Credit).
  > PHARM 104: Pharmacological Treatment of Disease (1 Credit).
  > PHARM 105: Administration of Medications (1 Credit).
  > HLTH 150: Introduction to Diseases (1 Credit).
  > SOSER 140: Individual Counselling (3 Credits).
  > SOSER 111: Community Action (3 Credits).
• Minnesota University offers a 17 Credit certificate curriculum that is provided through a blend of classroom and field-based learning for new learners interested in becoming Community Health Workers (CHW). The courses that make up this certificate include:
  > CMHW 1000: The Community Health Role Advocacy and Outreach (3 Credits).
  > CMHW 1015: Organisations and Resources: Community and Personal Strategies (2 Credits).
  > CMHW 1025: Community Health Worker’s Role in Teaching and Capacity Building (2 Credits).
  > CMHW 1035: The Community Health Worker: Legal and Ethical Responsibilities (1 Credit).
  > CMHW1045: Community Health Worker: Coordination, Documentation and Reporting (1 Credit).
  > CMHW 1055: Communication Skills and Cultural Competence (2 Credits).
  > CMHW 1065: Health Promotion Competencies (3 Credits).
  > CMST 1005: Public Speaking (3 Credits) or Eng 1110 College English 1 (3 Credits).

  Conclusion:
  The content of this curriculum covers most of the content in these certificates and much more.
  The curriculum is significantly similar to the emerging programmes in the countries studied but it is custom made for the specific situations in South Africa. The qualification appears as a uniquely comprehensive set of knowledge, skills and work experience.

• Higher Certificate in Social Auxiliary Work at NQF Level 5.
• Further Education and Training Certificate: Community Health Work at NQF Level 4.

  Notes Regarding the Progression:
  This curriculum is being developed in support of a national strategy to deliver quality primary health to all the citizens of the country. The strategy is based on a system where the Community Health Worker will form part of a ward based team of service providers. The related Occupations of Home Based Care and Palliative Care are related Occupational areas that might, in the future require additional qualifications. The urgency and focus is currently on the Community Health Worker as set out in this curriculum. This curriculum is at NQF Level 3 but contains a number of NQF Level 2 and 4 components.

The curriculum title and code is: 325301-001Community Health Worker.

In order to qualify for an external assessment, learners must provide proof of completion of all required modules by means of statements of results and work experience.
Foundational learning competence is a pre-requisite for the awarding of the qualification.

Physical:

• The learners must be adequately mobile to execute the work within a community.
• Adequate visual and hearing capacity to master the skills as described in the curriculum document.

  This qualification replaces the following qualifications:

• ID 64749: “National Certificate: Community Health Work”, Level 2, 140 Credits.
• ID 64769: “National Certificate: Community Health Work”, Level 3, 140 Credits.