From Village to Community Health Workers Uganda hopes to achieve health SDGs

By Esther Nakkazi

Uganda had an outbreak of Ebola Hemorrhagic Fever in 2000, there were deaths but it was also largely contained. At the time the Director General at the Ministry of Health was Prof Francis Omaswa.

Using this example at the first international symposium on community health workers ongoing in Kampala, Omaswa said what helped to not turn the outbreak into a catastrophic event like what happened in West Africa was among others village health workers.

Communities listened to village health workers who helped to disseminate information but the most important ingredient here was trust.

For 16 years now, Uganda has engaged Village Health Teams (VHTs) but it will this financial year 2016/ ending June 2017 switch to Community Health Extension Workers or the CHEW strategy.

The symposium is convened by Makerere University College of Health Sciences, School of Public Health, Uganda in partnership with Nottingham Trent University, UK and Ministry of Health, Uganda.

Dr. David Musoke is the symposium chair and its theme is community health workers and their contribution towards Sustainable Development Goals (SDGs).

Switch from VHT to CHEW strategy;

There is no doubt as to the positive contribution towards the promotion of health, community mobilization and helping to contain disease outbreaks made by VHTs in Uganda. But 16 years after their existence, 75% of the disease burden in Uganda, which is preventable persists and the top 10 killers are still the same!

So could it be that the VHTs strategy is wrong, was it a 'cut and paste' or it just needs an overhaul? Well, the government is now moving to the CHEW strategy. This does not mean that VHTs will disappear, no they won’t.

VHTs will remain with their role of community mobilization and some will be absorbed into the CHEW system said Dr. Christopher Oleke at the health workers symposium.

Currently, Uganda has 180,000 VHTs working as volunteers but only 60,000 have been trained. With lack of monitoring, supervision, and accountability these have been engaged in an unharmonized and uncoordinated structure.

One of the challenges with VHTs has been the supporting partners who have been messy as each trains their own VHT. Imagine this scenario; in one parish a partner trains a VHT to distribute bednets and check for malaria, another partner trains the same VHT to preach nutritious feeding, another train on delivering healthy babies and looking out for pregnancy problems,  and to encourage delivery in health centers etc.

Where would a VHTs loyalty lie and why don't the partners work togather to synchronize their trainings? Why doesn't the Ministry of Health play it supervisory role and be in charge?

By the way, the interventions are not bad and they have produced some visible results as in the case of Kanungu district in South Western Uganda where they have improved maternal and newborn health outcomes or the Malaria Consortium STARS project that has enabled safe delivery of healthy babies. But the governance and lack of leadership among supporting partners have created chaos rather than progress.

You cannot blame partners entirely, the voluntary role can carry only so many responsibilities. Some VHTs are working 7 days a week for long hours and are untrained.

Now Uganda wants to fix it. The CHEW strategy will engage only 15,000 health workers. They have to be between 18-35 years and with a minimum education to qualify. They will be paid a salary by the government and get regular training. Their roles will be defined among them conducting baseline and other important surveys.

As Prof Francis Omaswa says, ‘they should not be the big doctors in the villages’, any more so they will be monitored, supervised and supported by a proper governance structure. “They should not be left in isolation,” he cautions.

But most importantly, the CHEWs will 'reorient' the minds of Ugandans towards healthy living. How? According to Dr. Oleke, many Ugandans think that having medicines in health facilities and doctors equals good health.

The CHEWs will focus on the household as a totality promoting good hygiene, standard health practices like immunization and most of all promote the use of less alcohol which is causing Ugandans numerous health issues says Dr. Oleke.

They will also play an important role in registering all pregnant women and newborns electronically who will be followed through the system - that way Uganda hopes to improve the mother and newborn well being.

The CHEW strategy will have strong monitoring, supervisory, accountability and will be under a harmonized structure says Dr. Oleke.

Innovative financing for health workers;

But there are cautionary voices and suggestions before the rollout begins this financial year. Dr. Elizabeth Ekirapa from the School of Public Health warns this should not create a parallel administrative structure instead they should be integrated within the national health care system.

Ekirapa also says the CHEW strategy should be sustainable and be homegrown or customized to Uganda. It copies a lot from Ghana and Ethiopia CHEWs.

Dr. Patrick Kadama from ACHEST is concerned about the financing structure, which if not well thought out might distort equity. It comes amidst Uganda trying to create a national social healthcare insurance scheme and other tax-based systems.

Dr. Kadama also thinks the CHEW strategy implementers should ensure good returns on the investment thus a specific investment case should be done before roll out. They should also ensure that the CHEWs boost primary health care.

Concurring with everyone else he said the CHEWs should work in tandem and in sync within a defined national health care system - read - ‘not in isolation’ and the rollout should be gradual. Talk about the best of the best but let us wait for implementation. 

ends

Who should try accused health workers?

By Esther Nakkazi

Ugandan health workers are fighting back. As cases of what the public view as health workers negligence build up, most of them end up detained in police cells and tried by public courts.

Today the Executive Director for African Centre for Global Health and Social Transformation (ACHEST) Prof. Francis Omaswa said enough of the police officers interference and trials in public courts for Uganda health workers.

“It is wrong to arrest health workers and detain them at police stations,” Omaswa said to which we got a loud applause at the first International symposium on community health workers held in Kampala, Uganda.

The theme is contribution of community health workers in attainment of the Sustainable Development Goals (SDGs) convened by Makerere University College of Health Sciences, School of Public Health, Uganda in partnership with Nottingham Trent University, UK and Ministry of Health, Uganda.

He said doctors and nurses who commit offences should be tried by their respective professional governing bodies.

In this case the Uganda Medical and Dental Practitioners Council (UMDPC) responsible for licensing, monitoring and regulating the practice of medicine and dentistry for doctors and the Uganda Nurses and Midwives Council (UNMC).

Omaswa has a point after all armed forces accused of offences are court-martialled. Justice is dispensed by their own.

The reasoning could be that people who have no knowledge of the challenges and proceedings in an operation theatre have no business questioning and detaining an accused doctor whose patient has died on the table.

These cases now have a trend in Uganda. Usually, a patient whose case will be viewed as ‘non fatal’ by the concerned parties, such as a pregnancy will report to a health facility. The health workers will demand a fee, a pricey drug not available at the facility or even tell the patients to wait for a senior doctor.

Time is of the essence here. While demands are being made, the patient needs attention and by the time whatever is demanded is availed and the patient is taken to theatre or given treatment, it is the apex of an emergency. A life or two are lost.

With the health system clearly lacking some health workers find themselves in a tight corner inspite of every effort they put in to save lives. So the larger thinking would be to blame the system.

“The best way to manage a system is not to blame an individual,” said Omaswa. Quoting the law, Omaswa who is celebrated as the most efficient Director General at Uganda's Ministry of Health and is remembered for the phrase 'health is made at home and repaired in hospitals' said the Ministry should be led by a technical person and it should not have both a director general and a permanent secretary because it duplicates roles and wastes resources.

While Prof. Omaswa clearly makes a valid point, the larger public has no knowledge of the authorities in charge of accused health workers nor the governing bodies, UMDPC and UNMC, so their immediate action is to go to police.

It also does not help if in some cases the health workers put money ahead of saving lives to which they swear the hippocratic oath. To show that justice is attainable, the health workers governing bodies need to create awareness and show that they can indeed punish those found guilty.

There is a proverb in Uganda which says a person does not just die. The translation is that there is always someone to be blamed for a death.

The public will never understand the system nor medicine but if they for sure suspect that a life could have been saved their only option will be to turn to police for justice!

Abortions decline in Uganda; it could cut maternal deaths

By Esther Nakkazi

Uganda is gaining positive results in saving the mother with a decline in the rate of abortions a new  study by U.S based Guttmacher Institute and Makerere University indicates.

Over a decade, the number of women aged 15–49 years who carried out abortions in Uganda declined to 39 abortions per 1,000 women in 2013 from 51 in 2003. This in tandem reduced the annual hospitalisation rate for complications in the same age group to 12 per 1,000 women from 15 over the same period.

Naturally, less abortions would translate to less maternal deaths in Uganda, which are caused by four major preventable factors; unsafe abortions, haemorrhage, hypertension and sepsis.

According to a press release from the Institute, the study also found that 93,300 women were treated across the country for complications from unsafe procedures. Abortion is illegal in Uganda but the law allows it to save a woman’s life.

The 2012 National Policy Guidelines and Service Standards for Sexual and Reproductive Health and Rights permit abortion under additional circumstances—including in cases of fetal anomaly, rape and incest, or if the woman is HIV positive—in practice, legal abortion is both difficult to obtain and to provide.

The country’s abortion laws and policies are inconsistently interpreted by law enforcement officials and the judicial system, and many providers and women remain unaware of the circumstances under which abortion is legal. As a result, most abortions in Uganda are clandestine procedures, which are often unsafe.

“Close to one third of Ugandan women who have abortions each year are treated in health facilities for complications resulting from unsafe procedures, and many other women who experience complications do not get the care they need,” says Elena Prada, consultant with the Guttmacher Institute and the study’s lead author.

“Notwithstanding the Ugandan government’s efforts to improve postabortion care services, stigma and fear of mistreatment are significant barriers for many women in need of these services.”

Over 50% Ugandan women still have unintended pregnancies:

The study also produced new pregnancy estimates, finding that 52% of all pregnancies in Uganda in 2013 were unintended and about a quarter of these unintended pregnancies nationally ended in abortion.

Given that most abortions result from unintended pregnancies, improving family planning services is critical to reducing the incidence of unsafe abortion.

The high proportion of unintended pregnancies reflects the finding that among women of reproductive age, 38% of married women and 45% of unmarried sexually active women had an unmet need for modern contraception in 2011.

“Despite some gains in modern contraceptive use over the past decade, unmet need for contraception in Uganda remains high and must be addressed by improved family planning services,” says Professor Christopher Garimoi Orach, head of the department of community health at Makerere University’s School of Public Health and a study coauthor.

“For example, integrating comprehensive contraceptive counseling into all postabortion care visits can be a powerful intervention to help women avoid future unintended pregnancies.”

The study’s authors recommend efforts to expand existing postabortion care services to ensure that all women with abortion complications are able to get the care they need, particularly in rural areas.

In particular, contraceptive counseling should be strengthened to address high rates of method discontinuation and women’s concerns about side effects. The authors emphasize that counseling must acknowledge the challenges women experience and provide accurate information on the side effects of different methods.

Further, they recommend that family planning services provide a full range of modern contraceptive methods, including long-acting reversible methods such as IUDs and implants, so women can choose whichever method works best for them.

Finally, the researchers suggest clarifying and raising awareness of existing laws and policies on abortion in Uganda among the medical community, the judicial system and women.

Every woman who meets the criteria for a legal abortion should be able to obtain a safe procedure at an affordable cost from a trained health care provider.