Thursday, February 23, 2017

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 babiesBut 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. 


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