Centering community health workers at the core of public health strengthening in Uganda
Von Labila Sumayah Musoke,
Nassozi Rehema Ssozi und
Elizabeth Atori
Since the birth of the Alma-Ata Declaration (WHO, 1978), community health workers (CHWs) have increasingly become a relevant pillar in the promotion of primary health care. The unending COVID-19 pandemic has spotlighted their critical role in public health strengthening and reignited the urgency to tackle the invisibilization of their contribution by mandate holders in achieving universal health coverage as a right rather than a privilege. This paper is informed by the breadth of work the authors have collectively done over the past decade at both community and national level.
In 2016, I had the opportunity to benefit from a community baraza on health education and basic case management, provided by the Initiative for Social and Economic Rights in my local area (Initiative for Social and Economic Rights September 2016) [1].
I was immediately impressed to learn that the community has the power to negotiate quality healthcare service delivery. I learned that using demand-led governance as a social accountability tool, a community has power to demand for and hold mandate holders accountable for failure to provide and promote quality public healthcare services. This information motivated me to enroll as a community volunteer. Following a debrief, I was trained and recruited. I was then given a smart mobile telephone with a reporting tool installed. During one of my routine monitoring visits at Busana Health Centre III, I observed that it struggled with insufficient staff, stock-out of lifesaving medicines and lacked appropriate equipment like maternity beds.
With this background, I mobilized my community members to engage in dialogue with the area Town clerk and health facility In-Charge as to address the identified issues and improve service delivery. After a series of interface meetings and filing a written petition, 4 new maternity beds were delivered at the health facility. Since then, fellow residents reach-out to me and we collectively demand for accountability to problems that affect us.
I was immediately impressed to learn that the community has the power to negotiate quality healthcare service delivery.
Such CHW’s lived experiences and success stories demonstrate the spirit behind the 1978 Alma-Ata Declaration - ‘Health for All’ (WHO, 1978). They highlight the centrality of CHWs as an evidenced-based solution to helping communities especially remote and hard-to-reach, to access quality, comprehensive and integrated healthcare (John, Hernández-Gordon, Martínez and Hernández 2022).
Primary health care in Uganda?
44 years after the Alma-Ata Declaration, despite their critical role in promoting primary health care, community health workers (CHWs) still receive little attention in Uganda’s healthcare system. In 2001, to deliver on its global commitments, Uganda, adopted a CHWs program, locally known as village health teams (VHTs), as part of the implementation strategy for the health sector strategic plan(Ministry of Health, 2001).
Further, ten years later, government formally institutionalized VHTs as the first link between the community and the formal health system to combat shortage of human resources for health especially in rural communities through monitoring, mobilizingand making relevant referrals (Ministry of Health, 2010).
The above discussion notwithstanding, structural and systemic chuck holds like: inadequate skills, reliance on external donors, low renumeration, passive participation in health management, and low autonomy levels impede CHWs to exercise their full potential.
The above discussion notwithstanding, structural and systemic chuck holds like: inadequate skills, reliance on external donors, low renumeration, passive participation in health management, and low autonomy levels impede CHWs to exercise their full potential. A high cost of living compounded with all these bottlenecks demotivates CHWs to effectively execute their already voluntary duties, thereby widening gaps in quality health service delivery.
Why centering CHWs is critical: Lessons from COVID-19
COVID-19 continues to brutally spotlight the need to center CHWs as a strategy to address ‘formal’ healthcare worker shortage concerns. As Eunice Mallari opines, CHWs act as frontline health workers with the ability to mobilize and pass on culturally appropriate health information (Eunice Mallari, 2020). For instance, Uganda, like elsewhere imposed mandatory lock-downs as a measure to respond to the pandemic. Due to pre-existing health governance challenges, demand for community-based healthcare increased. Government, through its national community engagement strategy, constituted a village COVID-19 taskforce to promote community-based case management and ensure effective monitoring and information sharing in real time. Despite putting their lives on the line, CHWs decried a lack of personal protective equipment, and low wages among others.
COVID-19 continues to brutally spotlight the need to center CHWs as a strategy to address ‘formal’ healthcare worker shortage concerns.
Recommendation
Taking
COVID-19 as an entry point in health system strengthening, government
should adequately remunerate CHWs, steward and monitor existing CHWs
initiatives, provide CHWs with personal protective equipment, and invest
in refresher training modules.
Conclusion
The above
discussion and lived experience of a CHW underscores the urgent need to
revamp discourse on how to center CHW in health system strengthening,
and for government to recognize their contribution. Government should
address the underlying obstacles that obscure their full efficiency.
Footnote
Initiative for Social and Economic Rights (ISER) runs a social
mobilization and accountability Program. Through this program, ISER uses
a participatory approach where it merely facilitates communities to
identify, mobilize, engage and holder decision makers accountable.
References
John, et al. Community Health Workers Connecting Communities during COVID-19: A case study from Chicago, Journal of Ambulatory Care Management: January/March 2022- Volume 45, Issue 1- Page 2-12 DOI: 10.1097/JAC.0000000000000401
Mallari, E, et al. Connecting communities to primary care: a qualitative
study on the roles, motivations and lived experiences of community
health workers in the Philippines. BMC Health Serv Res 20, 860(2020). 11
September 2020. DOI: https://doi.org/10.1186/s12913-020-05699-0
Musoke, D, et al. Reflecting Strategic and Conforming gendered experiences of community health workers using photovoice in rural Wakiso District, Uganda. Hum Resour Health, 16, 41 (2018), 22 August 2018. DOI: https://doi.org/10.1186/s12960-018-0306-8
World Health Organisation (WHO) and UNICEF. Report of the International
Conference on Primary Health Care. 1978 Sep 6-12; Alma-Ata, USSR.
Geneva: WHO & UNICEF, p 2. http://apps.who.int/iris/handle/10665/39228
Labila Sumayah Musoke, Health and human rights activist,
Feminist Lawyer. Initiative for Social and Economic Rights. Email
Nassozi Rehema Ssozi, public health advocate, Initiative for Social and Economic Rights. Email
ElizabethAtori, Strategic public Litigation Lawyer, Initiative for Social and Economic Rights. Email
