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Potential Challenges of Implementing the Community Health Extension Worker Programme in Uganda

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Potential Challenges of Implementing the Community Health Extension Worker Programme in Uganda Commentary BMJ Glob Health: first published as 10.1136/bmjgh-2018-000960 on 10 August 2018. Downloaded from Potential challenges of implementing the Community Health Extension Worker programme in Uganda James O’Donovan,1,2 Christina Elise Stiles,2 Deogratias Sekimpi,3 Isaac Ddumba,4,5 Niall Winters,1 Edward O’Neil Jr2 To cite: O’Donovan J, Stiles CE, Uganda faces a significant shortage of trained Summary box Sekimpi D, et al. Potential healthcare professionals, especially in the challenges of implementing 1 the Community Health public sector and rural areas. As a result, the ► The proposed roll out of the Community Health Extension Worker programme Ministry of Health (MoH) have supported Extension Worker (CHEW) programme is due to take in Uganda. BMJ Glob Health delivery of the Village Health Team (VHT) place in Uganda in 2018 at an estimated cost of 2018;3:e000960. doi:10.1136/ model since 2001.2 VHTs are lay people, US$102 million over a 5-year period. bmjgh-2018-000960 working in a voluntary capacity, acting as a link ► Although this is a welcome move towards support- between the formal health sector and their ing the existing Village Health Team (VHTs) cadre of Handling editor Seye Abimbola communities.3 They are given basic training community health workers, several challenges and potential solutions are raised in this article. Received 17 May 2018 on major health issues, including childhood Uncertainties remain around potential tensions Revised 25 June 2018 diarrhoea, malaria and pneumonia, and play ► that may arise between current VHTs and the new Accepted 26 June 2018 a role in disease surveillance through activi- 3 CHEWs, the logistical implementation of the pro- ties such as data collection and reporting. gramme and financial sustainability. Although the exact selection process for ► Prior to roll out of the CHEW programme, greater at- those wishing to become a VHT member tention must be given to the practical, logistical and varies depending on location, individuals financial challenges of the proposed strategy, taking commonly undergo selection starting in their a health systems strengthening approach towards own communities. After a period of sensiti- implementation. sation and consensus building among local stakeholders, a popular vote is held. To be the Ethiopian community health strategy, selected as a VHT member, an individual CHEWs will be paid, full-time health workers, http://gh.bmj.com/ must meet several criteria. He or she must with an O-level standard of education, aged be ‘above 18 years of age, a village resident, between 18 and 35 and fluent in both local able to read and write in the local language, language and English.3 The initial aim of the a good community mobiliser and communi- MoH is to train and deploy 15 000 CHEWs cator, a dependable and trustworthy person, across 7500 parishes nationally by the end of © Author(s) (or their 3 someone interested in health and devel- on October 1, 2021 by guest. Protected copyright. employer(s)) 2018. Re-use 2020. VHTs who will not be absorbed into the permitted under CC BY. opment and someone willing to work for CHEW system will remain in their commu- 4 5 Published by BMJ. the community’. Unlike formally trained nities and continue to voluntarily provide 1Department of Education, healthcare professionals, such as doctors health services, supported by CHEWs.3 University of Oxford, Oxford, UK and nurses who are based at health facilities, 2 Given the impending implementation of the Department of Research, Omni VHT members are based in the communi- Med Uganda, Mukono, Uganda programme, this article outlines some of the 3Uganda National Association of ties in which they live and serve. This means challenges we anticipate will arise based on Community and Occupational the roles they play and the expectations that our extensive work with VHTs over the past Health, Kampala, Uganda community members have of them are likely decade. 4 Department of Community to be different. First, it is important to anticipate the poten- Health, District Health Office, Yet, despite reported successes of VHTs in Mukono, Uganda tial tensions that may occur. The strict CHEW 5Department of Research, improving and promoting health at a commu- selection criteria, including the upper age African Research Centre on nity level, challenges remain regarding their limit of 35, will rule out many members of the Aging and Dementia, Mukono, motivation, remuneration, training and reten- community who have previously worked as Uganda tion.2 6 To try and address these issues, the VHTs. This could lead to feelings of animosity Correspondence to Ugandan MoH has announced the planned between new CHEWs and existing VHTs, who Dr James O’Donovan; roll out of a Community Health Extension may feel overlooked and neglected, resulting james. odonovan@ seh. ox. ac. uk Worker (CHEW) programme.7Modelled on in strained relationships. Furthermore, with O’Donovan J, et al. BMJ Glob Health 2018;3:e000960. doi:10.1136/bmjgh-2018-000960 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2018-000960 on 10 August 2018. Downloaded from the introduction of a paid cadre of community-based the MoHs budget at present.7 Since the Ugandan public health workers, questions have been raised regarding health system is already underfunded,14 introducing whether VHTs will continue to be willing to volunteer this paid cadre of CHEWs may not be possible without their time. A study by Mbugua and colleagues, found the support of external donors or a restructuring of the that discrepancies in pay between volunteer and salaried budget.15 Furthermore, although this proposed invest- community health workers in Kenya resulted in poor ment into community health must be welcomed, appro- levels of motivation and higher levels of attrition in the priate long-term funding into the health system at every unpaid cadre.8 Those responsible for implementing the level should also be encouraged so that this intervention CHEW policy should therefore consider strategies that is not approached in a vertical manner, but rather contrib- have been shown to increase community health worker utes to a wider health systems strengthening approach. performance and motivation, in order to ensure existing Finally, CHEWs and VHTs cannot be regarded as a VHTs do not feel undervalued.9 10 This might include the panacea to address the dire shortage of health profes- provision of tangible incentives, such as equipment and sionals seen across all cadres. Continued investment supplies, but also ensuring VHTs ideas, interests and rela- into the recruitment and training of other cadres of tionships are duly considered so that tensions between health workers must occur simultaneously. Second, it is the two cadres are minimised. Whichever incentives are important to note that the complex and multifaceted chosen, they must be responsive to the needs of VHTs. challenges facing community level healthcare in Uganda Additionally, there is potential for tensions to arise extend beyond the recruitment, training and deploy- between CHEWs and community members. In a study by ment of CHEWs. As such CHEWs should not be seen Musinguzi and colleagues, it was noted that community as a ‘silver-bullet’ solution, but rather as one piece of a members in rural Uganda were distrusting of paid health complex, multifaceted puzzle, which requires concur- workers, since they were concerned they might be prof- rent strengthening of other key areas known to influence iting from referrals to health centres.11 Working closely community health.16 Taking this holistic approach will with community members so that they understand the help to ensure that strong foundations are in place to role of CHEWs will therefore be important. maximise the potential benefits of the CHEW strategy. The second challenge lies in the practical and logis- In conclusion, prior to roll out of the CHEW tical implementation of the programme. In the Mukono programme, greater attention must be given to the prac- District where we work, there are nine parishes in the tical, logistical and financial challenges of the proposed Ntenjeru subcounty alone, with a total population of strategy. If these issues can be addressed and the relation- approximately 550 000 people.12 Given the MoH have ship between CHEWs and VHTs harmonised, this initia- proposed allocating two CHEWs per parish, covering tive could represent an exciting opportunity to improve this number of households between 18 CHEWs will be the attention and support given to community-based extremely difficult, especially since they will spend just healthcare in Uganda. 60% of their time in the community and the remaining 3 Contributors JO conceived the initial idea for the manuscript and wrote the first 40% in health facilities. Despite initially proposing to draft with assistance from CS. DS, ID, NW and EO then significantly contributed to http://gh.bmj.com/ dissolve the VHT programme entirely and replace it a revision of the final manuscript for intellectual content and structure. All authors with the CHEW model, the Ugandan MoH have now approved the final version prior to final submission. stated that CHEWs will supervise VHTs who will remain Funding This study was funded by Economic and Social Research Council (ESRC). 13 active in the community. Utilising both cares of health Competing interests None declared. workers would make sense, given the logistical challenges Patient consent Not required. on October 1, 2021 by guest. Protected copyright. of covering such a large population over a vast area, Provenance and peer review Not commissioned; externally peer reviewed. however, as previously mentioned, consideration must be Data sharing statement This is not an original research article and thus no data given to the power dynamics and resulting conflicts that is available. might arise. Open access This is an open access article distributed in accordance with the It is also important to note the different, but compli- Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits mentary roles that CHEWs and VHTs might play.
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