Background

In 2018, the world commemorated 40 years of the Alma Ata Declaration on primary health care (PHC) which emphasised the importance of Community Health Workers (CHWs) in ensuring its vision of health for all. In line with the declaration, Uganda launched a CHW programme in 2001 in an effort to address the high disease burden and critical shortage of health professionals, as well as improve equitable access to health services.1

The programme established a cadre of volunteers charged with the responsibility of empowering communities to take control of their own health and well-being, and actively participate in the management of local health services. These volunteers in Uganda are called Village Health Teams (VHTs) and recognised as ‘health centre I’, being the first contact of the community with the health system.2 3 The main roles of the VHTs include: carrying out health education at household and community levels; conducting house-to-house visits for health improvement; participating in integrated community case management (iCCM) of childhood illnesses of pneumonia, malaria and diarrhoea; referral of patients to health facilities; as well as mobilisation of communities for public health interventions such as immunisation of children and distribution of mosquito nets.

VHTs are lay persons with the ability to read and write preferably in their local language, identified by their community, and offered basic training between 5 to 10 days on several topics such as communication, community mobilisation, child growth and development, sexual and reproductive health, sanitation and hygiene and common diseases such as malaria. These VHTs, who are supposed to be four per village, are not formally paid but sometimes provided with infrequent and non-standardised support including non-financial incentives such as t-shirts and bicycles, many times by health development partners working closely with the Ministry of Health (MOH). They are often provided with a refund of transport costs to attend meetings, and whenever called on for any official activity which is sometimes insufficient for the purpose.4 The work of VHTs is supported and supervised by a VHT parish coordinator and/or a health practitioner working in the area, with the overall supervision of the District Health Educator. Note that the sub-counties of Uganda are divided into parishes, which are further divided into villages.

Since 2001, the VHT programme has registered improved health outcomes especially contributing to reducing morbidity and mortality among children under 5 years of age particularly for malaria, pneumonia and diarrhoea under iCCM of childhood illnesses.4–7 However, challenges regarding training, transportation, remuneration, motivation and retention of VHTs continue to affect the programme.8–11 With an interest to strengthen the community health system and further improve health outcomes with emphasis on disease prevention, the MOH commissioned a comprehensive national assessment of the VHT programme in 2015 to establish its status and functionality in order to improve planning and health service delivery to communities.4 The assessment identified critical gaps in the VHT programme regarding funding, training, supervision and coordination of the programme across all levels of the health system. After the assessment, a desk-based review and benchmarking activity was conducted to gain a deeper understanding of other countries’ experiences.

Using evidence gained, the MOH recommended the introduction of the Community Health Extension Workers (CHEWs) policy and strategy in Uganda, largely modelled after the Ethiopian Health Extension Workers programme. The CHEWs would be formally institutionalised in the local government healthcare delivery structure, with two of them situated at parish level. The CHEWs are expected to be involved in various promotive, preventive and basic curative services at community and health facility levels. They will directly supervise and oversee the work of VHTs in communities. As opposed to the VHTs, CHEWs would need to be nominated by their parish, between the age of 20 to 35 years, have a minimum of ordinary level education, be fluent in both English and the local language, undergo a 6 months training before deployment and paid a standard monthly consolidated allowance by Government.12 13 Approximately, 15 000 CHEWs are planned to be rolled out to an estimated 7500 parishes across the country over a 5-year period by the MOH with the support of implementing partners.13

A recent publication in BMJ Global Health highlighted the potential challenges of implementing the CHEW programme in Uganda including logistical and financial concerns as well as the relationship between CHEWs and VHTs.14 In this article, we explore the pros and cons of this CHEWs strategy as well as propose what needs to be done for its success based on our experiences of working in community health in Uganda.

Pros

Countries such as Ethiopia, Nigeria and Kenya have developed and implemented paid CHW programmes to improve access to PHC services especially in low-resource communities and among vulnerable populations. These CHW programmes are aimed at providing quality promotive, preventive and selected curative health services at PHC centres in an accessible and equitable manner to all sections of the population, with special attention to mothers and children.15 In Ethiopia, two health extension workers are posted per primary health centre which serves a catchment population of 5000 people or more,16 17 while in Nigeria 20 CHEWs serve a population of 10 000 people.18 Paid CHWs undergo a relatively longer formal pre-service training (such as 36 months in Nigeria18) in comparison with volunteer CHWs, are usually required to have substantive level of formal education, and are normally residents of the community they serve19 as is normally the case with volunteer CHWs.

Unlike volunteer CHWs, CHEWs receive a financial incentive of a monthly salary.15 Where CHWs such as CHEWs have been financially compensated, they have made substantial impact on health outcomes of populations especially on maternal health.20–22 Indeed, the WHO has recommended remuneration of CHWs with a financial package commensurate with their work and training.23 CHWs effectiveness has been attributed to performance management, data driven decision making, cordial working relationships with communities, mentorship and supervision provided by health managers and provision of several innovative avenues for improving performance.24 Such experiences from other countries should be considered in implementation of the proposed CHEW programme in Uganda.

However, many stakeholders in Uganda are asking whether the introduction of CHEWs is the much-needed reform to accelerate Universal Health Coverage. Or could there be a missed opportunity of strengthening the existing CHW programme building on earlier successes? In our view, the proposed CHEWs are likely to have some benefits to the country’s health system. Introducing another health cadre focussed majorly on health promotion and disease preventive among the population would increase access to PHC which would lead to better health outcomes.24 Indeed, services of the CHEWs would be a complimentary link to other health professionals in the country including nurses, health assistants and clinical officers who all support community health.12

In addition, the CHEWs could significantly support the work of VHTs including their direct supervision, data collection and reporting. Referral and follow-up of patients from communities to health facilities is also likely to improve if the CHEWs work closely with VHTs in their day-to-day activities within their respective parishes. Since the CHEWs would spend part of their time at primary health centres, they would not only contribute to supporting community health but also service delivery at health facilities by reducing existing health worker burden through assisting in diagnosis and management of simple illnesses as seen elsewhere.18 21

Cons

However, there are a number of foreseeable concerns that if not adequately addressed, could negatively affect the CHEW programme and the community health system in general in Uganda. For optimum performance of CHEWs, they would require adequate support systems including performance management, regular refresher trainings, availability of necessities and supplies such as drugs, sufficient logistics such as motorcycles for transportation, regular supervision, mentorship from health practitioners, as well as community trust and acceptance. Logistical support including transportation is not only crucial for the performance of CHEWs but also in the proposed supervision of VHTs by the CHEWs in the community. These concerns have for long been known to affect the wider health workforce in Uganda including among VHTs.4 7 8 Therefore, introduction of CHEWs without addressing these health system challenges would most likely result in a health cadre that is not adequately supported to yield the desired results in improving population health.

Whereas the proposed two CHEWs per parish would be instrumental in supporting VHTs in that area, they would probably have minimal impact in reaching the vast population in several communities given that some parishes in the country have over 60 000 people.25 Furthermore, in a parish with over 25 villages, two CHEWs could be working in a geographical location with over 100 VHTs as one village is meant to be supported by four VHTs. This situation emphasises that even with deployment of CHEWs, the role of VHTs remains crucial in supporting the community health system. However, there is a likelihood that with the introduction of CHEWs, VHTs would be further neglected if not phased out hence undermining their role in providing PHC and public health services in the community. Indeed, the several challenges among VHTs identified by the national VHT assessment including training, coordination, supervision, monitoring, motivation and reporting,4 that are said to have contributed to introduction of the CHEWs,13 would not be completely addressed by this new cadre. It would therefore be important that concerted efforts are made to address the VHT-specific challenges established in the national survey to compliment and strengthen the proposed CHEW programme. More so given the evidence that the roles of VHTs are crucial for the performance of CHEWs and achieving desirable health outcomes in the community.

Given that CHEWs would be paid a monthly consolidated allowance while incentives for the existent VHTs have remained low and non-financial, there is a high possibility that the relationship between the two cadres may not be cordial which would potentially affect health service delivery in the community.14 Moreover, there is no guarantee that with the provided remuneration, the CHEWs would deliver on what is expected of them especially with a high record of absenteeism and low supervision rates reported among health workers in Uganda.26 Therefore, performance management at community level must be prioritised and strengthened.

Furthermore, the MOH should prioritise the urgent need to address the VHT concerns so as to benefit the community health system beyond the single cadre of CHEWs. In addition, the challenges affecting the wider health workforce in the country need to be addressed before the introduction of the CHEWs strategy. A mindset shift is further needed by the government, health workers, communities and other stakeholders to move from prioritisation of curative services to health promotion and disease prevention. Although it has been recommended that the existing VHTs would be prioritised during the selection of CHEWs, very few will be eligible given majority are above the entry age limit of 35 years.4 Minimal integration of VHTs into CHEWs is therefore likely to further negatively affect community embeddedness as well as the relationship between the two cadres.

Another concern is that the role being assigned to the CHEWs is one that health assistants, a cadre of certificate level Environmental Health professionals supposed to supervise VHTs, are meant to contribute to.2 It is therefore more plausible and efficient to enhance the performance of such a workforce, who receive a 2-year training to effectively carry out their responsibilities, than introduce another 6-month trained cadre to play closely related roles. With the introduction of this new strategy, CHEWs would serve as the current health centre 2s to coordinate their activities and offer services within the community.13 Despite the proposal that CHEWs would spend 60% of their time in the community, being based at health centres could likely lead to further extension of essential services away from the community. This may further disenfranchise community members and contribute to poor health outcomes given the long distances to health facilities in many areas.27 Another challenge that VHTs have been found to face is the lack of a clear career path.4 Although introduction of CHEWs may provide an opportunity for some VHTs particularly those with ordinary level qualification and within the age limit, the career path for CHEWs is yet to be clarified which could affect the strategy and its impact.