By Kate Hawkins, Rosalind Steege, Kingsley Chikaphupha, Carol Namata
“I went there with all of my heart because I needed to serve the nation.” Florence Namulindwa (PATH, Uganda)
“You know the pain that we go through and all the difficulties.” Henry Bugembe (VHT, Uganda)
If researchers are serious about doing justice to the needs and dreams of Community Health Workers (CHWs), we have to listen carefully to them and share their concerns. At the 1st Symposium on Community Health Workers and their Contribution towards the Sustainable Development Goals we were able to hear directly from Village Health Team members (VHTs) in Uganda and get inputs from other workers from around the world. This is a roundup of some of the issues that came to the fore.
Remuneration and recognition is important
Payment is an issue that came through strongly in the inputs from CHWs. For example, Mariam Nakirigya, a VHT, mentioned that monthly allowances were motivating. In the plenary panel on CHW’s voice we heard from Henry Bugembe that it is difficult for VHTs to do their job if they aren’t paid and that CHWs need to be motivated – not just through money – but through simple things like gumboots, umbrellas, solar chargers and airtime which would make VHTs happy and support them in performing their job more efficiently. Furthermore, medicine stock outs are a significant problem and it can be demotivating if you cannot give people the treatment that they require. Henry also suggested that preferential treatment should be given to CHWs at the health care centre and that it is demotivating when you serve the health of the community and you are expected to wait in line at the health centre with everyone else.
“As a VHT I do not want to wait in that long line when I visit a health centre with my patient. Health workers should give us immediate attention when we visit health centres.” Ugandan WhatsApp Group
Many CHWs mentioned that thanks from the community and health service staff would be welcomed. Speaking about the TB project that she works on, Agnes Nakate (Medical Sciences for Health, Uganda) explained how her clients can be challenging. Some of the patients are rude or they are happy at the beginning of their treatment when they go from being very sick to feeling much better. But then they can lose contact or shift addresses and following up with them can be a difficulty, especially if they are long distances away.
Carol Namata, of Makerere University, summarised the WhatsApp discussions that VHTs had held in Uganda. The need for recognition came through strongly here too – particularly from community leaders. In terms of motivation, VHTs suggested that they would like health tours to other areas of Uganda or overseas to learn from their peers about what works and to strategize about how to overcome challenges. VHTs also reported experiencing negative psychosocial effects because of their work and that the opportunity for sports activities and other avenues for releasing stress would be welcomed.
“We want health tours to countries like Kenya. This will help us learn more on the work of VHTs from other countries. We could also have a trip to other districts. Some of us do not know where Ministry of Health is, it will be great if we get a chance to go visit and meet the Minister of Health.”Ugandan WhatsApp Group
“We want our bosses to send us appreciation messages.”Ugandan WhatsApp Group
Through the HIFA discussion we heard that there are gendered stresses that have particular effects on both men and women. From Uganda and Kenya, we heard how male CHWs are often challenged by husbands who feel they spend too much time talking with their wives. Whereas in India, the female Accredited Social Health Activist (ASHA) WhatsApp group (kindly set up by Kavita Bhatia and Sunanda Reddy) told us that ASHAs required gender sensitization sessions, programmes and polices both within healthcare structures and the community to stop the harassment of ASHAs. This harassment can have a detrimental effect on their mental health as well as their ability to undertake their role
“Some in the community make comments because we step out of the village at all hours for our work”ASHA, India
Female CHWs also have a burden of unpaid household work and care that are not recognised when people think about the work burden of CHWs. In a panel session, Mariam Nakirigya from the University of Makerere’s CHWs project described how it was challenging to balance family and work life when, for example, drunk clients turn up at your house in the night and expect to be seen.
ASHAs also talked about the burden of administration and managerialism – the health system is expecting too much. CHWs are affected by growing targets, indicators, and reports and the number of CHWs is not increasing proportionally. ASHAs told us that they have too much documentation work and it effects their ability to provide care for their communities.
“Majority [of ASHAs] responded that they are given too much of documentation work and that leaves them little time to do other tasks” Sunanda Reddy, India
Whilst salaries are welcomed, in the plenary we heard from Scovia Nabwire, a Ugandan VHT working on an FHI360 project, that there may be some unanticipated consequences in moving from a voluntary system to paid Community Health Extension Workers (CHEWs). Because CHEWs can only be between 18 and 35 years old some older, very experienced VHTs will be unable to apply, resulting in younger people being promoted over them. Ensuring that the VHTs remain motivated will be critical.
Beyond studying: What can researchers do?
Henry Bugembe (Uganda) told us that being part of the Makerere study had given VHTs access to solar chargers for lights and phones, gumboots, and umbrellas. He argued that while these might appear to be simple, a lack of access to these things have led to demonstrations in protest in the past.
Summarising pre-conference discussions on HIFA, Rosalind Steege told us that CHWs want more avenues to voice their concerns – over issues like occupational hazards and a lack of free healthcare. It was suggested that participatory methods such as photovoice, blogs, and community groups are ways in which they can be heard. However, all the communications platforms in the world will not make a difference if when they do speak up they are not listened to.
“We have spent a long period of time asking for monthly/quarterly allowances but nothing has been done so far.” VHT, Uganda