Can Ethiopian health extension work in Ugandan context

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By Peter Waiswa

I will start this article with two news-worthy items in Uganda’s health sector.

First, according to the recently released UN Inter-agency Group for Child Mortality Estimation report for 2015 (here after called the UN IGME 2015 report), Uganda is one of nine Sub-Saharan African countries to have achieved the Millennium Development Goal four (MDG 4) target, which is to reduce child mortality by two thirds by 2015.

The other news is that Uganda’s top Ministry of Health officials have approved a new cadre of health workers to be called Health Extension Workers (HEWs) to worker at community level all over Uganda. These two developments (achieving MDG 4 and the HEWs) are of policy relevancy to Uganda’s health sector and need public attention and dialogue.

Millennium Development Goal four has been about reducing the number of children who die before five years. This age group includes neonatal deaths (babies dying before one month of life), infant deaths (babies one month to one year), and older children. Based on the UN IGME 2015 report, Uganda has been able to reduce under five deaths from 187 per 1000 live births in 1990 to about 55 per 1000 live births in 2015, thus beating a target of 62 per 1000 live births for 2015.

The infant and neonatal mortality rates are reported to have also reduced to 38 and 19 per 1000 live births respectively. These results are good news and should be celebrated by all especially those in the health sector and its partners. However, a close examination of past performances shows that this report is controversial.

First, its findings are based on modelling and statistical estimations. Our own Uganda Demographic and Health Survey (UDHS) done in 2010/2011 gave under five, infant and neonatal mortality rates of 90, 54 and 27 per 1000 live births. Assuming the UDHS which actually was based on actual measurement is correct, then it is unlikely that the rates for 2015 are that low as reported by the UN report.

For now we will celebrate the findings of the UN report and speculate on what could have driven the positive results. Like Dr Flavia Mpanga of UNICEF told me the other day, she things that seem to have contributed most include better immunization and a reduction in cases of malaria and availability of better antimalarials. To this I add improved water access, awareness (due to Village Health Teams, radios, phones and education), and may be the mushrooming private sector.

I refer to the conditions that have reduced in burden during the MDG era as the “easy” medical cases. The clinical services provided in our health centres and hospitals are unlikely to have contributed much since we know that there has been little investment and improvement. Indeed, in my opinion, improving access and quality of care in clinical services remains Uganda’s number one health challenge. It is, unfortunately, unlikely to be improved by community health workers such as the proposed HEWs.

I have the opportunity to have done a couple of consultancy works in Ethiopia where my main focus was studying HEWs. Health Extension workers in Ethiopia were introduced in a context where they were urgently needed: the country then had very poor access to care, only about 10-15% of women delivered in health facilities, inadequate human resources, limited health infrastructure and very difficult terrain. The Ethiopian government trained over 30000 women from within their communities who could read and write to become HEWs. They were deployed at health posts do preventive care and some basic curative care. However, my own experience and studies by others have shown that these HEWs are increasingly becoming curative, and most now carry out delivery of women in labour, just like some of our own HC IIs. In addition, attrition of HEWs is high in some regions where some go to Arab countries to work as nannies.

The government in Ethiopia is also retraining many HEWs into nurses because the HEWs were introduced as a stop gap measure but the ultimate solution was nurses and midwives. Two other factors have made the HEWs in Ethiopia very successful- a very strong government at all levels that harmonises all donors, and a 1 to 5 household network of 100% volunteers (equivalent to our VHTs). It is these volunteers, called Health Development Army, that now do most of the community mobilization with supervision from HEWs.

It is my considered opinion that the introduction of HEWs is not the right priority now. All available evidence shows that Ugandans everywhere are now coming to health facilities, private clinics, and hospitals but the quality of care there is so wanting, and the outcomes so poor. Here is an example of what goes on in Uganda’s clinical services. We have collected data from the six main Busoga hospitals and found that over a period of two years, there were 38,886 deliveries but these also resulted into about 2600 stillbirths, 723 neonatal deaths, and 145 maternal deaths? How can all these deaths occur in the boundaries of hospitals without causing any national inquiry?

I therefore find that the remaining challenge in Uganda’s health care system is quality of services provided, and access. Introducing the costly HEWs will increase demand and access but not quality of health care, which will result into limited impact. I strongly recommend that the top policy option for Uganda should be to standardize clinical services by upgrading some health centre IIs to III, and some health centre IVs to hospitals, and general hospitals to regional referrals. In addition, all services need to be accredited eg what facility qualifies to be a place for women to deliver or to have a birth?

The time for specialized care has also come to Uganda, and government and partners need to move into this direction. The kind of health problems we have now such as the need for skilled birth attendants, care for the elderly, Non-Communicable Diseases prevention and care, and injuries 9e.g from road traffic accidents) etc, cannot be managed by HEWs.

Indeed, by introducing HEWs we are going to crowd-out growth and development of clinical services as resources will be moved to communities. And like for MDGs, we will only achieve progress in the “easy” conditions such as immunisable diseases, malaria, and diarrhea, but deaths from maternal and neonatal conditions, surgical related cases, and deaths from NCDs and injuries will persist if clinical services are not urgently improved.

It is not too late to re-examine this new policy shift to HEWs, and instead invest those billions of shillings in upgrading clinical services. Of course, we still need community services, but they alone are not enough, and perhaps can be addressed by improving efficiency in current programs.

Indeed, Uganda already has HEWs in form of health assistants, health inspectors, and community development officers. However, these have been badly managed and supported.

If clinical care is not urgently addressed, the current talk of Universal Health Coverage in the SDG era will remain a myths, and we shall continue attending avoidable burials.

The writer is a lecturer at Makerere University College of Health Sciences and a health systems expert