Views From Rwanda: Why African countries should improve welfare, capacity of Community Health Workers

Cross section of the general auditorium during a section in Kigali convention centre.
Cross section of the general auditorium during a section in Kigali convention centre.

Community Health Workers in many African countries are increasingly complaining about their welfare.

Their major concern is that they are being sidelined and undermined, and worst still, underpaid, reports GroundUp, a South African based news medium.

“We do the same work as nurses and even more, yet we are labelled as uneducated, it is painful,” says community care worker Leamah Sixholo.

She was speaking to the South African Human Rights Commission (SAHRC) representatives during a dialogue in Braamfontein late last year, according to the report.

“Our concerns are never heard. We are underpaid,” she said.

Ms Sixholo said care workers were often forced to use their own money to buy uniforms and equipment. Care workers treated patients without gloves and masks which made them vulnerable to diseases such as Tuberculosis, she added.

Unfortunately, such experience as narrated by Ms Sixholo has become a common norm in many African countries.

The Role Of Health Workers

Community health workers, for most people living in rural Africa, serve as the link between structured health facilities and communities.

For more than four decades, community health workers (CHWs) have been globally recognised by the World Health Organisation as a vital element of primary health care coverage, and consequently, a significant component to achieving Universal Health Coverage (UHC).

Essentially, they provide life-saving integrated community case management diagnosis and treatment for pneumonia, diarrhoea, malaria and other diseases, which can be deadly for children under the age of 5.

They contribute to epidemic preparedness and response; deliver vaccinations that have brought the world much closer to being polio-free, among other vaccine-preventable diseases, according to WHO.

But still, these roles remain predominantly voluntary, with limited training options or financial spur needed to encourage delivery of quality health services.

“I want to ask the honourable minister and all policymakers, in most African countries, community health workers are not paid, so… how can you make them accountable … what are you doing to educate them?” Senait Fiseha Alemu, a community health worker asked during a panel discussion recently at the Africa Health Agenda International Conference in Kigali, Rwanda.

Diane Gashumba, Rwanda’s health minister, opened the first plenary session on access to care, in conversation with Mrs Alemu, a Health Extension Worker from Ethiopia, on the second day of the three-day biennial event held at the Kigali Convention Centre.

The discussions focused on a range of interventions that would help motivate the community health workers, including performance-based remuneration, education, professional development opportunities as well as placing emphasis on the importance of community recognition.

Mrs Alemu expounded challenges she faces while serving 9,000 families in her district, noting that she walks one to two hours by foot some days to visit patients.

 

The Nigerian side of the story

Two years ago, the Nigerian government said it had concluded plans to engage 200,000 voluntary health workers to improve delivery of immunisation, antenatal care and other health services in rural areas. The announcement followed the flag-off of a scheme to revitalise about 10,000 healthcare centres across Nigeria.

Ten months down the line, PREMIUM TIMES investigation revealed how Grace Diache, a trained nurse struggled to deliver services in a deplorable condition.

The 49-year-old mother of three was the only qualified health worker at the only health centre in Edikwu-Icho, a swampy community of about 2,500 people in Apa Local Government Area of Benue State.

Dominated by Tiv speaking people, the agrarian community is cut off whenever it rains, as five-foot deep flood water covers the only road that links it with the outside world.

Assisting Mrs Diashe at the centre, then, were three community extension workers. They all worked day and night with no shifts.

According to the nurse, the centre attends to about 15 patients from the community and its environs daily. In a month, she said, she takes about 25 deliveries.

Unfortunately, Mrs Diache could not be reached on phone to confirm the present situation of things there.

But while the government shuffles plans to provide adequate personnel and train health extension workers, the inability of PHCs to meet up with their design continues to force women in Nigeria to patronise untrained traditional birth attendants, despite the grave risks involved.

According to a survey conducted by the Civil Society Legislative Advocacy Centre (CISLAC), in Nigeria, one in 13 women dies during pregnancy or childbirth.

 

 

Keying into WHO’s Guideline, the way forward?

During AHAIC 2019, held between March 5 and 7 in Kigali, WHO launched a new guideline on health policy and system support to optimise community health worker programmes in alignment with the organisation’s Workforce 2030 global strategy on human resources for health.

The guideline lists 15 policy and effective workforce strategy recommendations ranging from CHW selection, training, management, and integration, to implementation and evaluation considerations at policy and local levels.

Regarding pay, the guideline makes a “strong” recommendation for a financial package based on the number of hours worked and job demands and suggests that countries move away from performance-based incentives.

The guideline also made a similar “strong” recommendation to provide paid CHWs with a written agreement specifying roles and responsibilities, working conditions, pay and workers’ rights.

The report suggests a general services training with an emphasis on practical experience, using e-learning where relevant.

“In terms of financing, we know that the health system is built from the top, not the bottom,” Githinji Gitahi, the CEO of Amref Health Africa stated.

In Nigeria for instance, the responsibility of PHCs rests largely on the local governments while the federal and states cater respectively for secondary and tertiary hospitals.

This means the bulk of the money remains at the top. Mr Gitahi said because of this, community health systems, which are a component of primary health care, suffer from a lower availability of resources.

While the guideline is not meant to instruct governments on what to do, Mr Gitahi said, it is meant to give recommendations.

Achieving Sustainable Development Goals by 2030 now will be rooted in the support of strong primary health care systems that will not only promote health and prevent disease but strengthen the capacity and welfare of CHWs, WHO Director-General Tedros Adhanom Ghebreyesus said in a video message on the opening day of the event.

Co-hosted by the Ministry of Health of Rwanda and the African Medical and Research Foundation (Amref Health Africa), the AHAIC 2019 encapsulated the greatest health challenges facing Africa under the theme “2030 Now: Multi-sectoral Action to Achieve UHC in Africa”.

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