Drugs for some but not all: inequity within community health worker teams during introduction of integrated community case management

Abstract

BackgroundThe Ugandan health system now supports integrated community case management (iCCM) by community health workers (CHWs) to treat young children ill with fever, presumed pneumonia, and diarrhea. During an iCCM pilot intervention study in southwest Uganda, two CHWs were selected from existing village teams of two to seven CHWs, to be trained in iCCM. Therefore, some villages had both ‘basic CHWs’ who were trained in standard health promotion and ‘iCCM CHWs’ who were trained in the iCCM intervention. A qualitative study was conducted to investigate how providing training, materials, and support for iCCM to some CHWs and not others in a CHW team impacts team functioning and CHW motivation.MethodsIn 2012, iCCM was implemented in Kyabugimbi sub-county of Bushenyi District in Uganda. Following seven months of iCCM intervention, focus group discussions and key informant interviews were conducted alongside other end line tools as part of a post-iCCM intervention study. Study participants were community leaders, caregivers of young children, and the CHWs themselves (‘basic’ and ‘iCCM’). Qualitative content analysis was used to identify prominent themes from the transcribed data.ResultsThe five main themes observed were: motivation and self-esteem; selection, training, and tools; community perceptions and rumours; social status and equity; and cooperation and team dynamics. ‘Basic CHWs’ reported feeling hurt and overshadowed by ‘iCCM CHWs’ and reported reduced self-esteem and motivation. iCCM training and tools were perceived to be a significant advantage, which fueled feelings of segregation. CHW cooperation and team dynamics varied from area to area, although there was an overall discord amongst CHWs regarding inequity in iCCM participation. Despite this discord, reasonable personal and working relationships within teams were retained.ConclusionsTraining and supporting only some CHWs within village teams unexpectedly and negatively impacted CHW motivation for ‘basic CHWs’, but not necessarily team functioning. A potential consequence might be reduced CHW productivity and increased attrition. CHW programmers should consider minimizing segregation when introducing new program opportunities through providing equal opportunities to participate and receive incentives, while seeking means to improve communication, CHW solidarity, and motivation.

Acceptability of a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda: a qualitative study

“…This could portray the value the community attaches to biomedical interventions. Indeed, research has shown that CHWs who give drugs or commodities to community members are more respected [36,40]. Norms and community perceptions of illness could also play a part in the high interest in biomedical interventions.…”

Community Health Volunteers in Primary Healthcare in Rural Uganda: Factors Influencing Performance

“…Individual, group, and program factors have each been shown to influence the performance of CHVs (1, 3, 5, 6, 8–15, 17–19, 25). Factors previously reported to result into improved performance include the female gender, regular supervision and provision of feedback, higher education, the availability of job aides and other tools, and feeling “connected” with the system (3, 5, 6, 9–11, 13, 14, 17, 18). …”

“…However, the findings have been heterogeneous and influenced by many factors (4, 8), including socio-demographic, political, economic, and workplace environments. Workload, attrition rates, gender roles, level of education, political commitment and employment status, job aides, and physical workplace environment have a significant influence on such workers’ performance (3–6, 9–15). Understanding the contextual factors and enablers that influence the performance of CHVs is relevant for many settings aiming to use them to achieve the SDGs.…”

Supportive supervision and constructive relationships with healthcare workers support CHW performance: Use of a qualitative framework to evaluate CHW programming in Uganda

“…Together, Mbarara University of Science and Technology (Uganda), the University of Calgary (Canada) and the Canadian Paediatric Society promote health system strengthening in rural districts using MNCH as an entry point. Through research, HCU has sought to better understand factors related to effective implementation and sustainability of related programming [ 22 – 24 ].…”