Introduction of VHTs: misinformation, hope and excitement
The introduction of the VHT strategy in Luwero was welcomed with hope and excitement in the community. Many people gladly anticipated having a group of “doctors” (abasawo) in their village to whom they could turn when illness struck them. At first, information about the VHTs was spread through rumour, and the community was ignorant about who these doctors were going to be and how they would be chosen. The process of informing the community about the VHT strategy was poorly managed in terms of clarifying who informs the community, what they tell the community and in how. Community members seemed to have received unclear information about the VHTs and what to expect from them as the information was generally spread informally. Through informal conversations, we learned that some expected that the training of VHTs meant that health services would be closer to their villages. This expectation not only brought high hopes but also some strife and competition among those who wanted to become the “village doctors”. George, a 30-year-old man, expressed this hope in an interview:
The rumors were that we are going to have village doctors. We thought that they are going to have medicine and treat us when we fall sick. We heard that they would be trained to treat diseases, so that we do not need to go to Kasana Health Center every time that we fall sick.
Sunday, a man aged about 40, explained why community members were excited when the idea of VHTs was introduced:
We were told and everybody heard that the selected persons would be the equivalent of medical doctors, where we could go if we fell sick. They were going to be trained to treat malaria and other small illnesses and also be given bicycles to transport the sick to the health center. Everybody was happy that finally the journey to Kasana [where the health center is located] is going to be reduced. The health centers are far and malaria medicines are expensive. That is why everybody was excited that at last the government had remembered to bring services closer to the people at the village level.
It is common that people living in rural areas of developing countries like Uganda have challenges in accessing health services, and sometimes, even when they manage to access the health centre, they find that drugs are out of stock. The promise that VHTs, fellow residents in the community, were to be equipped with essential drugs led to hope and excitement.
Selection of VHTs: sidelining the community
Membership of a VHT was perceived as influential in the community and so attracted a lot of interest. The guidelines established by the Ministry of Health provided that VHT members must be selected by the community through popular vote. Each VHT was to be composed of about five people, depending on the size of the village, with each team responsible for about 30 households. Political leaders such as village council committee members were not eligible for membership in order to ensure checks and balances.
Despite these guidelines, village council leaders influenced the process and appointed themselves to the VHTs. In all of the villages in the area studied, chairpersons of local councils were members of the VHTs, after being required by the sub-county governments to mobilize and sensitize their respective communities for VHT selection. Local council chairs also selected other members. Concerning her selection as a member of a VHT, Sharon, a 58-year-old woman, said:
It is the local council chairman who knows the way we were selected. They were assigned with the task of looking for people who can read and write. When the chairmen sent the names of the persons they had selected, they informed us when the time for training had arrived. After the training we were allocated homesteads to oversee concerning issues of health.
Nakimuli, a 62-year-old female VHT member, similarly told us:
I was told by the chairman that I was selected to be trained to take care of our community and guide people in health issues. He told me I was selected because I was a friend and a trusted person in the community.
It appeared that the local leaders had usurped the community’s power to vote and select people to the VHTs. This was further confirmed when one evening, while walking through a trading centre past a bar, one member of our research team overheard people asking each other about him, which compelled him to join the conversation. In the discussion that ensued, a person who had participated in an FGD conducted earlier told the group that the researcher was studying the VHTs. They were all eager to find out what the VHTs were doing. One man, about 50 years old, said:
We cannot be sure what they [VHTs] are doing, because the district people came here and gave them money to help the community. As far as we can tell, they are not doing anything. … The chairman selected the names of the people he wanted and sent their names to the district—we heard that they had been called and then we only heard that they are getting money. The chairman and his deputy are the ones who always know what is happening. … These days the money must be finished because they are doing nothing and you do not hear them talking about being VHTs.
From this comment and others like it, we learned that many people in the community thought the VHTs were paid. They did not seem to believe that the VHTs were supposed to work as unpaid volunteers to help fellow community members. The manner in which the local leaders handled the selection seemed to have fueled the suspicions of many in the community who though that VHTs were profiting in the name of helping the community. In another village, a member of our research team was having an informal conversation with Scovia, a 42-year-old woman, who talked about her community’s leaders:
I told you that these people always do things among their own cliques. They will make sure that the rest of the community will not have their way. When Annet [a member of the VHT] left, she was replaced by Sarah. Can anyone honestly say that they are surprised the chairman chose her? Don’t you see that she is in the same group of acquaintances with the chairman? Of course, I cannot say for sure whether that is the reason, but let me also ask you: Why didn’t they choose another one? Those people will be the ones doing everything. I do not think they are bad, but they reflect one side. Why was she chosen to become a VHT for people of the other side, [who] even do not know how she was chosen?
Annet’s replacement, Sarah, also served as the vice chairperson of the village council. During a conversation with the Kagugo parish chairman of the VHTs, we talked about the role of local council leaders deciding the membership of the VHTs instead of the community voting to select those they were comfortable with. He said:
People in our communities are very stubborn and they do not respect authorities anymore. Democracy has blocked their ears from listening. … People are not seeing us as friends and they think we are a burden. When we go to them, they say, “Here they are again, now what do they want?” Before we know it they have turned hostile. They do not want to respect the fact that we have something good for them. If we are to follow what the community wants, we would stop everything and choose new VHTs. If you call them for a meeting they will not come, but will complain if we choose for them. Even if they choose their very best friends, they will not listen to them. The people are lazy on issues of sanitation and hygiene—that’s why they hate us.
This leader dismissed the community’s concern as a non-issue and seemed to place himself and other VHTs apart from the community, which is indeed, we found, a significant problem.
Literacy requirement: excuse for sidelining community in selection of VHTs?
One of the Ministry of Health-mandated qualifications for those selected to serve on the VHTs was the ability to read and write, at least in a local language. In an interview with the local council leader of Sakabusolo, we were told that this mandate made it easy for him to choose those he knew to be literate. Asked whether that requirement could have influenced his community’s perception of the VHTs, he said:
Local council leaders were invited to the sub-county where they told us that the people to become VHTs should be able to read and write, especially in Luganda. Even then, many of the documents were in English. So, when we came to the community and told them that not everybody was qualified, some people did not believe us. There are not so many people who can read and write in this community. The choice for me was then easy, as I could count them on my finger.
In another conversation with the chairwoman of Kagugo village, we were told how the literacy requirement turned out to work against some of those who could have been VHTs:
In my village there are very few people who know how to write their names. At the sub-county, before they trained us, we had to write our names and parish on a piece of paper. I did not want my parish to be ashamed by sending people who cannot write their name. If someone cannot write their name, but is loved by everyone, you cannot send their name. It was hard to get five literate people to send to the sub-county who were willing to volunteer in this village because they work in other places.
These statements reveal that local leaders found it convenient to make their own choices using the literacy requirement as an excuse. The requirement seemed to constrain the community’s choice of who could serve them as a helper. Informally, some of the community members remained sceptical and suspicious, wondering if local leaders might have invented the requirement in order to influence the selection.
Interestingly, the district health officer for Luwero doubted the capacity of VHTs with basic literacy to manage childhood illnesses collection of health data. In the evaluation report for AMREF’s project, he stated that he preferred that VHTs meet higher educational qualifications, if they were intended to competently manage those roles.
Community distrust towards selected VHTs: “Those are not the ones who help us!”
There was a sense of distrust and resentment of VHTs because many members of the community felt that the way in which VHTs were selected ignored their preferences. They reasoned that since VHTs were supposed to be community helpers, the community should have had a greater say in their selection than the local council leaders. They became frustrated and suspicious of the government’s and AMREF’s stated intentions to offer help. This frustration was evident when one woman, aged about 40, while in a conversation with other community members, said:
These people [from AMREF] who come to this community pretending to help us should stop lying to us. They are also working for their other goals. … If they want to help us, how could they agree to work with people they know clearly were not chosen by the community? If they come and ally with the chairman and his friends, are they helping us? If they wanted to help us, they should have asked us, because we know the people that can help us. Have they ever seen anybody going to the chairman for help? Only Kyambadde, among the VHTs, helps people, but I think that the rest of them are interested in stealing whatever is sent to the community.
When this respondent articulated both her distrust of the VHTs’ intentions and her suspicion that they were stealing, others listening nodded their heads in agreement. The reputation of the VHTs was clearly tarnished. Lydia, a woman aged about 45, told me of her experience with the VHTs:
The VHT reported me to the sub-county that I did not have a toilet. But since I am not a man and this home is not mine, they were supposed to go to my husband, who had abandoned me. On the VHT, it was Kyambadde who understood my problems since my husband left me with children. She came to my home and we talked and she went to inform the sub-county officials to look for him. She is a very kind woman. She does not hate people and she does not judge without listening to you.
Even when people distrusted and suspected many members of the VHT, they were able to identify others whom they perceived to be good. They appreciated that someone could listen and talk to them and understand their problems.
In an interview, the health assistant responsible for supervising all VHTs in Luwero sub-county stated that she was aware that local council leaders were VHT members in many villages, contrary to the Ministry’s guidelines. However, she seemed to have gone along with the selection of VHTs, saying:
Community members are stubborn and hard to manage. When they are called for meetings, they do not come but show up to complain when you decide for them. AMREF gave us money for sensitization meetings but when community meetings did not happen in the stipulated time, they became impatient. Concerning the issue that some people in the community take all the opportunities,—sometimes it is due to stringent requirements like the ability to co-fund [to contribute some resources]. In most cases it is the leaders who are able.
The assistant appeared reluctant to ensure that the community had their say in the selection of VHTs. She easily sided with the leaders’ version without listening to the other community members. Since she supervised the selection and did not take a keen interest in ensuring that the guidelines were followed, she became an accomplice in elite capture. While the relationship between the VHTs and the community lacked trust and was instead filled with suspicion and misunderstanding, an AMREF report was largely silent on this dynamics save for the recommendation that authorities and their development partners should look for appropriate methods to select motivated volunteers.
VHT adaptations as a result of resentment from the community
Initially, each VHT member was to be allocated about 25 households, all of which would have participated in selecting him/her. However, we found that in Luwero VHTs instead began working in groups, visiting homes together. Among their first assignments was sensitizing the community on hygiene and sanitation, but many people resisted these efforts and did not welcome or listen to the VHTs. During an FGD with VHTs in Kyetume, one said:
Some of them were very stubborn and not willing to cooperate with us. They would even ask us who made us their boss. They claimed that the government had given us money to construct toilets but instead we were asking the households to do it themselves!
A similar scenario was mentioned in an FGD with VHTs in Sakabusolo, when another VHT member described their challenges:
We went somewhere and then a man wanted to cut us with machete. He was arguing that he was poor and we [had] come to tell him useless things. He said that if we want them to have a toilet, we should build it. He claimed that we are being paid a lot of money. One day I tried to explain that we volunteer but no one believed [me]. They demanded that we share the money with them.
In an interview, Tito, a VHT member, said that VHTs believed that they might have more success in groups because community members might know at least one member of the VHT:
We decided to go in groups to avoid those questions from the community. They will surely not say “who are you?” when she comes with other VHTs whom they know.
When asked if it would not be simpler to do a one-on-one visit between a VHT and someone from each of the households, as that would be much friendlier than a group of five people coming in at once, Tito replied:
People in this community are hard and they do not want to be advised. It is when things are too hard for them that they become humble. So we decided to go in groups to make it hard for them to attack us as they did when people tried to go as individuals.
The VHTs began working as groups because they did not get a friendly reception. The adaptation meant they had to walk longer distances as a group, to cover all the homesteads, rather than each walking only to the homesteads allocated to him/her. This later played a role in their loss of morale for their work.
VHTs as friendly visitors or as sanitation inspectors: the dilemma
There is one time I did not go to the field—my colleagues told me that some people in Bukuma village ran away when they saw the team approaching their homes because they did not have latrines.
The above quote from Sajjabi, a 58-year-old woman and VHT member, illustrates the problematic relationship between the VHTs and some members of the community. The friendly team of helpers sometimes created fear among the community members due to the power and authority they used to enforce their work. In an FGD, exchanges between VHTs and other community members illustrated the how the work of the VHTs proceeded from providing sanitation advice to a campaign of sanitation inspections:
VHT-1: It was not easy to convince someone that the toilet is in their own interest. Sometimes the people became harsh though some later accepted our advice. But sometimes we could be forced to arrest those who don’t see what we were telling them to be useful.
Interviewer: How did you arrest them without the police?
VHT-1:We could take the report to the sub-county, of all those people who refused to have toilets. Then the sub-county offices would send soldiers to arrest them and we would give clear directions to the homesteads.
R4: But in your method of work, I don’t think you just go abruptly and arrest him. You first go to him, warn him and educate him about the benefits of having a latrine/toilet. You only arrest him when he refuses.
VHT-2: But if he fails to listen to me and I report him, they begin complaining that we are harsh. For example at Bwaziba, VHTs there invited us to arrest some family without toilets because they feared to arrest them and then be hated in their own village. So we went and did the work for them.
The VHTs found themselves in a dilemma: they were working as inspectors and using a force that did not portray them as helpers. As they did not like to be viewed like that in their own communities, they opted to swap villages with their colleagues from neighbouring villages. The chairman of the VHTs in the parish told me:
People need an iron hand because they do not listen. But the last time we inspected homesteads, some people were harsh, which intimidated many of our colleagues and we became demoralized. Sometimes the language that the people will hear is that the one that scares them.
The use of the words “arrest”, “hate” and “iron hand” in these conversations show that the relationship between VHTs and the community had deteriorated. The VHTs found themselves having to issue threats of arrest for non-compliance with sanitation rules. This kind of relationship demoralized the VHTs themselves who did not want to create grievances with community members.