Results in this section are arranged based on the key themes from the data: enthusiasm about VHTs, perceptions that VHTs work for “other” people, masking the challenges of the health care system, VHTs as a tool to control people, government neglect, lack of support and recognition from formal health care providers and the perceived failure of VHTs to address social determinants of health in the face of an ailing health care system.
From early enthusiasm to sceptical apathy
The recruitment and training of VHTs in Luwero District in 2006, according to discussions with community members and VHTs, generated enthusiasm among the local people and the VHTs, especially when the first incentive-led rewards for VHTs yielded creditable results as VHTs interacted with community members and formal health care workers. AMREF, the NGO that trained VHTs, initially provided financial incentives and facilitated their work; for example, they routinely wrote reports and submitted them to their supervisors. They were given bicycles, T-shirts and metallic boxes for keeping drugs they were meant to distribute.
For the community members, the VHT strategy created a belief that VHTs were there to solve all their health problems. These expectations were heightened by the initial enthusiasm with which the VHTs performed their duties under supervision from the health workers. As a result, the interactions between the VHTs, the health workers and the community members showed signs of hope. The community members believed in the VHTs’ work and took their support seriously.
One day as I moved around mobilizing people for vaccination, I came across a home that I had never visited. When I arrived, I saw this child lying down. His mother told me he was six years old. This child was six years but could not move at all; he was lame and I think the parents did not even know what to do with the child…So, I gave them a form and we filled it out together. I told them to take the child to a rehabilitation centre called Katalemwa. They took the child there, the doctors helped him with walking aids and with time, he gained strength and he is now doing well….This was about three years ago. (Interview with a VHT)
Nonetheless, the early bout of enthusiasm gradually waned into indifference and feelings of desperation when community expectations of receiving drugs from VHTs were not forthcoming.
Ever since they (VHTs) were trained up to now, they (VHTs) have never received any Coartem (anti-malarial) to distribute. Yet they (VHTs) were given T-shirts and boxes where they were supposed to keep medicines but up to now, they only have empty boxes and won out bicycles. (Interview with Health Assistant)
According to the community members, the failure to equip VHTs with essential medicines to distribute to community members whenever sick resulted into a loss of trust of the VHTs.
Respondent 1: I wonder why they said those people [VHTs] were going to be our village doctors. Even witchdoctors have what they need to use. Now for VHTs, they are here; we see them every day, but they have nothing (no materials) to help us with. (FGD with community members)
This statement suggests that community members had expectations of the VHTs, which were not met.
VHTs work for “other” people
In one FGD we conducted with community members, participants unanimously mentioned “They (VHTs) work on instructions from their bosses. They do what they are told to do.”
The label “bosses” was echoed in most discussions with community members to refer to the officials at the district health office, district hospital and NGOs who use the VHTs to undertake community mobilisation during health campaigns, immunisation programs and other outreach activities. The district health office keeps phone contacts of all VHTs from which they are called to mobilise communities. Take an example of a community health and personal hygiene sensitization outreach event organised on June 18, 2013, by the district health department, supported by Korean International Cooperation Agency (KOICA) and Sahmyook University based in Korea. The community members who attended (11 male and 15 females) were mobilised and informed about the program by the local council (LCI) chairperson who was a member of the VHT. He had been given instructions to mobilise people on phone two days to the event.
During a discussion with the in-charge (the head of the health workers) at Kasana HCIV, he revealed that VHTs were critical mobilisation agents who are occasionally given an activity allowance to mobilise communities for government programs like distribution of insecticide-treated mosquito nets.
Whenever there is an outreach the VHTs are the people we use to mobilise for us. Recently we used VHTs to distribute insecticide treated mosquito nets.
Besides the mobilisation of community members on behalf of the formal health care providers, sometimes VHTs are trained to implement programs initiated by NGOs or government in the community. Community members interpreted such actions (using VHTs to mobilise communities and training VHTs to implement NGO or government programs) to mean that health workers were using the VHTs to pursue their (health workers) interests. In an interview with a health assistant, she recounted how the community members tasked her during one of the health outreaches to explain why the VHTs only work for the health workers.
Fears that the VHTs were working for the “other” were heightened by accusations that they were drawing salaries and other favours from the government; this is likely attributed to the earlier financial incentive-led work they did in the community and the fact that VHTs are given an allowance whenever engaged in a short term activity by the “bosses”.
Respondent 7: If you go out to advise someone to go to the hospital, he or she will tell you, “you are telling me, yet you are the ones who receive salaries, you get some of the money you are paid so that you take me to the health facility; you are government workers”. They take us as government workers; they think we get salaries. (FGD with VHTs)
We also learnt that local government authorities sometimes used police to enforce hygiene standards at community level.
VHTs from one of the parishes came and told me that “we are tired of people in our parish who do not want to construct latrines. You should come with police for us we are ready to take you to every home that has no latrine and arrest them”. With the help of VHTs and the LC chairpersons, we got police and a car from the district and arrested the people who had no latrines and charged them (Interview with health assistant)
While reflecting on the use of VHTs as police agents to arrest people, some community members wondered why the same was not done to VHTs who did not have latrines and were not showing a good example. While we did not witness any arrests of such nature by VHTs or police during fieldwork, VHTs told us that they had to stop because it was leading to hatred.
We learnt, however, that what the community members perceived as working on the instruction of “others” is a function enshrined in the VHT national strategy. It states: “All health activities at community level by the government, NGOs and or partners targeting communities shall be coordinated through VHTs.” ([11], p. 19). The assumption was that by implementing all activities through VHTs it would make “the community value and continue demanding and utilizing their services” ([11] p.19). However, discussions with community members depict VHTs as powerless; they do what “their bosses” want them to do than what the community needs. To some of the community members, the VHTs were simply a programme like any other programme that comes and goes. The participants positioned the VHTs as a shop that was opened, did not serve its purpose and should be closed. However, some community members blamed their (VHTs) failures on the government’s inability and perceived lack of interest in equipping VHTs with the necessary facilities including medicines to distribute to the people.
VHTs as a tool to mask the challenges of the health care system
Facility-based health workers mentioned that VHTs are not “experts”, yet they seem to expect preferential treatment.
They [VHTs] even want to bring patients and skip the queues! It is not possible, those people are not experts; they should simply refer people here. If they send someone to our centre, he/she should come as any other regular patients. (Interview with district health official)
The VHTs we talked to noted that the patients they refer should not be made to line up at the health facilities, which, to them (VHTs), is a source of motivation for people to visit health facilities. These conflicting expectations reveal some tensions and minimal contact between the formal health care workers and VHTs.
Some health workers also questioned the idea of introducing VHTs and wondered why the government that failed to equip the health centres with drugs, equipment and medicines would do the same for VHTs at the community level and later on be able to motivate them (VHTs) to link the community to formal health care facilities. A health worker wondered, “If the health facilities are not equipped with drugs, how do the VHTs refer people here?”. While public health facilities offer free medical services including drugs, government reports have often reported drugs stock outs [49]. VHTs told us it was fruitless to refer people to health facilities that are ailing with no drugs and equipment.
Respondent 7: There are those (people) that have lost hope in the health facilities; whenever they go there they do not get medication.
Respondent 3: When you ask someone to go to the health facility, they will ask you if you are sure that they will get drugs. You are not even sure what to tell them; in the end, people stay home. (FGD with VHTs)
The facility-based health workers also mentioned that public health facilities are not well equipped.
Here [Kasana HCIV], we do not have an operating theatre. How can that be? The doctor is here, everything, and you just cannot put up a theatre? … I think the government was not honest in saying that they wanted to give anti-malaria drugs to the VHTs. How can they do that if the hospitals are not stocked with medicines? (Interview with the person in-charge at Kasana HCIV)
According to the Ministry of Health structure, HCIVs are supposed to have an operating theatre. The revelation by the person in-charge that the HCIV that serves the study community lacked an operating theatre was in itself revealing of the bigger challenges facing the formal health care system. According to the health workers, the creation of VHTs demonstrates the government hypocrisy and an attempt to mask the health sector challenges. The arguments made by health workers were that the government could have simply facilitated the health inspectors and health assistants who are already in the national health care delivery structure, instead of poorly facilitated VHTs to do their work.
The health workers argued that after failing to equip the health facilities and structures such as health inspectors and health assistants, the government recruited the VHTs to work as volunteers. When we talked to the VHTs, they mentioned that AMREF initially facilitated them with a monthly allowance to do their (VHTs) work, and some VHTs received other incentives like T-shirts, bicycles, among others. The monthly facilitation allowance stopped when the VHTs were transferred to the local government structure because it was too expensive for government to manage. At the time of fieldwork, the VHTs only wait to do work occasionally given to them by NGOs working in the area (e.g. the mobilisation of community for KOICA community hygiene campaign) and special government programs like immunisation or distribution of insecticide-treated mosquito nets. When they do this work, they (VHTs) receive a facilitation allowance. The idea that VHTs were supposed to do the work voluntarily was, according to the health workers, an attempt to shift responsibility.
If we were to go by this argument, it would also imply that the fears of health workers are embedded in the realisation that by fronting the VHT structure, the government was inhibiting the effective functioning of formal health systems. In fact if the government mooted idea of creating “the health extension workers” (HEWs) [50, 51] goes through it would then completely sidestep the positions of health assistants and health inspectors and continue to mask critical health sector challenges.
VHTs as a tool to control people
The creation of the VHT structure, according to some health workers, was simply a ploy by the government to control people after failing to meet the cardinal obligations such as equipping health facilities. In some discussions, health workers argued that the government established such structures as VHTs to facilitate the “politics of control” over people and use them (VHTs) to mobilise support for the ruling regime during elections.
There is something you do not understand about the politics of control. You see, these structures like VHTs and Local Councils and all these groups being formed are to help the government in case of organized rebellion. The problems they set them up to address are just used as an excuse. Politicians use them (VHTs) as mobilizers during elections. (Interview with the in-charge Kasana HCIV)
However, given that when we did fieldwork there were no elections organised, we could not competently verify this claim. What we note, however, is that contrary to the VHT strategy guidelines that spelt out that political leaders, especially local council leaders at village level were not supposed to be elected as members of VHTs, we found that almost all the VHTs in this community were either local council chairpersons or members of the local council executive committee.
Government neglect, lack of support and recognition from formal health care providers
The public health services delivery structure in Uganda places VHTs at health centre I (HCI) at the community level and they serve as the first point of contact. VHTs revealed their uncertainty about their position in the structure. They mentioned that the government abandoned them by reneging on the promise to give them medicines to distribute in the community. Some VHTs mentioned that they struggle to get attention and recognition from the formal health care providers. In one FGD with VHTs, they mentioned that they are not recognized and the attitude of the health workers leaves them uncertain of their position in their interactions.
Respondent 7: The VHT is not taken as someone who is part of the formal health system. The health workers at the government health facilities do not respect you; so, you find that as a VHT you lose interest in following up issues. For example, we have many sick people but we no longer know them. Making follow ups at the health facilities, for example, TB or even HIV patients is no longer done because our bosses (government and district officials) are no longer helpful. (FGD with VHTs)
The attitudes of formal health care providers, according to VHTs, amount to humiliation that partly contributes to the lack of interest in VHT work.
The truth is that we lost interest in the VHT work, not only in this village, but elsewhere too. Those days (when VHTs had just started) you could call the health assistant to help you, but now they first ask for transport; sometimes they ask you, “Who are you to call me?” (Interview with VHT)
The VHTs’ complaints about the lack of support to follow up on sick people in the community appear to push their work to perfunctory advice on basic health issues. For example, on January 17, 2013, Mr. Okello, a community member, lost his son of 4 years. Before his death, one of the VHTs (John) had advised Okello and his wife to take their son to a bigger hospital in a neighbouring district where they had been referred by the medical doctor at a public health facility for further tuberculosis (TB) tests and treatment. When we spoke to John, he told us the boy was not taken for further TB tests because his parents did not believe it was TB. According to John, the parents believed the boy had been bewitched by one of his relatives. When asked what he thought the problem was, John said that whenever he visited, the boy’s parents always claimed they did not have sufficient funds to take the boy to the hospital, yet “the mother runs a food joint and the father is a businessman.” Surprisingly, according to John, the boy’s parents found money to take the boy to traditional healers three times before his death. In the interpretation of the problem, John said “helping a person who has not asked for help is hard.” The VHTs also mentioned lack of support from the formal health care system to overcome barriers presented by a clash between community cultural understanding of illness and disease and the biomedical interpretation. If a VHT hits a deadlock, i.e. if a community member does not take the VHT’s advice, VHTs have no available support from the formal health care system to help them overcome this challenge.
Failure to address social determinants of health
The 2010 Uganda National Health Policy identified several social determinants of health including household income, education, status of housing and social and cultural beliefs [14]. The 2006 Uganda Demographic and Health Survey showed a direct relationship between poverty and various health indicators including prevalence of diseases [52]. Poverty, poor transport networks and distance to health facilities limit community members’ access to health care.
In one of the pile sorting sessions, participants argued that poverty and poor hygiene are greater health problems than the lack of health facilities. One person stated, “… you would not worry about treatment facilities if you had money to access them even if they are far away from the community.” The nearest private and public health facilities are approximately 5 km away, and it costs about USh 2500 (Ugandan Shillings, equal to US$ 0.70) to travel this distance by boda boda. Participants in pile sorting sessions mentioned that such problems are solved by “mobilising ourselves”, which meant actively marshalling resources including borrowing money from friends and neighbours, organizing transport and caring for “unable” community members. None of the participants mentioned relying on VHTs for solving some of these problems.
For the most part, VHTs acknowledged factors beyond their own control. The VHTs mentioned that even in rare situations when people received their (VHTs) advice to visit a health facility for any ailment, they still needed money and transport to enable access to a health facility.
Respondent 1: Many people fail to access health care because they do not have money, others might have the money but fail to reach the health facility, maybe the boda bodas that usually take them are not available.
Respondent 5: Once, I went to someone’s home and found that the woman was at the point of delivering a child. I told her to go to a health centre. She explained that she did not have any money to get there … This showed that our only difficulty was finding a way to get to the health centre. (FGD with VHTs)
The reflections captured in the discussion with VHTs above show that accessing a health facility for rural people requires much more than giving advice and information about the existence of a service at a health facility as is currently done by the VHTs.