According to the World Health Organization, at least 400 million people still lack access to one or more essential health services. Universal health coverage (UHC) is a goal adopted by the United Nations to ensure that everyone can access quality health services, be safeguarded from public health risks and be protected from impoverishment caused by illness.
Central to achieving universal health coverage for any population is the level of commitment of the national government. We took the opportunity to speak with Dr George Upenytho, Uganda’s Ministry of Health’s Commissioner of Community Health, to hear his perspective on the role of community health and primary healthcare in achieving universal health coverage for all Ugandans.
In February 2023, Uganda developed its first five-year National Community Health Strategy (NCHS). Tell us about this strategy and how you envision it bridging the health service delivery gap?
In pursuit of Uganda Vision 2040, the health sector aims to ensure a healthy and productive population which effectively contributes to socio-economic growth. This can be achieved through the scale up of primary healthcare, a universal approach to health that aims to promote health and wellbeing by focusing on the equitable delivery of services and targeted interventions which address people’s needs and preferences along the continuum of care.
In 2001, Uganda’s Ministry of Health established the Village Health Teams (VHT) strategy, an innovative approach to empower communities to participate in improving their own health as well as strengthen the delivery of health services at both the community and household levels. A key recommendation from a 2014–2015 assessment of this strategy was to develop a robust case for investment in community health to ensure that the community health programme can continue to contribute to prevention and control of disease at the community level through community engagement and behaviour change education on disease prevention, and community-based hygiene and sanitation interventions.
Why is a strengthened community health system important for primary healthcare in Uganda?
Community-level health promotion and disease prevention programmes have become national priorities for the health sector. By 2025, we aim to enhance capacity to provide integrated and quality health services including preventive and promotional measures at all levels of care, particularly within the community. The National Community Health Strategy (NCHS) aims to align stakeholders toward delivering community-level health services, strengthening community health systems and leveraging existing policies, guidelines, and experiences; with a view of leaving no one behind.
VHTs, as part of Uganda’s community health workforce, can actively engage in promoting key family care practices and disease prevention. They also play a crucial role in integrated community case management (iCCM), providing treatment for common childhood illnesses among children under five years. The strength of the community health system relies on the extent and effectiveness of linkages between political, technical, and administrative functions. VHTs can also collaborate with various community resource persons, including local council leaders, religious leaders and teachers, facilitating coordination and harmonisation between sectors.
How can innovation help to make progress towards the UHC 2030 targets?
According to the World Health Organization’s 2015 report, investing in community health programming is one of the ‘best buys’ in healthcare. This has resulted in positive returns as high as ten to one from increased productivity from a healthier population and creating short-term cost savings in other parts of the health system. Broader economic benefits reported include increased income generation and poverty alleviation — as would be the case for investments in community health programmes in Uganda.
Despite this favourable return on investment and the role of community health programming in driving the attainment of UHC, community health is yet to attract optimal attention and prioritisation. Public expenditure on the health sector remains low at approximately seven percent of the national budget (below the Abuja Declaration target of 15 percent for health). Furthermore, a large proportion of the national health budget continues to go to the hospitals located in towns rather than peripheral units and health centres at the lower units. A report undertaken by the Ministry of Health in 2020, showed that community health service financing shrunk in real terms when looking at the availability of commodities at health facilities in 2019-20 compared with in 2018-19 and was far below the Health Sector Development Plan target of 75 percent. A community health investment case, yet to be developed, would help mitigate against some of the existing financial shortfalls.
What should the global community and partners do to ensure that community health initiatives are adequately supported?
Stakeholder support should align with national plans, strategies and policies, adopting a ‘one team-one plan’ system to support the design of people-centred interventions, catalyse resourcing for primary healthcare, and building resilient heath systems that withstand future public health threats.
We must also recognise that the private sector plays an important role in the delivery of primary healthcare. Engaging the private sector can contribute towards ensuring systems, workforce and resources are sustainable and aligned towards the singular ambition of Health for All. It is also important to leverage innovative approaches to primary healthcare such as digital health, service delivery and financing mechanisms, including blended-financing and demand-side financing mechanisms.
How and where can organisations like Malaria Consortium add value to Uganda’s vision?
Understanding Uganda’s priorities and vision for achieving UHC is integral to ensuring that investment and resources can be integrated efficiently and effectively and can be built on in a sustainable and impactful way. The long history that Malaria Consortium has working alongside us in Uganda has helped drive forward innovations and provide evidence to inform decision making that is aligned to the country’s strategy.
The Ministry of Health is committed to strengthening its community-level service delivery as one of the ways to achieve UHC. As part of this process, an electronic community health information system (eCHIS) will be implemented for use by VHTs with modules including iCCM; maternal, newborn and child health; family planning; health promotion, antenatal and postnatal care; nutrition and immunisation. Also included will be stock monitoring and VHT supervision dashboards.
VHTS will use the eCHIS as digital job aid as they deliver services across nine districts including Koboko, Maracha, Lira, Oyam, Nebbi, Ntungamo, Lamwo, Buikwe and Amuru. In areas where the eCHIS is deployed, we have observed improvements in service delivery at the community level by over 30 percent. With Malaria Consortium’s expertise and reach, it would give us much delight to see them in a position to step in to support this initiative in all the districts where they implement their activities.
Reagan Wamajji is Malaria Consortium’s Policy & Advocacy Manager
Read more in our technical brief, Paving the Way for Universal Health Coverage
Read more in our capacity statement, Integrated Community Case Management