“One who sees something good must narrate it” – Ugandan proverb
In Uganda, malaria is a leading cause of death, particularly in pregnant women and children. Infections occur throughout the year in most parts of the country and are a heavy burden on the health system. Seeking accessible treatment is an insurmountable challenge for many. In 2021, Malaria Consortium began a phased implementation study and evaluation of seasonal malaria chemoprevention (SMC) as an intervention in Karamoja, a region of north-eastern Uganda where malaria transmission is seasonal. Karamoja also bears the highest burden of malaria incidence in the country. Prior to this, SMC had never been tested in Uganda and results so far have shown that it is feasible, safe and effective in preventing cases of malaria in children under five.
As I settled into my new role as Senior Epidemiologist at Malaria Consortium in the early summer of this year, I wanted to make sure I really, fundamentally, understood the country-level and local contexts in which Malaria Consortium’s SMC projects are implemented and knew the most effective way to do this would be to meet with colleagues in Uganda and witness first-hand Malaria Consortium’s implementation and research activities in practice. I expected my visit to be memorable – and it was, from the magnificent view of the Nile in Jinja, the scenic stretch of the Karamoja mountains to the warm hospitality of my colleagues in the Uganda country office and people in the communities I visited – but more than that, I came away with many lessons.
One thing I found particularly remarkable from a programmatic point of view was the level of community engagement and local ownership of the SMC programme implemented in Karamoja. In the following sections, I share my reflections on how I experienced the SMC programme’s community engagement and ownership in this context and what these imply for the acceptability, effectiveness and sustainability of the programme and similar public health interventions.
The role of VHTs in SMC implementation in the Karamoja region of Uganda
From the first morning in Nabilatuk, one of our SMC implementing districts in Karamoja, I immediately appreciated the value of the Village Health Teams (VHT) in the implementation of SMC. I later learnt that the VHT programme was introduced in Uganda in 2001, as part of efforts to accelerate the linkage of communities with health services, particularly rural and hard-to-reach populations. 1 Broadly, VHTs are responsible for health promotion, health education, community mobilisation for health service utilisation, community case management of common illnesses and follow up, and the distribution of health commodities. The appointment of individual VHT members is done through a community-driven nomination and selection process. To qualify to be a VHT member, a person must meet several criteria, including being above 18 years of age, a village resident, able to read and write in the local language, a good community mobiliser and communicator, a dependable and trustworthy person, interested in health and development and someone willing to work for the community.2
In many ways, the formal involvement of VHTs in a community-based intervention like SMC represents a good example of fostering local participation and ownership at the community level. I experienced firsthand the role of VHTs in supporting with key SMC programme components; community engagement, administration of SMC medicines, case management and pharmacovigilance, and monitoring and evaluation. In the context of SMC implementation in Karamoja, community engagement is mainly done through trained ‘peers’, selected from VHTs. SMC medicine distribution is primarily undertaken by VHTs, who also directly observe caregivers in administering the first doses of SMC medicines. VHTs help to engage with the community, building trust and acceptability, particularly for a health programme involving the administration of medicines to children in historically disadvantaged communities – where health system trust and acceptability might be challenging.
Although typically less skilled than facility-based healthcare providers, community-based health workers like VHTs are a valuable resource to instil positive perceptions and community-wide acceptance of health interventions, through delivering health services in ways that reflect local values. As they live in the communities in which they serve, VHTs provide rich information for assessing community perception and informing community engagement. I was glad to witness the VHTs interact with households and caregivers, observing how these interactions reassure community members and help to ensure a smooth SMC campaign.
Through VHTs, the SMC programme taps into an already existing local network of community members to drive forward key components of SMC implementation. This positively impacts not only community participation, but also the sense of community ownership of the intervention – which is vital for programme success and sustainability. Evidence suggests that community ownership of health interventions through the commitment and active involvement of community members or their representatives, is a reliable strategy towards achieving sustainability of health interventions.3 Moreover, implementing SMC, or any other novel interventions within existing community human and material resources may yield cost-saving benefits that can strengthen the sustainability of that intervention.
Strengthening VHT engagement in SMC implementation
While VHTs help to foster community engagement and local ownership of donor-supported health programmes, there are indeed opportunities for strengthening that engagement. The effective deployment of local health workers like VHTs depend on a range of factors, including clarity of roles. It is often found in large scale health programme implementation contexts that if community stakeholders were unclear about their roles and responsibilities in the execution of projects, this resulted in poor performance and implementation outcomes.3 Clarifying roles and responsibilities of the different sections and groups of the target community is vital, right from the early phase of engagement.
Another critical factor in engaging community actors like VHTs and nurturing a sense of community ownership is the contextualisation of their roles and responsibilities. In the Karamoja context of SMC implementation, this could mean optimising SMC messaging and communication by VHTs to be most relevant to the local context – adapting messaging to be contextually accurate and culturally-sensitive – potentially co-creating these at the community level with inputs from VHTs and other community members.
Strengthening the deployment of VHTs to drive key implementation components, such as awareness campaigns and distribution of SMC medicines, requires addressing gaps in training and core competences. VHTs vary in their levels of literacy, SMC knowledge and drug distribution competencies. As such, VHT training and supervision should always consider the varied level of individual VHT members’ competencies and training needs. They should be able to tailor their engagement with the communities they serve, while being capable of responding to concerns that community members might have, such as the safety of SMC medicines. VHTs must be adequately equipped and renumerated to boost their competences, motivation and retention, while increasing community confidence in the quality of services they provide. The importance of clear and sufficient communication and information sharing between VHTs, their supervisors and other higher level health system actors cannot be overemphasised. Other considerations could include engaging VHTs and community members in needs assessment and priority setting exercises and avoiding frequent changes in implementation plans, tools and methods.
The use of existing, community-based health workers, as exemplified by the VHTs in the Karamoja SMC implementation, demonstrates the ways in which their involvement can help foster greater community participation and ownership of health interventions – vital for ensuring the acceptability, effectiveness and sustainability of health programmes. This is particularly so for health programmes implemented in historically disadvantaged settings where there might be low levels of trust and acceptability.
And as the famous Ugandan proverb quoted at the beginning of this piece says, one owes a debt of duty to not only see the good but tell it.
Chuks Nnaji is a Senior Epidemiologist at Malaria Consortium and is based in London.
- Agarwal S, Abuya T, Kintu R, Mwanga D, Obadha M, Pandya S, Warren CE. Understanding community health worker incentive preferences in Uganda using a discrete choice experiment. J Glob Health. 2021 Mar 10;11:07005. doi: 10.7189/jogh.11.07005.
- Sekimpi KD. Report on study of community health workers in Uganda (with focus on village health team strategy- VHT). WHO Global Health Workforce Alliance. Geneva; 2007.
- Ilesanmi OS, Afolabi AA. Sustainability of Donor-Funded Health-Related Programs Beyond the Funding Lifecycle in Africa: A Systematic Review. Cureus. 2022 May 1;14(5):e24643. doi: 10.7759/cureus.24643.