Abstract
BackgroundCommunity health worker (CHW) programmes have received much attention since the 1978 Declaration of Alma-Ata, with many initiatives established in developing countries. However, CHW programmes often suffer high attrition once the initial enthusiasm of volunteers wanes. In 2002, Uganda began implementing a national CHW programme called the village health teams (VHTs), but their performance has been poor in many communities. It is argued that poor community involvement in the selection of the CHWs affects their embeddedness in communities and success. The question of how selection can be implemented creatively to sustain CHW programmes has not been sufficiently explored. In this paper, our aim was to examine the process of the introduction of the VHT strategy in one rural community, including the selection of VHT members and how these processes may have influenced their work in relation to the ideals of the natural helper model of health promotion.MethodsAs part of a broader research project, an ethnographic study was carried out in Luwero district. Data collection involved participant observation, 12 focus group discussions (FGDs), 14 in-depth interviews with community members and members of the VHTs and four key informant interviews. Interviews and FGD were recorded, transcribed and coded in NVivo. Emerging themes were further explored and developed using text query searches. Interpretations were confirmed by comparison with findings of other team members.ResultsThe VHT selection process created distrust, damaging the programme’s legitimacy. While the Luwero community initially had high expectations of the programme, local leaders selected VHTs in a way that sidelined the majority of the community’s members. Community members questioned the credentials of those who were selected, not seeing the VHTs as those to whom they would go to for help and support. Resentment grew, and as a result, the ways in which the VHTs operated alienated them further from the community. Without the support of the community, the VHTs soon lost morale and stopped their work.ConclusionAs the natural helper model recommends, in order for CHW programmes to gain and maintain community support, it is necessary to utilize naturally existing informal helping networks by drawing on volunteers already trusted by the people being served. That way, the community will be more inclined to trust the advice of volunteers and offer them support in return, increasing the likelihood of the sustainability of their service in the community.
Highlights
In 1978, world leaders created the Declaration of AlmaAta, which reaffirmed access to health as a fundamental human right and identified primary health care as the key to the attainment of the goal of health for all
Though the use of volunteer community health workers has become popular as a means of achieving health goals in communities in the developing world, there is little consensus on how to address the challenges of attrition that have plagued many Community health worker (CHW) programmes [59,60,61]
Our findings show what may happen when the natural helper model is not used in the selection of CHW volunteers
Summary
In 1978, world leaders created the Declaration of AlmaAta, which reaffirmed access to health as a fundamental human right and identified primary health care as the key to the attainment of the goal of health for all. The 30th anniversary of Alma-Ata coincided with the halfway mark of the United Nations’ Millennium Development Goals, stimulating discussion about the role of primary health care in facilitating the achievement of those goals and led to revitalized calls for use of community health workers (CHWs) as a form of community participation [1]. International health actors promoted CHWs as a means to achieve the World Health Organization’s goal of health access for all by the year 2000 through social interventions for behaviour change [10,11]. Community health worker (CHW) programmes have received much attention since the 1978 Declaration of Alma-Ata, with many initiatives established in developing countries. In 2002, Uganda began implementing a national CHW programme called the village health teams (VHTs), but their performance has been poor in many communities. Our aim was to examine the process of the introduction of the VHT strategy in one rural community, including the selection of VHT members and how these processes may have influenced their work in relation to the ideals of the natural helper model of health promotion
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