Kampala — ABISAAGI Rusoke, a mother of ten, has lost four of her children, albeit to disparate causes. She is also a grandmother of 12 children and has observed up-close, the high infant mortality in rural Uganda.
Rusoke is not alone. Official reports indicate that 70,000 to 100,000 people die of malaria per year, or about 270 per day, making the disease the leading killer in the country.
Rusoke, 66, has lived in Lusalira village, Mubende district for the last 28 years and she says in the last three years, "every child who gets malaria dies." According to her, the local health facility, Lusalira Clinic, hardly has health workers, let alone drugs.
The Ministry of Health and Malaria Consortium, with support from donor Canadian International Development Agency (CIDA), WHO and UNICEF are implementing a new approach to manage the common child-killer diseases; malaria, pneumonia and diarrhoea.
The approach, called integrated Community Case Management (iCCM), is funded by CIDA in Hoima, Kiboga, Kibaale, Buliisa, Masindi and Kyenjojo. Malaria Consortium gives support to the health ministry to implement the programme in partnership with the districts. This is complemented by a grant from the Bill and Melinda Gates Foundation. It is anticipated that the programme would have moved to 33% of all districts within five years.
By using village teams, the programme uses local people, respected and trusted by the community. The teams will rely on professional health workers for supervision and medicine supplies.
"These teams get basic skills to identify illnesses, prevent, and or treat them. They will be trained in identifying signs of malaria, pneumonia and diarrhoea and if the children are not very sick, they will dispense drugs supplied to them. We are using them to treat sick children so that they do not get worse. But if the children are very sick, they will be referred to the nearest health facility," says Dr Godfrey Magumba, the Uganda Country Director of Malaria Consortium.
The programme stakeholder meeting held recently was concerned that motivation and inadequate supervision could undermine such strategies. Research presented by Dr Flavia Mpanga-Kaggwa, a health specialist at UNICEF, revealed that the key motivating factors for volunteers to join village teams were financial reward and recognition.
However, the assistant commissioner in charge of health promotion, Paul Kaggwa, said there was no money to pay all the teams. "We are still working on performance-related incentives. We are studying other models like in Madagascar, where communities do contribute financially. But we are also looking to donors and the finance ministry for support."
The stakeholder analysis presented by Dr. Karin Källander, programme coordinator for the Gates foundation and the programme, identifies supervision of community medicine distributors as a major concern. It requires planning, money, quality supervisors and the supervisors should also be monitored.
In his Buso-Lulagala village in Gombe sub-county, Wakiso district, Kabanda has watched, with mixed feelings, community health workers carry out their duties. "They are good at mobilising the community for HIV tests and immunisation. However, some of them give out (anti-malaria) tablets, but do not do any follow-up. The medicines may expire but are kept right in the house till the next patient comes," he said.
Dr. Mpanga-Kaggwa'also cites supervision, monitoring and evaluation; documentation and measuring of impact; effective linkage with the health system; effective planning and coordination as priorities for the system.
Village health teams and community medicine distributors are not necessarily attached to the health system, like health centres I or II, although health workers from the nearest health centres oversee them. But the whole strategy, according Paul Kaggwa, is to have an all-embracing system where district and local leadership is involved. That, with guidelines on who to train, continuous training, replenishing of drugs, refresher courses and referral of patients, should help ensure quality of the service. "We want the structure to work for all health programmes, other than each having parallel programmes," says Kaggwa.
But the structure needs to be backed by data management. Principal Epidemiologist Dr Rachel Seruyange points out the importance of "gathering health data, analysing and using it for decision-making, resource allocation, planning and policy formulation for success in all efforts to improve health care".
There are challenges such as the formation of new districts which has taken away health facilities from pre-existing districts and hence distort the structure.
Martin Olowo Oteba, the Assistant Commissioner, in charge of pharmacy in the health ministry, also points out a technical issue: "Questions are already being asked how we can prescribe, through village teams, expensive drugs without being sure that we are treating malaria."
Dan Kabanda observes: "At our health centre III, you have to describe the way you feel, and then they will treat you according to the description you make." There are no tests, laboratory or otherwise.
Oteba sees a supply chain structure for drugs that links health facility stores, health workers and households, going back and forth, but also interspersed with returns, referrals and fresh orders for medicines.
The challenges notwithstanding, iCCM is headed the right way as the government and other stakeholders work to overcome structural bottlenecks in effective health delivery. Dr Kallander noted this key stakeholder finding: "This is the means for bringing health services closer to the community.
This intervention is a good way of reaching the communities with treatment of common killer diseases among children. It has a potential to reduce child mortality rate up to 30%".