Sub-Saharan Africa - Prosperity, Peace and Development Co-operation Inquiry
January 2020
1. Executive summary
1.1. This submission provides evidence of the significance of a partnership approach to strengthen primary health care system resilience in Uganda, sub-Saharan Africa.
1.2. The need to strengthen primary health care system resilience in sub-Saharan Africa builds on the health for all mandate (which is a global mandate) as a precursor to wealth and prosperity.
1.3. The evidence draws on a ten-year institutional partnership project between the School of Social Sciences at Nottingham Trent University (NTU) and Makerere School of Public Health, Uganda (MakSPH) led by Dr Linda Gibson and Dr David Musoke (Uganda). We are happy to present further evidence if so required.
1.4. Our partnership is underpinned by core principles of shared ownership which has enabled our success in enhancing existing research environments at both institutions and delivering significant research grant capture and impact on primary health system strengthening.
1.5. We have developed seven core principles over the years of our partnership based on our experiences, learnings and challenges. These principles include: Investment in people and communities, Trust, Reciprocity, Cultural Appropriateness, Sustaining Activities, Transparency and Global thinking.
1.6. Drawing on our recent programme on strengthening the community health workers programme in a semi-rural district in Uganda, our submission presents seven recommendations with evidence to inform how the partnership between the UK and AU can be sustained to promote shared prosperity. These recommendations are underpinned by our seven principles of shared ownership.
2. About the authors
2.1. Dr Linda Gibson: is an Associate Professor in Public Health. Current roles include postgraduate teaching and supervision, research and consultancy. Linda set up the MA Public Health programme at NTU with colleagues and successfully led it for 10 years (2008-2018). Linda is passionate about the promotion of health and upstream interventions to improve health systems at individual, community and global levels. She is an experienced international researcher and has led several research projects in Europe, Uganda, Kenya, Burkina Faso, Nigeria and the UK.
Linda Gibson is the UK lead for the very successful Institutional Partnership with Makerere University’s School of Public Health in Uganda. The Department for International Development (DfID) through Tropical Health Education Trust (THET) and the EU Commission (Horizon 2020) funds their current research activities.
Linda’s research focus is on health promotion and health systems, primary care services and community development and engagement, through the lens of the social determinants of health, and a socio-ecological model of health.
2.2. Deborah Ikhile is an early career researcher supporting Linda Gibson on several international projects. She provides research and project management support to all activities carried out by the NTU-MakSPH partnership. Her first involvement in the partnership projects was through volunteering in 2015 during her MA Public Health programme at NTU.
She is also completing her doctoral research, which explores how the primary health care system in a semi-rural community in Uganda can be strengthened to promote breast cancer detection.
2.3. This submission has been supported by Rich Pickford from Nottingham Civic Exchange, NTUs civic think tank.
3. About NTU-MakSPH partnership
3.1. The NTU-MakSPH partnership is based on a shared ownership approach and focuses on three core strands: mobility, knowledge exchange and social enterprise.
3.2. At the start of the partnership in 2009, the partnership leads at both institution applied for series of grants from external funders to ‘kick-off’ the partnership which were unsuccessful. This led both leads to shift their focus from applying for grants towards establishing a partnership that is not reliant on periodic external funding. The aim of the partnership is to support the shared vision and strategic mission of both institutions, one of which is Connecting Globally. This creates a platform to deliver research activities which are aligned to real-world needs and challenges. We have now come to articulate this as a shared ownership approach.
3.3. Our shared ownership approach appreciates the value of local knowledge and expertise and reverse knowledge innovation (i.e. what NTU has learnt working with our Uganda partners). The partnership has focused on establishing its core strands of mobility and knowledge exchange through University visits and seminar presentations. The social enterprise strand was and still remains underdeveloped.
3.4. Over the years, we have developed seven core principles guiding our shared ownership approach: Investment in people and communities, Trust, Reciprocity, Cultural Appropriateness, Sustaining Activities, Transparency and Global thinking.
3.5. The partnership secured its first successful grant from DFID through THET in 2012, a Health Partnership start-up grant. This has led to a series of successful grants from DFID and other funders to support strengthening primary health care resilience in Uganda.
4. Strengthening the community health workers project in Uganda
4.1. The “strengthening the community health workers (CHWs) programme” project was active between 2012 to 2017 and focused on the CHWs programme in Ssisa sub-county, Wakiso district, Uganda.
4.2. Community Health Workers , referred to as Village Health Teams (VHTs) in Uganda are volunteer workers who support the primary health care system in Uganda. They are selected by their own community to promote the health and wellbeing of all village members. They carry out a range of health promotion activities across the spectrum of health, water and sanitation, improvement of maternal and child health. Every village is mandated to have 4 VHTs. Whereas all are involved in health promotion activities, 2 of the VHTs per village are specifically involved in treatment of children suffering from malaria, diarrhoea and pneumonia under the integrated community case management of childhood illnesses (iCCM) programme. The other 2 are therefore involved in all other responsibilities of VHTs including health education, household visiting, mobilization of the community for public health interventions, and other health promotion activities.
4.3. From the Uganda National Housing and Population Census 2014, Ssisa sub-county has a population of 93,238 and 23,992 households. This implies that each of the currently available VHTs in the area serves approximately 125 households far beyond the recommended 20 to 30 households.
4.4. Our focus on CHWs is because CHWs are integral to primary health care delivery as they act as a link between the formal health care system and communities. They have also been identified globally as integral for achieving SDG 3 mandate of ‘Health for all’ through primary health system strengthening. Thus, strengthening this cadre of health workers in sub-Saharan Africa is crucial for catalysing strong primary health care systems.
4.5. Between 2014 and 2015, the NTU-MakSPH partnership conducted a baseline study which revealed that CHWs in Ssisa sub-county did not perform optimally due to lack of continuous training, poor supervision and inadequate motivation packages. These have implications for the primary health care system. The sub-county has a semi-rural setting with 62 villages. Although there should have been at least 248 CHWs during the baseline studies, there were 191 were available. Other CHWs had dropped due to:
- Lack of trainings
- Lack of transportation means to move within the sub-county
- Irregular supervision
- Lack of motivation.
4.6. Twenty-four CHW VHT coordinators reported transport as the main challenge in performing the duties they perform which include: delivering supplies to VHTs, compiling and collecting monthly reports from CHWs, and delivering reports to the health facilities.
4.7. Dr Linda Gibson and her colleagues at MakSPH designed and led a successful project from 2015 to 2017 to provide a coherent, structured and standardised training, supervision and motivation package in Ssisa sub-county Wakiso.
5. Recommendations to the United Kingdom - African Union Partnership towards attainment of their 2063 agenda
5.1. Our partnership has been about working collaboratively with colleagues in Uganda to identify the primary health care system challenges and co-produce workable solutions with them.
5.2. To achieve the UK and AU’s partnership agenda to strengthen resilience, we recommend a shared ownership approach enshrined in the following principles:
5.3. Recommendation one: The partnership should invest in people and communities to enhance resilience
Investments in people and the communities where we work is at the heart of any partnership. From our CHWs project, we show how our partnership has invested in building the capacities of CHWs through:
- Training of 301 CHWs from Ssisa sub-county; the 191 and new 100 community volunteers who became upgraded to CHWs. The training content for the 301 CHWs was divided into two: general disease management training on water, sanitation and hygiene; health promotion and home visiting; maternal and child health; communicable and non-communicable diseases. Additionally, 75 of the CHWs were trained in integrated community case management of childhood illnesses (iCCM) focusing on Rapid Diagnostic Tests (RDTs) for diagnosis and management of malaria; diagnosis and management of diarrhoea and pneumonia; and mTrac reporting. In addition, all 24 supervisors in the sub-county were also trained.
- Provision of non-financial incentives: t-shirts, which greatly improved CHWs recognition; gum boots and umbrellas to support with their activities during rainy periods, and certificate of participation in the training as a means of acknowledgement both for the training and their roles as CHWs. The CHWs trained in iCCM also received solar chargers to provide electricity supply in case of treatment at night since there is erratic supply of electricity in the sub-county. This solar equipment also served as a source of income for CHWs.
- Enhanced supervision of CHWs by training supervisors and providing 3 motorcycles to the supervisors to enable them carry out their job more effectively. All 24 supervisors reported competence in their ability to carry out their roles.
One supervisor and one CHW were supported as a result of their involvement in the project to visit the UK (in 2017 and 2019). The supervisor got the opportunity to present at the THET conference in London, October 2017 while the CHW presented at the International Health Congress in Oxford, June 2019. This has enabled sets of people who would not normally get together to be able to learn from each other such as CHWs coming into the UK.
At a community level, our project investment in the primary health care system is demonstrated through provision of infrastructure to support research and primary health care service delivery in the sub-county evidenced by:
- Number of people receiving health education from the CHWs increased from 1327 (Male: 582; Female: 745) at baseline to 127,011 (Male:56415; Female:70596)
- Number of household visits made by CHWs increased from 369 at baseline to 40,213
- Number of children under 5 treated for malaria, pneumonia and diarrhoea: increased from 78 to 19,387
- Reduction in number of hospital visits: interviews with health centre workers revealed that health workers currently receive less patients (especially children under 5 years of age) which was attributed to the work of the CHWs in treating sick children.
- The 3 project motorcycles greatly enhanced transportation (and continue to do so as they are retained in the community settings) for other aspects of the health system. For instance, the motorcycles were used during mass immunisation of children under 5 years of age against polio in Ssisa sub-county in September 2017. They were also used recently in January 2019 to transport CHWs from one household to another during the national birth registration of children under 5 years in the sub-county.
- The project led to the establishment of a field office in Ssisa sub-county in 2015 that serves as a hub which supports CHWs with supervision activities; trainings for CHWs; and project activities in the sub-county. For instance, the field office facilitated coordination of the Roll Back Malaria programme in the sub-county. It has also served as a hub for local and international visitors and researchers, for example, delegates from Minnesota School of Public Health visited the field office in 2016.
- The project has been regarded as a model by the Ugandan Ministry of Health to inform primary health system strengthening in other sub-counties. Based on the successful project model, Linda was awarded additional funding of £119,712.08 (by THET, grant ID: AGL14 2017-2018) to promote sustainability, scale-up and access in three other sub-counties (Kasanje, Katabi and Bussi) in Wakiso district.
5.4. Recommendation two: Partnership should be built on trust
Trust between partners engenders trust with project communities. We have been able to establish trust with the CHWs/communities through our partnership with MakSPH. We acknowledge that NTU would not have been able to deliver the CHWs project successfully without building trusted relationship with MakSPH. It is obvious from our experience on this project that the communities trust MakSPH and have also transferred the trust to NTU. For example, one CHW said ‘we know this funding is coming to an end, but we always know that you will come back again’.
This trust between the partners has been fundamental to our success in securing additional grants from other funders including:
- British Academy International Partnerships and Mobility grant (2016-2017) on reverse innovation in the sociology of global health and development; Grant value: £8752.
- EU Horizon 2020 Framework Programme (2017-2021): Scaling-up Packages of Interventions for Cardiovascular disease prevention in selected sites in Europe and Sub-Saharan Africa: An implementation research (SPICES Project ID: SEP-210347333); Grant value: £512,082.
- The NTU Global Challenges Research Fund to conduct a baseline survey of non-communicable diseases in Wakiso district; Grant value: £60K.
- Erasmus Plus International Credit Mobility (2018-2020) between NTU and MakSPH; Grant value: £145K.
- Fleming Trust grant (2019 - 2020): Commonwealth Partnerships for Antimicrobial Stewardship; Grant value: £60K.
5.5. Recommendation three: Partnership benefits should be reciprocal
A partnership based on shared ownership should value the importance of actions that are mutually beneficial to both partners. Our shared ownership principles challenge the misconception that the UK has the capacity to ‘address’ growing issues and challenges in sub-Saharan Africa. A notion which has wrongly portrayed sub-Saharan African as a helpless region waiting to be ‘rescued’ by the UK and other countries in the global north.
Our success on the CHWs project, demonstrates that deep and trusted partnership builds and sustains long term collaborations between global North and South Higher Education Institutions (HEIs) which allows sharing and integration of best practice in teaching and research; facilitating collaborative research and development of project opportunities; and raising the internationalisation and modernisation profiles of our institutions.
5.6. Recommendation four: External support is required to sustain partnership activities
Without doubt, our partnership efforts have been sustained through external funding. Although the partnership secured its first successful grant from DFID through THET in 2012, we have been able to sustain and grow stronger in our partnership through our success in securing additional grants from other funders.
It is also important to ensure continuous management/high-level strategic commitment to sustain partnership activities when there are funding gaps. For instance, the cost of the field office in Uganda has been sustained by NTU after the project funding.
5.7. Recommendation five: Partnership activities should be culturally appropriate
Our project was not designed for ‘experts’ in the UK to go and deliver training programmes for CHWs. Through establishing trust with our colleagues in Uganda, we were able to engage with them to ensure that projects are designed and delivered in ways that are appropriate and respectful to their culture. The project was designed such that local health practitioners and staff from MakSPH were responsible for the training component to ensure cultural appropriateness and suitability.
5.8. Recommendation six: Have a MoU to provide a roadmap and enhance transparency of partnership responsibilities
Having a MoU in place which clearly defines responsibilities and expectations from both parties enhances transparency. The NTU-MakSPH partnership has had a series of existing MoUs from 2012-2023 which supports mobility and knowledge exchange around research activities which focus on promoting right to health as a route to development and shared prosperity (as good health equals good wealth).
In addition, we recommend open/honest and continuous communication between both partners and other stakeholders.
5.9. Recommendation seven: Act locally but think globally
The world is a global community; hence any partnership should always consider the global implications of their local actions. A good way of doing this is through knowledge sharing and dissemination. For instance, Dr Linda was invited by THET in 2018 to share the NTU-MakSPH experience and shared ownership principles on a webinar titled “Exploring how partnerships can better practice shared ownership”. The webinar was attended by THET Health Partnership Scheme Award holders from different parts of the world.
Specifically, our project influenced global health discourse and practice as it attracted additional funding from THET (Grant value: £9,955) to organise the first International Symposium on CHWs, 21-23 February 2017 (hosted by the NTU-MakSPH partnership) which attracted over 450 delegates from 22 countries. The theme was Contribution of Community Health Workers in attainment of the Sustainable Development Goals. The output from this symposium was the Kampala Statement (PDF, 217KB). The focus on SDGs was timely due to the timing of the recently launched Sustainable Development Goals (SDGs), as many countries were planning and implementing programmes to achieve these international targets. CHW programmes can be a huge driving force to attain at least seven SDGs namely: SDGs 1 (ending poverty), 2 (ending hunger and ensuring food security), 3 (health and wellbeing), 5 (gender equality), 6 (clean water and sanitation), 10 (reduce inequalities), and 17 (partnerships for global health).
Building on the success of the Kampala symposium, a 2-year CHWs symposium was institutionalised and a second symposium followed in Bangladesh in November, 2019 which focused on the contribution of CHWs in non-communicable diseases management. Again, this was timely as NCDs are the major causes of morbidity and mortality globally. The establishment of these symposium is instrumental to understanding the roles of CHWs in contemporary health and development challenges by sharing best practices, innovative models and lessons learned across various countries.
Dr Linda Gibson and Deborah Ikhile are happy to speak with the Committee to answer any questions they may have on our methods of work and how this partnership has made a difference. We can also facilitate conversations with colleagues in Uganda to share their expertise and knowledge.