It is a cool, still morning in Seeta Nazigo Village, Central Uganda. The heavy seasonal rains have ceased and the sun begins to glint through the cracked windowpanes of the local health center’s Anti-Retroviral Clinic. Fourteen community health workers are packed into the small room.
Community health workers, who have formed the bedrock of Uganda’s primary health system since 2001, are lay persons acting in a voluntary capacity to deliver vital health services in their respective villages. These services range from recognizing and treating common childhood illnesses, such as malaria and pneumonia, to providing maternal health services where otherwise none would be available. Now they’ll be facing Covid-19, a disease that has countries with highly developed health care systems scrambling to keep up.
Allan Namanda and Rebecca Hamala, community health worker supervisors in their early 20s, stand at the front of the clinic. As I talked with Rebecca by WhatsApp later that day to discuss some of the training material I had provided them, she described the scene in the clinic.
Allan begins the meeting by saying, “My dear community health workers, I am here to train you about coronavirus so we are prepared for what is coming.”
A battery-powered projector whirs in the middle of the room as it casts a presentation onto a white bedsheet draped across a wall of the clinic. Allan methodically transitions through each slide of the presentation, covering information from what coronavirus is to how it spreads and what community health workers will need to do over the coming days and months to prepare their villages for what could become a long, deadly fight.
Uganda’s first case of coronavirus was announced by Jane Aceng, Uganda’s minister of health, on March 21. This led Yoweri Museveni, the country’s president, to issue a nationwide order to close all schools and places of worship for 30 days, and to stop all travel in and out of the country with the hope that such measures will slow the spread of disease. These preventive measures are certainly a good start, but they may not be enough, especially given the systemic and deep-rooted challenges facing Uganda’s public health system.
What the Ugandan government spends on health care is one of the lowest in the world. The World Bank estimated its per capita spending on health at 6% of its gross domestic product, one-third that of the United States. Because of this chronic underfunding of the health system, Uganda has just 55 intensive care beds for its more than 42 million people. Of these, 20 have no ventilatory capacity and only one-third are part of the public health system. And these beds can be found only in the regional and national referral hospitals, located in major urban hubs.
Accessing these hospitals is challenging and expensive for those living in remote and rural areas, such as Seeta Nazigo. During the rainy season, the dirt roads are often impassable and crowded public transport to Kampala, the nation’s capital, can cost almost a week’s wage. And if someone does reach one of these hospitals, they are often required to make “informal payments” in order to receive care. These out-of-pocket payments can mean financial catastrophe for many.
The importance of community health workers is greater now than ever. For many people in remote and rural regions of Uganda, and sub-Saharan African more generally, they will be the first — and possibly only — line of defense against coronavirus. Last Mile Health — a U.S.-Liberian nongovernmental organization supporting 3,500 community health workers — has recognized this and developed a framework suggesting key roles for these workers in the prevention, detection, and response to this pandemic.
“For me, I have lived with disease my whole life. Malaria, TB, HIV — we have seen it all,” Margaret, a 45-year-old community health worker, subsistence farmer, and mother of three children who serves more than 200 people, told me via WhatsApp. “I do not fear disease. But right now we don’t have any treatment for this coronavirus so we need to do as much prevention as possible.”
Margaret is right: Prevention will be key to protecting the lives of people across low-income countries where health systems are weak. Over the past fortnight, community health workers have been constructing hand-washing stations, known locally as “tippy-taps,” at important communal locations and in people’s homes. Tippy-taps, which are made out of locally sourced materials such as tree branches, rope, and recycled jerry cans filled with liquid soap, are just one example of the resourcefulness and innovation that is occurring in response to the current crisis.
Increasing ownership of low-cost smartphones and cellular coverage has also enabled community health workers to connect with each other remotely to share best practices, up-to-date policy changes, and messages of encouragement — something which is especially important at this time. By accessing the World Health Organization’s WhatsApp group, community health workers have also been able to access timely and accurate information which they have relayed to local community members in order to dispel unfounded rumors or misinformation that are being spread at a time of heightened anxiety.
Community health workers are also faced with local challenges. Although social distancing is being encouraged by the government, that’s a luxury many people cannot afford. Some families live 10 people to a room. It will also be difficult for the government to enforce the ban on religious gatherings, since these are highly important social events which the community place great emphasis on. So community health workers have been brainstorming with local leaders and key stakeholders to devise pragmatic solutions to social distancing. It is these locally generated solutions that are likely to be most successful, rather than top-down authoritarian approaches.
As community health workers continue their preparations in earnest, it is vital that the government and nongovernmental organizations support them. This will include ensuring they are provided with testing kits and appropriate protective equipment.
“I would be lying if I said I wasn’t scared. I think all of us have that small bit of fear,” Allan shared with me. “But we will always be there for those who need us most. That is our duty.”
The health of a nation and continent lies in the hands of these brave, courageous individuals.
James O’Donovan is a physician and researcher in global health at the University of Oxford and Omni Med, a Ugandan nongovernmental organization.