The proposed roll out of the Community Health Extension Worker (CHEW) programme is
due to take place in Uganda in 2018 at an estimated cost of US$102 million over a
Although this is a welcome move towards supporting the existing Village Health Team
(VHTs) cadre of community health workers, several challenges and potential solutions
are raised in this article.
Uncertainties remain around potential tensions that may arise between current VHTs
and the new CHEWs, the logistical implementation of the programme and financial sustainability.
Prior to roll out of the CHEW programme, greater attention must be given to the practical,
logistical and financial challenges of the proposed strategy, taking a health systems
strengthening approach towards implementation.
Uganda faces a significant shortage of trained healthcare professionals, especially
in the public sector and rural areas.1 As a result, the Ministry of Health (MoH) have
supported delivery of the Village Health Team (VHT) model since 2001.2 VHTs are lay
people, working in a voluntary capacity, acting as a link between the formal health
sector and their communities.3 They are given basic training on major health issues,
including childhood diarrhoea, malaria and pneumonia, and play a role in disease surveillance
through activities such as data collection and reporting.3
Although the exact selection process for those wishing to become a VHT member varies
depending on location, individuals commonly undergo selection starting in their own
communities. After a period of sensitisation and consensus building among local stakeholders,
a popular vote is held. To be selected as a VHT member, an individual must meet several
criteria. He or she must be ‘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, someone interested in health and development and someone willing
to work for the community’.4 5 Unlike formally trained healthcare professionals, such
as doctors and nurses who are based at health facilities, VHT members are based in
the communities in which they live and serve. This means the roles they play and the
expectations that community members have of them are likely to be different.
Yet, despite reported successes of VHTs in improving and promoting health at a community
level, challenges remain regarding their motivation, remuneration, training and retention.2
6 To try and address these issues, the Ugandan MoH has announced the planned roll
out of a Community Health Extension Worker (CHEW) programme.7Modelled on the Ethiopian
community health strategy, CHEWs will be paid, full-time health workers, with an O-level
standard of education, aged between 18 and 35 and fluent in both local language and
English.3 The initial aim of the MoH is to train and deploy 15 000 CHEWs across 7500
parishes nationally by the end of 2020.3 VHTs who will not be absorbed into the CHEW
system will remain in their communities and continue to voluntarily provide health
services, supported by CHEWs.3 Given the impending implementation of the programme,
this article outlines some of the challenges we anticipate will arise based on our
extensive work with VHTs over the past decade.
First, it is important to anticipate the potential tensions that may occur. The strict
CHEW selection criteria, including the upper age limit of 35, will rule out many members
of the community who have previously worked as VHTs. This could lead to feelings of
animosity between new CHEWs and existing VHTs, who may feel overlooked and neglected,
resulting in strained relationships. Furthermore, with the introduction of a paid
cadre of community-based health workers, questions have been raised regarding whether
VHTs will continue to be willing to volunteer their time. A study by Mbugua and colleagues,
found that discrepancies in pay between volunteer and salaried community health workers
in Kenya resulted in poor levels of motivation and higher levels of attrition in the
unpaid cadre.8 Those responsible for implementing the CHEW policy should therefore
consider strategies that have been shown to increase community health worker performance
and motivation, in order to ensure existing VHTs do not feel undervalued.9 10 This
might include the provision of tangible incentives, such as equipment and supplies,
but also ensuring VHTs ideas, interests and relationships are duly considered so that
tensions between the two cadres are minimised. Whichever incentives are chosen, they
must be responsive to the needs of VHTs.
Additionally, there is potential for tensions to arise between CHEWs and community
members. In a study by Musinguzi and colleagues, it was noted that community members
in rural Uganda were distrusting of paid health workers, since they were concerned
they might be profiting from referrals to health centres.11 Working closely with community
members so that they understand the role of CHEWs will therefore be important.
The second challenge lies in the practical and logistical implementation of the programme.
In the Mukono District where we work, there are nine parishes in the Ntenjeru subcounty
alone, with a total population of approximately 550 000 people.12 Given the MoH have
proposed allocating two CHEWs per parish, covering this number of households between
18 CHEWs will be extremely difficult, especially since they will spend just 60% of
their time in the community and the remaining 40% in health facilities.3 Despite initially
proposing to dissolve the VHT programme entirely and replace it with the CHEW model,
the Ugandan MoH have now stated that CHEWs will supervise VHTs who will remain active
in the community.13 Utilising both cares of health workers would make sense, given
the logistical challenges of covering such a large population over a vast area, however,
as previously mentioned, consideration must be given to the power dynamics and resulting
conflicts that might arise.
It is also important to note the different, but complimentary roles that CHEWs and
VHTs might play. Compared with the selection criteria for CHEWs, which largely focuses
on the pre-service level of education, the selection criteria for VHTs places greater
emphasis on community engagement, communication, trust and respect. Additionally,
unlike CHEWs, VHTs are specifically selected by their own communities, meaning they
could continue to play important roles in community mobilisation and advocacy.
The third challenge lies in the financial costs and sustainability of the programme.
Implementing the CHEW strategy will cost an estimated US$102 million over a 5-year
period, representing approximately 10% of the MoHs budget at present.7 Since the Ugandan
public health system is already underfunded,14 introducing this paid cadre of CHEWs
may not be possible without the support of external donors or a restructuring of the
budget.15 Furthermore, although this proposed investment into community health must
be welcomed, appropriate long-term funding into the health system at every level should
also be encouraged so that this intervention is not approached in a vertical manner,
but rather contributes to a wider health systems strengthening approach.
Finally, CHEWs and VHTs cannot be regarded as a panacea to address the dire shortage
of health professionals seen across all cadres. Continued investment into the recruitment
and training of other cadres of health workers must occur simultaneously. Second,
it is important to note that the complex and multifaceted challenges facing community
level healthcare in Uganda extend beyond the recruitment, training and deployment
of CHEWs. As such CHEWs should not be seen as a ‘silver-bullet’ solution, but rather
as one piece of a complex, multifaceted puzzle, which requires concurrent strengthening
of other key areas known to influence community health.16 Taking this holistic approach
will help to ensure that strong foundations are in place to maximise the potential
benefits of the CHEW strategy.
In conclusion, prior to roll out of the CHEW programme, greater attention must be
given to the practical, logistical and financial challenges of the proposed strategy.
If these issues can be addressed and the relationship between CHEWs and VHTs harmonised,
this initiative could represent an exciting opportunity to improve the attention and
support given to community-based healthcare in Uganda.