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EAST AFRICA: Improving Local Access to Family Planning

KAMPALA, Feb 22 2010 (IPS) - A severe shortage of highly-trained medical personnel is one of the many challenges to providing health care at a local level across Africa. Task shifting – permitting less-specialised people to carry out certain functions – is one proposal to over come this, but it is meeting resistance.

Primary health care in Uganda is increasingly entrusted to community-based workers: is the strategy safe? Credit:  Charles Akena/IRIN

Primary health care in Uganda is increasingly entrusted to community-based workers: is the strategy safe? Credit: Charles Akena/IRIN

In Uganda, community health workers may soon be allowed to administer injectable contraceptives in a strategy geared towards meeting family planning needs. The same plan has so far been rejected by Kenya’s medical establishment.

In both Kenya and Uganda, thousands of trained nurses are either unemployed, or are working in sectors not related to their profession, Kenyan government records show the country has more than 8,000 unemployed nurses – at the same time as the public health system reports a shortfall of 44,000 nurses.

“We are concerned about the need for more healthcare workers in our healthcare facilities,” says Dr Francis Kimani, Kenya’s Director of Medical Services, explaining that financial constraints have led to positions remaining unfilled.

“But the government has implemented an arrangement known as Economic Stimulus Program, through which 4,200 nurses have already been interviewed and will be employed by the month of March this year. In January, we recruited 400 nurses and they will be posted to various workstations any time now.”

Community Health

If it is adopted, community-based delivery of injectable contraceptives will be the latest component in Uganda's growing system of primary health care. Healthcare professionals are already supplemented at the local level by 'Village Health Teams’.

"These are people working on voluntary basis, and my experience shows that they are very effective in delivering primary healthcare services," says national health services director Dr Kenya-Mugisha Nathan.

Keep injections in trained hands?

But, Kimani says, the government will not allow community-based workers to take on a function previously reserved for nurses, despite the acute shortage of trained professionals in healthcare facilities countrywide.

Kimani argues that allowing non-professionals to take charge of giving contraceptive injections could compromise service delivery; infection through improper sterilisation is one risk, failing to recognise when the contraceptive is contraindicated is another.

But non-governmental organisations working in the health sector argue that evidence suggests the best and cheapest method of effectively providing healthcare at the local level is by shifting tasks to community health workers.

This is what informed a pilot study by the secretariat of the East, Central and Southern African Health Community (ECSA HC) to find out whether local health workers, who already distribute condoms and birth control pills, could also give injections safely.

The pilot in Uganda’s Nakasongola district demonstrated that trained community health workers, supervised by a more highly-trained professional, can handle the procedure.

The findings tally with trials in parts of Asia. Early results from a similar ongoing pilot study in Tharaka district in Kenya show similar positive results.

Success in Kenya too

Patrick Maina survived the dreaded multi-drug resistant tuberculosis. He attributes his recovery to home-based carers.

"It was not easy to go through the two year treatment that involved an injection every day, over 20 pills to swallow on daily basis, and observing a particular diet at the same time," says Maina.

"They gave me daily visits to encourage me never to give up, and to remind me of the importance of taking the drugs on time. When they were not available, at least one would call to persuade me to continue with the dose, which had terrible side effects," he said.

Uganda considering the shift

Uganda’s Director of Health Services, Dr Kenya-Mugisha Nathan, is receptive to the proposal.

“As professionals, we can only make a decision that is informed by evidence. And evidence is based on research findings. We are in the process of studying the ECSA HC report before we present a policy statement to our policy makers for implementation,” said Dr Nathan.

He argues that training the community health workers on how to administer injectable contraceptives is precisely how to avoid compromising services. “When we include the word training, it means equipping an individual with necessary skills to perform a given duty,” he says.

Should the practice be approved in Uganda, he says that the community health workers will be monitored and supervised at all stages to minimise the chance of errors.

Learn from experience

However, Kenyan government officials base their resistance on past experience with task-shifting in a related area.

Traditional birth attendants, who are the first people called to assist rural and low-income pregnant women in Kenya, were given training to help them identify complications early and refer these cases to better-equipped health centres and personnel.

In many cases, however, these birth attendants instead used the fact of their training to present themselves as qualified doctors, opting to try and handle complications themselves and putting mothers and children at great risk by referring them to hospitals desperately late.

“As much as we appreciate the good work being done by community health workers, we must as well learn from experience,” says Dr Josephine Kibaru of the Kenya’s Ministry of Public Health and Sanitation. “We trusted the traditional birth attendants so much, and as a result, they ended up putting women’s lives at greater risks instead of saving their lives.”

She however noted that the government of Kenya recognises the community as the first level of healthcare. “Our ministries of health have established a community based strategy to provide guidance for the delivery of particular services at community levels,” she said.

Officials from the ECSA Health Community say that they will continue advocating for a legislation to be implemented in countries that look at it as a positive move.

“This does not mean that we are sidelining Kenya. No. Kenya is still an ECSA member state, and we have several other things we do together in order to improve health delivery in the country,” said Dr. Odiyo Odongo, the ECSA Health Community Manager for Family and Reproductive Health Program.

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