1. Uganda: Public Health and
Education in the Community
Nikki Rasmussen
University of Wisconsin – Madison
Dietetics and Life Sciences Communications
2. What is public health?
It is "the science and art of preventing disease, prolonging life and
promoting health through organized efforts and informed choices of
society, organizations, public and private, communities and
individuals."
3. “People pay for survival. They do
not pay to be healthy.”
Survival
Fishing
Food
Labor
Large family
Health
Malaria
Multivitamins
Education
Contraceptives
4. The Health
Care System
• National hospital
• Regional hospital
• District hospital
• Health center IV
• Health center III
• Health center II
• Health center I/VHTs
6. VHTs vs. Health Center II,
III, and IV
VHTs are volunteers
They know the community
best
Specifically trained and can
make referrals
Clinics and labs
Nurses, midwives, clinical
officers, lab technicians,
medical doctors, etc.
#1 goal is maternal health
8. VHTs vs. Transportation
Stationed in every village
Know their community and its members very well
Especially trained to help with mobilization and
education
Can recommend how to get the help the village
needs without going to the doctors
“Bring the health center to the community”
9. Transportation: Various
Costs
Boda-boda ride to a health center in Mukono:
2,000 UGX = 0.70 USD
Monthly salary of a primary school teacher in Lweza:
4300,000 UGX = 149.57 USD
One tomato in Mukono:
1,000 UGX = 0.35 USD
18. “Health is not treating. If you are
treating patients, then you’ve failed the
health system. Health facilities that are
full of patients are failing the health
system.”
– Dr. Tulwagaruka John
Editor's Notes
What is public health?
It’s the science and art of preventing disease, prolonging life, and promoting health.
At UW-Madison, we have the Village Health Project. It’s a student, nonprofit organization formed in 2006 by students who went on the same trip. Their missions is: To support sustainable projects that improve sanitation, nutrition, and education in rural Uganda; and to facilitate collaboration between University of Wisconsin-Madison students, the Lweza community, and other organizations in working for this cause.
In Uganda, at the forefront are the village health teams, or VHTs.
One thing that I found to be the most interesting and surprising when coming to Uganda and exploring the culture, health, agriculture, and just everyday life is that everything is interconnected. It seems pretty obvious at first and I know it’s true in the US, but it was a gratifying experience to see it outside of the US and outside my own element. I learned that most health issues are issues because of “non-health” reasons. The people in Uganda have the knowledge, many just lack the resources. I found cultural barriers to be the most surprising, but it’s true even in the US. How many Americans are against evolution or vaccines? Just the same, how many Ugandans are against birth control or any other pharmaceutical drug? We have people in the US who believe that their faith and praying will save them from illness and the same is true in Uganda.
We learned from Dr. Tulwagaruka John that “people pay for survival, not for health” or they simply refuse to take action for external reasons. It’s not that they lack the knowledge, there are just other factors (value predispositions) that play into their decision making. (Ho, S. S., Brossard, D., & Schedufele, D. A. (2008) Effects of value predispositiions, mass media use, and knowledge on public attitudes toward embryonic stem cell research. International Journal of Public Opinion Research, 20(2), 171-192.)
Looking at these two lists, each item corresponds to the ordered item on the other list. They have one common link. What are they?
Mosquito nets
Money/time
Where to send your children or how use your time
Family planning
This is Harriet and Francis. They are the VHT of Lweza village in the Mukono district, the same village we stayed for our trip.
The first day we met them, we had the opportunity to go around the community with them and delivery bags of goods to the elderly. The bags had sugar, iodized salt, soap, and Vaseline. My group met a woman who was over 100 years old!
VHTS = Trained volunteers in villages facilitating health promotion, service delivery, community participation, and empowerment and education.
There are some clear differences between the VHTs and the other health centers: pay, equipment, training, etc. However, they share challenges and have a common goal: overall promotion of health for the community in which they serve. And their weapon of choice is education.
In urban areas, the biggest challenge when trying to address the health of the community is sanitation. While we were there, we had a chance to see one of the most impoverished and unsanitary slums in all of Uganda. It was a very eye opening experience. I unfortunately do not have any photographs of it, but I was given a description of very poor living conditions; a mix of trash and human waste in the sewers, people’s homes, and in public places; and no running water.
In rural areas, transportation is a huge challenge. We were able to visit a health center II and III in rural areas. The two were located in the Masinidi district and shared the community they served. We were fortunate to drive from one to the other, but the distance between the two would’ve made quite the haul even on a boda boda (similar to a moped). The roads were not paved and were only dirt and sand. It was dry and the sand would get everywhere. While Lweza village is in a rural setting, I was able to find out that a boda boda ride from Lweza to the health center IV in Mukono is 2,000 shillings round-trip.
These challenges are evident according to the doctors we spoke to, but what does it mean for the community and the VHTs?
So, how do the VHTs play into this?
As I said, the VHTs are rained volunteers in villages facilitating health promotion, service delivery, community participation, and empowerment and education. They’re the link between the health centers and the community. They’re like the mobilized workers the health centers can utilize to educate communities they cannot reach otherwise. In a small way, VHTs are just a small solution to the bigger problem at hand.
I was unable to get the price of a boda-boda ride in Masindi, and I have the price of tomatoes on there just for a comparison, but I think these numbers speak some powerful words.
Before we left for our trip, we were told about some of the tough choices that people had to make on a day to day basis. Let’s pretend you are that teacher, who makes less than $150 a month. You have four children to care for. How difficult do you think it is to make it through the month given daily living expenses: food, transportation, schooling, etc. What if one of your children falls ill? Just fact alone that you have a job puts you above a good majority of the population. As shown on the previous slide, people face different challenges even based on location. What might take a 10-15 minute boda-boda ride might be an hour or two walk for someone else.
As a prime example, when we went to visit Mwanamugimu, the nutrition rehabilitation unit in Mulago, we met parents, grandmothers, aunts, and other care takers who’d been there for days or even weeks to months. So, imagine having to choose between getting your sick child to the hospital leaving your other three children and your home for longer than a day because it takes that long just to get to the hospital or doing your best to care of your sick child yourself while tending to your daily chores at home.
Small things like transportation, something we in the US may take for granted, has huge ramifications. Even in the US we see transportation as an issue, but not nearly to the same magnitude as Uganda. So you can see here why the VHT’s are so important and how they help combat the challenge of transportation, especially in rural areas
Like I said, the VHTs and local health centers collaborate with each other to educate the communities. While we were at the health center III, we were given a chance to see the types of education sessions they conduct in the community. These are just two of many pamphlets that were passed around. At the health center III in the Masindi district, they had VHTs and paid staff go out into the community to educate the community in what they called dialogue meetings. Lesson plans include “How to feed a 0-6 month old infant,” “How to breast feed,” “How to make safe drinking water,” “Sanitization and personal hygiene” and “How to may a tippy tap.”
Access to lean drinking water is a major challenge for people even in rural areas. I saw a variety of ways people got their water. In Lweza, there is a public tap near the school that is turned on early in the morning and late in the afternoon. If community members miss it in the morning, then many go to the bohr hole to retrieve water. I had a chance to talk to two primary school teachers, and they told us that they were always sure to boil their water before drinking it. However, that may not be as easy for more impoverished individuals. Firewood is expensive.
When we drove to northern Uganda, I witnessed children collecting water from the Nile River. I asked one boy if his mother boiled the water for them to drink, and he said, “Sometimes. We don’t always have firewood, but she tries.” I asked if he or any of his siblings had gotten ill from drinking unboiled water and he shook his head yes.
These health centers do their very best to reach out to the communities.
Through ATC and and their CLTS project, CLTS trainers, local/community leaders, women’s groups, and VHTs work together to implement positive Water Sanitation and Hygiene (WASH) practices, especially in rural communities where they do not have access to city waters or sewer systems. Sanitation is then managed at a household level and is often done poorly due to lack of knowledge and technology. The objectives of CLTS are:
Acquire knowledge and thorough understanding of CLTS as an approach
Gain and develop CLTS facilitation skills
Develop action plans for introducing and implementing CLTS in areas of operation
Additionally, these health centers (III and II) had demo gardens, and they are exactly as their name implies. The communities members are able to come to the health centers to learn and observe gardening and various techniques. They try to communicate to the community members that their gardens need to be at the house level and should be growing food to make a balanced diet.
Among rural areas especially, “peasant farms” are common. They farm only for their own consumption. Initially, you’d think that it’s great that they are self-sustaining. However, there are diverse ramifications behind the scenes.
One of our last days in Uganda was set aside for our service project learning experience. We had an agriculturist from the Ministry of Agriculture Extension program come and teach us how to make sac garden!
(Explain how to make a sac garden and personal experience working with the community members)
(Explain how to make a sac garden and personal experience working with the community members)
(Explain how to make a sac garden and personal experience working with the community members)
(Explain how to make a sac garden and personal experience working with the community members)
Nearly all of the doctors and medical staff I talked to put a huge emphasis on public health and preventative measures for communicable and non-communicable diseases and a promotion of health. I believe Dr. Tulwagaruke has it spot on: it’s about promotion of healthy lifestyles and preventions of diseases before we have to resort to treatment.
