A muddy forest clearing shaded by palm trees doubles as a makeshift clinic for Ugandan health worker Simon Kabugo. After unwrapping a blister pack of tablets from a plastic bag strapped to the rack of his rickety bike, he sits down with HIV-positive Tito, who also has TB, to explain how and when to take the life-giving drugs.
Simon is a volunteer from a nearby community in rural central Uganda, trained by global health NGO the African Medical and Research Foundation (AMREF) to give basic medical care to local villagers. In a country with only one doctor per 10,000 people, he fulfils a vital role linking expertise with those who need it most.
Tuberculosis, malaria and HIV/AIDS are big killers in Uganda, explains AMREF’s training director Dr Peter Ngatia, even though when treated together TB and malaria can be cured and HIV/AIDS can be managed effectively.
6,000 skilled-up volunteers like Simon help people in the remote Luwero and Kiboga districts survive, by offering preventative and practical help, from mosquito nets to nutrition advice and counselling, and interpreting symptoms to judge when someone needs to go to the health centre to see a doctor.
“I’m really happy to see the difference treatment has made to this community. Before many people died of TB – now they are getting better,” says Simon.
Two years into the pilot scheme, AMREF reports huge increases in the numbers of people taking HIV and malaria tests, while new TB cases are down 10% a year and deaths from malaria have halved.
Dr Ngatia believes training more volunteers is essential to cover the acute lack of health professionals in rural Uganda, home to 88% of its population but only a third of doctors and around half of nurses and midwives.
“Clinical officers – I call them doctors of Africa – are trained at a fifth of the cost and can do almost 70% of what a doctor would do in a rural environment,” he explains. “Training health workers is saving lives.”
International development group VSO agrees that volunteer health workers must be part of the solution. But it believes they can only do their job effectively if qualified doctors and nurses are also there to provide medical care, as their role is geared more to education than direct treatment.
VSO’s recent report Brain Gain shows that Uganda’s medical schools churn out hundreds of health professionals each year. The problem, according to the organisation’s health officer, Catherine Dawson, is keeping them in the country.
“They do public health degrees and go to South Sudan, where there’s more money, or South Africa and the West, where they can earn a better living and services are better run. People leave the country because they feel happier, or more fulfilled, in other places,” she explains.
“The working conditions in Uganda are very challenging. Health workers are frequently overworked due to staff shortages – one manager told us about a midwife who had worked alone and on-call for five months without a break.”
Health workers surveyed by VSO spoke of their frustration at not being able to work effectively, faced with X-ray machines with blown bulbs, no drugs except Paracetamol and the risk of infection performing bloody procedures without protective gloves and masks.
The situation for nurses was particularly dismal – earning just £50 a month, compared to £300 for a junior doctor. Nurses told researchers their salaries weren’t enough to cover living costs and they felt unappreciated in a country where respect comes with how much you earn.
So what would make them stay?
“Health workers need to be valued for what they do. This isn’t just through fair pay, but by ensuring working conditions enable them to do the job they want and are trained to do – provide good-quality health care to patients,” Ms Dawson says.
VSO is calling on the Ministry of Health and professional associations to work together on measures such as a living wage and better on-going career development.
There’s also a role for countries like the UK, where many Ugandan health workers end up in hospitals and care homes. VSO research reveals the majority of African health workers in Britain would like to return and use their skills to make a difference – but better coordinated UK immigration and development policies are needed to make ‘circular migration’ easier.
As Uganda’s population rockets, its Government faces the challenge of dealing with the increased burden this will place on an already stretched health system. It has committed to allocate 15% of the budget to resolve the medical care crisis, but so far health spending has never exceeded 10%.
Dr Ngatia says Government policy needs to recognise that it’s not only doctors and nurses who can provide services – it can be clinical workers, community health workers or volunteers.
“Health workers at all levels should be able to work with their communities and be recognised by the health system as providing an essential service,” he adds.
Back in the forest clearing, Tito says the support from a health volunteer has made an enormous difference to his family.
“I had given up – but now I’m sure I will stay alive and be able to look after my children. We have a future.”