By: Enock Musungwini, MPH, MBA
The Zimbabwe Village Health Worker programme began in the 1980s, soon after independence, with the aim of enhancing access to primary health care (PHC) services in line with the then Alma Ata Declaration (1978) and now the Astana Declaration (2018) and Universal Health Coverage (UHC 2030). According to the World Health Organisation, “primary health care is a whole-of-society approach to health that aims at ensuring the highest possible level of health and well-being and their equitable distribution by focusing on people’s needs and as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation, and palliative care, and as close as feasible to people’s everyday environment.”. The concept of PHC was conceived at the 1978 International Conference on Primary Health Care, which brought together 134 countries and 67 international organisations and was held in Alma Ata, Kazakhstan, and became known as the “Alma Ata Declaration”. It was the Alma-Ata conference that defined and granted international recognition to the concept of primary health care as a public health strategy to achieve the World Health Organization’s Health for All by Year 2000 goal.
A key pillar and an element of PHC, community participation is described by Rifkin et al. (1988) as a social process whereby communities with shared needs actively work together to identify these needs, find solutions, and establish mechanisms to meet their health goals. Community participation means the community is actively consulted on health provision, has a say in the delivery of health services by the local clinic, and has representation in the governance affairs of the clinic through the Health Centre Committees (HCCs). A study by Loewenson et al. (2004) in Zimbabwe showed that community participation had a positive impact on the quality of health services delivered by clinics because health facilities that had functional health centre committees with community representation had more resources (financial and staff), fewer drug stockouts, and a higher coverage of primary health care services in the community catchment area. Village health workers are a vital cog in PHC as they help to promote community participation in health services and clinic affairs and make communities able to demand health services. With the effect of health worker brain drain in Zimbabwe, the importance of village health workers is even more critical, hence this opinion piece and the proposed recommendations.
The World Health Organisation describes community health workers (also referred to as village health workers) as health care providers who live in the community they serve and usually have a lower level of formal education and training than nurses and doctors but provide a vital link between the community and the health facilities. The importance of village health workers (VHWs) cannot be overemphasised, and many national, regional, and international organisations echoed similar sentiments, chief among them the World Health Organisation, the Health Systems Global Thematic Working Group (TWG) on community health workers, and Health Information for All (HIFA). A 2021 report by the United Nations Children’s Fund (UNICEF) put forward that village health workers form a critical backbone of Zimbabwe’s public health system, especially in rural areas, and this was even evidenced during the COVID-19 pandemic.
The village health workers in Zimbabwe are involved in various activities and roles as they provide the vital link between the community and health facilities. These include health promotion and education on many common conditions, support in disease surveillance and reporting, screening and referral of clients and patients to the nearest health facility, and treatment of minor ailments. They are also involved in identifying TB suspects and making referrals for further investigations, community mobilisation and awareness, coordinating health services, activities, and programmes with different stakeholders, providing health support services at the community level, and giving regular feedback and updates to the nurses and other healthcare workers at health facilities. They compile and submit reports on activities they will have undertaken in the community, including the number of clients reached, major problems encountered, and even administering emergency medicines at the household level.
The current set-up, support, and approach for supporting village health worker programmes, although doing better, requires revamping, strengthening, and more support in many facets. This opinion piece proffers some recommendations, including the need to standardise and rationalise all allowances and incentives for village health workers so that there is no disparity in allowances and incentives across districts, provinces, and countrywide. If there are partners supporting village health workers in some districts and provinces with additional incentives and allowances on top of what is offered to all VHWs, then there should be mechanisms to ensure all VHWs benefit.
Another recommendation is that there should be a clear career pathway and progression for village health workers, especially those with a better academic foundation and background that can be combined with work experience to enrol in government nursing, health, and related social care training programmes at colleges and nursing schools. This will serve as a motivating factor for village health workers and will likely curb the problem of brain drain, especially at the primary health level, as those who will be supported to go for training in village health work are more likely to go back to serve their community after training and stay there. This recommendation has been echoed in a publication in Community Health Worker Central, an online community of practise bringing together programmers and experts in community health worker programmes globally.
It is further recommended that the Government of Zimbabwe, through the Ministry of Health, increase the allocation of funding towards the village health worker programmes, and the partners should follow suit so that the programme gets the same recognition and visibility as HIV/AIDS and other well-supported partner programmes. The recent pledge by the Kenyan President, His Excellency William Ruto, to fund the recruitment, equipping, and support of 100 000 village health workers in Kenya as a key step to ensure universal health coverage, among others, is a bold step in the right direction, and Zimbabwe can take steps relative to our context. Adequate training and tools for village health workers will ensure they are well equipped and able to provide correct, up-to-date, and verified information in the communities they serve, which will go a long way in fighting health misinformation and disinformation as advocated by Health Information for All (HIFA), especially with the challenge of health related myths and misconceptions from social media and others.
It is evident that village health workers in Zimbabwe and elsewhere have been a vital cog in sustaining and or ensuring success of primary health care and progress towards universal health coverage. The role of village health workers in Zimbabwe is visible including helping the country towards achieving the United Nations Sustainable Development Goals (SDGs) in particular particularly SDG 3 on good health and wellbeing. In support of this piece, a study by Ndambo et al. (2022) showed that village health workers can facilitate social connectedness, builds trust, decrease stigma, and link communities to essential healthcare and social support at community and house hold level.
Another study by Le Roux et al. (2020) in South Africa has shown that by conducting home visits, village health workers improve maternal and child health service delivery and outcomes, although they recommended that village health workers require more support, which is what this opinion piece is also advocating for. Another study by Kambarami et al. (2016) focusing on Zimbabwe found that village health workers are key in ensuring the delivery of primary health care services, but they recommended that where there is multitasking, there should be more support to enable a facilitative and supportive environment. Busya et al. (2018), in a qualitative study on village health worker experiences in Zimbabwe, found that village health workers build rapport and trust with community members and make HIV/AIDS interventions more acceptable by the community because they hail from the community and are familiar with the dynamics, social, and cultural contexts of those communities.
It is therefore my strong conviction that improved funding, support, and recognition of village health workers, coupled with other recommendations made earlier, will go a long way in motivating and improving the visibility of our hard-working village health workers, who are a backbone to our much-revered primary health care delivery system. This will go a long way in the country’s progress towards universal health coverage and leaving no one behind.
About the author:
Enock Musungwini is a public health practitioner, health management consultant, and development practitioner with research interests in health system strengthening, community health, and social determinants of health. He holds an MSc Public Health degree with a research award from the London School of Hygiene and Tropical Medicine in the UK, a Masters in Business Administration from the Graduate School of Business Leadership at Midlands State University, a BSc Hons Psychology, and many other qualifications. He was awarded the 2022 Country Representative of the Year by Health Information for All (HIFA) for his role in continuously advocating for increased access to correct and verified health information in Zimbabwe and the regions through various platforms and professional networks. He is a member of various professional associations, networks, and organisations in Zimbabwe, Africa, and internationally, namely the Africa Evidence Network Reference Group committee member (South Africa), the International Government Science Advice Africa chapter steering committee member (INGSA-Africa), the Consortium of Universities for Global Health member (CUGH USA), the Health Systems Global Thematic Working Group on Community Health Workers, the Royal Society for Tropical Medicine and Hygiene (UK), and the Alumni Ambassador for the London School of Hygiene and Tropical Medicine (UK). He can be reached at firstname.lastname@example.org. While the author acknowledged and referenced articles from other organisations and individuals, the views expressed in this opinion piece, as well as any errors or omissions, are the sole responsibility of the author.