Day 13: VHTs & TBAs

After our visits ended at HC3 the day before, we were ready to complete our understanding of the remaining health center tiers that rural communities had access to. HC2s are community-based healthcare centers aimed at being within reach of everyone who might need access to care. There is a push to upgrade more HC2s to HC3s by improving their infrastructure and equipment capabilities. In the meantime, HC2s serve as a baseline center that allows patients to be within reach of basic medical services. At Prisons (name of the HC) HC2, we saw a vaccination room, STI/STD clinics, teenage counseling, and antenatal clinic. The building was no bigger than the size of a street soccer court. We were particularly interested in the fact that this HC2 had a dedicated teenage STI/STD counseling center - essentially a false wall to give teenagers privacy - so that they are able to seek out treatment without fear of judgment or repercussions from the community. This was inspiring for us because we have heard stories of teenagers just letting their conditions fester and avoid seeking help because of those very fears.

VHTs

If HC2s were the veins, then HC1s - a hierarchical term for the Village Health Teams (VHTs) would be the capillaries, stretching out to individual members of the community. Interestingly, these roles are voluntary. VHTs are selected on the basis of moral character, their ability to rally the community, and basic literacy in the language of use in their community. They work closely with the village leadership and the local health centers. In the village we visited, for example, there were 3 VHTs serving the entire village. One was a young, 18 year-old boy who was liked by the elderlies and could reach out to them; Another was a man who had links with families in the village; Lastly, we were talking to a female business owner who was running a Chapati store for livelihood aside from her tasks as a VHT.

When asked about what was the biggest challenge VHTs faced, she said it was transportation. Mothers who needed to visit a hospital were not able to find transportation or afford one. This would be especially bad for emergency situations. VHTs sometimes fork out money from their one pockets to show that they care for the health of community members and maintain respect. In this way, community members are more likely to cooperate with her when she goes around to advise the community on the latest health recommendations. Patients also complained of poor treatment from healthcare staff from health centers. Our VHT had a strong mediating role in fostering trust between community members and the government health centers.

I found it very respectable that the VHT was keeping tabs on how many mothers in the village were carrying a child or had delivered. As she walked us to the HC2 health center, she casually pointed us to some mothers and greeted them. She knew how many months in labor these mothers were. She would know if a mother delivered in their own houses or with a Traditional Birth Attendant (TBA) against her recommendation to go to a government hospital. All in all, we left the village with a strong sense of respect to the duty and dedication of the VHTs.

TBAs

We also had the unique opportunity of seeing the work of TBAs. This is because TBAs are not recognized by the government. In fact, mothers were advised against going to TBAs because of a lack of regulation for their services. TBAs are not governmentally-certified. Their skill levels vary greatly. One point of contention is that the Ugandan government used to laud TBAs for their work in a time when healthcare services were in shortage. The TBA we interviewed with even had a handful of certificates that showed that she received training from government hospitals.

The VHT brought us to meet the TBA. When asked about why she maintains a relationship with TBAs even though she advised against them, she said something quotable: “When you want to effect a change, you have to start from an angle of empathy.”. She also used the example of working with sex workers under that principle. That was how we went on a 5-minute van ride to a islamic house which housed the TBA’s clients. Surprisingly, the house was only slightly smaller than the HC2 at Prisons. It also boasted a large backyard where there were trees and plants - some of which were herbal medicines that the TBA used to treat her patients. As we stepped into the house, we saw 3 recently-delivered babies. There was a mother in labor in a separate room at the back of the house. Stepping beyond the door in the back room, we came to the backyard where more mothers were strolling around, some with their kids. The entire compound was larger than the Prisons HC2 at its current state: before its ongoing construction was to be completed and fully upgraded to a HC3.

We conducted most of our interviews under an avocado tree outside the front of the house. It was a picturesque, serene setting with the sound of children in the background. Mothers glanced over in our direction as strange visitors. The TBA sat on the ground before us as we posed our questions and she told her story: She was a TBA as her grandmother was. As a child, she would pick herbs for her grandmother and assist in taking care of her grandmother’s clients. She even showed us the leaves from some herbs she would use. In those days there were not as many restrictions.

She also showed us a comprehensive booklet of the clients that she took care of. It was impressive - it contained the highest education level, job, name, village of origin, among a host of other information about her clients. One could see it was something she was proud of - she was careful to wrap the book around with a plastic wrap to keep it safe from the elements. She pointed at a particular entry and we could see that someone came as far as from Kampala to obtain her services as a birth attendant. In the month of July-August, she delivered 74 babies - that was more than what we observed in Bugweri HC4, which was equipped with a surgical unit. She did everything from antenatal care to delivery, but was sure to tell us that she referred any problem patients speedily - one of the key reasons TBAs were frowned upon is that they are blamed for the delay in proper care that mothers would otherwise receive if they were to visit a hospital directly. All in all, we learnt about the level of trust the community places in TBAs, and wondered to ourselves what their role could be in our mission to improve maternal care.