Musinguzi Laban Kashaija, Turinawe Emmanueil Benon, Rwemisisi Jude T, de Vries Daniel H, Mafigiri David K, Muhangi Denis, de Groot Marije, Katamba Achilles, Pool Robert
Department of Social Work and Social Administration, Makerere University, P.O. Box 7062, Kampala, Uganda.
Amsterdam Institute of Social Science Research, AISSR, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV, Amsterdam, Netherlands.
Hum Resour Health. 2017 Jan 11;15(1):4. doi: 10.1186/s12960-016-0177-9.
Community-based programmes, particularly community health workers (CHWs), have been portrayed as a cost-effective alternative to the shortage of health workers in low-income countries. Usually, literature emphasises how easily CHWs link and connect communities to formal health care services. There is little evidence in Uganda to support or dispute such claims. Drawing from linking social capital framework, this paper examines the claim that village health teams (VHTs), as an example of CHWs, link and connect communities with formal health care services.
Data were collected through ethnographic fieldwork undertaken as part of a larger research program in Luwero District, Uganda, between 2012 and 2014. The main methods of data collection were participant observation in events organised by VHTs. In addition, a total of 91 in-depth interviews and 42 focus group discussions (FGD) were conducted with adult community members as part of the larger project. After preliminary analysis of the data, we conducted an additional six in-depth interviews and three FGD with VHTs and four FGD with community members on the role of VHTs. Key informant interviews were conducted with local government staff, health workers, local leaders, and NGO staff with health programs in Luwero. Thematic analysis was used during data analysis.
The ability of VHTs to link communities with formal health care was affected by the stakeholders' perception of their roles. Community members perceive VHTs as working for and under instructions of "others", which makes them powerless in the formal health care system. One of the challenges associated with VHTs' linking roles is support from the government and formal health care providers. Formal health care providers perceived VHTs as interested in special recognition for their services yet they are not "experts". For some health workers, the introduction of VHTs is seen as a ploy by the government to control people and hide its inability to provide health services. Having received training and initial support from an NGO, VHTs suffered transition failure from NGO to the formal public health care structure. As a result, VHTs are entangled in power relations that affect their role of linking community members with formal health care services. We also found that factors such as lack of money for treatment, poor transport networks, the attitudes of health workers and the existence of multiple health care systems, all factors that hinder access to formal health care, cannot be addressed by the VHTs.
As linking social capital framework shows, for VHTs to effectively act as links between the community and formal health care and harness the resources that exist in institutions beyond the community, it is important to take into account the power relationships embedded in vertical relationships and forge a partnership between public health providers and the communities they serve. This will ensure strengthened partnerships and the improved capacity of local people to leverage resources embedded in vertical power networks.
基于社区的项目，尤其是社区卫生工作者，被视为低收入国家解决卫生工作者短缺问题的一种经济有效的替代方案。通常，文献强调社区卫生工作者能多么轻松地将社区与正规医疗服务联系起来。在乌干达，几乎没有证据支持或反驳这些说法。本文借鉴社会资本联系框架，以村卫生队（作为社区卫生工作者的一个例子）为例，研究其将社区与正规医疗服务联系起来的说法。
数据收集于2012年至2014年在乌干达卢韦罗区开展的一项更大规模研究项目的民族志田野调查。数据收集的主要方法是参与观察村卫生队组织的活动。此外，作为该更大项目的一部分，还与成年社区成员进行了总共91次深入访谈和42次焦点小组讨论。在对数据进行初步分析后，我们又与村卫生队进行了6次深入访谈和3次焦点小组讨论，并与社区成员进行了4次关于村卫生队作用的焦点小组讨论。还与当地政府工作人员、卫生工作者、地方领导人和在卢韦罗开展卫生项目的非政府组织工作人员进行了关键信息访谈。数据分析过程中采用了主题分析法。
村卫生队将社区与正规医疗服务联系起来的能力受到利益相关者对其角色认知的影响。社区成员认为村卫生队是为“他人”工作并听从其指示，这使得他们在正规医疗系统中无权无势。与村卫生队联系角色相关的挑战之一是政府和正规医疗服务提供者的支持。正规医疗服务提供者认为村卫生队对其服务的特殊认可感兴趣，但他们不是“专家”。对一些卫生工作者来说，村卫生队的引入被视为政府控制民众并掩盖其无法提供卫生服务能力的策略。在接受了一个非政府组织的培训和初步支持后，村卫生队在从非政府组织向正规公共卫生保健结构的过渡中失败了。结果，村卫生队陷入了权力关系之中，这影响了他们将社区成员与正规医疗服务联系起来的角色。我们还发现，诸如缺乏治疗资金、交通网络不佳、卫生工作者的态度以及多种卫生保健系统的存在等所有阻碍获得正规医疗服务的因素，村卫生队都无法解决。
正如社会资本联系框架所示，为了使村卫生队有效地充当社区与正规医疗服务之间的联系，并利用社区之外机构中存在的资源，重要的是要考虑垂直关系中所固有的权力关系，并在公共卫生服务提供者与其服务的社区之间建立伙伴关系。这将确保加强伙伴关系，并提高当地民众利用垂直权力网络中所蕴含资源的能力。
