Introduce community nurses at the parish level as part of PDM

Uganda has made tremendous improvements in the health sector; e.g., the under-five mortality has declined from 96 to 43 per 1000 and the maternal mortality from 438 to 335 per 100,000 live births but especially in the case of maternal mortality, this is still a far cry of the Sustainable Development Goals target of under 70 maternal deaths per 100,000 live births. Among under 5 children, leading causes of death the complications of preterm birth, birth asphyxia, newborn infections, pneumonia, diarrhoea and malaria, all of which are preventable or treatable with better access to affordable interventions in health and sanitation. Moreover, today, we are transitioning into a double epidemic of both communicable and non-communicable diseases (NCDs). The situation of NCDs is alarming; e.g., 1 in 4 Ugandan adults has high blood pressure, almost all, not known by the individuals. In a 2021 audit in rural Adjumani, over 60 percent of adult deaths were due hypertensive stroke, alcoholic liver failure, road traffic accidents, cancer and diabetes. All these problems can be reduced by community based interventions that focus on public education and disease prevention, screening and early diagnosis, and early treatment and appropriate referrals.

Uganda is blessed with a large pool of over 70,000 nurses and midwives and annually another over 4,000 newly qualified nurses and midwives are released into the pool. Many remain unemployed yet an investment into these nurses and retooling them as community nurses can significantly transform the health sector.

I propose the improving community health Services with the Deployment of Nurses as community nurses in each parish (as part of the Parish Development Model [PDM]) as innovative strategy to transform Uganda’s Health Sector. 

The PDM is the new Government development program conceived under the National Development Plan III that aims to deliver a package of services at the Parish. The objective is to deepen the decentralization process; improve household incomes; enable inclusive, sustainable, balanced and equitable socio-economic transformation; and increase accountability at local levels. It  presents a unique opportunity to improve and enhance community based healthcare at the household level in Uganda.

Uganda has a total of 10,595 parishes. Health services at the parish are overseen by the untrained Village Health Workers yet we have over 10,000 unemployed nurses. I propose that Ministries of Public Service and Local Government create two Posts of Community Nurse/Midwife in each parish linked and reporting to the Health Centre III at the sub-county. Recruitment can be phased.

The nurses will be expected to work directly with the community in homes. They will:

Liaise with the records assistant at the HC III to maintain a health register of all the residents of the parish. Lead health promotion and disease prevention.  Oversee maternal and child health services including infant, child and maternal vaccinations, child growth and development monitoring, family planning, antenatal care and other reproductive health services.  Lead school health services of all school children in the parish

Screen and conduct early detection of NCDs including annual checks for high blood pressure, diabetes, cancer in persons 40 years or older.

Initiate and ensure appropriate emergency referrals and care to higher level health services work with the Health Assistants to ensure proper sanitation and a clean environment in the parish.

The estimated annual wage cost is about 186 billion. Non-wage costs include equipment that can be replaced every 5 years. Also, the supplies budget at the HC III will need to increase.   Community members will have direct contact and receive health services from trained personnel right in the home.

Linking this to changes already proposed at the HC III (e.g., planned deployment of Medical Officers at the HC III), the country will greatly prevent disease, reduce the consequences and costs of late diagnosis and injuries, the costs of self-medication including the spiraling antimicrobial resistance and emergence of antibiotic resistant super germs, extortion by quacks and improve livelihood and the outcomes of healthcare services. Beyond the immediate health service benefits, the proposed intervention will provide employment for 21,000 nurses/midwives, paying taxes and supporting families.   

Dr Richard Idro, associate professor of Paediatrics and Child Health, Makerere University, Consultant Paediatrician, Mulago hospital.