Why Investments in Frontline Health Workers Matter - Preventing needless deaths through trusted healthcare relationships

By Samalie Kitooleko, Nurse In-Charge of Uganda Rheumatic Heart Disease Registry and Belinda Ngongo, Global Health Leaders Fellow, Public Health Institute

This blog was originally posted at the Global Health Council blog. 

It all started when I nursed a young female university student with Rheumatic Heart Disease (RHD). As a teen she had received a mechanical valve replacement requiring her to take an anticoagulant daily, which she did without fail. During her third year, she became pregnant and stopped taking her anticoagulant medication without medical consultation, thinking she was looking out for the best interest of her baby. Several days later, she lost her baby and I saw her passing away on her graduation day, suffering from valve thrombosis, a condition which could have easily been prevented if she hadn't defaulted her medication. In that moment, I vowed to never see another woman die of preventable complications. No one should die because they lack appropriate healthcare knowledge in today’s world.

I began counselling women intending to undergo mechanical valve replacement, educating them about necessary medications and lifestyle changes. Initially, I dealt with very few women however in 2013, when the RHD register was established in Uganda, the numbers become rather overwhelming so I developed novel ways of addressing them at scale, forming a patient support group on WhatsApp. Patients used this platform as a way to pose questions to the broader group and it became an incredible group to share knowledge with.

As a nurse in Uganda, I spend most of my time caring for patients affected with chronic cardiovascular illnesses such as congenital heart disease, myocardial infarction, and rheumatic heart disease (RHD). My typical day starts at 7 AM and ends at 9 PM. During this time, my work involves updating the RHD registry with new patients, those that have died and identifying those that are lost to follow-up. I then spend the day in the outpatient clinic counseling patients, enrolling patients in the RHD registry, and administering Benzathine Penicillin injections in the Coumadin clinic which I run concurrently. Due to limited staff, I also work closely with patients affected by all other noncommunicable diseases including diabetes, hypertension and cancer. I’m proud to provide a patient-centered approach during delivery of care, spending time getting to know and following up with the women I serve. The Case for Frontline Health Workers Like Samalie, there are many other frontline health workers (FHWs) in developing countries committed to caring for patients and pressured to work long hours under poor conditions in deplorable infrastructure and limited sundries. To make matters worse, their hard work is rarely recognized and they are compensated poorly for their incessant efforts to improve health and wellbeing of populations. The exodus of FHWs from the health sector can be attributed to some of the current chaotic and constrained environment. The pursuit of non-health related employment opportunities compromises the quality of care already aggravated by the major shortage of staff in most health care facilities.  It is therefore important that we answer these questions - Why do we need to care about FHWs? What do we need to do to retain, satisfy and support FHWs?

• Undoubtedly, to improve service delivery and lower staff turnover, appropriate compensation and recognition of frontlines’ efforts is imperative for increased motivation and morale. Such recognition can be in form of being acknowledged as best performers of a given period, promotions and better wages and including them in critical global health and health systems conversations. FHWs need to be well equipped with knowledge and skills and understand trends and strategies to accelerate the implementation of appropriate interventions to effectively combat disease. They also need to be provided with ongoing training and career advancement opportunities in order to ensure persistent delivery of quality services.
• One stumbling block in the health systems arises from the fact that FHWs have limited decision making power and their potential contributions are hindered by certain rules and regulations. For example, in Uganda nurses are now allowed to provide a prescription but are limited to making a nursing diagnosis and care plan. Policies need to be reviewed and where appropriate influence of frontline should to be augmented and task shifting implemented. Promising models of how FHWs are managing NCDs can be found here.
• The gender lens aspect is important to ponder when alluding to FHWs, especially since it is recognized that 75% of global health work is done by women. Women deliver the bulk of health care worldwide in the formal and informal sectors. Most FHWs are women. They usually work under pressure to balance family and societal responsibilities in resource - limited settings, leaving their lives and those of their families at stake. Despite working tirelessly to restore the health of other people, on many occasions’ health and life of FHWs are not carted and likewise despite their important contribution to global health and the dependence on women as providers of health care, according to a recent report women have very few leadership positions in the health systems.
• FHWs play a vital role in initiating the referral process through timely and comprehensive communication, provide ongoing support and care to patients and their families. Referral of patients may affect treatment and continuity of care and can affect clinical outcomes and costs thus clear guidance from facility staff is critical. They need to be part of the referral process.

In sum, FHWs deserve to be recognized for their dedicated and generous contribution towards the health and wellbeing of the populations they serve. In return, they also need to be healthy in all aspects, valued, respected, supported, protected, compensated adequately and work in appropriate.

This week, WHA70 gives us an opportunity to further elevate the voice of FHWs to encourage further investment and support for those saving lives on the frontline. Join us in helping to elevate their voice!

Learn More: “The Case for Frontline Health Workers in Addressing Non-Communicable Diseases Globally.” By IntraHealth RHD Action