"Even When People Live Just Across the Road...They Won't Go": Community Health Worker Perspectives on Incentivized Delays to Under-Five Care-Seeking in Urban Slums of Kampala, Uganda

"Given the strong ties between VHTs and the formal health sector, it is possible that VHTs could serve to boost families' 'social capital' and ensure they receive high quality care."

Up to two-thirds of Kampala, Uganda's urban population live in informal settlements, or "slums". This study explored the perspectives of volunteer community health workers, called Village Health Teams (VHTs), on why children under five in Kampala's slums are still dying despite living in close proximity to nearby health facilities.

This exploratory qualitative study took place between January and March 2020 in the Rubaga division of Kampala, Uganda. A trained local interviewer talked with 20 VHTs from the slums of Kawaala and Nankulabye parishes to determine their perceptions of barriers to care-seeking and attribution for U5 childhood deaths. Their close proximity to a government-sponsored health centre helps mitigate factors like cost and transportation when evaluating care-seeking behaviours of residents.

The interviews yielded two themes. The first focused on VHTs' perceptions of their role in the community to promote positive health outcomes. Participants listed a variety of duties: sensitising the community before immunisations, administering immunisations, educating families about positive health practices, providing preventative measures such as bed nets, handing out deworming tablets, encouraging families to go to the health centre for treatment, and arranging transportation when necessary. Several VHTs highlighted the important role they play in introducing immunisation campaigns to the community, and how without this step, many people in the community would be unwilling to immunise their children.

The second theme that emerged from the data related to the many ways that prompt care-seeking is disincentivised in the informal settlements. Within this theme, three inter-related sub-themes emerged: (i) disincentives for care-seeking at the health system level (e.g., judgmental attitudes of medical professionals), which can drive (ii) negative beliefs held by families about the health system (reinforcing distrust of the health system that makes preventative health efforts, such as immunisations, difficult to implement in the community), and in turn drive (iii) incentives for alternative health behaviours (e.g., herbal/traditional medicine). These incentivised delays can in turn reinforce health system disincentives. For example, arriving at the health centre only when symptoms are severe can add to the work burden of the health providers and fuel the perceived unprofessional behaviour by healthcare staff.

While discussing opportunities to improve the situation for U5 children living in the slums of Kampala, the VHTs called for strengthening the role of the VHT in the urban slum community. Both willing and well-positioned, VHTs see the opportunity to leverage the existing community health worker network, to extend their role in family education, to serve as patient navigators within the health system, and to mitigate community members' feelings of marginalisation.

Other suggestions include:

• Pursue multi-pronged approaches. Efforts to sensitise community members to increase care-seeking at local facilities are likely to fall short when their experiences at those facilities reinforce negative beliefs and deter care-seeking. At the same time, intervening at the health system level requires significant engagement at the government level, from hospital leadership, and from individual providers.
• Recognise that care-seeking is nested within a broader cultural context. Efforts that genuinely address community members' feelings of marginalisation - to help assuage their distrust of the health system and the broader government - are a necessary precursor to efforts to improve care-seeking at government-run facilities.
• Explore future research and programmatic efforts that incentivise providers to be more responsive to the needs of the economically poor, such as offering results-based financing, leveraging public- and private-sector partnerships, and developing a public healthcare strategy that empowers providers with the tools to offer high-quality care.

In conclusion: "VHTs have enormous potential to foster improvement if given adequate resources, training, and support."