A mountain to climb: often – too often – the “last mile” is a health worker’s extra mile
Michelline Uwimana treks through the mountainous terrain of rural Uganda come rain or shine. The walk is gruelling, but the alternative – communities going without vital healthcare – would be worse.
One morning in late July, Michelline Uwimana of Kisoro, Uganda, neat in a navy blue, skirted nurse’s uniform and good sturdy sneakers, carried the rudiments of a health clinic into the mountains. The sky above Mukungu was scumbled with dust, the vegetation anaemic from lack of rain, and the weather so blustery along the ridges that Uwimana cut a figure in italics, wedging forward into the wind.
Had it been April instead of July, it would have been wet instead of windy, the paths gummed with mud, but the nurse, her backpack, her vaccine cooler box, and armful of soft cardboard patient files would have been here just the same.
If the hamlets on these remote slopes have decent immunisation rates, it’s only because the health workers of Bukimbiri Health Centre III make a determined point of conducting door-to-door outreach sessions each month.
Uganda’s immunisation coverage has taken a hit in recent years, with the numbers of completely unimmunised “zero-dose children” growing between 2015 and 2020, according to Gavi estimates, and the numbers of children reached with the third dose of the diphtheria, pertussis and tetanus-containing (DTP) vaccine, the conventional yardstick for immunisation coverage as a whole, in 2020 and 2021 stalling below 2016 levels.
If the hamlets on these remote slopes have decent immunisation rates, Uwimana says, it’s only because the health workers of Bukimbiri Health Centre III – located a good distance away on swampy flat land edging Lake Mutanda, but still the nearest clinic – make a determined point of conducting door-to-door outreach sessions each month.
Repetition does not make the commute any easier. Transportation is the thorniest challenge of Uwimana’s working life, her 16-year nursing career. “Our facility has only one motorcycle,” she says. Even when the terrain allows for the vehicle’s use, the journey is a hassle and a risk. “It’s really a challenge. Sometimes you find two health workers with all the logistics and the one who is driving the motorcycle, we are all seated on the motorcycle, and it’s really uncomfortable.” Recently, fuel prices have spiked beyond the health centre’s anticipation, and Uwimana and her colleagues find themselves fronting the cash for a full tank. “It’s not lovely for us,” she acknowledges.
The fact is that in Kisoro, like in many other places, the health system’s last mile is too routinely a health worker’s extra mile. It’s not how it ought to be, Uwimana acknowledges, but the immediate alternative – fair-weather healthcare for the most vulnerable – is unconscionable.
The soil in Mukungu is poor, she explains, and so are the people. The rains here can be aggressive enough to wipe a crop right off a slope, sluicing waste and excrement into downhill reservoirs, imperilling the drinking water. On nutritional assessment days, she says, most kids here register as underweight.
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Many Mukungu villagers are Batwa, an ethnic group once more commonly described as pygmy, isolated as much by a ruptured history as by ungenerous geography. Decades ago, Uganda’s Batwa were evicted from the forests that were their homes and livelihoods, turning them into conservation refugees. Today, Batwa people in southwest Uganda remain at disproportionate risk from disease – under-five mortality rates are much higher than in the population at large, and life expectancy among adults is lower. Access is an issue for most: according to a 2021 report, 69% of Batwa people surveyed said that the nearest clinic was more than 5km away.
“When I deliver a live baby, I’m motivated. When I treat a case, and that person becomes fine, I get motivated,” she says. There are targets to meet, and she pursues them competitively. “I really work hard.”
That’s true of people in Mukungu, for whom the journey down to the health centre is arduous. It costs twice – once in money and again in time – and can be made abruptly impossible by bad weather or a shortage of cash. “We get mothers who come from Mukungu to Bukimbiri Health Centre when they are pregnant, and they wait for one full month, just sleeping at the health centre, waiting for their labour.” They spend that time, she says, “dormant” – not working, still consuming, mortgaging an already insecure financial future for the confidence of access to obstetric care.
So Michelline Uwimana puts on her trainers, shoulders her vaccine cooler bag and makes herself a mobile buffer against the hazards of inequality; a patch, if not a solution. She takes the role seriously. “If a child misses [a vaccination] in a village, we call the local council, we call the Village Health Teams: ‘So-and-so is not accessing services. What happened?’ As the public health nurse, mostly, that’s my big responsibility. I make sure we follow them up, that we really complete.”
The energy for the work comes from the work itself. “When I deliver a live baby, I’m motivated. When I treat a case, and that person becomes fine, I get motivated,” she says. There are targets to meet, and she pursues them competitively. “I really work hard.”
It’s evening before she starts her way back across the hill ridges, towards Bukimbiri and the end of her day. It’ll be late when she gets home, but that’s not unusual. The Mukungu villages aren’t Uwimana’s only hard-to-reach community. Just this week, she and two colleagues boarded a boat across Lake Mutanda to a large island, then hiked a steep trail to the island’s brow, to visit a community of firewood-sellers. At an improvised health camp in the mud-walled church, she examined a baby who had been running a fever for two straight weeks. Cases like these have to wait until the health care system moors up – which sometimes requires Uwimana to pay the boatman out of pocket.
Uwimana is clear on this much: these are the “sacrifices” she and her colleagues make to do their jobs. She’s not a martyr: the sacrifices as unwelcome as they are unnecessary, and she isn’t after applause. Her aspirations are robustly practical: “I recommend that public health nurses and workers be given more facilitation, be given means of transport, so the work is done well,” she says.