Health care systems across the globe have always been based on a provider-to-client model. However, the introduction of new technology and products, and the increasing ease of access to information, has caused a shift in how health services can be delivered—placing clients at the center of health care. Various health areas, including sexual and reproductive health and rights (SRHR), have embraced self-care interventions. These methods increase access to and use of essential health services. This is especially important as health care systems become increasingly overburdened, coupled with the urgency to respond to individuals’ and communities’ SRHR needs across all life stages.
This question-and-answer piece highlights the progress and benefits of advancing self-care for SRHR in Uganda, through the lens of the Self-Care Expert Group (SCEG), a technical working group in Uganda.
What is self-care in the context of health care, specifically SRHR? Is this a new and different concept from what individuals know and have practiced over the years?
Dr. Dinah Nakiganda, assistant commissioner for adolescent and school health at the Ministry of Health/co-chair, Self-Care Expert Group (SCEG) in Uganda: Self-care in the form of individual self-awareness, self-testing, and self-management of health care is not new to Uganda; it is an age-old practice where people provide themselves with information, products, or services to maintain, preserve, and promote their health and well-being.
Over the years, new products, information, technology, and other interventions have given self-care a different application, with health areas, including SRHR, taking on the concept and practice. For instance, women could self-test for pregnancy and utilize self-injectable contraceptives, and individuals could self-test for HIV even before the global self-care guidelines were put in place.
How has COVID-19 changed the overall perceptions of self-care, especially as health systems are stretched and lockdowns limit access to traditional services?
Dr. Lillian Sekabembe, deputy country representative of Population Services International, Uganda: The one benefit Uganda and other countries are having now is that the COVID-19 pandemic is forcing individuals to either resurrect, design, adapt, or immediately utilize solutions with the potential to relieve the burden on the already overwhelmed and under-resourced health care system. As such, self-care interventions and their use have been amplified by the effects of the COVID-19 pandemic.
The pandemic has availed the opportunity to appreciate the value of self-care as it has elevated and brought greater control among stakeholders. The value of self-care to improve access to and health care coverage, while reducing dependency on facility-based services and the overburdened health workforce, has been so pronounced during the pandemic and associated lockdown. More so, COVID-19 has revealed unique opportunities to advance self-care, making it more consistently available, safe, effective, affordable, and convenient to those who need it.
In 2019, the WHO launched the Consolidated Guidelines for Self-Care Interventions for SRHR. Just recently, in June 2021, the WHO released revised version 2.1 of the guidelines. How is Uganda leveraging this global framework to advance self-care at the national level?
Dr. Dinah Nakiganda: The launch of the Consolidated Guideline for Self-Care Interventions for Health in June 2019 increased momentum for self-care globally. For Uganda, the introduction of the guideline kick-started the process of structuring self-care and introducing it within the existing health care system. The onset of COVID-19 added urgency to self-care approaches to take pressure off the health care system and facilities to improve access to essential SRHR services.
Uganda adopted a two-pronged approach for developing the self-care guideline. First, the guideline document development itself, and second, the integration of the guideline into the existing health system, also referred to as the implementation of the guideline. The first stage of this process was successfully completed, and the SCEG is in the process of test implementing the draft guideline. The purpose of implementing the guideline is to optimize opportunities for self-care uptake within the existing health care system. The lessons learned can then be applied to finalize and launch the National Guideline for Self-Care Interventions for SRHR. Six task-force teams, namely Quality of Care (QoC), Social Behavioral Chance (SBC), Finance, Human Resources, Medicines and Supplies, and Monitoring Evaluation Adaptation & Learning (MEA&L), have been formulated to facilitate seamless integration of self-care within the existing health system.
What are some of the self-care interventions for SRHR that have been proposed/focused on for scale-up in Uganda? Which of these interventions already have stakeholder and/or public support?
Dr. Moses Muwonge, executive director of SAMASHA Medical Foundation: While the WHO Consolidated Guideline for Self-Care Interventions for Health published in June 2019 enlists five key recommendations with various self-care interventions to be considered for scale-up, the National Guideline for Self-Care Interventions for SRHR [in Uganda] highlights four of these recommendations and respective interventions, which include: Antenatal Care, Family Planning, Post-Abortion Care, and STIs. Stakeholders in Uganda are prioritizing the contextualization of guidance for self-care interventions for the SRHR health area as a blueprint for other health areas.
Considering the practice of self-care is with or without the support of a health provider, how can some of the critical components of health care such as quality of care, proper and effective use, continuity of care, be ensured?
Dr. Moses Muwonge: For self-care to thrive, there must be an enabling environment, quality products, and interventions available outside of formal health systems. Ensuring quality in self-care is critical, thus the WHO conceptual framework facilitates thinking around the complexities of promoting quality self-care. The quality-of-care framework for self-care, which is hinged on five pillars namely, technical competence, client safety, information exchange, inter-person connection and choice, and continuity of care, was integrated within the National Self-Care Guideline for Self-Care Interventions for SRHR [for Uganda].
Professor Fredrick Edward Makumbi, deputy dean at the Makerere School of Public Health (MaKSPH): There are some essential practical strategies for ensuring quality self-care, such as:
- Training providers in counseling clients on the proper use of commodities.
- Counseling clients who are initiating family planning methods on side effects.
- Providing information on opportunities for method change.
- Proper product storage as well as waste disposal and management.
Social components, like partner involvement in self-care, remain key and must be promoted, as this may enable the implementation of safe practices including proper storage for effective use of self-care products.
How can the health system attain data on self-care (e.g. uptake, perceptions, and attitudes, etc.)? How can self-care be measured?
Professor Fredrick Makumbi: Data on self-care can be attained through village health teams, which should be trained to ensure that data is collected correctly. Other sources for self-care data may include drug shops, which should similarly be trained, empowered, and supported to generate such data; local and national level surveys; and monitoring of the HMIS on family planning services.
What are some of the benefits (to individuals and health systems) of advancing self-care for SRHR?
Dr. Olive Sentumbwe, the Family Health and Population Officer at the World Health Organization (WHO) Country Office in Uganda: Self-care interventions offer a strategy to reach people with quality health care services and information. They enable individuals to access and utilize SRHR information and services without discrimination or experiencing stigma. In addition, self-care increases confidentiality, eliminates barriers to access, improves individuals’ autonomy, and enables them to make decisions regarding their own health without feeling pressured, especially among vulnerable populations like the young people. For some individuals, self-care is acceptable as it preserves their privacy and confidentiality and removes bias and stigma which may result from providers during times of client-provider interaction. In the long run, once the individual beneficiary learns where to get the product and how to use it effectively, it becomes cheaper and under the control of the user. Self-care will bring improved mental well-being and increase agency and autonomy particularly for the vulnerable groups. Research suggests that self-care promotes positive health outcomes, such as fostering resilience, living longer, and becoming better equipped to manage stress.
Self-care eases the stretch on the health system and enhances efficiencies in handling critical health issues. For instance, the management of the COVID-19 pandemic resulted in the reassignment of a significant portion of health providers to COVID-19 case management, hence reducing the bandwidth of skilled human resource available to respond to the non-COVID-19-related health needs of individuals. Self-care increases coverage of some services to the public, however, when self-care is not a positive choice but born out of fear or because there is no alternative, it can increase vulnerabilities and lead to poor health outcomes.
How can self-care for SRHR facilitate the advancement of the gender equality and equity agenda in Uganda and enable women to exercise their health rights?
Ms. Fatia Kiyange, deputy executive director at Center for Health Human Rights and Development: Self-care interventions for SRHR unleash power into the hands of women and girls. This allows them to take care of their own health, giving them choice and autonomy.
Women and girls grapple with a range of SRHR-related issues, ranging from the inability to access and utilize modern methods of contraception to preventing sexually transmitted infections and reproductive-health cancers.
As such, self-care becomes a reliable and effective approach for responding to the SRHR needs of women and girls in the most affordable, confidential, and effective manner while maintaining quality of care.
What challenges/lessons/best practices have you observed in the process of advancing self-care interventions at the national level, using DMPA-SC as an example?
Ms. Fiona Walugembe, project director at Advancing Contraceptives Options, PATH Uganda: Disposal of used injectables, integration of data on self-care into the Health Management Information System (HMIS), inadequate time for health providers to effectively train users in self-injection, stakeholder buy-in for self-care and lengthy policy approval processes were the most outstanding challenges encountered as we scaled up the DMPA-SC in Uganda.
Dr. Lillian Sekabembe: Potential product stock-out due to interruptions in the supply chain and the health system’s readiness to entrust individuals with information and products have been key challenges that affect advancing self-care.
Ms. Fiona Walugembe: Whereas self-care has been in existence, its use in the SRHR realm is relatively new. Stakeholders need to think creatively, use evidence, and collaborate with experts as well as influential leaders in championing the concept. Best practices, such as the use of human-centered design approaches for program design, establishing monitoring and evaluation frameworks as well as leveraging existing health systems are critical.
What can be done to ensure that self-care does not become “a poor man’s” solution to the problems of the health system?
Dr. Moses Muwonge: Self-care for SRHR will be implemented in the public sector where free services are [already] provided. This will include community health workers who will reach out to vulnerable communities and build their self-care awareness. While on the other hand, the expectation is that those who can afford it will access products for self-care from the private sector, where individuals buy commodities and services they need.
What’s the vision for success for self-care in Uganda?
Dr. Dinah Nakiganda: At the start of the process, stakeholders struggled with developing a vision for structuring self-care in Uganda. However, through the SCEG, stakeholders hope to see an increase in awareness of the self-care concept, community acceptance of self-care, and integration of self-care interventions with respect to governance in order to strengthen health systems and achieve universal health care coverage.