Raising Her Voice to Demand for Improved Maternal Health Service Delivery

Ms Aisha Nalinnya presenting the maternal Health Service delivery status report to leaders on behalf of the community members

By Senfuka Samuel

With its recognized role and contribution to maternal health in Uganda and globally, The White Ribbon Alliance For Safe Motherhood Uganda was chosen by Akina Mama wa Afrika (AMwA) the coordinating agency of Women First Coalition to contribute towards the popularization and domestication of the Maputo Protocol, which was signed and ratified by the Government of Uganda on 22nd July 2010 with reservations on article 14 (1a and c) regarding abortion. 

WRA Uganda focuses specifically on increasing maternal health services as stipulated in article 14:2a and 2b of the protocol.

Article 14: Health and Reproductive Rights  

a)  States Parties shall ensure that the right to health of women, including sexual and reproductive health is respected and promoted.

b)States Parties shall take all appropriate measures to provide adequate, affordable and accessible health services, including information, education and communication programmes to women, especially those in rural areas; establish and strengthen existing prenatal, delivery and postnatal health and nutritional services for women during pregnancy..............

To realize the above, WRA Uganda chose to pilot the initiative in Mityana district working with her regional members, Community members, community and district leaders, area members of Parliament, District Health Team (DHO, Health Center Managers, Health Management Committees, Village Health Teams etc) and private health service providers.

Community members under the guidance of WRA Uganda and WRA members in Mityana district mobilized themselves and carried out an assessment of maternal health services delivery at Kalangaalo Health Centre II, Kyamusisi Health Centre III and Kyantungo Health Centre IV. This was aimed at gathering evidence and information for lobby and advocating to their leaders and service providers as well as taking own responsibility. 

Community members analyzing data after assessment of health facilities

Members analysed the data and the assessment resulted into the following:

1. A maternal health service delivery status report to the District Health Officer and leaders with specific asks.

2. Training of over 30 people in advocacy skills by WRA Uganda who formed Kyamusisi Community Based Advocacy Group to voice out their maternal health needs.

3. Development of Kyamusisi Community Based Maternal Health Advocacy Plan by community members
4. Community members organized a dialogue meeting including community members, community and district leaders, Workers of the Health Centres, Area Member of Parliament. During the dialogue Community members presented their maternal health service delivery status report and agreed to first address the issues of Kyamusisi Health Centre III and thereafter Kalangaalo and Kyantungo Health Centre II and IV respectively.

 Key issues of the maternal health service delivery assessment

§  Out of the ministry of health recommended 19 staff for a Health Centre III, Kyamusisi has only 8 staff.

§  Lack of electricity at Kyamusisi Health Centre. At night midwives deliver mothers using candles or their cell phone torches or mothers are asked to buy kerosene/paraffin for the lump

§  Security. The facility has no security guard making it risky for health workers to receive clients at night. Lack of security resulted into theft of the facility property like the solar panels that had been provided at the opening of the unit.

§  There is no running water in the maternity unit and OPD despite the available water tanks. The two water pumps meant to supply water have been faulty for a long time.

A health worker showing one of the two faulty water pumps

§ Inadequate and untimely provision of essential medicines which is worsened by the push system at health centre IIs and IIIs. The facilities do not make their own orders based on demand but rather National Medical Stores pushes medicines which are not priority many times.

§ There is no ambulance to transport mothers with complications to Kyantungo HCIV or to the district hospital which are 30km and 45 km away respectively. This is complicated by the poor road to HC IV and district hospital.

§  Lack of resuscitation machine  for infants

§  Non functional Blood Pressure machine

§  Very few mattresses and those available are uncovered

§  Lack of blankets at the unit

§  Only one delivery bed

§  No wheel chair

§  Health workers improvise delivery instruments

§  inadequate infusion stands

§  Lack of sterilizer/Autoclave.  Instruments are boiled using a a charcoal or paraffin stove as shown in the photos below.

           

The dialogue attracted over 100 participants representing various stakeholders who all acknowledged the urgent need to address and strengthen maternal health services in the district. The DHO reported that annually over 320 women die from preventable pregnancy and childbirth related causes in Mityana district!

Commitments at the Dialogue

§  The DHO gave an assurance of installing solar energy at the facility before end of 2012

§  Hon. Kiwanda SSubi, area Member of Parliament contributed 10 blankets in cash.

§  Two delivery instrument sets were contributed

§  Community members contributed 4 blankets

§  Hon. Kiwanda Ssubi committed to lead a fundraising activity to raise all the essential requirements for the facility before 20^th November 2012 by working with WRA Uganda, district and community leaders, DHO and community members.

The next meeting of all stak eholders will convene again to mobilize support for Kyamusisi HC III give feedback to the community. WRA Uganda will continue to work with all stakeholders to bridge the district and national level efforts for improved maternal health and to ensure that health workers are recruited at HC IIIs and IVs as committed by the government in FY 2012/2013. 

Photos speak more than words! WRA Uganda reserves all the rights of the photos. Request for permission at info@wrauganda.org to use them and quote the source.

Members of Kyamusisi Community Based Maternal Health 

Advocacy Group pose for a group photo

Community members at Kyamusisi HC III conducting an assessment of maternal health services

 Kalangaalo Sub-county Chief, Ms Nabaggala did a good job as MC

Community members attending the dialogue

A community member makes his submission during the dialogue

Hon. Kiwandu Ssubi speaking during the dialogue

Dr Kigongo, Acting DHO speaking during the dialogue

A community member handing over the assessment report to Hon. Kiwanda, MP

Ssebuggwawo David of WRA addressing members during the dialogue

From left: LC III Chairperson, Kalangaalo sub-county, Area MP Hon. Kiwanda and the District Health Inspector

Health workers of Kyamusisi HC III led by the In-charge on extreme left speaking to participants at the dialogue

Kalangaalo Sub-county LC III Chairperson responding to issues raised by community members

Hon. Kiwanda appreciates members of Kyamusisi Community Based Maternal Health Advocacy Group for their noble  initiative

Maries Stopes Uganda were one of the services providers at the dialogue-educating 

community members and providing information about family planning services

Hillary Musiima, WRA youth maternal health champion performs safe 

motherhood music which appeals to all individuals to play their part to save mothers!

Dancing to safe motherhood music by Hillary Musiima

Government of Uganda Makes a Bold Step to Recruit 6,176 More Health Workers!

 A cross section of parliamentarians and CSOs reps during one of the several budget lobby meetings organized by the Coalition to End Maternal Mortality for additional allocation of money for recruitment of health workers.

By Senfuka Samuel

25^th September 2012, - The government of Uganda committed to recruit the recommended number of health workers as per Ministry of Health staffing norms at Health Centre III and IV based and managed at district level across the country. This will be achieved with a provision of additional shs 49.5billion (approx US $19.8 billion) to the health sector.

With this allocation, Government will recruit 19 health workers-all cadres at each Health Centre III and 49 at Health Centre IV in the financial year 2012/2013 with immediate budgetary provision of shs. 6.5 billion (Approx US $2.6 million). The balance of over shs.43 billion will be financed through a supplementary budget after the Minister of Health together with Public Service submit to Ministry of Finance an implementation plan with costs for recruitment within one month of budget passing.

If this is fully met it will increase the health sector budget to about 8% of the national budget. The Government also took action to double the number of Medical Doctors at every Health Centre IV and to increase their salary from shs 1.2 million (Approx US $480) to 2.5M (US $1,000) per month to improve recruitment and retention in rural, hard-to-serve areas across the country.

This assurance  was given by the Rt. Hon Prime Minister who is also the Leader of Government Business in Parliament, Patrick Amama Mbabazi, on the floor of Parliament with immediate provision of shs.3billion (approx US $1.2million) for the recruitment costs and shs.3.5billion (approx $1.4million) for wages of all those recruited.. This follows a stalemate between Parliament and Executive during the budget discussions for the current financial year 2012/2013 with the former demanding additional shs.39.2bn to health sector.

This outcome and move into action by the Executive arm of government did not come on a silver platter but rather concerted and sustained advocacy efforts of WRA Uganda, World Vision, Uganda National Health Consumers Organization and other members of the Coalition to End Maternal Mortality, Members of Parliament regardless of political party line, Health Committee of Parliament, Media, maternal health champions among other stakeholders and ministry of health at the backstage.

Our advocacy campaign was premised on the Human Resource for Health Crisis the country is facing especially at the district healthcare level. The 2012 Human Resources for Health Bi-Annual Report by Ministry of Health shows that the proportion of approved positions filled by health workers at all levels nationally is 58%, with a vacancy rate of 42% and some district hospitals having as low as only 16% filled posts, as well as health workers being poorly motivated and facing very poor working conditions. With a total of 803 Health Centre III government units in the country, they have a staffing gap of 40% with each facility requiring 19 health workers.

This level of healthcare is the first point of maternal health services delivery nearer to the people and essential for the management of safe pregnancies. Similarly, the staffing gap at Health Centre IVs is at 40% with a total of 164 government units nationally. Each sub district health unit requires 49 health workers to effectively offer comprehensive emergency obstetric and newborn care and other services.

In addition, the Uganda demographic health survey results (UDHS 2011) indicate an increase in the maternal mortality ratio at 438/100,000 live births as compared to 435/100,000 in 2006 despite improvement in other maternal and child health indicators. This was not helped by the dwindling share of the health sector budget out of the national budget from approved 8.3% in FY 2011/12 to projected 7.7% in 2012/13!

The above disappointing healthcare situation accelerated our efforts to push for urgent need of more financial investment for recruitment of additional health workers and enhancement of their salaries at a minimum of shs.260 billion (Approx US $104m) to kick start the process.

White Ribbon Alliance Uganda and partners' Advocacy Tactics

§ Budget analysis which generated information for lobbying and influencing reallocation in      the Health Committee of Parliament

§  Lobby meetings for Parliamentarians especially those from the ruling party who are the majority in Parliament to support the additional allocation of Shs 39.2bn as recommended by the budget committee of parliament. Over four lobby meetings were held and MPs committed to support the allocation.

§  Petitioned the Rt. Hon Speaker with specific appeals especially to clearly state the urgent need to find at minimum Shs 260billion in the budget for the recruitment and enhancement of salaries for health workers, encourage and oversee debate on the floor of Parliament regarding the matter rather than restricting the deliberations only to the Budget Committee, to seek clarity from Ministry of Public Service on unjustified ban on recruitment of health workers in the country hindering delivery of maternal health care services, commit to the Health Sector Strategic priorities of allocating at least 8% budget increases to the health sector and recruiting additional 2,000 health workers particularly midwives. Because of its urgency, the Speaker gave the petition a priority and allowed it to be presented to the House during the budget debate before the normal procedure of discussing it first by the relevant committee.

 Presenting the petition to Rt. Hon. Deputy Speaker of Parliament Jacob Olanyah in his 

chambers at Parliamentary Building

§Held numerous press conferences and issued press releases to keep momentum of the public debate as well as continuous feedback and information dissemination

§Produced advocacy and awareness materials targeting parliamentarians and, media to support the budget allocation. This included a video-watch the video at the bottom of this article or click on this link https://www.dropbox.com/s/8j217nrtlllnd9m/Uganda%20Citizens%27%20Voice%2C%20UNGA%20September%202012.mp4 an infographic (sticker) with a message "I support 39.2bn for health workers Now", white ribbons were given for all those especially MPs who were identifying with the additional allocation

§  One-on-one phone calls to MPs was another strategy used for the campaign

§  SMS, emails and social media platforms were used by sending messages requesting MPs to support the allocation as well as mobilizing the general public to take action and ask their MPs to support the additional budget for health.

SMS TO MPs

“Please as our representative DON’T pass the budget without shs 39.2bn to support the health sector. IT’s NOW or NEVER.”

“As a people’s representative DON’T TURN your back on our mothers! DON’T pass the budget without a minimum shs39.2bn for health workers to save lives of Ugandans.”

Results:

·    Appreciation and positive change of attitude by the Executive arm of government to the urgent need for more health workers especially at lower healthcare level which serve majority of the population.

·   Over 1,014 Enrolled Midwives, 1,436 Enrolled Nurses, 758 Nursing Officers (Nurse/Midwife), 223 Medical Doctors, 283 Anesthetists, 1,101 Clinical Officers and 1,360 Laboratory Technicians will be recruited in post at both Health Centre IIIs and IVs accordingly. This is anticipated to reduce on the workload of existing cadres where some have been doing work meant for two or three people yet not commensurate with the pay

·   Unprecedented galvanization of parliamentarians to speak with one voice in saving lives of Ugandans from preventable causes

·   Enhancement of medical doctors’ salary at HC IV. Though our push was to enhance allowances for all cadres to promote equity and gender equality given that most midwives and nurses are women whereas most medical doctors are men!

 Next Steps:

·    WRA Uganda and the Coalition members will convene a reflection meeting  and one of the key focus areas will be monitoring and accountability mechanisms for the funds allocated to the health sector

·   Work with Health Committee of Parliament to ensure that MoH and Public Service expeditiously finalize and submits the implementation plan with costs and the fulfillment of the Executive assurance

· Mobilize and inform WRA members at the district/regional level about the proposed recruitment of health workers at their districts to enable them push for filling the existing vacant posts.

           Hon. Bitekyerezo speaking to the media immediately after a lobby meeting 

           where MPs committed to support additional budget to  address the Human 

           Resources for Health Crisis in Uganda.