Accountability for Maternal Health Service Delivery

Senfuka Samuel

Accountability Matters: Ministry of Health through its Uganda Health Systems Strengthening Project committed to deliver the Uganda Minimum Healthcare Package to Ugandans with a focus on #maternal health, #newborn care and #family planning. This was planned to be achieved through improving human resources for health, physical health infrastructure as well as management, leadership and accountability for health service delivery.

The project was to start off by reconstructing and or rehabilitating and fully equip Mubende and Moroto regional referral hospitals, 28 Health centre IVs and 17 District General Hospitals including Bugiri, Iganga, Entebbe, Apac, Pallisa, Nebbi, Kiryandongo, Itojo, Kitgum, Moyo, Anaka, Kawolo, Nakaseke, Buwenge, Bukwo and Mityana District Hospital. This led to a loan request of US $ 130 million from World Bank, which was subsequently approved and passed by the Parliament of Uganda in FY 2010/2011. However, a visit to Mityana General Hospital in central Uganda is a testimony that apart from the foundation stone which was laid about a year now, nothing much has happened! As seen in the photos below, the facility buildings are in a sorry state requiring urgent action. The maternity unit at the hospital was reconstructed in 1995/97 but also requires urgent rehabilitation. 

A call to Parliamentarians to fast track the World Bank loan and the funds so far released to facilitate the works on the targeted facilities.

Bulera Health Centre III Gets a New Maternity Unit and Staff Boost!

Last year, our collective advocacy efforts of civil society organizations in health, Parliamentarians and other stakeholders led to Government's bold decision to recruit and increase the number of health workers at Health Centre IIIs and IVs. A field visit to Bulera HC III (Mityana district) managed by our own WRA Uganda member, Ms Barbara Zzalwango (Health worker representative on WRA Mityana regional committee) has already tested on the benefits by getting additional 4 nurses, 1 midwife, 1 Lab Technician. Congratulations to Ms Barbara who was also promoted to the post of Nursing Officer (Midwifery)! Bulera HC III has also constructed a maternity unit to serve better the increasing population in the catchment area. According to the In-charge, Midwife Barbara, the unit remains only to be equipped with necessary maternity facilities to start operations. 

Do you know a Maama kit, Have you heard about it, Do you know its contents and importance to pregnant women? A visit at Kyamusisi Health Centre III, Mityana District for community engagement in maternal health.

            

A maama kit contains basic items required by a woman at time of delivery/childbirth. It contains gauze, cotton wool, 3 pairs of gloves, a piece of bathing soap and 2 plastic bags-one for delivering on and the other for the newborn. After finding that it was one of the reasons stopping women from delivering from health facilities due to lack of money to buy these items, the Government of Uganda made it a policy for every mother who delivers from the public health facility to get a free maama kit and it was eventually included on the list of essential medicines and supplies that are distributed to health facilities (Health centre III to National Referral Hospital). 

Midwife Oliver Tebakaanya at Kyamusisi HC III, cautioned women and men who turned up for a community feedback meeting on improving maternal health service delivery NOT to accept to be charged for a maama kit at a Government Health facility by any unscrupulous people. 

According to Midwife Sarah Kirabira- In-charge of Kyamusi Health Centre III who is also a WRA Uganda  member and Chairperson of WRA Mityana Regional Committee was happy about the advocacy efforts which has resulted into recruitment and deployment of a Clinical Officer, Lab Technician and an additional midwife.

anticipating to reduce on the workload.

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.

A Holistic Approach to Family Planning

A Service Provider shows a man how vasectomy is done as a male family planning method at Marie Stopes Centre, Mbale district

By Senfuka Samuel

Uganda’s population growth rate is one of the highest in the world at 3.2% and the biggest percentage of is the population is young people. In addition, Uganda’s women are very fertile with each producing an average of 6.2 children. According to the Uganda Demographic Health Survey (UDHS) 2011 preliminary findings, the maternal mortality rate is still unacceptably high at 354 from 435 per 100,000 live births.

The World Health Organization estimates that about 300,000 abortions are carried out every year in Uganda and abortion related complications are one of the leading causes of admissions to gynaecological wards in hospitals across the country. There is no doubt that most of unsafe abortions are because of unintended pregnancies and the failure to prevent those pregnancies through access to timely family planning services and information.

To reverse this trend, we must ensure universal access to family planning services and commodities to Ugandans, who have demanded for it. Uganda’s unmet need for family planning currently stands at 41% and the contraceptive prevalence rate (CPR) is below average at 30%. The CPR varies by residence, region and methods used. It stands at 46% and 27% in urban and rural areas respectively whereas 26% use modern methods and 4% still use traditional ones.

It is known that Family Planning is one of the key proven strategies to reduce maternal mortality and an opportunity to reduce unintended pregnancies, this is especially important in Uganda where abortion is illegal under the Constitution if not recommended by a medical officer for saving the life of a mother. During my independent visits and interactions with key players in family planning and maternal health in general including NGOs, Donor agencies and development partners, private healthcare providers, health professionals, media representatives, politicians and  maternal health champions, I found out the following key issues which limit uptake of the services. Addressing these barriers need a holistic approach.

• More information -It was evident that the biggest barrier to family planning use rotates around accessibility to information and services. The approach of stocking and storing contraceptives at health facilities is not very attractive to would be users.  Family planning is not a disease that will force people to seek medical attention hence an urgent need to rethink about the approach and adopt some innovative ways such as social marketing, use of pharmacies, clinics, integrating it to the antenatal care among others. There growing views of adopting a community based approach for administering some methods which do not require high skills training. It was also noted that some rural based health facilities close early without being insensitive to women’s time poverty due to their gender roles. It should also be noted that nearly 95% of contraceptives are procured by donors and the little that government allocates it is not released at times making the supplies inadequate.

• Tackle myths -Myths and perceptions about family planning impact negatively on the uptake of the services.  There so many negative views held by different people including some health workers on family planning methods. For instance there myths and perceptions that it causes infertility, abnormal fattening, weakening women’s sexual libido and energy to work on their farms among others. There is need to package appropriate and harmonized messages and information at all levels before it is disseminated to the target audience. It is also widely perceived that family planning is for only women-few people are aware about methods for males. There should be deliberate efforts to mobilize and work with community structures to raise awareness and ensure confidence among the targeted community members.

• Increase choice - Method mix. In some instances there is limited choice available to the clients. It is important to ensure that all methods are available at access points because some are preferred against the others. It has been reported that contraceptive pills get expired at health centre IIs and IIIs where the procurement and supply of drugs and supplies is based on a push approach (supply driven).  

• More health workers - Skills gap to deliver various methods and management of side effects is also a critical obstacle to family planning. Some methods like implants, intrauterine devices (IUDs)/coils and vasectomy require a well trained provider to give adequate information about the methods, likely side effects and carrying out the procedures and managing the side effects. Such skilled health workers are inadequate or lacking in some communities or health facilities.

• Empower women - Gender and cultural biases have also proved to limit utilization of family planning services even where they are accessible. Still being a patriarchal society, women have to get consent of their spouses before making a decision to use family planning. Most of the times they face stiff resistance from their spouses and the consequences are always regrettable including a lot of pressure from the man’s family members. It’s strategically important to target and increase the male involvement in provision of family planning services and information.

• Work with faith based groups - There strong faith based views which do not recommend or accept some family planning methods. It will be important to use some biblical views and approaches to engage faith based leaders for their buy in. For instance in the book of Genesis 1:28 it says that: God blessed them and said to them “Be fruitful and increase in number; fill the earth and SUBDUE it. Rule over the fish of the sea and the birds of the air and over every living creature that moves on the ground.”

• Include young people - Youth friendly environment for family planning services lacks in most access points. This prevents the young adolescents who are most vulnerable to access information and family planning services.

Linking the above, it was a very important political statement from the Uganda head of state to attend the London Summit on Family Planning on 11^th July 2012 which coincided with the World Population Day. From an advocate point of view there were some wins and opportunity for continuous engagement.    

• The President made a commitment to increase the family planning budget to US $ 25 million for over the next five years translating into US $ 5m each financial year from the current US $ 3.3m. This will be a good tool for holding him and the government accountable but also to ensure that the funds are allocated in priority areas. Increasing domestic budget allocation for family planning supplies and commodities is a good pointer to sustainability.
• The President has always been perceived to have negative attitude towards family planning by asserting that Uganda and Africa need a big population to propel economic growth through provision of market for goods and services. There is need to use this opportunity to nurture his interest and views on family planning and enlist him as strategic ally for family planning.

Simultaneously, the Prime Minister Hon. John Patrick Mbabazi as a Chief Guest at the official marking of World Population Day pledged to follow on an earlier government decision to waive taxes on the contraceptives. This is an opportunity for CSOs and other players to advocate for immediate issuance of an instrument by Government of Uganda stopping Uganda Revenue Authority from collecting the tax.

For efficient and effective delivery on the commitments there is a need to strengthen the technical and institutional functionality of the key players involved in the supplies distribution chain. This calls for strong Public Private Partnerships to close the gap where government does not have existence (public health facilities).

Also published at http://whiteribbonalliance.org/index.cfm/news-blogs/wra-blogs/a-holistic-approach-to-family-planning/