It is 11:22am and I arrive at Nyadri health centre III in the West Nile district of Maracha.
As patients and caretakers sit outside the pharmacy, a mother in a tattered black dress catches my attention. She rubs her slightly-swollen left cheek, a signal that she possibly has a toothache.
She softly tells me that fever and headache are the other ailments that have brought her to this facility.
“I have had this toothache for the last three days, but I will be fine,” Jessica Maturu says, adjusting a rusty safety pin on her buttonless dress that is exposing her breasts.
Her wailing 13-month-old baby strapped to her back is an obvious added burden for this 27-year-old mother-of-seven. Despite her illnesses, Maturu is at least pleased with the changing service delivery at this facility that enables patients to leave early.
“There was a time when people would come and they were not attended to, or they would leave late. I walked three kilometres to reach here at 9am, and if it was not for the hepatitis B vaccination, I would have left by 11am,” she says, abandoning the interview to pick her drugs.
Other patients agree; general health service delivery has greatly improved in the district. This is thanks to a three-year Community and District Empowerment for Scale-up (CODES) project that has been implemented by ChildFund Uganda in partnership with Liverpool School of Tropical Medicine (LSTM).
Funded by Unicef, the project sought to demonstrate the importance of a district-focused strategy to strengthen management performance complemented by community engagement to improve equitable coverage and the quality of key interventions for children under five years.
ChildFund and LSTM also expected to reduce childhood illness and deaths due to diarrhoea, malaria and pneumonia. The CODES project was first rolled out in five districts of Masaka, Bukomansimbi, Mukono, Wakiso and Buikwe in 2011, before expanding.
With a population of 198,666, Maracha district has 10 health centre IIIs, seven health centre IIs and one private not-for-profit hospital owned by the Uganda Catholic Medical Bureau.
According to Zac Ssinabulya, the regional health supervisor of the CODES project, a survey found Maracha district with high mortality and morbidity rates of malaria, diarrhoea and pneumonia in children below five years.
“In 2014, we found the district performing generally well but something was lacking in their district health teams (DHTs), communities, management and health practioners to improve services,” Ssinabulya says.
Findings from the survey came with a Bottleneck Analysis (BNA) tool that enables the community and health service providers to identify supply and demand challenges and how to act on them.
For instance, health facilities like Nyadri have been able to adapt the five S component – sort the workplace, set it well, make it shine, standardize it and sustain your work – all designed within the BNA tool. Patrick Andima, a clinical officer in charge of Nyadri health centre III, attests that the components have become routine in most facilities.
“This BNA tool is very simple. Once you know the challenges around you, you can serve better,” Andima says. “If the bottleneck is arriving late on duty, sort that challenge, report early and attend to your patients. Here, arrival on duty strictly closes at 8:45am.”
Using the BNA tool, it was also discovered that doctors prescribed drugs without lab testing and health facilities lacked essential equipment including measuring tapes, infant weighing machines, and respiratory timers for testing pneumonia and Mid-Upper Arm Circumference (MUAC) tapes to assess nutrition in children.
There were also findings of family members sharing drugs.
“All these shortcomings are now history in Maracha. The communities are informed, the equipment were bought and doctors were trained on testing and counseling before prescribing drugs,” says Andima.
Before the project, Nyadri outpatients department would receive up to 80 patients daily but this has reduced to 40 – thanks to community health dialogues. Statistics at the facility indicate that in the last two years, there have been no maternal deaths while only one baby in 2015 and another in April this year suffered intrauterine foetal deaths.
When the CODES project was launched in 2014, little did ChildFund and LSTM know that the BNA tool would be adopted by the ministry of health. According to the 2016 local government planning guidelines for the health sector, district working plans without the BNA tool will not be approved.
“The bottleneck analysis should be followed… for each of the identified bottleneck, the district health management team should conduct an in-depth analysis to determine the underlying causes of the bottleneck,” reads part of the guidelines.
Sunday Cadribo, the acting district health officer in Maracha, says the tool has seen the district improve in its rankings in just three years.
“The project found us in a situation where you don’t know that you don’t know. Our health planning system was poor and uncoordinated; it was not informed by anything at all but just copy and paste,” Cadribo says. “[But] after one year, we started doing things differently.”
Every year, the health ministry assesses districts and places them into what is known as the national league table. In 2013/14, out of 112 districts, Maracha was ranked 69 and 4th in the West Nile region. In 2014/15, the district sunk to position 90 and 5th in the region. But after fully embracing the BNA tool, it rose to position 21 and first in the region in 2015/16.
“Our health budgets did not change much. It was little money, but we put it to good use with informed plans,” he says.
He says the district emphasized more community engagements and introduced attendance registers to track rampant absenteeism.
“We now have daily attendance registrars and forms that in-charges of facilities forward to district headquarters every two weeks. Other forms are digital and reflect overall attendance of health workers,” Cadribo says.
He cites an incident in one of the health facilities where the temperature of the fridge used to store some vaccines was not checked for three days.
“The temperature must be checked daily, every morning and evening. This means internal supervision was the bottleneck and we fixed it,” Cadribo adds.
Initially, health workers thought it was a witch-hunt, but they adjusted to the new regulations and improved service delivery. With the limited funding to the health sector, Cadribo has advice for district health officers:
“Before you ask government for more money, build health centres in the minds of the people so that they avoid diseases, observe personal hygiene and live a healthy life. Secondly, endeavour to properly utilise the minimal funds.”
Currently, the district has an estimated health budget of Shs 3.3bn for the 2017/18 financial year. According to the health sector ministerial policy statement for the 2017/18 financial year, the sector will be underfunded after Shs 964m was cut off its budget.
This implies that scaling up interventions to address the high burden of HIV/TB, malaria, nutritional challenges, environmental sanitation and hygiene, immunization, Hepatitis B and Non Communicable diseases will remain a challenge. At least Shs 275 billion is required annually.
While the sector will also grapple with inadequate operational funds for Primary Health Care services (PHC), Maracha district is set to address such shortcomings with skills obtained during the CODES project. During a recent visit, Ssinabulya urged district officials to continue on the set pace.
“The project is closing but Maracha people should not close with us. Let them continue implementing what they have learnt. We have left behind the necessary skills and knowledge,” he said.
Maracha’s health service delivery leads in West Nile, followed by Zombo, Yumbe, Moyo, Nebbi, Adjumani, Arua and Koboko in last place.