In 2011, the Uganda National Health Consumers’ Organisation (UNHCO) initiated a community-monitoring programme for health facilities in Oyam district. It had emerged that many pregnant women were dying everyday in the district during childbirth.
The project is in line with the rights-based approach to maternal health care issues, which aims at eradicating maternal deaths in the region, and is being spearheaded by the First Ladies of East Africa.
Supported by the Open Society Foundations (OSF) Public Health Programme and the Open Society Initiative for Eastern Africa (OSIEA), a pilot project was started at the Agulurude health centre III in Oyam district.
Similar projects were later set up at the Anyeke health centre IV, Otwal health centre III and the Atipe health centre II. Nelson Aula, a community health monitor in Oyam district, recalls what led to this initiative.
“The relationship between the community and health facilities in Oyam was very bad. The community and, particularly, expectant mothers were not accessing sufficient medical assistance, which in many cases would lead to death of both the mother and the child. Health workers seemed to neglect their patients,” Aula recalls.
Moses Kirigwajjo, the UNHCO focal point person for Oyam and Dokolo, recounts the difficulties the programme encountered.
“Agulurude and Anyeke health centres would receive up to 500 pregnant women each a month but less than 50 would have successful deliveries. At Agulurude, the community held several meetings, some of which become very explosive. The community believed the health workers were being paid for nothing at the expense of Oyam residence,” Kirigwajjo says.
Agulurude health centre was started as a parish health centre II. In 2000, following the scaling down of the northern Uganda insurgency, the facility was upgraded to a health centre III. By then, it had an out-patient department (OPD), a maternity unit and staff accommodation for three health workers
Following several meetings between the communities that use the three health centers and the health workers, it emerged that the maternal death were as a result of several factors, some of which were beyond the control of both the community and the health workers.
Among other factors, maternal deaths were caused by late response to emergencies by pregnant mothers and their spouses. Also, most mothers neglected modern health facilities during the first months of their pregnancy and only went to health centers two to three months before their delivery. In most cases, some complications that arise during pregnancies would be detected at a very late stage.
Additionally, the ratio of patients to health workers was so huge. It was estimated that each health worker, on average, attended to over 200 patients a day. In 2011, it emerged that only four doctors were available in the entire district. Health workers in Oyam had very little time to effectively concentrate on pregnant mothers and their problems.
Health workers also did not have adequate accommodation facilities; hence, they only came to these health centers at their will. In January 2011, following an understanding between Oyam health workers and the community, a community score card project was initiated at the Agulurude health centre III.
The project engaged health workers and patients separately on various aspects of service delivery and then brought them together in an interface meeting to agree on priority service delivery issues.
Community-based monitoring (CBM), or social accountability, is a form of public oversight, ideally driven by local information needs and community values, to increase the accountability and quality of social services. It can also be described as an approach towards building accountability that relies on civic engagement where citizens and civil society organizations directly or indirectly participate in extracting accountability.
According to a recently-released UNHCO report, the scorecard project was to facilitate effective participation of communities to monitor aspects of health services including medicines and human resources and demand accountability.
The report reveals that the workload at Agulurude HC III was not commensurate with the number of professional staff; the attitude of staff was very poor; financial resources were not explained to the public and nobody knew their existence; the management committee was compromised by the in-charge of the facility as they thought he was solely responsible for the health care of the people of the area.
The scorecard was applied as the major tool at Agulurude with a view of empowering communities to demand delivery of quality health services and hold duty bearers at that level accountable.
Connie Atim, the head midwife and in-charge at Atipe health centre II, has achieved tremendous success in maternal deliveries, following numerous engagements with the community that yielded better understanding of the responsibilities of each party.
“At Atipe, we deliver nearly 67 mothers every month. This was made possible after the community scorecard enabled the community to understand our limitations and their responsibilities to every expecting mother. The burden is now not only on us health workers, but also on the spouses,” Atim says.
Atipe health centre II is 20 kilometres from the Anyeke health centre IV, yet in some instances, Atim said, patients prefer to deliver from Atipe. Previously, like many other health units, Atipe had only a nursing assistant who was overwhelmed by patients.
“We have a policy that when an expectant mother is brought here, we pay for their transportation. I also do home rounds. I have a motorcycle and have delivered children at some homes in cases of night emergencies. We have a 24-hour mobile number known to the entire community,” Atim adds.
The centre also has a new maternal ward built by the Atipe community.
“The old maternal ward was also the out-patient unit. There was no privacy for expectant mothers. The community agreed to help construct a new maternal unit,” Atim says.
Kirigwajjo says Oyam continues to register fewer maternal deaths but more needs to be done.
“Our community health monitors struggle to reach deep villages where we still have unexplained maternal deaths. Most of them do not have transportation. We are also battling with traditional practices like witchcraft that is stoping mothers from visiting modern health facilities,” he says.
He adds that participation of husbands in the affairs of childbirth has significantly improved.
“Previously it was unheard of that men accompanied their wives for antenatal care in Oyam. Our community engagement now shows that 40 percent of the pregnant women in Oyam are accompanied by their husbands regularly for antenatal care,” he affirmed.
In January 2015, statistics show, out of 400 women attending antenatal care at the Anyeke health centre, about 350 mothers ended up delivering at the centre. At Atipe health centre II, the last maternal death registered was in November 2013.
“In just three years, we have successfully fully reduced maternal death in Oyam district by nearly 60 percent. If we had more resources, we would engage the community more regularly and maternal death in this district would be a thing of the past,” Kirigwajjo says.