GENDER AND DEVELOPMENT Uganda Case Study: Increasing Access to Maternal and Child Health Services
The Context World Vision has been active in working with local communities to increase access to health services and clean water in rural areas of Uganda, particularly for mothers and children. While the government officially provides medical care, in practice much of the population does not have access to health facilities: In Uganda, rural areas experience higher levels of child mortality, with only 38 percent of rural births attended by skilled health personnel in contrast to the 80 percent rate experienced in urban centres 1. Makerere University published a report in 2011 that indicated child mortality rates in Uganda were increasing, with three deaths for every 100 live births, due to either poor childbirth services at hospitals, prolonged labour of the mother, or as a result of diseases such as pneumonia or other infections. In 2010, the World Health Organization estimated the maternal mortality ratio in Uganda at 310 per 100,000 live births, an improvement from the 1990 figure of 600 deaths for every 100,000 live births 2. Women lacking health information is also a significant issue. World Vision s research found that when many people in rural Uganda fell sick, a popular option was to first seek traditional herbal medicine advice and remedies; with incidences of ill-health worsening to a critical condition by the time health facilities were reached. Traditional practices like child marriage can also result in adolescent girls who are too young to bear children falling pregnant, facing serious risks to their health as their bodies are not yet fully mature for childbirth. This combination of limited community awareness in areas of public health coupled with cultural factors has seen maternal and child mortality rates remain high in countries like Uganda. World Vision s Intervention World Vision introduced Village Health Teams (VHTs) to help build community awareness of medical services and to bridge the gap between communities and medical services. World Vision provided VHTs with bicycles to better facilitate their movement throughout districts in promoting messages on hygiene, sanitation and malnutrition to households. By working directly with communities, VHTs aimed to reduce congestion at local health centres. 1 World Health Organization (WHO), May 2012, Uganda: Health profile, [Online] Available at: http://www.who.int/gho/countries/uga.pdf 2 For further information see WHO Global Health Observatory, Maternal and reproductive health Uganda, [Online] Available at: http://www.who.int/gho/mdg/maternal_health/situation_trends_maternal_mortality Page 2
The project also focused on improving access to clean water and use of better sanitation practices. In 2010, only around 64 percent of Uganda s population had access to clean water; while lack of access to safe drinking water and basic sanitation facilities significantly increases the risk of diarrhoeal diseases. The Nabiswera sub-county is a water-stressed area; previously communities were sharing water sources with animals and natural boreholes were non-functional. As part of the Nabiswera Area Development Programme (ADP), in partnership with the government, World Vision has trained 82 VHT members to deal with water and sanitation challenges 3. Nindye Health Centre is one of three health centres constructed by World Vision in partnership with the government and community in Nkozi sub-county, to address the lack of health facilities available for mothers and children seeking medical treatment. The facility comprises an outpatients department and a fully-fledged maternity department with personnel, as well as staff quarters; and it offers both immunisation services and general treatment. Health centres like this one are critical to building sustainable solutions for women. Family planning information can help women decide the number and timing of their pregnancies, as well as in making informed decisions about their own sexual and reproductive health. Women from many rural areas in Uganda still face numerous challenges to autonomy over their reproductive health despite improved access to public health facilities; as predominant social and cultural norms may leave women with limited decision-making power in negotiating use of contraceptives in marriage. Christine Achari, a midwife at Nabiswera Health Centre in the Nakasongola district, has also observed an increase in the number of patients accessing services despite long distances; as well as an increased number of healthcare staff as a result of advocacy from various stakeholders led by World Vision and community members. World Vision is promoting gender equality through interventions such as the Citizen Voice and Action approach being used to sensitise communities on key areas in human rights in Nkozi ADP. Impact of the Project The introduction of World Vision s Village Health Teams (VHTs) has made a positive impact on improving public health in rural districts, through initiatives to build community knowledge, advocacy campaigns and empowering women. The VHTs have played an important role in addressing information gaps that women face, providing critical health information and also advocating issues like child marriage, which have significant health consequences for adolescent girls. 3 An Area Development Programme (ADP) is World Vision s signature approach to fighting poverty. ADPs operate in geographically-defined areas and have populations of 20,000 40,000 people. They are primarily funded through child sponsorship; sponsors contributions are pooled to fund projects benefiting all children and families living in the community. Page 3
The increasing presence of VHTs trained by World Vision has brought tangible results in the health of mothers and their children through introducing preventative measures in nutrition and sanitation. Overall levels of public health have improved as a result of VHT initiatives to promote increased latrine coverage, reduce incidence of early marriage and child labour, and to promote adequate nutrition at the household level. An example relates to residents of Nkozi Village, who received seeds According to Charles Kaboggoza, a to grow fruit and vegetables in order to combat malnutrition; and have Community Development Facilitator been visited by VHTs to make sure that every home has a latrine, with the Nkozi ADP, World Vision s interventions such as the construction kitchen, facility for boiling drinking water and an enclosure for animals. of health centres and implementation The VHTs mobilised communities to form water committees for of advocacy initiatives help to ensure boreholes and dams to ensure sanitation and proper handling. The that communities have sustainable creation of water committees has also meant that mothers and children mechanisms towards addressing maternal and child health issues. no longer need to trek long distances in search for water. World Vision also implements similar programmes in the Wabinyonyi and Kalongo The VHTs are Level 1 health areas; and has observed that public health levels have improved even centres for these communities, he in communities where long distances to water sources and health says. centres remain a challenge as a result of proper sanitation and safe drinking water sources reducing levels of disease and ill-health. Access to infrastructural services such as water and transportation is crucial, as long hours spent gathering resources such as water and firewood are chiefly borne unpaid by women. The health centre has helped to address issues such as transport costs, medical fees and the number of mothers dying on their way to hospital; with around 40 pregnant women a month now using the new centre s services. Between July and December 2011, a total of 173 mothers accessed services at Nindye Health Centre, while 171 women accepted family planning services for the first time. An expectant mother receives advice and treatment at Nindye Health Centre Since the construction of the health centres, further approaches to enhance public health awareness and encourage people to access the free services are also underway, with the Citizen Voice and Action initiative empowering communities to demand quality health services. Politicians and religious leaders have participated in these initiatives, with some supervising the centres to ensure the provision of quality services. Page 4
As a result of VHTs and Citizen Voice & Action, gender balance through strengthening male involvement; with some husbands now accompanying their wives during ante-natal visits, as well as increasing levels of male participation in both community and domestic activities. As for the future, Olive Namuwonge, the Community Development Facilitator in charge of the Wabinyonyi ADP in Nakasongola, is optimistic that traditions adversely impacting women will gradually change and that their lives will improve; especially with World Vision s interventions in advocating for better nutrition practices, training VHTs and mobilising mothers and children in accessing better health services. Lessons Learned Addressing information gaps at the community level as well as improving effectiveness of health systems can dramatically reduce maternal and child mortality. VHTs have an important role to play in communicating health messages and bringing services closer to the community. Initiatives which build the health literacy of women, families and communities are essential in supporting women to make informed choices about reproductive health (including family planning), childbirth, nutrition and sanitation. Building women s knowledge about prenatal care and the assistance of skilled birth attendants during pregnancy and childbirth are important steps towards reaching MDG 5 targets to reduce the maternal mortality ratio and achieve universal access to reproductive health. It is also critical to ensure men have access to health information, so they can take a stronger role in supporting their wives during pregnancy. Engagement at this level can trigger other changes in gender roles, encouraging men to be involved in domestic tasks and caring for children. Access to clean water and basic sanitation is critical for the health of mothers and children. When water services are located closer to communities, women s workloads lessen. Other Information This project was funded by World Vision Australia. This case study was developed with support from World Vision Uganda and World Vision Australia as well as an intern, Lucy Fenton. For further information about this project, please contact Patrick Obita: patrick_obita@wvi.org. 2013 World Vision Australia. World Vision Australia ABN 28 004 778 081 is a Christian relief, development and advocacy organisation dedicated to working with children, families and communities to overcome poverty and injustice. Ref # 6463 Page 5