Empowering communities to demand better health services

In Uganda, 16 women die every day from pregnancy and childbirth-related causes; 94 babies are stillborn and 81 new-born babies die within their first month; totalling 69,570 deaths every year. 

Most of these deaths occur at birth or within 24 hours of birth from causes that are largely preventable. The maternal deaths are caused by four major factors – haemorrhage/bleeding, hypertension, unsafe abortions and sepsis. Conversely, prematurity and birth asphyxia/trauma are major causes of neonatal mortality, accounting for 27.9% and 28.6% of deaths respectively (Uganda Demographic Health Survey, 2016).

Access to a trained healthcare workers, along with basic medicines (such as antiseptics and antibiotics), vital equipment, and a clean environment to work in can save the lives of nearly-born and new-born babies. However, only 57% of births in Uganda occur with the support of a skilled healthcare worker and many health facilities are under-equipped and under-staffed. 

To stop women and babies dying unnecessarily during labour, birth and the first day and week of life, key changes in the delivery of basic healthcare are urgently needed. A well-equipped and adequately staffed maternity ward is key in the provision of quality basic emergency obstetric and neonatal care.

The promise

For many years, residents of Majanji sub-county had never had this primary healthcare level initiative to reduce maternal and new-born mortality. Located on the shores of Lake Victoria, Majanji is one of the 16 sub-counties in Busia District in eastern Uganda with high numbers of baby deaths; 18 new-born deaths per month were reported in 2018, according to Benah Anyama, the Assistant District Health Officer in charge of Maternal Health.

In 2016, the Ministry of Health announced an expansion and upgrade of Majanji Health Centre II. For Majanji residents, who for years had trekked long distances in search of health services, the announcement was the best news ever. But their hopes were soon dashed when the Busia local government could not walk the talk. Government officials were rescinding on their decision because Majanji facility did not have ‘enough land for expansion’.

World Vision training pays off

World Vision trained Majanji community leaders on a social accountability approach known as Citizen Voice and Action (CVA*) . Equipped with knowledge and skills in advocacy and influencing, the community leaders swung into action to reverse the decision.

First, they successfully mobilised and engaged the community to procure land to allow the expansion of the health facility. With the land question no longer a deterrent, the leaders lobbied district authorities to proceed with the expansion and upgrade plans the health centre. Initially, the district health officials would not see them. But giving up was not an option.

“It was not easy to go to them directly,” says Godfrey Okumu, chairperson of Majanji CVA Association. “But as citizens, we realised that when we work together as a unit, we have the capacity to change almost anything in our community.”

After many requests for a meeting, community members organised a meeting where children and women were invited to speak about the impact of not having access to health services. More than 100 people attended, including district officials and politicians.

“They saw the demand and pressure from the community,” Godfrey says, “The meeting was so hot. We were not relenting on our demands for better health services.”

Over the course of a few weeks, the Parish Development Association, on behalf of the community, held quarterly meetings with district officials. They presented their research on health issues, including health data showing how long distances and negative experiences of female patients, in particular, were deterring many women from returning to seek further medical help; especially pre- and post-natal care, and for children under five who are especially vulnerable to diseases.

“Health officials continued dragging their feet but we persisted with our lobbying and regular meetings,” Godfrey continues, “Eventually, our relentless efforts yielded results when we managed to persuade the district to allocate funds for the construction of the maternity ward.”

Today, a beautiful 16-bed capacity maternity ward stands at the facility, courtesy of people coming together to voice their concerns and demand government officials to account. Robert Atuta, the Busia district health officer, says all the lobbying and determination by the community put pressure on district authorities to respond: “Service improvement is something that we are seeing because of this kind of effort from the community, where people are able to voice their concerns,” he says. “They are actually [the community] giving us very good feedback. With CVA, things are getting better. It is a kind of auditing system for our inputs.”

Picking up pace

Community leaders were not done. The success at having a maternity ward constructed only increased their appetite to lobby and demand for more and better services.

“We had just discovered that change is possible and we needed to pick up the pace,” says Walter Oundo, chairperson of Majanji Health Unit Management Committee. “Our morale had been boosted by the initial victory, and we felt we should continue.”

They went on a mission to improve the outpatient department at the health centre. They identified Julius Maganda, their area Member of Parliament who is also a State Minister for the East African Community, as key to pushing for this to happen.

In April 2019, after several promises, their request was granted. They received financial support from the State House for construction of a new outpatient department: “With Community Voice and Action, many changes have taken place in the community,” says Walter. “People know where to demand services and for accountability and to take part in decision-making. Now that the community takes part in decision making, it’s like decentralising the powers to the community and they know how to follow up.”

Pressure on government to deliver services is real: “The trend now because of civic awareness is that communities are demanding for accountability from their leaders. All of us are on our toes now. We are under pressure to deliver and if we don’t, we have to explain why. We are waking up!” adds Robert.

Taking a leaf

Some of the 16 sub-counties in Busia District have picked up a leaf and other community leaders are beginning to replicate Majanji’s success. Godfrey says that every month, they receive at least one delegation of leaders from neighbouring areas seeking to understand how issues are being managed in Majanji sub-county.

“This is because of the progress we are making,” concludes Godfrey. “Before, our sub-county was one of the underserved in the district, but now we are getting to the top if we are not there already. We are really different. When we are discussing with other leaders they are wondering how we are doing these things.”

*World Vision is implementing the AIM Health Project funded by Irish Aid in Busia district. The organisation works with local advocacy groups to discuss local health issues and create solutions for the problems they face. The advocacy groups hold duty bearers to account and follow up on promises they made in order to strengthen health services. Through CVA, there have been enhanced relationships between healthcare staff and patients, leading to increased health-seeking behaviour, higher outpatient numbers and more women giving birth at clinics and using antenatal services.

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Story by Fred Ouma, Development Communications Coordinator, World Vision Uganda