Making crowds count: Citizens need to be empowered to achieve universal health

As we celebrate the Universal Health Coverage (UHC) day on December 12, it is important to reflect on what reforms and strategies will be critical to achieving UHC in Uganda. A key issue that has been identified as critical to improving health service delivery is the concept of accountability.

 It has been argued theoretically that as long as service providers are accountable to individuals or an institution, they will act in the best interest of these institutions.

While ordinarily the ministry of health (MOH) has a mandate to monitor and supervise health service delivery, this mandate is constrained by a number of capacity challenges, including limited financial and human resources. With the proliferation of districts and health facilities without corresponding increases in funding, the capacity challenges have manifested even more deeply.

Amidst these challenges, new approaches to fostering accountability in health should be looked at – especially those that take advantage of existing resources within communities. Studies have documented how indeed communities can successfully foster and promote accountability using approaches such as community scorecards.

A community approach would successfully supplement the ministry of health efforts of monitoring, evaluation and supervision. Traditionally, the concept of Health Unit Management Committees (HUMCs) has been around for some time.

The HUMCs comprised a team of selected community members who were responsible for overseeing a local health facility, acted as a link between community and facility management, and monitored drug deliveries and other facility operations.

The HUMCs were similar to Parents-Teachers’ Associations (PTAs) in Schools. These played a critical role in putting management to account for certain actions. They were a community voice.

The HUMCs have slowly disappeared, others have been co-opted by facility management – and at times are accomplices to wrongdoing – and others have been politicised. Yet, this was a good approach to utilising existing community resources to better health service delivery.

One of the tenets of UHC is “improved access to better quality health care”, but ensuring quality will only come if we strengthen systems that demand accountability for actions or inactions of providers. It seems to me that now is the time to reflect on the HUMC model and re-define how and what place the community should get involved in monitoring and supervision of services that not only benefit them, but for which they also inherently pay – through general taxation. The politics is ready for it and the communities seem to have waited longer to participate, and a few examples are already around us of what communities can do to foster accountability.

Learning their lessons from the last concluded 2016 general elections, the National Resistance Movement (NRM) government has code-named this term – Kisanja hakuna mchezo translated as a term of hard work in as far as service delivery and accountability to the people of Uganda, is concerned.

  Some commentators have argued that the health sector might have been one of such sectors that may have significantly influenced the election dynamics witnessed. Following a presidential visit to one health facility in Wakiso District, the community received a platform to air their long held grievances against health workers at a local health facility, resulting into their summary dismissal by the president at the excitement of the community. This example is an illustration of the power that communities or “voters” have, that if this power is appropriately used, could change health service delivery for the better.

  The approach used in this example may not have been the most appropriate, but it indicates that empowering communities to demand for accountability could generate quick returns and should be looked at as part of the solutions going forward.

Another approach, the barazas, which government is already implementing at county, district, and local levels, fits well within the community empowerment strategy and should be embraced and supported to foster accountability, good governance and streamline health service delivery. In short, achieving Universal Health Coverage in Uganda will entail putting the community – who are beneficiaries – at the center of health service delivery.

The writer is a CARTA PhD Fellow & Health Economist – SPEED Program – Makerere University School of Public Health