What you need to know:
- Maternal deaths and diseases are major public health problems in the world but are much pronounced in poor Sub-Saharan African countries such as Uganda where the health sector is crippled with ailing infrastructure, a despondent and poorly remunerated workforce and shoe-string funding. In Uganda, according to the last 2016 demographic and health survey, maternal deaths accounted for 18 percent of all deaths among women between the ages 15 and 49; that is at least three dead mothers for every 1,000 births. In response, government and donors have spent lots of funds to address these issues but it is until one spends time on the ground that they understand it is more than just money, writes Frederic Musisi & Rita Kemigisa.
This infant was Saufa Namulondo’s second delivery. As soon as she developed labour contractions, she was immediately rushed to Mayuge Health Centre IV, like any expectant mother, hoping for the best.
First, there were no beds while the heath workers shirked their duties and paid no attention to her.
“I almost gave birth on the verandah,” Namulondo recalled, painfully.
When her caretakers eventually agreed to part with some money, Namulondo was accorded some attention, but it was too late.
“I had been going for antenatal care at the same facility and from checkups the baby was fine. Now at the delivery, I think the way they tossed me around, something happened to the baby. After delivery, the baby wasn’t breathing; I asked them what was happening but they had gone back to their business,” she narrates.
It wasn’t long before Namulondo’s baby was declared dead.
“That pain. They ignored me because they wanted money but even after paying, their attitude to work was very bad. Just like that we buried my boy,” she said.
Besides cajoling the midwives on duty that day to get assistance, she used her paltry savings to purchase gloves, cotton wool, a disposable plastic sheet, surgical blades, gauzes to assist in the childbirth.
“We are told these things are supposed to be free, but the greed of these people is unspeakable. The mama kits (set of materials given to a mother to be utilised during the delivery process) we are told government provides are all ripped apart; they take out several items of their choice which they give to private clinics to sell to us. So, they refer you to private clinics for everything. It is broad day thuggery,” Namulondo said.
As part of the wide-ranging interventions to curb the high rates of maternal deaths and diseases, the World Bank through its International Development Association in mid-2016 conceived the Uganda Reproductive, Maternal, and Child Health Services Improvement project running until December 2022, to among others improve utilisation of essential health services with a focus on reproductive, maternal, newborn, child and adolescent health services in target districts, and scale up birth and death registration services.
The primary project beneficiaries, according to one brief, included women of childbearing age, adolescents, and children under-five (including newborns and infants) from selected districts in the country with a high disease burden.
They were to benefit from a package of high impact quality and cost-effective RMNCAH interventions such as Results-Based Financing for Primary Health Care Services— where health centres receive financial incentive for the number of mothers delivering in health centres as opposed to say home or with traditional birth attendants—and strengthen health systems to deliver RMNCAH services, including training of targeted health workers through provision of scholarships, and procurement and distribution of among others, mama kits, manual vacuum aspiration kits, and contraceptives.
Mixed bag of fortunes
The provision of mama kits, among others, was seemingly a good idea but there are concerns about a practice by unscrupulous health workers to sell these items.
A recent Ministry of Finance budget monitoring report into the project details that while about 1,031 scholarships were awarded, of which 487 (47 percent) have completed their training in various disciplines relating to maternal, reproductive and child health, many graduates have not been allocated roles due to wage limitations.
Additionally, the Ministry of Health under the project was supposed to construct 81 maternity units.
The contracts were signed on March 15 and sites were handed over to the selected contractors. With less than a year left towards the period for completion, works remain incomplete.
Several deliverables under the project, according to the budget monitoring report, were given an average score.
Earlier on, the World Bank bankrolled the Uganda reproductive health voucher project to a tune of $17.3m (Shs61.6b) focused on poor women in the districts of Mbarara, Kabale, Kanungu, Ntungamo Kiruhura, Sheema, Buhweju, Mitooma, Ibanda, Isingiro, Bushenyi, Rubirizi, Jinja, Bugiri Kamuli, Buyende, Kaliro, Luuka, Mayuge, Iganga, Namutumba, Kibuku, Tororo, Namayingo, and Busia, who face challenges with accessing safe delivery services. Many of these women live in rural backwaters where safe delivery services in general are inadequate.
A December 2019 audit by the Auditor General’s office into the project detailed that majority of mothers who benefited were assessed not to be poor.
A separate July 2020 report titled “Failing to Reach the Poorest?” by the NGO, Initiative for Social and Economic Rights, detailed among other inadequacies, limited stewardship and involvement of the government in planning and executing the project, particularly local government.
Uganda has made significant progress in reducing the number of mothers who die from complications during labour and after childbirth in the last 15 years. The lingering question is whether the country can make great strides towards the improvement of maternal health while the rest of the health sector remains dysfunctional.
The gains made notwithstanding, part of the problem one official speaking anonymously said, is throwing money at the crisis hoping it will yield better results.
“The poor work attitude reflected in health facilities is the same one reflected at police when you walk in there to lodge a complaint or at any government office to get a service. These things are interlinked in one way or another. And with a dysfunctional everything including politics, service delivery can’t be an exception. Fixing attitudes is key,” the official noted.
The Ministry of Health and Uganda Bureau of Statistics (Ubos) are currently working on the periodic demographic and health survey that intends to capture the state of the country’s reproductive, maternal, new-born, child and adolescent health during the last five years.
But according to the last Demographic and Health Survey study in 2016, maternal deaths accounted for 18 percent of all deaths among women between the ages 15 and 49; that is at least three dead mothers for every 1,000.
Mr Peter Eceru, the programme specialist for health and human rights advocacy at the NGO, Centre for Health, Human Rights and Development, says there is more lip service than pragmatism towards the crisis.
Same old problems
“We have seen many successes, especially in child health area but not in the maternal new born area. The government’s commitment stands out-having the right policies and the right tools—although that doesn’t mean we shouldn’t be working on one or two other things,” Dr Atnafu Getachew, the health manager at Unicef Uganda, said.
Whilst the right strategies are in place, Mr Getachew said this is not necessarily being cross-matched by other key elements like human resource and retooling for new skills, attitude change and financial support.
“It has to be a persistent effort if we are to see any meaningful impact,” he argued. “Additionally, we need to empower communities to demand what is right—not just better services—but also to be involved in problem analysis, designing solutions, so that a mechanism of accountability is established.”
The current health care system, Mr Getachew and a host of other actors we talked to, said accords too much power to the healthcare service provider but there is little or no mechanism for holding them accountable.
This partly explains the outright incompetence and near-misses that lead to fatalities at health facilities that go unpunished most times, while medicines unexplainably run out. For health workers to be prosecuted, it requires a smoking gun.
For instance, those who are caught red handed stealing medicines could be prosecuted but this cogent evidence is usually hard to unravel.
The health sector is sullied with bribery, poor attitude of health workers, poorly trained medical staff—poorly remunerated and working long hours and rampant cases of medical negligence.
Dr Richard Mugahi, the assistant commissioner for reproductive and infant health at the Ministry of Health, told Daily Monitor that efforts are ongoing “to pull all strings together” in tackling the problem.
“First, we know what’s killing mothers and where they are dying, so the missing piece is getting done with what needs to be done,” he argued.
Mayuge Health Centre IV where Namulondo gave birth from, visibly stands out with a towering signboard that welcomes both patients and strangers by the roadside towards Mayuge Town. It is easy to access and the recently added dull orange-fresh coat of paint radiates in the afternoon sun like a sodium lump. But like they say, looks can be deceiving. For many residents, contact with the facility—one of the two health centre IVs in the district—is an unavoidable routine.
To a first-time visitor, who is not accustomed to the country’s ailing public health system, the experience can be distressing. Health workers here carry on their duties without the slightest sense of urgency; some barking orders at the noticeably anxious patients. This is peppered with long queues and congested patient rooms in the morning, and as the day wears on in the afternoon, hardly any staff can be found around the premises.
There is not enough space for beds donated to the facility, so they rust away in the compound. Disposed medical waste litters the precincts of the hospital.
But there is more misery as officials we spoke to admitted the deplorable state of health care in Mayuge District. This area is also grappling with high levels of teenage pregnancies and malnutrition.
We also spent some time in the deeper recesses of Mityana District but the situation did not differ much from Mayuge. At Maanyi Health Centre III, expectant mothers had to part with money to buy the items used in delivery.
At Kabuule Health Centre III, health workers were apathetic towards their duties; some spent time on their phones, ostensibly on social media, and others chatting away.
To be adequately assisted during childbirth, a few women we talked to said one has to part with an amount between Shs10,000 and Shs100,000 depending on the health complication or the mood of staff on duty. At Tanda Health Centre III, electricity has been disconnected for many months so health workers work until early evening and retire at dusk. All patients with emergency cases are referred to better facilities.
The missing links
It is not uncommon for government officials to claim that the health system has changed for the better, often citing the Uganda Bureau of Statistics findings that 86 percent of Ugandans live within 5km of a health facility. But across the 146 districts in the country, the quality of health service leaves a lot to be desired; one that is partly contributory to the failing efforts to curb maternal deaths and diseases.
A Ministry of Health’s internal maternal and perinatal death surveillance and response report for the period between January and the last week of November details that at least 768 mothers have died in maternity, an average of 16 dead mothers per week or simply two per day.
The probable causes of death are, obstetric haemorrhage including postpartum haemorrhage-— when a woman has heavy bleeding after giving birth—ruptured uterus owing to obstructed labour, hypertensive disorders of pregnancy, induced abortion, among others. About 33 percent causes of deaths were not reviewed.
“The causes of deaths are three: the delay at community level, by the time they come to health facility it’s too late; delays at the facility, over this and that including lack of health facilities or the bad attitude of health workers; and then there are the technical delays like the bad roads which we have no control over,” Dr Mugahi said.
But ultimately, he says everything depends on funding.
“All health centre IIs have only two midwives who are supposed to work in shifts but for 24 hours, so we need to recruit many of them to ease the work burden which results in stress and sometimes bad attitude—that requires money. We need to build/upgrade more health centres to take services closer to the people—that requires money. What is not usually said is that while the services stagnate the mothers seeking the same services have increased,” he said
But Mr Eceru said: “It doesn’t necessarily have to be money,” citing the recent Auditor General’s findings into a World Bank funded project to refurbish and equip several hospitals around the country but barely a year after the project had closed most of the machines had broken down and there was no budget for repairs or the equipment were merely stored over lack of specialists to operate them.
“It is important to do effective planning. We need to go beyond talking about the same things over and over again. There has to be a mechanism for monitoring for health service delivery, and specifically holding someone accountable for what isn’t working.”
About the health sector
Budgetary allocation to the health sector has grown from Shs660b in the Financial Year 2010/2011 to Shs2.5 trillion in this Financial Year 2021/2022.
The health infrastructure network today currently consists of 6,937 health facilities, of which 3,133 (45.16 percent) is a public healthcare system which is designed to provide equitable access to essential services, 2,976 (42 percent) are private for profit, and the remainder are private not-for profit.
The stock of health workers stood at 107,284 in 2019. But the health sector is fraught with monumental challenges that many expectant mothers face the prospect of dying in scores annually.
What some of the key players say...
Official from Initiative for Social and Economic Rights. The poor work attitude reflected in health facilities is the same one reflected at police when you walk in there to lodge a complaint or at any government office to get a service. With a dysfunctional everything including politics, service delivery can’t be an exception.
Dr Atnafu Getachew, the health manager at Unicef -Uganda. We have seen many successes, especially in child health area but not in the maternal new born area. The government’s commitment stands out-having the right policies and the right tools—although that doesn’t mean we shouldn’t be working on one or two other things.
Dr Richard Mugahi, commissioner in Health ministry. The causes of deaths are three: the delay at community level, by the time they come to health facility it’s too late; delays at the facility, over this and that including lack of health facilities or the bad attitude of health workers; and then are there the technical delays.
Mr Peter Eceru, human rights advocate. It is important to do effective planning. We need to go beyond talking about the same things over and over again. There has to be a mechanism for monitoring health service delivery, and specifically holding someone accountable for what isn’t working.