More women giving birth at health centres. There’s more to this story.

Ref: New Vision and Daily Monitor, June 29, 2015

Uganda, like many developing countries, can be defined by its contradictions. While more women are able to safely give birth every year, there is a lack of sufficient health facilities to ensure this safety.

The 29 June, 2015 editions of New Vision and Daily Monitor published three stories that illustrate this contradiction and provide a good launch pad to explore more ideas for analytical reporting on health in Uganda.

On one page in New Vision, it was reported that there was “a remarkable increase in the number of mothers seeking services at medical facilities” in Mpigi district. The paper quoted Trade minister, Amelia Kyambadde, as attributing this to the “improvement of facilities in health centres.”

At Muduuma health centre, for instance, the number of expectant mothers received each month has risen from eight, five years ago, to 60 today.

Unfortunately all is not well in Mpigi. During Ms Kyambadde’s tour of the district’s health units, she also visited Kampiringisa Health Centre where only one midwife has been employed to serve about 320 mothers who deliver babies there every month.

The situation in Mpigi is typical of much of the Uganda.

The same paper, on the same page, reported a severe shortage of healthcare facilities on six islands on Lake Victoria. According to New Vision, a survey conducted by the Lake Victoria Fisheries Organisation found that 67 percent of people living in the communities sampled had no access to good healthcare.

Several hundreds of kilometers north of Lake Victoria, at the maternity ward at Ongica Health Centre III in Lira district, the unit built to house only 15 expectant mothers, is overflowing with 50 women being attended to every day. Daily Monitor reported that the severe shortage of space at Ongica can be blamed on the fact that a large section of the maternity ward is used as an immunization centre and for the storage of chemicals.

Of course none of this is new to the Ugandan reader.

A study published on online journal, PLoS One, found that from January to December 2012 both New Vision and Daily Monitor published 229 articles on human resources and health services in Uganda. This is commendable quality by any measure. However the study found that the reporting was “insufficient to generate informed debate on what political actions need to be taken to improve the crisis in healthcare and services” because less than half the articles discussed government responsibility, negligence, corruption and misbehavior by the health workers and issues of pervasive corruption.

It therefore behooves the media not to merely report alarming healthcare cases, but to use them as a basis for more in depth study of public policy and systems that have led to the current state of affairs, as well as analysis of interventions to rectify it.

New data, new reporting

Data about health indicators, hospitals and health centres, mortality, and Uganda’s progress towards the Millennium Development Goals is abundant. It can inform the curious journalist interested in enterprising and novel story ideas about the issues that plague this sector. Here are some sources to mine.

MINISTRY OF HEALTH APPROVED STAFFING NORMS

Kampiringisa Health Centre (earlier mentioned) is not an outlier. The Ministry of Health approved staffing norms recommend the following midwifery staffing numbers for health centres II to IV.

• Health Centre IV – Nursing officer midwifery – 1; Enrolled midwives – 3
• Health Centre III – Nursing officer midwifery – 0; Enrolled midwives – 2
• Health Centre II – Nursing officer midwifery – 0; Enrolled midwives – 1

Furthermore, nearly 40% of nurses and midwives, are in urban areas serving only 13% of the population.

TIP

The easiest, most important story, is the obvious one: with Uganda’s growing population and the increased strain on the existing health facilities, is there a revision of this staffing policy? What are the globally recommended nursing and midwifery levels at community, regional and national health facilities and how does Uganda compare? What is the experience of midwives at the lower level health centres? What are they paid and what are their prospects for continuing education and career advancement? How, if at all, are traditional midwives integrated into the ‘official’ healthcare system and to what effect?

Additionally, the Ministry of Health publishes a bi-annual report titled ‘Human resources for health’. It contains vital information regarding national health staffing plans, budgeting and human resource needs. The October 2012-March 2013 report notes that although there is a great demand for midwives, comprehensive nurses who applied for, and passed interviews for available jobs, could not be appointed as midwives because the ‘vertical training’ of midwives ended in 2006, the same year that training of comprehensive nurses started.

What has been done to rectify this policy disconnect? How many students are being trained as comprehensive nurses around the country? Is there a programme to retrain qualifying comprehensive nurses? Will this satisfy the great need for midwifery services?

The midterm review report of Uganda’s Health Sector Strategic and Investment Plan 2010/11-2014/15 recommended accelerated production of midwives through the training of 2,000 comprehensive nurses and an increase in the enrolment of midwifery trainees to 200 per year. What was the investment cost in financial and human terms? What progress has been made as the Plan winds down?

The Plan also noted that midwives in Uganda receive far less for their services than midwives in other regions. The average monthly salary for a senior nurse/midwife is $341 in Uganda compared to $630 in Tanzania and $1,384 in Kenya.

Reducing midwife attrition obviously requires considerable public finance investment. Has the Ugandan government followed through with its commitments? How? Why or why not?

THE COST OF HEALTHCARE

In 2014 the Ministry of Health released the Uganda Family Planning Costed Implementation Plan, 2015-2020. (So many ‘plans’=Such great strides?) It is intended to reduce the “unmet need for family planning to 10 percent, and increase the modern contraceptive prevalence rate amongst married and women in union to 50 percent by 2020.” Central to this is the globally-recognised fact that scaling up family planning services is one of the most cost-effective interventions to prevent maternal, infant and child deaths.

TIP

The launch of the Family Planning Costed Implementation Plan was covered fairly widely in the Ugandan media. Since then, little has been done to investigate the numbers, the financing and the implementation and the progress of the Plan.

Results of the Plan will be monitored with effect from this year. It is therefore a very useful resource for the health beat reporter bank and continuously assess government’s progress in averting maternal and child death, and the cumulative number and impact of unintended pregnancies and abortions averted.

INTERNATIONAL PARTNERSHIPS AND STRATEGIES

Uganda has partnered with regional governments and international organisations on a number of strategies to improve women and children’s health. Each strategy came with a different commitment by government to achieve Millennium Development Goals on a considerable reduction in maternal and infant deaths.

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To what extent has Uganda’s participation in these international commitments led to an improvement in delivery of health services? What do both internal and independent audits of these programmes say about their ability to deliver government’s maternal and infant mortality targets? Is there a replication of programmes and roles presented by large money, donor-backed strategies? Is this a problem or not? What role does the Ministry of Health play in creating a coherent results-based strategy given the large number of domestic and foreign players involved in maternal and child health?

Programmes to investigate:

• The Global Strategy on Women and Children’s Health
• Family Planning 2020
• Call to Child Survival
• Scaling Up Nutrition movement
• Campaign to Accelerated Reduction of Maternal Mortality in Africa
• Global Vaccine Action Plan

Of interest to journalists may be the USAID-backed programme, Saving Mothers, Giving Life. This public-private partnership claims to have achieved a 30 percent reduction in maternal mortality in the districts in which it is being implemented. How was this achieved? Can this data be independently verified? What can the Government of Uganda learn from those interventions?

BIG DATA

Uganda has an annual maternal mortality rate of 438 per 100,000 live births, according to the 2011 Uganda Demographic Health Survey. In his 2015/16 budget speech, Finance minister Matiya Kasaija said government would, this financial year, enhance the provision of emergency obstetric care medical supplies to reduce this figure to 220 per 100,000 live births. It is hoped that this same investment will also lead to an 18.5 percentage decrease in infant mortality rates.

How will government achieve this? The Ministry of Health Ministerial Policy Statement is a great place to mine data on government’s past and future interventions and to investigate the value for money. In addition to this, there is a wealth of numbers to investigate on midwife recruitment, retention and investment in improved ante- and post-natal services.

A FEW MORE TITBITS

• What informs the decision of expectant mothers to use health centres rather than the services of traditional birth attendants? How, if at all, has the number of women giving birth at hospitals and health centres increased over the years?
• What are the stories of mothers who have had successful deliveries and professional care at the health centers?
• What do they say about the midwife, the nurse or the state of the doctor who was by their bedside?