By: Rebecca Carr

As I was buying souvenirs from Uganda’s craft village in Kampala, last weekend, I began chatting to several vendors about maternal health. I usually try to avoid harping on about work, and about the human rights related issues I’ve encountered; especially on a weekend, but for some reason: small talk, maybe? Interest, perhaps, in what a “Muzungu” (white person) would be doing in Uganda for more than a few, vacation-appropriate length weeks? – Many a probing question about my activities was sent my way.

Compliantly, I told them I was working on issues concerning Ugandan’s rights to health and of recent, on issues of maternal mortality in particular. That, however, was more than enough to get the conversation flowing; as each had some personal story to share concerning their wives and or other female relations’ encounters with issues of maternal health; issues that fuelled visible despair and upset among them as to the current, and often shocking, status quo.

Despite the global hype and dogged hope that has surrounded the Millennium Development Goals’ (MDGs) objectives, government efforts to achieve the fifth MDG in Uganda: to reduce by three quarters, between 1990 and 2015, the country’s maternal mortality ratio, to a rate of 131 per 10,000 live births, have been disappointing.

The rate of maternal mortality in Uganda, at an estimated 438 per 100,000 live births in 2011, remains far above what a number of other countries in the region have been able to achieve and, being socially stratified, is also largely preventable. Arguably, the main factor prohibiting the rate’s amelioration is resources: and further, underpinning this is a lack of political will to make maternal health spending a clear priority.

For instance, the government of Uganda does not currently allocate the resources that are required to deliver Uganda’s Minimum Health Care Package; a policy which has as an objective: the improvement of maternal and child health through, amongst others, the supply of basic maternal health commodities and increased health worker staffing.

In fact, since the millennial year the MDGs were announced, Uganda’s budgetary allocation towards the health sector has remained inadequate, with government health expenditure averaging at around 10.2% between 2009-13 according to the World Bank (which is below the 15% that is required and was pledged by Uganda in the African, Abuja declaration).

This stands in contrast to the 17.2% of government expenditure the World Bank says was devoted to Uganda’s military expenditure in 2010/11: which included the controversial purchasing of top-notch Russian military fighter jets that reportedly cost USD $740 million to buy, at such a time when Uganda was even being taken to court to account for the country’s high rate of maternal deaths (See discussion of Constitutional Petition No. 16 of 2011, below). Uganda, however, is not at war; but with 16 preventable maternal deaths a day, there are clear health battles at home to be reckoned with.

The cases of Jennifer Anguko and Sylvia Nalubowa expound this. Jennifer, a mother of three, needlessly bled to death in the maternity ward of one of Uganda’s major public hospitals. There was no available doctor to examine her for over 12 hours and the nurses repeatedly ignored Jennifer’s family’s pleas for help; even rebuking her husband for interrupting their idle conversations with his protests. By the time an obstetrician eventually arrived, it was tragically too late, and she had died.

Sylvia Nalubowa, a farmer and mother of 7 arrived at hospital needing emergency obstetric care to deliver her second child; she was unexpectedly having twins. Sylvia, however, arrived with none of essential items that women are expected to bring (including razor blades, gloves, cotton wool etc.,) for the birth of this second twin, given its unexpectedness, nor did she have any money to pay for the airtime the nurses allegedly demanded she pay to enable them call a doctor.

According to family members, Sylvia was consequently taken to the maternity ward and simply left there, unattended to for the 7 hours that she suffered: screaming in agonising pain, even “pledging her kibanja [squatter piece of land], hens and pigs if the nurses helped her out.” The nurses, however, were not interested in her pleas and instead of giving birth that day Sylvia also left hospital in a coffin, along with her unborn child.

These cases are not isolated events. They are symptomatic of the broader inequities that women face in Uganda and require systemic action in order to effectively address their causes. This is the rhetoric of human rights and indeed, providing women with access to maternal care is a core obligation “of comparable priority” in international human rights law, that is incumbent upon Uganda, as a party to the relevant treaties, to fulfil.

Holding the government to account for its progress (or lack of) in realizing this obligation is something that, according to recent technical guidance produced by the UN Human Rights Council on reducing preventable maternal mortalities, may include the typically unchartered avenue of judicial remedy.

Where government is failing to act, as the guardian of individuals’ fundamental rights and freedoms, the judiciary must act to protect the basic human rights of its country’s peoples. According to the guidance, this may even stretch to the judiciary’s reformation of “laws, polices and budgets that do not adequately protect sexual and reproductive health rights” in accordance with international law.

Incisively, in 2011 the Centre for Health, Human Rights and Development (CEHURD) filed a Constitutional Petition (Constitutional Petition No. 16 of 2011) that sought, among others, a declaration that the non-provision of the essential maternal health commodities that had led to the deaths of Jennifer and Sylvia, among others, infringed their fundamental rights to health and life.

The case – after a number of delays caused by the responding Attorney General – was, however, struck out following a preliminary objection that the case raised questions of a political nature, to which the court allegedly lacked jurisdiction to respond.

This week, however, the case will re-appear on appeal by CEHURD, before Uganda’s Supreme Court, to enable them determine whether the litigation should proceed. The occasion is a critical moment for maternal health in Uganda since, if CEHURD is allowed to proceed with the case, their petition may ultimately result in the budget increments that are required to secure the fundamental (and constitutionally protected) rights of women, to adequate maternal healthcare, that women and their families all over the country, as they have told me, so desperately desire.

For two years now, CEHURD has undertaken various community empowerment initiatives in Buikwe district. These include among others consulting and training community health advocates on human rights issues including violations of health rights, stigma and discrimination against PLHIV/AIDS and TB and also consulting communities on goals and governance for global health under the GO4Health project. It is from these engagements that a health camp was held in order to bring health education, services and resources closer to the community.

CEHURD through its advocacy networks reached out to various service providers who it partnered with to hold a health Camp held from the 19th to 22nd August 2014. The first half of the camp was in Nyenga and the second half in Najja, sub-counties of Buikwe district. Before the camp officially started, community members eagerly waited at the sites for the camp to begin.

The camp brought a variety of service providers to the community and included; St. Francis Nyenga Hospital, Reproductive helth Uganda, Marie stopes Uganda, Nakasero Blood bank, UNDP, ASDHI, Buikwe Hospital, St Francis Njeru, St Francis Nyenga, Buwagajjo Health center III, Makindu Health centre III, and Buikwe NGO board. Services ranged from HIV testing and counselling, safe male circumcision, family planning, nutrition, and sensitization on non-communicable diseases. Throughout the camp, CEHURD inquired feedback from participants, service providers and spectators about the strengths and challenges of the camp.

The following provides a summary of key recommendations, observations and lessons gathered from partners and participants:
1. Community members expected on-site treatment, particularly drugs
Although there was a generous turn up on the first day of the camp, many participants left disappointed because they anticipated free drugs. The objective of the camp was to primarily provide testing, counseling, and sensitization about critical health issues identified by the community. Unfortunately, the camp did not have the capacity (specifically, medical personnel) to prescribe the drugs many participants sought—such drugs included anti malaria drugs, deworming tablets, pain killers, and other drugs for non-communicable diseases such as diabetes, high blood pressure among others. First days of the camp ended with a lot of frustration from the community members who expected to walk back home with drugs which did not happen due to some constraints. It was until the health camp was boosted with drugs from Kampala pharmaceutical industries (KPI) and Makindu Health center III in Najja Sub County. This was welcomed by community members who had to receive all services and at the same time receive medication. This is a great pointer to the community perception on what accessing health care means. Access to health care in their opinion is not complete if a product like tablets or injections is not given to the patient.

2. Need for sensitization about existing health services in health facilities
To the dismay of many service providers, many community members shared that they were unaware of the same services and institutions being available in their communities. This is therefore an eye opener to health facilities in the communities to work with existing structures at the local level on informing members of the communities about the existence of all services available in the institutions. This is evident in a way that the health camp was attended by members of community with illnesses that can be handled by the existing health facilities in their communities. The health camp was a wakeup call for health facilities to always make sure community members are aware of the health services in the health facilities they are operating in.

3. Community participation
The camp evidenced how it is critical to involve community members as active participants in the planning of health activities. CEHURD worked with community health advocates trained by the organization’s staff together with village health teams and local leaders. This helped in mobilizing members to come and enjoy the services availed at the camp. Community mobilization is a key prerequisite for effective participation and the means of mobilization determine whether communities will respond to the communication or not. We established that the people in the rural communities in Najja and Nyenga respond more positively to local means of mobilization like community radios and village health teams than they do to for example to national radio.

4. Need to avail more health services in health facilities.
Although HIV, family planning and reproductive health services were identified as major health priorities many community members arrived to get treatment of other conditions such as old age complications, eye, skin and dental problems. This therefore calls for the need to diversify the types of services offered.

5. Stigma stills a problem in communities.
When we talk about stigma, most people look at HIV as the major problem associated with stigma. However, it was discovered that there other health problems that people are living with but scared to talk about. The major one identified was fistula as none of the patient came out in public to say they had this problem but instead to talk to health workers in secret to have their problem worked on. Furthermore, people were more willing to go for HIV testing in a health camp as compared to going to a health facility because they could not risk being seen going to a health facility lest someone think they are infected with HIV.

6. Family planning not embraced by men
Family planning services were among the package of the health camp. However, when we talked to the service providers who were giving these services acknowledged that most of the women who came to seek for these services where doing it in hiding in fear that there would be problems if their husbands know about it. Women are more responsive to family planning services if they are supported and accompanied by their men to the health facility. In other cases, they can’t go alone except in hiding because they fear being seen by the community which sees a woman accessing family planning services as a woman of lose morals.

7. Buy in from community leaders is essential
The camp was attended by different local leaders such as Local council leaders at all level, district leaders and Member of Parliament. When the woman MP of the area showed up at the camp, she was so appreciative about the services that she sponsored for more advertisements on the community based radio stations which helped in pulling more masses to attend the camp. Community leaders therefore give legitimacy to such gatherings and their presence at the camp encouraged more people to attend it as was evidenced by the turn up after the Woman MP had come to the camp.

8. Health camps provide an opportunity to collaborate with local health organizations
The health camp took place during the health days in Najja Sub County. The organizers of the health days found it necessary to have one of the days devoted to the health camp. This helped in rendering more services to the members of the community.

9. Safe male circumcision embraced by community members
One of the health services provided during the health camp was safe male circumcision. It was among the mostly attended to service. The general understanding is that safe male circumcision helps to reduce the possibility of one getting infected by STDs including AIDS. There is however need for further sensitization to inform the community that SMC does not necessarily mean that one will not be infected with STDs.

10. Limited knowledge about Non communicable diseases(NCDs)
Non communicable diseases are still a silent killer among people that their ignorance about how to go about them calls for more action. With support from UNDP, there was sensitization of community members about how to avoid contracting NCDs. With emphasis on diet, it was realized that people hardly know the benefits of natural foods like fruits and vegetables as they thought eating good is when you can afford meat and fish.

All in all, the health camp would not be a success without support from partners; St. Francis Nyenga Hospital, Marie stopes Uganda, Reproductive Health Uganda, Nakasero Blood bank, UNDP, ASDHI, Buikwe Hospital, St Francis Njeru, Buwagajjo Health centre III, Makindu Health centre III, Buikwe NGO board, community VHTs, area MP, Sacred heart Senior Secondary school, and Allied Teachers secondary school.

Nevertheless, by the end of the 4days, hundreds of people had received Medical attention, Circumcision, Family planning services, HIV counseling and testing, general sensitization, all at no cost, thanks to all our partners.

The Center for Health, Human Rights and Development (CEHURD) will be holding a 4-day health camp in the Buikwe District from Tuesday 19th August to Friday 22nd August 2014. Buikwe is a predominantly fishing community located in the central region of Uganda.

The health camp follows the community consultations conducted by CEHURD under the Go4Health (Goals and Governance for Global Health) process from which a number of issues arose as health concerns in this district: family planning services, antenatal care, postnatal care, post-abortion care, HIV services (particularly mother-to-child transmission of HIV), lack of testing and counseling services, malaria treatment, diarrhea, and non-communicable diseases (including diabetes, cancer, and hypertension).

As an intervention, CEHURD reacted with organizing a health camp where local health centers, service providers, and NGOs have collaborated to provide free services to the community members of Najja and Nyenga (sub-counties). This health camp will act as an opportunity for the community to engage in health education, obtain testing, screening and counseling services, and receive a variety of hygiene and nutrition tips.

The health camp will also create a platform for health service providers, agencies, and advocacy groups to learn immediate health concerns from community members in order to strategize how to build capacity.

The Health camp will be held in two shifts. It will be held in Nyenga Sub County on the 19th and 20th August 2014 at Allied teachers’ School playground and 21st to 22nd August 2014 at Sacred Heart Senior Secondary school playground.