Linking People With Their Governments
A White Ribbon Alliance Strategic Approach
By Robina Biteyi, National Coordinator, White Ribbon Alliance Uganda
“I have seen more change happen in the last two years than I have seen in the previous 40 years of my career,” said Philomena Okello, a nursing officer in Lira District, Northern Uganda.
Philomena has experienced the “before and after” of improvements to maternal health service delivery in Lira that accelerated only after White Ribbon Alliance Uganda brought citizens into the process, specifically to inform government decisions around health.
“We have asked for and received these improvements because we have learned of our rights through the citizens’ hearings. We became empowered and demanded accountability. This is just the beginning, because we know that it is not just our right to be heard, but involving us, listening to us, is the only answer for long-term, rapid and sustainable change,” Philomena said.
Linking people with their governments and global bodies is a key strategic approach of White Ribbon Alliance (WRA) and is an approach that has been instrumental in driving progress across many WRA National Alliances.
After participating in citizens’ hearings at the country level, Philomena was chosen to represent her community during the 70th UN General Assembly. Her statement caused a stir as she told an audience of 200 leaders from around the world, including government ministers and UN chiefs who were gathered at the Partnership for Maternal and Newborn Health Accountability Brunch, that citizen participation is what changed and finally brought about progress for mothers and babies in Lira. When she returned to Lira with stories of speaking with then WHO Director General Margaret Chan and other global health leaders, Philomena gained newfound respect from the community. She embraced this responsibility and brought others with her.
The advocacy efforts of Philomena and other community members, led by WRA Uganda, have resulted in the recruitment of health workers, the building and renovation of health facilities and ensuring they had enough of the right medicines, supplies and equipment. Despite decades of health worker shortages, medicine stock outs and substandard facilities that frustrated caregivers and patients, WRA Uganda achieved these results in two short years. By demonstrating the benefits to all those involved in maternal health — policy makers, health providers, women and other community members — everyone embraced their roles, claimed responsibility and worked together to bring about the desired results in service delivery.
A CLOSER LOOK
Government makes a commitment to maternal health service delivery
In 2011, WRA Uganda lobbied the government of Uganda to make a commitment to Every Woman, Every Child, to improve maternal health services in Uganda. In response, the government committed to ensuring that, by 2015, all sub-county and county health centers will provide Basic Emergency Obstetric and Newborn Care (BEmONC) services, and that half of county health centers will provide Comprehensive Emergency Obstetric and Newborn Care (CEmONC) services. This government pledge came in the wake of Uganda’s appalling maternal health statistics which showed that 17 women and 106 newborns were dying every day due to inadequate government investment in lifesaving emergency obstetric and newborn care.
WRA Uganda spearheads the collection of evidence on maternal health service delivery
There was no data on the state of emergency obstetric and newborn care in Uganda, no facts upon which WRA Uganda could use to petition the government to act on its commitment. WRA Uganda then mobilized district leaders, District Health Officers, community members, midwives and media to conduct health facility assessments in 43 government-funded health centers. None of the health centers in question met the minimum requirements for providing emergency maternal and neonatal treatment for complications like severe bleeding, infections, high blood pressure and resuscitation of newborns. There were other shocking findings: Not one of the 43 health centers had the mandatory blood bank to provide blood transfusions. Nor did any of the districts met the minimum staffing requirements and, outstandingly, Lira District’s Kabale had not one of the 14 required medical officers. Many other gaps were also discovered.
WRA Uganda starts a campaign
Armed with this information, WRA Uganda started a campaign dubbed Act Now to Save Mothers and embarked on educating citizens about the government’s commitment to improve maternal health services, the state of maternal and neonatal care in their health centers, their rights to quality, equitable and dignified health care, and their specific role in improving the system. Some people in the communities were recruited and trained as citizen journalists to document the evidence from the health facility assessments and the progress of the campaign.
WRA Uganda equipped citizens with advocacy skills, enabling them to demand changes in maternal and neonatal health service delivery. Citizens’ hearings — a social accountability tool in villages, districts and cities — were also used as part of the campaign. In addition, citizens were encouraged to write and sign petitions calling upon the government to act. These petitions were presented to local district and political leaders, who then presented them to national government leaders.
“Do not sit in the ministry to plan for our health without consulting us to find out our health needs,” a citizen courageously told the Minister of Health Hon. Dr. Chris Baryomunsi during a citizens’ hearing in Kampala. Minister Baryomunsi was moved, and promised to ensure that citizens are engaged in the design, planning and monitoring of government programs.
Engaging all relevant stakeholders
Throughout the campaign, WRA Uganda avoided blaming government leaders and instead highlighted ways district officials, parliamentarians, technical committees and government ministries could collaborate to address the problem, helping to build strong relationships. In return, WRA Uganda obtained the necessary cooperation needed. The political leaders were excited about the campaign, the citizens’ hearings, and the opportunity they provided to listen to their constituent’s concerns. It was through this campaign that they said they learnt how to identify gaps in service delivery and to budget for improvements.
Hon. Atim Joy Ongom, a Member of Parliament of Lira District, was happy to engage with citizens. “I’m grateful the community already knows what is needed. Previously, they were dying innocently. They didn’t know government had a responsibility to do certain things for them, but now the citizens have raised their own voices, they are saying we need this and that done,” she said.
When these political leaders presented the concerns of their people regarding the state of maternal and neonatal healthcare on the floor of Parliament, other members of Parliament acknowledged that their communities were facing the same challenges, and, perhaps more importantly, that the government needed to consider their communities’ perspectives when responding to maternal health concerns.
WRA Uganda also leveraged its strong relationships with the media, which amplified the voices of citizens to ensure they reached all decision-making platforms at the districts, Ministry of Health, Parliament, national medical suppliers and other service providers.
“The awareness [of citizens about their rights and obligations] culminated into a petition that we presented to Parliament. The Speaker referred the petition to the [Health Committee of Parliament] which decided to visit Kabale district to learn first-hand. They confirmed White Ribbon Alliance findings. The process helped us focus on finding solutions for the entire country,” said the Hon. Ninsiima Rhona Ritah of Kabale District.
Several achievements were realized because of the campaign:
Health worker recruitment
Kabale district, which faced the most severe health worker shortage among the three districts which were assessed, recruited and placed a medical doctor in every health center in the district.
More women delivering in health facilities.
Ms. Kihembo, a nursing officer in Kabale declared, “We used to refer many mothers to Kabale Regional Referral Hospital but since the deployment of Dr. Mulindwa, Medical Officer I/C of Health Centre Hamurwa, more mothers are delivering at the health center.”
Improved health worker morale
Improvements in infrastructure boosted the morale of the care givers. “Generally, staffing and accommodation for staff have improved,” said Dr. Lwassampijja, District Health Officer of Mityana.
· Effective use of citizen-led accountability has had a ripple effect beyond the three target districts. Even after the campaign ended, people have continued to engage leaders about safe motherhood. Key events including budget preparations and health facility monitoring visits have been used by citizens to demand changes.
· The campaign achieved results because it was evidence-based and commitment-specific.
· Taking citizens to the UN General Assembly increased campaign momentum from the grassroots, to the national and the global levels.
· Getting citizens to understand their rights and engage their leaders was the way out of what they had been used to — and changing this mindset took time. It took lots of engagement between leaders and citizens to change the status quo.
WRA Uganda’s pivotal role in linking citizen with their government has been commendable. Leaders were happy that the campaign put them in touch with their constituencies and made them more relevant to the community, while citizens benefited from engaging their leaders. They are now able to access quality services because of this engagement.
White Ribbon Alliance unites citizens to demand the right to a safe birth for every woman, everywhere. We harness the power of local women and men to achieve lasting change. Our approach is working. Subscribe to WRA’s newsletter VOICES and follow us on Facebook and Twitter to keep up to date on White Ribbon Alliance’s global maternal health campaigns.