This is a three year  project funded by the Results for Development Institute Inc (R4D) under the transparency  and accountability Programme (TAP). It has  research and advocacy  components which are intended to improve accountability for health expenditures and health service delivery.   Its goal is to improve the effectiveness of public spending and service delivery. It is jointly implemented by UNHCO and HEPS-Uganda in Bushenyi and Lira districts respectively.

The project has so far been operational for two years during which a Quantitative Service Delivery Survey (QSDS) and Citizen Report Card have been conducted. The 3^rd year involves implementation of the Community Score Card augmented with continued advocacy at community, district and national levels.

The QSDS focused on the service provider perspective.

Key findings of the QSDS included (full report at - http://unhco.or.ug/library/?did=17):

• Infrastructure for health service delivery is not available at lower levels while in higher level health facilities is inadequate due high patient loads
• Newly constructed health facilities especially HC IIs and IVs are not put to use immediately because of lack of staff and equipment
• Inadequate storage facilities for medicines
• There is acute lack of lighting in the facilities; less than ¾ of thefacilities were connected to electricity and most of them were disconnected.
• Health financing still remains low in all districts with unfinanced gaps.

On the other hand, the Citizens’ Report Card (CRC) provides perceptions of healthcare users on service accessibility, availability and quality at selected health facilities in the districts of Bushenyi and Lira.

The key findings of the CRC study are:

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In 2005 the world ratified the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), the first public health treaty in history. It was negotiated by 193 World Health Organization member states and has so far been signed and ratified by 176 countries, representing nearly 90% of the world’s population. We are proud to mention that Uganda is one of the 46 African countries which signed and ratified this important public healthy treaty. However, it’s also important to note that our country is not among the eleven African countries that have tobacco control laws in place. By ratifying this treaty, our leaders made a promise to our children and people that they will protect them from death, disease and disabilities resulting from tobacco use and exposure to secondhand smoke. Now is the time to deliver on those promises and our leaders cannot backtrack on their commitment to save millions of Ugandans dying of tobacco attributable disease. In order to protect the health and lives of her people, Uganda must act urgently and collectively to enact a comprehensive and WHO FCTC compliant tobacco control legislation.

We know that about 22% of Ugandan males and 4% of females between 15 and 49 years of age, currently, use tobacco products. We also know that tobacco use is highly addictive and kills one-third to one-half of all lifetime users and an estimated 6 million people die each year from lung cancer, heart disease and other tobacco related illness (1 in 10 adult deaths). By 2030, 80% of those deaths will be in developing countries, where Uganda lies, unless something is done. Scientific research tells us that on average, smokers lose 15 years of life and half of all smokers will die of tobacco-related diseases. It’s sad to note that about 600,000 of the deaths are attributed to second hand-smoke. Unless we take a preventive action now, Uganda will be one of those countries to bear the brunt of this death toll.

To date, our country has been a role model in the fight against HIV/AIDS and we have the opportunity to show the world that we still attach great value to human life by simply adopting the world’s proven best practices to prevent the tobacco epidemic, perhaps the biggest threat to our health, economy and development. For instance, we know that 100% smoke-free environments, tax increases on cigarettes, pictorial warning labels, total bans on tobacco advertising, promotion and sponsorship have prevented the youth from starting to smoke and forced the poor to quit smoking.

Faced with a declining market and strong tobacco control measures in developed economies, multinational companies are targeting low and middle-income countries as their future market for their death, disease and disability causing trade. We are aware that the Tobacco Industry in Uganda is marshalling huge funds, their usual tricks and tactics to frustrate the tobacco control legislation process.  I would like to encourage us to be the watch dogs of their works having in mind the health burden of tobacco and how it is denying the citizens their right to health. They may have all the money to frustrate us but we also have scientific facts to prove the enormous health, economic and environmental burden caused by their lethal products.

It’s important to note that tobacco affects every sphere of a country and policies to prevent tobacco related deaths and diseases are only effective when all arms of a Government work together. We all have to be alert and committed because we are fighting for a noble cause.

The Campaign for Tobacco Free Kids has provided support to civil society and other partners involved in this struggle. The Ministry of Health and World Health Organisation have also provided continuous support towards this initiative.

JOIN THE CAMPAIGN!!

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In 1999 Dr. Samuel Lwanga led colleagues and advocates to create an institutional voice for patients. This gave birth to the Uganda National Health Users’/Consumers’ Organisation (UNHCO).

Late Dr. Samuel Lwanga

Fourteen (14) years on, UNHCO, popularly known as the “consumers’ representative” in the health sector is a formidable Non Government Organisation empowering communities to stand-up for their right to quality health services and contributing to policy processes at national level.

Dr. Lwanga will be dearly missed by UNHCO community, Staff and Board of Directors. May God rest his soul in eternal peace.

If you wish, type a condolence message in the text-box below.

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The Community Score Card (CSC) engages providers of services (duty bearers/health workers/ DHTs) and service users (Right Holders/health consumers/users) separately on various aspects of service delivery and then brings them together in an interface meeting to agree on priority service delivery issues and develop appropriate action plans to improve healthcare service delivery. The CSC uses the “community” as its unit of analysis, and is focused on assessing and capturing opinions and perceptions of the community at the local/facility level.

Supported by the Open Society Foundations’ (OSF) Public Health Programme and the Open Society Initiative for Eastern Africa (OSIEA), UNHCO currently implements a project to promote transparency and accountability in health service delivery in the public sector in the districts of Oyam and Masaka in Uganda.

The project employs the CSC to facilitate effective participation of communities to monitor aspects of health services including medicines and Human Resources and demand accountability.

The major changes influenced through Community Monitoring in the Oyam and Masaka Districts:

With increased awareness on consumer rights, entitlements, standards, the communities were more organized and could easily be mobilized. This was very empowering and was useful in getting community members to get involved in collectively identifying problems at the facility, looking for solutions, and planning for actions.

Three major achievements were realized at Agulurude HCIII:

A) Provision of safe water to the Agulurude community:

The water problem was part of the issues that was identified. The water-point at the health center was close to the latrine at the health centre.  It had been observed that the water source was contaminated with faecal waste but no action had been taken. This was taken on as a priority during action-planning in the community score card exercise. During the follow up of the implementation of the action plan, the community monitors raised the matter with the local council III chairperson asking for the closure and replacement of the latrine at a location far from the water point. Together, they approached several organizations to help in the construction of the latrine. After a two months period of searching, the Victory Outreach Ministries and Crossroads Mission offered the Agulurude community with a safer latrine.

The newly constructed latrine was completed in August 2011.

‘Communication between us and the community members has greatly improved. They trust us now and they have helped us improve on issues that have been failing us”. – Opio Daniel Patrick. Medical clinical officer/ incharge Agulurude HC/III

B) Construction of staff quarters for Agulurude health centre

 Staff accommodation at Agulurude HC III had for long been an issue of discussion amongst district health staff, health workers and the community. The poor time keeping of health workers was largely blamed on the lack of adequate staff quarters. As a result, the Government provided funds for the construction of three staff quarters at the health centre to improve punctuality of health workers and increase quality of service delivery. This construction was to be handled by Oyam district Local Government.

The staff-quarters construction project was, in June 2011, reported to be completed but actually found to be abandoned at trench (foundation) level. The contractor had failed to construct the staff house since excavation six months before the intervention of the community members in December 2011. This was priority number two of the community monitors. This finally won them full support and backing of the health centre staff. The monitors held a meeting with the District Health Officer, Engineer, and Chief Executive Officer to follow up on the matter. In a letter to the District Health Officer, they requested for detailed explanation on the status of the project copying the district engineer, Resident District Commissioner and Chief Administrative Officer. This effort from the community monitors revived the construction of the staff quarters.

Following this meeting and feedback to the community on the findings of the community monitors, the monitors with massive support from the community members called for a meeting with the contractor during which a warning letter was issued to the contractor to deliver on the project deliverables in three months. The contractor subsequently resumed the work at the site. It was due to this pressure from the community members, monitors and district officials that the contractor re-started the project. The staff-quarters are now at beam level as shown in the photo below.

“There is increased collaboration between the district, health workers and the community monitors. At first, i thought these people had come to fight the staff but our achievements within this short period of time through this group is un imaginable!” – Oyam District Health Officer.

C) Improving cleanliness at Agulurude HCIII

Filling the positions of porters (cleaners) is among the biggest human resource for health challenges that affect Oyam district. The government raised the qualifications for porters at health centres requiring only holders of Uganda Certificate of Education (Senior 4) to apply for the position – a high qualification for the position. Noticeably in the district, when these over-qualified individuals are hired they feel ashamed to be seen sweeping, slashing and dusting the health centre. Cleaners were reported to be absent. The compound was bushy and generally not clean. This became the third issue of interest of the community monitors. Together with the area LC-1 chairperson, the community monitors met the DHO on the issue. The DHO immediately issued a directive withholding the porters’ salaries and later transferred one of them. However, this did not change the situation at the health centre.

In response, the HUMC members and the community monitors sought help from within the community to ensure that the health centre is cleaned regularly. A community member offered to volunteer to clean the facility who was welcomed by the health workers. The HUMC requested the In-Charge of the health centre to provide a motivational fee to the volunteer from the Primary Healthcare (PHC) Funds of the health centre.

At Mpugwe HCIII, in Masaka District, communities successfully advocated for:

1. Connection of the health centre to the electricity grid and construction of a second rain-water harvesting tank.

The first community score card exercise conducted in Mukungwe sub-county in July 2011 identified the lack of electricity and inadequacy of water at the health center as a major obstacle toward realizing quality service delivery. Consequently, the community members led by the community monitors had several lobby meetings with sub-county authorities on the issue. These were forwarded to the district and

2. Provision of a dental clinic at the health centre

3. Expansion of the OPD and provision of extra land for expansion of the health centre.

The major drivers of the changes achieved

• The composition of the community monitors had community resource persons who had served the communities on voluntary basis for a relatively long time and their positive attitude towards development was a key factor in their success. It also comprised of some HUMC members, retired civil servants, women and men and youth. This brought a lot of experience and vibe to the activities of the group. Regular meetings, dialogues at the facility and invitation of opinion leaders (Local council chairpersons, sub-county chiefs, etc) and coordinators of related accountability programmes attracted support from the community and the district.
• The responsiveness of the sub county and district officials towards the plight of the community monitors encouraged them to pursue their cause. Whenever the CAO and DHO sees at the district they call us for a discussion before entering the relevant offices, remarked the team leader.
• Regular and participatory monitoring by UNHCO helped them in identifying key challenges and possible action s for improvement, applying a technical mix of approaches at various levels of the community and the district

Lessons and best practices

• Empowered Communities can define and design the best ways for quality health care.

• Working with the district improves responsibility and ownership of programmes

• While establishing community structures, opportunity should be given to the community to select the individuals they trust most rather than the district selecting on their behalf.

• Community monitoring is empowering to both the monitors and the community at large. Communities are more aware of their entitlements and standards at facility level.

• The community monitoring enhances the service provider’s responsiveness to the needs of the communities they serve. The Service providers get honest feedback from the consumers through the scorecard.

• Through constructive dialogue and honest continuous engagement, transparency and confidence is restored in the service providers and other public actors.

• Community members feel appreciated when they are involved in service delivery. They were very happy being part of the district monitoring team.

Future Plans

• Roll out community monitoring at all HCIIIs and HCIVs in the entire district.

• Use the Agulurude H/CIII and Mpugwe HCIII case studies as a model for promoting transparency and accountability

Supported by, Open Society Initiative for Eastern Africa

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RATN currently has 33 Member Institutions (MIs) in Kenya, Uganda, Tanzania, Rwanda, Zambia, Malawi, Zimbabwe, Botswana, South Africa, Swaziland and Lesotho with its secretariat based in Nairobi, Kenya.

RATN’s mandate is to ensure capacity for HIV and AIDS response is developed and strengthened in ESA region. RATN through training, support for training, curriculum development, knowledge and information management, and networking develops and integrates into its programmes modules that aim at skills and competency development on design and effective implementation of HIV interventions.

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The District Chairperson’s View:
The first stop was at the Lyantonde District Offices where we met the LC V Chairperson to share with us what he knew about the maternal deaths. The Chairperson informed us that he had heard of the allegations against the health workers but was waiting for a detailed report of the maternal death incidences from the District Health Officer. He however noted that there is a lack of follow-up by doctors who take-up treatment of pregnant mothers but along the way never follow-up.
“This is a doctor who operates on a mother. The mother is dumped in a maternity ward and she reaches at the time of being discharged when the same doctor who did the caesarean has never seen this mother again. This is a big shame. ” – District Chairman, Lyantonde District
“We are hampered by public standing orders. When we try to get the culprits punished, our hands are tied” – District Chairman, Lyantonde District

At Lyantonde Hospital
Our next stop was at Lyantonde Hospital where we intended to speak to the Hospital Administrator. Unfortunately he was engaged in a meeting. Efforts to speak to the District Health Officer were also futile.
Fortunately, we talked to the PMTCT In-Charge at the Hospital who informed us that she is not aware of the specific deaths in question but knew of some isolated cases that occurred mid last year (2011) and some at the beginning of the year. She shared with us her views on why some mothers lose their lives and babies during pregnancy: “They come at a stage wher we can’t save them. For example, last month there were two mothers who died on arrival at the hospital due to retained placentas. Also some mothers do not share with us all the information about their health. In this case, one died due to ‘coagulation defect’. Though she came early and could have been saved, she did not disclose that she had this defect. Unfortunately the hospital lacked platelets that could have saved her.”
She however denied allegations of negligence at the hospital and further emphasized that mothers always report to the hospital when it is too late.

Visiting the Victims’ Homes
The team visited two of the victims at their homes to get first hand information of their experiences at the health centre.
The Case of Sanyu Kasaga:
The first case is of 25 year-old Sanyu Kasaga of Bitooke-Bisalire village, Malongo sub-county in Lwengo district. Sanyu was taken to Lyantonde Hospital in labor where she was attended to by the health workers. Later, the same day her situation worsened and she was referred to Mbarara Hospital as, according to the information given to her husband, the Hospital lacked the appropriate equipment to handle her worsening situation. As they departed, Sanyu had a boda-boad accident right at the Hospital Gate. The husband tried to get his pregnant wife re-admitted in vain. The hospital staff simply told them to go Mbarara Hospital as fast they could. Half-way to Mbarara, Sarah breathed her last and died on road-side. Confused and frustrated, the husband took the body back home where his neighbors advised him not to bury the dead wife’s body together with that of the baby who was still in the womb. The family then hired the services of a local grave digger to carry-out the ‘surgery’ to remove the baby which was apparently done and eventually the two victims were buried. Sanyu left behind three children.
However, just before the burial, the police learnt about the case and arrested the doctor that had attended to the patient. Apparently he was released a few days later because the number of patients at the Hospital was increasing and there was no other doctor to attend to them.
The team also found out that Lyantonde Hospital does not have an Ambulance which is a probable contributor to the increasing number of deaths.

The Case of Sarah Nalukwago
42 year-old Nalukwago Sarah first complained of sharp pains in the abdomen and a feeling that the baby was not moving in her womb. This bothered her and together with the her husband, Mr. Jackson Bareebe decided to seek medical care. The two then left their home in Kabusirabo-A village, Malong sub-county in Lwengo district to a health center in Kyazanga – a neighboring town. In Kyazanga, they were referred to Lyantonde Hospital where they immediately set-off to.
In his own words, Jackson told us this; “When we got to the hospital, we could not readily find a health worker to talk to. When we finally got someone to attend to us, my wife was told to undergo an ultra-sound scan for which I had to part with UGX 20,000 for it to be done. However, we were given the results the following morning. The baby had died in the womb. I tried to enquire whether they could at least operate on her and remove the baby but my plea fell on deaf ears Around 1pm the same day, my wife became very sick. That’s when the health workers got concerned and as she struggled to breath she was put on emergency oxygen. Moments later she died”.

That is the story of how Sarah’s six children lost their mother.

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The exercise will continue and roll-out in the other two districts of Kamuli and Lyantonde.

Supported By:

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Over the last decade, government has formulated a wide range of policies, action plans, enacted new laws and established new institutions to lead its anti-corruption efforts. However, these efforts have yielded substandard results and the recent developments raise doubts about the willingness of government to effectively address corruption. High profile corruption cases such as the Temangalo Scandal, the Global Fund Scandal, and the CHOGM scandal clearly show that we are losing the race against corruption.

World Bank estimates show that Uganda loses an estimate of $300 million (Ugx 500 billion) annually to corruption. Likewise, the 2011 Transparency International Perception Index gives Uganda a decimal score of 2.4 on scale of 10, placing it as the 143rd of the world’s 183 countries.

As part of a wider civic action against the corruption vice in Uganda and in a bid to build a citizen movement in the fight against corruption, Civil Society Organizations organized the 1st National Annual Anti-Corruption Convention. The Convention which took place on 8th December 2011 at Imperial Royale Hotel brought together over 600 participants from all walks of life including; women groups, youth, private sector, farmers groups, government officials, Members’ of parliament, development partners and presentatives of Civil Society Organizations. The overall objective of the convention was to kick start the process of building a national anti-corruption movement of patriotic citizens to work towards total elimination of corruption and abuse of office in Uganda.

The Convention gained from presentations and discussions by elder statesmen and women with a proven record of integrity and high moral standing. These included; Hon. Maria Matembe, Prof. Joy Kwesiga, Prof. George Kanyeihamba, Mrs Rhoda Kalema, Mr.Paul Etyang, Prof. George Kirya and Gen. Elly Tumwine, Bishop Zac Niringye and Bishop Muhima among others. Parallel sessions were held to bring together constituent groups with the aim of discussing corruption in their respective constituencies. They included; The youth and corruption; Women’s movement in Uganda and corruption; Workers Movement in Uganda and corruption; Corruption and service delivery in health and education sectors (Uganda National Health Consumers’ Organisation; and Transparency International Uganda organized this session ); Corruption and the role of Parliament and the media and corruption.

The Convention participants agreed to the following broad actions;

• To identify and elect leaders and holders of public office of high integrity that would make decisions in public interest and not personal gains by making corruption an election and performance issue
• Organize Regional Anti-Corruption Conventions country wide as a build up to the annual National Convention
• Constitute a task team to write to the President demanding that he stops appointing people implicated in corruption to public offices
• To expose /shun all corrupt leaders through a regular list of name and shame to reverse the glorification of corruption.
• Widely disseminate the Kampala Communiqué to all citizens of Uganda

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