| Uganda:
Sustainability Achieved Through Partnership
Source: Rose M. Kershbaumer
The rolling hills of Kabale District typify the description
given by Winston Churchill in his 1908 description of Uganda,
Africa – The Pearl of Africa. Many things have changed
over the years but the two constants are the natural beauty
of the country and its warm and welcoming people. The peoples
of Uganda are indeed a resilient people who have survived
many internal and external conflicts since their 1962 independence.
It is a country of great promise and is held up as a prototype
in its efforts to combat the scourge of HIV.
The selection of Rubanda, Uganda for the replication of the
community based safe motherhood program, established in Malawi
in 1996, was based on the following criteria: (1) a remote
rural area with a high maternal morbidity and mortality rate,
(2) an established primary health care program with a record
of community rapport and dedicated health services (3) an
invitation by Medical Mission Sisters, an international congregation
of religious women responsible for community services in Rubanda,
to augment the knowledge and skills of the already trained
Community Health Workers (CHWs). A needs assessment conducted
in 1999 and dialogue with Sr. Edith Dug-yi, RN, PHN and the
primary health care staff, confirmed that the addition of
knowledge related to the empowerment of women and safe motherhood
to the existing CHW program, would contribute to the reduction
of maternal morbidity and mortality. The resulting Uganda/Penn
partnership is making a difference in the health and social
status of women in this area of Uganda.
The major difference between the Community Based Safe Motherhood
Advisor (CBSMA) of Chimutu, Malawi and the Family Focused
Safe Motherhood Community Health Worker (FFSMCHW) of Rubanda
Uganda is the gender of the health advisor. The FFSMCHW program
built on the strengths of the existing CHW program that includes
men and women. Similarities are both programs: (a) had a pre-intervention
survey conducted before the initiation of the program and
(b) are built on volunteers who have been selected by their
village communities and who are an integral part of their
respective communities. A strength of the Rubanda program
is the already existing strong supervisory team of Ugandan
CHWs, a schedule of supervisory visits known well in advance
by the FFSMCHW and the availability of a driver and 4W vehicle
to bring each to the area of supervision. Albeit, there will
always be a walk of 30 to 60 minutes for the supervising CHW
after the vehicle reaches the end of any passable road or
path.
Driving from the capital city of Kampala to Kigezi in the
District of Kabale is a trip of magnificent natural beauty.
The people of Kigezi are hard working and cultivate all available
land. Tiers of cultivation on the rolling hills is a sight
to behold. What is not apparent to the visitor enjoying this
scenery is the lack of infrastructure in this beautiful landscape
and the inaccessibility of health care. The Rubanda Primary
Health Care Program (PHCP) focuses on preventive care in the
community. It does have a maternity service for complicated
deliveries as well as a daily dispensary. To reach the dispensary
clients and family members may walk, over a very difficult
terrain, for miles. Each village has a stretcher committee.
On any given day a common sight at the Dispensary is a row
of locally constructed stretchers with 8 to 10 stretcher-bearers
awaiting the outcome of the examination of the villager they
have carried to the dispensary. The large number of carriers
per stretcher is to enable change of bearers from and to the
village. A gathering of women is indicative that the person
carried to the dispensary is a woman experiencing a difficult
labor or a retained placenta.
The stretcher-bearers are a captive audience for the daily
health education given at the dispensary, which now has a
strong component on safe motherhood. Prior to the inauguration
of the safe motherhood program men thought women’s pregnancy
and illnesses were for the ‘women’ and the sole
duty of men was to carry those in need to the dispensary.
Education of men, both at the dispensary and in the villages,
is bringing a decided change in attitude. It is not unusual
to hear comments such as “ I wish I had this information
when my wife/sister/daughter was pregnant”, “I
did not know the dangers of a retained placenta”, “I
did not know bleeding during pregnancy was a danger sign”,
etc. The Rubanda PHCP vehicle takes clients who need intervention
and care, beyond what can be offered in Rubanda, to the Kabale
District Hospital – an hour’s drive over a less
than desirable road. The well-paved road from Kampala terminates
in Kabale.
Penn’s files have many records related to this Uganda/Penn
Family Focused Safe Motherhood Program (FFSMP). It includes
documentation of the pre and post intervention surveys, safe
motherhood content of the syllabus/curriculum built on the
concepts of justice and equity and hence with a strong focus
on the empowerment of women and the girl child, summaries
of the three training sessions given to each in the five groups
who have received the FFSMCHW Certificate, supervisor reports,
feedback from the FFSMCHW giving examples of challenges as
well as successes. Ninety-one men and women are actively teaching
in their respective villages. A sixth group will begin the
program in January 2003. All members of the six groups began
as CHWs. The next group of volunteers are be trained in an
integrated CHW program that includes the empowerment of women
and safe motherhood concepts.
During a recent visit to Rubanda I had the privilege of spending
some time with Agnes Ngabirano, FFSMCHW, married with a family
and a long history of community service. I was interested
in learning her experience as a FFSMCHW. In our dialogue she
gave a fascinating account and demonstration of the development
of her potential for personal and community service. Agnes
began by saying she is an elected Counselor for her political
area LC 3. She then attributed this to her opportunities beginning
in 1988 when the primary health care program was initiated
and she received training as a Traditional Birth Attendant
(TBA). In 1991 she began her training as a Community Health
Worker that was augmented in 2000 with the safe motherhood
component. She very simply stated, “I only dig. My husband
and I dig to get money for taxes, clothing and food for the
family”. [Digging is the term used for cultivating in
the small family plot] “I have a big family. I work
hard. I help many”. “I was a TBA and CHW and when
I was asked if I wanted safe motherhood training I was very
happy. I wanted it very much because as a TBA I saw many problems
and I wanted to know more to help women and children and particularly
the girl child. This was an opportunity for me to get more
knowledge on how to help the girl child get more status and
rights in the community.”
She further explained, “Parents did not know how to
teach their children. Slowly the parents learned and are now
teaching their daughters and sons. I teach the old women,
mother in laws and husbands on the importance of women and
the girl child. How to treat the pregnant woman and the woman
in labor. I am an instructor in functional literacy. The men
are few. I use the safe motherhood messages in my teaching”.
In response to what she thinks are the three most important
messages to reduce maternal morbidity and mortality she stated
without hesitation: “The importance of woman and the
girl child.” “The importance of taking care of
the cord and not removing it in 4 days after delivery. Removal
of the cord is because there is not understanding.”
[There is a strong cultural belief that there must be a sexual
relationship 4 days after the birth of the child. However,
the cord must also be off. There is also a belief that the
sexual relationship is needed to cleanse the woman. A consequence
of this belief is umbilical hemorrhage and/or infection as
well as post-partum complications.] “Informing men and
women which conditions in pregnancy are high risk and requires
the mother to be seen during pregnancy by a trained TBA or
at the clinic.”
It was both a humbling and edifying experience to spend time
with Agnes. Her openness and sincerity is surely related to
her trust and confidence in the team of which she is an integral
part. There is so much good in each culture. As Agnes so clearly
stated, “Some things are done because there is no understanding.
We must help the older people understand.”
Ownership by the community can ensure sustainability of health
promotion programs. Rubanda is one example of a partnership
contributing to the reduction of maternal morbidity and mortality.
Rose M. Kershbaumer, RN, CNM, EdD |
back
to International
Reflections
