Change, from the muddy bottom up

After slipping and sliding across the rain-soaked roads of Ivunamba village in eastern Uganda, gripping the seat of the boda boda (motorcycle taxi) and praying I don’t get catapulted into one of the innumerable brown puddles creating an impressive obstacle course in our path, I approach the Health Center II that serves the basic medical needs of six villages here in rural Jinja District.

As the boda driver meanders his way between crops and mud huts, between herds of cattle and scattering children chanting the obligatory “bye mzungu” to the white foreigner passing them by, I can’t help but wonder why a government health facility would be located so far from the main roads, making access to health care even more of a challenge for the community.

Then again, the “main roads” are in no better shape. The rain pounded the whole area for an ostensibly endless afternoon just the day before, and again late into the night.

Like nearly every government health facility, the simplicity of the Health Center is striking: a basic cement structure, 4-5 rooms, torn posters on health topics in a language few can read, a crowd of women, children and men squeezed onto a solitary bench rested atop the mud-streaked veranda. I greet them and pass through an additional waiting area where I see a child being examined by the resident nursing assistant for all in the waiting room to see.

Like all health centers I have visited over the past 8 months, patient privacy certainly leaves something to be desired.

I greet the nursing assistant, her face already drained of energy at only 10am, and I can tell that she has been running the facility alone since she woke this morning. I ask for midwife in charge, and she informs me that the midwife recently lost her own child during childbirth and is no longer coming into the health center for work. The other 2 staff members simply failed to show up today.

I think back to months of interviews, to the countless stories I have heard from health workers working in Jinja District’s most rural areas. I have seen that face more times than I can count – weathered from the exhaustion that consumes these women as they attempt to muster all their strength to tend to the dozens, if not hundreds of women and children that flood their Health Center’s doorstep each day in need of basic medical care.

Several of the women waiting outside are pregnant, some cradle newborns in their arms. Waiting for antenatal care. Waiting for immunizations. Waiting to be seen. Waiting to be heard.

Some will wait all day. Many will find that the health center does not have the supplies or drugs they need. Several hours from now, a few mothers will be sent home without being served at all.

This health center seems to perfectly illustrate the challenges in Uganda’s health care system, plagued by inadequate funding and a staggering list of barriers to access. As Dr. Joachim Osur, head of reproductive and child health at Amref Health Africa, writes in The Guardian:

“The consequences are tragic, with maternal health epitomising the impact that underfunding can have on a health system. Too many Africans, including mothers, are dying of preventable diseases. The main causes include weak health systems characterised by poor infrastructure, inadequate supplies of drugs and equipment, a critical shortage of health workers, and weak management capacity.”

Osur also notes that across Sub-Saharan Africa, at the current rate of health staffing increases, it will take 29 years to reach the World Health Organization’s recommended numbers of medical staff.

At S.O.U.L. Foundation, our aim is to foster a better awareness and understanding among local mothers of the importance of adequate maternal care, and of navigating the challenges to accessing it. Much of this maternal health education programming will focus on instructing women how to effectively engage with a defunct health system – education on avoiding obstetric complications should they be unable to reach a health facility, planning for transportation problems, and savings cooperatives for money needed for supplies that should be freely provided by the government.

At the systemic level, increased funding for maternal health and for rural healthcare in general in Uganda needs to be better prioritized, both nationally and globally. That goes without saying.

At the grassroots level, communities and community health workers require more knowledge and training on how to interface with the health system, as it exists today. Women will often fail to seek antenatal care or will choose not to deliver in a health facility simply because they have heard that the health workers are rude, or that they will be required to bring supplies they do not have. Preparing women and their male partners throughout the pregnancy period will enable families to better plan for and mitigate these potential negative interactions with the health system, and the health system does not need to change for them to acquire this knowledge.

All of this can be accomplished cheaply and effectively through interventions focused on education. Sustainable improvements to any health system require not only that the system itself is strengthened in its capacity to adequately care for the health needs of the population, but also require the population itself to be able to take full advantage of that capacity. Without proper education and mobilization, communities will continue to fail to access the healthcare that they need simply because they are unaware that is available to them.

When we started working for S.O.U.L. Foundation, the organization did two things, and did them well: education and women’s empowerment. Through our research and the design of trainings to reach community health workers and community members themselves, this tiny organization nested in this quiet pocket of eastern Uganda is now equipped to move forward with community based – and community led – interventions that address maternal health issues as they affect this specific context. We will start with in-depth trainings with local Village Health Team members on how to improve maternal health in their communities, then move on to training the community members themselves.

In this way, S.O.U.L. will continue its valued work in education, but use this approach to do our part to improve health outcomes in our community.

While we cannot change the system, we and other organizations of our limited capacity can effectively change the way individuals interact with the systems at their disposal.

Yes, change is required from the top down, but that does not mean we cannot start building sustainable change from the bottom up while we wait.

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