GW 1# ;] - Kampala

PUBLIC HEALTH &

ENVIRONMENT

BULLETIN

IN THIS ISSUE

DIRECTORATE OF PUBL IC HEALTH AND ENV IRONMENT

V O L . 1 . | I S S U E 3 | J A N U A R Y 2 0 2 1

HIV CLIENT-RETENTIONINTERVENTIONS02

MATERNAL AND NEW-BORN HEALTH SERVICES

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https://www.kcca.go.ug @kccaug @kccaug| 0800 99 00 00 | [email protected] | |

KCCA & BLOOMBERG'SPARTNERSHIP ON ROAD SAFETY07

GENDER BASED VIOLENCE08

E D I T O R I A L T E A M

Daniel Ayen Okello

Najib Lukoya Bateganya

Director Public Health & Environment

Deputy Director Public Health & Environment

Sarah Zalwango

Manager Medical Services

Christopher Oundo

Supervisor Medical Services

Alex Ndyabakira

Epidemiologist

Elizabeth Katana

Epidemiologist

Dear Reader, Happy New year 2021! Congratulations upon concluding the game changing year inpublic health (2020)

Enjoy your reading!!Thank you.

While thanking you, we invite you to share with us your ideasand feedback. Yes, we are excited to hear from you andready to extend our Bulletin family. For further informationwith regards to anything in this bulletin please contact any ofus: [email protected], [email protected]

In this issue, we are excited to share with you a wide varietyof articles focusing on Kampala’s health and environmentincluding: COVID-19 highlights and other PHEs, timelytesting for Presumptive TB, participation of HIV clients indeveloping client-retention interventions, Maternal and New-born health care services, KCCA and Bloomberg’sPartnership on road safety and Gender Based Violence.

We welcome you to issue 3, volume 1 of the KCCA-PublicHealth and Environment Bulletin. The aim of this Bulletin isto document and communicate the works, achievements,and key challenges with regards to Kampala’s Public Health,Environment and other related events. The end goal is todisseminate this information to the policy makers, healthprofessionals, the public, implementing partners and allstakeholders.

Kampala city continues to report the highest number ofconfirmed COVID-19 cases dominated by alerts and personstesting for travel purposes. Since March 2020, the COVID-19task force at the Kampala Capital City Authority (KCCA) hasdeveloped and strengthened key interventions including; 1)organizing the city response into key pillars that included co-ordination and leadership, surveillance, case management,laboratory, risk communication, and social mobilisation,logistics and strategic information 2) setting up of anEmergency Operations Centre (EOC) with a toll-free callcentre (0800 990000). By August 2020 the task force andresponse strategies were expanded to cover the GreaterKampala Metropolitan Area (GKMA) districts of Mukono andWakiso.

P H E S | C O V I D - 1 9

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The situation remains challenging requiring a Joint effort andmobilization by the public and all the stakeholders to achieveeffective control of the COVID-19 epidemic. As we await thevaccine in mid-2021 expected to cover 20% of the population,we encourage the public to strongly comply with the preventivemeasures including consistent and proper face mask use,social distancing, and practise of good hand hygiene.

Institution: Directorate of Public Health and Environment, Kampala CapitalCity Authority, Kampala, Uganda Uganda Public Health Fellowship Program, Ministry of Health, Kampala,Uganda

Authors : *Alex Ndyabakira , Elizabeth Katana , Cathbert

Tumusiime , Daniel A . Okello

COVID-19 outbreak highlights, December2020

1,2, 1,2

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*Correspondence: [email protected]

Globally, COVID-19 continues to affect countries, withalmost 80 million confirmed cases, and more than 1.7 milliondeaths. The COVID-19 outbreak response has encounteredchallenges with many countries that had apparent success insuppressing initial outbreaks, are seeing a rise in infectionsand reporting new waves with reinstitution of lockdowns, somecountries are struggling to flatten the curves, and there havebeen reports of a new variant strain in some countriesincluding the United Kingdom, South Africa and Nigeria.

As of December 31, 2020, there was a cumulative totalof 35,507 COVID-19 confirmed cases from 135/136 districts inUganda. 96% of the cases were locally transmitted while 4%were imported cases. Cumulative deaths due to COVID-19were 285 with a Case Fatality Rate of 0.82%. By November2020, the COVID-19 epidemic in Uganda was in phase four (4)with intense and widespread community transmission in nearlyall the districts. By mid-December 2020, Uganda was reportinga weekly average of 3,600 confirmed cases from 85 districts.

Kampala curve as of December 31, 2020

Important to note is that the COVID-19 pandemic was not theonly emergency the world dealt with in 2020, this pandemicwas just one of the many public health emergencies globally. In2020, The World Health Organisation responded to more than60 health emergencies including:

A large measles outbreak in the Democratic Republic ofCongo (DRC) with 380,766 confirmed cases and more than7,018 deaths, early 2019 to August 24, 2020 Measles in Mexico with more than 1,300 probable cases,April 2020· Yellow fever in Gabon and Togo, June 2020An 18-month struggle that ended the world’s second-largestEbola outbreak in the Democratic Republic of Congo(DRC), with 3,481 cases, 2,299 of them died, June 2020A devastating blast in Beirut, Lebanon, causing at least 204deaths, 6,500 injuries and leaving an estimated 300,000people homeless, August 2020WHO Africa region declared wild polio-free, August 2020Flooding in Sudan with about 100 deaths and over 50injuries, destroying more than 50,000 homes, September2020A major outbreak of Chikungunya in Chad with over 27,500cases, September 2020 Storms in Philippines and VietNam, damaging thousands of homes and agriculture,November 2020Mystery illness cluster in India possibly due to a neurotoxinwith more than 500 people hospitalized and one death,December 2020

Background.

Improving Community – Health facil ityteams’ coordination for Timely testing ofpresumptive TB cases in Nakawa division -Kampala City


Authors : *Herbert Kisamba , Harriet Komujuni , Hajjarah

Nanteza , Disan Lukanga , Daniel A . Okello , Angella

Kigonya , Abel Nkolo

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Institutions: USAID Defeat TB project, Reach out Mbuya community Health initiative (ROM), Directorate of Public Health and Environment, Kampala Capital CityAuthority

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Tuberculosis (TB) disease is caused by a bacterium and isdiagnosed through bacteriological confirmatory testing andclinical evaluation of Presumptive TB cases. PresumptiveTB case refers to a patient who presents with symptoms orsigns suggestive of TB.

(continued on next page)

M E D I C A L S E R V I C E S

Several diagnostic options including, sputum smear, urine TBLipoarabinomannan (LAM) and chest X-ray can be used todetect TB. However according to World Health Organization(WHO) one third of the TB patients still go undetected and inUganda more 30% of the TB cases go undetected eitherbecause of missed opportunities during care at health facilitiesor failure to access information and diagnostic services by thecommunity.

Interventions.In Feb 2020, TB care data analysis was done in Nakawadivision to fully understand the underlying reasons for delayand non-evaluation of some Presumptive TB patients. Theanalysis indicated that; sputum samples collected by thecommunity linkage facilitators (CLFs) were inadequate and thusrejected by labs. In addition, some presumptive TB patientscould not access health facilities while some weredelayed, and TB testing services were not consistentlyavailable at some health facilities.

The proportion of presumptive TB cases identified throughcommunity interventions that were evaluated within 7 days ofbeing presumptive TB cases increased from 23% at the 3intervention HFs (0% at Butabika hospital) prior to theintervention to 87% by the end of week 5 into the intervention(2nd week of March 2020) and remained high thereafter. Thenumber of identified TB case also raised during the interventionperiod compared to the preintervention period.

Conclusion.Improved coordination between the community TB providersand the health facility teams promotes timely access to TBdiagnosis among presumptive TB cases through addressingbarriers to TB testing.

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USAID Defeat TB project has since September 2017 beenworking with Ministry of Health and the Directorate of Healthand Environment at Kampala Capital City Authority (KCCA)to improve TB case finding in Kampala city.

The support by Defeat TB includes interventions at nationaland subnational levels including the community level. As oneof the approaches for community level TB control, Defeat TBproject sub granted 3 Civil Society organizations (CSOs) in 3urban divisions in Kampala city -Kawempe Homecare (KHC) inKawempe division, Reach out Mbuya community Healthinitiative (ROM) in Nakawa division and National women livingwith HIV in Uganda (NACWOLA) in Makindye division toimplement community TB control activities. While executingtheir roles, CSOs noticed a delay in testing of presumptive TBpatients identified through community interventions with some,missing the testing.

Interventions were executed to address the noted gaps whilemonitoring the proportions of presumptive TB cases identifiedthrough community activities that were evaluated for TB within7 days. A joint team of ROM staff and health facility TB focalpersons within Nakawa division reoriented the CLF on thesputum sample collection procedures to avoid sample rejectionat the laboratories, Lab personnel were coopted on thecommunity TB outreach teams to support sputum samplecollection and bi-weekly meetings were held between ROMstaff, /CLFs, health facilities in charges and or TB focalpersons to review progress and address any barriers.

Results.

Exploring the participation of HIV clients indeveloping client-retention interventions inKampala City Council Authority and SuburbsAuthors : *Henry Magala , Miisa Nanyingi1 2

Institutions: AIDS Healthcare Foundation-Uganda Cares Uganda Martyrs University

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SummaryParticipation of people living with HIV/AIDS in the developmentof client-retention interventions guarantees effectiveness of theinterventions. It empowers beneficiaries to initiate, implementand monitor performance of their own retention interventions.Unfortunately, many HIV service providers do not practicallysupport participation. This could be because of the costsinvolved in engendering participation.


In addition, participation apparently disempowers serviceproviders from taking the lead in developing the retentioninterventions. The expert-driven medical system and stigmafurther undermine participation.


Hence, many retention interventions are top-down and notvery appropriate for HIV clients. This could explain whyglobally only 20-40% of HIV clients are retained on treatmentdespite the many retention interventions. The study aimed atcontributing to the third goal of UNAIDS, attaining 90% viralsuppression. Effective retention interventions facilitate drugadherence leading to viral suppression. The study wasinformed by Arnstein’s model of citizen participation. It was aqualitative study conducted in Kampala Capital City Authorityand Wakiso District from August to December 2017. It involved15 FGDs and 6 key informants from six HIV service providersthat included civil society organizations, public and privatehealth facilities. The study had four objectives namely: First,to find out the existing HIV client-retention interventions.Second, to find out the level of awareness and experience ofHIV clients regarding retention interventions. Third, to find outthe level of participation by HIV clients and Fourth, to find outfactors determining participation of HIV clients in developingretention interventions. The results of the study were: Twelveretention interventions were found to be in use. However,participation of HIV clients in developing retention interventionsas alternative intervention to retain HIV clients was not known.HIV clients were aware of the retention interventions but mostof their experience was in implementing and not initiation.Wherever HIV clients participated, it was at a token level.Stigma and the operational environment of HIV clients weremajor factors influencing participation. Inconclusion, participation of HIV clients in developing retentioninterventions was influenced by the recognition thatparticipation is a necessity, prevalence of stigma andenvironment where HIV clients are served. The serviceenvironment also influenced stigma which reinforced absenceof participation. The study recommends adoption of theprinciples of beneficiary participation, affirmative action for HIVclients in developing retention interventions, evaluation of non-discrimination policy for HIV clients being led by Ministry ofGender Labour and Social Development and scaling up mediacampaign against stigmatization of HIV clients. Futureresearch on effectiveness of retention interventions developedby HIV clients would be required.

The study focused on exploring participation of HIV clients indeveloping interventions which facilitate retention of HIVclients in the care and treatment program. Participation of HIVclients delivers retention interventions which are owned andacceptable to the initiators. Therefore, such interventionsenhance retention of HIV clients in care and treatment. Retention of HIV clients is very important because HIV is achronic disease. Once started on treatment, there must becontinuity to benefit from the intended health outcomes likeviral suppression.


Achieving 90% viral suppression is one of the UNAIDS 2020targets. Falling out of treatment program leads to drugresistance, morbidity and eventually death. It is scientificallyknown that retention contributes to HIV prevention since HIVclients on medication are less infectious by 96%. Participationof people living with HIV clients is affected by stigma and theenvironment in which the clients are served. The attitude ofhealth service providers was noted as one of the componentsof this environment which determines participation. Additionally,health service providers often decide the package of retentionintervention for clients. According to Kranzer et al (2012)retention interventions for HIV clients are developed in highincome countries and transferred to Sub-Saharan countrieswhere health systems are poorly developed. Many of suchinterventions do not fit into local context and therefore not veryappropriate. Appropriate retention interventions according toKranzer et al (2012) require participation of the beneficiaries.This makes them acceptable and accessible. Uganda hastraditionally followed the medical approach of service deliverywhere professional health workers entirely determine thecontent of medical service and not patients. This could accountfor gaps in participation of HIV clients in developing retentioninterventions. Therefore, the study attempts to explore theexisting retention interventions and level of awareness andexperience of the retention interventions by HIV clients, thestages of participation by HIV clients in developing retentioninterventions and the most important factors that determineparticipation of HIV clients in Uganda.

The study was conducted in Kampala Capital City Authority andWakiso District. It was specifically conducted in the divisions ofKawempe, Rubaga, Nakawa, Kampala Central and Lwezalocated in Kyadondo South Constituency, Wakiso District. Theparticipants were drawn from TASO Mulago,Mildmay, Rubaga Hospital, Kawaala HCIII, Kisenyi HCIV andChild AIDS Fund. The study was descriptive and based on thegrounded theory by Glaser and Straus (1967). According to thetheory, analysis of the textual data is done to generate themeswhich form results of the study and the theory which forms theconclusion to the study. The study involved 15 focus groupdiscussions which were categorized under the age groups 18-24 years and 25-49 years. There were 113 participants inFGDs. In addition, the study involved Heads of HIV programsas key informants. Participants provided varied opinion andexperience related to the study objectives.

Methods

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IntroductionResultsThe study revealed 12 retention interventions for HIV clientsnamely: client follow up, health education, experience sharingby HIV clients, psychosocial activities, community pharmacy,client or service differentiation, treatment supporters, treatmentbuddies, medical monitoring of clients, referral system, incomegenerating activities, and the family-centred model.Participation of HIV clients in developing retention was nevermentioned by either HIV clients or key informants. Thelevel of participation by HIV clients was token and hardly


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making decisions on retention issues. Under token partici-pation, involvement developing retention intervention wasfound to be low, devoid of leadership role and ability toinfluence decisions. Factors affecting participation of HIVclients were noted to be both internal and external to HIVclients. The major internal factors cited were stigma andavailability of time to participate. The major external factor wasthe environment where clients are served. The environmentincluded attitude of health workers reflected in the relationshipwith HIV clients.

Participation of HIV clients in developing retention interventionsis determined by three main factors namely: recognition thatparticipation of HIV clients in developing retention is also anintervention, stigma and environment where clients are served.

Conclusion

curtains for privacy(98.2%), majority (>50%) don’t haverequired labor and delivery guidelines, Looking at performanceon Basic Emergency Obstetric and Newborn Care services,results showed that only 32.1% PFPs perform newbornresuscitation using a bag and a mask, 44.4% perform removalof retained products and only 3.6% perform assisted vacuumdelivery, concerning evidence based Care, whereas 91.0% ofPFPs routinely practice active management of thirds stagelabor and 75% routinely use partographs to monitor labor, fewperform breech delivery (17.9%), give special or intensive careto a preterm or low birth weight baby (12.5%), conduct maternaldeath reviews (5.4%) and perinatal death reviews (3.6%). Thefindings affirm that to a large extent, PFPs have gaps inprovision of BEMONC services, and in using partographs tomonitor labor. Furthermore, to a large extent PFPs don’t domaternal and perinatal death notifications and reviews, and lackMNH guidelines, protocols and tools. Werecommend continuous mentorship of health service providersin PFPs in provision of Basic Emergency Obstetric andNewborn Care (BEMOC), the value of evidence-based careespecially maternal and perinatal death notifications, andon job mentorships on the use of partographs. We alsorecommend that the different health partners working in theGreater Kampala Metropolitan should support PFPs to acquirekey MNH guidelines, protocols and data tools. To improvegeneral service availability and referral practices, PFPs shouldbe encouraged to utilize the new KCCA digital emergencytransportation system as a way of enhancing travel fromreferring to receiving facilities.

The United States Agency for International Development(USAID) is supporting the Kampala Slum Maternal andNewborn (MaNe) Health project, a partnership initiativebetween Population Services International (PSI) and KampalaCapital City Authority (KCCA). The project is testinginnovations to improve the provision of quality of care for bettermaternal and newborn health (MNH) outcomes in urban slumsettings of Lubaga and Makindye divisions of Kampala.

Background

HIV service providers should develop a participation frameworkand engender contribution of HIV clients in developing retentioninterventions. Civil society organizations should enhanceadvocacy campaign against stigmatization and discrimination ofHIV clients which affect their participation. Additional researchon effectiveness of retention interventions developed by HIVclients should be carried out. Ministry of Gender Labour andSocial Development should evaluate policy on non-discrimination of HIV clients and address the gaps.

Recommendations

A baseline health facil ity assessment revealsthe capacity levels and gaps of privatehealth facil it ies to provide Maternal andNewborn health care services in Kampala

*Correspondence: [email protected]; [email protected];[email protected];

Authors : *Andrew Magunda , Henry Kaula , Yvonne

Mugerwa , Sam Ononge , Daniel A . Okello , Sarah

Zalwango

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Institutions: Population Services International, Kampala, Uganda Kampala Slum Maternal and Newborn Health (MaNe) Project, Directorateof Public Health and Environment, Kampala, Uganda Directorate of Public Health and Environment, Kampala Capital CityAuthority, Kampala, Uganda

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We present findings from a quantitative cross-sectional surveywith 56 Private For Profit (PFPs) health facilities providingdelivery and newborn care services in Lubaga and Makindyedivisions in Kampala. The key results were; Majority of PFPs(94.6%) have midwives and 51.8% have doctors. All assessedPFPs (100%) offer normal deliveries but only 19.6% of thesecan conduct caesarean section deliveries, regarding clientvolumes, majority of PFPs (71.4%) deliver less than 20 mothersin 3 months and the same number of deliveries is recorded bymajority of PFPs (44.6%) in 12 months, results also show thatmajority of PFPs use other motor vehicles for referraltransportation and only 10.7% of PFPs have motor vehicleambulances to transport referred clients to otherfacilities, In terms of labor and delivery Management, while allPFPs assessed had gloves (100%), sufficient lighting (94.6%),and means of ventilation(94.6%), and functional toilets and

SummaryThe project conducted a baseline assessment in 125 healthfacilities located in and around slums of Makindye and Lubagadivisions to determine the current capacity of privatehealth facilities that provide MNH care services and establishgaps in provision of MNH care services that can be fixed byMaNe project activities. The assessment was conducted for aperiod of two months collecting service data for the last 3months and last 12 months to ascertain the client load offacilities that provide MNH services.

A quantitative cross-sectional survey design using a standardfacility assessment tool adopted from the USAID SavingMothers Giving Life (SMGL) project was used involving allhealth facilities which provide MNH services in Lubaga andMakindye divisions. Using data from the health facility censusconducted by KCCA in 2017, a total of 125 health facilitieswithin or close to slums in the two divisions were purposively

Methods:

in the two divisions were purposively selected from the 444health facilities and 5 public facilities offering MNH services inMakindye and Lubaga divisions. A total of 15 enumeratorswho were post graduate students at Makerere UniversityDepartment of Obstetrics and Gynecology collected the datafor a period of two weeks, using the electronic Open Data Kit(ODK), and supervised by the MaNe project staff. Data wasdownloaded in excel and exported to SPSS for analysis.Analysis and results presented in this article are based on 56PFP health facilities which provided delivery and newborncare services for a period of one year (May 2018 - April 2019).Data was disaggregated by division and status of use of thePFP medical doctors. Pearson Chi-Square tests were run at 5% level of confidence to determine the statistical differencesamong the disaggregation groups for the different variablesanalyzed.

Service availability and general referral: The assessmentfindings revealed that majority of PFPs (94.6%) are open 24hours and 7 days a week and these offer obstetric andneonatal care. All PFPs which don’t operate 24/7 are fromthe category of PFPs without doctors. In relation to referral ofmaternal complications, majority of PFPs (29.2%) in Lubagadivision refer to Lubaga and Mengo Hospitals. In Makindyedivision, majority of PFPs (62.5%) refer to Nsambya andKawempe Hospitals (18.8%). For neonatal complications,majority of PFPs (29.2%) in Lubaga division refer to Lubagaand Mengo Hospitals. In Makindye division, majority of PFPs(56.5%) refer to Nsambya and Kawempe Hospitals (21.9%).Majority of PFPs (92.9%) reported that the roads to thereferral sites for maternal complications and neonatalcomplications are paved. On average it takes less than 20minutes to travel from the referring to the receiving facilities.

Staffing and training at PFPs: 94.6% of PFPs havemidwives and 51.8% have doctors. There is a significantstatistical difference in the number of doctors, clinical officersand registered nurses employed by PFPs with doctors andthose without doctors. PFPs with doctors employ morestaff of the above categories compared to PFPs withoutdoctors. There are PFPs (5.4%) which deliver motherswithout any midwife among their staff. Majority of these arePFPs without doctors although the difference in theproportions of PFPs of the two categories is not statisticallysignificant. Only 25% of PFPs have at least one staff trainedin maternal death reviews and 26.8% of PFPs have at leastone staff trained in perinatal death reviews. All PFPsassessed (100%) offer normal deliveries but only 19.6% ofthese can conduct caesarean section deliveries (Figure 1)



Facility Capacity and Infrastructure: On average, PFPshave a total of 8 beds. Out of these, 3 are dedicated to sickantenatal mothers, 1 for laboring women and 2 for post-partum mothers. Overall, majority of PFPs have electricity(96.4%) and water (94.6%), with piped water as the mainwater source (94.3%). However, only 40.7% have backupgenerators, and functioning toilets designated for client use(98.2%). All facilities without electricity, water, designatedtoilets and backup generators are PFPs without doctors.

Labour and delivery Management: All PFPs assessed hadgloves (100%), 94.6% had sufficient lighting, 94.6% hadmeans of ventilation, 98.2% had functional toiles and curtainsfor privacy and 94.6% had waiting areas for visitors. However,majority of facilities (>50%) did not have the required labourand delivery guidelines. More PFPs with doctors haveEclampsia –Pre-eclampsia management guidelines comparedto PFPs without doctors. There is no significant statisticaldifference in availability of other labour and delivery

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Results:

Figure 1: C-section Deliveries and Blood TransfusionAntenatal Care (ANC) Visits, deliveries and postnatalcare (PNC) Attendances: Results on the volumes of clientsfor ANC, deliveries and PNC show that majority of PFPs(71.4%) deliver less than 20 mothers in 3 months and thesame number of deliveries is recorded by majority of PFPs(44.6%) in the 12 months period. Only 1.8% of PFPs whichoffer delivery services didn’t register any delivery in the last12 months. In a period of 3 months, on average PFPs get 23mothers for the 1st ANC visit, 11 mothers for the 4th ANCvisit and 13 mothers for PNC visits. This implies that majorityof mothers don’t complete the 4 ANC visits and don’t turn upfor PNC.

Communication and Referral transportation: Thefindings from the assessment show that majority of PFPs(94.4%) have facility owned cell phones for making referralcommunications but only 55.4% of the communications made(calls) are paid for by the facility while 44.6% of thecommunications are paid for by facility staff. Majority of PFPsuse other motor vehicles for referral transportation with only10.7% of PFPs having motor vehicle ambulances to transportreferred clients to other facilities, and 5.4% of the facilitiesusing motorcycles to transport referred clients to referralfacilities.

Essential drugs and Supplies: In relation to availability ofmarker drugs, results show that all facilities haveDexamethasone, 96.4% have Oxytocin, 94.6% have folic acidand 96.9% have Nifedipine. Only 19.6% had pethidine, 23.5%had calcium gluconate and 32.1% had Betamethasone.Calcium gluconate was more available in PFPs with doctorscompared to PFPs without doctors. Majority of the delays indelivery of drugs and supplies in PFPs are due to financialproblems (38.2%) and administrative difficulties (20.0%)

Antenatal and Postnatal Care: Data on availability of keydrugs, registrars and guidelines for ANC and PNC shows thatout of 56 PFPs assessed, 39.2% don’t have Fansidar, 70.4%don’t have ANC clinical guidelines and 35.7% don’t have ANCregisters.

The findings of the study showed that there are gaps inservice providers performing the BEMONC functions. Thereshould be continuous mentorship of health service providersin PFPs on use of parenteral anticonvulsants, conductingassisted vacuum delivery, manual removal of the placenta,removal of retained products and newborn resuscitation.

guidelines in the PFPs with doctors and those without doctors.It is also important to note that Oxygen cylinders, Ultrasoundscans, Doptone, Uristix, Partographs and Newbornresuscitation tables are all more available in PFPs with doctorscompared to PFPs without doctors. On average, each PFPhas only 2 complete delivery kits (Figure 2)


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Figure 2: Availability of basic items for labour and delivery

Facility data Management: Only 3.6% of PFPshave all the required death notification forms and deathreview forms for maternal and perinatal deaths. There is nosignificant statistical difference in the availability of deathreview and notification forms in PFPs with doctors and thosewithout doctors. Also, 23.2% of the PFPs did not have labourand delivery registers, 86.0% had complete and up-to-dateregisters, 37.5 % did not have ANC registers and 17.9% hadANC registers but not fully filled.

Performance of BEMONC functions: The assessmentlooked at how PFPs are performing on the Basic EmergencyObstetric and Newborn Care (BEMOC) signal functions. Theresults show that all facilities administer parenteralantibiotics and 85.7% of PFPs use misoprostol. Misoprostolis mainly used for management of postpartum hemorrhage(89.6%) and post abortion care (64.6%). Only 41.4% ofPFPs use parenteral anticonvulsants and only 30.4% ofPFPs perform manual removal of the placenta. It’s notsurprising that PFPs with doctors perform manual removal ofthe placenta more than those without doctors, 44.4% offacilities perform removal of retained products and only 3.6%perform assisted vacuum delivery. Only 32.1% performnewborn resuscitation using a bag and a mask.

Evidence based Care: Majority of PFPs (91.0%) routinelypractice active management of third stage labour and 75%of PFPs routinely use partographs to monitor labour. Majorityof PFPs (76.2%) which don’t use partographs claim not tohave blank partograph forms to use, while only 17.9% ofPFPs perform breech delivery and only 12.5% give specialor intensive care to a preterm or low birth weight baby.Results further disclosed that only 5.4% of PFPs conductmaternal death reviews and 3.6% conduct perinatal deathreviews (Figure 3).

and Partograph useFigure 3: Routine Active Management of Third Stage Labour

Linkage to Community: The assessment gathered data onhow community health workers have been actively engaged inprovision of MNH services. The results show that only 37.5%of PFPs work with maternal health Village Health Teams(VHTs). Majority of maternal VHTs are mainly used incommunity works (91.6%).

Conclusions and Recommendations:

Additionally, majority of PFPs don’t have MNH guidelines andprotocols. Some PFPs didn’t have maternity registers. ThesePFPs should be supported to get these guidelines from MOHand other partners supporting MNH in Kampala City. Withsupport from KCCA HMIS department, these PFPs should beavailed with MOH Maternal registers (ANC, Maternity andPNC) and trained on use of these registers to collect qualitydata.

The results from the assessment showed gaps in usingpartographs in monitoring progress of labor due to lack ofskills and lack of partograph forms. The Maternal healthservice providers in PFPs should have on job mentorships onthe use of partographs and they should be availed withpartograph forms which they can photocopy when their stocklevels go down.

Majority of the PFPs don’t do maternal and perinatal deathnotifications and reviews. Each PFP should assign one healthworker the role of making maternal and perinatal deathnotifications to the MPDR committee in the division to comeand do the audits/reviews.

P U B L I C H E A L T H S U R V E I L L A N C E

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According to the World Health Organization, road trafficinjuries are the eighth leading cause of death worldwideand the leading cause of death for people aged between 5and 29 years. Each year, road traffic crashes kill over 1.35million people and injure up to 50 million more around theworld.


to make urban mobility safer, promoting safe driving and,building public support to road safety through masscommunication campaigns and use of data from high-qualitymonitoring and evaluation systems for policy and planning.

For more information please visit:www.bloomberg.org/program/public-health/road-safety/


Speeding and Road Safety: KCCA partnerswith the Bloomberg Philanthropies Initiativefor Global Road Safety (BIGRS)Authors : *Leah Kahunde , Elizabeth Katana , Daniel A .

Okello

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Institutions: Bloomberg Philanthropies Initiative for Global Road Safety(BIGRS), Kampala, Uganda Uganda Public Health Fellowship Program, Ministry of Health, Kampala, Directorate of Public Health and Environment, Kampala Capital CityAuthority, Kampala Uganda

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Over 90% of the world’s deaths on the roads occur inlow-income and middle-income countries, which have lessthan half of the world’s vehicles and sadly, many of thesedeaths are preventable. In Uganda, four of the 10 peoplekilled in road crashes every day are pedestrians, accordingto the 2019 Police Annual Crime Report. The reportindicates a 0.4% increase from 2018 and of the 3880that died in road crashes in 2019, 600 (15.5%) werechildren.

As part of efforts to curb this trend, the Kampala CapitalCity Authority (KCCA) entered a six-year partnership withthe Bloomberg Philanthropies Initiative for Global RoadSafety (BIGRS) in July 2020. BIGRS is a multi-countryprogramme that aims to reduce road crash fatalities andinjuries, supported by Bloomberg Philanthropies.

This third phase of BIGRS builds on the success andimpact of Bloomberg Philanthropies' more than 10 years ofinvestment in road safety, which has saved up to anestimated 312,000 lives and prevented up to 11.5 millioninjuries since 2007. BIGRS phase 3 will run from 2020 to2025 and aims to bring the lives saved total up to 600,000and prevent up to 22 million injuries in low- and middle-income countries.Kampala joins the other priority cities in this phaseincluding Accra, Addis Ababa, Bengaluru, Bogota, BuenosAires, Guadalajara, Hanoi, Ho Chi Minh City, Kumasi,Mumbai, New Delhi, Sao Paulo, Salvador and Recife, withmore expected to follow.On this project/partnership, KCCA is working with otherstakeholders in road safety including The Directorate ofTraffic at the Uganda Police, Makerere University School ofPublic Health and, the Ministry of Works and Transport.

The project will focus on these areas; enforcing road safetylaws on (speeding, drink driving, motorcycle helmets, andseat belts), designing and building safer roads, managingspeed effectively, implementing transportation systems

Phase 3 of BIGRS places special focus on speeding which isat the core of the road traffic injury problem.The road safety risk relating to speed is associated withbehavioural and non-behavioural factors, including roadinfrastructure or design, and vehicle safety elements. Speeding increases the likelihood of crash involvement, crashseverity, and injury severity because of a transfer of kineticenergy when things collide. Excessive speeding means totravel faster than the prescribed speed limit whileInappropriate speeding means to travel too fast for theprevailing conditions, which could be within the prescribedspeed limit. With regards to road safety, speeding cantherefore be considered as traveling at both excessive andinappropriate speeds.

Speeding and Road Safety

There is evidence that pedestrians have a 90% chance ofsurvival when struck by a car traveling at 30 km/h or below,but less than 50% chance of surviving an impact at 45km/h, and would have almost no chance of surviving animpact should a vehicle be traveling at 80 km/h. Excessand/or inappropriate speeding account for a high proportionof injury and death that result from road crashes, in additionto reducing the reaction time a driver could stop a vehicleand avoid a crash.

The Ministry of Works and Transport Traffic and RoadSafety (Speed Limits) Regulations, 2004 guides 50km/h asthe acceptable speed limit in Uganda’s urban areas, tradingcenters and, other built-up areas including Kampala capitalcity. However, being both a residential and commercial city,it is more practical to have and enforce speed limitsaccording to the environment within which therespective roads exist.

It is therefore important that ardent and deliberate effort isgeared towards behavioral change advocacy, revampedenforcement strategies, better road designs, and post-crash management in a bid to contribute to the global goalof halving traffic deaths by 2030, recently announced bythe United Nations as the Second Decade for Road Safetycommencing in 2021.

Zebra crossings are commonly used on pedestriancrossings controlled by traffic signals or lights andpedestrians will only have priority when the lights showgreen to them. There is low coverage of zebra crossingswith signal systems on the Kampala roads resulting inchallenges related to their use on high speedroads, roadswith high volumes of traffic or with heavy flow ofpedestrians.


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This Year: Sunday, November 21, 2021On November 15, 2020, Kampala City joined the rest of theworld in commemorating the World Day of Remembrance forRoad Traffic Victims at the Uganda Youth Aid Nursery andPrimary School Mbuya. This day was started by a British roadcrash victim charity, Road Peace, in 1993 and was adopted bythe United Nations General Assembly in 2005.

(worlddayofremembrance.org) was launched to make theday more widely known and to link countries through sharingcommon objectives and the remembrance of people killed andinjured in crashes.

*Correspondence: [email protected] [email protected]

Ending Gender Based Violence: We need tofocus on prevention.

Institution: Reach Out Mbuya Community Health Initiative (ROM),Kampala, Uganda

Authors : *Ofwono Opondo ,John Paul Opus

Gender Based Violence (GBV) is defined as harmful actsdirected at an individual based on their gender. It is rooted ingender inequality, abuse of power and harmful norms.Women and girls are more affected by GBV than men andboys. The most predominant forms of violence against womenand girls include domestic, sexual and psychologicalviolence.

Image: City Lead Eng. Jacob Byamukama and team adding a zebra crossing to a city road, 2020.

Ensuring safety of pedestrians in Kampala city is of priorityvalue to KCCA and BIGRS partnership.

World Day of Remembrance for Road TrafficVictims, November 15, 2020, 3 Sunday inNovember – Every Year

rd

This day is commemorated to remember the many millionskilled and injured in the world’s roads, together with theirfamilies, friends and many others who are also affected. It isalso in this day on which we thank the emergency services andreflect on the tremendous burden and cost of this continuingdaily disaster to families, communities and countries, andon ways to halt it. A dedicated website

Background

According to an analysis made by the World Bank and itspartners, worldwide, almost one third (30%) of women whohave been in a relationship report having experienced someform of physical and/or sexual violence by their intimatepartner in their lifetime. Additionally, as many as 38% ofmurders of women are committed by a male intimate partner.

In Uganda violence against women and girls has reportedlyincreased with the COVID 19 pandemic. There has been anincrease in GBV cases as the country instituted lockdownsand stay at home restrictions to prevent the spread of COVID-19. Some of these cases have already claimed lives ofUgandans even before COVID-19 does so as reported byUganda’s ministry of gender, labor and social development.

In homes, domestic violence is cited whenever families spendmore time together with the perpetuators such as relativesincluding uncles, biological fathers etc. This was instigatedmore by the “stay home campaign” seen as a necessary evilduring the COVID-19 response. This isolation shatteredsupport networks including community-based network of thelocal council, school’s administration support etc., making itfar more difficult for victims to get help. This has causedhigher levels of family instabilities as well as damaged theemotional, physical and mental status of the victims.

Reach Out Mbuya (ROM) conducts surveillance, for violenceagainst women and girls in the areas of Kampala in addition toother services including HIV/AIDS (related services, Orphanand Vulnerable Children (OVC) related services,grandmothers’ program and Non-communicable diseaseservices.Approaches and interventionsIn January–March 2020 Reach Out Mbuya (ROM) recorded345 GBV cases compared to 65 cases recorded betweenOctober – December 2019 at the different ROM sites ofMbuya, Banda and Kinawataka. ROM is using the holisticapproach of care to ably identify the victims and help affectedfamilies achieve peace in their homes as follows.


reported were due to limited movement of our team to thecommunity and facilities to screen people for GBV and limitedmovement of our clients to the facilities to report the GBVcases. This does imply that the cases were not there butrather highlights the limitations.


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ROM has continued to work closely with partners like Center forHealth, Human Rights and Development (CEHURD),International Justice Mission, the Uganda Local Council at alllevels were some cases have been referred. ROM hasexperienced some challenges in managing GBV cases more soduring the COVID 19 crisis. Some of the partners where ROMhas been referring cases withdrew because of the lock down. Inothers, the victims withdrew cases from police or legal office,most defilement and rape cases were dropped since the clientscould not pay for medical examination because they lackedmoney, instead choose to settle the cases in communitythrough settlements.

The journey of ending violence against women and girls beginswith prevention. Having well-grounded community structuresthat support to root out the structural causes of violence, earlysensitization of the community plus involvement of men andboys is pivotal in this fight. Multiple interventions at differentlevels individual, community, institutional, legal, and policy arealso needed. We also still need to address the CBV cases wehave in our community. Public awareness and increasedpolitical will and resources towards fighting GBV are also key.

For couples Living with HIV/AIDS one of the commonchallenges they face is non-disclosure even amongst themarried. Disclosing one’s status to a sexual partner meanstalking honestly about one’s HIV serostatus. Disclosure hasbeen shown to result in better adherence to therapy, eliminationof stigma, good clinical outcomes and reduction in the risk ofHIV transmission among couples and reduce incidences ofGBV. (It’s only for people living with HIV failing to disclose theirHIV status of fear of the outcome).

Despite these challenges, ROM has come up with interventionsto ensure the continuity of service delivery to the victims ofGender Based Violence. Through locally mobilizing funds tosupport our clients with medical examinations in cases of rapeand defilement. ROM also plans to rollout GBV screening in allprogram areas.

ResultsIn the areas of Mbuya, Kinawataka and Banda, 372 cases wererecorded in 2018, 288 cases for 2019, while as of October2020, an almost triple number of 915 cases had been recordedfor the year 2020 as shown in graph 2. This is because of thedifferent interventions put in place to identify and record thosecases. These interventions include screening all our clients whocome at the facilities, GBV screening at house hold level andlastly screening young people at every activity. In addition tothat, the GBV cases increased during the COVID 19 asopposed to the previous years.

The overall number of cases was highest from January toMarch 2020, followed by July to September 2020, while a lowernumber was reported from April to June 2020 as shown ingraph 1. The reduced number of cases between April and Junecould have resulted from the lockdown restrictions whichhindered reporting and community response. The fewer cases

In Mbuya, the number of cases was above 100 for all thethree quarters, in Kinawataka more cases were reported inthe first and third quarters, while in Banda almost equalnumbers were reported in all the three quarters. Bandareported fewer cases because the community has mostly university students who had already gone back home.Therefore, the GBV numbers were few due to a reducedpopulation.

Graph 1: Trend of GBV cases between January 2020 and September 2020, from Nakawa Division and 85%accounts for women and girls as victims of GenderBased violence.

Graph 2: The trend of Gender Based Violence over the three years.

The study included women who had used the selectedservices at the selected health facilities from the month ofSeptember 2020; were current residents of the slums of eitherof the two divisions; and women with contact phone numberswhich were captured at the facility level registers (ANC,delivery & postnatal). The women were clients who receivedantenatal, intrapartum (maternity) and postnatal services frompublic and private health facilities. For childbirth experiences,we excluded women who had delivered stillbirth in period. Werecruited 30 women for the qualitative interviews (Objective 1)as shown in table 1, and 257 women for the quantitative(Objective 2).

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November 25 was designated by the United Nations GeneralAssembly as the International Day for the Elimination ofViolence Against Women. The role of the day is to raiseawareness of the fact that women around the world aresubject to rape, domestic violence and other forms ofviolence; furthermore, one of the aims of the day is to highlightthat the scale and true nature of the issue is often hidden.

disrespectful and ill-treatment of women at health facilities.Following the findings from this study, among the severalinterventions, MaNe project implemented several innovativeapproaches to address barriers to provision of quality MNHcare in urban settings in Kampala city especially among theurban poor. One key specific intervention was to strengthenclient-centered and respectful maternity and newborn care(RMNC) in public and private health facilities in Kampala city.Therefore, the objectives of this study were in line with thisthought: 1) To assess client satisfaction among women whoreceived antenatal, intrapartum (maternity) and postnatalservices from public and private health facilities from themonth of September using in-depth qualitative interviews, and2) To determine and recognise/reward the best performingfacility, departments, and health providers among selectedpublic facilities using client feedback on receiving respectfulmaternity care.

IntroductionThere is growing evidence that disrespect and abuse ofwomen during childbirth is a deterrent to women utilisingmaternity services especially in low- and middle-incomecountries (LMIC). Literature suggests that fear of disrespectand abuse may sometimes be a more powerful deterrent tothe use of skilled birth care than geographical and financialobstacles [1,2]. For instance, In Uganda the current facilitybirth rate is at 73% but is 94% in urban settings like Kampala[3]. Despite this high rate of facility birth, a formative studyconducted by Kampala Slums Maternal and NewbornHealth (MaNe) project in 2019 showed several aspects of

Ending Gender Based Violence: We need tofocus on prevention.

For 2014, the official Theme framed by the UN Secretary-General’s campaign UNiTE to End Violence against Women,was Orange your Neighbourhood. For 2018, the official themewas "Orange the World: #HearMeToo". For 2019 it was"Orange the World: Generation Equality Stands AgainstRape" and for 2020 it was "Orange the World: Fund,Respond, Prevent, Collect!". Every year Uganda joins the restof the world to commemorate the international day for theElimination of Violence against Women on 25 November.

Strengthening client-centred and respectfulmaternity and newborn care in public andprivate health facil it ies in Lubaga andMakindye divisions in Kampala city

*Correspondence: [email protected]; [email protected];[email protected];

Authors : *Yvonne Mugerwa , Dorothy Balaba , Daniel A .

Okello , Sarah Zalwango , Henry Kaula , Andrew Magunda ,

Sam Ononge

1,2 1

3

Institutions: Population Services International, Kampala, Uganda Kampala Slum Maternal and Newborn Health (MaNe) Project, Directorateof Public Health and Environment, Kampala, Uganda Directorate of Public Health and Environment, Kampala Capital CityAuthority, Kampala, Uganda

12

3

3 1,2 1,2

1,2

MethodsThis was a mixed methods cross-section survey that utilisedboth qualitative (in-depth interviews) and quantitative methodsof data collection. The data collection was carried out betweenOctober and November 2020, in Lubaga and Makindyedivisions, the two MaNe project sites. Within this two divisions,12 facilities were purposively selected because they hadreceived training in RMNC. Four of them were public healthfacilities (table 1). The participants who visited private facilitiesanswered to only objective 1 (participated in only qualitativein-depth interviews) while those that received services frompublic facilities answered both objectives 1&2.

Table 1: Selected public and private facilities that took part in thestudy and participants enrolled for the qualitative in-depth interviews*The public health facilities



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Qualitative and quantitative questionnaires were adopted fromtools produced in Heshima project in Kenya [4], focussing onkey aspects of RMNC in the continuum of maternity careincluding rapport, confidentiality, preservation of dignity duringcare, privacy, right for information, consented care, solicitationof informal payments by health workers and any form ofabuse. In addition, the tools had and questions on observedhealth care quality, satisfaction and future health careutilisation. The data collection also assessed the women’srecollection of the health system issues that impacted onquality of care. For identification of health provider whodeserved to be recognised and rewarded, we asked the studyparticipant to give a name of one provider, whom she feltdeserved recognition and a reward. Given that the survey wascarried out during Covid19 period, a strict observation ofCovid19 SOPs was done.

1

Data management: For qualitative interviews, data wastranscribed and analysed manually using content andnarrative analysis to identify patterns, themes, andrelationships. Based on the understanding of the studyexpectations the team agreed on six themes including; 1)Satisfaction of clients and willingness to recommend theservice to other users/clients; 2) General client experiences asthey moved from home to access services and while in care;3) Dignified care 4) Provision of information regarding thetreatment /ailment by the providers; 5) Privacy andconfidentiality; and 6) Asking for money or payment

1 On satisfaction of clients and willingness to recommend theservice to other users /clients, most of the women were nothappy with the services they had received. This was the casefor almost all the public facilities. The mothers were notsatisfied with the services and didn’t intend to go back nexttime or even refer other mothers to those facilities.

For some mothers they have resigned to the fact that they stillhave to seek services at those facilities despite the poorattitudes and treatment received.

Regarding quantitative data, data was entered into excel andlater exported to Stata version 12 for analysis. Descriptivestatistics were computed for the sociodemographic character-istics of the participants and presented as frequencies,percentages and means. The different dimensions of RMNCwere analysed as a binary outcome (occurred or not) asreported by the woman. To compute the score for thedepartment (ANC, childbirth and postnatal clinic) of the facility,the attributes of RMC were added with equal weights to createa composite score with maximum of 44 points for ANC, 58points for childbirth and 51 points for postnatal clinic,generating average scores that were useful to identify the bestperforming department within the facility. The mean score forthe facility was computed to compare the performance of thefour public health facilities.

ResultsAs it shown in the flowchart below, the total number of womenwho visited the four public facilities in the month of September2020 and whose records the team was able to get, was 1,617.Out of this number, 970 (60%) women had their phonenumbers captured at the facilities, while the rest did not havetheir phone contact details. Out of those whose phone detailswere captured, 449 women were not reachable due todifferent reasons, while the team managed to reach to 521(54%) that agreed for an interview. However, the study teamwas not able to reach 264 participants because either thephones were off despite several attempts, were not interested,spouse with the phone/not consenting for interview or failed tolocate the residence.

Figure 1: Flow chart show participants reached in the four public health facilities

Qualitative findings on client satisfaction among womenwho received antenatal, intrapartum (maternity) andpostnatal services from public and private healthfacilities

“I felt so bad on the way I was treated because we gothere when we are in sorry state, we don’t need to bark atus, we don’t to leave us au attended to, that eventannoyed me and I can’t forget it. A mother at Publichealth facility, Makindye“personally I can’t (go back) because of the way I wastreated, I even had one of my neighbours who came andasked me because she knew I delivered from there, shewas attending ANC from there whether she can getenough support from Kisenyi, I told her to go and see forherself but she was very hesitant”- A mother whoreceived care at a public health facility

“I used to deliver from Gayaza side, most of my childrenwere delivered from that side and others in Mulago so thisit’s only this one that I delivered from this way because Ijust moved this way not long ago and I don’t have anyother hospital that I can comfortably say that that’s myalternative for the moment Kisenyi is my only choicearound here - Mother who received care at Publicfacility Makindye


However, the women attending private health facilities reporthigh level of satisfaction. In fact, the reverse held true therespondents were happy with the services even if it cost themsome money.

The respondents from the private facilities reported betterexperiences with the health workers as regards the care thatthey sought. The experience of being treated with dignity wasmostly reported by mothers that sought care among privatefacilities


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while some received harsh treatment from the healthproviders.

“I was very satisfied because the health workers are good,they chat with the patients, they are so caring, they evenask you whether you have eaten food, you can even sendthem to go and buy for you something from the shop” - Amother who received care at a private health facility.Lubaga

On general client experiences while in health care facility, therespondents reported having received mixed experienceswhen they reached the facilities where they sought services.They reported having experienced good and welcomingreception at the private facility and a generally less welcomingreception at public facilities.

“When we reached the facility they welcomed us,someone came and picked our things from themotorcycle, a lady came and took our language inside,they gave me a bed and the health worker came andmade my bed, my mother went back home to attend to mysiblings and the health worker remained there attending tome, my husband came and spent a night but the healthworkers kept checking on me, the health workers evenprepared for me some tea at night” - A mother that gavebirth at a private health facility, Lubaga

“When we reached (the facility) the nurse was in herroom, my attendants knocked and the nurse came out(because I was very weak) and I knelt down; she asked ‘isthat one going to deliver from here, what has she beenwaiting for’?, then one of my attendant responded ‘nursedon’t ask us first help us and show us where to go we willexplain to you later, our patient is badly off’”- A motherthat gave birth at public health facility, Makindye

However, few clients that received services at public healthfacilities acknowledged that the health workers had receivedthem well, though this seemed to happen in instances wherethe health workers already knew the mothers from past healthcare engagements.

“On reaching there (the health facility) the nurse receivedme, I gave her my mother’s card and she told me to geton bed and started examining me. She worked on mevery well and didn’t get problem with them because that’swhere I have been delivering all my children at Kawaalahealth Centre” - A mother that gave birth at publichealth facility in Makindye

As regards dignified care and how clients are handled at thehealth facility, the study looked at how clients were handledduring care at the facility for instance, how were they talkedto? Was it with dignity? Were they shouted at or harassed?Were they asked to consent to be examined etc.? As pointedout earlier the mothers noted having experienced betterdignified care at private facilities in comparison to publicfacilities. The women were ignored (left alone unattended),

“Even if they found you crying because of the pain theycould say don’t shout for us, sit down and keep quiet,health workers were harsh you just see a health worker ata distance and imagine what she is going to abuse you.Their facial expression is not bad but what comes out ofthem is not good, they are rude” - A mother at a publichealth facility, Lubaga

“I think what I loved most was that at the time of delivery,the health workers weren’t harsh on me because whenyou pregnant, people always tell you that the healthworkers are harsh, that they slap women but for me Ididn’t experience any of the sort even mere barking at medidn’t happen” - Respondent at a private facility inLubaga

This experience could partly be explained by the fewernumber of clients seen at the private facilities in comparison topublic facilities. One respondent however was on side ofhealth workers. She felt that the clients were treated inaccordance to how they themselves approached the healthworkers. Although this should not be the case, from therespondents’ narrations this practice seems to be presentamong health workers at public facilities.

That (mistreatment) can only happen when you had aproblem with the health worker, but if the relationship wasgood then I don’t see why he/she treats you badly.Sometimes we mothers carry our bad behaviors tohospital, this prompts them to revenge in turn. For me Ihave never gotten any mistreatment from nurses - Amother at public health facility in Rubaga

It was interesting to note that even in the midst of the poorundignified treatment that many respondents talked about,there were experiences of good and polite treatment fromother staff in the same facility and even in the same unit.Many mothers seemed to have had better experiences duringANC but undesirable ones during childbirth (in labour wards).

“so the other nurse also appeared after sometime and Iasked her to check on me but she shouted at me that Ishouldn’t bother her because she told me to take tea and Iignored her and she went out quarrelling without eventouching me…. I forced myself and walked to thereception where they normally sit and they were there, Iasked them to come check on me because I felt it wastime for me to deliver but that nurse who shouted at mefor not replying, with a harsh tone ordered me to go backto the room…. after a few minutes another more politenurse came and checked on me and told me the deliverytime had reached, the other (harsh) nurse came also


and continued to shout at me but colleague told her to stopuntil am done delivering and the she can say whatever shewanted” - A mother at public facility in Makindye division

As regards to right to information from providers regarding theailment suffered or treatment received, the respondents wereasked if they were provided information about their illness oreducation about how to take care of their babies. From theirresponses it was apparent that the health workers preferred togive information about how to take care of their children tonew mothers. Once they realise that a mother had given birthbefore they do not even bother to try to educate them at all. This applied to both the private and public facilities.


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When money is asked directly from the clients, usually it is inthe guise of buying the items to use such as gloves ormedicines because it is common knowledge that the suppliesat government facilities are never enough.

“They didn’t tell me that because they asked me howmany children do you have, I told them I have two and thisone is the third one so she thought I know how to feedbaby and she just told me on 20th November 2020, comeback here for examination”- A mother at private facilityin Makindye division

“They usually do that (educating mothers) when it’s yourfirst born but for us who are veterans they don’t. Evenwhen you reach hospital health workers usually asks thenumber of children you have, and she doesn’t give youmuch attention if it’s not your first delivery” - A mother atpublic facility in Lubaga division

However, during ANC the respondents in some facilities notedthat they were offered health education either as individuals oras groups

“They even teach us and they explain to us the meaningof the results they have found and they ask you if youhave some pain experiences then they recommend theappropriate medicine for that”- A mother at publicfacility in Lubaga division

On privacy and confidentiality during clerking andexamination, respondents generally felt that the facilities(public & private) offered privacy. To a great extent, they feltthat their privacy and confidentiality were respected largely onaccount of the way the facilities were organized either byhaving a separate room or rooms separated by curtains.

“You go one by one into the examination room and whenyou a ready you don’t come back you stay there anddeliver” - A mother at public facility in makindyedivision“Yes, there was enough privacy because it was inside aroom with curtains and could only be accessed by healthworkers and at the time of my check up, we were only,two me and the nurse”- A mother at a public facility inLubaga division

Asking for inappropriate payment during care while atthe facility outside normal paymentsThere were experiences of seeking inappropriate paymentsreported by the respondents at almost all public facilities, but itwas not even mentioned at the private facilities. In someinstances, the payments were not requested for directly butindirectly by withholding services or outright patient neglect.

“yes (they asked for) UGX 20,000 but we accept becausewe know there is nothing for free in this Uganda of ours…they get you in your time of need and you have no optionbut pay in fact if I had that money then I would have givenit to them but that money is a lot” - A mother at a publicfacility in Makindye division

No, it (asking for money) didn’t happen at all and we spentthe whole day and nurse would come and check on meand my baby and asked have you eaten and breast fedthe baby, she told me to start breast feeding the baby - Amother at a public facility in Makindye division

“The health worker told me about the buying of thingswithin the hospital, I asked her (whether this applied toeverything we needed), she told me yes, I also asked thetotal amount of money and she said UGX 60,000…. Thiswas for ten pairs of gloves, Cotton and other things theyuse in the delivery process; she didn’t give me any kind oflist of those things so I don’t know exactly what else shewould be providing - A mother at a public facility inMakindye division

Findings from assessing public health facilities for thebest performing facility, and departments at thefacilities.A total of 257 women were interview. Out of these, 142 hadvisited the facilities for ANC, 70 for delivery while 45 hadvisited the facilities for PNC services. The table 4 belowrepresents the numbers of women reached per department ineach facility, their characteristics, and those reportingdisrespect, and abuse during their visit to the facilities.


Table 2 above shows different forms of disrespect and abuseas reported by the clients who received care at the four publichealth facilities. The most reported forms of disrespect andabuses across the continuum of care were; Failure of the healthproviders to introduce themselves to the clients (54.6%),no consent sought before physical examination (41.1%) andvaginal examination (34.1%), failure to educate women on foodto eat (56.6%) and feed their babies (42.0%). Health workerssoliciting for a bribe was reported in 88.6% and making threatsin 59.7%. The respondents reported crowded health facilities(58.6%) with inadequate staff (57%). However, the facilitiesperformed well on cleanliness. Almost one in two women hadno access to water, more in the antenatal and childbirth clients.

M E D I C A L S E R V I C E S | A C K N O W L E D G E M E N T S

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Assessing and recognizing the best performing individualwithin the public facility

Table 2: Occurrence of disrespect and abuse during antenatal care, childbirth, and postnatal care (immunisation) among participantsfrom four public health facilities in Kampala, Uganda.

Table 3: Client’s acceptability of the facility and average scores forfacility based on the positive respectful maternity care

*TBN: to be named

On table 3, almost all women expressed that they will in futureutilize the facility for the services (92.6%) and recommend otherwomen (96.5%).The recognition and award of the health facility had not yethappened, and we opted to keep the names of the facilitiesanonymous till the function is conducted. This also applies forthe recognition of the individual health provider. The bestperforming facility is TBN_01 with score of 73.6%, meanwhileacross all the facilities, postnatal departments excelled.

Clients were also asked to name individual health providerswho had provided outstanding services to them in the month ofSeptembers, 2020. This was based on the experience thewomen had with the health providers when they visited thefacilities and specifically, the different departments within thefacility that they visited. Table 4 below shows the names ofhealth providers whom the women felt should be recognised fortheir exemplary care.

ConclusionMNCH services at public health facilities are perceived bymothers as less satisfactory with several of them feelingthat health providers are harsh to them, not respectful andnot treating them in dignified manner.Private facilities were generally perceived as providinggood services and several mothers will recommend or seekcare from them in future.Privacy and confidentiality in both public and privatefacilities was acceptable to the mothers.

1.

2.

3.

Way forwardThe results of the findings shall be disseminated to healthfacilities with the hope that respective providers willundertake reflection and suggest action to improve qualityof MNH services.The reward and recognition of the health facilities,departments and individual is hoped to motivate healthproviders to be more accountable in their actions andpromote provision of RMCAs a program, MaNe will repeat this survey to evaluate thechanges that have occurred using a similar methodology.

1.

2.

3.

Azhar, Z., O. Oyebode, and H. Masud, Disrespect and abuseduring childbirth in district Gujrat, Pakistan: A quest for respectfulmaternity care. PLoS One, 2018. 13(7): p. e0200318.Denny, E., Respectful maternity care needs to be the standardfor all women worldwide. BJOG, 2018. 125 (8): p. 943.Uganda Bureau of Statistics - UBOS and ICF, UgandaDemographic and Health Survey 2016. 2018, UBOS and ICF:Kampala, Uganda.Heshima:, CLIENT PROVIDER INTERACTION and CASENARRATIVE GUIDE: Promoting dignified and respectful careduring childbirth in Kenya. Population Council : TranslatingEvidence into action.

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References

Acknowledgements


A C K N O W L E D G E M E N T S

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Please visit the KCCA COVID-19 Response Hubhttps://coronavirus-response-19-ctf-kcca-gisservices.hub.arcgis.com/

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