|
Background and Project justification
According to the Uganda 2011 District Health Survey (DHS), statistics for Maternal and Child health show that one in every 19 Ugandan children dies before their first birthday, and one in every 11 children dies before the fifth birthday, with childhood mortality higher in rural areas. Maternal death accounts for 18 percent of all deaths of women aged 15-49. While national health indicators are still poor at national level, those for rural areas, especially hard-to-reach areas are dire. Kalangala district, also called Ssese Islands is one such area. The district is located in the middle of Lake Victoria; and has an area of 9,066.8 sq km of which only 432.1 sq km (4.8%) is land, the rest is water mass. It is composed of 84 islands of which 64 are inhabited with an estimated population of 64,000 people.
Problem Statement
Implementation of Maternal New-born and Child Health (MNCH) services has failed to fully reach communities targeted in this project because of a number of reasons. Firstly, geographically Kalangala district is one of the largest districts in Uganda consisting of 84 islands widely scattered in Lake Victoria. Despite its big size and its uniqueness as an islands district, Kalangala is connected to the rest of Uganda by only 2 public vessels (MV Kalangala ship and Bukakata - Lukku ferry); and both these vessels only dock on the main island of Bugala at scheduled times. There is no public transport system between the remaining islands; and with the mainland. This has not only made MNCH service delivery in the district inaccessible but also difficult and very expensive. Patients also have to incur high transport and maintenance costs while at the distant health facilities.
Secondly, the district has only 16 health facilities; 13 government-aided and 3 private health units. Eight of the 16 health centers including Kalangala Health Center IV (HC IV) are located on the main island of Bugala. Only 7 out of the 64 habited islands have health centres. There are 2 health centre IVs but both lack a fully functional surgical theatre. Moreover, the district has no referral hospital and is therefore incapacitated to handle major emergencies and surgeries. The nearest referral hospitals are Masaka and Entebbe Hospitals which are about 74 kms and 68 kms away from the district respectively. Masaka is about two hours away by ferry, while Entebbe is at least three and a half hours away by ship. There is no single running ambulance in the district and the few available health centres are understaffed and ill-equipped, and often lack even the basic medical supplies. Our observation noted staff gaps in all health centres in the district, especially nurses and midwives. Additionally, health personnel are often poorly trained and motivated. Being a hard-to reach area, the district is unable to attract and retain motivated staff. No wonder many mothers seek services of unskilled personnel, like traditional birth attendants (TBAs), despite the eminent life threatening risks associated with them.
Furthermore, our observation noted that the link between the formal health systems and community level structures are weak; and community health structures such as Community Health Volunteers (CHVs) are undervalued by the formal system and are poorly resourced. Health literacy is also a big issue among women in the district as most households have limited access to MNCH information; and poor health seeking behaviour. People with disabilities and those living with HIV and AIDS face additional barriers to good MNCH as they are often stigmatized and discriminated. To compound the problem, like with many African and Ugandan communities, decision making power in families usually rests with men, influencing women's choices about health care. This power relationship means that the option to appreciate and adopt good maternal and child health practices (including good nutrition, hygiene and where the woman will give birth from) is not always a woman's decision, but generally rests with the husbands. Women with a disability face further disadvantage as they generally have greater dependence on their husbands and others.
The above factors, among others have contributed to the following unfavourable MNCH state of affairs in Kalangala district.
Maternal Health
According to the District Health Management information Systems reports, the percentage of mothers delivering in health facilities in Kalangala was a paltry 16% in 2011/12. This is less than half of the national average of 39%. Moreover, the lack of Emergency Newborn and Obstetric Care (EMNOC) services means all at-risk mothers have to travel to the mainland where facilities that can handle obstetric emergencies exist. Little wonder the number of pregnant women attending 4 or more Ante Natal Care sessions was as low as 29.6% in 2011/12, significantly below the national average of 47%. Only 30.5 % of pregnant women received 2 doses or more of Intermittent Presumptive Treatment (IPT) in comparison with national average of 42%. The low IPT coverage is worsened by the low utilization of Insect Treated Nets (ITNs) with only 45.3% mothers sleeping under ITNs during their last pregnancy. Moreover Village Health Teams (VHTs) only exist in 43 out of the 92 villages and they are poorly motivated hence making early detection of complications and timely referral almost non-existent. Compounded by the long distances that mothers have to travel to health centres, the lack of ready transport and unavailability of EMNOC services, this situation has resulted in a high maternal mortality rate of 550/100,000 live birth against the national average of 431/100.
Child Health
The child health situation in the district is equally very poor. Malaria, which is endemic in Uganda, is the leading cause of morbidity in Kalangala district contributing 38.3% of all cases. This is despite the fact that coverage of ITNs is higher than the national average; according to UMIS 2011, up to 64.2% of children slept under ITNs compared to the national figure of 33%. However, only 41.5% of children aged 0-23 months had ever received treatment within 24 hours of onset compared to national average of 70 percent. Despite their existence in 43 out of 92 villages, VHTs are not so much involved in malaria control. Apart from use of ITNs there are no other modern preventive methods being used. Moreover, the district is hard hit by other common childhood illnesses including diarrhea, fever and pneumonia. The UMIS 2011 shows that among children aged 0-11 months with diarrhea in the last two weeks, only 44.4% were receiving Oral Rehydration Treatment. Yet among children aged 0-23 months with any form of fever, diarrhea or pneumonia, the proportion seeking care from health workers within 24 hours of illness was only 71.3%. Perhaps this is why the district infant mortality rate is 102 /1,000 live births), twice the national figure of 54/1,000; and the under-five mortality rate is 159/1,000 compared with national figure of 90/1,000.
HIV/AIDS
The HIV/AIDS prevalence rate of fishing communities in the district is 29%, almost five times higher than the current national average of 6.4%. The prevalence rate is higher in women than men peaking levels of around 40% in some communities. Comparatively higher levels are seen during early adulthood with 12% and 26% in men and women aged 18-24years respectively. A high proportion of the population still engages in risky behavior like multiple sex partners, low condom use even with partners known to be HIV infected, transactional sex and sex under the influence of alcohol or drugs. Fishing communities in the district are a 'hot-spot' for HIV/AIDS because of the conditions and styles of living together; and the nature of work (fishing) that leaves the communities with a lot of redundant time that increases sexual vulnerability. In addition, economic activities that don't favor female participation like fishing, oil palm growing and lumbering make women economically vulnerable. The migratory tendencies of fishermen, the dominance of male population over female, readily available daily income and people living away from their families all contribute to the high HIV/AIDS prevalence in the district.
Non-functional surgical theatres
Although Government policy requires that every HC IV should have a fully functional theatre; and despite the district having 2 HC IVs; and notwithstanding the recent recruitment of the two medical officers in the district, Kalangala district lacks a fully functional theatre. This is a sad situation given the key importance of cesarean sections for women experiencing obstructed labour to prevent hemorrhage, development of a fistula, or even death of the mother or baby. In their current state, both theatres cannot provide quality MNCH care. While the theatre at Kyamuswa HC IV has never worked, the one at Kalangala HC IV often lacks even basic instruments and materials for common surgical procedures; not to mention the theatre building that needs total refurbishment. No wonder, cesarean sections in the district only account for less than 0.1% of all births, while the general consensus for an ideal global cesarean section rate is 10 - 15%.
Project Objectives
a. To increase the capacity of health centre facilities and staff to deliver equitable and quality MNCH care and services
b. To enhance the capacity of community structures to deliver sustainable MNCH at household level
c. To improve MNCH care seeking behaviours and practices by pregnant and breastfeeding women
d. To improve nutrition knowledge amongst women and their households
e. To reduce under‐five mortality from disease through improved nutrition and hygiene promotion
f. To reduce incident HIV infections and mother to child transmission of HIV
g. To empower local communities including women, children and civil society to demand for improved and equitable access to MNCH services
h. To educate the men on health best practices as they influence the women and children's health care access and attitudes
Project beneficiaries (both direct and indirect)
a. 1,500 Women of reproductive age
b. 1,200 Pregnant and breast feeding women
c. 500 New-borns
d. 1,000 Children 0-5 years old
e. 80 Health centre personnel
f. 350 VHTs, CHVs and other community health workers and men
g. 30 Community birth attendants
h. Kalangala District Local Government
i. Ministry of Health
Project Activities
a. Training of staff at health facilities to refresh their skills and build new knowledge and attitudes of best practices for MNCH as well as build their capacity in core clinical skills that directly impact on quality MNCH care
b. Training, sensitization, mentoring, strengthening and equipping of community health structures (CHVs and other relevant groups) to be able to deliver sustainable MNCH care and services at household level
c. Renovation and equipping operating theatres
d. Equipping of labour suits at Kalangala and Kyamuswa HC IVs
e. Provision of emergency boat ambulances to facilitate patient treatment and referrals
f. Provision of community motor cycle ambulances to facilitate patient referrals
g. Equipping health centers with telephone communication systems
Project Approach
Health systems strengthening will be the priority implementation approach for this project. The design process has already been rigorously led by Kalangala district health team; and this team will remain at the forefront of implementing the project. The District Health Officer will enable joint planning, close supervision of project activities and promote transparency and accountability. The project will adopt the 360 degrees approach of delivery at household, community and national level. At household level, VHTs and CHVs will be used to promote adoption of the low cost high impact interventions to promote maternal and child health. At the community level, caregivers will be mobilised for social accountability in regard to access to health care for children below two years; while health facility capacities will be enhanced to deliver primary health care and curative services.
Budget Estimates
Training of health center staff US$ 15,000
Training, strengthening and equipping community structures US$ 20,000
Renovation and equipping theatres at 2 HC IVs US$ 60,000
Cost of 3 emergency boat ambulances with engines US$ 18,000
Cost of 5 motor cycle ambulances (with trailers) US$ 10,000
Equipping labour suits at 2 HC IVs US$ 12,000
Equipment and birthing materials for skilled birth attendants US$ 6,000
Telephone systems for health centre US$ 1,200
Supervision, Monitoring & Evaluation US$ 3,500
Total US$ 145,700
| 
