The missing link in primary health care

Stifled by perennial under-funding, inadequate health care workers and a critical shortage of infrastructure, Uganda’s modest primary health care system has a more significant challenge to contend with: building effective demand among poor and vulnerable people. The Alma-Ata declaration on Primary Health Care (PHC) declared health to be a fundamental right, but also observed that this called for full participation of communities in their health services.

Official statistics show however that only a third of the population uses the government-supported health system in Uganda, both public and private not-for-profit. This means that a large share of poor and vulnerable people, including disabled people, families led by single mothers, orphans and internally displaced people, are not reached by public investments in health. They may seek services in private clinics, or buy medication from pharmacies or herbalists, but many poor people are likely to self-medicate at home, or hope for a natural healing process.

This still limited uptake of public sector health services obviously has many roots. The Coalition for Health Promotion and Social Development (HEPS-Uganda), a local health rights civil society organisation, advocates for access to affordable health care and essential medicines, especially for disadvantaged people. The evidence HEPS-Uganda has gathered from eight of the 85 districts of the country in which it operates suggests that both service providers and users lack awareness of their rights and responsibilities in health. The Uganda Human Rights Commission confirmed this picture in 2007, observing that health rights of many Ugandans are being violated, especially the right to information, dignity and access to essential medicines. This is surely one contributor to the poor use of services, and a barrier to effective organisation of the health system around PHC.

Through its Community Outreach and Health Complaints and Counselling (C&C) programmes, HEPS-Uganda has worked with communities and health providers in eight Ugandan districts to implement initiatives aimed at increasing public and community participation in planning and implementing primary health care, including in the rational use of medicines.

The results have been telling. When expectant mothers in Kamwenge District in western Uganda, in Kawempe Division of the capital Kampala, in the districts of Pallisa and Budaka in eastern Uganda, and in the Lira District in the North of the country have increased their understanding of their health rights and the services that meet them, their uptake of antenatal services and their delivery at health centres under professional supervision has in some cases doubled over the course of a year to eighteen months.

Through the C&C programme, HEPS-Uganda has established an independent feedback mechanism that receives complaints of health rights violations from health consumers, which it then tries to resolve through mediation with health providers and counselling. The process creates awareness of health rights and responsibilities on both sides, and has proved an effective way to identify and improve the whole system, both within the community and within the local level health services.

The Uganda Human Rights Commission has observed that the violation of health rights has not been given adequate attention in Uganda. But programmes like HEPS-Uganda’s C&C programme create confidence and hope: Community members can approach health providers in an informed manner and demand the services to which they are entitled. Equally, health providers themselves also recognise their duties and play their roles more effectively. The benefits are tangible for poor communities. In Pallisa and Budaka districts, community representation on health centre management committees is now more effective in the programme areas, and decisions are more responsive to community needs and preferences. Health centres have now scrapped illegal charges that consumers have continued to incur across the country in spite of government abolishing of cost-sharing as far back as 2001. The end result is a more people-centred, friendlier health care environment for communities as well as health workers, and the initiative is successfully demonstrating people’s power in improving their health.

It is not that the country’s policy makers do not appreciate the value of community empowerment in the effort to achieve ‘Health for All.’ Uganda is among the countries to have adopted the Alma-Ata Declaration 30 years ago, committing itself among other things to a human rights approach to health in which ‘the people have the right and duty to participate individually and collectively in the planning and implementation of their health care.’

At the country level, the national health policy commits the government ‘to ensure that communities are empowered to take responsibility for their own health and well being, and to participate actively in the management of their local health services.’

With ill-health identified in official surveys as the leading cause of high levels of poverty, national development plans, including the Health Sector Strategic Plan and the Poverty Eradication Action Plan, contain planned activities aimed at empowering communities for health.

There are numerous examples of how communities are playing a role in efforts to create a community-based primary health care system. Community drug distributors dispense anti-malarial medicines door-to-door, village health teams mobilise communities for sanitation and HIV prevention and treatment, and community members are involved in implementing the ‘directly-observed treatment’ strategy to manage Tuberculosis (TB). There have also been policies to entrust management of lower level health units to local governments and to management committees with community representatives.

With the exception of the TB management strategy, the performance of the rest of the initiatives leaves a lot to be desired however. Nearly a decade since the policy and other development plans were published, other planned activities, which would have empowered communities and consolidated the success of those already underway, remain at the planning level. For example, there has not been any national programme of community capacity building ‘for effective participation of health problems, planning of health services, in resource mobilization and in the monitoring of health activities’.

Uganda has made the important step of guaranteeing a minimum health care package, albeit with minimal resources. Instead of the estimated US$34 per person outlined by the Macroeconomic Commission on Health, the country is trying to attain universal access to primary health care with only US$8 per person. Without effective and collective demand from community level, people will carry on ‘making do’ with poorly resourced health systems and under-using resources that are applied.

Effective and collective demand calls however for a system that involves the intended beneficiaries in planning and implementation, and for an informed and empowered community able to demand and use the services it needs. In a resource poor setting like Uganda, the case for community empowerment for health is even stronger. It is needed in setting priorities, deciding on resource allocation, monitoring the performance of service providers and in building health care seeking behaviours. The government will have to live up to its commitment to empower communities if it is to guarantee their right to quality health care.

* Please send comments to [email protected] or comment online at http://www.pambazuka.org/

The missing link in primary health care Empowering demand from communities in Uganda

¬¬¬Through examining the experience of the Ugandan Coalition for Health Promotion and Social Development (HEPS-Uganda), Rosette Mutambi highlights the extent to which ordinary Ugandans remain without effective official health care. While stressing the role of government in empowering local communities, she argues that genuine improvement in primary health care rests on involving an informed population in the planning and implementation of the system overall, a consideration of even greater importance in a resource-poor nation like Uganda.

Rosette Mutambi, Coalition for Health Promotion and Social Development, Uganda

Stifled by perennial under-funding, inadequate health care workers and a critical shortage of infrastructure, Uganda’s modest primary health care system has a more significant challenge to contend with: building effective demand among poor and vulnerable people. The Alma-Ata declaration on Primary Health Care (PHC) declared health to be a fundamental right, but also observed that this called for full participation of communities in their health services.

Official statistics show however that only a third of the population uses the government-supported health system in Uganda, both public and private not-for-profit. This means that a large share of poor and vulnerable people, including disabled people, families led by single mothers, orphans and internally displaced people, are not reached by public investments in health. They may seek services in private clinics, or buy medication from pharmacies or herbalists, but many poor people are likely to self-medicate at home, or hope for a natural healing process.

This still limited uptake of public sector health services obviously has many roots. The Coalition for Health Promotion and Social Development (HEPS-Uganda), a local health rights civil society organisation, advocates for access to affordable health care and essential medicines, especially for disadvantaged people. The evidence HEPS-Uganda has gathered from eight of the 85 districts of the country in which it operates suggests that both service providers and users lack awareness of their rights and responsibilities in health. The Uganda Human Rights Commission confirmed this picture in 2007, observing that health rights of many Ugandans are being violated, especially the right to information, dignity and access to essential medicines. This is surely one contributor to the poor use of services, and a barrier to effective organisation of the health system around PHC.

Through its Community Outreach and Health Complaints and Counselling (C&C) programmes, HEPS-Uganda has worked with communities and health providers in eight Ugandan districts to implement initiatives aimed at increasing public and community participation in planning and implementing primary health care, including in the rational use of medicines.

The results have been telling. When expectant mothers in Kamwenge District in western Uganda, in Kawempe Division of the capital Kampala, in the districts of Pallisa and Budaka in eastern Uganda, and in the Lira District in the North of the country have increased their understanding of their health rights and the services that meet them, their uptake of antenatal services and their delivery at health centres under professional supervision has in some cases doubled over the course of a year to eighteen months.

Through the C&C programme, HEPS-Uganda has established an independent feedback mechanism that receives complaints of health rights violations from health consumers, which it then tries to resolve through mediation with health providers and counselling. The process creates awareness of health rights and responsibilities on both sides, and has proved an effective way to identify and improve the whole system, both within the community and within the local level health services.

The Uganda Human Rights Commission has observed that the violation of health rights has not been given adequate attention in Uganda. But programmes like HEPS-Uganda’s C&C programme create confidence and hope: Community members can approach health providers in an informed manner and demand the services to which they are entitled. Equally, health providers themselves also recognise their duties and play their roles more effectively. The benefits are tangible for poor communities. In Pallisa and Budaka districts, community representation on health centre management committees is now more effective in the programme areas, and decisions are more responsive to community needs and preferences. Health centres have now scrapped illegal charges that consumers have continued to incur across the country in spite of government abolishing of cost-sharing as far back as 2001. The end result is a more people-centred, friendlier health care environment for communities as well as health workers, and the initiative is successfully demonstrating people’s power in improving their health.

It is not that the country’s policy makers do not appreciate the value of community empowerment in the effort to achieve ‘Health for All.’ Uganda is among the countries to have adopted the Alma-Ata Declaration 30 years ago, committing itself among other things to a human rights approach to health in which ‘the people have the right and duty to participate individually and collectively in the planning and implementation of their health care.’

At the country level, the national health policy commits the government ‘to ensure that communities are empowered to take responsibility for their own health and well being, and to participate actively in the management of their local health services.’

With ill-health identified in official surveys as the leading cause of high levels of poverty, national development plans, including the Health Sector Strategic Plan and the Poverty Eradication Action Plan, contain planned activities aimed at empowering communities for health.

There are numerous examples of how communities are playing a role in efforts to create a community-based primary health care system. Community drug distributors dispense anti-malarial medicines door-to-door, village health teams mobilise communities for sanitation and HIV prevention and treatment, and community members are involved in implementing the ‘directly-observed treatment’ strategy to manage Tuberculosis (TB). There have also been policies to entrust management of lower level health units to local governments and to management committees with community representatives.

With the exception of the TB management strategy, the performance of the rest of the initiatives leaves a lot to be desired however. Nearly a decade since the policy and other development plans were published, other planned activities, which would have empowered communities and consolidated the success of those already underway, remain at the planning level. For example, there has not been any national programme of community capacity building ‘for effective participation of health problems, planning of health services, in resource mobilization and in the monitoring of health activities’.

Uganda has made the important step of guaranteeing a minimum health care package, albeit with minimal resources. Instead of the estimated US$34 per person outlined by the Macroeconomic Commission on Health, the country is trying to attain universal access to primary health care with only US$8 per person. Without effective and collective demand from community level, people will carry on ‘making do’ with poorly resourced health systems and under-using resources that are applied.

Effective and collective demand calls however for a system that involves the intended beneficiaries in planning and implementation, and for an informed and empowered community able to demand and use the services it needs. In a resource poor setting like Uganda, the case for community empowerment for health is even stronger. It is needed in setting priorities, deciding on resource allocation, monitoring the performance of service providers and in building health care seeking behaviours. The government will have to live up to its commitment to empower communities if it is to guarantee their right to quality health care.

* Rosette Mutambi, Coalition for Health Promotion and Social Development, Uganda

* Please send comments to [email protected] or comment online at http://www.pambazuka.org/