By Joy Asasira

There is not a day that goes by that we do not hear of a mother somewhere in Uganda who has lost her life (and that of her baby) while delivering.

In many of the local dialects in Uganda, there is a word to describe this death. To say the least, this has been accepted as, “normal”, but is it? What is unfortunately a common practice, is that when women are faced with complications related to pregnancy or delivery, these women continue to choose high risk options such as delivering at home or with the assistance of traditional birth attendants.

The factors that lead to maternal death are known, these have been explained categorized to include; the socio-economic, cultural and accessibility and actual quality of care of health facilities. These contribute to what have been referred to as the three delays. These delays include; delay of women at home in making the decision to seek care, delay by the women to identify and reach the medical facility and delays at the health facility for the woman before receiving adequate and appropriate treatment.

Whereas the first and second delays are complex to address owing to the need for attitudinal shift, economic empowerment and doing away with deeply rooted cultural practices. The third delay, which is characterised by poorly-equipped facilities that lack among others; health workers, medicines, equipment and blood for transfusion as has been the case in Uganda in the recent past due to rampant blood stock outs. Maybe addressed through systemic and programmatic interventions can improve financing of health care and particularly maternal health care.

As we commemorate the maternal health month, I cannot help but wonder whether the non-affordability of maternal health services among others, is not one of the reasons our women continue to die form preventable maternal mortality causes.

Universal Health Coverage then becomes a possible solution for addressing the high cost of healthcare for maternal healthcare. Simply put, Universal Health Coverage (UHC) refers to the idea of access to health services for all without exposing the user to financial hardship. This is not to say that Universal Health Coverage is a silver bullet, however, it would mean one more step towards accessibility of healthcare, including maternal health services and family planning.

Ensuring affordable, accessible, acceptable and good quality health care for Uganda’s women of reproductive age is inevitable if we are to tackle the persistently high maternal mortality that stands at 336 per 100,000 live births.

The reality is that many Ugandans are just getting by and for every two Ugandans that get out of poverty, three more fall back into poverty. Since reproduction is not a reserve of those with means, those living in poverty also find themselves pregnant and in need of good quality and dignified maternal care.

This means that of the more than two million pregnancies in Uganda annually, many of these happen to women that are living below the poverty line (and these same women probably already have more children than they can care for). Let us not forget about our teenage girls; one in four of these girls have either had sex or been pregnant before their 19th birthday, but can they afford the healthcare that they desperately need?

It is not a surprise that that the media is awash with stories of women giving birth in taxis, at the entrance of hospitals, in corridors and on floors. There is also a new practice of detention of women in health facilities due to failure to clear the medical bills.

It is a fact that the high cost of healthcare is forcing women to make life threatening decisions about how to manage their pregnancies and where to deliver. This high cost must be addressed in order to ensure universal health coverage through a multi-pronged approach that includes investing such as primary healthcare, where we would have issues like malaria in pregnancy addressed.

Secondly, through building upon and strengthening partnerships between the public and private sector, this also includes regulating the operations of the private sector, including the pricing of services.

Thirdly, the creation of innovative financing models such as Uganda’s proposed National Health Insurance Scheme (NHIS). However the proposed NHIS is not without criticism even as its efficacy remains to be seen. Some have pointed out that a scheme that seeks to operate within a health system that is plagued by inequalities, including access to and distribution of health facilities between the rural and urban areas and disparities in staffing levels between facilities of the same level in different parts of the country.

There are lessons to be learned from countries like Rwanda that developed and is currently implementing the Community Based Health Insurance (CBHI) scheme, where a scale of the population based on their income and then worked to subsidize income the contributions for those considered the poorest and vulnerable.
While others considered able, pay a contribution towards their healthcare. It is no wonder that Rwanda was able to achieve Millennium Development Goal 5A, which was to reduce by three quarters between 1990 and 2015, maternal mortality ratio.

Rwanda reduced its maternal mortality ratio by 78% from 1,300/100, 00 live births to 567/100,00 live births in 2005 and 290/100,000 live births in 2015. It is also not surprising that the most significant changes were registered in rural areas where best practices like the women have embraced facility-based birth as opposed to home births.

The cost of health services continues to influence women’s choice of whether to seek health care during pregnancy and also skilled attendance at birth, With the number of women living in abject poverty, the need for government and stakeholder interventions to ensure access to health care without the fear of facing financial hardship becomes a pertinent issue for consideration in order to ensure improved maternal and child health outcomes in Uganda
Address maternal mortality in Uganda by ensuring affordable, accessible, acceptable and good quality health care service delivery.

A crossroad of ideas reflective of cultural and religious morals, beliefs and values affects young people of all social standings without sufficient attention given to scientific evidence that speaks to Sexual Reproductive Health and Rights SRHR issues. Teenage pregnancies have increased according to the 2016 Uganda Demographic and Health Survey, the school dropout rate especially in the hard to reach areas is still outrageous, sexually transmitted infections are still on the rise with 500 HIV infections happening among young people every week according to UNAIDS. Unsafe abortions also happen in a setting that still remains open to quack doctors operating in an unregulated environment due to the stay and disownment of different SRHR policy guidelines and service standards.

While they are at the center of SRHR decisions and service provision, cultural and religious leaders still remain a critical constituency that has not been tapped into by advocates for a progressive SRHR legal and policy environment in Uganda. They are a significant constituency because policies cannot be declared right with engaging them through consultations. However, this is a constituency that remains out of reach of scientific evidence that gives a clear and true picture of Uganda’s laughable SRHR record in comparison with other East African countries.

It is at this time that advocates must recognize that the influence of cultural and religious institutions cannot be go unnoticed, and they hold the key to ensuring that young people’s SRHR is realized. The role of religious and cultural institutions in child and human development is seen in church programs like Sunday school, youth camps/guild, and missions, the Kisakaate of the Nabagereka of Buganda and the girl-power conference of Pastor Jessica Kayanja for instance. Some of Uganda’s communication platforms are equally owned and operated by the religious and cultural institutions.

These include lighthouse television, Top TV and Radio, CBS Radio, Power FM, BBS Telefayina, Radio Sapientia, Radio Maria among others as important channels that we can leverage to enforce our support for the young people. Religious founded institutions through the Catholic Education Secretariat, Church of Uganda Schools, UMEA, and tertiary institutions like Uganda Christian University, Busoga University, Muteesa I Royal University, Ndejje University, and Uganda Martyrs University among others is other avenues in the education arena that are critical. It is therefore to the advantage of young people that this is another avenue the government is considering in the implementation of the recently launched Sexuality Education Framework.

The cultural and religious camps need to embrace access to SRHR information by young people through this avenue. They are equally at the center of health service provision and handle health predicaments of a significant number of people, including the SRH of young people.

The Medical bureaus (Uganda Catholic Medical Bureau, Uganda Protestant Medical Bureau, and Uganda Muslim Medical Bureau) are centers of power in determining the kind of services provided including on SRH. It is therefore important to emphasize these synergies with cultural and religious institutions in ensuring provision and access to a wide range of SRH services that remain out of reach by the young people. This is when Uganda will be able to score high on the different SRHR indicators.

Dennis Jjuuko
Programme Officer – Research, Documentation and Advocacy
Center for Health, Human Rights and Development