Health
First-Ever Harmonized Health Facility Assessment by MakSPH and MoH Reveals Improvements in Uganda’s Overall Health Services
By Julius Tukacungurwa & Davidson Ndyabahika
The first ever Harmonized Health Facility Assessment (HHFA) jointly conducted by MakSPH and the Ministry of Health (MoH) has illuminated significant advancements in Uganda’s healthcare landscape. This ground-breaking survey, which serves as a robust benchmark for evaluating health services across the country, offers a comprehensive overview of service availability and readiness within Ugandan health facilities.
The HHFA, a successor to the esteemed Service Availability and Readiness Assessment (SARA) tool endorsed by the WHO, probes into four critical modules: service availability, service readiness, quality of care and safety, and management and finance.
Focusing initially on service availability and readiness, the HHFA embarked on a cross-sectional analysis of 642 facilities in April 2022, spanning National Referral Hospitals (NRHs), Regional Referral Hospitals (RRHs), General Hospitals (GHs), primary healthcare facilities at levels II, III, and IV.
The findings, while highlighting disparities in service availability and facility capacity across different healthcare sectors, underscore a promising trajectory towards enhancing overall health services nationwide.
Dr. Christopher Garimoi Orach, a Professor of Community Health at Makerere University School of Public Health (MakSPH), led the team that conducted the survey. He presented the report which was subsequently launched by Uganda’s Minister of Health Hon. Dr. Jane Ruth Aceng Ocero on Tuesday 12th.March.2024 during the 10th Annual National Health Care Quality Improvement Conference at Imperial Resort Beach Hotel, Entebbe.
The findings of the HHFA report indicate that Reproductive Maternal Newborn Care and Adolescent Health (RMNACH) services were available in most health care facilities across the country. In Uganda, healthcare facilities offer a wide range of essential services, including pediatric care, antenatal and postnatal care, malaria prevention during pregnancy, and newborn care, with over 95% providing these services according to the report. Findings also show that continuous antenatal care is available in about 79% of facilities, while skilled delivery services are offered in 89%. Additionally, family planning, emergency obstetric care, immunization, and adolescent health services are widely accessible, with percentages ranging from 77% to 91%.
During the launch event, Dr. Aceng underscored the significant steps made by the health sector in meeting crucial performance benchmarks. These include a notable 47% reduction in Maternal Mortality between 2016 and 2022, a commendable 12% decrease in Under 5 Mortality over the same period, and a promising 7% decline in Infant Mortality rates as highlighted in the Uganda Demographic Survey (UDHS) Report 2022.
“As you might know, overall, the health sector has made good progress towards achieving the key performance indicator targets. I wish to appreciate each one of you for the job well done,” said Dr. Aceng.
Adding that; “The Ministry of Health continues to make big investments in the national health system. Mulago National Referral Hospital, Mulago Specialised Women and Neonatal Hospital, and several Regional Referral Hospitals have received infrastructure development including installation of modern medical equipment.
There is also deliberate effort to improve access to health service, delivery to the community through purposeful upgrade of some HC IIs to corresponding equipping and general review of the human resource requirements in the health sector. There is also deliberate effort to improve access to health services, delivery to the community through purposeful upgrade of some HC lIs to HC Ills with corresponding equipping and general review of the human resource requirements in the health sector.”
The also study highlights a significant increase in Uganda’s general service index, rising from 48% in 2018 to 59% presently. Utilizing a similar survey methodology, researchers observed notable improvements in the availability of health interventions across various domains. Particularly in Reproductive Maternal Adolescent Health services, higher provision rates were evident, especially at higher-level health facilities. Moreover, delivery assistance at Health Centres IIIs and above by skilled attendants has become standard practice, with nine out of ten cases receiving skilled care.
Immunization services have also witnessed widespread availability, notably in hospital settings. However, while all surveyed facilities now offer malaria treatment services, access to non-communicable disease management, such as cancer diagnosis and treatment, remains limited, and readiness to provide transportation services for community members in need is inadequate.
According to Professor Orach, the Ministry of Health should strengthen and improve diagnosis and treatment of cancers generally across the country, especially at the National and Regional Referral Hospitals so that many more people at community levels can access the services. He also notes that the Ministry needs to quickly do everything possible to strengthen the transportation systems for patients from communities to reach and access health services.
The research noted that salary enhancement is a step in the right direction for improving how health workers perform. “We need to enhance that by ensuring that, ‘the health system, which is a complex system’, when we enhance salaries, we still need to continue to monitoring the health workers, we still need to continue to provide other requirements for the performance of health services, like drugs should be available,” noted Professor Orach.
Adding that; “Transport should be available, other ways of ensuring that their performance can be up to the expected standard. So, in other words, that’s an important step and we must thank the government for what they’ve done here for we should still support them in other ways and monitor them closely to ensure, guidelines are available for services, that drugs are available, so that they can continue to provide good services.”
“Our findings also show that for instance, the private health practitioners are not carrying out a lot of immunization, but government health facilities and private not for profit facilities are providing immunization services. This means that the private health practitioners don’t focus on immunization since it may not be bringing them money, they sought the ministry to engage with them to ensure that they’re brought on board so that they can provide their services in an integrated manner,” he noted.
During the event, Associate Professor Peter Waiswa from the Health Policy, Planning and Management Department at MakSPH delivered a keynote address on ‘Understanding Health Systems Strengthening in a resource limited set-up.’ Professor Waiswa has had research work in maternal, new-born and child health in low and middle-income countries.
According to Dr. Diana Atwiine, the Permanent Secretary of the Ministry of Health, this health facility assessment and report will significantly enhance MoH’s institutional capacity for strategic planning and policy development in Uganda’s health sector.
“The Makerere University School of Public Health (MakSPH) Team led by Prof. Christopher Garimoi Orach is appreciated for spearheading the entire process of undertaking the HHFA and developing the report. The MoH is very grateful for the diligent work well-done by the various actors that included the technical officers, research assistants and the administration staff to have the final report meticulously developed,” said Dr. Atwiine.
Dr. Henry G. Mwebesa, Director General of Health Services, emphasizes the pivotal role of robust health systems in achieving lasting health advancements. He underscores that the findings will facilitate the country’s ability to track health service progress, advancing towards Universal Health Coverage (UHC) and Sustainable Development Goals (SDGs). This data supports evidence-based decision-making, fortifying national health system planning and policy-making.
“This HHFA report is recommended for use by the various key stakeholders including health service managers, district leaders, ministry of health officials, both government, private sector, civil society organizations and development partners at different levels to inform and improve planning and implementation of effective health services delivery in Uganda,” says Dr. Mwebesa.
Photos by Julius Tukacungurwa.
Health
Mak Researchers Partner with Safe Bangle Technologies to Roll out a Real-Time Domestic Violence Reporting Bracelet
By Joseph Odoi
A Consortium of Researchers from Makerere University School of Public Health/Resilient Africa Network (MakSPH/RAN), Medical College of Wisconsin (MCW), Somero Uganda together with Safe Bangle Technologies have rolled out a real time domestic violence reporting bracelet.
This roll out was made possible with support from the United States Agency for International Development (USAID) under the PARTNERSHIPS FOR ENHANCED ENGAGEMENT IN RESEARCH (PEER) program and the National Academies of Sciences.
Dr. Juliet Kiguli, the Principal Investigator from Makerere University, along with Dr. Roy Mayega, Deputy Chief of Party at RAN, and Dr. Agnes Nyabigambo, the study coordinator, initiated the PEER program to identify entry points for testing SafeBangle Technologies (a social enterprise based at Resilient Africa Network (RAN) with a mission to create a safer and more secure environment for women and children through innovative, affordable, and creative technology solutions to curb GBV in Africa.) wearable safety bracelet in the informal settlements. This decision stemmed from findings of increased intimate partner violence (IPV) and gender-based violence (GBV) in three informal settlements in Kampala, Uganda, following a longitudinal study, geospatial mapping, and interviews. The project, titled ‘The Impact of the COVID-19 Pandemic on Gender-Based Violence among Women and Girls in Informal Settlements in Kampala,’ highlighted the urgent need for affordable and immediate reporting mechanisms for violence.”
‘’While carrying out a study after the Covid-19 Pandemic, we identified gaps when it comes to reporting and response to Gender Based Violence (GBV) among women in informal settlements. Therefore, we used incorporated the SafeBangle intervention to solve the problem of lack of affordable and immediate reporting mechanisms for violence using a bracelet that reports violence in real time’’ explained Dr. Kiguli.
Innovation details
According to Saul Kabali and Messach Luminsa, the innovators behind SafeBangle from SafeBangle Technologies, hosted at the Resilient African Network Lab. ‘’The inspiration behind SafeBangle came from a deeply personal place. ‘’We heard countless stories of women who couldn’t call for help during moments of danger. We were deeply affected by the story of Aisha, a young woman in a rural village who was attacked while walking home alone at night. With no way to call for help, she felt helpless and vulnerable. This incident made us realize the critical need for immediate reporting alert tools, accessible to women like Aisha. We knew technology could play a crucial role and this incident awakened a strong desire in us to create a solution’’
“While developing SafeBangle, we tested with the users in both rural and urban contexts. We piloted the innovation around Kampala with support from Digital Human Righs Lab and Naguru Youth Health Network as well as it in five districts of Karamoja region with support from Save the Children and Response Innovation Lab. Right now it has become handy in Kamapala‘s informal settlements. We envision a future where SafeBangle becomes a standard tool in the fight against GBV, ensuring every woman feels safe and secure as it has the potential to transform how we respond to GBV in Africa” added Kabali.
HOW THE SAFEBANGLE TECHNOLOGY WORKS
The SafeBangle is wearable technology similar to a smartwatch that sends an alarm by SMS to people chosen by a woman herself if she feels threatened.
In terms of the acceptability of the SafeBangle innovation as a solution to GBV among at-risk women in informal settlements Of the 72 adolescent girls and women who received the SafeBangle, 22 activated the reporting button, resulting in 19 receiving immediate and appropriate support, including counseling, police intervention, and health services.
All adolescent girls and women who experienced GBV received a phone call from Somero Uganda to discuss the most appropriate intervention, including counseling, police cases being handled by the probation office, referral for health services, and post-exposure prophylaxis. All the GBV survivors received support and are still receiving continuous follow-up.
Researchers conducted a survey among 644 girls and women in Kinawataka (Nakawa Division) and Bwaise (Kawempe Division) to gain insights into awareness and understanding of sexual and gender-based violence among adolescent girls and women in informal settlements. The survey measured socioeconomic factors, mental health symptoms, and exposure to GBV. Focus group interviews were conducted with a separate sample of women over 18 in the settlements to explore responses to GBV.
A tabular representation of the key findings and lessons learned from your study on gender-based violence (GBV)
| Key Findings | Lessons learned |
| Prevalence of GBV. – Overall prevalence: 34.1% of women and girls reported experiencing GBV. – Among adolescents (15-19 years): Over 50% reported experiencing GBV. | – The pandemic highlighted the need for accessible and comprehensive support services for GBV survivors. – Schools emerged as crucial safe spaces for girls, emphasizing their well-being during crises. – Economic independence proved crucial, enabling women to leave abusive environments. – Involving men and boys as allies in GBV prevention efforts is essential. |
| Age-related trends | – GBV prevalence tends to decrease with increasing age. |
| Physical and health consequences. | – Women and girls suffered physical violence, injuries, and deaths, primarily from domestic violence and unsafe abortions due to limited healthcare access. – GBV resulted in unintended pregnancies, unsafe abortions, and increased risk of sexually transmitted diseases (STIs) like HIV/AIDS. |
| Social and economic impact. . | – GBV contributed to family breakups, strained marriages due to financial stress. – Economic hardships forced some women and girls into transactional sex, exposing them to further health risks and exploitation. – Pandemic-related job losses and economic constraints increased financial dependence on abusers, trapping women in violent situations. – School closures and increased household responsibilities limited women’s job opportunities and subjected them to sexual harassment. |
| Psychological effects | – Survivors experienced guilt, shame, anxiety, fear, and suicidal thoughts due to ongoing abuse. |
| Long-term effects | – Post-COVID-19, survivors faced disrupted education, early marriages, pregnancies, social stigma, and persistent mental health issues. |
Reproductive Health Consequences: GBV resulted in unintended pregnancies, unsafe abortions, and increased risk of sexually transmitted diseases (STIs) like HIV/AIDS.
Family Breakdown: The rise in GBV led to family breakups as women fled abusive relationships. Marriages were strained due to increased financial stress.
Transactional Sex for Survival: Desperate for basic needs due to job losses and economic hardship, some women and girls resorted to transactional sex, exposing them to further health risks and exploitation.
One study participant stated, “The time of COVID-19 was so terrible for some of us. We in fact got a lot of diseases from it because you would want to get food and didn’t have money. That way you would be forced to get a man who would use you and pay.” – (FGD_Girls_19–24years_Kinawataka).
Economic Effects: COVID-19 restrictions caused job losses and limited economic opportunities, particularly for women in the informal sector. This increased financial dependence on abusers and trapped women in violent situations.
Limited Access to Employment: School closures and increased household chores limited women’s ability to seek employment, perpetuating gender inequality in the workforce. Some faced sexual harassment from potential employers.
Psychological Effects: Survivors of GBV experienced guilt, shame, anxiety, fear, and even suicidal thoughts due to the constant threat and unpredictability of abuse.
Post-COVID Effects: GBV survivors faced long-term consequences, including disrupted education, early marriage, early pregnancy, social stigma, and persistent mental health issues.
Lessons learned
The pandemic highlighted the need for accessible and comprehensive support services for survivors of GBV, the significance of schools as safe spaces for girls, and the need to prioritize their well-being during crises. Economic empowerment emerged as a significant protective factor for women and girls. Those with greater economic independence were better equipped to leave abusive environments and secure their safety and well-being, while dependent ones suffered abuses. Engaging men and boys as allies in the fight against GBV and involving them in prevention efforts can help promote positive behavior change and foster more equitable relationships.
Recommendations
To address GBV against women and girls, the researchers recommend the following moving forward;
- There is need to integrate technology-driven solutions like SafeBangle into national GBV prevention and response strategies. SafeBangle can be a valuable tool for policymakers as cases of violence that would have gone unreported will be brought to light and the would-be victims will be able to get immediate help from trusted relatives and friends.
- Provide economic opportunities and vocational training for women and girls to enhance their financial independence and reduce vulnerability to violence. There is therefore a need to introduce education and training programs that empower women and girls, by providing them with skills, resources, and opportunities to start their own ventures and to participate fully in community affairs.
- Strengthen and enforce existing laws and policies related to GBV, including laws against domestic violence, child marriage, and sexual assault without discrimination be it for law enforcers, leaders, and employers where such cases were suffocated. Ensure that perpetrators are held accountable through swift and fair legal processes that have no room for corruption.
- Establish and promote effective, accessible, and confidential reporting mechanisms for GBV incidents that provide confidence and can be trusted by survivors to enhance reporting of such incidences of GBV. Community Engagement and Involvement: Involve community leaders, religious leaders, and elders in discussions about GBV to promote gender equality, change social norms, and reinforce the message that violence against women and girls is unacceptable.
- Launch extensive public awareness campaigns to challenge harmful gender norms, report cases of GBV, raise awareness about the consequences of GBV, and promote positive behaviors and attitudes towards women and girls.
- Implement comprehensive sexuality education in schools and communities, educating young people about healthy relationships, consent, and reproductive rights to be able to make informed decisions about their own lives and well-being.
- Engage men and boys as allies in the fight against GBV, encouraging them to challenge harmful masculinity norms and behaviors. This will help minimize GBV because mostly they are the perpetrators. Strengthening Support for Survivors: Provide ongoing support and follow-up services for survivors of GBV mostly counselling services to aid their recovery and facilitate their reintegration into society.
- Provide ongoing support and follow-up services for survivors of GBV, mostly counseling services to aid their recovery and facilitate their reintegration into society.
- Provide avenues to seek free or subsidized services by survivors of GBV medical services and legal processes by survivors of GBV to enhance reporting of GBV cases, access to medical care, counseling, legal support, and other essential services.
- Encourage and support more research and innovations like SafeBangle to curb incidents of GBV.
- A comprehensive and inclusive approach is required. The efforts should involve government institutions, civil society organizations, community leaders, and individuals working together to address the root causes and provide support to survivors.
- Involve media in GBV prevention activities and for enhancing campaigns against GBV mostly on radio and TV.
MORE ABOUT THE STUDY
The core project team, included researchers at Makerere University School of Public Health (MakSPH), Medical College of Wisconsin (MCW) led by Prof. Julia Dickson-Gomez, SafeBangle Technologies, and Somero Uganda, a community-focused NGO, began the project by designing their research protocol and taking a CITI Program course on human subjects social/behavioral research. Team members also met with the Ministry of Gender, Labour, and Social Development (MGLSG) in support of the gender-based violence policy process, Ministry of Health and local government. They also established relationships with the Kampala Capital City Authority (KCCA) and Nakawa and Kawempe probation offices to support legal processes for the GBV survivors. SafeBangle Team also received an award from Defenders Protection Initiative.
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