Uganda Final Country Report
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Uganda Final Country Report January 2000 The goal of the Family Planning Service Expansion and Technical Support (SEATS) Project is to expand access to and use of high-quality, sustainable family planning and reproductive health services. John Snow, Inc. (JSI), an international public health management consulting firm, heads a group of organizations implementing the SEATS Project. These include the American College of Nurse-Midwives (ACNM), AVSC International, Initiatives, Inc., the Program for Appropriate Technology in Health (PATH), World Education, and partner organizations in each country where SEATS is active. This publication was made possible through support provided by the Office of Population and the Bureau for Africa, the Office of Sustainable Development, United States Agency for International Development (USAID) under the terms of Contract No. CCP-C-00-94-00004-10, and by John Snow, Inc. (JSI). The contents and opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID or JSI. Table of Contents Table of Contents i List of Tables ii List of Charts ii Acronyms iii I. Executive Summary 1 II. Project Background 2 A. Country Background 2 B. Demographic and Health Indicators 3 C. The Ugandan Health Care System 5 D. Private Midwives in Uganda 6 E. Uganda Private Midwives Association 8 III. Goals and Objectives 8 A. USAID Uganda Strategy 8 B. SEATS Country Strategy 10 IV. Project Implementation 12 A. MAPS I Subproject: 1995-1997 12 B. MAPS II Subproject: 1998-1999 17 V. Accomplishments 28 A. Improved Access to FP/RHC Services 28 B. Improved Quality 30 C. Improved Institutional Capacity and Sustainability 35 VI. Key Lessons Learned 38 VII. Recommendations 39 Appendix 1. Map of Uganda Appendix 2. Standards for Private Midwifery Practice Appendix 3. Client Interview Data Appendix 4. Relevant Documents Uganda Final Country Report |i List of Tables Table 1. UPMA Membership ...................................................................................................21 Table 2. DISH Training Average Scores by Skill for Midwives During MAPS II......................31 Table 3. Performance on Selected Standards ............................................................................33 Table 4. Leveraging Activities ..................................................................................................37 List of Charts Chart 1. CYP by Method..........................................................................................................30 Chart 2. New and Returning Clients.........................................................................................29 ii| Uganda Final Country Report Acronyms ACNM American College of Nurse-Midwives AIDS Acquired Immune Deficiency Syndrome ANSFS Association Nationale des Sage Femmes du Senegal ARO Africa Regional Office (SEATS) CA Cooperating Agency CAFS Center for African Family Studies CMS Commercial Marketing Strategies CPR Contraceptive Prevalence Rate CQI Continuous Quality Improvement CYP Couple-Years of Protection DHS Demographic and Health Survey DISH Delivery of Improved Services for Health DMO District Medical Office FINCA The Foundation for International Community Assistance FP Family Planning GOU Government of Uganda HIV Human Immunodeficiency Virus ICM International Confederation of Midwives ICO Independent Clinics Organization IDR Institute for Development Research IEC Information, Education and Communication IMF International Monetary Fund INTRAH International Training and Health JHU/PCS Johns Hopkins University/Population Communication Services JSI John Snow, Inc. LAM Lactational Amenorrhea Method LC Local Council LTPM Long-term and Permanent Methods MAPS Midwifery Association Partnerships for Sustainability MIS Management Information Systems MOH Ministry of Health MW Midwife NGO Non-Governmental Organization NRM National Resistance Movement PR3 Performance Result #3 (Leveraging) PSI Population Services International PVO Private Voluntary Organization PY Project Year QOC Quality of Care RA Resident Advisor RHC Reproductive Health Care Uganda Final Country Report |iii SEATS Family Planning Service Expansion and Technical Support Project SDP Service Delivery Point STI/STD Sexually Transmitted Infection/ Disease SOMARC Social Marketing for Change TA Technical Assistance TFG The Futures Group TFR Total Fertility Rate TOT Training of Trainers UNDP United Nations Development Programme UNMC Uganda Nurses and Midwives Council UPMA Uganda Private Midwives Association USAID United States Agency for International Development VSC Voluntary Surgical Contraception WHO World Health Organization WRA Women of Reproductive Age ZNA Zambia Nurses Association iv| Uganda Final Country Report I. EXECUTIVE SUMMARY Uganda, often referred to as “The Pearl of Africa,” was once one of the leading countries in Africa in terms of economics, education, and health care. Between 1972 and 1986, however, Uganda had seven different ruling regimes and suffered greatly during 14 years of civil war. The infrastructure and economy of the country collapsed, many professional leaders and workers left Uganda or were killed, and the lives and morale of the populace were decimated. In 1986, the National Resistance Movement (NRM) gained control of the government and remains in place today. Uganda is once again emerging as a leader in the African and global communities, undertaking economic, political and healthcare reforms and programs. The Uganda Private Midwives Association (UPMA), the professional organization for private midwives, was founded in 1948. During the civil war it became non-functional and was not fully re-organized until approximately 10 years ago. In 1991, UPMA requested assistance from the United States Agency for International Development (USAID)/Uganda and the USAID-funded Family Planning Service Expansion and Technical Assistance (SEATS) I Project implemented by John Snow, Inc. Between 1991-1994, SEATS I with its partner, the American College of Nurse- Midwives (ACNM), provided training in family planning/reproductive health care (FP/RHC) service delivery for 137 private midwives and developed a system of regional representatives within UPMA. The effectiveness of this subproject highlighted the important contribution private midwives could play in meeting family planning needs in Uganda and laid the groundwork for successive interventions under SEATS II. In November 1995, SEATS II conducted a needs assessment that showed the main constraints facing UPMA were insufficient finances, inadequate financial and organizational management skills, unrealistic time demands placed on volunteer officers and a limited infrastructure. At the same time, the bilateral Delivery of Improved Services for Health (DISH) Project was mandated to provide comprehensive FP/RHC training for both public and private sector midwives, but no interventions were planned to address the sustainability of private providers or of UPMA through capacity building. Under the SEATS II Special Initiative, Midwifery Association Partnerships for Sustainability (MAPS), a two-year (1995-1997) subproject was designed and implemented to address these issues. During the lifetime of that subproject, the organizational structure of UPMA was expanded to include a Board of Directors (including a financial advisor) and a full-time administrator. In addition, 145 private midwives were trained in business management skills and community mobilization. Follow-up visits to these trained midwives showed impressive increases in the number of clients utilizing their services as a result of interaction with the community as well as improved management of clinic finances and resources. A second MAPS subproject (1998-1999) continued capacity building with UPMA through interventions that included developing an Association-owned and operated model clinic and training center, installing computerized financial and membership data systems, training administrative staff and UPMA leaders in financial and organizational management, developing strategic and business plans, conducting membership drives, and assisting aspiring private midwives. Linkages were developed between UPMA and the Uganda Nurses and Midwives Council (UNMC) for the development of private practice standards, and with the Commercial Uganda Final Country Report |1 Marketing Strategies (CMS) Project for development of strategies to market and promote both UPMA and the new clinic. SEATS II monitored and evaluated selected quality interventions and was able to demonstrate improved knowledge and skills, baseline level of compliance with standards, increased access to family planning services and a high percentage of surveyed clients who were satisfied with the care provided by private midwives. After almost a decade of interventions in Uganda under SEATS I and SEATS II, the institutional capability of UPMA is greatly improved and it is well positioned to enter the next century as a leader of FP/RHC services and an advocate for private midwives. As UPMA becomes more self- sufficient, it will be able to develop and sustain the types of programs and activities to ensure the quality of and access to FP/RHC services provided by its members, with decreased dependency on external funding and technical assistance. II. PROJECT BACKGROUND A. Country Background Uganda is a landlocked nation more than 2,000 kilometers from the Indian Ocean and divided by the equator. There is a total land area of 241,038 square kilometers, comprised of wetlands,