Summary
In the Iganga District of Uganda, a
UNFPA-supported Rural Extended Services and Care for Ultimate Emergency
Relief (RESCUER) Project seeking to reduce maternal mortality equipped
Traditional Birth Attendants (TBA) with modern communication technology. This
involved the installation of a solar powered VHF radio communication system
that included fixed based stations at the Primary Health Center, walkie-talkies
for the TBAs and ambulance vehicles. Improved communication and
transportation links between the TBAs and the health posts resulted in
increased and more timely referrals as well as the improved delivery of
healthcare to a large number of pregnant women. Getting connected bridged the
distance between traditional healers and public health providers. A notable
impact of the project was that maternal morality reportedly declined by more
than 50 percent over three years.
The Challenge
The Iganga District is located in eastern Uganda
and had one of the highest rates of maternal mortality with a population of
about 900,000 people in the 1980s.
In Uganda, the main
causes of high maternal mortality are
- Insufficient access to
timely healthcare, especially during pregnancies and labor
- Low quality of care at a
given health facility as determined by personnel, equipment, supplies
and the referral systems
- Individual characteristics
pre-disposing the mother to high-risk pregnancies
Previous attempts and
lessons learnt showed that to reduce maternal mortality the following factors
are important:
- Timely detection of
complications
- Improving women’s access to
prompt, effective treatment of obstetric complications
- System should build upon
existing cadres of health service providers
- Improve quality and
responsiveness of reproductive health care
- System must be cost
effective and sustainable to work for poor with poor human and financial
resources in remote areas
- Programs must be community
based and should convince families, husbands and leaders that maternal
mortality can be prevented.
The RESCUER
Project
A pilot project to
reduce maternal mortality, Rural Extended Services and Care for Ultimate
Relief (RESCUER) was implemented in the Iganga District in March 1996.
It involved the collaborative effort among UNFPA, the Ugandan Ministry of
Health and the Iganga District.
The RESCUER Project
developed an innovative referral system that addressed the three problems of
communication, transportation and quality emergency care.
Communication: a VHF solar-powered radio
communication with base stations at the referral units and walkie-talkies
available to Traditional Birth Attendants (TBAs). In case of emergency, the
TBA is able to instantly establish contact with the identified referral
point. The referral point then sends transport to the village to transport
the mother quickly to the health unit.
Transportation: initially, a three-wheeled
motorized vehicle (tricycle) was designed which was simple, economical, easy
to maintain with a simple structure to accommodate the expectant woman and
her attendant.
Identifying Referral
points: A
mapping exercise of the available health facilities was undertaken, followed
by an in-depth needs assessment of identified referral points. A work plan to
address the weaknesses, gaps and to ensure at least an acceptable minimum
level of referral care and services through training, renovation, logistics,
equipment was developed.
Project
Impact
Improved
communication and transportation links between the TBAs and the health posts
resulted in increased and more timely referrals as well as the improved
delivery of healthcare to a large number of pregnant women.
Panic situations and
uncertain management of complications were reduced considerably.
Improved communications
made the work of the midwives easier as they were alerted in advance and
could be well prepared for the emergency. For example, before the project,
the existence of a high risk pregnancy (say a woman going through her tenth
pregnancy) would generally not be brought to the attention of the modern
health service system. As a result of the project’s approach, such a case
would be given prompt attention due to the new communications and
transportation systems in place.
The walkie-talkies also
helped empower the TBAs by improving their image and credibility, thus
increasing compliance with referral advice, and also augmented their income,
by increasing the number of patients they attended to.
Getting connected
bridged the distance between traditional healers and public health providers.
A notable impact of
the project was that maternal morality reportedly declined by more than 50
percent over three years.
Lessons Learned
Ø A critical mass of complementary
activities is needed to achieve maximum impact. For example, although the
communications component made a very significant contribution to the success
of the RESCUER project, it could not stand on its own. For the project to
achieve its objectives of improved referrals leading to increased deliveries
of trained personnel, the other two components (transportation and quality of
services delivery had to play their complementary role.
Ø The project built on existing
infrastructure and local capacity including traditional knowledge systems.
The TBAs knowledge of local culture, values and their ability to connect the
traditional and modern practices was important to the project. Indeed
the project started at the grassroots with the traditional knowledge held by
the TBAs, and improved it by conducting refresher courses and equipping TBAs,
as well as professional health workers with simple ICT, transport and regular
supplies.
Ø Leveraging traditional and
modern knowledge systems can increase impact. For example, the RESCUER
project brought together traditional and modern health practitioners and
inculcated mutual understanding and trust that has enhanced maternal health
care.
Ø Decentralization is probably the
most critical precondition for success: decentralized medical services staff
have more direct exposure and contact to traditional practitioners and can
appreciate their strengths and limitations, can learn from them and address
problems of charlatanry in cooperation with the serious practitioners (in the
case of maternal mortality it is essential that at sub-district level basic
obstetrics and C-sections can be performed and only the most severe cases
need to be referred to the next higher level).
Ø Adequate public investment is a precondition
to achieve decentralization; while cost sharing by patients increases
sustainability of decentralized services, when addressing poverty, especially
in rural areas even maintenance of decentralized health services may require
transfers.
Ø The impact of ICTs is enhanced
if the technology is appropriate to the local conditions. As indicated,
the ICT choice was made after careful considerations of the local problems in
rural Uganda.
Ø The use of solar power by the
radio communication system could also benefit rural health units, which have
no electricity. In particular, it is recommended that the solar power should
be extended to provide light in the maternity wards / labour suites in the
first-level referral units.
Ø The simplicity of design of the
radio communication system facilitated its access and use by the entire
community, as all the people interviewed reported that the system was very
simple and easy to use.
Ø The public audibility of the
radio communication system renders it difficult to abuse or misuse.
Interviewees reported that calls made are usually brief and to the point, and
that the nature of this ICT protects it from theft.
Ø A multi-tiered ICT approach can
help bring the benefits of advanced technology to the rural population in
Sub-Saharan Africa. Such an approach will cater for the different
capabilities in African situations. For example, telemedicine and other
advanced technology facilities (e.g. the Internet) can be adopted at the
district hospital, while simple technologies like radio can serve lower
levels (rural health units, TBAs, etc). The consultations made by lower units
to the district hospital would ensure that the rural population benefits
indirectly from the advanced technology.
Ø Community involvement is also an
important factor, demonstrated in the fact that based on their concerns
inappropriate tricycles were replaced with small 4WD vehicles that could
navigate better on poor roads.
Ø Sustaining the impact requires
an assured flow of transfers to support project activities. In the case
of Iganga, some of the gains made under the project were reportedly reversed
recently due to insufficient funding of the key services, especially the
provision of fuel for the new ambulances.
Replication
and Scaling Up
The Iganga experience
has clear potential for replication and scaling up. The generic lessons could
be applied in other regions of Uganda as well as in other countries.
However, it is important to keep in mind that any replication and or scaling
up will have to adapt the basic approach to the local conditions. Such
adaptation is critical to leveraging maximum impact.
Efforts are underway to
scale up the RESCUER Project to other parts of Uganda and possibly other
regions of Africa. For example, a community-to-community exchange of the
Iganga experience is under preparation, supported by the Africa Region of the
World Bank and its partners. For further information on these activities
contact Siddhartha Prakash (Email: Sprakash@worldbank.org,
Phone: 1-202-473 5863).
The key to success is
to understand the inter-linkages between the three critical elements of the
project: communications, transportation and the quality of healthcare
services. The combined efforts of these three factors working together led to
the reduction of maternal mortality by 50% in three years.
Communications helped
bring together traditional and modern health practitioners in a joint
partnership to provide effective healthcare.
Transportation helped
reduce the distance between remote areas and district hospitals, thereby
improving peoples access to healthcare.
Effective training on
emergency and other complications related to maternal healthcare practices
helped improve the overall quality and delivery of healthcare services.
There are different
approaches that can be adopted to scale up the Iganga case. The Commissioner
of Health Services, Ministry of Health, Uganda, Professor E.M. Kaijuka,
has recommended the following steps:
1. Consultations with
districts to explain the relevance of the RESCUER Project and assess
the demand and interest from the communities.
2. Feasibility study to examine the
conditions on the ground and assess whether it is viable to establish the
Project in the proposed location.
3. Formation of a Task Force or
Organization Committee to organize the communities and manage the overall
project from design to implementation.
4. Community sensitization and
mobilization to ensure local ownership, buy in and active involvement.
5. Human resource development,
through recruitment and training of medical staff (TBAs, public health
workers) and other personnel.
6. Selection of appropriate health
units in terms of access to communities and distance to other health centers.
7. Procurement of required
equipment and medical supplies.
8. Renovation of existing health
units that are run down.
9. Strategic partnerships between government
agencies, traditional health practitioners, Telecom authorities, hospitals
and communities to work together.
10. Monitoring and Evaluation system to help monitor the
progress of the project implementation and evaluate its success in reducing
maternal mortality.
Web Links: to reports on the
Iganga Case:
The
Rescuer’s Experience
The Rescuer Project
Report
Telemedicine
in Africa
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