Far in the deep south-western corner of Uganda on the border with the Congo, in an area of dense rainforest and steep-sided mountains, lies the remote region of Kayonza.
Although it’s remote, it is an area frequented by many a visitor to the country, a fact that is immediately noticeable by the kids shouting ‘Mzungu give me money’ with their hands stretched out. This is markedly different from the kids you find in Kampala and most other places we’ve been to, for whom an ‘Mzungu’ is seen as a curiosity not a cash machine. We were told that there are stories of misguided tourists throwing dollar bills out of the windows of their four by fours as they drive through villages, hence the demanding shouts.
The reason for the influx of Mzungus to this corner of Uganda is the presence of the world famous Mountain Gorilla. The Bwindi Impenetrable Forest is home to more than half the world’s Mountain Gorilla population. The Impenetrable Forest is a truly descriptive name in that this is rainforest at its prime. The forest has an average annual rainfall of 1,500mm…and it felt as if a large proportion of this fell on us whilst we were there! The steep slopes are layered with trees and twisting climbers of different greens. One of the nurses at the health centre we visited said it sometimes felt like the forest was taking over, inching in and suffocating the inhabitants.
The reason we were whisked to this romantic area within our first week of landing in the country is that one of the first tasks I have been assigned is finding funds for an innovative community health scheme being set up by Bwindi Community Hospital. Now this isn’t your average Ugandan Community Hospital. Started as a missionary hospital in 2003, it pottered along as a small health centre until a couple doing a 2-year VSO placement took over management. They’re still there after 4 years and in this time the facility has advanced to become one of Uganda’s most efficiently run and innovative community hospitals.
On the back of a child health initiative providing free healthcare for the under 5 year olds in the area, a team of motivated community workers have compiled a database of demographic, socio-economic and health indicators for every household member in the region. For any researcher or public health graduate this database signifies a goldmine of information – it even includes GIS coordinates for every household and uses fingerprint scanning to identify individuals, thereby notifying the healthcare provider if the individual is registered on any of the free healthcare schemes and providing immediate details of their medical history. Now this may seem run of the mill for those of us who are used to detailed data being held on us covering every element of our lives from the kind of washing powder we prefer to whether we pay our credit card bills on time, but I can tell you that for this part of the world it’s pretty impressive and goes a long way towards designing more effective outreach services targeted to those most in need.
In addition to this, there is a great maternal health scheme funded by Marie Stopes whereby expecting mothers can buy a voucher for 3,000 shillings (£1) which allows them 4 antenatal visits, a hospital based delivery (including c-section if required) and one post-natal visit. Without this scheme the cost for the mother for this would be 170,000 (£56) shillings for a normal delivery package and 320,000 shillings (£140) if a c-section is required. Understandable then why usually most choose to deliver at home and maybe only afford one antenatal visit. Large numbers (550 in 100,000) mothers die in childbirth in Uganda, largely due to the fact that they are giving birth far from the emergency obstetric services they might need.
In addition to removing the financial barriers to these services through the vouchers scheme, Bwindi Hospital offers the option for mothers to use their waiting mothers hostel. This is a service whereby accommodation is provided free of charge for mothers for up to 2 weeks prior to their delivery. By getting the expecting mothers in prior to going into labour, a number of important interventions come into play:
- A reduction in time spent travelling along the treacherous roads in Kayonza whilst in labour
- The time that the mothers are at the hostel is used to provide education on care of the newborn, basic hygiene, nutrition and family planning.
- The hospital can monitor those showing potential signs of complications
It is our intention to try to replicate similar community level interventions in two health centres the northern parts of Uganda (more on this at a later date!).
Now, although we were keen on learning about the maternal and child health work going on in Bwindi, we were really there to learn about eQuality Health. This is essentially a community health insurance scheme, yet there are a few important differentiating elements to it.
The basis of it is that every individual above the age of 5 years pays 6,000 shillings (£2) for a year’s healthcare at Bwindi Community Hospital. A further 6,000 shillings per person is then paid to the Hospital by IMF (who I work for), financed externally by donors (where I fit in…), and assuming a minimum of 80% of the community (45,000 people) join the scheme, this should cover hospital running costs for the year. A minimal fee of 1,000 shillings is charged to patients per visit to avoid time-wasting visits.
Built into this is a quality monitoring aspect (hence the title) which means that an external assessor carries out regular checks on the standards of services provided. If the Hospital fails on any of these standards, we (IMF) don’t pay the hospital the 6,000 per person…essentially protecting the community from the common problem of poor inadequate standards of healthcare that seem to be endemic here.
Now to a good few people the idea of paying only £2 per year for good quality healthcare seems more than reasonable (particularly if you’re used to American style fees). However, we attended a meeting of community leaders who will be charged with the task of persuading their batakas to join the scheme. Batakas are ‘funeral groups’. The local population are organised into these groups to help share the costs of funerals and weddings etc, and this is the social framework we’re using to collect payments/registrations for the scheme, hopefully encouraging the batakas to work together to cover the 6,000 shillings for those who can’t afford as they do with other social payments.
It was fascinating listening to the bataka leaders voicing the challenges they had been coming across to the scheme managers. eQuality Health is only in its infancy (running since late Jan) and there are inevitable worries being thrown up from the community. A lot of them are just teething problems which will I am sure evaporate once momentum grows, however some of them highlighted to me stark differences in the mentality of these people in comparison to a western way of thinking. For instance, it came up many times that community members were requesting the choice of just register
ing household heads and not children / other dependents (one of the requirements for the scheme to finance itself is for all members of the household to join or else adverse selection occurs as we end up with only the sick people on the scheme and it is not sustainable).
Now I can understand the thinking behind this – Uganda is a society were family size is large; on average a Ugandan woman gives birth to 7 children during her lifetime, and these leaders were talking about some families with 15 dependents. However, what struck me was the importance that this society places on household heads over their children. In the west we are right at the other end of spectrum where children are wrapped in cotton wool and treated like fine porcelain.
In addition to this, we heard many protestations that they use traditional medicine (cue the witch doctor) over medical care and that if they are ill they do not go to the hospital, they pray to God instead. All of these points are valid and need to be listened to as they are key to whether this scheme gets off the ground. If it works many people are keen to see it rolled out elsewhere as it takes us away from a purely aid-dependent model of healthcare and encourages the communities to start paying into a system based on quality standards that they have ownership of and can trust.
Below is a picture of the bataka leaders proudly wearing their new eQuality Health t-shirts. Bataka Twetambire means ‘Bataka let’s heal ourselves’.