4.1 Participation in health in Uganda
In Uganda, community participation is seen as a mechanism for empowering and encouraging the active participation of all citizens at all levels in their own governance. The National Health Policy (NHP) states that government will continue to ensure that communities, households and individuals are empowered to play their role and take responsibility for their own health and wellbeing. (23) Community participation has also been incorporated as a democratic principle under the National Objectives and Directive Principles of State Policy of the Constitution of the Republic of Uganda.(24) Objective II(i) requires that the state should be based on democratic principles that empower and encourage the active participation of all citizens at all levels in their own governance.(24) One of the suggested policy strategies is building capacity to ensure the participation of communities in the design, planning and management of health services, including ensuring the functioning of the Health Unit Management Committees (HUMCs) and boards of autonomous and semi-autonomous institutions.(25)
4.2 The districts of Kiboga and Kyankwanzi
This study makes a case study of the health unit management committees in Kiboga and Kyankwanzi Districts. These two districts were previously under one local government of Kiboga District that was later split into the two districts with distinct administrative units.
4.2.1 Kiboga District
Kiboga District was formerly Ssingo County of Mubende until 1991, when it received district status. At its creation, the county marked the boundaries of the district with five sub counties, but later expanded to 13 sub-counties and one Town Council until June 2010, when it was reduced to one constituency of Kiboga-East with six sub-counties and one Town Council.(26) The district is made up of one county, Kiboga, whose boundaries are the same as those of the higher Local Government. Then it is sub-divided into 6 sub-counties 2 town councils with only 41 parishes and two hundred fifty-seven villages. Kiboga District is located in the central region of Uganda about one hundred twenty kilometers from Kampala by road. Kiboga District is surrounded by the districts of Kyankwanzi in the North, Nakaseke in the East, Mubende in the West and Mityana in the South. The population is estimated to have been 154,800 in 2016, with a 4.3% annual population growth rate. (26)
According to Kiboga District Local Government Development Plan, the people of Kiboga are generally poor and their poverty can be attributed to high levels of illiteracy, large family sizes and general ill health.(26) The poverty situation in the district is such that over 64.4% of the people live below the poverty line, a phenomenon that has been exacerbated by general literacy that stands at 60% male and 50% female making an average of 55.6% compared to the national average of 65%. The infant mortality rate of 128 per 1000 live births is still high compared to 83 per 1000 live births at the national level. The total fertility rate is 7.4 birth per woman compared to 6.9 per woman at national level. The common causes of morbidity and mortality (for all age) in the district is malaria 32%, cold and pneumonia Cough 13% HIV/AIDS 8%, intestinal worms 7%, Sexually Transmitted Infections (STIs) 4%, and other diseases constitute about 36%.(26)
The district has a total of twenty-four health facilities including health centers and hospitals, of which there are fourteen Health Centre II, eight Health Centre III, one Health Centre IV and one Hospital in the district. On the other hand there are twenty government health facilities, 4 private, of which two are not for profit. Existing staff levels are; four Medical Officers, four Dentists, three Registered Pharmacists, one hundred thirty-four Nurses, fifty-nine Allied Health Professionals and seventeen Administrative Staff. (26) As Rujumba et al note, although Kiboga district has the basic physical infrastructure for provision of services, irregular supply of drugs and sundries, inadequate equipment, skills gap among health care providers and community perceptions, poverty and gender power relations remain key challenges.(27) These are the kind of challenges that need functional health unit management committees as spaces for community participation to air out such challenges and work with authorities to fix them.
4.2.2 Kyankwanzi District
Kyankwanzi District was cut off Kiboga district and declared an autonomous district on December 22nd2009. This cut off was premised on the argument that residents in the then Kiboga district sub-county moved long distances to access services that were majorly centralised in Kiboga Town Council.(28 Kyankwanzi district is about 150 Kilometers by road from the central business district Kampala and is bordered by Masindi District in the north, Hoima District in the northwest, Nakaseke District in the east, Kiboga District in the southeast, Mubende District in the south and Kibaale District in the southwest. The district covers a total land area of about 2 326 square kilometers. The population size of Kyankwanzi district has been growing from 43 454 in 1991 to approximately 120 575 in 2002 through to 214 693 in 2014 and now estimated at 23800 in 2016.(28) Administratively, the district is comprised of one county, namely Kyankwanzi County which is divided into seven sub-counties and two Town Councils. The district has 53 parishes and 298 villages.
The district statistical abstract report indicates that poverty is the main underlying cause of poor health in the district. This is attributed to the high rate of illiteracy especially among women, high prevalence of preventable diseases, emergence of diseases of lifestyles, inadequate provision and distribution of health services and other social services such as safe water supply and sanitation facilities.(28) The district has a total of twenty-eight health facilities categorized as one health centre IV, five (5) health centre IIIs and twenty-two Health Centre IIs. Out of the twenty-eight facilities, twelve are privately owned while four are owned by non-governmental organizations and twelve are government owned. (28) The Total Fertility Rate is 5.8 children per woman while the infant Mortality Rate is 53 deaths per 1,000 live births. The Life Expectancy is 63.3 years.(29)
4.3 The Health Unit Management Committees
4.3.1 Nyamiringa Health Unit Management Committee
Nyamiringa Health Centre III is located in Kiboga district in Nyamiringa sub-county. While the ministry documents indicated that the facility has a total of 9 staff (28) on the ground it was established that facility had three health workers and two causal labourers. This is far short of the nineteen approved staffing levels of a health centre III (28) As a health centre III Nyamiringa Health Centre should have these nineteen staff, led by a senior clinical officer and it should also have a functioning laboratory.
First, by the time of this research, although Nyamiringa facility had a well-constituted committee, they had not had any meeting either as a committee or even with the health centre in-charge. In fact, since the new facility in-charge had been posted to the facility about five months ago, the committee and the new in-charge had never met and so did not know each other. The in-charge at this facility highlighted that one of the major challenges was that community members preferred to seek services from the district hospital even for services that could be provided at the facility even when the district hospital is far away from this community. In the community dialogues held at Nyamiringa health facility, the community members on the other hand indicated that health workers are continuously absent and sometimes the facility is locked when they need services.
During the research process, we noted that this facility had a maternity ward that was not functional due to lack of water supply, bathrooms and toilets to support its operation. It was the position of the facility in-charge during an interview that this maternity ward would not be opened until all the required facilities to support its functionality were put in place. The facility also had a pit latrine that had been damaged as a result of heavy rains. However, no mobilisation had been done within the community to address this issue.
We also got to understand that a key characteristic of this community is that it is a mainly pastoralist community. During interviews with the HUMCs members, it was evident that the response to this community’s calls to participate in activities at the health facility was low. Most of the families together with their children preferred to attend to their cattle in the fields. During interviews, the committee members indicated that the community also has key days during which major buying and selling of cattle takes place and on such days response to health programmes or even services like immunization every Wednesday is low. We also got to know that this facility does not have any form of accommodation for the health workers and professionals. They instead have to travel a long distance every-day to the health facility. Also, this means that any emergencies that happen late in the night cannot be attended to at the health center, which also does not have an ambulance to transport patients to the main hospital. These are the kinds of challenges that the health committees would engage on with the districts authorities as they affect their functionality.
4.3.2 Kikoolimbo Health Unite Management Committee
Kikoolimbo health centre is located in Kyankwanzi district’s Wattuba Sub-county. Just like Nyamiringa, this facility was also in transition to upgrading from a health centre II to the level of health centre III. This meant it would be required to provide a wider range of services. It is also important to note that Kyankwanzi district was curved out of Kiboga district and thus separated administratively from mother district. It is therefore a fairly new district, implying that most of the health system structures are still being put in place. For example; the former level IV in this district is also in a transition to become a district Hospital since Kiboga hospital that was originally serving both areas is now located in another district. This partly explains why this Health Centre has also had to be upgraded to a Health Centre III status.
Since its opening, this Health facility had only one health unit management committee which had served for about ten years. Although it started off with a fully constituted health committee, it had six members left out of the nine required members. It also did not have any record of previous meetings and or minutes recorded during committee meetings, neither was there a record of interaction between the committee and the service providers at the health facility. The health unit management committee needed to be reconstituted for various reasons including the facts that: it was not functional and had not met for months; it was not constituted as required by health unit management committee guidelines and that there was a lack of understanding of the roles by its members.
Another key aspect that was noted during the interviews with the health unit management committees is that the land on which the health centre is constructed was donated by a member of the community who also mobilised key leaders within the community during the process of its construction. This particular member felt that serving as committee chair was his permanent reward for the donation made. As such, no attempt had been made to change leadership of the committee. Other committee members also had held onto their positions on the committee given the prestige that is attached to being a committee member.
This health centre also had challenges relating to the social determinants of health, which though not directly linked to service delivery, can affect delivery of services. These included: the facility was understaffed with only one midwife and one clinician far below the standard of nineteen and further lower than what the government documents indicated as fourteen staff deployed (30) yet it was expected to be delivering a wider range of services especially maternal health services; secondly, the lack of electricity at the facility to support health service delivery especially during the night was a challenge as the facility only had access to a solar panel that cannot last throughout the night. Third is the non-availability of water at this facility where a nearby borehole was no longer functioning; and lastly is the state of the housing for the health workers and professionals at the facility. The housing is insufficient to accommodate all the facility staff. This results in complaints that health workers arrive late to start work at the facilities, as well as complaints by staff about the conditions of their housing. All these are challenges that would make the health unit management committee inactive.
4.4.1 Result One: Limited Community Roles and non-representation in HUMCs
The community members in this study reported not being aware of who represents them at the health unit management committees of the health facility nearest to them. This made them feel that neither they nor their interests were represented by the health unit management committees. Community members who participated in the community dialogues held at the two health facilities indicated that they were not aware of the existence of these structures and, in most cases, were not even aware of who were the members serving on these committees. The community dialogue was an opportunity to address this identified barrier to participation, and to inform the community of what they should expect from the committee and the key activities within their work plans. This community dialogue acted as a space for participation and empowerment which is a key aspect of the rights-based approach. As one community member stated:
‘I don’t think that those committee members are meant to represent me and my family at this health facility. But I know that they are big people and the community and have authority. During all the social functions they have a front seat and are given a microphone to greet us. … how can a person I don’t vote represent me? I think that other big people in at the district sent them here to oversee their own interest but not our interest’. (Community member, Nyamiringa Health Center).
For each of the target health committees, a capacity assessment process was undertaken. They included a capacity assessment tool developed to help in establishing the health unit management committee’s understanding on issues including their selection, mandate and composition, the mechanism for their performance, the reporting and feedback mechanism, and the challenges and recommendations for dealing with these challenges. During the assessment, it was found that there was limited knowledge of the Ministry of Health’s guidelines for HUMCs, particularly on the roles and responsibilities of committee members, as well as among community members, local leaders, and other stakeholders. The health unit management committees at Kikoolimbo HCIII and Nyamiringa HCIII were not very active largely due to limited knowledge of what was expected of them. The capacity assessment process was key in informing the groups through the reading and interpretation of the guidelines verbatim in a participatory methodology. This did not only introduce the groups to their purpose, mandate and functionality mechanisms, it also generated debate on how the few times they had met things has been done incorrectly.
‘Do you mean that I have authority to appoint members to the HUMCs committee? This has never crossed my mind, for all the years that I have been the LC 3 chairperson of this area. I thought that these committees are occupied by the families of people who donated land to these facilities. If this is true, will you help me interpret these guidelines when I next organise a community meeting? If it’s true that I indeed have powers to do these appointments, I should now make it a priority. Our current Committee chairmanship has been occupied by family members of those that donated land on which the health facility was built. The chairperson has been chairing the committee for close to 20 years now. Other members of the committee were sent to us from the political leaders. We have no idea how these get to be sent to our facility. (Local leader in Kiboga district)
It was noted that although health unit management committees are a participation structure, there is no mechanism or process within the guidelines that require these committees to report back and account to the members of the communities they represent. This was a critical issue because accountability is a key component of a rights-based approach. However, it was clear that communities were not receiving feedback from their reporting and this may be one of the reasons communities did not support the HUMCs to enable them be functional. Additionally, the Health Unit Management Committees also mentioned that they thought they were answerable to their appointing authority, which is the political leader at the respective sub-county level. This clearly dominated the understanding of the committees and necessitated creation of awareness about their accountability to the community as opposed to the appointing authorities.
In addition, the guidelines on the representation on the committee are not clear. Although there is a requirement for women representation on the committee, there are other critical groups that do not have any special provisions for inclusion, such as disabled persons and youth. As a result, they are poorly represented on the committee. This presents major challenges in advancing their health rights.
‘I am a person with a disability, and I make use of this facility all the time and this is why I had to attend this dialogue, which I think is the first I have seen that is not discussing politics and campaigns. While I see disability representation in many other spaces of political representation, we have not seen a space where disability issues are channeled as part of this facility. Women with disabilities particularly face challenges when they come here to deliver, some shy away and use the traditional birth attendants. Now that you are talking about representation through the HUMCs, the next appointment needs to be mindful of special people like us. (Participant in community dialogue at Kikolimbo health center).
As part of the values of the health unit management committees, they should be able to call for the protection of self-determination as an important ingredient in enabling the community to decide the rules by which they live and by which they are bound.
4.4.2 Results Two: Devolution of Power and Implications for HUMCs
The health unit management committees of Nyamiringa and Kikoolimbo operate as part of the overall devolution of powers to local governments in Uganda. The 1997 legislation on Local Government (LG) was enacted to put into effect the provisions of the Constitution that devolved powers previously exercised by the central government to the district local authorities. In line with this decentralisation, health care was also redesigned with a corresponding health unit level for each level of local government or administrative unit. The Act mandates the district chairperson to assign one of the secretaries to be responsible for health and child welfare. The law further creates executive committees at each parish and village administrative unit, which should consist of a number of people including a public health co-ordinator. The second schedule of the Act superficially highlights health policy as one of the functions and services for which the government is responsible.
On the other hand, district councils are responsible for the medical and health services including hospitals, other than hospitals providing referral and medical training, health centres, dispensaries, sub-dispensaries and first-aid posts; maternity and child welfare services. HUMCs are seen, at least in official policy, as essential elements for decentralization.
The entire idea of HUMCs is about actualising decentralisation. We at the Ministry can no longer be able to effectively oversee the realisation of health at the lower district levels without support of the local government. Despite a few challenges like financing, we have showed the will and interest to fully devolve power and service delivery as demonstrated in the policies and political positions created. The HUMCs are just an example of such structures. (Interview with the Commissioner from the Ministry of Health).
For proper functioning of these health unit management committees, the Ministry of Health developed a set of guidelines to be followed for operationalising these committees. The guidelines of health unit management committees are for health centres at levels two, three and four. According to the guidelines, the HUMCs for health centres two and three are appointed and approved by local council three. On the other hand, the health unit management committees for health centre four are nominated by the district health committee with the approval of the district council. During the study, the research team engaged Kyankwanzi district local council III chairperson regarding the health unit management committee that was not well constituted. He informed the team that he did not know that it is at the discretion of the local council III Chairperson to appoint and the council approves the health unit management committee members. By the end of the project, he had exercised his powers under the guidelines and had participated in the orientation process which the research project supported.
It was further revealed that although the guidelines make mention of the role of the Committee in budgeting and planning, during the assessment it was pointed out that this was not practical since most of the resources received at the health facility were already pre-determined at another level unknown to the committee members. As such, even if mechanisms and spaces for participation identified during the first two years encouraged bottom-up planning, some aspects, particularly budgeting, remained a top-down process that undermines this function as contained in the guidelines and therefore undermines the roles of the committees.
‘The funds that come to us as HUMCs is under the primary health care budget. This budget already predetermined and no matter how much work we need to do, we don’t have much opportunity to change. It possible to observe and hear many cries in our community about some issues impacting in the community health but the limitations that come with the budget make it complicated to support these initiatives. You have seen that our maternity ward was opened without a placenta pit but we can´t do much as a committee. We need to have a more transparent and non-fixed way of engaging with the budget cycle. The funds needed should cover both our processes and the needs of the community. It’s very disempowering for the committees to have assumed authority that is not supported by funds.’ (Interview with a member of the HUMCs Committee at Nyamiringa)
4.4.3 Result Three: Legitimacy through a clear legal framework for HUMCs
Providing a legislative authority as a basis for community participation through the HUMCs was considered important in both our document review and by our participants. Despite the existence of guidelines and policies meant to ensure fair and equal participation, and providing advice on what each role entails, the participants from Nyamiringa and Kikoolimbo report that the HUMCs have no specific operational legal framework to effect their work. They, however, seek guidance from the local government and the Ministry of Health Guidelines for Health Unit Management Committees.
HUMCs are an important part of the health system, unfortunately they lack a substantive law which is a fundamental gap, and this goes to the core of there existence and operations. The guidelines provided by the Ministry of Health are very brief, unclear and not reflecting the reality on ground. These guidelines are founded on politics and less on democratic values. They assume that the appointing authority will have the mind and understanding of the health system. They reduce the community members to spectators and yet they are the beneficiaries. (Interview with a key informant from an national NGO).
The Local Government Act (31) seeks, among others, aspects to amend, consolidate and streamline the existing law on local governments in line with the Constitution and to give effect to the decentralisation and devolution of functions, powers and services. This Act provides for decentralisation at all levels of local governments to ensure good governance and democratic participation in, and control of, decision making by the people. Despite these promising provision, the Act falls short of recognising health unit management committees as a community participatory structure on matters of health. This is a missed opportunity because, according to the committee members, there are many conflicts of interests that limit accountability pathways and hinder a community’s ability to complain about service provision.
‘The other problem with the existing guidelines is the requirement that the in charge of the health facility should be the secretary to the HUMCs. We have found this a serious governance problem in the operations of the HUMCs. At many health facilities, the in-charges don’t have an understanding of their roles as secretaries and their unique position as overall supervisors of the health facilities also makes it complicated for them to participate in the meeting, take note, treat patients as they come during the meetings and then keep the records of the meetings. Because of these complexities, HUMCs end up without minutes and follow up on discussed matters is complicated. The in-charges are less bothered because this function does not usually form part of their assessment’. (Interview with a key informant working as a program advisor to an international organisation)
The guidelines are also not clear on a procedure that happens after Committee meeting minutes are written. When asked what happens after meetings and what is done with the meeting recommendations, different committee members also had different answers and mentioned different duty bearers to whom they thought meeting follow-ups were taken. For example, some mentioned the chief administrative officer, and others the District Health Officer (DHO). The absence of particulars in the guidelines on how meeting deliberations should be followed up makes it complex for the committees and hence affects their capacities to engage beyond the meetings in some cases.