The health clinic in Nnalinya, a village in central Uganda was in very poor shape. And as things go in Nnalinya, being one of the poorest and least serviced parts of Uganda, it would have remained that way for many years if not for the determined advocacy efforts of local residents with the support of World Vision. But the real gem in this success story is how the impact of their advocacy went far beyond the local village.
Promises vs. reality
World Vision brought to the citizens of Nnalinya a social accountability approach called Citizen Voice in Action (CVA). The program equips citizens, governments and service providers to work collaboratively in order to improve services at the local level.
To begin, local residents used the government-endorsed Patients’ Charter and Uganda’s National Health Policy to raise awareness about the services that patients in Nnalinya should expect to receive. Next, they used a scorecard and social audit to compare their lived reality to the criteria in the charter and the health policy. Through these exercises they documented gaps – such as equipment shortages, illegitimate user fees and, most egregiously, the fact that the facility had lacked a midwife for 10 years.
Equipped with this evidence, the community undertook the next stage in the CVA process. They convened a town-hall style meeting to discuss how the situation could be improved. Community members, clinic staff and local government officials all contributed to the development of an action plan. Together, they were able to solve some of the clinic’s gaps and shortfalls, including administrative, user-fee, and supply problems. But in the meeting it soon became clear that the community’s highest priority was to ensure that the clinic had a midwife.
Because of the lack of a midwife, many women avoided the clinic entirely, some walking long distances to the district hospital and others using local, non-professional services. According to clinical officer Sophia Ampire, “Because so many mothers were going to traditional birth attendants, they were having medical complications, like bleeding. Some of them lost their babies, and others lost their lives.”
From local to national
But there was a problem. Budgets for staffing lay beyond the control of the local government. The argument had to be taken up not one, but many levels. Undaunted, Nnalinya residents joined with other communities and service providers and began to document a pattern of understaffing at village health centres. They then used this documentation to make their case at higher levels of government.
Through CVA, World Vision and other organizations helped them gather evidence in more than 120 clinics in 40 districts. A growing coalition of health-focused organizations also mobilized people to send thousands of text messages to their parliamentarians asking them to increase the budget for midwives.
The deeper impact
With the power of their collective efforts, their smart use of parliamentary champions, and the solid evidence they had gathered, the movement gained national-level audiences with parliamentary committees and ministerial officials, all carefully timed to the passage of the budget for the Ministry of Health.
In response, key MPs blocked the passage of the annual budget for two weeks until an additional 49.5 million Ugandan Shillings (US$19.8 million) was added for the recruitment and retention of approximately 6,172 additional health workers, including 1,014 new midwives.
Local efforts, united and taken professionally to the national level, resulted in larger and sustained change. Not only will the children of Nnalinya and other villages receive the health care they need today, but so will the children who follow.