“ACT NOW TO SAVE MOTHERS” The power of participation
“ACT NOW TO SAVE MOTHERS” The power of participation
Pregnancy should be a time of great joy. But for many women in Uganda, who risk death or serious disability due to low-quality health services, it can also be a time of great peril. According to the 2011 Uganda Demographic and Health Survey, 438 Ugandan women die for every 100,000 live births in the country. This figure compares to 140 per 100,000 in South Africa and just four in Norway.
White Ribbon Alliance Uganda (WRA) has spent years working to protect maternal and newborn health. In the process, it has built a broad-based network of decision-makers, organizations, professionals, and citizens committed to maternal health. Between 2013–2015, WRA enacted a campaign “Act Now to Save Mothers” to hold the Government of Uganda accountable to its commitment to provide emergency obstetric and newborn care (EmONC). The campaign had three objectives: (1) Ministry of Health to request and allocate sufficient funds for EmONC services in three pilot districts by 2015. (2) Minister of Health to allocate sufficient funds to improve recruitment, deployment, and motivation of health workers at designated Level III and IV health centers by 2015. (3) Minister of Health and Head of National Medical Stores to allocate sufficient funds for the procurement and delivery of EmONC equipment and supplies by 2015.
The campaign explicitly pursued a two-pronged approach to get government officials at the district and national levels to prioritize funding for EmONC by simultaneously working from a top-down and bottom-up approach.
From the bottom, communities and health facilities were mobilized to apply pressure on district officials to prioritize funds for maternal health in their budgets, and also to raise these up to the national level. Then working with district health officials, they applied pressure on members of parliament (MPs), Ministry of Health officials, and other government agencies. The key activities to engage, mobilize and connect people across levels from the bottom-up included:
- Highly participatory assessment of EmONC service provision in the three districts. Hundreds of people participated in joint assessments of services in all health facilities across the three districts.
- Evidence-based advocacy through public petitions. WRA engaged citizens in preparation of petitions and events at the subnational level. Petitions were presented by citizens to district officials and their MPs who were asked to raise these to Parliament. MPs did submit these to Parliament where the Committee on Health was appointed to investigate the matter and report back to the full body.
From the top down, the alliance worked with the Ministry of Health, MPs, and the relevant committees in parliament, to influence key decision makers to apply downward pressure on the districts to prioritize funds for maternity-related services, as well as to persuade the ruling party and the Ministry of Finance to expand financing in this area at the national level.
- Technical support and credibility. WRA had been actively collaborating with the Ministry of Health and the Technical Working Groups within it, and various other committees of parliament, including the Committee on Health and the Budget Committee.
After two years of the three-year campaign, it had already achieved results at the health facility and district levels. For example, in Kabale district- one of the pilot areas, six medical doctors were recruited – one for each of the six level IV health centers. In the same fiscal year, the three districts increased spending on areas improving maternal health services. At the national level, WRA succeeded in getting the inclusion of the Primary Health Care Non-Wage priorities as “unfunded,” with a request for UGX 39.5 billion (about US $11.7 million in 2015) the Ministry of Health Ministerial Policy Statement on the budget for the fiscal year 2015/16, and the inclusion of this issue in the Health Committee report. Getting included as an “unfunded priority” means budget’s prioritization in future years, and sometimes it is used by donors to identify priorities and funding gaps they can contribute to. The Parliament of Uganda responded to the citizen petition by instructing the Committee on Health to investigate the issues in the petition.
- Inclusivity and shared ownership of the campaign: At the heart of WRA’s way of working, and its success, is the ability and experience in creating and leading effective, diverse coalitions. In Uganda, WRA drew support and expertise from a broad range of stakeholders, including individual community members, government officials, health workers, civil society organizations, journalists, and many more, all working in partnership throughout the campaign, from its inception and development, to undertaking a participatory assessment, and eventually to finding solutions for challenges. This inclusiveness multiplied the campaign’s effectiveness as it meant that all stakeholders developed strong knowledge and ownership of the campaign, which ultimately let them undertake joint problem solving.
- Integration across policy levels: The campaign explicitly connected grassroots voices to the district level, the district level to the national level, and the national level to the international WRA activities. It also pursued a bottom up and a top down approach simultaneously, applying pressure from both sides and engaging all stakeholders. By working across policy levels, they were able to have an outsized impact relative to the campaign investment.
 Uganda has a tiered health system with levels 1 – 4 providing services at the (1) village, (2) parish, (3) sub-county and (4) county levels.
 For example, construction of maternity wards, rehabilitation of operating theaters and health center facilities, and increased allocation of funds for EmONC medicines.
 Non-wage recurrent funding is used for operational and running costs of health such as medical and office equipment, utilities, training cost, monitoring and supervision, etc.
About the Author
Jillian Larsen is currently the Advocacy and Accountability Advisor at the White Ribbon Alliance Global Secretariat. In this capacity, she is coordinating the organization's work on global advocacy for social accountability and citizen engagement. She is also supporting advocacy delivered by the WRA National Alliances to achieve accountability and wider campaign goals for reproductive, newborn and child health. Prior to joining the White Ribbon Alliance, she worked as an independent consultant focused on governance, accountability and citizen engagement. This included work with the World Bank, where she designed social accountability and governance arrangements to ensure the effective delivery of social protection programs in fragile and conflict-affected settings, as well as research and learning work with the International Budget Partnership to collect and analyze evidence of civil society impact on government budget processes and policies. The case study presented here was written in 2015 when she was a consultant with the International Budget Partnership, and had no affiliation with WRA.
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