Uganda : final country report

Between 1991-1994, SEATS I with its partner, the American College of Nurse-Midwives (ACNM), provided training in family planning/reproductive health care (FP/RHC) service delivery for 137 private midwives and developed a system of regional representatives within UPMA. Building on this foundation, SEATS II designed a special 2-year (1995-97) initiative, Midwifery Association Partnerships for Sustainability (MAPS), to address UPMA"s insufficiencies in financing, management, and staff resources. Under this initiative, UPMA"s organizational structure was expanded to include a Board of Directors (including a financial advisor) and a full-time administrator. In addition, 145 private midwives were trained in business management skills and community mobilization. Follow-up visits to these trained midwives showed impressive increases in the number of clients utilizing their services as well as improved management of clinic finances and resources. A second MAPS subproject (1998-99) continued capacity building with UPMA, developing an Association-owned and -operated model clinic and training center, installing computerized financial and membership data systems, training administrative staff and UPMA leaders in financial and organizational management, developing strategic and business plans, conducting membership drives, and assisting aspiring private midwives. Linkages were developed between UPMA and the Uganda Nurses and Midwives Council (UNMC) to develop private practice standards, and with the Commercial Strategies (CMS) Project to develop strategies to promote both UPMA and the new clinic. SEATS II monitored selected quality interventions and demonstrated improved knowledge and skills, baseline levels of compliance with standards, increased access to FP services, and a high percentage of satisfied clients. After almost a decade of interventions under SEATS I and II, UPMA has greatly improved its institutional capability and is well positioned to enter the next century as a leader of FP/RHC services and an advocate for private midwives. As UPMA becomes more self-sufficient, it will be able to sustain its activities with decreased dependency on external funding and TA. The following lessons were learned: (1) Private midwives are highly motivated to provide quality services, as their reputation and livelihood depend on it. (2) Private midwives provide affordable alternatives for clients who can afford to pay a reasonable fee for quality services, thus relieving some of the burden on public facilities. (3) Private practice offers an option to midwives who are leaving public service and who otherwise would be lost to the national health care delivery system. (4) The demand for FP/RHC services is growing in Uganda; most women need to work in order to support large families, especially after losing working age family members to AIDS. (5) Vibrant professional associations such as UPMA can successfully leverage additional resources from multiple donors, but require capacity building to ensure they can manage multiple programs effectively. (6) Midwives with community mobilization training actively seek interaction with and feedback from the community and clients, thereby significantly increasing the number of their clients. (7) Basic business management skills are critical to the viability of private midwives. Budgeting is an especially difficult concept to learn, since the culture has not provided women the experience of having or handling their own money and property. A change in thinking and planning in this area is a gradual process that requires special emphasis in the training curriculum as well as on-the-job follow- up and supervised practice. (8) Working with midwives involves consideration of gender barriers. Most midwives wishing to open their own clinics in Uganda lack access to start up capital, and some become the targets of domestic violence once they begin to earn money of their own. (9) Midwives" proximity to local communities also means that they are dispersed widely throughout the country, making it a challenge to work with them in programs that target their services. (10) To sustain project successes, UPMA must be assisted with capacity building and with developing a strong managerial capability and diversified financial base. (11) Lessons learned by networking with sister countries improves the quality of care.