Mapping Maternal Health Advocacy: A Case Study of Uganda

This 16-page summary report discusses the findings and insights gained from research conducted by Family Care International on the maternal health advocacy situation in Uganda, and includes information about Uganda’s maternal health policy framework, stakeholders working in maternal health advocacy, and opportunities and challenges for maternal health advocates. The report also "describes the potential for engaging the Ugandan private sector on maternal health issues, and concludes with a set of recommendations for strengthening maternal health advocacy efforts in the country."

According to the report, while there is some progress, "advocacy organisations are not coordinating their efforts, and the maternal health advocacy climate is fragmented. Maternal health advocacy organisations face critical resource constraints and have the tendency to focus on maternal mortality, poor maternal health service delivery, and other problems, rather than on the promotion of innovative solutions."

The report lists the nine key priority areas for advocacy work based upon the Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Uganda and supported by the Third National Health Sector Strategic Plan (2010/11-2014/15) (NHSSP III), which range from community-level promotion of high-impact interventions to high-level advocacy on health-sector financing and human resources. "These priorities are being advanced in a number of ways, by a range of stakeholders, and are supported by a strong policy environment that emphasises the integration and mainstreaming of maternal health". NHSSP III "focuses on the improvement of overall health service delivery, but also emphasises that maternal and child health conditions account for 20.4% of the total disease burden in Uganda. The strategy prioritises EmONC emergency obstetric and neonatal care (EmONC), human resources for maternal health, improved supply of health commodities, and the development of better transport and communications for referral."

However, the research found that the 72 organisations engaged in advocacy mostly focused on implementing interventions or service provision, usually at the central level, with few stakeholders having links to districts and communities. While "the primary goal of maternal health advocacy organisations in Uganda is to ensure that government adopts and implements a series of high-impact interventions to fast-track the reduction of under-five childhood and maternal mortality," the research also found that goals identified by government and goals identified by civil society did not always match up.

The report outlines a number of key messages and their targets that stakeholders are using in their advocacy strategies (See table 5 in the report). For example, Save the Children directs messages to all stakeholders which focus on the need for access to health workers, the fact that no mother or child should die in childbirth, and the fact that maternal health is everyone’s responsibility. The Centre for Health, Human Rights and Development directs their advocacy efforts specifically to the judiciary on maternal health justice issues. Other organisations focus on advocating political leadership on the need for policies and sufficient budgeting. Others focus on, for example, secondary schools to encourage students to study midwifery, or focus on health care workers to advocate among their peers for better care services. The report observes that, "very few messages are being shared across organisations, highlighting a lack of coordination."

The report goes on to discuss the variety of dissemination strategies being used by advocacy organisations. Information gathered through surveys and focus groups found that the most popular approach is mass media, such as radio, television, and print media, which is used to "convey information, raise awareness, and encourage government accountability." Other strategies include petitions, budget tracking, and maternal death audits, which are all designed to press the government towards being accountable. Some advocacy efforts are also starting to use strategic public litigation.

The report outlines how the large number and active range of stakeholders - civil society, media, health professionals, and private sector - as well as the generally positive policy framework combine to create a good enabling environment for maternal health advocacy in Uganda. "This diverse array of stakeholders means that different organisations are able to create synergies by focusing on the specific areas of expertise to which they add value, such as service delivery or legal support." Yet, despite the number of stakeholders, challenges such as lack of resources, poor capacity, inadequate monitoring, and lack of coordination are hampering maternal health advocacy. The report highlights the need to engage with the private health care sector, though it cautions that there are a number of challenges to overcome in order to minimise any negative impacts from undue reliance on the private sector.

Based on the findings, the report outlines a number of recommendations:

• Advocacy efforts should be focused on the following priorities: providing support for maternal health service delivery, supporting maternal health workers and other human resources inputs, ensuring that there are functioning communications and referral systems, and empowering communities to demand improved maternal health services.
• "Maternal health advocates should strive to 'speak with one voice.' There should be a coordinated mechanism by which the growing and diverse body of advocacy organisations in the country can work together, thereby promoting synergy, rather than fragmentation. Umbrella organisations for maternal health advocacy should help with advancing common messages, agendas, and strategies."
• "Advocacy should also highlight the non-health sector systems that support or enable improved maternal health. For example, organisations should ensure that infrastructure, education, and other systems that indirectly affect maternal health outcomes are part of their advocacy messaging."
• Maternal health messaging "should move from 'problem-narratives' to solution-centred strategies, with an emphasis on innovations to support programme implementation."
• "Organisations working on maternal health advocacy require technical and financial support, including help with coordination, monitoring and evaluation, documentation and budget-tracking skills, and improving their institutional capacity to conduct effective advocacy."
• "Monitoring and evaluation of maternal health advocacy initiatives, with an emphasis on measuring impact, should be made an immediate priority."
• Maternal health advocacy stakeholders should think about supporting the Policy on Public-Private Partnership for Health (PPPH) and the National Health Insurance Scheme Bill in order to facilitate the involvement of the private sector.