Final Report:

Improving integration of gender

equality, the rights based approach to
health and adolescent health in the
Uganda Reproductive, Maternal and
Child Health Services Improvement
Project

Lincie Kusters, Advisor SRHR

Royal Tropical Institute, Amsterdam
September 2018
Contents
1. Introduction .................................................................................................................................... 3
2. HRBA and Gender Equality/Equity within a result based financing mechanism ............................ 4
3. Ways to improve the integration of HRBA...................................................................................... 5
3.1 Meaningful engagement of community representatives: ............................................................ 5
3.2 Component 1: Results-Based Financing for Primary Health Care Services .................................. 5
3.3 Component 2: Strengthen Health Systems to Deliver RMNCAH Services .................................... 5
3.5 Strengthening Accountability Structures: ..................................................................................... 6
3.6 Implementing tools and guidelines:.............................................................................................. 7
3.7 Quality of Care: ............................................................................................................................. 7
4. Component 3: Strengthen Capacity to Scale-up Delivery of Births and Death Registration Services8
5. Improving integration of adolescent health ...................................................................................... 8
6. Working towards Gender Equality/equity ......................................................................................... 9
7. Conclusions ....................................................................................................................................... 10

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 1. Introduction
This report is a result of two monitoring visits and documentation analysis of the Reproductive,
Maternal and Child Health Services Improvement Project (URMCHIP) funded by the Global Financing
Facility (GFF), the World Bank and the Swedish Embassy and implemented by the Ugandan Ministry
of Health (MoH).

The aim of this report is to provide an overview of decided actions and observations made to improve
the integration of gender equality, equity and human rights based approach (HRBA) in health and
adolescent health, based on the input received and dialogues held during the two missions and from
assessing project documentation. While the Sharpened Plan1 emphasizes the importance of these
areas, it was noted that there was little focus on HRBA, gender equity and equality in the Project
Appraisal Document (PAD) as well as the Project Implementation Manual (PIM). HRBA, gender equity
and equality was also not integrated in project indicators. Adolescent health is another key area that
was assessed not to be addressed sufficiently in the project design, although one of the three main
beneficiaries of the URMCHIP are adolescents. No specific strategy was developed to work with
adolescents, especially on how to reach out to girls who are seriously at risk of maternal deaths due
to teenage pregnancies. Three out of ten maternal deaths in Uganda occur among young women aged
15-24 and the adolescent birth rate among teenage women aged 15-19 is 135 per 1000 live births, the
highest in Sub-Saharan Africa. Information and services at health facilities were mentioned in the PAD,
although most emphasis was given to Adolescent Sexual and Reproductive Health and Rights (ASRHR)
education, which is often provided in schools and not a core activity of the URMCHIP.

The Swedish Embassy identified the low integration of gender and HRBA as a risk related to the impact,
sustainability and effectiveness of the URMCHIP. To improve the integration of gender equality, HRBA
and adolescent health in the URMCHIP, a consultant in the person of Lincie Kusters, SRHR advisor from
the Royal Tropical Institute – KIT (that Sida has a framework agreement with), was requested to guide
this process in the first year of the URMCHIP, in collaboration with the MoH and World Bank, aiming
at providing recommendations on how to better integrate these key priorities.

The previous mission report, written in October 2017, provided in-depth recommendations on how
the integration of gender equality/equity, HRBA and adolescent health could be further improved
under the three components of the project. The Ministry of Health, the World Bank and the Swedish
Embassy had extensive discussions to decide which recommendations to take on in the project. A
second mission -with a different purpose- was planned in 2018. This mission was meant to contribute
to a more hands-on approach of how the three topics could be further implemented.

The objectives of the mission in April 2018 were: to conduct a field visit to one of the intervention
areas where the URMCHIP will be implemented; to discuss the state of affairs of the URMCHIP and to
scope the specific needs from MoH staff with regard to the three identified priorities; and to facilitate
a one-day workshop to further discuss HRBA, gender and adolescent health and what kind of actions
could be taken to improve the integration of these three areas. This four-day long mission took place
from 9 April to 12 April in Kampala and Mukono districts. During this mission, Lincie Kusters was
accompanied by Jurien Toonen, senior health advisor from KIT and expert in Health Systems
Strengthening and Results-Based Financing (RBF). The mission entailed a visit to Mukono Health
facility and the District Health Office in Mukono. Furthermore, a World Health Day Seminar focusing
on RBF was attended on April 10th at Hotel Africa, organized by Enabel where RBF related research

1
Investment Case for Reproductive, Maternal, Neonatal, Child and Adolescent Health Sharpened Plan in
Uganda (April 2016)
3
and good practices were presented in the light of reaching Universal Health Coverage. In addition,
several meetings with representatives from the MoH, World Bank and the Swedish Embassy were
conducted in order to prepare for the one-day workshop with the MoH, World Bank, WHO and World
Vision, representing a network of NGOs that has come together in a GFF NGO coalition. On the 11
April a workshop was held to further discuss hands-on ways to strengthen the integration of HRBA,
gender equality/equity and adolescent health in the URMCHIP. The last day was used to review the
visit and the follow-up steps to be taken with the World Bank and the Swedish Embassy. The following
section describes the main suggestions that were provided during the mission and ends with some
final observations from KIT.

2. Human Rights Based Approach to Health and Gender

Equality/Equity within a results based financing mechanism
Result based financing is an important part of URMCHIP. RBF is a strategic purchase mechanism that
can contribute to better health outcomes. Health service providers – and eventually users - are paid
for predefined and verified results. The basic principle is that ‘money follows the patient’ i.e. if
healthcare facilities provide better quality services and attract more patients, health facilities will
receive more incentive payments2. According to a widely recognized conceptual framework by Peters
et al. (2008), healthcare access should follow four dimensions, each with a supply and demand
component. These components are: geographical accessibility, availability of health care, financial
accessibility and acceptability of health services matching the needs and expectations of the users, as
well as individual user’s knowledge and attitudes3. Yet, most results-based financing approaches are
specific financing mechanisms that can foremost influence three out of these four components to
improve access and utilization of health services. These three components are about interventions
that improve the financial accessibility, availability and the acceptability of services by users. Looking
at acceptability of health services, communities require co-ownership and a say with regard to health
service provision and prevention – to invite health services to be responsive to the needs, wants and
demands of the users. This would increase utilization, and consequently RBF payments. By integrating
the HRBA for health effectively within the result based financing component, acceptability of services
by users will be enhanced. Beneficiaries are no longer a target to reach, but are aware about their
health rights and duties – and find in RBF an instrument to express these.

When integrating HRBA the following five principles require attention throughout the project: social
accountability, transparency, community involvement, non-discrimination and equality and
legislation. This is to ensure that everybody has the right to health and access to health services
despite their gender, age, ethnicity, disability or health status. Applying a HRBA to health and gender
equality and equity integration is also needed to ensure that women and men have equal access to
necessary opportunities to achieve their full health potential and health equity. Because of social
(gender) and biological (sex) differences, women and men experience different health risks, health-
seeking behavior, health outcomes and responses from health systems.4 By analyzing and addressing
inequalities, discriminatory practices and unjust power relations - that are often at the heart of
development and universal health coverage problems - a difference can be made in the lives of
disadvantaged citizens.5

2 J. Toonen, B. van der Wal (2012) Result based financing in health care. Developing an RBF approach for health care in different contexts:
the cases of Mali and Ghana. KIT Publishers
3 Peters, D.H., Garg, A., Bloom, G., Walker, D.G., Brieger, W.R. and Hafizur Rahman, M., 2008. Poverty and access to health care in

developing countries. Annals of the New York Academy of Sciences, 1136(1), pp.161-171.
4 http://www.afro.who.int/health-topics/womens-health
5 WHO (2010) A human rights based approach to health

http://www.who.int/hhr/news/hrba_to_health2.pdf
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 3. Ways to improve the integration of HRBA
During the workshop, specific emphasize was given to discuss what HRBA and gender equality means
and how it can be translated under component 1 of the project. Also, suggestions were given by the
different stakeholders on how to improve the integration of HRBA, gender equality/equity and
adolescent health. The following sections give an overview of the main points discussed and
recommended during the workshop by the participants and KIT advisors:

3.1 Meaningful engagement of community representatives

Increased utilization of reproductive, maternal, newborn, child and adolescent health services is a
major goal of the project.

Through RBF, utilization of services can increase by structurally and meaningfully engaging community
representatives/ patients and end-users of the services in the decision-making processes/spaces of
the project. Several suggestions were given by the participants during the workshop on how to
increase accountability and a human rights-based approach to health.

3.2 Component 1: Results-Based Financing for Primary Health Care Services

• The Health Unit Management Committees (HUMC) and village health teams (VHT) are existing
structures in place that could become more meaningful in the set-up of the roles under the RBF
component – for example by taking up a role of purchasers of health care.
• To strengthen social accountability by working towards functional HUMCs; to monitor progress,
participation of HUMC’s in decision-making on RBF payments; and having regular meetings that
result in actions.
• Key stakeholders’ inclusion by representation in the design, monitoring and evaluation of the
health program – and decision-making on strategies and actions to be undertaken to improve RBF
indicators; such as youth and specific vulnerable people, women that risk maternal morbidity and
mortality to ensure that services respond better to the demand/needs/wants of the population.
• Set up feedback mechanisms and complaints, for example through suggestion boxes, exit
interviews and community scoring cards, and make sure these are applied and inform the project.
• To organize community dialogues that inform communities about the URMCHIP and discuss
specific health services provision needs for adolescents, parents and couples. Dialogues that work
towards clear goals and actions and accountability mechanisms for the key stakeholders to be able
to monitor health provision, to play a role in improving health education and to take a
responsibility on preventive health actions within the communities. The outcomes can be used in
defining the RBF “business plans” and RBF contracts.

3.3 Component 2: Strengthen Health Systems to Deliver RMNCAH Services

During the workshop specific ideas were also shared to improve the quality of care activities under
component 2.

Quality of Care:

• Making displays of Client Charters available and visible on health facility Notice Boards,
• Communication: provide regular information of health services in the local language through
radio programs

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• Integrate specific objectives to be able to reflect on the implementation progress of HRBA,
gender equality and equity issues in the reporting on URMCHIP, to keep track and to jointly
analyze the results
• Visibility of integration of relevant stakeholders’ engagement and actions in improving health
provision
• Integration of qualitative indicators that assess issues of adolescent health, gender and HRBA at
health facility level
• Strengthen the quality of care component in RBF – e.g. by adapting the RBF scoring card that has
an influence on RBF payments; e.g. by focusing more on results in terms of quality of care and
less on “structure” (verifying availability of structure elements)

Besides these suggested actions, it is advisable to empower community members, including young
women, by informing them about the URMCHIP. These actions will contribute to a more meaningful
engagement and for community members to be able to organize themselves in decision making spaces
to contribute to and take account of health outcomes at facility, household and community level. In
collaboration with NGOs and CSOs, health providers and community representatives can be trained in
HRBA for health and gender in relation to RBF. Community representatives could be trained in public
health issues for instance with help from Village Health Teams (VHTs). Still more structural efforts are
needed and possibilities are available to integrate HRBA for health under component 1 and 2 of the
project since they are very much interlinked. Other recommendations are:

1) Awareness creation and co-defining what quality of care means from the user perspective by
community representatives;
2) For community representatives to make decisions on exemptions of payments; on decisions
around payment of health staff or on where to spend the profits on, when results are achieved
at the health facility level.
3) To integrate certain indicators for the quality of care scoring list at health facilities that
correspond with these definitions.

3.5 Strengthening Accountability Structures

In many settings healthcare is most often managed by one single institution, the MoH, which is at the
same time policy-maker, regulator, purchaser, verifier and provider of care –based on an input-based
financing structure through a hierarchical deconcentrated system. Splitting responsibilities and having
contracts stimulates transparency and accountability, because expectations and responsibilities are
clearly defined and avoid conflicts of interests when paying for results. The development of the
contract is essential, as different stakeholders need to be able to hold each other accountable.
Splitting responsibilities and roles as verifier, purchaser and provider will, preferably, lead to different
levels of performance contracts: (i) between the purchaser and the provider; (ii) between the facility
and its healthcare staff; and (iii) between the purchaser and the regulator6. In the case of the URMCHIP
in Uganda, these roles are not very well defined yet. For year two, when contract adjustments can be
made, it is recommended to further adjust and define roles and responsibilities for different
stakeholders that take on the role of purchaser, provider and verifier.

6 6
J. Toonen, B. van der Wal (2012) Result based financing in health care. Developing an RBF approach for health care in different
contexts: the cases of Mali and Ghana. KIT Publishers
6
3.6 Implementing tools and guidelines
Several existing and also some planned tools, guidelines and policies in Uganda focusing on HRBA,
gender and adolescent health are available. These tools, policies and guidelines were briefly presented
by the MoH during the workshop. Most of the tools and guidelines are already in place or are being
finalized. Often, beneficiaries and CSOs are consulted in the development stages of these tools and
guidelines. The implementation and application of the tools and guidelines are however a challenge.
Challenges are issues related to printing and dissemination of material, as well as capacity to provide
the training. The project team concluded that funding is available for printing and dissemination of
relevant protocols and guidelines. The Reproductive Health Unit should assist in prioritizing the most
relevant tools and to include these tools and guidelines in training for relevant stakeholders. A special
training module on HRBA, gender and adolescent health is already planned for, to be developed and
integrated in trainings for health facility staff under the RBF.

3.7 Quality of Care

Currently there are several existing tools available that covers quality of care. Under component 1 the
quality of care scoring card list has many indicators embedded, with some overlap or with no direct
reference to the quality of care perspective of patients and end-users. It was noted that existing RBF
tools need to be further harmonized and reviewed so they are responsive to gender equity/equality
and HRBA. At the same time the number of indicators should not overburden health workers.
Therefore, it is advised to review the quality of care scoring card, to reduce the number of indicators
and to better integrate HRBA and gender equity by including proxy indicators.

Other aspects that were suggested under component 2 of the project, that need to be taken into
account to further improve the quality of care, are listed below:

Attitudes and skills of health workers

• Emotional support – Health workers behavior and attitudes towards patients
• Health workers to be around to explain, listen to the patient, be empathic
• Companion witnessing
• Respect and dignity – privacy, confidentiality, non-discrimination etc. – certainly vis a vis the less
advantaged members of the community, the poor and vulnerable
• Communication towards clients – Knowledge on Rights, Expectations and Obligations –
Patient/Clients Charters

Improving Services Provided:

• Access – geographically, within the Health Facilities (improving waiting time, environment,
privacy etc.)
• Maternal Child Health: Need for skilled birth attendants, quality improvement of Emergency and
Obstetric and Neonatal Care (EMoNC). Screens for privacy, Post Natal Care (PNC) job aids, scale
up immunization coverage.
• Gender based violence (GBV): provision of treatment kits that include emergency
contraceptives, PEP, and forensic screening of survivors of Sexual and Gender based Violence
(S)GBV cases, to provide for medical certificate forms and consent forms to screen (S)GBV
survivors; confidentiality regulations and community information packages
• The rights of health workers and patients and their safety should be prioritized
• Need to increase information and sensitization on Family Planning and SRHR, including age-
appropriate sexuality information

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• Post Abortion Care: need of equipment and training
• ANC: develop job aids and protocols for family planning and Post-Partum Family Planning (PPFP),
ANC cards and “baby/mother passports”
• Women with disabilities are neglected. Train health workers in sign language

4. Component 3: Strengthen Capacity to Scale-up Delivery of Births

and Death Registration Services
The objective of this component is to strengthen institutional capacity for Civil Registration and
Vital Statistics (CRVS) and to scale up birth and death registration. Although not discussed during
the second workshop in April, CVRS is fundamental to improve gender equality and equity and for
the empowerment and claiming of human rights, because registration gives people the ability to
do everything that requires proof of identity—vote, claim entitlements, inherit property, and
access to financial services among other things. Moreover, they are vital for national and
subnational statistics to inform the design and implementation of government projects and
programs7. Although CRVS play a vital role for both men and women, birth and death registrations
are even more important for women, because of the many rights violations they face, including
gender discrimination and increased vulnerability to early marriage, widowhood or divorce, which
lack of registration and legal identity help to entrench. There are several obstacles to be found in
the process of registration that the URMCHIP should prevent from happening by learning from
other organizations that went through these experiences. Some are to simplify registration
processes, occasions of registration, location of registration, fees that some cannot afford to pay,
and constraints on time and mobility require extra attention in the set-up of the system. To be
able to quickly identify gender based constraints, the CVRS M&E system should as well be set up
in such a way that sex and age disaggregated data is included, to have an overview of who, where
and how registration is happening and if disadvantaged people are insufficiently reached. When
this is the case, there is a need to improve the registration system to make sure disadvantaged
women, men, girls and boys are included.

5. Improving integration of adolescent health

Several actions have been discussed and suggested to further improve the integration of adolescent
health in the project, during the workshop and meetings held before:

• There is a need for strengthening analysis and applying evidence based knowledge for
interventions on adolescent health by acquiring and using gender and age-specific data within the
Ugandan context.
• Health workers should be trained in youth friendly health services and approaches, also involving
youth peers as a component under the mentorship program.
• Working with health workers acceptance, attitudes and beliefs with regard to adolescent health;
placing professional health values in front of personal values.
• Provision of specific information and awareness targeting adolescent girls and boys on sexual and
reproductive health
• Adolescent ANC: Specific mobilization for first visit, need to work with VHTs, information provision
via radio and other media and encouraging community dialogues
• Adopting the Adolescent Health Policy and Service standards

7
Worldbank group CVRS event Thursday 23 June 2016
https://www.cgdev.org/blog/why-registration-and-id-are-gender-equality-issues
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• Media campaigns could be used to address teenage pregnancies, for example involving youth
leaders and popular artists in media messaging.
• Make use of ICT material, working with peers, using Universities/Institutes for service provision,
scale up mobile apps.
• Ensure health budgets cover adolescent health

From a public health perspective, more analysis is needed how the URMCHIP can have the most
impact. Adolescent girls are particularly subject to unwanted pregnancies after initiating sexual
relations (willingly or coerced), which leads them to either undergo unsafe abortions and/or drop out
of school. This could be reduced if all adolescents, boys and girls, had access to comprehensive
sexuality education and information and contraceptive services. Under the URMCHIP youth friendly
health services, focusing on health professionals’ youth friendly attitudes and provision of information
and adolescent health services, including access to contraceptives, are activities that are important to
be taken on by health facilities to improve adolescent health. Secondly, to further strengthen
knowledge and information on SRHR amongst adolescents focusing on aspects that influence young
people’s sexual health behavior, it is recommended to build on existing ASRHR information and
education initiatives with other agencies. Many NGOs work on ASRHR education and some on popular
edutainment to bring out SRHR messages. The URMCHIP should invest in connecting, and finding ways
to collaborate and scale-up existing initiatives with NGOs and the Ministry of Education and Gender,
Labor and Social Development, not to re-invent the wheel.

6. Working towards Gender Equality/Equity

Women’s empowerment and men’s engagement and participation in reproductive, maternal, new
born, child and adolescent health are equally important to encourage gender equality and positive
health outcomes for families and to reduce domestic violence/GBV8. During the workshop, emphasis
was given to improve the engagement of men. It was suggested to promote male involvement in
health care delivery, for example through Male Action Groups, male friendly services and by
championing males etc.

These are good suggestions, but more thorough thinking is required to define the purpose of male
involvement. Male engagement can lead to changing decision-making power in the household on
RMNCAH; to transform gender norms and values in specific communities; to adjust gender assigned
roles and responsibilities; to increase awareness of men on gender roles and to challenge these roles
by allying with women; or to enhance the decision-making role of the husband by strengthening his
knowledge to make better decisions with regard to the health of his family.

Whether or not men’s engagement is a way to improve RMNCAH only, or also to transform gender
roles and norms, depends on the purposes set. In several international projects the goal of involving
men in RMNCAH was not clearly defined, instead an instrumentalist or reductionist approach was
applied9. For instance, when only specific instances of support are provided by men to women, such
as saving money for emergency transportation in case of birth complications, transformation with
regard to gender inequality will not occur because adaptation of behavior does not touch upon the
root causes of inequality, how decisions are being made around health in the family. Instead, the
intervention enhances the decision-making role of men, and does not look to the more substantive
changes in how men and women relate to each other, such as patterns of communication and

8
Brian Heilman with Gary Baker (2018) Masculine norms and violence; making the connections Washington; DC, Promundo US.
9
Comrie-Thomson, L., Tokhi, M., Ampt, F., Portela, A., Chersich, M., Khanna, R., & Luchters, S. (2015). Challenging gender
inequity through male involvement in maternal and newborn health: critical assessment of an emerging evidence base. Culture,
Health & Sexuality, 17(sup2), 177–189. http://doi.org/10.1080/13691058.2015.1053412
9
decision-making about what support a woman may want or need from her male partner during
pregnancy and how he can best provide this.10

From a gender equality and human rights for health point of view both women and men should be
able to have knowledge about their own health and rights, define their needs with regard to health
services at household level and to be able to take decisions about their health and wellbeing. If
strategies are chosen to temporarily alter men’s behavior, without addressing the underlying causes
that contribute to the current situation of limited uptake of maternal health services, the impact of
engaging men will not be sustainable.

Another example that has been expressed in the URMCHIP is the engagement of men in maternal
health programmes, whereby health workers promote queue skipping when pregnant women arrive
with their husband for ANC visits. Although husbands become more knowledgeable about
pregnancies11, men’s behavior will most likely remain the same in other areas of the couples’ life.
Therefore, more in-depth reflection is needed in the URMCHIP to integrate gender transformative
approaches that can bring systematic change with regard to patriarchal roles and responsibilities that
contribute to disadvantage health situations, especially with regard to the sexual, reproductive and
maternal health of women and girls.

7. Conclusions
Based on the two missions, analysis of the project proposal and implementation plan, reports written
and meetings held with the MoH, Sida and the World Bank, many action points have been suggested
in the first mission report and a selection was made and agreed upon. Still, KIT recommends the MoH
to prioritize the following:

1. Gender transformative programming: In-depth analysis and defining what the objectives of
the project would be with regard to gender transformative programming is a vital step to take.
These objectives should include reinforcing women’s empowerment, women’s agency and
strategies on how men and boys can be engaged to address structural change in reproductive,
maternal, newborn, child and adolescent health care utilization.
2. Most emphasis in the RBF component is given to improving the supply side performance of
the health system/services, while RBF is also about increasing utilization by working on the
barriers that influence the demand side of services uptake. Strengthening accountability
mechanisms are actions that are planned for within the project, but more depth should be
given to a diverse representation of end-users their voices by actively engaging them in the
accountability structures of the project, e.g. as purchaser of care at health facility level.
3. Adjusting and shortening the quality of care scoring list that integrates indicators that relate
to gender equity, HRBA and adolescent health.
4. Hardly any reference is made explicit in the PIM and PAD and no clear objectives and
indicators are formulated under the URMCHIP that can measure and look into the progress of
these three areas. Therefore, it is required to still develop specific objectives and indicators
on HRBA, gender equality/equity and adolescent health to measure the progress in the overall
project. Extra resources and capacity within the project team is needed. Indicators can
measure progress and developments become visible with regard to striving for gender

10Comrie-Thomson, L., Tokhi, M., Ampt, F., Portela, A., Chersich, M., Khanna, R., & Luchters, S. (2015). Challenging gender
inequity through male involvement in maternal and newborn health: critical assessment of an emerging evidence base. Culture,
Health & Sexuality, 17(sup2), 177–189. http://doi.org/10.1080/13691058.2015.1053412
11 A negative unethical consequence is that women without husbands are discriminated and some women arrive with their boda boda
driver to skip the queue.
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 equality, equity and HRBA for health and ASRHR. When results are visible, motivation of staff
increases as well.
5. There are many ways to address adolescent health sufficiently in the project. A prioritization
exercise can help to identify where the URMCHIP can have the biggest impact in line with the
project objectives. Urgent actions are needed at health facility level, looking at the rates of
teenage pregnancy and maternal mortality in Uganda, as suggested under section 5 of this
report. Scoping studies could be conducted with the NGO representatives engaged in
URMCHIP to identify available ADH information and services and ASRHR edutainment
activities in Uganda and the effect of these activities available on ADH information and health
edutainment programs1213. Collaboration can be sought with existing initiatives to upscale
edutainment approaches and ASRHR education in the districts where URMCHIP is being
implemented.

12 Svanemyr, Joar et al. (2014)

Creating an Enabling Environment for Adolescent Sexual and Reproductive Health: A Framework and Promising Approaches. Journal of
Adolescent Health, Volume 56, Issue 1, S7 – S14
13
Thierry Claudien, Uhawenimana. (2014). An assessment of the effectiveness of urunana edutainment radio drama in promoting safe
pregnancy practices among rural couples in Rwanda.
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