Nicole deBrabander is CARE USA’s Program Officer and she is traveling in Uganda on a CARE Learning Tour - a comprehensive, multi-day tour for policymakers and those who can influence policy to gain firsthand knowledge of the core issues poor communities face. To learn more about the Learning Tours Program, please visit: www.care.org/learningtours.

The population of Uganda is growing exponentially. With 1.2 million additional people born each year, and a fertility rate of 6.6, the need for innovative and sustainable programs has never been greater.

We began the last day of the Learning Tour by meeting with three women parliamentarians who are leading the way toward change in their country. Speaker Rebecca Kadaga welcomed the group by emphasizing the focus of her work: To ensure that the principles of gender equity underscore all programs in Uganda. During her tenure, she has worked to ensure 30 percent women’s representation in parliament. Betty Aol, who represents the Gulu district, discussed the challenges that still face the country, including gender inequality, water and sanitation and health care. She explained the gap that exists in staffing community health workers: Only 179 community health workers currently exist while 500 are needed in the district. We then heard from Betty Bigombe, the State Minister for Water Resources in Parliament. Betty was instrumental in the peace process in Northern Uganda, working as the chief mediator with the Lord’s Resistance Army (LRA). She emphasized the need to address the challenges of Ugandan women, including poor health services and sexual and gender-based violence (SGBV).

Representative Barbara Lee greeting Speaker Kadaga.

After a robust discussion with the women parliamentarians, our delegation headed to Mildmay Uganda (MUg), a faith-based health facility that promotes comprehensive and integrated care to its patients, and is considered to be a center of excellence by the Ministry of Health. Here, people living with HIV (and their families) receive sexual and reproductive health services as part of their routine HIV care. They also receive specialist care, such as dental and vision, and participate in income-generating activities that help to support their families and create sustainable change in their lives. What is most unique about this facility is their psychosocial support initiatives and focus on women and children. After our delegation split into two groups to tour the clinics, youth center, school and income-generating shop, we joined back together to watch a performance by the youth group.

The youth group performs at the Mildmay Center in Kampala.

The group performed a short skit that told a promising story of a HIV-positive mother who learned, through prevention of mother to child transmission (PMTCT) measures, she could give birth to a negative child. They also performed a beautiful song called “Thank You” and a young man educated our group on the importance of taking his antiretroviral treatment (ARV) through an inspiring dance to Michael Jackson’s, “Smooth Criminal.”

Catherine Connors (Babble) and Derreck Kayongo (CARE) dance along with the youth group at Mildmay Center.

This program is a true example of integrated programming where people receive the care they need not in sectors, but in one comprehensive package. With funding from the Center for Disease Control (CDC), Mildmay currently supports almost 44,000 people (54% are women; 13% are children).

In closing, I know I speak for all of the delegation when I say we are excited to go home and share these amazing stories and experiences with our family, friends and colleagues! Thank you (webale)!

All photos: Josh Estey

Stephanie Chen is CARE USA’s Policy and Communications Manager traveling in Uganda on a CARE Learning Tour - a comprehensive, multi-day tour for policymakers and those who can influence policy to gain firsthand knowledge of the core issues poor communities face. To learn more about the Learning Tours Program, please visit: www.care.org/learningtours.

CARE USA CEO Helene Gayle congratulates the women in the NUWEP program for their progress.

Photo credit Josh Estey

The delegation, including Sen. Johnny Isakson (R-GA.), Rep. Jack Kingston(R-GA.), Rep. Barbara Lee (D-CA), departed from Kampala this morning to a village in Gulu – a district in northern Uganda – to visit CARE’s Northern Uganda Women Empowerment Program (NUWEP) program. For several members of the delegation, this was their first visit to the post-conflict area where many Ugandan families are finally returning to their homes after years of civil war and displacement.

NUWEP is a holistic development program implemented by CARE that focuses on the safety and protection of the people affected by the conflict, especially women. Part of the program includes CARE’s signature Village Savings and Loans Program, which has increased the community’s capacity to be productive in agriculture and small enterprises.



CARE’s Board Chairman Bo Cutter

Photo credit Josh Estey

Despite their past, the participants the delegation met showed remarkable resilience: Many of the women – and men -- have started their own small businesses raising life stock and selling food. Many of them shared with us how the gender empowerment aspect of the programs also helped improve many women’s relationships with their husbands and allowed them to be a bigger part of the decision making process.

After the greeting the delegation with a traditional song, the group of 30 women in a VSLA helped the delegation understand the positive impact of the VSLA program by performing a skit. The skit called “We Will Never Give Up” centered on a poor woman in rural northern Uganda whose alcoholic husband refused to help her raise the children and tend to their crops. When the woman receives counseling from the NUWEP and joins the VSLA, her life begins to slowly improve. Eventually, her husband see’s her ability to save and invest money. He soon helps her with the work.

While the skit was short, it gave a glimpse into the positive changes many of these women have faced since joining the program. Afterwards the delegation visited each of the women’s small businesses. One group of women sold seeds, grains and vegetables. Another tapestry business where money from the VSLA was spent on the sewing machine.

Catherine Connors, writer and blogger for Babble.com shares a moment with the children in Gulu during the NUWEP visit

Photo Credit Josh Estey

Photo Credit Josh Estey

CARE's CEO Dr. Helene Gayle presents Ugandan Prime Minister Amama Mbabzi with CARE's I Am Powerful book with Senator Johnny Isakson (R-GA), Congresswoman Barbara Lee (D-CA), Congressman Jack Kingston (R-GA) and CARE's Board Chairman Bo Cutter.

The Learning Tours delegation met Ugandan Prime Minister Amama Mbabzi to discuss development programs in Uganda and the impact of U.S. investments in foreign assistance.

Photo Credit Josh Estey

Stephanie Chen is CARE USA’s Policy and Communications Manager traveling in Uganda on a CARE Learning Tour - a comprehensive, multi-day tour for policymakers and those who can influence policy to gain firsthand knowledge of the core issues poor communities face. To learn more about the Learning Tours Program, please visit: www.care.org/learningtours.

During the first morning of our Learning Tour, the delegation, including Senator Johnny Isakson (R-GA) pictured below, visited Nsambya Home Care, a faith-based health care organization with funding from the Center for Disease Control (CDC). The delegation met Possy, a shy young mother with two children coping with HIV in the slums of Kampala. Several times a month, a volunteer from Nsambya Home Care will travel to Possy’s home to give counseling and make sure she is properly taking her medication.

Senator Isakson at Nsambya Home Care
Photo Credit Josh Estey

The HIV/AIDS rate in Uganda is just less than seven percent, a sharp decline from 21 percent in 1990. But the infection rates are often higher in poorer areas like Possy’s neighborhood, and still remain a major challenge for the country.

While testing for HIV and handing out drugs is a vital component of HIV treatment and prevention, one very significant part of the process that is often overlooked is ensuring that patients are taking their medications.

That’s where Nsambya’s volunteers come in. With an average of 60 patients each, Nsambya’s volunteers make rounds to each home to teach their patients what drugs to take and when to make health clinic visits for check-ups. Many of the patients, who are often impoverished and struggling to feed their families, have trouble remembering when to take their medication or they may have other counseling needs but don’t have immediate access to health clinics.

In Uganda, the stigma against HIV is still very pervasive, particularly in the community the Learning Tour visited. That is why the home-based care provided by Nsambya’s volunteers is so critical, to ensure privacy and allow patients to feel secure asking questions about their condition.

Home visits are just one of the many services Nsambya provides for more than 8,900 people in Kampala. Other services at Nsambya include: pediatric counseling, provision of food and income-generating activities.

Next, the delegation headed to Reach Out Mbuya, a comprehensive faith-based organization in Kampala with funding and support from CDC and PEPFAR. The delegation was greeted with a vibrant and dynamic traditional dance from a local youth group:

Reach Our Mbuya Youth Group

Photo Credit Josh Estey

CARE under the Integrated Family Health Initiative (IFHI) is working in Bihar, India to improve Maternal and Newborn healthcare practices, including the quality of care. As part of the project, health system strengthening is being undertaken through participatory approaches by creating Quality Improvement Teams at the health facility level comprised of Doctors, Managers, Nurses and front line health workers. The following experience was shared with a CARE staff by Gayatri who gave birth at the Primary Health Centre in Naubatpur block, Patna, Bihar, that is supported by the initiative.

It was in the wee hours of the morning, when I first felt the pain. It was more like a cramp in my stomach. I ignored it till the time I could not bear it any longer. From that moment onwards till I reached the room for delivery in the Primary Health Centre (PHC) was something I can never forget; it was like sitting on the roof of a crowded bus. I was cold yet seemed like I was suffocating to death!

But I kept reminding myself that worst was yet to come. I had heard that our PHC, Naubatpur was not one of the best places to deliver. Yet thinking of nothing else at that early hour, we had rushed to the same PHC.

Thankfully, things at the PHC had changed. This time, it was not very difficult to find the nurse that day, as she was in the typical white saree worn by nurses. I don’t think I had seen her in a white saree on previous visits. What had brought about that change?

As I entered the Labour room, I couldn’t help but wonder who had done the magic there? It was clean, very clean for that matter. I had come to the PHC about 6 months before, and it was smelling worse than a cow shed. The labour table had even had a rubber sheet on it! I still can’t make up my mind, whether it was due to looking at the Labour room or due to the Nurse’s dress that I felt as if I was in safe hands! Whatever gruesome stories I may have heard about the hospital, I suddenly felt there was no other place better than this to welcome my baby into the world. Something was surely happening here, but I could not figure out what. Well, truly at that moment, I had no energy to think about it!

It was well past 10 am that my little angel finally came. When I came to my senses (literally), I was assisted to breastfeed my baby by an attendant. There was a quiet demure lady standing at a corner, smiling at me. Her smile was saying; ‘You and your baby are perfectly alright’. I smiled back.

Then some further memories of that smile came back. She was Seema, from an organization called CARE[1]. I had also seen her earlier when I came for my antenatal care visit (ANC). That time I had seen her talking sense into a few men[2] who were lingering around Labour room. At that time, the Out-Patient-Department (OPD) and Labour room were practically next to each other, so one could hear the women screaming in the Labour room even from the OPD. And to tell you the truth, those screams from the Labour room during my ANC visit actually scared me to come there! As part of the changes at the facility, the Labour room was shifted to a more private place and curtains were hung. These changes made a huge difference!

Photo Credit: Jaspreet Mahal

Six months earlier, when I had accompanied my sister-in-law for her delivery in the same hospital, it was very scary. There was a huge commotion in the Labour room, for a baby just born had not been breathing. I remember Seema taking charge of the situation. She had put the baby in some machine in the ‘Child corner’ and used oxygen to make him breathe again. I learned that day there was something special in our PHC for new born babies to help them survive.

As I was being taken to the ward after my delivery, I heard Seema say to the Nurse, “You really did a great job for this woman, Gayatri, you should be so proud of yourself!” I don’t know about the Nurse, but I was filled with so much love for this wonderful lady. I am sure the Nurse also felt so much pride and responsibility at that moment. Seema then helped the Nurse refill her delivery tray for the next woman.

The posting below from Blossum Gilmour, Mamayo Health Project Manager at CARE, describes CARE Papua New Guinea's training program for Village Birth Attendants (VBAs) in remote areas and their efforts to increase the number of women seeking maternity care at health centers.

Credit: © Josh Estey/CARE

Where did you give birth?

In my family's coffee garden.

Who assisted you?

No one.

This is how a conversation started between CARE PNG staff and a new mother in rural Papua New Guinea. CARE had agreed to help the provincial government assess the support available to pregnant women and new mothers, and while the conversation above was common, the reasons why women were alone in the bush while giving birth are as individual as the women themselves.

The staff tried to delve to the root of women’s reasons for not going to a health centre to give birth and most of it came down to fear: fear of the health worker who is not from their village and doesn’t speak their language, fear of seeking help from a male health worker, fear that their family will be asked to pay for the service, fear that the medications they’re given will hurt them, fear that the health worker will yell at them and make them do things that feel painful or wrong.

It is a generally accepted fact that health workers in rural areas are ill equipped to deal with obstetric emergencies—they have not received the training or tools needed—and the nearest hospital is an expensive flight away.

Their inability, and in some cases unwillingness, to provide basic antenatal and obstetric care speaks to a more deeply-rooted issue.

‘Do you know what the women of PNG call midwives? Barking dogs… because they never stop making a terrifying racket’ said a teacher in a university midwifery program. She went on to explain that the unit on bedside manner has just been taken out of the new midwifery curriculum. She wants to teach new midwives that they are service providers and need to have empathy for their clients but there are other priorities for the time being.

So what is the solution? Where to begin?

CARE PNG, in collaboration with the Provincial Division of Health, is training Village Birth Attendants (VBAs) in some of the most remote areas of PNG. The primary role of the VBAs is to decrease the number of barriers to women giving birth at a health facility. VBAs are chosen by the women of their community and they are women themselves. This alone seems to engender trust. VBAs are then trained. They learn how to recognise the signs of high risk pregnancy and how to counsel women to go to the health centre for an antenatal check-up, but also to address the individual fears that women have. VBAs then accompany each mother to the health centre and act as her advocate - both translating and explaining what the health workers is doing and ensuring the woman agrees to the interventions. VBAs assist the health worker throughout the antenatal checks and delivery, a constant companion and champion for the mother. Finally, when they are not able to get a woman to a health centre, VBAs are able to safely attend an uncomplicated delivery.

It’s far from perfect—VBAs are a stop-gap measure in the floundering health care system. That said, they are having an impact by championing Respectful Maternity Care and providing companionship to women in facility-based labor and birth—more women are having antenatal check-ups and it’s hoped more will agree to professionally assisted births. VBAs are changing how women view the health care centre—one mother at a timeCredit:

© Josh Estey/CARE