World fistula day Q and A from Uganda country program: Theme 2021 “Women’s Rights are Human Rights ” End fistula now!

Insights from Emmanuel Ebitu: Project Manager – Medical Specialized Outreaches, Amref Health Africa in Uganda

Amref Health Africa is among the first organizations to highlight the devastating condition of obstetric fistula in Uganda. Ministry of Health Approached Amref in 2004 to support the government in carrying out corrective surgeries. At that time Amref health Africa had to fly in specialized medical personnel to undertake the task of over 200 women and girls. The very first camp was held in Arua district regional referral hospital, it is now about 17 years since Amref Health Africa has implemented specialized medical outreaches to treat women and girls affected by Fistula and we have brought back their dignity.

1. In your view basing on this background what have you achieved as an organization, the country and the women and girls whose lives you have changed

Amref Health Africa, Ministry of Health and partners have achieved a lot over the past 15 years. Since 2005 Amref Health Africa in collaboration with the Ministry of Health through the Flying Doctors Programme had to invite fistula surgeons from Kenya to carry out repairs in Uganda. By then Uganda did not have obstetric fistula surgeons. Over the years Amref supported the training of Ugandan doctors as fistula surgeons. Today the trained surgeons continue to provide services in various hospitals across the country. In areas like northern Uganda where some of the first trained doctors are based, the backlog of fistula cases have significantly reduced due to the increased access to fistula health care services through medical camp and routine repairs provided at Lacor hospital.

2. What is the cost of one surgery this includes the medical fees, and other elements

The cost of repair in a medical camp per patient including treating is approximately USD 287 . This covers mobilization of clients; transportation and 14-day hospital stay for the client; honorarium and accommodation for the fistula surgeon, and contributes to lunch for outreach hospital staff; medicines/sundries and project costs related to conducting the medical camp. During Fistula medical camps about 20 health workers are involved.

3. Why has this condition persisted to date Uganda keeps getting new cases and we also still have a backlog of old cases, what are we missing in this fight to end fistula with in the generation

Teenage pregnancy, delay in seeking obstetric care during childbirth, poor quality of delivery services, and non-attendance of antenatal care are some of the strong factors leading to new cases of fistula. This is worsened by poverty, child marriages, school dropout, and cultural beliefs. Addressing the issue requires a multi-sectoral approach involving community, political, religious, and different opinion leaders to address the root cause of the problem. The backlog remains to limited access to fistula repairs as women who suffer from fistula are usually young, poor, uneducated living far from specialized health services. Women and girls with fistula are also ostracized making it difficult for them to seek care.

4. How has Amref Health Africa supported the health sector in regards to eliminating fistula within the generation?

Amref Health Africa has worked in collaboration with the Ministry of Health and various partners to end obstetric fistula since the year 2004. Amref’s contribution spirals from community to national level interventions. The interventions comprise of capacity building for community and facility based health worker on obstetric fistula; awareness creation and advocacy across various platforms; building capacity of partner hospitals to treat fistula and Social Reintegration of fistula survivors.

5. Looking at the past five years can you provide some data regarding recoveries?

Over the past five years, Amref has supported treatment for over 1500 women across various regions in the country. Most women recover fully after the operation. However, a few cases may re-occur due to failure by the client to follow recovery instructions a few months after the operation, they start physical sexual activity soonest, which may cause the fistula to reoccur.

6. How do you handle social integration of victims back into the community and more so in their homes?

We work with the Village Health Teams to provide psychosocial support to the clients and their families during follow up visits. In case of clients living with their spouses, we ensure involvement of the partner right from the time of treatment to reintegration. We also link up clients to Village Saving Loan groups within their communities and provide them with some seed funding for them to join and restart their lives.

7. Who are the other major contributors and partners in this fight and what message do you have for them.

There many partners involved, such as the Ministry of Health, UNFPA, MTI, Elite Ambassadors, and many others. I encourage all the partners to continue with the invaluable efforts towards ending obstetric fistula in Uganda and the world over every woman and girl deserves a dignified life.

8. Culture has its’ positives and negatives, based on this statement what is your contribution to both elements and what advice do you have as a Project Manager of the Fistula projects at Amref Health Africa in Uganda.

We take cultural and gender transformation very seriously during implementation as an organization and in all our programmes. At every stage of implementation, we engage the cultural, religious, political, and various opinion leaders within our project area. In many areas where we work, marrying off young girls, denial of access to family planning resources, lack of decision-making power by fistula victims is still a practice. Our role is to engage the communities and their leaders provide them with accurate health information to enable them to change their culture and address the root causes of vulnerabilities to fistula.

9. Has Amref passed on knowledge to younger medical teams through your specialized surgeons?

During medical camps, the specialized teams work with junior health workers such as doctors. nurses, midwives, and anesthesia providers as part of continuous medical education and professional development This way, the knowledge is passed on to upcoming medical practitioners.

10. Is there a connection between FGMC, Fistula and SGBV

Yes! Some types of female genital mutilation/cutting (FGMC) especially those which affect the birth canal are recognized risk factors that lead to fistula. This is because healing from FGMC causes scarring which eliminates the elasticity of the birth canal leading to tears. Similarly, Sexual Gender-Based Violence actions like rape, assault, and insertion of foreign objects like in torture or abortions can lead to fistula.

11. The so-called “Orange Manuel ” has long been the only authoritative, gold-standard guide to the holistic comprehensive, and bigger picture aspects of eliminating Obstetric fistula. Does Uganda have other guiding policies, strategies, or costed plans to provide critical guidance that Ugandans need especially organizations like Amref Health Africa?

Yes, Uganda has the national obstetric fistula strategy and other related sister health policy documents. This can be found on the Ministry of Health website under publications, strategies, and policies docket. https://www.health.go.ug

12. What is your call to action to the Governments of Africa, Development partners, political leaders, Health workers, Cultural and other community leaders, women, and girls? Let us know at least one ask that you have for each of these people.

Across the different community divide, my call is for all to work together to end poverty in all its forms, end early child marriages, FGM/SGBV and keep the girl child in school. Strengthen reproductive health services provision especially family planning, antenatal and obstetric care services, at all levels of the health system to stop obstetric fistula. Support the treatment and reintegration of the women who have had obstetric fistula.

Allow me to take this opportunity to recognize and thank the Ministry of Health, the fistula surgery teams, our colleagues at the Amref Flying Doctors service in Kenya, Amref UK and Amref Flying Doctors service in Netherlands. They for the last 17 years made these unique services available to the most venerable women and girls who if such interventions are not availed would never have sought for treatment or regained their diginity.

“Women Rights are Human Rights – End Fistula Now.”