How a community-led model has improved Healthcare Access in Kalangala

Play Video

A canoe loaded with cartons of medical assortments and health workers glides through the mid-morning waves of Lake Victoria, toward Bugaba Island landing site.

As it bumps against the beach, the waiting men quickly clear its load and sling it on their shoulders heading for the neighboring Nakawa village.

In the community, people had already gathered at a cinema hall—a wooden structure with a corrugated iron roof—clutching small exercise books, which contained their medical history.

The hall doubles as a village clinic once a month, and they are here for treatment.

“Community members come together to pull resources to get medics here every month. They are at the center of this initiative,” said Mark Kayongo, who coordinates the community outreaches.

Medical workers disembark from a canoe at Bugaba landing site ahead of the medical outreach clinic. PHOTO by Dan Ayebare

Bugaba is one of the 84 (eighty-four) small and remote Islands that make Uganda’s archipelago of Kalangala, a 9,103 square kilometer expanse in the middle of Lake Victoria, Africa’s largest freshwater lake. But community members love it for its commercial promise.

“The land here is good for food, and fishing presents a good opportunity for money. Compared to the mainland, this is a unique place” says Byakatonda, 30, who chose to relocate his family here from the mainland about 8 years ago.

However, the island presents a unique challenge for most of its inhibitors, healthcare access.

'We Are Happy Here'

Ibrahim Byakatonda speaks during interviews at his home in Nakawa village, Bugaba Island Kalangala (Photo by Dan Ayebare).

According to Nakawa Local Council (LC1) chairperson David Masaba, close to 2,000 people reside on the island. However, there is neither a private nor public health facility. Supposing a painkiller here is to ask for too much.

Bugaba’s closest health facility is Bufimira Health Center III, situated on Bufumira island which is a one-hour ride on a motorized canoe and costs residents between Ushs 50,000 – 100,000, (about $15-30), only if the canoes are available.

“We recently had a pregnant mother who was in pain but there was no means to take her to the hospital. We used almost 400,000 shillings (About $107) to get her to Kalangala hospital,” Chairman Masaba said, emphasizing that such stories are commonplace.

Byakatonda’s third child also came in a related situation, nearly at the life of his wife, Delillah Ireneeza. Her waters broke late night, and there was not a canoe to evacuate her.

“We got a boat after almost four hours, and at an exaggerated cost.  When we reached Bufumira Health III, nurses could not handle her situation. We were referred to Kalangala hospital and that was another cost,” Byakatonda says.

“The transport infrastructure is  a major challenge for us. Health facilities are too far “

 Nakawa village Local Council (LC1) chairperson David Masaba.

Byakatonda’s third child also came in a related situation, nearly at the life of his wife, Delillah Ireneeza. Her waters broke late night, and there was not a canoe to evacuate her.

“We got a boat after almost four hours, and at an exaggerated cost.  When we reached Bufumira Health III, nurses could not handle her situation. We were referred to Kalangala hospital and that was another cost,” Byakatonda says.

Malaria and other waterborne infections like bilharzia, diarrhea, and typhoid are very common in catchment areas yet healthcare access is hindered by distance, cost, availability, and infrastructure.

The over 60,000 residents of the Kalangala district are served by 15 health facilities, including 2 Health Center IVs, 6 Health Center IIIs, and 7 Health Center IIs, according to the district Local Government dataset. 

Fishermen pictured while at their routine evening catch a few meters from Kalangala mainland. PHOTO by Dan Ayebare. 

We can deal with it

Officials say a plan is underway to build an efficient medical evacuation system to deliver residents to medical facilities in times of emergency in addition to the existing structures. 

“We have acquired a boat to ensure that people who need referrals out of Kalangala are evacuated using the water boat ambulances to Masaka, and Entebbe regional referral hospitals or even Kampala,” says Emmanuel Ainebyona, the Health Ministry spokesperson.

Essential healthcare service coverage is one of sub-Saharan Africa’s development challenges. Only 48% of the people in Africa received the healthcare services that they need in 2021 according to the African Health Agenda. This means that approximately 615 million people are on their own.

In Uganda, only 7% of the national budget went into health care in the financial year 2021-22, way below the 2001 Abuja declaration which requires African governments to commit 15% of their budget to health access.

A signpost of a private health facility in Kalangala town (mainland). Uganda spends only $14 per-capita on health. Of this, $9 is out-of-pocket and $5 from public sector (government and donor funding). PHOTO by Dan Ayebare 

Even then, the largest portion of the health budget is retained at the center under the Ministry of Health vote while local governments like Kalangala, where the bulk of services are delivered constitute only 22% of the last financial year.

“The geographical setup of this site for example is not that friendly …. most of the catchment areas of this facility are in water so it is hard for them to access the health center. So, I think we need another facility or more resources and personnel,” says Proscovia Charles, a nurse who has served at Bufumira Health Center III for the last four years.

Bufumira Health Center III. It serves over 3000 residents from nearby islands. PHOTO by Dan Ayebare. 

Communities are in charge

While the Ministry takes time to cover the Islands of Kalangala, the outreach is the new medical access lifeline for isolated communities around Lake Victoria.

The community-led system is being pioneered by Health Access Connect (HAC) Uganda and seeking to change the health access story for these communities from “needy” to “self-sustaining”.

It relies on community existing transport structures like motorcycle taxis (Boda bodas), boats, and canoes to set up monthly, one-day health clinics to allow people access to essential health services like anti-retroviral treatment, and maternal health services, malaria treatment, child checkups, and family planning.

Men exchange pleasantries as they head to the treatment camp at Nakawa Village, Bugaba Island in Kalangala district. PHOTO by Dan Ayebare.

According to the Project’s Manager Costaritah Nalukwago, the model mobilizes medicines and health workers from public facilities and works with community leaders to deliver them to hard-to-reach areas.

“The model works in a way that the health services are taken to the community but with community members fully involved. Compared to other models, it is the community that funds and mobilizes for the outreach to happen,” she explains.

The initiative, which started in 2015 has now empowered over 50 remote communities that have received over 40,000 patient services over the years, at monthly outreach clinics in areas such as include Kyotera, Lyantonde, Ssembabule, Lwengo, Rakai, Masaka, and the island areas of Kalangala.

From the right: HAC Project Manager Costaritah Nalukwago (Right), Solutions Now Africa reporter Rhonet Atwiine, HAC Communications Manager Mercy Ahukana and a medical worker pause for a photo before getting on a canoe for Bugaba community outreach. PHOTO by Dan Ayebare. 

Joining hands

Members of the Village Health Team — who are the first point of patient contact, and responsible for basic health interventions within local communities and villages in Uganda’s health structure— inform the organization about the challenges in their community through Kayongo.

They then mobilize fuel for canoes to transport health workers and medicines. The VHTs also work within the community to provide makeshift treatment centers where patients can be treated with privacy.

Residents of Nakawa line up for treatment at the makeshift treatment center staged by Health Access Connect. PHOTO by Dan Ayebare. 

The Bugaba outreach meant that the HAC team travels for close to an hour from Kalangala landing site on a motorized canoe to Bufumira Health Center III to meet the nurses and the medicines, where the community sailor was waiting.

Proscovia Nanono, a health worker on the trip said it “offers the facility an opportunity to address needs at a community level because sometimes they come to the facility when the condition is worse”.

“As a health worker, you also feel the need to go to hard-to-reach areas where the needs are sometimes immense,” notes the 35-year-old laboratory technician adding that the camps can be quite challenging because you lack prior information about the challenges.

“Preparation for camp is more of guesswork on our side. We can’t tell what to carry or leave, yet only a small number of people turn up at the bigger health care centres,” she says. 

Proscovia Charles, a laboratory attendant at Bufumira Health Center III takes stock of medical assortments in preparation for Bugaba community outreach. PHOTO by Dan Ayebare. 

The camp targets Out Patient Department (OPD) which includes TB, general diseases, and a mobile laboratory for HIV, Syphilis, Malaria, diabetes screening, and counseling plus antenatal services for expectant mothers. 

Despite their challenges, community-led models have been recommended by WHO as the best alternative means of transportation to access health care in low-resource settings like Bugaba Island.

A nurse attends to a patient at Nakawa community medical outreach clinic. PHOTO by Dan Ayebare. 

However, Ireneeza says since her community’s healthcare needs are not limited to outreach, there is a need for members to join hands and build a health center, “because only this camp can’t be enough for us”.

“The camp is better than nothing. I think as a community we shall need to work with the organization to see what it takes to bring a mobile laboratory on the next visit and also maybe build a community clinic where we can at least find aspirin,” she says.