Babies and Mothers Alive

From an initial investment of $5,000 in cash, over two million Ugandan women and infants are now getting improved health care. It’s been a long and often bumpy road, but Babies and Mothers Alive (BAMA) has been making their name a reality over the course of two decades, saving lives one community at a time.

Doctors Daniel Murokora and Marc Sklar, both Ob-Gyns, first met as co-investigators twenty-three years ago, researching cervical cancer screening in limited resource settings such as Uganda. They shared a passion for transforming health systems in that area and also shared a frustration with the parachute models of funded care that came in and left again at the end of the granting cycle. Starting with that first annual budget of $5,000 in 2004 – cash in a money belt – they began creating a new model that partnered with national and local governments, was deeply rooted and managed in the communities being served, and could be both sustainable and scalable.

BAMA’s first year included investing in data systems so everything would be evidence-based as they grew their programs. Initially, the budget was too small to do anything beyond a bit of health work and fundraising in public schools, in the Rakai District. They expanded into sexual, reproductive, and menstrual health programming, then into maternal and newborn health, where the need was great. As they grew, they provided the health systems and the community with training, quality data for decision making, clinical skills development, and put in place systems that improved quality of care and supply lines for critical supplies.

By 2019 they were starting to see improved care in health facilities, but many people were not getting to those facilities, or not getting there fast enough to save lives. There are three main delays responsible for the overwhelming majority of preventable maternal and newborn deaths globally: making the decision to seek help in the first place; getting transportation to a health facility once the decision to seek care has been made; and receiving appropriate care once reaching a health facility. To address these delays, BAMA developed a coordinated intervention approach, beginning at the village level and continuing through to health facilities and the district government. Critical funding at that juncture allowed them to launch the full BAMA model and bring on board Dr. Eleanor Nakintu as Program Director.

This is the kind of tenacity required to make progress in the lengthy cycle of envisioning, testing, assessing and revising complex models for complex systems in a country with very limited resources. As Marc puts it, “System change takes time. It’s built on trust between many partners; communities, facilities, NGOs, Community Health Workers and District Health teams, and national and district governments. It can take not just years but decades to see a real return. It’s like planting trees rather than corn. You don’t get fruit after only one season.”

Their core focus is on skills development for Community Health Workers (CHWs), physicians, midwives and technicians at every step of the health system, from home to hospital. CHWs, empowered as BAMA Mama and Papa Ambassadors, are the key primary care and knowledge providers, respected and embedded in their communities. They are the ones who help clients make the first important decision to seek greater care in a health center, when they’ve identified the need for it. In Uganda, where health care is free and government budgets are limited, they are not paid for their services. Life-saving supplies and equipment, as well as the necessary training for their use, are part of these essential BAMA supports.

A Mama and Papa Ambassador Program has been developed specifically to support adolescent mothers and their babies, who represent 24% of the pregnancies and also experience a high level of sexual and gender-based violence. The Mama Rescue Program links rural women in labor to motorcycle taxis, transporting them from home to health facility, as well as emergency referral transportation in life-threatening situations, reducing access times from hours to minutes.

Overall, BAMA has supported more than 113,000 deliveries with an 84% reduction in institutional maternal deaths, and a 61% reduction in perinatal deaths since 2016. And of the almost 3,000 sick newborns treated in BAMA’s NICUs, 97% have been discharged alive.

Delivering this model across multiple communities and districts requires constant adaptations to local situations and insecure government funding. “It’s important to take a comprehensive approach to address all elements,” says Eleanor. “We start with a baseline assessment of skills, attitudes, data usage, local government involvement, and levels of supervision in a new community. Then we create an implementation and capacity building plan. But continual assessment will identify more gaps as we go along, in training, funds, or systems, so the process is ongoing.”

Funding is always a challenge, as the government tends to reduce funding when an NGO has received donor grants. “It’s rarely a smooth trajectory of interventions,” says Daniel. “District government partners are more engaged and responsive because they’re of their communities and close to the people being served, but they don’t always have sufficient funds to meet their area’s needs.” BAMA tries to streamline supply and administration systems  to make the most of these imperfect situations.

Despite the ongoing challenges, BAMA has expanded its health care programs from serving a single district to serving ten districts and millions of women, modifying continually along the way. “It’s a very iterative process of system making,” says Marc, “in full engagement with the communities, the mothers, and government. The Patchwork Collective has made our latest expansion possible, with a level of trust in our use of the grant funds that allows us the necessary room to pivot as we navigate this complex, evolving health care environment.”

We applaud our partners at BAMA for their incredible tenacity and thoroughness in this work.

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