Berkley Center

Background: Sister Jane Frances Kabagaaju, DST, has focused sharply her career as a Catholic sister on health care in poor areas of Uganda, and she is recognized in Uganda and internationally as a social entrepreneur, seeking and piloting new approaches to health care for marginal and rural communities. This discussion with Katherine Marshall in Washington, DC, during a fellowship visit explored her career working at different levels and places on basic health care for communities within the Catholic medical system of Uganda. It focused on the different dimensions of her work to advance health especially for Uganda’s marginalized communities and girls and women. Among the topics discussed are maternal health, natural family planning, the development of results-based financing systems, income support programs, school drop outs, early marriage, and the impact of the COVID-19 pandemic.

The discussion with Sister Jane Frances forms part of a series of exchanges with the sisters participating in the Women in Faith Leadership Fellowship. The fellowship works to amplify the visibility, vitality, and voice of Catholic sisters in responding to the complex challenges and opportunities faced by women religious leaders within their organizations and communities. The Bill & Melinda Gates Foundation, Conrad N. Hilton Foundation, Joint Learning Initiative on Faith & Local Communities, the Berkley Center for Religion, Peace, and World Affairs at Georgetown University, and the Center for Public and Nonprofit Leadership at Georgetown University have collaborated in the design and delivery of the Women in Faith Leadership Fellowship. Funding was provided by the Bill & Melinda Gates Foundation and the Conrad N. Hilton Foundation. Sister Jane Frances is a fellow in the inaugural cohort, and this discussion forms part of a series of exchanges with the sisters in that context.

Where do you come from, and how did you become a sister?

I come from the western part of Uganda in the Kabarole District town of Fort Portal, from the village called Mumbagane/Nyabusenyi II. I grew up in a family of staunch Catholics. They instructed me in faith and for that I thank my parents. My father was a head teacher, and at that time a teacher was someone prominent in the community, able to support his family. So I thank God for that also, that he gave us someone who supported us. Unfortunately, he died when we were still in the course of our studies. I had finished my Senior 4 then and was looking forward to joining the sisterhood. My aunts and my niece took on the family responsibility, and thank God that they were there to cater for my sisters and my brothers so they could get an education.

How many were in your family?

We were 10, and I am the fourth born and the first girl. So my family were very happy to have a girl child. After giving birth to three boys consecutively, they were very happy. They gave me a lot of names. That’s why you see me having a line of names: Sister Jane Frances Kabagaaju Ahaisibwe—Ahaisibwe is like “praise God that we got a girl.” One brother and one sister died, and eight of us are still alive.

Which schools did you go to? Government schools?

Yes, I went to government schools. I didn’t have an opportunity of going to the Catholic-founded schools; Catholic schools were all boarding schools and because we were many our parents could not manage boarding schools.

So when did you think you might be a sister?

I was in Primary 3 when Medical Mission Sisters came to immunize us against smallpox. There was an outbreak of smallpox by then and they were immunizing people, going from school to school. They asked me a question—just me, not the whole class. They said, “What would you like to be in the future?” After seeing them and what they were doing, I was inspired and I said “I will be a sister.” They were very happy, and they directed me where to go when I wanted to be a sister. That’s how my journey started. I began to go to the parish to meet with my fellow young girls where we were instructed on how to become sisters. Then after Senior 4, I still had that desire of becoming a sister, so I joined.

What is your order? Where was it founded?

The Daughters of Saint Therese of the Child Jesus. We are based in Uganda, it was founded in 1937 by Bishop Francis Xavier in Uganda, and its headquarters are also in the Kabarole District. We are about 400-plus sisters. We are working in different countries: Uganda, Kenya, Rwanda, Sudan. We have yet to come to the United States. We have many different ministries. We have health, education, social work, and other church-related activities.

Where did you study to be a nurse?

I studied at the Virika School of Nursing and Midwifery in Fort Portal in the Rwenzori region in Uganda.

What led you to want to be a nurse, or a health administrator?

My father died suddenly, immediately. His veins were not visible, and nurses failed to put a cannula or do any resuscitation to save my father’s life. My father’s death thus came quickly. I think that contributed to my wish. And I had seen what the other sisters who inspired me to become a nun, who were in the medical field, had done. I liked it. Even in my family, we have many nurses: my nieces are nurses and we have clinical officers. Some of our grands are doctors. I was inspired by the sisters who came to do the immunizations when I was in Primary 3. And I have an auntie who is a sister, and she also did public health. I think they started instilling in me some desire to become a nurse.

What happened after you finished your training? What did you do next?

They gave me a year of experience in the hospital, but after just six months they posted me to a health facility. So I started working in the rural area (my sisters laugh at that). It was in a different district. I worked there for eight years as an in-charge.

Then, my superior said that I needed to go and upgrade and get more skills. So, I joined the clinical officers’ school in Fort Portal for a three-year diploma course. When I finished it, they sent me back to the very facility where I had worked. I worked there for two years. And then they said, you go back again for health services management in Nkozi (Uganda Martyrs University). It was a one-year course in health services management. Then I was again posted to where I had worked, in the very same health facility in the Hoima District.

After one year of being trained in health service management, I was appointed to work as diocesan health coordinator, coordinating health services in four districts—Kibaale, Hoima, Masindi, and Kiryandongo—and still going again to the rural health facilities to supervise and support them. I worked there for two years. My mother general appointed and transferred me to a big hospital to coordinate primary health care services to meet the needs of rural communities, again to rural places. After working as director of Public Health Care Services in that hospital for two years, I was transferred to another health center as an in-charge—Nkuruba Health Center. That is where I am working today.

So all my life I’ve been a health administrator. I want to tell you that God has really been at my side, getting partners to work with me so that I meet the needs of the people where I’m posted.

When I went to a health center in Hoima, as an in-charge, I met Manos Unidas, an organization from Spain. I was given their address by my mother general, and the idea was to expand the health facility. I wrote to them, and [they] gave us a donation to construct maternity and children’s wards, an outpatient department, and a staff house. Before, we were operating in a three-room structure offering a variety of services in a small space. Again, when I was transferred to coordinate health services in Hoima, I wrote a proposal for a project on maternal health that would cover the whole diocese. I wrote a project, and I handed it over to my sister nun. My sister continued with that project and went into rural places, meeting mothers and educating them.

What was your central goal as you took on increased responsibilities for health services in the district?

My central goal was to improve maternal health. After working for a long time in the rural areas, I picked a passion for pregnant mothers because any minute, any hour during pregnancy, during childbirth, or after birth, instantly, they can die due to hemorrhage or other conditions related to pregnancy. How can we help these mothers? Being pregnant, it’s not a disease. All of us were delivered by mothers; we are who we are because of our mothers. So, I developed a desire to focus on maternal health.

I handed over the project to sister to carry on, and I was transferred to Virika Hospital as a primary health care coordinator. Looking at the services that we offered under my department, I saw there was a need to promote natural family planning, again for mothers. The bishop was saying, “You are stopping people from using artificial contraception, but what are you giving them?” He challenged me and he gave me an address for the Church in Need. They responded positively to my proposal.

Then we started working on natural family planning. We contacted Uganda Catholic Medical Bureau. We shared our ideas with them. Then we started using church structures to give information to mothers. Midwives and peer mothers were trained to meet the needs of the program. People could not believe in sisters to offer natural family planning, so we trained young girls and women, peer mothers, to go and meet these mothers and discuss and teach them how natural family planning works.

When I left Virika, I went to Nkuruba Health Centre where I am now. I found the same challenges in the rural communities, and I remembered the good relationships I had with Manos Unidas. I wrote to them: “Today, I’m again in another rural place. Could you please give me support to expand this facility?” They responded positively and we constructed maternity and outpatient departments. Now mothers have a fully-fledged maternity ward.

I opened an outreach maternity clinic at Mwegenywa village after seeing that many mothers were coming from that place, which is far from our health center. During the time of COVID-19, I got a loan to put up a three-room structure to cater to our mothers from this hard-to-reach geographical area. It is not yet finished; we need support to finish it.

I know that the health system in Uganda is a bit complicated, because you have the government facilities and then ones that are run by different religious organizations, as well as private operators. Have you been working in private facilities or in the government ones?

Always in the faith-based systems owned by the Catholic Church, whether the diocese or the congregation. For the two health facilities where I worked, the offices were owned by the diocese and the facilities by the congregation.

And how do you work and relate with the government health system?

We have partnerships to some extent. We get training from the government workshops; they invite us for workshops. The government gives us primary health care conditional grants—which now are going to be reduced by more than 50%—which we use to cater for primary health care services. We implemented result-based funding together, although it started with faith-based facilities and then it was scaled to government facilities. So we meet and do review meetings together

How did that happen?

Faith-based facilities, we charge user fees from our patients. So when the government was implementing universal health care coverage, it invited faith-based facilities to reduce on user fees so that people can access services at a subsidized fee. Then the government tops up on the subsidized fee.

Can you explain that to me? How does that work? You charge a fee?

Yes, we charge. We charge a medical fee. An organization called Enabel agreed to provide a subsidy. 

They said, “We’ll subsidize. We’ll pay,” instead of the patient. The patient would pay less compared to the bill. This was a regional project for all faith-based facilities in the Rwenzori region. They started with faith-based facilities, and the idea was to enable people access health services. The project, with Enabel, has been handed over to the government now. It was sort of like starting health insurance; the government has taken over the subsidies. So they pay instead of the organization, directly to the health facility.

The subsidies are directly to enable services, deliveries, postnatal children under five years and quality of service.

Has it been successful?

At first it was very successful, and many people started coming for services. Later, Enabel’s program was scaled to government facilities. Then we started the implementation together. Because of the COVID-19 pandemic things have not moved so well, and there have been delays in releasing funds. This has led faith-based facilities into financial crisis and has created a very big gap. We have accumulated debts with pharmacies because we could not do much. We subsidized on user fees expecting top up, but all in vain. The government is promising to resume after recovering from post-COVID-19 effects.

So that’s still the problem now?

Yes. It’s still the problem. We are recovering slowly from post-COVID-19 effects.

You say that your focus and your passion is for mothers. And working in rural areas where it’s so difficult for women to come to facilities. What do you see as the answer to the problem?

That’s why I came here! As per the WHO’s constitution, “health is a state of complete physical, mental, social, emotional and spiritual well-being, not merely absence of diseases and infirmity.”

The answer is to uproot the causes of maternal morbidity. In order to uproot the causes of maternal morbidity and mortality, it needs a multisectoral approach. The multi-sectoral approach will look at three delays:

1. Delay in reaching an appropriate obstetric facility.

This is a direct consequence of transportation systems which is expensive, poor, non-existent or a combination of factors. Studies in Gambia, Kenya, and Uganda indicate that pregnant women experience transport-related delays including geographical inaccessibility, roads in rural areas are usually bad (especially during rainy seasons), and lack of money to pay for transport to health facility.

2. Delay in decision to seek appropriate medical care due to 

• The low status of women.
• Poor understanding of complications and risk factors in pregnancy and when to seek medical help.
• Previous poor experience of health care.
• Acceptance of maternal death.
• Financial implications.
• The health condition of postpartum hemorrhage: mothers die due to the delay in making a decision; they die at home, at the hands of their families, on the road, or in the health facility; or they survive but with long-term complications.

3. Delay in receiving adequate care when a facility is reached.

This is due to inadequate obstetric equipment and infrastructures, as well as a lack of trained competent personnel.

The multisectoral approach will also consider three clusters:

1. ICT/MCH-e-Health

This cluster will look at information, communication, and technology used to address maternal health. It will deal with community sensitization about maternal health, including health education, radio programming, word of mouth through churches and other gatherings, education groups for these mothers about early detection of danger signs of pregnancy complications. This also includes continuous professional development for health workers, data analysis, usage, reporting, and research.

2. Capital development

This cluster will look at the construction of health facility departments—like theater, a sonography department, and outreach maternal clinics—as well as the purchase of ambulances to save the lives of these mothers, especially when it calls for emergency obstetric care. This also includes the construction of staff houses to create a good working environment, renovations, the purchase of equipment (such as delivery beds, ultrasound scanners, delivery sets, bed lockers, and drip stands), the provision of water and light, the construction of incinerators, and the improvement of cooking places for women to help control climate and maintenance.

I will partner with impact investors to support us with funds to improve utilization of maternal health services like antenatal care, delivery, and postnatal care. Being pregnant is not a disease; mothers bring new life into the world, so they need to be supported.

Another area to invest in is education, with the help of a school fees conditional grant. Many girls and boys from single mothers and poor families, coupled with the effects of COVID-19, are struggling to get education. I would like to partner with impact investors to prevent poverty in the near future, especially in the rural areas. These are the husbands and wives of tomorrow who will reverse the trend if not educated.

3. Poverty eradication

This cluster will look at empowering women to address poverty as one of the root causes of delay to seek and reach medical care in time. We shall develop income-generating projects like poultry and piggery. For sustainability, we shall purchase machines to incubate eggs and supply them to mothers, which will be a source of income. Then we shall also purchase a grinding machine for feeds which will also generate income.

Empowering women, especially women in childbearing age, with start-up capital for income-generating projects will improve maternal health. When there is a need, they should not have to wait for their husband. In this culture, they wait for the husband to decide and the husband is trying to keep costs to a minimum. It’s not because they don’t want to help their wives. It’s because they don’t have money. So they put off going to the health facility and wait until the mother is at the point of death. That’s when they say, “Let’s look for help at the facility.”

Uganda is one of the places where HIV/AIDS has been so serious. How much are you still seeing of HIV/AIDS? Is it still a serious problem?

It is, because at my health facility we have 600 people on ARTs [antiretroviral therapy], and we are enrolling. It is still a problem because of polygamy. They also need a decent clinic where they would receive their treatment and care from.

What are the other major illnesses or health issues, and how was COVID-19 an issue for you?

Uganda, being in the tropical area, experiences episodes of malaria. Malaria is a common disease affecting mostly pregnant women and children under five years. Every day, the government of Uganda distributes mosquito nets which have reduced the incidences of malaria. But still some people suffer from malaria.

COVID-19 came and went, but it affected us. It affected me. I’m a victim. I got it from patients. It left me with complications. I’m a pre-diabetic and pre-hypertensive. I’m on dietary measures.

COVID-19 really affected the small incomes of the people we are serving. It was an injury for the economy, as people’s incomes were reduced. We had people coming to our facility, but after we treated them, they ran away because they don’t have money. We are in recovery from COVID-19, but we are still there. It left us with debts. I think the results-based financing problems I spoke about are a result. The money was diverted by the ministry to cater to other activities. That’s why they delayed giving us that money. So we are still part of that crisis. We still have debts with pharmacists and stores. But we are recovering slowly. We are moving on, but with the difficulties in our services.

We have a big number of patients with chronic diseases like diabetes, hypertension, and cancer. These patients in rural communities also find it hard to pay for their bills. Some, because of finances, default from treatment, experience complications like stroke, and become burden to their families. Impact investment can be of help to them.

You studied health services management for a long time. Do you have the authority you need to run your programs?

Yes. I have authority to run health programs at all regional levels in Uganda because of the health service management course I took at Uganda Martyrs University in Nkozi. This qualification, and working as a diocesan health coordinator, gives me a mandate and authority to run health programs and other programs related to health in the Rwenzori region. Health cuts across many sectors. I will work with other partners like schools, agriculture, fishery offices, and Caritas using their structures.

Who are you responsible to, to your community? And how do you relate to the government system?

I am responsible for the sisters in my community who work in the health center, health facility staff, village health teams, peer mothers, and the community at large.

The district health officer is my supervisor. There are government projects like HIV/AIDs projects that we implement together. We use the same village health teams in the community.

Do you meet regularly?

We meet with district health office team and government health facility quarterly for performance review meetings.

Caritas has local officers?

Every diocese has a Caritas office, and these are local offices. I want to work with more partners. I was thinking of creating strong relationships with these bodies, and then we can come up with a big program to handle maternal health holistically.

Do you do work on nutrition?

We teach mothers how to breastfeed their babies and how to wean them. We teach them the proper diet during pregnancy and the balanced diet. But we could do programs like demonstration gardens at the facility, where the mothers could come see and learn to do it at home. We could even teach them how to prepare meals at a facility. That could be a good project.

In your area, do you have any refugees? Or are you too far away?

No, we don’t have that problem. There are refugees in the next district.

But we have a problem of school dropouts. Having many school dropouts is a future danger, leading to poverty. It’s not because they want to, but because their parents are poor. I am also passionate about the problem. They come to us and say, “Sister, I have finished my Senior 6. I want to go to a tertiary institution, to a university, but I don’t have money.” So they can’t go on. Boys and girls. They’re there and they come to us, but, being religious, we are a bit constrained because we don’t have funds to help them. But one of our visitors who came to talk with us said that she was helped by the sisters. She says she is who she is because of the sisters. And during that session, they talked about student conditional fees. I wanted also to look at that possibility, whether my organization can do that. If we form a joint team, for example with Caritas, and invite them to look for a sort of student conditional grant, it could help those students.

Do you see more dropouts after the COVID-19 crisis?

Yes, especially among girls. After around three years of COVID-19, they got married and they’re in the community. And there are dropouts because the economy is down and the parents could not afford the school costs.

How much are you thinking about early marriage? Is that something that is on people’s minds?

Early marriage is indeed a problem. It is no longer a cultural thing in our area; it is a lack of school fees to continue studies. So when a girl fails to continue at the primary level, they resolve the problem by marriage. That is the only choice they have. We can’t do everything, but if we have an opportunity, we can look at such girls and we could assist them, support them to join vocational institutions.

But that’s very interesting that you say it’s not in the culture.

No, it’s not. Or it is no longer, because people want their children to get educated, and after finishing education, someone is already an adult. So we have problems now with these dropouts. They get married when they are younger, and then they experience obstructed labor because [their bodies] are inadequate. Obstructed labor is one of the causes of maternal death. They’re too young, coupled with being in the rural area. When they come, they need cesarean sections, which the small clinics can’t do.

I’m also looking at upgrading the health facility to a health center where we could have a theater for cesarean sections. I’m going to lobby to have such facilities in the rural areas. It would be a facility of its own kind where we could have a theater. When these young girls and women come with complications, they could be attended to instead of needing to be referred. They can’t go far, and it increases the expense. We can manage them from our facility.

It’s very important work that you do. Are there other passions we should mention?

My passions are really in these areas: pregnant mothers, poverty in the rural communities, and school dropouts due to poverty. The girls are very clever. Thank God that we manage to reach where we have reached. The problems are not of their making; it is their environment. I feel pain for them.

This fellowship has empowered me in leadership skills. It has helped me to find my inner strength that can transform our communities. We can’t work in isolation. There is need to resolve conflicts, so that we can work with other people like government leaders, our brother priests, and other networks that could help us resolve some community challenges. 

Also, we have to work together to heal the pain of the world. To touch the pain of the world. There are so many pains and we have to come together and touch them, together. I hope all will join me in my struggle to touch the pain of the world.