Sarah Bosley’s post on the Guardian Katine website on December 2nd has raised some very important questions about why this health service is not delivering the basic services that it should be delivering: providing anti-malarial drugs, drugs for preventing mother-to-child transmission of HIV and other essential services. Instead there are empty shelves in the dispensary, the ambulance is elsewhere and there has not been an assigned doctor present for months. In her view the health centre “was in a worse state than when the Guardian/Amref project began, 12 months earlier.”

She then questions the role of AMREF, and whether there was not something the AMREF staff could have done to address these problems, in addition to their work of installing clean water supplies, supplying mosquito-nets and the training of village health teams and clinic staff.

Visitors to the website have been both sympathetic and critical of these comments. Some emphasised that these problems are not unique to Katine, or Uganda even, and that their systematic causes need to be addressed. Not the provision of stop gap supplies from other local NGOs or AMREF itself. But meanwhile the problem of lack of drugs and a doctor is a very real and pressing one for the people of Katine, regardless of what is happening elsewhere in Africa.

AMREF have responded, and there are now some interim supplies on their way. But these are recognised as stop gap solutions. They have commented:

Given the limited scope of our resources, AMREF must make strategic, sustainable investments in health. Until the national health system in Uganda is robust enough to reach and truly serve rural communities, we must build the system from the bottom up, empowering communities to take care of their own health.

This means focusing on long-term but essential activities such as training communities in disease prevention and early detection, improving health information systems so that a true picture of community health needs is understood by the district health authorities, and for better planning.

The other key aspect of our work is building the health system from the top down. We continue to advocate at the national, district, and local levels for improved drug delivery and improved health care delivery and resources (doctors, nurses, equipment, and so on). Changing government policy is slow, difficult, and necessary work. The alternative is a perpetually weak health care system based on short-term fixes.

To me the debate that Sarah has promoted raises important questions of what should donors, and other stakeholders, expect of AMREFs work in Katine on health issues at the end of three years. What sort of outcomes should be expected? This question is closely tied into a similar question, about what the Katine community should expect from the Tiriri health centre.

Simply listing the inputs that have been provided (e.g. number of people trained, meetings held with government officials etc.) will not be very satisfactory.  AMREF have already been very active, but to outsiders the health centre seems to be going backwards.

What would be much more useful are some realistic performance objectives for the health centre as a whole. These need to be ones that local officials agree with, and which local communities could understand and relate to. They would be largely about the availability and quality of services that should be provided. Once established, there then needs to be some transparent public reporting on how the Tiriri, and other local health centres, are performing on these criteria. If AMREF wants to empower people then providing public information is essential, both about what they can officially expect from their health centres and about what is actually being provided. Ultimately it is the people’s evaluation that matters and which should be heard.

One possible way is to move forward with a local adaptation of the Yellow Star program, already trialled elsewhere in Uganda. Fortunately, one member of the AMREF Katine staff have had some experience with this program. In doing so it would be important to see this not just as an improved health information system, but also as a means of community empowerment, to demand better services.