By Dr. Bob Marley Achura (PhD)

In 2014, while conducting operational research on maternal and child health in Oyam District, Northern Uganda, I encountered a disturbing pattern, one so ordinary it risked being invisible. Health facilities required every expectant mother to carry an exercise book to record her antenatal and delivery information. A 48-page booklet, sold for less than 1,000 shillings, stood between life-saving care and denial.

It seemed like a harmless, even practical, requirement. But what I found was far more troubling: the “exercise book dilemma,” as it came to be known locally, was quietly sabotaging efforts to improve skilled deliveries and maternal outcomes. This simple paper booklet had become a gatekeeper, one that too often shut out the most vulnerable women.

A Walk of Pain and Shame.

Take Acen, a 28-year-old mother from Abela parish in Otwal sub-county. She walked three hours, under the punishing sun, to reach the nearest health centre, carrying her toddler on her back and her hopes in her heart. But when she arrived, the midwife frowned. “Where is your exercise book?” Acen had forgotten it. She was turned away. “Come back with your book,” they told her. The walk home was longer. Her body ached. Her spirit, too. That was her last antenatal visit during that pregnancy.

This is not an isolated story. From Alebtong to Amuru, women are carrying more than pregnancies; they’re carrying the burden of poverty, distance, stigma, and now, bureaucracy. Many mothers in Otwal confess they cannot afford even a single exercise book. Some tear out pages from their children’s schoolbooks. Others scribble health information on scraps of paper. A few have used old funeral programs, just to show something when they reach the clinic. In one heartbreaking case, a mother said her school-going child had taken her ANC book after being sent away for not having one. Another woman said her husband had used the pages to roll cigarettes.

What may sound absurd is, in reality, a quiet emergency. A paper book barely worth a coin has become the gatekeeper of life.

A Paper Barrier to Safe Motherhood

We often talk about Uganda’s maternal mortality challenge, about long distances to health centres, the lack of ambulances, and understaffed facilities. But rarely do we stop to examine these invisible, small barriers that tip the scales toward tragedy.

Let’s name them:

• Accessibility and Storage: Most rural families lack safe, dry spaces to store documents. Exercise books are destroyed by rain, eaten by rats, or misplaced entirely.
• Data Loss and Isolation: The information trapped inside these books is siloed. Health officers can’t analyze trends, track high-risk pregnancies, or make timely interventions.
• Out-of-Pocket Burden: Each year, thousands of shillings are spent by households on these books, money that could buy soap, food, or school fees.
• Stigma and Discrimination: Illiterate mothers are often humiliated or turned away when they present a “messy” book. Some stop returning out of shame.

These paper barriers are costing lives. They are reinforcing inequality. And yet, they persist, unchallenged and unfixed.

A Digital Ray of Hope: Then Bureaucracy Killed It!

In 2016, with support from Duke University postgraduate students and in partnership with the Oyam District Health Office, we piloted a simple but powerful solution: the Mothers Health Information Management System (MHIMS). It was a user-friendly mobile app tailored for frontline health workers. It worked offline, synced with the cloud when internet was available, and provided secure digital storage of maternal health records.

We deployed it at Agulurude Health Centre III. The impact was immediate and transformative:

• Midwives could retrieve a mother’s ANC history in seconds.
• Mothers no longer needed to carry paper books.
• Communication between providers and patients improved.
• Antenatal attendance increased.
• Skilled deliveries rose by 29.3% within just one year.

Financially, the case was even stronger. We found that maintaining MHIMS was 47% cheaper than the paper-based exercise book system. The difference? Digital costs are absorbed institutionally. The paper cost is carried by the mother.

But despite the glowing data, the pilot was never scaled. No further funding. No rollout. Just silence. Bureaucracy. Budget inertia. Leadership turnover.

I call it a betrayal.

Lessons from Across Africa.

Uganda is not alone in facing these barriers, but other countries are responding more boldly. In Rwanda, the RapidSMS system has transformed maternal care across rural districts. By using simple mobile phones, community health workers send real-time updates about pregnant women to district hospitals, allowing timely referrals and interventions. Maternal deaths have dropped significantly in pilot districts, and the model is now expanding nationwide.

In Kenya, the Linda Mama program (meaning “Protect the Mother”) enables digital registration of pregnant women and links them with free maternity services across public and some private facilities. Through NHIF’s digital platform, women no longer need to carry paper records, just their ID numbers.

These are not expensive, high-tech dreams. They are African realities, our continent proving that bold ideas can work.

A Call to Action: Now, Not Later

The exercise book dilemma is not about stationery. It is about values. It is about the invisible wall we place between mothers and the care they deserve. It is about the indignity of asking a woman in labour to produce a receipt before being helped.

This is not a call for tablets in every village. It is a call for:

• Immediate policy revisions to end the punitive rejection of mothers without exercise books.
• Investment in scalable, digital maternal health record systems.
• Training health workers to uphold compassion over compliance.
• Empowering community health workers to serve as record-keepers for vulnerable households.

A mother’s womb should never be treated with less dignity than a book.

Who Bewitched This Country?

Who decides that a child should be born or die because their mother didn’t bring a 1,000-shilling book? Who lets proven digital innovations rot on shelves while our maternal mortality rates remain unacceptably high?

We have solutions. We have champions. We have evidence. What we lack is the courage to act.

Let us unshackle our health system from outdated paper chains. Let us centre dignity in maternal care. Let us dare to build a system where no woman is turned away for lack of a booklet. Let the exercise book dilemma not be Uganda’s legacy. Let it be the turning point.

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Uganda’s democratic bar has, during the Yoweri Museveni administration’s epochal supretendence, been raised to unprecedented levels rendering several old and new parties on the country’s political canvass failures and unable to cope with the dictates of the political parties and organizations act.
The resumption of political party activities on the canvass after the referendum of 2005 as a consequence of the  enactment of political parties and organizations law, the renaissance of the rule law in 1986 devoid of extrajudicial killings that had dogged the country before plus the bounteous dividends of peace, security and tranquility for the last four decades have all combined to throw off-balance not only Uganda’s independence parties like the UPC and DP but also the fledgling political was nymphs like FDC and NUP.

First, with the current rising political temperatures due to the upcoming election season, several of those nymphs have either sold candidatures for various electoral positions to highest bidders by cobbling together small cabals of oligarchs in party headquarter droughty rooms or appointed family and gullible flag bearers for various electoral offices. By doing so, they have fragrantly flouted the length and breadth of the PPOA provisions.
The NUP for instance is said to have recently convened a secret delegates conference of 120 people to ostensibly rubber stamp Bobi Wine and a couple of others for the top jobs in their nestling party. In an ideal situation, the PPOA provisions would have caught up with that Bwaise-based party.

Secondly, on the other hand the NRM has methodically and in accordance with the PPOA religiously undertaken the pre-primary election processes of democratically registering candidates in preparation for the internal elections for all the echelons of the party as well as the national elections. All these things have been made possible within the NRM thanks to Uganda’s best President since independence, Yoweri Museveni, who has cultivated and buttressed the revered political pedigree and culture that were once practiced during the five year bush war.

The political calculus here is that you can’t give to others what you don’t have; as others merchandise in candidatures, the NRM is the only party that has, conversely, nurtured and grown intra-party democracy in accordance with the law.

Thirdly, all Uganda’s independence parties including the UPC, CP/Kabaka Yeka and DP having initially responded to a stimuli; namely the fight to obtain our independence; their leaderships were largely clueless about planning for the political exigencies of post-independent Uganda; they neither sufficiently grew nor deepened internal democracy amongst their rank and file because they lacked the calculus that the NRM has enjoyed. They have tried to punch above their weight during all past electoral and non-electoral seasons by introducing small doses of democracy and lip servicing the processes thereof to no avail.

They also, for example, didn’t have the dexterity and temerity of juggling global influences vis a vis the always recalcitrant national constituents. The newer parties are not any better; NUP and FDC for example  have had their behavior thoroughly controlled by  the invisible hands of foreign interests; the reason why their leaderships cluelessly gravitate towards western capitals to accuse the NRM whenever the going gets tough here. And because of that the bombastic Ugandan voter has made them pay the hefty political price at every round of polls.

Fourthly, when a juxtaposition is made between the NRM and the other players, one detects a marked difference; whereas the governing party will in due course have its national conference (that will among others stamp its presidential candidate) preceded by its other organs like the national executive committee and the central executive committee, such a sequence of meetings is largely unheard of in Uganda’s opposition parties.

Fifthly, the level of tribalism in Uganda’s opposition parties is unprecedented and it can’t permit the growth of democracy; those parties are tribally based. Whereas the UPC is largely a Lango affair, the NUP and DP have remained Buganda phenomena. Excruciatingly, during the last electoral cycle, many in those parties were heard carelessly throwing around tribal tantrums.

Lastly, when all parties are scale-weighted, the NRM has performed best by respecting the provisions of the PPOA which amongst others stipulate: the 30% women and youth representation  throughout party governance committees, accountability for government funding and parties’ participation in IPOD etc. Some opposition oligarchs have even disavowed the IPOD umbrella by bleating that it’s a “Museveni controlled body.”

Ambassador Henry Mayega

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