Publications by authors named "Elizabeth Ekirapa-Kiracho"

58 Publications

The economic burden of pneumonia in children under five in Uganda.

Vaccine X 2021 Aug 2;8:100095. Epub 2021 Apr 2.

International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, United States.

Background: There were about 138 million new episodes of pneumonia and 0.9 million deaths globally in 2015. In Uganda, pneumonia was the fourth leading cause of death in children under five years of age in 2017-18. However, the economic burden of pneumonia, particularly for households and caregivers, is poorly documented.

Aim: To estimate the costs associated with an episode of pneumonia from the household, government, and societal perspectives.

Methods: We selected 48 healthcare facilities from the public and private sector across all care levels (primary, secondary, and tertiary), based on the number of pneumonia episodes reported for 2015-16. Adult caregivers of children with pneumonia diagnosis at discharge were selected. Using an ingredient-based approach, we collected cost and utilization data from administrative databases, medical records, and patient caregiver surveys. Household costs included direct medical and non-medical costs, as well as indirect costs estimated through a human capital approach. All costs are presented in 2018 U.S. dollars.

Results: The treatment of pneumonia puts a substantial economic burden on households. The average societal cost per episode of pneumonia across all sectors and types of visits was $42; hospitalized episodes costed an average of $62 per episode, while episodes only requiring ambulatory care was $16 per episode. Public healthcare facilities covered $12 and $7 on average per hospitalized or ambulatory episode, respectively. Caregivers using the public system faced lower out-of-pocket payments, evaluated at $17, than those who used private for-profit ($21) and not-for-profit ($50) for hospitalized care. For ambulatory care, out-of-pocket payments amounted to $8, $18, and $9 for public, private for-profit, and not-for-profit healthcare facilities, respectively. About 39% of households experienced catastrophic health expenditures due to out-of-pocket payments related to the treatment of pneumonia.
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http://dx.doi.org/10.1016/j.jvacx.2021.100095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8135046PMC
August 2021

Fitting Health Financing Reforms to Context: Examining the Evolution of Results-Based Financing Models and the Slow National Scale-Up in Uganda (2003-2015).

Glob Health Action 2021 01;14(1):1919393

Department of Health Policy Planning and Management, School of Public Health, Makerere University, Kampala, Uganda.

: Results-based financing has been promoted as an innovative mechanism to improve the performance of health systems in achieving universal health coverage. Several results-based financing models were implemented in Uganda between 2003 and 2015 but with limited national scale-up.: This paper examines the evolution of results-based financing models and the reasons for the slow national adoption and implementation in Uganda.: This was a qualitative study based on document review and key informant interviews. The models were compared to show modifications overtime. The reasons for the slow national scale-up were analyzed using variables from the Diffusion of Innovations Theory.: This study covered seven schemes implemented in the Ugandan health sector between 2003 and 2015. The models evolved in several aspects: 1) donor reliance with fundholding and purchasing delegated to non-state organizations; 2) establishment of ad-hoc structures for learning; 3) recent involvement of the government agencies in verification processes; 4) Involvement of public providers, and 5) expansion of services purchased from the national minimum health-care package. The main reasons for slow national adoption were the perceived complexity and incompatibility with public sector systems. The early phases comprised barriers to public sector reforms. However, recent adjustments to the schemes have enabled greater involvement of public providers and government stewardship. Stakeholders also reported progressive learning across projects and time.: Overall, the study findings show scheme actors' deliberate efforts to adapt their models to the Ugandan health system and public sector context. Results-based financing is a complex intervention that takes time for the capacity to be built among vital actors. Progressive re-designing of models enhances fitness to the health systems context. From this study, we advise that Uganda and similar countries should undertake deliberate efforts to customize such models to the capacity and institutional architecture of their health systems.
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http://dx.doi.org/10.1080/16549716.2021.1919393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8118422PMC
January 2021

Household preferences and willingness to pay for health insurance in Kampala City: a discrete choice experiment.

Cost Eff Resour Alloc 2021 Apr 20;19(1):21. Epub 2021 Apr 20.

Department of Health Policy and Planning, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.

Introduction: Uganda is in discussions to introduce a national health insurance scheme. However, there is a paucity of information on household preferences and willingness to pay for health insurance attributes that may guide the design of an acceptable health insurance scheme. Our study sought to assess household preferences and willingness to pay for health insurance in Kampala city using a discrete choice experiment.

Methods: This study was conducted from 16th February 2020 to 10th April 2020 on 240 households in the Kawempe division of Kampala city stratified into slum and non-slum communities in order to get a representative sample of the area. We purposively selected the communities that represented slum and non-slum communities and thereafter applied systematic sampling in the selection of the households that participated in the study from each of the communities. Four household and policy-relevant attributes were used in the experimental design of the study. Each respondent attended to 9 binary choice sets of health insurance plans that included one fixed choice set. Data were analyzed using mixed logit models.

Results: Households in both the non-slum and slum communities had a high preference for health insurance plans that included both private and public health care providers as compared to plans that included public health care providers only (non-slum coefficient β = 0.81, P < 0.05; slum β = 0.87, p < 0.05) and; health insurance plans that covered extended family members as compared to plans that had limitations on the number of family members allowed (non-slum β = 0.44, P < 0.05; slum β = 0.36, p < 0.05). Households in non-slum communities, in particular, had a high preference for health insurance plans that covered chronic illnesses and major surgeries to other plans (0.97 β, P < 0.05). Our findings suggest that location of the household influences willingness to pay with households from non-slum communities willing to pay more for the preferred attributes.

Conclusion: Potential health insurance schemes should consider including both private and public health care providers and allow more household members to be enrolled in both slum and non-slum communities. However, the inclusion of more HH members should be weighed against the possible depletion of resources and other attributes. Potential health insurance schemes should also prioritize coverage for chronic illnesses and major surgeries in non-slum communities, in particular, to make the scheme attractive and acceptable for these communities.
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http://dx.doi.org/10.1186/s12962-021-00274-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8056698PMC
April 2021

Designing for Scale and taking scale to account: lessons from a community score card project in Uganda.

Int J Equity Health 2021 Jan 11;20(1):31. Epub 2021 Jan 11.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, 21205, Baltimore, MD, United States of America.

Background: Planning for the implementation of community scorecards (CSC) is an important, though seldom documented process. Makerere University School of Public Health (MakSPH) and Future Health Systems Consortium set out to develop and test a sustainable and scalable CSC model. This paper documents the process of planning and adapting the design of the CSC, incorporating key domains of the scalable model such as embeddedness, legitimacy, feasibility and ownership, challenges encountered in this process and how they were mitigated.

Methods: The CSC intervention comprised of five rounds of scoring in five sub counties and one town council of Kibuku district. Data was drawn from ten focus group discussions, seven key informant interviews with local and sub national leaders, and one reflection meeting with the project team from MakSPH. More data was abstracted from notes of six quarterly stakeholder meetings and six quarterly project meetings. Data was analyzed using a thematic approach, drawing constructs outlined in the project's theory of change.

Results: Embeddedness, legitimacy and ownership were promoted through aligning the model with existing processes and systems as well as the meaningful and strategic involvement of stakeholders and leaders at local and sub national level. The challenges encountered included limited technical capacity of stakeholders facilitating the CSC, poor functionality of existing community engagement platforms, and difficulty in promoting community participation without financial incentives. However, these challenges were mitigated through adjustments to the intervention design based on the feedback received.

Conclusion: Governments seeking to scale up CSCs and to take scale to account should keenly adapt existing models to the local implementation context with strategic and meaningful involvement of key legitimate local and sub national leaders in decision making during the design and implementation process. However, they should watch out for elite capture and develop mitigating strategies. Social accountability practitioners should document their planning and adaptive design efforts to share good practices and lessons learned. Enhancing local capacity to implement CSCs should be ensured through use of existing local structures and provision of technical support by external or local partners familiar with the skill until the local partners are competent.
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http://dx.doi.org/10.1186/s12939-020-01367-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802338PMC
January 2021

Estimating the cost of implementing a facility and community score card for maternal and newborn care service delivery in a rural district in Uganda.

Int J Equity Health 2021 Jan 2;20(1). Epub 2021 Jan 2.

Department of Health Policy, Planning, and Management, Makerere University School of Public Health, New Mulago Hospital Complex, P.O. Box 7072, Kampala, Uganda.

Introduction: This paper aimed at estimating the resources required to implement a community Score Card by a typical rural district health team in Uganda, as a mechanism for fostering accountability, utilization and quality of maternal and child healthcare service.

Methods: This costing analysis was done from the payer's perspective using the ingredients approach over five quarterly rounds of scoring between 2017 and 2018. Expenditure data was obtained from project records, entered and analyzed in Microsoft excel. Two scale-up scenarios, scenario one (considered cost inputs by the MakSPH research teams) and scenario two (considering cost inputs based on contextual knowledge from district implementing teams), were simulated to better understand the cost implications of integrating the Community Score Card (CSC) into a district health system.

Results: The total and average cost of implementing CSC for five quarterly rounds over a period of 18 months were USD 59,962 and USD 11,992 per round of scoring, respectively. Considering the six sub-counties (including one Town Council) in Kibuku district that were included in this analysis, the average cost of implementating the CSC in each sub-county was USD 1998 per scoring round. Scaling-up of the intervention across the entire district (included 22 sub-counties) under the first scenario would cost a total of USD 19,003 per scoring round. Under the second scaleup scenario, the cost would be lower at USD 7116. The total annual cost of scaling CSC in the entire district would be USD 76,012 under scenario one compared to USD 28,465 under scenario two. The main cost drivers identified were transportation costs, coordination and supervision costs, and technical support to supplement local implementers.

Conclusion: Our analysis suggests that it is financially feasible to implement and scale-up the CSC initiative, as an accountability tool for enhancing service delivery. However, the CSC design and approach needs to be embedded within local systems and implemented in collaboration with existing stakeholders so as to optimise costs. A comprehensive economic analysis of the costs associated with transportation, involvement of the district teams in coordination, supervision as well as provision of technical support is necessary to determine the cost-effectiveness of the CSC approach.
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http://dx.doi.org/10.1186/s12939-020-01335-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7777411PMC
January 2021

Use of photovoice to explore the potential role of youth in contributing to maternal health in rural Wakiso district, Uganda.

Sex Reprod Health Matters 2020 Dec;28(1):1854152

Senior Lecturer, Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.

Despite youth constituting a large portion of the population in Uganda, their involvement in improving maternal health in their communities has been minimal. This paper explores the potential role of youth in contributing to maternal health in rural communities in Wakiso district, Uganda using photovoice. Photovoice was used as a community-based participatory research method among 10 youth (5 males and 5 females) over a period of 5 months. The photos taken by the youth were discussed in monthly meetings, and emerging data was analysed using thematic content analysis. Four themes emerged regarding how youth can contribute to improving maternal health in their communities. These themes were: community health education; advocacy for health improvement; community voluntary work; and being exemplary. The fifth and final theme provides the avenues, including drama and sports, that the youth suggested they could use for conveying messages to the community concerning maternal and general health. Health education on topics such as the importance of delivering at health facilities was emphasised. Regarding advocacy, the youth said they can be involved in reaching out to various stakeholders to raise concerns affecting maternal health. Voluntary work such as construction of energy stoves for pregnant women emerged. The youth also highlighted that they could be exemplary for instance by males accompanying their spouses during antenatal visits. With the need to continuously engage community actors in health initiatives, youth should be considered and supported as important stakeholders so they may engage in activities to improve health within their communities.
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http://dx.doi.org/10.1080/26410397.2020.1854152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7888067PMC
December 2020

Influence of community scorecards on maternal and newborn health service delivery and utilization.

Int J Equity Health 2020 11 2;19(1):145. Epub 2020 Nov 2.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.

Introduction: The community score card (CSC) is a participatory monitoring and evaluation tool that has been employed to strengthen the mutual accountability of health system and community actors. In this paper we describe the influence of the CSC on selected maternal and newborn service delivery and utilization indicators.

Methods: This was a mixed methods study that used both quantitative and qualitative data collection methods. It was implemented in five sub-counties and one town council in Kibuku district in Uganda. Data was collected through 17 key informant interviews and 10 focus group discussions as well as CSC scoring and stakeholder meeting reports. The repeated measures ANOVA test was used to test for statistical significance. Qualitative data was analyzed manually using content analysis. The analysis about the change pathways was guided by the Wild and Harris dimensions of change framework.

Results: There was an overall improvement in the common indicators across sub-counties in the project area between the 1st and 5th round scores. Almost all the red scores had changed to green or yellow by round five except for availability of drugs and mothers attending Antenatal care (ANC) in the first trimester. There were statistically significant differences in mean scores for men escorting their wives for ante natal care (ANC) (F(4,20) = 5.45, P = 0.01), availability of midwives (F(4,16) =5.77, P < 0.01), availability of delivery beds (F(4,12) =9.00, P < 0.01) and mothers delivering from traditional birth attendants (TBAs), F(4,16) = 3.86, p = 0.02). The qualitative findings suggest that strengthening of citizens' demand, availability of resources through collaborative problem solving, increased awareness about targeted maternal health services and increased top down performance pressure contributed to positive changes as perceived by community members and their leaders.

Conclusions And Recommendations: The community score cards created opportunities for community leaders and communities to work together to identify innovative ways of dealing with the health service delivery and utilization challenges that they face. Local leaders should encourage the availability of safe spaces for dialogue between communities, health workers and leaders where performance and utilization challenges can be identified and solutions proposed and implemented jointly.
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http://dx.doi.org/10.1186/s12939-020-01184-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7604954PMC
November 2020

The economic burden of measles in children under five in Uganda.

Vaccine X 2020 Dec 9;6:100077. Epub 2020 Sep 9.

International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, United States.

Background: There is very limited evidence about the economic cost of measles in low-income countries. We estimated the cost of treating measles in Uganda from a societal perspective.

Methods: We conducted an incidence-based cost-of-illness study in Uganda. We surveyed the facility staff, recording hospital-related expenditures for measles patients. We interviewed caregivers of children with measles at 48 selected healthcare facilities. We conducted phone interviews with caregivers 7-14 days post-discharge to capture additional out-of-pocket expenses and time costs.

Results: From a societal perspective, a hospitalized and an ambulatory episode of measles cost 2018 US$ 60 and $15, respectively. The government spent on average $12 and $5 per hospitalized and ambulatory episode of measles. Including both public and private facilities, caregivers incurred approximately $44 in economic costs, including $23 in out-of-pocket expenses. In 2018, 2614 cases of measles were confirmed, resulting in $135,627 in societal costs, including $59,357 in economic costs to Ugandan households.

Conclusion: This cost-of-illness study is the first to use empirical methods to quantify the economic burden of measles in a low-income country. Information related to the cost of treating measles is important for guiding decisions related to changes in measles control and prevention.
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http://dx.doi.org/10.1016/j.jvacx.2020.100077DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7548439PMC
December 2020

Ethical practice in my work: community health workers' perspectives using photovoice in Wakiso district, Uganda.

BMC Med Ethics 2020 08 3;21(1):68. Epub 2020 Aug 3.

Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.

Background: Health service delivery should ensure ethical principles are observed at all levels of healthcare. Working towards this goal requires understanding the ethics-related priorities and concerns in the day-to-day activities among different health practitioners. These practitioners include community health workers (CHWs) who are involved in healthcare delivery in communities in many low-and middle-income countries such as Uganda. In this study, we used photovoice, an innovative community based participatory research method that uses photography, to examine CHWs' perspectives on ethical concerns in their work.

Methods: We explored perspectives of 10 CHWs (5 females and 5 males) on ethical dimensions of their work for 5 months using photovoice in a rural community in Wakiso district, Uganda. As part of the study, we: 1. Oriented CHWs on photovoice research and ethics; 2. Asked CHWs to take photographs of key ethical dimensions of their work; 3. Held monthly meetings to discuss and reflect on the photos; and 4. Disseminated the findings. The discussions from the monthly meetings were audio recorded, transcribed, and emerging data analysed using conventional content analysis with the help of Atlas ti version 6.0.15.

Results: CHWs were aware of and highly concerned about the need to observe ethical principles while carrying out their roles. The ethical principles CHWs were aware of and endeavoured to observe during their work were: maintaining professional integrity and abiding by ethical principles of practice; ethical responsibility in patient care; maintaining confidentiality while handling clients; respect for persons and communities; and enhancing their knowledge and skills for better practice. However, CHWs also identified challenges concerning their observance of ethical principles including: low commitment to their work due to other obligations; availability of some reference materials and guidelines in English yet majority could only read in the local language; and minimal avenues for knowledge enhancement such as trainings.

Conclusions: CHWs were aware of and keen to discuss ethical issues in their work. However, there is need to address the challenges they face so as to facilitate observing ethical principles during the course of their work in communities.
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http://dx.doi.org/10.1186/s12910-020-00505-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7397610PMC
August 2020

Operationalising kangaroo Mother care before stabilisation amongst low birth Weight Neonates in Africa (OMWaNA): protocol for a randomised controlled trial to examine mortality impact in Uganda.

Trials 2020 Jan 31;21(1):126. Epub 2020 Jan 31.

Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.

Background: There are 2.5 million neonatal deaths each year; the majority occur within 48 h of birth, before stabilisation. Evidence from 11 trials shows that kangaroo mother care (KMC) significantly reduces mortality in stabilised neonates; however, data on its effect among neonates before stabilisation are lacking. The OMWaNA trial aims to determine the effect of initiating KMC before stabilisation on mortality within seven days relative to standard care. Secondary objectives include exploring pathways for the intervention's effects and assessing incremental costs and cost-effectiveness between arms.

Methods: We will conduct a four-centre, open-label, individually randomised, superiority trial in Uganda with two parallel groups: an intervention arm allocated to receive KMC and a control arm receiving standard care. We will enrol 2188 neonates (1094 per arm) for whom the indication for KMC is 'uncertain', defined as receiving ≥ 1 therapy (e.g. oxygen). Admitted singleton, twin and triplet neonates (triplet if demise before admission of ≥ 1 baby) weighing ≥ 700-≤ 2000 g and aged ≥ 1-< 48 h are eligible. Treatment allocation is random in a 1:1 ratio between groups, stratified by weight and recruitment site. The primary outcome is mortality within seven days. Secondary outcomes include mortality within 28 days, hypothermia prevalence at 24 h, time from randomisation to stabilisation or death, admission duration, time from randomisation to exclusive breastmilk feeding, readmission frequency, daily weight gain, infant-caregiver attachment and women's wellbeing at 28 days. Primary analyses will be by intention-to-treat. Quantitative and qualitative data will be integrated in a process evaluation. Cost data will be collected and used in economic modelling.

Discussion: The OMWaNA trial aims to assess the effectiveness of KMC in reducing mortality among neonates before stabilisation, a vulnerable population for whom its benefits are uncertain. The trial will improve understanding of pathways underlying the intervention's effects and will be among the first to rigorously compare the incremental cost and cost-effectiveness of KMC relative to standard care. The findings are expected to have broad applicability to hospitals in sub-Saharan Africa and southern Asia, where three-quarters of global newborn deaths occur, as well as important policy and programme implications.

Trial Registration: ClinicalTrials.gov, NCT02811432. Registered on 23 June 2016.
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http://dx.doi.org/10.1186/s13063-019-4044-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6995072PMC
January 2020

Dietary patterns and practices in rural eastern Uganda: Implications for prevention and management of type 2 diabetes.

Appetite 2019 12 22;143:104409. Epub 2019 Aug 22.

Department of Public Health Sciences Karolinska Institutet, Stockholm, Sweden; Dept. of Food, Nutrition and Dietetics, Uppsala University, Uppsala, Sweden; Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.

Background: The burden of type 2 diabetes in Sub-Saharan Africa is projected to double by 2040, partly attributable to rapidly changing diets. In this paper, we analysed how community members in rural Uganda understood the concept of a healthy or unhealthy diet, food preparation and serving practices to inform the process of facilitating knowledge and skill necessary for self-management and care for type 2 diabetes. This was a qualitative study involving 20 focus group discussions and eight in-depth interviews among those at risk, patients with type 2 diabetes and the general community members without diabetes mellitus. Data was coded and entered into Atlas ti version 7.5.12 and interpreted using thematic analysis. We identified three main themes, which revealed, the perceptions on food and diet concerning health; the social dimensions of food and influence on diet practices; and food as a gendered activity. Participants noted that eating and cooking practices resulted in unhealthy diets. Their practices were affected by beliefs, poverty and food insecurity. Women determined which foods to prepare, but men prepared only some of the foods such as delicacies like a rice dish "pilau." New commercial and processed foods were increasingly available and consumed even in rural areas. Participants linked signs and symptoms of illness to diet as they narrated changes from past to current food preparation behaviours. Their view of overweight and obesity was also gendered and linked to social status. Participants' perception of disease influenced by diet was similar among those with and without type 2 diabetes, and those at risk. People described what is a healthy diet was as recommended by the health workers, but stated that their practices differed greatly from their knowledge. There was high awareness about healthy and balanced diets, but food is entrenched within social and gendered paradigms, which are slowly changing. Social and gender dimensions of food will need to be addressed through interventions in communities to promote change on a society level.
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http://dx.doi.org/10.1016/j.appet.2019.104409DOI Listing
December 2019

Applying the model of diffusion of innovations to understand facilitators for the implementation of maternal and neonatal health programmes in rural Uganda.

Global Health 2019 06 13;15(1):38. Epub 2019 Jun 13.

Department of Health Policy, Planning and Management, Makerere University School of Public Health, New Mulago Complex, Kampala, Uganda.

In Uganda, more than 336 out of every 100,000 women die annually during childbirth. Pregnant women, particularly in rural areas, often lack the financial resources and means to access health facilities in a timely manner for quality antenatal, delivery, and post-natal services. For nearly the past decade, the Makerere University School of Public Health researchers, through various projects, have been spearheading innovative interventions, embedded in implementation research, to reduce barriers to access to care. In this paper, we describe two of projects that were initially conceived to tackle the financial barriers to access to care - through a voucher program in the community - on the demand side - and a series of health systems strengthening activities at the district and facility level - on the supply side. Over time, the projects diverged in the content of the intervention and the modality in which they were implemented, providing an opportunity for reflection on innovation and scaling up. In this short report, we used an adaptation of Greenhalgh's Model of Diffusion to reflect on these projects' approaches to implementing innovative interventions, with the ultimate goal of reducing maternal and neonatal mortality in rural Uganda. We found that the adapted model of diffusion of innovations facilitated the emergence of insights on barriers and facilitators to the implementation of health systems interventions. Health systems research projects would benefit from analyses beyond the implementation period, in order to better understand how adoption and diffusion happen, or not, over time, after the external catalyst departs.
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http://dx.doi.org/10.1186/s12992-019-0483-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6567581PMC
June 2019

Reflecting strategic and conforming gendered experiences of community health workers using photovoice in rural Wakiso district, Uganda.

Hum Resour Health 2018 08 22;16(1):41. Epub 2018 Aug 22.

University of the Western Cape, Cape Town, South Africa.

Background: Community health workers (CHWs) are an important human resource in Uganda as they are the first contact of the population with the health system. Understanding gendered roles of CHWs is important in establishing how they influence their performance and relationships in communities. This paper explores the differential roles of male and female CHWs in rural Wakiso district, Uganda, using photovoice, an innovative community-based participatory research approach.

Methods: We trained ten CHWs (five males and five females) on key concepts about gender and photovoice. The CHWs took photographs for 5 months on their gender-related roles which were discussed in monthly meetings. The discussions from the meetings were recorded, transcribed, and translated to English, and emerging data were analysed using content analysis in Atlas ti version 6.0.15.

Results: Although responsibilities were the same for both male and female CHWs, they reported that in practice, CHWs were predominantly involved in different types of work depending on their gender. Social norms led to men being more comfortable seeking care from male CHWs and females turning to female CHWs. Due to their privileged ownership and access to motorcycles, male CHWs were noted to be able to assist patients faster with referrals to facilities during health emergencies, cover larger geographic distances during community mobilization activities, and take up supervisory responsibilities. Due to the gendered division of labour in communities, male CHWs were also observed to be more involved in manual work such as cleaning wells. The gendered division of labour also reinforced female caregiving roles related to child care, and also made female CHWs more available to address local problems.

Conclusions: CHWs reflected both strategic and conformist gendered implications of their community work. The differing roles and perspectives about the nature of male and female CHWs while performing their roles should be considered while designing and implementing CHW programmes, without further retrenching gender inequalities or norms.
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http://dx.doi.org/10.1186/s12960-018-0306-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6104020PMC
August 2018

Private retail drug shops: what they are, how they operate, and implications for health care delivery in rural Uganda.

BMC Health Serv Res 2018 07 9;18(1):532. Epub 2018 Jul 9.

Department of Community Health and Behavioral Sciences, Makerere University School of Public Health, PO Box 7072, Kampala, Uganda.

Background: Retail drug shops play a significant role in managing pediatric fevers in rural areas in Uganda. Targeted interventions to improve drug seller practices require understanding of the retail drug shop market and motivations that influence practices. This study aimed at describing the operational environment in relation to the Uganda National Drug Authority guidelines for setup of drug shops; characteristics, and dispensing practices of private retail drug shops in managing febrile conditions among under-five children in rural western Uganda.

Methods: Cross sectional survey of 74 registered drug shops, observation checklist, and 428 exit interviews using a semi-structured questionnaire with care-seekers of children under five years of age, who sought care at drug shops during the survey period. The survey was conducted in Mbarara and Bushenyi districts, South Western Uganda, in May 2013.

Results: Up to 90 and 79% of surveyed drug shops in Mbarara and Bushenyi, largely operate in premises that meet National Drug Authority requirements for operational suitability and ensuring medicines safety and quality. Drug shop attendants had some health or medical related training with 60% in Mbarara and 59% in Bushenyi being nurses or midwives. The rest were clinical officers, pharmacists. The most commonly stocked medicines at drug shops were Paracetamol, Quinine, Cough syrup, ORS/Zinc, Amoxicillin syrup, Septrin® syrup, Artemisinin-based combination therapies, and multivitamins, among others. Decisions on what medicines to stock were influenced by among others: recommended medicines from Ministry of Health, consumer demand, most profitable medicines, and seasonal disease patterns. Dispensing decisions were influenced by: prescriptions presented by client, patients' finances, and patient preferences, among others. Most drug shops surveyed had clinical guidelines, iCCM guidelines, malaria and diarrhea treatment algorithms and charts as recommended by the Ministry of Health. Some drug shops offered additional services such as immunization and sold non-medical goods, as a mechanism for diversification.

Conclusion: Most drug shops premises adhered to the recommended guidelines. Market factors, including client demand and preferences, pricing and profitability, and seasonality largely influenced dispensing and stocking practices. Improving retail drug shop practices and quality of services, requires designing and implementing both supply-side and demand side strategies.
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http://dx.doi.org/10.1186/s12913-018-3343-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6038354PMC
July 2018

Elements for harnessing participatory action research to strengthen health managers' capacity: a critical interpretative synthesis.

Health Res Policy Syst 2018 Apr 19;16(1):33. Epub 2018 Apr 19.

Sociology Department, Umeå University, 901 87, Umeå, Sweden.

Background: Health managers play a key role in ensuring that health services are responsive to the needs of the population. Participatory action research (PAR) is one of the approaches that have been used to strengthen managers' capacity. However, collated knowledge on elements for harnessing PAR to strengthen managers' capacity is missing. This paper bridges this gap by reviewing existing literature on the subject matter.

Methods: A critical interpretive synthesis method was used to interrogate eight selected articles. These articles reported the use of PAR to strengthen health managers' capacity. The critical interpretive synthesis method's approach to analysis guided the synthesis. Here, the authors interpretively made connections and linkages between different elements identified in the literature. Finally, the Atun et al. (Heal Pol Plann, 25:104-111, 2010) framework on integration was used to model the elements synthesised in the literature into five main domains.

Results: Five elements with intricate bi-directional interactions were identified in the literature reviewed. These included a shared purpose, skilled facilitation and psychological safety, activity integration into organisational procedures, organisational support, and external supportive monitoring. A shared purpose of the managers' capacity strengthening initiative created commitment and motivation to learn. This purpose was built upon a set of facilitation skills that included promoting participation, self-efficacy and reflection, thereby creating a safe psychological space within which the managers interacted and learnt from each other and their actions. Additionally, an integrated intervention strengthened local capacity and harnessed organisational support for learning. Finally, supportive monitoring from external partners, such as researchers, ensured quality, building of local capacity and professional safety networks essential for continued learning.

Conclusions: The five elements identified in this synthesis provide a basis upon which the use of PAR can be harnessed, not only to strengthen health managers' capacity, but also to foster other health systems strengthening initiatives involving implementation research. In addition, the findings demonstrated the intricate and complex relations between the elements, which further affirms the need for a systems thinking approach to tackling health systems challenges.
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http://dx.doi.org/10.1186/s12961-018-0306-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5907405PMC
April 2018

Study protocol for the SMART2D adaptive implementation trial: a cluster randomised trial comparing facility-only care with integrated facility and community care to improve type 2 diabetes outcomes in Uganda, South Africa and Sweden.

BMJ Open 2018 03 17;8(3):e019981. Epub 2018 Mar 17.

Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.

Introduction: Type 2 diabetes (T2D) is increasingly contributing to the global burden of disease. Health systems in most parts of the world are struggling to diagnose and manage T2D, especially in low-income and middle-income countries, and among disadvantaged populations in high-income countries. The aim of this study is to determine the added benefit of community interventions onto health facility interventions, towards glycaemic control among persons with diabetes, and towards reduction in plasma glucose among persons with prediabetes.

Methods And Analysis: An adaptive implementation cluster randomised trial is being implemented in two rural districts in Uganda with three clusters per study arm, in an urban township in South Africa with one cluster per study arm, and in socially disadvantaged suburbs in Stockholm, Sweden with one cluster per study arm. Clusters are communities within the catchment areas of participating primary healthcare facilities. There are two study arms comprising a facility plus community interventions arm and a facility-only interventions arm. Uganda has a third arm comprising usual care. Intervention strategies focus on organisation of care, linkage between health facility and the community, and strengthening patient role in self-management, community mobilisation and a supportive environment. Among T2D participants, the primary outcome is controlled plasma glucose; whereas among prediabetes participants the primary outcome is reduction in plasma glucose.

Ethics And Dissemination: The study has received approval in Uganda from the Higher Degrees, Research and Ethics Committee of Makerere University School of Public Health and from the Uganda National Council for Science and Technology; in South Africa from the Biomedical Science Research Ethics Committee of the University of the Western Cape; and in Sweden from the Regional Ethical Board in Stockholm. Findings will be disseminated through peer-reviewed publications and scientific meetings.

Trial Registration Number: ISRCTN11913581; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2017-019981DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5879646PMC
March 2018

Participatory monitoring and evaluation approaches that influence decision-making: lessons from a maternal and newborn study in Eastern Uganda.

Health Res Policy Syst 2017 Dec 28;15(Suppl 2):107. Epub 2017 Dec 28.

Department of International Health, Johns Hopkins University School of Public Health, Baltimore, MD, United States of America.

Background: The use of participatory monitoring and evaluation (M&E) approaches is important for guiding local decision-making, promoting the implementation of effective interventions and addressing emerging issues in the course of implementation. In this article, we explore how participatory M&E approaches helped to identify key design and implementation issues and how they influenced stakeholders' decision-making in eastern Uganda.

Method: The data for this paper is drawn from a retrospective reflection of various M&E approaches used in a maternal and newborn health project that was implemented in three districts in eastern Uganda. The methods included qualitative and quantitative M&E techniques such as  key informant interviews, formal surveys and supportive supervision, as well as participatory approaches, notably participatory impact pathway analysis.

Results: At the design stage, the M&E approaches were useful for identifying key local problems and feasible local solutions and informing the activities that were subsequently implemented. During the implementation phase, the M&E approaches provided evidence that informed decision-making and helped identify emerging issues, such as weak implementation by some village health teams, health facility constraints such as poor use of standard guidelines, lack of placenta disposal pits, inadequate fuel for the ambulance at some facilities, and poor care for low birth weight infants. Sharing this information with key stakeholders prompted them to take appropriate actions. For example, the sub-county leadership constructed placenta disposal pits, the district health officer provided fuel for ambulances, and health workers received refresher training and mentorship on how to care for newborns.

Conclusion: Diverse sources of information and perspectives can help researchers and decision-makers understand and adapt evidence to contexts for more effective interventions. Supporting districts to have crosscutting, routine information generating and sharing platforms that bring together stakeholders from different sectors is therefore crucial for the successful implementation of complex development interventions.
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http://dx.doi.org/10.1186/s12961-017-0274-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5751403PMC
December 2017

Using Theories of Change to inform implementation of health systems research and innovation: experiences of Future Health Systems consortium partners in Bangladesh, India and Uganda.

Health Res Policy Syst 2017 Dec 28;15(Suppl 2):109. Epub 2017 Dec 28.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, United States of America.

Background: The Theory of Change (ToC) is a management and evaluation tool supporting critical thinking in the design, implementation and evaluation of development programmes. We document the experience of Future Health Systems (FHS) Consortium research teams in Bangladesh, India and Uganda with using ToC. We seek to understand how and why ToCs were applied and to clarify how they facilitate the implementation of iterative intervention designs and stakeholder engagement in health systems research and strengthening.

Methods: This paper combines literature on ToC, with a summary of reflections by FHS research members on the motivation, development, revision and use of the ToC, as well as on the benefits and challenges of the process. We describe three FHS teams' experiences along four potential uses of ToCs, namely planning, communication, learning and accountability.

Results: The three teams developed ToCs for planning and evaluation purposes as required for their initial plans for FHS in 2011 and revised them half-way through the project, based on assumptions informed by and adjusted through the teams' experiences during the previous 2 years of implementation. All teams found that the revised ToCs and their accompanying narratives recognised greater feedback among intervention components and among key stakeholders. The ToC development and revision fostered channels for both internal and external communication, among research team members and with key stakeholders, respectively. The process of revising the ToCs challenged the teams' initial assumptions based on new evidence and experience. In contrast, the ToCs were only minimally used for accountability purposes.

Conclusions: The ToC development and revision process helped FHS research teams, and occasionally key local stakeholders, to reflect on and make their assumptions and mental models about their respective interventions explicit. Other projects using the ToC should allow time for revising and reflecting upon the ToCs, to recognise and document the adaptive nature of health systems, and to foster the time, space and flexibility that health systems strengthening programmes must have to learn from implementation and stakeholder engagement.
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http://dx.doi.org/10.1186/s12961-017-0272-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5751673PMC
December 2017

Strengthening scaling up through learning from implementation: comparing experiences from Afghanistan, Bangladesh and Uganda.

Health Res Policy Syst 2017 Dec 28;15(Suppl 2):108. Epub 2017 Dec 28.

Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.

Background: Many effective innovations and interventions are never effectively scaled up. Implementation research (IR) has the promise of supporting scale-up through enabling rapid learning about the intervention and its fit with the context in which it is implemented. We integrate conceptual frameworks addressing different dimensions of scaling up (specifically, the attributes of the service or innovation being scaled, the actors involved, the context, and the scale-up strategy) and questions commonly addressed by IR (concerning acceptability, appropriateness, adoption, feasibility, fidelity to original design, implementation costs, coverage and sustainability) to explore how IR can support scale-up.

Methods: We draw upon three IR studies conducted by Future Health Systems (FHS) in Afghanistan, Bangladesh and Uganda. We reviewed project documents from the period 2011-2016 to identify information related to the dimensions of scaling up. Further, for each country, we developed rich descriptions of how the research teams approached scaling up, and how IR contributed to scale-up. The rich descriptions were checked by FHS research teams. We identified common patterns and differences across the three cases.

Results: The three cases planned quite different innovations/interventions and had very different types of scale-up strategies. In all three cases, the research teams had extensive prior experience within the study communities, and little explicit attention was paid to contextual factors. All three cases involved complex interactions between the research teams and other stakeholders, among stakeholders, and between stakeholders and the intervention. The IR planned by the research teams focussed primarily on feasibility and effectiveness, but in practice, the research teams also had critical insights into other factors such as sustainability, acceptability, cost-effectiveness and appropriateness. Stakeholder analyses and other project management tools further complemented IR.

Conclusions: IR can provide significant insights into how best to scale-up a particular intervention. To take advantage of insights from IR, scale-up strategies require flexibility and IR must also be sufficiently flexible to respond to new emerging questions. While commonly used conceptual frameworks for scale-up clearly delineate actors, such as implementers, target communities and the support team, in our experience, IR blurred the links between these groups.
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http://dx.doi.org/10.1186/s12961-017-0270-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5751808PMC
December 2017

A participatory action research approach to strengthening health managers' capacity at district level in Eastern Uganda.

Health Res Policy Syst 2017 Dec 28;15(Suppl 2):110. Epub 2017 Dec 28.

Makerere University School of Public Health (MakSPH), Makerere University, New Mulago Complex, P.O. B0X 7072, Kampala, Uganda.

Background: Many approaches to improving health managers' capacity in poor countries, particularly those pursued by external agencies, employ non-participatory approaches and often seek to circumvent (rather than strengthen) weak public management structures. This limits opportunities for strengthening local health managers' capacity, improving resource utilisation and enhancing service delivery. This study explored the contribution of a participatory action research approach to strengthening health managers' capacity in Eastern Uganda.

Methods: This was a qualitative study that used open-ended key informant interviews, combined with review of meeting minutes and observations to collect data. Both inductive and deductive thematic analysis was undertaken. The Competing Values Framework of organisational management functions guided the deductive process of analysis and the interpretation of the findings. The framework builds on four earlier models of management and regards them as complementary rather than conflicting, and identifies four managers' capacities (collaborate, create, compete and control) by categorising them along two axes, one contrasting flexibility versus control and the other internal versus external organisational focus.

Results: The findings indicate that the participatory action research approach enhanced health managers' capacity to collaborate with others, be creative, attain goals and review progress. The enablers included expanded interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability. Tension and conflict across different management functions was apparent; for example, while there was a need to collaborate, maintaining control over processes was also needed. These tensions meant that managers needed to learn to simultaneously draw upon and use different capacities as reflected by the Competing Values Framework in order to maximise their effectiveness.

Conclusions: Improved health manager capacity is essential if sustained improvements in health outcomes in low-income countries are to be attained. The expansion of interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability were the key means by which participatory action research strengthened health managers' capacity. The participatory approach to implementation therefore created opportunities to strengthen health managers' capacity.
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http://dx.doi.org/10.1186/s12961-017-0273-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5751402PMC
December 2017

Engaging stakeholders: lessons from the use of participatory tools for improving maternal and child care health services.

Health Res Policy Syst 2017 Dec 28;15(Suppl 2):106. Epub 2017 Dec 28.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, United States of America.

Background: Effective stakeholder engagement in research and implementation is important for improving the development and implementation of policies and programmes. A varied number of tools have been employed for stakeholder engagement. In this paper, we discuss two participatory methods for engaging with stakeholders - participatory social network analysis (PSNA) and participatory impact pathways analysis (PIPA). Based on our experience, we derive lessons about when and how to apply these tools.

Methods: This paper was informed by a review of project reports and documents in addition to reflection meetings with the researchers who applied the tools. These reports were synthesised and used to make thick descriptions of the applications of the methods while highlighting key lessons.

Results: PSNA and PIPA both allowed a deep understanding of how the system actors are interconnected and how they influence maternal health and maternal healthcare services. The findings from the PSNA provided guidance on how stakeholders of a health system are interconnected and how they can stimulate more positive interaction between the stakeholders by exposing existing gaps. The PIPA meeting enabled the participants to envision how they could expand their networks and resources by mentally thinking about the contributions that they could make to the project. The processes that were considered critical for successful application of the tools and achievement of outcomes included training of facilitators, language used during the facilitation, the number of times the tool is applied, length of the tools, pretesting of the tools, and use of quantitative and qualitative methods.

Conclusions: Whereas both tools allowed the identification of stakeholders and provided a deeper understanding of the type of networks and dynamics within the network, PIPA had a higher potential for promoting collaboration between stakeholders, likely due to allowing interaction between them. Additionally, it was implemented within a participatory action research project. PIPA also allowed participatory evaluation of the project from the perspective of the community. This paper provides lessons about the use of these participatory tools.
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http://dx.doi.org/10.1186/s12961-017-0271-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5751791PMC
December 2017

Gender dynamics affecting maternal health and health care access and use in Uganda.

Health Policy Plan 2017 Dec;32(suppl_5):v13-v21

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Despite its reduction over the last decade, the maternal mortality rate in Uganda remains high, due to in part a lack of access to maternal health care. In an effort to increase access to care, a quasi-experimental trial using vouchers was implemented in Eastern Uganda between 2009 and 2011. Findings from the trial reported a dramatic increase in pregnant women's access to institutional delivery. Sustainability of such interventions, however, is an important challenge. While such interventions are able to successfully address immediate access barriers, such as lack of financial resources and transportation, they are reliant on external resources to sustain them and are not designed to address the underlying causes contributing to women's lack of access, including those related to gender. In an effort to examine ways to sustain the intervention beyond external financial resources, project implementers conducted a follow-up qualitative study to explore the root causes of women's lack of maternal health care access and utilization. Based on emergent findings, a gender analysis of the data was conducted to identify key gender dynamics affecting maternal health and maternal health care. This paper reports the key gender dynamics identified during the analysis, by detailing how gender power relations affect maternal health care access and utilization in relation to: access to resources; division of labour, including women's workload during and after pregnancy and lack of male involvement at health facilities; social norms, including perceptions of women's attitudes and behaviour during pregnancy, men's attitudes towards fatherhood, attitudes towards domestic violence, and health worker attitudes and behaviour; and decision-making. It concludes by discussing the need for integrating gender into maternal health care interventions if they are to address the root causes of barriers to maternal health access and utilization and improve access to and use of maternal health care in the long term.
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http://dx.doi.org/10.1093/heapol/czx011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5886085PMC
December 2017

Persisting demand and supply gap for maternal and newborn care in eastern Uganda: a mixed-method cross-sectional study.

Reprod Health 2017 Oct 24;14(1):136. Epub 2017 Oct 24.

Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.

Background: The slow progress in reducing maternal and newborn death in low and middle-income countries is attributed to both demand and supply-side factors. This study assessed the changes in maternal and newborn services in health facilities as well as demand for maternal and newborn health services in Eastern Uganda.

Methods: The health assessment data were collected in August 2013 and September 2015 in the districts of Kamuli, Pallisa, and Kibuku. We purposively collected data on the availability of services from 40 health facilities that provided maternal and newborn services. In addition, we conducted 24 focus group discussions (FGDs) with women and men; and 18 key informant interviews (KIs) with health workers.

Results: On the supply side, most health facilities persistently lacked lifesaving medicines such as misoprostol, IV Ampicillin, IV Gentamycin, IV Metronidazole, Magnesium Sulphate, Ergometrine, Corticosteroids, ferrous Sulphate, Folic Acid, Combined ferrous, Benzyl penicillin, and Diazepam (IM or IV). Basic newborn equipment such as stethoscope, fetal scope, working baby scale, newborn suction devices, newborn resuscitation device, and thermometer were persistently not available in most of the health facilities. Binders for Kangaroo Mother Care, blanket to wrap newborn, baby warmer or heat lamp were persistently not available in at least 80% of the health facilities. Other equipment for the management of labor and abortions such as Manual vacuum aspirator for abortion care, blank partographs and vacuum extractor were not available in most of the health facilities including referral facilities at baseline and follow-up. On the demand side, the qualitative interviews exposed long distances and inadequate transport to the health facilities, inadequate information, poverty, and poor services at the health facilities as major factors that impede women to utilize/access maternal and newborn services.

Conclusion: There are distinct influences on both demand and supply side, which restrain both health care uptake and its quality. The frequent disparity between the health facility readiness to provide services and the women readiness to utilize them needs to be addressed as the country intensifies its efforts to reduce maternal and newborn deaths through boosting facility deliveries.
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http://dx.doi.org/10.1186/s12978-017-0402-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5655951PMC
October 2017

Uganda Newborn Study (UNEST) trial: Community-based maternal and newborn care economic analysis.

Health Policy Plan 2017 Oct;32(suppl_1):i42-i52

Health Systems Research Unit, Medical Research Council, Cape Town, South Africa.

The Uganda Newborn Study (UNEST) was a two-arm cluster Randomized Control Trial to study the effect of pregnancy and postnatal home visits by local community health workers called 'Village Health Teams' (VHT) coupled with health systems strengthening. To inform programme planning and decision making, additional economic and financial costs of community and facility components were estimated from the perspective of the provider using the Excel-based Cost of Integrating Newborn Care Tool. Additional costs excluded costs already paid by the government for the routine health system and covered design, set-up, and 1-year implementation phases. Improved efficiency was modelled by reducing the number of VHT per village from two to one and varying the number of home visits/mother, the programme's financial cost at scale was projected (population of 100 000). 92% of expectant mothers (n = 1584) in the intervention area were attended by VHTs who performed an average of three home visits per mother. The annualized additional financial cost of the programme was $83 360 of which 4% ($3266) was for design, 24% ($20 026) for set-up and 72% ($60 068) for implementation. 56% ($47 030) went towards health facility strengthening, whereas 44% ($36 330) was spent at the community level. The average cost/mother for the community programme, excluding one-off design costs, amounted to $22.70 and the average cost per home visit was $7.50. The additional cost of the preventive home visit programme staffed by volunteer VHTs represents $1.04 per capita, 1.8% of Uganda's public health expenditure per capita ($59.00). If VHTs were to spend an average of 6 h a week on the programme, costs per mother would drop to $13.00 and cost per home visit to $3.20, in a population of 100 000 at 95% coverage. Additional resources are needed to rollout the government's VHT strategy nationally, maintaining high quality and linkages to quality facility-based care.
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http://dx.doi.org/10.1093/heapol/czw092DOI Listing
October 2017

Effect of a participatory multisectoral maternal and newborn intervention on maternal health service utilization and newborn care practices: a quasi-experimental study in three rural Ugandan districts.

Glob Health Action 2017 Aug;10(sup4):1363506

a Department of Health Policy Planning and Management , Makerere University School of Public Health , Kampala , Uganda.

Background: The MANIFEST study in eastern Uganda employed a participatory multisectoral approach to reduce barriers to access to maternal and newborn care services.

Objectives: This study analyses the effect of the intervention on the utilization of maternal and newborn services and care practices.

Methods: The quasi-experimental pre- and post-comparison design had two main components: community mobilization and empowerment, and health provider capacity building. The primary outcomes were utilization of antenatal care (ANC), delivery and postnatal care, and newborn care practices. Baseline (n = 2237) and endline (n = 1946) data were collected from women of reproductive age. The  data was analysed using difference in differences (DiD) analysis and  logistic regression.

Results: The DiD results revealed an 8% difference in early ANC attendance (p < 0.01) and facility delivery (p < 0.01). Facility delivery increased from 66% to 73% in the intervention area, but remained unchanged in the comparison area (64% vs 63%, p < 0.01). The DiD results also demonstrated a 20% difference in clean cord care (p < 0.001) and an 8% difference in delayed bathing (p < 0.001). The intervention elements that predicted facility delivery were attending ANC four times [adjusted odds ratio (aOR) 1.42, 95% confidence interval (CI) 1.17-1.74] and saving for maternal health (aOR 2.11, 95% CI 1.39-3.21). Facility delivery and village health team (VHT) home visits were key predictors for clean cord care and skin-to-skin care.

Conclusions: The multisectoral approach had positive effects on early ANC attendance, facility deliveries and newborn care practices. Community resources such as VHTs and savings are crucial to maternal and newborn outcomes and should be supported. VHT-led health education should incorporate practical measures that enable families to save and access transport services to enhance adequate preparation for birth.
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http://dx.doi.org/10.1080/16549716.2017.1363506DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5645678PMC
August 2017

Characteristics of community savings groups in rural Eastern Uganda: opportunities for improving access to maternal health services.

Glob Health Action 2017 Aug;10(sup4):1347363

a Makerere University School of Public Health , Department of Health Policy Planning and Management , Kampala , Uganda.

Background: Rural populations in Uganda have limited access to formal financial Institutions, but a growing majority belong to saving groups. These saving groups could have the potential to improve household income and access to health services.

Objective: To understand organizational characteristics, benefits and challenges, of savings groups in rural Uganda.

Methods: This was a cross-sectional descriptive study that employed both quantitative and qualitative data collection techniques. Data on the characteristics of community-based savings groups (CBSGs) were collected from 247 CBSG leaders in the districts of Kamuli, Kibukuand Pallisa using self-administered open-ended questionnaires. To triangulate the findings, we conducted in-depth interviews with seven CBSG leaders. Descriptive quantitative and content analysis for qualitative data was undertaken respectively.

Results: Almost a quarter of the savings groups had 5-14 members and slightly more than half of the saving groups had 15-30 members. Ninety-three percent of the CBSGs indicated electing their management committees democratically to select the group leaders and held meetings at least once a week. Eighty-nine percent of the CBSGs had used metallic boxes to keep their money, while 10% of the CBSGs kept their money using mobile money and banks,respectively. The main reasons for the formation of CBSGs were to increase household income, developing the community and saving for emergencies. The most common challenges associated with CBSG management included high illiteracy (35%) among the leaders,irregular attendance of meetings (22%), and lack of training on management and leadership(19%). The qualitative findings agreed with the quantitative findings and served to triangulate the main results.

Conclusions: Saving groups in Uganda have the basic required structures; however, challenges exist in relation to training and management of the groups and their assets. The government and development partners should work together to provide technical support to the groups.
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http://dx.doi.org/10.1080/16549716.2017.1347363DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5645720PMC
August 2017

Experiences of using a participatory action research approach to strengthen district local capacity in Eastern Uganda.

Glob Health Action 2017 Aug;10(sup4):1346038

a Department of Health Policy, Planning and Management , Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH) , Kampala , Uganda.

Background: To achieve a sustained improvement in health outcomes, the way health interventions are designed and implemented is critical. A participatory action research approach is applauded for building local capacity such as health management. Thereby increasing the chances of sustaining health interventions.

Objective: This study explored stakeholder experiences of using PAR to implement an intervention meant to strengthen the local district capacity.

Methods: This was a qualitative study featuring 18 informant interviews and a focus group discussion. Respondents included politicians, administrators, health managers and external researchers in three rural districts of eastern Uganda where PAR was used. Qualitative content analysis was used to explore stakeholders' experiences.

Results: 'Being awakened' emerged as an overarching category capturing stakeholder experiences of using PAR. This was described in four interrelated and sequential categories, which included: stakeholder involvement, being invigorated, the risk of wide stakeholder engagement and balancing the risk of wide stakeholder engagement. In terms of involvement, the stakeholders felt engaged, a sense of ownership, felt valued and responsible during the implementation of the project. Being invigorated meant being awakened, inspired and supported. On the other hand, risks such as conflict, stress and uncertainty were reported, and finally these risks were balanced through tolerance, risk-awareness and collaboration.

Conclusions: The PAR approach was desirable because it created opportunities for building local capacity and enhancing continuity of interventions. Stakeholders were awakened by the approach, as it made them more responsive to systems challenges and possible local solutions. Nonetheless, the use of PAR should be considered in full knowledge of the undesirable and complex experiences, such as uncertainty, conflict and stress. This will enable adequate preparation and management of stakeholder expectations to maximize the benefits of the approach.
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http://dx.doi.org/10.1080/16549716.2017.1346038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5645723PMC
August 2017

Effect of a participatory multisectoral maternal and newborn intervention on birth preparedness and knowledge of maternal and newborn danger signs among women in Eastern Uganda: a quasi-experiment study.

Glob Health Action 2017 08;10(sup4):1362826

a Department of Health Policy Planning and Management , Makerere University School of Public Health , Kampala , Uganda.

Background: Knowledge of obstetric danger signs and adequate birth preparedness (BP) are critical for improving maternal services utilization.

Objectives: This study assessed the effect of a participatory multi-sectoral maternal and newborn intervention on BP and knowledge of obstetric danger signs among women in Eastern Uganda.

Methods: The Maternal and Neonatal Implementation for Equitable Systems (MANIFEST) study was implemented in three districts from 2013 to 2015 using a quasi-experimental pre-post comparison design. Data were collected from women who delivered in the last 12 months. Difference-in-differences (DiD) and generalized linear modelling analysis were used to assess the effect of the intervention on BP practices and knowledge of obstetric danger signs.

Results: The overall BP practices increased after the intervention (DiD = 5, p < 0.05). The increase was significant in both intervention and comparison areas (7-39% vs. 7-36%, respectively), with a slightly higher increase in the intervention area. Individual savings, group savings, and identification of a transporter increased in both intervention and comparison area (7-69% vs. 10-64%, 0-11% vs. 0-5%, and 9-14% vs. 9-13%, respectively). The intervention significantly increased the knowledge of at least three obstetric danger signs (DiD = 31%) and knowledge of at least two newborn danger signs (DiD = 21%). Having knowledge of at least three BP components and attending community dialogue meetings increased the odds of BP practices and obstetric danger signs' knowledge, respectively. Village health teams' home visits, intervention area residence, and being in the 25+ age group increased the odds of both BP practices and obstetric danger signs' knowledge.

Conclusions: The intervention resulted in a modest increase in BP practices and knowledge of obstetric danger signs. Multiple strategies targeting women, in particular the adolescent group, are needed to promote behavior change for improved BP and knowledge of obstetric danger signs.
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http://dx.doi.org/10.1080/16549716.2017.1362826DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5645681PMC
August 2017

Maternal and neonatal implementation for equitable systems. A study design paper.

Glob Health Action 2017 Aug;10(sup4):1346925

a Makerere University School of Public Health (MakSPH) , Makerere University , Kampala , Uganda.

Background: Evidence on effective ways of improving maternal and neonatal health outcomes is widely available. The challenge that most low-income countries grapple with is implementation at scale and sustainability.

Objectives: The study aimed at improving access to quality maternal and neonatal health services in a sustainable manner by using a participatory action research approach.

Methods:  The  study consisted of a quasi-experimental design, with a participatory action research approach to implementation in three rural districts (Pallisa, Kibuku and Kamuli) in Eastern Uganda. The intervention had two main components; namely, community empowerment for comprehensive birth preparedness, and health provider and management capacity-building. We collected data using both quantitative and qualitative methods using household and facility-level structured surveys, record reviews, key informant interviews and focus group discussions. We purposively selected the participants for the qualitative data collection, while for the surveys we interviewed all eligible participants in the sampled households and health facilities. Descriptive statistics were used to describe the data, while the difference in difference analysis was used to measure the effect of the intervention. Qualitative data were analysed using thematic analysis.

Conclusions: This study was implemented to generate evidence on how to increase access to quality maternal and newborn health services in a sustainable manner using a multisectoral participatory  approach.
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http://dx.doi.org/10.1080/16549716.2017.1346925DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5645657PMC
August 2017

Working with community health workers to improve maternal and newborn health outcomes: implementation and scale-up lessons from eastern Uganda.

Glob Health Action 2017 Aug;10(sup4):1345495

a Makerere University , School of Public Health (MakSPH) , Kampala , Uganda.

Background: Preventable maternal and newborn deaths can be averted through simple evidence-based interventions, such as the use of community health workers (CHWs), also known in Uganda as village health teams. However, the CHW strategy faces implementation challenges regarding training packages, supervision, and motivation.

Objectives: This paper explores knowledge levels of CHWs, describes the coverage of home visits, and shares lessons learnt from setting up and implementing the CHW strategy.

Methods: The CHWs were trained to conduct four home visits: two during pregnancy and two after delivery. The aim of the visits was to promote birth preparedness and utilization of maternal and newborn health (MNH) services. Mixed methods of data collection were employed. Quantitative data were analyzed using Stata version 13.0 to determine the level and predictors of CHW knowledge of MNH. Qualitative data from 10 key informants and 15 CHW interviews were thematically analyzed to assess the implementation experiences.

Results: CHWs' knowledge of MNH improved from 41.3% to 77.4% after training, and to 79.9% 1 year post-training. However, knowledge of newborn danger signs declined from 85.5% after training to 58.9% 1 year later. The main predictors of CHW knowledge were age (≥ 35 years) and post-primary level of education. The level of coverage of at least one CHW visit to pregnant and newly delivered mothers was 57.3%. Notably, CHW reports complemented the facility-based health information. CHWs formed associations, which improved teamwork, reporting, and general performance, and thus maintained low dropout rates at 3.6%. Challenges included dissatisfaction with the quarterly transport refund of 6 USD and lack of means of transportation such as bicycles.

Conclusions: CHWs are an important resource in community-based health information and improving demand for MNH services. However, the CHW training and supervision models require strengthening for improved performance. Local solutions regarding CHW motivation are necessary for sustainability.
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Source
http://dx.doi.org/10.1080/16549716.2017.1345495DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5786312PMC
August 2017