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Matte M, Ntaro M, Kenney J, Wesuta A, Kawungezi PC, Bwambale S, Ayebare D, Baguma S, Bagenda F, Stone G, Mulogo E. Assessment of pre-referral treatment for malaria, diarrhea, and pneumonia by rural community health workers in Southwestern Uganda: a cross-sectional study. BMC Health Serv Res 2024; 24:95. [PMID: 38233841 PMCID: PMC10795398 DOI: 10.1186/s12913-024-10598-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 01/12/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Pre-referral treatment aims to stabilize the child's condition before transferring them to a higher level of healthcare. This study explored pre-referral treatment for diarrhea, malaria and pneumonia in children U5. The study aims to assess pre-referral treatment practices among community health workers (CHWs) for children aged 2 to 59 months diagnosed with malaria, diarrhea, and pneumonia. METHODS Conducted in 2023, this study employed a quantitative retrospective analysis of secondary data gathered from March 2014 to December 2018. Among the subjects, 171 patients received pre-referral treatment, serving as the foundation for categorical data analysis, presenting proportions and 95% confidence intervals across different categories. RESULTS In this cohort, 90 (53%) of the 177 children U5 were male, and age distribution showed 39 (23%), 70 (41%), and 62 (36%) in the 2-11 months, 12-35 months, and 36-60 months categories, respectively. Rapid Diagnostic Test (RDT) malaria results indicated a negative outcome in 83(60%) and positive in 55 (40%) of cases. Symptomatically, 45 (26%) had diarrhea, 52 (30%) exhibited fast breathing, and 109 (63%) presented with fever. Furthermore, 59 (35%) displayed danger signs, while 104 (61%) sought medical attention within 24 h. CONCLUSION The study analyzed a sample of 171 children under 5 years old to assess various characteristics and variables related to pre-referral treatment. The findings reveal notable proportions in gender distribution, age categories, RDT results, presence of diarrhea, fast breathing, fever, danger signs, and timely medical visits. The results highlight the need to strengthen pre-referral treatment interventions and enhance iCCM programs.
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Affiliation(s)
- Michael Matte
- Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda.
| | - Moses Ntaro
- Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
| | - Jessica Kenney
- Center for Global Health, Massachusetts General Hospital, 125 Nashua Street, Boston, MA, 02114, USA
| | - Andrew Wesuta
- Bugoye Community Health Collaboration, Bugoye Health Centre III, PO Box 149, Kasese District, Uganda
| | - Peter Chris Kawungezi
- Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
| | - Shem Bwambale
- Bugoye Community Health Collaboration, Bugoye Health Centre III, PO Box 149, Kasese District, Uganda
| | - David Ayebare
- Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
| | - Stephen Baguma
- Bugoye Community Health Collaboration, Bugoye Health Centre III, PO Box 149, Kasese District, Uganda
| | - Fred Bagenda
- Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
| | - Geren Stone
- Center for Global Health, Massachusetts General Hospital, 125 Nashua Street, Boston, MA, 02114, USA
| | - Edgar Mulogo
- Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
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Abimbola S, Liu H. Adoption and scale-up of the cardiovascular Polypill: a realist institutional analysis. Health Policy Plan 2023; 38:15-27. [PMID: 36271837 PMCID: PMC9825725 DOI: 10.1093/heapol/czac088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/28/2022] [Accepted: 10/21/2022] [Indexed: 01/12/2023] Open
Abstract
Efforts to promote the adoption and scale-up of health system innovations must contend with the existing institutional context. But there are no commonly used frameworks to ensure that the insights of actors involved in such institutional efforts connect to one another. To test and modify a potential framework-the 'four-by-four' framework-we interviewed researcher-entrepreneurs involved in the unfolding story of the cardiovascular Polypill. The framework has four types/levels of institutions that affect adoption and scale-up: (1) informal institutions (L1, e.g. social norms), (2) formal institutions (L2, e.g. government policies and regulation), (3) organizational structures (L3, e.g. organizational boards and mission) and (4) everyday exchange (L4, e.g. service delivery), vis-à-vis four potential entrepreneurial strategies in response: (1) abide by existing institutions, (2) evade them, (3) alter them and/or (4) exit entrepreneurial action. Using this framework, we conducted a realist-informed analysis to understand how context (i.e. institutions) and mechanism (i.e. entrepreneurial strategies) influence each other to shape outcomes (i.e. adoption and scale-up). We found that researcher-entrepreneurs began with efforts to abide with existing institutions but encountered institutional obstacles at each level. Efforts to abide were followed by seeking to evade and/or alter unfavourable institutions, with greater success evading and/or altering lower (L3 and L4) than upper (L1 and L2) institutions. Exit considerations followed the failure of the evade or alter strategy. Shifts between strategies were propelled by 'learning'. The 'four-by-four' framework can be used as a scaffold to generate narratives of adoption or scale-up efforts, a sensitizing tool to prospectively map out contingencies and a matrix to synthesize narratives and experiences across multiple innovations or settings. Used in these ways, the 'four-by-four' framework can help to optimize the transferability and cumulation of insights on how to promote the adoption and scale-up of health system innovations.
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Affiliation(s)
- Seye Abimbola
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Hueiming Liu
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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Awor P, Kalyango JN, Stålsby Lundborg C, Ssengooba F, Eriksen J, Rutebemberwa E. Policy Challenges Facing the Scale Up of Integrated Community Case Management (iCCM) in Uganda. Int J Health Policy Manag 2022; 11:1432-1441. [PMID: 34124867 PMCID: PMC9808347 DOI: 10.34172/ijhpm.2021.39] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 04/11/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Integrated Community Case Management (iCCM) of malaria, pneumonia and diarrhoea is an equity focused strategy, to increase access to care for febrile illness in children under-5 years of age, in rural communities. Lay community members are trained to diagnose and treat malaria, pneumonia and diarrhoea in children, and to identify and refer very ill children. Today, many low-income countries including Uganda, have a policy for iCCM which is being rolled out through public sector community health workers (CHWs). Ten years after the introduction of the iCCM strategy in Uganda, it is important to take stock and understand the barriers and facilitators affecting implementation of the iCCM policy. METHODS We conducted an iCCM policy analysis in order to identify the challenges, enablers and priorities for scale-up of the iCCM strategy in Uganda. This was a qualitative case study research which included a document review (n=52) and key informant interviews (n=15) with Ugandan stakeholders. Interviews were conducted in 2017 and the desk review included literature up to 2019. RESULTS This paper highlights the iCCM policy trajectory since 2010 in Uganda and includes a policy timeline. The iCCM policy process was mainly led by international agencies from inception, with little ownership of the government. Many implementation challenges including low government funding, weak coordination and contradicting policies were identified, which could contribute to the slow scale up of the iCCM program. Despite the challenges, many enablers and opportunities also exist within the health system, which should be further harnessed to scale up iCCM in Uganda. These enabling factors include strong community commitment, existing policy instruments and the potential of utilizing also the private sector for iCCM implementation. CONCLUSION The iCCM program in Uganda needs to be strengthen through increased domestic funding, strong coordination and a focus on monitoring, evaluation and operational research.
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Affiliation(s)
- Phyllis Awor
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joan Nakayaga Kalyango
- Clinical Epidemiology Unit, College of Health Sciences, Makerere University Kampala, Kampala, Uganda
- Department of Pharmacy, College of Health Sciences, Makerere University Kampala, Kampala, Uganda
| | - Cecilia Stålsby Lundborg
- Health Systems and Policy, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Freddie Ssengooba
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jaran Eriksen
- Health Systems and Policy, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Unit of Infectious Diseases/Venhälsan, Södersjukhuset, Stockholm, Sweden
| | - Elizeus Rutebemberwa
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
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Karim A, de Savigny D, Awor P, Cobos Muñoz D, Mäusezahl D, Kitoto Tshefu A, Ngaima JS, Enebeli U, Isiguzo C, Nsona H, Ogbonnaya I, Ngoy P, Alegbeleye A. The building blocks of community health systems: a systems framework for the design, implementation and evaluation of iCCM programs and community-based interventions. BMJ Glob Health 2022; 7:bmjgh-2022-008493. [PMID: 35772810 PMCID: PMC9247653 DOI: 10.1136/bmjgh-2022-008493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/30/2022] [Indexed: 11/08/2022] Open
Abstract
Introduction Almost all sub-Saharan African countries have adopted some form of integrated community case management (iCCM) to reduce child mortality, a strategy targeting common childhood diseases in hard-to-reach communities. These programs are complex, maintain diverse implementation typologies and involve many components that can influence the potential success of a program or its ability to effectively perform at scale. While tools and methods exist to support the design and implementation of iCCM and measure its progress, these may not holistically consider some of its key components, which can include program structure, setting context and the interplay between community, human resources, program inputs and health system processes. Methods We propose a Global South-driven, systems-based framework that aims to capture these different elements and expand on the fundamental domains of iCCM program implementation. We conducted a content analysis developing a code frame based on iCCM literature, a review of policy documents and discussions with key informants. The framework development was guided by a combination of health systems conceptual frameworks and iCCM indices. Results The resulting framework yielded 10 thematic domains comprising 106 categories. These are complemented by a catalogue of critical questions that program designers, implementers and evaluators can ask at various stages of program development to stimulate meaningful discussion and explore the potential implications of implementation in decentralised settings. Conclusion The iCCM Systems Framework proposed here aims to complement existing intervention benchmarks and indicators by expanding the scope and depth of the thematic components that comprise it. Its elements can also be adapted for other complex community interventions. While not exhaustive, the framework is intended to highlight the many forces involved in iCCM to help managers better harmonise the organisation and evaluation of their programs and examine their interactions within the larger health system.
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Affiliation(s)
- Aliya Karim
- University of Basel, Basel, Switzerland .,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Don de Savigny
- University of Basel, Basel, Switzerland.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Phyllis Awor
- Department of Community Health and Behavioural Sciences, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daniel Cobos Muñoz
- University of Basel, Basel, Switzerland.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Daniel Mäusezahl
- University of Basel, Basel, Switzerland.,Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | - Jean Serge Ngaima
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Ugo Enebeli
- Department of Community Medicine, University of Port Harcourt, Choba, Rivers State, Nigeria
| | - Chinwoke Isiguzo
- School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Society for Family Health Nigeria, Abuja, Nigeria
| | - Humphreys Nsona
- IMCI, Malawi Ministry of Health, Lilongwe, Central Region, Malawi
| | - Ikechi Ogbonnaya
- Department of Health, Planning, Research & Statistics, Federal Ministry of Health, Abuja, Federal Capital Territory, Nigeria
| | - Pascal Ngoy
- PROSANI, USAID, Washington, District of Columbia, USA
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Emerson C, Meline J, Linn A, Wallace J, Kapella BK, Venkatesan M, Steketee R. End Malaria Faster: Taking Lifesaving Tools Beyond “Access” to “Reach” All People in Need. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-22-00118. [PMID: 35487558 PMCID: PMC9053156 DOI: 10.9745/ghsp-d-22-00118] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 04/04/2022] [Indexed: 11/23/2022]
Abstract
To “reach the unreached” with preventive and curative malaria services, we must know which individuals and communities remain unreached and then bring tailored services from the clinic to the community and home.
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Affiliation(s)
- Courtney Emerson
- U.S. President's Malaria Initiative, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Jed Meline
- U.S. President's Malaria Initiative, United States Agency for International Development, Washington, DC, USA
| | - Anne Linn
- U.S. President's Malaria Initiative, United States Agency for International Development, Washington, DC, USA
| | - Julie Wallace
- U.S. President's Malaria Initiative, United States Agency for International Development, Washington, DC, USA
| | - Bryan K Kapella
- U.S. President's Malaria Initiative, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Meera Venkatesan
- U.S. President's Malaria Initiative, United States Agency for International Development, Washington, DC, USA
| | - Richard Steketee
- U.S. President's Malaria Initiative, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
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Ghazinoory S, Majidi B, Nasri S, Zandi E, Farrokhi H, Javedani M, Barzanouni M. Differences between health technology assessment topics in high- and middle-income countries: a scoping review. Arch Public Health 2021; 79:225. [PMID: 34906239 PMCID: PMC8669423 DOI: 10.1186/s13690-021-00754-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Health Technology Assessment (HTA) has encountered different issues and challenges over the last two decades. The main purpose of this research is to review the issues and challenges in high- and middle-income countries through reviewing studies related to the HTA. METHODS The HTA area literature of different countries was collected from 2009 to 2020 and analyzed using scoping review, based on Scopus and WoS databases. RESULTS Given the fact that the HTA is practically done in high- and middle-income countries, the results of reviewing the studies and articles of countries reveal that high-income countries seek to increase the participation of stakeholders and enhance the transparency of processes, policy-making, and regulation of the HTA, as well as the systematization of various participant institutions in this area. Middle-income countries, on the other hand, are mostly involved in raising awareness, training and skill development of HTA-related staff, institutionalizing the concept of HTA, and allocating appropriate resources for effective and safe decision-making in their health system. CONCLUSION The problem of incoordination between stakeholders (participant institutions) in the HTA, and thereby, problems in decision-making were found in many of the studied reports and articles. Thus, one of the useful efforts to be made by different countries to maintain the integrity of this system would be the process of involving all members of this system and the formation of a healthy ecosystem in the HTA.
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Affiliation(s)
- Sepehr Ghazinoory
- Department of Information Technology Management, Tarbiat Modares University, Tehran, Iran
| | | | - Shohreh Nasri
- National Research Institution for Science Policy, Tehran, Iran.
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Story WT, Pritchard S, Hejna E, Olivas E, Sarriot E. The role of integrated community case management projects in strengthening health systems: case study analysis in Ethiopia, Malawi and Mozambique. Health Policy Plan 2021; 36:900-912. [PMID: 33930137 DOI: 10.1093/heapol/czaa177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 11/14/2022] Open
Abstract
Integrated community case management (iCCM) has now been implemented at scale globally. Literature to-date has focused primarily on the effectiveness of iCCM and the systems conditions required to sustain iCCM. In this study, we sought to explore opportunities taken and lost for strengthening health systems through successive iCCM programmes. We employed a systematic, embedded, multiple case study design for three countries-Ethiopia, Malawi and Mozambique-where Save the Children implemented iCCM programmes between 2009 and 2017. We used textual analysis to code 62 project documents on nine categories of functions of health systems using NVivo 11.0. The document review was supplemented by four key informant interviews. This study makes important contributions to the theoretical understanding of the role of projects in health systems strengthening by not only documenting evidence of systems strengthening in multi-year iCCM projects, but also emphasizing important deficiencies in systems strengthening efforts. Projects operated on a spectrum, ranging from gap-filling interventions, to support, to actual strengthening. While there were natural limits to the influence of a project on the health system, all successive projects found constructive opportunities to try to strengthen systems. Alignment with the Ministry of Health was not always static and simple, and ministries themselves have shown pluralism in their perspectives and orientations. We conclude that systems strengthening remains 'everybody's business' and places demands for realism and transparency on government and the development architecture. While mid-size projects have limited decision space, there is value in better defining where systems strengthening contributions can actually be made. Furthermore, systems strengthening is not solely about macro-level changes, as operational and efficiency gains at meso and micro levels can have value to the system. Claims of 'systems strengthening' are, however, bounded within the quality of evaluation and learning investments.
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Affiliation(s)
- William T Story
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA
| | - Susannah Pritchard
- Formerly Save the Children, Health Department, 1 St. John's Lane, London EC1M 4AR, UK
| | - Emily Hejna
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA
| | - Elijah Olivas
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA
| | - Eric Sarriot
- Formerly Save the Children, Department of Global Health, 899 North Capitol St NE #900, Washington, DC 20002, USA
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de Broucker G, Sim SY, Brenzel L, Gross M, Patenaude B, Constenla DO. Cost of Nine Pediatric Infectious Illnesses in Low- and Middle-Income Countries: A Systematic Review of Cost-of-Illness Studies. PHARMACOECONOMICS 2020; 38:1071-1094. [PMID: 32748334 PMCID: PMC7578143 DOI: 10.1007/s40273-020-00940-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Cost-of-illness data from empirical studies provide insights into the use of healthcare resources including both expenditures and the opportunity cost related to receiving treatment. OBJECTIVE The objective of this systematic review was to gather cost data and relevant parameters for hepatitis B, pneumonia, meningitis, encephalitis caused by Japanese encephalitis, rubella, yellow fever, measles, influenza, and acute gastroenteritis in children in low- and middle-income countries. DATA SOURCES Peer-reviewed studies published in public health, medical, and economic journals indexed in PubMed (MEDLINE), Embase, and EconLit. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS Studies must (1) be peer reviewed, (2) be published in 2000-2016, (3) provide cost data for one of the nine diseases in children aged under 5 years in low- and middle-income countries, and (4) generated from primary data collection. LIMITATIONS We cannot exclude missing a few articles in our review. Measures were taken to reduce this risk. Several articles published since 2016 are omitted from the systematic review results, these articles are included in the discussion. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS The review yielded 37 articles and 267 sets of cost estimates. We found no cost-of-illness studies with cost estimates for hepatitis B, measles, rubella, or yellow fever from primary data. Most estimates were from countries in Gavi preparatory (28%) and accelerated (28%) transition, followed by those who are initiating self-financing (22%) and those not eligible for Gavi support (19%). Thirteen articles compared household expenses to manage illnesses with income and two articles with other household expenses, such as food, clothing, and rent. An episode of illness represented 1-75% of the household's monthly income or 10-83% of its monthly expenses. Articles that presented both household and government perspectives showed that most often governments incurred greater costs than households, including non-medical and indirect costs, across countries of all income statuses, with a few notable exceptions. Although limited for low- and middle-income country settings, cost estimates generated from primary data collection provided a 'real-world' estimate of the economic burden of vaccine-preventable diseases. Additional information on whether common situations preventing the application of official clinical guidelines (such as medication stock-outs) occurred would help reveal deficiencies in the health system. Improving the availability of cost-of-illness evidence can inform the public policy agenda about healthcare priorities and can help to operationalize the healthcare budget in local health systems to respond adequately to the burden of illness in the community.
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Affiliation(s)
- Gatien de Broucker
- International Vaccine Access Center, 415 North Washington Street, Suite #530, Baltimore, MD, 21231, USA.
| | - So Yoon Sim
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Margaret Gross
- Welch Medical Library, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Bryan Patenaude
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dagna O Constenla
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- GlaxoSmithKline Plc, Panama City, Panama
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Nanyonjo A, Kertho E, Tibenderana J, Källander K. District Health Teams' Readiness to Institutionalize Integrated Community Case Management in the Uganda Local Health Systems: A Repeated Qualitative Study. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:190-204. [PMID: 32606091 PMCID: PMC7326515 DOI: 10.9745/ghsp-d-19-00318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 03/04/2020] [Indexed: 11/28/2022]
Abstract
District health teams failed to transition from partner-supported integrated community case management (iCCM) programs to locally-run and fully-institutionalized programs. Successful iCCM institutionalization requires local ownership with increased coordination among governmental and nongovernmental actors at the national and district levels. Introduction: Several countries have adopted integrated community case management (iCCM) as a strategy for improved health service delivery in areas with poor health facility coverage. Early implementation of iCCM is often run by nongovernmental organizations financed by donors through projects. Such projects risk failure to transition into programs run by the local health system upon project closure. Engagement of subnational health authorities such as district health teams (DHTs) is essential for a smooth transition. Methods: We used a repeated qualitative study design to assess the readiness of and progress made by DHTs in institutionalizing iCCM into the functions of locally decentralized health systems in 9 western Uganda districts. Readiness data were derived from structured group interviews with DHTs before iCCM policy adoption in 2010 and again in 2015. Progressive institutionalization achievements were assessed through key informant interviews with targeted DHT members and local government district planners in the same areas. Findings: In the readiness study, DHTs expressed commitment to institutionalize iCCM into the local health system through the development of district-specific iCCM activity work plans and budgets. The DHTs further suggested that they would implement district-led training, motivation, and supervision of community health workers; procurement of iCCM medicines and supplies; and advocacy activities for inclusion of iCCM indicators into the national health information systems. After iCCM policy adoption, follow-up study data findings showed that iCCM was largely not institutionalized into the local district health system functions. The poor institutionalization was attributed to lack of stewardship on how to transition from externally supported implementation to district-led programming, conflicting guidelines on community distribution of medicines, poor community-level accountability systems, and limited decision-making autonomy at the district level. Conclusion: Successful institutionalization of iCCM requires local ownership with increased coordination and cooperation among governmental and nongovernmental actors at both the national and district levels.
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Affiliation(s)
| | | | | | - Karin Källander
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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