Decision-making in district health planning in Uganda: does use of district-specific evidence matter?

Assessing the integration of refugee health data into national health information systems in Jordan, Lebanon, and Uganda

BACKGROUND

With the increasing number of protracted refugee crises globally, it is essential to ensure strong national health information systems (HIS) in displacement settings that include refugee-sensitive data and disaggregation by refugee status. This multi-country study aims to assess the degree of integration of refugee health data into national HIS in Jordan, Lebanon, and Uganda and identify the strengths and weaknesses of their national HIS in terms of collecting and reporting on refugee-related health indicators.

METHODS

The study employs a comparative country analysis approach using a three-phase framework. The first phase involved reviewing 4120 indicators compiled from global health organizations, followed by a multi-stage refinement process, resulting in 45 indicators distributed across five themes. The second phase consisted of selecting relevant criteria from the literature, including data sources, annual reporting, disaggregation by refugee status, refugee population adjustments, accuracy, and consistency. The third phase involved assessing data availability and quality of the selected indicators against these criteria.

RESULTS

Our analysis uncovered significant challenges in assessing the health status of refugees in Jordan, Lebanon, and Uganda, primarily stemming from limitations in the available health data and indicators. Specifically, we identified significant issues including incomplete local data collection with reliance on international data sources, fragmented data collection from various entities leading to discrepancies, and a lack of distinction between refugees and host populations in most indicators. These limitations hinder accurate comparisons and analyses. In light of these findings, a set of actionable recommendations was proposed to guide policymakers in the three countries to improve the integration of refugee health data into their national HIS ultimately enhancing refugees' well-being and access to healthcare services.

CONCLUSION

The current status of refugee-related health data in Jordan, Lebanon, and Uganda indicates the need for improved data collection and reporting practices, disaggregation by refugee status and better integration of refugee health data into national HIS to capture the health status and needs of refugees in host countries. Key improvement strategies include establishing a centralized authority for consistent and efficient data management, fostering transparent and inclusive data governance, and strengthening workforce capacity to manage refugee health data effectively.

A comparative analysis of COVID-19 physical distancing policies in South Africa and Uganda

COVID-19 responses internationally have depended on physical distancing policies to manage virus transmission, given the initial absence of treatments and limitations on vaccine availability. Different jurisdictions have different contexts affecting their responses such as past epidemic experience, ratings of epidemic preparedness, and income level. COVID-19 responses in African countries have not been well-studied. A qualitative multiple embedded case study design was used to examine the COVID-19 policies in South Africa and Uganda from January 2020 to November 2021. This study included a documentary review using government websites and reports, news articles, and peer-reviewed journal articles to obtain data on policy responses and contextual factors. Epidemiological data were collected from public sources. Key informant interviews with relevant stakeholders were used to confirm findings and cover missing information. A comparative analysis was conducted to explore differences in implementation of different types of physical distancing policies and potential consequences of lifting or prolonging public health measures. South African and Ugandan policy responses included physical distancing measures such as lockdown, international travel bans, school closures, public transportation measures, and curfew, in addition to socioeconomic relief programs and vaccinations. Differences between jurisdiction policy responses existed in terms of overarching strategy, timing, and stringency. This study provided in-depth comparisons of COVID-19 policy responses and relevant contextual factors in South Africa and Uganda. The study showed how contextual factors such as population age, geographic distribution, and recent epidemic response experience can influence COVID-19 transmission and response. The study also showed differences in overall strategy, timing, and strictness of epidemic management policies in these jurisdictions. These findings suggest it may be important to have sustained, strict measures to limit the spread of COVID-19 and manage the course of a pandemic, which need to be further explored alongside other important social and economic pandemic outcomes.

Health research evidence: its current usage in health planning, determinants and readiness to use knowledge translation tools among health planning teams in Tanzania-an exploratory mixed-methods study protocol

INTRODUCTION

Achieving universal health coverage requires using research evidence to inform decision-making. However, little information is available on the use of research evidence in planning in lower middle-income countries, including Tanzania. This paper presents a protocol that aims to investigate the usage of research evidence in health planning, determinants and readiness of the planning team members to use knowledge translation tools in Tanzania.

METHODS AND ANALYSIS

This study will employ a sequential exploratory mixed-methods design, with participants selected from national, regional and council levels. Qualitative data will be collected through a maximum of 52 in-depth interviews and 12 focused group discussions until saturation. To collect quantitative data, a structured questionnaire will be used to survey 422 participants, and a document review will be conducted from health facilities. Qualitative data will be analysed using thematic analysis, while descriptive and inferential analyses will be employed for quantitative data.

ETHICS AND DISSEMINATION

The study participants will provide written informed consent, and all recorded data will be stored on a secured research server accessible only to the investigators. Ethical approval has been obtained from the University of Dodoma Research Ethics Committee (ref. MA.84/261/02/'A'/64/91). The findings of this study will inform policymakers, researchers and implementers in the country on the use of research evidence in decision-making. We will disseminate our findings through publications, conferences, workshops and interactive communication with national, regional, council and health facility planning teams.

Putting the local back into planning-experiences and perceptions of state and district health functionaries of seven aspirational districts in India on an innovative planning capacity building approach

District functionaries have ostensibly a major responsibility to develop evidence based plans. However, this responsibility is not commensurate with skills and expertise among functionaries in many Indian states. Vriddhi project-technical partner of the government, developed a planning tool for maternal and neonatal health programmes, called RMNCH + A Action Agenda using Strategic Approach (RAASTA), which was introduced in a workshop format in two states and attended by program officers. Qualitative feedback was obtained from selected participants to understand their experience of the workshop and of the planning tool. It emerged that previous planning process had little application of local evidence based solutions. Participants appreciated the alternative approach as RAASTA equipped them to use local evidence. Several action plans derived at the workshop were included in the state plan. At the same time, apprehension was expressed by participants about translating their learnings to practical application as planning was not a central priority in their scheme of duties and tasks. Enhanced support from states in refreshing district planners' skills would be an important step. One state government has scaled up the RAASTA tool while an electronic version is being developed for future use as it demonstrates great potential to equip and aid district officials in developing evidence based plans.

Transitioning health workers from PEPFAR contracts to the Uganda government payroll

Although increasing public spending on health worker (HW) recruitments could reduce workforce shortages in sub-Saharan Africa, effective strategies for achieving this are still unclear. We aimed to understand the process of transitioning HWs from President's Emergency Plan for AIDS Relief (PEPFAR) to Government of Uganda (GoU) payrolls and to explore the facilitators and barriers encountered in increasing domestic financial responsibility for absorbing this expanded workforce. We conducted a multiple case study of 10 (out of 87) districts in Uganda which received PEPFAR support between 2013 and 2015 to expand their health workforce. We purposively selected eight districts with the highest absorption rates ('high absorbers') and two with the lowest absorption rates ('low absorbers'). A total of 66 interviews were conducted with high-level officials in three Ministries of Finance, Health and Public Service (n = 14), representatives of PEPFAR-implementing organizations (n = 16), district health teams (n = 15) and facility managers (n = 22). Twelve focus groups were conducted with 87 HWs absorbed on GoU payrolls. We utilized the Consolidated Framework for Implementation Research to guide thematic analysis. At the sub-national level, facilitators of transition in 'high absorber' districts were identified as the presence of transition 'champions', prioritizing HWs in district wage bill commitments, host facilities providing 'bridge financing' to transition workforce during salary delays and receiving donor technical support in district wage bill analysis-attributes that were absent in 'low absorber' districts. At the national level, multi-sectoral engagements (incorporating the influential Ministry of Finance), developing a joint transition road map, aligning with GoU salary scales and recruitment processes emerged as facilitators of the transition process. Our case studies offer implementation research lessons on effective donor transition and insights into pragmatic strategies for increasing public spending on expanding the health workforce in a low-income setting.

Child health and the implementation of Community and District-management Empowerment for Scale-up (CODES) in Uganda: a randomised controlled trial

Introduction

Uganda’s district-level administrative units buttress the public healthcare system. In many districts, however, local capacity is incommensurate with that required to plan and implement quality health interventions. This study investigates how a district management strategy informed by local data and community dialogue influences health services.

Methods

A 3-year randomised controlled trial (RCT) comprised of 16 Ugandan districts tested a management approach, Community and District-management Empowerment for Scale-up (CODES). Eight districts were randomly selected for each of the intervention and comparison areas. The approach relies on a customised set of data-driven diagnostic tools to identify and resolve health system bottlenecks. Using a difference-in-differences approach, the authors performed an intention-to-treat analysis of protective, preventive and curative practices for malaria, pneumonia and diarrhoea among children aged 5 and younger.

Results

Intervention districts reported significant net increases in the treatment of malaria (+23%), pneumonia (+19%) and diarrhoea (+13%) and improved stool disposal (+10%). Coverage rates for immunisation and vitamin A consumption saw similar improvements. By engaging communities and district managers in a common quest to solve local bottlenecks, CODES fostered demand for health services. However, limited fiscal space-constrained district managers’ ability to implement solutions identified through CODES.

Conclusion

Data-driven district management interventions can positively impact child health outcomes, with clinically significant improvements in the treatment of malaria, pneumonia and diarrhoea as well as stool disposal. The findings recommend the model’s suitability for health systems strengthening in Uganda and other decentralised contexts.

Trial registration number

ISRCTN15705788.

Acceptability and feasibility of inter-related activities to improve agency among African district health managers: A four-country study

District health managers (DHMs) lead and manage Ministry of Health programmes and system performance. We report on the acceptability and feasibility of inter-related activities to increase the agency of DHMs in Kenya, Nigeria, South Africa and Uganda using a cross-sectional rapid appraisal with 372 DHMs employing structured questionnaires. We found differences and similarities between the countries, in particular, who becomes a DHM. The opportunity to provide leadership and effect change and being part of a team were reported as rewarding aspects of DHMs' work. Demotivating factors included limited resources, bureaucracy, staff shortages, lack of support from leadership and inadequate delegation of authority. District managers ranked the acceptability of the inter-related activities similarly despite differences between contexts. Activities highly ranked by DHMs were to employ someone to support primary care staff to compile and analyse district-level data; to undertake study tours to well-functioning districts; and joining an African Regional DHM Association. DHMs rated these activities as feasible to implement. This study confirms that DHMs are in support of a process to promote bottom-up, data-driven, context-specific actions that can promote self-actualisation, recognises the roles DHMs play, provides opportunities for peer learning and can potentially improve quality of care.

Applying the Community Health Worker Coverage and Capacity Tool for Time-Use Modeling for Program Planning in Rwanda and Zanzibar

Community health worker (CHW) programs are a critical component of health systems, notably in lower- and middle-income countries. However, when policy recommendations exceed what is feasible to implement, CHWs are overstretched by the volume of activities, implementation strength is diluted, and programs fail to produce promised outcomes. To counteract this, we developed a time-use modeling tool-the CHW Coverage and Capacity (C3) Tool-and used it with government partners in Rwanda and Zanzibar to address common policy questions related to CHW needs, coverage, and time optimization.In Rwanda, the C3 Tool was used to analyze 2 well-established cadres of CHWs and 1 new one. The well-established CHW cadres were within a "manageable" workload range whereas the new cadre was projected to achieve less than half of assigned activities. This is informing ongoing changes to the CHWs' scopes of work. In Zanzibar, the C3 Tool was used to update the national community health strategy to include community health volunteers (CHVs) for the first time and determine how many CHVs were needed. The tool projected that 2,200 CHVs could achieve approximately 90% coverage of all defined services. Based on these figures, Zanzibar updated its national community health strategy, which officially launched in February 2020.We discuss lessons from these 2 experiences. Translating analysis into decision making depends not only on the programmatic will and motivation of governments but also on finding opportune timing for when policy and program processes allow for optimization of CHW investments. Further research is needed but our experience supports the value of a modeling tool to ground program plans within estimated constraints on CHW time.