Health workforce incentives and dis-incentives during the COVID-19 pandemic: experiences from Democratic Republic of Congo, Nigeria, Senegal, and Uganda

BACKGROUND

The COVID-19 pandemic presented a myriad of challenges for the health workforce around the world due to its escalating demand on service delivery. A motivated health workforce is critical to effectual emergency response and in some settings, incentivizing health workers motivates them and ensures continuity in the provision of health services. We describe health workforce experiences with incentives and dis-incentives during the COVID-19 response in the Democratic Republic of Congo (DRC), Senegal, Nigeria, and Uganda.

METHODS

This is a multi-country qualitative research study involving four African countries namely: DRC, Nigeria, Senegal, and Uganda which assessed the workplace incentives instituted in response to the COVID-19 pandemic. Key informant interviews (n = 60) were conducted with staff at ministries of health, policy makers and health workers. Interviews were virtual using the telephone or Zoom. They were audio recorded, transcribed verbatim, and analyzed thematically. Themes were identified and quotes were used to support findings.

RESULTS

Health worker incentives included (i) financial rewards in the form of allowances and salary increments. These motivated health workers, sustaining the health system and the health workers' efforts during the COVID-19 response across the four countries. (ii) Non-financial incentives related to COVID-19 management such as provision of medicines/supplies, on the job trainings, medical care for health workers, social welfare including meals, transportation and housing, recognition, health insurance, psychosocial support, and supervision. Improvised determination and distribution of both financial and non-financial incentives were common across the countries. Dis-incentives included the lack of personal protective equipment, lack of transportation to health facilities during lockdown, long working hours, harassment by security forces and perceived unfairness in access to and inadequacy of financial incentives.

CONCLUSION

Although important for worker motivation, financial and non-financial incentives generated some dis-incentives because of the perceived unfairness in their provision. Financial and non-financial incentives deployed during health emergencies should preferably be pre-determined, equitably and transparently provided because when arbitrarily applied, these same financial and non-financial incentives can potentially become dis-incentives. Moreover, financial incentives are useful only as far as they are administered together with non-financial incentives such as supportive and well-resourced work environments. The potential negative impacts of interventions such as service delivery re-organization and lockdown within already weakened systems need to be anticipated and due precautions exercised to reduce dis-incentives during emergencies.

Equity in family planning policies and programs in Uganda: conceptualization, dimensions and implementation constraints

BACKGROUND

Equity is at the core and a fundamental principle of achieving the family planning (FP) 2030 Agenda. However, the conceptualization, definition, and measurement of equity remain inconsistent and unclear in many FP programs and policies. This paper aims to document the conceptualization, dimensions and implementation constraints of equity in FP policies and programs in Uganda.

METHODS

A review of Ugandan literature and key informant interviews with 25 key stakeholders on equity in FP was undertaken between April and July 2020. We searched Google, Google Scholar and PubMed for published and grey literature from Uganda on equity in FP. A total of 112 documents were identified, 25 met the inclusion criteria and were reviewed. Data from the selected documents were extracted into a Google master matrix in MS Excel. Data analysis was done across the thematic areas by collating similar information. Data were analyzed using thematic content analysis approach.

RESULTS

A limited number of documents had an explicit definition of equity, which varied across documents and stakeholders. The definitions revolved around universal access to FP information and services. There was a limited focus on equity in FP programs in Uganda. The dimensions most commonly used to assess equity were either geographical location, or socio-demographics, or wealth quintile. Almost all the key informants noted that equity is a very important element, which needs to be part of FP programming. However, implementation constraints (e.g. lack of quality comprehensive FP services, duplicated FP programs and a generic design of FP programs with limited targeting of the underserved populations) continue to hinder effective implementation of equitable FP programs in Uganda. Clients' constraints (e.g. limited contraceptive information) and policy constraints (inadequate focus on equity in policy documents) also remain key challenges.

CONCLUSIONS

There is lack of a common understanding and definition of equity in FP programs in Uganda. There is need to build consensus on the definitions and measurements of equity with a multidimensional lens to inform clear policy and programming focus on equity in FP programs and outcomes. To improve equitable access to and use of FP services, attention must be paid to addressing implementation, client and policy constraints.

Extent of integration of nutrition assessment counselling and support interventions in the health system and respective drivers: A case of Tororo district, Uganda

BACKGROUND

Uganda embraced Nutrition Assessment Counselling and Support (NACS) since 2009 as a health system strengthening approach to improve health and nutrition outcomes. However, scant evidence exists on NACS integration and drivers. This study therefore assessed the extent of NACS integration in the health system and identified key drivers and barriers.

METHODS

A mixed method design was employed. In a facilitated panel discussions at each of the 17 health facilities, 4-5 health staff participated, responding to a semi-structured questionnaire. Integration was assessed on a 5-point scoring scale of 1 for not done nor integrated, 2-4 for partial and 5 for fully integration. Data was captured, analysed in microsoft excel and presented using as bar and spider charts. Integration drivers were identified deductively from key informant and in-depth interviews using Atlas.ti 9 and thematic analysis.

RESULTS

The NACS integration across the health facility level was partial at a score of 2.9 indicating a weak integration into the health system. Integration across the health system building blocks was partial at; service delivery (3.8), health work force (3.7), health information (3.3), community support system (3.0), governance and leadership (3.0) signifying that NACS activities are provided by Ministry of Health but sub-optimal due to weak capacities. Health financing (2.2) and Health supplies (1.5) were the least integrated due to partner dependence. Under service delivery, deworming (5) was fully integrated and provided by Ministry of Health. The key drivers for integration were; good leadership, financing, competent staff, quality improvement approaches, nutrition talks, community dialogues, nutrition logistics and supplies.

CONCLUSION

The NACS integration in the health system was generally low and lacked adequate support. Governance, financing and community follow-up under service delivery require more government investment for enhanced integration.

Improving testing capacity for COVID-19: experiences and lessons from Senegal, Uganda, Nigeria, and the Democratic Republic of Congo

Background

African countries leveraged testing capacities to enhance public health action in response to the COVID-19 pandemic. This paper describes experiences and lessons learned during the improvement of testing capacity throughout the COVID-19 response in Senegal, Uganda, Nigeria, and the Democratic Republic of the Congo (DRC).

Methods

The four countries' testing strategies were studied using a mixed-methods approach. Desk research on COVID-19 testing strategies was conducted and complemented by interviewing key informants. The findings were synthesized to demonstrate learning outcomes across the four countries.

Results

The four countries demonstrated severely limited testing capacities at the onset of the pandemic. These countries decentralized COVID-19 testing services by leveraging preexisting laboratory systems such as PCR and GeneXpert used for the diagnosis of tuberculosis (TB) to address this gap and the related inequities, engaging the private sector, establishing new laboratories, and using rapid diagnostic tests (RDTs) to expand testing capacity and reduce the turnaround time (TAT). The use of digital platforms improved the TAT. Testing supplies were sourced through partners, although access to global markets was challenging. Case detection remains suboptimal due to high costs, restrictive testing strategies, testing access challenges, and misinformation, which hinder the demand for testing. The TAT for PCR remained a challenge, while RDT use was underreported, although Senegal manufactured RDTs locally. Key findings indicate that regionally coordinated procurement and manufacturing mechanisms are required, that testing modalities must be simplified for improved access, and that the risk-based testing strategy limits comprehensive understanding of the disease burden.

Conclusion

Although testing capacities improved significantly during the pandemic, case detection and access to testing remained suboptimal. The four countries could benefit from further simplification of testing modalities and cost reduction. Local manufacturing and pooled procurement mechanisms for diagnostics are needed for optimal pandemic preparedness and response.

Consequences of school closures due to COVID-19 in DRC, Nigeria, Senegal, and Uganda

In 2020 and 2021, Governments across the globe instituted school closures to reduce social interaction and interrupt COVID-19 transmission. We examined the consequences of school closures due to COVID-19 across four sub-Saharan African countries: the Democratic Republic of Congo (DRC), Nigeria, Senegal, and Uganda. We conducted a qualitative study among key informants including policymakers, school heads, students, parents, civil society representatives, and local leaders. The assessment of the consequences of school closures was informed by the Diffusion of Innovations theory which informed the interview guide and analysis. Interview transcripts were thematically analysed. Across the four countries, schools were totally closed for 120 weeks and partially closed for 48 weeks. School closures led to: i) Desirable and anticipated consequences: enhanced adoption of online platforms and mass media for learning and increased involvement of parents in their children's education. ii) Desirable and unanticipated consequences: improvement in information, communication, and technology (ICT) infrastructure in schools, development and improvement of computer skills, and created an opportunity to take leave from hectic schedules. iii) Undesirable anticipated consequences: inadequate education continuity among students, an adjustment in academic schedules and programmes, and disrupted student progress and grades. iv) Undesirable unanticipated: increase in sexual violence including engaging in transactional sex, a rise in teenage pregnancy, and school dropouts, demotivation of teachers due to reduced incomes, and reduced school revenues. v) Neutral consequences: engagement in revenue-generating activities, increased access to phones and computers among learners, and promoted less structured learning. The consequences of school closures for COVID-19 control were largely negative with the potential for both short-term and far-reaching longer-term consequences. In future pandemics, careful consideration of the type and duration of education closure measures and examination of their potential consequences in the short and long term is important before deploying them.

Harnessing digital technology for COVID-19 response in Uganda: lessons and implications for future public health emergencies

COVID-19 was one of the greatest disruptors of the 21st century, causing significant morbidity and mortality globally. Countries around the world adopted digital technologies and innovations to support the containment of the pandemic. This study explored the use of digital technology and barriers to its utilisation in responding to COVID-19 and sustaining essential health services in Uganda to inform response to future public health emergencies in low-resource settings. We reviewed published and grey literature on the use of digital technology in Uganda's response from March 2020 to April 2021 and conducted interviews with key informants. We thematically synthesised and summarised information on digital technology use as well as related challenges. During the COVID-19 response, digital technology was used in testing, contact tracing and surveillance, risk communication, supportive supervision and training, and maintenance of essential health services. The challenges with technology use were the disparate digital tools and health information systems leading to duplication of effort; limited access and coverage of digital tools, poor data quality; inaccessibility of data and an inability to support data manipulation, analysis and visualisation. Moreover, the inherent inadequate technology support systems such as poor internet and electricity infrastructure in some areas posed challenges of inequity. The harnessing of technology was key in supporting the COVID-19 response in Uganda. However, gaps existed in access, adoption, harmonisation, evaluation, sustainability and scale up of technology options. These issues should be addressed in preparedness efforts to foster technology adoption and application in public health emergencies with a focus on equity.

Defining Collective Priorities: Research and Learning Agendas for Family Planning Across 6 Countries

Evidence should be the foundation for a well-designed family planning (FP) program, but existing evidence is rarely aligned with and/or synthesized to speak directly to FP programmatic needs. Based on our experience cocreating FP research and learning agendas (FP RLAs) in Côte d'Ivoire, Malawi, Mozambique, Nepal, Niger, and Uganda, we argue that FP RLAs can drive the production of coordinated research that aligns with national priorities.To cocreate FP RLAs, stakeholders across 6 countries conducted desk reviews of 349 documents and 106 key informant interviews, organized consultation meetings in each country to prioritize evidence gaps and generate research and learning questions, and, ultimately, formed 6 FP RLAs comprising 190 unique questions. We outline the process for consensus-driven development of FP RLAs and communicate the results of an analysis of the questions in each FP RLA across 4 technical areas: self-care, equity, high impact practices, and youth. Each question was categorized as a learning versus research question, the former indicating an opportunity to synthesize existing evidence and the latter to conduct new research to answer the question. Themes emerging from the data shed light on shared evidence gaps across the 6 countries. We argue that similarities and differences in the questions in each FP RLA reflect the unique implementation experience and context, as well as each country's placement on the FP S-curve. Early uses of the FP RLAs include informing the development of FP costed implementation plans and FP2030 commitments. FP RLAs have also been discussed in multiple thematic working groups. For FP stakeholders, these FP RLAs represent a consensus-based agenda that can guide the generation and synthesis of evidence to answer each country's most pressing questions, ultimately driving progress toward increasingly evidence-based programming and policy.

Knowledge, perceptions and uptake of human papilloma virus vaccine among adolescent girls in Kampala, Uganda; a mixed-methods school-based study

BACKGROUND

Cervical cancer is a major public health challenge, accounting for substantial morbidity and mortality. Human Papilloma Virus (HPV) vaccination is the recommended primary public health intervention for HPV infection prevention. However, there's limited evidence on the level of knowledge, attitude, and practices of adolescent girls regarding HPV vaccination in Kampala city, Uganda. This study assessed the knowledge, perceptions, and practices of adolescent girls aged 10-14 years towards HPV vaccination program in Kampala, Uganda to generate evidence to guide programs targeted at improving uptake of the vaccine.

METHODS

A convergent parallel mixed methods study was conducted in Kampala, Uganda. A structured questionnaire was used to elicit data from 524 adolescent girls. In addition, 6 Focus group discussions, and 24 key informant interviews (teacher and parents) were conducted. Multistage and purposive sampling techniques were used to select quantitative and qualitative participants respectively. Quantitative data were entered using epidata, cleaned and analyzed using Stata v14 while qualitative data were analyzed using thematic content analysis in atlas ti version 8.

RESULTS

Overall, only 8.6% (45/524) of the girls had completed the HPV vaccine schedule of two dozes, 49.2% (258/524) of the girls had low knowledge about the HPV vaccine and teachers and parents affirmed this lack of knowledge among adolescent girls especially concerning the target age group, dosage, and vaccine interval. About 51.9% (272/524) of girls had negative perceptions towards HPV vaccination. Parents expressed negative perceptions, beliefs, superstitions, and safety concerns of the vaccine.Girls residing in rural areas (adjusted prevalence ratio, aPR = 0.35, C. I = 0.14-0.85) had lower knowledge levels compared to those in urban areas. Girls whose mothers were healthcare providers (aPR = 1.94, C. I = 1.10-3.41), girls with high knowledge levels (aPR = 1.79, C. I = 1.21-2.63) and positive perceptions (aPR = 2.87, C. I = 1.93-4.27) had a higher prevalence of being fully vaccinated.

CONCLUSION

Girls generally had low levels of knowledge, negative perceptions, and poor uptake of HPV vaccination. We recommend sensitization campaigns in schools and communities to improve awareness, perceptions, and practices of stakeholders towards HPV vaccination.

Unintended consequences of implementing non-pharmaceutical interventions for the COVID-19 response in Africa: experiences from DRC, Nigeria, Senegal, and Uganda

INTRODUCTION

The coronavirus (COVID 19) pandemic is one of the most terrifying disasters of the twenty-first century. The non-pharmaceutical interventions (NPIs) implemented to control the spread of the disease had numerous positive consequences. However, there were also unintended consequences-positively or negatively related to the nature of the interventions, the target, the level and duration of implementation. This article describes the unintended economic, Psychosocial and environmental consequences of NPIs in four African countries.

METHODS

We conducted a mixed-methods study in the Democratic Republic of Congo (DRC), Nigeria, Senegal and Uganda. A comprehensive conceptual framework, supported by a clear theory of change was adopted to encompass both systemic and non-systemic interventions. The data collection approaches included: (i) review of literature; (ii) analysis of secondary data for selected indicators; and (ii) key informant interviews with policy makers, civil society, local leaders, and law enforcement staff. The results were synthesized around thematic areas.

RESULTS

Over the first six to nine months of the pandemic, NPIs especially lockdowns, travel restrictions, curfews, school closures, and prohibition of mass gathering resulted into both positive and negative unintended consequences cutting across economic, psychological, and environmental platforms. DRC, Nigeria, and Uganda observed reduced crime rates and road traffic accidents, while Uganda also reported reduced air pollution. In addition, hygiene practices have improved through health promotion measures that have been promoted for the response to the pandemic. All countries experienced economic slowdown, job losses heavily impacting women and poor households, increased sexual and gender-based violence, teenage pregnancies, and early marriages, increased poor mental health conditions, increased waste generation with poor disposal, among others.

CONCLUSION

Despite achieving pandemic control, the stringent NPIs had several negative and few positive unintended consequences. Governments need to balance the negative and positive consequences of NPIs by anticipating and instituting measures that will support and protect vulnerable groups especially the poor, the elderly, women, and children. Noticeable efforts, including measures to avoid forced into marriage, increasing inequities, economic support to urban poor; those living with disabilities, migrant workers, and refugees, had been conducted to mitigate the negative effects of the NIPs.

Uptake of COVID-19 vaccines and associated factors among adults in Uganda: a cross-sectional survey

OBJECTIVE

COVID-19 pandemic remains one of the most significant public health challenges ever faced globally. Vaccines are key to ending the pandemic as well as minimise its consequences. This study determined the uptake of COVID-19 vaccines and associated factors among adults in Uganda.

DESIGN, SETTING AND PARTICIPANTS

We conducted a cross-sectional mobile phone survey among adults in Uganda.

MAIN OUTCOME VARIABLE

Participants reported their uptake of COVID-19 vaccines.

RESULTS

Of the participants contacted, 94% (1173) completed the survey. Overall, 49.7% had received COVID-19 vaccines with 19.2% having obtained a full dose and 30.5% an incomplete dose. Among the unvaccinated, 91.0% indicated intention to vaccinate. Major reasons for vaccine uptake were protection of self from COVID-19 (86.8%) and a high perceived risk of getting the virus (19.6%). On the other hand, non-uptake was related to vaccine unavailability (42.4%), lack of time (24.1%) and perceived safety (12.5%) and effectiveness concerns (6.9%). The factors associated with receiving COVID-19 vaccines were older age (≥65 years) (Adjusted Prevalence Ratio (APR)=1.32 (95% CI: 1.08 to 1.61)), secondary (APR=1.36 (95% CI: 1.12 to 1.65)) or tertiary education (APR=1.62 (95% CI: 1.31 to 2.00)) and health workers as a source of information on COVID-19 (APR=1.26 (95% CI: 1.10 to 1.45)). Also, reporting a medium-income (APR=1.24 (95% CI: 1.02 to 1.52)) and residence in Northern (APR=1.55, 95% CI: 1.18 to 2.02) and Central regions (APR=1.48, 95% CI: 1.16 to 1.89) were associated with vaccine uptake.

CONCLUSIONS

Uptake of COVID-19 vaccines was moderate in this sample and was associated with older age, secondary and tertiary education, medium-income, region of residence and health workers as a source of COVID-19 information. Efforts are needed to increase access to vaccines and should use health workers as champions to enhance uptake.

Designed to Fail? Revisiting Uganda's Maternal Health Policies to Understand Policy Design Issues Underpinning Missed Targets for Reduction of Maternal Mortality Ratio (MMR): 2000-2015

BACKGROUND

Despite Uganda and other sub-Saharan African countries missing their maternal mortality ratio (MMR) targets for Millennium Development Goal (MDG) 5, limited attention has been paid to policy design in the literature examining the persistence of preventable maternal mortality. This study examined the specific policy interventions designed to reduce maternal deaths in Uganda and identified particular policy design issues that underpinned MDG 5 performance. We suggest a novel prescriptive and analytical (re)conceptualization of policy in terms of its fidelity to '3Cs' (coherence of design, comprehensiveness of coverage and consistency in application) that could have implications for future healthcare programming.

METHODS

We conducted a retrospective study. Sixteen Ugandan maternal health policy documents and 21 national programme performance reports were examined, and six key informant interviews conducted with national stakeholders managing maternal health programmes during the reference period 2000-2015. We applied the analytical framework of the 'three delay model' combined with a broader literature on 'policy mixing.'

RESULTS

Despite introducing fourteen separate policy instruments over 15 years with the goal of reducing maternal mortality, by the end of the MDG period in 2015, only 87.5% of the interventions for the three delays were covered with a notable lack of coherence and consistency evident among the instruments. The three delays persisted at the frontline with 70% of deaths by 2014 attributed to failures in referral policies while 67% of maternal deaths were due to inadequacies in healthcare facilities and trained personnel in the same period. By 2015, 37.3% of deaths were due to transportation issues.

CONCLUSION

The piecemeal introduction of additional policy instruments frequently distorted existing synergies among policies resulting in persistence of the three delays and missed MDG 5 target. Future policy reforms should address the 'three delays' but also ensure fidelity of policy design to coherence, comprehensiveness and consistency.

Interventions for Maintenance of Essential Health Service Delivery during the COVID-19 Response in Uganda, between March 2020 and April 2021

INTRODUCTION

The COVID-19 pandemic overwhelmed health systems globally and affected the delivery of health services. We conducted a study in Uganda to describe the interventions adopted to maintain the delivery of other health services.

METHODS

We reviewed documents and interviewed 21 key informants. Thematic analysis was conducted to identify themes using the World Health Organization health system building blocks as a guiding framework.

RESULTS

Governance strategies included the establishment of coordination committees and the development and dissemination of guidelines. Infrastructure and commodity strategies included the review of drug supply plans and allowing emergency orders. Workforce strategies included the provision of infection prevention and control equipment, recruitment and provision of incentives. Service delivery modifications included the designation of facilities for COVID-19 management, patient self-management, dispensing drugs for longer periods and the leveraging community patient networks to distribute medicines. However, multi-month drug dispensing led to drug stock-outs while community drug distribution was associated with stigma.

CONCLUSIONS

Health service maintenance during emergencies requires coordination to harness existing health system investments. The essential services continuity committee coordinated efforts to maintain services and should remain a critical element of emergency response. Self-management and leveraging patient networks should address stigma to support service continuity in similar settings and strengthen service delivery beyond the pandemic.

Private sector engagement in the COVID-19 response: experiences and lessons from the Democratic Republic of Congo, Nigeria, Senegal and Uganda

BACKGROUND

Private entities play a major role in health globally. However, their contribution has not been fully optimized to strengthen delivery of public health services. The COVID-19 pandemic has overwhelmed health systems and precipitated coalitions between public and private sectors to address critical gaps in the response. We conducted a study to document the public and private sector partnerships and engagements to inform current and future responses to public health emergencies.

METHODS

This was a multi-country cross-sectional study conducted in the Democratic Republic of Congo, Nigeria, Senegal and Uganda between November 2020 and March 2021 to assess responses to the COVID-19 pandemic. We conducted a scoping literature review and key informant interviews (KIIs) with private and public health sector stakeholders. The literature reviewed included COVID-19 country guidelines and response plans, program reports and peer-reviewed and non-peer-reviewed publications. KIIs elicited information on country approaches and response strategies specifically the engagement of the private sector in any of the strategic response operations.

RESULTS

Across the 4 countries, private sector strengthened laboratory systems, COVID-19 case management, risk communication and health service continuity. In the DRC and Nigeria, private entities supported contact tracing and surveillance activities. Across the 4 countries, the private sector supported expansion of access to COVID-19 testing services through establishing partnerships with the public health sector albeit at unregulated fees. In Senegal and Uganda, governments established partnerships with private sector to manufacture COVID-19 rapid diagnostic tests. The private sector also contributed to treatment and management of COVID-19 cases. In addition, private entities provided personal protective equipment, conducted risk communication to promote adherence to safety procedures and health promotion for health service continuity. However, there were concerns related to reporting, quality and cost of services, calling for quality and price regulation in the provision of services.

CONCLUSIONS

The private sector contributed to the COVID-19 response through engagement in COVID-19 surveillance and testing, management of COVID-19 cases, and health promotion to maintain health access. There is a need to develop regulatory frameworks for sustainable public-private engagements including regulation of pricing, quality assurance and alignment with national plans and priorities during response to epidemics.

Primary care provider notions on instituting community-based geriatric support in Uganda

Background

Understanding of the most economical and sustainable models of providing geriatric care to Africa’s rising ageing population is critical. In Uganda, the number of old adults (60 years and above) continues to rise against absence of policies and guidelines, and models for providing care to this critical population. Our study explored public primary health care provider views on how best community-based geriatric support (CBGS) could be instituted as an adaptable model for delivering geriatric care in Uganda’s resource-limited primary public health care settings.

Methods

We interviewed 20 key informants from four districts of Bukomansimbi, Kalungu, Rakai, and Lwengo in Southern Central Uganda. Respondents were leads (in-charges) of public primary health units that had spent at least 6 months at the fore said facilities. All interviews were audio-recorded, transcribed verbatim, and analysed based on Hsieh and Shannon’s approach to conventional manifest content analysis.

Results

During analysis, four themes emerged: 1) Structures to leverage for CBGS, 2) How to promote CBGS, 3) Who should be involved in CBGS, and 4) What activities need to be leveraged to advance CBGS? The majority of the respondents viewed using the existing village health team and local leadership structures as key to the successful institutionalization of CBGS; leveraging community education and sensitization using radio, television, and engaging health workers, family relatives, and neighbors. Health outreach activities were mentioned as one of the avenues that could be leveraged to provide CBGS.

Conclusion

Provider notions pointed to CBGS as a viable model for instituting geriatric care in Uganda’s public primary healthcare system. However, this requires policymakers to leverage existing village health team and local governance structures, conduct community education and sensitization about CBGS, and bring onboard health workers, family relatives, and neighbors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02897-9.

Challenges in implementing emergency obstetric care (EmOC) policies: perspectives and behaviours of frontline health workers in Uganda

Uganda is among the sub-Saharan African Countries which continue to experience high preventable maternal mortality due to obstetric emergencies. Several Emergency Obstetric Care (EmOC) policies rolled out have never achieved their intended targets to date. To explore why upstream policy expectations were not achieved at the frontline during the MDG period, we examined the implementation of EmOC policies in Uganda by; exploring the barriers frontline implementers of EmOC policies faced, their coping behaviours and the consequences for maternal health. We conducted a retrospective exploratory qualitative study between March and June 2019 in Luwero, Iganga and Masindi districts selected based on differences in maternal mortality. Data were collected using 8 in-depth interviews with doctors and 17 midwives who provided EmOC services in Uganda's public health facilities during the MDG period. We reviewed two national maternal health policy documents and interviewed two Ministry of Health Officials on referral by participants. Data analysis was guided by the theory of Street-Level Bureaucracy (SLB). Implementation of EmOC was affected by the incompatibility of policies with implementation systems. Street-level bureaucrats were expected to offer to their continuously increasing clients, sometimes presenting late, ideal EmOC services using an incomplete and unreliable package of inputs, supplies, inadequate workforce size and skills mix. To continue performing their duties and prevent services from total collapse, frontline implementers' coping behaviours oftentimes involved improvization leading to delivery of incomplete and inconsistent EmOC service packages. This resulted in unresponsive EmOC services with mothers receiving inadequate interventions sometimes after major delays across different levels of care. We suggest that SLB theory can be enriched by reflecting on the consequences of the coping behaviours of street-level bureaucrats. Future reforms should align policies to implementation contexts and resources for optimal results.

"The Actor Is Policy": Application of Elite Theory to Explore Actors' Interests and Power Underlying Maternal Health Policies in Uganda, 2000-2015

Background: The persistence of high maternal mortality and consistent failure in low- and middle-income countries to achieve global targets such as Millennium Development Goal five (MDG 5) is usually explained from epidemiological, interventional and health systems perspectives. The role of policy elites and their interests remains inadequately explored in this debate. This study examined elites and how their interests drove maternal health policies and actions in ways that could explain policy failure for MDG 5 in Uganda.

Methods: We conducted a retrospective qualitative study of Uganda’s maternal health policies from 2000 to 2015 (MDG period). Thirty key informant interviews and 2 focus group discussions (FGDs) were conducted with national policy-makers, who directly participated in the formulation of Uganda’s maternal health policies during the MDG period. We reviewed 9 National Maternal Health Policy documents. Data were analysed inductively using elite theory.

Results: Maternal health policies were mainly driven by a small elite group comprised of Senior Ministry of Health (MoH) officials, some members of cabinet and health development partners (HDPs) who wielded more power than other actors. The resulting policies often appeared to be skewed towards elites’ personal political and economic interests, rather than maternal mortality reduction. For a few, however, interests aligned with reducing maternal mortality. Since complying with the government policy-making processes would have exposed elites’ personal interests, they mainly drafted policies as service standards and programme documents to bypass the formal policy process.

Conclusion: Uganda’s maternal health policies were mainly influenced by the elites’ personal interests rather than by the goal of reducing maternal mortality. This was enabled by the formal guidance for policy-making which gives elites control over the policy process. Accelerating maternal mortality reduction will require re-engineering the policy process to prevent public officials from infusing policies with their interests, and enable percolation of ideas from the public and frontline.

Maternal health challenges experienced by adolescents; could community score cards address them? A case study of Kibuku District- Uganda

INTRODUCTION

Approximately 34.8% of the Ugandan population is adolescents. The national teenage pregnancy rate is 25% and in Kibuku district, 17.6% of adolescents aged 12-19 years have begun child bearing. Adolescents mothers are vulnerable to many maternal health challenges including; stigma, unfriendly services and early marriages. The community score card (CSC) is a social accountability tool that can be used to point out challenges faced by the community in service delivery and utilization and ultimately address them. In this paper we aimed to document the challenges faced by adolescents during pregnancy, delivery and postnatal period and the extent to which the community score card could address these challenges.

METHODS

This qualitative study utilized in-depth interviews conducted in August 2018 among 15 purposively selected adolescent women who had given birth 2 years prior to the study and had attended CSC meetings. The study was conducted in six sub counties of Kibuku district where the CSC intervention was implemented. Research assistants transcribed the audio-recorded interviews verbatim, and data was analyzed manually using the framework analysis approach.

FINDINGS

This study found five major maternal health challenges faced by adolescents during pregnancy namely; psychosocial challenges, physical abuse, denial of basic human rights, unfriendly adolescent services, lack of legal and cultural protection, and lack of birth preparedness. The CSC addressed general maternal and new born health issues of the community as a whole rather than specific adolescent health related maternal health challenges.

CONCLUSION

The maternal health challenges faced by adolescents in Kibuku have a cultural, legal, social and health service dimension. There is therefore need to look at a multi-faceted approach to holistically address them. CSCs that are targeted at the entire community are unlikely to address specific needs of vulnerable groups such as adolescents. To address the maternal health challenges of adolescents, there is need to have separate meetings with adolescents, targeted mobilization for adolescents to attend meetings and deliberate inclusion of their maternal health challenges into the CSC.

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

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.

Uganda's laboratory human resource in the era of global health initiatives: experiences, constraints and opportunities-an assessment of 100 facilities

INTRODUCTION

Laboratories are vital in disease diagnosis, prevention, treatment and outbreak investigations. Although recent decades have seen rapid advancements in modernised equipment and laboratory processes, minimal investments have been made towards strengthening laboratory professionals in Africa. This workforce is characterised by insufficient numbers, skewed rural-urban distribution, inadequate qualifications, inadequate skill-mix and limited career opportunities. These factors adversely affect the performance of laboratory professionals, who are the backbone of quality services. In the era of Global Health Initiatives, this study describes the status of laboratory human resource and assesses the experiences, constrains and opportunities for strengthening them in Uganda.

METHODS

This paper is part of a study, which assessed laboratory capacity in 21 districts during December 2015 to January 2016. We collected data using a laboratory assessment tool adapted from the WHO and USAID assessment tool for laboratory services and supply chain (ATLAS), 2006. Of the 100 laboratories, 16 were referral laboratories (hubs). To assess human resource constraints, we conducted 100 key informant interviews with laboratory managers and in charges.

RESULTS

Across the facilities, there was an excess number of laboratory technicians at Health Center (HC) IV level by 30% and laboratory assistants were in excess by 90%. There was a shortage of laboratory technologists with only 50% of the posts filled at general hospitals. About 87.5% of hub laboratories had conducted formal onsite training compared to 51.2% of the non-hub laboratories. Less than half of HC III laboratories had conducted a formal onsite training; hospital laboratories had not conducted training on the use and maintenance of equipment. Almost all HC III laboratories had been supervised though supervision focused on HIV/AIDS. Financial resources, workload and lack of supervision were major constraints to human resource strengthening.

CONCLUSION

Although opportunities for continuous education have emerged over the past decade, they are still threatened by inadequate staffing, skill mix and escalating workload. Moreover, excesses in staffing are more in favour of HIV, TB and malaria. The Ministry of Health needs to develop work-based staffing models to ensure adequate staff numbers and skill mix. Staffing norms need to be revised to accommodate laboratory technologists and scientists at high-level laboratories. Training needs to extend beyond HIV, TB and malaria.

Health systems readiness to provide geriatric friendly care services in Uganda: a cross-sectional study

Background

As ageing emerges as the next public health threat in Africa, there is a paucity of information on how prepared its health systems are to provide geriatric friendly care services. In this study, we explored the readiness of Uganda’s public health system to offer geriatric friendly care services in Southern Central Uganda.

Methods

Four districts with the highest proportion of old persons in Southern Central Uganda were purposively selected, and a cross-section of 18 randomly selected health facilities (HFs) were visited and assessed for availability of critical items deemed important for provision of geriatric friendly services; as derived from World Health Organization’s Age-friendly primary health care centres toolkit. Data was collected using an adapted health facility geriatric assessment tool, entered into Epi-data software and analysed using STATA version 14. Kruskal-Wallis and Dunn’s post hoc tests were conducted to determine any associations between readiness, health facility level, and district.

Results

The overall readiness index was 16.92 (SD ±4.19) (range 10.8–26.6). This differed across districts; Lwengo 17.91 (SD ±3.15), Rakai 17.63 (SD ±4.55), Bukomansimbi 16.51 (SD ±7.18), Kalungu 13.74 (SD ±2.56) and facility levels; Hospitals 26.62, Health centers four (HCIV) 20.05 and Health centers three (HCIII) 14.80. Low readiness was due to poor scores concerning; leadership (0%), financing (0%), human resources (1.7%) and health management information systems (HMIS) (11.8%) WHO building blocks. Higher-level HFs were statistically significantly friendlier than lower-level HFs (p = 0.015). The difference in readiness between HCIIIs and HCIVs was 2.39 (p = 0.025).

Conclusion

There is a low readiness for public health facilities to provide geriatric friendly care services in Uganda. This is due to gaps in all of the health system building blocks. There is a need for health system reforms in Uganda to adequately cater for service provision for older adults if the 2020 global healthy ageing goal is to be met.

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

Maternal and newborn health needs for women with walking disabilities; "the twists and turns": a case study in Kibuku District Uganda

Background

In Uganda 13% of persons have at least one form of disability. The United Nations’ Convention on the Rights of Persons with Disabilities guarantees persons with disabilities the same level of right to access quality and affordable healthcare as persons without disability. Understanding the needs of women with walking disabilities is key in formulating flexible, acceptable and responsive health systems to their needs and hence to improve their access to care. This study therefore explores the maternal and newborn health (MNH)-related needs of women with walking disabilities in Kibuku District Uganda.

Methods

We carried out a qualitative study in September 2017 in three sub-counties of Kibuku district. Four In-depth Interviews (IDIs) among purposively selected women who had walking disabilities and who had given birth within two years from the study date were conducted. Trained research assistants used a pretested IDI guide translated into the local language to collect data. All IDIs were audio recorded and transcribed verbatim before analysis. The thematic areas explored during analysis included psychosocial, mobility, health facility and personal needs of women with walking disabilities. Data was analyzed manually using framework analysis.

Results

We found that women with walking disabilities had psychosocial, mobility, special services and personal needs.

Psychosocial needs included; partners’, communities’, families’ and health workers’ acceptance. Mobility needs were associated with transport unsuitability, difficulty in finding transport and high cost of transport. Health facility needs included; infrastructure, and responsive health services needs while personal MNH needs were; personal protective wear, basic needs and birth preparedness items.

Conclusions

Women with walking disabilities have needs addressable by their communities and the health system. Communities, and health workers need to be sensitized on these needs and policies to meet and implement health system-related needs of women with disability.

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

'Nurture the sprouting bud; do not uproot it'. Using saving groups to save for maternal and newborn health: lessons from rural Eastern Uganda

Background: Saving groups are increasingly being used to save in many developing countries. However, there is limited literature about how they can be exploited to improve maternal and newborn health.

Objectives: This paper describes saving practices, factors that encourage and constrain saving with saving groups, and lessons learnt while supporting communities to save through saving groups.

Methods: This qualitative study was done in three districts in Eastern Uganda. Saving groups were identified and provided with support to enhance members’ access to maternal and newborn health. Fifteen focus group discussions (FGDs) and 18 key informant interviews (KIIs) were conducted to elicit members’ views about saving practices. Document review was undertaken to identify key lessons for supporting saving groups. Qualitative data are presented thematically.

Results: Awareness of the importance of saving, safe custody of money saved, flexible saving arrangements and easy access to loans for personal needs including transport during obstetric emergencies increased willingness to save with saving groups. Saving groups therefore provided a safety net for the poor during emergencies. Poor management of saving groups and detrimental economic practices like gambling constrained saving. Efficient running of saving groups requires that they have a clear management structure, which is legally registered with relevant authorities and that it is governed by a constitution.

Conclusions: Saving groups were considered a useful form of saving that enabled easy acess to cash for birth preparedness and transportation during emergencies. They are like ‘a sprouting bud that needs to be nurtured rather than uprooted’, as they appear to have the potential to act as a safety net for poor communities that have no health insurance. Local governments should therefore strengthen the management capacity of saving groups so as to ensure their efficient running through partnerships with non-governmental organizations that can provide support to such groups.

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

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.

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

Electronic supplementary material

The online version of this article (doi:10.1186/s12961-017-0273-x) contains supplementary material, which is available to authorized users.

A structural equation analysis on the relationship between maternal health services utilization and newborn health outcomes: a cross-sectional study in Eastern Uganda

Background

Neonatal and maternal health services have a bearing on neonatal mortality. Direct and indirect factors affecting neonatal health outcomes therefore require understanding to enable well-targeted interventions. This study, therefore, assessed the interrelationship between newborn health outcomes and maternal service utilization factors.

Methods

We investigated maternal health utilization factors using health facility delivery and at least four Antenatal Care (ANC) visits; and newborn health outcomes using newborn death and low birth weight (LBW). We used data from a household cross-sectional survey that was conducted in 2015 in Kamuli, Pallisa and Kibuku districts. We interviewed 1946 women who had delivered in the last 12 months. The four interrelated (Endogenous) outcomes were ANC attendance, health facility delivery, newborn death, and LBW. We performed analysis using a structural equation modeling technique.

Results

A history of newborn death (aOR = 12.64, 95% CI 5.31–30.10) and birth of a LBW baby (aOR = 3.51, 95% CI 1.48–8.37) were directly related to increased odds of newborn death. Factors that reduced the odds of LBW as a mediating factor for newborn death were ANC fourth time attendance (aOR = 0.62, 95% CI 0.45–0.85), having post-primary level education (aOR = 0.68, 95% CI 0.46–0.98) compared to none and being gravida three (aOR = 0.49, 95% CI 0.26–0.94) compared to being gravida one. Mother’s age group, 20–24 (aOR = 0.24, 95% CI 0.08–0.75) and 25–29 years (aOR = 0.20, 95% CI 0.05–0.86) compared to 15–19 years was also associated with reduced odds of LBW. Additionally, ANC visits during the first trimester (aOR = 2.04, 95% CI 1.79–2.34), and village health teams (VHTs) visits while pregnant (aOR = 1.14, 95% CI 1.01–1.30) were associated with increased odds of at least four ANC visits, which is a mediating factor for health facility delivery, LBW and newborn death. Surprisingly, newborn death was not significantly different between health facility and community deliveries.

Conclusions

Attending ANC at least four times was a mediating factor for reduced newborn death and low birth weight. Interventions in maternal health and newborn health should focus on factors that increase ANC fourth time attendance and those that reduce LBW especially in resource-limited settings. Targeting women with high-risk pregnancies is also crucial for reducing newborn deaths.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1289-5) contains supplementary material, which is available to authorized users.

Building a competent health manager at district level: a grounded theory study from Eastern Uganda

BACKGROUND

Health systems in low-income countries are often characterized by poor health outcomes. While many reasons have been advanced to explain the persistently poor outcomes, management of the system has been found to play a key role. According to a WHO framework, the management of health systems is central to its ability to deliver needed health services. In this study, we examined how district managers in a rural setting in Uganda perceived existing approaches to strengthening management so as to provide a pragmatic and synergistic model for improving management capacity building.

METHODS

Twenty-two interviews were conducted with district level administrative and political managers, district level health managers and health facility managers to understand their perceptions and definitions of management and capacity building. Kathy Charmaz's constructive approach to grounded theory informed the data analysis process.

RESULTS

An interative, dynamic and complex model with three sub-process of building a competent health manager was developed. A competent manager was understood as one who knew his/her roles, was well informed and was empowered to execute management functions. Professionalizing health managers which was viewed as the foundation, the use of engaging learning approaches as the inside contents and having a supportive work environment the frame of the model were the sub-processes involved in the model. The sub-processes were interconnected although the respondents agreed that having a supportive work environment was more time and effort intensive relative to the other two sub-processes.

CONCLUSIONS

The model developed in our study makes four central contributions to enhance the WHO framework and the existing literature. First, it emphasizes management capacity building as an iterative, dynamic and complex process rather than a set of characteristics of competent managers. Second, our model suggests the need for professionalization of health managers at different levels of the health system. Third, our model underscores the benefits that could be accrued from the use of engaging learning approaches through prolonged and sustained processes that act in synergy. Lastly, our model postulates that different resource investments and a varied range of stakeholders could be required at each of the sub-processes.

Regulatory mechanisms for absenteeism in the health sector: a systematic review of strategies and their implementation

BACKGROUND

A systematic review was undertaken to identify regulatory mechanisms aimed at mitigating health care worker absenteeism, to describe where and how they have been implemented as well as their possible effects. The goal was to propose potential policy options for managing the problem of absenteeism among human resources for health in low- and middle-income countries. Mechanisms described in this review are at the local workplace and broader national policy level.

METHODS

A comprehensive online search was conducted on EMBASE, CINAHL, PubMed, Google Scholar, Google, and Social Science Citation Index using MEDLINE search terms. Retrieved studies were uploaded onto reference manager and screened by two independent reviewers. Only publications in English were included. Data were extracted and synthesized according to the objectives of the review.

RESULTS

Twenty six of the 4,975 published articles retrieved were included. All were from high-income countries and covered all cadres of health workers. The regulatory mechanisms and possible effects include 1) organizational-level mechanisms being reported as effective in curbing absenteeism in low- and middle-income countries (LMICs); 2) prohibition of private sector activities in LMICs offering benefits but presenting a challenge for the government to monitor the health workforce; 3) contractual changes from temporary to fixed posts having been associated with no reduction in absenteeism and not being appropriate for LMICs; 4) multifaceted work interventions being implemented in most settings; 5) the possibility of using financial and incentive regulatory mechanisms in LMICs; 6) health intervention mechanisms reducing absenteeism when integrated with exercise programs; and 7) attendance by legislation during emergencies being criticized for violating human rights in the United States and not being effective in curbing absenteeism.

CONCLUSION

Most countries have applied multiple strategies to mitigate health care worker absenteeism. The success of these interventions is heavily influenced by the context within which they are applied.

The neonatal mortality and its determinants in rural communities of Eastern Uganda

Background

In Uganda, neonatal mortality rate (NMR) remains high at 27 deaths per 1000 live births. There is paucity of data on factors associated with NMR in rural communities in Uganda. The objective of this study was to determine NMR as well as factors associated with neonatal mortality in the rural communities of three districts from eastern Uganda.

Methods

Data from a baseline survey of a maternal and newborn intervention in the districts of Pallisa, Kibuku and Kamuli, Eastern Uganda was analyzed. A total of 2237 women who had delivered in the last 12 months irrespective of birth outcome were interviewed in the survey. The primary outcome for this paper was neonatal mortality. The risk ratio (RR) was used to determine the factors associated with neonatal mortality using log - binomial model.

Results

The neonatal mortality was found to be 34 per 1000 live births (95 % CI = 27.1–42.8); Kamuli 31.9, Pallisa 36.5 and Kibuku 30.8. Factors associated with increased neonatal deaths were parity of 5+ (adj. RR =2.53, 95 % CI =1.14–5.65) relative to parity of 4 and below, newborn low birth weight (adj. RR = 3.10, 95 % CI = 1.47–6.56) and presence of newborn danger signs (adj. RR = 2.42, 95 % CI = 1.04–5.62). Factors associated with lower risk of neonatal death were, home visits by community health workers’ (CHW) (adj. RR =0.13, 95 % CI = 0.02–0.91), and attendance of at least 4 antenatal visits (adj. RR = 0.65, 95 % CI = 0.43–0.98).

Conclusions

Neonatal mortality in rural communities is higher than the national average. The use of CHW’s to mobilize and sensitize households on appropriate maternal and newborn care practices could play a key role in reducing neonatal mortality.

Evaluation of a health systems knowledge translation network for Africa (KTNET): a study protocol

Background

Despite the increasing investment in health-related research in Sub-Saharan Africa, a large gulf remains between what is known and what is practiced in health systems. Knowledge translation programs aim to ensure that a wide range of stakeholders are aware of and use research evidence to inform their health and health-care decision-making. The purpose of this study is to provide insight into the impacts on capacity building for knowledge translation and knowledge translation activities by a coalition of eight research groups in Africa.

Methods/design

We will use a mixed methods approach. Key informant interviews and document reviews will be employed to evaluate changes in knowledge translation capacity and to evaluate the effects of knowledge translation on potential users of research. Quarterly teleconferences will be done to evaluate the impacts of knowledge translation activities on users of research. Using website tracking, we will be able to explore the influence of knowledge translation networking and dynamics of the knowledge translation network.

Discussion

We have adopted the dynamic knowledge transfer model and the Landry framework to come up with a framework for this study so as to explore the capacity of producers and users of research to generate, disseminate, and use research findings, while highlighting their strengths and weaknesses. This information will be useful for guiding implementers that seek to build capacity on knowledge translation so as to promote the utilization of research findings for informing programs, practice, and policy.

Evaluation of a health systems knowledge translation network for Africa (KTNET): a study protocol

BACKGROUND

Despite the increasing investment in health-related research in Sub-Saharan Africa, a large gulf remains between what is known and what is practiced in health systems. Knowledge translation programs aim to ensure that a wide range of stakeholders are aware of and use research evidence to inform their health and health-care decision-making. The purpose of this study is to provide insight into the impacts on capacity building for knowledge translation and knowledge translation activities by a coalition of eight research groups in Africa.

METHODS/DESIGN

We will use a mixed methods approach. Key informant interviews and document reviews will be employed to evaluate changes in knowledge translation capacity and to evaluate the effects of knowledge translation on potential users of research. Quarterly teleconferences will be done to evaluate the impacts of knowledge translation activities on users of research. Using website tracking, we will be able to explore the influence of knowledge translation networking and dynamics of the knowledge translation network.

DISCUSSION

We have adopted the dynamic knowledge transfer model and the Landry framework to come up with a framework for this study so as to explore the capacity of producers and users of research to generate, disseminate, and use research findings, while highlighting their strengths and weaknesses. This information will be useful for guiding implementers that seek to build capacity on knowledge translation so as to promote the utilization of research findings for informing programs, practice, and policy.

Knowledge and perceptions of brucellosis in the pastoral communities adjacent to Lake Mburo National Park, Uganda

Background

Brucellosis is one of the most common zoonotic infections globally. Lack of knowledge about brucellosis may affect the health-seeking behavior of patients, thus leading to sustained transmission in these communities. Our study assessed knowledge and perceptions of brucellosis among pastoral communities adjacent to Lake Mburo National Park (LMNP), Kiruhura District, Uganda.

Methods

A community cross-sectional questionnaire survey involving 371 randomly selected household heads from three sub-counties neighboring LMNP were interviewed between June and August 2012. Data collected included communities’ knowledge on causes, symptoms, transmission, treatment, prevention and risk factors of brucellosis. Multivariable logistic regression analysis was performed to explore strength of association between overall knowledge of brucellosis and various individual factors using odds ratios and 95% confidence intervals.

Results

Only 70 (19%) knew the symptoms of brucellosis in animals, and three quarters (279, 75.5%) mentioned joint and muscle pain as a common symptom in humans. Almost all participants (370, 99.3%) had ever heard about brucellosis, majority (311, 84.7%) believed it affects all sexes and two thirds (67.7%) of the respondents believed close proximity to wildlife contributes to the presence of the disease. Almost all (352, 95.4%) knew that brucellosis in humans could be treatable using modern drugs. The main routes of infection in humans such as consumption of unpasteurized dairy products were known by 97% (360/371); eating of half-cooked meat by 91.4% and eating contaminated pasture in animals by 97.4%. There was moderate overall knowledge of brucellosis 197 (53.1%). Factors associated with higher overall knowledge were being agro-pastoralists (aOR: 2.08, CI: 1.17-3.71) compared to pure pastoralists while those who reported that the disease was a health problem (aOR: 0.18, CI: 0.06-0.56) compared to those who said it was not were less likely to be knowledgeable.

Conclusions

There was moderate overall knowledge of human and animal brucellosis among the participants. Majority of the participants believed that close proximity to wildlife contributes to the presence of the disease in the area. There is a need for collaboration between the public health, veterinary and wildlife sectors to provide health education on brucellosis for better management of the disease in the communities.

Financial interventions and movement restrictions for managing the movement of health workers between public and private organizations in low- and middle-income countries

BACKGROUND

Health workers move between public and private organizations in both urban and rural areas during the course of their career. Depending on the proportion of the population served by public or private organizations in a particular setting, this movement may result in imbalances in the number of healthcare providers available relative to the population receiving care from that sector. However, both public and private organizations are needed as each sector has unique contributions to make to the effective delivery of health services.

OBJECTIVES

To assess the effects of financial incentives and movement restriction interventions to manage the movement of health workers between public and private organizations in low- and middle-income countries.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (10 November 2012); EMBASE (7 June 2011); LILACS (9 June 2011); MEDLINE (10 November 2012); CINAHL (13 August 2012); and the British Nursing Index (13 August 2012).

SELECTION CRITERIA

Randomized controlled trials and non-randomized controlled trials; controlled before-and-after studies if pre- and post-intervention periods for study and control groups were the same and there were at least two units included in both the intervention and control groups; uncontrolled and controlled interrupted time series studies if the point in time when the intervention occurred was clearly defined and there were at least three or more data points before and after the intervention. Interventions included payment of special allowances, increasing salaries, bonding health workers, offering bursary schemes, scholarships or lucrative terminal benefits, and hiring people on contract basis.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the criteria for inclusion and exclusion of studies to the titles and abstracts of all articles obtained from the search. The same two review authors independently screened the full reports of the selected citations. At each stage, we compared the results and resolved discrepancies through discussion with a third review author.

MAIN RESULTS

We found no studies that were eligible for inclusion in this review.

AUTHORS' CONCLUSIONS

We identified no rigorous studies on the effects of interventions to manage the movement of health workers between public and private organizations in low- and middle-income countries. Health worker availability is a key obstacle in delivery of health services. Interventions to make the health sector more responsive to the expectations of populations by having more health workers in the sector that serves most people would contribute to the more efficient use of the health workforce. More research is needed to assess the effect of increase in salaries, offering scholarships or bonding on movement of health workers in one sector compared with another.

Interventions to manage dual practice among health workers

BACKGROUND

Dual practice, whereby health workers hold two or more jobs, is a common phenomenon globally. In resource constrained low- and middle-income countries dual practice poses an ongoing threat to the efficiency, quality and equity of health services, especially in the public sector. Identifying effective interventions to manage dual practice is important.

OBJECTIVES

To assess the effects of regulations implemented to manage dual practice.

SEARCH STRATEGY

Databases searched included: The Cochrane Central Register of Controlled Trials (CENTRAL) 2011, Issue 4, part of The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 26 May 2011); MEDLINE In-Process & Other Non-Indexed Citations May 24, 2011 (searched 26 May 2011); MEDLINE, Ovid (1948 to May week 2 2011) (searched 26 May 2011); EMBASE, Ovid (1980 to 2011 week 20) (searched 26 May 2011); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 04 December 2009); LILACS (searched January 2010); and AIM (December 2009) (searched 18 December 2009).

SELECTION CRITERIA

Randomized controlled trials, non-randomized controlled trials, controlled before-and-after studies and interrupted-time-series studies. Dual practice was defined as holding more than one job. Studies for inclusion were those focusing on interventions to manage dual practice among health professionals employed in the public health sector.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the criteria for inclusion and exclusion of studies when scanning the identified titles and abstracts. The same two review authors independently screened full reports of selected citations. At each stage, results were compared and discrepancies settled through discussion.

MAIN RESULTS

No studies were found which were eligible for inclusion in this review.

AUTHORS' CONCLUSIONS

There is a need to rigorously evaluate the effects of interventions implemented to manage dual practice among health workers. However, there is still much that is unknown about dual practice itself. The designing of studies to evaluate the effects of interventions to manage dual practice could benefit from prior studies to assess the various manifestations of dual practice, their prevalence and their likely impacts on health services delivery. These findings would then inform the design of studies to evaluate interventions to manage dual practice.

Research translation to inform national health policies: learning from multiple perspectives in Uganda

BACKGROUND

Research and evidence can have an impact on policy and practice, resulting in positive outcomes. However, research translation is a complex, dynamic and non-linear process. Although universities in Africa play a major role in generating research evidence, their strategic approaches to influence health policies and decision making are weak. This study was conducted with the aim of understanding the process of translating research into policy in order to guide the strategic direction of Makerere University College of Health Sciences (MakCHS) and similar institutions in their quest to influence health outcomes nationally and globally.

METHODS

A case study approach using 30 in-depth interviews with stakeholders involved in two HIV prevention research project was purposively selected. The study sought to analyze the research-to-policy discourses for the prevention of mother-to-child transmission (PMTCT) and safe male circumcision (SMC). The analysis sought to identify entry points, strengths and challenges for research-to-policy processes by interviewing three major groups of stakeholders in Uganda - researchers (8), policy makers (12) and media practitioners (12).

RESULTS

Among the factors that facilitated PMTCT policy uptake and continued implementation were: shared platforms for learning and decision making among stakeholders, implementation pilots to assess feasibility of intervention, the emerging of agencies to undertake operations research and the high visibility of policy benefits to child survival. In contrast, SMC policy processes were stalled for over two years after the findings of the Uganda study was made public. Among other factors, policy makers demanded additional research to assess implementation feasibility of SMC within ordinary health system context. High level leaders also publicly contested the SMC evidence and the underlying values and messages - a situation that reduced the coalition of policy champions.

CONCLUSIONS

This study shows that effective translation of PMTCT and SMC research results demanded a "360 degree" approach to assembling additional evidence to inform the implementation feasibility for these two HIV prevention interventions. MakCHS and similar institutions should prioritize implementation research to guide the policy processes about the feasibility of implementing new and effective innovations (e.g. PMTCT or SMC) at a large scale in contexts that may be different from the research environments.

Evidence summaries tailored to health policy-makers in low- and middle-income countries

OBJECTIVE

To describe how the SUPPORT collaboration developed a short summary format for presenting the results of systematic reviews to policy-makers in low- and middle-income countries (LMICs).

METHODS

We carried out 21 user tests in six countries to explore users' experiences with the summary format. We modified the summaries based on the results and checked our conclusions through 13 follow-up interviews. To solve the problems uncovered by the user testing, we also obtained advisory group feedback and conducted working group workshops.

FINDINGS

Policy-makers liked a graded entry format (i.e. short summary with key messages up front). They particularly valued the section on the relevance of the summaries for LMICs, which compensated for the lack of locally-relevant detail in the original review. Some struggled to understand the text and numbers. Three issues made redesigning the summaries particularly challenging: (i) participants had a poor understanding of what a systematic review was; (ii) they expected information not found in the systematic reviews and (iii) they wanted shorter, clearer summaries. Solutions included adding information to help understand the nature of a systematic review, adding more references and making the content clearer and the document quicker to scan.

CONCLUSION

Presenting evidence from systematic reviews to policy-makers in LMICs in the form of short summaries can render the information easier to assimilate and more useful, but summaries must be clear and easy to read or scan quickly. They should also explain the nature of the information provided by systematic reviews and its relevance for policy decisions.

Effects of changes in the pre-licensure education of health workers on health-worker supply

BACKGROUND

The current and projected crisis because of a shortage of health workers in low and middle-income countries (LMICs) requires that effective strategies for expanding the numbers of health workers are quickly identified in order to inform action by policymakers, educators, and health managers.

OBJECTIVES

To assess the effect of changes in the pre-licensure education of health professionals on health-worker supply.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 3), EMBASE, Ovid (1980 to week 3, October 2007), MEDLINE, Ovid (1950 to week 3, October 2007), CINAHL (October 2007), LILACS (week 4, November 2007), ERIC (1966 to week 3, February 2008), and Sociological Abstracts (October 2007). We searched WHO (WHOLIS) (February 2008), World Bank, Google Scholar, and human resources on health-related websites to obtain grey literature. Key experts in human resources for health were contacted to identify unpublished studies. The reference lists of included studies were searched for additional articles.

SELECTION CRITERIA

Randomised controlled trials, non-randomised controlled trials, controlled before and after studies, and interrupted time-series studies that measured increased numbers of health workers ultimately available for recruitment into the health workforce or improved patient to health professional ratios as their primary outcomes were considered. Although the focus of the review was on LMIC, we included studies regardless of where they were done.

DATA COLLECTION AND ANALYSIS

Heterogeneity between the two included studies precluded meta-analysis; therefore, data were presented separately for each study.

MAIN RESULTS

Two studies of the 7880 identified from searching the electronic databases met the inclusion criteria. Both studies were controlled before and after studies, of moderate to high risk of bias, that explored the effects of interventions to improve retention of minority groups in health professional training institutions. These studies reported that an intervention comprising of a package of student support activities including social, academic, and career guidance and mentorship resulted in an increase in the number of minority students who enrolled and graduated from health training institutions.

AUTHORS' CONCLUSIONS

The evidence to estimate the likely effects of interventions in pre-licensure education to increase health-worker supply is generally insufficient or unavailable, particularly in LMICs. Promising innovations from a high-income country include providing financial support to health professional students or introducing mechanisms to identify and encourage potential students and offering support to 'at risk' students. These and other promising interventions should be evaluated in LMIC.

Access to and utilisation of health services for the poor in Uganda: a systematic review of available evidence

Inequalities in the burden of disease and access to health care is a prominent concern in Uganda and other sub-Saharan African countries. This is a systematic review of socio-economic differences in morbidity and access to health care in Uganda. It includes published studies from electronic databases and official reports from surveys done by government, bilateral and multilateral agencies and universities. The outcome measures studied were: the distribution of HIV/AIDS; maternal and child morbidity; and access to and utilisation of health services for people belonging to different socio-economic and vulnerability groups. Forty-eight of 678 identified studies met our inclusion criteria. Results indicate that the poor and vulnerable experience a greater burden of disease but have lower access to health services than the less poor. Barriers to access arise from both the service providers and the consumers. Distance to service points, perceived quality of care and availability of drugs are key determinants of utilisation. Other barriers are perceived lack of skilled staff in public facilities, late referrals, health worker attitude, costs of care and lack of knowledge. Longitudinal and controlled studies are needed to see if strategies to improve access to services reach the poor.

Sugar snack consumption in Ugandan schoolchildren: validity and reliability of a food frequency questionnaire

OBJECTIVES

This study assessed the reproducibility and relative validity of an eight-item self-administered food frequency questionnaire (FFQ) on intake of sugared snacks in Ugandan schoolchildren. A 5-day precoded food behaviour checklist (FBC) was used as validation criteria. Sociodemographic correlates of a sum frequency sugar score were explored.

METHODS

The study was conducted in Kampala, Uganda, in 2004. Six hundred and fourteen schoolchildren (mean age 12.4 years) completed the FFQ on cakes/biscuits, chocolate, ice sticks, soft drinks, coffee, tea, sugared desserts and sweets/candies at school. They were examined clinically for dental caries. Forty students completed the FFQ twice, 1 week apart and 325 students completed the 5 day FBC at school.

RESULTS

The mean decayed, missing and filled tooth index score was 0.98 (SD 1.6, range 0-15). Reproducibility scores (Cohen's kappa) for the sugar items ranged from 0.17 (ice sticks) to 0.55 (biscuits). No differences were seen between the average intakes at test and retest. Higher intake was reported in FFQ than in FBC across all sugar items. Crude agreement between students reporting intake at least 3-5 times a week/less than three times a week ranged from 50% to 55% (e.g. biscuits, chocolate) to 87% (tea). Spearman's correlation coefficients ranged from 0.14 (desserts) to 0.27 (sweets). anova revealed significant increase (P = 0.001) in the mean FBC sum scores by increasing quartiles of the FFQ sum scores. The average sum FFQ sugar scores were higher in girls than in boys and higher in older than in younger students.

CONCLUSION

Fair reproducibility was established for the FFQ sugar items. The FFQ was acceptable in classifying individuals into broad categories of low and high sugar consumption.

Examining intention to control preschool children's sugar snacking: a study of carers in Uganda

AIM

The aims of this study were to investigate parents' intention to control their children's sugar consumption and whether that behaviour is reported to occur in 3-5-year-old preschool children according to sociodemographics and attitudinal factors derived from the Theory of Planned Behaviour (TPB).

DESIGN

Some 589 children aged 3-5 years (51% boys, response rate = 85%) attending nursery schools in Kampala Central (urban) and Nakawa (suburban), Uganda, were examined clinically for dental caries. A questionnaire to assess sociodemographic factors, sugar intake and the constructs of the TPB was completed by their parents'/caregivers in face-to-face interviews.

RESULTS

Analyses of variance revealed more positive attitudes and stronger intention to control children's intake of sugared snacks in highly as compared to less highly educated parents. Independent of educational level, parents having children with caries perceived themselves to have less control over their child's intake of sugared snacks and perceived them to be more susceptible to tooth decay compared to parents of children without caries. In multiple linear regression, the TPB provided a significant prediction of intention with attitude (b = 0.16, P < 0.001), subjective norms (b = 0.18, P < 0.001) and perceived barriers (b = 0.11, P = 0.01), significant and reported sugar intake with attitudes (b = -0.10, P = 0.02), and perceived susceptibility (b = 16, P < 0.001) all significant.

CONCLUSION

The TPB components predict parental intention to control sugar snacking and whether that behaviour occurs in preschool children. The strengths of parents' attitudes and reported level of child sugar snacking varied between diverse socioeconomic family groups. Implications for oral health education are discussed.

Dental caries experience and its relationship to social and behavioural factors among 3-5-year-old children in Uganda

OBJECTIVE

The aim of this study was to assess the socio-demographic and behavioural correlates of caries experience and sugar intake patterns among pre-school children in Uganda.

METHODS

Five hundred and eighty-nine, 3-5-year-old children (51% boys, response rate = 85%), attending nursery schools in urban and peri-urban settings in central Kampala and Nakawa, respectively, were clinically examined for dental caries using the dmft index. Visible plaque on the labial surfaces of their maxillary incisors was recorded as a proxy for oral hygiene habits. A questionnaire designed to assess socio-demographic factors and sugar habits was completed by their caregivers in face-to-face interviews.

RESULTS

The mean dmft scores were 1.7, 2.4 and 3.1, and 42%, 44% and 42% had visible plaque among 3-, 4- and 5-year-olds, respectively. In Nakawa, a total of 64%, 62% and 22% of the subjects had dmft > 0, decayed teeth (dt) > 0 and missing teeth > 0, respectively. The corresponding rates in central Kampala were 56%, 55% and 17%. Multivariate analyses revealed that attending school in Nakawa, having a mother with a lower level of education, reporting the intake of cough syrup, visiting a dentist and scoring positively for plaque were associated with higher odds (1.6, 1.5, 3.7 and 2.7) for having dmft > 0. The adjusted mean frequency sugar scores varied systematically between mothers with low and high levels of education (mean scores = 11.0 vs. 10.4), and for children with negative and positive plaque scores (mean scores = 10.6 vs. 10.9).

CONCLUSION

The caries experience was highest among children attending nursery schools in Nakawa and those who had had longer periods of cough syrup consumption, whereas children from the two locations were equally exposed to sugar consumption generally. Both caries experience and frequency of sugar consumption was highest among children of less-well-educated mothers.