Continuous quality improvement as a tool to implement evidence-informed problem solving: experiences from the district and health facility level in Uganda

Background: Continuous quality improvement processes in health care were developed for use at health facility level, and that is where they have been used the most, often addressing defined care processes. However, in different settings different factors have been important to support institutionalization. This study explores how continuous quality improvement processes were institutionalized at the district level and at the health facility level in Uganda. Methods: This qualitative study was carried out in seven districts in Uganda. Semi-structured interviews with key informants from the district health management teams and document review were conducted. Thematic analysis was used to analyze the data. Results: All districts that participated in the study formed Continuous Quality Improvement (CQI) teams both at the district level and at the health facilities. The district CQI teams comprised of members from different departments within the district health office. District level CQI teams were mandated to take the lead in addressing management gaps and follow up CQI activities at the health facility level. Acceptability of quality improvement processes by the district leadership was identified across districts as supporting the successful implementation of CQI. However, high turnover of staff at health facility level was also reported as a detrimental to the successful implementation of quality improvement processes. Also the district health management teams did not engage much in addressing their own roles using continuous quality improvement. Conclusion: The leadership and management provided by the district health management team was an important factor for the use of Continuous Quality Improvement principles within the district. The key roles of the district health team revolved around the institutionalisation of CQI at different levels of the health system, monitoring results of continuous quality improvement implementation, mobilising resources and health care delivery hence promoting the culture of quality, direct implementation of CQI, and creating an enabling environment for the lower-level health facilities to engage in CQI. High turnover of staff at health facility level was also reported as one of the challenges to the successful implementation of continuous quality improvement. The DHT did not engage much in addressing gaps in their own roles using continuous quality improvement. Keywords: Continuous quality improvement, District health management team, Quality improvement, Uganda, Health facilit

Community participation to improve health services for children: a methodology for a community dialogue intervention in Uganda

Background: Like other developing countries, Uganda still struggles to meaningfully reduce child mortality. A strategy of giving information to communities to spark interest in improving child survival through inducing responsibility and social sanctioning in the health workforce was postulated. By focusing on diarrhea, pneumonia and malaria, a Community and District Empow- erment for Scale up (CODES) undertaking used “community dialogues” to arm communities with health system performance information. This empowered them to monitor health service provision and demand for quality child-health services.Methods: We describe a process of community dialoguing through use of citizen report cards, short-text-messages, media and post-dialogue monitoring. Each community dialogue assembled 70-100 members including health workers and community leaders. After each community dialogue, participants implemented activities outlined in generated community contracts. Radio messages promoted demand for child-health services and elicited support to implement accepted activities.Conclusion: The perception that community dialoging is “a lot of talk” that never advances meaningful action was debunked since participant-initiated actions were conceived and implemented. Potential for use of electronic communication in real-time feedback and stimulating discussion proved viable. Post-dialogue monitoring captured in community contracts facilitated pro- cess evaluation and added plausibility for observed effects. Capacitated organizations during post-dialogue monitoring guaran- teed sustainability.Keywords: Community dialogues, post-dialogue monitoring, sustainability, strategy, community, child survival

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

Introduction Uganda's district-level administrative units buttress the public healthcare system. In many districts, however, local capacity is incommensurate with that required to plan and implement quality health interventions. This study investigates how a district management strategy informed by local data and community dialogue influences health services. Methods A 3-year randomised controlled trial (RCT) comprised of 16 Ugandan districts tested a management approach, Community and District-management Empowerment for Scale-up (CODES). Eight districts were randomly selected for each of the intervention and comparison areas. The approach relies on a customised set of data-driven diagnostic tools to identify and resolve health system bottlenecks. Using a difference-in-differences approach, the authors performed an intention-to-treat analysis of protective, preventive and curative practices for malaria, pneumonia and diarrhoea among children aged 5 and younger. Results Intervention districts reported significant net increases in the treatment of malaria (+23%), pneumonia (+19%) and diarrhoea (+13%) and improved stool disposal (+10%). Coverage rates for immunisation and vitamin A consumption saw similar improvements. By engaging communities and district managers in a common quest to solve local bottlenecks, CODES fostered demand for health services. However, limited fiscal space-constrained district managers' ability to implement solutions identified through CODES. Conclusion Data-driven district management interventions can positively impact child health outcomes, with clinically significant improvements in the treatment of malaria, pneumonia and diarrhoea as well as stool disposal. The findings recommend the model's suitability for health systems strengthening in Uganda and other decentralised contexts. Trial registration number ISRCTN15705788

Community participation to improve health services for children: a methodology for a community dialogue intervention in Uganda

Background: Like other developing countries, Uganda still struggles to meaningfully reduce child mortality. A strategy of giving information to communities to spark interest in improving child survival through inducing responsibility and social sanctioning in the health workforce was postulated. By focusing on diarrhea, pneumonia and malaria, a Community and District Empowerment for Scale up (CODES) undertaking used \u201ccommunity dialogues\u201d to arm communities with health system performance information. This empowered them to monitor health service provision and demand for quality child-health services. Methods: We describe a process of community dialoguing through use of citizen report cards, short-text-messages, media and post-dialogue monitoring. Each community dialogue assembled 70-100 members including health workers and community leaders. After each community dialogue, participants implemented activities outlined in generated community contracts. Radio messages promoted demand for child-health services and elicited support to implement accepted activities. Conclusion: The perception that community dialoging is \u201ca lot of talk\u201d that never advances meaningful action was debunked since participant-initiated actions were conceived and implemented. Potential for use of electronic communication in real-time feedback and stimulating discussion proved viable. Post-dialogue monitoring captured in community contracts facilitated process evaluation and added plausibility for observed effects. Capacitated organizations during post-dialogue monitoring guaranteed sustainability. DOI: https://dx.doi.org/10.4314/ahs.v19i1.32 Cite as: Muhwezi WW, Palchik EA, Kiwanuka DH, Mpanga F, Mukundane M, Nanungi A, et al. Community participation to improve health services for children: a methodology for a community dialogue intervention in Uganda. Afri Health Sci. 2019;19(1). 1574-1581. https://dx.doi. org/10.4314/ahs.v19i1.3

Health systems bottlenecks and evidence-based district health planning : Experiences from the district health system in Uganda

In low-income countries where maternal and child mortality remains high, there is limited use of context-specific evidence for decision making and prioritization of interventions in the planning process at the sub-national level, such as the district level. Knowledge on the utility of tools and interventions to promote use of district-specific evidence in the planning process is limited, yet it could contribute to the prioritization of high-impact interventions for women and children. This thesis aims to investigate, in the planning process, the use of district-specific evidence to identify gaps in service delivery in the district health system in Uganda in order to contribute to improving health services for women and children. Study I evaluated the use of the modified Tanahashi model to identify bottlenecks for service delivery of maternal and newborn interventions. Study II and III used qualitative methods to document the experiences of district managers in adopting tools to facilitate the utilization of district-specific evidence, and the barriers and enablers to the use of these tools in the planning process. Study IV used qualitative methods, and analysis of district annual health work plans and reports. District managers were able to adopt tools for the utilization of district-specific evidence in the planning process. Governance and leadership were a major influence on the use of district-specific evidence. Limited decision space and fiscal space, and limited financial resources, and inadequate routine health information systems were also barriers to the utilization of district-specific evidence. Use of district-specific evidence in the planning process is not an end in itself but part of a process to improve the prioritization of interventions for women and children. In order to prioritize high impact interventions at the district level, a multifaceted approach needs to be taken that not only focuses on use of evidence, but also focuses on broader health system aspects like governance and leadership, the decision and fiscal space available to the district managers, limited resources, and inadequate routine health information systems

Decision making in district health planning in Uganda : Does use of local evidence matter?

Introduction In a decentralized health system, district health managers are tasked with planning for health service delivery which should be evidence-based. However, planning in low-income countries such as Uganda, has been described as ad hoc. A systematic approach to the planning process using district-specific evidence was introduced to district health managers in Uganda. However, little is known about how the use of district-specific evidence does inform the planning process. In this study we further investigate how the use of this evidence affects the annual planning process. Methodology The study was conducted in two districts that were introduced to the systematic approach of using district-specific evidence in the planning process. District annual health work plans for financial years 2012/13; 2013/14; 2014/15 and 2015/16 and bottleneck analysis reports for 2012, 2013, 2014 and 2015 were reviewed. Semi-structured interviews with key informants from the districts were also conducted. Results District managers reported that they were able to produce more robust district annual work plans when they used district-specific evidence. About half of the priority activities that were identified using district-specific evidence were included in the annual work plans. Procurement and logistics, training and support supervision activities were the most prioritized. Use of local evidence was viewed positively by the health managers. However, there was a lack of clarity on what activities should be incorporated in the annual work plans and district managers considered the lack of autonomy or decision space as a constraint to the use of district-specific evidence. Conclusion District-specific evidence and a structured process for its use to prioritize activities and make decisions in the planning process at the district level helped systematize the planning process. Health managers were able to articulate and advocate for priorities related to child survival. However, the reported limited decision and fiscal space, human resource gaps, inadequate funding and high dependency on donor funding did not always allow for use of district-specific evidence in the planning process.

Bottleneck analysis at district level to illustrate gaps within the district health system in Uganda

BACKGROUND: Poor quality of care and access to effective and affordable interventions have been attributed to constraints and bottlenecks within and outside the health system. However, there is limited understanding of health system barriers to utilization and delivery of appropriate, high-impact, and cost-effective interventions at the point of service delivery in districts and sub-districts in low-income countries. In this study we illustrate the use of the bottleneck analysis approach, which could be used to identify bottlenecks in service delivery within the district health system. METHODS: A modified Tanahashi model with six determinants for effective coverage was used to determine bottlenecks in service provision for maternal and newborn care. The following interventions provided during antenatal care were used as tracer interventions: use of iron and folic acid, intermittent presumptive treatment for malaria, HIV counseling and testing, and syphilis testing. Data from cross-sectional household and health facility surveys in Mayuge and Namayingo districts in Uganda were used in this study. RESULTS: Effective coverage and human resource gaps were identified as the biggest bottlenecks in both districts, with coverage ranging from 0% to 66% for effective coverage and from 46% to 58% for availability of health facility staff. Our findings revealed a similar pattern in bottlenecks in both districts for particular interventions although the districts are functionally independent. CONCLUSION: The modified Tanahashi model is an analysis tool that can be used to identify bottlenecks to effective coverage within the district health system, for instance, the effective coverage for maternal and newborn care interventions. However, the analysis is highly dependent on the availability of data to populate all six determinants and could benefit from further validation analysis for the causes of bottlenecks identified

Health facility management and access : a qualitative analysis of challenges to seeking healthcare for children under five in Uganda

While several studies have documented the various barriers that caretakers of children under five routinely confront when seeking healthcare in Uganda, few have sought to capture the ways in which caretakers themselves prioritize their own barriers to seeking services. To that end, we asked focus groups of caretakers to list their five greatest challenges to seeking care on behalf of children under five. Using qualitative content analysis, we grouped responses according to four categories: (1) geographical access barriers; (2) facility supplies, staffing, and infrastructural barriers; (3) facility management and administration barriers (e.g. health worker professionalism, absenteeism and customer care); and (4) household barriers related to financial circumstances, domestic conflicts with male partners and a stated lack of knowledge about health-related issues. Among all focus groups, caretakers mentioned supplies, staffing and infrastructure barriers most often and facility management and administration barriers the least. Caretakers living furthest from public facilities (8-10 km) more commonly mentioned geographical barriers to care and barriers related to financial and other personal circumstances. Caretakers who lived closest to health facilities mentioned facility management and administration barriers twice as often as those who lived further away. While targeting managerial barriers is vitally important-and increasingly popular among national planners and donors-it should be done while recognizing that alleviating such barriers may have a more muted effect on caretakers who are geographically harder to reach - and by extension, those whose children have an increased risk of mortality. In light of calls for greater equity in child survival programming - and given the limited resource envelopes that policymakers often have at their disposal - attention to the barriers considered most vital among caretakers in different settings should be weighed