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

Evaluation of Integrated Community Case Management in Eight Districts of Central Uganda

Objective Evidence is limited on whether Integrated Community Case Management (iCCM) improves treatment coverage of the top causes of childhood mortality (acute respiratory illnesses (ARI), diarrhoea and malaria). The coverage impact of iCCM in Central Uganda was evaluated. Methods Between July 2010 and December 2012 a pre-post quasi-experimental study in eight districts with iCCM was conducted; 3 districts without iCCM served as controls. A two-stage household cluster survey at baseline (n = 1036 and 1042) and end line (n = 3890 and 3844) was done in the intervention and comparison groups respectively. Changes in treatment coverage and timeliness were assessed using difference in differences analysis (DID). Mortality impact was modelled using the Lives Saved Tool. Findings 5,586 Village Health Team members delivered 1,907,746 treatments to children under age five. Use of oral rehydration solution (ORS) and zinc treatment of diarrhoea increased in the intervention area, while there was a decrease in the comparison area (DID = 22.9, p = 0.001). Due to national stock-outs of amoxicillin, there was a decrease in antibiotic treatment for ARI in both areas; however, the decrease was significantly greater in the comparison area (DID = 5.18; p<0.001). There was a greater increase in Artemisinin Combination Therapy treatment for fever in the intervention areas than in the comparison area but this was not significant (DID = 1.57, p = 0.105). In the intervention area, timeliness of treatments for fever and ARI increased significantly higher in the intervention area than in the comparison area (DID = 2.12, p = 0.029 and 7.95, p<0.001, respectively). An estimated 106 lives were saved in the intervention area while 611 lives were lost in the comparison area. Conclusion iCCM significantly increased treatment coverage for diarrhoea and fever, mitigated the effect of national stock outs of amoxicillin on ARI treatment, improved timeliness of treatments for fever and ARI and saved lives

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

Community and District Empowerment for Scale-up (CODES) : a complex district-level management intervention to improve child survival in Uganda: study protocol for a randomized controlled trial

BACKGROUND: Innovative and sustainable strategies to strengthen districts and other sub-national health systems and management are urgently required to reduce child mortality. Although highly effective evidence-based and affordable child survival interventions are well-known, at the district level, lack of data, motivation, analytic and planning capacity often impedes prioritization and management weaknesses impede implementation. The Community and District Empowerment for Scale-up (CODES) project is a complex management intervention designed to test whether districts when empowered with data and management tools can prioritize and implement evidence-based child survival interventions equitably. METHODS: The CODES strategy combines management, diagnostic, and evaluation tools to identify and analyze the causes of bottlenecks to implementation, build capacity of district management teams to implement context-specific solutions, and to foster community monitoring and social accountability to increase demand for services. CODES combines UNICEF tools designed to systematize priority setting, allocation of resources and problem solving with Community dialogues based on Citizen Report Cards and U-Reports used to engage and empower communities in monitoring health service provision and to demand for quality services. Implementation and all data collection will be by the districts teams or local Community-based Organizations who will be supported by two local implementing partners. The study will be evaluated as a cluster randomized trial with eight intervention and eight comparison districts over a period of 3 years. Evaluation will focus on differences in uptake of child survival interventions and will follow an intention-to-treat analysis. We will also document and analyze experiences in implementation including changes in management practices. DISCUSSION: By increasing the District Health Management Teams' capacity to prioritize and implement context-specific solutions, and empowering communities to become active partners in service delivery, coverage of child survival interventions will increase. Lessons learned on strengthening district-level managerial capacities and mechanisms for community monitoring may have implications, not only in Uganda but also in other similar settings, especially with regard to accelerating effective coverage of key child survival interventions using locally available resources

Family Health Days program contributions in vaccination of unreached and under-immunized children during routine vaccinations in Uganda.

BACKGROUND:We explored the contributions of the Family Health Days (FHDs) concept, which was developed by the Uganda Ministry of Health (MOH) and UNICEF as a supplementary quarterly outreach program in addition to strengthening the routine expanded program for immunization (EPI), with the aim to increase coverage, through improved access to the unimmunized or unreached and under-immunized children under 5 years. METHOD:A cross-sectional descriptive study of the Uganda MOH, Health Management Information Systems (HMIS) and UNICEF in house FHDs data was conducted covering six quarterly implementations of the program between April 2012 and December 2013. The FHDs program was implemented in 31 priority districts with low routine vaccination coverage from seven sub-regions in Uganda in a phased manner using places of worship for service delivery. RESULTS:During the six rounds of FHDs in the 31 districts, a total of 178,709 and 191,223 children received measles and Diphtheria-Pertussis-Tetanus (DPT3) vaccinations, respectively. The FHDs' contributions were 126% and 144% for measles and 103% and 122% for DPT3 in 2012 and 2013, respectively of the estimated unreached annual target populations. All implementing sub-regions after two rounds in 2012 attained over and above the desired target for DPT3 (85%) and measles (90%). The same was true in 2013 after four rounds, except for Karamoja and West Nile sub-regions, where in some districts a substantial proportion of children remained unimmunized. The administrative data for both DPT3 and measles immunization showed prominent and noticeable increase in coverage trend in FHDS regions for the months when the program was implemented. CONCLUSION:The FHDs program improved vaccination equity by reaching the unreached and hard-to-reach children and bridging the gap in immunization coverage, and fast tracking the achievement of targets recommended by the Global Vaccine Action Plan (GVAP) for measles and DPT3 (85% and 90% respectively) in implementing sub-regions and districts. The FHDs is an innovative program to supplement routine immunizations designed to reach the unreached and under immunized children

Starting at the community: Treatment-seeking pathways of children with suspected severe malaria in Uganda.

Community health workers (CHW) usually refer children with suspected severe malaria to the nearest public health facility or a designated public referral health facility (RHF). Caregivers do not always follow this recommendation. This study aimed at identifying post-referral treatment-seeking pathways that lead to appropriate antimalarial treatment for children less than five years with suspected severe malaria. An observational study in Uganda enrolled children below five years presenting to CHWs with signs of severe malaria. Children were followed up 28 days after enrolment to assess their condition and treatment-seeking history, including referral advice and provision of antimalarial treatment from visited providers. Of 2211 children included in the analysis, 96% visited a second provider after attending a CHW. The majority of CHWs recommended caregivers to take their child to a designated RHF (65%); however, only 59% followed this recommendation. Many children were brought to a private clinic (33%), even though CHWs rarely recommended this type of provider (3%). Children who were brought to a private clinic were more likely to receive an injection than children brought to a RHF (78% vs 51%, p<0.001) and more likely to receive the second or third-line injectable antimalarial (artemether: 22% vs. 2%, p<0.001, quinine: 12% vs. 3%, p<0.001). Children who only went to non-RHF providers were less likely to receive an artemisinin-based combination therapy (ACT) than children who attended a RHF (odds ratio [OR] = 0.64, 95% CI 0.51-0.79, p<0.001). Children who did not go to any provider after seeing a CHW were the least likely to receive an ACT (OR = 0.21, 95% CI 0.14-0.34, p<0.001). Health policies should recognise local treatment-seeking practices and ensure adequate quality of care at the various public and private sector providers where caregivers of children with suspected severe malaria actually seek care

Information on program implementation and treatments from routine reporting from Village Health Teams and Health Facilities, Central Uganda Integrated Community Case Management Program, 2011–2012.

<p>VHT, Village Health Team; ACT, Artemisinin-based combination therapies; ORS, Oral Rehydration Solution</p><p>Information on program implementation and treatments from routine reporting from Village Health Teams and Health Facilities, Central Uganda Integrated Community Case Management Program, 2011–2012.</p

Sources of treatment for children with fever, acute respiratory illness and diarrhoea in intervention area comparing baseline to end line, Uganda 2010–2012.

<p>Sources of treatment for children with fever, acute respiratory illness and diarrhoea in intervention area comparing baseline to end line, Uganda 2010–2012.</p