Can routine health facility data be used to monitor subnational coverage of maternal, newborn and child health services in Uganda?

Background: Routine health facility data are a critical source of local monitoring of progress and performance at the subnational level. Uganda has been using district health statistics from facility data for many years. We aimed to systematically assess data quality and examine different methods to obtain plausible subnational estimates of coverage for maternal, newborn and child health interventions. Methods: Annual data from the Uganda routine health facility information system 2015–2019 for all 135 districts were used, as well as national surveys for external comparison and the identification of near-universal coverage interventions. The quality of reported data on antenatal and delivery care and child immunization was assessed through completeness of facility reporting, presence of extreme outliers and internal data consistencies. Adjustments were made when necessary. The denominators for the coverage indicators were derived from population projections and health facility data on near-universal coverage interventions. The coverage results with different denominators were compared with the results from household surveys. Results: Uganda’s completeness of reporting by facilities was near 100% and extreme outliers were rare. Inconsistencies in reported events, measured by annual fluctuations and between intervention consistency, were common and more among the 135 districts than the 15 subregions. The reported numbers of vaccinations were improbably high compared to the projected population of births or first antenatal visits – and especially so in 2015–2016. There were also inconsistencies between the population projections and the expected target population based on reported numbers of antenatal visits or immunizations. An alternative approach with denominators derived from facility data gave results that were more plausible and more consistent with survey results than based on population projections, although inconsistent results remained for substantive number of subregions and districts. Conclusion: Our systematic assessment of the quality of routine reports of key events and denominators shows that computation of district health statistics is possible with transparent adjustments and methods, providing a general idea of levels and trends for most districts and subregions, but that improvements in data quality are essential to obtain more accurate monitoring

“Trading daughters for livestock”: An ethnographic study of facilitators of child marriage in Lira district, Northern Uganda

Child marriage remains a significant challenge in Uganda despite national policies, legislation and programs for improved rights of girls. This ethnographic study aimed to explore underlying drivers of child marriage in Lira district, Northern Uganda. We applied a triangulation of qualitative methods; in-depth interviews, focus group discussions, key informant interviews and observations. Data were analysed using qualitative thematic content analysis. Our study findings showed that child marriage is still prevalent in the study area and the practice was also carried out at designated markets, at which girls were traded in exchange of livestock. The main drivers of child marriage were identified as poverty and survival strategies; socio-cultural beliefs and norms; and school dropouts. Determined efforts are needed to address the socio-cultural drivers of child marriage, keep girls in school, address poverty through targeting the family and individual level with appropriate incentives to address the economic needs of girls and families to delay marriage, enforce laws prohibiting the practice of child marriage, equip teenagers with accurate information on SRHR and ensure that parents support their daughters to be educated and responsible adults.   Le mariage d’enfants reste un défi majeur en Ouganda malgré les politiques, la législation et les programmes nationaux pour l'amélioration des droits des filles. Cette étude ethnographique visait à examiner les facteurs sous-jacents du mariage d’enfants dans le district de Lira, dans le nord de l'Ouganda. Nous avons utilisé une triangulation des méthodes qualitatives; des entretiens approfondis, des groupes de discussion, des entretiens avec des informateurs clés et des observations. Les données ont été analysées à l’aide d’une thématique qualitative pour l’analyse de données. Les résultats de notre étude ont montré que le mariage d’enfants est toujours répandu dans la zone d'étude et que la pratique a été également effectuée dans des marchés désignés, où les filles étaient échangées contre du bétail. Les principaux moteurs du mariage d’enfants ont été identifiés comme étant la pauvreté et les stratégies de survie, croyances et normes socioculturelles et le décrochage scolaire. Des efforts résolus sont nécessaires pour traiter les facteurs socioculturels du mariage d’enfants, faire en sorte que les filles restent à l'école, lutter contre la pauvreté tout en ciblant des incitations appropriées pour répondre aux besoins économiques des filles au niveau individuel et familial et des familles pour retarder le mariage, faire appliquer les lois interdisant cette pratique du mariage d’enfants, fournir aux adolescents des informations précises sur la SDSR et veiller à ce que les parents donnent soutien à leurs filles à devenir des adultes éduqués et responsables

Community willingness to pay for maternal transport in Kabarole District, Western Uganda: A cross-sectional study

Introduction: Saving Mothers Giving Life project in Kabarole district has supported maternal transportation to health facilities since 2012. There is need to sustain project outcomes when it winds up. We assessed community willingness to pay (WTP) for the maternal transport services and associated factors. Methods: We conducted a crosssectional study among household heads in Kabarole district. We used simple random sampling to select the villages and households and purposively selected household heads. We administered structured questionnaires to household heads. A household ead who reported that he/she was willing to contribute financially to the maternal transport services in the district was categorized as willing to pay. We obtained preferred entity to coordinate and manage the funds, preferred transport means, payment mode and amount of money through structured interviews. We used modified Poisson regression models to determine associations between WTP and the various characteristics of participants. Results: A total of 646 household heads were interviewed. The mean age was 33.8 years (SD±8.85). Most, 68% (442/646) were willing to pay for maternal transport. Of the 442 willing to pay, 65.38% preferred monthly payment with an average of UGX 2,207.6/= (<1.00 USD). Education was positively associated with WTP at all levels. Being married, participating in a saving scheme and staying more than five kilometers away from a heath facility were also associated with WTP: (APR 1.15, 95% CI 1.02-1.30), (APR 1.12, 95% CI 1.01-1.25), (APR 1.32, 95% CI 1.15-1.50) respectively. Conclusion: Households need to be mobilized, educated about the outcomes of accessing maternal services, and the need to pay for maternal transport. Payment modalities can be agreed upon by all stakeholders in a participatory and iterative proces

Surgical need among the ageing population of Uganda

Background: Uganda’s ageing population (age 50 years and older) will nearly double from 2015 to 2050. HIV/AIDS, diabetes, stroke among other disease processes have been studied in the elderly population. However, the burden of disease from surgi- cally-treatable conditions is unknown. Objectives: To determine the proportion of adults above 50 years with unmet surgical need and deaths attributable to probable surgically-treatable conditions. Methods: A cluster randomized sample representing the national population of Uganda was enumerated. The previously vali- dated Surgeons Overseas assessment of surgical need instrument, a head-to-toe verbal interview, was used to determine any sur- gically-treatable conditions in two randomly-selected living household members. Deaths were detailed by heads of households. Weighted metrics are calculated taking sampling design into consideration and Taylor series linearization was used for sampling error estimation.   Results: The study enumerated 425 individuals above age 50 years. The prevalence proportion of unmet surgical need was 27.8% (95%CI, 22.1-34.3). This extrapolates to 694,722 (95%CI, 552,279-857,157) individuals living with one or more surgically treatable conditions. The North sub-region was observed to have the highest prevalence proportion. Nearly two out of five household deaths (37.9%) were attributed to probable surgically treatable causes.Conclusion: There is disproportionately high need for surgical care among the ageing population of Uganda with approximate- ly 700,000 consultations needed.Keywords: Surgical need, ageing population, Uganda

Gender and innovation for climate-smart agriculture. Assessment of gender-responsiveness of RAN's agricultural-focused innovations

Ownership of agricultural production resources has generally been shown by research to be male dominated and to have wide disparities between males and females. The disparities are more pronounced in rural areas where women have less income, smaller pieces of land, and have inadequate market for their produce. In dealing with Climate Smart Agriculture (CSA) adoption and with agricultural technology adoption, there has been increasing recognition of the importance of focusing on the gender-based needs behind the adoption choice itself. Grounded in the belief that solutions to Africa’s resilience challenges lie in understanding what makes communities thrive in adversity, ResilientAfrica Network (RAN) is a multidisciplinary innovation lab that leverages the creativity and talent of youth, students, scholars and communities to develop and scale innovative ideas. Given how dominant agriculture is among RAN's problem sets for strengthening resilience through innovation, RAN sought to understand how supported innovations had contributed to gender-responsive climate smart agriculture solutions. What lessons could be learned from Women of Uganda Network (WOUGNET) in their history of engagement with women farmers to co-create a gender-responsive innovation process to strengthen resilience through the agricultural sector? With the support of CCAFS, RAN and WOUGNET conducted a gender assessment exercise to evaluate if the current solutions/innovations are gender responsive or not. Three innovations were selected that are primarily focused towards CSA and that had affordability and ease of use as key objectives. The gender assessment embraced a qualitative research approach. This choice was guided by the need to appreciate respondents’ understanding and experiences or perceptions of the different innovations that RAN has been nurturing and developing over the years. The respondents were purposively selected based on availability and on being located in any of the four Northern Uganda districts of Apac, Kole, Lira and Oyam where WOUGNET has actively engaged with women farmers. From the study, it was clear that men and women farmers are willing to embrace new technologies, practices and innovations in their pursuit of enhanced agricultural productivity and new opportunities. That said, a clearly gendered view emerged from the assessment in that uptake of the innovations was to a large extent driven by socio-cultural norms and expectations related to issues of ownership, work, decision making capacity, and income generation and control. For instance, use of the innovations can reduce time spent on farming activities and can open up time and space to explore new opportunities. However, if gender considerations are not taken into account, such time could be used to negatively impact on the work burden for women farmers as it may be taken that the women are now free to take on new work – even that which would have been previously done by the men in their households

Optimizing Care for Ugandans with Untreated Abdominal Surgical Conditions

Background: Abdominal operations account for a majority of surgical volume in low-income countries, yet population-level prevalence data on surgically treatable abdominal conditions are scarce. Objective: In this study, our objective was to quantify the burden of surgically treatable abdominal conditions in Uganda. Methods: In 2014, we administered a two-stage cluster-randomized Surgeons OverSeas Assessment of Surgical Need survey to 4,248 individuals in 105 randomly selected clusters (representing the national population of Uganda). Findings: Of the 4,248 respondents, 185 reported at least one surgically treatable abdominal condition in their lifetime, giving an estimated lifetime prevalence of 3.7% (95% CI: 3.0 to 4.6%). Of those 185 respondents, 76 reported an untreated condition, giving an untreated prevalence of 1.7% (95% CI: 1.3 to 2.3%). Obstructed labor (52.9%) accounted for most of the 238 abdominal conditions reported and was untreated in only 5.6% of reported conditions. In contrast, 73.3% of reported abdominal masses were untreated. Conclusions: Individuals in Uganda with nonobstetric abdominal surgical conditions are disproportionately undertreated. Major health system investments in obstetric surgical capacity have been beneficial, but our data suggest that further investments should aim at matching overall surgical care capacity with surgical need, rather than focusing on a single operation for obstructed labor

Surgical need among the ageing population of Uganda

Background: Uganda\u2019s ageing population (age 50 years and older) will nearly double from 2015 to 2050. HIV/AIDS, diabetes, stroke among other disease processes have been studied in the elderly population. However, the burden of disease from surgically-treatable conditions is unknown. Objectives: To determine the proportion of adults above 50 years with unmet surgical need and deaths attributable to probable surgically-treatable conditions. Methods: A cluster randomized sample representing the national population of Uganda was enumerated. The previously validated Surgeons Overseas assessment of surgical need instrument, a head-to-toe verbal interview, was used to determine any surgically-treatable conditions in two randomly-selected living household members. Deaths were detailed by heads of households. Weighted metrics are calculated taking sampling design into consideration and Taylor series linearization was used for sampling error estimation. Results: The study enumerated 425 individuals above age 50 years. The prevalence proportion of unmet surgical need was 27.8% (95%CI, 22.1-34.3). This extrapolates to 694,722 (95%CI, 552,279-857,157) individuals living with one or more surgically treatable conditions. The North sub-region was observed to have the highest prevalence proportion. Nearly two out of five household deaths (37.9%) were attributed to probable surgically treatable causes. Conclusion: There is disproportionately high need for surgical care among the ageing population of Uganda with approximately 700,000 consultations needed. DOI: https://dx.doi.org/10.4314/ahs.v19i1.54 Cite as: Tran TM, Fuller AT, Butler EK, Muhumuza C, Ssennono VF, Vissoci JR, et al. Surgical need among the ageing population of Uganda. Afri Health Sci. 2019;19(1). 1778-1788. https:// dx.doi. org/10.4314/ ahs. v19i1.5

Early care and support for young children with developmental disabilities and their caregivers in Uganda: The Baby Ubuntu feasibility trial.

Background: Early care and support provision for young children with developmental disabilities is frequently lacking, yet has potential to improve child and family outcomes, and is crucial for promoting access to healthcare and early education. We evaluated the feasibility, acceptability, early evidence of impact and provider costs of the Baby Ubuntu participatory, peer-facilitated, group program for young children with developmental disabilities and their caregivers in Uganda. Materials and methods: A feasibility trial, with two parallel groups, compared Baby Ubuntu with standard care. Caregivers and children, aged 6-11 months with moderate-severe neurodevelopmental impairment, were recruited and followed for 12 months. Quantitative and qualitative methods captured information on feasibility (ability to recruit), acceptability (satisfactory attendance), preliminary evidence of impact (family quality of life) and provider costs. Results: One hundred twenty-six infants (median developmental quotient, 28.7) were recruited and randomized (63 per arm) over 9 months, demonstrating feasibility; 101 (80%) completed the 12-month follow-up assessment (9 died, 12 were lost to follow up, 4 withdrew). Of 63 randomized to the intervention, 59 survived (93%); of these, 51 (86%) attended ≥6 modules meeting acceptability criteria, and 49 (83%) completed the 12 month follow-up assessment. Qualitatively, Baby Ubuntu was feasible and acceptable to caregivers and facilitators. Enabling factors included community sensitization by local champions, positive and caring attitudes of facilitators toward children with disability, peer support, and the participatory approach to learning. Among 101 (86%) surviving children seen at 12 months, mixed methods evaluation provided qualitative evidence of impact on family knowledge, skills, and attitudes, however impact on a scored family quality of life tool was inconclusive. Barriers included stigma and exclusion, poverty, and the need to manage expectations around the child's progress. Total provider cost for delivering the program per participant was USD 232. Conclusion: A pilot feasibility trial of the Baby Ubuntu program found it to be feasible and acceptable to children, caregivers and healthcare workers in Uganda. A mixed methods evaluation provided rich programmatic learning including qualitative, but not quantitative, evidence of impact. The cost estimate represents a feasible intervention for this vulnerable group, encouraging financial sustainability at scale. Clinical trial registration: [https://doi.org/10.1186/ISRCTN44380971], identifier [ISRCTN44380971]

Antenatal syphilis screening using point-of-care testing in low- and middle-income countries in Asia and latin america: a cost-effectiveness analysis

Untreated syphilis in pregnancy is associated with adverse clinical outcomes to the infant. In low- and middle-income countries in Asia and Latin America, 20%-30% of women are not tested for syphilis during pregnancy. We evaluated the cost-effectiveness of increasing the coverage for antenatal syphilis screening in 11 Asian and 20 Latin American countries, using a point-of-care immunochromatographic strip (ICS) test.The decision analytical cost-effectiveness models reported incremental costs per disability-adjusted life years (DALYs) averted from the perspectives of the national health care payer. Clinical outcomes were stillbirths, neonatal deaths, and congenital syphilis. DALYs were computed using WHO disability weights. Costs included the ICS test, three injections of benzathine penicillin, and nurse wages. Country-specific inputs included the antenatal prevalence of syphilis and the proportion of women in the antenatal care setting that are screened for syphilis infection as reported in the 2014 WHO baseline report on global sexually transmitted infection surveillance. Country-specific data on the annual number of live births, proportion of women with at least one antenatal care visit, and per capita gross national income were also included in the model.The incremental cost/DALY averted of syphilis screening is US$53 (range: US$10-US$332; Prob<1*per capita GDP=99.71$60 (range: US$5-US$225; Prob<1*per capita GDP=99.77%) in Latin America. Universal screening may reduce the annual number of stillbirths by 20,344 and 4,270, neonatal deaths by 8,201 and 1,721, cases of congenital syphilis by 10,952 and 2,298, and avert 925,039 and 197,454 DALYs in the aggregate Asian and Latin American panel, respectively.Antenatal syphilis screening is highly cost-effective in all the 11 Asian and 20 Latin American countries assessed. Our findings support the decision to expand syphilis screening in countries with currently low screening rates or continue national syphilis screening programs in countries with high rates