Healthcare markets in post-conflict settings: Experiences of formal private-for-profit healthcare organisations in Gulu District, Northern Uganda

There is a paradox between the post-conflict setting and the healthcare market in Northern Uganda. While there is a strong missionary sector and apparent ongoing rehabilitation of the government facilities, the popularity of the formal private for-profit sector has steadily increased in Gulu municipality, northern Uganda, which has a high poverty-afflicted population. Therefore, there is need to understand why and how we can leverage the potential of the formal private for-profit providers (FPFPs) to accelerate Universal Health Coverage (UHC) goals. The study explored the experiences of the FPFPs based in Gulu municipality regarding the market in which they operated during and after the conflict. In particular, the study sought to understand the characteristics of and changes in FPFPs over time, as well as the challenges, coping strategies, opportunities, and linkages with others in the market. This was a case study using mixed methods with a quant-qual sequential approach. The methods included organisational survey, life-history interviews, key informant interviews and observation. This study utilised the New Institutional Economics (NIE) theory as an analytical lens. Data analysis was conducted using SPSS, ATLAS.ti ver. 7.0 and UCINET ver. 11.0 software. The findings suggest that FPFPs increased in number and experienced internal changes within individual businesses across the conflict periods. Conflict provides the context in which the FPFP businesses started and operate (d) and explains their survival patterns and the emergent regulatory context. The FPFPs were faced with diverse challenges embedded in the active conflict that further complicated operational costs and regulatory mechanisms. Notably, some of the coping strategies compromise the quality of the services provided. There is a dense relational network for FPFPs in Gulu municipality, and these numerous relational links have positive implications for the broader coverage of the goal for UHC, the reduction of transaction costs as well as their continued relevance in the market. FPFPs were continuously faced with a dilemma of balancing optimization of their incomes with their altruism objectives. In the period following conflict, FPFPs attempted to implement various mechanisms to ensure that the poor could access health care. The mechanisms were enabled by the managers’ ad hoc judgements as well as partnerships with the local government and NGOs in the area. These ranged from price exemptions and reductions to price discrimination and breaking down doses. The study concludes by noting that FPFPs play a critical role in service provision in post-conflict northern Uganda. However, they cannot be ‘exclusively’ pro-poor, given that they are formed with a profit maximization objective. Some coping strategies and some mechanisms to enable the poor to access services may compromise quality. Hence, the government needs to enforce regulations to control the number of FPFPs opening business as well as quality. There is evidence of partnerships between the government and FPFPs. This needs to be continuous and expanded to include more FPFPs if UHC goals are to be achieved

‘They say we are money minded’ exploring experiences of formal private for-profit health providers towards contribution to pro-poor access in post conflict Northern Uganda

From Crossref journal articles via Jisc Publications RouterSuzanne Fustukian - ORCID: 0000-0002-4570-5800 https://orcid.org/0000-0002-4570-5800Background: The perception within literature and populace is that the private for-profit sector is for the rich only, and this characteristic results in behaviours that hinder advancement of Universal health coverage (UHC) goals. The context of Northern Uganda presents an opportunity for understanding how the private sector continues to thrive in settings with high poverty levels and history of conflict.Objective: The study aimed at understanding access mechanisms employed by the formal private for-profit providers (FPFPs) to enable pro-poor access to health services in post conflict Northern Uganda.Methods: Data collection was conducted in Gulu municipality in 2015 using Organisational survey of 45 registered formal private for-profit providers (FPFPs),10 life histories, and 13 key informant interviews. Descriptive statistics were generated for the quantitative findings whereas qualitative findings were analysed thematically.Results: FPFPs pragmatically employed various access mechanisms and these included fee exemptions and provision of free services, fee reductions, use of loan books, breaking down doses and partial payments. Most mechanisms were preceded by managers’ subjective identification of the poor, while operationalisation heavily depended on the managers’ availability and trust between the provider and the customer. For a few FPFPs, partnerships with Non-governmental organisations (NGOs) and government enabled provision of free, albeit mainly preventive services, including immunisation, consultations, screening for blood pressure and family planning. Challenges such as quality issues, information asymmetry and standardisation of charges arose during implementation of the mechanisms.Conclusion: The identification of the poor by the FPFPs was subjective and unsystematic. FPFPs implemented various innovations to ensure pro-poor access to health services. However, they face a continuous dilemma of balancing the profit maximization and altruism objectives. Implementation of some pro-poor mechanisms raises concerns included those related to quality and standardisation of pricing.The publication of this work has also been funded as part of a supplement under SPEED project [HUM/2014/341-585], funding code is ZGHA-2020-C4168..pubpu

Implementation of intensified tuberculosis case finding among people living with HIV in Kampala, Uganda: a cross sectional study

Introduction: Intensified Case Finding (ICF) is a cost-effective strategy for tuberculosis (TB) control and improving quality of life however, its implementation by health workers is generally reported as low in Uganda. There is limited information on the level of ICF implementation and the barriers or facilitators to its implementation among public health facilities in Kampala Capital City Authority (KCCA). In this study we determined the level of ICF implementation, facilitators and its barriers in KCCA public health facilities. Methods: We conducted a cross-sectional study between May-July 2015. We purposively selected six KCCA public health facilities and conducted exit interviews with patients attending Anti-Retroviral Therapy (ART) clinics to assess whether they were screened for TB. In-depth and key informant interviews with health workers were conducted to explore their experiences in implementing ICF. Results: Overall, ICF implementation was sub optimal. Less than 10% (30/321) clients reported being screened for current cough, fever, weight loss or night sweats. Conversely, 90.0% (289/321) clients screened for at least one TB symptom with cough being the most frequently asked symptom 87.5% (281/321). Of 131 clients who were screened and reported having at least one TB symptom, 36.6% (48/131) were sent to the laboratory, 2.3% (3/131) for X-Ray and 61.1% (80/131) to pharmacy. Training, support supervision, proper coordination, and support from implementing partners were facilitators of ICF implementation. Poor staff attitude, irregular supply of ICF related inputs/materials, high workload, transport and stigma were key barriers to ICF policy implementation. Conclusion: ICF implementation at ART clinics in KCCA public health facilities was sub optimal. Health workers’ attitude, training, support supervision and stigma of TB clients should be addressed for better ICF implementation

Health worker experiences of and movement between public and private not-for-profit sectors-findings from post-conflict Northern Uganda

Background Northern Uganda suffered 20 years of conflict which devastated lives and the health system. Since 2006, there has been investment in reconstruction, which includes efforts to rebuild the health workforce. This article has two objectives: first, to understand health workers' experiences of working in public and private not-for-profit (PNFP) sectors during and after the conflict in Northern Uganda, and second, to understand the factors that influenced health workers' movement between public and PNFP sectors during and after the conflict. Methods A life history approach was used with 26 health staff purposively selected from public and PNFP facilities in four districts of Northern Uganda. Staff with at least 10 years' experience were selected, which resulted in a sample which was largely female and mid-level. Two thirds were currently employed in the public sector and just over a third in the PNFP sector. A thematic data analysis was guided by the framework analysis approach, analysis framework stages and ATLAS.ti software version 7.0. Results Analysis reveals that most of the current staff were trained in the PNFP sector, which appears to offer higher quality training experiences. During the conflict period, the PNFP sector also functioned more effectively and was relatively better able to support its staff. However, since the end of the conflict, the public sector has been reconstructed and is now viewed as offering a better overall package for staff. Most reported movement has been in that direction, and many in the PNFP sector state intention to move to the public sector. While there is sectoral loyalty on both sides and some bonds created through training, the PNFP sector needs to become more competitive to retain staff so as to continue delivering services to deprived communities in Northern Uganda. Conclusions There has been limited previous longitudinal analysis of how health staff perceive different sectors and why they move between them, particularly in conflict-affected contexts. This article adds to our understanding, particularly for mid-level cadres, and highlights the need to ensure balanced health labour market incentives which take into account not only the changing context but also needs at different points in individuals' life cycles and across all core service delivery sectors.sch_iih14pub4347pub

Ebola in the context of conflict affected states and health systems: Case studies of Northern Uganda and Sierra Leone

Ebola seems to be a particular risk in conflict affected contexts. All three of the countries most affected by the 2014-15 outbreak have a complex conflict-affected recent history. Other major outbreaks in the recent past, in Northern Uganda and in the Democratic Republic of Congo are similarly afflicted although outbreaks have also occurred in stable settings. Although the 2014-15 outbreak in West Africa has received more attention than almost any other public health issue in recent months, very little of that attention has focused on the complex interaction between conflict and its aftermath and its implications for health systems, the emergence of the disease and the success or failure in controlling it. The health systems of conflict-affected states are characterized by a series of weaknesses, some common to other low and even middle income countries, others specifically conflict-related. Added to this is the burden placed on health systems by the aggravated health problems associated with conflict. Other features of post conflict health systems are a consequence of the global institutional response. Comparing the experience of Northern Uganda and Sierra Leone in the emergence and management of Ebola outbreaks in 2000-1 and in 2014-15 respectively highlights how the various elements of these conflict affected societies came together with international agencies responses to permit the outbreak of the disease and then to successfully contain it (in Northern Uganda) or to fail to do so before a catastrophic cost had been incurred (in Sierra Leone). These case studies have implications for the types of investments in health systems that are needed to enable effective response to Ebola and other zoonotic diseases where they arise in conflict- affected settings.sch_iih9pub3969pu

How does RBF strengthen strategic purchasing of health care? Comparing the experience of Uganda, Zimbabwe and the Democratic Republic of the Congo

Sophie Witter - orcid: 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Maria Paola Bertone - orcid: 0000-0001-8890-583X https://orcid.org/0000-0001-8890-583XBackground - Results-Based Financing (RBF) has proliferated in health sectors of low and middle income countries, especially fragile and conflict-affected ones, and has been presented as a way of reforming and strengthening strategic purchasing. However, few studies have empirically examined how RBF impacts on health care purchasing in these settings. This article examines the effects of several RBF programmes on health care purchasing functions in three fragile and post-conflict settings: Uganda, Zimbabwe and the Democratic Republic of Congo (DRC) over the past decade.Methods - The article is based on a documentary review, including 110 documents from 2004 to 2018, and 98 key informant (KI) interviews conducted with international, national and district level stakeholders in early 2018 in the selected districts of the three countries. Interviews and analysis followed an adapted framework for strategic purchasing, which was also used to compare across the case studies.Results - Across the cases, at the government level, we find little change to the accountability of purchasers, but RBF does mobilise additional resources to support entitlements. In relation to the population, RBF appears to bring in improvements in specifying and informing about entitlements for some services. However, the engagement and consultation with the population on their needs was found to be limited. In relation to providers, RBF did not impact in any major way on provider accreditation and selection, or on treatment guidelines. However, it did introduce a more contractual relationship for some providers and bring about (at least partial) improvements in provider payment systems, data quality, increased financial autonomy for primary providers and enforcing equitable strategies. More generally, RBF has been a source of much-needed revenue at primary care level in under-funded health systems. The context – particularly the degree of stability and authority of government–, the design of the RBF programme and the potential for effective integration of RBF in existing systems and its stage of development were key factors behind differences observed.Conclusions - Our evidence suggests that expectations of RBF as an instrument of systemic reform should be nuanced, while focusing instead on expanding the key areas of potential gain and ensuring better integration and institutionalisation, towards which two of the three case study countries are working.Funding: This work was funded by the Department for International Development (DFID), UK Aid, under the ReBUILD grant. For the Ugandan component, this work received contribution from Alliance for Health Policy and Systems Research at WHO Geneva and SPEED project supported by the European Union under which the previous round of interviews were carried out. However, the funders take no responsibility for the views expressed in this article.4 [3]pubpu

Evolution of policies on human resources for health: opportunities and constraints in four post-conflict and post-crisis settings

Background Few studies look at policy making in the health sector in the aftermath of a conflict or crisis and even fewer specifically focus on Human Resources for Health, which is a critical domain for health sector performance. The main objective of the article is to shed light on the patterns and drivers of post-conflict policy-making. In particular, we explore whether the post -conflict period offers increased chances for the opening of 'windows for opportunity' for change and reform and the potential to reset health systems. Methods This article uses a comparative policy analysis framework. It is based on qualitative data, collected using three main tools - stakeholder mapping, key informant interviews and document reviews - in Uganda, Sierra Leone, Cambodia and Zimbabwe. Results We found that HRH challenges were widely shared across the four cases in the post-conflict period but that the policy trajectories were different - driven by the nature of the conflicts but also the wider context. Our findings suggest that there is no formula for whether or when a 'window of opportunity' will arise which allows health systems to be reset. Problems are well understood in all four cases but core issues - such as adequate pay, effective distribution and HRH management - are to a greater or lesser degree unresolved. These problems are not confined to post-conflict settings, but underlying challenges to addressing them - including fiscal space, political consensus, willingness to pursue public objectives over private, and personal and institutional capacity to manage technical solutions - are liable to be even more acute in these settings. The role of the MoH emerged as weaker than expected, while the shift from donor dependence was clearly not linear and can take a considerable time. Conclusions Windows of opportunity for change and reform can occur but are by no means guaranteed by a crisis - rather they depend on a constellation of leadership, financing, and capacity. Recognition of urgency is certainly a facilitator but not sufficient alone. Post-conflict environments face particularly severe challenges to evidence-based policy making and policy implementation, which also constrain their ability to effectively use the windows which are presented.sch_iih10pub4648pub

Management of human resources for health in health districts in Uganda: A decision space

Background: Decentralisation has been adopted by many governments to strengthen national systems, including the health system. Decision space is used to describe the decision‐making power devolved to local government. Human resource Management (HRM) is a challenging area that District Health Management Teams (DHMT) need some control over its functions to develop innovative ways of improving health services. The study aims to examine the use of DHMTs' reported decision space for HRM functions in Uganda. Methods: Mixed methods approach was used to examine the DHMTs' reported decision space for HRM functions in three districts in Uganda, which included self‐assessment questionnaires and focus group discussions (FGDs). Results: The decision space available for the DHMTs varied across districts, with Bunyangabu and Ntoroko DHMTs reporting having more control than Kabarole. All DHMTs reported full control over the functions of performance management, monitoring policy implementation, forecasting staffing needs, staff deployment, and identifying capacity needs. However, they reported narrow decision space for developing job descriptions, resources mobilisation, and organising training; and no control over modifying staffing norms, setting salaries and developing an HR information system (HRIS). Nevertheless, DHMTs tried to overcome their limitations by adjusting HR policies locally, better utilising available resources and adapting the HRIS to local needs. Conclusions: Decentralisation provides a critical opportunity to strengthen HRM in low‐and‐middle‐income countries. Examining decision space for HRM functions can help identify areas where district health managers can change or improve their actions. In Uganda, decentralisation helped the DHMTs be more responsive to the local workforce needs and analysing decision space helped identify areas for improvement in HRM. There are some limitations and more power over HRM functions and strong management competencies would help them become more resourceful

The gendered health workforce: Mixed methods analysis from four fragile and post-conflict contexts

** From PubMed via Jisc Publications Router.It is well known that the health workforce composition is influenced by gender relations. However, little research has been done which examines the experiences of health workers through a gender lens, especially in fragile and post-conflict states. In these contexts, there may not only be opportunities to (re)shape occupational norms and responsibilities in the light of challenges in the health workforce, but also threats that put pressure on resources and undermine gender balance, diversity and gender responsive human resources for health (HRH). We present mixed method research on HRH in four fragile and post-conflict contexts (Sierra Leone, Zimbabwe, northern Uganda and Cambodia) with different histories to understand how gender influences the health workforce. We apply a gender analysis framework to explore access to resources, occupations, values, decision-making and power. We draw largely on life histories with male and female health workers to explore their lived experiences, but complement the analysis with evidence from surveys, document reviews, key informant interviews, human resource data and stakeholder mapping. Our findings shed light on patterns of employment: in all contexts women predominate in nursing and midwifery cadres, are under-represented in management positions and are clustered in lower paying positions. Gendered power relations shaped by caring responsibilities at the household level, affect attitudes to rural deployment and women in all contexts face challenges in accessing both pre- and in-service training. Coping strategies within conflict emerged as a key theme, with experiences here shaped by gender, poverty and household structure. Most HRH regulatory frameworks did not sufficiently address gender concerns. Unless these are proactively addressed post-crisis, health workforces will remain too few, poorly distributed and unable to meet the health needs of vulnerable populations. Practical steps need to be taken to identify gender barriers proactively and engage staff and communities on best approaches for change.sch_iih32pub5112pubsuppl_

A new scale to assess health-facility level management: the development and validation of the facility management scale in Ghana, Uganda, and Malawi

Background: The increased recognition of governance, leadership, and management as determinants of health system performance has prompted calls for research focusing on the nature, quality, and measurement of this key health system building block. In low- or middle-income contexts (LMIC), where facility-level management and performance remain a challenge, valid tools to measure management have the potential to boost performance and accelerate improvements. We, therefore, sought to develop a Facility-level Management Scale (FMS) and test its reliability in the psychometric properties in three African contexts. Methods: The FMS was administered to 881 health workers in; Ghana (n = 287; 32.6%), Malawi (n = 66; 7.5%) and Uganda (n = 528; 59.9%). Half of the sample data was randomly subjected to exploratory factor analysis (EFA) and Monte Carlo Parallel Component Analysis to explore the FMS’ latent structure. The construct validity of this structure was then tested on the remaining half of the sample using confirmatory factor analysis (CFA). The FMS’ convergent and divergent validity, as well as internal consistency, were also tested. Results: Findings from the EFA and Monte Carlo PCA suggested the retention of three factors (labelled ‘Supportive Management’, ‘Resource Management’ and ‘Time management’). The 3-factor solution explained 51% of the variance in perceived facility management. These results were supported by the results of the CFA (N = 381; χ2 = 256.8, df = 61, p < 0.001; CFI = 0.94; TLI = 0.92; RMSEA [95% CI] = 0.065 [0.057–0.074]; SRMR = 0.047). Conclusion: The FMS is an open-access, short, easy-to-administer scale that can be used to assess how health workers perceive facility-level management in LMICs. When used as a regular monitoring tool, the FMS can identify key strengths or challenges pertaining to time, resources, and supportive management functions at the health facility level