Assessing access barriers to maternal health care: measuring bypassing to identify health centre needs in rural Uganda.

BACKGROUND: In low income countries, several barriers exist to the use of health services for child delivery, including distance, transportation, informal costs or low perceived quality. Yet there is rarely information about which barriers are more or less important to the use of a given health facility. This study assessed the relative importance of different barriers to maternal health facility use in rural Uganda through the use of simple indicators based on locally available data. METHODS: Data from public health facilities performing deliveries in a rural district were used along with census information to construct a set of indicators useful for diagnosing barriers to delivery service use. Indicators included the number of facility-based deliveries per 1000 women served, the proportion of users from a facility's local area, and a new indicator, the 'bypassing ratio', defined as the number of women from a facility's local area who delivered in other facilities, divided by the number of local women using the facility itself. RESULTS: Numbers of deliveries varied greatly between facilities of the same level. A few very low use facilities saw over 75% of women come from the local area, while other facilities services attracted a large majority of women from other areas. The phenomenon of bypassing provides additional insight into the relative importance of distance or transport as opposed to internal facility factors preventing use. CONCLUSIONS: Simple and easily replicable tools are essential to assist health managers to identify communities and facilities needing improvements in access to delivery care. The methods developed in this paper could be utilized by local officials in other areas to assist planning and improvement of both maternal care and other health services

Uganda's minimum health care package: rationing within the minimum?

Essential/minimum health care packages (MHCP) have appeared on the primary health care scene as a means of setting priorities for national health budgets. A technical approach of cost-effectiveness was sought to guide the political and group bargaining approaches. In Uganda, the application of the cost-effectiveness techniques seem not to have had an effect on the priority setting. A package of minimum services that is written into the sector plan has turnout to be more then the resources available in the medium term. At the operational level, the delivery of the minimum package has been rendered ineffective and inefficient, by trying to attain universal access with $8 per capita instead of$28. System capacity constraints for effective and equitable delivery of the MCHP are traced at the infrastructure-based planning and in explicit and implicit re-prioritization and rationing within the minimum package

Overcoming access barriers for facility-based delivery in low-income settings: insights from Bangladesh and Uganda.

Women in both Bangladesh and Uganda face a number of barriers to delivery in professional health facilities, including costs, transportation problems, and sociocultural norms to deliver at home. Some women in both the countries manage to overcome these barriers. This paper reports on a comparative qualitative study investigating how some women and their families were able to use professional delivery services. The study provides insights into the decision-making processes and overcoming access barriers. Husbands were found to be particularly important in Uganda, while, in Bangladesh, a number of individuals could influence care-seeking, including unqualified local healers or traditional birth attendants. In both the settings, cost and transport barriers were often overcome through social networks. Social prohibitions on birth in the health facility did not feature strongly in women's accounts, with several Ugandan women explaining that friends or peers also used facilities, while, in Bangladesh, perceived complications apparently justified the use of professional medical care. Investigating the ways in which some women can overcome common barriers can help inform policy and planning to increase the use of health facilities for child delivery

Aid alignment: a longer term lens on trends in development assistance for health in Uganda

Background Over the past decade, development assistance for health (DAH) in Uganda has increased dramatically, surpassing the government’s own expenditures on health. Yet primary health care and other priorities identified in Uganda’s health sector strategic plan remain underfunded. Methods Using data available from the Creditor Reporting System (CRS), National Health Accounts (NHA), and government financial reports, we examined trends in how donors channel DAH and the extent to which DAH is aligned with sector priorities. The study follows the flow of DAH from the donor to the implementing organization, specifying the modality used for disbursing funds and categorizing funds based on program area or support function. Findings Despite efforts to improve alignment through the formation of a sector-wide approach (SWAp) for health in 1999 and the creation of a fund to pool resources for identified priorities, increasingly DAH is provided as short-term, project-based support for disease-specific initiatives, in particular HIV/AIDS. Conclusion These findings highlight the need to better align external resources with country priorities and refocus attention on longer-term sector-wide objectives.UKai

Can donor aid for health be effective in a poor country? Assessment of prerequisites for aid effectiveness in Uganda

Background: Inadequate funding for health is a challenge to attaining health-related Millennium Development Goals. Significant increase in health funding was recommended by the Commission for Macroeconomics and Health. Indeed Official Development Assistance has increased significantly in Uganda. However, the effectiveness of donor aid has come under greater scrutiny. This paper scrutinizes the prerequisites for aid effectiveness. The objective of the study was to assess the prerequisites for effectiveness of donor aid, specifically, its proportion to overall health funding, predictability, comprehensiveness, alignment to country priorities, and channeling mechanisms. Methods:Secondary data obtained from various official reports and surveys were analyzed against the variables mentioned under objectives. This was augmented by observations and participation in discussions with all stakeholders to discuss sector performance including health financing. Results:Between 2004−2007, the level of aid increased from US$6 per capita to US$11. Aid was found to be unpredictable with expenditure varying between 174−360 percent from budgets. More than 50% of aid was found to be off budget and unavailable for comprehensive planning. There was disproportionate funding for some items such as drugs. Key health system elements such as human resources and infrastructure have not been given due attention in investment. The government’s health funding from domestic sources grew only modestly which did not guarantee fiscal sustainability. Conclusion: Although donor aid is significant there is need to invest in the prerequisites that would guarantee its effective use

‘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

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

Cost of care for preterm babies to Clients and influence of costs on care in resource limited settings - Societal perspective: A case of Jinja Regional Referral Hospital in East central Uganda

Introduction: The costs of care for preterm birth to clients and the influence of costs on preterm care remain a significant issue to the health system and families globally especially in the low-middle income countries particularly, in Asia and sub-Saharan Africa with already constrained economies. However, this has not received worthwhile attention. We estimated the costs of care for preterm babies to families (clients) and the influence of costs on the care for preterm babies from a societal perspective in Jinja Regional Referral Hospital. Methods: This was a one-month survey from August 2016 — September 2016 through which we had exit interviews with 100 mothers to determine the costs on admission and followed up 82 mothers to determine follow up costs of all babies that were born preterm and weighed less than 2.5 kg either at discharge or follow up. A micro costing approach was used to compute client costs for preterm care. Mothers were asked to identify absolute costs incurred. We also reviewed medical records of patients and receipts that were available from clients. A likert scale was used to assess influence of costs on preterm care to mothers. This ranged from -5 to 5, where (+5 to +1) was high influence, (0) was neutral, (-5 to -1) was low influence. Respondents were also asked to give reasons for their answers. From the provider perspective, we conducted key informant interviews with health care workers to ascertain the influence of costs on preterm care from the provider perspective. Analysis of findings was done using the Microsoft excel sheet. Statistical analysis was done using Stata Version 13 to determine the influence of costs on the care of preterm babies from the client's perspective. Thematic analysis was used to analyze the influence of costs on care from the provider perspective. Costs were converted to US$for the annual exchange average rate of 2016. One-way sensitivity analysis was done to establish the impact of cost drivers on the total cost. Results: The total annual cost of preterm care from the client perspective was US$ 10,520.36 and the unit cost of care per preterm baby was US$ 105.2 at Jinja Regional Referral Hospital. Cost drivers included opportunity costs (i.e., potential benefits foregone by clients to take care of preterm babies), drug costs on follow up, supplies and feeding costs to the mothers/caregivers during admission. Drugs, supplies thermal care and feeding costs during admission were found to have a high influence on preterm care from a societal perspective. Conclusion: The cost of preterm care is high from the client perspective and is characterized by longer stay in hospital because of missed treatment due to stock outs and affordability constraints to clients, but also discharge against medical advice leading to poor survival of preterm babies. Improving funding for preterm care and welfare for caregivers during hospitalization may lead to better outcomes for preterm babies

Building the Field of Health Policy and Systems Research: Social Science Matters

In the second in a series of articles addressing the current challenges and opportunities for the development of Health Policy and Systems Research (HPSR), Lucy Gilson and colleagues argue the importance of insights from the social sciences

Advancing the application of systems thinking in health: exploring dual practice and its management in Kampala, Uganda

Many full-time Ugandan government health providers take on additional jobs; this dual practice prevails because public and private sector incentives, non-financial and financial, are complementary. Understanding how dual practice evolves and how it is managed locally is essential for health workforce policy, planning, and performance discussions in Uganda and similar settings. Available literature examines dual practice rather narrowly and generally only from the perspective of physicians. In this study we describe the complex patterns that characterize the evolution of dual practice in Uganda, and the local management practices that emerged in response, in five government facilities