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

Evaluating childbirth service readiness and the provision of person-centered maternity care at health facilities in Ethiopia

Background. Increased use of facility childbirth services—without the assurance of quality—has not consistently improved maternal and newborn health outcomes to the extent expected in low- and middle-income countries. To address service quality gaps, the World Health Organization (WHO) released standards in 2016 for improving quality of maternal and newborn care. This dissertation utilizes the WHO quality framework to evaluate facility readiness to provide childbirth care and assess maternity care experiences at health facilities in Ethiopia. Methods. This three-part study used 2019 data from a nationally representative sample of households in Ethiopia linked with data from facilities serving the same areas. The first paper compared methods for measuring facility readiness to provide childbirth services using different guidelines and aggregation techniques. The second examined the odds of residing within 10 kilometers of a service-ready facility by population characteristics, and the odds of a facility delivery given the readiness of nearby facilities. The third used a validated scale to measure person-centered maternity care (PCMC) and tested for differences in mean PCMC scores by individual and community characteristics. Results. Different methods for measuring childbirth service readiness showed moderate agreement with one another. The odds of residing within 10 kilometers of a service-ready facility were significantly greater for women with greater wealth, more formal education, and urban residence. The adjusted odds of using facility childbirth services were 1.23 (95% CI: 1.03, 1.48) times greater for each 0.10-unit increase (on 0-1 scale) in readiness of nearby facilities. PCMC scores were significantly higher for women with greater wealth, more formal education, and non-adolescents (≥20 years). PCMC items related to respect, dignity, trust, and supportive care scored relatively higher, whereas effective communication and support of women’s autonomy scored lower. Conclusion. Access to quality childbirth care is not equal for Ethiopian women. Those living in rural areas and the poorest must travel farther to reach childbirth services, and the nearest facilities serving these women were less prepared to provide quality care than those available to urban, wealthier women. Furthermore, those with less formal education, less wealth, and adolescents tended to receive less respectful treatment than their counterparts

Evaluating childbirth service readiness and the provision of person-centered maternity care at health facilities in Ethiopia

Background. Increased use of facility childbirth services—without the assurance of quality—has not consistently improved maternal and newborn health outcomes to the extent expected in low- and middle-income countries. To address service quality gaps, the World Health Organization (WHO) released standards in 2016 for improving quality of maternal and newborn care. This dissertation utilizes the WHO quality framework to evaluate facility readiness to provide childbirth care and assess maternity care experiences at health facilities in Ethiopia. Methods. This three-part study used 2019 data from a nationally representative sample of households in Ethiopia linked with data from facilities serving the same areas. The first paper compared methods for measuring facility readiness to provide childbirth services using different guidelines and aggregation techniques. The second examined the odds of residing within 10 kilometers of a service-ready facility by population characteristics, and the odds of a facility delivery given the readiness of nearby facilities. The third used a validated scale to measure person-centered maternity care (PCMC) and tested for differences in mean PCMC scores by individual and community characteristics. Results. Different methods for measuring childbirth service readiness showed moderate agreement with one another. The odds of residing within 10 kilometers of a service-ready facility were significantly greater for women with greater wealth, more formal education, and urban residence. The adjusted odds of using facility childbirth services were 1.23 (95% CI: 1.03, 1.48) times greater for each 0.10-unit increase (on 0-1 scale) in readiness of nearby facilities. PCMC scores were significantly higher for women with greater wealth, more formal education, and non-adolescents (≥20 years). PCMC items related to respect, dignity, trust, and supportive care scored relatively higher, whereas effective communication and support of women’s autonomy scored lower. Conclusion. Access to quality childbirth care is not equal for Ethiopian women. Those living in rural areas and the poorest must travel farther to reach childbirth services, and the nearest facilities serving these women were less prepared to provide quality care than those available to urban, wealthier women. Furthermore, those with less formal education, less wealth, and adolescents tended to receive less respectful treatment than their counterparts

Measuring facility readiness to provide childbirth care: a comparison of indices using data from a health facility survey in Ethiopia

Background Actionable information about the readiness of health facilities is needed to inform quality improvement efforts in maternity care, but there is no consensus on the best approach to measure readiness. Many countries use the WHO’s Service Availability and Readiness Assessment (SARA) or the Demographic and Health Survey (DHS) Programme’s Service Provision Assessment to measure facility readiness. This study compares measures of childbirth service readiness based on SARA and DHS guidance to an index based on WHO’s quality of maternal and newborn care standards.Methods We used cross-sectional data from Performance Monitoring for Action Ethiopia’s 2019 survey of 406 health facilities providing childbirth services. We calculated childbirth service readiness scores using items based on SARA, DHS and WHO standards. For each, we used three aggregation methods for generating indices: simple addition, domain-weighted addition and principal components analysis. We compared central tendency, spread and item variation between the readiness indices; concordance between health facility scores and rankings; and correlations between readiness scores and delivery volume.Results Indices showed moderate agreement with one another, and all had a small but significant positive correlation with monthly delivery volume. Ties were more frequent for indices with fewer items. More than two-thirds of items in the relatively shorter SARA and DHS indices were widely (>90%) available in hospitals, and half of the SARA items were widely (>90%) available in health centres/clinics. Items based on the WHO standards showed greater variation and captured unique aspects of readiness (eg, quality improvement processes, actionable information systems) not included in either the SARA or DHS indices.Conclusion SARA and DHS indices rely on a small set of widely available items to assess facility readiness to provide childbirth care. Expanded selection of items based on the WHO standards can better differentiate between levels of service readiness

Readiness, access, and use of facility childbirth care in Ethiopia: results from nationally representative linked household and health facility surveys

# Background Facility readiness is an important prerequisite for providing safe, effective childbirth care. This study assesses the readiness of health facilities in Ethiopia to provide childbirth services, describes variations in geographic access to service-ready facilities, and evaluates how facility readiness relates to childbirth service usage with a lens on equity. # Methods The study used cross-sectional data from a nationally representative sample of households in Ethiopia linked with data from health facilities serving the same areas. We explored variation in childbirth service readiness across facilities and classified facilities as "service-ready" if they had a readiness score of 0.75 or higher on a 0-1 scale. We used logistic regression modeling to examine the odds of residing within 10 kilometers of a service-ready facility by socioeconomic and geographic characteristics, and the odds of a facility delivery given the readiness of nearby facilities. # Results Childbirth service readiness was generally high for hospitals (median score: 0.92) with minimal variation (interquartile range, IQR: 0.88 to 0.96). Health centers and clinics displayed lower and more variable readiness (median: 0.75, IQR: 0.66 to 0.84). In both crude and adjusted regression analyses, odds of residing within 10 kilometers of a service-ready facility were significantly greater for women with higher education levels, greater wealth, and urban residence. We found the adjusted odds of using facility childbirth services were 1.23 (95% CI: 1.03, 1.48) times greater for each 0.10-unit increase in the readiness level of nearby facilities. # Conclusions Access to childbirth care is not equal for Ethiopian women. Those living in rural areas and the poor must travel farther to reach facility childbirth services, and the nearest facilities serving these women were less prepared to provide quality care. This may contribute to lower service utilization by such disadvantaged groups of women

Data for local decision-making, not a mere reporting requirement: development of an index to measure facility-level use of HMIS data

# Background Well-functioning health management information systems (HMIS) enable decision-making at all health system levels. This study develops an index to measure the use of HMIS data at the facility level. # Methods We used two rounds of cross-sectional data collected from 305 health facilities in Ethiopia in 2019 (pre-COVID-19) and 2020 (post-COVID-19). We constructed a summative, 10-item index using exploratory factor analysis and 2019 index development data; and used Cronbach's alpha to assess reliability. To examine content validity, we mapped items against a previously published conceptual framework and consulted Ethiopian experts. We then employed one-way ANOVA and t-tests comparing the mean index scores overall and by key facility characteristics between 2019 and 2020. # Results The 10-item index loaded on one factor (Cronbach's alpha=0.74), and the index scores did not differ significantly by facility characteristics in 2019. The mean index score increased from 7.2 in 2019 to 7.9 in 2020 (*P*\<0.01). During this period, more facilities received feedback on HMIS reports from facility leadership (19.3% difference); received actionable recommendations on performance targets and resource allocation (7.5% and 12.3% difference, respectively); and reviewed maternal deaths (15.1% difference); conversely, the proportion of facilities that held participatory performance review meetings monthly or more often decreased by 13.8% (all *P* \<0.05). # Conclusions We propose a facility-level HMIS data use index and document an upward trend in HMIS data use in Ethiopia immediately after the COVID-19 pandemic was declared. Future research should further evaluate and refine the proposed index to support the measurement of HMIS data quality and utilization in Ethiopia and like settings

The Potential of Digital Data Collection Tools for Long-lasting Insecticide-Treated Net Mass Campaigns in Nigeria: Formative Study

BackgroundNigeria has the world’s largest malaria burden, accounting for 27% of the world’s malaria cases and 23% of malaria mortality globally. This formative study describes the operational process of the mass distribution of long-lasting insecticide-treated nets (LLINs) during a campaign program in Nigeria. ObjectiveThis study aims to assess whether and how digital data collection and management tools can change current practices and help resolve major implementation issues. MethodsQualitative data on the technical features and operational processes of paper-based and information and communication technology (ICT)–based systems in the Edo and Kwara states from June 2 to 30, 2017, were collected on the basis of documented operation manuals, field observations, and informant interviews. During the LLIN campaign in Edo State, we recruited 6 local government area focal persons and monitors and documented daily review meetings during household mobilization (9 days) and net distribution (5 days) to understand the major program implementation issues associated with the following three aspects: logistic issues, technical issues, and demand creation. Each issue was categorized according to the expected degree (low, mid, and high) of change by the ICT system. ResultsThe net campaign started with microplanning and training, followed by a month-long implementation process, which included household mobilization, net movement, net distribution, and end process monitoring. The ICT system can improve management and oversight issues related to data reporting and processes through user-centered interface design, built-in data quality control logic flow or algorithms, and workflow automation. These often require more than 50% of staff time and effort in the current paper-based practice. Compared with the current paper-based system, the real-time system is expected to reduce the time to payment compensation for health workers by about 20 days and produce summary campaign statistics for at least 20 to 30 days. ConclusionsThe ICT system can facilitate the measurement of population coverage beyond program coverage during an LLIN campaign with greater data reliability and timeliness, which are often compromised due to the limited workforce capacity in a paper-based system