Health System In Uganda Research Articles

Contextualised digital health communication infrastructure standards for resource-constrained settings: Perception of digital health stakeholders regarding suitability for Uganda's health system.

Ignoring the need to contextualise international standards has caused low-resourced countries to implement digital health systems on the ad-hoc, thereby often failing to meet the local needs or scale up. Authors have recommended adapting standards to a country's context. However, to date, most resources constrained countries like Uganda have not done so, affecting their success in attaining the full benefits of using ICT to support their health systems. They apply the standards 'as is' with little regard for their fitness for potential use and ability to fulfil the country's digital health needs. A design science approach was followed to elicit digital health communication infrastructure (DHCI) requirements and develop the contextual DHCI standards for Uganda. The design science methodology's design cycle supported DHCI standards' construction and evaluation activities. Whereas two workgroup sessions were held to craft the standards, three cycles of evaluation and refinement were performed. The final refinement produces the contextualised DHCI standards approved by Uganda's DH stakeholders through summative evaluation. Results of the summative evaluation show that DH stakeholders agree that the statement of the standards and the requirements specification are suitable to guide DHCI standards implementation in Uganda. Stakeholders agreed that the standards are complete, have the potential to realise DHCI requirements in Uganda, that have been well structured and follow international style for standards, and finally, that the standards are fit to realise their intended use in Uganda. Having been endorsed by DH stakeholders in Uganda's health system, the standards should be piloted to establish their potency to improve health information exchange and healthcare outcomes. Also, we recommend other low middle income countries (LMICs) with similar challenges to those in Uganda adopt the same set of contextualised DHCI standards.

Supporting health systems in Uganda: a call for action

Supporting health systems in Uganda: a call for action

Enterprise architecture requirements for standardising digital health in Uganda's health system

ObjectiveThis research aimed to develop and validate enterprise architecture (EA) requirements to standardise digital health (DH) in Uganda's health system. These requirements were generated from DH challenges identified in an earlier prerequisite empirical study that was conducted to explore the feasibility of contextualising existing international DH standards to improve data use in Uganda's health system. MethodsThe study followed a cross-sectional research design, with the HIV/AIDS and TB disease model as a case study. A walkthrough approach was adopted to validate the derived requirements using purposively selected participants at national and sub-national levels of Uganda's healthcare system. Questionnaires (Google forms) were used to collect validation responses, while quantitative data was analysed using MS Excel. ResultsThe results show that the respondents agreed with the DH EA requirements for standardising Uganda's health system. The results represent views from 65.67% of the expected participants drawn from all Uganda's DH stakeholders. Although a few respondents (3.3%) did not agree, most (96.7%) agreed with the requirements as-is. Therefore, the derived EA requirements are deemed suitable for standardising and strengthening Uganda's DH system. ConclusionProper implementation of the EA requirements is expected to produce efficient, cost-effective, quality and safe digital health initiatives for Uganda.

An exploration of health workers’ experiences in providing bereavement care to mothers following a stillbirth: results from a subnational level health system in Uganda

BackgroundStillbirth is a profound emotion-laden event to the mothers and health workers who provide care due to its sudden and unexpected occurrence. Health workers offering support in regions shouldering the highest-burden experience providing support to a stillbirth mother in their professional lifetime. However, their experiences seldom get documented as much of the focus is on mothers causing a dissonance between parental and clinical priorities. This study aimed to explore the health worker’s experiences in the provision of bereavement care to mothers following a stillbirth.MethodsAn exploratory cross-sectional qualitative study was undertaken on a purposively selected sample of key informants drawn from frontline health workers and health systems managers providing maternal health services at a subnational level health system in Uganda. An interview guide was used to collect data with the audio-recorded interviews transcribed using Microsoft office word. Atlas. ti a qualitative data management software aided in coding with analysis following a thematic content analysis technique.ResultsThere was no specialised bereavement care provided due to inadequate skills, knowledge of content, resources and support supervision for the same. However, health workers improvised within the available resources to comfort mothers upon news of a stillbirth. Disclosure to mothers about the stillbirth loss often took the form of forewarnings, direct and sometimes delayed disclosure. A feeling of unpreparedness to initiate the disclosure process to the mother was common while the whole experience had an emotional effect on the health workers when establishing the cause, particularly for cases without clear risk factors. The emotional breakdown was often a reflexive response from the mothers which equally affected the care providers. Health workers engaged in comforting and rebuilding the mothers to transition through the loss and validate the loss. Efforts to identify the skills and health systems gaps for address were a common response targeted at improving the quality of maternal healthcare services to avert similar occurrences in the future.ConclusionProviding care to mothers after stillbirth was an emotional and challenging experience for health workers requiring different approaches to disclosure and provision of emotional support. The aspect of specialised bereavement care was lacking within the current response. Reflection of unpreparedness to handle the tasks demonstrates a deficit in the required skills. It is a critical gap missing hence calling for dedicated efforts to address it. Targeting efforts to improve health workers’ competencies and preparedness to manage grieving mothers is one way to approach it.

Effects of timed and targeted counselling by community health workers on maternal and household practices, and pregnancy and newborn outcomes in rural Uganda

IntroductionPregnancy and birth-related complications claim the lives of millions of women and newborns every year. Improving their survival chances remains an urgent global challenge, including in Uganda. Community health workers (CHWs) play a crucial role in bridging the gap between the community and the official health system in Uganda. Timed and targeted Counselling (ttC) is an individual-level behavioral change communication method used by CHWs, aimed at pregnant women and caregivers of children under the age of two. AimThis study examined whether the implementation of the ttC intervention by the CHWs was associated with improved household practices and outcomes during the pregnancy and newborn period. MethodsA multi-stage sampling technique was employed with a total of 749 participants in the intervention group (ttC intervention), and 744 participants in the control group (no ttC). Data on quality of maternal and household antenatal care (ANC) and essential newborn care (ENC) practices, as well as on pregnancy and newborn outcomes were collected through questionnaires from May 2018 to May 2020. McNemar’s Chi-square tests were used to compare outcomes before and after implementation, and between the intervention and control group. ResultsResults showed that, compared to baseline, ttC contributed significantly to the demand for quality of service during ANC, ENC and partner involvement in maternal and newborn health. In comparison to the control group, the ttC group showed significantly higher early ANC attendance rates and higher quality of ANC and ENC. ConclusionttC is a comprehensive, goal-driven approach that seems to contribute to the improvement of quality of maternal and household practices, and pregnancy and newborn outcomes in Uganda. Trial registrationPACTR, PACTR202002812123868, registered on 25 February 2020, http://www.pactr.org/PACTR202002812123868.

Information Streams in Health Facilities: The Case of Uganda

Abstract With the prevailing COVID-19 pandemic, the lack of digitally-recorded and connected health data poses a challenge for analysing the situation. Virus outbreaks, such as the current pandemic, allow for the optimisation and reuse of data, which can be beneficial in managing future outbreaks. However, there is a general lack of knowledge about the actual flow of information in health facilities, which is also the case in Uganda. In Uganda, where this case study was conducted, there is no comprehensive knowledge about what type of data is collected or how it is collected along the journey of a patient through a health facility. This study investigates information flows of clinical patient data in health facilities in Uganda. The study found that almost all health facilities in Uganda store patient information in paper files on shelves. Hospitals in Uganda are provided with paper tools, such as reporting forms, registers and manuals, in which district data is collected as aggregate data and submitted in the form of digital reports to the Ministry of Health Resource Center. These reporting forms are not digitised and, thus, not machine-actionable. Hence, it is not easy for health facilities, researchers, and others to find and access patient and research data. It is also not easy to reuse and connect this data with other digital health data worldwide, leading to the incorrect conclusion that there is less health data in Uganda. The a FAIR architecture has the potential to solve such problems and facilitate the transition from paper to digital records in the Uganda health system.

Health workers' social networks and their influence in the adoption of strategies to address the stillbirth burden at a subnational level health system in Uganda.

Health workers' peer networks are known to influence members' behaviours and practices while translating policies into service delivery. However, little remains known about the extent to which this remains true within interventions aimed at addressing the stillbirth burden in low-resource settings like Uganda. The objective of this study was to examine the health workers' social networks and their influence on the adoption of strategies to address the stillbirth burden at a subnational level health system in Uganda. A qualitative exploratory design was adopted on a purposively selected sample of 16 key informants. The study was conducted in Mukono district among sub-national health systems, managers, health facility in-charges, and frontline health workers. Data was collected using semi-structured interview guides in a face-to-face interview with respondents. The analysis adopted a thematic approach utilising Atlas. ti software for data management. Participants acknowledged that workplace social networks were influential during the implementation of policies to address stillbirth. The influence exerted was in form of linkage with other services, caution, and advice regarding strict adherence to policy recommendations perhaps reflective of the level of trust in providers' ability to adhere to policy provisions. At the district health management level and among non-state actors, support in perceived areas of weak performance in policy implementation was observed. In addition, timely initiation of contact and subsequent referral was another aspect where health workers exerted influence while translating policies to address the stillbirth burden. While the level of support from among network peers was observed to influence health workers' adoption and implementation of strategies to address the stillbirth burden, different mechanisms triggered subsequent response and level of adherence to recommended policy aspects. Drawing from the elicited responses, we infer that health workers' social networks influence the direction and extent of success in policy implementation to address the stillbirth burden at the subnational level.

Personal Experience, Involvement and Activism for the Reform of Uganda's Mental Health System.

This Fresh Focus commentary describes the author's grassroots perspective on and advocacy efforts to bring about change within the mental health system in Uganda. The essay draws on personal narrative, first-hand description of human rights violations, grassroots efforts to bring about change through legal advocacy and development of peer support and service user leadership initiatives, and ultimately charts a course for deeper change.

Male involvement in reproductive, maternal, newborn, and child health: evaluating gaps between policy and practice in Uganda

IntroductionMale involvement in maternal and child health is a practice wherein fathers and male community members actively participate in caring for women and supporting their family to access better health services. There is positive association between male involvement and better maternal and child health outcomes. However, the practice is not always practiced optimally, especially in low- and middle-income countries, where women may not have access to economic resources and decision-making power.AimThis study investigates how key stakeholders within the health system in Uganda engage with the ‘male involvement’ agenda and implement related policies. We also analyzed men’s perceptions of male involvement initiatives, and how these are influenced by different political, economic, and organizational factors.MethodologyThis is a qualitative study utilizing data from 17 in-depth interviews and two focus group discussions conducted in Kasese and Kampala, Uganda. Study participants included men involved in a maternal health project, their wives, and individuals and organizations working to improve male involvement; all purposively selected.ResultThrough thematic analysis, four major themes were identified: ‘gaps between policy and practice’, ‘resources and skills’, ‘inadequate participation by key actors’, and ‘types of dissemination’. These themes represent the barriers to effective implementation of male involvement policies. Most health workers interviewed have not been adequately trained to provide male-friendly services or to mobilize men. Interventions are highly dependent on external aid and support, which in turn renders them unsustainable. Furthermore, community and religious leaders, and men themselves, are often left out of the design and management of male involvement interventions. Finally, communication and feedback mechanisms were found to be inadequate.ConclusionTo enable sustainable behavior change, we suggest a ‘bottom-up’ approach to male involvement that emphasizes solutions developed by or in tandem with community members, specifically, fathers and community leaders who are privy to the social norms, structures, and challenges of the community.

Roles and challenges of family physicians in Uganda: A qualitative study.

BackgroundThe World Health report (2008), the World Health Assembly (2009) and the Declaration of Astana (2018) acknowledge the significant contribution of family physicians (FPs) in clinical and primary healthcare. Given the lack of resources and low numbers of FPs coupled with the contextual nature of family medicine (FM), the scope of practice of African FPs is likely to differ from that of colleagues in America and Europe. Thus, this study explored the roles of Ugandan FPs and the challenges they face.MethodsThis cross-sectional qualitative study was conducted through in-depth interviews with FPs who are working in Uganda. Participants who work in public and private healthcare systems including non-governmental organisations and in all geographical regions were purposively selected. Interviews were conducted from July 2016 to June 2017. Qualitative thematic content analysis of the transcripts was performed using a framework approach.ResultsThe study team identified three and six thematic roles and challenges, respectively, from the interview transcripts. The roles were clinician, leadership and teaching and learning. Challenges included lack of common identity, low numbers of FPs, conflicting roles, unrealistic expectations, poor organisational infrastructure and lack of incentives.ConclusionThe major roles of FPs in Uganda are similar to those of their counterparts in other parts of the world. Family physicians provide clinical care for patients, including preventive and curative services; providing leadership, management and mentorship to clinical teams; and teaching and learning. However, their roles are exercised differently as a result of lack of proper institutionalisation of FM within the Uganda health system. Family physicians in Uganda have found many opportunities to contribute to healthcare leadership, education and service, but have not yet found a stable niche within the healthcare system.

The outcome of a training programme (RESPECT) on staff's attitudes towards causes and management of aggression in a Regional Referral Hospital of northern Uganda.

WHAT IS KNOWN ON THE SUBJECT?: Health systems in many low- to middle-income countries (LMICs) are heavily underfunded, and staff training opportunities are limited. There is a lack of empirical data on the development and use of sustainable training programmes in aggression management skills in LMICs. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: After RESPECT, participants showed greater agreement with statements about the role of environmental and relational factors as antecedents of aggression and described favouring the use of non-physical techniques to manage aggressive behaviour. Attitudes towards management practices of seclusion, medication and restraint remained unchanged after RESPECT training. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Training programmes like RESPECT may be useful to improve attitudes towards causes of aggression and its management in LMIC hospitals. However, further evidence is required to demonstrate whether these results can be sustained over time and whether these attitudinal changes are associated with reduction of workplace violence. Mental health nurses and other mental health professionals can play a key role in establishing hospital-wide training and sharing skills across geographical boundaries. Abstract Introduction Occupational violence has been demonstrated to impact negatively on the well-being of nurses and patients. Staff attitudes towards causes and management of patients' aggression influence their practice. Training is likely to influence attitudes towards aggression; however, Uganda's health system lacks adequate resources to provide aggression management training for staff. Aim To assess the impact of a training programme (RESPECT) on staff attitudes towards causes and management of patient's aggression in a Ugandan hospital. Methods This study used a mixed-methods convergent design. A convenience sample of nurses and support staff employed in the psychiatric ward and other services across the hospital (N=90) completed the Management of Aggression and Violence Attitude Scale (MAVAS) pre- and post-training. The views of a smaller sample (n=35) were captured via interviews and focus groups and analysed using thematic analysis. Results Participants reported greater agreement with patients' physical and social environment (external and situational causative models) as factors influencing patient's aggression. Qualitative findings substantiated the results identified in the survey. Attitudes towards seclusion, restraint and medication remained unchanged. Discussion and implications for practice RESPECT has the potential to change staff attitudes towards aggression in the short term. Further research is needed to investigate long-term effects and impact on incidents of aggression.

Evaluating user experiences of a clearing house for health policy and systems.

Timely access to evidence increases the prospects for evidence informed decision making. We evaluated user experiences of a Clearing House for Health Policy with the aim of increasing access to evidence about the Uganda health system and interventions. We conducted in-depth interviews with 15 potential users including policymakers, health policy advisors, health managers and researchers to provide evidence on their experience with the clearinghouse. On average participants took 20minutes to first navigate the site and 45minutes to perform search tasks and complete the interview. Most respondents successfully searched for information with accuracy and completeness in a short time. Participants commended the performance and expressed high regard for the credibility of the clearinghouse. The majority felt that using the resource was worth their effort. The clearinghouse provided appropriate functionalities for information searching. Navigating and finding information from the site was achievable. However, inadequate background information about the site and lack of current information were widely reported. Our paper provides insights on the issues that can be addressed to improve online resources for health policy and system information in a limited resource setting. Users' experience of such resources can be improved by regularly appraising and appropriately indexing the contents, and optimising the capacity to customise information.

Uganda public health fellowship program’s contribution to building a resilient and sustainable public health system in Uganda

ABSTRACTBackground: Low-income countries with relatively weak-health systems are highly vulnerable to public health threats. Effective public health system with a workforce to investigate outbreaks can reduce disease impact on livelihoods and economic development. Building effective public health partnerships is critical for sustainability of such a system. Uganda has made significant progress in responding to emergencies during the past quarter century, but its public health workforce is still inadequate in number and competency.Objectives: To reinforce implementation of priority public health programs in Uganda and cultivate core capacities for compliance with International Health Regulations.Methods: To develop a competent workforce to manage epidemics and improve disease surveillance, Uganda Ministry of Health (MoH) established an advanced-level Field Epidemiology Training Program, called Public Health Fellowship Program (PHFP); closely modelled after the US CDC’s Epidemic Intelligence Service. PHFP is a 2-year, full-time, non-degree granting program targeting mid-career public health professionals. Fellows spend 85% of their field time in MoH placements learning through service delivery and gaining competencies in major domains.Results: During 2015–2018, PHFP enrolled 41 fellows, and graduated 30. Fellows were placed in 19 priority areas at MoH and completed 235 projects (91 outbreaks, 12 refugee assessments, 50 surveillance, and 60 epidemiologic studies, 3 cost analysis and 18 quality improvement); made 194 conference presentations; prepared 63 manuscripts for peer-reviewed publications (27 published as of December 2018); produced MoH bulletins, and developed three case studies. Projects have resulted in public health interventions with improvements in surveillance systems and disease control.Conclusion: During the 4 years of existence, PHFP has contributed greatly to improving real-time disease surveillance and outbreak response core capacities. Enhanced focus on evidence-based targeted approaches has increased effectiveness in outbreak response and control, and integration of PHFP within MoH has contributed to building a resilient and sustainable health system in Uganda.

Ugandan providers\u2019 views on the acceptability of contraceptive self-injection for adolescents: a qualitative study

BackgroundSelf-injection of subcutaneous depot medroxyprogesterone acetate may offer greater discretion and increase access to injectable contraception, particularly for those who face challenges accessing clinic services. In particular, unmarried adolescents often encounter stigma when seeking services, and may also lack the financial means to travel to clinics on the quarterly basis that injectable contraception requires. Whether self-injection is offered to women on a wide scale basis, and to adolescents specifically, will depend in part upon the willingness of providers to train clients of diverse ages and educational backgrounds. This study explores the views of providers with regard to self-injection as an option for women and adolescents in Uganda.MethodsIn-depth qualitative interviews were conducted with family planning providers in Gulu district, to understand their views on injectable self-injection for women, with a specific focus on unmarried adolescents ages 15 to 19 years. The in-depth interviews, which lasted up to 60 min were audio-recorded, translated and transcribed simultaneously, and analyzed using Atlas.ti software to identify key themes and common perspectives.ResultsA total of 40 health care providers were interviewed with equal numbers of each type (public, NGO, and private clinics, pharmacies, and community-based health workers). While most providers were receptive to self-injection for adult women, fewer than half were supportive of adolescent self-injection. Their reservations focused on age, marital status and parity concerns around adolescent use of the injectable more broadly, and concerns about the ability of adolescents to self-inject safely.ConclusionsSelf-injection presents an opportunity to reduce the enormous burden on the public sector health system in Uganda, which is particularly compounded by the heavy reliance on injectable contraception requiring quarterly clinic visits. The results of this study reveal a level of cautious support for self-injection among providers when it comes to self-injection by adult women. With respect to adolescent clients, family planning policymakers and program implementers should design, implement, and evaluate self-injection interventions with the needs of adolescent clients uppermost in mind, recognizing that extra attention will likely be needed to reduce provider-imposed restrictions on adolescent access to this injectable delivery modality.

Understanding the persistence of vertical (stand-alone) HIV clinics in the health system in Uganda: a qualitative synthesis of patient and provider perspectives

BackgroundAlthough there is mounting evidence and policy guidance urging the integration of HIV services into general health systems in countries with a high HIV burden, vertical (stand-alone) HIV clinics are still common in Uganda. We sought to describe the specific contexts underpinning the endurance of vertical HIV clinics in Uganda.MethodsA qualitative research design was adopted. Semi-structured interviews were conducted with the heads of HIV clinics, clinicians and facility in-charges (n = 78), coupled with eight focus group discussions (64 participants) with patients from 16 health facilities purposively selected, from a nationally-representative sample of 195 health facilities across Uganda, because they run stand-alone HIV clinics. Data were analyzed by thematic approach as guided by the theory proposed by Shediac-Rizkallah & Bone (1998) which identifies; Intervention characteristics, organizational context, and broader environment factors as potentially influential on health programme sustainability.ResultsIntervention characteristics: Provider stigma was reported to have been widespread in the integrated care experience of participating health facilities which necessitated the establishment of stand-alone HIV clinics. HIV disease management was described as highly specialized which necessitated a dedicated workforce and vertical HIV infrastructure such as counselling rooms. Organizational context: Participating health facilities reported health-system capacity constraints in implementing integrated systems of care due to a shortage of ART-proficient personnel and physical space, a lack of laboratory capacity to concurrently conduct HIV and non-HIV tests and increased workloads associated with implementing integrated care. Broader environment factors: Escalating HIV client loads and external HIV funding architectures were perceived to have perpetuated verticalized HIV programming over the past decade.ConclusionOur study offers in-depth, contextualized insights into the factors contributing to the endurance of vertical HIV clinics in Uganda. Our analysis suggests that there is a complex interaction in supply-side constraints (shortage of ART-proficient personnel, increased workloads, laboratory capacity deficiencies) and demand-side factors (escalating demand for HIV services, psychosocial barriers to HIV care) as well as the specialized nature of HIV disease management which pose challenges to the integrated-health services agenda.

\u201cWe are like co-wives\u201d: Traditional healers' views on collaborating with the formal Child and Adolescent Mental Health System in Uganda

BackgroundEarly identification and management of mental illness in childhood and adolescence helps to avert debilitating mental illness in adulthood but the attention given to Child and Adolescent Mental Health (CAMH) has until recently been low. Traditional healers are often consulted by patients with mental illness and in Uganda, up to 60% of patients attending traditional healers have moderate to severe mental illness. Poor access to CAMH care in Uganda creates a treatment gap that could be met through enhanced collaboration between traditional healers and biomedical health systems. The aim of this study was to explore traditional healers’ views on their collaboration with biomedical health systems so as to inform the implementation of strategies to improve access to CAMH services in Uganda.MethodsIn-depth interviews with 20 purposively selected traditional healers were conducted in November 2015. A semi-structured interview guide was used to explore: 1) The experiences of traditional healers with mental ill-health in children and adolescents; 2) their willingness to collaborate with the formal health system; and 3) their perception of clinicians’ willingness to collaborate with them. Interviews were conducted in local languages and tape recorded. Data were analysed using thematic analysis.ResultsTraditional healers described several experiences managing children and adolescents with mental illness, which they ascribed to spiritual and physical causes. The spiritual explanations were a consequence of unhappy ancestral spirits, modern religions and witchcraft, while physical causes mentioned included substance abuse and fevers. No traditional healer had received a patient referred to them from a medical clinic although all had referred patients to clinics for non-mental health reasons.Traditional healers expressed distrust in biomedical health systems and believed their treatments were superior to medical therapies in alleviating mental suffering. They expressed willingness to collaborate with biomedical providers. However, traditional healers believe clinicians disregard them and would not be willing to collaborate with them.ConclusionPotential for collaboration between traditional healers and biomedical health systems for improving access to CAMH services in Uganda exists, but is undermined by mutual mistrust and competition between traditional healers and clinicians.

NATIONAL FRAMEWORK FOR THE SUSTAINABILITY OF HEALTH KNOWLEDGE TRANSLATION INITIATIVES IN UGANDA.

The aim of this study was to provide evidence about the design and implementation of policies for advancing the sustainability of knowledge translation (KT) initiatives and policies in Uganda's health system. We searched for and reviewed evidence about KT sustainability issues in Uganda, the impacts of options, barriers to implementing these options, and implementation strategies to address such barriers. In instances where the systematic reviews provided limited evidence, these were supplemented with relevant primary studies. Documents such as the government reports and unpublished literature were also included in the search. Key informant interviews and a policy dialogue were conducted, and an expert working group guided the study. The KT sustainability issues identified were: the absence of a specific unit within the health sector to coordinate and synthesize research; health worker not familiar with KT activities and not often used. Furthermore, Uganda lacks a mechanism to sustain its current national health frameworks or platforms, and does not have a system to ensure the sustained coordination of existing national health KT platforms. The policy options proposed include: (i) the identification of a KT champion; (ii) the establishment of an operational KT framework; (iii) KT capacity building for researchers and research users, as well as policy and decision makers. The sustainability of KT will be influenced by the prevailing context and concerns within healthcare both in Uganda and internationally. Furthermore, the availability of resources for KT advocacy, communication, and program design will impact on the sustainability of Uganda's KT activities.

How do health workers experience and cope with shocks? Learning from four fragile and conflict-affected health systems in Uganda, Sierra Leone, Zimbabwe and Cambodia.

This article is grounded in a research programme which set out to understand how to rebuild health systems post-conflict. Four countries were studied-Uganda, Sierra Leone, Zimbabwe and Cambodia-which were at different distances from conflict and crisis, as well as having unique conflict stories. During the research process, the Ebola epidemic broke out in West Africa. Zimbabwe has continued to face a profound economic crisis. Within our research on health worker incentives, we captured insights from 128 life histories and in-depth interviews with a variety of staff that had remained in service. This article aims to draw together lessons from these contexts which can provide lessons for enhancing staff and therefore health system resilience in future, especially in similarly fragile and conflict-affected contexts. We examine the reported effects, both personal and professional, of the three different types of shock (conflicts, epidemics and prolonged political-economic crises), and how staff coped. We find that the impact of shocks and coping strategies are similar between conflict/post-conflict and epidemic contexts-particularly in relation to physical threats and psychosocial threats-while all three contexts create challenges and staff responses for working conditions and remuneration. Health staff showed considerable inventiveness and resilience, and also benefited from external assistance of various kinds, but there are important gaps which point to ways in which they should be better protected and supported in the future. Health systems are increasingly fragile and conflict-prone, and shocks are often prolonged or repeated. Resilience should not be taken for granted or used as an excuse for abandoning frontline health staff. Strategies should be in place at local, national and international levels to prepare for predictable crises of various sorts, rather than waiting for them to occur and responding belatedly, or relying on personal sacrifices by staff to keep services functioning.

Enablers and barriers to evidence based planning in the district health system in Uganda; perceptions of district health managers

BackgroundThe District Health System was endorsed as the key strategy to achieve ‘Health for all’ during the WHO organized inter-regional meeting in Harare in 1987. Many expectations were put upon the district health system, including planning. Although planning should be evidence based to prioritize activities, in Uganda it has been described as occurring more by chance than by choice. The role of planning is entrusted to the district health managers with support from the Ministry of Health and other stakeholders, but there is limited knowledge on the district health manager’s capacity to carry out evidence-based planning. The aim of this study was to determine the barriers and enablers to evidence-based planning at the district level.MethodsThis qualitative study collected data through key informant interviews with district managers from two purposefully selected districts in Uganda that have been implementing evidence-based planning. A deductive process of thematic analysis was used to classify responses within themes.ResultsThere were considerable differences between the districts in regard to the barriers and enablers for evidence-based planning. Variations could be attributed to specific contextual and environmental differences such as human resource levels, date of establishment of the district, funding and the sociopolitical environment. The perceived lack of local decision space coupled with the perception that the politicians had all the power while having limited knowledge on evidence-based planning was considered an important barrier.ConclusionThere is a need to review the mandate of the district managers to make decisions in the planning process and the range of decision space available within the district health system. Given the important role elected officials play in a decentralized system a concerted effort should be made to increase their knowledge on evidence-based planning and the district health system as a whole.

Bottleneck analysis at district level to illustrate gaps within the district health system in Uganda

ABSTRACT Background: Poor quality of care and access to effective and affordable interventions have been attributed to constraints and bottlenecks within and outside the health system. However, there is limited understanding of health system barriers to utilization and delivery of appropriate, high-impact, and cost-effective interventions at the point of service delivery in districts and sub-districts in low-income countries. In this study we illustrate the use of the bottleneck analysis approach, which could be used to identify bottlenecks in service delivery within the district health system. Methods: A modified Tanahashi model with six determinants for effective coverage was used to determine bottlenecks in service provision for maternal and newborn care. The following interventions provided during antenatal care were used as tracer interventions: use of iron and folic acid, intermittent presumptive treatment for malaria, HIV counseling and testing, and syphilis testing. Data from cross-sectional household and health facility surveys in Mayuge and Namayingo districts in Uganda were used in this study. Results: Effective coverage and human resource gaps were identified as the biggest bottlenecks in both districts, with coverage ranging from 0% to 66% for effective coverage and from 46% to 58% for availability of health facility staff. Our findings revealed a similar pattern in bottlenecks in both districts for particular interventions although the districts are functionally independent. Conclusion: The modified Tanahashi model is an analysis tool that can be used to identify bottlenecks to effective coverage within the district health system, for instance, the effective coverage for maternal and newborn care interventions. However, the analysis is highly dependent on the availability of data to populate all six determinants and could benefit from further validation analysis for the causes of bottlenecks identified.