scholarly journals Unlocking fiscal space of expanding the health workforce in district health systems in Uganda in the context of PEPFAR transition  

2021 ◽  
Author(s):  
Henry Zakumumpa ◽  
Joseph Rujumba ◽  
Amde Woldekidan ◽  
Respicius Damian Shumbusho ◽  
Freddie Ssengooba
Keyword(s):  
Low Income ◽  
Health Workforce ◽  
Implementation Research ◽  
Health Workers ◽  
National Level ◽  
Transition Process ◽  
Sub Saharan Africa ◽  
District Health ◽  
Wage Bill ◽  
Fiscal Space

Abstract Although expanding fiscal space for health worker recruitments could reduce workforce shortages in Sub-Saharan Africa, effective strategies for achieving this are still unclear. We aimed to understand the process of transitioning health workers (HWs) from PEPFAR to Government of Uganda (GoU) payrolls and to explore the facilitators and barriers encountered in increasing domestic financial responsibility for absorbing this transitioned workforce. We conducted a multiple case-study of 10 (out of 87) districts in Uganda which received PEPFAR support between 2013 and 2015 to expand their health workforce. We purposively selected eight districts with the highest absorption rates (‘High absorbers’) and two with the lowest absorption rates (‘Low absorbers’). A total of 66 interviews were conducted with high-level officials in three Ministries of Finance, Health and Public Service (n = 14), representatives of PEPFAR implementing organizations (n = 16), District Health Teams (n = 15) and facility managers (n = 22). Twelve focus groups were conducted with 87 HWs absorbed on GoU payrolls. We utilized the Consolidated Framework for Implementation Research (CFIR) to guide thematic analysis. At sub-national level, facilitators of transition in ‘high absorber’ districts were identified as the presence of transition ‘champions’, prioritizing HWs in district wage bill commitments, host facilities providing ‘bridge financing’ to transition workforce during salary delays and receiving donor technical support in district wage bill analysis- attributes which were absent in ‘low absorber’ districts. At national-level, multi-sectoral engagements (incorporating the influential Ministry of Finance), developing a joint transition road map, aligning with GoU salary scales and recruitment processes emerged as facilitators of the transition process. Overall, PEPFAR support acted as a catalyst for increasing GoU and facility-level budget allocations towards expanding the health workforce in focus districts in Uganda. Our case-studies offer implementation research lessons on effective donor transition and insights into pragmatic strategies for expanding fiscal space for health in a low-income setting.

scholarly journals Assessing feasibility of establishing antimicrobial stewardship programmes in two provincial-level hospitals in Vietnam: an implementation research study

BMJ Open ◽  
2021 ◽  
Vol 11 (10) ◽  
pp. e053343
Author(s):  
Vu Thi Lan Huong ◽  
Ta Thi Dieu Ngan ◽  
Huynh Phuong Thao ◽  
Le Minh Quang ◽  
Tran Thi Thu Hanh ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Low Income ◽  
Implementation Research ◽  
Swot Analysis ◽  
Core Competencies ◽  
National Level ◽  
Baseline Data ◽  
Provincial Level ◽  
Data Feedback ◽  
Days Of Therapy

ObjectivesTo investigate the feasibility of establishing hospital-based antimicrobial stewardship (AMS) programmes comprising action-planning, educational interventions and data feedback in two provincial-level hospitals in Viet Nam.Design and settingThis was an implementation research using participatory action process and existing resources from the Duke Antimicrobial Stewardship Outreach Network with local adjustments. A national stakeholder meeting and Strengths-Weaknesses-Opportunities-Threats (SWOT) analysis were conducted to identify gaps and potential interventions.ParticipantsHospital AMS staff implemented activities throughout the study phases. Routinely collected patient data were analysed to support planning, implementation and evaluation.InterventionsHospitals were considered as a complex adaptive system and leveraged their unique characteristics and interconnections to develop 1-year plans containing core interventions (data use, educational training, prospective audit with feedback (PAF) and evaluations).Outcome measuresWe assessed feasibility using outputs from stakeholder meeting, SWOT analysis, baseline data, planning process and implementation.ResultsThe stakeholder meeting identified three gaps for AMS at national level: supportive policies, AMS training and core competencies and collaboration. At the hospitals, AMS programmes took 1 year for planning due to lack of hospital-specific procedures and relevant staff competencies. Baseline data (January–December 2019) showed variations in antibiotic consumption: 951 days of therapy (DOT) per 1000 days present in the control and 496 in the intervention wards in hospital 1, and 737 and 714 in hospital 2, respectively. During 1-year implementation, clinical pharmacists audited 1890 antibiotic prescriptions in hospital 1 (June 2020–May 2021) and 1628 in hospital 2 (July 2020–July 2021), and will continue PAF in their daily work.ConclusionOur data confirmed the need to contextualise AMS programmes in low-income and middle-income countries (LMICs) and demonstrated the usefulness of implementation research design in assessing programme feasibility. Developing staff competencies, using local data to stimulate actions and integrating programme activities in routine hospital work are key to success in LMICs.

scholarly journals Barriers and facilitators of implementation of a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda using the Consolidated Framework for Implementation Research

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Rawlance Ndejjo ◽  
Rhoda K. Wanyenze ◽  
Fred Nuwaha ◽  
Hilde Bastiaens ◽  
Geofrey Musinguzi
Keyword(s):  
Cardiovascular Disease ◽  
Low Income ◽  
Implementation Research ◽  
Health Workers ◽  
Scale Up ◽  
Barriers And Facilitators ◽  
Prevention Programme ◽  
Intervention Implementation ◽  
Design Quality ◽  
Middle Income

Abstract Background In low- and middle-income countries, there is an increasing attention towards community approaches to deal with the growing burden of cardiovascular disease (CVD). However, few studies have explored the implementation processes of such interventions to inform their scale up and sustainability. Using the consolidated framework for implementation research (CFIR), we examined the barriers and facilitators influencing the implementation of a community CVD programme led by community health workers (CHWs) in Mukono and Buikwe districts in Uganda. Methods This qualitative study is a process evaluation of an ongoing type II hybrid stepped wedge cluster trial guided by the CFIR. Data for this analysis were collected through regular meetings and focus group discussions (FGDs) conducted during the first cycle (6 months) of intervention implementation. A total of 20 CHWs participated in the implementation programme in 20 villages during the first cycle. Meeting reports and FGD transcripts were analysed following inductive thematic analysis with the aid of Nvivo 12.6 to generate emerging themes and sub-themes and thereafter deductive analysis was used to map themes and sub-themes onto the CFIR domains and constructs. Results The barriers to intervention implementation were the complexity of the intervention (complexity), compatibility with community culture (culture), the lack of an enabling environment for behaviour change (patient needs and resources) and mistrust of CHWs by community members (relative priority). In addition, the low community awareness of CVD (tension for change), competing demands (other personal attributes) and unfavourable policies (external policy and incentives) impeded intervention implementation. On the other hand, facilitators of intervention implementation were availability of inputs and protective equipment (design quality and packaging), training of CHWs (Available resources), working with community structures including leaders and groups (process—opinion leaders), frequent support supervision and engagements (process—formally appointed internal implementation leaders) and access to quality health services (process—champions). Conclusion Using the CFIR, we identified drivers of implementation success or failure for a community CVD prevention programme in a low-income context. These findings are key to inform the design of impactful, scalable and sustainable CHW programmes for non-communicable diseases prevention and control.

scholarly journals Producing routine malaria data: an exploration of the micro-practices and processes shaping routine malaria data quality in frontline health facilities in Kenya

2019 ◽  
Vol 18 (1) ◽  
Author(s):  
George Okello ◽  
Sassy Molyneux ◽  
Scholastica Zakayo ◽  
Rene Gerrets ◽  
Caroline Jones
Keyword(s):  
Information Systems ◽  
Data Collection ◽  
Health Information ◽  
Low Income ◽  
Health Workers ◽  
National Level ◽  
Health Information Systems ◽  
Health Facilities ◽  
Careful Examination ◽  
Data Generation

Abstract Background Routine health information systems can provide near real-time data for malaria programme management, monitoring and evaluation, and surveillance. There are widespread concerns about the quality of the malaria data generated through routine information systems in many low-income countries. However, there has been little careful examination of micro-level practices of data collection which are central to the production of routine malaria data. Methods Drawing on fieldwork conducted in two malaria endemic sub-counties in Kenya, this study examined the processes and practices that shape routine malaria data generation at frontline health facilities. The study employed ethnographic methods—including observations, records review, and interviews—over 18-months in four frontline health facilities and two sub-county health records offices. Data were analysed using a thematic analysis approach. Results Malaria data generation was influenced by a range of factors including human resource shortages, tool design, and stock-out of data collection tools. Most of the challenges encountered by health workers in routine malaria data generation had their roots in wider system issues and at the national level where the framing of indicators and development of data collection tools takes place. In response to these challenges, health workers adopted various coping mechanisms such as informal task shifting and use of improvised tools. While these initiatives sustained the data collection process, they also had considerable implications for the data recorded and led to discrepancies in data that were recorded in primary registers. These discrepancies were concealed in aggregated monthly reports that were subsequently entered into the District Health Information Software 2. Conclusion Challenges to routine malaria data generation at frontline health facilities are not malaria or health information systems specific; they reflect wider health system weaknesses. Any interventions seeking to improve routine malaria data generation must look beyond just malaria or health information system initiatives and include consideration of the broader contextual factors that shape malaria data generation.

scholarly journals Data for tracking SDGs: challenges in capturing neonatal data from hospitals in Kenya

2020 ◽  
Vol 5 (3) ◽  
pp. e002108 ◽  
Author(s):  
Christiane Hagel ◽  
Chris Paton ◽  
George Mbevi ◽  
Mike English
Keyword(s):  
Health Information ◽  
Neonatal Mortality ◽  
Low Income ◽  
National Level ◽  
Use Cases ◽  
Information Flows ◽  
Hospital Data ◽  
District Health ◽  
Policy Documents ◽  
Data Reporting

BackgroundTarget 3.2 of the United Nations Sustainable Development Goals (SDGs) is to reduce neonatal mortality. In low-income and middle-income countries (LMICs), the District Health Information Software, V.2 (DHIS2) is widely used to help improve indicator data reporting. There are few reports on its use for collecting neonatal hospital data that are of increasing importance as births within facilities increase. To address this gap, we investigated implementation experiences of DHIS2 in LMICs and mapped the information flow relevant for neonatal data reporting in Kenyan hospitals.MethodsA narrative review of published literature and policy documents from LMICs was conducted. Information gathered was used to identify the challenges around DHIS2 and to map information flows from healthcare facilities to the national level. Two use cases explore how newborn data collection and reporting happens in hospitals. The results were validated, adjusted and system challenges identified.ResultsLiterature and policy documents report that DHIS2 is a useful tool with strong technical capabilities, but significant challenges can emerge with the implementation. Visualisations of information flows highlight how a complex, people-based and paper-based subsystem for inpatient information capture precedes digitisation. Use cases point to major challenges in these subsystems in accurately identifying newborn deaths and appropriate data for the calculation of mortality even in hospitals.ConclusionsDHIS2 is a tool with potential to improve availability of health information that is key to health systems, but it critically depends on people-based and paper-based subsystems. In hospitals, the subsystems are subject to multiple micro level challenges. Work is needed to design and implement better standardised information processes, recording and reporting tools, and to strengthen the information system workforce. If the challenges are addressed and data quality improved, DHIS2 can support countries to track progress towards the SDG target of improving neonatal mortality.

scholarly journals Scaling up interventions for depression in sub-Saharan Africa: lessons from Zimbabwe

2016 ◽  
Vol 3 ◽  
Author(s):  
D. Chibanda ◽  
R. Verhey ◽  
E. Munetsi ◽  
S. Rusakaniko ◽  
F. Cowan ◽  
...  
Keyword(s):  
Health Workers ◽  
Core Competencies ◽  
Scale Up ◽  
Health Care Facilities ◽  
Sub Saharan Africa ◽  
District Health ◽  
Key Stakeholders ◽  
Extensive Consultation ◽  
Sub Saharan ◽  
Hiv Programs

BackgroundThere is a dearth of information on how to scale-up evidence-based psychological interventions, particularly within the context of existing HIV programs. This paper describes a strategy for the scale-up of an intervention delivered by lay health workers (LHWs) to 60 primary health care facilities in Zimbabwe.MethodsA mixed methods approach was utilized as follows: (1) needs assessment using a semi-structured questionnaire to obtain information from nurses (n = 48) and focus group discussions with District Health Promoters (n = 12) to identify key priority areas; (2) skills assessment to identify core competencies and current gaps of LHWs (n = 300) employed in the 60 clinics; (3) consultation workshops (n = 2) with key stakeholders to determine referral pathways; and (4) in-depth interviews and consultations to determine funding mechanisms for the scale-up.ResultsFive cross-cutting issues were identified as critical and needing to be addressed for a successful scale-up. These included: the lack of training in mental health, unavailability of psychiatric drugs, depleted clinical staff levels, unavailability of time for counseling, and poor and unreliable referral systems for people suffering with depression. Consensus was reached by stakeholders on supervision and support structure to address the cross-cutting issues described above and funding was successfully secured for the scale-up.ConclusionKey requirements for success included early buy-in from key stakeholders, extensive consultation at each point of the scale-up journey, financial support both locally and externally, and a coherent sustainability plan endorsed by both government and private sectors.

scholarly journals Building a new platform to support public health emergency response in Africa: the AFENET Corps of Disease Detectives, 2018–2019

2020 ◽  
Vol 5 (10) ◽  
pp. e002874
Author(s):  
Ben Masiira ◽  
Simon N Antara ◽  
Herbert B Kazoora ◽  
Olivia Namusisi ◽  
Notion T Gombe ◽  
...  
Keyword(s):  
Public Health ◽  
Health Workforce ◽  
Health Workers ◽  
Rapid Response Team ◽  
Public Health Emergency ◽  
Sub Saharan Africa ◽  
Public Health Workforce ◽  
Health Security ◽  
Field Epidemiology ◽  
Sub Saharan

Public health emergency (PHE) response in sub-Saharan Africa is constrained by inadequate skilled public health workforce and underfunding. Since 2005, the African Field Epidemiology Network (AFENET) has been supporting field epidemiology capacity development and innovative strategies are required to use this workforce. In 2018, AFENET launched a continental rapid response team: the AFENET Corps of Disease Detectives (ACoDD). ACoDD comprises field epidemiology graduates and residents and was established to support PHE response. Since 2018, AFENET has deployed the ACoDD to support response to several PHEs. The main challenges faced during ACoDD deployments were financing of operations, ACoDD safety and security, resistance to interventions and distrust of the responders by some communities. Our experience during these deployments showed that it was feasible to mobilise and deploy ACoDD within 48 hours. However, the sustainability of deployments will depend on establishing strong linkages with the employers of ACoDD members. PHEs are effectively controlled when there is a fast deployment and strong linkages between the stakeholders. There are ongoing efforts to strengthen PHE preparedness and response in sub-Saharan Africa. ACoDD members are a competent workforce that can effectively augment PHE response. ACoDD teams mentored front-line health workers and community health workers who are critical in PHE response. Public health emergence response in sub-Saharan Africa is constrained by inadequacies in a skilled workforce and underfunding. ACoDD can be utilised to overcome the challenges of accessing a skilled public health workforce. To improve health security in sub-Saharan Africa, more financing of PHE response is needed.

scholarly journals Health workforce financing in Uganda: challenges and opportunities

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
M Koutsoumpa ◽  
R Odedo ◽  
A Banda ◽  
M Meurs ◽  
C Hinlopen ◽  
...  
Keyword(s):  
Low Income ◽  
Health Workforce ◽  
Management Practices ◽  
Health Workers ◽  
Human Resources For Health ◽  
Health Sector ◽  
Adverse Outcomes ◽  
Low Income Countries ◽  
Current Status ◽  
Poor Management

Abstract Background For health systems to operate well and improve people's health by leaving no one behind, they need a fit-for-purpose health workforce. Shortage of health workers leads to reduced access to healthcare, health inequities, and adverse outcomes in the population's health. A key challenge in many low-income countries is mobilising the needed investment for health workforce development. This study evaluated the policy environment of the health workforce in Uganda, analysed its current status, and identified financing mechanisms and management practices that affect the country's health resource envelope. Methods The study was conducted in 2018/19. It entailed literature review, key informant interviews and stakeholder consultations for validation of the findings. Results The shortage of health workers is persevering, despite efforts of the Ugandan Government and development partners. The health workforce is not keeping up with the population growth, nor the epidemiologic changes and demographic trends. Paradoxically, there is a large pool of qualified and licensed health professionals, who remain unabsorbed. Notably, even if all of them were absorbed, Uganda would be still far from the international requirements for universal health coverage. The issues are recognized at the policy level, but insufficient funding and poor management are impeding the recruitment and retention of health workers. Domestic resources are insufficient to fund a health system which can offer a minimum healthcare package and most donors are reluctant to contribute to health workers' salaries. Besides, Uganda is lacking a national health insurance scheme, which keeps out-of-pocket spending on health at very high rates. Moreover, increases in external financing have been accompanied by decreases in domestic government financing, despite economic growth. Conclusions The health sector financing is influenced by a complex political economy, which impedes investments in the health workforce. Key messages The problems and gaps of the Ugandan human resources for health are persisting due to the insufficient financial allocation and the poor management of the health workforce and existing funds. The shortage of health workers is a global health issue that goes beyond national borders and the health sector. It is an essential requirement for exercising the universal right to health.

scholarly journals Who dies where? Estimating the percentage of deaths that occur at home

2021 ◽  
Vol 6 (9) ◽  
pp. e006766
Author(s):  
Tim Adair
Keyword(s):  
Low Income ◽  
Verbal Autopsy ◽  
Causes Of Death ◽  
Bayesian Model Averaging ◽  
National Level ◽  
Sub Saharan Africa ◽  
Low Income Countries ◽  
Home Death ◽  
Level Model ◽  
At Home

IntroductionThe majority of low-income and middle-income countries (LMICs) have incomplete death registration systems and so the proportion of deaths that occur at home (ie, home death percentage) is generally unknown. However, home death percentage is important to estimate population-level causes of death from integration of data of deaths at home (verbal autopsies) and in hospitals (medical certification), and to monitor completeness of death notification and verbal autopsy data collection systems. This study proposes a method to estimate home death percentage using data readily available at the national and subnational level.MethodsData on place of death from 152 country-years in 49 countries from 2005 to 2019, predominantly from vital registration systems, were used to model home death percentage standardised for population age and cause distribution. A national-level model was developed using Bayesian model averaging to estimate national, regional and global home death percentage. A subnational-level model was also developed and assessed in populations where alternative data on home death percentage were available.ResultsGlobally, it is estimated that 53.4% (95% uncertainty interval (UI) 50.8%–55.9%) of deaths occur at home, slightly higher (59.7%, 95% UI 56.5%–62.7%) in LMICs, substantially higher in low-income countries (79.5%, 95% UI 77.3%–81.5%) and much lower (27.3%, 95% UI 25.2%–29.6%) in high-income countries. Countries with the highest home death percentage are mostly found in South, East and Southeast Asia and sub-Saharan Africa (above 90% in Ethiopia, Chad and South Sudan). As expected, the national model has smaller error than the subnational model.ConclusionThe study demonstrates substantial diversity in the location of deaths in LMICs and fills a significant gap in knowledge about where people die, given its importance for health systems and policies. The high proportion of deaths in LMICs that occur at home reinforces the need for routine verbal autopsy to determine the causes of death.

scholarly journals Demand for Family Planning among Poor Women in Uganda: Analysis of the Uganda Demographic and Health Surveys

2020 ◽  
Author(s):  
Allen Kabagenyi ◽  
Pamela Kakande ◽  
Vianney Owayezu
Keyword(s):  
Family Planning ◽  
Health Facility ◽  
Low Income ◽  
Rural Women ◽  
Health Surveys ◽  
Health Workers ◽  
Sub Saharan Africa ◽  
Demographic And Health Surveys ◽  
The Poor ◽  
Poor Women

Abstract Background: Family planning is one of the major cost-effective interventions to improve maternal health, reduce maternal and child mortality, and prevent unplanned pregnancies, yet its use remains low in sub-Saharan Africa, especially among the poor. In Uganda, little is known about the factors influencing the demand for family planning among the poor. This study examines the determinants of demand for family planning among poor women in a low income country.Methods: The study is based on data from the 2006, 2011, and 2016 Uganda Demographic and Health Surveys (UDHS). The analysis was carried using weighted samples of 2,238 in 2006, 2,164 in 2011, and 4,370 in 2016. Descriptive statistics, and binary logistic regressions presenting both the unadjusted and adjusted were used to examine the influence of different demographic, behavioral, and socioeconomic factors on poor women’s demand for family planning.Results: Our findings showed demand for family planning was 56% in 2006, 60% in 2011, and 65% in 2016 among women in the poorest and poorer household health quintiles who were married or in union. In all three surveys, women age 25-39 had higher odds of demand for family planning compared with women age 15-24 (AOR=1.5, 95% CI=1.1-1.9 in 2006, AOR=2.2, 95% CI=1.7-2.7 in 2011, AOR=1.7, 95% CI=1.5-2.0 in 2016). Women with no education had lower odds of demand for family planning compared with those with secondary education (AOR=0.4, 95% CI=0.3-0.6, pooled results). Also, in the 2011 UDHS, women who had heard about family planning on the radio had higher odds of demand (AOR=1.4, 95% CI=1.1-1.7, pooled) for family planning compared with those who had not, and in the 2006 survey women who had discussed family planning at a health facility had higher odds of demand for family planning (AOR=1.0, 95% CI=0.8-1.2) compared with women who had not done so.Conclusions: Demand for family planning is influenced by a woman’s age, educational attainment, religion, exposure to family planning messages on the radio, and discussion on family planning at a health facility. This study underscores the need for increased family planning counseling by health workers and more discussion about family planning at the health facility. The findings further suggest the need to provide increased adequate family planning services and information for the poor, uneducated, and rural women to meet the demand for family planning.

scholarly journals Health Policy in Nepal: An Assessment of Clinical Guidelines in Relation to the Burden of Disease

2018 ◽  
Vol 3 (1) ◽  
pp. 24-35
Author(s):  
Sara Hodgkinson ◽  
Muhammad Saddiq ◽  
Julie Balen
Keyword(s):  
Low Income ◽  
Clinical Guidelines ◽  
Disease Burden ◽  
Health Workers ◽  
National Level ◽  
Low Income Countries ◽  
Mortality Data ◽  
Accurate Information ◽  
Health And Development ◽  
Context Specific

Background: Clinical guidelines provide health workers with valuable information on how to diagnose and treat patients. In many low-income countries, there appears to be a lack of appropriate clinical guidelines for conditions with high rates of morbidity; Nepal is one such nation. It is useful to examine clinical guidelines in relation to disease burden to establish any gaps which might be addressed through changes in policy and practice.Methods: The research adopted a mixed-methods approach, quantifying disease burden both nationally and in five districts served by PHASE Nepal – an NGO working in health and development – before contrasting this with available clinical guidelines in Nepal.  Key informant interviews were subsequently conducted to gain greater insight into disease burden and guideline availability.Results: Of the 10 diseases found to be most burdensome in the PHASE-served districts, 3 lacked any context-specific guidelines. NCDs were found to be prevalent at both district and national level, yet guideline provision for such conditions was minimal. Mental illness was highlighted by interview participants as a growing problem; however, Nepal does not currently have any utilisable clinical guidelines for mental health. Missing data was identified as a significant issue, with lack of mortality data hindering accurate quantification of local and national disease burden.Conclusions: There is evident need for more context-appropriate clinical guidelines in Nepal to effectively diagnose and treat diseases that are most burdensome within communities. Improving health data quality is fundamental to ensuring policy makers are equipped with accurate information from which to develop appropriate protocol.Journal of Manmohan Memorial Institute of Health SciencesVol. 3, No. 1, 2017, page: 24-35

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