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- Henriksson, Dorcus Kiwanuka, 1976-, et al.
(författare)
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Bottleneck analysis at district level to illustrate gaps within the district health system in Uganda
- 2017
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Ingår i: Global Health Action. - : Informa UK Limited. - 1654-9716 .- 1654-9880. ; 10:1
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Tidskriftsartikel (refereegranskat)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.
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| 2. |
- Henriksson, Dorcus Kiwanuka, 1976-, et al.
(författare)
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Decision making in district health planning in Uganda : Does use of local evidence matter?
- 2019
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Ingår i: Health Research Policy and Systems. - : Springer Science and Business Media LLC. - 1478-4505. ; 17
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Tidskriftsartikel (refereegranskat)abstract
- IntroductionIn a decentralized health system, district health managers are tasked with planning for health service delivery which should be evidence-based. However, planning in low-income countries such as Uganda, has been described as ad hoc. A systematic approach to the planning process using district-specific evidence was introduced to district health managers in Uganda. However, little is known about how the use of district-specific evidence does inform the planning process. In this study we further investigate how the use of this evidence affects the annual planning process.MethodologyThe study was conducted in two districts that were introduced to the systematic approach of using district-specific evidence in the planning process. District annual health work plans for financial years 2012/13; 2013/14; 2014/15 and 2015/16 and bottleneck analysis reports for 2012, 2013, 2014 and 2015 were reviewed. Semi-structured interviews with key informants from the districts were also conducted.ResultsDistrict managers reported that they were able to produce more robust district annual work plans when they used district-specific evidence. About half of the priority activities that were identified using district-specific evidence were included in the annual work plans. Procurement and logistics, training and support supervision activities were the most prioritized. Use of local evidence was viewed positively by the health managers. However, there was a lack of clarity on what activities should be incorporated in the annual work plans and district managers considered the lack of autonomy or decision space as a constraint to the use of district-specific evidence.ConclusionDistrict-specific evidence and a structured process for its use to prioritize activities and make decisions in the planning process at the district level helped systematize the planning process. Health managers were able to articulate and advocate for priorities related to child survival. However, the reported limited decision and fiscal space, human resource gaps, inadequate funding and high dependency on donor funding did not always allow for use of district-specific evidence in the planning process.
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| 3. |
- Allen, Elizabeth Palchik, et al.
(författare)
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Health facility management and access : a qualitative analysis of challenges to seeking healthcare for children under five in Uganda
- 2017
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Ingår i: Health Policy and Planning. - : Oxford University Press. - 0268-1080 .- 1460-2237. ; 32:7, s. 934-942
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Tidskriftsartikel (refereegranskat)abstract
- While several studies have documented the various barriers that caretakers of children under five routinely confront when seeking healthcare in Uganda, few have sought to capture the ways in which caretakers themselves prioritize their own barriers to seeking services. To that end, we asked focus groups of caretakers to list their five greatest challenges to seeking care on behalf of children under five. Using qualitative content analysis, we grouped responses according to four categories: (1) geographical access barriers; (2) facility supplies, staffing, and infrastructural barriers; (3) facility management and administration barriers (e.g. health worker professionalism, absenteeism and customer care); and (4) household barriers related to financial circumstances, domestic conflicts with male partners and a stated lack of knowledge about health-related issues. Among all focus groups, caretakers mentioned supplies, staffing and infrastructure barriers most often and facility management and administration barriers the least. Caretakers living furthest from public facilities (8-10 km) more commonly mentioned geographical barriers to care and barriers related to financial and other personal circumstances. Caretakers who lived closest to health facilities mentioned facility management and administration barriers twice as often as those who lived further away. While targeting managerial barriers is vitally important-and increasingly popular among national planners and donors-it should be done while recognizing that alleviating such barriers may have a more muted effect on caretakers who are geographically harder to reach - and by extension, those whose children have an increased risk of mortality. In light of calls for greater equity in child survival programming - and given the limited resource envelopes that policymakers often have at their disposal - attention to the barriers considered most vital among caretakers in different settings should be weighed.
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| 4. |
- Henriksson, Dorcus Kiwanuka, 1976-
(författare)
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Health systems bottlenecks and evidence-based district health planning : Experiences from the district health system in Uganda
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- In low-income countries where maternal and child mortality remains high, there is limited use of context-specific evidence for decision making and prioritization of interventions in the planning process at the sub-national level, such as the district level. Knowledge on the utility of tools and interventions to promote use of district-specific evidence in the planning process is limited, yet it could contribute to the prioritization of high-impact interventions for women and children.This thesis aims to investigate, in the planning process, the use of district-specific evidence to identify gaps in service delivery in the district health system in Uganda in order to contribute to improving health services for women and children.Study I evaluated the use of the modified Tanahashi model to identify bottlenecks for service delivery of maternal and newborn interventions. Study II and III used qualitative methods to document the experiences of district managers in adopting tools to facilitate the utilization of district-specific evidence, and the barriers and enablers to the use of these tools in the planning process. Study IV used qualitative methods, and analysis of district annual health work plans and reports.District managers were able to adopt tools for the utilization of district-specific evidence in the planning process. Governance and leadership were a major influence on the use of district-specific evidence. Limited decision space and fiscal space, and limited financial resources, and inadequate routine health information systems were also barriers to the utilization of district-specific evidence.Use of district-specific evidence in the planning process is not an end in itself but part of a process to improve the prioritization of interventions for women and children. In order to prioritize high impact interventions at the district level, a multifaceted approach needs to be taken that not only focuses on use of evidence, but also focuses on broader health system aspects like governance and leadership, the decision and fiscal space available to the district managers, limited resources, and inadequate routine health information systems.
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| 5. |
- Katahoire, Anne Ruhweza, et al.
(författare)
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Improving child survival through a district management strengthening and community empowerment intervention : early implementation experiences from Uganda
- 2015
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Ingår i: BMC Public Health. - : Springer Science and Business Media LLC. - 1471-2458. ; 15
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Tidskriftsartikel (refereegranskat)abstract
- Background: The Community and District Empowerment for Scale-up (CODES) project pioneered the implementation of a comprehensive district management and community empowerment intervention in five districts in Uganda. In order to improve effective coverage and quality of child survival interventions CODES combines UNICEF tools designed to systematize priority setting, allocation of resources and problem solving with Community dialogues based on Citizen Report Cards and U-Reports used to engage and empower communities in monitoring health service provision and to demand for quality services. This paper presents early implementation experiences in five pilot districts and lessons learnt during the first 2 years of implementation. Methods: This qualitative study was comprised of 38 in-depth interviews with members of the District Health Teams (DHTs) and two implementing partners. These were supplemented by observations during implementation and documents review. Thematic analysis was used to distill early implementation experiences and lessons learnt from the process. Results: All five districts health teams with support from the implementing partners were able to adopt the UNICEF tools and to develop district health operational work plans that were evidence-based. Members of the DHTs described the approach introduced by the CODES project as a more systematic planning process and very much appreciated it. Districts were also able to implement some of the priority activities included in their work plans but limited financial resources and fiscal decision space constrained the implementation of some activities that were prioritized. Community dialogues based on Citizen Report Cards (CRC) increased community awareness of available health care services, their utilization and led to discussions on service delivery, barriers to service utilization and processes for improvement. Community dialogues were also instrumental in bringing together service users, providers and leaders to discuss problems and find solutions. The dialogues however are more likely to be sustainable if embedded in existing community structures and conducted by district based facilitators. U report as a community feedback mechanism registered a low response rate. Conclusion: The UNICEF tools were adopted at district level and generally well perceived by the DHTs. The limited resources and fiscal decision space however can hinder implementation of prioritized activities. Community dialogues based on CRCs can bring service providers and the community together but need to be embedded in existing community structures for sustainability.
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| 6. |
- Waiswa, Peter, et al.
(författare)
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Community and District Empowerment for Scale-up (CODES) : a complex district-level management intervention to improve child survival in Uganda: study protocol for a randomized controlled trial
- 2016
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Ingår i: Trials. - : Springer Science and Business Media LLC. - 1745-6215. ; 17
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Innovative and sustainable strategies to strengthen districts and other sub-national health systems and management are urgently required to reduce child mortality. Although highly effective evidence-based and affordable child survival interventions are well-known, at the district level, lack of data, motivation, analytic and planning capacity often impedes prioritization and management weaknesses impede implementation. The Community and District Empowerment for Scale-up (CODES) project is a complex management intervention designed to test whether districts when empowered with data and management tools can prioritize and implement evidence-based child survival interventions equitably.METHODS: The CODES strategy combines management, diagnostic, and evaluation tools to identify and analyze the causes of bottlenecks to implementation, build capacity of district management teams to implement context-specific solutions, and to foster community monitoring and social accountability to increase demand for services. CODES combines UNICEF tools designed to systematize priority setting, allocation of resources and problem solving with Community dialogues based on Citizen Report Cards and U-Reports used to engage and empower communities in monitoring health service provision and to demand for quality services. Implementation and all data collection will be by the districts teams or local Community-based Organizations who will be supported by two local implementing partners. The study will be evaluated as a cluster randomized trial with eight intervention and eight comparison districts over a period of 3 years. Evaluation will focus on differences in uptake of child survival interventions and will follow an intention-to-treat analysis. We will also document and analyze experiences in implementation including changes in management practices.DISCUSSION: By increasing the District Health Management Teams' capacity to prioritize and implement context-specific solutions, and empowering communities to become active partners in service delivery, coverage of child survival interventions will increase. Lessons learned on strengthening district-level managerial capacities and mechanisms for community monitoring may have implications, not only in Uganda but also in other similar settings, especially with regard to accelerating effective coverage of key child survival interventions using locally available resources.
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