Female partners of AIDS patients in Uganda: reported knowledge, perceptions and plans.

OBJECTIVE: To assess reported knowledge of a partner's AIDS diagnosis, perceived risk of HIV infection, need for HIV testing and future support plans among women partners of male Ugandan AIDS patients. SUBJECTS AND METHODS: A cross-sectional descriptive survey was conducted at New Mulago Hospital, Kampala, Uganda. The subjects were women partners of consecutive male AIDS patients admitted to medical wards. RESULTS: Only 12% reported their partner's AIDS diagnosis; women who reported knowing were less likely to be financially dependent on the partner. Most women (76%) reported being at risk of HIV; in general, these women were older, in a newer relationship, had less children and were in customary rather than civil or cohabiting marriages. More than half (56%) of the women reported a need for HIV testing, though few (5%) had been tested. Those who stated the need for HIV testing were in a newer relationship, had less children and were more financially independent of their husbands; women in a cohabiting type marriage were less likely to report their need for testing than those in a civil or customary marriage. About half (56%) reported plans for future support if their husbands did not recover; these women were more likely to be in an older relationship and to have more children. CONCLUSIONS: Most women partners of AIDS patients in New Mulago Hospital reported no knowledge of their husbands' diagnosis. Over half perceived a need to be tested but very few reported having been tested, and only half reported having planned for the future of their families. Interventions are urgently needed to address barriers to knowledge and to acknowledgement of a partner's AIDS diagnosis, to HIV testing and to planning for the future.

Introducing quality improvement management methods into primary health care services in Uganda.

PIP: Uganda's National Quality Assurance Program was established in 1994 to monitor the process of decentralization of primary health care services. Guidelines were developed to address problems (e.g., in obtaining health funds channeled through local government) identified at district meetings. Bringing together District Health Teams with local administrators and political leaders to share responsibility for strengthening health services has been a significant program achievement. A smoother functioning referral system from health units to district hospitals has resulted. The response to a measles outbreak in the Arua district in 1993-94 confirmed the utility of the quality management approach. Weaknesses in the district cold chain, problems with diagnostic accuracy, and a poorly functioning information system were identified as key causative factors, and corrective action in these areas led to a subsequent decline in measles cases. Patient dissatisfaction with long waiting times at Masaka Hospital was another concern addressed through the quality assurance approach. Five salient areas were identified for action: low health worker morale, supply shortages, inadequate supervision by hospital management, poor patient flow, and inefficient drug dispensing. As a result, long delays were eliminated and utilization of hospital outpatient services increased by 28%.^ieng

Introducing quality management into primary health care services in Uganda.

In 1994, a national quality assurance programme was established in Uganda to strengthen district-level management of primary health care services. Within 18 months both objective and subjective improvements in the quality of services had been observed. In the examples documented here, there was a major reduction in maternal mortality among pregnant women referred to Jinja District Hospital, a reduction in waiting times and increased patient satisfaction at Masaka District Hospital, and a marked reduction in reported cases of measles in Arua District. Beyond these quantitative improvements, increased morale of district health team members, improved satisfaction among patients, and greater involvement of local government in the decisions of district health committees have been observed. At the central level, the increased coordination of activities has led to new guidelines for financial management and the procurement of supplies. District quality management workshops followed up by regular support visits from the Ministry of Health headquarters have led to a greater understanding by central staff of the issues faced at the district level. The quality assurance programme has also fostered improved coordination among national disease-control programmes. Difficulties encountered at the central level have included delays in carrying out district support visits and the failure to provide appropriate support. At the district level, some health teams tackled problems over which they had little control or which were overly complex; others lacked the management capacity for problem solving.

PIP: To strengthen district-level management of primary health care services in Uganda, a national quality assurance program was introduced in 1994. This approach includes the development and dissemination of standards and guidelines, determining the needs of patients and their families, strengthened communication between health care providers and users, and the use of data to identify gaps in service quality. Among the gains documented in the first 18 months of implementation of this strategy were a reduction in maternal mortality among pregnant women referred to Jinja District Hospital from 13.5% to 2.9%, elimination of lengthy waiting times and increased patient satisfaction at Masaka District Hospital, and a marked decrease in reported measles cases in Arua District. More subjective improvements have included increased morale among district health team members, improved patient satisfaction, and greater local government involvement in district health committee decision making. District quality management workshops, followed up with regular support visits from the Ministry of Health headquarters, have enhanced central staff understanding of district-level needs and issues. Implementation of this program has been achieved largely with existing resources. Difficulties encountered at the district level have included a tendency for some teams to select overly complex problems and a lack of management capacity for problem solving. Overall, however, the principles of quality management are highly applicable to the Ugandan context and can be easily mastered by health workers.