Supporting the revision of the health benefits package in Uganda: A constrained optimisation approach.

This study demonstrates how the linear constrained optimization approach can be used to design a health benefits package (HBP) which maximises the net disability adjusted life years (DALYs) averted given the health system constraints faced by a country, and how the approach can help assess the marginal value of relaxing health system constraints. In the analysis performed for Uganda, 45 interventions were included in the HBP in the base scenario, resulting in a total of 26.7 million net DALYs averted. When task shifting of pharmacists' and nutrition officers' tasks to nurses is allowed, 73 interventions were included in the HBP resulting in a total of 32 million net DALYs averted (a 20% increase). Further, investing only $58 towards hiring additional nutrition officers' time could avert one net DALY; this increased to $60 and $64 for pharmacists and nurses respectively, and $100,000 for expanding the consumable budget, since human resources present the main constraint to the system.

Glycated haemoglobin and fasting plasma glucose tests in the screening of outpatients for diabetes and abnormal glucose regulation in Uganda: A diagnostic accuracy study.

BACKGROUND AND OBJECTIVES: To understand the utility of glycated haemoglobin (HBA1C) in screening for diabetes and Abnormal Glucose Regulation (AGR) in primary care, we compared its performance to that of the fasting plasma glucose (FPG) test. METHODS: This was a prospective diagnostic accuracy study conducted in eastern Uganda. Patients eligible for inclusion were consecutive adults, 30-75 years, receiving care at the outpatient department of a general hospital in eastern Uganda. We determined the sensitivity, specificity and optimum cut-off points for HBA1C and FPG tests using the oral glucose tolerance test (OGTT) as a clinical reference standard. RESULTS: A total of 1659 participants underwent FPG testing of whom 310 were also HBA1C and OGTT tested. A total of 113 tested positive for diabetes and 168 for AGR on the OGTT. At recommended cut-off points for diabetes, the HBA1C and FPG tests had comparable sensitivity [69.8% (95% CI 46.3-86.1) versus 62.6% (95% CI 41.5-79.8), respectively] and specificity [98.6% (95% CI 95.4-99.6) versus 99.4% (95% CI 98.9-99.7), respectively]. Similarly, the sensitivity of HBA1C and the FPG tests for Abnormal Glucose Regulation (AGR) at ADA cut-offs were comparable [58.9% (95% CI 46.7-70.2) vs 47.7% (95% CI 37.3-58.4), respectively]; however, the HBA1C test had lower specificity [70.7% (95% CI 65.1-75.8)] than the FPG test [93.5% (95% CI 88.6-96.4)]. At the optimum cut-offs points for diabetes [45.0 mmol/mol (6.3%) for HBA1C and 6.4 mmol/L (115.2 mg/dl) for FPG], HBA1C and FPG sensitivity [71.2% (95% CI 46.9-87.8) versus 72.7% (95% CI 49.5-87.8), respectively] and specificity [95.1% (95% CI91.8 97.2) versus 98.7% (95% CI 98.0 99.2), respectively] were comparable. Similarly, at the optimum cut-off points for AGR [42.0 mmol/mol (6.0%) for the HBA1C and 5.5 mmol/l (99.0 mg/dl) for the FPG test], HBA1C and FPG sensitivity [42.3% (95% CI 31.8-53.6) and 53.2 (95% CI 43.1-63.1), respectively] and specificity [89.1% (95% CI 84.1 92.7) and 92.7% (95% CI 91.0 94.1), respectively] were comparable. DISCUSSION: HBA1C is a viable alternative diabetes screening and confirmatory test to the FPG test; however, the utility of both tests in screening for prediabetes in this outpatient population is limited.

Prevention and management of type 2 diabetes mellitus in Uganda and South Africa: Findings from the SMART2D pragmatic implementation trial.

Health systems in many low- and middle-income countries are struggling to manage type 2 diabetes (T2D). Management of glycaemia via well-organized care can reduce T2D incidence, and associated morbidity and mortality. The primary aim of this study was to evaluate the effectiveness of facility plus community care interventions (integrated care), compared to facility only care interventions (facility care) towards improvement of T2D outcomes in Uganda and South Africa. A pragmatic cluster randomized trial design was used to compare outcomes among participants with T2D and those at high risk. The trial had two study arms; the integrated care arm, and the facility care arm; and in Uganda only, an additional usual care arm. Participants were enrolled at nine primary health facilities in Uganda, and two in South Africa. Participants were adults aged 30 to 75 years, and followed for up to 12 months. Primary outcomes were glycaemic control among participants with T2D, and reduction in HbA1c > = 3 mmol/mol among participants at high risk. Secondary outcomes were retention into care and incident T2D. Adjusted analysis revealed significantly higher retention into care comparing integrated care and facility care versus usual care in Uganda and integrated care versus facility care in South Africa. The effect was particularly high among participants at high risk in Uganda with an incident rate ratio of 2.46 [1.33-4.53] for the facility care arm and 3.52 [2.13-5.80] for the integrated care arm. No improvement in glycaemic control or reduction in HbA1c was found in either country. However, considerable and unbalanced loss to follow-up compromised assessment of the intervention effect on HbA1c. Study interventions significantly improved retention into care, especially compared to usual care in Uganda. This highlights the need for adequate primary care for T2D and suggest a role for the community in T2D prevention. Trial registration number: ISRCTN11913581.

Household preferences and willingness to pay for health insurance in Kampala City: a discrete choice experiment.

INTRODUCTION: Uganda is in discussions to introduce a national health insurance scheme. However, there is a paucity of information on household preferences and willingness to pay for health insurance attributes that may guide the design of an acceptable health insurance scheme. Our study sought to assess household preferences and willingness to pay for health insurance in Kampala city using a discrete choice experiment. METHODS: This study was conducted from 16th February 2020 to 10th April 2020 on 240 households in the Kawempe division of Kampala city stratified into slum and non-slum communities in order to get a representative sample of the area. We purposively selected the communities that represented slum and non-slum communities and thereafter applied systematic sampling in the selection of the households that participated in the study from each of the communities. Four household and policy-relevant attributes were used in the experimental design of the study. Each respondent attended to 9 binary choice sets of health insurance plans that included one fixed choice set. Data were analyzed using mixed logit models. RESULTS: Households in both the non-slum and slum communities had a high preference for health insurance plans that included both private and public health care providers as compared to plans that included public health care providers only (non-slum coefficient ß = 0.81, P < 0.05; slum ß = 0.87, p < 0.05) and; health insurance plans that covered extended family members as compared to plans that had limitations on the number of family members allowed (non-slum ß = 0.44, P < 0.05; slum ß = 0.36, p < 0.05). Households in non-slum communities, in particular, had a high preference for health insurance plans that covered chronic illnesses and major surgeries to other plans (0.97 ß, P < 0.05). Our findings suggest that location of the household influences willingness to pay with households from non-slum communities willing to pay more for the preferred attributes. CONCLUSION: Potential health insurance schemes should consider including both private and public health care providers and allow more household members to be enrolled in both slum and non-slum communities. However, the inclusion of more HH members should be weighed against the possible depletion of resources and other attributes. Potential health insurance schemes should also prioritize coverage for chronic illnesses and major surgeries in non-slum communities, in particular, to make the scheme attractive and acceptable for these communities.

Designing for Scale and taking scale to account: lessons from a community score card project in Uganda.

BACKGROUND: Planning for the implementation of community scorecards (CSC) is an important, though seldom documented process. Makerere University School of Public Health (MakSPH) and Future Health Systems Consortium set out to develop and test a sustainable and scalable CSC model. This paper documents the process of planning and adapting the design of the CSC, incorporating key domains of the scalable model such as embeddedness, legitimacy, feasibility and ownership, challenges encountered in this process and how they were mitigated. METHODS: The CSC intervention comprised of five rounds of scoring in five sub counties and one town council of Kibuku district. Data was drawn from ten focus group discussions, seven key informant interviews with local and sub national leaders, and one reflection meeting with the project team from MakSPH. More data was abstracted from notes of six quarterly stakeholder meetings and six quarterly project meetings. Data was analyzed using a thematic approach, drawing constructs outlined in the project's theory of change. RESULTS: Embeddedness, legitimacy and ownership were promoted through aligning the model with existing processes and systems as well as the meaningful and strategic involvement of stakeholders and leaders at local and sub national level. The challenges encountered included limited technical capacity of stakeholders facilitating the CSC, poor functionality of existing community engagement platforms, and difficulty in promoting community participation without financial incentives. However, these challenges were mitigated through adjustments to the intervention design based on the feedback received. CONCLUSION: Governments seeking to scale up CSCs and to take scale to account should keenly adapt existing models to the local implementation context with strategic and meaningful involvement of key legitimate local and sub national leaders in decision making during the design and implementation process. However, they should watch out for elite capture and develop mitigating strategies. Social accountability practitioners should document their planning and adaptive design efforts to share good practices and lessons learned. Enhancing local capacity to implement CSCs should be ensured through use of existing local structures and provision of technical support by external or local partners familiar with the skill until the local partners are competent.

Influence of community scorecards on maternal and newborn health service delivery and utilization.

INTRODUCTION: The community score card (CSC) is a participatory monitoring and evaluation tool that has been employed to strengthen the mutual accountability of health system and community actors. In this paper we describe the influence of the CSC on selected maternal and newborn service delivery and utilization indicators. METHODS: This was a mixed methods study that used both quantitative and qualitative data collection methods. It was implemented in five sub-counties and one town council in Kibuku district in Uganda. Data was collected through 17 key informant interviews and 10 focus group discussions as well as CSC scoring and stakeholder meeting reports. The repeated measures ANOVA test was used to test for statistical significance. Qualitative data was analyzed manually using content analysis. The analysis about the change pathways was guided by the Wild and Harris dimensions of change framework. RESULTS: There was an overall improvement in the common indicators across sub-counties in the project area between the 1st and 5th round scores. Almost all the red scores had changed to green or yellow by round five except for availability of drugs and mothers attending Antenatal care (ANC) in the first trimester. There were statistically significant differences in mean scores for men escorting their wives for ante natal care (ANC) (F(4,20) = 5.45, P = 0.01), availability of midwives (F(4,16) =5.77, P < 0.01), availability of delivery beds (F(4,12) =9.00, P < 0.01) and mothers delivering from traditional birth attendants (TBAs), F(4,16) = 3.86, p = 0.02). The qualitative findings suggest that strengthening of citizens' demand, availability of resources through collaborative problem solving, increased awareness about targeted maternal health services and increased top down performance pressure contributed to positive changes as perceived by community members and their leaders. CONCLUSIONS AND RECOMMENDATIONS: The community score cards created opportunities for community leaders and communities to work together to identify innovative ways of dealing with the health service delivery and utilization challenges that they face. Local leaders should encourage the availability of safe spaces for dialogue between communities, health workers and leaders where performance and utilization challenges can be identified and solutions proposed and implemented jointly.

A participatory action research approach to strengthening health managers' capacity at district level in Eastern Uganda.

BACKGROUND: Many approaches to improving health managers' capacity in poor countries, particularly those pursued by external agencies, employ non-participatory approaches and often seek to circumvent (rather than strengthen) weak public management structures. This limits opportunities for strengthening local health managers' capacity, improving resource utilisation and enhancing service delivery. This study explored the contribution of a participatory action research approach to strengthening health managers' capacity in Eastern Uganda. METHODS: This was a qualitative study that used open-ended key informant interviews, combined with review of meeting minutes and observations to collect data. Both inductive and deductive thematic analysis was undertaken. The Competing Values Framework of organisational management functions guided the deductive process of analysis and the interpretation of the findings. The framework builds on four earlier models of management and regards them as complementary rather than conflicting, and identifies four managers' capacities (collaborate, create, compete and control) by categorising them along two axes, one contrasting flexibility versus control and the other internal versus external organisational focus. RESULTS: The findings indicate that the participatory action research approach enhanced health managers' capacity to collaborate with others, be creative, attain goals and review progress. The enablers included expanded interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability. Tension and conflict across different management functions was apparent; for example, while there was a need to collaborate, maintaining control over processes was also needed. These tensions meant that managers needed to learn to simultaneously draw upon and use different capacities as reflected by the Competing Values Framework in order to maximise their effectiveness. CONCLUSIONS: Improved health manager capacity is essential if sustained improvements in health outcomes in low-income countries are to be attained. The expansion of interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability were the key means by which participatory action research strengthened health managers' capacity. The participatory approach to implementation therefore created opportunities to strengthen health managers' capacity.

The conduct of maternal and perinatal death reviews in Oyam District, Uganda: a descriptive cross-sectional study.

BACKGROUND: Uganda like many developing countries still experiences high levels of maternal and perinatal deaths despite a decade of maternal and perinatal death review (MPDR) program. Oyam district has been implementing MPDR since 2008 with varying successes among the health facilities. This paper presents the factors that influence the conduct of maternal and perinatal death reviews in Oyam District, Uganda. METHODS: This was a cross-sectional study where both qualitative and quantitative data were collected. Semi-structured interviews were administered to 66 health workers and ten key informants (KIs) to assess the factors influencing the conduct of MPDR. Univariate and Bivariate analysis of quantitative data was done using SPSS version 17.0. A Pearson Chi-Square test was done to determine factors associated with conduct of MPDR. Factors with a p-value < 0.05 were considered statistically significant. Qualitative data was analyzed using content analysis. RESULTS: Only 34.8 % of the health workers had ever participated in MPDR. The factors that influenced conduct of MPDR were existence of MPDR committees (p < 0.001), attendance of review meetings (p < 0.001) and knowledge of objectives of MPDR (p < 0.001), implementation of MPDR recommendations (p < 0.001), observed improvement in maternal and newborn care (p < 0.001) and provision of feedback (p < 0.001). Hindrance to conduct of MPDR was obtained from KIs: the health workers were not made aware of the MPDR process, committee formation and training of MPDR committee members was not effectively done, inadequate support supervision, and lack of financial motivation of MPDR committee members. Challenges to MPDR included: heavy workload to health workers, high number of perinatal deaths, and non-implementation of recommendations. CONCLUSION: The proportion of maternal and perinatal death reviews conducted in Oyam was low. This was due to poor initiation of the review process and a lack of support supervision. The district and Ministry of Health needs to put more emphasis on monitoring the conduct of maternal and perinatal death reviews by: forming and training MPDR committees and ensuring they are financially supported, providing overall coordination, and ensuring effective support supervision.

Lessons learnt during the process of setup and implementation of the voucher scheme in Eastern Uganda: a mixed methods study.

BACKGROUND: In spite of the investments made by the Ugandan Government, the utilisation of maternal health services has remained low, resulting in a high maternal mortality (438 maternal deaths per 100,000 live births). Aiming to reduce poor women's constraints to the utilisation of services, an intervention consisting of a voucher scheme and health system strengthening was implemented. This paper presents the lessons learnt during the setup and implementation of the intervention in Eastern Uganda, in order to inform the design and scale up of similar future interventions. METHODS: The key lessons were synthesised from a variety of project reports, as well as qualitative data drawn from six focus group discussions and four in-depth interviews conducted in the Buyende and Pallisa districts during the implementation phase of the voucher scheme. RESULTS AND CONCLUSIONS: To promote the successful implementation of interventions with demand and supply side initiatives, such as voucher schemes, the health system should be able to respond to the demand created by providing the additional required resources such as health workers, essential supplies and equipment. Involving a diverse, multi-sectoral group of stakeholders is important for addressing the different barriers experienced by women when seeking maternal health services. Voucher schemes should have a mechanism of detecting unintended consequences and mitigating them. Sustainability plans should be built into such interventions to maintain the gains achieved. Lastly, health policy planners can use this information to develop follow-up programmes to test modified versions that are more sustainable. Such programmes could use locally existing community structures for management and resource mobilisation for self-sustainment.

Uptake of mass drug administration programme for schistosomiasis control in Koome Islands, Central Uganda.

INTRODUCTION: Schistosomiasis is one of the neglected tropical diseases targeted for elimination in Uganda through the Mass Drug Administration (MDA) programme. Praziquantel has been distributed using community resource persons in fixed sites and house-to-house visits; however the uptake is still below target coverage. In 2011/2012 MDA exercise, uptake stood at 50% yet WHO target coverage is 75% at community level. We assessed the uptake of MDA and the associated factors in Koome Islands, Central Uganda. METHODS: In March 2013, we conducted a mixed methods cross sectional study in 15 randomly selected villages. We interviewed a total of 615 respondents aged 18 years and above using semi structured questionnaires and five key informants were also purposively selected. Univariate and multivariate analysis was done. MDA uptake was defined as self reported swallowing of praziquantel during the last (2012) MDA campaign. We conducted key informant interviews with Ministry of Health, district health personnel and community health workers. RESULTS: Self reported uptake of praziquantel was 44.7% (275/615), 95% confidence interval (CI) 40.8-48.7%. Of the 275 community members who said they had swallowed praziquantel, 142 (51.6%) reported that they had developed side effects. Uptake of MDA was more likely if the respondent was knowledgeable about schistosomiasis transmission and prevention (adjusted odds ratio [AOR] 1.85, 95% CI 1.22-2.81) and reported to have received health education from the health personnel (AOR 5.95, 95% CI 3.67-9.65). Service delivery challenges such as drug shortages and community health worker attrition also influenced MDA in Koome Islands. CONCLUSIONS: Uptake of MDA for schistosomiasis control in Koome was sub optimal. Lack of knowledge about schistosomiasis transmission and prevention, inadequate health education and drug shortages are some of the major factors associated with low uptake. These could be addressed through routine health education and systematic drug supply for the successful elimination of schistosomiasis on the islands.