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1.
BMC Public Health ; 20(1): 1409, 2020 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-32938411

RESUMO

BACKGROUND: Tuberculosis (TB) patients in Uganda incur large costs related to the illness, and while seeking and receiving health care. Such costs create access and adherence barriers which affect health outcomes and increase transmission of disease. The study ascertained the proportion of Ugandan TB affected households incurring catastrophic costs and the main cost drivers. METHODS: A cross-sectional survey with retrospective data collection and projections was conducted in 2017. A total of 1178 drug resistant (DR) TB (44) and drug sensitive (DS) TB patients (1134), 2 weeks into intensive or continuation phase of treatment were consecutively enrolled across 67 randomly selected TB treatment facilities. RESULTS: Of the 1178 respondents, 62.7% were male, 44.7% were aged 15-34 years and 55.5% were HIV positive. For each TB episode, patients on average incurred costs of USD 396 for a DS-TB episode and USD 3722 for a Multi drug resistant tuberculosis (MDR TB) episode. Up to 48.5% of households borrowed, used savings or sold assets to defray these costs. More than half (53.1%) of TB affected households experienced TB-related costs above 20% of their annual household expenditure, with the main cost drivers being non-medical expenditure such as travel, nutritional supplements and food. CONCLUSION: Despite free health care in public health facilities, over half of Ugandan TB affected households experience catastrophic costs. Roll out of social protection interventions like TB assistance programs, insurance schemes, and enforcement of legislation related to social protection through multi-sectoral action plans with central NTP involvement would palliate these costs.

2.
BMJ Open ; 10(6): e034738, 2020 06 11.
Artigo em Inglês | MEDLINE | ID: mdl-32532769

RESUMO

OBJECTIVES: 5.0 million annual deaths in low-income and middle-income countries are due to poor quality of care (QOC). We evaluated the QOC provided to malnourished children in West Nile Region in Uganda. DESIGN: Cross-sectional study. SETTING: West Nile Region, an area hosting over one million refugees. PARTICIPANTS: Among 148 facilities providing nutritional services, 30 randomly selected facilities (20%) and the records of 1467 children with severe acute malnutrition (100% of those attending the 30 facilities during last year) were assessed. OUTCOMES: The national Nutrition Service Delivery Assessment (NSDA) tool was used to assess capacity areas related to QOC. Case management, data quality and health outcomes were assessed from official health records. Multivariate analysis was performed to explore factors significantly associated with better cure rates. RESULTS: Of 305 NSDA scores allocated to 30 participating centres, 201 (65.9%) were 'good' or 'excellent'. However, 20 (66.7%) facilities had 'poor' 'quality improvement mechanisms' and 13 (43.3%) had 'poor' 'human resources'. Overall data quality in official records was poor, while recorded quality of case management was overall fair. Average cure rate was significantly lower than international Sphere standards (50.4% vs 75% p<0.001) with a higher default rate (23.2% vs 15% p<0.001). Large heterogeneity among facilities was detected for all indicators. Refugee-hosting and non-refugee-hosting facilities had a similar cure rate (47.1% vs 52.1%) though transfer rates were higher for those hosting refugees (21.5% vs 1.9%, p<0.001) despite better 'equipment and supplies'. 'Good/excellent' 'equipment' and 'store management' were significantly associated with better cure rates in outpatient therapeutic centres (+55.9, p<0.001; +65.4, p=0.041, respectively) in multivariate analysis. CONCLUSIONS: Though most NSDA capacity areas were rated good or excellent, health outcomes of malnourished children in West Nile Region, both in refugee-hosting and non-refugee-hosting facilities, are significantly below international standards. Effective and sustainable approaches to improve malnourished child health outcomes are needed.

3.
Afr Health Sci ; 20(3): 1053-1065, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33402951

RESUMO

Introduction: Sexual and reproductive health (SRH) and Human Immunodeficiency Virus (HIV) are crucial global health issues. Uganda continues to sustain a huge burden of HIV and AIDS. Methods: A cross-sectional health facility-based assessment was performed in November and December 2016 in Karamoja Region, northern Uganda. All the 126 health facilities (HFs) in Karamoja, including 5 hospitals and 121 Health Centers (HCs), covering 51 sub-counties of the 7 districts were assessed. We assessed the capacity of a) leadership and governance, b) human resource, c) service delivery, d) SRH and HIV service integration and e) users satisfaction and perceptions. Results: 64% of the established health staffing positions were filled leaving an absolute gap of 704 units in terms of human resources. As for service delivery capacity, on 5 domains assessed, the best performing was basic hygiene and safety measures in which 33% HCs scored "excellent", followed by the presence of basic equipment. The level of integration of SRH/HIV services was 55.56%. Conclusion: HFs in Karamoja have capacity gaps in a number of health system building blocks. Many of these gaps can be addressed through improved planning. To invest in improvements for these services would have a great gain for Uganda.


Assuntos
Fortalecimento Institucional , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Infecções por HIV/prevenção & controle , Serviços de Saúde Reprodutiva/estatística & dados numéricos , Adolescente , Adulto , Estudos Transversais , Prestação Integrada de Cuidados de Saúde/organização & administração , Feminino , Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Instalações de Saúde , Humanos , Pessoa de Meia-Idade , Saúde Reprodutiva , Serviços de Saúde Reprodutiva/organização & administração , Saúde Sexual , Fatores Socioeconômicos , Inquéritos e Questionários , Uganda/epidemiologia , Adulto Jovem
4.
BMJ Open ; 9(9): e026851, 2019 09 08.
Artigo em Inglês | MEDLINE | ID: mdl-31501099

RESUMO

OBJECTIVE: To examine the perceptions of community members and other stakeholders on the use of baby kits and transport vouchers to improve the utilisation of childbirth services. DESIGN: A qualitative study. SETTING: Oyam district, Uganda. PARTICIPANTS: We conducted 10 focus group discussions with 59 women and 55 men, and 18 key informant interviews with local leaders, village health team members, health facility staff and district health management team members. We analysed the data using qualitative content analysis. RESULTS: Five broad themes emerged: (1) context, (2) community support for the interventions, (3) health-seeking behaviours postintervention, (4) undesirable effects of the interventions and (5) implementation issues and lessons learnt. Context regarded perceived long distances to health facilities and high transport costs. Regarding community support for the interventions, the schemes were perceived to be acceptable and helpful particularly to the most vulnerable. Transport vouchers were preferred over baby kits, although both interventions were perceived to be necessary. Health-seeking behaviours entailed perceived increased utilisation of maternal health services and 'bypassing', promotion of collaboration between traditional birth attendants and formal health workers, stimulation of men's involvement in maternal health, and increased community awareness of maternal health. Undesirable effects of the interventions included increased workload for health workers, sustainability concerns and perceived encouragement to reproduce and dependency. Implementation issues included information gaps leading to confusion, mistrust and discontent, transport voucher scheme design; implementation; and payment problems, poor attitude of some health workers and poor quality of care, insecurity, and a shortage of baby kits. Community involvement was key to solving the challenges. CONCLUSIONS: The study provides further insights into the implementation of incentive schemes to improve maternal health services utilisation. The findings are relevant for planning and implementing similar schemes in low-income countries.


Assuntos
Participação da Comunidade/métodos , Acesso aos Serviços de Saúde , Mau Uso de Serviços de Saúde , Serviços de Saúde Materna , Aceitação pelo Paciente de Cuidados de Saúde , Gestantes/psicologia , Adulto , Feminino , Acesso aos Serviços de Saúde/organização & administração , Acesso aos Serviços de Saúde/normas , Mau Uso de Serviços de Saúde/prevenção & controle , Mau Uso de Serviços de Saúde/estatística & dados numéricos , Humanos , Serviços de Saúde Materna/organização & administração , Serviços de Saúde Materna/normas , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Gravidez , Pesquisa Qualitativa , Melhoria de Qualidade , Percepção Social , Transportes/economia , Uganda
5.
BMJ Glob Health ; 4(4): e001339, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31406583

RESUMO

Introduction: Suboptimal quality of paediatric care has been reported in resource-limited settings, but little evidence exists on interventions to improve it in such settings. This study aimed at testing supportive supervision (SS) for improving health status of malnourished children, quality of case management, overall quality of care, and the absolute number of children enrolled in the nutritional services. Methods: This was a cluster randomised trial conducted in Arua district. Six health centres (HCs) with the highest volume of work were randomised to either SS or no intervention. SS was delivered by to HCs staff (phase 1), and later extended to community health workers (CHWs) (phase 2). The primary outcome was the cure rate, measured at children level. Quality of case management was assessed by six pre-defined indicators. Quality of care was assessed using the national Nutrition Service Delivery Assessment (NSDA) tool. Access to care was estimated with the number of children accessing HC nutritional services. Results: Overall, 737 children were enrolled. In the intervention arm, the cure rate (83.8% vs 44.9%, risk ratio (RR)=1.91, 95% CI: 1.56-2.34, p=0.001), quality of care as scored by NSDA (RR=1.57, 95% CI: 1.01-2.44, p=0.035) and correctness in complementary treatment (RR=1.52, 95% CI: 1.40-1.67, p=0.001) were significantly higher compared with control. With the extension of SS to CHWs (phase 2), there was a significant 38.6% more children accessing care in the intervention HCs (RR=1.26, 95% CI: 1.11-1.44, p=0.001) compared with control. Conclusion: SS significantly improved the cure rate of malnourished children, and the overall quality of care, SS to CHWs significantly increased the crude number of children enrolled in the nutritional services. More studies should confirm these results, and evaluate the cost-effectiveness of SS.

6.
BMC Health Serv Res ; 18(1): 561, 2018 07 17.
Artigo em Inglês | MEDLINE | ID: mdl-30016954

RESUMO

BACKGROUND: Arua district, in Uganda, hosts some of the largest refugee camps in the country. The estimated prevalence of moderate and severe acute malnutrition in children is higher than the national estimates (10.4 and 5.6% respectively, compared to 3.6 and 1.3%). This study aimed at assessing the quality of care provided to children with acute malnutrition at out-patient level in such a setting. METHODS: Six facilities with the highest number of children with malnutrition were selected. The main tool used was the National Nutrition Service Delivery Assessment Tool, assessing 10 key areas of service delivery and assigned a score as either poor, fair, good or excellent. Health outcomes, quality of case management and data quality were assessed from the health management information system and from the official nutrition registers. RESULTS: All facilities except two scored either poor or fair under all the 10 assessment areas. Overall, 33/60 (55%) areas scored as poor, 25/60 (41%) as fair, 2/60 (3.3%) as good, and none as excellent. Main gaps identified included: lack of trained staff; disorganised patient flow; poor case management; stock out of essential supplies including ready-to-use therapeutic foods; weak community linkage. A sample coverage of 45.4% (1020/2248) of total children admitted in the district during the 2016 financial year were included. The overall mean cure rate was 52.9% while the default rate was 38.3%. There was great heterogeneity across health facilities in health outcomes, quality of case management, and data quality. CONCLUSION: This study suggests that quality of care provided to children with malnutrition at health center level is substandard with unacceptable low cure rates. It is essential to identify effective approaches to enhance adherence to national guidelines, provision of essential nutritional commodities, regular monitoring of services and better linkage with the community through village health teams.


Assuntos
Transtornos da Nutrição Infantil/terapia , Instalações de Saúde/normas , Qualidade da Assistência à Saúde , Campos de Refugiados , Refugiados , Pré-Escolar , Estudos Transversais , Humanos , Avaliação Nutricional , Estado Nutricional , Prevalência , Uganda
7.
BMC Pregnancy Childbirth ; 17(1): 431, 2017 Dec 19.
Artigo em Inglês | MEDLINE | ID: mdl-29258475

RESUMO

BACKGROUND: We evaluated the effects and financial costs of two interventions with respect to utilisation of institutional deliveries and other maternal health services in Oyam District in Uganda. METHODS: We conducted a quasi-experimental study involving intervention and comparable/control sub-counties in Oyam District for 12 months (January-December 2014). Participants were women receiving antenatal care, delivery and postnatal care services. We evaluated two interventions: the provision of (1) transport vouchers to women receiving antenatal care and delivering at two health centres (level II) in Acaba sub-county, and (2) baby kits to women who delivered at Ngai Health Centre (level III) in Ngai sub-county. The study outcomes included service coverage of institutional deliveries, four antenatal care visits, postnatal care, and the percentage of women 'bypassing' maternal health services inside their resident sub-counties. We calculated the effect of each intervention on study outcomes using the difference in differences analysis. We calculated the cost per institutional delivery and the cost per unit increment in institutional deliveries for each intervention. RESULTS: Overall, transport vouchers had greater effects on all four outcomes, whereas baby kits mainly influenced institutional deliveries. The absolute increase in institutional deliveries attributable to vouchers was 42.9%; the equivalent for baby kits was 30.0%. Additionally, transport vouchers increased the coverage of four antenatal care visits and postnatal care service coverage by 60.0% and 49.2%, respectively. 'Bypassing' was mainly related to transport vouchers and ranged from 7.2% for postnatal care to 11.9% for deliveries. The financial cost of institutional delivery was US$9.4 per transport voucher provided, and US$10.5 per baby kit. The incremental cost per unit increment in institutional deliveries in the transport-voucher system was US$15.9; the equivalent for the baby kit was US$30.6. CONCLUSION: The transport voucher scheme effectively increased utilisation of maternal health services whereas the baby-kit scheme was only effective in increasing institutional deliveries. The transport vouchers were less costly than the baby kits in the promotion of institutional deliveries. Such incentives can be sustainable if the Ministry of Health integrates them in the health system.


Assuntos
Centros Comunitários de Saúde/estatística & dados numéricos , Parto Obstétrico/estatística & dados numéricos , Motivação , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Transportes/economia , Custos e Análise de Custo , Feminino , Humanos , Cuidado Pós-Natal/estatística & dados numéricos , Gravidez , Cuidado Pré-Natal/estatística & dados numéricos , Uganda
8.
Reprod Health ; 12: 30, 2015 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-25884616

RESUMO

BACKGROUND: Maternal mortality is persistently high in Uganda. Access to quality emergency obstetrics care (EmOC) is fundamental to reducing maternal and newborn deaths and is a possible way of achieving the target of the fifth millennium development goal. Karamoja region in north-eastern Uganda has consistently demonstrated the nation's lowest scores on key development and health indicators and presents a substantial challenge to Uganda's stability and poverty eradication ambitions. The objectives of this study were: to establish the availability of maternal and neonatal healthcare services at different levels of health units; to assess their utilisation; and to determine the quality of services provided. METHODS: A cross sectional study of all health facilities in Napak and Moroto districts was conducted in 2010. Data were collected by reviewing clinical records and registers, interviewing staff and women attending antenatal and postnatal clinics, and by observation. Data were summarized using frequencies and percentages and EmOC indicators were calculated. RESULTS: There were gaps in the availability of essential infrastructure, equipment, supplies, drugs and staff for maternal and neonatal care particularly at health centres (HCs). Utilisation of the available antenatal, intrapartum, and postnatal care services was low. In addition, there were gaps in the quality of care received across these services. Two hospitals, each located in the study districts, qualified as comprehensive EmOC facilities. The number of EmOC facilities per 500,000 population was 3.7. None of the HCs met the criteria for basic EmOC. Assisted vaginal delivery and removal of retained products were the most frequently missing signal functions. Direct obstetric case fatality rate was 3%, the met need for EmOC was 9.9%, and 1.7% of expected deliveries were carried out by caesarean section. CONCLUSIONS: To reduce maternal and newborn morbidity and mortality in Karamoja region, there is a need to increase the availability and the accessibility of skilled birth care, address the low utilisation of maternity services and improve the quality of care rendered. There is also a need to improve the availability and accessibility of EmOC services, with particular attention to basic EmOC.


Assuntos
Instalações de Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde , Serviços de Saúde Materna/estatística & dados numéricos , Garantia da Qualidade dos Cuidados de Saúde , Adulto , Estudos Transversais , Equipamentos e Provisões , Feminino , Humanos , Recém-Nascido , Uganda
9.
Afr J Reprod Health ; 18(3): 87-94, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25438513

RESUMO

Reduction in maternal mortality has not been appreciable in most low-income countries. Improved access to transport for mothers is one way to improve maternal health. This study evaluated a free-of-charge 24-hour ambulance and communication services intervention in Oyam district using 'Caesarean section rate' (CSR) and compared with the neighbouring non-intervention district. Ecological data were collected retrospectively from maternity/theatre registers in October 2010 for 3 years pre and 3 years intervention period. The average CSR in the intervention district increased from 0.57% before the intervention to 1.21% (p = 0.022) during the intervention, while there was no change in the neighbouring district (0.51% to 0.58%, p = 0.512). Hospital deliveries increased by over 50% per year with a slight reduction in the average hospital stillbirths per 1000 hospital births in the intervention district (46.6 to 37.5, p = 0.253). Reliable communication and transport services increased access to and utilization of maternal health services, particularly caesarean delivery services.


Assuntos
Cesárea/estatística & dados numéricos , Acesso aos Serviços de Saúde , Complicações na Gravidez , Natimorto/epidemiologia , Transporte de Pacientes , Sistemas de Comunicação entre Serviços de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Acesso aos Serviços de Saúde/normas , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Mortalidade Materna/tendências , Determinação de Necessidades de Cuidados de Saúde , Unidade Hospitalar de Ginecologia e Obstetrícia/estatística & dados numéricos , Gravidez , Complicações na Gravidez/mortalidade , Complicações na Gravidez/cirurgia , Melhoria de Qualidade , Sistema de Registros , Estudos Retrospectivos , Transporte de Pacientes/métodos , Transporte de Pacientes/organização & administração , Uganda/epidemiologia
10.
BMC Pregnancy Childbirth ; 14: 259, 2014 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-25091866

RESUMO

BACKGROUND: Skilled attendance at delivery is critical in prevention of maternal deaths. However, many women in low- and middle-income countries still deliver without skilled assistance. This study was carried out to identify perceived barriers to utilisation of institutional delivery in two districts in Karamoja, Uganda. METHODS: Data were collected through participatory rural appraisal (PRA) with 887 participants (459 women and 428 men) in 20 villages in Moroto and Napak districts. Data were analysed using deductive content analysis. Notes taken during PRA session were edited, triangulated and coded according to recurring issues. Additionally, participants used matrix ranking to express their perceived relative significance of the barriers identified. RESULTS: The main barriers to utilisation of maternal health services were perceived to be: insecurity, poverty, socio-cultural factors, long distances to health facilities, lack of food at home and at health facilities, lack of supplies, drugs and basic infrastructure at health facilities, poor quality of care at health facilities, lack of participation in planning for health services and the ready availability of traditional birth attendants (TBAs). Factors related to economic and physical inaccessibility and lack of infrastructure, drugs and supplies at health facilities were highly ranked barriers to utilisation of institutional delivery. CONCLUSION: A comprehensive approach to increasing the utilisation of maternal health care services in Karamoja is needed. This should tackle both demand and supply side barriers using a multi-sectorial approach since the main barriers are outside the scope of the health sector. TBAs are still active in Karamoja and their role and influence on maternal health in this region cannot be ignored. A model for collaboration between skilled health workers and TBAs in order to increase institutional deliveries is needed.


Assuntos
Parto Obstétrico/estatística & dados numéricos , Países em Desenvolvimento , Instalações de Saúde/estatística & dados numéricos , Serviços de Saúde Rural/estatística & dados numéricos , Atitude do Pessoal de Saúde , Cultura , Parto Obstétrico/economia , Feminino , Abastecimento de Alimentos , Instalações de Saúde/economia , Recursos em Saúde/provisão & distribução , Acesso aos Serviços de Saúde , Humanos , Masculino , Participação do Paciente , Pobreza , Pesquisa Qualitativa , Serviços de Saúde Rural/economia , Uganda
11.
Trop Med Int Health ; 16(9): 1151-8, 2011 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-21692959

RESUMO

OBJECTIVE: To assess the cost-effectiveness of an ambulance service within a comprehensive hospital/community-based program aimed at improving access and quality of reproductive health in poor-resources settings. METHODS: Obstetrical cases referred to the hospital with the ambulance during a 3-month period were prospectively recorded. Clinical indications were used to determine the effectiveness of the referral; the direct costs of the service were calculated. Overall effectiveness was then measured against WHO thresholds. RESULTS: Ninety-two obstetrical referrals were recorded. Eleven (12%) were considered effective, corresponding to 611.7 years saved. Cost per year saved was 15.82 US dollars which about half of WHO's 30 US dollar benchmark defining very attractive interventions. Sensitivity analyses on the costs of the ambulance and the rate of effective referrals emphasized the robustness of the result. CONCLUSIONS: The cost-effectiveness profile of an ambulance service within a series of interventions aimed at improving reproductive health in remote settings is very attractive.


Assuntos
Ambulâncias/economia , Ambulâncias/estatística & dados numéricos , Parto Obstétrico/normas , Saúde Reprodutiva/estatística & dados numéricos , Serviços de Saúde Rural/estatística & dados numéricos , Adolescente , Serviços de Saúde Comunitária , Análise Custo-Benefício , Feminino , Humanos , Gravidez , Estudos Prospectivos , Saúde Reprodutiva/normas , Serviços de Saúde Rural/normas , População Rural , Uganda , Organização Mundial da Saúde/economia , Adulto Jovem
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