Implementing the skilled birth attendance strategy in Uganda: a policy analysis.

BACKGROUND: Uganda, a low resource country, implemented the skilled attendance at birth strategy, to meet a key target of the 5th Millenium Development Goal (MDG), 75% reduction in maternal mortality ratio. Maternal mortality rates remained high, despite the improvement in facility delivery rates. In this paper, we analyse the strategies implemented and bottlenecks experienced as Uganda's skilled birth attendance policy was rolled out. These experiences provide important lessons for decision makers as they implement policies to further improve maternity care. METHODS: This is a case study of the implementation process, involving a document review and in-depth interviews among key informants selected from the Ministry of Health, Professional Organisations, Ugandan Parliament, the Health Service Commission, the private not-for-profit sector, non-government organisations, and District Health Officers. The Walt and Gilson health policy triangle guided data collection and analysis. RESULTS: The skilled birth attendance policy was an important priority on Uganda's maternal health agenda and received strong political commitment, and support from development partners and national stakeholders. Considerable effort was devoted to implementation of this policy through strategies to increase the availability of skilled health workers for instance through expanded midwifery training, and creation of the comprehensive nurse midwife cadre. In addition, access to emergency obstetric care improved to some extent as the physical infrastructure expanded, and distribution of medicines and supplies improved. However, health worker recruitment was slow in part due to the restrictive staff norms that were remnants of previous policies. Despite considerable resources allocated to creating the comprehensive nurse midwife cadre, this resulted in nurses that lacked midwifery skills, while the training of specialised midwives reduced. The rate of expansion of the physical infrastructure outpaced the available human resources, equipment, blood infrastructure, and several health facilities were not fully functional. CONCLUSION: Uganda's skilled birth attendance policy aimed to increase access to obstetric care, but recruitment of human resources, and infrastructural capacity to provide good quality care remain a challenge. This study highlights the complex issues and unexpected consequences of policy implementation. Further evaluation of this policy is needed as decision-makers develop strategies to improve access to skilled care at birth.

Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis.

BACKGROUND: In many low- and middle-income countries women are encouraged to give birth in clinics and hospitals so that they can receive care from skilled birth attendants. A skilled birth attendant (SBA) is a health worker such as a midwife, doctor, or nurse who is trained to manage normal pregnancy and childbirth. (S)he is also trained to identify, manage, and refer any health problems that arise for mother and baby. The skills, attitudes and behaviour of SBAs, and the extent to which they work in an enabling working environment, impact on the quality of care provided. If any of these factors are missing, mothers and babies are likely to receive suboptimal care. OBJECTIVES: To explore the views, experiences, and behaviours of skilled birth attendants and those who support them; to identify factors that influence the delivery of intrapartum and postnatal care in low- and middle-income countries; and to explore the extent to which these factors were reflected in intervention studies. SEARCH METHODS: Our search strategies specified key and free text terms related to the perinatal period, and the health provider, and included methodological filters for qualitative evidence syntheses and for low- and middle-income countries. We searched MEDLINE, OvidSP (searched 21 November 2016), Embase, OvidSP (searched 28 November 2016), PsycINFO, OvidSP (searched 30 November 2016), POPLINE, K4Health (searched 30 November 2016), CINAHL, EBSCOhost (searched 30 November 2016), ProQuest Dissertations and Theses (searched 15 August 2013), Web of Science (searched 1 December 2016), World Health Organization Reproductive Health Library (searched 16 August 2013), and World Health Organization Global Health Library for WHO databases (searched 1 December 2016). SELECTION CRITERIA: We included qualitative studies that focused on the views, experiences, and behaviours of SBAs and those who work with them as part of the team. We included studies from all levels of health care in low- and middle-income countries. DATA COLLECTION AND ANALYSIS: One review author extracted data and assessed study quality, and another review author checked the data. We synthesised data using the best fit framework synthesis approach and assessed confidence in the evidence using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether the factors identified by health workers in our synthesis as important for providing maternity care were reflected in the interventions evaluated in the studies in a related intervention review. MAIN RESULTS: We included 31 studies that explored the views and experiences of different types of SBAs, including doctors, midwives, nurses, auxiliary nurses and their managers. The included studies took place in Africa, Asia, and Latin America.Our synthesis pointed to a number of factors affecting SBAs' provision of quality care. The following factors were based on evidence assessed as of moderate to high confidence. Skilled birth attendants reported that they were not always given sufficient training during their education or after they had begun clinical work. Also, inadequate staffing of facilities could increase the workloads of skilled birth attendants, make it difficult to provide supervision and result in mothers being offered poorer care. In addition, SBAs did not always believe that their salaries and benefits reflected their tasks and responsibilities and the personal risks they undertook. Together with poor living and working conditions, these issues were seen to increase stress and to negatively affect family life. Some SBAs also felt that managers lacked capacity and skills, and felt unsupported when their workplace concerns were not addressed.Possible causes of staff shortages in facilities included problems with hiring and assigning health workers to facilities where they were needed; lack of funding; poor management and bureaucratic systems; and low salaries. Skilled birth attendants and their managers suggested factors that could help recruit, keep, and motivate health workers, and improve the quality of care; these included good-quality housing, allowances for extra work, paid vacations, continuing education, appropriate assessments of their work, and rewards.Skilled birth attendants' ability to provide quality care was also limited by a lack of equipment, supplies, and drugs; blood and the infrastructure to manage blood transfusions; electricity and water supplies; and adequate space and amenities on maternity wards. These factors were seen to reduce SBAs' morale, increase their workload and infection risk, and make them less efficient in their work. A lack of transport sometimes made it difficult for SBAs to refer women on to higher levels of care. In addition, women's negative perceptions of the health system could make them reluctant to accept referral.We identified some other factors that also may have affected the quality of care, which were based on findings assessed as of low or very low confidence. Poor teamwork and lack of trust and collaboration between health workers appeared to negatively influence care. In contrast, good collaboration and teamwork appeared to increase skilled birth attendants' motivation, their decision-making abilities, and the quality of care. Skilled birth attendants' workloads and staff shortages influenced their interactions with mothers. In addition, poor communication undermined trust between skilled birth attendants and mothers. AUTHORS' CONCLUSIONS: Many factors influence the care that SBAs are able to provide to mothers during childbirth. These include access to training and supervision; staff numbers and workloads; salaries and living conditions; and access to well-equipped, well-organised healthcare facilities with water, electricity, and transport. Other factors that may play a role include the existence of teamwork and of trust, collaboration, and communication between health workers and with mothers. Skilled birth attendants reported many problems tied to all of these factors.

Advancing palliative care in the Uganda health system: an evidence-based policy brief.

OBJECTIVES: This paper describes the development and findings for a policy brief on "Advancing the Integration of Palliative Care into the National Health System" and the subsequent use of this report. METHODS: Key stakeholders involved with palliative care helped identify the problem and potential policy solutions to scale up these services within the health system. A working group of national stakeholder representatives and external reviewers commented on and contributed to successive drafts of the report. Research describing the problem, policy options and implementation considerations was identified by reviewing government documents, routinely collected data, electronic literature searches, contact with key informants, and reviewing the reference lists of relevant documents that were retrieved. RESULTS: The palliative burden is not only high but increasing due to the rise in population and life expectancy. A few options for holistic, supportive care include: Home-based care increases chances of a peaceful death for the terminally ill surrounded by their loved ones; supporting informal caregivers improves their quality of life and discharge planning reduces unscheduled admissions and has the potential to free up capacity for acute care services. A combination of strategies is needed to effectively implement the proposed options as discussed further in this article. CONCLUSIONS: The policy brief report was used as a background document for two stakeholder dialogues whose main outcome was that a comprehensive national palliative care policy should be instituted to include all the options, which need to be integrated within the public health system. A draft policy is now in process.

Improving access to skilled attendance at delivery: a policy brief for Uganda.

OBJECTIVE: This study describes the process of production, findings for a policy brief on Increasing Access to Skilled Birth Attendance, and subsequent use of the report by policy makers and others from the health sector in Uganda. METHODS: The methods used to prepare the policy brief use the SUPPORT Tools for evidence-informed health policy making. The problem that this evidence brief addresses was identified through an explicit priority setting process involving policy makers and other stakeholders, further clarification with key informant interviews of relevant policy makers, and review of relevant documents. A working group of national stakeholder representatives and external reviewers commented on and contributed to successive drafts of the report. Research describing the problem, policy options, and implementation considerations was identified by reviewing government documents, routinely collected data, electronic literature searches, contact with key informants, and reviewing the reference lists of relevant documents that were retrieved. RESULTS: The proportion of pregnant women delivering from public and private non-profit facilities was low at 34 percent in 2008/09. The three policy options discussed in the report could be adopted independently or complementary to the other to increase access to skilled care. The Ministry of Health in deliberating to provide intrapartum care at first level health facilities from the second level of care, requested for research evidence to support these decisions. Maternal waiting shelters and working with the private-for-profit sector to facilitate deliveries in health facilities are promising complementary interventions that have been piloted in both the public and private health sector. A combination of strategies is needed to effectively implement the proposed options as discussed further in this article. CONCLUSIONS: The policy brief report was used as a background document for two stakeholder dialogue meetings involving members of parliament, policy makers, health managers, researchers, civil society, professional organizations, and the media.

Task shifting in maternal and child health care: an evidence brief for Uganda.

THE PROBLEM: There is a shortage and maldistribution of medically trained health professionals to deliver cost-effective maternal and child health (MCH) services. Hence, cost-effective MCH services are not available to over half the population of Uganda and progress toward the Millennium Development Goals for MCH is slow. Optimizing the roles of less specialized health workers ("task shifting") is one strategy to address the shortage and maldistribution of more specialized health professionals. POLICY OPTIONS: (i) Lay health workers (community health workers) may reduce morbidity and mortality in children under five and neonates; and training for traditional birth attendants may improve perinatal outcomes and appropriate referrals. (ii) Nursing assistants in facilities might increase the time available from nurses, midwives, and doctors to provide care that requires more training. (iii) Nurses and midwives to deliver cost-effective MCH interventions in areas where there is a shortage of doctors. (iv) Drug dispensers to promote and deliver cost-effective MCH interventions and improve the quality of the services they provide. The costs and cost-effectiveness of all four options are uncertain. Given the limitations of the currently available evidence, rigorous evaluation and monitoring of resource use and activities is warranted for all four options. IMPLEMENTATION STRATEGIES: A clear policy on optimizing health worker roles. Community mobilization and reduction of out-of-pocket costs to improve mothers' knowledge and care-seeking behaviors, continuing education, and incentives to ensure health workers are competent and motivated, and community referral and transport schemes for MCH care are needed.

Ugandan health workers' and mothers' views and experiences of the quality of maternity care and the use of informal solutions: A qualitative study.

INTRODUCTION: Although the coverage of maternity services in some low and middle-income countries (LMIC) has greatly improved, the quality of maternity care remains poor, and maternal mortality rates are high. In this study, we describe the meaning and determinants of maternity care quality from the perspective of health workers and mothers in Uganda, the informal solutions used by health workers to manage their daily challenges, and we suggest ways in which maternal care quality can be improved. METHODS: We conducted a qualitative study in the Mpigi and Rukungiri districts of Uganda. Twenty-eight health workers based at selected health centres participated in structured interviews. Thirty-six mothers, half of whom had delivered at health facilities, participated in focus group discussions. Data were analysed thematically, and informed by the WHO framework on quality of care for maternal and newborn health and by Lipsky's street level bureaucracy concept. RESULTS: According to health workers, knowledge of clinical standards and processes, timeliness, and women's choice during labour, as well as resources, physical infrastructure; collaboration with mothers, professionals and community health workers; were important aspects of good quality care. Mothers' perceptions of good quality care were largely similar to health workers' views, though mothers were more concerned about health workers' interaction skills. Structural challenges sometimes led health workers to develop informal solutions such as asking mothers to purchase their own supplies with variable implications on the quality of care. While several of these informal solutions were useful in addressing bottlenecks in the health system, they sometimes placed additional burdens and personal costs on health workers, created mistrust, inequity in care and negative experiences among mothers who could not afford the extra costs. CONCLUSIONS: Health system structural factors; including technical, interpersonal, resource and infrastructural factors; impede the provision and experience of good quality maternity care at health centres in Uganda. Improving the quality of care will require strategies that address these core problems in the health system structure. Such structural reforms will require political support to commit resources, skilful management and leadership that seek to change organisational behaviour and build trust through good quality, woman-centred maternity care.

Improving knowledge translation in Uganda: more needs to be done.

INTRODUCTION: Meeting the health-related Millennium Development Goals in Africa calls for better access to and higher utilisation of quality evidence. The mechanisms through which research evidence can effectively guide public health policy and implementation of health programmes are not fully understood. Challenges to the use of evidence to inform policy and practice include the lack of a common understanding of what constitutes evidence and limited insight on the effectiveness of different research uptake activities. Available Knowledge Translation (KT) models have mainly been developed in high income countries and may not be directly applicable in resource-limited settings. In this study we examine the uptake of evidence in public health policy making in Uganda. METHODS: We conducted a cross-sectional qualitative study consisting of in-depth interviews with 17 purposively-selected health policy makers and researchers. The study explored respondents' perceptions of the role of evidence in public health policy development, their understanding of KT and their views on the appropriateness of different KT activities that are currently implemented in Uganda. RESULTS: Although all respondents stated that evidence should inform health policies and programmes, they noted that this occurred infrequently. We noted a lack of conceptual clarity about KT and what precisely constitutes evidence. Respondents reported having been involved in different KT activities, including partnerships and platforms created for knowledge sharing between researchers and end users, but with very mixed results. CONCLUSION: There is need for conceptual clarity on the notion of KT and an understanding of the most appropriate KT strategies in low-income settings.

Improving access to skilled attendance at delivery: executive summary

Uganda´s maternal mortality has moderately declined from 670 per 100,000 live births in 1990 to 430 per 100,000 live births in 2008. This annual decline of 13 maternal deaths per 100,000 live births is unlikely to achieve the MDG target of 168 per 100,000 live births by 2015. The proportion of pregnant women delivering from public and private non-profit facilities was low at 34% in 2008/09. Increasing skilled birth attendance is desirable to reduce maternal mortality.

Increasing access to skilled birth attendance: report

The Director General of the Uganda National Health Research Organisation (UNHRO), Dr Sam Okware welcomed participants and asserted the role of UNHRO not only in coordinating national health research but translating research findings into policy and practice. The REACH policy initiative ­ SURE project under UNHRO in collaboration with the College of Health Sciences, Makerere University had produced a policy brief on increasing access to skilled birth attendance which was the focus for discussion in this meeting. The brief describes the problem, highlights three policy options and implementation considerations that need to be taken into account. He requested the participants to introduce themselves. He introduced the moderator, Dr Freddie Ssengooba, from the School of Public Health, Makerere University, and requested him to facilitate the proceedings. Dr Ssengooba assured the participants that a record of the meeting would be kept but would not attribute comments to the participant speakers and thus encouraged them to freely express their views

Improving access to skilled attendance at delivery: full report

The problem: High Maternal Mortality. Uganda?s maternal mortality has moderately declined from 670 per 100,000 live births in 1990 to 430 per 100,000 live births in 2008. This annual decline of 13 maternal deaths per 100,000 live births is unlikely to achievemeet the MDG target of 168 per 100,000 live births by 2015. The proportion of pregnant women delivering from public and private non-profit facilities was low at 34% in 2008/09. Increasing skilled birth attendance is desirable to reduce maternal mortality. The policy options: 1- Providing Intrapartum Care at first level Health Centre; 2- Involving the Private-for-Profit sector; 3- Maternity Shelters.

Task shifting to optimise the roles of health workers to improve the delivery of maternal and child healthcare: full report

The purpose of this policy brief is to inform deliberations among policymakers and stakeholders on optimising roles of health cadres in the delivery of maternal and child health. It summarises the best available evidence regarding the design and implementation of policies for extending the roles of non-medically trained primary health care workers ("task shifting") to deliver cost-effective maternal and child health interventions. This brief was prepared for discussion at meetings of those engaged in developing policies for task shifting and other stakeholders with an interest in these policy decisions. In addition, it is intended to inform other stakeholders and to engage them in deliberations about those policies. It is not intended to prescribe or proscribe specific options or implementation strategies. Rather, its purpose is to allow stakeholders to systematically and transparently consider the available evidence about the likely impacts of different options for task shifting.

Task shifting to optimise the roles of health workers to improve the delivery of maternal and child healthcare: executive summary

There is a shortage and maldistribution of medically trained health professionals. These are important reasons why cost-effective MCH services are not available to over half the population of Uganda and progress towards the Millennium Development Goals for MCH is slow. Optimising the roles of less specialised health workers (?task shifting?) is one strategy to address the shortage and maldistribution of more specialised health professionals. However, the lack of an explicit policy limits the implementation and coordination of task shifting.

Policy brief on improving access to artemisinin-based combination therapies for malaria in the East African community

The World Health Organization (WHO) since June 1998 has advocated for the use of artemisinin-based combination therapies (ACTs) in countries where Plasmodium falciparum malaria is resistant to traditional antimalarial therapies such as chloroquine, sulfadoxine-pyrimethamine, and amodiaquine (19;22). In 2006, WHO released evidence-based guidelines for the treatment of malaria backed by findings from various scientific studies (21). During the period between 2002 and 2006, all the five East African states Tanzania, Kenya, Uganda, Rwanda, and Burundi changed their national antimalarial treatment policies to use ACTs as first-line treatments for uncomplicated falciparum malaria and commenced with deployment of the drugs in the state-managed health facilities (12­15). To scale up the use of ACTs in the East African region to combat malaria and speed up progress toward the sixth Millennium Development Goal, a combination of delivery, financial, and governance arrangements tailored to national or subnational contexts needs to be considered.

Policy dialogue on task shifting for health workers in maternal and child healthcare: report

This dialogue to discuss the policy brief which outlines health policy options using the current research evidence is a fulfillment of one of UNHRO?s responsibilities of supporting evidence-based policy decisions. It was noted that there is an acute shortage of human resources for health in Africa and Uganda and slow progress towards meeting the MDGs. In addition, there is lack of access to surgical services for persons who suffer injury in road traffic accidents and persons who suffer debilitating, chronic conditions. In Uganda, about 100 doctors are produced per medical school of the 3 medical schools per year. However, Uganda seems unable to employ the doctors it produces. The issue is not numbers, there are doctors and nurses on the streets and hospitals are empty. There is no recruitment. There is need for a policy on recruitment and retention of workers.

Policy dialogue Increasing Access to Skilled Birth Attendance: report

The REACH policy initiative SURE project under UNHRO in collaboration with the College of Health Sciences, Makerere University had produced a policy brief on increasing access to skilled birth attendance which was the focus for discussion in this meeting. The brief describes the problem, highlights three policy options and implementation considerations that need to be taken into account. He requested the participants to introduce themselves. He introduced the moderator, Dr Freddie Ssengooba, from the School of Public Health, Makerere University, and requested him to facilitate the proceedings. Dr Ssengooba assured the participants that a record of the meeting would be kept but would not attribute comments to the participant speakers and thus encouraged them to freely express their views.