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Improving child survival through a district management strengthening and community empowerment intervention: early implementation experiences from Uganda
Child Health and Development Centre, Makerere University, Kampala, Uganda.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. (Internationell barnhälsa och nutrition/Persson)
School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
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2015 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 15, 797Article in journal (Refereed) Published
Abstract [en]

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.

Place, publisher, year, edition, pages
2015. Vol. 15, 797
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-262578DOI: 10.1186/s12889-015-2129-zISI: 000359690800008PubMedID: 26286146OAI: oai:DiVA.org:uu-262578DiVA: diva2:854421
Available from: 2015-09-16 Created: 2015-09-16 Last updated: 2017-12-05
In thesis
1. Health systems bottlenecks and evidence-based district health planning: Experiences from the district health system in Uganda
Open this publication in new window or tab >>Health systems bottlenecks and evidence-based district health planning: Experiences from the district health system in Uganda
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

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.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2017. 71 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1371
Keyword
District, health systems, decentralization, evidence, planning, bottleneck analysis, governance, decision space, health information systems, maternal and newborn care, child survival, Uganda
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
International Health
Identifiers
urn:nbn:se:uu:diva-329082 (URN)978-91-513-0066-5 (ISBN)
Public defence
2017-10-26, Rosénsalen, Akademiska Sjukhuset, Uppsala, 09:15 (English)
Opponent
Supervisors
Available from: 2017-10-03 Created: 2017-09-07 Last updated: 2017-10-18

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Henriksson, Dorcus KiwanukaPeterson, Stefan Swartling

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