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Health systems bottlenecks and evidence-based district health planning: Experiences from the district health system in Uganda
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).ORCID iD: 0000-0002-2359-9891
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. , p. 71
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1371
Keywords [en]
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: urn:nbn:se:uu:diva-329082ISBN: 978-91-513-0066-5 (print)OAI: oai:DiVA.org:uu-329082DiVA, id: diva2:1139476
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
List of papers
1. Bottleneck analysis at district level to illustrate gaps within the district health system in Uganda
Open this publication in new window or tab >>Bottleneck analysis at district level to illustrate gaps within the district health system in Uganda
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2017 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1327256Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Poor quality of care and access to effective and affordable interventions have been attributed to constraints and bottlenecks within and outside the health system. However, there is limited understanding of health system barriers to utilization and delivery of appropriate, high-impact, and cost-effective interventions at the point of service delivery in districts and sub-districts in low-income countries. In this study we illustrate the use of the bottleneck analysis approach, which could be used to identify bottlenecks in service delivery within the district health system.

METHODS: A modified Tanahashi model with six determinants for effective coverage was used to determine bottlenecks in service provision for maternal and newborn care. The following interventions provided during antenatal care were used as tracer interventions: use of iron and folic acid, intermittent presumptive treatment for malaria, HIV counseling and testing, and syphilis testing. Data from cross-sectional household and health facility surveys in Mayuge and Namayingo districts in Uganda were used in this study.

RESULTS: Effective coverage and human resource gaps were identified as the biggest bottlenecks in both districts, with coverage ranging from 0% to 66% for effective coverage and from 46% to 58% for availability of health facility staff. Our findings revealed a similar pattern in bottlenecks in both districts for particular interventions although the districts are functionally independent.

CONCLUSION: The modified Tanahashi model is an analysis tool that can be used to identify bottlenecks to effective coverage within the district health system, for instance, the effective coverage for maternal and newborn care interventions. However, the analysis is highly dependent on the availability of data to populate all six determinants and could benefit from further validation analysis for the causes of bottlenecks identified.

Keywords
Tanahashi model, bottleneck analysis, demand-side determinants, district health systems, maternal and newborn care, supply-side determinants
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-329444 (URN)10.1080/16549716.2017.1327256 (DOI)000403496400001 ()28581379 (PubMedID)
Funder
EU, FP7, Seventh Framework Programme, 265827
Available from: 2017-09-15 Created: 2017-09-15 Last updated: 2017-10-26Bibliographically approved
2. Improving child survival through a district management strengthening and community empowerment intervention: early implementation experiences from Uganda
Open this publication in new window or tab >>Improving child survival through a district management strengthening and community empowerment intervention: early implementation experiences from Uganda
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2015 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 15, article id 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.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-262578 (URN)10.1186/s12889-015-2129-z (DOI)000359690800008 ()26286146 (PubMedID)
Available from: 2015-09-16 Created: 2015-09-16 Last updated: 2017-12-05
3. Enablers and barriers to evidence based planning in the district health system in Uganda; perceptions of district health managers
Open this publication in new window or tab >>Enablers and barriers to evidence based planning in the district health system in Uganda; perceptions of district health managers
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2017 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, article id 103Article in journal (Refereed) Published
Abstract [en]

Background: The District Health System was endorsed as the key strategy to achieve 'Health for all' during the WHO organized inter-regional meeting in Harare in 1987. Many expectations were put upon the district health system, including planning. Although planning should be evidence based to prioritize activities, in Uganda it has been described as occurring more by chance than by choice. The role of planning is entrusted to the district health managers with support from the Ministry of Health and other stakeholders, but there is limited knowledge on the district health manager's capacity to carry out evidence-based planning. The aim of this study was to determine the barriers and enablers to evidence-based planning at the district level.

Methods: This qualitative study collected data through key informant interviews with district managers from two purposefully selected districts in Uganda that have been implementing evidence-based planning. A deductive process of thematic analysis was used to classify responses within themes.

Results: There were considerable differences between the districts in regard to the barriers and enablers for evidence-based planning. Variations could be attributed to specific contextual and environmental differences such as human resource levels, date of establishment of the district, funding and the sociopolitical environment. The perceived lack of local decision space coupled with the perception that the politicians had all the power while having limited knowledge on evidence-based planning was considered an important barrier.

Conclusion: There is a need to review the mandate of the district managers to make decisions in the planning process and the range of decision space available within the district health system. Given the important role elected officials play in a decentralized system a concerted effort should be made to increase their knowledge on evidence-based planning and the district health system as a whole.

Keywords
District, Planning, Health systems, Evidence, Managers, Decentralization, Politicians, Uganda
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-317589 (URN)10.1186/s12913-017-2059-9 (DOI)000393277300001 ()28148251 (PubMedID)
Available from: 2017-03-24 Created: 2017-03-24 Last updated: 2017-11-29Bibliographically approved
4. Decision making in district health planning in Uganda: Does use of local evidence matter?
Open this publication in new window or tab >>Decision making in district health planning in Uganda: Does use of local evidence matter?
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Introduction

In a decentralized health system, district health managers are tasked with planning for health service delivery which should be evidence-based. However, planning in low-income countries such as Uganda, has been described as ad hoc. A systematic approach to the planning process using district-specific evidence was introduced to district health managers in Uganda. However, little is known about how the use of district-specific evidence does inform the planning process. In this study we further investigate how the use of this evidence affects the annual planning process.

Methodology

The study was conducted in two districts that were introduced to the systematic approach of using district-specific evidence in the planning process. District annual health work plans for financial years 2012/13; 2013/14; 2014/15 and 2015/16 and bottleneck analysis reports for 2012, 2013, 2014 and 2015 were reviewed. Semi-structured interviews with key informants from the districts were also conducted.

Results

District managers reported that they were able to produce more robust district annual work plans when they used district-specific evidence. About half of the priority activities that were identified using district-specific evidence were included in the annual work plans. Procurement and logistics, training and support supervision activities were the most prioritized. Use of local evidence was viewed positively by the health managers. However, there was a lack of clarity on what activities should be incorporated in the annual work plans and district managers considered the lack of autonomy or decision space as a constraint to the use of district-specific evidence.

Conclusion

District-specific evidence and a structured process for its use to prioritize activities and make decisions in the planning process at the district level helped systematize the planning process. Health managers were able to articulate and advocate for priorities related to child survival. However, the reported limited decision and fiscal space, human resource gaps, inadequate funding and high dependency on donor funding did not always allow for use of district-specific evidence in the planning process. 

Keywords
District health planning, evidence, district health systems
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-329080 (URN)
Available from: 2017-09-07 Created: 2017-09-07 Last updated: 2017-09-07

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