Dorcus Kiwanuka Henriksson

Swedish International Development Cooperation Agency

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Stefan Peterson

Karolinska Institutet

Anthony K. Mbonye

Makerere University

Florence Ayebare

Infectious Diseases Research Collaboration

Peter Waiswa

Makerere University

Mio Fredriksson

Uppsala University

Danstan Bagenda

University of Nebraska Medical Center

Eric Ssegujja

Makerere University

Anne Katahoire

Makerere University

Peter Waiswa

Karolinska Institutet

Hector Tibeihaho

Cooperative Institutions

Makerere University

Liverpool School of Tropical Medicine

Johns Hopkins University

World Health Organization

United Nations Children's Fund

World Health Organization - Uganda

Centers for Disease Control and Prevention

Karolinska Institutet

London School of Hygiene & Tropical Medicine

Innovations for Poverty Action

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Improving child survival through a district management strengthening and community empowerment intervention: early implementation experiences from Uganda

BMC Public Health (2015)

Anne Katahoire Dorcus Kiwanuka Henriksson Eric Ssegujja Peter Waiswa Florence Ayebare

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. 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. 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. 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.

Implementation research

Thematic Analysis

Community Health

10.1186/s12889-015-2129-z

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Child health and the implementation of Community and District-management Empowerment for Scale-up (CODES) in Uganda: a randomised controlled trial

BMJ Global Health (2021)

Peter Waiswa Flavia Mpanga Danstan Bagenda Rornald Muhumuza Kananura Thomas O’Connell

Introduction Uganda’s district-level administrative units buttress the public healthcare system. In many districts, however, local capacity is incommensurate with that required to plan and implement quality health interventions. This study investigates how a district management strategy informed by local data and community dialogue influences health services. Methods A 3-year randomised controlled trial (RCT) comprised of 16 Ugandan districts tested a management approach, Community and District-management Empowerment for Scale-up (CODES). Eight districts were randomly selected for each of the intervention and comparison areas. The approach relies on a customised set of data-driven diagnostic tools to identify and resolve health system bottlenecks. Using a difference-in-differences approach, the authors performed an intention-to-treat analysis of protective, preventive and curative practices for malaria, pneumonia and diarrhoea among children aged 5 and younger. Results Intervention districts reported significant net increases in the treatment of malaria (+23%), pneumonia (+19%) and diarrhoea (+13%) and improved stool disposal (+10%). Coverage rates for immunisation and vitamin A consumption saw similar improvements. By engaging communities and district managers in a common quest to solve local bottlenecks, CODES fostered demand for health services. However, limited fiscal space-constrained district managers’ ability to implement solutions identified through CODES. Conclusion Data-driven district management interventions can positively impact child health outcomes, with clinically significant improvements in the treatment of malaria, pneumonia and diarrhoea as well as stool disposal. The findings recommend the model’s suitability for health systems strengthening in Uganda and other decentralised contexts. Trial registration number ISRCTN15705788 .

Community Health

10.1136/bmjgh-2021-006084

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Continuous quality improvement as a tool to implement evidence-informed problem solving: experiences from the district and health facility level in Uganda

BMC Health Services Research (2021)

Hector Tibeihaho Charles Nkolo Robert Anguyo Florence Ayebare Dorcus Kiwanuka Henriksson

Abstract Background Continuous quality improvement processes in health care were developed for use at health facility level, and that is where they have been used the most, often addressing defined care processes. However, in different settings different factors have been important to support institutionalization. This study explores how continuous quality improvement processes were institutionalized at the district level and at the health facility level in Uganda. Methods This qualitative study was carried out in seven districts in Uganda. Semi-structured interviews with key informants from the district health management teams and document review were conducted. Thematic analysis was used to analyze the data. Results All districts that participated in the study formed Continuous Quality Improvement (CQI) teams both at the district level and at the health facilities. The district CQI teams comprised of members from different departments within the district health office. District level CQI teams were mandated to take the lead in addressing management gaps and follow up CQI activities at the health facility level. Acceptability of quality improvement processes by the district leadership was identified across districts as supporting the successful implementation of CQI. However, high turnover of staff at health facility level was also reported as a detrimental to the successful implementation of quality improvement processes. Also the district health management teams did not engage much in addressing their own roles using continuous quality improvement. Conclusion The leadership and management provided by the district health management team was an important factor for the use of Continuous Quality Improvement principles within the district. The key roles of the district health team revolved around the institutionalisation of CQI at different levels of the health system, monitoring results of continuous quality improvement implementation, mobilising resources and health care delivery hence promoting the culture of quality, direct implementation of CQI, and creating an enabling environment for the lower-level health facilities to engage in CQI. High turnover of staff at health facility level was also reported as one of the challenges to the successful implementation of continuous quality improvement. The DHT did not engage much in addressing gaps in their own roles using continuous quality improvement.

Health administration

Thematic Analysis

10.1186/s12913-021-06061-8

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Empowering districts to target priorities for improving child health service in Uganda using change management and rapid assessment methods

Global Health Action (2016)

John Odaga Dorcus Kiwanuka Henriksson Charles Nkolo Hector Tibeihaho Richard Musabe

Local health system managers in low- and middle-income countries have the responsibility to set health priorities and allocate resources accordingly. Although tools exist to aid this process, they are not widely applied for various reasons including non-availability, poor knowledge of the tools, and poor adaptability into the local context. In Uganda, delivery of basic services is devolved to the District Local Governments through the District Health Teams (DHTs). The Community and District Empowerment for Scale-up (CODES) project aims to provide a set of management tools that aid contextualised priority setting, fund allocation, and problem-solving in a systematic way to improve effective coverage and quality of child survival interventions.Although the various tools have previously been used at the national level, the project aims to combine them in an integral way for implementation at the district level. These tools include Lot Quality Assurance Sampling (LQAS) surveys to generate local evidence, Bottleneck analysis and Causal analysis as analytical tools, Continuous Quality Improvement, and Community Dialogues based on Citizen Report Cards and U reports. The tools enable identification of gaps, prioritisation of possible solutions, and allocation of resources accordingly. This paper presents some of the tools used by the project in five districts in Uganda during the proof-of-concept phase of the project.All five districts were trained and participated in LQAS surveys and readily adopted the tools for priority setting and resource allocation. All districts developed health operational work plans, which were based on the evidence and each of the districts implemented more than three of the priority activities which were included in their work plans.In the five districts, the CODES project demonstrated that DHTs can adopt and integrate these tools in the planning process by systematically identifying gaps and setting priority interventions for child survival.

Monitoring and evaluation

10.3402/gha.v9.30983

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Decision-making in district health planning in Uganda: does use of district-specific evidence matter?

Health Research Policy and Systems (2019)

Dorcus Kiwanuka Henriksson Stefan Peterson Peter Waiswa Mio Fredriksson

In a decentralised 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 informs the planning process. In this study, we investigate how the use of this evidence affects decision-making in the planning process and how stakeholders in the planning process perceived the use of evidence.

Health Services Research

Evidence-Based Practice

10.1186/s12961-019-0458-6

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Citations (21)

Community and District Empowerment for Scale-up (CODES): a complex district-level management intervention to improve child survival in Uganda: study protocol for a randomized controlled trial

Trials (2016)

Peter Waiswa Thomas O’Connell Danstan Bagenda Pricila H. Mullachery Flavia Mpanga

Innovative and sustainable strategies to strengthen districts and other sub-national health systems and management are urgently required to reduce child mortality. Although highly effective evidence-based and affordable child survival interventions are well-known, at the district level, lack of data, motivation, analytic and planning capacity often impedes prioritization and management weaknesses impede implementation. The Community and District Empowerment for Scale-up (CODES) project is a complex management intervention designed to test whether districts when empowered with data and management tools can prioritize and implement evidence-based child survival interventions equitably. The CODES strategy combines management, diagnostic, and evaluation tools to identify and analyze the causes of bottlenecks to implementation, build capacity of district management teams to implement context-specific solutions, and to foster community monitoring and social accountability to increase demand for services. 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. Implementation and all data collection will be by the districts teams or local Community-based Organizations who will be supported by two local implementing partners. The study will be evaluated as a cluster randomized trial with eight intervention and eight comparison districts over a period of 3 years. Evaluation will focus on differences in uptake of child survival interventions and will follow an intention-to-treat analysis. We will also document and analyze experiences in implementation including changes in management practices. By increasing the District Health Management Teams' capacity to prioritize and implement context-specific solutions, and empowering communities to become active partners in service delivery, coverage of child survival interventions will increase. Lessons learned on strengthening district-level managerial capacities and mechanisms for community monitoring may have implications, not only in Uganda but also in other similar settings, especially with regard to accelerating effective coverage of key child survival interventions using locally available resources. ISRCTN15705788 , Date of registration; 24 July 2015.

Research Design

10.1186/s13063-016-1241-4

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Citations (33)

Health systems bottlenecks and evidence-based district health planning : Experiences from the district health system in Uganda

Dorcus Kiwanuka Henriksson

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 pr ...

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Health facility management and access: a qualitative analysis of challenges to seeking healthcare for children under five in Uganda

Health Policy and Planning (2017)

Elizabeth Allen Wilson Winstons Muhwezi Dorcus Kiwanuka Henriksson Anthony K. Mbonye

While several studies have documented the various barriers that caretakers of children under five routinely confront when seeking healthcare in Uganda, few have sought to capture the ways in which caretakers themselves prioritize their own barriers to seeking services. To that end, we asked focus groups of caretakers to list their five greatest challenges to seeking care on behalf of children under five. Using qualitative content analysis, we grouped responses according to four categories: (1) geographical access barriers; (2) facility supplies, staffing, and infrastructural barriers; (3) facility management and administration barriers (e.g. health worker professionalism, absenteeism and customer care); and (4) household barriers related to financial circumstances, domestic conflicts with male partners and a stated lack of knowledge about health-related issues. Among all focus groups, caretakers mentioned supplies, staffing and infrastructure barriers most often and facility management and administration barriers the least. Caretakers living furthest from public facilities (8-10 km) more commonly mentioned geographical barriers to care and barriers related to financial and other personal circumstances. Caretakers who lived closest to health facilities mentioned facility management and administration barriers twice as often as those who lived further away. While targeting managerial barriers is vitally important-and increasingly popular among national planners and donors-it should be done while recognizing that alleviating such barriers may have a more muted effect on caretakers who are geographically harder to reach - and by extension, those whose children have an increased risk of mortality. In light of calls for greater equity in child survival programming - and given the limited resource envelopes that policymakers often have at their disposal - attention to the barriers considered most vital among caretakers in different settings should be weighed.

Staffing

Qualitative property

10.1093/heapol/czw180

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Citations (17)

Agile Government and Healthcare: An Example of Telemedicine during the COVID-19 Crisis

WORLD SCIENTIFIC eBooks (2022)

Immanuel Azaad Moonesar Melodena Stephens Balakrishnan Reem Gaafar Kulaithem Saif Al Mazrouei Dorcus Kiwanuka Henriksson

2019-20 coronavirus outbreak

10.1142/9789811239700_0021

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“Together we move a mountain”: celebrating a decade of the Emerging Voices for Global Health network

BMJ Global Health (2020)

Prashanth Nuggehalli Srinivas Dorcus Kiwanuka Henriksson Vladimir Sergeevich Gordeev Kristof Decoster Stephanie M. Topp

It was otherwise an unremarkable November bus ride from Antwerp to Montreux; cold, but in the rather warm company of early career researchers who were to soon become the first cohort of Emerging Voices for Global Health (EV4GH; http://www.ev4gh.net). On that ride, 52 early career health system researchers from 30 countries began a journey. Little did they know it would continue for over a decade, gathering in its wake, 208 more early career researchers from 60 countries, overwhelmingly from the global south. The EV4GH programme has come a long way, from the first meeting at the 2010 annual colloquium of Institute of Tropical Medicine, Antwerp, Belgium, and the subsequent road trip from Antwerp to the first Global Symposium on Health Systems Research at Montreux, Switzerland. EV4GH began as a leadership and capacity-building programme incubated within the Institute of Tropical Medicine, Antwerp (ITM-A) by a team led by Professor Wim Van Damme. With an explicit commitment to switching the poles (between the global north to the global south), the team at ITM-A sought to design a unique programme to provide early career researchers with communication skills to critically examine global health agendas and events, and more importantly to not become passive consumers of evidence in global health events (such as the one that was, at the time, coming up in Montreux). This was a disruptive idea. Early career researchers typically enter global events in awe of the authoritative and prominent names featured in keynotes and panels. Indeed, the first EV4GH programme began by acknowledging the elderly white male high-income country dominance of the global health agenda. The programme wanted to do something about it, beginning at that first symposium in Montreux. This year, 2020, marks the 10th year of this programme and offers an opportunity to look back and look within. …

Global Health

10.1136/bmjgh-2020-003015

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Citations (2)