ORIGINAL RESEARCH PAPER
Year : 2007 | Volume
: 20 | Issue : 2 | Page : 58-
Promoting Unity of Purpose in District Health Service Delivery in Uganda through Partnerships, Trust Building and Evidence-based Decision-making
N Orobaton1, X Nsabagasani2, E Ekochu2, J Oki2, S Kironde2, T Lippeveld3,
1 The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
2 UPHOLD, Kampala, Uganda
3 John Snow Inc., Boston, MA, USA
Chemin de Blandonnet 8, 1214 Vernier, Geneva
Context: The Uganda Program for Human and Holistic Development (UPHOLD), a USAID-funded project which supports health services in 34 Ugandan districts, was conceived at a time when promising interventions could not be expanded due to fragmented systems. This paper focuses on how the program addressed fragmentation to improve service delivery in the health sector.
Approach: UPHOLD achieved results by utilizing grants and technical support to strengthen capacity in a decentralized setting to foster institutional behavior change, promote strengthened partnerships among stakeholders in health, and produce increased transparency and accountability. In addition, the Lot Quality Assurance Sampling (LQAS) survey methodology was institutionalized to promote a culture of evidence-based decision-making at the district level.
Results: Evidence-based decision-making and partnership-oriented implementation led to programmatic results and institutional behavior change in districts through synergetic relationships between local governments and Civil Society Organizations. The use of Insecticide Treated Nets increased from 11.2% in 2004 to 17.2% in 2005, clients utilizing HIV/AIDS counselling and testing services increased from 6,205 in 2004 to 85 947 in 2005 and using Lot Quality Assurance Sampling methodology has begun to positively influence district and national staff mind sets leading to more evidence-based planning and decision-making.
Conclusion: The pillars of «SQ»evidence-based decision-making«SQ» and «SQ»partnerships«SQ», together with approaches which strengthen existing synergies, produced more results, faster. Programs designed to work with fragmented settings should consider using the same pillars and blocks to ultimately make a difference in the lives of program beneficiaries.
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Orobaton N, Nsabagasani X, Ekochu E, Oki J, Kironde S, Lippeveld T. Promoting Unity of Purpose in District Health Service Delivery in Uganda through Partnerships, Trust Building and Evidence-based Decision-making.Educ Health 2007;20:58-58
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Orobaton N, Nsabagasani X, Ekochu E, Oki J, Kironde S, Lippeveld T. Promoting Unity of Purpose in District Health Service Delivery in Uganda through Partnerships, Trust Building and Evidence-based Decision-making. Educ Health [serial online] 2007 [cited 2021 Sep 19 ];20:58-58
Available from: https://www.educationforhealth.net/text.asp?2007/20/2/58/101618
This work describes the UPHOLD project that is funded by the United States Agency for International Development (USAID) under contract no. 617-A-00-02-00012-00
This paper seeks to contribute to the ongoing debate on the need to strengthen health systems in order to achieve the Millennium Development Goals of:
Eradicate extreme poverty and hunger
Achieve Universal Primary Education
Promote gender equality
Reduce child mortality
Improve maternal health
Combat HIV/AIDS, malaria and other diseases
Ensure environmental sustainability
Develop a global partnership for development
(Travis et al., 2004, van Etten et al., 2005).
Uganda’s human development indicators remain low: the under-five mortality rate is high at 152/1,000 live births (Uganda DHS EdData Survey, 2002) and the total fertility rate is the highest in Africa at 7.11 children per woman (UNFPA, 2006). Scale up and sustainability of promising health interventions in the country remains a challenge, as implementation strategies are often weak and fragmented. Whereas national policies on service delivery are well conceived, a wide “policy-practice chasm” persists. Though planning and budget development occur at district and lower levels, sector-specific strategies and funding levels remain largely determined by central government, through vertical programs. Additionally, local governments lack localized evidence for decision-making and although their efforts to deliver health services are supplemented by the civil society organizations (CSOs) that operate mainly in hard-to-reach areas, mutual mistrust prevails between local governments and CSOs (Birungi et al., 2001).
The Uganda Program for Human and Holistic Development (UPHOLD), a five year project (2002-2007) funded by the United States Agency for International Development (USAID), operates in 34 districts in Uganda, and is managed by John Snow Inc. (JSI). It was designed to improve access, utilization and quality of education, health and HIV/AIDS services in 20 districts in a decentralized context. UPHOLD contributes to the objectives of the Uganda Poverty Eradication Action Plan through grants and technical assistance to local governments and civil society organizations. Other partners include educational institutions. [These districts have now increased to 34 due to creation of new districts in UPHOLD’s geographical area of operation.]
This paper focuses on UPHOLD’s experiences in addressing the above sources of fragmentation in the health sector (including HIV/AIDS).
Conceptual framework and implementation approaches
UPHOLD’s implementation strategy has two key pillars which underpin the overall implementation framework:
The promotion of trust between players in the service delivery systems, which is essential to cooperation and coordination and to increased exchange of information and ideas.
Evidence-informed, transparent decision-making, which promotes unity of purpose and trust by reducing asymmetry in information flow.
To these overarching pillars, UPHOLD added the building blocks described in Figure 1, which with time emerged as critical to creating productive synergies within the system in order to achieve program results and build institutional capacity. Each of these blocks is built on existing synergies to scale-up and strengthen existing interventions and addresses key sources of fragmentation at the district level.
Figure 1: UPHOLD Conceptual Framework.
UPHOLD contends that “greater unity of purpose” is a strategic approach for obtaining more results, more quickly to more people. It entails actions that yield to institutional behavior change especially increased use of evidence for planning and decision-making, strengthened public-private partnerships, increased transparency in accounting for results and finances, and increased receptivity to innovation (good practices). Over time, changes in behavior reinforce trust and result in increased district capacity to provide integrated services.
Design and Implementation Approaches for Greater Unity of Purpose
The following section describes the building blocks in program design and how they were executed to promote unity of purpose.
At program design, the leadership identified a set of core values to guide UPHOLD staff and make them more credible and effective among partners, while advancing the goal of better integration in service delivery. The original core values were: teamwork, empowerment, excellence, innovation, boundarylessness (no boundaries) and responsible speed in program implementation (see table 1).
Table 1: UPHOLD core values.
UPHOLD interventions covered about 42% of the country’s population in well-defined administrative units: districts, counties, sub-counties, parishes and villages. These areas were important programmatic loci to determine units of analysis for monitoring and evaluation purposes as well as to plan and target interventions. To be closer to the districts, UPHOLD set up seven regional offices to closely address district needs and provide prompt and relevant technical assistance. Over time, regional office staff built trust with district personnel and the program relied on this trust for dialogue on implementation decisions.
The Grants Program
UPHOLD insisted that comparative strengths be the principal basis for increasing the number and diversity of actors to reduce fragmentation. Hence, a $15 million competitive grants program brought together both CSOs and local governments to conduct specific activities based on their comparative advantages. CSO grants were designated for community-based services, while local governments were funded to increase service availability, quality and access at facilities and outreach.
Functional and optimal partnerships exist when there is mutual trust and the advancement of individual and collective objectives. To this end, UPHOLD brought together traditional and non-traditional stakeholders to ensure transparency and trust. The local government-UPHOLD partnership entailed a negotiated memorandum of understanding with districts focusing on outlined priority targets, clear work plans and approved budgets based on agreed-upon government allowances and other standardized costs factors. Initially, personnel from different departments within districts had individualistic mindsets and were often disinclined to receive support from cross-cutting district units including Planning and Community Development Departments, hampering development of district-wide work plans. To strengthen integration, UPHOLD’s grants requirements included joint work planning sessions for a ceiling of funds which had to be allocated among the sectors in a transparent manner. In addition, UPHOLD’s requirement that districts prepare integrated work plans, with quality objectives and activity based budgets required attention to the core values of teamwork and excellence, rather than competition for scarce resources. Over time, the unease between departments gradually reduced and this promoted transparency in resource deployment, reporting and accountability.
The main vehicle for Local Government-CSO and CSO-CSO partnerships was the Family and Community Action Grant Program. [See UPHOLD website (http://uphold.jsi.com/Highlights.htm) for details.] In a highly participatory, competitive and transparent process, UPHOLD and local governments jointly selected implementing CSOs against a set of pre-defined criteria. As part of its overall skills building strategy, UPHOLD implemented a structured CSO support mechanism, providing on-site support and documenting progress in CSO capacity for partnership, financial management, data collection, reporting and technical areas. This engagement promoted trust and partnership between CSOs and districts, as well as between UPHOLD and the CSOs. Within and outside UPHOLD, the “boundaryless” culture which promoted integration between traditionally vertical programs, as well as access to colleagues and partners throughout the project without restrictive protocol, was often appreciated.
Several UPHOLD supported interventions such as home-based management of fever (HBMF) and Community-Based Growth Promotion included communities in health service delivery. Training was provided to resource persons selected by communities to deliver specific services at the village level, under the supervision of the nearest health facility. Furthermore, the Yellow Star Program, a quality improvement initiative, encouraged communities to partner with facilities in the definition, monitoring, support and reward of quality achievements.
Ensuring Evidence-Based Planning and Decision-Making
The Lot Quality Assurance Sampling (LQAS) survey method was institutionalized in the UPHOLD work planning process to ensure that both programmatic and district targets were appropriately set. LQAS was introduced to Uganda in 2003 by the World Bank and UPHOLD built on the pilot experience to train district level staff to conduct the baseline survey of facilities and households in 2004 and the subsequent household surveys. The results of each annual survey were discussed with each district to ensure that data were widely available for evidence-based planning and decision-making, thus, providing a rational basis for allocation of scarce technical, human and financial resources within the districts. Politicians as well as technical staff were involved in this process to ensure high levels of awareness on the progress of key indicators. As a result, politicians now hold technical staff accountable for performance.
UPHOLD’s participation in Uganda’s health system has contributed to the improvement of key indicators in the country. We now present illustrative examples of how these pillars and blocks contributed to increased and better results and institutional ehaviour change in the context of promoting integration, partnerships, trust and evidence-based planning.
Prevention and prompt management of malaria
UPHOLD’s evidence-based, partnership-oriented implementation of the prevention and management of malaria interventions, showed an increase in the coverage of insecticide treated nets (ITNs) and the proportion of children with fever who are treated for that fever within 24 hours. Early in 2005, the UPHOLD target was to increase ITN coverage by 15% in the supported districts. Using 2004 LQAS results to identify recipient sub-counties, 205 155 ITNs were distributed in nine targeted districts with either low coverage or in conflict situations between December 2005 and March 2006. Bushenyi, a district that is epidemic-prone to malaria, improved its ITN coverage among children less than five years of age from 4.2% in 2004 to 31.4% in 2006 as shown in Figure 2. Engaging local leaders in developing criteria for distribution also ensured that the neediest people were reached and that there was transparency and accountability in the process.
Figure 2: Proportion of children under five sleeping under an ITN in Bushenyi District.
The HBMF strategy was designed by the Ministry of Health (MoH) to ensure that pre-packed anti-malarials were distributed to children under five-years by locally selected and trained Community Medicine Distributors (CMDs) at the village level. However, the support systems for this strategy were weak, resulting in high CMD attrition rates. Working with national and district personnel, UPHOLD helped strengthen the delivery and consumption of drugs through training, behavior change communication campaigns, supervision and record keeping support to a network of 38 218 CMDs. As a result of these interventions, the LQAS surveys revealed a significant increase from 30.7% in 2004 to 39.7% in 2005 in the proportion of children under five years of age with fever two weeks prior to the survey, who received appropriate treatment within 24 hours of fever onset (Mabirizi et al., 2004).
Increasing Access and Utilization of HIV/AIDS Services
Synergetic partnerships between local governments and CSOs resulted in increased access and utilisation of HIV/AIDS services in UPHOLD supported districts. CSOs not only increased the number of service outlets and outreach to underserved populations including camps for internally displaced persons and fishing communities, but also mobilized people for public service outlets. This was most evident with HIV/AIDS Counseling and Testing (HCT) and Prevention of Mother-to-Child Transmission of HIV (PMTCT) services. In participating districts, the number of mothers counseled and tested for HIV increased dramatically from 1,409 in 2004 to 20 032 in 2005. In 2004, CSO sites contributed only 4% of the HCT achievements but this contribution had increased to 56% by 2005. Similarly, in 2004, PMTCT services were a preserve of the local government facilities but by 2005, CSO sites contributed 74% of PMTCT achievements from UPHOLD supported sites.
Table 2: Clients receiving HIV/AIDS services by site ownership.
A CSO partnership study commissioned by UPHOLD in 2006 reports that district governments have finally begun to increase their acknowledgement and respect for the CSO contributions (Magumba et al., 2006a). This change in district government mindset was greatly assisted by the availability of verifiable evidence quantifying the number of clients mobilized and served by CSOs. CSOs reporting data to district governments enables districts to better plan services, including outreach, and to ensure that services are available in areas where CSOs have the capacity to mobilize for outreach. The results of this partnership and data sharing are evident in the results displayed in Table 2.
Changes in Institutional Behaviour
Three examples of changes in institutional behavior have been noted as a result of UPHOLD’s approach to implementation. 1) The districts and the national government have indicated continued, sustainable support for LQAS after realizing the value of this exercise as a source of good planning information. The first surveys (2004 and 2005) were clearly UPHOLD-led but this year (2006) district officials are querying UPHOLD for the dates of the exercise demanding to fit it within their schedules. 2) Two studies on CSO capacity and partnership (Magumba et al., 2006a; Magumba et al., 2006b) indicate that partnerships have indeed been strengthened for increased and better results in mobilization and service delivery. 3) Three UPHOLD partner districts have institutionalized community dialogue into their regular health facility quality assessments under the Yellow Star Program.
Partnerships between UPHOLD and Educational Institutions
To achieve set objectives, UPHOLD has innovatively partnered with education institutions in three major ways. First, UPHOLD has provided undergraduate medical students an opportunity to utilize project sites and activities for their training. The Community-Based Education Services (COBES) program of Makerere University attaches student interns to UPHOLD, an example being during the 2006 LQAS survey. Second, UPHOLD has both local and international internships that provide graduate students an opportunity to conduct research and participate in diverse program activities. Third, there is utilization of consultants from the major universities to conduct training activities as well as special research studies.
In this paper, we argue that de-fragmentation in the health sector is feasible and has the potential to increase the effectiveness and efficiency of programs. We emphasized values and behaviors which are important determinants of health and healthcare (WHO Task force on Research Priorities for Equity in Health & the WHO Equity Team, 2005). A thorough understanding of the behaviors of institutions, their context, and how those contribute to fragmentation are vital to the identification of approaches that achieve towards unity for health (Boelen C., 2000). In the Ugandan context, where sound policies already exist alongside moderately available trained personnel in a decentralized setting, the synergetic and transparent application of values-driven technical support, evidence-based decision-making and the promotion of trust among partners proved to be very helpful.
The availability of substantial technical and financial resources secured the attention and participation of district governments in this experiment. Nevertheless, while necessary, these resources alone were unlikely to be sufficient to advance de-fragmentation. While transparency and the use of evidence to make decisions are powerful measures in their own rights, the combination of the two in the Uganda context may have helped to reinforce the different elements in the conceptual framework, promoting more unified institutional behaviors that led to measurable improvements in the lives of Ugandans.
Although the evidence presented here suggests some association between de-fragmentation and better results, we concede that other factors have contributed. For example, additional resources available to finance more implementation efforts helped. In addition, the combination of a values-driven approach and available technical assistance may have also influenced the results. There are several other contextual factors that may not be immediately apparent to the authors that could have helped improve results. Without a controlled study design, the real effects of de-fragmentation on the efficacy of decentralized health programs will not be fully known. On balance, the experience in Uganda indicates that more trust-based cooperation, not less, is needed at the district level to advance unity of purpose in service delivery. More research is needed to tease out how trust-based cooperation influences health system performance.
The pillar of trust-building and evidence-based decision-making along with the building blocks presented in this model can be effective in producing results as well as changes in institutional behavior of stakeholders in health. UPHOLD’s experience in promoting greater unity of purpose was a learning experience, which needs to be validated through expanded application in large scale decentralized programs. Notwithstanding, UPHOLD recommends that programs designed to work in developing countries with fragmented settings should seriously consider using these pillars and blocks to make a difference in the lives of program beneficiaries.
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