Missed opportunities in tuberculosis investigation and associated factors at public health facilities in Uganda.

BACKGROUND: The incidence of tuberculosis (TB) is high in Uganda; yet, TB case detection is low. The population-based survey on the prevalence of TB in Uganda revealed that only 16% of presumptive TB patients seeking care at health facilities were offered sputum microscopy or chest-X ray (CXR). This study aimed to determine the magnitude of, and patient factors associated with missed opportunities in TB investigation at public health facilities of Wakiso District in Uganda. METHODS: A facility-based cross-sectional survey was conducted at 10 high volume public health facilities offering comprehensive TB services in Wakiso, Uganda, among adults (≥18 years) with at least one symptom suggestive of TB predefined according to the World Health Organisation criteria. Using exit interviews, data on demographics, TB symptoms, and clinical data relevant to TB diagnosis were collected. A missed opportunity in TB investigation was defined as a patient with symptoms suggestive of TB who did not have sputum and/or CXR evaluation to rule out TB. Poisson regression analysis was performed to determine factors associated with missed opportunities in TB investigation. RESULTS: Two hundred forty-seven (247) patients with presumptive TB exiting at antiretroviral therapy (ART) clinics (n = 132) or general outpatient clinics (n = 115) at public health facilities were recruited into this study. Majority of participants were female (161/247, 65.2%) with a mean + SD age of 35.1 + 11.5 years. Overall, 138 (55.9%) patients with symptoms suggestive of TB disease did not have sputum and/or CXR examinations. Patients who did not inform health workers about their TB related symptoms were more likely to miss a TB investigation (adjusted prevalence ratio (aPR): 1.68, 95%CI; 1.36-2.08, P < 0.001). However, patients who reported duration of cough of 2 weeks or more were less likely to be missed for TB screening (aPR; 0.69, 95%CI; 0.56-0.86, p < 0.001). CONCLUSION: There are substantial missed opportunities for TB diagnosis in Wakiso District. While it is important that patients should be empowered to report symptoms, health workers need to proactively implement the WHO TB symptom screen tool and complete the subsequent steps in the TB diagnostic cascade.

Effect of the eQuality Health Bwindi Scheme on Utilization of Health Services at Bwindi Community Hospital in Uganda.

Introduction: eQuality Health Bwindi (eQHB), a Community Based Health Insurance (CBHI) scheme was launched in March 2010 with the aim of generating income to maintain high quality care as well as increasing access to and utilization of health services at Bwindi Community Hospital (BCH). The main objective of this study was to explore evidence showing that eQHB scheme affected access and utilization of health services at BCH. The evidence generated would be used to inform decision making, policy and scale up of the scheme. Methods and Materials: This study applied qualitative and quantitative research methods. It involved a review of hospital records for the period July 2009-June 2014, a survey of 272 households, four focus group discussions, and six key informant interviews. Both quantitative and qualitative analysis techniques were applied for the analysis. Results: Outpatient attendance, inpatient admissions, and deliveries at the hospital increased by 65, 73, and 27%, respectively between FY 2009/10 and FY 2012/13. Utilization of health services by sick children from insured participants was greater than that of the uninsured members of the community (p-value = 0.0038). BCH services became more affordable. However, opting out of the scheme at a later stage in the review period was attributed to rising unaffordable premiums and co-payments. Failure to afford scheme membership, residing far from BCH and limited understanding of health insurance led to reduced BCH service utilization. Conclusions: eQHB has potential to increase access and utilization of health services at BCH. The challenges are; limited understanding of the concept of health insurance and unaffordable premiums and co-payments set to enable provision of high quality services. Recommendations: Based on these findings, intensified community sensitization on health insurance, establishment of satellite health facilities by BCH to bring services closer to members and transformation of eQHB to a savings/credit society in order to grow savings and subsequently reduce premiums are recommended. Government of Uganda should engage CBHIs countrywide to discuss achievement of UHC and establishment of a national health insurance scheme. A further study to guide setting of affordable premiums and copayments for eQHB is also recommended.

Development of the Kisiizi hospital health insurance scheme: lessons learned and implications for universal health coverage.

BACKGROUND: Kisiizi Hospital Health Insurance scheme started in 1996 to; improve access to health services, and provide a stable source of funding and reduce bad debts to Kisiizi hospital. Objectives of this study were; to describe Kisiizi Hospital Health Insurance scheme and to document lessons learned and implications for universal health coverage. METHODS: This was a descriptive cross-sectional study. Data from different sources were triangulated and thematically analysed. RESULTS: Most households (96%) were organized in Engozi societies (e-Societies), met monthly, and made financial contributions. Cultural solidarity in e-Societies provided a platform for the Kisiizi hospital health insurance scheme establishment, operation and made it compulsory for members. e-Societies disciplinary measures and fear of high out-of-pocket payment for health care enforced enrolment, retention and increased membership. Community sensitisation and community participation in setting premiums and co-payments provided for better understanding of health insurance and rendered them acceptable, affordable and equitable. Membership increased from 330 in 1996 to 38,400 families in 2017. Kisiizi hospital health insurance scheme covered only health services obtained from Kisiizi hospital. Kisiizi hospital health insurance scheme offered no exemption, credit and referral facilities. e-Societies sometimes paid premiums for members from savings and offered them loans to. Kisiizi hospital provided good quality health services, which were easily accessed by insured members. Kisiizi hospital got a stable source of funding and reduced debt burden. CONCLUSIONS: Kisiizi hospital health insurance scheme improved access to health services, provided a stable source of funding and reduced bad debts to the hospital. Internal and external factors to e-Society enforced enrolment and retention of members in Kisiizi hospital health insurance scheme. Good quality health services at Kisiizi hospital demonstrated value for money and offered incentives for enrolment and retention, and coverage expansion. Community sensitization and participation in setting premiums and co-payments rendered Kisiizi hospital health insurance scheme acceptable, affordable and catered for equity. Insured members enjoyed benefits; protection against catastrophic health spending, impoverishment, and easy access to quality health care.

Task shifting in health service delivery from a decision and policy makers' perspective: a case of Uganda.

BACKGROUND: Documented evidence shows that task shifting has been practiced in Uganda to bridge the gaps in the health workers' numbers since 1918. The objectives of this study were to provide a synthesis of the available evidence on task shifting in Uganda; to establish levels of understanding, perceptions on task shifting and acceptability from the decision and policy makers' perspective; and to provide recommendations on the implications of task shifting for the health of the population in Ugandan and human resource management policy. METHODS: This was a qualitative study. Data collection involved review of published and unpublished literature, key informant interviews and group discussion for stakeholders in policy and decision making positions. Data was analyzed by thematic content analysis (ethical clearance number: SS 2444). RESULTS: Task shifting was implemented with minimal compliance to the WHO recommendations and guidelines. Uganda does not have a national policy and guidelines on task shifting. Task shifting was unacceptable to majority of policy and decision makers mainly because less-skilled health workers were perceived to be incompetent due to cases of failed minor surgery, inappropriate medicine use, overwork, and inadequate support supervision. CONCLUSIONS: Task shifting has been implemented in Uganda for a long time without policy guidance and regulation. Policy makers were not in support of task shifting because it was perceived to put patients at risk of drug abuse, development of drug resistance, and surgical complications. Evidence showed the presence of unemployed higher-skilled health workers in Uganda. They could not be absorbed into public service because of the low wage bill and lack of political commitment to do so. Less-skilled health workers were remarked to be incompetent and already overworked; yet, the support supervision and continuous medical education systems were not well resourced and effective. Hiring the existing unemployed higher-skilled health workers, fully implementing the human resource motivation and retention strategy, and enforcing the bonding policy for Government-sponsored graduates were recommended.

Strengthening health district management competencies in Ghana, Tanzania and Uganda: lessons from using action research to improve health workforce performance.

BACKGROUND: To achieve Universal Health Coverage (UHC), more health workers are needed; also critical is supporting optimal performance of existing staff. Integrated human resource management (HRM) strategies, complemented by other health systems strategies, are needed to improve health workforce performance, which is possible at district level in decentralised contexts. To strengthen the capacity of district management teams to develop and implement workplans containing integrated strategies for workforce performance improvement, we introduced an action-research-based management strengthening intervention (MSI). This consisted of two workshops, follow-up by facilitators and meetings between participating districts. Although often used in the health sector, there is little evaluation of this approach in middle-income and low-income country contexts. The MSI was tested in three districts in Ghana, Tanzania and Uganda. This paper reports on the appropriateness of the MSI to the contexts and its effects. METHODS: Documentary evidence (workshop reports, workplans, diaries, follow-up visit reports) was collected throughout the implementation of the MSI in each district and interviews (50) and focus-group discussions (6) were conducted with managers at the end of the MSI. The findings were analysed using Kirkpatrick's evaluation framework to identify effects at different levels. FINDINGS: The MSI was appropriate to the needs and work patterns of District Health Management Teams (DHMTs) in all contexts. DHMT members improved management competencies for problem analysis, prioritisation and integrated HRM and health systems strategy development. They learnt how to refine plans as more information became available and the importance of monitoring implementation. The MSI produced changes in team behaviours and confidence. There were positive results regarding workforce performance or service delivery; these would increase with repetition of the MSI. CONCLUSIONS: The MSI is appropriate to the contexts where tested and can improve staff performance. However, for significant impact on service delivery and UHC, a method of scaling up and sustaining the MSI is required.

Disability Characteristics of Community-Based Rehabilitation Participants in Kayunga District, Uganda.

BACKGROUND: Approximately 80% of individuals with disability reside in low- and middle-income countries where community-based rehabilitation (CBR) has been used as a strategy to improve disability. However, data relating to disability severity among CBR beneficiaries in low-income countries like Uganda remain scarce, particularly at the community or district level. OBJECTIVES: To describe severity of disability and associated factors for persons with physical disabilities receiving CBR services in the Kayunga district of Uganda. METHODS: A cross-sectional sample of 293 adults with physical disabilities receiving a CBR service in the Kayunga district was recruited. Disability severity was measured using the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS2.0), and analyzed as a binary outcome (low: 0-9, high: 10-48). Inferential statistics using odds ratios were used to determine factors associated with impairment severity. FINDINGS: The mean WHODAS 2.0 score of persons with physical disabilities was 12.7 (standard deviation = 8.3). More than half (52.90%) of people with physical disabilities reported a high level of functional impairment. Increased disability severity was significantly associated with limited access to assistive devices (adjusted odds ratio [AOR] = 4.55, 95% confidence interval [CI]: 1.87-14.08, P < .001), and increased use of medical health care (AOR = 5.55, 95% CI: 1.84-16.79, P = .002). CONCLUSION: These findings suggest a high level of moderate to severe functional impairments in persons with physical disabilities receiving CBR in Kayunga district. These data provide support for efforts to enhance CBR's ability to liaise with local health care, education, and community resources to promote access to needed services and ultimately improve the functional status of persons with disabilities in low-resource settings.

The health cost of tobacco use in Uganda.

The economic cost of tobacco use is well documented in high-income countries. It has been measured in relatively fewer low-and middle-income countries, and much less in sub-Saharan Africa despite the longstanding recognition of significant current and future health risk to people attributed by tobacco use in this region. This article fills this gap by estimating the economic cost of tobacco use in Uganda, a low-income country in sub-Saharan Africa. This study estimates the economic cost of tobacco use in Uganda using the cost-of-illnesses approach based on data collected from a survey of patients and caregivers in four major service centers in Mulago National Referral Hospital, namely, Uganda Cancer Institute, Uganda Heart Institute, Chest Clinic and Diabetic Clinic, key informant interviews and secondary sources for the year 2014. The total direct health care and non-health care cost of tobacco-related illnesses in Uganda was USD 41.56 million. The total indirect morbidity and mortality costs from the loss of productivity due to tobacco-related illnesses were USD 11.91 million and USD 73.01 million, respectively. The direct and indirect costs of tobacco use added up to USD 126.48 million, which is equivalent to 0.5% of GDP, a proportion comparable to the estimated health cost of tobacco use in other countries. The total health care cost of tobacco-related illnesses constitutes 2.3% of the national health care account which is already over-burdened with the cost of infectious diseases, limited medical personnel and infrastructure. In addition, tobacco-related illnesses heavily reduce life expectancy of tobacco users and ultimately their economic productivity. The cost of tobacco-related illnesses in Uganda far outweighs the benefits of employment and tax revenue generated from the tobacco sector. Stronger tobacco control measures need to be undertaken to reduce the disease and economic burden of tobacco use in this country.

Using a human resource management approach to support community health workers: experiences from five African countries.

BACKGROUND: Like any other health worker, community health workers (CHWs) need to be supported to ensure that they are able to contribute effectively to health programmes. Management challenges, similar to those of managing any other health worker, relate to improving attraction, retention and performance. METHODS: Exploratory case studies of CHW programmes in the Democratic Republic of Congo, Ghana, Senegal, Uganda and Zimbabwe were conducted to provide an understanding of the practices for supporting and managing CHWs from a multi-actor perspective. Document reviews (n = 43), in-depth interviews with programme managers, supervisors and community members involved in managing CHWs (n = 31) and focus group discussions with CHWs (n = 13) were conducted across the five countries. Data were transcribed, translated and analysed using the framework approach. RESULTS: CHWs had many expectations of their role in healthcare, including serving the community, enhancing skills, receiving financial benefits and their role as a CHW fitting in with their other responsibilities. Many human resource management (HRM) practices are employed, but how well they are implemented, the degree to which they meet the expectations of the CHWs and their effects on human resource (HR) outcomes vary across contexts. Front-line supervisors, such as health centre nurses and senior CHWs, play a major role in the management of CHWs and are central to the implementation of HRM practices. On the other hand, community members and programme managers have little involvement with managing the CHWs. CONCLUSIONS: This study highlighted that CHW expectations are not always met through HRM practices. This paper calls for a coordinated HRM approach to support CHWs, whereby HRM practices are designed to not only address expectations but also ensure that the CHW programme meets its goals. There is a need to work with all three groups of management actors (front-line supervisors, programme managers and community members) to ensure the use of an effective HRM approach. A larger multi-country study is needed to test an HRM approach that integrates context-appropriate strategies and coordinates relevant management actors. Ensuring that CHWs are adequately supported is vital if CHWs are to fulfil the critical role that they can play in improving the health of their communities.

Incremental cost of increasing access to maternal health care services: perspectives from a demand and supply side intervention in Eastern Uganda.

INTRODUCTION: High maternal and infant mortality continue to be major challenges to the attainment of the Millennium Development Goals for many low and middle-income countries. There is now evidence that voucher initiatives can increase access to maternal health services. However, a dearth of knowledge exists on the cost implications of voucher schemes. This paper estimates the incremental costs of a demand and supply side intervention aimed at increasing access to maternal health care services. METHODS: This costing study was part of a quasi-experimental voucher study conducted in two districts in Eastern Uganda to explore the impact of demand and supply - side incentives on increasing access to maternal health services. The provider's perspective was used and the ingredients approach to costing was employed. Costs were based on market prices as recorded in program records. Total, unit, and incremental costs were calculated. RESULTS: The estimated total financial cost of the intervention for the one year of implementation was US$525,472 (US$1 = 2200UgShs). The major cost drivers included costs for transport vouchers (35.3%), health system strengthening (29.2%) and vouchers for maternal health services (18.2%). The average cost of transport per woman to and from the health facility was US$4.6. The total incremental costs incurred on deliveries (excluding caesarean section) was US$317,157 and US$107,890 for post natal care (PNC). The incremental costs per additional delivery and PNC attendance were US$23.9 and US$7.6 respectively. CONCLUSION: Subsidizing maternal health care costs through demand and supply - side initiatives may not require significant amounts of resources contrary to what would be expected. With Uganda's Gross Domestic Product (GDP) per capita of US$55` (2012), the incremental cost per additional delivery (US$23.9) represents about 5% of GDP per capita to save a mother and probably her new born. For many low income countries, this may not be affordable, yet reliance on donor funding is often not sustainable. Alternative ways of raising additional resources for health must be explored. These include; encouraging private investments in critical sectors such as rural transport, health service provision; mobilizing households to save financial resources for preparedness, and financial targeting for the most vulnerable.

A scoping study on task shifting; the case of Uganda.

BACKGROUND: Task shifting has been implemented in Uganda for decades with little documentation. This study's objectives were to; gather evidence on task-shifting experiences in Uganda, establish its acceptability and perceptions among health managers and policymakers, and make recommendations. METHODS: This was a qualitative study. Data collection involved; review of published and gray literature, and key informant interviews of stakeholders in health policy and decision making in Uganda. Data was analyzed by thematic content analysis. RESULTS: Task shifting was the mainstay of health service delivery in Uganda. Lower cadre of health workers performed duties of specialized health workers. However, Uganda has no task shifting policy and guidelines, and task shifting was practiced informally. Lower cadre of health workers were deemed to be incompetent to handle shifted roles and already overworked, and support supervision was poor. Advocates of task shifting argued that lower cadre of health workers already performed the roles of highly trained health workers. They needed a supporting policy and support supervision. Opponents argued that lower cadre of health workers were; incompetent, overworked, and task shifting was more expensive than recruiting appropriately trained health workers. CONCLUSIONS: Task shifting was unacceptable to most health managers and policy makers because lower cadres of health workers were; incompetent, overworked and support supervision was poor. Recruitment of existing unemployed well trained health workers, implementation of human resource motivation and retention strategies, and government sponsored graduates to work for a defined mandatory period of time were recommended.

Self reported risk reduction behavior associated with HIV counseling and testing: a comparative analysis of facility- and home-based models in rural Uganda.

Home-based human immunodeficiency virus (HIV) voluntary counseling and testing (VCT) in Uganda is being promoted to increase coverage, in addition to main stay approach of service provision through health facilities. The aim of this study was to compare self reported risk reduction behavior among clients receiving facility and home-based HIV VCT within a rural context. Pre-post intervention client surveys were conducted in November 2007 (baseline) and March 2008 (follow up) in southwestern Uganda. The facility-based VCT intervention was provided to 500 clients and home-based VCT to 494 clients at baseline, in 2 different sub-counties. A total of 76% (759/994) of these clients were interviewed at the follow up visit. The respondents who received facility-based VCT were more likely to report abstinence (adjusted Odds Ratio [aOR]=1.47, 95% CI 1.074, 2.02), reducing multi sexual relationships (aOR=3.23, 95% CI 2.02, 5.16) and more frequent use of condoms (aOR=3.14, 95% CI 1.60, 6.18). However, they were less likely to report, discussing HIV (aOR=0.63, 95% CI 0.46, 0.85) with their sexual partner/s and having sex with only one partner (aOR=0.72, 95% CI 0.519-0.99). While facility-based VCT appears to promote abstinence and condom use home-based VCT on the other hand promotes faithfulness and disclosure. VCT services should, therefore, be provided through both models in a complementary relationship and not as surrogates within given settings.

Acceptability of male circumcision for prevention of HIV infection among men and women in Uganda.

In the last decade, three randomized controlled trials in Kenya, South Africa, and Uganda have shown that medical male circumcision (MMC) reduces the sexual transmission of HIV from women to men. Objectives of this assessment were to measure acceptability of adult MMC and circumcision of children to inform policies regarding whether and how to promote MMC as an HIV prevention strategy. This mixed-method study, conducted across four Ugandan districts, included a two-stage household survey of 833 adult males and 842 adult females, focus group discussions, and a health provider survey. Respondents' acceptability of MMC was positive and substantial after being informed about the results of recent randomized trials. In uncircumcised men, between 40% and 62% across the districts would consider getting circumcised. Across the four districts between 60% and 86% of fathers and 49% and 95% of mothers were supportive of MMC for sons. Widespread support exists among men and women in this study for promoting MMC as part of Uganda's current 'ABC + ' HIV prevention strategy.

Facility and home based HIV Counseling and Testing: a comparative analysis of uptake of services by rural communities in southwestern Uganda.

BACKGROUND: In Uganda, public human immunodeficiency virus (HIV) Voluntary Counseling and Testing (VCT) services are mainly provided through the facility based model, although the home based approach is being promoted as a strategy for improving access to VCT. However the uptake of VCT varies according to service delivery model and is influenced by a number of factors. The aim of this study therefore, was to compare predictors for uptake of facility and home based VCT in a rural context. METHODS: A longitudinal study with cross-sectional investigative phases was conducted at two sites (Rugando and Kabingo) in southwestern Uganda between November 2007 (baseline) and March 2008 (follow up). During the baseline visit, facility based VCT was offered at the main health centre in Rugando while home based VCT was offered at the household level in Kabingo and a mixed survey questionnaire administered to the respondents. The results presented in this paper are derived from only the baseline data. RESULTS: Nine hundred ninety four (994) respondents were interviewed, of whom 500 received facility based VCT in Rugando and 494 home based VCT in Kabingo during the baseline visit. The respondents had a mean age of 32.2 years (SD 10.9) and were mainly female (68 percent). Clients who received facility based VCT were less likely to be residents of the more rural households (adjusted Odds Ratio (aOR)=0.14, 95% CI 0.07, 0.22). The clients who received home based VCT were less likely to report having an STI symptom (aOR=0.63, 95% CI 0.46, 0.86), and more likely to be worried about discrimination if they contracted AIDS (aOR=1.78, 95% CI 1.22, 2.61). CONCLUSION: The uptake of VCT provided through either the facility or home based models is influenced by client characteristics such as proximity to service delivery points, HIV related symptoms, and fear of discrimination in rural Uganda. Interventions that seek to improve uptake of VCT should provide potential clients with both facility and home based VCT options within a given setting. The clients are then able to select a model for VCT that best fits their characteristics. This is likely to have positive implications for both service coverage and uptake by different sub-groups within particular communities.