Implementing the skilled birth attendance strategy in Uganda: a policy analysis.

BACKGROUND: Uganda, a low resource country, implemented the skilled attendance at birth strategy, to meet a key target of the 5th Millenium Development Goal (MDG), 75% reduction in maternal mortality ratio. Maternal mortality rates remained high, despite the improvement in facility delivery rates. In this paper, we analyse the strategies implemented and bottlenecks experienced as Uganda's skilled birth attendance policy was rolled out. These experiences provide important lessons for decision makers as they implement policies to further improve maternity care. METHODS: This is a case study of the implementation process, involving a document review and in-depth interviews among key informants selected from the Ministry of Health, Professional Organisations, Ugandan Parliament, the Health Service Commission, the private not-for-profit sector, non-government organisations, and District Health Officers. The Walt and Gilson health policy triangle guided data collection and analysis. RESULTS: The skilled birth attendance policy was an important priority on Uganda's maternal health agenda and received strong political commitment, and support from development partners and national stakeholders. Considerable effort was devoted to implementation of this policy through strategies to increase the availability of skilled health workers for instance through expanded midwifery training, and creation of the comprehensive nurse midwife cadre. In addition, access to emergency obstetric care improved to some extent as the physical infrastructure expanded, and distribution of medicines and supplies improved. However, health worker recruitment was slow in part due to the restrictive staff norms that were remnants of previous policies. Despite considerable resources allocated to creating the comprehensive nurse midwife cadre, this resulted in nurses that lacked midwifery skills, while the training of specialised midwives reduced. The rate of expansion of the physical infrastructure outpaced the available human resources, equipment, blood infrastructure, and several health facilities were not fully functional. CONCLUSION: Uganda's skilled birth attendance policy aimed to increase access to obstetric care, but recruitment of human resources, and infrastructural capacity to provide good quality care remain a challenge. This study highlights the complex issues and unexpected consequences of policy implementation. Further evaluation of this policy is needed as decision-makers develop strategies to improve access to skilled care at birth.

Improving access to skilled attendance at delivery: a policy brief for Uganda.

OBJECTIVE: This study describes the process of production, findings for a policy brief on Increasing Access to Skilled Birth Attendance, and subsequent use of the report by policy makers and others from the health sector in Uganda. METHODS: The methods used to prepare the policy brief use the SUPPORT Tools for evidence-informed health policy making. The problem that this evidence brief addresses was identified through an explicit priority setting process involving policy makers and other stakeholders, further clarification with key informant interviews of relevant policy makers, and review of relevant documents. A working group of national stakeholder representatives and external reviewers commented on and contributed to successive drafts of the report. Research describing the problem, policy options, and implementation considerations was identified by reviewing government documents, routinely collected data, electronic literature searches, contact with key informants, and reviewing the reference lists of relevant documents that were retrieved. RESULTS: The proportion of pregnant women delivering from public and private non-profit facilities was low at 34 percent in 2008/09. The three policy options discussed in the report could be adopted independently or complementary to the other to increase access to skilled care. The Ministry of Health in deliberating to provide intrapartum care at first level health facilities from the second level of care, requested for research evidence to support these decisions. Maternal waiting shelters and working with the private-for-profit sector to facilitate deliveries in health facilities are promising complementary interventions that have been piloted in both the public and private health sector. A combination of strategies is needed to effectively implement the proposed options as discussed further in this article. CONCLUSIONS: The policy brief report was used as a background document for two stakeholder dialogue meetings involving members of parliament, policy makers, health managers, researchers, civil society, professional organizations, and the media.

Improving access to skilled attendance at delivery: executive summary

Uganda´s maternal mortality has moderately declined from 670 per 100,000 live births in 1990 to 430 per 100,000 live births in 2008. This annual decline of 13 maternal deaths per 100,000 live births is unlikely to achieve the MDG target of 168 per 100,000 live births by 2015. The proportion of pregnant women delivering from public and private non-profit facilities was low at 34% in 2008/09. Increasing skilled birth attendance is desirable to reduce maternal mortality.

A qualitative analysis of vaccine safety perceptions and concerns among caretakers in Uganda.

Parents and caretakers of young children often have concerns about vaccine safety and adverse events following immunization (AEFI). Little is known about vaccine safety perceptions in Uganda and their influence on parental decision-making about infant immunization. The study objectives were: to identify community sources of information on immunization, vaccine safety and AEFI; determine caretakers' knowledge of immunization; identify community concerns/fears about immunization and AEFI and their influence on caretakers' decisions to vaccinate; and obtain an understanding of knowledge, perceptions, and experience of health care workers (HCWs) and policy administrators on vaccine safety and AEFI. Twelve focus group discussions with 136 caretakers who were very or somewhat concerned about vaccine safety and 25 key informant interviews were conducted in two districts (1 urban and 1 rural) with district authorities and health facility staff as well as national level decision-makers between December and April 2006. Content analysis was used to analyze the results. The main themes identified related to general lack of information among caretakers about immunization, perceived immunization benefits, immunization concerns, and misconceptions. Specific caretaker concerns related to vaccine administration, immunization services and vaccine safety. Experiences with AEFI and concerns about vaccine safety negatively affected caretakers' decisions to vaccinate their children, notably in rural areas. HCWs demonstrated knowledge about AEFI and their management although incidences reported to facilities were rare. Inadequate communication between HCWs and caretakers was noted. Concerns and misconceptions about vaccination still exist among caretakers in Uganda and influence decisions to vaccinate. Effective inter personal communication initiated by HCWs towards caretakers is needed.

Policy dialogue on task shifting for health workers in maternal and child healthcare: report

This dialogue to discuss the policy brief which outlines health policy options using the current research evidence is a fulfillment of one of UNHRO?s responsibilities of supporting evidence-based policy decisions. It was noted that there is an acute shortage of human resources for health in Africa and Uganda and slow progress towards meeting the MDGs. In addition, there is lack of access to surgical services for persons who suffer injury in road traffic accidents and persons who suffer debilitating, chronic conditions. In Uganda, about 100 doctors are produced per medical school of the 3 medical schools per year. However, Uganda seems unable to employ the doctors it produces. The issue is not numbers, there are doctors and nurses on the streets and hospitals are empty. There is no recruitment. There is need for a policy on recruitment and retention of workers.

Policy dialogue Increasing Access to Skilled Birth Attendance: report

The REACH policy initiative SURE project under UNHRO in collaboration with the College of Health Sciences, Makerere University had produced a policy brief on increasing access to skilled birth attendance which was the focus for discussion in this meeting. The brief describes the problem, highlights three policy options and implementation considerations that need to be taken into account. He requested the participants to introduce themselves. He introduced the moderator, Dr Freddie Ssengooba, from the School of Public Health, Makerere University, and requested him to facilitate the proceedings. Dr Ssengooba assured the participants that a record of the meeting would be kept but would not attribute comments to the participant speakers and thus encouraged them to freely express their views.

Increasing access to skilled birth attendance: report

The Director General of the Uganda National Health Research Organisation (UNHRO), Dr Sam Okware welcomed participants and asserted the role of UNHRO not only in coordinating national health research but translating research findings into policy and practice. The REACH policy initiative ­ SURE project under UNHRO in collaboration with the College of Health Sciences, Makerere University had produced a policy brief on increasing access to skilled birth attendance which was the focus for discussion in this meeting. The brief describes the problem, highlights three policy options and implementation considerations that need to be taken into account. He requested the participants to introduce themselves. He introduced the moderator, Dr Freddie Ssengooba, from the School of Public Health, Makerere University, and requested him to facilitate the proceedings. Dr Ssengooba assured the participants that a record of the meeting would be kept but would not attribute comments to the participant speakers and thus encouraged them to freely express their views

Improving access to skilled attendance at delivery: full report

The problem: High Maternal Mortality. Uganda?s maternal mortality has moderately declined from 670 per 100,000 live births in 1990 to 430 per 100,000 live births in 2008. This annual decline of 13 maternal deaths per 100,000 live births is unlikely to achievemeet the MDG target of 168 per 100,000 live births by 2015. The proportion of pregnant women delivering from public and private non-profit facilities was low at 34% in 2008/09. Increasing skilled birth attendance is desirable to reduce maternal mortality. The policy options: 1- Providing Intrapartum Care at first level Health Centre; 2- Involving the Private-for-Profit sector; 3- Maternity Shelters.

Task shifting in maternal and child health care: an evidence brief for Uganda.

THE PROBLEM: There is a shortage and maldistribution of medically trained health professionals to deliver cost-effective maternal and child health (MCH) services. Hence, cost-effective MCH services are not available to over half the population of Uganda and progress toward the Millennium Development Goals for MCH is slow. Optimizing the roles of less specialized health workers ("task shifting") is one strategy to address the shortage and maldistribution of more specialized health professionals. POLICY OPTIONS: (i) Lay health workers (community health workers) may reduce morbidity and mortality in children under five and neonates; and training for traditional birth attendants may improve perinatal outcomes and appropriate referrals. (ii) Nursing assistants in facilities might increase the time available from nurses, midwives, and doctors to provide care that requires more training. (iii) Nurses and midwives to deliver cost-effective MCH interventions in areas where there is a shortage of doctors. (iv) Drug dispensers to promote and deliver cost-effective MCH interventions and improve the quality of the services they provide. The costs and cost-effectiveness of all four options are uncertain. Given the limitations of the currently available evidence, rigorous evaluation and monitoring of resource use and activities is warranted for all four options. IMPLEMENTATION STRATEGIES: A clear policy on optimizing health worker roles. Community mobilization and reduction of out-of-pocket costs to improve mothers' knowledge and care-seeking behaviors, continuing education, and incentives to ensure health workers are competent and motivated, and community referral and transport schemes for MCH care are needed.

Task shifting to optimise the roles of health workers to improve the delivery of maternal and child healthcare: executive summary

There is a shortage and maldistribution of medically trained health professionals. These are important reasons why cost-effective MCH services are not available to over half the population of Uganda and progress towards the Millennium Development Goals for MCH is slow. Optimising the roles of less specialised health workers (?task shifting?) is one strategy to address the shortage and maldistribution of more specialised health professionals. However, the lack of an explicit policy limits the implementation and coordination of task shifting.

Task shifting to optimise the roles of health workers to improve the delivery of maternal and child healthcare: full report

The purpose of this policy brief is to inform deliberations among policymakers and stakeholders on optimising roles of health cadres in the delivery of maternal and child health. It summarises the best available evidence regarding the design and implementation of policies for extending the roles of non-medically trained primary health care workers ("task shifting") to deliver cost-effective maternal and child health interventions. This brief was prepared for discussion at meetings of those engaged in developing policies for task shifting and other stakeholders with an interest in these policy decisions. In addition, it is intended to inform other stakeholders and to engage them in deliberations about those policies. It is not intended to prescribe or proscribe specific options or implementation strategies. Rather, its purpose is to allow stakeholders to systematically and transparently consider the available evidence about the likely impacts of different options for task shifting.