Joseph K. B. Matovu

Strengthening district-based health reporting through the district health management information software system: the Ugandan experience

BackgroundUntimely, incomplete and inaccurate data are common challenges in planning, monitoring and evaluation of health sector performance, and health service delivery in many sub-Saharan African settings. We document Uganda’s experience in strengthening routine health data reporting through the roll-out of the District Health Management Information Software System version 2 (DHIS2).MethodsDHIS2 was adopted at the national level in January 2011. The system was initially piloted in 4 districts, before it was rolled out to all the 112 districts by July 2012. As part of the roll-out process, 35 training workshops targeting 972 users were conducted throughout the country. Those trained included Records Assistants (168, 17.3%), District Health Officers (112, 11.5%), Health Management Information System Focal Persons (HMIS-FPs) (112, 11.5%), District Biostatisticians (107, 11%) and other health workers (473, 48.7%). To assess improvements in health reporting, we compared data on completeness and timeliness of outpatient and inpatient reporting for the period before (2011/12) and after (2012/13) the introduction of DHIS2. We reviewed data on the reporting of selected health service coverage indicators as a proxy for improved health reporting, and documented implementation challenges and lessons learned during the DHIS2 roll-out process.ResultsCompleteness of outpatient reporting increased from 36.3% in 2011/12 to 85.3% in 2012/13 while timeliness of outpatient reporting increased from 22.4% to 77.6%. Similarly, completeness of inpatient reporting increased from 20.6% to 57.9% while timeliness of inpatient reporting increased from 22.5% to 75.6%. There was increased reporting on selected health coverage indicators (e.g. the reporting of one-year old children who were immunized with three doses of pentavelent vaccine increased from 57% in 2011/12 to 87% in 2012/13). Implementation challenges included limited access to computers and internet (34%), inadequate technical support (23%) and limited worker force (18%).ConclusionImplementation of DHIS2 resulted in improved timeliness and completeness in reporting of routine outpatient, inpatient and health service usage data from the district to the national level. Continued onsite support supervision and mentorship and additional system/infrastructure enhancements, including internet connectivity, are needed to further enhance the performance of DHIS2.

“Men are always scared to test with their partners … it is like taking them to the Police”: Motivations for and barriers to couples’ HIV counselling and testing in Rakai, Uganda: a qualitative study

Uptake of couples’ HIV counselling and testing (couples’ HCT) can positively influence sexual risk behaviours and improve linkage to HIV care among HIV‐positive couples. However, less than 30% of married couples have ever tested for HIV together with their partners. We explored the motivations for and barriers to couples’ HCT among married couples in Rakai, Uganda.

Sexual risk behaviours, condom use and sexually transmitted infection treatment-seeking behaviours among female sex workers and truck drivers in Uganda.

We assessed sexual risk behaviours, condom use and sexually transmitted infection (STI) treatment-seeking behaviours among truckers and female sex workers (FSWs) operating at 12 hotspots along two major transport corridors in Uganda. Participants were identified through local contact persons: 261 truckers and 259 FSWs were interviewed. FSWs reported a mean number of 28 partners in the past 30 days while truckers reported a mean of seven partners. Ninety-four percent of FSWs and 87% of truckers reported condom use in the past month; however, only 21% of truckers and 45% of FSWs reported using condoms consistently during that time. More than half of truckers (n = 261) and 77% of FSWs (n = 259) reported that they suffered from STIs in the past year, and 93% of FSWs and 92.9% of truckers sought treatment for STIs in the past year. Of these, 78% of truckers and 86% of FSWs sought treatment at least three days following recognition of symptoms. These findings suggest that FSWs and truckers engage in high-risk sexual behaviours characterized by multiple sexual partnerships, low consistent condom use and delayed treatment-seeking behaviours.

Barriers to Condom Use among High Risk Men Who Have Sex with Men in Uganda: A Qualitative Study.

Background Unprotected sexual intercourse is a major risk factor for HIV transmission. Men who have sex with men (MSM) face challenges in accessing HIV prevention services, including condoms. However, there is limited in-depth assessment and documentation of the barriers to condom use among MSM in sub-Saharan Africa. In this paper, we examine the barriers to condom use among MSM in Uganda. Methods The data for this study were extracted from a larger qualitative study conducted among 85 self-identified adult (>18 years) MSM in 11 districts in Uganda between July and December 2013. Data on sexual behaviours and access and barriers to condom use were collected using semi-structured interviews. All interviews were audio-recorded and transcribed verbatim. This paper presents an analysis of data for 33 MSM who did not use condoms at last sex, with a focus on barriers to condom use. Analysis was conducted using the content analysis approach. Results Six major barriers to condom use were identified: Difficulties with using condoms, access challenges, lack of knowledge and misinformation about condom use, partner and relationship related issues, financial incentives and socio-economic vulnerability, and alcohol consumption. Conclusion The findings suggest that several reasons account for lack of condom use among high-risk MSM. The findings are valuable to inform interventions needed to increase condom use among MSM.

Strengthening health workforce capacity through work-based training.

BackgroundAlthough much attention has been given to increasing the number of health workers, less focus has been directed at developing models of training that address real-life workplace needs. Makerere University School of Public Health (MakSPH) with funding support from the Centers for Disease Control and Prevention (CDC) developed an eight-month modular, in-service work-based training program aimed at strengthening the capacity for monitoring and evaluation (M&E) and continuous quality improvement (CQI) in health service delivery.MethodsThis capacity building program, initiated in 2008, is offered to in-service health professionals working in Uganda. The purpose of the training is to strengthen the capacity to provide quality health services through hands-on training that allows for skills building with minimum work disruptions while encouraging greater involvement of other institutional staff to enhance continuity and sustainability. The hands-on training uses practical gaps and challenges at the workplace through a highly participatory process. Trainees work with other staff to design and implement ‘projects’ meant to address work-related priority problems, working closely with mentors. Trainees’ knowledge and skills are enhanced through short courses offered at specific intervals throughout the course.ResultsOverall, 143 trainees were admitted between 2008 and 2011. Of these, 120 (84%) from 66 institutions completed the training successfully. Of the trainees, 37% were Social Scientists, 34% were Medical/Nursing/Clinical Officers, 5.8% were Statisticians, while 23% belonged to other professions. Majority of the trainees (80%) were employed by Non-Government Organizations while 20% worked with the public health sector. Trainees implemented 66 projects which addressed issues such as improving access to health care services; reducing waiting time for patients; strengthening M&E systems; and improving data collection and reporting. The projects implemented aimed to improve trainees’ skills and competencies in M&E and CQI and the design of the projects was such that they could share these skills with other staff, with minimal interruptions of their work.ConclusionsThe modular, work-based training model strengthens the capacity of the health workforce through hands-on, real-life experiences in the work-setting and improves institutional capacity, thereby providing a practical example of health systems strengthening through health workforce capacity building.

Building capacity for HIV/AIDS program leadership and management in Uganda through mentored Fellowships.

Background: Around the world, health professionals and program managers are leading and managing public and private health organizations with little or no formal management and leadership training and experience. Objective: To describe an innovative 2-year, long-term apprenticeship Fellowship training program implemented by Makerere University School of Public Health (MakSPH) to strengthen capacity for leadership and management of HIV/AIDS programs in Uganda. Implementation process: The program, which began in 2002, is a 2-year, full-time, non-degree Fellowship. It is open to Ugandan nationals with postgraduate training in health-related disciplines. Enrolled Fellows are attached to host institutions implementing HIV/AIDS programs and placed under the supervision of host institution and academic mentors. Fellows spend 75% of their apprenticeship at the host institutions while the remaining 25% is dedicated to didactic short courses conducted at MakSPH to enhance their knowledge base. Achievements: Overall, 77 Fellows have been enrolled since 2002. Of the 57 Fellows who were admitted between 2002 and 2008, 94.7% (54) completed the Fellowship successfully and 50 (92.3%) are employed in senior leadership and management positions in Uganda and internationally. Eighty-eight percent of those employed (44/54) work in institutions registered in Uganda, indicating a high level of in-country retention. Nineteen of the 20 Fellows who were admitted between 2009 and 2010 are still undergoing training. A total of 67 institutions have hosted Fellows since 2002. The host institutions have benefited through staff training and technical expertise from the Fellows as well as through grant support to Fellows to develop and implement innovative pilot projects. The success of the program hinges on support from mentors, stakeholder involvement, and the hands-on approach employed in training. Conclusion: The Fellowship Program offers a unique opportunity for hands-on training in HIV/AIDS program leadership and management for both Fellows and host institutions.

If You Tell People That You Had Sex with a Fellow Man, It Is Hard to Be Helped and Treated: Barriers and Opportunities for Increasing Access to HIV Services among Men Who Have Sex with Men in Uganda.

Background Despite the high HIV prevalence among men who have sex with men (MSM) in sub-Saharan Africa, little is known about their access to HIV services. This study assessed barriers and opportunities for expanding access to HIV services among MSM in Uganda. Methods In October-December 2013, a cross-sectional qualitative study was conducted in 12 districts of Uganda. Semi-structured in-depth interviews were conducted with 85 self-identified MSM by snowball sampling and 61 key informants including HIV service providers and policy makers. Data were analysed using manifest content analysis and Atlas.ti software. Results Three quarters of the MSM (n = 62, 72.9%) were not comfortable disclosing their sexual orientation to providers and 69 (81.1%) felt providers did not respect MSM. Half (n = 44, 51.8%) experienced difficulties in accessing health services. Nine major barriers to access were identified, including: (i) unwelcoming provider behaviours; (ii) limited provider skills and knowledge; (iii) negative community perceptions towards MSM; (iv) fear of being exposed as MSM; (v) limited access to MSM-specific services; (vi) high mobility of MSM, (vii) lack of guidelines on MSM health services; viii) a harsh legal environment; and ix) HIV related stigma. Two-thirds (n = 56, 66%) participated in MSM social networks and 86% of these (48) received support from the networks to overcome barriers to accessing services. Conclusions Negative perceptions among providers and the community present barriers to service access among MSM. Guidelines, provider skills building and use of social networks for mobilization and service delivery could expand access to HIV services among MSM in Uganda.

Opt-out cervical cancer screening increases coverage of cervical cancer screening in HIV clinical care settings: Experiences from Mildmay, Uganda

Background Cervical cancer is highly prevalent in developing countries. In Uganda, overall incidence rate is estimated at 44 per 100,000 women and 60 per 100,000 among HIV infected women. However, only 30% of women have ever been screened for cervical cancer and linkage to treatment after diagnosis is suboptimal. For HIV infected women, who are at highest risk of cervical cancer, the HIV care delivery system provides an opportunity for cervical cancer services. In this paper we share the Mildmay Uganda (MUg) experiences in integrating cervical cancer services into HIV care.

Challenges in accessing sexual and reproductive health services by people with physical disabilities in Kampala, Uganda

IntroductionDespite the universal right to access the same range, quality and standard of free or affordable health care and programs as provided to other persons, people with physical disabilities (PWPDs) continue to experience challenges in accessing these services. This article presents the challenges faced by PWPDs in accessing sexual and reproductive health (SRH) services in Kampala, Uganda.MethodsThis was a qualitative study that was conducted with male and female PWPDs in Kampala in 2007. Data on the challenges experienced by PWPDs in accessing SRH services were collected using in-depth interviews with 40 PWPDs and key informant interviews with 10 PWPDs’ representatives, staff of agencies supporting PWPDs and health workers. All data were captured verbatim using an audio-tape recorder, entered into a Microsoft Word computer program and analyzed manually following a content thematic approach.ResultsThe study findings show that PWPDs face a multitude of challenges in accessing SRH services including negative attitudes of service providers, long queues at health facilities, distant health facilities, high costs of services involved, unfriendly physical structures and the perception from able-bodied people that PWPDs should be asexual.ConclusionPeople with physical disabilities (PWPDs) face health facility-related (service provider and facility-related challenges), economic and societal challenges in accessing SRH services. These findings call for a need to sensitize service providers on SRH needs of PWPDs for better support and for the government to enforce the provision of PWPD-friendly services in all health facilities.

Community knowledge and perceptions about indoor residual spraying for malaria prevention in Soroti district, Uganda: a cross-sectional study

BackgroundMalaria is the leading cause of morbidity and mortality in Uganda. The Ministry of Health (MoH) plans to scale up indoor residual spraying (IRS) for malaria vector control. However, there is limited information on community knowledge and perceptions towards IRS. This study assessed community knowledge and perceptions about IRS in Soroti district, eastern Uganda.MethodsThe study was cross-sectional and it covered 770 randomly selected households in urban and rural settings in Soroti district, Eastern Uganda. The respondents were heads of household and or their proxies. The data were collected on the sociodemographic characteristics, knowledge of the insecticides that could be used for IRS, parts of the houses that would be sprayed, importance of IRS, role of household heads in IRS programme, frequency and the time of spraying. Responses to the questions on these areas were used to create a composite dependent variable categorized as knowledgeable if they had responded correctly to at least three questions or not knowledgeable about IRS if they responded correctly to less than three questions. In addition, respondents were asked if they thought the IRS programme would be beneficial or not. Bivariate and multivariate logistic regression analyses were carried out using SPSS version 17.ResultsLess than half, (48.6%, 374/770) of the respondents were knowledgeable about IRS. Urban residents (AOR 1.92, 95% CI 1.04-3.56) and those with secondary education or higher (AOR 4.81, 95% CI 2.72-8.52) were knowledgeable about IRS. Three-quarters, (74.4%, 354/473) of respondents who had ever heard of IRS, perceived it as beneficial. Two-thirds, (66.4%, 314/473) reported that IRS would have negative effects. Respondents who reported that, IRS programme is beneficial were: 23 years or older (AOR 2.17, 95% CI 1.07-4.38), had attained secondary education or higher (AOR 2.16, 95% CI 1.22-3.83) and were knowledgeable about IRS (AOR 2.21, 95% CI 1.17-4.17).ConclusionsKnowledge about IRS is inadequate and negative perceptions about its use are prominent especially among the rural and less educated individuals. To ensure householders’ cooperation and participation in the IRS programme, adequate community mobilization and sensitization is needed prior to use of IRS for effective malaria control.