Iam a Professor of maternal health, malaria and infectious diseases control at the College of Health Sciences, Makerere University. I hold an MBChB, MA, MPH, PhD and an FRCP (UK). Formerly I worked with ministry of Health Uganda as a Director General of Health Services.
The observation that many people in Africa seek care for
febrile illness in the retail sector has... more The observation that many people in Africa seek care for febrile illness in the retail sector has led to a number of public health initiatives to try to improve the quality of care provided in these settings. The potential to support the introduction of rapid diagnostic tests for malaria (mRDTs) into drug shops is coming under increased scrutiny. Those in favour argue that it enables the harmonisation of policy around testing and treatment for malaria and maintains a focus on market-based solutions to healthcare. Despite the enthusiasm among many global health actors for this policy option, there is a limited understanding of the consequences of the introduction of mRDTs in the retail sector. We undertook an interpretive, mixed methods study with drug shop vendors (DSVs), their clients and local health workers to explore the uses and interpretations of mRDTs as they became part of daily practice in drug shops during a trial in Mukono District, Uganda. This paper reports the unintended consequences of their introduction. It describes how the test engendered trust in the professional competence of DSVs; was misconstrued by clients and providers as enabling a more definitive diagnosis of disease in general rather than malaria alone; that blood testing made drug shops more attractive places to seek care than they had previously been; was described as shifting treatment- seeking behaviour away from formal health centres and into drug shops; and influenced an increase in sales of medications, particularly antibiotics
Sayana® Press (SP), a subcutaneous formulation of depot medroxyprogesterone acetate (DMPA) in Uni... more Sayana® Press (SP), a subcutaneous formulation of depot medroxyprogesterone acetate (DMPA) in Uniject™, has potential to be a valuable innovation in family planning (FP) because it may overcome logistic and safety challenges in delivering intramuscular DMPA (DMPA IM). However, SP's acceptability is unknown. We measured acceptability of SP among clinic-based providers (Senegal only) and community health workers. This open-label observational study was conducted in clinics in three districts in Senegal and community-based services in two districts in Uganda. Providers administered SP to clients seeking reinjection of DMPA IM. We conducted in-depth interviews with 86 providers (52 in Senegal, 34 in Uganda) to assess their experiences providing SP to clients. Almost all providers (84/86; 98%) preferred SP over DMPA IM. The main reason Uganda providers preferred SP was the prefilled/all-in-one design made preparation and administration easier and faster. Some providers thought the SP all-in-one feature may decrease stock outs (DMPA IM requires syringe and vial). Providers also felt clients preferred the shorter SP needle because it is less intimidating and less painful. Similarly, the main reasons Senegal providers preferred SP were its characteristics (prefilled/all-in-one) and client preference (especially less pain). They also saw a potential to increase access to FP, especially through community-based distribution. Providers from both countries reported SP introduction would be enhanced through client counseling and community engagement. Providers also said SP must be accessible, affordable and in stock. Almost all providers preferred SP over DMPA IM. Provider recommendations should be considered during SP introduction planning. We found that SP was acceptable to both clinic-based FP providers and community health workers. Providers' positive attitudes towards SP may facilitate introduction and uptake of this method.
Local health system managers in low- and middle-income countries have the responsibility to set h... more 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.
We aimed to assess the acceptability of a variety of formulations of female-controlled methods of... more We aimed to assess the acceptability of a variety of formulations of female-controlled methods of protection against HIV and STDs among men and women in south-western Uganda. Pilot interviews were carried out with 50 men and 55 women and 25 focus group discussions (FGDs) were held with 138 women and 42 men. The female condom, foaming tablets, sponge, foam, gel and film were demonstrated to 146 women and 35 of their male partners, who then tried out 2 of the products. They were interviewed 7 times during the course of 5 months. At the end experiences were evaluated during a second series of FGDs. Sixty-five (45%) women completed the trial. The main reasons for non-completion were related to geographical mobility. Product preference after the initial demonstration was similar to that at the end of the trial. The most popular formulations were the sponge (25% of the women), foaming tablets (23%), and the female condom (19%). The foam was of medium popularity (16%). The gel (9%) and film (7%) were least popular. Ten per cent of the women and 14% of the men reported products interfering with sexual enjoyment; 24% of the women and 67% of the men said products increased enjoyment. 'Dry sex' is not popular in this area and increased lubrication was an important determinant of acceptability. Age, level of education and location did have some effect on preference. Although secrecy was a dominant theme in the FGDs, 87% of the women had informed their partners by the end of the trial. The products were generally well received. Female control was an important issue for both sexes. Male attitudes were ambivalent because female ownership of products increased women's control. Although they have clear preferences, women appear to accept the products generally and might use a single available product just as readily if choice was limited, as long as it conforms to general cultural preferences, such as those relating to wet/dry sex.
English: Uganda has experienced a slight decline in total fertility rate from 7.1 to 6.9 over the... more English: Uganda has experienced a slight decline in total fertility rate from 7.1 to 6.9 over the last twelve years. This has created a national drive to strengthen family planning services in order to have a substantial decline in fertility. This paper presents findings of a cross-sectional study carried out in 15 health units among pregnant women attending prenatal care
There is a declining trend of child health indicators in Uganda despite intensified program effor... more There is a declining trend of child health indicators in Uganda despite intensified program efforts to improve child care. For example, the infant mortality rate increased from 81/1,000 in 1995 to 88/1,000 in the year 2000. This paper presents results of a study that assessed factors responsible for this trend. The objectives were to assess the prevalence of childhood illnesses and care-seeking practices for children with fever, diarrhea, and upper respiratory tract infections (URTI) in the Sembabule district of Central Uganda. A cross-sectional survey, using a WHO 30 cluster-sampling technique, was used to obtain data from 300 women with children aged less than 2 years. Prevalence of childhood illnesses and care-seeking practices were obtained using a structured questionnaire supplemented by in-depth interviews. The results showed that the 300 women interviewed had 323 children of whom 37.9% had an episode of fever 2 weeks before the survey, 40.3% had diarrhea, 37.4% had URTI, and ...
In a recent study of the acceptability of the female condom, foaming tablets, sponge, foam, film ... more In a recent study of the acceptability of the female condom, foaming tablets, sponge, foam, film and gel among 146 women and 35 of their male partners in south-west Uganda, we found a clear demand for, and consistent use of, these products. Although the participants understood that, with the exception of the female condom, there was no certainty about how much protection, if any, the products provided against HIV and sexually transmitted diseases (STD), they nonetheless said that the main reason for using the products was the partial ...
Malaria in pregnancy is a major public health problem in Uganda; and it is the leading cause of a... more Malaria in pregnancy is a major public health problem in Uganda; and it is the leading cause of anaemia among pregnant women and low birth weight in infants. Previous studies have noted poor quality of care in the private sector. Thus there is need to explore ways of improving quality of care in the private sector that provides almost a half of health services in Uganda. A survey was conducted from August to October 2014 within 57 parishes in Mukono district, central Uganda. The selected parishes had a minimum of 200 households and at least one registered drug shop, pharmacy or private clinic. Data was collected using a structured questionnaire targeting one provider who was found on duty in each selected private health facility and consented to the study. The main variables were: provider characteristics, previous training received, type of drugs stocked, treatment and prevention practices for malaria among pregnant women. The main study outcome was the proportion of private health facilities who prescribe treatment of fever among pregnant women as recommended in the guidelines. A total of 241 private health facilities were surveyed; 70.5 % were registered drug shops, 24.5 % private clinics and 5.0 % pharmacies. Treatment of fever among pregnant women in accordance with the national treatment guidelines was poor: 40.7 % in private clinics, decreasing to 28.2 % in drug shops and 16.7 % at pharmacies. Anti-malarial monotherapies sulphadoxine-pyrimethamine and quinine were commonly prescribed, often without consideration of gestational age. The majority of providers (>75 %) at all private facilities prescribed SP for intermittent preventive treatment but artemisinin-based combination therapy was prescribed: 8.3, 6.9 and 8.3 % respectively at drug shops, private clinics and pharmacies for prevention of malaria in pregnancy. Few facilities had malaria treatment guidelines; (44.1 % of private clinics, 17.9 % of drug shops, and 41.7 % at pharmacies. Knowledge of people at risk of malaria, P = 0.02 and availability of malaria treatment guidelines, P = 0.03 were the factors that most influenced correct treatment of fever in pregnancy. Treatment of fever during pregnancy was poor in this study setting. These data highlight the need to develop interventions to improve patient safety and quality of care for pregnant women in the private health sector in Uganda.
ABSTRACT In rural Uganda there is a growing trend of CHW participation in health services. Since ... more ABSTRACT In rural Uganda there is a growing trend of CHW participation in health services. Since 2005 CHWs have been administering the injectable contraception depot medroxyprogesterone acetate (DMPA) to clients. As the responsibilities of CHWs expands, their exposure to and role in clinical trials will increase. However, CHWs with previous research experience is rare. Clinical trials traditionally take place in clinic settings and adhere to stringent guidelines called Good Clinical Practice (GCP) to protect human subjects involved in trials. Thirty-eight CHWs from Mubende and Nakasongola districts were trained to be staff family planning (FP) providers in a clinical trial studying the acceptability of depo-subQ in Uniject. The study assessed FP provider and DMPA client acceptability of this new injectable contraceptive method. To assess acceptability, the study was designed to maintain CHW current working practices as close as possible. CHWs routinely collect FP supplies from local clinics, transport and store the supplies in their home, and provide FP counseling and services to clients in a variety of community settings including their home. In this presentation, we will discuss the challenges faced and strategies used to meet GCP guidelines in this non-clinic setting, with a focus on CHW training and oversight, and CHWs' role in meeting documentation requirements, client participant recruitment and consent, and study product storage and accountability. As CHW participation in health services continues to grow, the challenges and lessons learned from this example will help inform future research strategies considering engaging CHWs as researchers.
The main objective of this study was to assess practices of antibiotic prescription at registered... more The main objective of this study was to assess practices of antibiotic prescription at registered drug shops with a focus on upper respiratory tract infections among children in order to provide data for policy discussions aimed at improving quality of care and patient safety in the private health sector in Uganda. A survey was conducted within 57 parishes from August to October 2014 in Mukono District, Uganda. Data was captured on the following variables: drug shop characteristics, training of staff in management of pneumonia, availability of guidelines and basic equipment, available antibiotics, knowledge on treatment of pneumonia in children aged <5 years. The main study outcome was the proportion of private health facilities prescribing an antibiotic. A total of 170 registered drug shops were surveyed between August and October 2014. The majority of drug shops, 93.5% were prescribing antibiotics, especially amoxicillin and trimethoprim-sulfamethoxazole (septrin). The professi...
International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases, Jan 14, 2016
Nodding syndrome is a devastating neurological disorder affecting children in mostly eastern Afri... more Nodding syndrome is a devastating neurological disorder affecting children in mostly eastern Africa. An estimated 10,000 children are affected. Uganda, one of the most affected countries, systematically set out to investigate the disease and developed interventions for it. On 21(st) December 2015, the Ministry of Health held a meeting with community leaders from the affected areas to disseminate results of investigations to date. This paper summarizes the presentation and shares the story of studies into this peculiar disease. It also shares results of preliminary studies of pathogenesis and puts into perspective an upcoming treatment intervention. Clinical and electrophysiological studies demonstrated nodding syndrome is a complex epilepsy disorder. A definitive aetiological agent has not been established but in agreement with other affected countries, a consistent epidemiologic association has been demonstrated with infection by Onchocerca volvulus. Preliminary studies of pathogen...
Innovative and sustainable strategies to strengthen districts and other sub-national health syste... more 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&amp;amp;amp;amp;amp;#39; 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.
Malaria is a major public health problem in Uganda and the current policy recommends introduction... more Malaria is a major public health problem in Uganda and the current policy recommends introduction of rapid diagnostic tests for malaria (RDTs) to facilitate effective case management. However, provision of RDTs in drug shops potentially raises a new set of issues, such as adherence to RDTs results, management of severe illnesses, referral of patients, and relationship with caretakers. The main objective of the study was to examine the impact of introducing RDTs in registered drug shops in Uganda and document lessons and policy implications for future scale-up of malaria control in the private health sector. A cluster-randomized trial introducing RDTs into registered drug shops was implemented in central Uganda from October 2010 to July 2012. An evaluation was undertaken to assess the impact and the processes involved with the introduction of RDTs into drug shops, the lessons learned and policy implications. Introducing RDTs into drug shops was feasible. To scale-up this intervention however, drug shop practices need to be regulated since the registration process was not clear, supervision was inadequate and record keeping was poor. Although initially it was anticipated that introducing a new practice of record keeping would be cumbersome, but at evaluation this was not found to be a constraint. This presents an important lesson for introducing health management information system into drug shops. Involving stakeholders, especially the district health team, in the design was important for ownership and sustainability. The involvement of village health teams in community sensitization to the new malaria treatment and diagnosis policy was a success and this strategy is recommended for future interventions. Introducing RDTs into drug shops was feasible and it increased appropriate treatment of malaria with artemisinin-based combination therapy. It is anticipated that the lessons presented will help better implementation of similar interventions in the private sector.
The Community and District Empowerment for Scale-up (CODES) project pioneered the implementation ... more 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.
Inappropriate treatment of malaria is widely reported particularly in areas where there is poor a... more Inappropriate treatment of malaria is widely reported particularly in areas where there is poor access to health facilities and self-treatment of fevers with anti-malarial drugs bought in shops is the most common form of care-seeking. The main objective of the study was to examine the impact of introducing rapid diagnostic tests for malaria (mRDTs) in registered drug shops in Uganda, with the aim to increase appropriate treatment of malaria with artemisinin-based combination therapy (ACT) in patients seeking treatment for fever in drug shops. A cluster-randomized trial of introducing mRDTs in registered drug shops was implemented in 20 geographical clusters of drug shops in Mukono district, central Uganda. Ten clusters were randomly allocated to the intervention (diagnostic confirmation of malaria by mRDT followed by ACT) and ten clusters to the control arm (presumptive treatment of fevers with ACT). Treatment decisions by providers were validated by microscopy on a reference blood ...
The observation that many people in Africa seek care for
febrile illness in the retail sector has... more The observation that many people in Africa seek care for febrile illness in the retail sector has led to a number of public health initiatives to try to improve the quality of care provided in these settings. The potential to support the introduction of rapid diagnostic tests for malaria (mRDTs) into drug shops is coming under increased scrutiny. Those in favour argue that it enables the harmonisation of policy around testing and treatment for malaria and maintains a focus on market-based solutions to healthcare. Despite the enthusiasm among many global health actors for this policy option, there is a limited understanding of the consequences of the introduction of mRDTs in the retail sector. We undertook an interpretive, mixed methods study with drug shop vendors (DSVs), their clients and local health workers to explore the uses and interpretations of mRDTs as they became part of daily practice in drug shops during a trial in Mukono District, Uganda. This paper reports the unintended consequences of their introduction. It describes how the test engendered trust in the professional competence of DSVs; was misconstrued by clients and providers as enabling a more definitive diagnosis of disease in general rather than malaria alone; that blood testing made drug shops more attractive places to seek care than they had previously been; was described as shifting treatment- seeking behaviour away from formal health centres and into drug shops; and influenced an increase in sales of medications, particularly antibiotics
Sayana® Press (SP), a subcutaneous formulation of depot medroxyprogesterone acetate (DMPA) in Uni... more Sayana® Press (SP), a subcutaneous formulation of depot medroxyprogesterone acetate (DMPA) in Uniject™, has potential to be a valuable innovation in family planning (FP) because it may overcome logistic and safety challenges in delivering intramuscular DMPA (DMPA IM). However, SP&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s acceptability is unknown. We measured acceptability of SP among clinic-based providers (Senegal only) and community health workers. This open-label observational study was conducted in clinics in three districts in Senegal and community-based services in two districts in Uganda. Providers administered SP to clients seeking reinjection of DMPA IM. We conducted in-depth interviews with 86 providers (52 in Senegal, 34 in Uganda) to assess their experiences providing SP to clients. Almost all providers (84/86; 98%) preferred SP over DMPA IM. The main reason Uganda providers preferred SP was the prefilled/all-in-one design made preparation and administration easier and faster. Some providers thought the SP all-in-one feature may decrease stock outs (DMPA IM requires syringe and vial). Providers also felt clients preferred the shorter SP needle because it is less intimidating and less painful. Similarly, the main reasons Senegal providers preferred SP were its characteristics (prefilled/all-in-one) and client preference (especially less pain). They also saw a potential to increase access to FP, especially through community-based distribution. Providers from both countries reported SP introduction would be enhanced through client counseling and community engagement. Providers also said SP must be accessible, affordable and in stock. Almost all providers preferred SP over DMPA IM. Provider recommendations should be considered during SP introduction planning. We found that SP was acceptable to both clinic-based FP providers and community health workers. Providers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; positive attitudes towards SP may facilitate introduction and uptake of this method.
Local health system managers in low- and middle-income countries have the responsibility to set h... more 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.
We aimed to assess the acceptability of a variety of formulations of female-controlled methods of... more We aimed to assess the acceptability of a variety of formulations of female-controlled methods of protection against HIV and STDs among men and women in south-western Uganda. Pilot interviews were carried out with 50 men and 55 women and 25 focus group discussions (FGDs) were held with 138 women and 42 men. The female condom, foaming tablets, sponge, foam, gel and film were demonstrated to 146 women and 35 of their male partners, who then tried out 2 of the products. They were interviewed 7 times during the course of 5 months. At the end experiences were evaluated during a second series of FGDs. Sixty-five (45%) women completed the trial. The main reasons for non-completion were related to geographical mobility. Product preference after the initial demonstration was similar to that at the end of the trial. The most popular formulations were the sponge (25% of the women), foaming tablets (23%), and the female condom (19%). The foam was of medium popularity (16%). The gel (9%) and film (7%) were least popular. Ten per cent of the women and 14% of the men reported products interfering with sexual enjoyment; 24% of the women and 67% of the men said products increased enjoyment. &#39;Dry sex&#39; is not popular in this area and increased lubrication was an important determinant of acceptability. Age, level of education and location did have some effect on preference. Although secrecy was a dominant theme in the FGDs, 87% of the women had informed their partners by the end of the trial. The products were generally well received. Female control was an important issue for both sexes. Male attitudes were ambivalent because female ownership of products increased women&#39;s control. Although they have clear preferences, women appear to accept the products generally and might use a single available product just as readily if choice was limited, as long as it conforms to general cultural preferences, such as those relating to wet/dry sex.
English: Uganda has experienced a slight decline in total fertility rate from 7.1 to 6.9 over the... more English: Uganda has experienced a slight decline in total fertility rate from 7.1 to 6.9 over the last twelve years. This has created a national drive to strengthen family planning services in order to have a substantial decline in fertility. This paper presents findings of a cross-sectional study carried out in 15 health units among pregnant women attending prenatal care
There is a declining trend of child health indicators in Uganda despite intensified program effor... more There is a declining trend of child health indicators in Uganda despite intensified program efforts to improve child care. For example, the infant mortality rate increased from 81/1,000 in 1995 to 88/1,000 in the year 2000. This paper presents results of a study that assessed factors responsible for this trend. The objectives were to assess the prevalence of childhood illnesses and care-seeking practices for children with fever, diarrhea, and upper respiratory tract infections (URTI) in the Sembabule district of Central Uganda. A cross-sectional survey, using a WHO 30 cluster-sampling technique, was used to obtain data from 300 women with children aged less than 2 years. Prevalence of childhood illnesses and care-seeking practices were obtained using a structured questionnaire supplemented by in-depth interviews. The results showed that the 300 women interviewed had 323 children of whom 37.9% had an episode of fever 2 weeks before the survey, 40.3% had diarrhea, 37.4% had URTI, and ...
In a recent study of the acceptability of the female condom, foaming tablets, sponge, foam, film ... more In a recent study of the acceptability of the female condom, foaming tablets, sponge, foam, film and gel among 146 women and 35 of their male partners in south-west Uganda, we found a clear demand for, and consistent use of, these products. Although the participants understood that, with the exception of the female condom, there was no certainty about how much protection, if any, the products provided against HIV and sexually transmitted diseases (STD), they nonetheless said that the main reason for using the products was the partial ...
Malaria in pregnancy is a major public health problem in Uganda; and it is the leading cause of a... more Malaria in pregnancy is a major public health problem in Uganda; and it is the leading cause of anaemia among pregnant women and low birth weight in infants. Previous studies have noted poor quality of care in the private sector. Thus there is need to explore ways of improving quality of care in the private sector that provides almost a half of health services in Uganda. A survey was conducted from August to October 2014 within 57 parishes in Mukono district, central Uganda. The selected parishes had a minimum of 200 households and at least one registered drug shop, pharmacy or private clinic. Data was collected using a structured questionnaire targeting one provider who was found on duty in each selected private health facility and consented to the study. The main variables were: provider characteristics, previous training received, type of drugs stocked, treatment and prevention practices for malaria among pregnant women. The main study outcome was the proportion of private health facilities who prescribe treatment of fever among pregnant women as recommended in the guidelines. A total of 241 private health facilities were surveyed; 70.5 % were registered drug shops, 24.5 % private clinics and 5.0 % pharmacies. Treatment of fever among pregnant women in accordance with the national treatment guidelines was poor: 40.7 % in private clinics, decreasing to 28.2 % in drug shops and 16.7 % at pharmacies. Anti-malarial monotherapies sulphadoxine-pyrimethamine and quinine were commonly prescribed, often without consideration of gestational age. The majority of providers (&gt;75 %) at all private facilities prescribed SP for intermittent preventive treatment but artemisinin-based combination therapy was prescribed: 8.3, 6.9 and 8.3 % respectively at drug shops, private clinics and pharmacies for prevention of malaria in pregnancy. Few facilities had malaria treatment guidelines; (44.1 % of private clinics, 17.9 % of drug shops, and 41.7 % at pharmacies. Knowledge of people at risk of malaria, P = 0.02 and availability of malaria treatment guidelines, P = 0.03 were the factors that most influenced correct treatment of fever in pregnancy. Treatment of fever during pregnancy was poor in this study setting. These data highlight the need to develop interventions to improve patient safety and quality of care for pregnant women in the private health sector in Uganda.
ABSTRACT In rural Uganda there is a growing trend of CHW participation in health services. Since ... more ABSTRACT In rural Uganda there is a growing trend of CHW participation in health services. Since 2005 CHWs have been administering the injectable contraception depot medroxyprogesterone acetate (DMPA) to clients. As the responsibilities of CHWs expands, their exposure to and role in clinical trials will increase. However, CHWs with previous research experience is rare. Clinical trials traditionally take place in clinic settings and adhere to stringent guidelines called Good Clinical Practice (GCP) to protect human subjects involved in trials. Thirty-eight CHWs from Mubende and Nakasongola districts were trained to be staff family planning (FP) providers in a clinical trial studying the acceptability of depo-subQ in Uniject. The study assessed FP provider and DMPA client acceptability of this new injectable contraceptive method. To assess acceptability, the study was designed to maintain CHW current working practices as close as possible. CHWs routinely collect FP supplies from local clinics, transport and store the supplies in their home, and provide FP counseling and services to clients in a variety of community settings including their home. In this presentation, we will discuss the challenges faced and strategies used to meet GCP guidelines in this non-clinic setting, with a focus on CHW training and oversight, and CHWs&#39; role in meeting documentation requirements, client participant recruitment and consent, and study product storage and accountability. As CHW participation in health services continues to grow, the challenges and lessons learned from this example will help inform future research strategies considering engaging CHWs as researchers.
The main objective of this study was to assess practices of antibiotic prescription at registered... more The main objective of this study was to assess practices of antibiotic prescription at registered drug shops with a focus on upper respiratory tract infections among children in order to provide data for policy discussions aimed at improving quality of care and patient safety in the private health sector in Uganda. A survey was conducted within 57 parishes from August to October 2014 in Mukono District, Uganda. Data was captured on the following variables: drug shop characteristics, training of staff in management of pneumonia, availability of guidelines and basic equipment, available antibiotics, knowledge on treatment of pneumonia in children aged <5 years. The main study outcome was the proportion of private health facilities prescribing an antibiotic. A total of 170 registered drug shops were surveyed between August and October 2014. The majority of drug shops, 93.5% were prescribing antibiotics, especially amoxicillin and trimethoprim-sulfamethoxazole (septrin). The professi...
International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases, Jan 14, 2016
Nodding syndrome is a devastating neurological disorder affecting children in mostly eastern Afri... more Nodding syndrome is a devastating neurological disorder affecting children in mostly eastern Africa. An estimated 10,000 children are affected. Uganda, one of the most affected countries, systematically set out to investigate the disease and developed interventions for it. On 21(st) December 2015, the Ministry of Health held a meeting with community leaders from the affected areas to disseminate results of investigations to date. This paper summarizes the presentation and shares the story of studies into this peculiar disease. It also shares results of preliminary studies of pathogenesis and puts into perspective an upcoming treatment intervention. Clinical and electrophysiological studies demonstrated nodding syndrome is a complex epilepsy disorder. A definitive aetiological agent has not been established but in agreement with other affected countries, a consistent epidemiologic association has been demonstrated with infection by Onchocerca volvulus. Preliminary studies of pathogen...
Innovative and sustainable strategies to strengthen districts and other sub-national health syste... more 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&amp;amp;amp;amp;amp;#39; 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.
Malaria is a major public health problem in Uganda and the current policy recommends introduction... more Malaria is a major public health problem in Uganda and the current policy recommends introduction of rapid diagnostic tests for malaria (RDTs) to facilitate effective case management. However, provision of RDTs in drug shops potentially raises a new set of issues, such as adherence to RDTs results, management of severe illnesses, referral of patients, and relationship with caretakers. The main objective of the study was to examine the impact of introducing RDTs in registered drug shops in Uganda and document lessons and policy implications for future scale-up of malaria control in the private health sector. A cluster-randomized trial introducing RDTs into registered drug shops was implemented in central Uganda from October 2010 to July 2012. An evaluation was undertaken to assess the impact and the processes involved with the introduction of RDTs into drug shops, the lessons learned and policy implications. Introducing RDTs into drug shops was feasible. To scale-up this intervention however, drug shop practices need to be regulated since the registration process was not clear, supervision was inadequate and record keeping was poor. Although initially it was anticipated that introducing a new practice of record keeping would be cumbersome, but at evaluation this was not found to be a constraint. This presents an important lesson for introducing health management information system into drug shops. Involving stakeholders, especially the district health team, in the design was important for ownership and sustainability. The involvement of village health teams in community sensitization to the new malaria treatment and diagnosis policy was a success and this strategy is recommended for future interventions. Introducing RDTs into drug shops was feasible and it increased appropriate treatment of malaria with artemisinin-based combination therapy. It is anticipated that the lessons presented will help better implementation of similar interventions in the private sector.
The Community and District Empowerment for Scale-up (CODES) project pioneered the implementation ... more 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.
Inappropriate treatment of malaria is widely reported particularly in areas where there is poor a... more Inappropriate treatment of malaria is widely reported particularly in areas where there is poor access to health facilities and self-treatment of fevers with anti-malarial drugs bought in shops is the most common form of care-seeking. The main objective of the study was to examine the impact of introducing rapid diagnostic tests for malaria (mRDTs) in registered drug shops in Uganda, with the aim to increase appropriate treatment of malaria with artemisinin-based combination therapy (ACT) in patients seeking treatment for fever in drug shops. A cluster-randomized trial of introducing mRDTs in registered drug shops was implemented in 20 geographical clusters of drug shops in Mukono district, central Uganda. Ten clusters were randomly allocated to the intervention (diagnostic confirmation of malaria by mRDT followed by ACT) and ten clusters to the control arm (presumptive treatment of fevers with ACT). Treatment decisions by providers were validated by microscopy on a reference blood ...
Uploads
Papers by Anthony Mbonye
febrile illness in the retail sector has led to a number of
public health initiatives to try to improve the quality of
care provided in these settings. The potential to support
the introduction of rapid diagnostic tests for malaria
(mRDTs) into drug shops is coming under increased
scrutiny. Those in favour argue that it enables the
harmonisation of policy around testing and treatment
for malaria and maintains a focus on market-based
solutions to healthcare. Despite the enthusiasm among
many global health actors for this policy option, there is
a limited understanding of the consequences of the
introduction of mRDTs in the retail sector. We
undertook an interpretive, mixed methods study with
drug shop vendors (DSVs), their clients and local health
workers to explore the uses and interpretations of
mRDTs as they became part of daily practice in drug
shops during a trial in Mukono District, Uganda. This
paper reports the unintended consequences of their
introduction. It describes how the test engendered trust
in the professional competence of DSVs; was
misconstrued by clients and providers as enabling a
more definitive diagnosis of disease in general rather
than malaria alone; that blood testing made drug shops
more attractive places to seek care than they had
previously been; was described as shifting treatment-
seeking behaviour away from formal health centres and
into drug shops; and influenced an increase in sales of
medications, particularly antibiotics
febrile illness in the retail sector has led to a number of
public health initiatives to try to improve the quality of
care provided in these settings. The potential to support
the introduction of rapid diagnostic tests for malaria
(mRDTs) into drug shops is coming under increased
scrutiny. Those in favour argue that it enables the
harmonisation of policy around testing and treatment
for malaria and maintains a focus on market-based
solutions to healthcare. Despite the enthusiasm among
many global health actors for this policy option, there is
a limited understanding of the consequences of the
introduction of mRDTs in the retail sector. We
undertook an interpretive, mixed methods study with
drug shop vendors (DSVs), their clients and local health
workers to explore the uses and interpretations of
mRDTs as they became part of daily practice in drug
shops during a trial in Mukono District, Uganda. This
paper reports the unintended consequences of their
introduction. It describes how the test engendered trust
in the professional competence of DSVs; was
misconstrued by clients and providers as enabling a
more definitive diagnosis of disease in general rather
than malaria alone; that blood testing made drug shops
more attractive places to seek care than they had
previously been; was described as shifting treatment-
seeking behaviour away from formal health centres and
into drug shops; and influenced an increase in sales of
medications, particularly antibiotics