Although expanding fiscal space for health worker recruitments could reduce workforce shortages in Sub-Saharan Africa, effective strategies for achieving this are still unclear. We aimed to understand the process of transitioning health workers (HWs) from PEPFAR to Government of Uganda (GoU) payrolls and to explore the facilitators and barriers encountered in increasing domestic financial responsibility for absorbing this transitioned workforce. We conducted a multiple case-study of 10 (out of 87) districts in Uganda which received PEPFAR support between 2013 and 2015 to expand their health workforce. We purposively selected eight districts with the highest absorption rates (‘High absorbers’) and two with the lowest absorption rates (‘Low absorbers’). A total of 66 interviews were conducted with high-level officials in three Ministries of Finance, Health and Public Service (n = 14), representatives of PEPFAR implementing organizations (n = 16), District Health Teams (n = 15) and facility managers (n = 22). Twelve focus groups were conducted with 87 HWs absorbed on GoU payrolls. We utilized the Consolidated Framework for Implementation Research (CFIR) to guide thematic analysis. At sub-national level, facilitators of transition in ‘high absorber’ districts were identified as the presence of transition ‘champions’, prioritizing HWs in district wage bill commitments, host facilities providing ‘bridge financing’ to transition workforce during salary delays and receiving donor technical support in district wage bill analysis- attributes which were absent in ‘low absorber’ districts. At national-level, multi-sectoral engagements (incorporating the influential Ministry of Finance), developing a joint transition road map, aligning with GoU salary scales and recruitment processes emerged as facilitators of the transition process. Overall, PEPFAR support acted as a catalyst for increasing GoU and facility-level budget allocations towards expanding the health workforce in focus districts in Uganda. Our case-studies offer implementation research lessons on effective donor transition and insights into pragmatic strategies for expanding fiscal space for health in a low-income setting.
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Background Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)’s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients’ and HIV service managers’ perceptions of the early implementation experiences of national DSD roll-out across Uganda. Methods We utilized a qualitative research design involving 124 participants. Between April and June 2019 we conducted 76 semi-structured interviews with national-level HIV program managers (n=18), District Health Team leaders (n=24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by the multi-level analytical framework by Levesque et al. (2013): Individual-level factors; Health-system factors; Community factors; and Context. Results Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level factors: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system factors: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community factors: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations. Contextual factors: Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating drug pick-ups. Conclusion This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing self-stigma barriers, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).
Background: AIDS is the leading cause of death among young people in sub-Saharan Africa. Adherence to antiretroviral therapy is the principal determinant for achieving and sustaining viral suppression, which decreases progression to AIDS and reduces risk of mortality. Few studies have evaluated mHealth adherence tools among youths in resource-limited settings.We aim to evaluate whethermHealth tool improves ART adherence outcomes among youth receiving ART at a rural district in Western Uganda. The Corona virus disease outbreak was announced a Public Health Emergency of International concern on Jan 2020; and declared a global pandemic by World Health Organization on Mar, 2020.In rural areas, there is little data on knowledge and myths on COVID among youths.General objective:To assessacceptability, effect and cost of themHealth tool on ART adherence, knowledge and myths on COVID-19among youth initiating and on ART at KiryandongoDistrict.Methods: This is a mixed methodsequential exploratory study, with the qualitative study conducted first followed by a randomized control trial and healthcare cost evaluation.The qualitative study will assess barriers, enablers of adherence and acceptability of mHealth among youths receiving care at three health facilities inKiryandongo District.The randomized control trial of 206 youth initiatingARTto either Standard of Care or mHealth tool plus Standard of care to assesseffect of mHealth tool on ART adherence and retention in care. Through a basic cell phone, participants in the intervention arm will receive pill reminders, clinic appointment reminders, health voice messages and self-reported symptoms in addition to standard of care. Collection of data on knowledge and myths on COVID-19, HIV and sexual behavior. The health care evaluationnested within randomized trial, will assess the cost of interventionin comparison to Standard of care.Discussion: This project will determine acceptability, effectiveness of mHealth, knowledge & myths on COVID-19and cost of delivering pill and clinic appointment reminders, and voice messages to a population with suboptimal ART adherence in a resource-limited setting.Trial registration: Fully registered under clinicaltrials.gov by 20th Jan 2021. The study is ongoing. Recruitment started Aug 2020.Clinical Trial registration: NCT 04718974
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