BackgroundUse of evidence in health policymaking plays an important role, especially in resource-constrained settings where informed decisions on resource allocation are paramount. Several knowledge translation (KT) models have been developed, but few have been applied to health policymaking in low income countries. If KT models are expected to explain evidence uptake and implementation, or lack of it, they must be contextualized and take into account the specificity of low income countries for example, the strong influence of donors. The main objective of this research is to elaborate a Middle Range Theory (MRT) of KT in Uganda that can also serve as a reference for other low- and middle income countries.MethodsThis two-step study employed qualitative approaches to examine the principal barriers and facilitating factors to KT. Step 1 involved a literature review and identification of common themes. The results informed the development of the initial MRT, which details the facilitating factors and barriers to KT at the different stages of research and policy development. In Step 2, these were further refined through key informant interviews with policymakers and researchers in Uganda. Deductive content and thematic analysis was carried out to assess the degree of convergence with the elements of the initial MRT and to identify other emerging issues.ResultsReview of the literature revealed that the most common emerging facilitating factors could be grouped under institutional strengthening for KT, research characteristics, dissemination, partnerships and political context. The analysis of interviews, however, showed that policymakers and researchers ranked institutional strengthening for KT, research characteristics and partnerships as the most important. New factors emphasized by respondents were the use of mainstreamed structures within MoH to coordinate and disseminate research, the separation of roles between researchers and policymakers, and the role of the community and civil society in KT.ConclusionsThis study refined an initial MRT on KT in policymaking in the health sector in Uganda that was based on a literature review. It provides a framework that can be used in empirical research of the process of KT on specific policy issues.

Inadequate health financing is one of the major challenges health systems in low-income countries currently face. Health financing reforms are being implemented with an increasing interest in policies that abolish user fees. Data from three nationally representative surveys conducted in Uganda in 1999/2000, 2002/03 and 2005/06 were used to investigate the impact of user fee abolition on the attainment of universal coverage objectives. An increase in illness reporting was noted over the three surveys, especially among the poorer quintiles. An increase in utilization was registered in the period immediately following the abolition of user fees and was most pronounced in the poorest quintile. Overall, there was an increase in utilization in both public and private health care delivery sectors, but only at clinic and health centre level, not at hospitals. Our study shows important changes in health-care-seeking behaviour. In 2002/03, the poorest population quintile started using government health centres more often than private clinics whereas in 1999/2000 private clinics were the main source of health care. The richest quintile has increasingly used private clinics. Overall, it appears that the private sector remains a significant source of health care. Following abolition of user fees, we note an increase in the use of lower levels of care with subsequent reductions in use of hospitals. Total annual average expenditures on health per household remained fairly stable between the 1999/2000 and 2002/03 surveys. There was, however, an increase of US$21 in expenditure between the 2002/03 and 2005/06 surveys. Abolition of user fees improved access to health services and efficiency in utilization. On the negative side is the fact that financial protection is yet to be achieved. Out-of-pocket expenditure remains high and mainly affects the poorer population quintiles. A dual system seems to have emerged where wealthier population groups are switching to the private sector.

BackgroundThe objectives of this study were to assess the patterns of treatment seeking behaviour for children under five with malaria; and to examine the statistical relationship between out-of-pocket expenditure (OOP) on malaria treatment for under-fives and source of treatment, place of residence, education and wealth characteristics of Uganda households. OOP expenditure on health care is now a development concern due to its negative effect on households’ ability to finance consumption of other basic needs.MethodsThe 2009 Uganda Malaria Indicator Survey was the source of data on treatment seeking behaviour for under-five children with malaria, and patterns and levels of OOP expenditure for malaria treatment. Binomial logit and Log-lin regression models were estimated. In logit model the dependent variable was a dummy (1=incurred some OOP, 0=none incurred) and independent variables were wealth quintiles, rural versus urban, place of treatment, education level, sub-region, and normal duty disruption. The dependent variable in Log-lin model was natural logarithm of OOP and the independent variables were the same as mentioned above.ResultsFive key descriptive analysis findings emerge. First, malaria is quite prevalent at 44.7% among children below the age of five. Second, a significant proportion seeks treatment (81.8%). Third, private providers are the preferred option for the under-fives for the treatment of malaria. Fourth, the majority pay about 70.9% for either consultation, medicines, transport or hospitalization but the biggest percent of those who pay, do so for medicines (54.0%). Fifth, hospitalization is the most expensive at an average expenditure of US$7.6 per child, even though only 2.9% of those that seek treatment are hospitalized.The binomial logit model slope coefficients for the variables richest wealth quintile, Private facility as first source of treatment, and sub-regions Central 2, East central, Mid-eastern, Mid-western, and Normal duties disrupted were positive and statistically significant at 99% level of confidence. On the other hand, the Log-lin model slope coefficients for Traditional healer, Sought treatment from one source, Primary educational level, North East, Mid Northern and West Nile variables had a negative sign and were statistically significant at 95% level of confidence.ConclusionThe fact that OOP expenditure is still prevalent and private provider is the preferred choice, increasing public provision may not be the sole answer. Plans to improve malaria treatment should explicitly incorporate efforts to protect households from high OOP expenditures. This calls for provision of subsidies to enable the private sector to reduce prices, regulation of prices of malaria medicines, and reduction/removal of import duties on such medicines.

Malaria due to P. falciparum is the number one cause of morbidity and mortality in Uganda where it is highly endemic in 95% of the country. The use of efficacious and effective antimalarial medicines is one of the key strategies for malaria control. Until 2000, Chloroquine (CQ) was the first-line drug for treatment of uncomplicated malaria in Uganda. Due to progressive resistance to CQ and to a combination of CQ with Sulfadoxine-Pyrimethamine, Uganda in 2004 adopted the use of ACTs as first-line drug for treating uncomplicated malaria. A review of the drug policy change process and postimplementation reports highlight the importance of managing the policy change process, generating evidence for policy decisions and availability of adequate and predictable funding for effective policy roll-out. These and other lessons learnt can be used to guide countries that are considering anti-malarial drug change in future.

BackgroundA guideline contains processes and procedures intended to guide health service delivery. However, the presence of guidelines may not guarantee their implementation, which may be a result of weaknesses in the development process. This study was undertaken to describe the processes of developing health planning, services management, and clinical guidelines within the health sector in Uganda, with the goal of understanding how these processes facilitate or abate the utility of guidelines.MethodsQualitative and quantitative research methods were used to collect and analyze data. Data collection was undertaken at the levels of the central Ministry of Health, the district, and service delivery. Qualitative methods included review of documents, observations, and key informant interviews, as well as quantitative aspects included counting guidelines. Quantitative data were analyzed with Microsoft Excel, and qualitative data were analyzed using deductive content thematic analysis.ResultsThere were 137 guidelines in the health sector, with programs related to Millennium Development Goals having the highest number (n = 83). The impetus for guideline development was stated in 78% of cases. Several guidelines duplicated content, and some conflicted with each other. The level of consultation varied, and some guidelines did not consider government-wide policies and circumstances at the service delivery level. Booklets were the main format of presentation, which was not tailored to the service delivery level. There was no framework for systematic dissemination, and target users were defined broadly in most cases. Over 60% of guidelines available at the central level were not available at the service delivery level, but there were good examples in isolated cases. There was no framework for systematic monitoring of use, evaluation, and review of guidelines. Suboptimal performance of the supervision framework that would encourage the use of guidelines, assess their utilization, and provide feedback was noted.ConclusionsGuideline effectiveness is compromised by the development process. To ensure the production of high-quality guidelines, efforts must be employed at the country and regional levels. The regional level can facilitate pooling resources and expertise in knowledge generation, methodology development, guideline repositories, and capacity building. Countries should establish and enforce systems and guidance on guideline development.

BackgroundAn estimated 147,741 maternal deaths occurred in 2010 in 45 of the 47 countries in the African Region of the World Health Organization (WHO). The objective of this study was to estimate the indirect cost of maternal deaths in the Region to provide data for use in advocacy for increased domestic and external investment in multisectoral policy interventions to curb maternal mortality.MethodsThis study used the cost-of-illness method to estimate the indirect cost of maternal mortality, i.e. the loss in non-health gross domestic product (GDP) attributable to maternal deaths. Estimates on maternal mortality for 2010 from Trends in maternal mortality: 1990 to 2010 published by WHO, UNICEF, UNFPA and the World Bank were used in these calculations. Values for future non-health GDP lost were converted into their present values by applying a 3% discount rate. One-way sensitivity analysis at 5% and 10% discount rates assessed the impact on non-health GDP loss. Indirect cost analysis was undertaken for the countries, categorized under three income groups. Group 1 consisted of nine high and upper middle income countries, Group 2 of 12 lower middle income countries, and Group 3 of 26 low income countries. Estimates for Seychelles in Group 1 and South Sudan in Group 3 were not provided in the source used.ResultsThe 147,741 maternal deaths that occurred in 45 countries in the African Region in 2010 resulted in a total non-health GDP loss of Int$ 4.5 billion (PPP). About 24.5% of the loss was in Group 1 countries, 44.9% in Group 2 countries and 30.6% in Group 3 countries. This translated into losses in non-health GDP of Int$ 139,219, Int$ 35,440 and Int$ 16,397 per maternal death, respectively, for the three groups. Using discount rates of 5% and 10% reduced the total non-health GDP loss by 19.1% and 47.7%, respectively.ConclusionMaternal mortality is responsible for a noteworthy level of non-health GDP loss among the countries in the African Region. There is urgent need, therefore, to increase domestic and external investment to scale up coverage of existing cost-effective, multisectoral women’s health interventions to reduce maternal morbidity and mortality.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2393-14-299) contains supplementary material, which is available to authorized users.

BackgroundThe burden of malaria is a key challenge to both human and economic development in malaria endemic countries. The impact of malaria can be categorized from three dimensions, namely: health, social and economic. The objective of this study was to estimate the impact of malaria morbidity on gross domestic product (GDP) of Uganda.MethodsThe impact of malaria morbidity on GDP of Uganda was estimated using double-log econometric model. The 1997-2003 time series macro-data used in the analysis were for 28 quarters, i.e. 7 years times 4 quarters per year. It was obtained from national and international secondary sources.ResultsThe slope coefficient for Malaria Index (M) was -0.00767; which indicates that when malaria morbidity increases by one unit, while holding all other explanatory variables constant, per capita GDP decreases by US$0.00767 per year. In 2003 Uganda lost US$ 49,825,003 of GDP due to malaria morbidity. Dividing the total loss of US$49.8 million by a population of 25,827,000 yields a loss in GDP of US$1.93 per person in Uganda in 2003.ConclusionMalaria morbidity results in a substantive loss in GDP of Uganda. The high burden of malaria leads to decreased long-term economic growth, and works against poverty eradication efforts and socioeconomic development of the country.

BackgroundUganda is proposing introduction of the National Health Insurance scheme (NHIS) in a phased manner with the view to obtaining additional funding for the health sector and promoting financial risk protection. In this paper, we have assessed the proposed NHIS from an equity perspective, exploring the extent to which NHIS would improve existing disparities in the health sector.MethodsWe reviewed the proposed design and other relevant documents that enhanced our understanding of contextual issues. We used the Kutzin and fair financing frameworks to critically assess the impact of NHIS on overall equity in financing in Uganda.ResultsThe introduction of NHIS is being proposed against the backdrop of inequalities in the distribution of health system inputs between rural and urban areas, different levels of care and geographic areas. In this assessment, we find that gradual implementation of NHIS will result in low coverage initially, which might pose a challenge for effective management of the scheme. The process for accreditation of service providers during the first phase is not explicit on how it will ensure that a two-tier service provision arrangement does not emerge to cater for different types of patients. If the proposed fee-for-service mechanism of reimbursing providers is pursued, utilisation patterns will determine how resources are allocated. This implies that equity in resource allocation will be determined by the distribution of accredited providers, and checks put in place to prohibit frivolous use. The current design does not explicitly mention how these two issues will be tackled. Lastly, there is no clarity on how the NHIS will fit into, and integrate within existing financing mechanisms.ConclusionUnder the current NHIS design, the initial low coverage in the first years will inhibit optimal achievement of the important equity characteristics of pooling, cross-subsidisation and financial protection. Depending on the distribution of accredited providers and utilisation patterns, the NHIS could worsen existing disparities in access to services, given the fee-for-service reimbursement mechanisms currently proposed. Lastly, if equity in financing and resource allocation are not explicit objectives of the NHIS, it might inadvertently worsen the existing disparities in service provision.