Article 2: Longitudinal study assessing the one-year effects of supervision performance assessment and recognition strategy (SPARS) to improve medicines management in Uganda health facilities

Abstract

BackgroundIn late 2010, Uganda introduced a supervision, performance assessment, and recognition strategy (SPARS) to improve staff capacity in medicines management in government and private not-for-profit health facilities. This paper assesses the impact of SPARS in health facilities during their first year of supervision.MethodsSPARS uses health workers trained as Medicines Management Supervisors (MMS) to supervise health facilities and address issues identified through indicatorbased performance assessment in five domains: stock management, storage management, ordering and reporting, prescribing quality, and dispensing quality. We used routine data generated during SPARS visits to 1222 health facilities to evaluate performance changes during the first year of supervision as well as the time until achieving an adequate score in this period. We also explored variables related to facilities, MMS, and intensity of implementation as predictors of performance improvement and time until achieving an adequate score.ResultsHealth facilities received an average of 3.4 MMS visits during the first year of supervision, with an average of 88 days between visits; each MMS implemented a median of 28 visits per year. Overall SPARS scores (maximum of 25) improved by 2.3 points (22.3%) per visit from a mean baseline score of 10.3. The adjusted improvement in overall SPARS score was significantly higher in primary health care facilities (2.36) versus higher-level health facilities and hospitals (2.15) (p = 0.001). The incremental improvement was highest at visit 2, with decreasing but continuing positive gains in subsequent visits. The adjusted mean incremental improvement per visit was highest in the prescribing quality domain, followed by dispensing quality, ordering and reporting, stock management, and storage management. Adjusted improvement in SPARS scores varied by region, year of implementation, and facility ownership. After one year of SPARS, 22% of facilities achieved an adequate score of 18.75 (75% of maximum score).ConclusionsSPARS was effective in building health facility capacity in medicines management, with a median overall improvement of almost 70% during the first year. The greatest improvements occurred in prescribing quality and at lower levels of care, although the highest level of performance was achieved in storage management. We recommend broad dissemination of the SPARS approach in all Ugandan health facilities as well as in other countries seeking a practical strategy to improve medicines management performance.Electronic supplementary materialThe online version of this article (10.1186/s40545-018-0142-1) contains supplementary material, which is available to authorized users.

“The number of clients is increasing but the supplies are reducing”: provider strategies for responding to chronic antiretroviral (ARV) medicines stock-outs in resource-limited settings: a qualitative study from Uganda

“…The stock-out of antiretroviral and concomitant drugs is an increasingly chronic bottleneck in HIV service delivery in Uganda and the broader Sub-Saharan Africa region [8, 10–12]. Previous approaches have examined this phenomenon from a macro-level lens such as studies interrogating national-level drivers of stock-outs in countries with weak medicines supply chain systems [10, 12, 17, 19, 31]. However, there has been limited empirical attention devoted to strategies devised at the front-line level of service delivery in response to the chronic stock-outs of antiretroviral medicines [44].…”

“…The private sector accounts for about 20–30% of ART provision in Uganda [6, 26]. Public health facilities from the level of health centre IVs (sub-district) and higher-level hospitals [31] make formal requisitions for supply of medicines and other commodities based on patient data such as the number of patients and type of regimen (whether first or second line) and therefore the medicines they need. Hence, facility-level dynamics are influential on the adequacy of the stock of ARVs available for dispensing to patients.…”

1-year impact of supervision, performance assessment, and recognition strategy (SPARS) on prescribing and dispensing quality in Ugandan health facilities

“…We randomly selected 44 districts from the three strata (high, medium, and low) using systematic sampling of 20, 12, and 12 districts, respectively, and checked that all four regions were equally represented; one more Western district was later selected randomly from all districts to reach a total of 45 districts, resulting in 15, 13, 9, and 8 districts from the Western, Eastern, Northern, and Central regions, respectively [7,17]. This analysis includes 1222 SPARS supervised facilities from within the selected district that had at least two visits during a 12-month period of SPARS implementation.…”

“…The predictor variables used in this analysis have been described in a previous article in this series [17]. We identified two categories of predictor variables-facilitylevel and MMS-level predictors.…”

“…Poor availability of medicines and high out-of-pocket costs can result in not all prescribed medicines being dispensed. In the Ugandan context, the availability of six tracer medicines at health facility level increased from 61 to 88% from 2010/2011 to 2012/2013 following improved stock and storage management and increased per capita expenditures on essential medicines [15,17]. Furthermore, medicines are provided free of charge in the government sector and some medicines are also donated in the PNFP sector.…”