Improving child survival through a district management strengthening and community empowerment intervention: early implementation experiences from Uganda

Abstract

BackgroundThe 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.MethodsThis 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.ResultsAll 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.ConclusionThe 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.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-2129-z) contains supplementary material, which is available to authorized users.

Understanding the local context and its possible influences on shaping, implementing and running social accountability initiatives for maternal health services in rural Democratic Republic of the Congo: a contextual factor analysis

“…Contextual factors such as described in the present study are more likely to be somewhat found at the local level in several low-and middle income countries, as reported in existing literature from Benin [23, 51], Burundi [48], Uganda [58], Tanzania [60] and India [26, 44]. This highlights that the conceptual model as adapted can be used in other setting in order to generate information about local contexts.…”

“…They would then be involved in defining, implementing, monitoring, and evaluating health activities. Some examples of successful capacity-building interventions in local settings using participative approaches are provided by Swaans et al(2008) in South Africa [57], Björkman and Svensson (2009) in Uganda [53], Katahoire et al (2015) in Kenya [58], and Manandhar et al (2004) in Nepal [22]. …”

Community perceptions on demand-side incentives to promote institutional delivery in Oyam district, Uganda: a qualitative study

“…Given the concerns of some community leaders regarding sustainability of the interventions beyond the funded period, CUAMM (the implementing non-governmental organisation (NGO)) initiated dialogues with the district local government, health authorities and community leaders to explore ways of mitigating some of the potential untoward effects of the interventions 14. Furthermore, the organisation commissioned a study to investigate the feasibility of setting up a community health insurance scheme that could support the transport voucher scheme in the district 35…”

“…Interventions designed with inputs from the beneficiary communities are more likely to succeed. Early dialogues involving beneficiary communities before and during the design and implementation of interventions may identify and prioritise the needs of the communities, explore and address potential barriers, and promote community engagement, which may generate a sense of ownership among the beneficiaries 12–14…”

Experiences of using a participatory action research approach to strengthen district local capacity in Eastern Uganda

“…[10] Because the health system has inadequate financing, management, infrastructure and resources, external agencies such as universities, non-governmental organizations and other donor or development agencies often implement interventions to fill existing gaps. [11] Makerere University College of Health Sciences – School of Public Health (MakCHS-SPH) is one such external agency within the country. To strengthen the health system at district level, a research team (at MakCHS-SPH), in collaboration with three local districts in Eastern Uganda, used the PAR approach to design and implement a maternal and neonatal health project.…”