Baylor-Uganda employs a health systems strengthening approach benchmarked by the World Health Organization framework of the six building blocks, namely: Leadership and Governance, Healthcare Financing, Health Workforce, Medical Products and Technologies, Information and Research plus Service Delivery. With an emphasis on the district led programming model, health systems strengthening is implemented through a number of programs including Capacity Building, Caring Together Project, Grants Management, ABT project, Laboratory and Pharmacy Services.
Laboratory support is very crucial for improvement of quality of health services in the healthcare system. Baylor Uganda continued to support health facilities to provide testing commensurate to their level of service as established by the MOH test menu either through direct delivery or referral of samples to over 90% from the previous 60% sample transport and result transmission network.
During the period, Viral Load Testing and Monitoring was scaled up in addition to interventions ranging from infrastructure improvement, Strengthening Laboratory Management Towards Accreditation (SLMTA) to 18 Hub laboratories, Laboratory Quality Management Systems (LQMS) to over 200 non Hub labs, equipment and human resource support (HRS), monitoring quality of testing and laboratory staff in-service training and mentorships. Such interventions markedly improved coordination, functionality and quality of laboratory services within the districts as evidenced by 100% ordering of commodities, improved availability of lab commodities, improved participation in external quality assurance (92% for HIV and 87% for TB DTUs) and overall quality management system by all the laboratories.
In this reporting period, the Centre of Excellence (COE) laboratory renewed its accreditation with the College of American Pathologists (CAP) until April 2017. A total of 54 Laboratory Managers and Quality Officers were trained in SLMTA and as resident mentors, 208 staff in LQMS and biosafety, and 28 additional microscopes procured to support quality TB diagnosis in the supported regions.
Baylor-Uganda commits to strengthening efficiencies in management of medical commodities to promote equitable allocation/distribution of medicines and other health supplies. Efforts that include training of health workers, use of technologies for quantification, ordering of supplies is improving availability and proper use of medicines and essential commodities.In the reporting period, the support strategy that includes onsite mentorship, use of bulk SMS reminders on ordering timelines, holding ordering review meetings, redistribution of medicines and information sharing via email groups lead to a 2% decrease in stock-outs of essential commodities. A total of 60 district & Health facility staff were trained on Good Medicines Quantifications Practices and Web-based ARV Ordering System (WAOS) to improve quantification quality. Health workers have been supported to make orders for supplies priotizing on vital or life-saving commodities in the categories of essential Medicines, General Laboratory Supplies and HIV test kits Storage of medicines has been improved with 75% of HFs implementing 5S principles of sorting, setting in order, shining, standardizing and sustaining while the introduction of the Ministry of Health pharmaceutical stock management software ‘Rxsolution’ is strengthening stock management. The software supports timely tracking of stock levels, improved monitoring/ tracking for expiration of stored medicines. To minimize wastage in overstocked health facilities, Baylor-Uganda redistributed medicines from overstocked health facilities to those that had stock outs. We continue to support districts on emergency ordering for supplies that are low in stock in the region. Late reporting and delayed supply of health commodities leading to stock outs is still a challenge. Colloboration with donors: with support from American Foundation for Children with AIDS (AFCA), 5 hospitals (Kilembe mine, Kibiito, Atutur, Katakwi, Kaabong) have rreceived hospital equipment worth $1.3million dollars. Includes hospital beds and mattresses, furniture for staff and patients, baby warmers, assorted surgical tools and consumables like gloves and diapers.
Human resources for health
The project Human Resource technical team conducted integrated onsite mentorships to 25 health facilities addressing staffing needs for the HIV clinics, staff performance(appraisals),availability of job descriptions as well as ensure the above site(DHT) human resource management systems for the 7 districts. Subsequent CDC SIMs assessments for supported sites showed good scores for the HRH component across the region.
The regional project HR coordinators worked with DLGs (DHOs) to identify critical staffing gaps over the period, the project with PEPFAR grants has supported absorption of 20 cadres by the DLG across the region. Additionally with support from Intra-health the project officers started strengthening the utilization of HRIS through ensuring a fully updated HRIS database with staff records, training and performance with so far 4 of the 7 districts technically supported. This is an ongoing activity that will be scaled up across the rest of the districts.
Through twinning of the project M&E officers and district biostatistician, we carried out HMIS, Data modelling trainings, integrated and M&E specific mentorship, CQI Facility specific performance dissemination, Joint Data quality Validation and Assessment, as well as logistical support in form of patient files, filing cabinets, computer set and suspension files to both facility and CBO’s. The average reporting rate was 96.1% in DHIS2 with system breakdown in July 2017. In order to enhance the capacity of districts in electronic data management, the Biostatisticians were trained in Uganda EMR as trainers of trainers. Currently sixty five (65) health facilities have got a functional Uganda EMR and 25 CBOs have an e-data base to capture community data. Medical logistics and commodities – Since October 2016, Baylor Uganda has consistently achieved 100% ordering for medical commodities for HIV/AIDS in WAOS. However only 61% of commodities ordered were accurately quantified and this is attributed to limitation in quantification skills and low health facility/district leadership involvement in the ordering process. To mitigate this gap, the project supported ordering review meetings with stakeholders and targeted technical support to problematic health facilities to address poor quantification for HIV commodities. Additionally health workers will be given onsite training on an improved WAOS tool to achieve 100% quantification accuracy. Over the reporting period, stock outs for HIV commodities were significantly minimized despite the increased demand following the roll out of test and treat guidelines. Stock outs were mitigated by vigorous redistribution and tracking of stock levels for TDF/3TC/EFV and NVP syrup that were in high demand and limited supply from NMS since January 2017. However stock outs of Nevirapine syrup and Lopinavir/Ritonavir 200/50mg tablets continue to hamper HIV service delivery due to lack of supply from NMS. The project plans to address this gap in the interim through soliciting redistribution of these items from other regions.
The project supports District Local Governments, CBOs and PHA networks to plan and allocate resources for HIV response. As mandated by CDC,the SNAPS west project allocates 30% of the total CDC grant to health facilities and community based organization in form of sub-grants, conduct district planning meetings. Following successful planning & budgeting at district level, a total fund of Ug. Shs1,188,086,500 was sub granted to 125 health facilities and Ug. Shs. 931,802,072 to 25 CBOs to facilitate health services delivery as well as strengthen and functionalize the community –facility referral framework. Implementation is ongoing and currently visible outcomes are being realized due to the effect of this financial support.
Leadership and governance
The project working in close collaboration with the Caring Together project has strengthened leadership skills among frontline health workers, health unit management committee members (HUMC), sub-county and district leaders. Onsite quarterly leadership mentorships targeting frontline health workers were conducted across the region to deliver trainings, review previous improvement action plans and promote use of data at facility level for planning and decision making. Orientations were jointly conducted for HUMC members, sub county leaders and DHT members. These were targeted at improving their supervisory roles to health facilities, heighten coordination for improved reporting and implementation of identified action plans to close the gaps noted in site support supervision. Findings gathered from the site mentorship follow up visits were shared with the District Health Officers at the performance review meetings, and actions to address issues of staff absenteeism, strengthening joint support supervision to health facilities drawn. A cross cultural leadership training to explore the facility leadership trainings sustainability and tools developed, integration, research, advocacy and communication of best practices arising from this intervention was conducted in the region for project mentors and leaders from Jansen Pharmaceuticals in Belgium and facilitated by leadership experts from London Business School. During this exchange, the idea of Caring Together approach to improve quality of health care was piloted among the clinical and nursing students from institutions around Rwenzori region, at a leadership seminar that was hosted by Mountains of the Moon University. To enhance data use at facility level and Increase the number of sites having regular and effective performance review meetings, the Team Performance Monitoring Tools (TPMT) and customized meeting books were rolled out in all the sites.