Uganda

Background

Uganda was the third country site for the GREAT Network’s in-country guideline prioritization and implementation planning work. In August 2014, local stakeholders including clinicians, healthcare providers, healthcare administrators, researchers/academics, non-governmental organizations, policymakers, and professional associations from Uganda gathered as participants of a two-day workshop that involved focus group discussions followed by a prioritization meeting.

Informed by joint consultations with Makerere University, PATH, WHO, and the Ministry of Health Uganda, the following four maternal guidelines were selected as key priorities for implementation activities in Uganda:

To identify barriers and facilitators to the implementation of the priority guidelines in Uganda; and

To develop a cross-cutting, multi-level implementation strategy to improve the use of the guidelines.

Methods

Multiple methods were used to collect data on priorities, barriers and facilitators, as well as to determine potential implementation strategies for the four identified guidelines in Uganda. Primary data collection occurred during an in-country two-day workshop involving focus group (FG) discussions, a ranking exercise, and small and large group discussions to explore barriers and facilitators, identify guideline priority areas, and develop action-oriented and tailored implementation strategies. Prior to the workshop, a survey was administered to inform workshop proceedings.

Findings

The process of selecting priority maternal and perinatal health recommendations and exploring barriers and facilitators to implementation of the four priority WHO guidelines yielded rich information to inform implementation planning in Uganda. Participants across all FGs describedissues at the level of the healthcare system, which included various factors related to policies and wider systemic conditions in Uganda that can affect the implementation of the WHO guideline recommendations. These factors include: access to resources; drug procurement, distribution, and management; human resources; access to site-specific data; accountability and monitoring; and policies/political context. Issues at the level of the healthcare provider were prevalent, where factors related directly to frontline implementers (e.g., physicians, midwives) were described. Specific factors discussed include: beliefs, attitudes, and buy-in; knowledge and skills; training, mentorship, and professional development; and scope of roles. Finally, issues at the level of the patient/community were described and include: traditional beliefs; knowledge and awareness; and socioeconomic status.

The individual ranking exercise resulted in a participant-driven assessment of the feasibility of each of the 16 guideline recommendations that were deemed to be priorities in Uganda. Within the small group discussions that followed, a variety of strategies targeted at various levels were suggested to overcome barriers, serving as the building blocks for a guideline implementation action plan.

Recommendations

The findings of the pre-workshop survey aligned with those of the in-person workshop; both data collection methods helped to shape concrete strategies for facilitating the implementation of priority guideline recommendations. The most salient points that emerged from the pre-workshop and workshop activities were as follows:

There is a need and an opportunity to improve implementation of the priority recommendations across the four selected WHO guidelines (Prevention and treatment ofPPH; Prevention and treatment of pre-eclampsia and eclampsia; Induction of Labour; and Augmentation of Labour).

Drug procurement, management, and distribution practices are not operating at an optimal level. There are cases where drugs are expiring on the shelves and other examples where drugs are unavailable. This suggests a need for current drug ordering and monitoring policies and practices to be reviewed at both the level of healthcare facilities and nationally.

There is a concern around the misuse of misoprostol to increase the speed of labour (either inappropriately administered by healthcare workers or self-administered by the patient by securing the drug over the counter). Further research is required to better understand the misuse of misoprostol and the resultant harms. Results of this research could be used to provide evidence to support a change to the regulation of misoprostol in the market.

Recruitment of more healthcare workers is needed across the healthcare system, but particularly in rural/remote areas; infrastructure (e.g., housing for healthcare workers, schools for the children of healthcare workers, etc.) and incentives (i.e., a competitive salary comparable to urban centres) are needed as a preliminary step. Lifting the current recruitment ban in Uganda may also be considered.

The role of village health teams is expanding to include maternal and perinatal care. There is a need to create more formal linkages between healthcare facilities and village health teams to better coordinate and standardize maternal healthcare for the community.

Patients and the wider community would benefit from increased awareness about the harms and benefits of certain guideline recommendations (e.g., potential harms of misoprostol misuse; benefits of a companion during labour; medical causes of eclampsia). This could be achieved through strategies and activities directed at patients and the wider community (e.g., radio/SMS campaigns, birth plans, educational materials, community talks/meetings).

Increased opportunities for training, mentorship, and professional development are essential to improving the implementation of guideline recommendations including: onsite orientation for new staff; use of simulation training/simulation centres; training at the bedside; improved supervision; use of clinical instructors; and development of mentorship programs between more experienced healthcare workers and new professionals.

Many of the barriers, facilitators, and resultant implementation strategies identified regarding the four WHO maternal and perinatal guidelines are applicable to other priority areas in healthcare; therefore, these findings can inform and be integrated into future barrier and facilitator assessments and guideline implementation planning initiatives in Uganda.