2. Improving the Quality of Health Service Delivery through Hands-on, Work-based Training: Experiences from the District Capacity Building Program, Uganda Violet Gwokyalya, Joseph KB Matovu, Rhoda K. Wanyenze, David Serwadda MakSPH-CDC Fellowship Program, Makerere University School of Public Health, Kampala, Uganda

3. Background  Most low income countries continue to suffer poor quality of health care (Nana 2014)  Health system challenges like staff absenteeism, long client waiting times, ineffective follow-up systems hamper effective health care  Efforts to address real work challenges are very limited especially at public health facilities  MakSPH in partnership with MoH/CDC conducted capacity assessments to establish the challenges as well as capacity gaps to delivery of quality health care in public facilities  Also held several stakeholder consultative meetings to understand better what the gaps were and how we could intervene

4. Background  Main focus was on districts as the nucleus of health service delivery  Finding showed that frontline workers have limited skills in QI and M&E of health service delivery  Existing QI efforts exist as parallel efforts with limited integration into routine service delivery and are not institutionalized  Health workers have limited support from the managers  Managers have inadequate skills to steer service improvements and have surrendered their responsibility to implementing partners (NGOs)

5. District performance on leadership and management domains % Score

6. Support needed by managers to perform the various functions (n=144) Management functions

7. Response to the findings  Disseminated findings to stakeholders; wider MoH, CDC, Implementing Partners, Local Governments, Regional Managers  Developed the District Capacity Building Program  Aim is to enhance district capacity to lead the design, implementation, monitoring and evaluation of health service delivery  Implemented in collaboration with the Ministry of Health, Uganda

8. Framework for the District Capacity Building Program Supports the management and delivery of Health services Supports the coordination and Institutionali zation QI efforts Intervention - DCP Expected Results Improved health services managem ent Improved quality of services Efficient utilization of resources DCP courses District Health Managers’ Course Health Service Improvement Course Induction Course for Newly Recruited Managers Quality Improvement Champions’ Course 1.Limited skills of Frontline service providers 2.Weak institutionalization of QI efforts 3.Limited support from Managers 4.Limited skills in management of service delivery 1.Poor quality services 2.Weak supervision and support systems 3.Mismanagement of resources for health The gap

9. Training Approach  8-9 moths Fellowships: Modular work-based, hands-on trainings  competence-based and output driven  Short (1-2 weeks) face-to-face sessions  Periods of Onsite mentorship and Coaching between face-to-face sessions  Fellows identify performance gaps at the work place  5-6 months of implementation of improvement projects to address performance gaps  Project implementation is done by teams not individuals

10. CourseHealth Service Improvement Course District Health Managers’ Course Induction Course for New Managers QI Champions’ Course Roll out March 2014August 2015April 2016June 2016 Target group Health workers at Hospitals and HC IV Directors of RRH Heads of Community Health Departments Principal Medical Officers District Health Teams Regional Performance Monitoring Teams New District Health Officers, HSD in-charges, Members of the DHT QI focal persons of National, District, HSD and Facility level QI advisors of NGOs Progress 42 Fellows trained 19 projects implemented 60 Fellows enrolled Fellows embarking on project implementation (33 projects) Ongoing preparatory activities for the roll out Program Roll out and target group

11. Implementation of the HSI Course  We enrolled 42 health workers from 16 districts (6 Hospitals and 13 HC IV)  Selection of districts based on performance in the national district league table  60% poor performance, 20% middle performers, 20% top performers  Selection of trainees based on the role the health workers play at the facility  Nomination done by the District Health Officers

12. Implementation cont’d  Trainees had 3 interrelated face-face sessions (1-2 weeks) which equipped them with quality improvement and monitoring and evaluation skills  Between sessions, they identified gaps in health care delivery at their work stations  Developed identified gaps into projects which they implemented as health facility teams  Received at least 2 onsite mentorship visits to support them in application of skills, implementation & institutionalization of their projects.

13. Implementation cont’d  On going support provided through email, telephone and skype calls  Project implementation lasted for 6 months (Jun –Nov 2014)  We analyzed the outcomes of 19 improvement projects

14. Outcomes of improvement projects implemented % change Categories of improvement projects Note. Client waiting time reduced from 288min to 90 mins

15. Results of selected health facility projects  Improving access to TT for pregnant women in Obongi HC IV Number of women vaccinated for TT Months 2013/2014

16. Results of selected health facility projects  Improving follow up of TB clients in Amolatar HC IV Number of clients Reporting period

17. Lessons learnt  Hands-on work-based trainings anchor providers within their institutions, allowing continuity of work while providing real life learning experiences  They achieve quick impact with limited resources and provide opportunity to scale up and institutionalize improvement efforts  Mentorship is very critical in transferring skills and addressing behavior and attitude challenges at the work place  Involvement of institutional leadership is key in promoting institutionalization, sustainability & scalability of improvements

18. Acknowledgement  CDC  The Global Fund  Ministry of Health  Implementing partners  District Local Governments  Health workers