Institutionalization of Projects Into Districts in Low- and Middle-Income Countries Needs Stewardship, Autonomy, and Resources

Waiswa, Peter

doi:10.9745/ghsp-d-20-00170

Cited by 12 publications

(13 citation statements)

References 9 publications

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“…The lower-level facilities are often more accessible to rural families, so if the baby needs a checkup or monitoring, they could be the first point of call before traveling to the hospital. This is also in line with our prior recommendations for newborn care to be strengthened at lower-level facilities ( 22 ).…”

Section: Discussionsupporting

confidence: 89%

Improving Post-discharge Practice of Kangaroo Mother Care: Perspectives From Communities in East-Central Uganda

et al. 2022

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IntroductionKangaroo mother care (KMC) is among the most cost-effective and easily accessible solutions for improving the survival and wellbeing of small newborns. In this study, we examined the barriers and facilitators to continuity of KMC at home following hospital discharge in rural Uganda.MethodsWe conducted this study in five districts in east-central Uganda, within six hospitals and at the community level. We used a qualitative approach, with two phases of data collection. Phase 1 comprised in-depth interviews with mothers who practiced KMC with their babies and caretakers who supported them and key informant interviews with health workers, district health office staff, community health workers, and traditional birth attendants. We then conducted group discussions with mothers of small newborns and their caretakers. We held 65 interviews and five group discussions with 133 respondents in total and used a thematic approach to data analysis.ResultsIn hospital, mothers were sensitized and taught KMC. They were expected to continue practicing it at home with regular returns to the hospital post-discharge. However, mothers practiced KMC for a shorter time at home than in the hospital. Reasons included being overburdened with competing domestic chores that did not allow time for KMC and a lack of community follow-up support by health workers. There were increased psycho-social challenges for mothers, alongside some dangerous practices like placing plastic cans of hot water near the baby to provide warmth. Respondents suggested various ways to improve the KMC experience at home, including the development of a peer-to-peer intervention led by mothers who had successfully done KMC and community follow-up of mothers by qualified health workers and community health workers.ConclusionDespite wide acceptance of KMC by health workers, challenges to effective implementation persist. Amid the global and national push to scale up KMC, potential difficulties to its adherence post-discharge in a rural, resource-limited setting remain. This study provides insights on KMC implementation and sustainability from the perspectives of key stakeholders, highlighting the need for a holistic approach to KMC that incorporates its adaptability to community settings and contexts.

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Section: Discussionsupporting

confidence: 89%

Improving Post-discharge Practice of Kangaroo Mother Care: Perspectives From Communities in East-Central Uganda

et al. 2022

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“…Sustainability of such initiatives is key; unless systematically built-in, when the initial investment and intensive efforts of the funders cease, these initiatives collapse 24 29. Though the above-mentioned ‘contaminations’ might have diluted the effects of EMEN-QI on mortality outcomes, they are clear indications that the governments of all three countries have adopted the standards—a pathway to sustainability.…”

Section: Discussionmentioning

confidence: 99%

Institutionalising maternal and newborn quality-of-care standards in Bangladesh, Ghana and Tanzania: a quasi-experimental study

et al. 2022

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IntroductionFacility interventions to improve quality of care around childbirth are known but need to be packaged, tested and institutionalised within health systems to impact on maternal and newborn outcomes.MethodsWe conducted cross-sectional assessments at baseline (2016) and after 18 months of provider-led implementation of UNICEF/WHO’s Every Mother Every Newborn Quality Improvement (EMEN-QI) standards (preceding the WHO Standards for improving quality of maternal and newborn care in health facilities). 19 hospitals and health centres (2.8M catchment population) in Bangladesh, Ghana and Tanzania were involved and 24 from adjoining districts served for ‘comparison’. We interviewed 43 facility managers and 818 providers, observed 1516 client–provider interactions, reviewed 12 020 records and exit-interviewed 1826 newly delivered women. We computed a 39-criteria institutionalisation score combining clinical, patient rights and cross-cutting domains from EMEN-QI and used routine/District Health Information System V.2 data to assess the impact on perinatal and maternal mortality.ResultsEMEN-QI standards institutionalisation score increased from 61% to 80% during EMEN-QI implementation, exceeding 75% target. All mortality indicators showed a downward trajectory though not all reached statistical significance. Newborn case-fatality rate fell significantly by 25% in Bangladesh (RR=0·75 (95% CI=0·59 to 0·96), p=0·017) and 85% in Tanzania (RR=0.15 (95% CI=0.08 to 0.29), p<0.001), but not in Ghana. Similarly, stillbirth (RR=0.64 (95% CI=0.45 to 0.92), p<0.01) and perinatal mortality in Tanzania reduced significantly (RR=0.59 (95% CI=0.40 to 0.87), p=0.007). Institutional maternal mortality ratios generally reduced but were only significant in Ghana: 362/100 000 to 207/100 000 livebirths (RR=0.57 (95% CI=0.33 to 0.99), p=0.046). Routine mortality data from comparison facilities were limited and scarce. Systematic death audits and clinical mentorship drove these achievements but challenges still remain around human resource management and equipment maintenance systems.ConclusionInstitutionalisation of the UNICEF/WHO EMEN-QI standards as a package is feasible within existing health systems and may reduce mortality around childbirth. Critical gaps around sustainability must be fundamental considerations for scale-up.

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“…When external support ends at the closeout of a project, changes made and improved health outcomes often fall back to preproject levels. Not all programs are sustained beyond their initial implementation period partly due to uncertainty regarding sustainability, including infrequent or inappropriate use of sustainability assessments 3. Determining whether programs can be sustained, and whether there is commitment on behalf of local governments and health systems to consistently monitor such programs, is critical in ensuring long-term, systemic changes 4…”

Section: Contextmentioning

confidence: 99%

“…Not all programs are sustained beyond their initial implementation period partly due to uncertainty regarding sustainability, including infrequent or inappropriate use of sustainability assessments. 3 Determining whether programs can be sustained, and whether there is commitment on behalf of local governments and health systems to consistently monitor such programs, is critical in ensuring long-term, systemic changes. 4 There are societal and systems challenges that cannot be easily fixed, including complex administrative systems, health care worker strikes, political elections, and supply chain management issues.…”

Section: Contextmentioning

confidence: 99%

RAISE: A Management and Organizational Sustainability Tool for Local Governments to Systematically Self-Evaluate the Effectiveness of Their Programs

Malik

Graham

O'Donnell

et al. 2022

Journal of Public Health Management and Practice

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Context: Many donor-driven public health programs are now seeking evidence for sustainability prior to investment, creating the need for tools to better appraise these capabilities. Assessing the sustainability of programs and interventions at the local level remains a community-wide challenge. Program: This article presents a new self-assessment tool, the Reflection and Action to Improve Self-reliance and Effectiveness (RAISE) Tool ("the Tool"), modeled after The Challenge Initiative's (TCI) Sustainability Pillars. It describes the evolution of the Tool, explores its structure and applications, demonstrates its data analysis capabilities, and illustrates how it can be used for continuous program self-assessment by local governments, which TCI considers an indicator of program sustainability at the local level. Implementation: Developed in 2019, the Tool has been adapted, adopted, and implemented by 92 local governments across 11 countries. The Challenge Initiative works with these local governments over a minimum of 3 years, providing management and technical coaching on high-impact interventions. Using the Tool, local governments self-assess and evaluate the quality and effectiveness of their activity implementation and identify gaps for improvement. The Tool helps both local governments and TCI track their readiness toward becoming self-reliant and taking ownership of their family planning programs. Evaluation: As of June 30, 2021, 39 of the 92 local governments reached the final stage of maturity, self-reliance. Discussion: Experts have stated that it can take 15 years for a sustainability assessment tool such as RAISE to be adopted into government policies. After 2 years of using the Tool on a quarterly basis, on average 87.3% of eligible local governments completed the self-assessments, made course corrections, and have taken steps toward program independence. The 39 local governments that successfully progressed to self-reliance continue to use the Tool without TCI's coaching support and have expressed interest in adapting the Tool for other health interventions.

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Institutionalization of Projects Into Districts in Low- and Middle-Income Countries Needs Stewardship, Autonomy, and Resources

Abstract: See related article by Nanyonjo et al.

Cited by 12 publications

References 9 publications

Improving Post-discharge Practice of Kangaroo Mother Care: Perspectives From Communities in East-Central Uganda

Improving Post-discharge Practice of Kangaroo Mother Care: Perspectives From Communities in East-Central Uganda

Institutionalising maternal and newborn quality-of-care standards in Bangladesh, Ghana and Tanzania: a quasi-experimental study

RAISE: A Management and Organizational Sustainability Tool for Local Governments to Systematically Self-Evaluate the Effectiveness of Their Programs

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