Aspirations for quality health care in Uganda: How do we get there?

Human Resources for Health

Sarah G Staedke¹  Deborah DiLiberto¹  Miriam Kayendeke²  Christine Nabirye²  Lilian Taaka²  James Kizito²  Clare I R Chandler³ 

[1] Department of Clinical Research, London School of Hygiene & Tropical Medicine, Keppel St, London, WCIE 7HT, UK;Infectious Diseases Research Collaboration, Mulago Hospital Complex, PO Box 7475, Kampala, Uganda;Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK

关键词: Health care;    Relationships;    Quality of care;    Power/empowerment;    Access to health care;    Africa;   

Others  :  822566
DOI  :  10.1186/1478-4491-11-13

 received in 2013-01-16, accepted in 2013-02-28,  发布年份 2013

【 摘 要 】

Background

Despite significant investments and reforms, health care remains poor for many in Africa. To design an intervention to improve access and quality of health care at health facilities in eastern Uganda, we aimed to understand local priorities for qualities in health care, and factors that enable or prevent these qualities from being enacted.

Methods

In 2009 to 2010, we carried out 69 in-depth interviews and 6 focus group discussions with 65 health workers at 17 health facilities, and 10 focus group discussions with 113 community members in Tororo District, Uganda.

Results

Health-care workers and seekers valued technical, interpersonal and resource qualities in their aspirations for health care. However, such qualities were frequently not enacted, and our analysis suggests that meeting aspirations required social and financial resources to negotiate various power structures.

Conclusions

We argue that achieving aspirations for qualities valued in health care will require a genuine reorientation of focus by health workers and their managers toward patients, through renewed respect and support for these providers as professionals.

【 授权许可】

   
2013 Chandler et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Lozano R, Wang H, Foreman KJ, Rajaratnam JK, Naghavi M, Marcus JR, Dwyer-Lindgren L, Lofgren KT, Phillips D, Atkinson C, Lopez AD, Murray CJ: Progress towards millennium development goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet 2011, 378:1139-1165.
• [2]Reich MR, Takemi K, Roberts MJ, Hsiao WC: Global action on health systems: a proposal for the Toyako G8 summit. Lancet 2008, 371:865-869.
• [3]Bhutta ZA, Chopra M, Axelson H, Berman P, Boerma T, Bryce J, Bustreo F, Cavagnero E, Cometto G, Daelmans B, de Francisco A, Fogstad H, Gupta N, Laski L, Lawn J, Maliqi B, Mason E, Pitt C, Requejo J, Starrs A, Victora CG, Wardlaw T: Countdown to 2015 decade report (2000–10): taking stock of maternal, newborn, and child survival. Lancet 2010, 375:2032-2044.
• [4]Bloom G, Standing H: Future health systems: why future? why now? Soc Sci Med 2008, 66:2067-2075.
• [5]Mackian S, Bedri N, Lovel H: Up the garden path and over the edge: where might health-seeking behaviour take us? Health Policy Plan 2004, 19:137-146.
• [6]World Health Organisation: World health report 2000. Health systems: improving performance. Geneva: WHO; 2000.
• [7]Franco LM, Bennett S, Kanfer R: Health sector reform and public sector health worker motivation: a conceptual framework. Soc Sci Med 2002, 54:1255-1266.
• [8]World Health Organisation: Increasing access to health workers in remote and rural areas through improved retention. Global Policy Recommendations. Geneva: WHO; 2010.
• [9]Lagarde M, Palmer N: The impact of user fees on access to health services in low- and middle-income countries. Cochrane Database Syst Rev 2011, CD009094.
• [10]Oxman AD, Thomson MA, Davis DA, Haynes RB: No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. Can Med Assoc J 1995, 153:1423-1431.
• [11]Rowe AK, de Savigny D, Lanata CF, Victora CG: How can we achieve and maintain high-quality performance of health workers in low-resource settings? Lancet 2005, 366:1026-1035.
• [12]Kiwanuka SN, Ekirapa EK, Peterson S, Okui O, Rahman MH, Peters D, Pariyo GW: Access to and utilisation of health services for the poor in Uganda: a systematic review of available evidence. Trans R Soc Trop Med Hyg 2008, 102:1067-1074.
• [13]Gonzaga B, Kiyaga JN, Reynolds Whyte S, Jitta J: Health system profile: decentralisation of the health care system. A study of Tororo and Busia districts. Kampala, Uganda. http://www.chdc.mak.ac.ug/publications/Busulwa%20Gonzzaga%201999_Health%20Systems%20Profile%20Decentralisation%20of%20the%20Health%20Care%20System.pdf webcite.
• [14]Jitta J, Reynolds Whyte S, Nshakira N: The availability of drugs: what does it mean in Ugandan primary care. Health Policy 2003, 65:167-179.
• [15]Kyaddondo D, Whyte SR: Working in a decentralized system: a threat to health workers’ respect and survival in Uganda. Int J Heal Plan Manag 2003, 18:329-342.
• [16]Mogensen HO: Finding a path through the health unit: practical experience of Ugandan patients. Med Anthropol 2005, 24:209-236.
• [17]Mutumba A: The effect of decentralisation on the performance of district personnel in Uganda. A case-study of Tororo district health directorate. Kampala: Makerere University; 2005.
• [18]Lock M, Nguyen V: An Anthropology of Biomedicine. Chichester: Wiley-Blackwell; 2010.
• [19]Mol A: The logic of care. Health and the problem of patient choice. London: Routledge; 2008.
• [20]Nichter M: Global health. Why cultural perceptions, social representations, and biopolitics matter. Tucson: University of Arizona Press; 2008.
• [21]Whyte SR, Van der Geest S, Hardon A: Social lives of medicines. Cambridge: Cambridge University Press; 2002.
• [22]Singer M, Baer H: Critical medical anthropology. Amityville, New York: Baywood Publishing Company; 1995.
• [23]Balbanova D, Parkhurst J, McKee M, McPake B: Access to health care: taking into account health systems complexity. http://www.dfid.gov.uk/R4D/PDF/Outputs/HealthSysDev_KP/Access_to_health_care_web_version.pdf webcite
• [24]Montgomery CM, Mwengee W, Kong’ong’o M, Pool R: ‘To help them is to educate them’: power and pedagogy in the prevention and treatment of malaria in Tanzania. Trop Med Int Health 2006, 11:1661-1669.
• [25]Obrist B, Iteba N, Lengeler C, Makemba A, Mshana C, Nathan R, Alba S, Dillip A, Hetzel MW, Mayumana I, Schulze A, Mshinda H: Access to health care in contexts of livelihood insecurity: a framework for analysis and action. PLoS Med 2007, 4:1584-1588.
• [26]Ribera JM, Hausmann-Muela S: The straw that breaks the camel’s back. Redirecting health-seeking behavior studies on malaria and vulnerability. Med Anthropol Q 2011, 25:103-121.
• [27]Iliffe J: East African doctors. A history of the modern profession. Cambridge: Cambridge University Press; 1998.
• [28]van der Heijden T, Jitta J: Economic survival strategies of health workers in Uganda. A study report submitted to Child Health and Development Centre. Kampala: Makerere University; 1993.
• [29]Birungi H, Mugisha F, Nsabagasani X, Okuonzi S, Jeppsson A: The policy on public-private mix in the Ugandan health sector: catching up with reality. Health Policy Plan 2001, 16(Supplement 2):80-87.
• [30]Asiimwe D, McPake B, Mwesigye F, Ofoumbi M, Oertenblad L, Streefland P, Turinde A: The private sector activities of public-sector health workers in Uganda. In Private health providers in developing countries serving the public interest?. Edited by Bennett S, McPake B, Mills A. London and New Jersey: Zed Books; 1996:140-157.
• [31]McPake B, Asiimwe D, Mweisigye F, Ofumbi M, Ortenblad L, Streefland P, Trinde A: Informal economic activities of public health workers in Uganda: Implications for quality and accessibility of care. Soc Sci Med 1999, 49:849-865.
• [32]Ssengooba F, Rahman SA, Hongoro C, Rutebemberwa E, Mustafa A, Kielmann T, McPake B: Health sector reforms and human resources for health in Uganda and Bangladesh: mechanisms of effect. Hum Resour Health 2007, 5:3. BioMed Central Full Text
• [33]The Republic of Uganda Ministry of Health: Health Sector Strategic Plan I 2000/01 – 2004/05. http://siteresources.worldbank.org/INTPRS1/Resources/383606-1201883571938/Uganda_HSSP.pdf webcite
• [34]Nabyonga-Orem J, Karamagi H, Atuyambe L, Bagenda F, Okuonzi SA, Walker O: Maintaining quality of health services after abolition of user fees: a Uganda case study. BMC Health Serv Res 2008, 8:102. BioMed Central Full Text
• [35]Xu K, Evans DB, Kadama P, Nabyonga J, Ogwal PO, Nabukhonzo P, Aguilar AM: Understanding the impact of eliminating user fees: utilization and catastrophic health expenditures in Uganda. Soc Sci Med 2006, 62:866-876.
• [36]TORCH: Quality of care study II. Kampala, Uganda: Tororo Community Health (TORCH) Project; 2006.
• [37]Ekochu E, Kalyowa F, Lwanga JB: Indicators of change in the health care system. Tororo and Busia Districts. http://www.chdc.mak.ac.ug/publications/Kalyowa%20Fred%202001%20Indicators%20of%20Change%20in%20the%20Health%20Care%20System.pdf webcite
• [38]Staedke SG: Phase 1 report: Tororo district survey project. Characterizing the population and local health services. Kampala, Uganda: Uganda Malaria Surveillance Project; 2010. http://www.actconsortium.org/data/files/actc_tororo_phase_i_report_final_10june10.pdf webcite
• [39]The Republic of Uganda Ministry of Health: Health Sector Strategic Plan II 2005/06 - 2009/10. http://siteresources.worldbank.org/INTPRS1/Resources/383606-1201883571938/Uganda_HSSP_2.pdf webcite
• [40]Kivumbi GW, Arube-wani J: Maternal and Child Health in Old Tororo District: 1996 and 2003. http://www.chdc.mak.ac.ug/publications/Kivumbi%20George%20Washington%202004%20Maternal%20and%20Child%20Health%20in%20Old%20Tororo%20District%201996%20And%202003.pdf webcite
• [41]Kaharuza F, Bagenda D, Scheutz F, Sabroe S: The maternal and child health baseline survey report. http://chdc.mak.ac.ug/publications/Kaharuza%20Frank%201998_Maternal%20and%20Child%20Health%20Final%20report.pdf webcite
• [42]Haaland A, Molyneux CS, Marsh V: Quality information in field research: Training manual on practical communication skills for field researchers and project personnel. http://whqlibdoc.who.int/hq/2006/TDR_IRM_PCT_05.1_eng.pdf webcite
• [43]United Nations: Road map towards the implementation of the United Nations Millennium Declaration. Report of the Secretary-General. Geneva: United Nations General Assembly; 2001.
• [44]Adome RO, Whyte SR, Hardon A: Popular pills: community drug use in Uganda. Amsterdam: Het Spinhuis; 1996.
• [45]Kiguli J, Ekirapa-Kiracho E, Okui O, Mutebi A, Macgregor H, Pariyo GW: Increasing access to quality health care for the poor: community perceptions on quality care in Uganda. Patient Preference and Adherence 2009, 3:77-85.
• [46]Haddad S, Fournier P, Machouf N, Yatara F: What does quality mean to lay people? Community perceptions of primary health care services in Guinea. Soc Sci Med 1998, 47:381-394.
• [47]Hanson K, McPake B, Nakamba P, Archard L: Preferences for hospital quality in Zambia: results from a discrete choice experiment. Heal Econ 2005, 14:687-701.
• [48]Onwujekwe O: Inequities in healthcare seeking in the treatment of communicable endemic diseases in Southeast Nigeria. Soc Sci Med 2005, 61:455-463.
• [49]Kizito J, Kayendeke M, Nabirye C, Staedke SG, Chandler CIR: Improving access to health care for malaria in Africa: a review of literature on what attracts patients. Malar J 2012, 11:55. BioMed Central Full Text
• [50]D’Ambruoso L, Abbey M, Hussein J: Please understand when I cry out in pain: women’s accounts of maternity services during labour and delivery in Ghana. BMC Publ Health 2005, 5:140. BioMed Central Full Text
• [51]Mbaruku G, Bergstrom S: Reducing maternal mortality in Kigoma, Tanzania. Health Policy Plan 1995, 10:71-78.
• [52]World Health Organisation: World Health Report. Primary Health Care: Now more than ever. Geneva: WHO; 2008.
• [53]Mead N, Bower P: Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med 2000, 51:1087-1110.
• [54]Grol RP, Bosch MC, Hulscher ME, Eccles MP, Wensing M: Planning and studying improvement in patient care: the use of theoretical perspectives. Milbank Q 2007, 85:93-138.
• [55]Blaise P, Kegels G: A realistic approach to the evaluation of the quality management movement in health care systems: a comparison between European and African contexts based on Mintzberg’s organizational models. Int J Heal Plan Manag 2004, 19:337-364.
• [56]Pariyo GW, Gouws E, Bryce J, Burnham G: Improving facility-based care for sick children in Uganda: training is not enough. Health Policy Plan 2005, 20(Suppl 1):i58-i68.
• [57]Chandler CIR, Jones C, Boniface G, Juma K, Reyburn H, Whitty CJM: Guidelines and mindlines: why do clinical staff over-diagnose malaria in Tanzania?A qualitative study. Malar J 2008, 7:53. BioMed Central Full Text
• [58]Fonn S, Ray S, Blaauw D: Innovation to improve health care provision and health systems in sub-Saharan Africa - promoting agency in mid-level workers and district managers. Glob Public Health 2011, 6:657-668.
• [59]Chandler CIR, Chonya S, Mtei F, Reyburn H, Whitty CJ: Motivation, money and respect: a mixed-method study of Tanzanian non-physician clinicians. Soc Sci Med 2009, 68:2078-2088.
• [60]Wenger E: Communities of Practice. Learning, meaning, and identity. New York: Cambridge University Press; 1998.
• [61]Chandler CIR, Whitty CJ, Ansah EK: How can malaria rapid diagnostic tests achieve their potential? A qualitative study of a trial at health facilities in Ghana. Malar J 2010, 9:95. BioMed Central Full Text
• [62]Haaland A, Vlassoff C: Introducing Health Workers for Change: from transformation theory to health systems in developing countries. Health Policy Plan 2001, 16(Suppl 1):1-6.
• [63]Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ, Quill TE: Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 2009, 302:1284-1293.