Improving availability of human resources for health, essential medicines and supplies by district leaders using QI methods:

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1 U G A N D A C H A N G E PA C K A G E Improving availability of human resources for health, essential medicines and supplies by district leaders using QI methods: Tested changes implemented in six districts of Uganda DECEMBER 2017 This change package for Improving availability of human resources for health, essential medicines and supplies was prepared by University Research Co., LLC (URC) for review by the United States Agency for International Development (USAID) and authored by Hellen Kyokutamba, Mirwais Rahimzai, John Byabagambi, and Esther Karamagi of URC through the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. It was funded by the U.S. President s Emergency Plan for AIDS Relief (PEPFAR) and carried out under the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, which is made possible by the generous support of the American people through USAID.

2 Cover photo: District and health facility leaders quality improvement team meeting. Photo by Hellen Kyokutamba, URC.

3 UGANDA CHANGE PACKAGE Improving availability of human resources for health, essential medicines and supplies by district leaders using QI methods: Tested changes implemented in six districts of Uganda DECEMBER 2017 Hellen Kyokutamba, University Research Co., LLC Mirwais Rahimzai, University Research Co., LLC John Byabagambi, University Research Co., LLC Esther Karamagi, University Research Co., LLC DISCLAIMER The contents of this report are the sole responsibility of University Research Co., LLC (URC) and do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

4 Acknowledgements The changes tested at the district level to improve the availability of human resources for health and essential medicines and supplies in Uganda documented in this change package were developed for the United States Agency for International Development (USAID) as part of the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. The authors would like to thank Angella Kigonya, Alex Kakala, Julius Amumpe, and Benson Tumwesigye of University Research Co., LLC (URC) for their support in facilitating processes to harvest and synthesize the changes presented below. We also acknowledge the district health management team staff from six USAID ASSIST-supported districts of Kaliro, Ngora, Mbale, Lira, Lamwo and Kiruhura for their commitment to improving the availability of human resources for health, and essential medicines and supplies, and for providing the opportunity to learn about and improve health service delivery through the Leadership for Quality initiative. We appreciate the contributions of the Ministry of Health (MOH) and the Leadership for Quality implementing partners (IP), African Center for Global Health and Social Transformation (ACHEST) and Uganda Management Institute (UMI), to the health service delivery improvements observed in these districts. The USAID ASSIST Project is made possible by the generous support of the American people through USAID s Bureau for Global Health, Office of Health Systems. Support for the Leadership for Quality Initiative was provided by the U.S. President s Emergency Plan for AIDS Relief (PEPFAR). The USAID ASSIST Project is managed by University Research Co., LLC (URC) under the terms of Cooperative Agreement Number AID-OAA-A URC s global partners for the USAID ASSIST Project include: Encompass LLC; FHI 360; Harvard T. H. Chan School of Public Health; HEALTHQUAL International; Initiatives Inc.; Institute for Healthcare Improvement; Johns Hopkins Center for Communications Programs; and WI-HER, LLC. For more information on the work of the USAID ASSIST Project, please visit or write assist-info@urc-chs.com. Recommended citation Kyokutamba H, Rahimzai M, Byabagambi J, Karamagi E Improving availability of human resources for health, essential medicines and supplies by district leaders using QI methods: Tested changes implemented in six districts of Uganda. Change Package. Published by the USAID ASSIST Project. Chevy Chase, MD: University Research Co., LLC (URC).

5 TABLE OF CONTENTS I. INTRODUCTION... 1 A. Background of District Health Systems in Uganda... 1 B. Baseline analysis... 1 C. Continuous QI approach... 2 D. Results... 3 E. Intended Use of this Change Package Document... 3 II. CHANGE PACKAGE... 4 A. Aim 1: Improving the availability of human resources for health by reducing health worker absenteeism... 4 B. Aim 2: Improving availability of essential medicines and supplies... 6 III. DISCUSSION... 7 A. Lessons learned... 7 B. Challenges... 7 C. Recommendations... 8 List of Figures Figure 1. Factors contributing to health worker absenteeism in the supported districts... 2 Figure 2. Factors contributing to frequent stock out of essential medicines and supplies... 2

6 Acronyms ACHEST ARV ASSIST DHO HR MOH NGO PDSA PEPFAR TB QI UMI URC USAID African Centre for Global health and Social Transformation Antiretroviral USAID Applying Science to Strengthen and Improve Systems Project District Health Officer Human Resource Ministry of Health Non-governmental organization Plan-do-study-act U.S. President s Emergency Plan for AIDS Relief Tuberculosis Quality improvement Uganda Management Institute University Research Co., LLC United States Agency for International Development

7 I. INTRODUCTION In January 2017, the USAID Applying Science to Strengthen and Improve Systems (ASSIST) project, in partnership with the Ministry of Health (MOH), African Center for Global Health and Social Transformation (ACHEST), Uganda Management Institute (UMI), began implementing the Leadership for Quality Improvement Initiative in the six Ugandan districts of Kaliro, Kiruhura, Mbale, Ngora, Lamwo, and Lira. One of the objectives of the initiative is to enhance the capacity of district political and administrative leaders in stewardship, leadership, and governance of district health services for improving quality of health services in Uganda with focus on improving availability of human resources for health, essential medicines, and supplies. A. Background of District Health Systems in Uganda The 1995 Constitution and the 1997 Local Government Act mandate the District Local Government to plan, budget, and implement health policies and health sector plans. The Local Governments have the responsibility for the delivery of health services, including: the recruitment, deployment, development, and management of human resource (HR) for district health services; the development and passing of health-related by-laws; and monitoring of overall health sector performance. The Local Governments also manage public general hospitals and health centers and provide supervision and monitoring health activities in their respective areas of responsibility. Quality improvement (QI) methods have been shown to improve health systems at all levels. Yet in Uganda, there was a gap in political and administrative district leaders engagement in QI as part of an evaluation of the National Quality Improvement Framework Specifically, these leaders did not have clear understanding of their roles in QI. While QI should be a bottomup approach, it is imperative to have strong leadership to enable it from the top. In Uganda, there are major challenges with inadequate human resources for health, essential medicines and supplies. Yet still, the available human resources, essential medicines and supplies are not used optimally to improve health services: there is 40% health worker absenteeism (Uganda MOH Strategy for Improving Health Service Delivery ). Use of QI methods by district leaders can improve the availability and utilization of human resources for health, essential medicines and supplies. B. Baseline analysis This change package focuses on the objective of increasing access to information on improving availability of human resources for health, essential medicines and supplies. In March 2017 a baseline survey was conducted by the MOH with support from ASSIST, ACHEST and UMI in 28 health facilities from the six implementing districts of Lira, Lamwo, Kaliro, Kiruhura, Mbale, and Ngora. The health worker absenteeism was at 25.5% in January 2017 across the six districts and the stock out rates of ARVs and TB drugs in Kaliro District was 54.4%. Health worker absenteeism was calculated as the number of days health workers were unofficially away from duty station relative to the total scheduled number of work days by heath workers. This information was obtained from the attendance registers, duty rosters, and documented leave awarded. From the baseline assessment, the factors leading to health worker absenteeism, frequent stock outs of essential medicines and supplies as illustrated in Figure 1 and Figure 2 were the focus of ASSIST s QI efforts in Uganda. Improving availability of human resources for health, essential medicines and supplies 1

8 Figure 1. Factors contributing to health worker absenteeism in the supported districts Staff attendance to duty not monitored and discussed No system in place to track health workers who are officially absent from duty station Disjointed health monitoring activities by district leaders Poorly motivated health workers Health worker absenteeism Uncoordinated outreaches, trainings and supervision visits by health workers No mechanism of regulating number of health workers on study leave Figure 2. Factors contributing to frequent stock out of essential medicines and supplies : Delayed and inaccurate ordering of drugs Poor data records for proper quantification No individual department accountability of drugs issued from the health facility drug stores Frequent stock out of essential medicines and supplies No district level mechanism to track health facility drug stock levels and facilitate timely redistribution C. Continuous QI approach In line with the MOH Quality Improvement Framework and Strategic Plan, ASSIST used the Model for Improvement, which includes the Plan-Do-Study-Act (PDSA) cycle and was applied as part of the Leadership for QI Initiative. District leadership-level QI teams were initially trained by ASSIST on QI, leadership, and management. The district QI team was typically composed of the District Chairperson, Resident District Commissioner, Chief Administrative Officer, District Health Officer (DHO), and District Health Team members. QI coaches from ASSIST, MOH, ACHEST, and UMI supported teams at their monthly meetings to identify gaps in availability of human resources for health, medicines and supplies, prioritize areas of improvement, and develop, test, and implement change ideas. 2 Improving availability of human resources for health, essential medicines and supplies

9 The six district QI teams were brought together in a peer-to-peer learning meeting to share their experiences and harvest the best changes in improving availability of human resources for health, medicines and supplies. This session also provided a platform for spreading best practices among the QI teams. D. Results During the district health QI meetings, the political and administrative leaders had an opportunity to analyze challenges of the health sector which improved their health-related decision-making and resource allocation. Highlights of improved outcomes achieved Health worker absenteeism reduced from 25.5% in January 2017 to 6.9% in August 2017 Improved documentation and data use on staff attendance to duty Motivation through establishment and implementation of reward and sanction mechanisms Redistribution and recruitment of health workers according to patient load Setting and adhering to criteria for awarding off days for staff Kaliro district stock out rate of ARVs and TB drugs reduced from 54.4% in December 2016 to 0% in June 2017 Joint ordering of drugs by health facility leaders and district medicines supervisor Issuing drugs from the health facility main store to each department on a weekly basis based on data of weekly consumption Using mtrac phone messaging system for drug redistribution. The accountability of the district health sector also improved. At one of the district QI meetings, the local council chairperson asked the DHO, Why is it that the health workers who left the district have never been replaced? This needs to be rectified immediately! The DHO replied, This is noted and I will immediately generate the list of those to be replaced so that we can immediately advertise for these positions. In another district, the local council chairperson declared, If the absenteeism of midwives at night is causing a high perinatal mortality due to lack of a security house at the health facility, let us immediately construct one using our local resources to save their lives! DHO obtain the budget and start on this as soon as possible. The health worker absenteeism across the six implementation districts reduced from 25.5% in January 2017 to 6.9% in August The Kaliro District stock out rate of ARVs and TB drugs reduced from 54.4% in December 2016 to 0% in June This change package describes successful changes (actions taken) the QI teams in the six districts implemented to address and improve specific gaps and provides details on how to implement each change. E. Intended Use of this Change Package Document The purpose of this change package is to provide guidelines and knowledge on improving availability of human resources, essential medicines and supplies by district political and administrative leaders using QI methods. District leaders and health facility managers should adapt the suggested changes to the specific contexts in their districts, health facilities and the resources available. In addition, non-governmental organizations (NGOs), MOH officials and projects involved in improving availability of human resources for health, essential medicines and supplies will find the changes described in this report useful and can adapt them for their work as well. Improving availability of human resources for health, essential medicines and supplies 3

10 The change package aims to convey a synthesis of learning from ASSIST s experience in implementing QI approaches to improve availability of human resources for health, essential medicines and supplies. The change package provides a detailed description of what changes led to improvement for each of the two improvement aims being worked on. Each section outlines the problem being addressed, the change ideas tested, steps followed in introducing each change idea, and the evidence that it led to improvement. II. CHANGE PACKAGE A. Aim 1: Improving the availability of human resources for health by reducing health worker absenteeism Logic for change (Gap/ Problem) Change Idea How change was implemented Improving staff duty attendance data capture and use for reducing absenteeism Staff attendance to duty was not documented. In places where it was recorded, it was irregular and incomplete. Staff absent from the duty station were sometimes registered as present by colleagues. Even after documentation improved, the records were not discussed/reviewed for improvement. The staff who were officially away from work station were not recorded for accountability. The staff would only verbally communicate their absence from duty station occasionally Improving support supervision Staff duty attendance including arrival and departure time recorded in counter book managed by different staff on a rotational basis. Spot checks by the district political and administrative leaders to verify recorded and actual duty attendance. Monthly staff duty attendance analyzed and discussed during district and health facility QI meetings for improvement. A box file to track all written communication documenting reasons from staff for being away from duty station. Health facilities improvised with counter books as attendance registers placed at outpatient department to record attendance, including time of arrival and departure for duty on each day. On a rotational basis, health workers, including facility in-charge, were given the responsibility of managing the duty register and signing off attendance at the set time deadlines. The district political and administrative leaders visit the health facility to verify recorded and actual duty attendance for improvement discussion with the staff responsible for the attendance register at the given time. The district Biostatistician summarizes the staff duty attendance monthly and shares with the district and health facility QI teams. During the monthly district and health facility QI meetings, staff attendance to duty discussed. Staff required to provide written communication for all officiallyapproved absences from work station. A box file was introduced and managed by the health facility incharge where all written official reasons from duty station were kept for accountability. 4 Improving availability of human resources for health, essential medicines and supplies

11 Logic for change (Gap/ Problem) Change Idea How change was implemented Support supervision visits and monitoring of health facilities was done separately by the district administrative and political leaders which lead to a lack of harmony in the messages given to health workers about attendance to duty. The administrative leaders focused on technical support to the health facilities and the political leaders on intimidating health workers to attend duty. Joint support supervision and monitoring activities by political leaders, administrators, and technical officers monthly using a QI approach. Improving staff motivation to attend duty Some health facilities consistently had high absenteeism rates while others had greatly improved because of the different levels of implementing the QI changes. Work overload was sometimes due to a large number staff away on study leave, officially or unofficially. There was no system to regulate the number of staff away for long periods on study leave. Staff out of duty station for trainings, meetings and outreaches was uncoordinated leaving health facilities with a few demotivated staff to work. There was no mechanism of regulating number of staff officially away from health facilities. The staff in the high patient load health facilities were demotivated due to work overload. Other health Ranking of health facilities and health sub-districts performance and display at the health facilities and DHO s office. Formation of the study leave committee that formulated criteria for awarding study leave to ensure adequate staffing at the health facilities. Allocation of out-of-dutystation activities done centrally by the DHO using a monitoring tool to regulate number of staff officially away at one time. Development of a training database to regulate and monitor staff attendance of trainings. Redistribution of health workers from high to low patient load health facilities. The district political and administrative leaders started to jointly support the health facilities and work with the staff to address health service delivery challenges, including absenteeism, using QI methods. The health workers met with the district leaders, shared their challenges and together came up with solutions that were monitored by the QI teams. The intimidation and fault-finding reduced. The leadership and management skills of health facility managers were supported by the district leaders during the supervision visits. To motivate the health facilities that were not performing well, ranking, dissemination and displaying performance of all the health facilities was done. This helped the health facilities not performing well to learn from those performing well. The district administrative leaders formed a study leave committee that formulated criteria for awarding study leave bi-annually. Study leave was awarded to maintain adequate number of staff at the health facilities. The DHO was assigned the responsibility of assigning staff from the district going for trainings, meetings and outreaches. Using a tool designed to monitor staff away from duty station, the number of staff working at the health facilities improved. A training database to monitor staff previously trained in different areas was also used to guide allocation of staff participate in trainings. The district administrative leaders reviewed data on the different health facility patient load and number of staff and redistributed health workers Improving availability of human resources for health, essential medicines and supplies 5

12 Logic for change (Gap/ Problem) facilities with less work load had more staff. Change Idea How change was implemented according to the work load. The work load at some of the health facilities reduced and motivated the health workers to attend duty. B. Aim 2: Improving availability of essential medicines and supplies Logic for change (Gap/Problem) Change idea How change was implemented Improving documentation and data use on availability of essential medicines and supplies The poor quality of drug stock balance was largely found to be due to missing and inaccurate entries in the dispensing log and stock cards. A focal person at the dispensing area to check for proper filling of dispensing logs and balancing of the stock cards. A nurse from the outpatient department was allocated to work with the drug dispenser and cross check for proper filling of the dispensing log and balancing stock cards at the end of each working day. Improving timeliness and quality of essential medicines and supplies orders The health facility incharges were routinely ordering for same type of and quantity of drugs irrespective of consumption rates and stock levels despite prior training on making drug orders. Joint ordering of drugs done by the health facility incharges lead by the district medicines supervisor within the set time deadline. The district allocated funds to support all the health facility in-charges for a monthly 1-day meeting to support each other place orders led by the district medicines and supplies supervisor. The health facility in-charges used the stock and consumption records to correctly quantify the drug orders. The district medicines and supplies supervisor was unable to do onsite supervision for all the all health facilities at the time for ordering drugs. The district biostatistician frequently made errors while entering the drug orders. This was mainly due to lack of understanding of the orders. The district medicines and supplies supervisor on a monthly basis worked with the biostatistician to enter drug orders online. The District medicines and supplies supervisor supported the biostatistician to enter the online drug orders to minimize errors. Improving accountability of drugs issued to every health facility department No departmental accountability of drugs issued from the main drug store. Drug wastage and mishandling was high due to large quantities drugs Issuing drugs from the main store to each department on a weekly basis based on data of weekly consumption. On a weekly basis, drugs were issued from the store according to the average weekly consumption and stock balancing. 6 Improving availability of human resources for health, essential medicines and supplies

13 available on the shelves at the dispensing area. This also contributed to the monthly poor drug stock balancing. Improving redistribution of essential medicines and supplies There was no mechanism of monitoring health facilities overstocked drugs or those with stock outs of drugs in order to redistribute them within the district. The MTRAC system is a phone-based system that used mainly for district DHIS2 data reporting. Using telephone mtrac system for weekly reporting of stock levels of essential medicines and supplies. This aided timely redistribution of drugs. The district QI team met with the health facility in-charges and agreed to report drug stock outs and over stocks on the mtrac system for ease of redistribution. III. DISCUSSION A. Lessons learned Engagement of district political and administrative leaders in QI enhances their understanding of health service delivery and improves their support, advocacy and resource allocation for better health service delivery. Health worker absenteeism can be reduced by district and health facility leaders using QI methods through improving documentation and use of data on duty attendance, joint supportive supervision, motivation, and strengthening the reward and sanction mechanisms. Availability of essential medicines and supplies can be improved through better documentation and use of data on stock levels for timely and accurate drug orders, mtrac phone messaging for redistribution, and health facility departmental drug accountability. The leadership and management skills of health facility managers can be improved by district leaders support during the supervision visits in addition to technical support. B. Challenges There was limited time allocated for health QI interventions by district leaders. The formation of QI structures with delegation enabled continuity of QI interventions in the districts. The fixed MOH health facility staffing structure and the inadequate drug supplies were not corresponding to the increasing population served. The district leaders are continuously advocating for increased budgetary allocation to the health sector. Important health worker cadres, such as anesthetists, are inadequate and mostly centered around urban areas. The districts have begun supporting some of the district health workers, such as nurses, to train as anesthetists and fill the vacancies. Poor and inadequate health facility infrastructure including staff housing a major challenge contributing to health worker absenteeism. Leaders are lobbying for funding to construct health facility staff houses from different development partners. Improving availability of human resources for health, essential medicines and supplies 7

14 C. Recommendations Health facility and district political and administrative leaders should be supported to implement QI for health through forming district leadership QI teams and implementing changes to improve health service delivery. Availability of health workers should be improved by reducing health worker absenteeism through better documentation and data use, support supervision, and health worker motivation. Availability of essential medicines and supplies should be improved through better documentation and use of data on stock levels for timely and accurate drug orders, improving health facility departmental drug accountability and using mtrac phone messaging system for drug redistribution. Improvement of health facility managers leadership and management skills by district leaders should be incorporated in routine health facility supervision visits. 8 Improving availability of human resources for health, essential medicines and supplies

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