MAKERERE UNIVERSITY COLLEGE OF HEALTH SCIENCES

MOH-MAKSPH DISTRICT CAPACITY BUILDING PROGRAM

SUMMARY REPORT ON THE GRADUATION OF FELLOWS OF THE WESTERN COHORT

Makerere University School of Public Health (MakSPH) in conjunction with the Ministry of Health (MoH), with support from the US Centres for Disease Control and Prevention (US CDC), has been implementing a health leadership and management capacity building program since 2002. The program focuses on two inter-related activities, namely; the Public Health Fellowship Program and the District Capacity Building Program . The Public Health Fellowship Program follows in the foot-steps of the 2-year Long-term Fellowship Program that was implemented between 2002 and 2014. The long-term Fellowship Program initially focused on HIV/AIDS program management (2002-2010), but progressively expanded to include other health programs between 2011 and 2014; including Maternal and Child Health, Malaria, TB and Health Informatics, among others. In 2015, this program was strategically redesigned as the Public Health Fellowship Program with five inter-related tracks including Field Epidemiology. On the other hand, the District Capacity Building Program started off as an 8-month Medium-term Fellowship offering two independent but inter-related courses in Monitoring and Evaluation (M&E) and Continuous Quality Improvement (CQI) Fellowships (2008 – 2013). In 2014, the two courses were merged to form the Health Service Improvement Course (2014) – which targeted frontline health workers operating at Health Center IVs and District/General Hospitals. In 2015, the Health Service Improvement Course was strategically adjusted to target health managers at district and regional levels under the District Capacity Building Program (DCBP). The DCBP offers three independent but inter-related courses, namely: a) the 9-month Fellowship in Governance, Leadership and Management (GLM) of District Health Services; b) the 9-month Quality Improvement Champions’ Course; and c) the one-week Induction Course for newly recruited health managers at national and sub-national levels. The GLM Fellowship enrolled its first intake in August 2015 and has continued to enroll Fellows throughout the country, with a total of 134 district and regional health managers enrolled to-date.

The overall goal of the GLM Fellowship is to build the capacity of district and regional health managers to effectively accelerate health services performance at district level. Specifically, the Fellowship aims at improving the skills and competencies of health managers at district and regional level in order to improve health services delivery in terms of more and better outputs, improved quality of service delivery processes as well better health outcomes through improved leadership and management. The Fellowship specifically targets District Health Teams, Regional Performance Monitoring Teams (RPMTs), and Managers of the Regional Referral Hospitals (RRH) including Managers of the Community Health Departments.

Implementation approach The GLM Fellowship uses a modular, work-based training approach that allows trainees to attend the course without leaving their formal employment. As part of training, trainees identify and implement a hands-on project to demonstrate acquisition of skills. Trainings are conducted at regional level and last for nine months; the training is arranged in three modules that are spread throughout the 9 months duration of the training. The first module introduces trainees to the concepts in governance, leadership and management, data, M&E and concepts of quality improvement and prepares them to start thinking about a problem or gap within the organization that they intend to address as part of the training. This constitutes the trainees’ hands-on ‘project’. The projects are reviewed and cleared by the team at MakSPH in conjunction with the institution’s leadership and this increases prospects for project

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continuity and scale-up to other units. During the second module, trainees from each institution present their proposed projects to Fellowship program staff and trainers who review the projects prior to full proposal development. Trainees continue to engage in didactic instruction during the second module and finalize their project proposals before they return to their institutions. These proposals are subsequently approved for implementation.

At the end of the project implementation period, trainees return for the third module where they present progress reports on the projects implemented and receive guidance on how to communicate the project results including report writing and presentations. Trainees write and submit final project reports that describe the interventions implemented, improvements achieved, lessons learned, challenges experienced and any plans for scaling up lessons learnt/best practices identified. On satisfactory completion of the Fellowship requirements and obligations, trainees (managers) receive a Fellowship Certificate in Governance, Leadership and Management of District Health Services.

Graduation of the first cohort of trainees and summary of the Fellows’ projects Twenty two (22) Fellows (representing 12 teams from Western : 6 DHOs, 3 RPMTs, 2 Regional Referral Hospitals and 1 Urban Authority) completed their training in June 2016 and presented their projects at a grand dissemination workshop which was held on July 14, 2016 at Golf Course Hotel in , Uganda. The occasion was attended by the Permanent Secretary, Ministry of Health, representatives of the donor community, faculty from MakSPH, district representatives from the Western, Central and Eastern regions of the country, the alumni Fellows, and the graduating Fellows (some of whom are shown in the photo below).

Some of the Fellows who disseminated their project reports on July 14th, 2016 at Golf Course Hotel, Kampala

After the presentations, the most committed and dedicated team (Mbarara RPMT) received a Certificate of Recognition. All Fellows presented their hands-on projects to demonstrate acquisition of skills but most importantly, to address priority work-place challenges that affected health service delivery as summarized in Table 1 and in the subsequent summary below the table. 2

Table 1: List of Projects Implemented by Fellows Enrolled on the Fellowship in Governance, Leadership and Management of District of Health Services from the Western Cohort: August 2015 – June 2016

Name Project Title District/Facility/RPMT A: DISTRICT HEALTH OFFICERS

Dr. Kamya Ivan Improving deliveries under skilled birth attendants at HCIVs in Kiruhura district Dr. Sakor Moses Functionalizing quality improvement teams at the district and health facilities to improve uptake of DPT3 and Measles Immunization services in Rakai district Dr. Imam Mutyaba Improving the retention of HIV+ Mother Enrolled for EMTCT Services in Kiryandongo through functionalizing the Quality Improvement teams Dr. Fred Lwasampijja Improving Data quality and weekly surveillance reporting rates in Mityana District Dr. Joseph Ruyonga Increasing Immunization coverage in Bugambe and Buseruka sub-counties in Hoima district Dr. Joseph Okware Improving weekly epidemiological disease surveillance Luwero District reporting in Luwero District. B: REGIONAL PERFORMANCE MONITORING TEAMS

Bakahirwa Philip Improving Coordination of Health Service Delivery in Hoima Hoima RPMT Kasambula Lordwin Region Omoding Alex Tabani Gabriel Tumwesigye Livingstone Improving Weekly Epidemiological Surveillance Reporting in Mbarara RPMT Beinomugisha Geofrey Dr. Birungi David Kyorikunda Julian

C: REGIONAL REFERRAL HOSPITALS

Dr. Andema Alex Improving the Quality of Data generated and reported in Kabale Kabale RRH Turinawe Pelegrino RRH

Dr. Francis Mulwanyi Using data for decision making to improve health service Hoima RRH Dr. Michael Mulowoza delivery in Hoima Regional Referral Hospital Bwambale Borniface

Kauma Abbey Improving medical waste management as a strategy for Fort-Portal RRH Mutema Prossy B infection control in Fort-portal Regional Referral Hospital

D: URBAN AUTHORITIES

Dr. Tinkasimire Charles Improving timeliness and completeness of HMIS data from Mbarara Municipality John lower health centers in Mbarara Municipality

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SUMMARY OF INDIVIDUAL PROJECTS

1.0 Improving timely Weekly Epidemiological Surveillance reporting rates in Ibanda district – by Mbarara Regional Performance Monitoring Team (RPMT)

**Mbarara RPMT received a Certificate of Recognition for their outstanding performance, dedication to Fellowship deliverables, and strong stakeholder engagement within the context of district-led programming**

The main objective was to improve timely Weekly Epidemiological Surveillance reporting in Ibanda district from 38.7% in October 2015 to 80% by June 2016. Specifically the project was intended to: (i) increase the proportion of health facilities in Ibanda district submiting Weekly Epidemiological Surveillance reports from a monthly average of 51.4% to 80%; (ii) improve timely submission of Weekly Epidemiological Surveillance reports in Ibanda district from 38.7% to 80%; and (iii) establish a district-led system for supporting and monitoring the submission of quality and timely weekly surveillance reports in Ibanda district.

Interventions and achievements The team trained and re-oriented three (3) facility-based health workers in mTrac reporting to address knowledge gap in using the system; formed and re-activated data teams at health facilities; reactivated phones to enable submission of mTrac messages; conducted supportive supervision and mentorship visits focusing on data generation, compilation and reporting in the 48 selected health facilities in the district; conducted dialogue meetings at health facility level to build team work and iron out data management related challenges; conducted continous monitoring and feedback on health facility weekly reporting status in the district; worked with the team to develop sub processes and standard operating procedures for collection of surveillance data and ensure clear allocation of tasks related to those processes to avoid failures in timely reporting; established weekly reviews by the facility data teams on timely submission of data; made weekly telephone calls to facilities with delayed/missing reports; involved the district leadership and health team members at every level of implementation; and emphasized data utilization at all levels as well as sharing lessons and best practices towards timely epidemiological surveillance data reporting. Average weekly reporting rates for epidemiological surveillance improved from 51% to 94% while average timeliness for 033b increased from 39% to 90%.

2.0 Improving Coordination of Health Service Delivery in Hoima Region - by Hoima Regional Performance Monitoring Team

The main objective was to improve coordination of health service delivery and weekly surveillance reporting from 67.5% to 80% in Kiryandongo and within 6 months. Specifically the team aimed at: (i) supporting the districts formalize their relationship with the Implementing Partners, (ii) establishing monthly fora for joint planning, and implementation of health activities; and (iii) establishing joint quarterly district review meetings for collective assessment of performance and challenges.

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Interventions & achievements The team worked with the district to update activity profiles of all IPs; develop/update Memoranda of understanding with IPs; conducted joint planning, and implementation of health service delivery; conducted quarterly district level performance review meetings in which individual facility level performance were reviewed against targets; conducted joint targeted supportive supervision and tracked performance of selected service indicators. As a result of these interventions, weekly reporting rates improved from 70% to 93% in Kiboga and from 65% to 89% in Kiryandongo district.

3.0 Improving the completeness and accuracy of data generated in 5 data generation points in Kabale Regional Referral Hospital – by Kabala RRH team

The project was intended to improve completeness and accuracy of data generated in 5 data generation points in Kabale Regional Referral Hospital from 48.7% and 35% respectively to 80% within a period of 6 months.

Interventions & achievements This was achieved through building capacity of health teams on data quality, equipping the facility with adequate data collection tools at all 35 data generation points in the hospital and improving management support for collection of complete and accurate data and involving the Quality Improvement team in supporting data quality. Data completeness improved from 48.7% to 84% while data accuracy improved from 35% to 75%.

4.0 Improving the timeliness and completeness of reports submitted from lower health centers in Mbarara Municipality – by Mbarara Principal Medical Officer

The project was intended to improve the timeliness of HMIS reports and completeness of Registers in 3 public lower health centers in Mbarara Municipality from 41% and 56% to 100% and 80% respectively within six months.

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Interventions and achievements The interventions focused on building health workers’ knowledge and skills in the use of the revised HMIS tools to collect, compile and submit timely and complete monthly HMIS reports, ensuring continued availability of revised HIMS reporting tools in all health facilities and improving leadership skills of all health unit managers. Timeliness of reporting improved from 41% to 100% while completeness of selected facility registers (OPD, ART & ANC registers) improved from 56% to 90%.

5.0 Improving the quality of health data reported from health facilities to the district and weekly surveillance reporting in Mityana District – by Mityana District Health Officer

The project was intended to improve the quality of health data generated and reported from health facilities to the district as well as weekly surveillance reporting in Mityana district. Specifically the project was intended to improve: a) completeness of HMIS 105 reporting tool in 5 high volume health facilities from 42% to 80% within a period of 6 months; b) the accuracy of HMIS 106a reporting tool in 5 high volume health facilities from 52.3% to 80% within a period of 6 months; c) timely submission of inpatient reports (HMIS 108) from 87% to 100% in 9 poorly performing health facilities within a period of 6 months; and d) weekly surveillance reporting rates from 57.3% to 65% in 22 health facilities within a period of 6 months.

Interventions and achievements The interventions focused on building capacity of facility teams in data quality assessments, equipping facilities with standard MoH data tools, formation of facility data teams to review and analyze their data before submission to the district, strengthening support supervision and conducting performance review meetings that were data driven including providing regular feedback to the facilities that generate data, and registering alternative phones at every health facility to ensure uninterrupted submission of mTrac reports. HMIS 105 completeness improved from 42% to100%. Accuracy of HMIS 106 data improved from 52.3% to 100%, timely submission of HMIS 108 in 9 poorly performing facilities improved from 87% to 100%; while weekly surveillance reporting rates in 22 selected health facilities improved from 57% to 80%.

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6.0 Improving uptake of DPT3 and measles Immunization services in Hoima District – by Hoima District Health Officer

The main objective was to increase immunization coverage (DPT3 and measles) to at least 90% in Bugambe and Buseruka sub counties by end of June 2016 in order to improve the quality of life of children in Hoima district.

Interventions and achievements The interventions focused on increasing the number of outreach sites for immunization for the two sub-counties; supporting facilities to work with communities to develop micro plans for immunization outreaches using REC strategy and monitoring the implementation of the plans; engaging the private sector in supporting immunization activities, building capacity of health workers to offer quality immunization services both at static and outreach sites as well as strengthening support supervision by the District Health team with focus on data analysis and utilization, planning, target setting and estimating vaccine requirements. Immunization coverage for DPT3 increased from 53% to 105% while coverage for measles improved from 67.5 to 91% .

7.0 Establishing functional QI committees and institutionalize quality improvement to improve immunization coverage in Rakai District by Rakai District Health Officer

The project was intended to establish functional QI committees and teams and institutionalize Quality improvement in Rakai district in order to improve DPT3 and Measles coverage from 31% and 37% respectively to 90% by June 2016.

Interventions & achievements Specifically the project focused on: (i) establishing Quality Improvement committees at the district level and five quality improvement teams at facilities; (ii) equipping the District and HSD quality improvement committees and facility QI teams with skills to lead the continuous improvement in service delivery; (iii) designing and disseminating a QI reporting system in Rakai; (iv) equipping members of the DHT and facility in charges with knowledge and skills in governance, leadership and management so that they can effectively support the functionality of the QI teams and (v) supporting the facility teams to implement QI projects. The district has established five functional quality improvement teams and one district QI committee. These teams conducted monthly meetings to review performance, used documentation journals and are currently being supported by the DHT to analyze data and use them for decision 7

making including developing and implementing action plans. Average monthly DPT3 coverage improved (within a period of 6 months) from 48% to 151% while the average monthly Measles coverage improved from 42% to 106%.

8.0 Improving Epidemiological Weekly Disease Surveillance Reporting in District – by Luwero District Health Officer The main objective was to improve weekly disease surveillance reporting by health units in Luwero District from 63% in November 2015 to 80% by June 2016 to increase the capacity of the district to detect and timely respond to any disease outbreak.

Interventions and achievements The interventions focused on increasing the number of health workers with knowledge and skills to collect, compile and submit 100% weekly surveillance reports using mTrac; increasing availability and accessibility of Weekly Epidemiological Disease Surveillance reporting tools and equipment in all 74 health facilities; improving information sharing and feedback on disease surveillance between Health facilities and DHOs office; and improving leadership skills of all health unit in- charges in Luwero district. Average weekly disease surveillance reporting rates improved from 63% to 97%. This was realized through; training health workers in weekly reporting, availing a phone to each of the health units to support reporting, weekly DHMT meetings where data quality reviews including reporting formed part of the agenda and informed the DHT to take decisions and follow up on the non- reporting facilities. As a best practice the districts has allocated DHMT members an average of 4-5 health facilities to follow up and support to ensure weekly 033b reports are submitted. The DHT also established an editorial committee which designed a weekly bulletin to disseminate weekly surveillance data to all stakeholders in the district.

9.0 Improving the Proportion of Mothers Delivering at Health Facilities in Kiruhura District – by District Health Officer Kiruhura District

The project was intended to increase the proportion of deliveries supervised by skilled health workers in Kiruhura district from 36.8% to 60% by June 2016. Specifically the project team focused on: (i) documenting the interventions and factors that affect access to facility deliveries in Kiruhura district and (ii) improving the deliveries supervised by skilled health workers at the two high level health facilities in Kiruhura district i.e. Kazo and Kiruhura HC IVs. The overall objective was to increase the proportion of mothers who deliver at health facilities from an average of 40 deliveries per month to an average of 50 deliveries per month within a period of 6 months.

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Interventions and achievements The team increased community awareness about the importance of health facility deliveries through community dialogues and radio talk shows, enhanced technical competence and interpersonal skills of medical officers and midwives, conducted supervision and monitoring of staffs so as to improve the outputs, conducted monthly district quality improvement meetings with a focus on deliveries, and strengthened the ambulance referral system. In addition the theater at Kazo Health centre IV was made functional with close supervision for outputs and an anesthetists was recruited for Kiruhura HC IV. Health facility delivered for Kazo HC4 improved from 47 to 67 per month while those for Kiruhura HC4 improved from 34 to 56 per month. The team established and functionalized quality improvement teams at both Kazo and Kiruhura HCIV.

10. Improving Retention of HIV+ Mother Enrolled for EMTCT Services in Kiryandongo district – by Kiryandongo District Health Officer The main objective was to improve retention of HIV positive mothers enrolled into Option B+ from 48% to 80% through functionalizing quality improvement teams in Kiryandongo district by June 2016.

Interventions and achievements The team established a District Quality Improvement Team and Facility Quality Improvement Teams in 10 facilities to improve retention of mothers for eMTCT services; supported the 10 CQI teams to implement eMTCT specific projects that collectively improved retention from 48% to 63% in a period of 6 months

11. Improving Medical Waste Management as a Strategy for Infection Control at Fort Portal Regional Referral Hospital Wards - Case Study of the Surgical Ward. By Fort portal RRH Team

The main goal was to improve medical waste management as a strategy for infection control at Fort portal regional referral hospital within six months, starting with the surgical ward through: (i) Equipping health workers with knowledge in handling medical waste from 58% to 80% within 6 months; (ii) Improving the accessibility and proper use of appropriate medical waste colour coded bins in surgical ward from 55% to 100%; and (iii)

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Improving medical waste transportation to dispose facility from 40% to 70%

Achievements: Health workers knowledge in MWM increased from 58% to 85% against a target of 80%; accessibility and use of medical waste bins increased from 55% to 75% against a target of 100%; and medical waste transportation increased from 40% to 100% against a target of 70%

12. Improving the Use of Data for Decision-making at Hoima Regional Referral Hospital –By Hoima RRH Team

The main objective was to increase the proportion of hospital units using data for action from the current level of 13% to 100% within a period of six months. This was achieved through:  Conducting trainings on data use for decision making for 100% of health workers.  Conducting manager - led monthly data review meetings.  Implementing monthly software aided data analysis of reports using a trained data volunteer.  Carrying out monthly data improvement activities.

Achievements:  83% of health workers have been trained in data use for decision-making  The proportion of health units supported to analyze and use data for decision-making has been improved from 13% to 63%.  Through analysis of data the team identified sepsis as the commonest cause of admission on neonatal unit and implemented measures to reduce sepsis. Also noted that the most cause of death among mothers was anemia, and as a result, a committee was set up to oversee the availability of blood in the hospital.

FOR MORE INFORMATION, PLEASE CONTACT:

Mr Joseph KB Matovu Training Manager Mr Charles Isabirye MakSPH-CDC Fellowship Program Assistant Commissioner – Human Resource Development P.O. Box 7072, Kampala, Uganda Ministry of Health Tel. +256 772 972 330 P.O.Box 7272, Kampala Uganda Email: [email protected] Tel: +256 772893011 Fax: +256 414 533 958 Email: [email protected]

Dr Violet Gwokyalya Program Officer - District Capacity Building MakSPH-CDC Fellowship Program P.O.Box 7072, Kampala, Uganda Tel: +256 772308902 Email: [email protected] Fax: +256 414533958 10