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Institutionalizing and sustaining social change in health systems: the case of Uganda.

ABSTRACT: The key to high impact health services is institutionalizing and sustaining programme evaluation. Uganda represents a success story in the use of a specific programme evaluation method: Lot Quality Assurance Sampling (LQAS). Institutionalization is defined by two C's: competent programme evaluators and control mechanisms that effectively use evaluation data to improve health services. Sustainability means continued training and funding for the evaluation approach. Social science literature that researches institutionalization has emphasized 'stability', whereas in global health, the issue is determining how to improve the impact of services by 'changing' programmes. In Uganda, we measured the extent of the institutionalization and sustainability of evaluating programmes that produce change in nine districts sampled to represent three largely rural regions and varying levels of effective health programmes. We used the proportion of mothers with children aged 0-11?months who delivered in a health facility as the principal indicator to measure programme effectiveness. Interviews and focus groups were conducted among directors, evaluation supervisors, data collectors in the district health offices, and informant interviews conducted individually at the central government level. Seven of the nine districts demonstrated a high level of institutionalization of evaluation. The two others had only conducted one round of programme evaluation. When we control for the availability of health facilities, we find that the degree of institutionalization is moderately related to the prevalence of the delivery of a baby in a health facility. Evaluation was institutionalized at the central government level. Sustainability existed at both levels. Several measures indicate that lessons from the nine district case studies may be relevant to the 74 districts that had at least two rounds of programme evaluation. We note that there is an association between the evaluation data being used to change health services, and the four separate indicators being used to measure women's health and child survival services. We conclude that the two C's (competent evaluators and control mechanisms) have been critical for sustaining programme evaluation in Uganda.

SUBMITTER: Hage J

PROVIDER: S-EPMC5886222 | biostudies-literature | 2017 Nov

REPOSITORIES: biostudies-literature

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Institutionalizing and sustaining social change in health systems: the case of Uganda.

Hage Jerald J Valadez Joseph J JJ

Health policy and planning 20171101 9

The key to high impact health services is institutionalizing and sustaining programme evaluation. Uganda represents a success story in the use of a specific programme evaluation method: Lot Quality Assurance Sampling (LQAS). Institutionalization is defined by two C's: competent programme evaluators and control mechanisms that effectively use evaluation data to improve health services. Sustainability means continued training and funding for the evaluation approach. Social science literature that ...[more]

PMID: 28981663

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Project description:BackgroundThere is a general expectation within healthcare that organizations should use evidence-based practice (EBP) as an approach to improving the quality of care. However, challenges exist regarding how to make EBP a reality, particularly at an organizational level and as a routine, sustained aspect of professional practice.MethodsA mixed method explanatory case study was conducted to study context; i.e., in terms of the presence or absence of multiple, inter-related contextual elements and associated strategic approaches required for integrated, routine use of EBP ('institutionalization'). The Pettigrew et al. Content, Context, and Process model was used as the theoretical framework. Two sites in the US were purposively sampled to provide contrasting cases: i.e., a 'role model' site, widely recognized as demonstrating capacity to successfully implement and sustain EBP to a greater degree than others; and a 'beginner' site, self-perceived as early in the journey towards institutionalization.ResultsThe two sites were clearly different in terms of their organizational context, level of EBP activity, and degree of institutionalization. For example, the role model site had a pervasive, integrated presence of EBP versus a sporadic, isolated presence in the beginner site. Within the inner context of the role model site, there was also a combination of the Pettigrew and colleagues' receptive elements that, together, appeared to enhance its ability to effectively implement EBP-related change at multiple levels. In contrast, the beginner site, which had been involved for a few years in EBP-related efforts, had primarily non-receptive conditions in several contextual elements and a fairly low overall level of EBP receptivity. The beginner site thus appeared, at the time of data collection, to lack an integrated context to either support or facilitate the institutionalization of EBP.ConclusionOur findings provide evidence of some of the key contextual elements that may require attention if institutionalization of EBP is to be realized. They also suggest the need for an integrated set of receptive contextual elements to achieve EBP institutionalization; and they further support the importance of specific interactions among these elements, including ways in which leadership affects other contextual elements positively or negatively.

Project description:BACKGROUND:The Theory of Change (ToC) is a management and evaluation tool supporting critical thinking in the design, implementation and evaluation of development programmes. We document the experience of Future Health Systems (FHS) Consortium research teams in Bangladesh, India and Uganda with using ToC. We seek to understand how and why ToCs were applied and to clarify how they facilitate the implementation of iterative intervention designs and stakeholder engagement in health systems research and strengthening. METHODS:This paper combines literature on ToC, with a summary of reflections by FHS research members on the motivation, development, revision and use of the ToC, as well as on the benefits and challenges of the process. We describe three FHS teams' experiences along four potential uses of ToCs, namely planning, communication, learning and accountability. RESULTS:The three teams developed ToCs for planning and evaluation purposes as required for their initial plans for FHS in 2011 and revised them half-way through the project, based on assumptions informed by and adjusted through the teams' experiences during the previous 2 years of implementation. All teams found that the revised ToCs and their accompanying narratives recognised greater feedback among intervention components and among key stakeholders. The ToC development and revision fostered channels for both internal and external communication, among research team members and with key stakeholders, respectively. The process of revising the ToCs challenged the teams' initial assumptions based on new evidence and experience. In contrast, the ToCs were only minimally used for accountability purposes. CONCLUSIONS:The ToC development and revision process helped FHS research teams, and occasionally key local stakeholders, to reflect on and make their assumptions and mental models about their respective interventions explicit. Other projects using the ToC should allow time for revising and reflecting upon the ToCs, to recognise and document the adaptive nature of health systems, and to foster the time, space and flexibility that health systems strengthening programmes must have to learn from implementation and stakeholder engagement.

Project description:BackgroundIndia has been at the forefront of innovations around social accountability mechanisms in improving the delivery of public services, including health and nutrition. Yet little is known about how such initiatives are faring now that they are incorporated formally into government programmes and implemented at scale. This brings greater impetus to understand their effectiveness. This formative qualitative study focuses on how such mechanisms have sought to strengthen community-level nutrition and health services (the Integrated Child Development Services and the National Rural Health Mission) in the state of Odisha. It fills a gap in the literature on considering how such initiatives are running when institutionalised at scale. The primary research questions were 'what kinds of community level mechanisms are functioning in randomly selected villages in 3 districts of state of Odisha' and 'how are they perceived to function by their members and frontline workers'.MethodsThe study is based on focus group discussions with pregnant women and mothers of children below the age of 2 (n = 12) and with women's self-help groups (n = 12); interviews with frontline health workers (n = 24) and with members of community committees (n = 36). Interviews were analysed thematically using a priori coding derived from wider literature on key accountability themes.ResultsFour main types of community-based mechanisms were examined - Mothers committees, Jaanch committees, Village Health and Sanitation Committees and Self-Help Groups. The degree of their effectiveness varied depending on their ability to offer meaningful avenues for participation of their members and empower women for autonomous action. Notably, in most of these mechanisms community participation is very weak, with committees largely controlled by the frontline workers who are supposed to be held to account. However, self-help groups showed real levels of autonomy and collective power. Despite not having an explicit accountability role, these groups were nevertheless effective in advocating for better service delivery and the broader needs of their members to a level not seen in institutional committees.ConclusionsThe study points to the need for community-level mechanisms in India to adequately address issues of participation and empowerment of community members to be successful in contributing to service improvements in health and nutrition.

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Institutionalizing and sustaining social change in health systems: the case of Uganda.

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Institutionalizing and sustaining social change in health systems: the case of Uganda.

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