Lessons for strengthening district health systems from India and Uganda

Wednesday, May 30th, 9:00-10:00 am ET (Washington, D.C.)

For many health systems, the district level is where ‘the rubber hits the road’—where national-level policies and programs and local realities finally meet. As such, the district level is a great place to develop and spread feasible solutions to strengthen health systems.

On Wednesday, May 30th ASSIST hosted webinar on strengthening district health systems as part of the ASSIST Legacy Webinar Series. Esther Karamagi, Chief of Party - Uganda, presented key learning from ASSIST’s work strengthening tuberculosis case notification at the district level in Uganda and Nigel Livesley, ASSIST Regional Director for South Asia, presented lessons from ASSIST’s work institutionalizing quality improvement at the district level in India to improve maternal and newborn health outcomes.

The discussion was moderated by Mirwais Rahimzai, ASSIST Regional Director for East Africa (formerly COP in Uganda and Afghanistan and Deputy COP in India), with commentary provided by Seyoum Dejene, TB/HIV Advisor, and Estella Birabwa, Program Management Specialist for TB, from the USAID Uganda Mission.


Moderator: Mirwais Rahimzai, Regional Director for East Africa (and former Chief of Party - Uganda and Afghanistan and Deputy COP - India), USAID ASSIST Project, URC
Presenter: Esther Karamagi, Chief of Party - Uganda, USAID ASSIST Project, URC
Presenter: Nigel Livesley, Regional Director for South Asia, USAID ASSIST Project, URC
  Commentator: Seyoum Dejene, TB/HIV Advisor, USAID/Uganda
  Commentator: Estella Birabwa, Program Management Specialist for TB, USAID/Uganda


Responses to additional questions posed by participants in the May 27, 2018 ASSIST Legacy Webinar, Lessons for strengthening district health systems from India and Uganda, that could not be addressed due to lack of time.

  1. What role does ASSIST see in improving the district health systems using technology?

There are multiple opportunities for use of technology, including data analytics, interactions between district leaders and their health workforce, predicting stock-outs of medicines and supplies, and managing coaching visits for improvement. Since technology usually comes with heavy inputs in terms of hardware and skill, ASSIST is careful to efficiently apply technology only when it will help identify or solve a performance gap.

  1. There seems to be an improvement in results (India).  How did you attribute this improvement across the interventions for skills, system, culture, etc.?

We think these improvements were due to the application of QI skills at the facilities. Setting up structures and changing systems and culture don’t themselves lead to better patient care – something different has to happen at the patient level. Structures, systems, etc. are required for organizations to sustainably support health workers to use QI skills.

  1. How do we ensure behavioral change in participating teams? This is essential when introducing and sustaining QI ant district and sub-district levels.

Agreed. This is crucial. We focus a lot on helping people get quick wins. We use two approaches to do this: 1) We don’t teach a lot of theory around QI and don’t introduce complex QI topics at the beginning; 2) We also ask new teams to work on problems that are relatively easier to fix within the facility level.  This helps at least some teams to get results quickly. We then use peer-to-peer learning methods to share initial successes between staff in different facilities so that the people who get results quickly can show off their results (which they like); this also helps to motivate staff in teams that are struggling (which is useful for getting more teams up to speed).

  1. Buy-in for QI is usually challenging for teams at site and district levels; was this the case in your experience? How do you advise others to handle this?

See above.  Buy-in happens when people see results (particularly improvements in mortality and other key outcomes). So setting things up to get results quickly is critical.

  1. What mechanism has been put in place for districts like Kitgum to continue using data collected at their sites to get actionable insights to improve the health system?

Primarily QI team activities are driven by data. Maintaining functionality of QI teams will ensure data is guiding changes in processes and systems at the frontline to address patient needs. At higher levels, including district and national levels, there are opportunities to use data through the DHIS2 that provides a platform for analysis, and multiple progress review and data review meetings inherent in the health system. The more functional these structures are, the more data is used.

  1. Governments usually are in a hurry to scale up quality initiatives across the country in a short period of time. Are quality improvement efforts easy to implement at a large scale (e.g., across all districts in a country)? What lessons do you have for leaders at national level about what should be the initial scale of these efforts?

There are a lot of factors that influence how easy it is to implement a QI program nationally.  Organizations that are large, have staff with diverse technical skills, that have good communication systems, support decentralized decision making and adaptation, and have extra resources that can be used to support new initiatives are better at implementing new innovations in general (including QI methods which are innovations in most settings. 

Organizations that focus on building QI skills, structures to support QI skill use, adapt existing systems to support QI skill use and a culture of quality, and have leaders who are supportive of the above, are better at implementing and institutionalizing QI programs.   

QI methods which are presented in a way that is compatible with the new organization, are simplified, have been used in similar settings and been found to be successful, and have data and champions to support them are more likely to be adopted by new organizations.  So, how you approach working with a new government (or other organization) depends on the above factors and on their interest.

  1. How was the project in Uganda able to track clients reached at the community level to ensure they are linked to a facility and followed up for compliance to TB drugs? Did the project use technology to do this?

The project focused more on process improvement and less on inputs like technology. Clients were brought in by the VHT structures and linked directly to health workers. The standardized follow-up system in place includes referral to the health facility nearest to the patient’s home and use of sub county health workers to apply DOTS. These follow-up structures were in place in Kitgum – the work was to ensure every patient gets followed up as prescribed by the guidelines.

Learn more:

This flyer discusses ASSIST's work strengthening district health systems in India and Uganda.

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About the ASSIST Legacy Webinar Series

ASSIST will host seven webinars between March and September 2018 to provide an opportunity for participants to learn from results and achievements of the project. The webinars will be held monthly at 9:00-10:00 am EST (Washington, D.C.) and each will address a different topic, drawing on results and learning from multiple countries. They will consist of one or two short presentations, followed by comments and discussion with the moderator and/or expert commentators and audience questions, and will be recorded for later viewing.

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Wednesday, May 30, 2018 - 09:00 to 10:00
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