Applying an Improvement Process to a Difficult Long-Term Problem of Gas Cylinder Supply Yields Positive Results for the Masaka District, Uganda
The Masaka District Health Office is the government administrative office which oversees health service delivery in the Masaka District. In addition to management of other health programs, this District Office is responsible for routine immunization service delivery and management of the cold chain. For at least the past ten years there has been only one gas cylinder in each of its 33 health units instead of two. This shortage affects the cold chain. For example, during the time it takes to refill the one existing cylinder (up to one month), vaccines may be improperly stored with potency compromised, may be wasted and routine services may be interrupted, resulting in lower immunization coverage.
In collaboration with UNEPI and five Masaka HUs we participated in a year- long quality improvement process with Makerere University School of Public Health, Dartmouth College and John Snow, Inc., (African Routine Immunization Essentials – Systems Innovation Project: ARISE-SI) which is framed by the Dartmouth Microsystem Quality Improvement Approach. This project was funded by the Bill and Melinda Gates Foundation. During this year, we participated in four workshops and on-going coaching in regard to a quality improvement project chosen by each team. At the first workshop the District Health Improvement Team (DHIT) was formed. Our team acknowledged that the lack of a second gas cylinder was affecting the district’s ability to provide quality services. Thus, we chose as our quality improvement project to obtain a second gas cylinder for every health unit in our district (not just for the five who were participated in ARISE-SI). Using the knowledge gained through the project workshops, and from our Ugandan Coach we developed an Improvement Plan to address the entrenched problem of the gas cylinders. We used QI tools taught by the Dartmouth faculty to identify leverage points of action and barriers and enablers to this work. Our team initiated a process whereby we negotiated this Improvement Plan among ourselves, with the DHO, and then together as a team proposed and negotiated with the District Health Committee that we reallocate existing health services resources from the Primary Health Care budget to this problem. The DHIT had a clear vision of the impact that this reallocation would have on other services. We also proposed, and then instituted, a tracking system to monitor the flow of the gas and gas cylinders.
We procured a total of 22 gas cylinders the total needed to supply each unit using gas (11 use electricity or solar) with 2 gas cylinders. These cylinders have been delivered to each Health Unit and the monitoring of cylinders has been integrated into our quarterly support supervision process. We also have developed a rigorous inventory control process in which we physically count cylinders daily and weekly and tally this against the stock cards.
For want of two million Ugandan Shillings (about $900) children’s lives were being lost. For over ten years getting a second gas cylinder for every health unit seemed like an insurmountable problem. However, when we took a team approach and used the structured process and QI tools of the Dartmouth Microsystem Quality Improvement Approach for problem solving we were able to implement small and then bigger steps of change and solve this problem. We now know that it is essential for us to take ownership for finding solutions to problems such as these and that with the right tools and approach it is possible for us to lead these changes.