Bottleneck analysis to support district health systems strengthening in Uganda

In 2011, the Ugandan Ministry of Health (MOH) initiated district health systems strengthening activities in several districts. Along with their in-country partners, the MOH brought together District Health Management Teams (DHMTs) to assess local data, identify supply-side bottlenecks and their causes and develop solutions appropriate to decision and fiscal space limits. Community interviews explored perceptions on financial and social barriers to accessing health services to better understand the causes of demand-side bottlenecks.

Using the information gathered, participating DHMTs identified key barriers to health, nutrition and water and sanitation interventions at the facility, outreach and community levels of service delivery, as well as their underlying causes. These included illegal fees and bribes demanded of mothers for services that are supposed to be free; persistent stock-outs of antimalarials and zinc; lack of community awareness of hand-washing and sanitation practices; lack of familiarity with pneumonia, malaria and diarrhoea danger signs among both mothers of children under five and community health workers; and insufficient outreach sessions. Using data from a Lot Quality Assurance Sampling (LQAS) household survey, inter-district differences in immunization were identified. These data indicated that several rural districts faced chronic staff shortages due to low staff retention, while more urban districts had better staffing. In part, this resulted from inequitable investments, with some districts receiving more financing for human resources. Another factor was illegal user fees, which community members in all five districts identified as one of the greatest barriers to use of services, particularly in the case of poorer households.

Based on these and other findings from the bottleneck analysis exercises, the DHMTs developed locally tailored interventions they identified as feasible, such as improving initial utilization and effective coverage through radio spots, village health team quarterly meetings chaired by local political and community leaders, increased messaging via churches/mosques, implementation of the SMS-based and community-empowering “uReport” monitoring system, expanded use of an SMS-based ‘mTrac’ system to report human resources and stock shortfalls and complete birth registration for children under five. In addition, DHMTs developed a plan for each facility to be assessed regularly by managers and community members (via SMS-based community oversight) to ensure the fee schedule was visible and complete and that staff members wore name badges to improve accountability for the care they provide.