Nestled in eastern and southern Africa, with a population of just over 39 million,
Uganda reported a maternal mortality ratio of 360 per 100,000 live births, a neonatal
mortality rate of 19 per 1000 live births and an infant mortality of 38 per 1000 live
births in 2016 [1,2]. While health outcomes have been improving, much more progress
could be realized, particularly given that the majority of maternal and child health
deaths are avoidable. Contact with the health system occurs, but not when it is most
needed. In Uganda, although 95% of mothers received antenatal care from a skilled
provider for their most recent live birth, only 59% of live births in the past 5 years
were delivered by a doctor or nurse/midwife, and 57% were delivered in a health facility
in 2011 [3].
Progress is also constrained by barriers to accessing healthcare for women and children
that interact across health-system levels and increase across the continuum of care
[4–6]. Once the need for healthcare seeking is recognized, lack of preparedness to
mobilize transport, funds, family and community support can delay access to care.
Even after family members mobilize their resources to reach a health provider, the
poor quality of care provided can still negate the efforts made to seek care in the
first place. These penalties of low awareness and low preparedness on the demand side
combine with poor access and poor quality of care on the supply side, disproportionately
prejudicing those who are most marginalized.
The dynamics of inequality that characterize maternal and child health in Uganda have
multiple dimensions. The percentage of births delivered by a skilled provider is substantially
higher in urban areas (90%) than in rural areas (54%) [3]. Coverage of maternal and
child health interventions also varies by geographic region, from 57% to 70% [7].
Although these geographic inequalities are decreasing, income inequality in maternal
healthcare is increasing [8]. Social norms that replicate inequalities related to
gender, age and marital status, among other forms of social hierarchy, also debilitate
maternal and child health.
Rather than being daunted by these substantial and varied barriers, a team at the
Makerere University School of Public Health, Kampala, embraced the importance of a
systems lens that considers how numerous levels and partners dynamically interact
to advance or stall maternal and newborn health [9]. They built on previous interventions
that led to significant gains in community newborn health practices and facility deliveries
[10]. The extent to which these single interventions sustained health gains was partly
limited by their isolated implementation within the dynamic, broader health systems
in which they were embedded [9]. Knowing that they had to address capacity gaps across
health-system levels, the team sought to consolidate the gains previously realized
by embarking on the Maternal and Neonatal Implementation for Equitable Systems project
(MANIFEST) detailed in this volume [11].
MANIFEST supported community outreach in the form of community health worker (CHW)
home visits, coupled with community awareness (dialogues, radio) and community capacity
strengthening (community savings and transport initiatives) to ensure that, with community
support, mothers and families felt empowered to seek timely care [12,13]. To ensure
that this increased demand was met with quality services, MANIFEST also facilitated
enabling environments for healthcare workers to respond through supportive supervision,
clinical mentoring and participatory action research steered by local district health
teams [9,14,15].
Programme outcomes
Through these multi-layered initiatives, the MANIFEST project demonstrated significant
improvements in early antenatal care attendance, facility deliveries and newborn care
practices [9,16]. Kananura et al. also demonstrated significant improvements from
baseline levels in birth preparedness and knowledge of obstetric danger signs in rural
communities [16]. The increases in knowledge of at least two newborn danger signs
and at least three obstetric danger signs are higher than those achieved in other
parts of the country [17,18].
While improvements in newborn care practices were statistically significant, the absolute
changes in kangaroo mother care for low-birth-weight newborns and delayed bathing
for all babies were minimal. Social norms and hierarchies that inhibit care seeking
remain a challenge. Younger women aged 15–24 years compared to those aged 35 years
and above were associated with reduced odds of birth preparedness given knowledge
of obstetric danger signs [16]. Changing the behavioural practices embedded in sociocultural
contexts requires time and engagement with multiple stakeholders at both family and
community level [19].
Another concern was that some of the improvements seen were not significantly higher
than those in comparison areas, as other implementing partners were promoting similar
safe motherhood initiatives in comparison areas. The lack of virgin comparison areas
when implementing effective interventions challenges evaluators to pursue other evaluation
metrics and questions that examine not just programme outcomes [20], but also pathways
of change and partnerships formed. This editorial seeks to highlight some of those
lessons related to critical pathways and partnerships based on the papers included
in this special issue.
Pathways of change
Catalysing health workers to improve provision of quality services
MANIFEST-supported health workers improve service provision through a system of cascade
mentoring, with external specialists mentoring teams of local mentors [15]. Key improvements
in increased productivity, improved management of patients, increased problem identification
and solving, and improved health worker skills were reported. Yet implementation was
not straightforward. Documentation of the mentorship process through mentees’ self-assessment
tools was unpopular, and these tools were not used owing to their being perceived
as burdensome and to fears about assessment. Despite careful selection, several local
mentors dropped out and only those who were passionate about maternal and newborn
care remained. Higher level cadres were less likely to be consistent mentors owing
to their own workload and poor attitude towards mentorship. Nonetheless, key supportive
elements included the role of district leadership and the initial involvement of external
mentors. Overall, Ajeani et al. [15] indicate that local staff with the right aptitude,
with training and mentoring themselves, can support frontline health workers to improve
service delivery through mentoring, provided that facilitation in terms of transportation
and compensation of time/work demands can be addressed. Emerging research on mentoring
in other low- and middle-income contexts indicates cost-effective improvements in
facility readiness, nurse knowledge and adherence to protocols, as shown by case sheets
[21].
In addition to mentoring, MANIFEST strengthened quarterly supportive supervision focused
on maternity care services and key system inputs to ensure quality provision of such
care [14]. Supervisors and health workers jointly identified opportunities for improvement
through observation and review of health-facility data at each of the facilities.
Joint problem solving and follow-up of action points were undertaken in a participatory
manner, resulting in improvements in laboratories, basic pharmacy, lighting in the
maternity and delivery wards, infection control, waste segregation and placenta pits.
Engagement by district managers enabled in the process facilitated support from other
system partners and levels. Nonetheless, Kisayke et al. [14] also found that some
elements of service quality, such as referral readiness and running water in facilities,
were harder to achieve. While the engagement of midwives improved, the majority of
the doctors did not participate in the mentorship sessions. Iterative team engagement
with data to identify problems and track progress on implementing local solutions
is a hallmark of quality improvement cycles [22], but they also need to address organizational
culture and norms that may inhibit frontline health workers’ critical engagement and
ability to implement the required changes [22,23].
In examining the organizational factors that motivated health workers to stay in rural
areas, Kiwanuka et al. [24] found that these health workers accepted their work environment
with an attitude of resignation and rationalized that working in a difficult environment
proved their mettle. Improved infrastructure was not seen as a motivator, possibly
as all rural districts were uniformly bad. Incentives also were minimally valued,
as they rarely materialized despite being mandated. While staff accommodation reduced
travel expenses and living costs and kept families together, health workers highlighted
the advantage of staying far away from health facilities as a strategy to avoid excessive
workloads. Despite these difficult working conditions, they valued working for the
public sector, given the comparative lack of job security in the private sector. Elements
of vocation, the need to be near family, maintaining community ties and having opportunities
to invest locally kept health workers in rural districts. Retaining health workers
in rural areas requires bundled interventions that address both intrinsic and extrinsic
motivation linked to living environments, working conditions and development opportunities
tailored to local contexts [25,26].
Strengthening CHWs
MANIFEST raised awareness of maternal and newborn health at community level through
a variety of communication channels, including CHWs and village health teams (VHTs),
community dialogue meetings, radio talk shows and health facility workers. Kananura
et al. [16] found that knowledge of obstetric danger signs and facility delivery seeking
were higher among intervention residents who were visited by the VHTs. This is triangulated
by another finding from the study that found that VHTs were the highest source of
maternal and newborn health information at community level. Nonetheless, 1 year after
VHTs were trained in maternal and newborn health, Namazzi et al. [12] found that while
VHT knowledge on maternal danger signs remained stable, at over 70%, their knowledge
of newborn danger signs and care practices declined, from 85.5% to 58.9% and from
75.3% to 50.3%, respectively.
Considering the costs of facility supervision and retraining, MANIFEST supported peer
supervision of VHTs and found that it was cheaper and more reliable as VHTs were able
to relate to and learn better from their peers. Research on CHWs in other contexts
has also supported innovations in CHW supervision going beyond their facility-based
supervisors [27–29]. MANIFEST also found that non-monetary incentives such as T-shirts,
certificates and musawo (doctor) status in the community motivated VHTs to continue
working. At the same time, monetary incentives and means of transport such as bicycles
were found to be essential for VHTs to undertake their roles. Other studies also indicate
a nuanced approach to CHW motivation requiring both financial and non-financial incentives
[30–32].
Despite being such a resource, supporting CHWs requires ongoing efforts and entails
addressing health system challenges related to the training, supervision and motivation
of this important workforce [33]. Over the past 10 years there has been a seven-fold
increase in low- and middle-income country CHW publications, driven largely by vertical
programmes [34]. While CHWs are now recognized as vital actors in realizing health
outcomes, issues of sustainability linked to supervision, motivation and performance
indicate that initiatives need to move beyond specific programmes and address how
CHWs serve and are supported by the communities and health systems to which they belong
[35].
Enabling community savings and transport groups
In addition to CHWs, MANIFEST sought other ways of building community capacity to
support their role in improving maternal and child health outcomes. Mutebi et al.
found that despite widespread poverty, there were many savings groups, albeit not
necessarily for health [36]. Yet savings groups for emergency illness and death presented
an opportunity to include savings for maternal and newborn health. In addition, some
savings groups supported educational and sensitization activities, providing an opportunity
to educate members about health. Several reviews on microfinance indicate its important
effects on health awareness and care seeking. While some reviews affirm impacts on
health outcomes, others are more cautious, suggesting the need for further longitudinal
research to evaluate impact pathways and effects [37–39].
In Uganda, MANIFEST found that many of the savings groups assessed were in need of
strengthening [36]. Most were informally keeping money in a safe box or with a treasurer,
leaving them prone to mismanagement, with few using innovations linking them to banking
via mobile phones. Challenges faced by savings group members included failure to recover
loans from members, lack of training in financial management, irregular group meeting
attendance, registration challenges, and high illiteracy levels among members.
In evaluating their experience of supporting community savings for maternal and newborn
health, Ekirapa-Kiracho et al. found that families saved more for health and that
having saved money was a predictor for facility delivery [13]. There was a 6% increase
in the proportion of women who saved for health through savings groups in the intervention
compared to the control; however, the majority seemed to have saved informally and
on their own. Although the savings groups seem to hold potential to improve saving
for health, more evidence about their effectiveness in comparison to other informal
saving methods is required. Exclusionary practices such as having a fixed monthly
savings target and age criteria for membership had to be revised, particularly since
they discriminated against the young and the poorest, who were already at risk for
poor maternal and newborn health outcomes. Another key lesson was the need to include
husbands in sensitization activities since they are the key decision-makers, particularly
with household finances. Finally, MANIFEST also realized that local community development
officers were not able to support the savings groups owing to their lack of transport
funds and competing responsibilities. More partnerships with other local existing
government staff and non-governmental organizations are therefore required to provide
the much-needed support to savings groups.
While the project initially prioritized identifying transport before delivery, because
of the availability of drivers, particularly during the day, women tended not to secure
transport in advance. It appears that having money was more crucial for securing transport
once it was needed [13,36]. The benefits of having preidentified transport was more
critical at night, when it is generally difficult to get transport. In Tanzania, CHWs
and community financing of transport services for maternal health continued to be
sustained beyond the original project timelines. Given the rising recognition of multi-sectoral
action in improving health, these lessons on how to work with savings and transport
groups have direct relevance for the Sustainable Development Goals [40,41].
Partnerships
In contrast to previous efforts, MANIFEST not only sought to work with multiple health
systems levels and actors concurrently, but did so by enabling local partners to lead
in implementation and learning. Collaboration in this manner enabled the testing of
ideas during iterative cycles of action, review of data and reflection on experiences
[42]. The pathways of change were not uniformly successful and at times they revealed
new facets of implementation.
In identifying health worker mentor candidates, criteria linked to relational skills,
trust and commitment were more important than formal qualifications and professional
hierarchy. Similarly, supervision and mentorship also yielded improvements, despite
uneven participation across professional hierarchies. The partnerships forged with
district-level teams and external mentors were critical in providing additional support
to these supply-side initiatives.
On the demand side, while awareness of certain health conditions improved, this did
not stay constant even among CHWs. Health behaviours that entailed changing social
norms required further support and engagement with a broader range of cultural brokers.
Similarly, partnerships with community savings groups and transporters also led to
new learning. Savings groups required significant capacity building and reform to
ensure the inclusion and trust essential for handing over savings by those most marginalized.
Men emerged as a key stakeholder in changing savings for maternal health and in supporting
care seeking. Transportation needs and preparedness strategies needed to be adapted
to time of day. VHTs were a critical resource supporting these varied community relationships.
At the same time, MANIFEST showed clearly that VHTs also require further community
and health system support to sustain their contributions.
The lessons learned from working closely together to address these implementation
experiences as they emerged played an important role in invigorating stakeholders
across health systems levels and implementation structures. At the same time, stakeholders
faced risks in welcoming constructive yet challenging dialogue about their roles in
improving maternal health outcomes within the local health system. Differing points
of view emerged between key stakeholders, including between Makerere researchers and
the district health teams. The researchers were concerned with the ambiguity of boundaries
among stakeholders and the lack of clear delineation of responsibility, yet the health
managers felt too closely monitored by the researchers. Furthermore, facilitating
wide stakeholder involvement entailed conflict, stress and uncertainty. Through this
process of transformative learning to improve and sustain maternal health outcomes,
tolerance, collaboration and being risk conscious emerged as critical values and skills
for the partnerships involved [42].
A central ethos underpinning MANIFEST was the participatory manner in which it supported
stakeholder engagement, local ownership and responsibility. As the papers in the special
issue indicate, this was not without risks and unanticipated implementation outcomes.
However, the learning and relationships generated form a critical basis for sustaining
progress. Makerere colleagues and the MANIFEST project are at the forefront of current
trends that emphasize the importance of embedded implementation research. In this
way, they strengthened inclusive partnerships and supported varied pathways tailored
to catalyse and transform context-specific programmatic learning into sustained health
outcomes [43,44].