The Ministry of Health has long prioritised assuring and improving quality of care for all people in Uganda. Since 1994, we have worked hard to ensure there are formal structures in the health care system to assure, improve, and foster quality of care in all health facilities across the country. In 1994, the Ministry of Health established the Quality Assurance Programme to support quality health service delivery. Although the

programme made great strides, it was soon determined in 1998 that more resources were necessary to improve quality of care. This led the Ministry of Health to turn the Quality Assurance Programme into the now existing Quality Assurance and Inspection Department.

Since the establishment of Quality Assurance and Inspection Department, the Ministry of Health has made achievements in improving the capacity of health workers to assure and continuously improve quality and improve service coverage. Specifically, in the areas of immunisation coverage and health service utilisation.

In an effort to continuously improve quality of service delivery and health outcomes across the country, the Ministry of Health conducted a situation analysis in 2010 to identify gaps and challenges to address. We identified the following:

• The need to better institutionalise quality improvement in health service delivery;

• Further integrate quality improvement interventions in all programmatic areas;

• Better streamline and guide efforts among partners and health facilities; and

• Set clear national standards, recommended tools and approaches.

This led us to develop the first Health Sector Quality Improvement

Framework & Strategic Plan 2010/11-2014/15. The goal of this plan was to provide a common framework for all stakeholders to coordinate, plan, mobilise resources, implement, monitor and evaluate quality improvement initiatives in Uganda.

Last year, we again rigorously evaluated our work in quality by commissioning an external evaluation of the implementation of the Health Sector Quality Improvement Framework & Strategic Plan 2010/11-2014/15. The evaluator found that over the period of 2010 to 2015, we had many achievements in the area of quality. As the first quality improvement framework for the country, it provided clear guidance to government, partners, health facilities and others working on quality interventions. Furthermore, we established quality improvement coordination structures from the centre at the Ministry of Health Headquarters (the National Quality Improvement Coordination Committee) to the regional level (Regional Quality Improvement Committee), District, and Health Facility Quality Improvement Committees. We established designated quality focal persons across Uganda. This assisted in institutionalising continuous quality improvement and accountability for quality in a decentralised manner. In strengthening the formal infrastructure for quality improvement and assurance, we have been able to have greater participation and motivation among health workers and partners to improve quality in their facility of operation.

Over the past few years, the health sector has registered improvements in a number of key performance indicators as reflected in ART coverage. Coverage improved from 56% in 2014/15 to 88% in 2016. There was an increase in health sector staffing levels from 69% in 2014/15 to 71% in 2016. Antenatal care 4th visit coverage improved from 37% in 2014/15 to 38% in 2016. Health facility deliveries increased from 53% in 2014/15 to 55% in 2016.

Significant improvements have been made in long term health outcomes such as the maternal mortality ratio, which has reduced from 438 deaths per 100,000 live births in 2011 to 336 deaths per 100,000 live births in 2016. Infant mortality rate has also reduced from 54 deaths per 1,000 live births in 2011 to 43 deaths per 1,000 live births in 2016.

This signifies quality improvement in health care, but there is need to continue to work together to ensure that our mothers and

children survive birth and that all have the ability to access safe and better quality health care.As Ministry of Health, we are committed to providing the best quality of care for the people of Uganda and to continue to improve health outcomes for all. Today, we work closely with local government and partners to ensure we are consistently and constantly evaluating and improving the service delivered to patients across the country. In efforts to continuously evaluate and improve our work as the health sector, we have started hosting annual quality improvement conferences. These conferences bring together all key stakeholders working on quality across the country and international experts to discuss Uganda’s successes and challenges in health service delivery. This year, 2017, the Ministry of Health has organised the 4th Annual Quality Improvement Conference with the theme of “Transforming Health Care through Leadership, Innovation, and Accountability”. The Ministry of Health has brought together international experts and key stakeholders from all levels of our health system to discuss best practices, lessons learned, and way forward in strengthening and improving the health system. The focus of this year’s conference is on governance structures, supply chains, information systems, financing, human resources, infrastructure, service delivery, and patient safety.

Specifically during this conference, we will review successes, innovations, leadership roles, and accountability in quality improvement in the health sector. It will also outline the challenges in relation to quality service delivery and strengthened systems for sustained quality improvement. The conference will create a platform for scientists, clinicians, activists, and community workers to showcase their significant contribution towards improving quality of health care in Uganda. It will feature a wide range of sessions and learning opportunities on the current methods, approaches and developments in quality improvement. We are focused and committed on strengthening and improving our leadership and accountability structures at all levels through innovative approaches to ensure high quality of care for every person in Uganda.

For God and My Country.

Dr. Diana AtwinePermamnent Secretary - Ministry Health

Ending preventable maternal mortality (EPMM) is a priority under the Sustainable Development Goals (SDG) agenda and aims to reduce the average global Maternal Mortality Ratio (MMR) to less than 70 maternal deaths per 100,000 live births by 2030. In Uganda, great strides have been made in increasing skilled birth attendance from 59% in 2011 to 73% in 2016. However, slow progress has been made in reduction of maternal and perinatal mortality with the maternal mortality reducing to 336/100,000 live births (UDHS, 2016) from the previous 438/100,000 live births (UDHS 2011). Neonatal mortality has stagnated at 27/1000 live births (UDHS 2016). The time of childbirth and the period immediately after are particularly critical for maternal, foetal and neonatal survival and represent an opportunity to increase the return on investments to improve care.

Ministry of Health in Uganda sees a future in which “Every pregnant woman and newborn receives high-quality care throughout pregnancy, childbirth and the postnatal period that will translate to the desired outcome of Maternal and Newborn Health”, (WHO,2016). Effective, high-quality care to prevent and manage complications during this critical period is likely to reduce the numbers of maternal deaths, stillbirths and early neonatal deaths significantly.

In May 2016, through the updated Global Health Strategy (GSWC) for women’s, children’s and Adolescent’s Health, Uganda committed to ensure universal free access to comprehensive emergency obstetric and newborn care (CEmONC) services from 43% to 90%.

Ensuring CEmONC Access for Underserved Communities in Northern UgandaA tangible example of how Uganda will meet this goal is found in Northern Uganda. Four HCIVs (Awach, Pajule, Lalogi and Ogur HCIVs) could not perform life-saving emergency cesarean sections (C-sections) for pregnant women. Starting February 2015, the Ministry of Health, with support from the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project under the USAID Saving Mothers Giving Life (SMGL) initiative, supported these facilities to be able to offer comprehensive emergency obstetric care services.

Gaps that existed included; infrastructural gaps including cracks on the floor, no lighting, poor drainage of theatres; theatre staff lacked skills in standard operating procedures and surgical skills; lack of blood transfusion services at Pajule and Ogur HCIVs; and critical human resource gaps like the lack of an anesthetic officer at Pajule HCIV.

Interventions began at the district level, including; identification of facility-specific gaps leading to theatre non-functionality through field assessment visits by USAID ASSIST, the respective DHOs and regional referral hospital representatives; quantifications and development of budgets by the district authorities that led to resource mobilization and renovation of theatres; capacity building of theatre staff in surgical skills and

theatre standard operating procedures through placements at Gulu and Lira RRHs; engagement of the regional blood bank of Gulu to assess the HCIVs that did not have blood transfusion services and final approval for blood transfusion services; and district support for training of a nurse for an anesthetic course at Pajule HC IV in Pader District with USAID ASSIST hiring a short-term anesthetist for 9 months as the district staff completed the training.

As a result; 3/5 non-functional HCIV theatres were made functional (Lalogi, Pajule and Ogur HCIVs); blood transfusion services were established at 2 HCIVs (Ogur HCIV and Pajule HCIV); and the number of HCIVs offering C-sections in the six SMGL-supported districts of Northern Uganda increased from 3 to 6 out of the 8 HCIVs. The C-Section rate increased by 7.7%, from 3.9% to 4.2% between 2014 and 2016.

The Way Forward for High-Quality Maternal and Newborn CareTo further improve on the quality of maternal and newborn care services, the World Health Organization has proposed 8 standards, which if implemented, would improve the quality of care and lead to halving of maternal and newborn deaths. The standards include; evidence-based care, actionable Health information system, referral, communication, respect, emotional support, competent motivated staff for emergency obstetric & newborn care and appropriate physical environment. Uganda was selected as one of the nine first-wave countries to implement the WHO Quality of Care (QoC) Initiative for Maternal and Newborn Health (MNH) with the aim of reducing maternal and perinatal mortality by 50% by the year 2020. To realize this vision, Ministry of Health has defined “quality of care” and adapted the WHO standards for improving the quality of care for mothers and newborns around the time of childbirth. Districts for initial implementation of the Quality of Care initiative are spread across the country. Implementation is based on a continuous quality improvement approach by improvement teams as per the National Quality Improvement Framework. Leadership, action, learning and accountability at all levels are being advocated for the success of the initiative.

Quality of Care for Maternal and Newborn Health

Dr Jimmy Opee, In-Charge Pajule HCIV, performing the first emergency caesarean section being conducted at Pajule HCIV in 16 years on 18/02/16

Theme: “Transforming Health Care through Leadership, Innovation, and Accountability”Improving Work Environment through 5S ActivitiesFor Establishing of Fundation of Quality Assurance in Health Services

Ministry of Health (MOH), in collaboration with Japan International Cooperation Agency (JICA), is promoting implementation of 5S-CQI-TQM approach for improving quality of health services in Uganda.

Clean, comfortable and well-organised work environment can bring you improvement of service-providers’ motivation and efficiency of service provision and subsequently quality of services with uplifted clients’ satisfaction. Five (5) S-CQI-TQM is a series of actions to ensure quality of goods and services.

Five (5) S (Seiri, Seiton, Seiso, Seiketsu and Shitsuke in Japanese; Sort, Set, Shine, Standardise and Sustain in English), which originated in the Japanese industrial sector in early 1960s, is an approach aiming at improvement of work environment.

CQI (Continuous Quality Improvement) is a mode of problem-solving by staff for staff and for clients and patients. This

activity allow health facilities to improve the operational processes through the repetition of the cycle of PDCA (Plan-Do-Check-Act). TQM (Total Quality Management) is a situation, where top management make maximal use of results of CQI and 5S for his or her decision-making for systematic operation that enables to make health services satisfactory for both providers and customers.

After commencement of 5S activities at Tororo General Hospital in 2007, MOH/JICA has been implementing the Project on Improvement of Health Services through Health Infrastructure Management since 2011 to roll out 5S-CQI-TQM approach. Using better work environment through 5S, health facilities can implement activities to improve management of health infrastructure with focus to medical equipment by means of CQI.

Seven (7) Regional Referral Hospitals (RRH) and two (2) General Hospitals (GH) were targeted health facilities for training and technical supervision of 5S-CQI-TQM approach at the 1st phase of Project (2011-14). 5S Implementation Guidelines and 5S Handbook were developed in conjuction of the above-mentioned project activities.

The results of impact assessment conducted by the Project in 2014 revealed that clients’ satisfaction on health services was significantly improved at general hospital level, and that reduction of clients’ waiting time for receiving services was also observed.The Project is now in the 2nd phase (2016 to 2020) for extending its coverage to all RRHs and two (2) Districts having GHs, which were intervened at the 1st phase.The 2nd phase of the Project specially focuses on CQI implementation and the improvement of quality dimensions of hospital services utilising the results of work environment improvement through 5S.

Activities in the 2nd phase include training of 5S-CQI-TQM facilitators, transformation of existing 5S Guidelines into 5S-CQI-TQM Implementation Guidelines, development of Facilitators’ Guidebook and strengthening technical supervision of 5S and CQI, monitoring and evaluation activities including modification of 5S monitoring and evaluation tools.

The Project is spearheading establishment of the self-reliant mechanism to sutain 5S-CQI-TQM approach for government sector hospital management.

Ministry of Health and partners work together to strengthen leadershipand accountability to improve health services across the country

Over the past 5 years, Uganda has seen many improvements in health outcomes of the population. This is due to a wide-range of interventions and approaches strengthening leadership and accountability in order to achieve accessible, safe, person-centred, and high quality health care. Great achievements have been made due to the collaborative efforts of Ministry of Health and development partners. Most notable success was the recent reduction in maternal and infant mortality rates.

Strengthening leadership and management skills to improve health care service delivery In partnership with the Ministry of Health, two leadership-focused initiatives were implemented by (1) the United States Agency for International Development (USAID) Applying Science to Strengthen and Improve Systems (ASSIST) Project with the African Centre for Global Health and Social Transformation (ACHEST) and the Uganda Management Institute (UMI); and (2) Makerere University School of Public Health with the Center for Disease Control (CDC) achieved outstanding results.

The Leadership for Quality Improvement Initiative is being implemented by the Ministry of Health, USAID ASSIST Project, ACHEST, and UMI. Since March 2017, it engaged 24 district leaders and 16 health facility leaders from six districts of Lira, Lamwo, Kaliro, Kiruhura, Mbale, and Ngora to improve health care in their districts. Leaders were trained in quality improvement, leadership and management, monthly coaching and mentorship, peer learning sessions and review meetings.

The Mbale District Health Officer said “most of us got appointed to health centre IVs right immediately after school without any background/ experience/ training in leadership and management. This is the cause of the management gaps, building our capacity as Health Facility Managers will improve the institutional outputs.” And he was right.

Across the four districts participating in the Initiative, absenteeism of health workers reduced from 35.2% to 19.3% across all health facilities in the districts. Improvements were made in redistribution of health worker workloads (between health facilities). This ensured those who were overworked were able to task shift to those with lighter workloads. District leaders also identified another reason for absenteeism to be safety fears. In Ngora, the leaders mobilised resources to construct a security guard’s house at a Health Centre IV to reduce poor night duty attendance by staff due to their fear of insecurity while working the night shift.

The District Capacity Building Project was offered by Makerere University School of Public Health (MakSPH)-CDC Fellowship Programme between August 2015 and June 2017. Targeted health managers included District Health Officers, Directors of Regional Referral Hospitals, members of the Regional Performance Monitoring Teams, Principal Medical Officers of Urban Authorities, and other health managers. Enrolled health managers participated in a nine-month fellowship in governance, leadership and management of district health services. The Governance, Leadership and Management Course was implemented in 53 districts targeting 104 health managers. The ultimate goal of the project was to improve health service delivery at district and regional levels through improving the capacity of leaders and managers of health services to effectively and efficiently plan for as well as address challenges inherent in health service delivery through a practical, hands-on, work-based approach.

In Kayunga district, targeted interventions increased the percentage of health workers who ensure they test every suspected case of malaria before treatment from 7% to 93% at Kayunga Hospital. As a result of these initiatives, stock-outs of malaria drugs reduced substantially.

In Napak district, through the establishment of an internal absenteeism monitoring system, which included capturing data on habitual absentees and taking action to apprehend them, the level of absenteeism reduced from 40% in June 2016 to 11% by May 2017. The district performance on malaria test and treat (i.e. the proportion of suspected malaria cases that were treated after malaria testing at district level) improved from 68% before the project (August 2015) to 99.7% at the end of the project (June 2017).

Improving health outcomesIn addition to the leadership initiatives and programmes implemented by partners, strategic improvement interventions have been implemented, which resulted in improvements in maternal and newborn health, prevention of HIV/ AIDS and sexually transmitted infections, TB case notification, among other areas.

In partnership with the Ministry of Health, the USAID ASSIST Project, established 928 quality improvement teams across 64 districts, 280 health facilities and 634 communities. These efforts have resulted in improvements in governance and coordination of service delivery at the local level, increased demand for services, increased access to services, and improved quality of services.

Maternal and child health improvements• Reduction of fresh still birth rates from 1.8% in 2013 to 1.0% in 16 districts in Northern Uganda in

2017. • Nationally, skilled birth attendance increased from 59% in 2011 to 73% in 2016.

• Reduction of maternal mortality from 438/100,000 live births in 2011 to 336/100,000 live births in 2016.

Reduction of infection rate of HIV/ AIDS and sexually transmitted infections • Improved client follow-up within 48 hours of receiving safe male circumcision from 10% 2012 to

over 80% in 30 health facilities. • Retention of mother-baby pairs in care from 44% to 71% in PMTCT sites in 16 districts in Northern

Uganda; reduction in HIV positivity rates for exposed babies from 4% to less than 3% in the last 2 years.

Next step: achieving these great results nationallyThe Ministry of Health is working hard with partners to document these efforts in order to scale up the improvements nationally. The 4th Annual Quality Improvement Conference held at the Kampala Serena Conference Centre on 29-31st August, 2017 is focused on “Transforming Health Care through Leadership, Innovation, and Accountability”. The conference is a platform for government officials, health workers, implementing partners, researchers, academics, community members, and policy makers to discuss best practices and lessons learned from national and international experiences of improvement interventions. The learnings from this conference will assist us as Ministry of Health continuously improve and strive to achieve high quality, safe, accessible, and equitable health care for all Ugandans across the Nation.

29-31 August, 2017 | Kampala Serena Conference Centre

Regional coaches conducting providing Quality Improvement mentorship to health teams

2 Director USAID ASSIST East Africa Dr Mirwais Rahimzai, (3rd from left) hands over a prize certificate to Kulinga Village Savings and Loan Association- a HIV positives community QI initiative