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Introduction: Sexual and reproductive health (SRH) and Human Immunodeficiency Virus (HIV) are crucial global health issues. Uganda continues to sustain a huge burden of HIV and AIDS. Methods: A cross-sectional health facility-based assessment was performed in November and December 2016 in Karamoja Region, northern Uganda. All the 126 health facilities (HFs) in Karamoja, including 5 hospitals and 121 Health Centers (HCs), covering 51 sub-counties of the 7 districts were assessed. We assessed the capacity of a) leadership and governance, b) human resource, c) service delivery, d) SRH and HIV service integration and e) users satisfaction and perceptions. Results: 64% of the established health staffing positions were filled leaving an absolute gap of 704 units in terms of human resources. As for service delivery capacity, on 5 domains assessed, the best performing was basic hygiene and safety measures in which 33% HCs scored “excellent”, followed by the presence of basic equipment. The level of integration of SRH/HIV services was 55.56%. Conclusion: HFs in Karamoja have capacity gaps in a number of health system building blocks. Many of these gaps can be addressed through improved planning. To invest in improvements for these services would have a great gain for Uganda.
A cross-sectional health facility-based assessment was performed in November and December 2016 in Karamoja. Karamoja region is predominantly inhabited by pastoral and agro-pastoral groups that share common languages, culture, history and livelihood systems across northeastern Uganda, NorthWestern Kenya, southeastern South Sudan and SouthWestern Ethiopia. Karamoja is a semi-arid region characterized by low level, erratic rainfall patterns and is considered marginal. The region presents a unique socio-economic and cultural background that requires a unique interventional approach, necessary for meeting the livestock development needs. The dominating livelihood activities are pastoralism and agro-pastoralism with a focus on livestock production. In Karamoja there are 126 HFs including 5 hospitals and 121 Health Centers (HCs) (4 HC IVs, 41 HC IIIs and 76 HC IIs), covering 51 sub-counties of the 7 districts (Abim, Amudat, Kaabong, Kotido, Moroto, Nakapiripirit, Napak) were assessed 31. The population covered by all of the health facilities was estimated at 1,023,248 individuals in 2015, with 206,696 women in child-bearing age and 51,162 expected pregnancies (pregnant women) and 49,628 expected deliveries (pregnant women achieving birth). Semi-structured questionnaires were elaborated and administered to respondents at three different levels: – District level: the questionnaire was administered to the district health officers (DHO) or any other person of the district health team (DHT) acting for and on behalf of the DHO; – Health Facility level: the questionnaire was administered to the person in charge of the health unit or any other person acting for and on behalf of the in charge; – Exit level: questionnaires were administered to clients, accessing the facility to utilize health services, on the day of the assessment. At least 20 clients were consecutively interviewed from each hospital, 15 from each HC IV, 10 from each HC III and 5 from each HC II. For each level a specific questionnaire was developed in agreement with the MoH. The questionnaires elaborated were pretested in a sample of 10 health units from the Lango sub-region and all the inconsistencies noted were corrected. In order to ensure accuracy, verification of reported information was made from the existing health unit record or records at the district health offices, when applicable. At the end of each day of data collection, the filled questionnaires were checked for completeness and correctness by trained investigators. In order to perform a comprehensive capacity assessment, the building blocks conceptual framework for the health system, as defined by WHO 20, has been adapted to the SRH and HIV services 21 (Figure 1) and used to develop the data collection tools. We assessed the capacity of a) leadership and governance, b) human resource, c) service delivery, d) SRH and HIV service integration and e) users satisfaction and perceptions. Governance and leadership capacity was investigated in terms of presence of a governing body-health unit management committee (HUMC) or board and their functionality (meetings, issues discussed and actions taken). In particular, the attention of the governing structures to the discussion on issues dealing with sexual and reproductive health and HIV/AIDS was investigated. In addition, the presence of a functional supervision (visits, issued followed) from higher levels of the Ugandan health system, presence of oversight committees for particular services particularly Reproductive, Maternal, Newborn and Child Health (RMNCH) Committee and Maternal and Perinatal Death Review (MPDR) committee and joint planning meetings at the health units were explored. We collected information on the available staff compared to the standards recommended by MoH and analyzed gaps for selected cadres of health staff, excluding support staff. The existing staff at the district health office included 11officers, 7 of these directly involved in health-related work: a district health officer, an assistant district health officer for maternal child health, an assistant district health officer for environmental health, a senior environmental health officer, a senior health educator, a biostatistician and a cold chain technician. The recommended health facility staffing in Karamoja is 1,934 positions overall. The presence of service delivery guidelines, infrastructure, equipment, medicines and diagnostic services, together with trained staff, is considered a prerequisite to guarantee the quality of SRH and HIV services. We assessed the presence of basic amenities (electricity power, improved water source, room with privacy, adequate sanitation facilities, communication equipment, access to computer, staff accommodation and transport equipment), basic equipment (blood pressure machine, stethoscope, fetoscope, adult weighing scale, examination couch, infant weighing scale, thermometer, refrigerator), hygiene and safety measures (sterilization equipment, disinfectant, hand washing facilities, gloves, safe disposal of waste), laboratory services (general microscopy, HIV test, Syphilis diagnosis, urine dipstick, pregnancy test, hemoglobin, CD4 cell count), essential medicines (Cotrimoxazole, Nevirapine, first-line antiretrovirals (ARVs), HIV test kit, injectable and oral contraceptives, Moon Beads, Amoxycillin/Ampicillin, Oxytocin/Misoprostol, Ferrous Sulphate, Fansidar (Sulphadoxine – Pyrimethamne), Artemisinin Combination Therapy (ACT), Tetracycline eye ointment, Vitamin A, Metronidazole, Doxycycline, Lignocaine, suture materials, intravenous (IV fluids) and Magnesium Sulphate) in the health units. All these requirements were further categorized by the percentage of the items available graded as: 0–20% = poor, 30–50% = fair, 60–70% = good and 80–100% = excellent. The delivery capacity for selected HIV and SRH services was further evaluated through the availability guidelines, the presence of at least one trained worker, the availability of tracer medicine, supplies and equipment for three specific sectors: family planning services, ANC and labor and delivery services. For each facility level, we evaluated both the model of integration between the SRH and HIV services implemented and the specific integration service in place. Four models of integration were evaluated; the “kiosk” model where SRH and HIV services are offered in the same site on the same day by the same provider, the “supermarket” model where services are offered in the same site on the same day by different providers, the “mall model” where services are offered by different providers, at different service sites within the same facility and the “referral model” where services are offered in different facilities. We assessed the perception and satisfaction pattern of the users through exit interview to randomly selected health unit service users. The areas evaluated included the waiting time at health units, communication with the health service provider, privacy, cleanliness of the unit, availability of medical drugs, kindness of medical workers, the overall impression of the services received and the willingness to return for additional services. All the collected quantitative data were coded and double entered, cleaned, and edited in the statistical software Epidata version 3.1 and thereafter exported to STATA version 13.0 for analysis. Descriptive and comparative analyses were performed. Categorical variables were summarized into frequencies and proportions. The continuous variables were summarized as means, median, standard deviation and range. Ethical approval was obtained from the Mbale Regional Referral Hospital Institutional Review Board and the Uganda National Council of Science and Technology (UNCST) and participants provided written infrmed consent.
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