NRU :: Browsing by Author "Bennett, Sara"

Browsing by Author "Bennett, Sara"

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Accounting for variations in ART program sustainability outcomes in health facilities in Uganda: a comparative case study analysis
(BMC health services research, 2016) Zakumumpa, Henry; Bennett, Sara; Ssengooba, Freddie
Uganda implemented a national ART scale-up program at public and private health facilities between 2004 and 2009. Little is known about how and why some health facilities have sustained ART programs and why others have not sustained these interventions. The objective of the study was to identify facilitators and barriers to the long-term sustainability of ART programs at six health facilities in Uganda which received donor support to commence ART between 2004 and 2009. Methods: A case-study approach was adopted. Six health facilities were purposively selected for in-depth study from a national sample of 195 health facilities across Uganda which participated in an earlier study phase. The six health facilities were placed in three categories of sustainability; High Sustainers (2), Low Sustainers (2) and Non- Sustainers (2). Semi-structured interviews with ART Clinic managers (N = 18) were conducted. Questionnaire data were analyzed (N = 12). Document review augmented respondent data. Based on the data generated, across-case comparative analyses were performed. Data were collected between February and June 2015. Results: Several distinguishing features were found between High Sustainers, and Low and Non-Sustainers’ ART program characteristics. High Sustainers had larger ART programs with higher staffing and patient volumes, a broader ‘menu’ of ART services and more stable program leadership compared to the other cases. High Sustainers associated sustained ART programs with multiple funding streams, robust ART program evaluation systems and having internal and external program champions. Low and Non Sustainers reported similar barriers of shortage and attrition of ART-proficient staff, low capacity for ART program reporting, irregular and insufficient supply of ARV drugs and a lack of alignment between ART scale-up and their for-profit orientation in three of the cases.
Alternative financing mechanisms for ART programs in health facilities in Uganda: a mixed-methods approach
(BMC health services research, 2017) Zakumumpa, Henry; Bennett, Sara; Ssengooba, Freddie
Sub-Saharan Africa is heavily dependent on global health initiatives (GHIs) for funding antiretroviral therapy (ART) scale-up. There are indications that global investments for ART scale-up are flattening. It is unclear what new funding channels can bridge the funding gap for ART service delivery. Many previous studies have focused on domestic government spending and international funding especially from GHIs. The objective of this study was to identify the funding strategies adopted by health facilities in Uganda to sustain ART programs between 2004 and 2014 and to explore variations in financing mechanisms by ownership of health facility. Methods: A mixed-methods approach was employed. A survey of health facilities (N = 195) across Uganda which commenced ART delivery between 2004 and 2009 was conducted. Six health facilities were purposively selected for in-depth examination. Semi-structured interviews (N = 18) were conducted with ART Clinic managers (three from each of the six health facilities). Statistical analyses were performed in STATA (Version 12.0) and qualitative data were analyzed by coding and thematic analysis. Results: Multiple funding sources for ART programs were common with 140 (72%) of the health facilities indicating at least two concurrent grants supporting ART service delivery between 2009 and 2014. Private philanthropic aid emerged as an important source of supplemental funding for ART service delivery. ART financing strategies were differentiated by ownership of health facility. Private not-for-profit providers were more externally-focused (multiple grants, philanthropic aid). For-profit providers were more client-oriented (fee-for-service, insurance schemes). Public facilities sought additional funding streams not dissimilar to other health facility ownership-types.
Building the Field of Health Policy and Systems Research: Social Science Matters
(PLoS medicine, 2011) Gilson, Lucy; Hanson, Kara; Sheikh, Kabir; Akua Agyepong, Irene; Ssengooba, Freddie; Bennett, Sara
The first paper in this series on building mthe field of Health Policy and Systems Research (HPSR) in low- and middle income countries (LMICs) [1] outlined the scope and questions of the field and highlighted the key challenges and opportunities it is currently facing. This paper examines more closely one key challenge, the risk of disciplinary capture the imposition of a particular knowledge frame on the field, privileging some questions and methodologies above others. In HPSR the risk of disciplinary capture can be seen in the current methodological critique of the field, with consequences for its status and development (especially when expressed by research leaders). The main criticisms are reported to be: that the context specificity of the research makes generalisation from its findings difficult; lack of sufficiently clear conclusions for policy makers; and questionable quality and rigour [2].
Closing the Gaps: From Science to Action in Maternal, Newborn, and Child Health in Africa
(PLoS medicine, 2010) Bennett, Sara; Ssengooba, Freddie
The previous papers in the PLoS Medicine series [1,2] demonstrate that the technical basis for improving maternal, newborn, and child health (MNCH) in sub-Saharan Africa is largely known, but too often policy and practice are not well informed by science. There are two distinct aspects to this ‘‘gap.’’ First there is a ‘‘science to policy and practice’’ gap. Accumulated scientific research on the severity of MNCH problems and strategies to promote MNCH has, at least in part, failed to ensure that MNCH reaches the domestic policy agendas of African countries, and stays there. Furthermore, local, context-specific evidence frequently is not applied in planning and programming interventions to address MNCH. Second there is a ‘‘policy to practice’’ gap: even where clear policy commitments to MNCH are made, there may be substantial challenges to getting such policies implemented. These include challenges related to stakeholder management through the implementation process and challenges associated with the negotiation of health system constraints.
The differential impacts of PEPFAR transition on private for-profit, private not-for-profit and publicly owned health facilities in Uganda
(Health policy and planning, 2020) Alan Wilhelm, Jess; Paina, Ligia; Qiu, Mary; Zakumumpa, Henry; Bennett, Sara
While transition of donor programs to national control is increasingly common, there is a lack of evidence about the consequences of transition for private health care providers. In 2015, President’s Emergency Plan for AIDS Relief (PEPFAR) identified 734 facilities in Uganda for transition from PEPFAR support, including 137 private not-for-profits (PNFP) and 140 private for-profits (PFPs). We sought to understand the differential impacts of transition on facilities with differing ownership statuses. We used a survey conducted in mid-2017 among 145 public, 29 PNFP and 32 PFP facilities reporting transition from PEPFAR. The survey collected information on current and prior PEPFAR support, service provision, laboratory services and staff time allocation. We used both bivariate and logistic regression to analyse the association between ownership and survey responses. All analyses adjust for survey design. Public facilities were more likely to report increased disruption of sputum microscopy tests following transition than PFPs [odds ratio (OR)¼5.85, 1.79–19.23, P¼0.005]. Compared with public facilities, PNFPs were more likely to report declining frequency of supervision for human immunodeficiency virus (HIV) since transition (OR¼2.27, 1.136–4.518, P¼0.022). Workers in PFP facilities were more likely to report reduced time spent on HIV care since transition (OR¼6.241, 2.709–14.38, P<0.001), and PFP facilities were also more likely to discontinue HIV outreach following transition (OR¼3.029, 1.325–6.925; P¼0.011). PNFP facilities’ loss of supervision may require that public sector supervision be extended to them. Reduced HIV clinical care in PFPs, primarily HIV testing and counselling, increases burdens on public facilities. Prior PFP clients who preferred the confidentiality and service of private facilities may opt to forgo HIV testing altogether. Donors and governments should consider the roles and responses of PNFPs and PFPs when transitioning donor-funded health programs.
Exploring perceived effects from loss of PEPFAR support for outreach in Kenya and Uganda
(Globalization and health, 2021) Qiu, Mary; Paina, Ligia; Rodríguez, Daniela C.; Wilhelm, Jess A.; Eze-Ajoku, Ezinne; Searle, Alexandra; Zakumumpa, Henry; Ssengooba, Freddie; MacKenzie, Caroline; Bennett, Sara
In 2015, the President’s Emergency Plan for AIDS Relief undertook policy shifts to increase efficiencies in its programming, including transitioning HIV/AIDS funding away from low burden areas. We examine the impact of these changes on HIV outreach in Kenya and Uganda. Methods: Qualitative data collection was conducted as a part of a broader mixed-methods evaluation. Two rounds of facility-level case studies and national-level interviews were conducted in Kenya and Uganda, with health facility, sub-national and central Ministry of Health staff, HIV clients, and implementing partners. Results: In both countries, the loss of outreach support affected community-based HIV/AIDS education, testing, peer support, and defaulter tracing. Discussion: Loss of external support for outreach raises concerns for countries’ ability to reach the 90–90-90 UNAIDS target, as key linkages between vulnerable communities and health systems can be adversely affected. Conclusion: Development partners should consider how to mitigate potential consequences of transition policies to prevent negative effects at the community level
Exploring perceived effects from loss of PEPFAR support for outreach in Kenya and Uganda
(Globalization and health, 2021) Qiu, Mary; Paina, Ligia; Rodríguez, Daniela C.; Wilhelm, Jess A.; Eze-Ajoku, Ezinne; Searle, Alexandra; Zakumumpa, Henry; Ssengooba, Freddie; MacKenzie, Caroline; Bennett, Sara
In 2015, the President’s Emergency Plan for AIDS Relief undertook policy shifts to increase efficiencies in its programming, including transitioning HIV/AIDS funding away from low burden areas. We examine the impact of these changes on HIV outreach in Kenya and Uganda. Methods: Qualitative data collection was conducted as a part of a broader mixed-methods evaluation. Two rounds of facility-level case studies and national-level interviews were conducted in Kenya and Uganda, with health facility, sub-national and central Ministry of Health staff, HIV clients, and implementing partners. Results: In both countries, the loss of outreach support affected community-based HIV/AIDS education, testing, peer support, and defaulter tracing. Discussion: Loss of external support for outreach raises concerns for countries’ ability to reach the 90–90-90 UNAIDS target, as key linkages between vulnerable communities and health systems can be adversely affected. Conclusion: Development partners should consider how to mitigate potential consequences of transition policies to prevent negative effects at the community level.
The impact of Fogarty International Center research training programs on public health policy and program development in Kenya and Uganda
(BMC Public Health, 2013) Bennett, Sara; Paina, Ligia; Ssengooba, Freddie; Waswa, Douglas; M’Imunya, James M.
The Fogarty International Center (FIC) has supported research capacity development for over twenty years. While the mission of FIC is supporting and facilitating global health research conducted by U.S. and international investigators, building partnerships between health research institutions in the U.S. and abroad, and training the next generation of scientists to address global health needs, research capacity may impact health policies and programs and therefore have positive impacts on public health. We conducted an exploratory analysis of how FIC research training investments affected public health policy and program development in Kenya and Uganda. Methods: We explored the long term impacts of all FIC supported research training programs using case studies, in Kenya and Uganda. Semi-structured in-depth interviews were conducted with 53 respondents and 29 focus group discussion participants across the two countries. Qualitative methods were supplemented by structured surveys of trainees and document review, including a review of evidence cited in policy documents. Results: In the primary focal areas of FIC grants, notably HIV/AIDS, there were numerous examples of work conducted by former FIC trainees that influenced national and global policies. Facilitators for this influence included the strong technical skills and scientific reputations of the trainees, and professional networks spanning research and policy communities. Barriers included the fact that trainees typically had not received training in research communication, relatively few policy makers had received scientific training, and institutional constraints that undermined alignment of research with policy needs.
The impact of loss of PEPFAR support on HIV services at health facilities in low burden districts in Uganda
(BMC health services research, 2021) Zakumumpa, Henry; Paina, Ligia; Wilhelm, Jess; Ssengooba, Freddie; Ssegujja, Eric; Mukuru, Moses; Bennett, Sara
Although donor transitions from HIV programs are more frequent, little research exists seeking to understand the perceptions of patients and providers on this process. Between 2015 and 2017, PEPFAR implemented the ´geographic prioritization´ (GP) policy in Uganda whereby it shifted support from 734 ‘lowvolume’ facilities and 10 districts with low HIV burden and intensified support in select facilities in high-burden districts. Our analysis intends to explore patient and provider perspectives on the impact of loss of PEPFAR support on HIV services in transitioned health facilities in Uganda. Methods: We report qualitative findings from a larger mixed-methods evaluation. Six facilities were purposefully selected as case studies seeking to ensure diversity in facility ownership, size, and geographic location. Five out of the six selected facilities had experienced transition. A total of 62 in-depth interviews were conducted in June 2017 (round 1) and November 2017 (round 2) with facility in-charges (n = 13), ART clinic managers (n = 12), representatives of PEPFAR implementing organizations (n = 14), district health managers (n = 23) and 12 patient focus group discussions (n = 72) to elicit perceived effects of transition on HIV service delivery. Data were analyzed using thematic analysis. Results: While core HIV services, such as testing and treatment, offered by case-study facilities prior to transition were sustained, patients and providers reported changes in the range of HIV services offered and a decline in the quality of HIV services offered post-transition. Specifically, in some facilities we found that specialized pediatric HIV services ceased, free HIV testing services stopped, nutrition support to HIV clients ended and the ‘mentor mother’ ART adherence support mechanism was discontinued. Patients at three ART-providing facilities reported that HIV service provision had become less patient-centred compared to the pre-transition period. Patients at some facilities perceived waiting times at clinics to have become longer, stock-outs of anti-retroviral medicines to have been more frequent and out-of-pocket expenditure to have increased post-transition
Leveraging the lessons learned from financing HIV programs to advance the universal health coverage (UHC) agenda in the East African Community
(Global health research and policy, 2019) Zakumumpa, Henry; Bennett, Sara; Ssengooba, Freddie
Although there is broad consensus around the need to accelerate progress towards universal health coverage (UHC) in Sub-Saharan Africa, the financing strategies for achieving it are still unclear. We sought to leverage the lessons learned in financing HIV programs over the past two decades to inform efforts to advance the universal health coverage agenda in the East African Community. Methods: We conducted a literature review of studies reporting financing mechanisms for HIV programs between 2004 and 2014. This review is further underpinned by evidence from a mixed-methods study entailing a survey of 195 health facilities across Uganda supplemented with 18 semi-structured interviews with HIV service managers. Results: Our data shows that there are six broad HIV financing strategies with potential for application to the universal health coverage agenda in the East African Community (EAC); i) Bi-lateral and multi-lateral funding vehicles: The establishment of HIV-specific global financing vehicles such as PEPFAR and The Global Fund heralded an era of unprecedented levels of international funding of up to $ 500 billion over the past two decades ii) Eliciting private sector contribution to HIV funding: The private sector’s financial contribution to HIV services was leveraged through innovative engagement and collaborative interventions iii) Private sector-led alternative HIV financing mechanisms: The introduction of ‘VIP’ HIV clinics, special ‘HIV insurance’ schemes and the rise of private philanthropic aid were important alternatives to the traditional sources of funding iv) Commodity social marketing: Commodity social marketing campaigns led to an increase in condom use among low-income earners v) The use of vouchers: Issuing of HIV-test vouchers to the poor was an important demand-side financing approach vi) Earmark HIV taxes: Several countries in Africa have introduced ‘special HIV’ taxes to boost domestic HIV funding. Conclusions: The lessons learned from financing HIV programs suggest that a hybrid of funding strategies are advisable in the quest to achieve UHC in EAC partner states. The contribution of the private sector is indispensable and can be enhanced through targeted interventions towards UHC goals.
Mentorship in African Health Research Training Programs: An Exploratory Study of Fogarty International Center Programs in Kenya and Uganda
(Education for Health, 2013) Bennett, Sara; Paina, Ligia; Ssengooba, Freddie; Waswa, Douglas; M’Imunya, James M.
Mentorship is a critical element of capacity-building for health research as it can support career counseling, promote interest in health research and build professional networks. Few studies of mentorship have taken place in low- and middle-income countries. This paper explores the mentorship dimension of the Fogarty International Center's (FIC) support to research training in Kenya and Uganda.This exploratory study documents the nature of mentoring that occurred within FIC programs, considers the outcomes of mentoring, and the strengths and weaknesses of FIC trainee mentorship during and after training. Two case studies were conducted, at the University of Nairobi in Kenya and Makerere University in Uganda. Semi-structured interviews were conducted with former trainees, principal investigators and institutional leaders, exploring their perceptions of mentoring and its effects.Mentoring aspects of FIC programs were highly valued. Respondents felt that following formal training in the US there was much still to learn about conducting research, and mentoring relationships provided support in applying for and implementing research grants. Mentoring arrangements were initially with US collaborators, but over time relationships with senior African colleagues became critical, particularly in terms of navigating university administrative systems. Mentees were typically highly motivated to pass their skills on to others, and became eager mentors later in their careers. A minority of respondents raised concerns about directive approaches to mentorship that reflect more hierarchical rather than egalitarian approaches. Discussion: Mentorship during and after FIC research training programs, while largely informal in nature, appears to have very positive impacts upon career development and inclination to remain in health research. Local African mentors often play a critical mentorship role, and their contributions should be better recognized.
Modifications to ART service delivery models by health facilities in Uganda in promotion of intervention sustainability: a mixed methods study
(Implementation Science, 2017) Zakumumpa, Henry; Bennett, Sara; Ssengooba, Freddie
In November 2015, WHO released new treatment guidelines recommending that all diagnosed as HIV positive be enrolled on antiretroviral therapy (ART). Sustaining and expanding ART scale-up programs in resource-limited settings will require adaptations and modifications to traditional ART delivery models to meet the rapid increase in demand. We identify modifications to ART service delivery models by health facilities in Uganda to sustain ART interventions over a 10-year period (2004–2014). Methods: A mixed methods approach involving two study phases was adopted. In the first phase, a survey of a nationally representative sample of health facilities (n = 195) in Uganda which were accredited to provide ART between 2004 and 2009 was conducted. The second phase involved semi-structured interviews (n = 18) with ART clinic managers of 6 of the 195 health facilities purposively selected from the first study phase. We adopted a thematic framework consisting of four categories of modifications (format, setting, personnel, and population). Results: The majority of health facilities 185 (95%) reported making modifications to ART interventions between 2004 and 2014. Of the 195 health facilities, 157 (81%) rated the modifications made to ART as “major.” Modifications to ART were reported under all the four themes. The quantitative and qualitative findings are integrated and presented under four themes. Format: Reducing the frequency of clinic appointments and pharmacy-only refill programs was identified as important strategies for decongesting ART clinics. Setting: Home-based care programs were introduced to reduce provider ART delivery costs. Personnel: Task shifting to non-physician cadre was reported in 181 (93%) of the health facilities. Population: Visits to the ART clinic were rationalized in favor of the sub-population deemed to have more clinical need. Two health facilities focused on patients living nearer the health facilities to align with targets set by external donors.
A participatory action research approach to strengthening health managers’ capacity at district level in Eastern Uganda
(Health Research Policy and Systems, 2017) Tetui, Moses; Coe, Anna-Britt; Hurtig, Anna-Karin; Bennett, Sara; Kiwanuka, Suzanne N.; George, Asha; Ekirapa Kiracho, Elizabeth
Many approaches to improving health managers’ capacity in poor countries, particularly those pursued by external agencies, employ non-participatory approaches and often seek to circumvent (rather than strengthen) weak public management structures. This limits opportunities for strengthening local health managers’ capacity, improving resource utilisation and enhancing service delivery. This study explored the contribution of a participatory action research approach to strengthening health managers’ capacity in Eastern Uganda. Methods: This was a qualitative study that used open-ended key informant interviews, combined with review of meeting minutes and observations to collect data. Both inductive and deductive thematic analysis was undertaken. The Competing Values Framework of organisational management functions guided the deductive process of analysis and the interpretation of the findings. The framework builds on four earlier models of management and regards them as complementary rather than conflicting, and identifies four managers’ capacities (collaborate, create, compete and control) by categorising them along two axes, one contrasting flexibility versus control and the other internal versus external organisational focus. Results: The findings indicate that the participatory action research approach enhanced health managers’ capacity to collaborate with others, be creative, attain goals and review progress. The enablers included expanded interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability. Tension and conflict across different management functions was apparent; for example, while there was a need to collaborate, maintaining control over processes was also needed. These tensions meant that managers needed to learn to simultaneously draw upon and use different capacities as reflected by the Competing Values Framework in order to maximise their effectiveness. Conclusions: Improved health manager capacity is essential if sustained improvements in health outcomes in lowincome countries are to be attained. The expansion of interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability were the key means by which participatory action research strengthened health managers’ capacity. The participatory approach to implementation therefore created opportunities to strengthen health managers’ capacity.

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