Browsing by Author "Namakula, Justine"

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    Ebola in the context of conflict affected states and health systems: case studies of Northern Uganda and Sierra Leone
    (Conflict and health, 2015) McPake, Barbara; Witter, Sophie; Ssali, Sarah; Wurie, Haja; Namakula, Justine; Ssengooba, Freddie
    Ebola seems to be a particular risk in conflict affected contexts. All three of the countries most affected by the 2014-15 outbreak have a complex conflict-affected recent history. Other major outbreaks in the recent past, in Northern Uganda and in the Democratic Republic of Congo are similarly afflicted although outbreaks have also occurred in stable settings. Although the 2014-15 outbreak in West Africa has received more attention than almost any other public health issue in recent months, very little of that attention has focused on the complex interaction between conflict and its aftermath and its implications for health systems, the emergence of the disease and the success or failure in controlling it. The health systems of conflict-affected states are characterized by a series of weaknesses, some common to other low and even middle income countries, others specifically conflict-related. Added to this is the burden placed on health systems by the aggravated health problems associated with conflict. Other features of post conflict health systems are a consequence of the global institutional response. Comparing the experience of Northern Uganda and Sierra Leone in the emergence and management of Ebola outbreaks in 2000-1 and in 2014-15 respectively highlights how the various elements of these conflict affected societies came together with international agencies responses to permit the outbreak of the disease and then to successfully contain it (in Northern Uganda) or to fail to do so before a catastrophic cost had been incurred (in Sierra Leone). These case studies have implications for the types of investments in health systems that are needed to enable effective response to Ebola and other zoonotic diseases where they arise in conflict- affected settings.
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    Health worker experiences of and movement between public and private not-for-profit sectors—findings from post-conflict Northern Uganda
    (Human Resources for Health, 2016) Namakula, Justine; Witter, Sophie; Ssengooba, Freddie
    Northern Uganda suffered 20 years of conflict which devastated lives and the health system. Since 2006, there has been investment in reconstruction, which includes efforts to rebuild the health workforce. This article has two objectives: first, to understand health workers’ experiences of working in public and private not-for-profit (PNFP) sectors during and after the conflict in Northern Uganda, and second, to understand the factors that influenced health workers’ movement between public and PNFP sectors during and after the conflict. Methods: A life history approach was used with 26 health staff purposively selected from public and PNFP facilities in four districts of Northern Uganda. Staff with at least 10 years’ experience were selected, which resulted in a sample which was largely female and mid-level. Two thirds were currently employed in the public sector and just over a third in the PNFP sector. A thematic data analysis was guided by the framework analysis approach, analysis framework stages and ATLAS.ti software version 7.0. Results: Analysis reveals that most of the current staff were trained in the PNFP sector, which appears to offer higher quality training experiences. During the conflict period, the PNFP sector also functioned more effectively and was relatively better able to support its staff. However, since the end of the conflict, the public sector has been reconstructed and is now viewed as offering a better overall package for staff. Most reported movement has been in that direction, and many in the PNFP sector state intention to move to the public sector. While there is sectoral loyalty on both sides and some bonds created through training, the PNFP sector needs to become more competitive to retain staff so as to continue delivering services to deprived communities in Northern Uganda
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    How do health workers experience and cope with shocks? Learning from four fragile and conflict-affected health systems in Uganda, Sierra Leone, Zimbabwe and Cambodia
    (Health Policy and Planning, 2017) Witter, Sophie; Wurie, Haja; Chandiwana, Pamela; Namakula, Justine; Alonso-Garbayo, Alvaro; Ssengooba, Freddie; Raven, Joanna; So, Sovannarith
    This article is grounded in a research programme which set out to understand how to rebuild health systems post-conflict. Four countries were studied—Uganda, Sierra Leone, Zimbabwe and Cambodia—which were at different distances from conflict and crisis, as well as having unique conflict stories. During the research process, the Ebola epidemic broke out in West Africa. Zimbabwe has continued to face a profound economic crisis. Within our research on health worker incentives, we captured insights from 128 life histories and in-depth interviews with a variety of staff that had remained in service. This article aims to draw together lessons from these contexts which can provide lessons for enhancing staff and therefore health system resilience in future, especially in similarly fragile and conflict-affected contexts. We examine the reported effects, both personal and professional, of the three different types of shock (conflicts, epidemics and prolonged political-economic crises), and how staff coped. We find that the impact of shocks and coping strategies are similar between conflict/post-conflict and epidemic contexts—particularly in relation to physical threats and psychosocial threats—while all three contexts create challenges and staff responses for working conditions and remuneration. Health staff showed considerable inventiveness and resilience, and also benefited from external assistance of various kinds, but there are important gaps which point to ways in which they should be better protected and supported in the future. Health systems are increasingly fragile and conflict-prone, and shocks are often prolonged or repeated. Resilience should not be taken for granted or used as an excuse for abandoning frontline health staff. Strategies should be in place at local, national and international levels to prepare for predictable crises of various sorts, rather than waiting for them to occur and responding belatedly, or relying on personal sacrifices by staff to keep services functioning.
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    (How) does RBF strengthen strategic purchasing of health care? Comparing the experience of Uganda, Zimbabwe and the Democratic Republic of the Congo
    (Global Health Research and Policy, 2019) Witter, Sophie; Bertone, Maria P.; Namakula, Justine; Chandiwana, Pamela; Chirwa, Yotamu; Ssennyonjo, Aloysius; Ssengooba, Freddie
    Results-Based Financing (RBF) has proliferated in health sectors of low and middle income countries, especially fragile and conflict-affected ones, and has been presented as a way of reforming and strengthening strategic purchasing. However, few studies have empirically examined how RBF impacts on health care purchasing in these settings. This article examines the effects of several RBF programmes on health care purchasing functions in three fragile and post-conflict settings: Uganda, Zimbabwe and the Democratic Republic of Congo (DRC) over the past decade. Methods: The article is based on a documentary review, including 110 documents from 2004 to 2018, and 98 key informant (KI) interviews conducted with international, national and district level stakeholders in early 2018 in the selected districts of the three countries. Interviews and analysis followed an adapted framework for strategic purchasing, which was also used to compare across the case studies. Results: Across the cases, at the government level, we find little change to the accountability of purchasers, but RBF does mobilise additional resources to support entitlements. In relation to the population, RBF appears to bring in improvements in specifying and informing about entitlements for some services. However, the engagement and consultation with the population on their needs was found to be limited. In relation to providers, RBF did not impact in any major way on provider accreditation and selection, or on treatment guidelines. However, it did introduce a more contractual relationship for some providers and bring about (at least partial) improvements in provider payment systems, data quality, increased financial autonomy for primary providers and enforcing equitable strategies. More generally, RBF has been a source of much-needed revenue at primary care level in under-funded health systems. The context – particularly the degree of stability and authority of government–, the design of the RBF programme and the potential for effective integration of RBF in existing systems and its stage of development were key factors behind differences observed.
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    Sub-national assessment of aid effectiveness: A case study of post-conflict districts in Uganda
    (Globalization and health, 2017) Ssengooba, Freddie; Namakula, Justine; Kawooya, Vincent; Fustukian, Suzanne
    In post-conflict settings, many state and non-state actors interact at the sub-national levels in rebuilding health systems by providing funds, delivering vital interventions and building capacity of local governments to shoulder their roles. Aid relationships among actors at sub-national level represent a vital lever for health system development. This study was undertaken to assess the aid-effectiveness in post-conflict districts of northern Uganda. Method: This was a three district cross sectional study conducted from January to April 2013. A two stage snowball approach used to construct a relational-network for each district. Managers of organizations (ego) involved service delivery were interviewed and asked to list the external organizations (alters) that contribute to three key services. For each inter-organizational relationship (tie) a custom-made tool designed to reflect the aid-effectiveness in the Paris Declaration was used. Results: Three hundred eighty four relational ties between the organizations were generated from a total of 85 organizations interviewed. Satisfaction with aid relationships was mostly determined by 1) the extent ego was able to negotiate own priorities, 2) ego’s awareness of expected results, and 3) provision of feedback about ego’s performance. Respectively, the B coefficients were 16%, 38% and 19%. Disaggregated analysis show that satisfaction of fund-holders was also determined by addressing own priorities (30%), while provider satisfaction was mostly determined by awareness of expected results (66%) and feedback on performance (23%). All results were significant at p-value of 0.05. Overall, the regression models in these analyses accounted for 44% to 62% of the findings. Conclusion: Sub-national assessment of aid effectiveness is feasible with indicators adapted from the global parameters. These findings illustrate the focus on “results” domain and less on “ownership” and “resourcing” domains. The capacity and space for sub-national level authorities to negotiate local priorities requires more attention especially for health system development in post-conflict settings