NRU :: Browsing by Author "Paina, Ligia"

Browsing by Author "Paina, Ligia"

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Applying the model of diffusion of innovations to understand facilitators for the implementation of maternal and neonatal health programmes in rural Uganda
(Globalization and health, 2019) Paina, Ligia; Namazzi, Gertrude; Tetui, Moses; Mayora, Chrispus; Muhumuza Kananura, Rornald; Kiwanuka, Suzanne N.; Waiswa, Peter; Mutebi, Aloysius; Ekirapa-Kiracho, Elizabeth
In Uganda, more than 336 out of every 100,000 women die annually during childbirth. Pregnant women, particularly in rural areas, often lack the financial resources and means to access health facilities in a timely manner for quality antenatal, delivery, and post-natal services. For nearly the past decade, the Makerere University School of Public Health researchers, through various projects, have been spearheading innovative interventions, embedded in implementation research, to reduce barriers to access to care. In this paper, we describe two of projects that were initially conceived to tackle the financial barriers to access to care – through a voucher program in the community - on the demand side - and a series of health systems strengthening activities at the district and facility level - on the supply side. Over time, the projects diverged in the content of the intervention and the modality in which they were implemented, providing an opportunity for reflection on innovation and scaling up. In this short report, we used an adaptation of Greenhalgh’s Model of Diffusion to reflect on these projects’ approaches to implementing innovative interventions, with the ultimate goal of reducing maternal and neonatal mortality in rural Uganda. We found that the adapted model of diffusion of innovations facilitated the emergence of insights on barriers and facilitators to the implementation of health systems interventions. Health systems research projects would benefit from analyses beyond the implementation period, in order to better understand how adoption and diffusion happen, or not, over time, after the external catalyst departs.
Characteristics of community savings groups in rural Eastern Uganda: opportunities for improving access to maternal health services
(Global Health Action, 2017) Mutebi, Aloysius; Muhumuza Kananura, Rornald; Ekirapa-Kiracho, Elizabeth; Bua, John; Namusoke Kiwanuka, Suzanne; Nammazi, Gertrude; Paina, Ligia; Tetui, Moses
Rural populations in Uganda have limited access to formal financial Institutions, but a growing majority belong to saving groups. These saving groups could have the potential to improve household income and access to health services. Objective: To understand organizational characteristics, benefits and challenges, of savings groups in rural Uganda. Methods: This was a cross-sectional descriptive study that employed both quantitative and qualitative data collection techniques. Data on the characteristics of community-based savings groups (CBSGs) were collected from 247 CBSG leaders in the districts of Kamuli, Kibukuand Pallisa using self-administered open-ended questionnaires. To triangulate the findings, we conducted in-depth interviews with seven CBSG leaders. Descriptive quantitative and content analysis for qualitative data was undertaken respectively. Results: Almost a quarter of the savings groups had 5–14 members and slightly more than half of the saving groups had 15–30 members. Ninety-three percent of the CBSGs indicated electing their management committees democratically to select the group leaders and held meetings at least once a week. Eighty-nine percent of the CBSGs had used metallic boxes to keep their money, while 10% of the CBSGs kept their money using mobile money and banks, respectively. The main reasons for the formation of CBSGs were to increase household income, developing the community and saving for emergencies. The most common challenges associated with CBSG management included high illiteracy (35%) among the leaders, irregular attendance of meetings (22%), and lack of training on management and leadership (19%). The qualitative findings agreed with the quantitative findings and served to triangulate the main results. Conclusions: Saving groups in Uganda have the basic required structures; however, challenges exist in relation to training and management of the groups and their assets. The government and development partners should work together to provide technical support to the groups.
Designing for Scale and taking scale to account: lessons from a community score card project in Uganda
(International journal for equity in health, 2021) Ekirapa Kiracho, Elizabeth; Aanyu, Christine; Apolot, Rebecca Racheal; Namusoke Kiwanuka, Suzanne; Paina, Ligia
Planning for the implementation of community scorecards (CSC) is an important, though seldom documented process. Makerere University School of Public Health (MakSPH) and Future Health Systems Consortium set out to develop and test a sustainable and scalable CSC model. This paper documents the process of planning and adapting the design of the CSC, incorporating key domains of the scalable model such as embeddedness, legitimacy, feasibility and ownership, challenges encountered in this process and how they were mitigated. Methods: The CSC intervention comprised of five rounds of scoring in five sub counties and one town council of Kibuku district. Data was drawn from ten focus group discussions, seven key informant interviews with local and sub national leaders, and one reflection meeting with the project team from MakSPH. More data was abstracted from notes of six quarterly stakeholder meetings and six quarterly project meetings. Data was analyzed using a thematic approach, drawing constructs outlined in the project’s theory of change. Results: Embeddedness, legitimacy and ownership were promoted through aligning the model with existing processes and systems as well as the meaningful and strategic involvement of stakeholders and leaders at local and sub national level. The challenges encountered included limited technical capacity of stakeholders facilitating the CSC, poor functionality of existing community engagement platforms, and difficulty in promoting community participation without financial incentives. However, these challenges were mitigated through adjustments to the intervention design based on the feedback received. Conclusion: Governments seeking to scale up CSCs and to take scale to account should keenly adapt existing models to the local implementation context with strategic and meaningful involvement of key legitimate local and sub national leaders in decision making during the design and implementation process. However, they should watch out for elite capture and develop mitigating strategies. Social accountability practitioners should document their planning and adaptive design efforts to share good practices and lessons learned. Enhancing local capacity to implement CSCs should be ensured through use of existing local structures and provision of technical support by external or local partners familiar with the skill until the local partners are competent.
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.
Effect of a participatory multisectoral maternal and newborn intervention on maternal health service utilization and newborn care practices: a quasi-experimental study in three rural Ugandan districts
(Global Health Action, 2017) Ekirapa-Kiracho, Elizabeth; Muhumuza Kananura, Rornald; Tetui, Moses; Namazzi, Gertrude; Mutebi, Aloysius; George, Asha; Paina, Ligia; Waiswa, Peter; Bumba, Ahmed; Mulekwa, Godfrey; Nakiganda-Busiku, Dinah; Lyagoba, Moses; Naiga, Harriet; Putan, Mary; Kulwenza, Agatha; Ajeani, Judith; Kakaire- Kirunda, Ayub; Makumbi, Fred; Atuyambe, Lynn; Okui, Olico; Namusoke Kiwanuka, Suzanne
The MANIFEST study in eastern Uganda employed a participatory multisectoral approach to reduce barriers to access to maternal and newborn care services. Objectives: This study analyses the effect of the intervention on the utilization of maternal and newborn services and care practices. Methods: The quasi-experimental pre- and post-comparison design had two main components: community mobilization and empowerment, and health provider capacity building. The primary outcomes were utilization of antenatal care (ANC), delivery and postnatal care, and newborn care practices. Baseline (n = 2237) and endline (n = 1946) data were collected from women of reproductive age. The data was analysed using difference in differences (DiD) analysis and logistic regression. Results: The DiD results revealed an 8% difference in early ANC attendance (p < 0.01) and facility delivery (p < 0.01). Facility delivery increased from 66% to 73% in the intervention area, but remained unchanged in the comparison area (64% vs 63%, p < 0.01). The DiD results also demonstrated a 20% difference in clean cord care (p < 0.001) and an 8% difference in delayed bathing (p < 0.001). The intervention elements that predicted facility delivery were attending ANC four times [adjusted odds ratio (aOR) 1.42, 95% confidence interval (CI) 1.17– 1.74] and saving for maternal health (aOR 2.11, 95% CI 1.39–3.21). Facility delivery and village health team (VHT) home visits were key predictors for clean cord care and skin-to-skin care. Conclusions: The multisectoral approach had positive effects on early ANC attendance, facility deliveries and newborn care practices. Community resources such as VHTs and savings are crucial to maternal and newborn outcomes and should be supported. VHT-led health education should incorporate practical measures that enable families to save and access transport services to enhance adequate preparation for birth.
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
Maternal and neonatal implementation for equitable systems. A study design paper
(Global Health Action, 2017) Ekirapa-Kiracho, Elizabeth; Tetui, Moses; Bua, John; Muhumuza Kananura, Rornald; Waiswa, Peter; Makumbi, Fred; Atuyambe, Lynn; Ajeani, Judith; George, Asha; Mutebi, Aloysuis; Kakaire, Ayub; Namazzi, Gertrude; Paina, Ligia; Namusoke Kiwanuka, Suzanne
Evidence on effective ways of improving maternal and neonatal health outcomes is widely available. The challenge that most low-income countries grapple with is implementation at scale and sustainability. Objectives: The study aimed at improving access to quality maternal and neonatal health services in a sustainable manner by using a participatory action research approach. Methods: The study consisted of a quasi-experimental design, with a participatory action research approach to implementation in three rural districts (Pallisa, Kibuku and Kamuli) in Eastern Uganda. The intervention had two main components; namely, community empowerment for comprehensive birth preparedness, and health provider and management capacitybuilding. We collected data using both quantitative and qualitative methods using household and facility-level structured surveys, record reviews, key informant interviews and focus group discussions. We purposively selected the participants for the qualitative data collection, while for the surveys we interviewed all eligible participants in the sampled households and health facilities. Descriptive statistics were used to describe the data, while the difference in difference analysis was used to measure the effect of the intervention. Qualitative data were analysed using thematic analysis. Conclusions: This study was implemented to generate evidence on how to increase access to quality maternal and newborn health services in a sustainable manner using a multisectoral participatory approach.
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.
‘Nurture the sprouting bud; do not uproot it’. Using saving groups to save for maternal and newborn health: lessons from rural Eastern Uganda
(Global Health Action, 2017) Ekirapa-Kiracho, Elizabeth; Paina, Ligia; Muhumuza Kananura, Rornald; Mutebi, Aloysius; Jane, Pacuto; Tumuhairwe, Juliet; Tetui, Moses; Kiwanuka, Suzanne N.
Saving groups are increasingly being used to save in many developing countries. However, there is limited literature about how they can be exploited to improve maternal and newborn health. Objectives: This paper describes saving practices, factors that encourage and constrain saving with saving groups, and lessons learnt while supporting communities to save through saving groups. Methods: This qualitative study was done in three districts in Eastern Uganda. Saving groups were identified and provided with support to enhance members’ access to maternal and newborn health. Fifteen focus group discussions (FGDs) and 18 key informant interviews (KIIs) were conducted to elicit members’ views about saving practices. Document review was undertaken to identify key lessons for supporting saving groups. Qualitative data are presented thematically. Results: Awareness of the importance of saving, safe custody of money saved, flexible saving arrangements and easy access to loans for personal needs including transport during obstetric emergencies increased willingness to save with saving groups. Saving groups therefore provided a safety net for the poor during emergencies. Poor management of saving groups and detrimental economic practices like gambling constrained saving. Efficient running of saving groups requires that they have a clear management structure, which is legally registered with relevant authorities and that it is governed by a constitution. Conclusions: Saving groups were considered a useful form of saving that enabled easy acess to cash for birth preparedness and transportation during emergencies. They are like ‘a sprouting bud that needs to be nurtured rather than uprooted’, as they appear to have the potential to act as a safety net for poor communities that have no health insurance. Local governments should therefore strengthen the management capacity of saving groups so as to ensure their efficient running through partnerships with non-governmental organizations that can provide support to such groups.
Participatory monitoring and evaluation approaches that influence decision-making: lessons from a maternal and newborn study in Eastern Uganda
(Health research policy and systems, 2017) Muhumuza Kananura, Rornald; Ekirapa-Kiracho, Elizabeth; Paina, Ligia; Bumba, Ahmed; Mulekwa, Godfrey; Nakiganda-Busiku, Dinah; Lin Oo, Htet Nay; Namusoke Kiwanuka, Suzanne; George, Asha; Peters, David H.
The use of participatory monitoring and evaluation (M&E) approaches is important for guiding local decision-making, promoting the implementation of effective interventions and addressing emerging issues in the course of implementation. In this article, we explore how participatory M&E approaches helped to identify key design and implementation issues and how they influenced stakeholders’ decision-making in eastern Uganda. Method: The data for this paper is drawn from a retrospective reflection of various M&E approaches used in a maternal and newborn health project that was implemented in three districts in eastern Uganda. The methods included qualitative and quantitative M&E techniques such as key informant interviews, formal surveys and supportive supervision, as well as participatory approaches, notably participatory impact pathway analysis. Results: At the design stage, the M&E approaches were useful for identifying key local problems and feasible local solutions and informing the activities that were subsequently implemented. During the implementation phase, the M&E approaches provided evidence that informed decision-making and helped identify emerging issues, such as weak implementation by some village health teams, health facility constraints such as poor use of standard guidelines, lack of placenta disposal pits, inadequate fuel for the ambulance at some facilities, and poor care for low birth weight infants. Sharing this information with key stakeholders prompted them to take appropriate actions. For example, the sub-county leadership constructed placenta disposal pits, the district health officer provided fuel for ambulances, and health workers received refresher training and mentorship on how to care for newborns. Conclusion: Diverse sources of information and perspectives can help researchers and decision-makers understand and adapt evidence to contexts for more effective interventions. Supporting districts to have crosscutting, routine information generating and sharing platforms that bring together stakeholders from different sectors is therefore crucial for the successful implementation of complex development interventions.
Patients’ and HIV Service Managers’ Perceptions of The Impact of Loss of PEPFAR Support on HIV Services in Transitioned Health Facilities in Uganda: A Qualitative Study
(Research Square, 2020) Zakumumpa, Henry; Paina, Ligia; Wilhelm, Jess; Ssengooba, Freddie; Ssegujja, Eric; Mukuru, Moses; Charlotte 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 2016, PEPFAR implemented the ´geographic prioritization´ (GP) policy in Uganda whereby it withdrew direct support for HIV services from 734 health facilities and 10 districts with low HIV burden and intensified support to 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: In this paper 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 in-charges (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 posttransition. Conclusions: Overall, participants perceived transition to have had important impacts on HIV service delivery in transitioned health facilities. Replacing the HIV programming gap left by PEPFAR in transition districts with Uganda government services is critical to the attainment of 90-90-90 targets in Uganda.

Browsing by Author "Paina, Ligia"

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