Operationalizing supportive supervision guidelines in Uganda

Country Context

In Uganda, hospital expenditures account for a significant portion of health-related costs—around 26% of total health expenditure.¹  There is also significant patient congestion in hospitals, mostly due to underutilization of lower-level facilities and unnecessary referrals from PHC facilities. Over the past few years, Uganda has made significant progress towards achieving UHC, though in hospitals’ technical efficiency improvements have been lagging. Therefore, it was expected that a combination of effective regional implementation of the national supportive supervision guidelines (SSG) issued by the MoH in September 2020 and increased mentorship of health facility staff would lead to an efficient and sustainable health system. 

The Implementation Case

Through the PHCPI-JLN Learning Exchange, two government officials involved in the SSG process in Uganda—Mr. Aliyi Walimbwa and Dr. Victoria Masembe—proposed an implementation case during the Implementation Learning Phase of the Collaborative. The problem statement was as follows:

There is severe patient congestion in regional referral hospitals in Uganda, largely due to unnecessary referrals from lower-level facilities and from households bypassing lower-level facilities. Bypassing and unnecessary referrals are driven by inadequate service provision at lower-level facilities, including inadequate human resources; limitations of some medicines and health supplies, equipment, and infrastructure; poor leadership and governance; and a lack of fees/penalties for bypassing. In certain areas, the overcrowded private sector also contributes to this problem. These issues are underpinned by a lack of effective supportive supervision, due to a lack of supervisors and inadequate/mismatched skills to meet the needs of the facilities and identify/solve problems to improve the system.

The long-term vision is that “effective implementation of supportive supervision and mentorship of health facility staff from higher to lower levels (especially medical officers, laboratory staff, and health center- and village-level health workers) will lead to improved quality, utilization, and community trust of PHC services, efficiency in service delivery due to streamlined referral system, increased patient satisfaction, and reduced preventable mortality and morbidity.”

To achieve this, the Uganda Implementation Case team identified four near-term goals:

• Regional referral hospitals create a joint workplan and mobilize resources for supportive supervision (e.g., from government, partners, and regional referral hospitals).
• Develop structures and mechanisms for operationalizing the national SSG at the PHC level.
• Examine the root causes of PHC underutilization in order to inform the supportive supervision package.
• Develop an effective measurement system for monitoring the performance of supportive supervision.

The Implementation Case team then conducted the causal-chain analysis to define the series of steps to attain these goals, identify areas of uncertainty, and pinpoint where a breakdown may be occurring. Together with the peer learners and the technical facilitation team, the Uganda Implementation Case team identified learning priorities and formulated the several learning questions (see Uganda Learning Questions). 
 

Implementation Phase

Through a participatory approach, the Uganda MoH held national and regional meetings with implementers and stakeholders (e.g., academia, donors, and key organizations) to develop joint regional supportive supervision workplans and roadmaps that aligned to the five-year Regional Referral Hospitals Strategic Plans. Initial drafts of workplans were developed in a five-day workshop organized by the MoH and attended by representatives of regional referral hospitals and community health departments. A regional work planning meeting attended by regional referral hospitals staff, regional implementing partners, above-site technical advisors, and MoH staff followed, and the plans were aligned to priorities of the 3rd Uganda National Development Plan (UNDP III) and the MoH strategic plans.

The Uganda Implementation Case team encountered many challenges, including COVID-19 lock downs, financial resource reallocation, and poor internet connectivity. These challenges were partially overcome by using virtual platforms to host meetings and facilitate communication, obtaining funding from regional implementing partners, and allocating one or more development partners per region to provide support. Despite the obstacles, regional referral hospitals across the country obtained buy-in, technical support, and funding from the MoH, regional partners, international donors (GAVI, USAID, CDC), and district and community health departments to ensure M&E and implementation activities were carried out at the local level. As a result, costed regional plans were produced and are currently being implemented. One focal person per region was designated to oversee the implementation of the strategy, and a platform for stakeholder engagement at national and regional levels was established, all in an effort to shift from fragmented to coordinated action. 

To achieve this progress, the Implementation Case team performed the following actions:

1. Designed and used a communication strategy based on relevant statistical data that illustrate the current state of PHC in the country. The strategy also involved stakeholder analysis and key messages generated and tailored to different audiences (i.e., regional referral hospitals, health districts, community health departments, international donors, academia, and other regional actors) that articulated existing national health policies and priorities. The communication strategy centered on achieving UHC through primary care strengthening and a streamlined referral system, highlighting the central role of the SSG to improve quality of PHC, health outcomes, and efficiency in the health system while also promoting decentralization in the health sector and capacity building at regional and local levels. The team took advantage of efforts already in place to deploy COVID-19 emergency actions to lobby for and advocate in favor of the development of supportive supervision workplans; having ready-to-use information was key to this success. 
2. Conducted health financing analyses and developed advocacy tools to generate funding support, including a Health Care Budget Expenditure Analysis to identify underutilized resources, which were used to lobby for resource reallocation—as recommended by financial-expert peer learners. The team also specified, quantified, and costed items used at regional referral hospitals for diagnostic purposes and costed community health department workplans. The team produced an advocacy brief based on the generated information that is now being used for resource mobilization. The brief was presented to Parliament and will also be presented to a forum for development partners in health. 

The Implementation Case team adapted key elements from JLN technical documents, shared by the technical facilitation team, including the Strategic Communications for UHC Practical Guide and the Messaging Guide for Domestic Resource Mobilization. Peer learners also recommended creating a national program for the supportive supervision strategy, which would manage a budget earmarked to the regional referral hospitals, with specific channels through which the financial resources would flow. Additionally, a peer learner also suggested showing the short-term benefits of investing in supportive supervision by using secondary- and tertiary-level hospitals that were overcrowded due to COVID-19 as an example; using PHC strengthening and optimization of the referral system could have alleviated the hospital congestion. 

The Uganda Implementation Case team also performed the following:

3. Generated the operating guidelines for the SSG based on health technocrats’ inputs and a situational analysis of previously established structures and coordination procedures from lowest to highest levels of care. The guidelines specified structures through which supportive supervision would be conducted and described possible cadres of staff to be involved as well as their roles and responsibilities, all of which could be applied across various levels of health service delivery. The guidelines included strategies to promote skill-mix and task-shifting to make supportive supervision more efficient among existing staff. The guidelines are currently being rolled out across the country. From a capacity-building perspective, even though additional staff were progressively added to fill available vacancies, extra personnel need to be enrolled at referral hospitals and district health and community health departments. Additional trainings are also required to strengthen the SSG M&E and implementation, which will require time and funding not yet secured in some regions. This will be crucial to the successful dissemination of the SSG and training of management and health care staff in all PHC facilities. Additional roles and supportive supervision tasks were allocated to existing staff to ensure that activities began, albeit at a slow pace due to the high workload of personnel. Existing PCNs were mapped and private providers were included in the referral networks to extend access and improve efficiency, as some peer learners advised. However, this measure primarily benefited those with payment capacity, and due to the high turnover of staff in the private sector, it was difficult to sustain capacity building achievements.  
4. Conducted a root-cause analysis of PHC underutilization to inform the supportive supervision activities, which identified factors such as inappropriate infrastructure, lack of medicines and staff, poor technical skills in the health personnel, and low problem-solving capacities as reasons for bypassing PHC services. The facilitation team recommended conducting the root-cause analysis using client satisfaction surveys and health care facility exit interviews, given that funding for data collection was reallocated to COVID-19 activities. Periodic performance review meetings with regional referral hospitals complemented the data, revealing availability of information on PHC performance from health care facilities that is not currently in use for decision-making and advocacy purposes. Emerging data from the implementation of the SSG has also been useful to identify reasons for PHC underutilization. A good example of the application of the supportive supervision strategy is in the Mbale region, where tracking referrals and measures to tackle causes of PHC underutilization through supportive supervision are ongoing, and facilities have already reported up to 50% reductions in referrals. This success seems to be attributed at least in part to the leadership of the community health department and a high degree of cooperation among entities and partners.
5. Defined a M&E Framework, which is still ongoing, to track implementation of the supportive supervision strategy. The Implementation Case team developed a theory of change and logical framework to help define key aspects to be monitored, interventions to be assessed, and desired outcomes. The team adopted elements from extant M&E frameworks and indicators from the MoH and local health authorities, as well as measures of population and health care providers’ needs that are meaningful for regional referral hospitals. The team also used the JLN Vertical Integration Diagnostic and Readiness Tool to develop key aspects of integrated health care services to be measured. The facilitation team introduced the PHCPI Conceptual Framework, and the Framework for Selecting Indicators to Monitor Service Coverage, as references of essential domains, interventions, services, inputs, outputs, and outcomes that make a high-quality performing PHC system. Other aspects, such as essential service coverage (e.g., health promotion and prevention; reproductive, maternal, newborn and child health; infectious and noncommunicable diseases; rehabilitation; and palliative care), efficiency, responsiveness, equity, accountability, client satisfaction, and health outcomes were also recommended as aspects to take into consideration for the M&E framework. The COP suggested a stratification approach in the Supportive Supervision M&E framework that applied an equity lens to assess the extent to which the most vulnerable and at-risk populations are being targeted through the roll-out of the supportive supervision approach. Finally, the team discussed, mapped, and matched existing indicators in Uganda to the different components of the above-mentioned PHCPI and WHO frameworks and generated new indicators to cover the gaps and domains relevant to the country. The facilitators also shared the comprehensive M&E framework developed in Tanzania as an example for supportive supervision based on quality assessment of similar domains in the above-mentioned frameworks, which was embedded in a tool used by the assessment teams.² The Uganda team also generated a tool for assessing the maturity of regional referral hospitals in delivering the delegated mandate of supportive supervision as a way to assess implementation progress and gaps that required national- and regional-level support.

Key Lessons and Insights

A summary of the key lessons that arose from the Uganda Implementation Case are:

1. A strategic communication plan is necessary to obtain buy-in and cooperation on the implementation of SSG and other PHC improvement initiatives. A comprehensive plan includes a stakeholder assessment, ready-to-use information backed up by customized and evidence-based messages, strategies to utilize appropriate communication channels and impactful data visualizations, among others. Public health situations of high impact, such as COVID-19, can be leveraged to advocate in favor of PHC.
2. A healthcare budget expenditure analysis is crucial to identify under-utilized resources that could be reallocated for PHC strengthening and determine the gaps for resource mobilization. Technical briefs containing the results of this analysis then become fundamental resources when advocating for resource mobilization from relevant actors. 
3. Creating a National Supportive Supervision Program with earmarked resources facilitates commitment of involved actors and availability of required financial resources. 
4. Designating a focal person and engaging sub-national and local leaders is crucial to obtaining local buy-in and accelerating the dissemination and implementation of supportive supervision strategies. Appointing dedicated personnel allows for faster implementation progress and often leads to faster results. Skill-mix and task-shifting are valid alternatives to achieve efficiency in supportive supervision when limited staff resources are available.
5. Private health care providers included in public PCNs help expand access to PHC services and reduce unnecessary referrals. However, this strategy may widen equity gaps within a catchment population because the main users of these providers are only those that can afford services.
6. Tracking quality data on a SSG application contributes to the measure of PHC performance and improvement.
7. A comprehensive Supportive Supervision M&E framework should contain existing and new indicators of processes and results, which improves the ability to assess the SSG’s effect on the PHC performance within essential domains, services, and outcomes with an equity lens. 

Next Steps

While the SSG will continue to be disseminated across Uganda, the MoH will periodically assess progress with regional referral hospitals, focused on needs, compliance, and adherence to the guidelines. The MoH will support regions to fully implement the SSG and will help mobilize additional resources when required. Also, local root-cause analyses of PHC services underutilization will inform both local SSG action plans and solutions to overcome the causes. 

• The Government of Uganda is planning to use the JLN Vertical Integration Diagnostic and Readiness Tool as a guide to streamline the referral system. This will redefine the Uganda Basic Health Care Package and generate the National Health Insurance Scheme Benefits Package, restructuring the service access points at the PHC level to better respond to the population´s needs and thus reduce inappropriate use of higher levels of care. The government also plans to strengthen the information system to record data on PHC performance and facilitate the tracking of continuity of care and referrals within health care networks. 
• The Implementation Case team will mediate and advocate before local, regional, national health and intersectoral authorities and partners to gain buy-in and mobilize resources to support quality improvement in PHC facilities. The Uganda MoH will seek to improve horizontal integration of PHC providers, vertical integration with higher levels of care in a more efficient manner, and articulation of actions of PHC facilities with other sectors of the society to improve health outcomes and patients' satisfaction and meet populations’ health needs. 
• The Implementation Case team will work to achieve a common understanding of quality in health care across all relevant actors of the health system, including communities, to obtain a higher engagement and better results. The PHCPI Uganda Core PHC indicators will be a useful source of information to support advocacy activities. The M&E framework and indicators, which will soon be finalized in agreement with the stakeholders, will be vital when producing required data to measure the value of the supportive supervision strategy and define adjustments to improve it. Teams dedicated to M&E are expected to be appointed and an electronic system will be set up to ease communication and information accessibility, following examples from neighboring countries.³ 

Conclusion

Addressing resources, capacity building, and quality gaps in PHC service delivery in Uganda through the implementation of a supportive supervision national strategy with a decentralized approach is a complex and resource-intensive endeavor that requires political will and alignment of national, regional, and local health authorities with several stakeholders, partners, and target communities. The supportive supervision strategy has potential to strengthen PHC in the country and streamline information and referral systems. The PHCPI COP contributed evidence-based and real-life implementation knowledge, good practices, expertise, and applicable technical resources for the Uganda team to inform its ongoing implementation approach and allowed the peer learners involved in the process to exchange knowledge, while propitiating global connections and future collaborations among members of the learning collaboration.

Acknowledgements 

The Learning Exchange would like to thank Mr. Aliyi Walimbwa and Dr. Victoria Masembe, co-leads of the Uganda Implementation Case, for their high commitment and active participation. Special thanks to peer learners Damiano Stella, Phyllis Ogah, Zainab Hassan, Noor Ashad, Nighat Khan, and Samvel Hayrumyan, who selflessly contributed to the accomplishments of the Uganda Implementation Case team goals as peer learners. 

The Implementation Case teams were supported by technical facilitators: Dr Leizel Lagrada-Rombaua, Dr. Belinda Nimako, Muchiri Nyaggah, and Dr. Luis Gabriel Bernal Pulido. Linda Arogundade, Dany Chhan, Amanda Folsom, Chloe Lanzara, Tania Mathurin, and Emma Stewart at R4D provided technical and operational support to the teams. The development of this Learning Exchange was supported with funding from the Bill & Melinda Gates Foundation.
 

1. Mujasi, Paschal N et al. “How efficient are referral hospitals in Uganda? A data envelopment analysis and tobit regression approach.” BMC health services research vol. 16 230. 8 Jul. 2016, doi:10.1186/s12913-016-1472-9
2. Renggli, Sabine, et al. "Towards improved health service quality in Tanzania: An approach to increase efficiency and effectiveness of routine supportive supervision." PLoS ONE, vol. 13, no. 9, 7 Sept. 2018, p. e0202735. Gale OneFile: Health and Medicine, link.gale.com/apps/doc/A557791713/HRCA?u=googlescholar&sid=googleScholar&xid=a3769f41.
3. Ibid