Dr. Milly N. Kaggwa, Programs Director, PSI Uganda
I was a little apprehensive when my colleague Dr. Dorothy Balaba returned from the co-creation and co-design workshop on care-seeking and referral for maternal, newborn and child health in Johannesburg earlier this year.
Dr. Balaba shared some flip charts with pictures and diagrams that captured some of the discussion at the workshop. Prior to the workshop our PSI team had spent days brainstorming to prepare a concept note. Developing a project concept and being considered to attend the co-design workshop, along with other finalists, was a first for us. My doubt must have been written all over my face because she allayed my concerns and brought out a colorful flip chart, developed at the workshop, with pictures of little houses, an ambulance and a pregnant woman at the center. By placing the pregnant woman at the center and imagining her perspective, she explained, we might better understand her health problems, her community and environment, and how it all would link to our current mixed health system in Kampala, to develop an intervention that responds to her needs.
About the BAA
In late 2017, USAID called for expressions of interests to find solutions to improve timely care-seeking and referral systems for maternal, newborn and child health (MNCH) in priority countries. Earlier this year PSI Uganda participated in a co-creation workshop as a finalist for a USAID BAA on solutions to improve timely care-seeking and referral systems for maternal, newborn and child health (MNCH). The final teams in the co-design workshop comprised of people with perspectives ranging from implementer, policy maker and researcher. This ensured representation of the various stakeholder perspectives involved in project design and implementation. During this workshop participants reflected on the initial concepts they shared in their expressions of interest and explored new approaches through a process of co-design. The workshop was geared toward encouraging greater engagement with and learning from other participating teams, technical experts, and development partners so that the final approaches represent the best responses to the challenges and opportunities of MNCH care-seeking and referral. Click here to learn more about BAAs.
Maternity care in urban Kampala
Kampala’s metropolitan area contains over 11% of Uganda’s population with a growing migrant population. The city has over 57 recognized slums and a majority of urban poor live in slums. While the health system is decentralized and under the management of the City Council, funding gaps remain, which can lead to health challenges, particularly in urban slums. Major challenges in illness recognition, and care-seeking and referral impact MNCH outcomes, particularly newborns. For example, in rural Uganda, when a pregnant woman seeks care, the lack of easy access to a healthcare facility may affect her chances for a safe delivery. Many facilities lack appropriate personnel or equipment for a safe delivery. The time spent in the search for care is critical time lost and results in inevitably high rates of morbidity and mortality. There is a dearth of studies assessing similar situations in urban settings.
Although urban areas have better access to health facilities, timely use of services, especially amongst the poorest groups, is difficult due to poverty, lack of financing schemes, and the challenges of selecting the appropriate health facility from the many that are available because there is no accreditation system to ensure quality at these facilities. The poor health outcomes for mothers and newborns in Uganda have been well described in key national policies and publications. Most interventions target rural communities, yet few are focusing interventions to address the needs of the rapidly increasing urban population.
Unpublished work shows that many mothers have a pattern of temporary migration late in pregnancy to be closer to a healthcare facility. However, most of them migrate and live in slums where care is poor. As a result, public hospitals in the city are congested and have poor quality services. The lack of an urban MNCH plan and supporting investment is critical because 15% of the population live in the urban areas and the proportion is increasing.
Modifying our approach
Our initial proposal was based on the results of our literature review which indicated that women were not seeking care. We believed that women were not seeking care because they were unaware of the health services available to them. This guided our initial concept to utilize community health workers to inform women in urban slums about the importance of seeking care at a health facility. The thought was that this intervention would improve women’s care-seeking behavior in urban slums. However, our approach to developing interventions changed after attending the co-creation workshop.
We attended the BAA co-design workshop in Johannesburg, South Africa in May, with a researcher from Makerere University, as well as with the Deputy Director from the Kampala Capital City Authority. At the week-long workshop, we learned to better understand the needs of women and to use this as our focal point. Our initial thoughts about the factors affecting women’s decisions to seek care may not be the actual problems affecting care-seeking behavior. We learned to use human centered design to better understand the problems facing women in urban Kampala in order to create an intervention that meets the needs of these women.
Following the co-creation and design workshop, we were able to rethink our proposal from the point of view of our intended beneficiary, who we call “Sara.” For each intervention, we asked ourselves, what is “Sara’s” point of view? While we accepted that we might not know “Sara’s” entire perspective, this project has given us the opportunity to revisit health care from the point of view of the people we seek to help.
The workshop also informed our research strategy, underscoring the critical role of implementation research given its focus on iterative learning to inform and improve the intervention in real-time. We were able to use the guiding principles of implementation research to modify our concept and will continue to use them in the next phase of the project.
"We need to focus on getting it right, understanding the user’s perspective and identifying solutions that work for them instead of focusing on the implementer’s perspective."Dr. Dorothy Balaba - Country Representative, PSI Uganda
Moving forward we are mapping the social networks involved in Sara’s care. This process will include in-depth interviews and focus group discussions with women, their families and community members, and other important social groups to better understand the social determinants that affect women’s decisions to seek care in a community. We are also working to better engage private health providers given their prominent role in urban areas.
In November we invited a diverse group of stakeholders ranging from multilateral donor organizations, NGOs, public and private sector providers, and Ministry of Health representatives to participate in a project engagement meeting to gather information about their activities in care-seeking in Kampala. This process is ongoing, but thanks to the co-creation workshop we are moving forward with our implementation research effort and will continue to keep the end-user, “Sara,” in mind when designing our intervention.
To learn more about the Health Research Program and the BAA process visit www.harpnet.org
The “Implementation research for improving illness recognition, care seeking and referral linkages to quality health facility care for pregnant mothers and their babies in urban Kampala, Uganda” is being implemented by PSI Uganda in partnership with Makerere University School of Public Health, Maternal Newborn and Child Health Center of Excellence and The Kampala City Council Authority.