GCB-Joint-Scope-Assessment-Report.docx

Global Capacity Building ======================== Scoping Assessment Report: Uganda and Zambia ============================================ Contents {#contents.TOCHeading} ======== [1. Scoping Assessment: Overview 2](#_Toc141734994) [2. Scoping Assessment: Purpose and Methodology 3](#scoping-ass...

Global Capacity Building ======================== Scoping Assessment Report: Uganda and Zambia ============================================ Contents {#contents.TOCHeading} ======== [1. Scoping Assessment: Overview 2](#_Toc141734994) [2. Scoping Assessment: Purpose and Methodology 3](#scoping-assessment-purpose-and-methodology) [3. Scoping Assessment: Findings 4](#scoping-assessment-findings) [4. Next steps 7](#next-steps) []{#_Toc141734994.anchor} 1\. Scoping Assessment: Overview\ \ In April 2023 THET was awarded the Global Capacity Building Programme (GCB) by NHS England (NHSE). As part of this programme THET will act as the grant manager for Health Partnership (HP) projects in South Africa, Uganda and Zambia. The aim of GCB is to facilitate global learning opportunities with NHS partners in/with Low- and Middle- Income Country partners by providing specialist international development expertise, complementing NHS technical knowledge and expediting the positive impact of NHS global programmes. The GCB will support the development of stronger health systems by promoting HPs that are aligned to the national health priorities and strategies. The project will support blended volunteer placements and run for 18 months. The project aims will be achieved through the following outcomes, mapping onto NHSE's Global Strategy:    1. 2. 3. During the inception phase of the programme, May 2023 to July 2023, THET undertook three rapid scoping assessments in Uganda and Zambia to gain a better understanding of the current status of the health system in each country, and to identify the most pressing health priorities. THET Country Directors met with high level Ministry of Health (MoH) officials and FCDO Health Advisors to provide information on the GCB programme, discuss the level of engagement the Ministries could provide, and explore the countries' health system challenges and priorities, including gender equity and social inclusion (GESI) issues. Discussions focussed on how the GCB can contribute to help governments progress towards achieving Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs). Key priorities identified in each country are as follows (please read on for further details): +-----------------------------------+-----------------------------------+ | **Country** | **Priority Global Capacity | | | Strengthening themes** | +===================================+===================================+ | Uganda | - Increase access to quality | | | maternal and neonatal care | | | through specialist training | | | at referral hospitals/centres | | | of excellence. Priority sites | | | are Kawempe Referral Hospital | | | in Kampala and Hoima Regional | | | Referral Hospital in Western | | | Uganda. | | | | | | | | | | | | - Regional orientations of | | | nurses and midwives within | | | the catchment area of Kawempe | | | and Hoima Referral Hospitals | | | as well as other areas that | | | register high maternal and | | | neonatal deaths. | | | | | | | | | | | | - Leadership training and | | | capacity strengthening for | | | local government health | | | managers. | +-----------------------------------+-----------------------------------+ | Zambia | - Capacity strengthening | | | towards improving safe | | | anaesthesia service delivery | | | | | | - Capacity strengthening | | | towards an integrated | | | dietetics programme in public | | | health facilities | +-----------------------------------+-----------------------------------+ 2. Scoping Assessment: Purpose and Methodology ============================================== **2.1 Purpose of the scoping assessments** The scoping assessments explored health systems issues, challenges and priorities. They furthermore identified and validated health system priorities that HPs can address and/or contribute to in health system strengthening (HSS), whilst ensuring a GESI perspective. The assessment process also aimed to build relationships with key stakeholders. Assessment findings informed the grant call design and overall GCB programme monitoring processes, promoting HPs that are aligned with and supportive of national priorities and capacities, and ensuring a good fit with the supply of partners in England. **2.2 Approach and methodology ** Key stakeholder involvement to discuss the proposed HP interventions is critical, as is alignment with key stakeholders affected by the implementation of each intervention. MoH participation in the scoping process was essential to ensure full commitment throughout the programme, increasing the likelihood of HP interventions being implemented, achieving the expected results, and these results being sustained beyond the lifetime of the project. The THET team drew on the WHO Health System Framework and the 6 Building Blocks/core functions[^1^](#fn1){#fnref1.footnote-ref} to develop a flexible approach and tools for the scoping assessment that could be adapted to each country context. Key informant interviews (KIIs) were conducted with representatives from the MoH and in-country FCDO teams. Other professional bodies and associations were consulted if encouraged by the Ministry. The team also conducted a rapid desk review comprising mainly of country-specific health sector policies and strategies. The objectives of such stakeholder engagement were to: - Share information on the GCB and the HP model - Seek stakeholders' inputs, views and agree on the most pressing health priorities. - Collaboratively assess the potential of the HP model to address the identified priorities. - Obtain consensus on the interventions that could be implemented through HPs. A final meeting with each Ministry was held to provide an overview of the scoping assessment findings and validate the priorities for the GCB programme. Additionally, as part of this meeting, THET explained the function of the national oversight mechanism (NOM) and identified members, who have now been formally agreed and introduced to the programme. This group of key national stakeholders will provide country-level oversight of the programme, advising on grants selection and meeting quarterly to ensure the programme continues to align with national priorities. 3. Scoping Assessment: Findings =============================== **3.1 UGANDA** The Uganda Ministry of Health has a clear vision *"To have a healthy and productive population that contributes to socio-economic growth and national development"*. The mission is "To provide the highest possible level of health services to all people in Uganda through delivery of promotive, preventive, curative, palliative and rehabilitative health services at all levels".[^2^](#fn2){#fnref2.footnote-ref} In conducting the scoping assessment in Uganda, THET held stakeholder meetings with the FCDO Uganda Health Advisor and the Ministry of Health to identify and agree on the priorities for the GCB. The key priorities identified through the scoping assessment: **[PRIORITY 1: Increase access to quality maternal and neonatal care ]** Uganda is a low-income country in sub-Saharan Africa and, with a population 48,582,334 people (2023) is highly populated. Uganda has a 3% population growth rate and a fertility rate of 4.78 births per woman, resulting in an increase of over 1 million people each year[^3^](#fn3){#fnref3.footnote-ref}. Uganda also has one of the highest teenage pregnancy rates in the East Africa region with 25% of Ugandan women having given birth before the age of 18.[^4^](#fn4){#fnref4.footnote-ref} Uganda continues to register high maternal and newborn deaths at 336 deaths per 100,000 live births and 27 deaths per 1,000 live births respectively. While there has been a marked increase in institutional deliveries from 42% in 2006 to 73% in 2016, neonatal mortality has generally stagnated during this period at 28/1000 live births in 2006 and 27/100 live births in 2016.[^5^](#fn5){#fnref5.footnote-ref} During the latest review of the Uganda health sector performance, prematurity and other neonatal conditions were the leading cause of health facility deaths among all ages, accounting for 10.3% (5,899/57,447) of deaths[^6^](#fn6){#fnref6.footnote-ref}. Although maternal and neonatal health has been a long-standing concern for key stakeholders in Uganda, and much work has been done which has positively contributed to improving women\'s access to services and quality of care, gaps remain. The above-mentioned data underpins the urgency and need echoed by all key stakeholders interviewed. Based on discussions with FCDO and MoH in Uganda, the primary focus areas of the GCB programme is **[increasing access to quality maternal and neonatal care,]** and should prioritise: +-----------------------------------------------------------------------+ | - Specialist training at referral hospitals and centres of | | excellence for neonatologists, obstetricians, midwives and | | nurses. Priority sites are Kawempe Referral Hospital in Kampala | | and Hoima Regional Referral Hospital in Western Uganda. | | | | - Regional orientations of nurses and midwives in neonatal care for | | facilities within the catchment area of Kawempe and Hoima | | referral hospitals as well as other areas that register high | | maternal and neonatal deaths. | +-----------------------------------------------------------------------+ **[PRIORITY 2: Improved health leadership and governance at local government level]** Uganda has a decentralised health system with the district as the local level of decision-making for health services and the health sub-district as a functional sub-division of the district health system. The district health management team is led by a District Health Officer who works with a team of other health managers in the district office and health workers in charge of health centres.[^7^](#fn7){#fnref7.footnote-ref} District and sub-county Health Committees constituted by local council members are mandated to approve work plans and budgets prepared by the technical teams and to monitor their execution. One of the objectives for decentralising the Ugandan health system was to improve its management and, ultimately, the quality and equity of health services available to the population. However, leadership and management capacity for local government health managers was listed among the health system performance gaps during the 28th Joint Review Mission[^8^](#fn8){#fnref8.footnote-ref}. Turnover of health managers at the national and local government level, has created gaps in governance which need to be addressed urgently. There are furthermore concerns regarding ethics and moral conduct of those in charge and its negative impact on the quality of health services. Hence, based on discussions with FCDO and MoH local leadership and governance will form the second priority area in Uganda, particularly; +-----------------------------------------------------------------------+ | - Development of a Leadership Management and Planning Manual for | | subnational health managers. Content should include aspects of | | morals/behaviour change. | | | | - Pilot in-service training in leadership and management for local | | government health managers. | +-----------------------------------------------------------------------+ **3.2 ZAMBIA** Most of the Zambian population is affected by poverty, with 54.4% in 2015 classified as poor and 40.80% as extremely poor (CSO, 2015).[^9^](#fn9){#fnref9.footnote-ref} The outbreak of the COVID-19 pandemic in 2020 had devastating impacts on an already stretched health system, leading to significant numbers of mortalities and a deterioration in the health status of the population and the country\'s economy.[^10^](#fn10){#fnref10.footnote-ref} Additionally, the Zambian MoH has been faced with a rapidly rising burden of non-communicable diseases, including cancer diseases, mental health, diabetes mellitus, cardiovascular diseases (CVD) and trauma. Key priorities identified through the scoping assessment following meetings with the MoH and FCDO included: **[PRIORITY 1: Strengthening capacity in safe anaesthesia service delivery ]** Against a population of 19.6 million, Zambia has circa 250 anaesthesia providers, include physicians, clinical officers and nurses, for a population of 19.6 million. 80.7% of the population live more than two hours from a surgical facility. As a result, many common, easily treatable conditions become fatal, such as obstructed labour, appendicitis, road traffic injuries, burns and falls. With only 0.93 anaesthesia providers per 100,000 people, compared to 20.7 per 100,000 in the UK, anaesthesia services are speciality under-developed and under-resourced in Zambia. With support from UK technical partners, the MoH has made significant progress, including in the following areas: - The design and delivery of a first four-year postgraduate training programme for physician anaesthetists, (2011). - The development of a regional anaesthesia service at University Teaching Hospital, Ndola Central Hospital and Arthur Davison Children's Hospital, (2016). - Ensured that anaesthesia providers in Zambia were sufficiently trained and protected during the COVID-19 pandemic, working on a number of initiatives to improve the provision of safer anaesthesia in Zambia and equip graduates with the essential skills to become effective leaders in healthcare. The MoH and FCDO jointly agreed that anaesthesia remains a major challenge in need of ongoing support. Building on previous initiatives, Health Partnerships will be able to work together with the MoH and relevant key stakeholders to further strengthen and improve services, through capacity strengthening, quality improvement and the development of a robust national standardised system. **[PRIORITY 2: Capacity Strengthening for an Integrated Dietetics Programme in Public health facilities]** The provision of comprehensive clinical nutrition and dietetics, as well as public health nutrition services, is a key concern for the Zambian MoH. Health workers lack the capacity and time for the provision of appropriate quality services for the prevention, recognition and management of nutrition-related conditions. The rise of non-communicable diseases is an added burden on an otherwise already stretched health system. Nutrition has a core contribution in effective clinical treatment, therefore, enhancing nutrition and dietetics will contribute to improving overall health outcomes. Improving the nutritional status requires understanding of the multifaceted nature of malnutrition and the associated problems of inadequate food intake, poor sanitation, hygiene, and unfavourable health conditions. Training of competent clinical nutritionists, dieticians, and public health nutritionists is a major gap. With non-communicable diseases on the rise, and the on-going stresses of communicable diseases, the MoH's focus on integrating NCD care into the existing health system, particularly nutrition and diabetes, is a concept currently piloted across several global partners. Although PEN+ training has recently been piloted, major gaps in national policy, training resources and tools remain. This on top of a lack of investment in human resources and lack of knowledge in clinical nutrition and dietetics, demonstrates the need for technical support. Further a major concern is the lack of trained staff trained to provide therapeutic feeding (both intravenous and parenteral). The HPs supporting this initiative will be feeding into a programme recently launched by the MoH, 'Strengthening Nutrition Competencies in managing malnutrition in Public Institutions and Integration of NCDs in the training programmes'. Next steps ========== THET will launch the call for applications on Wednesday 16^th^ August 2023, with applications due by Friday 13^th^ October 2023. A call for applications for South Africa, along with a scoping report, will be released in September. For full details of how to apply along with the application form, please visit [www.thet.org](http://www.thet.org). ::: {.section.footnotes} ------------------------------------------------------------------------ 1. ::: {#fn1} World Health Organization (2007) Everybody's Business:  Strengthening health systems to improve health outcomes---WHO's Framework for Action.  Geneva:  WHO, 2007, p.3. [↩](#fnref1){.footnote-back} ::: 2. ::: {#fn2} https://www.health.go.ug/about-moh/[↩](#fnref2){.footnote-back} ::: 3. ::: {#fn3} https://worldpopulationreview.com/countries/uganda-population[↩](#fnref3){.footnote-back} ::: 4. ::: {#fn4} Uganda Bureau of Statistics (UBOS) and ICF. 2018. Uganda Demographic and Health Survey 2016. Kampala, Uganda and Rockville, Maryland, USA: UBOS and ICF. 2018.[↩](#fnref4){.footnote-back} ::: 5. ::: {#fn5} Uganda Bureau of Statistics (UBOS) and ICF. 2018. Uganda Demographic and Health Survey 2016. Kampala, Uganda and Rockville, Maryland, USA: UBOS and ICF. 2018.[↩](#fnref5){.footnote-back} ::: 6. ::: {#fn6} Performance issues/gaps identified during the 28^th^ National Health Sector Joint Review Mission, Uganda Ministry of Health.[↩](#fnref6){.footnote-back} ::: 7. ::: {#fn7} Murindwa G, Tashobya CK, Kyabaggu JH, Rutebemberwa E, Nabyonga J. Meeting the challenges of decentralised health service delivery in Uganda as a component of broader health sector reforms. In: Tashobya CK, Ssengooba F, Cruz VO, editors. Health Systems Reforms in Uganda: Processes and Outputs. London: Health Systems Development Programme, London School of Hygiene & Tropical Medicine, UK; 2006.[↩](#fnref7){.footnote-back} ::: 8. ::: {#fn8} Performance issues/gaps identified during the 28^th^ National Health Sector Joint Review Mission, Uganda Ministry of Health.[↩](#fnref8){.footnote-back} ::: 9. ::: {#fn9} [↩](#fnref9){.footnote-back} ::: 10. ::: {#fn10} [↩](#fnref10){.footnote-back} ::: :::