Measurement of district health system strengthening efforts for maternal and newborn health service delivery: synchronized application of evaluation models in the West Nile region, Uganda, 2019-2021.

Abstract

Introduction: Uganda has high maternal, neonatal, and under-five mortality rates. Between 2019 and 2021, the United Nations Children's Fund (UNICEF), in collaboration with the Ministry of Health and other partners, implemented a maternal and newborn health (MNH) quality improvement programme in the West Nile region of Uganda to improve the delivery and utilization of MNH services. This study describes the application of health system evaluation models to monitor changes in health system capacity and the quality of MNH services.

Methods: We designed two novel health system evaluation models-the Progression and ServQual models-which progressively monitor changes in health system capacity and quality of health services. The progression model was designed to measure changes in health system capacity using a set of indicators and benchmarks. For each health system component, the tool generates scores as follows: > 90% for level 4 progression (surpasses basic expectations); 70-90% for level 3 (meets basic expectations); 50- < 70% for level 2 (needs improvement); and < 50% for level 1 progression (needs urgent attention). The quality of MNH services was monitored through annual client satisfaction surveys using the ServQual model. The identified health system capacity and service quality gaps were used to inform corrective actions.

Results: Overall, the average health system capacity scores across the 12 districts increased from 62.9% (level 2) in 2019 to 71.2% (level 3) in 2021. The capacity scores for each health system component increased: governance and leadership increased from 67.7% to 74.1%, health financing increased from 67.4% to 69.3%, access to essential medicines increased from 50.2% to 77.0%, the health information system increased from 71.8% to 74.9%, the health workforce increased from 56.8% to 66.9%, and MNH service delivery slightly increased from 63.5% to 64.5%. Client satisfaction with the quality of MNH services increased from 26.5% in 2019 to 39.8% in 2021.

Conclusion: Synchronized application of the Progression and ServQual models is an important innovative strategy for monitoring changes in district health system capacity and quality of health services. The results of applying these models can be used to guide better targeting for health system capacity improvement.