Table 4.

Uganda: interventions, scale-up strategy and implementation research

Scaling-up dimensions informed by IR	Nature of intervention and scale-up strategy	Findings from IR
Implementing team	Makerere University, in collaboration with local health system actors (health facility staff and district health management teams) and community actors, including local councils and savings groups
Research aim and design	Aim to explore how mobilisation of community and other local stakeholders can enhance the delivery of quality maternal and neonatal health services in a sustainable fashion (feasibility and effectiveness) Designed as participatory action research, involving stakeholders in Susman’s action research cycle; draws on routine monitoring data (from health service, project documents), household and facility surveys, and qualitative methods, e.g. focus group discussions, in-depth interviews
Attributes of the innovation or service	Multifaceted intervention to enhance maternal and neonatal health outcomes; included stimulating demand (through transport vouchers, radio sensitisation and CHWs) and improving quality of care (through training, non-financial recognition and supportive supervision) Aim: Enhance the use and quality of maternity and neonatal services at primary care facilities	Appropriateness: Not assessed Fidelity: Investments in training, supportive supervision and mentorship did not always lead to improved quality due to lack of drugs and supplies Quality of mentorship provided was quite mixed
Attributes of the target community	Implemented in three rural districts in Eastern Uganda: Pallisa, Kibuku and Kamuli; community members welcomed initiative but there were initial concerns about how sensitive local women, and particularly men, were to the need for antenatal care and attended delivery	Acceptability: Not assessed Intention to adopt: Stimulating demand for services was key to promoting adoption: active VHTs helped to spread understanding of the intervention among community members, as did strong political support from local politicians and community leaders Coverage: 48% of pregnant women in the intervention area were visited by a CHW at least once during the end line compared to 22% of pregnant women in the control; facility delivery increased from 63% to 73% in the intervention area while it remained almost stagnant in the control (64% vs. 63%)
Context	Previous FHS work in the same districts had introduced a successful maternal health voucher scheme but had struggled to financially sustain this; focal districts characterised by considerable poverty and relatively remote rural communities with weak infrastructure, there was concern about the sustainability of the intervention	Feasibility: Recognised (1) extensive supportive supervision to CHWs and district implementation committees were needed to implement intervention well; (2) use of existing structures, such as savings groups and CHWs, was found to be effective; (3) payment for vouchers via mobile money schemes was complicated given the multiple processes involved and therefore took significant investment of time and effort to set up; (4) cost of voucher scheme was prohibitive; (5) danger of theft of savings accounts in rural areas without banking
Scaling-up strategy	Diversification – sought to encourage and engage Ministry of Health and other actors at national and district level to add or continue to include effective elements of Makerere packages in their own interventions	Implementation cost: Cost analysis not done, but team devised lower cost implementation strategies, e.g. used “Super VHTs” (i.e. high performing VHTs to train other VHTs), also sought to support some community savings groups to train others Sustainability: The use of local stakeholders and structures was found to be critical for buy-in, ownership and continuity; local stakeholder commitment was central to sustaining project strategies such as performance review for better service delivery Continued stakeholder engagement was found to be key to dealing with day-to-day challenges of service delivery and improved relations among stakeholders, but also heightened the level of responsibility at individual and structural levels

CHW community health worker, FHS Future Health Systems, IR implementation research, VHTs Village Health Teams