title: Strengthening health facilities for maternal and newborn care: experiences from rural eastern Uganda.
abstract: BACKGROUND
  In Uganda maternal and neonatal mortality remains high due to a number of factors, including poor quality of care at health facilities.
  
  
  OBJECTIVE
  This paper describes the experience of building capacity for maternal and newborn care at a district hospital and lower-level health facilities in eastern Uganda within the existing system parameters and a robust community outreach programme.
  
  
  METHODS
  This health system strengthening study, part of the Uganda Newborn Study (UNEST), aimed to increase frontline health worker capacity through district-led training, support supervision, and mentoring at one district hospital and 19 lower-level facilities. A once-off supply of essential medicines and equipment was provided to address immediate critical gaps. Health workers were empowered to requisition subsequent supplies through use of district resources. Minimal infrastructure adjustments were provided. Quantitative data collection was done within routine process monitoring and qualitative data were collected during support supervision visits. We use the World Health Organization Health System Building Blocks to describe the process of district-led health facility strengthening.
  
  
  RESULTS
  Seventy two per cent of eligible health workers were trained. The mean post-training knowledge score was 68% compared to 32% in the pre-training test, and 80% 1 year later. Health worker skills and competencies in care of high-risk babies improved following support supervision and mentoring. Health facility deliveries increased from 3,151 to 4,115 (a 30% increase) in 2 years. Of 547 preterm babies admitted to the newly introduced kangaroo mother care (KMC) unit, 85% were discharged alive to continue KMC at home. There was a non-significant declining trend for in-hospital neonatal deaths across the 2-year study period. While equipment levels remained high after initial improvement efforts, maintaining supply of even the most basic medications was a challenge, with less than 40% of health facilities reporting no stock-outs.
  
  
  CONCLUSIONS
  Health system strengthening for care at birth and the newborn period is possible even in low-resource settings and can be associated with improved utilisation and outcomes. Through a participatory process with wide engagement, training, and improvements to support supervision and logistics, health workers were able to change behaviours and practices for maternal and newborn care. Local solutions are needed to ensure sustainability of medical commodities.
authors.affiliation: School of Public Health, College of Health Science, Makerere University, Kampala, Uganda.|INDEPTH, Iganga/Mayuge Health Demographic Surveillance Site, Kampala, Uganda; namazzi_ge@yahoo.com.
authors.forename: Gertrude
authors.initials: G
authors.lastname: Namazzi
authors.affiliation: School of Public Health, College of Health Science, Makerere University, Kampala, Uganda.|INDEPTH, Iganga/Mayuge Health Demographic Surveillance Site, Kampala, Uganda.|Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Peter
authors.initials: P
authors.lastname: Waiswa
authors.affiliation: Kampala Children's Hospital, Kampala, Uganda.
authors.forename: Margaret
authors.initials: M
authors.lastname: Nakakeeto
authors.affiliation: St. Raphael of St. Francis Hospital, Nsambya, Kampala, Uganda.|School of Medicine, Uganda Martyrs University, Nkozi, Kampala, Uganda.
authors.forename: Victoria K
authors.initials: VK
authors.lastname: Nakibuuka
authors.affiliation: School of Public Health, College of Health Science, Makerere University, Kampala, Uganda.|INDEPTH, Iganga/Mayuge Health Demographic Surveillance Site, Kampala, Uganda.
authors.forename: Sarah
authors.initials: S
authors.lastname: Namutamba
authors.affiliation: Ministry of Health, Kampala, Uganda.
authors.forename: Maria
authors.initials: M
authors.lastname: Najjemba
authors.affiliation: Ministry of Health, Kampala, Uganda.
authors.forename: Ruth
authors.initials: R
authors.lastname: Namusaabi
authors.affiliation: Ministry of Health, Kampala, Uganda.
authors.forename: Abner
authors.initials: A
authors.lastname: Tagoola
authors.affiliation: Ministry of Health, Kampala, Uganda.
authors.forename: Grace
authors.initials: G
authors.lastname: Nakate
authors.affiliation: Ministry of Health, Kampala, Uganda.
authors.forename: Judith
authors.initials: J
authors.lastname: Ajeani
authors.affiliation: School of Public Health, College of Health Science, Makerere University, Kampala, Uganda.|INDEPTH, Iganga/Mayuge Health Demographic Surveillance Site, Kampala, Uganda.|Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.|International Maternal and Child Health Unit, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
authors.forename: Stefan
authors.initials: S
authors.lastname: Peterson
authors.affiliation: St. Raphael of St. Francis Hospital, Nsambya, Kampala, Uganda.|School of Medicine, Uganda Martyrs University, Nkozi, Kampala, Uganda.
authors.forename: Romano N
authors.initials: RN
authors.lastname: Byaruhanga
mesh_terms: D000328:Adult; D002983:Clinical Competence; D003153:Community Health Services / Q000458:organization & administration*; D003695:Delivery of Health Care / Q000458:organization & administration*; D005260:Female; D006282:Health Personnel / Q000193:education*; D006771:Hospitals, Maternity / Q000458:organization & administration*; D006801:Humans; D007223:Infant; D007224:Infant Care / Q000458:organization & administration*; D007226:Infant Mortality; D007231:Infant, Newborn; D000068101:Maternal-Child Health Services / Q000458:organization & administration*; D012424:Rural Population; D014454:Uganda / Q000453:epidemiology
keywords: Uganda; health system strengthening; kangaroo mother care; maternal care; neonatal mortality; newborn care
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