title: Bottlenecks in the implementation of essential screening tests in antenatal care: Syphilis, HIV, and anemia testing in rural Tanzania and Uganda.
abstract: OBJECTIVE
  To identify and compare implementation bottlenecks for effective coverage of screening for syphilis, HIV, and anemia in antenatal care in rural Tanzania and Uganda; and explore the underlying determinants and perceived solutions to overcome these bottlenecks.
  
  
  METHODS
  In this multiple case study, we analyzed data collected as part of the Expanded Quality Management Using Information Power (EQUIP) project between November 2011 and April 2014. Indicators from household interviews (n=4415 mothers) and health facility surveys (n=122) were linked to estimate coverage in stages of implementation between which bottlenecks can be identified. Key informant interviews (n=15) were conducted to explore underlying determinants and analyzed using a framework approach.
  
  
  RESULTS
  Large differences in implementation were found within and between countries. Availability and effective coverage was significantly lower for all tests in Uganda compared with Tanzania. Syphilis screening had the lowest availability and effective coverage in both countries. The main implementation bottleneck was poor availability of tests and equipment. Key informant interviews validated these findings and perceived solutions included the need for improved procurement at the central level.
  
  
  CONCLUSIONS
  Our findings reinforce essential screening as a missed opportunity, caused by a lack of integration of funding and support for comprehensive antenatal care programs.
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Karolinska Institutet, Stockholm, Sweden. Electronic address: ulrika.baker@ki.se.
authors.forename: Ulrika
authors.initials: U
authors.lastname: Baker
authors.affiliation: Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda.
authors.forename: Monica
authors.initials: M
authors.lastname: Okuga
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda.
authors.forename: Peter
authors.initials: P
authors.lastname: Waiswa
authors.affiliation: Ifakara Health Institute, Dar-es-Salaam, Tanzania.
authors.forename: Fatuma
authors.initials: F
authors.lastname: Manzi
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; Makerere University, College of Health Sciences, School of Public Health, Kampala, Uganda; International Maternal and Child Health Unit, Women's and Children's Health, Uppsala University, Sweden.
authors.forename: Stefan
authors.initials: S
authors.lastname: Peterson
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Claudia
authors.initials: C
authors.lastname: Hanson
mesh_terms: D000328:Adult; D000740:Anemia / Q000175:diagnosis*; D005260:Female; D015658:HIV Infections / Q000175:diagnosis*; D019538:Health Care Surveys; D006284:Health Plan Implementation; D006297:Health Services Accessibility; D006801:Humans; D008403:Mass Screening; D011247:Pregnancy; D011248:Pregnancy Complications / Q000175:diagnosis*; D011295:Prenatal Care / Q000592:standards; D011296:Prenatal Diagnosis / Q000379:methods / Q000592:standards*; D012424:Rural Population; D013587:Syphilis / Q000175:diagnosis*; D013636:Tanzania; D014454:Uganda
keywords: Antenatal care; Bottlenecks; Implementation; Supply chain; Syphilis