title: Community and District Empowerment for Scale-up (CODES): a complex district-level management intervention to improve child survival in Uganda: study protocol for a randomized controlled trial.
abstract: BACKGROUND
  Innovative and sustainable strategies to strengthen districts and other sub-national health systems and management are urgently required to reduce child mortality. Although highly effective evidence-based and affordable child survival interventions are well-known, at the district level, lack of data, motivation, analytic and planning capacity often impedes prioritization and management weaknesses impede implementation. The Community and District Empowerment for Scale-up (CODES) project is a complex management intervention designed to test whether districts when empowered with data and management tools can prioritize and implement evidence-based child survival interventions equitably.
  
  
  METHODS
  The CODES strategy combines management, diagnostic, and evaluation tools to identify and analyze the causes of bottlenecks to implementation, build capacity of district management teams to implement context-specific solutions, and to foster community monitoring and social accountability to increase demand for services. CODES combines UNICEF tools designed to systematize priority setting, allocation of resources and problem solving with Community dialogues based on Citizen Report Cards and U-Reports used to engage and empower communities in monitoring health service provision and to demand for quality services. Implementation and all data collection will be by the districts teams or local Community-based Organizations who will be supported by two local implementing partners. The study will be evaluated as a cluster randomized trial with eight intervention and eight comparison districts over a period of 3 years. Evaluation will focus on differences in uptake of child survival interventions and will follow an intention-to-treat analysis. We will also document and analyze experiences in implementation including changes in management practices.
  
  
  CONCLUSIONS
  By increasing the District Health Management Teams' capacity to prioritize and implement context-specific solutions, and empowering communities to become active partners in service delivery, coverage of child survival interventions will increase. Lessons learned on strengthening district-level managerial capacities and mechanisms for community monitoring may have implications, not only in Uganda but also in other similar settings, especially with regard to accelerating effective coverage of key child survival interventions using locally available resources.
  
  
  BACKGROUND
  ISRCTN15705788 , Date of registration; 24 July 2015.
authors.affiliation: School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda. pwaiswa2001@yahoo.com.|Karolinska Institutet, Solna, Sweden. pwaiswa2001@yahoo.com.
authors.forename: Peter
authors.initials: P
authors.lastname: Waiswa
authors.affiliation: Economics and Finance, UNICEF NewYork, Three UN Plaza, New York, NY, 10017, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: O'Connell
authors.affiliation: School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.|College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA.|Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA.
authors.forename: Danstan
authors.initials: D
authors.lastname: Bagenda
authors.affiliation: UNICEF NewYork, Three UN Plaza, New York, NY, 10017, USA.
authors.forename: Pricila
authors.initials: P
authors.lastname: Mullachery
authors.affiliation: Health Section, UNICEF Uganda Country Office, Box 7074, Kampala, Uganda.
authors.forename: Flavia
authors.initials: F
authors.lastname: Mpanga
authors.affiliation: Karolinska Institutet, Solna, Sweden.|Uppsala University, Uppsala, Sweden.
authors.forename: Dorcus Kiwanuka
authors.initials: DK
authors.lastname: Henriksson
authors.affiliation: Child Health and Development Centre, Makerere University, Kampala, Uganda.
authors.forename: Anne Ruhweza
authors.initials: AR
authors.lastname: Katahoire
authors.affiliation: School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
authors.forename: Eric
authors.initials: E
authors.lastname: Ssegujja
authors.affiliation: School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.|Director Health Services, Ministry of Health, Box 7272, Kampala, Uganda.
authors.forename: Anthony K
authors.initials: AK
authors.lastname: Mbonye
authors.affiliation: School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.|Uppsala University, Uppsala, Sweden.
authors.forename: Stefan Swartling
authors.initials: SS
authors.lastname: Peterson
mesh_terms: D000367:Age Factors; D002662:Child Health Services / Q000458:organization & administration* / Q000592:standards; D046688:Child Mortality; D002669:Child Welfare; D002675:Child, Preschool; D003967:Diarrhea / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D006292:Health Priorities / Q000458:organization & administration; D006297:Health Services Accessibility / Q000458:organization & administration; D006301:Health Services Needs and Demand / Q000458:organization & administration; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D033183:Interdisciplinary Communication; D000070516:Intersectoral Collaboration; D008288:Malaria / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D020380:Needs Assessment / Q000458:organization & administration; D010348:Patient Care Team / Q000458:organization & administration; D011014:Pneumonia / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D058996:Quality Improvement / Q000458:organization & administration* / Q000592:standards; D019984:Quality Indicators, Health Care / Q000458:organization & administration* / Q000592:standards; D012107:Research Design; D012307:Risk Factors; D013997:Time Factors; D014454:Uganda
keywords: Bottleneck analysis; Child survival; Community monitoring; District strengthening; Evidence-based; Health systems strengthening; LQAS; Management tools; Uganda