Comparing Integrated Management of Child Illnesses at Kawempe Health Center (IV) in Uganda, Vertically Integrated Health System and a Horizontally Integrated Health System at two centers in San Francisco County California USA

Comparing Integrated Management of Child Illnesses at Kawempe Health Center (IV) in Uganda, Vertically Integrated Health System and a Horizontally Integrated Health System at two centers in San Francisco County California USA

Muyunga-Mukasa, T.R.

                       Kawempe National Referral Hospital. Source: Google

                                                 INTRODUCTION

In Uganda, a country in East Africa, collaboration with International teaching Hospitals has helped create opportunities for transfer of knowledge, best-practices and skills that would otherwise not be available at lower level health facilities. The Liverpool-Mulago Collaboration is one such example. This resulted in the integrated management of childhood illnesses where: identifying families with expecting mothers; immunization drives; neonatal care; postnatal care; involving men in caring for expectant mothers; voluntary medical male circumcision; HIV/STIs checking; Partner counselling; and home-based nutrition plans are performed as packaged health services. In USA, the San Francisco Bay Area’s San Francisco County has various health delivery services that are combined as a single package. In this discussion, one will read briefly about Kawempe Health Center (IV),  Kaiser Permanente (KP) and Mercy Housing.

Access is a proxy measure for patient experience around which health delivery is built. Access can be initiated in form of collaboration, vertical integration or horizontal integration. These three strategies make the initiatives provide better health outcomes such as: collaboration, integration and service expansion accessible to the people who need them.  Collaboration creates space for transfer of  health delivery skills, human resource,  capital and logistics (LMP, 2014). Integration is as a result of acquisition, merger, alliance networks and joint ventures. Service integration includes extension of core product or service and this is known as horizontal integration. 

The kind that involves entry into a new type of service along the continuum of care provides diversified services is called vertical integration. Vertical integration provides proximity to different services, specialties, research, clinic trials and availability of different health professionals (Memorial Hermann, 2015).  For the sake of this discussion, access is the ability of a person to obtain health care services when needed (Shi, 2015).

                             Kawempe Health Center (IV), Kampala Uganda

Kawempe Health Centre (IV) is about 5-6 miles away from the National Referral Hospital, Mulago. The health facility is used as a primary health unit that offsets the congestion or referrals at Mulago. This ensured such activities that led to  over 6,000 deliveries per year (LMP, 2014). Funds to pay for resident doctors, a functioning operating theatre, blood transfusion facilities and Uganda government commitment to improve the functionality of Kawempe Health Centre have seen a fresh start there. Currently such services like caesarean sections and Voluntary Medical Male Circumcision are conducted there. This in turn is reducing the number of referrals to Mulago Hospital. Other services include: Mother and Child health services; Youth Friendly Services; HIV and STI counseling services; Laboratory Services;health Management Information Services; primary care;and a Health Centre (III) with a fully functional maternity unit. The long-term volunteers continue to offer support and training to the local midwives in areas such as neonatal resuscitation, patient monitoring and emergency obstetric skills. The form of collaboration has elements of vertical integration and is known for its cost-effective care with quality services to its enrollees. It is a yellow-star awardee providing quality services and access to healthcare services for a wide ranging population in Kawempe Division (a division of Kampala Capital City Authority-KCCA). 

The implications of  collaboration and integration for the management of the organization is that it has brought about facilitation that promotes healthy outcomes for the urban/sub-urban communities.

                        Kaiser Permanente, San Francisco Bay Area California USA

Kaiser Permanente is a vertically integrated health system that links services at different stages in the production process of health care, e.g., organization of primary care, acute care, post acute services and a hospital (Kaiser Permanente. (2014). The vertically integrated health system provides an environment in which an important element of health delivery or provision called access is possible. As one of America’s leading health care providers and not-for-profit health plans, founded in 1945, Kaiser Permanente has a mission to provide high-quality, affordable health care services and to improve the health of members and the communities. Kaiser Permenente serves more than 10 million members in eight states and the District of Columbia. Care for members and patients is focused on their total health and guided by their personal physicians, specialists and team of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the-art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health (kp.org/share). Kaiser Permenente provides employment, care, coverage, a list of doctors to choose from, get lab tests, and pick up medications all in one place. Under the same arrangement one is able to purchase individual or family health pan; Medicaid/Medical; Medicare; Employer-sponsored plans; as well as explore employment opportunities. Kaiser Permanente health plans ware expended to include breast cancer screenings and early detection (kp.org/healthy). The form of integration exhibited by Kaiser Permenente is known for its cost-effective care with quality services to its enrollees (Shi, 2015). It is a top-notch provider of quality services and it continues to provide access to healthcare services for a wide ranging population in Northern California. 

The implications of integration for the management of the organization is that scattered  entities are under one mutually cooperative arrangement. This has significant influence on patient well being as well as the patient/consumer experience along the continuum of care. Being under one roof the following six features, i.e., safety, effectiveness, patient-centeredness, timeliness, efficiency and equitable services that close the gap for minorities or underserved population groups are achievable.

                    Mercy Housing  San Francisco Bay Area California USA

Mercy Housing is in 41 states of US and is an example of horizontal integration that I chose to share with you. Mercy Housing, a national nonprofit organization, is working to build a more humane world where poverty is alleviated, communities are healthy and all people can develop to their full potential. Affordable housing and supportive programs improve the economic status of residents, revitalize neighborhoods and stabilize lives. Mercy Housing one of the nation’s largest affordable housing organizations participates in the development, preservation, management and/or financing of affordable, program-enriched housing across the country. It serves a variety of populations with housing projects for low-income families, seniors and people with special needs. It acquires and renovates existing housing, as well as develop new affordable rental properties. Mercy Housing created a stable foundation where residents can explore their full potential, supported by practical resident programs such as health classes, financial education, employment initiatives, parenting and after-school programs for children. Residents are supported with the resources they need to be good neighbors and members of a greater community. Mercy Housing begins with housing, but goes far beyond to strengthen the lives of the people who call Mercy Housing home. Whether it's educational support, a financial literacy program or health care education, Mercy Housing is always trying to provide services for local low-income community. Mercy Housing provides Resident Services that fall into four program areas: Economic Development, Education, Community and Health & Wellness. In an effort to assist the millions of people in need of stable affordable housing, Mercy Housing provides a wide range of affordable, low-income apartment rental opportunities across the United States.  The housing services are available for families, seniors and people with special needs, including those with developmental disabilities, HIV/AIDS, formerly homeless individuals and Veterans. 70% of  all residents are families;21% of our residents are seniors; 9% of residents are people with special needs (people with HIV/AIDS, formerly homeless individuals, veterans and people with physical and mental impairments). 

The implications of integration for the management of the organization is that the scattered housing are earmarked to serve different population groups geographically and health-wise. Mercy Housing can also go into mutual cooperative arrangement with other service providers. This has significant influence on resident well being as well as experience. Being that they are grounded in non-discrimination, Mercy Housing provides homes for vulnerable population groups. Other service providers are able to bring care to the home-bound and bed-ridden. Under such an arrangement, minorities or underserved population groups are able to access services that improve of their welfare (Mercy Housing Publications, 2015).

HIV/AIDS care systems and structures can learn from the USA and vice versa. Shared lessons and themes are opportunities for transfer of knowledge, best-practices and skills across health facilities. Diversifying care and prevention norms include the integrated management of childhood illnesses; identifying families with expecting mothers; immunization drives; neonatal care; postnatal care; involving men in caring for expectant mothers; voluntary medical male circumcision; HIV/STIs checking; Partner counselling; and home-based nutrition plans being part  of the comprehensive package of health services. This contributes the strengthened prevention, support and mitigation continuum necessary for ending HIV. 

Source: LMP

Source: LMP

Source: LMP

Source: LMP

REFERENCES:

1). Being the Best Saves Lives: Kaiser Permanente Leads the Nation in 21 Quality Measures. October 22 2015. http://share.kaiserpermanente.org/article/being-the-best-saves-lives-kaiser-permanente-leads-the-nation-in-21-quality-measures. Retrieved on December 22 2015. 

2). Kaiser Permanente. (2014). Kaiser Permanente. Retrieved from http://kp.kaiserpermanente.org. Retrieved on December 22 2015.

3). Mercy Housing Publications. (2015). http://www.mercyhousing.org/Publications. Retrieved on December 22 2015.

4). Memorial Hermann. (2015). Memorial Hermann. Retrieved from http://www.memorialhermann.org. Retrieved on December 22 2015.

5) Liverpool-Mulago Partnership For Women's and Children's Health. 2014. http://lmpcharity.org/index.php/lmpprojects/hciv/kawempehciv. Retrieved on December 23 2015.

6). Shi, L., & Singh, D. A. (2015). Delivering health care in America: A systems approach (6th ed.). Burlington, MA: Jones & Bartlett.

Aligning USAID Funding Targeting Adolescent girls and Young Women; Cues For Local Government Councils In Uganda

Aligning USAID Funding Targeting Adolescent girls and Young Women; Cues For Local Government Councils In Uganda    

Muyunga-Mukasa, T.R.                      

                                                     SUMMARY:

Local government officials can present over 25 performance indicators below following the use of USAID funds:

1) focus on the poor; 2) improve engagement of the private-for-profit sector; 3) enhance efficiency; 4) strengthen stakeholder coordination; 5) improve service quality; 6) stimulate consumer-based advocacy for better health;  7) programming in maternal; 8) newborn and child health; 9) immunization; 10) family planning and reproductive health; 11) nutrition; 12) health systems strengthening; 13) water/sanitation/hygiene; 14) malaria; breaking cycle of transmission of HIV; 15) pediatric HIV care and treatment; 16) increase in numbers of women attending at least one antenatal care visit with a health care provider; 17) Opportunities for women to deliver their babies with a skilled attendant present will increase; 18) planning meetings on targeted health themes;  19)  identify key persons to contact as far as HIV/AIDS, Adolescent girls and Young Women issues go; 20) develop a community health information management system with vital statistics, targets for treatment, prevention and anti-discrimination; 21) lists of partnerships such as schools, villages, faith-based organizations and traditional healers involved in promoting health;  22) existence of strategic plans at different levels of governance reflecting needs of communities;  23) realizable PEPFAR engagement and an expanded capacity to use Ambassador’s Small Grant Program for advocacy, community mobilization;  24) generating disaggregated statistics giving insight into population demographics and;  25) lists or action plans by Village Health Teams.

A PRIMARY SCHOOL IN A RURAL PART IN UGANDA. DOES THE GIRL CHILD HAVE OPPORTUNITY TO WASH HER HANDS AFTER USING THE WASHROOM?  DOES SHE GET A FAIR CHANGE OF SANITARY PADS?

Local governments in Uganda can design systems that promote the health and life of adolescent girls and young women (5-24 years). A mental, sexual and reproductive health plan targeting adolescent girls and young women, can be effective if it is integrated with other activities. At a three percent (3%) population growth by 2025, a young population and a high total fertility rate, Uganda’s high population rate will continue to drive health expenditures upwards. Local Governments in Uganda are entities that can mobilize for action through planning and partnerships. This is captured in the Health Sub-District concept bringing essential health services-especially basic surgical and obstetric care closer to the communities. The attendant staffing, infrastructure, equipment and operating costs become resources for promotion of health. A  comprehensive WHO review of Uganda’s Health System conducted in 2011, found that whereas significant efforts are being implemented to qualitatively and quantitatively improve health in Uganda, more needs to be done to a) focus on the poor; b) improve engagement of the private-for-profit sector; c) enhance efficiency; d) strengthen stakeholder coordination; e) improve service quality; and f) stimulate consumer-based advocacy for better health. At local government level there are opportunities to conduct local health assessment and devise community health improvement plans. These local government entities are in a better position to tap into, say, the USAID funding if a focus on quality of care, service integration, and equity are to become a reality. The generated mechanisms and resources at an initial phase may be costly but these costs are reimbursed under the inbuilt cost of doing the U.S. government’s PEPFAR Business (CODB). The critical fiscal space thus created is an opportunity to increase government expenditure on health.  This will in turn create a standardized service delivery across all local government regions. Uganda has a Maternal mortality ratio of 435/100,000 live births. By end of 2015, Uganda needs to reduce that figure to 131/100,000. Poor access to quality maternal care services, is a significant barrier to improving maternal mortality in Uganda. “HIV/AIDS, malaria and respiratory infections are the top three causes of overall disease burden in terms of Disability-Adjusted-Life-years (DALYs) lost,” (Fiscal Space For Health In Uganda).

THIS SCHOOL IN A RURAL PART OF UGANDA IS A CO-EDUCATION FACILITY. WILL THE GIRL CHILD THINK ABOUT A SANITARY PAD OR HOW EARLY SHE HAS TO RISE FROM BED IN ORDER TO COMPETE FOR WHERE TO SIT IN THAT OVERCROWDED CLASSROOM?

There are two documents I hope local government planners can use. One is the Country operational plan guidance document provided by USAID, with focus on eradicating HIV/AIDS. It is a comprehensive tool that local council members in Uganda can find useful as they try to utilize PEPFAR funds in a bid to align money in prevention investments. At the local government level, planned and costed investments are called votes, e.g., providing insecticide-treated mosquito nets to a given number of households. In a bottom-up planning, promoted by decentralization, it is possible to harmonize targets for treatment, prevention and anti-discrimination at Local Council I, II, III, IV, V, Town Council, Municipality, Division and district. There are two outcomes that come to mind. One, it will strengthen an existing local public system that ensures health promotion and prevention of diseases. Two, it will critical forces of change at community level with health promotion and prevention of diseases at the planning core.

A CLASSROOM

The second document is the:The Maternal and Child Survival Program (MCSP). MCSP supports programming in maternal, newborn and child health, immunization, family planning and reproductive health, nutrition, health systems strengthening, water/sanitation/hygiene, malaria, prevention of mother-to-child transmission of HIV, and pediatric HIV care and treatment. The Program places greater emphasis on key cross-cutting issues such as innovation, e/mHealth, equity, quality, gender, public-private partnerships, and involvement of civil society, community approaches and behavior change interventions. While maintaining focus on the technical high impact interventions, MCSP works toward sustainable scale up to include strengthening the health systems that deliver these interventions. (http://www.mcsprogram.org/). “It is at the heart of improving maternal-newborn health services globally: ensuring care is patient-focused; integrating programs to better serve the needs of mothers and babies; and extending innovative health services to the poorest and most socially vulnerable mothers and babies,” (Bliss, K. 2015). This USAID funding will help local governments mobilize for action through planning and partnerships where a woman in Uganda can seek appropriate counseling and maternal care services in any facility. There will be an increase in number of women attending at least one antenatal care visit with a health care provider. Opportunities for women to deliver their babies with a skilled attendant present will increase.

DO THESE MEN HAVE A PLAN TO PROVIDE THE ADOLESCENT GIRL WITH COMPREHENSIVE SEXUAL AND REPRODUCTIVE HEALTH COUNSELLING AT SCHOOL? THE PROFESSOR WHO IS ALSO A PRESIDENTIAL CANDIDATE IN UGANDA FOR THE 2016 PRESIDENTIAL ELECTIONS IS STANDING IN THE CENTRE WITH TWO TEACHERS. NB. ALL THESE PICTURES BELONG TO THE PRESIDENTIAL CANDIDATE PROFESSOR VENANSIUS BARYAMUREEBA.

The health sector at the district and sub district level in Uganda is governed by a district health management team (DHMT). The DHMT is led by the District Health Officer (DHO) and consists of managers of various health departments in the district. The heads of health sub districts (HC IV managers) are included on the DHMT. The DHMT oversees implementation of health services in the district, ensuring coherence with national policies. A Health Unit Management Committee (HUMC) composed of health staff, civil society and community leaders is charged with linking health facility governance with community needs (http://gov.ug/ministry/ministry-health).

USAID funding into a local government budget plan will cause: 1) planning meetings on targeted health themes including national and district indicators (UBOS, 2010)  2)  identify key persons to contact as far as HIV/AIDS, Adolescent girls and Young Women issues 3) develop a community health information management system with vital statistics, targets for treatment, prevention and anti-discrimination 4) lists of partnerships such as schools, villages, faith-based organizations and traditional healers involved in promoting health 5) existence of strategic plans at different levels of governance reflecting needs of communities 6) realizable PEPFAR engagement and an expanded capacity to use Ambassador’s Small Grant Program for advocacy, community mobilization 7) generating disaggregated statistics giving insight into population demographics and 8) lists or action plans by Village Health Teams as a continuum of response who bridge the gap and increase equity in access to health services ( http://www.pathfinder.org/). With the above it is more likely to have information on: voluntary medical male circumcision (VMMC), Test and treat, Viral load, TB/HIV, virology suppression, children health, pregnant women receiving B+, adults on life-saving anti-retro viral treatment, health needs of groups that are higher risk than total population, identified community resources  that support the public health system in promoting health and improving quality of life. A list of themes would be developed, which in turn could be used to assess community health status and community themes. 

Form a team amongst you and check with the US Embassy to see how your local government entity qualifies. A devolved institutionalized public health service is possible in Uganda. Turnock (2015) in “Essentials of Public Health” lists outcomes of deliberate community health improvement plans. I have chosen some points from the long list that I feel would be further outcomes of using USAID funds at a local government level. These are some of the further outcomes: 1) working with policy-makers, promote partnerships, educate, inform, develop policies and plans that support individual and community health efforts and plans 2) Social-community level activity plans 3) Social marketing and targeted media public 4) joint health education programs with schools, churches, Faith-based Organizations, cultural organizations and other entities 5) undertaking health improvement planning e.g., preventive screening, rehabilitation and support programs 6) building coalitions drawing from a wider range of potential human/material resources to improve community health.

REFERENCES:

1. Bliss Katherine (2015). http://www.smartglobalhealth.org/

2. Fiscal Space For Health in Uganda. World Bank Working Paper No. 186 Africa Human Development Series 

3. Government of Uganda, Ministry of Health. http://gov.ug/ministry/ministry-health

4. National Village Health Teams (VHT) Assessment In Uganda. 2015. http://www.pathfinder.org/

5. Statistical Abstract. Ministry of Health. 2010. http://www.ubos.org/

6. Turnock, B. J. (2016). Essentials of public health (3rd ed.). Burlington, MA: Jones & Bartlett.

7. USAID (2015). Country Operational Plan Guidance 2016 – Draft

8. USAID (2015). http://www.mcsprogram.org/our-work/