The West Nile region in Uganda, which is along the border with Congo and Sudan, is reported to have the second highest prevalence of malnutrition among children under the age of five (8.4 per cent is the combined prevalence for moderate and acute malnutrition). Assessment of nutrition data from the Health Management of Information System highlighted that the outcomes of children with malnutrition treated as outpatients at health centre (HC) level are unacceptably sub-standard. The mean recovery rate for children with acute malnutrition was 50 per cent despite the availability of national guidelines for treatment, substantially aligned with the World Health Organization’s (WHO) recommendations.
Doctors with Africa or CUAMM (the largest Italian NGO working in Sub-Saharan Africa and in Uganda since 1958) agreed to support the implementation of an intervention to improve the quality of care delivered to children with malnutrition at the HC level.
In Sub-Saharan Africa, undernutrition and HIV are two of the main causes of morbidity and mortality in children. Uganda is no exception, especially in its most deprived regions. The quality improvement intervention will mainly consist of supportive supervision visits, delivered at regular intervals by a team of trained local professionals (nutritionist and district officer) to the staff working at the HC level. Complementary interventions may include: a) the establishment of quality improvement teams; b) networking activities; c) basic equipment if needed; and d) brief up-training if needed.
This impact evaluation will help address the knowledge gap about which are the most effective interventions to improve quality of care in the context of the West Nile region of Uganda, particularly the effectiveness of supportive supervision.
The award has been granted to WHO Collaborating Centre for Maternal and Child Health.
The primary question that will be addressed by this impact evaluation:
Can supportive supervision provided by a team of local professionals to HC staff significantly improve the key health outcomes of children with acute malnutrition at HC level in the West Nile region in Uganda?
The impact evaluation will have a cluster randomised trial (RCT) design, with HC as the unit of randomisation. The evaluation will use mixed methods, combining quantitative and qualitative analyses. The primary outcome of the RCT is the rate of cured children. Secondary outcomes include: other health outcomes (i.e. rate of abandonment, transfer, died, not cured); process outcomes (key indicators of staff knowledge, staff motivation and satisfaction, quality of data); and equity outcomes (i.e. outcomes by socio-economic quintiles). The equity evaluation will seek to explore whether the intervention will impact equally different subgroups of the population (higher versus lower socio-economic quintile).
Sources of data will include: medical records, direct observation of cases, interviews and questionnaires with the staff and health service users. Strict quality assurance procedures will be put in place to ensure accountability of data. Data will be collected using pre-defined pilot-tested tools by trained staff whose performance will be pre-tested and entered in databases in real time. Monitoring indicators will also be used to assess the causal chain.