Supervision, Performance Assessment, and Recognition Strategy to Strengthen Medicines Management in Uganda

In 2009 and 2010, the availability of a basket of 22 vital items in public health facilities averaged 53%, with fewer than 10% of all facilities having six vital indicator tracer medicines available. By 2013, only 35% of public health care providers correctly diagnosed at least four of five common conditions, and providers at only 1% of health facilities provided the correct treatment for a simple cough and cold. The Ministry of Health (MoH) reported that fewer than 8% of 376 pharmacy posts in the public sector were filled, and 79% of all facilities lacked shelves, making it impossible to manage medicines appropriately. A public and private nonprofit health facility survey in 2011 found high staff turnover, irrational medicine use, and inadequacies in filling out stock cards, ordering, and reporting. For example, only 37% of private nonprofit facilities maintained an updated stock card for artemisinin-based combination therapies, which is required to accurately quantify drug needs. To address these challenges, the MoH nationalized a strategy developed with the USAID-funded program, Securing Ugandans' Right for Essential Medicines (Uganda SURE), to build capacity, motivate health facility staff and supervisors, and improve medicines management in public and nonprofit health facilities. The supervision, performance assessment, and recognition strategy (SPARS) combines supportive supervision and training, indicator-based performance assessment, and a recognition strategy with incentives for both supervisors and health workers. Medicines management supervisors (MMS) are district employees who provide supportive supervision and on-the-job training to improve health workers' medicines management skills. They also give managerial support to staff in the form of manuals and tools needed to standardize medicines management practices. MMS receive two weeks of training in the basics of medicines management, supportive supervision, mentoring, problem solving, and communication, as well as one week of practical work in the field. The MMS are provided a netbook to enter the findings from the performance assessment, and they receive three days of training in the use of the netbook and the electronic performance assessment tool. To increase their computer skills, they receive flash drives with self-paced learning aids about software packages and other technologies. To facilitate travel to their facilities, which are often in rural areas with rutted dirt roads, they also receive motorbikes, riding gear, and training in defensive riding. Performance assessment at the facilities is based on 25 indicators grouped into five areas: dispensing, prescribing, stock management, storage, and ordering and reporting. Five is the highest possible score in each area, with a target score of at least 20 out of 25. The SPARS data system has been fully computerized, from data capture through reporting, which ensures real-time access to high-quality information. The rewards system recognizes health facility staff improvements and motivates them through a combination of personal items, such as t-shirts, and items to improve the delivery of pharmacy services, such as dispensing trays. MMS and the corresponding district health officer receive airtime and a monetary allowance linked to defined milestones and submission of SPARS facility reports. To reduce the risk of fraud in the MMS allowance process, telephone verification of all MMS visit reports submitted into the database and physical audits when there is inconsistent recording at the facility level are conducted. Implementation tools, such as managerial tools, a medicines management manual, stock cards, stock books, dispensing logs, and standard operating procedures, are provided to the MMS and facilities to facilitate supervision. MMS also receive laminated job aids to guide their explanation of how to correctly dispense medicines and use the dispensing guidelines. A supervisory book is placed at the facility and filled out by the MMS at each visit to record findings and agreed-upon next steps. By September 2017, almost all government facilities had received at least one SPARS visit, and two-thirds of them had attained the target performance score of 20. In the private nonprofit sector, most facilities had received one or more SPARS visits, and half had achieved an adequate score of 20 or above. After three years of implementation, an assessment was conducted based on the 25 SPARS indicators, which included facilities at all service levels from 45 districts where SPARS had been implemented between 2010 and 2013. The assessment was based on data from 4,100 SPARS visits to 1,222 facilities that had at least one follow-up visit.