Uganda delivery of improved services for health (DISH II) : lessons learned

The goal of the evaluation was to help ensure the positive launch of USAID's new "Systems" and "Services" programs, that will continue support to the Ugandan health sector begun under DISH I.. DISH II expanded on DISH I with a broad mandate to provide technical and material assistance to 12 of Uganda's 56 health districts, in the process strengthening systems at the central Ministry of Health (MOH) level. Through grants to the 12 "DISH districts," accompanied by TA provided by DISH branch offices, the project made possible significant improvements in access to and quality of reproductive, child, and maternal health services at all levels. Despite its short duration, DISH II substantially strengthened the capacity of DISH districts to plan, manage, and supervise health services. Representatives of district health teams who were interviewed repeatedly expressed their appreciation for this support. Reinforcing national policy, DISH II successfully promoted the integration of services in health facilities through a combination of training in a range of clinical skills and enhanced support supervision. The DISH II Yellow Star program signaled a new approach to quality assurance that was universally appreciated and has been adopted by the MOH for national application. Through design of new health management information system software, training, and provision of computer equipment, the project demonstrated to its district health teams the value of using health service data for management decisionmaking and contributed to the MOH's drive to create a "culture of information" throughout the system. In a country where the sector-wide approach to health sector funding predominates, DISH II showed that the project approach still has its place. It did so by communicating and collaborating closely with the central MOH even as it focused on the specifics of TA and capacity building in its focus districts. It thus paved the way for helping the MOH plan for national application of innovations, such as Yellow Star, that had proved their worth. At the same time, it is important to note that the innovations in question remain "fragile." The project was far too short to fully achieve its ambitious goals, and there were signs that its relatively abrupt termination led in some cases to a distinct fall-off in performance and left some of its most significant products in a precarious state between success and failure, dependent on future support. The report singles out areas in which DISH II had significant impact, looks in detail at the strengths and weaknesses of its inputs, and summarizes what the review team sees as the key lessons that emerged in each area. In a concluding section, it restates those lessons in the form of recommendations as to how DISH successors might best build on DISH II's admirable contributions to Ugandan health systems. (Author abstract, modified)