In 1994, a national quality assurance programme was established in Uganda to strengthen district-level management of primary health care services. Within 18 months both objective and subjective improvements in the quality of services had been observed. In the examples documented here, there was a major reduction in maternal mortality among pregnant women referred to Jinja District Hospital, a reduction in waiting times and increased patient satisfaction at Masaka District Hospital, and a marked reduction in reported cases of measles in Arua District. Beyond these quantitative improvements, increased morale of district health team members, improved satisfaction among patients, and greater involvement of local government in the decisions of district health committees have been observed. At the central level, the increased coordination of activities has led to new guidelines for financial management and the procurement of supplies. District quality management workshops followed up by regular support visits from the Ministry of Health headquarters have led to a greater understanding by central staff of the issues faced at the district level. The quality assurance programme has also fostered improved coordination among national disease-control programmes. Difficulties encountered at the central level have included delays in carrying out district support visits and the failure to provide appropriate support. At the district level, some health teams tackled problems over which they had little control or which were overly complex; others lacked the management capacity for problem solving.
PIP: To strengthen district-level management of primary health care services in Uganda, a national quality assurance program was introduced in 1994. This approach includes the development and dissemination of standards and guidelines, determining the needs of patients and their families, strengthened communication between health care providers and users, and the use of data to identify gaps in service quality. Among the gains documented in the first 18 months of implementation of this strategy were a reduction in maternal mortality among pregnant women referred to Jinja District Hospital from 13.5% to 2.9%, elimination of lengthy waiting times and increased patient satisfaction at Masaka District Hospital, and a marked decrease in reported measles cases in Arua District. More subjective improvements have included increased morale among district health team members, improved patient satisfaction, and greater local government involvement in district health committee decision making. District quality management workshops, followed up with regular support visits from the Ministry of Health headquarters, have enhanced central staff understanding of district-level needs and issues. Implementation of this program has been achieved largely with existing resources. Difficulties encountered at the district level have included a tendency for some teams to select overly complex problems and a lack of management capacity for problem solving. Overall, however, the principles of quality management are highly applicable to the Ugandan context and can be easily mastered by health workers.