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West Nile Quality Design Project Integrates Refugee Health Services in Uganda
by Cynthia F. Young, Senior Staff Writer

Dr. Gilbert Burnham and Ms. Elizabeth Rowley, of the Johns Hopkins University School of Hygiene and Public Health, visited the Quality Assurance (QA) Project recently to discuss their work in the integration of refugee and district health systems in Uganda. This project was funded by REDSO/Nairobi (Regional Economic Development Services Office for East and Southern Africa) with support from the QA Project and funded by the U.S. Agency for International Development.

The West Nile Quality Design Project sought to strengthen district health planning to integrate refugee health services into three districts using Quality Design (QD) methodologies. In the West Nile area of Uganda (with a refugee population of almost 120,000), the districts of Arua, Moyo, and Adjumani are among the poorest in the country. The local population is served by an already stretched district health system. However, a parallel service delivery structure with better resources that is focused on the southern Sudanese refugee population has been established with the support of the United Nations High Commissioner for Refugees (UNHCR).

Inequities between quality of health services are typical of many refugee-hosting environments where service delivery is not integrated into local systems. The approach of parallel refugee services often becomes inequitable and unsustainable over time. In West Nile, where UNHCR has decided to significantly reduce its program investments, local technical managers are now called upon to accommodate refugee service responsibilities. The projects strategy was to systematically integrate refugee health systems into the local health system to improve quality of care for refugees and local communities. This was done with a focus on the needs of healthcare users, and by building the planning and implementation capacities of district health management systems. The approach also offered refugee and local communities the opportunity to contribute to the QD process. The QD methodology systematically creates new services or redesigns existing services to meet the needs of clients while taking into account the resources available.

With the largest refugee population of the three districts, Adjumani District faced the challenge of integrating service delivery throughout a large network of refugee health units. Therefore, most of the QD effort was focused on this district. The West Nile Project was implemented within the context of Ugandas Self-Reliance Strategy, which was developed by the Government of Uganda (Office of the Prime Minister) and UNHCR to promote refugee self-reliance and integration of refugee services into local systems. However, the Self-Reliance Strategy was designed with limited input from the Ministry of Health and district bodies. Therefore, one of QD projects challenges was to support district health management in creating a leadership role in the integration of services. Activities included consensus building, team formation, research on manager, provider, and user perspectives, and adaptation of QD steps to formulate an action plan for service integration, including immunization.

In Moyo District, although the district had endorsed the concept of integration, its political and administrative leadership was unsure of its position in implementing objectives. To begin the process, QD project staff offered the experience of Adjumani District to health sector managers and assisted them in resource-based research. Therefore, when the district is in a stronger position to undertake integration activities, it will be able to use this information to further its objectives.

In Arua District, the refugee health services were already being handed over from OxfamUK to the district health services when the project began. Therefore, QD staff assisted district staff with work plans and budgetary needs. This hand-over experience was used to analyze the type of systems integration taking place without the benefit of QD planning. Project staff observed the absence of clear leadership roles on the ground, which led to confusion in the integration management process. Significantly, UNHCR now considers the manner in which the hand-over was managed, which did not use a quality design approach, as unsustainable. Having concluded a post-integration survey of healthcare users, project staff observed that without using a systematic planning approach, such as quality design, some access and quality indicators have declined.

Looking forward, health managers in Adjumani district have used Quality Design to identify specific integration action points within the immunization activities, which they will include in the next annual work plan Indicators are included in these work plans, which are to be implemented during the coming months.

The project found that Quality Design, as a planning methodology, can be used in complex situations such as health system integration, and has potential for widespread replicability in both refugee and other settings. While modifications to the original QD approach were necessary, the West Nile experience retains the key features of Quality Design.

A case study on the West Nile Quality Design Project will be available on this website later in the Spring. (posted March 2002)

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The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development
(USAID) under Contract Number GPH-C-00-02-00004-00.