Rapidly responding to policy queries with evidence: learning from Rapid Response Services in Uganda
Summary
The Rapid Response Service (RRS) is a knowledge translation service in Uganda that responds to a decision maker’s needs for evidence with synthesised relevant evidence, contextualised and summarised in an accessible package. The RRS was set up in 2010 at the Regional East African Health Policy Initiative, Uganda node, at Makerere University, and has supported over 65 policy processes at the national and district levels. This chapter follows three cases where this evidence was used to inform policy or practice, one involving the RRS at national level, the mandatory food fortification policy, and two at district level, focusing on community distribution of misoprostol to women and reducing the turnaround time for Gene Xpert results, both in Mukono District. The evidence from the RRS was used in different ways, leading to the mandatory food fortification policy after a voluntary food fortification programme, sensitising stakeholders to implement a controversial misoprostol distribution programme to reduce postpartum haemorrhage, and to reduce the turnaround time for diagnosis of tuberculosis.
Introduction
The Rapid Response Service (RRS) is a promising knowledge translation innovation established to respond to urgent, targeted and tailored individual policy makers and institutional needs for evidence, initially in the health field. The evidence requested is synthesised, summarised and contextualised to a particular policy problem and local setting within the time needed for a policy decision to be made. The RRS at Makerere University in Uganda defines ‘urgent’ as a policy decision that must be taken within 28 days (Mijumbi et al., 2014).The RRS was piloted and set up in 2010 at the Regional East African Community Health Policy Initiative (REACH-PI), Uganda node, at Makerere University, College of Health Sciences, the largest and oldest academic university in Uganda. Since 2010, the service has supported over 65 health care policy processes (Mijumbi-Deve et al., 2017).
This case study uses three separate but related mini-cases to share experiences and lessons on the use of RRS and factors that enable or hinder its use. The first case relates to use at the national level, where RRS responded to policy questions on the national voluntary food fortification programme. The setting for the second and third cases is at the sub-national level, examining how RRS was used to support decisions by the district health team (DHT) in Mukono District.
Qualitative data collection methods, including document review and semistructured interviews, were employed for this case study.The document review included both published and unpublished documents related to the RRS food fortification programme and health services delivery at the district level. Nine key informants were purposively identified and interviewed using semistructured interviews based on their involvement in the three case studies.
Understanding the context
The health sector
The population of Uganda is estimated at 42 million as of 2018 (World Bank, 2019), with the majority residing in rural areas. Uganda is a low-income country with an estimated GDP growth of 5.3% in 2018 (African Development Bank, 2019). Health care funding is inadequate, with total health expenditure estimated at 7.2% of GDP. The sector is characterised by a household out-of-pocket health care expenditure estimated at 41% (WHO, 2017).
The Ugandan health care system is largely decentralised, with most primary services provided by local governments at the district or lower sub-county level, covering health care service delivery and implementation of primary health care (Bossert and Beauvais, 2002). Health care financing, planning, decision making, mobilisation of resources and coordination of services are part of the central function of the Ministry of Health (MOH) (Ministry of Environment, Water and Natural Resources, 2015).
Health care service delivery is organised through a hierarchy of administrative/ referral levels from the village health team (VHT), followed by Health Centres, which refer patients on to HC IV or district hospital level, responsible for the implementation of primary health care and supervision of the lower health facilities. The district is the next administrative level responsible for coordination, supervision and implementation ofhealth services at the district (Ministry ofHealth,2013).The regional and national referral hospitals are the higher points of health care service delivery, to which the lower health facilities eventually refer patients.
The lower level decision-making structural processes include the district health teams (DHTs) and the Health Sub-district (HSD) management team at the sub-county level, responsible for planning, organising and coordination of health services within the district and HSD, respectively. These form the extended DHT that meets once every quarter at the district and the HSD, respectively, to discuss challenges in the implementation and coordination of health programmes within the district.
Policy making can be influenced by a number of actors, such as Cabinet; other government entities, such as the Office of the Prime Minister and Ministry of Finance, Planning and Economic Development; other ministries, departments or agencies; Parliament; civil society or non-governmental organisations (e.g. Uganda National Health Consumers Organisation); the private sector;
Rapidly responding to policy queries 135 development partners (DPs), and public and private tertiary academic institutions involved in research.
