Person: Miller, James
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Miller, James
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Publication A process evaluation of performance-based incentives for village health workers in Kisoro district, Uganda(BioMed Central, 2014) Miller, James; Musominali, Sam; Baganizi, Michael; Paccione, Gerald ABackground: Designing effective incentive systems for village health workers (VHWs) represents a longstanding policy issue with substantial impact on the success and sustainability of VHW programs. Using performance-based incentives (PBI) for VHWs is an approach that has been proposed and implemented in some programs, but has not received adequate review and evaluation in the peer-reviewed literature. We conducted a process evaluation examining the use of PBI for VHWs in Kisoro, Uganda. In this system, VHWs are paid based on 20 indicators, divided among routine follow-up visits, health education activities, new patient identifications, sanitation coverage, and uptake of priority health services. Methods: Surveys of VHWs (n = 30) and program supervisors (n = 7) were conducted to assess acceptability and feasibility. Interviews were conducted with all 8 program supervisors and with 6 purposively selected VHWs to gain a deeper understanding of their views on the PBI system. Program budget records were used to assess the costs of the program. Detailed payment records were used to assess the fairness of the PBI system with respect to VHWs’ gender, education level, and village location. Results: In surveys and interviews, supervisors expressed high satisfaction with the PBI system, though some supervisors expressed concerns about possible negative effects from the variation in payments between VHWs and the uncertainty of reward for effort. VHWs perceived the system as generally fair, and preferred it to the previous payment system, but expressed a desire to be paid more. The annual program cost was $516 per VHW, with each VHW covering an average of 115 households. VHWs covering more households tended to earn more. There was some evidence that female gender was associated with higher earnings. Education level and proximity to the district hospital did not appear to be associated with earnings under the PBI system. Conclusions: In a one-year pilot of PBI within a small VHW program, both VHWs and supervisors found the PBI system acceptable and motivating. VHWs with relatively limited formal education were able to master the PBI system. Further research is needed to determine the long-term effects and scalability of PBI, as well as the effects across varied contexts.Publication Erratum to: Monitoring iCCM referral systems: Bugoye Integrated Community Case Management Initiative (BIMI) in Uganda(BioMed Central, 2016) English, Lacey; Miller, James; Mbusa, Rapheal; Matte, Michael; Kenney, Jessica; Bwambale, Shem; Ntaro, Moses; Patel, Palka; Mulogo, Edgar; Stone, GerenPublication Monitoring iCCM referral systems: Bugoye Integrated Community Case Management Initiative (BIMI) in Uganda(BioMed Central, 2016) English, Lacey; Miller, James; Mbusa, Rapheal; Matte, Michael; Kenney, Jessica; Bwambale, Shem; Ntaro, Moses; Patel, Palka; Mulogo, Edgar; Stone, GerenBackground: In Uganda, over half of under-five child mortality is attributed to three infectious diseases: malaria, pneumonia and diarrhoea. Integrated community case management (iCCM) trains village health workers (VHWs) to provide in-home diagnosis and treatment of these common childhood illnesses. For severely ill children, iCCM relies on a functioning referral system to ensure timely treatment at a health facility. However, referral completion rates vary widely among iCCM programmes and are difficult to monitor. The Bugoye Integrated Community Case Management Initiative (BIMI) is an iCCM programme operating in Bugoye sub-county, Uganda. This case study describes BIMI’s experience with monitoring referral completion at Bugoye Health Centre III (BHC), and outlines improvements to be made within iCCM referral systems. Methods: This study triangulated multiple data sources to evaluate the strengths and gaps in the BIMI referral system. Three quantitative data sources were reviewed: (1) VHW report of referred patients, (2) referral forms found at BHC, and (3) BHC patient records. These data sources were collated and triangulated from January–December 2014. The goal was to determine if patients were completing their referrals and if referrals were adequately documented using routine data sources. Results: From January–December 2014, there were 268 patients referred to BHC, as documented by VHWs. However, only 52 of these patients had referral forms stored at BHC. Of the 52 referral forms found, 22 of these patients were also found in BHC register books recorded by clinic staff. Thus, the study found a mismatch between VHW reports of patient referrals and the referral visits documented at BHC. This discrepancy may indicate several gaps: (1) referred patients may not be completing their referral, (2) referral forms may be getting lost at BHC, and, (3) referred patients may be going to other health facilities or drug shops, rather than BHC, for their referral. Conclusions: This study demonstrates the challenges of effectively monitoring iCCM referral completion, given identified limitations such as discordant data sources, incomplete record keeping and lack of unique identifiers. There is a need to innovate and improve the ways by which referral compliance is monitored using routine data, in order to improve the percentage of referrals completed. Through research and field experience, this study proposes programmatic and technological solutions to rectify these gaps within iCCM programmes facing similar challenges. With improved monitoring, VHWs will be empowered to increase referral completion, allowing critically ill children to access needed health services. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1300-z) contains supplementary material, which is available to authorized users.Publication Quality of Care in Integrated Community Case Management Services in Bugoye, Uganda: a Retrospective Observational Study(2016-05-17) Miller, JamesBackground: Village health workers (VHWs) in 5 villages in Bugoye subcounty (Kasese District, Uganda) provide integrated community case management (iCCM) services, in which VHWs evaluate and treat malaria, pneumonia, and diarrhea in children under 5 years of age. VHWs use a “Sick Child Job Aid” that guides them through the evaluation and treatment of these illnesses. Malaria is diagnosed by rapid diagnostic test, pneumonia by age-based respiratory rate cutoffs, and diarrhea by symptoms as described by the caregiver. Objectives: Measure the quality of iCCM services over time using routinely collected iCCM program data. Methods: We used existing aggregate program data to: 1) summarize the patient population and services provided, and 2) measure quality of care based on concordance between matching categories or actions in the treatment algorithm. We then employed lot quality assurance sampling to create a patient-level dataset, and created a secondary patient-level dataset of all patients with “danger signs” (evidence of severe illness). Using patient-level records, we: 1) describe adherence to the iCCM algorithm; 2) measure VHW-level quality using lot quality assurance sampling decision rules; 3) assess change over time in quality of care with generalized estimating equations regression modeling. Results: Most VHWs achieved greater than 90% concordance for all measures apart from concordance between number of patients presenting with fever and number of rapid diagnostic tests performed. From the main patient-level dataset, 97% (150) of patients with diarrhea were treated with oral rehydration and zinc, 95% (216) of patients with presumed pneumonia were treated with amoxicillin, and 94% (240) of patients with malaria were treated with artemisin combination therapy or rectal artesunate. However, only 44% (44) of patients with a negative rapid test for malaria were appropriately referred. Of patients with danger signs, 95% were appropriately referred to a health facility. Overall, 75% (434) of patients received all the correct evaluation and management steps. At the VHW level, 9 out of 23 VHWs have provided high-quality care over 2 years, based on the selected lot quality assurance sampling decision threshold (21 out of 25 patients with correct management). Quality of care increased significantly in the first 6 months after initiation of iCCM services (p = 0.003), and then plateaued in months 7-24. Conclusions: Quality of care was high for uncomplicated malaria, pneumonia and diarrhea. Overall quality of care was lower, partly because VHWs often did not follow the guidelines to refer patients who tested negative for malaria. Quality of care appears to improve as VHWs gain initial experience in iCCM care. Despite some limitations, lot quality assurance sampling and concordance are feasible and scalable approaches to measuring quality of iCCM care.