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Study Overview

Evaluating the Impact of the Health Sub-District Strategy on Maternal and Neonatal Health Outcomes in Uganda (2000-2020)
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Over the years, Uganda’s health system performance has improved over time. The maternal mortality ratio reduced from 505 deaths per 100,000 live births to 336/100,000 live births in 2016.  The neonatal mortality ratio decreased from 33 per 1000 live births between 2001 and 2006 but stagnated at 27 per 1000 live births. The physical access measured by the proportion of the population living with 5 km of a health facility is about 80%. Under its decentralised health service provision system, district authorities are mandated to oversee the implementation and develop by-laws to support service delivery[1]. As a result, the HSD was conceived as the functional fulcrum of the decentralisation process in the health sector to support service delivery within lower local government units and foster increased access to essential and quality health services by those in need.

To date, the HSD strategy and the implementation context have significantly evolved. Therefore, the HSD’s implementation and linkages to health system performance have been mediated by numerous events that have significantly affected the health outcomes in the country. The events included policy reforms such as a) the adoption of the first and second Health Sector Strategic Plans that introduced financing and health sector reforms like abolition of user fees, b) introduction of primary health care (PHC) grants that emphasised disease prevention and health promotion, c) community health workers like village health teams (VHTs) and d) recentralization of drug supply systems (Tashobya et al., 2018). We intend to study these dynamics over the 2000-2020 period and explore the complex direct and indirect pathways through which the impacts of the HSD strategy were elicited.



Registration Citation:

 Aloyisus Ssennyonga, Fredrick Makumbi, Sarah Nabukeera, Mary Kaakyo, Richard Mugahi, Sarah Byaakika, Rhoda Wanyenze

Health, Nutrition, and Population
Additional Keywords:
Health, health sub-district, decentralization, realist evaluation, maternal and neonatal outcomes, Uganda
Secondary ID Number(s):

Principal Investigator(s)

Name of First PI:
Aloysius Ssennyonjo
Makerere University School of public of health
Name of Second PI:
Rhoda Wanyenze
Makerere University School of Public Health

Study Sponsor

Hewlett Foundation
Study Sponsor Location:

Research Partner

Name of Partner Institution:
Ministry of Health
Type of Organization:
Government agency (eg., statistics office, Ministry of Health)

Intervention Overview


In 2000, the government of Uganda incorporated the strategy of the Health Sub Districts (HSD) into the health policy as a core element of the decentralisation in the health sector under the Health Sector Strategic Plan 2000/01 to 2004/05 (HSSP I). The four basic principles of the HSD concept were decentralisation, integration, improving access and community involvement. It de-linked the District Health Team (DHT) from routine operations at the service delivery level. It advocated for increased involvement of hospitals and HCs in public health and inter-linking of all levels of care. The specific objectives of the HSD health care system as designed were: (i) To ensure equity in access and utilisation; (ii) To deliver socio-culturally acceptable services; (iii) To provide continuous and integrated services; (iv) To use a comprehensive/holistic approach to service delivery and (v) To involve individuals, households and communities to take responsibility for their own health (Health literacy) and in the management and organisation of health services.

Theory of Change:

The HSD strategy was underpinned by health systems framework by WHO as the underlying conceptual framework to indicate the impact pathway. The HSD is the functional zone of the district health system responsible for implementing the UNMHCP delivery within its catchment area. It has a catchment area comprising several sub-counties and the health services providers therein. The HDS is a multifaceted health systems intervention that was envisaged to influence various aspects of health improvement pathway. At the core of the HSD design were interventions to spur health systems performance which would ultimately lead to improvements in health status of the population in Uganda. Several components were as a follows: a) Infrastructure development to improve physical access. It was planned that every HSD (serving approximately 100,000 people) should have an existing hospital or an upgraded functional Health Centre (HC) IV to serve as the HSD Referral Facility. Changes in health systems various inputs would lead to intermediate outcomes such as improved coverage of vital interventions, equity, access, safety. These outcomes would contribute to the ultimate impacts such as improvements in health status (measured by maternal and neonatal mortality indicators).

Multiple Treatment Arms Evaluated?

Implementing Agency

Name of Organization:
Makerere University School of public of health
Type of Organization:
Research Institution/University

Program Funder

Name of Organization:
Hewlett Foundation
Type of Organization:
NGO (International)

Intervention Timing

Intervention or Program Started at time of Registration?
Start Date:
End Date:
Evaluation Method

Evaluation Method Overview

Primary (or First) Evaluation Method:
Other (specify)
Other (not Listed) Method:
realist evaluation approach
Additional Evaluation Method (If Any):
Other (specify)
Other (not Listed) Method:
Interrupted Time series

Method Details

Details of Evaluation Approach:

Phase 1: Intervention mapping and theory

An exploratory qualitative study design will be used in this phase. The evaluation will begin with formulating the intervention theory by integrating the assumptions of the strategy designers and implementers.  This inquiry will explore and describe the adherence to the HSD strategy principles overtime. The changes in intervention design and underlying reasons such as contextual factors overtime will be explored. Three data collection methods i.e. document review, key informant interviews, stakeholder validation workshop will be used. The main output will be a timeline with critical junctures and explanatory factors overtime.

Phase 2: contribution analysis

A multiple case study design will be used for this phase. The case study design was selected because, ?rst, it is methodologically complementary to realistic evaluation. Second, it allows for the use of multiple methods of data collection, and third, it recognizes the importance of context. Within this study design, the convergent mixed method approach will be used.

Phase 3: Action planning phase

The findings will be subjected to stakeholder deliberations to determine key lessons and implication for policy and practice. Key actions to enhance the HSD strategy will be elicited.

Outcomes (Endpoints):

The primary outcome is to improve maternal and neonatal health outcomes including (Maternal mortality and neonatal mortality and morbidity). Intermediate/secondary outcomes for health systems performance include access, coverage, efficiency and effectiveness.

Unit of Analysis:
The health sub-district.

H0; The HSD policy implementation did not improve maternal and neonatal health outcomes in Uganda.

H1; The HSD policy implementation has improved maternal and neonatal health outcomes in Uganda.

Unit of Intervention or Assignment:
Health sub-district
Number of Clusters in Sample:
The number of clusters to be considered, will be informed by findings from the exploratory phase 1.
Number of Individuals in Sample:
The number of individual units to be considered, will be informed by findings from the exploratory phase 1.
Size of Treatment, Control, or Comparison Subsamples:
This will be informed by findings from the exploratory phase 1.

Supplementary Files

Analysis Plan:
Other Documents:

Outcomes Data

Qualitative data will be obtained from key informants and experts who will assist reconstruct the intervention pathway. The quantitative HSD performance data will be accrued from the DHIS2 and other relevant databases. The key indicators are newborn deaths (0-7 days), neonatal death 8-28 days, and maternal deaths for the study period 2000-2020. Other key data will include maternal and perinatal deaths audited/reviewed (community verbal autopsy). Data on some aspects of HSD systems inputs (govern
Data Already Collected?
Data Previously Used?
Data Access:
Restricted -- Access requires a formal approval process
Data Obtained by the Study Researchers?
Data Approval Process:
Permission to access the data bases will be sought form the relevant ministry of health officials, District Health officers and district biostatisticians
Approval Status:

Treatment Assignment Data

Participation or Assignment Information:
Data Obtained by the Study Researchers?
Data Previously Used?
Data Access:
Data Obtained by the Study Researchers?
Data Approval Process:
Approval Status:

Data Analysis

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Study Materials

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Registration Category

Registration Category:
Prospective, Category 2: Data for measuring impacts have been collected by others but not obtained or analyzed by the research team

Completion Overview

Intervention Completion Date:
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Unit of Analysis:
Clusters in Final Sample:
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Preliminary Report:
Preliminary Report URL:
Summary of Findings:
Paper Summary:
Paper Citation:

Data Availability

Data Availability (Primary Data):
Date of Data Availability:
Data URL or Contact:
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Other Materials

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Description of Changes:

Study Stopped