Piloting and Implementing the District Assessment Tool for Anemia in Uganda

Executive Summary

Uganda has experienced slight increases in the rates of anemia in the past decade, from 49 to 53 percent in children under five and 23 to 32 percent in women of reproductive age (WRA).¹ The most notable causes of anemia at the public health level are iron and other nutrient deficiencies, inflammation and infections (malaria and helminthes), and genetic blood disorders. Preventing and controlling anemia requires understanding the leading causes of anemia in a particular setting and implementing programs across various sectors to address those causes. SPRING developed a District Assessment Tool for Anemia (DATA) to help countries strengthen district-level anemia programming. The DATA is presented as part of a facilitated workshop to increase awareness about the multi-factorial nature of anemia, understand its causes in a given context, and help districts plan and prioritize anemia actions using local data in a multi-sectoral framework. The target audience for DATA is district-level technical officers, planners, data officers, and administrative and political leadership.

In Uganda, the Ministry of Health (MOH) and the multi-sectoral National Anemia Working Group (NAWG), represented by government ministries, civil society organizations (CSOs), development partners, academia and research institutions, and the private sector, are instrumental in creating an enabling environment to strengthen anemia reduction efforts. In 2015 and 2016, SPRING oriented the MOH and NAWG members to the concept of DATA and how it works, and demonstrated its usefulness for anemia programming in three pilot districts of Namutumba, Arua, and Amuria. In February 2017, SPRING, MOH, and NAWG collaborated with USAID/Regional Health Integration to Enhance Services (RHITES) in the rollout of DATA in four districts (Phase I). Scale-up in an additional 11 districts (phase II and III) will be facilitated by USAID/RHITES and the NAWG in the South Western region from October to December 2017.

The DATA was presented to the NAWG prior to its pilot and implementation. The NAWG reviewed the tool and provided inputs ranging from its length, global anemia indicators, applicability in the country context, and pilot plan for the three districts.

Overall the national and district stakeholders showed great interest in using the tool and prioritizing key actions. The district workshop findings revealed the status of anemia prevalence among children and women and the performance coverage of anemia interventions across the different sectors. All districts registered implementation of the national programs related to nutrition, disease control, WASH, reproductive health, agriculture, and education. Barriers that led to poor performance of anemia-reduction programs were lack and or inadequate supplies, equipment, and funding; understaffing; limited skills/capacity; poor data management and use; lack of prioritization of activities, inadequate materials, and guidelines; and limited supervision. Prioritized actions included mobilizing funds to strengthen anemia-reduction programs; timely and proper quantification of supplies and equipment; mentorship and supervision of health workers in data management; and promoting use of data results in decision making and planning.

Tracking progress was key to ensure successful implementation of the prioritized actions in the districts. In the pilot districts, department heads followed up priority activities by providing supportive supervision to the focal persons at the various levels. In the roll out districts, USAID/RHITES tracked progress of activities integrated within their routine services through supportive supervision. RHITES also committed to use the district nutrition coordination committees (DNCC) and the district health management teams (DHMT), which meet monthly, as a platform for monitoring progress.

In conclusion, DATA has been regarded as a good entry point to bridge NAWG and district anemia-reduction efforts. Districts understand anemia and know how to use the tool to measure performance and strengthen anemia-reduction programs using a multi-sectoral approach. However, funding for the provision of adequate anemia reduction services, including increased human resources, and improved management and use of data in prioritizing, planning, budgeting, and implementation is needed.

1.0 Background

Anemia is a critical public health problem in Uganda. Between 2011 and 2016, prevalence in children under five years increased from 49 to 53 percent and 23 to 32 percent among women of reproductive age (15–49 years) respectively.² These prevalence rates are considered to be of severe and moderate public health significance, respectively.³ Causes of anemia include deficient nutrient intake leading to iron and other micronutrient deficiencies; inflammation caused by chronic infections; helminth infections leading to internal bleeding; and malaria and genetic diseases that increase destruction and reduce production of red blood cells. The various causes of anemia require a multi-sectoral and context-specific approach to prevention and control.

The Ministry of Health (MOH) with support from SPRING/Uganda coordinates the multi-sectoral National Anemia Working Group (NAWG) to strengthen the policy environment, planning, implementation, coordination, and monitoring of anemia prevention and control initiatives. The NAWG has accelerated the response to anemia in Uganda through a number of activities, one of which was the adoption of the global DATA.

SPRING developed DATA to help countries strengthen district-level anemia programming. The objective of the tool is to increase awareness about the multi-factorial nature of anemia, understand of causes of anemia in a given context, and help districts plan and prioritize anemia interventions using local data. The target audience for DATA is district-level stakeholders in agriculture, water and sanitation, education, and health (which includes issues related to nutrition, reproductive health, malaria, and helminth infections), and cross-cutting areas like community development, statistics/health management information systems (HMIS), planning, and finance.

DATA’s comprehensive nature allows users to discover facets of anemia prevention and control they might have not considered and recognize the importance of multi-sectoral efforts (as shown in Figure 1). The tool also leverages existing local data and knowledge to help inform stakeholders about programmatic entry points for addressing anemia.

Figure 1. Programmatic Areas Showing the Multi-Disciplinary Nature of Anemia

DATA is implemented through a facilitated workshop to guide program managers and planners to improve anemia programs in their district. Users enter information into questionnaires in the tool’s Microsoft Excel interface drawing on their local data and knowledge of factors that contribute to anemia. After the information is gathered using the DATA, outputs are presented in two dashboard tabs. The dashboards help district managers determine the local contextual factors that contribute to anemia; identify the gaps, enablers, and barriers to mitigating the risk factors that lead to anemia; and identify and prioritize actions to improve anemia-related programming. In advance of the workshop, the implementing team collects national-level data to inform district personnel about the broader anemia situation in-country and existing priorities and policies.

This report details SPRING/Uganda’s experience, in partnership with the NAWG in piloting DATA in three districts and implementing DATA with USAID/RHITES project in four districts (Phase I).

2.0 Pilot and Implementation of DATA in Uganda

2.1 Orientation of the NAWG and Consultative Meetings to Review the Tool

With the assistance of SPRING/Uganda, the NAWG identified DATA as a means to increase awareness of anemia and strengthen anemia reduction efforts at the district level. Upon request from the NAWG, SPRING/Uganda conducted three orientation and consultative meetings between 2015 and 2016 to understand and review the draft global DATA for inputs. SPRING/Uganda demonstrated the use of the tool and facilitated discussions to review the tool, which contributed to the final global tool. The NAWG considered the tool timely and appropriate because it supports scaling down/decentralizing anemia reduction efforts to the district level. Discussions points included:

1. DATA is an entry point to raise awareness and a practical way to help districts prioritize and implement anemia reduction efforts.
2. Depending on need and availability of the data/information, the tool can be used quarterly, semi-annually, or annually.
3. DATA can be aligned with the district-level annual planning cycle, so that prioritized actions can be included in the plans and budgets.
4. DATA needs to be customized to each country.
5. DATA links national and district-level efforts in the reduction of anemia.

The discussions also recommended changes, which were included in the subsequent revision of the tool: removal of most of the biomarker indicators (with the exception of the iron deficiency and vitamin A deficiency) within the district tool, since most countries do not have micronutrient survey data; reduction in the number of indicators across the different sections of the tool to improve its usability; and alignment of definitions to WHO standard indicators and demographic health survey indicators. The NAWG then approved the pilot of the global tool at district level in Uganda.

2.2 Piloting DATA in Namutumba, Arua, and Amuria Districts

The NAWG selected Namutumba, Arua, and Amuria Districts for the piloting phase.

The selection criteria used by NAWG reflected the diversity of contextual factors related to anemia in the country:

• Namutumba in East Central Region has high levels of anemia and is a SPRING pilot district for micronutrient powders (MNP).
• Arua in West Nile Region has high levels of anemia and is a border district with refugee communities from Democratic Republic of Congo.
• Amuria district in Eastern Region has collected biomarker data on anemia and vitamin A deficiency, is a World Food Programme pilot district for MNP, and has moderate levels of anemia.

Pre-workshop visits to the districts on DATA

SPRING/Uganda and the NAWG secretariat visited the district offices in Namutumba, Arua, and Amuria in May, August, and November 2016, respectively, to explain the tool and gain approval for the pilot. They shared the DATA Overview and a one pager of Expectations of Participants for the DATA Workshop, two key pre-workshop materials. Discussions were held with the CAO, sector department heads, and biostatisticians and/or HMIS officer in the three districts on piloting the tool in their respective districts.

In the one-hour meetings, the DATA facilitators emphasized that each sector should come to the workshop with key data/information for indicators on production/agriculture, nutrition, health (disease control including malaria and helminth infections and reproductive health), education, and water, sanitation, and hygiene (WASH) (as highlighted in the Expectations of Participants one-pager). The biostatistician, HMIS officers, and data managers from key departments/sectors then met independently to discuss sources and availability of data and information that could be used to complete the tool during the pilot workshops.

Planning meetings by the NAWG and SPRING/Uganda facilitators

The NAWG, SPRING/Uganda and SPRING/Washington conducted additional national-level planning meetings in August and November 2016 to review the completed national questionnaire and agree on responses for prevalence rates and policy status, and review the facilitation process for the workshops. The NAWG as a multi-sectoral collaborative platform is familiar with each district in their respective regions, and could thus assess the usability and relevance across those districts/regions.

In addition, the planning meetings involved adapting the global presentations to suit the Ugandan context and a dry run of the presentations by the all the facilitators: Objectives and expected outputs of the workshop, which would be presented by a district official (coordinating office, usually DHO or district nutrition focal person); Overview of anemia and progress of anemia reduction efforts in Uganda; Overview of DATA; and Prioritization framework for anemia reduction actions to address barriers.

DATA pilot workshops

Following the national-level planning meetings, two-day district-level pilot workshops were conducted in Namutumba on August 17–18, 2016; Arua on August 22–23, 2016; and Amuria on November 31– December 1, 2016. The workshops were facilitated by SPRING/Washington and SPRING/Uganda, with the exception of Amuria where SPRING/Washington was not present, and all were co-facilitated by key members of NAWG.

Workshop participants included district administrative management, political leaders, department heads and technical officials from the different sectors: health (reproductive health, nutrition, and disease control), production (agriculture), education, WASH, community services, planning, and data managers (statisticians and HMIS focal persons). Since nutrition is a cross-cutting area, the nutritionist or appointed nutrition focal person was from the health department, although in other districts the nutrition focal person could come from any department. Participants also included staff from the district sub-county level, including health facility in-charges and antenatal care (ANC) focal persons/midwives, health assistants, head teachers, agriculture extension workers, and community development officers. In Namutumba, there were 36 district-level participants, five NAWG members, and four SPRING staff, while in Arua there were 44 district-level participants, four NAWG members, and three SPRING staff. Amuria had 37 district-level participants, two district representatives from Namutumba and Arua, six NAWG members, and three SPRING staff (see list of participants in Annex 1).

The district workshops comprised a mix of didactic lectures, facilitated use of the tool by participants, group work, group presentations, and plenary group discussions. The lectures comprised: 1) an overview on anemia (causes, consequences, and evidence-based interventions to mitigate it); 2) and overview and global approach to DATA; and 3) a prioritization framework. See Annex 2 for the workshop agenda.

During the workshop, participants provided information to populate the district questionnaire tab of DATA then used the output from the tool (Dashboards, Annex 3) to identify a list of prioritized anemia interventions by sector. They completed this activity in sectoral groups, focusing on relevant interventions within the tool (nutrition, disease control, WASH, reproductive health, education, and agriculture).

Each group used a prioritization template during the prioritization process, for their respective anemia-related interventions. The prioritization template is a guided approach to assessing the anemia program situation according to given implementation categories, which include commodities, funding, provider training, client demand, and other factors. For each implementation category, spaces are provided to list enablers, barriers, degree of barriers, priority actions, lead and collaborating sectors, and timeline. Through group discussions and feedback, each sector group completed the prioritization template, identifying key activities under each intervention, according to where priorities were established. A representative of each sector group then presented the outputs of the prioritization template to the plenary. See Annex 5 for the prioritization template, with the prioritization lists from all the districts where DATA was piloted and implemented.

During the DATA pilot workshop in Amuria, SPRING conducted interviews with sector department heads and political and administrative management to ask about their experience with the workshop, how prioritized actions will be implemented, and how they intend to use DATA to improve anemia situation. The information was used to develop a video on DATA in Uganda.

2.3 After the Pilot: DATA Implementation in the South Western Districts

Piloting DATA in three districts was critical to evaluate the suitability of the tool to the local context and provide feedback on its usability and relevance in the reduction of anemia. Results from the pilot demonstrated that DATA increased awareness about the multi-factorial causes of anemia, assessed the anemia situation in the district, and prioritized actions for a multi-sectoral effort to reduce anemia.

The success from the pilot led to interest by the NAWG and partners to scale up DATA in additional districts. As a result, SPRING/Uganda, the USAID-funded Regional Health Integration to Enhance Services (RHITES) project and the NAWG collaborated to implement DATA in 15 districts in the South West region where RHITES operates. RHITES is a comprehensive integrated package in quality health, HIV/AIDS, VMMC, TB/HIV, nutrition, ECD, WASH, MNCH, and malaria. The partnership between SPRING and RHITES is well aligned with USAID/Uganda’s 2017–2021 Country Development Cooperation Strategy (CDCS 2.0).

The approach that RHITES and SPRING/Uganda used in the scale-up districts was similar to that used in pilot districts, with exception of a few processes:

• SPRING/Uganda oriented and provided a training-of-trainers to more than 30 RHITES staff on DATA in Mbarara district. The two-day training helped the RHITES team support facilitation and implementation of DATA in 15 districts.
• Two existing entities, the district health management team (DHMT)⁴ and the district nutrition coordination committee (DNCC),⁵ helped coordinate the process, with facilitation by NAWG, RHITES, and SPRING. The aim was to ensure that existing systems and platforms are sustainable. The RHITES committed to facilitate the quarterly DNCCs meetings to track and discuss implementation of prioritized actions in the districts. RHITES committed to support health activities that were prioritized and are reflected in their work plan.
• The workshop included presentations from RHITES and the DNCCs on their responsibilities and key areas of focus. The presentations emphasized the need to use existing systems and resources to strengthen anemia reduction efforts.
• These Phase 1 workshops were funded by RHITES, which committed to fund the additional two phases of 11 districts, and to follow up with districts on progress of implementing prioritized actions.

3.0 Key Findings from Pilot and Implementation of DATA

The main findings from the DATA pilot in 3 districts and implementation in four districts in Uganda are detailed below.

3.1 Logistics and facilitation

• Overall, participants expressed satisfaction with the workshop format. There were positive reactions to the presentations and the group work session format, which promoted active participation. The educational and participatory nature of the workshop was also noted as positive.
• The two-day agenda was appropriate, but timetables need to be adhered to so that participants do not run out of time for group work and discussion.
• Joint facilitation between a national-level facilitator (e.g., SPRING/Uganda, NAWG) and a district-level facilitator led to strong collaboration on multi-sectoral issues.
• NAWG’s contributions linked national anemia efforts to district efforts, and advanced support for the tool.
• In addition to the NAWG facilitators, buy-in from all members of the NAWG is essential prior to piloting to ensure uptake at the district level. A few NAWG participants had not attended the prior national meeting, and thus were not as familiar with the tool as the facilitators but their technical contributions were essential during the sector group discussions.
• Prioritized action plans should be integrated in the district annual work plans and budgets to allocate resources for implementation.

3.2 Content and usability

• DATA outputs, including the assessment of barriers, are essential to prioritize anemia actions; and the prioritization template utilized in Uganda aided in the process. The global tool relies on prioritized actions to be listed by a designated note-taker and shared with district participants, along with the completed tool. In Uganda, the NAWG wanted a more structured process for prioritization so developed a template to be completed during the group work sessions. The template guided and structured the discussions of the sectoral groups during prioritization.
• Overall, participants were satisfied with the tool’s content, the sectors involved, and the indicators used for each sector.
• Inclusion of gender and community development sectors in the tool was mentioned. The Ministry of Gender, Labor, and Social Development, a key sector in the NAWG, was concerned that issues of gender and community development would not be addressed if not explicitly included in the tool. It was explained to participants that gender and community are cross-cutting and related issues would be brought up during the sector group discussions and prioritization process. District-level community development officers in the workshop were able to participate across the different sectoral group work sessions, and bring in issues related to gender and community development.
• The national and district questions are broad and do not necessarily reflect each district’s situation, but similar or proxy indicators can be used to answer these questions. There was a lot of discussion on which indicators could be used as a proxy for the global indicator. If there was confusion about which indicator to use or how to define the indictor (such as iron and folic acid [IFA] coverage definition, at first antennal care visit or fourth visit), then group consensus was sought. Participants used the indicators table, which noted the differences between the indicator questions asked in the tool and indicators collected at the local level.
• Along with customizing the indicators, there were questions about global definitions, for example: 1) The age range for adolescents, which the tool defined as 15–19 years. Uganda uses the WHO definition, which is 10–19 years), and; 2) exclusive breastfeeding was 0–5 months in the tool, but Uganda’s is 0–6 months, per the country’s infant and young child feeding (IYCF) guidelines.
• At first there was skepticism about the use of qualitative assessments for risk factor prevalence and program coverage. There was also a request for standard guidance for the assessments, particularly if the tool is to be used regularly (and potentially by different groups of people). It was noted that the qualitative assessments should be based on district staff’s expertise and knowledge about programs, and that reason or justification for the qualitative assessments will be recorded. After these discussions, groups were able to discuss and reach consensus on qualitative assessments.
• In areas where data did not exist, or did exist but had not been analyzed, participants expressed that these issues were useful in showing gaps and would encourage advocacy for data collection and use at the district level.
• The prioritization template outlines all interventions and all associated categories. In Namutumba, participants were inclined to come up with priority activities under each implementation category. Prioritized activities must be feasible within the given timeframe.
• In a few instances, there seemed to be discrepancy between the qualitative assessments of program coverage versus degree of barriers. A few programs were rated qualitatively as “good” but then identified as having barriers in two or more implementation categories. These discrepancies should be discussed and resolved during the workshop.
• Funding, which controls the feasibility of implementation, was the main barrier. Participants said that part of prioritizing certain activities would involve advocating for more funding and possibly being more creative about funding sources.
• The majority of the district health service providers had outdated guidelines and strategies for anemia-related interventions. Districts were unaware of up-to-date guidelines.

3.3 Program findings

• The district workshop findings revealed the status of anemia prevalence among children and women and the performance coverage of anemia interventions across the different sectors.
• All districts registered implementation of all the national programs related to nutrition, disease control, WASH, reproductive health, agriculture, and education, as follows.
  • Nutrition- IFA for pregnant women, vitamin A supplementation to children, exclusive and continued breast feeding [with the exception of IFA for women of reproductive age-non-pregnant and provision of micronutrient powders for most districts because it is a partner-driven intervention]
  • Disease control- intermittent preventive treatment in pregnancy (IPTp) of malaria for pregnant women, distribution of insecticide-treated nets, active case management in all age groups, deworming in children and pregnant women.
  • WASH- use of improved water source, household treatment of water for consumption, handwashing facility with soap and water, and access to improved sanitation.
  • Reproductive health- use of modern family planning and delayed cord clamping.
  • Agriculture-promotion of iron-rich beans and home food production.
  • Education- deworm children and hygiene education in schools.
• The most notable barriers across all the programs were lack or inadequate supplies including IFA, IPTp, deworming drugs, vitamin A supplements, anti-malarials, water treatment supplies, blood for transfusion, agricultural seedlings, WASH equipment, agricultural technologies and inputs, malaria diagnostic and treatment testing kits, cord clamps, Hemocues, medical and diagnostic technologies for anemia-related issues like helminth infections, and tools for measuring biomarkers.
• Limited funding, under-staffing, limited skills/capacity, poor data management and use, low priority given to the programs, lack of materials and guidelines, and limited supervision were emphasized as the major contributing issues to poor performance of district anemia-reduction programs.
• Key actions included prioritizing and mobilizing funds to strengthen anemia-reduction programs; timely and proper quantification of supplies and equipment; mentorship and supervision of health workers in data management; and use of data results in decision making and planning.

3.4 Commitment from districts and NAWG

• The DATA workshops concluded by solidifying ownership to implement key prioritized actions across the different sector by sector department heads and technical officials, administrative management, and political leaders. The CAO, political leaders (e.g., local chairperson), and secretaries responsible for key sectors committed to follow up with each department to ensure implementation of prioritized actions.
• The NAWG facilitators from the ministries—education and sports; health (National Medical Stores [NMS], Malaria Control Programme, and reproductive health); agriculture; and WASH—pledged to provide continued technical assistance and supportive supervision to the respective sectors to improve the anemia situation in the districts.
• USAID/RHITES will facilitate the DNCC quarterly meetings to track progress on nutrition-related activities. RHITES also committed to harmonizing health prioritized actions with its work plan.
• Unlike the rollout districts that plan to track progress of the prioritized actions through the DNCC with overall leadership from the district nutrition focal person and USAID/RHITES, the pilot districts preferred to use existing platforms like DHMT and DNCCs to track progress across sectors.

4.0 After the Workshops: Follow-up with Pilot Districts on DATA Action Plans

Following the DATA pilots in Namutumba and Arua in August 2016 and in Amuria in December in 2016, SPRING/Uganda followed up on the progress in the implementation of the prioritized actions in April and May 2017. In the pilot districts, SPRING/Uganda worked with district heads of departments to follow progress with the multi-sectoral action plans to reduce anemia. The NAWG and SPRING/Uganda then facilitated a meeting and conducted interviews to provide further technical assistance to districts as they implement action plans. Interview questions focused on how the districts are operationalizing DATA; how the tool has been helpful in addressing anemia challenges; lessons; and use of DATA in the future.

Progress in the pilot districts

Namutumba

Operationalization of DATA

The district routinely conducts prioritization and implementation of activities. The tool enabled ownership and commitment by different departments to strengthen anemia-reduction efforts. It has also brought different departments and communities to work together. Current efforts include:

Agriculture: The multi-sectoral food security and nutrition project supported by the World Bank was used to integrate and emphasize increased food production and consumption of iron and other micronutrient-rich foods.

The water department held a follow-up meeting with department officials and community department and health assistants to plan implementation of prioritized actions. Community sensitization was conducted during football matches in the sub-counties of Kagalama, Ivukula, and Mazuba. Progress includes three new boreholes constructed by the Kibo Group; 20 new boreholes being constructed by Field of Life; Kibo and Busoga Trust has started the rehabilitation of non-functional boreholes in the district. The District Water Grant prioritized construction of 30 new boreholes, establishment of 30 water user committees, and community sensitization visits before rehabilitation of 60 non-functional boreholes.

The health department used the prioritized actions to quantify adequate IFA supplements during a standardization meeting. Mentorship of health workers was included in the quarterly plans, which has led to improved health education for mothers on IYCF practices. Village health teams have been sensitizing communities on the need for IFA supplementation and IYCF practices. Though IFA supplementation for WRA (non-pregnant) was prioritized, due to limited resources the district has only been able to sensitize WRA on the importance of taking IFA supplementation.

Lessons

• DATA has raised awareness of the importance of multi-sectoral implementation in Namutumba. The district has moved to a holistic approach to anemia without duplication of efforts.
• The tool has enabled the district to focus on activities that contribute to the prevention of anemia.
• DATA was an opportunity for departments to appreciate their roles and how multi-sectoral engagement will be done through existing platforms like the DNCC.
• Strengthening coordination, ownership, and commitment among implementers is key to reducing anemia.
• DATA is a guiding tool and is being used to lobby for implementing partners to bridge the gap of funds for implementation.
• The tool is easy to use and has helped identify and track progress of appropriate interventions.

DATA use in the future

• Routine updates of the tool with new data/information on the performance of interventions.
• The district will conduct a comprehensive assessment to update DATA statistics.
• The tool has shown gaps that can only be filled if all stakeholders take action to realize the intended outputs.
• With supportive supervision from the national level (NAWG), the tool will be useful in providing technical assistance to strengthen key interventions.

Arua District

Operationalization of DATA

Prioritized actions listed during the DATA workshop were implemented to improve interventions in health, nutrition, education, and agriculture. The district integrated prioritized actions in the annual plans and budgets across the departments. In addition, the priority actions in nutrition have been used as a planning tool and integrated in the District Nutrition Action Plan (DNAP) to harness implementation of nutrition interventions.

Departments of health, education, and agriculture have mapped schools to ensure that adequate services are provided to prevent anemia.

Service delivery especially in maternity and outpatient departments, improved. The NMS delivered a supply of IFA for pregnant mothers and vitamin A supplements for children under five years as requested.

The district biostatistician has taken interest in monitoring anemia indicators, but frontline health workers need to be mentored to capture correct data.

Integration of the prioritized actions into ongoing projects like the multi-sectoral food and nutrition project by the World Bank synchronizes resources for implementation.

Lessons

• DATA is simple to use and helps identify gaps in performance of key interventions and implementation. Acknowledging gaps in data management caused data managers to take interest in anemia-related indicators.
• The tool has led district officials from health, production, community services, and education to work collaboratively to achieve a common goal. Political leaders are aware of the multiple causes of anemia, which has influenced planning and budgeting.

DATA use in the future

• NAWG should provide technical support to districts especially for tasks that can only be handled at the national level.
• The district plans to update the tool and track progress in anemia prevalence quarterly. To aid this process, the district is engaging development partners to support a comprehensive assessment to document the prevalence of anemia in the district, because health facility data is not representative of the district situation.
• DATA indicators need to be incorporated in the District Health Information System 2 for comprehensive data collection and reporting at the district and national level.

Amuria District

Operationalization of DATA

The prioritized actions were incorporated into district annual plans and budgets for 2017/18.

Nutritionists are strengthening practices, especially targeting community-level feeding practices. Sub-counties such as Asamuk have been able to prevent emerging cases of severe acute malnutrition through improved sensitization and education.

The water department is in the process of constructing sanitation facilities in schools.

Lessons

• DATA is simple to use but requires collaborative efforts to achieve the intended goal.
• The tool was an opportunity for all departments to appreciate anemia, its multifaceted causes, gaps and role of each department in filling them.

DATA use in the future

• Responsible sectors must coordination to track implementation of actions that have been integrated into the annual district plans and budgets.

5.0. Lessons and Recommendations

5.1 Lessons

• DATA is a way to evaluate the performance of programs/interventions in the prevention and control of anemia. DATA helps districts understand the multi-disciplinary nature of anemia and each sector’s role in the reduction of anemia.
• Commitment and ownership of the DATA process by administrative management, political leaders, district heads of key departments/sectors and technical officials, community and health service providers is key in moving the agenda forward.
• Since barriers to implementation stem from all levels, it is critical to have sector representation from NAWG to harmonize policy and programming for anemia reduction efforts. NAWG has a comprehensive understanding of DATA and the process of facilitation, which makes its participation essential, especially to link national level policy to district efforts.
• Partners are crucial to support gaps that districts cannot address because there is no funding. This must be in addition to district official’s ownership and commitment to implement prioritized actions.
• In the absence of quantitative data/information, expert opinions based on factors and indicators are essential for a valid rationale and justification of qualitative consensus responses.
• Prioritized actions are not parallel or additional tasks for the district; they are embedded in the routine services provided across sectors. DATA enables the district to recognize the importance of prioritizing such activities, most of which require limited resources.
• The global tool uses standard indicators—mostly WHO’s— that could be customized, and countries and districts are encouraged to change the indicators based on their context. Districts could also customize DATA facilitation to their own context, using the global tool and the global facilitation guide if resources permit. Due to absence of data/statistics for most of the standard indicators in the tool, districts could use proxy indicators as long as they are well-defined and justifiable.
• Pre-workshop visits are important to plan for the workshop and understand the information required for the workshops.
• Follow-up with the districts showed that DATA is a guiding tool and is being used to lobby implementing partners to bridge the gap of limited funds for implementation.

5.2. Recommendations for integration and scale up

If NAWG wants to integrate DATA into district level monitoring and planning cycles, the following critical issues must be considered.

• Ownership of DATA by NAWG. Develop a transition plan for regular use of the tool facilitated by NAWG and districts. SPRING/Uganda developed a training of trainer’s manual that will be shared with the NAWG for scale up.
• Scale up of DATA. The NAWG should seek support from other implementing partners when SPRING/Uganda ends.
• Implement prioritized actions. Districts should review and integrate the prioritization actions during annual planning and budgeting to tap adequate resources for implementation.
• Timelines for DATA workshops. The DATA workshops are planned for two full days. Timetables must be strictly adhered to ensure sufficient time for group discussions and the prioritization session.
• Routine use of DATA. Districts should routinely update the tool (quarterly/semi-annually/annually) follow up meetings.
• The prioritization session is most critical and facilitator should use the performance coverage rates for the interventions and degree of barriers to guide prioritization by sectors.
• Participant involvement. Engagement of key stakeholders within the district, community, and health facility aids commitment and ownership. Key stakeholder groups include administrative management; political leaders; district heads of departments and technical officials, community members, and health facility workers.
• Coordination. The NAWG has representation from all stakeholder groups including sectors/ministries, academia and research institutions, civil society organizations, development partners, and the private sector. NAWG involvement will ensure accountability and effective tracking and reporting of prioritized actions at the district and community levels.
• The NAWG will follow up with issues that need to be addressed at the national level, like supplies and equipment for anemia related interventions and funding.
• Coordination between the NAWG, the district, and partners is critical to track progress in implementation of prioritized actions.
• Commitment from the department responsible for coordination of sectors is critical to track progress in implementation of prioritized actions.
• Use of existing platforms to coordinate and track progress will support sustainable anemia reduction programs. Existing platforms like the DNCCs and DHMT or relevant platforms that foster multi-sectoral engagement.
• Data or information is fundamental to guide the workshops. To foster ownership, districts and partners should be supported to integrate anemia indicators in ongoing studies. The existing government data collection and analysis information systems should be strengthened to ensure reliable anemia data.
• Disseminate updated guidelines, strategies, and policies to service providers to improve efficiency and effectiveness of programs.
• Districts should identify and collaborate with partners supporting anemia reduction efforts to synchronize resources and improve anemia indicators.

6.0 Conclusion

The DATA pilot in three districts and implementation in the four districts increased understanding of anemia, its multiple causes, and the need for a multi-sectoral approach to reduce it. The tool was rated useful for linking national and district efforts. Data management was the main challenge to the use of DATA. The districts pledge to mobilize resources to strengthen data collection and use, and routinely update the tool to measure performance. The districts committed to implementing the prioritized actions in collaboration with key departments using existing platforms.

The follow-up activity by NAWG and SPRING showed that districts are committed to implementing the prioritized actions. It also indicated that challenges like stockouts and coordination during implementation had improved, though limited funding kept all the prioritized actions by the sectors from being implemented as planned. The districts also used the prioritized actions to solicit support from existing partners to bridge funding gaps in the future. If funding in annual plans and budget increases, existing district structures will be sustainable platforms for implementing anemia reduction efforts.