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ORIGINAL ARTICLE
Open Access

Sustainability and Scale of the Saving Mothers, Giving Life Approach in Uganda and Zambia

Jessica Healey, Claudia Morrissey Conlon, Kennedy Malama, Reeti Hobson, Frank Kaharuza, Adeodata Kekitiinwa, Marta Levitt, Davy Wadula Zulu and Lawrence Marum on behalf of the Saving Mothers,Giving Life Working Group
Global Health: Science and Practice March 2019, 7(Supplement 1):S188-S206; https://doi.org/10.9745/GHSP-D-18-00265
Jessica Healey
aU.S. Agency for International Development, Lusaka, Zambia. Now based in Monrovia, Liberia.
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  • For correspondence: jhealey@usaid.gov
Claudia Morrissey Conlon
bBureau for Global Health, U.S. Agency for International Development, Washington, DC, USA.
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Kennedy Malama
cMinistry of Health, Government of the Republic of Zambia, Lusaka, Zambia.
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Reeti Hobson
dICF, Rockville, Maryland, USA.
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Frank Kaharuza
eHIV Health Office, U.S. Agency for International Development, Kampala, Uganda.
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Adeodata Kekitiinwa
fBaylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda.
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Marta Levitt
gBureau for Global Health, U.S. Agency for International Development and RTI, Washington, DC, USA. Now with Palladium, Abuja, Nigeria.
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Davy Wadula Zulu
cMinistry of Health, Government of the Republic of Zambia, Lusaka, Zambia.
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Lawrence Marum
hU.S. Centers for Disease Control and Prevention, Lusaka, Zambia. Now retired.
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Figures

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  • FIGURE 1
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    FIGURE 1

    SMGL Theory of Change Model

    Abbreviations: EmONC, emergency obstetric and newborn care; MCH, maternal and child health; MDSR, maternal death surveillance and response; MMR, maternal mortality rate; NMR, neonatal mortality rate; SMGL, Saving Mothers, Giving Life; USG, U.S. government.

  • FIGURE 2
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    FIGURE 2

    Scale-Up of SMGL Approach in Zambia, 2016–2021

    Abbreviations: COC, continuum of care; RMNCAH/N, reproductive, maternal, newborn, child, adolescent health and nutrition; SMGL, Saving Mothers, Giving Life.

  • FIGURE 3
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    FIGURE 3

    Scale-Up of SMGL Approach in Uganda Through World Bank Support, 2016–2021

    Abbreviation: SMGL, Saving Mothers, Giving Life

  • FIGURE 4
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    FIGURE 4

    Scale-Up of SMGL Approach in Uganda Through Regional Health Integration to Enhance Services, 2012–2022

    Abbreviations: UBOS, Uganda Bureau of Statistics; URMNCAH, Uganda reproductive, maternal, newborn, child, and adolescent health.

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    Mothers wait with Safe Motherhood Action Group member at Lundazi Urban Health Centre, Zambia. © Amy Fowler/USAID

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    A service provider examines a client at the SMGL-supported Kakumiro Health Center in Uganda. © Amy Fowler/USAID

Tables

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    TABLE 1.

    SMGL Sustainability Index Domains and Key Questions

    DomainsPrompts/Questions for Ministry of Health Staff, Leadership, and Decision Makers at National, Provincial, and District Levels
    • Community normative change

    • Behaviors

    • Demand for quality services

    • Social norms

    • How has the % of deliveries in health facilities changed?

    • Is there a change in proper use of and demand for waiting shelters?

    • What % of women/families had a birth preparedness plan, saved money, and pre-arranged for transportation?

    • How has the use of vouchers in Uganda changed and been institutionalized?

    • What is the evidence of local customs/norms changing?

    • How has male engagement in birth planning and maternal health changed?

    • What is the sustained level of engagement of community health cadres for normative change (SMAGs in Zambia, VHTs in Uganda)?

    • Is there evidence of prolonged leadership of “change champions” in the community?

    • Governance, leadership and accountability

    • Willingness to champion change

    • Planning/coordination

    • Policies and governance

    • Civil society engagement

    • Private-sector engagement

    • Public access to information

    • Are there national or local champions that emerged from SMGL who successfully advocate for improved maternity services?

    • How has SMGL influenced changes in government policies and guidelines that are critical to long-term improvements in maternal and newborn survival?

    • At the national level, which guidelines, policies, or tools were updated? Has the implementation of policies been institutionalized at the lower level to sustain the benefits to maternal and newborn health?

    • Has the role of the community workers/VHTs in ensuring women are linked to appropriate care been institutionalized?

    • Will the role of the private sector in providing maternal and newborn health services continue after SMGL? Has the government established public–private partnerships?

    • What evidence exists of change in public access to information on maternal and newborn health at the district level or below?

    • Has the role of the community workers/VHTs in ensuring women are linked to appropriate care continued after SML?

    • Health system and service delivery

    • Service delivery

    • Human resources for health

    • Commodity security

    • Quality management

    • Have signal functions—such as newborn resuscitation, administration of anticonvulsants and oxytocics, cesarean section, and manual removal of placenta for EmONC and CEmONC—been institutionalized?

    • Has the government scaled up the district systems strengthening approach/key components of SMGL? Which components has the government picked up?

    • Has there been a transition of SMGL-supported human resources to government positions or has the government at the district level started to fund the SMGL-contracted positions? To what extent?

    • Has the government picked up the funding of lifesaving drugs such as oxytocin and commodities such as balloon tamponades or anti-shock garments to prevent and or treat postpartum hemorrhage and eclampsia?

    • Has the government institutionalized some type of district/health facility assessments/quality assurance approach to use as the basis of planning and budgeting?

    • Is the blood supply for transfusion adequate? Is fresh frozen plasma available?

    • Strategic investments, efficiency, and sustainable financing

    • Domestic resource mobilization (capital investments and recurring costs)

    • Technical and allocative efficiencies

    • Has there been an increase in domestic financial resources for maternal and newborn health in SMGL-supported districts to continue the quality of services?

    • Has the government budgeted and allocated funding for the scale-up of the SGML approach in other districts? Have they included funding considerations for both capital investments and recurring costs?

    • What key components were taken to scale by the government?

    • What components of SMGL were eliminated or reduced as they were not affordable or cost-effective? Was there any study on efficiency or cost-effectiveness?

    • Did SMGL influence planning of Ministry of Health resources or improve technical/allocative efficiencies?

    • Strategic information

    • Epidemiological and health data

    • Financial/expenditure data

    • Performance data

    • Were maternal death audits institutionalized?

    • Were data reviews institutionalized?

    • After SMGL, how are districts/facilities continuing to use data to improve maternal and newborn outcomes?

    • Abbreviations: CEmONC, comprehensive emergency obstetric and newborn care; EmONC, emergency obstetric and newborn care; SMAG, Safe Motherhood Action Group; SMGL, Saving Mothers, Giving Life; VHT, village health team.

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    TABLE 2.

    Key Informants for SMGL Sustainability Domains

    StakeholdersKIIs on Sustainability of SMGL
    (No.)
    Participants in Group Interviews on Sustainability
    (No.)
    U.S. Government, field
    Uganda40
    Zambia60
    Host government, national
    Uganda43
    Zambia20
    Host government, subnational
    Uganda70
    Zambia438
    In-country partner
    Uganda78
    Zambia50
    Total3949
    • Abbreviations: KIIs, key informant interviews; SMGL, Saving Mothers, Giving Life.

    • View popup
    TABLE 3.

    Indicators and Data on Community Norms

    UgandaZambia
    % change in institutional delivery rate (2012–2016)47% increase
    (from 45.5% to 67%)
    44% increase
    (from 63% to 90%)
    # trained SMAGs/VHTs reporting to health center (cumulative individuals trained from baseline)11,18913,658
    # of change championsN/A35023
    % of all institutional deliveries in SMGL-supported original districts supported by transport vouchers (2012–2016)24%N/A
    % change in number of facilities with a maternal waiting shelter from 2012 to 2016N/A69% increase
    • Abbreviations: HFA, health facility assessment; N/A, not available; SMGL, Saving Mothers, Giving Life; VHT, village health team.

    • aData from HFAs unless otherwise noted.

    • View popup
    TABLE 4.

    HFA Data on Health Systems and Service Delivery in Original 8 SMGL Districts, 2012–2016

    UgandaZambia
    BaselineEndlineBaselineEndline
    Infrastructure – facilities with electricity56%96%57%93%
    Infrastructure – facilities with running water75%100%90%97%
    No stock-out of medicines – oxytocin56%82%75%75%
    No stock-out of medicines – magnesium sulfate48%64%20%43%
    Population-based cesarean delivery rate5.3%9.0%2.7%4.8%
    24 hours a day/7 days a week services at facilities78%89% (NS)65%96%
    Facilities with available transportation (vehicle or motorcycle)61%59% (NS)55%73%
    Facilities with communications equipment93%99%45%100%
    • Abbreviations: HFA, health facility assessment; NS, not significant; SMGL, Saving Mothers, Giving Life.

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Global Health: Science and Practice: 7 (Supplement 1)
Global Health: Science and Practice
Vol. 7, No. Supplement 1
March 11, 2019
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Sustainability and Scale of the Saving Mothers, Giving Life Approach in Uganda and Zambia
Jessica Healey, Claudia Morrissey Conlon, Kennedy Malama, Reeti Hobson, Frank Kaharuza, Adeodata Kekitiinwa, Marta Levitt, Davy Wadula Zulu, Lawrence Marum
Global Health: Science and Practice Mar 2019, 7 (Supplement 1) S188-S206; DOI: 10.9745/GHSP-D-18-00265

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Sustainability and Scale of the Saving Mothers, Giving Life Approach in Uganda and Zambia
Jessica Healey, Claudia Morrissey Conlon, Kennedy Malama, Reeti Hobson, Frank Kaharuza, Adeodata Kekitiinwa, Marta Levitt, Davy Wadula Zulu, Lawrence Marum
Global Health: Science and Practice Mar 2019, 7 (Supplement 1) S188-S206; DOI: 10.9745/GHSP-D-18-00265
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