Date Published: February 8, 2018
Publisher: Public Library of Science
Author(s): Mari Armstrong-Hough, Sandeep P. Kishore, Sarah Byakika, Gerald Mutungi, Marcella Nunez-Smith, Jeremy I. Schwartz, Hafiz T.A. Khan.
Although the WHO-developed Service Availability and Readiness Assessment (SARA) tool is a comprehensive and widely applied survey of health facility preparedness, SARA data have not previously been used to model predictors of readiness. We sought to demonstrate that SARA data can be used to model availability of essential medicines for treating non-communicable diseases (EM-NCD).
We fit a Poisson regression model using 2013 SARA data from 196 Ugandan health facilities. The outcome was total number of different EM-NCD available. Basic amenities, equipment, region, health facility type, managing authority, NCD diagnostic capacity, and range of HIV services were tested as predictor variables.
In multivariate models, we found significant associations between EM-NCD availability and region, managing authority, facility type, and range of HIV services. For-profit facilities’ EM-NCD counts were 98% higher than public facilities (p < .001). General hospitals and referral health centers had 98% (p = .004) and 105% (p = .002) higher counts compared to primary health centers. Facilities in the North and East had significantly lower counts than those in the capital region (p = 0.015; p = 0.003). Offering HIV care was associated with 35% lower EM-NCD counts (p = 0.006). Offering HIV counseling and testing was associated with 57% higher counts (p = 0.048). We identified multiple within-country disparities in availability of EM-NCD in Uganda. Our findings can be used to identify gaps and guide distribution of limited resources. While the primary purpose of SARA is to assess and monitor health services readiness, we show that it can also be an important resource for answering complex research and policy questions requiring multivariate analysis.
Our findings support previous work that demonstrates that Ugandan health facilities are poorly prepared to address the growing burden of NCD.[12,16,18] We extend this previous work by identifying and quantifying clear within-country disparities in preparedness. We found significant associations between EM-NCD availability and geographic region, managing authority, health facility type, and the range of HIV services. The availability of EM-NCD was substantially higher in PFP facilities than in public facilities and strikingly lower in the North and East regions. Availability of EM-NCD had a mixed relationship to availability of care and counseling for HIV. On the one hand, facilities that offer HIV care and support had lower average EM-NCD availability. However, facilities that offer HIV counseling and testing were associated with 57% higher EM-NCD availability counts.
Given the complex sampling strategy and the possibility that health facilities in the same district may influence one another with regard to availability of EM-NCD, we also fit a multilevel mixed model to supplement our primary analysis. There was little evidence of need for a multilevel model and the parameter estimates of the multilevel mixed model were in general agreement with those of the easier-to-interpret Poisson model presented in the main analysis.