Abstract
The involvement of private hospitals in Tuberculosis care in Uganda is still limited. There is a lack of literature about the barriers and motivators to private hospitals’ engagement in Tuberculosis care in Uganda. To explore the barriers to and motivators of private hospitals’ engagement in Tuberculosis care. The study employed a qualitative study design that utilized in-depth interviews with 13 private healthcare workers purposively selected in June 2020 due to their active involvement in Tuberculosis care from four urban private hospitals in Mbarara Municipality. An inductive, content analytic approach framed by the Consolidated Framework for Implementation Research, was used for analysis. The interviews were transcribed and coded to identify key themes using content analysis. Focusing through the Consolidated Framework for Implementation Research, barriers to private hospitals’ engagement were related to cost, external policies and incentives, structure characteristics, networks and communications, and knowledge and beliefs about the intervention. These include concerns regarding the payment of care by patients; indirect income-generating nature of Tuberculosis management; lack of drugs, registers, and diagnostic tools; lack of accreditation from the Ugandan Ministry of Health; limited space for keeping Tuberculosis patients; lack of proper follow-up mechanism; lack of training and qualified human resources; and delayed seeking of health care by the patients. Perceived high-quality of care in the private hospitals; privacy and confidentiality concerns; proximity of private hospitals to patients; and formalization of partnerships between private hospitals and the government were the motivators that arose from the three constructs (relative advantage, patient needs, and resources, and engaging). The engagement of private hospitals in Tuberculosis care requires commitment from key stakeholders supplemented with the organizational shared beliefs towards this change. There is a need for ensuring mechanisms for lessening these barriers to ensure full engagement of private hospitals in Tuberculosis care.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Achan, J. (2019, May 12). Uganda health care system can thrive with the involvement of nurses. New Vision. https://www.newvision.co.ug/news/1500168/uganda-health-care-thrive-involvement-nurses
Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T
Anand, T., Babu, R., Jacob, A. G., Sagili, K., & Chadha, S. S. (2017). Enhancing the role of private practitioners in tuberculosis prevention and care activities in India. Lung India: Official Organ of Indian Chest Society, 34(6), 538. https://doi.org/10.4103/0970-2113.217577
Asuquo, A. E., Pokam, B. D. T., Ibeneme, E., Ekpereonne, E., Obot, V., & Asuquo, P. (2015). A public–private partnership to reduce tuberculosis burden in Akwa Ibom State Nigeria. International Journal of Mycobacteriology, 4(2), 143–150. https://doi.org/10.1016/j.ijmyco.2015.04.002
Babikako, H. M., Neuhauser, D., Katamba, A., & Mupere, E. (2011). Patient satisfaction, feasibility and reliability of satisfaction questionnaire among patients with pulmonary tuberculosis in urban Uganda: A cross-sectional study. Health Research Policy and Systems, 9(1), 6. https://doi.org/10.1186/1478-4505-9-6
Bennett, A., Avanceña, A. L., Wegbreit, J., Cotter, C., Roberts, K., & Gosling, R. (2017). Engaging the private sector in malaria surveillance: A review of strategies and recommendations for elimination settings. Malaria Journal, 16(1), 1–19. https://doi.org/10.1186/s12936-017-1901-1
Buregyeya, E., Criel, B., Nuwaha, F., & Colebunders, R. (2014). Delays in diagnosis and treatment of pulmonary tuberculosis in Wakiso and Mukono districts Uganda. BMC Public Health, 14(1), 586. https://doi.org/10.1186/1471-2458-14-586
Buregyeya, E., Kasasa, S., & Mitchell, E. M. (2016). Tuberculosis infection control knowledge and attitudes among health workers in Uganda: A cross-sectional study. BMC Infectious Diseases, 16(1), 416. https://doi.org/10.1186/s12879-016-1740-7
Cattamanchi, A., Miller, C. R., Tapley, A., Haguma, P., Ochom, E., Ackerman, S., & Handley, M. A. (2015). Health worker perspectives on barriers to delivery of routine tuberculosis diagnostic evaluation services in Uganda: A qualitative study to guide clinic-based interventions. BMC Health Services Research, 15(1), 10. https://doi.org/10.1186/s12913-014-0668-0
Centers for Disease Control and Prevention. (2016, March). TB and HIV Coinfection. https://www.cdc.gov/tb/topic/basics/tbhivcoinfection.htm
Cohen, J., Saran, I., & Yavuz, E. (2016). Drug Packaging, Health Information and Medication Adherence: Evidence from Malaria Treatment in Uganda.
Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4(1), 1–15. https://doi.org/10.1186/1748-5908-4-50
Dewan, P. K., Lal, S., Lonnroth, K., Wares, F., Uplekar, M., Sahu, S., & Chauhan, L. S. (2006). Improving tuberculosis control through public-private collaboration in India: Literature review. BMJ, 332(7541), 574–578. https://doi.org/10.1136/bmj.38738.473252.7C
Granich, R., Binkin, N. J., Jarvis, W. R., Simone, P. M., Rieder, H. L., Espinal, M. A., Organization, W. H. (1999) Guidelines for the prevention of tuberculosis in health care facilities in resource-limited settings: World Health Organization.
Gutierrez, R., Teshome, S., & Neilson, M. (2018). Uganda’s health care quality improvement journey. Technical Report. https://doi.org/10.13140/RG.2.2.17765.45281
Gyamfi, J., Allegrante, J. P., Iwelunmor, J., Williams, O., Plange-Rhule, J., Blackstone, S., & Ogedegbe, G. (2020). Application of the Consolidated Framework for Implementation Research to examine nurses’ perception of the task shifting strategy for hypertension control trial in Ghana. BMC Health Services Research, 20(1), 1–11. https://doi.org/10.1186/s12913-020-4912-5
Hsieh, H.-F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288. https://doi.org/10.1177/1049732305276687
Hudson, M., Rutherford, G. W., Weiser, S., & Fair, E. (2018). Linking private, for-profit providers to public sector services for HIV and tuberculosis co-infected patients: A systematic review. PLoS ONE, 13(4), e0194960. https://doi.org/10.1371/journal.pone.0194960
Keesara, S. R., Juma, P. A., & Harper, C. C. (2015). Why do women choose private over public facilities for family planning services? A qualitative study of post-partum women in an informal urban settlement in Kenya. BMC Health Services Research, 15(1), 335. https://doi.org/10.1186/s12913-015-0997-7
Keith, R. E., Crosson, J. C., O’Malley, A. S., Cromp, D., & Taylor, E. F. (2017). Using the consolidated framework for implementation research (CFIR) to produce actionable findings: A rapid-cycle evaluation approach to improving implementation. Implementation Science, 12(1), 1–12. https://doi.org/10.1186/s13012-017-0550-7
Lei, X., Liu, Q., Escobar, E., Philogene, J., Zhu, H., Wang, Y., & Tang, S. (2015). Public–private mix for tuberculosis care and control: A systematic review. International Journal of Infectious Diseases, 34, 20–32. https://doi.org/10.1016/j.ijid.2015.02.015
Lönnroth, K., Uplekar, M., & Blanc, L. (2006). Hard gains through soft contracts: Productive engagement of private providers in tuberculosis control. Bulletin of the World Health Organization, 84, 876–883. https://doi.org/10.2471/blt.06.029983
Ministry of Health. (2011). Uganda national guidelines for tuberculosis infection control in health care facilities, congregate settings and households. Kampala: Ministry of Health, Uganda. https://www.who.int/hiv/pub/guidelines/uganda_hiv_tb.pdf
Ministry of Health. (2017a). Annual Health Sector Performance Report: Financial Year 2017/18. http://library.health.go.ug/publications/annual-quarterly-performance-reports/annual-health-sector-performance-report-201718
Ministry of Health. (2017b). National Tuberculosis and Leprosy Control Programme. Revised National Strategic Plan 2015/16 - 2019/20. https://www.health.go.ug/cause/national-tuberculosis-and-leprosy-control-programme-revised-national-strategic-plan-2015-16-2019-20/
Ministry of Health. (2018). National Tuberculosis and Leprosy Programme. National Tuberculosis Agenda for Operations and Implementation Research.
Ministry of Health. (2019). Direct and Indirect costs due to Tuberculosis and proportion of Tuberculosis-affected households experiencing catastrophic costs due to TB in Uganda. Ministry of Health Uganda. https://www.health.go.ug/cause/direct-and-indirect-costs-due-to-tuberculosis-and-proportion-of-tuberculosis-affected-households-experiencing-catastrophic-costs-due-to-tb-in-uganda-febrauary-2019/
Musiimenta, A., Atukunda, E. C., Tumuhimbise, W., Pisarski, E. E., Tam, M., Wyatt, M. A., & Haberer, J. E. (2018). Acceptability and feasibility of real-time antiretroviral therapy adherence interventions in rural uganda: mixed-method pilot randomized controlled trial. JMIR mHealth and uHealth, 6(5), 122. https://doi.org/10.2196/mhealth.9031
Musiimenta, A., Tumuhimbise, W., Mugaba, A. T., Muzoora, C., Armstrong-Hough, M., Bangsberg, D., & Haberer, J. E. (2019). Digital monitoring technologies could enhance tuberculosis medication adherence in Uganda: Mixed methods study. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, 17, 100119. https://doi.org/10.1016/j.jctube.2019.100119
Nansera, D., Bajunirwe, F., Kabakyenga, J., & Asiimwe, P. (2010). Opportunities and barriers for implementation of integrated TB and HIV care in lower level health units: Experiences from a rural western Ugandan district. African Health Sciences, 10(4), 312–319.
Nshuti, L., Neuhauser, D., & Johnson, J. (2001). Public and private providers’ quality of care for tuberculosis patients in Kampala Uganda. The International Journal of Tuberculosis and Lung Disease, 5(11), 1006–1012.
Nwe, T. T., Saw, S., Mon, M. M., van Griensven, J., Zhou, S., Chinnakali, P., & Aung, S. T. (2017). Engagement of public and private medical facilities in tuberculosis care in Myanmar: Contributions and trends over an eight-year period. Infectious Diseases of Poverty, 6(1), 123. https://doi.org/10.1186/s40249-017-0337-8
O’Donovan, J., Bersin, A., & O’Donovan, C. (2015). The effectiveness of mobile health (mHealth) technologies to train healthcare professionals in developing countries: A review of the literature. BMJ Innovations, 1(1), 33–36. https://doi.org/10.1136/bmjinnov-2014-000013
O’Hanlon, B., Nakyanzi, A., Musembi, V., Busulwa, I., Husband, R., Okumu, R., Kanneganti, S. (2017) Exploring Partnership Opportunities to Achieve Universal Health Access. 2016 Uganda Private Sector Assessment in Health. USAID. https://pdf.usaid.gov/pdf_docs/PA00THHJ.pdf
Ogbuabor, D. C., & Onwujekwe, O. E. (2019). Governance of tuberculosis control programme in Nigeria. Infectious Diseases of Poverty, 8(1), 45. https://doi.org/10.1186/s40249-019-0556-2
Oliwa, J. N., Odero, S. A., Nzinga, J., van Hensbroek, M. B., Jones, C., English, M., & Hoog, A. V. T. (2020). Perspectives and practices of health workers around diagnosis of paediatric tuberculosis in hospitals in a resource-poor setting – modern diagnostics meet age-old challenges. BMC Health Services Research. https://doi.org/10.1186/s12913-020-05588-6
Shea, C. M., Jacobs, S. R., Esserman, D. A., Bruce, K., & Weiner, B. J. (2014). Organizational readiness for implementing change: a psychometric assessment of a new measure. Implementation Science, 9(1), 1–15. https://doi.org/10.1186/1748-5908-9-7
Stallworthy, G., Dias, H. M., & Pai, M. (2020). Quality of tuberculosis care in the private health sector. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases. https://doi.org/10.1016/j.jctube.2020.100171
StataCorp. (2013). Stata Statistical Software: Release 13. College Station, TX: StataCorp LP.
Tumuhimbise, W., Atukunda, E. C., Ayebaza, S., Katusiime, J., Mugyenyi, G., Pinkwart, N., & Musiimenta, A. (2020). Maternal health-related barriers and the potentials of mobile health technologies: Qualitative findings from a pilot randomized controlled trial in rural Southwestern Uganda. Journal of Family Medicine and Primary Care, 9(7), 3657. https://doi.org/10.4103/jfmpc.jfmpc_281_20
Tumuhimbise, W., & Musiimenta, A. (2021). A review of mobile health interventions for public private mix in tuberculosis care. Internet Interventions. https://doi.org/10.1016/j.invent.2021.100417
Uganda Bureau of Statistics. (2018). Uganda National Household Survey, 2016/2017. https://www.ubos.org/wp-content/uploads/publications/03_20182016_UNHS_FINAL_REPORT.pdf
Uplekar, M. (2003). Involving private health care providers in delivery of TB care: Global strategy. Tuberculosis, 83(1–3), 156–164. https://doi.org/10.1016/s1472-9792(02)00073-2
Uplekar, M. (2016). Public-private mix for tuberculosis care and prevention. What progress? What prospects? The International Journal of Tuberculosis and Lung Disease, 20(11), 1424–1429. https://doi.org/10.5588/ijtld.15.0536
United States Agency International Development. (2015). Mobile Money for health case study compendium. https://www.hfgproject.org/wp-content/uploads/2015/10/HFG-Mobile-Money-Compendium_October-2015.pdf
United States Agency International Development. (2017). Uganda’s Private Health Sector: Opportunities for Growth. https://banyanglobal.com/wp-content/uploads/2017/07/Ugandas-Private-Health-Sector-Opportunities-for-Growth.pdf
World Health Organization. (2001). Involving private practitioners in tuberculosis control: issues, interventions, and emerging policy framework. In Involving private practitioners in tuberculosis control: issues, interventions, and emerging policy framework.
World Health Organization. (2004). Public-private mix for DOTS: report of the second meeting of the PPM subgroup for DOTS expansion. Geneva: WHO; 2004. Report No WHO/HTM/TB/2004.338. http://whqlibdoc.who.int/hq/2004/WHO_HTM_TB_2004.338.pdf (accessed 11 Jan 2005).
World Health Organization . (2009). WHO policy on TB infection control in health-care facilities, congregate settings and households. http://apps.who.int/iris/bitstream/handle/10665/44148/9789241598323_eng.pdf?sequence=1
World Health Organization. (2017). Public-Private Mix for TB Care and Prevention. https://www.who.int/tb/publications/PPM_Factsheet2017.pdf
World Health Organization. (2018a). Engaging private health care providers in TB care and prevention: a landscape analysis. https://www.who.int/tb/publications/2018/PPMLandscapeAnalysis.pdf?ua=1
World Health Organization. (2018b). Public–private mix for TB prevention and care: a roadmap. Geneva: World Health Organization. https://www.who.int/tb/publications/2018/PPMRoadmap.pdf
World Health Organization. (2019). Global Tuberculosis Report 2019. https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-report-2019
World Health Organization. (2020). Global tuberculosis report 2020. https://www.who.int/publications/i/item/9789240013131
World Health Organization. (2021) Tuberculosis profile: Uganda, 21st July, 2021; https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&entity_type=%22country%22&lan=%22EN%22&iso2=%22UG%22.
Wynne, A., Richter, S., Banura, L., & Kipp, W. (2014). Challenges in tuberculosis care in Western Uganda: Health care worker and patient perspectives. International Journal of Africa Nursing Sciences, 1, 6–10. https://doi.org/10.1016/j.ijans.2014.05.001
Acknowledgements
This work is part of a PhD research approved by Mbarara University Research Ethics Committee – MUREC (Protocol Number: 32/03-20), and the Uganda National Council of Science and Technology – UNCST (Registration number: HS963ES) supervised by Dr. Angella Musiimenta (PhD), Dr. Daniel Atwine and Dr. Fred Kaggwa in the Faculty of Computing and Informatics (FCI) at Mbarara University of Science and Technology, who guided the investigator throughout the entire process and reviewed the manuscript for correctness and validity. Dr. Musiimenta is also supported by the Fogarty International Center of the National Institutes of Health under Award number K43TW010388-05S1, and the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number R21HD107985, and the Federal German Ministry of Education and Research (01DG21014). I would like to acknowledge Associate Professor Luke Davis (Yale School of Medicine) for the support in conceptualizing the research idea.
Funding
Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number R21HD107985. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
Author declare no conflict of interest.
Ethical Approval
Official permission was sought and obtained from the participating hospitals where the study was conducted. Ethical approval was obtained from Mbarara University Research Ethics Committee— MUREC (Protocol number: 32/03–20) and the Uganda National Council of Science and Technology— UNCST (Registration number: HS963ES). All participants provided written consent before participating in the study.
Rights and permissions
About this article
Cite this article
Tumuhimbise, W., Musiimenta, A. Barriers and Motivators of Private Hospitals’ Engagement in Tuberculosis Care in Uganda. Glob Implement Res Appl 1, 279–290 (2021). https://doi.org/10.1007/s43477-021-00030-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s43477-021-00030-3