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Introduction: Globally, out of 15 million babies born preterm each year, one million die. In Uganda, preterm deaths contribute 30% of the neonatal mortality rate. There is a paucity of information on the most critical time to conduct high impact interventions among neonate born preterm especially post-discharge from hospital. We determined the survival time to mortality and its predictors among preterm infants in the neonatal period post-discharge from hospital. Methods: We conducted a prospective cohort study in which 128 preterm infants were recruited from six hospitals including Jinja Regional Referral, St. Francis Buluba, Kamuli mission, Iganga, Kamuli and Bugiri district hospitals were prematurity was confirmed using gestation age and birth weight. Initially, background characteristics of the participants were assessed and then followed prospectively until 28 days. Kaplan-Meier survival analysis was used to estimate survival probabilities while time to preterm mortality was described using the 5thpercentile. Cox proportional hazards regression was used to determine predictors of survival. Results: Overall, 8% (10/128) of the preterm infants died; the 5th percentile survival time was 17 days. There was a 6-fold increase in hazard to mortality among preterm infants who had Kangaroo Mother Care (KMC) compared to those who did not (adjusted HR: 6.4, 95%CI: 1.7 – 24.5), a 5-fold increase in the hazard to preterm mortality among preterm infants born to HIV positive mothers compared to their counterparts who had HIV negative mothers (adjusted HR: 4.9, 95%CI: 1.1 – 22.2); and a 4-fold increase in the hazard to preterm mortality among preterm infants who were not exclusively breastfed compared to those who were exclusively breastfed (adjusted HR: 4.4, 95%CI: 1.1 – 18.3). Conclusion: Among babies who died, death occurred in the first 17 days while factors negatively associated with preterm survival included; not practicing Kangaroo Mother Care, not being breastfed exclusively and being born to an HIV positive mother. We recommend follow-up care for preterm infants following hospital discharge, implementation of prevention of mother to child transmission of HIV and exclusive breastfeeding of preterm babies.

Lessons learned from implementing evaluations for Gavi, the Vaccine Alliance and the Global Fund for AIDS, Tuberculosis, and Malaria can help inform the design and implementation of ongoing or future evaluations of complex interventions. We share 5 lessons distilled from over 7 years of experience implementing evaluations in 7 countries., Key Findings We present 5 key lessons distilled from 7 years of experience implementing evaluations in 7 countries, which include the importance of: Including an inception phase to engage stakeholders and inform a relevant, useful evaluation designAligning on the degree to which the evaluation is embedded in the program implementationMonitoring programmatic, organizational, or contextual changes and adapting the evaluation accordinglyHiring evaluators with mixed-methods expertise and using tools and approaches that facilitate mixing methodsContextualizing recommendations and clearly communicating their underlying strength of evidence Key Implications Global health initiatives, particularly those funding or implementing complex interventions, should consider embedding evaluations to understand how and why the programs are working to adapt as necessary and maximize impact.Evaluators of complex interventions should continue to share lessons learned related to balancing stakeholder priorities, aligning on “breadth” versus “depth” of the evaluation scope and ensuring use of the evaluation findings., Introduction: As global health programs have become increasingly complex, corresponding evaluations must be designed to assess the full complexity of these programs. Gavi and the Global Fund have commissioned 2 such evaluations to assess the full spectrum of their investments using a prospective mixed-methods approach. We aim to describe lessons learned from implementing these evaluations. Methods: This article presents a synthesis of lessons learned based on the Gavi and Global Fund prospective mixed-methods evaluations, with each evaluation considered a case study. The lessons are based on the evaluation team’s experience from over 7 years (2013–2020) implementing these evaluations. The Centers for Disease Control and Prevention Framework for Evaluation in Public Health was used to ground the identification of lessons learned. Results: We identified 5 lessons learned that build on existing evaluation best practices and include a mix of practical and conceptual considerations. The lessons cover the importance of (1) including an inception phase to engage stakeholders and inform a relevant, useful evaluation design; (2) aligning on the degree to which the evaluation is embedded in the program implementation; (3) monitoring programmatic, organizational, or contextual changes and adapting the evaluation accordingly; (4) hiring evaluators with mixed-methods expertise and using tools and approaches that facilitate mixing methods; and (5) contextualizing recommendations and clearly communicating their underlying strength of evidence. Conclusion: Global health initiatives, particularly those leveraging complex interventions, should consider embedding evaluations to understand how and why the programs are working. These initiatives can learn from the lessons presented here to inform the design and implementation of such evaluations.

Limited evidence exists regarding the drivers of vaccination coverage and equity in Kampala city, despite frequent measles outbreaks, inequities in vaccination coverage, and the decline in vaccination coverage rates. This study was designed to determine vaccine coverage among children aged 12-36 months and to understand its demand-side drivers.We utilized a mixed-methods parallel convergent study design. A household survey was conducted to quantify the drivers of vaccine coverage among households with children aged 12-36 months. We employed a multistage sampling approach to select households, using a primary sampling unit of an enumeration area. We conducted 30 key informant interviews, 7 focus group discussions, and 6 in-depth interviews with representatives from the immunization program, health workers, and parents residing in areas with low vaccine coverage.Of the 590 enrolled children, 340 (57.6%) were partially vaccinated, 244 (41.4%) were fully vaccinated and had received all the recommended vaccinations, and 6 (1.0%) had never received any vaccine. Of the 244 with all recommended vaccinations, only 65 (26.6%) received their vaccines on time. Access to vaccination services was high (first dose of diphtheria, pertussis, and tetanus [DPT1] coverage of 96%), but utilization decreased over time, as shown by a dropout rate of 17.3% from the first to third dose of DPT. The main driver of complete vaccination was the parents' appreciation of the benefits of vaccination. Among partially vaccinated children, the barriers to vaccination were inadequate information about vaccination (its benefits and schedule), vaccine stock-outs, long waiting times to receive vaccination services, and hidden vaccination costs.Vaccination needs to be targeted to all children irrespective of whether they reside in slum areas or nonslum areas, as most are under-vaccinated. Social mobilization and communication efforts should be tailored to the complexities of urban settings characterized by transient and diverse populations with different cultures.

Background In Uganda, there are persistent weaknesses in obtaining accurate, reliable and complete data on local and external investments in immunization to guide planning, financing, and resource mobilization. This study aimed to measure and describe the financial envelope for immunization from 2012 to 2016 and analyze expenditures at sub-national level. Methods The Systems of Health Accounts (SHA) 2011 methodology was used to quantify and map the resource envelope for immunization. Data was collected at national and sub-national levels from public and external sources of immunization. Data were coded, categorized and disaggregated by expenditure on immunization activities using the SHA 2011. Results Over the five-year period, funding for immunization increased fourfold from US$20.4 million in 2012 to US$ 85.6 million in 2016. The Ugandan government was the main contributor (55%) to immunization resources from 2012 to 2014 however, Gavi, the Vaccine Alliance contributed the majority (59%) of the resources to immunization in 2015 and 2016. Majority (66%) of the funds were managed by the National Medical Stores. Over the five-year period, 80% of the funds allocated to immunization activities were spent on facility based routine immunization (expenditure on human resources and outreaches). At sub-national level, districts allocated 15% of their total annual resources to immunization to support supervision of lower health facilities and distribution of vaccines. Health facilities spent 5.5% of their total annual resources on immunization to support outreaches. Conclusion Development partner support has aided the improvement of vaccine coverage and increased access to vaccines however, there is an increasing dependence on this support for a critical national program raising sustainability concerns alongside other challenges like being off-budget and unpredictable. To ensure financial sustainability, there is need to operationalize the immunization fund, advocate and mobilize additional resources for immunization from the Government of Uganda and the private sector, increase the reliability of resources for immunization as well as leverage on health financing reforms like the National Health Insurance.

Background: The Global Fund to Fight AIDS, Tuberculosis and Malaria was founded in 2002 as a public-private partnership between governments, the private sector, civil society, and populations affected by the three diseases. A key principle of the Global Fund is country ownership in accessing funding through “engagement of in-country stakeholders, including key and vulnerable populations, communities, and civil society.” Research documenting whether diverse stakeholders are actually engaged and on how stakeholder engagement affects processes and outcomes of grant applications is limited. Objective: To examine representation during the 2017 Global Fund application process in the Democratic Republic of the Congo (DRC) and Uganda and the benefits and drawbacks of partnership to the process. Methods: We developed a mixed-methods social network survey to measure network structure and assess perceptions of how working together in partnership with other individuals/organizations affected perceived effectiveness, efficiency, and country ownership of the application process. Surveys were administered from December 2017–May 2018, initially to a set of central actors, followed by any individuals named during the surveys (up to 10) as collaborators. Network analyses were conducted using R. Findings: Collaborators spanning many organizations and expertise areas contributed to the 2017 applications (DRC: 152 nodes, 237 ties; Uganda: 118 nodes, 241 ties). Participation from NGOs and civil society representatives was relatively strong, with most of their ties being to different organization types, Uganda (63%), and DRC (67%), highlighting their collaborative efforts across the network. Overall, the perceived benefits of partnership were high, including very strong ratings for effectiveness in both countries. Perceived drawbacks of partnership were minimal; however, less than half of respondents thought partnership helped reduce transaction costs or financial costs, suggesting an inclusive and participatory process may come with short-term efficiency tradeoffs. Conclusions: Social network analysis can be useful for identifying who is included and excluded from the process, which can support efforts to ensure stronger, more meaningful engagement in future Global Fund application processes.

Background Globally, out of 15 million babies born preterm every year, around 1 million will die. In Uganda, deaths in preterm infants make up 30% of all neonatal deaths. There is a paucity of information on the most critical time to conduct high-impact interventions among neonates born preterm especially after discharge from hospital. In this study, we determined the survival time to mortality and its predictors in preterm infants in the neonatal period after discharge from hospital. Methods We conducted a prospective cohort study in preterm infants in six district hospitals in Busoga Region, Uganda. Prematurity was confirmed using gestational age and birthweight. We assessed participants' background characteristics then followed them up prospectively until 28 days of life. We used Kaplan-Meier survival analysis to estimate survival probabilities while time-to-preterm mortality was described using the 5th percentile. We used Cox proportional hazards regression to determine predictors of survival. Findings Between June 1, 2017, and July 14, 2017, we recruited 128 preterm infants to the study. Mean gestational age was 4 days (SD 3) and mean birthweight was 1·8 kg (0·6). Overall, 8% (10/128) of preterm infants died; the 5th percentile survival time was 17 days. We noted a six-fold increase in hazard of mortality in preterm infants who did not have kangaroo mother care (KMC) compared with those who did (adjusted HR 6·4 [95%CI 1·7–24·5]), a five-fold increase in mortality hazard in preterm infants born to HIV-positive mothers compared with babies who had HIV-negative mothers (4·9 [1·1–22·2]); and a four-fold increase in the mortality hazard in preterm infants who were not exclusively breastfed compared with those who were exclusively breastfed (4·4 [1·1–18·3]). Interpretation To reduce neonatal mortality in Uganda, we recommend follow-up care for preterm infants following hospital discharge, implementation of prevention of mother-to-child transmission of HIV, and exclusive breastfeeding of preterm babies. Funding East Africa Preterm Birth Initiative sponsored by the Bill & Melinda Gates Foundation.

Background There are persistent weaknesses in obtaining accurate reliable and complete data on local and external investments in immunization and yet these are critical to estimate costs, resource needs and gaps so as to aid country financing, planning and resource mobilization. This study aimed to measure and describe the financial envelope for immunization activities and conduct an expenditure analysis at district level. Methods The Systems of Health Accounts (SHA) 2011 methodology was used to quantify and map out the resource envelope for immunization. Data were collected at national and district levels from public and external sources of immunization through key informant interviews coupled with document reviews. Data were coded (SHA), categorized and disaggregated to allow for greater detail on the types of immunization activities. Financing methodology used was largely drawn from Guthrie et al, 2015. Results Over a five-year period, funding for immunization has increased fourfold from US$20.4 million in 2012 to US$ 85.6 million in 2016. The increase in the resource envelope is attributed to the lift of the ban of Gavi funding to Uganda as well as new vaccine introduction. Gavi, the Vaccine Alliance became the biggest contributor (59%) in 2015 and 2016 with 66% of the funds managed by National Medical Stores. Eighty percent of the resources are spent on facility-based routine immunization which includes expenditure on human resources and immunization outreaches. At district level, the overall proportion of total funding to immunization was 15% of their Primary Health Care (PHC) Grant. The bulk (82%) of the PHC funds were spent on supervision to lower health centers (transport and distribution of vaccines) while majority (51%) development partner funds were spent on routine immunization activities (vaccine collection and per-diems/allowances to support outreaches). Conclusion The increasing dependence on development partner support raises issues around sustainability alongside other challenges like misalignment and displacement This warrants an increase in financial commitment to immunization by Government of Uganda, prioritization of resources for immunization at district level, and also operationalization of the existing financial sustainability plan for immunization.

Background Globally, cervical cancer is the fourth most common cancer in women with more than 85% of the burden in developing countries. In Uganda, cervical cancer has shown an increase of 1.8% per annum over the last 20 years. The availability of the Human Papillomavirus (HPV) vaccine presents an opportunity to prevent cervical cancer. Understanding how the health system influences uptake of the vaccine is critical to improve it. This study aimed to assess how the health systems is influencing uptake of HPV vaccine so as to inform policy for vaccine implementation and uptake in Mbale district, Eastern Uganda. Methods We conducted a cross sectional study of 407 respondents, selected from 56 villages. Six key informant interviews were conducted with District Health Officials involved in implementation of the HPV vaccine. Quantitative data was analyzed using Stata V.13. Prevalence ratios with their confidence intervals were reported. Qualitative data was audio recorded, transcribed verbatim and analyzed using MAXQDA V.12, using the six steps of thematic analysis developed by Braun and Clarke. Results Fifty six (14%) of 407 adolescents self-reported vaccine uptake. 182 (52.3%) of 348 reported lack of awareness about the HPV vaccine as the major reason for not having received it. Receiving vaccines from outreach clinics (p = 0.02), having many options from which to receive the vaccine (p = 0.02), getting an explanation on possible side-effects (p = 0.024), and receiving the vaccine alongside other services (p = 0.024) were positively associated with uptake. Key informants reported inconsistency in vaccine supply, inadequate training on HPV vaccine, and the lack of a clear target for HPV vaccine coverage as the factors that contribute to low uptake. Conclusion We recommend training of health workers to provide adequate information on HPV vaccine, raising awareness of the vaccine in markets, schools, and radio talk shows, and communicating the target to health workers. Uptake of the HPV vaccine was lower than the Ministry of Health target of 80%. We recommend training of health workers to clearly provide adequate information on HPV vaccine, increasing awareness about the vaccine to the adolescents and increasing access for girls in and out of school.

Background Early identification through newborn screening is the first step in active management of sickle cell disease (SCD). Uganda currently screens newborns and infants under 2 years for SCD in high HIV-burden districts using isoelectric focusing with dried blood spot samples. Our analysis sought to estimate the costs per child screened for SCD using this method in Uganda and then to use those data to estimate the price threshold for screening with a point-of-care (POC) test. Methods We estimated the financial and economic costs per child screened for SCD using data from health facilities and the Central Public Health Laboratory. These costs included sample collection, transportation, and laboratory processing. Price thresholds for a POC test were estimated using two scenarios. Results The price threshold of an SCD POC test used for diagnosis would be $3.77 when taking into account only financial costs and $5.14 when taking into account economic costs. Thresholds for a POC test used for screening would be $3.07–$3.51 and $4.38–$5.09, respectively, depending on test specificity. Conclusion The price threshold of a POC test for SCD will depend on the assumptions on how it will be used – either as a screening or diagnostic test. If used for screening, test specificity will have significant impact. Results from this type of costing study can allow developers to incorporate quantitatively estimated price thresholds for innovative products into target product profiles early in the product development cycle.

Background Global health partnerships have grown rapidly in number and scope, yet there has been less emphasis on their evaluation. Gavi, the Vaccine Alliance, is one such public-private partnership; in Gavi-eligible countries partnerships are dynamic networks of immunization actors who work together to support all stages and aspects of Gavi support. This paper describes a conceptual framework – the partnership framework – and analytic approach for evaluating the perceptions of partnerships’ added value as well as the results from an application to one case in Uganda. Methods We used a mixed-methods case study design embedded in the Gavi Full Country Evaluations (FCE) to test the partnership framework on Uganda’s human papillomavirus (HPV) vaccine application partnership. Data from document review, interviews, and social network surveys enabled the testing of the relationships between partnership framework domains (context, structure, practices, performance, and outcomes). Topic guides were based on the framework domains and network surveys identified working together relationships, professional trust, and perceptions of the effectiveness, efficiency, and legitimacy of the partnership’s role in this process. Results Data from seven in-depth interviews, 11 network surveys and document review were analyzed according to the partnership framework, confirming relationships between the framework domains. Trust was an important contributor to the perceived effectiveness of the process. The network was structured around the EPI program, who was considered the leader of this process. While the structure and composition of the network was largely viewed as supporting an effective and legitimate process, the absence of the Ministry of Education (MoE) may have had downstream consequences if this study’s results had not been shared with the Ministry of Health (MoH) and acted upon. The partnership was not perceived to have increased the efficiency of the process, perhaps as a result of unclear or absent guidelines around roles and responsibilities. Conclusion The health and functioning of global health partnerships can be evaluated using the framework and approach presented here. Network theory and methods added value to the conceptual and analytic processes and we recommend applying this approach to other global health partnerships to ensure that they are meeting the complex challenges they were designed to address.