The health status of people in sub-Saharan Africa continues to lag behind that of those in other regions (1, 2). Morbidity and mortality among children and adults remain unacceptably high. The health sector must meet increasing demands with resources that are often declining in real terms. As this is likely to continue, better management of existing resources offers the best and perhaps the only hope of improving the quality of health services and increasing the health status of the people (3).
In developing countries, a management-by-results approach is a common strategy for improving health care services, i.e. setting quantitative coverage targets for specific interventions combined with inspection-oriented supervision (4, 5). Yet sustainable quality improvements are rarely achieved because underlying managerial and logistical weaknesses are not addressed. These deficiencies often discourage health care workers from applying their skills and make it difficult for the health system to use effectively the external resources provided.
A fundamentally different management approach, variously termed total quality management (TQM) or continuous quality improvement (CQI), has been widely embraced by health services and industry in Japan, Europe, and North America (6). Broad-based, process-oriented management, the use of teams, and decentralized decision-making have generally replaced the traditional "top down" management approach in efforts to achieve quality in products and services.
In the Ugandan public sector, wide-ranging decentralization has devolved both the authority and funding of district-level health services to the district government, opening new possibilities for health management initiatives. We report here the introduction on a national basis of TQM methods for health services in Uganda, difficulties encountered during their introduction, and the results achieved in the first 18 months following their introduction.
Health Services in Uganda
After two decades of internal conflict that have seriously eroded health services, Uganda is undergoing major sociopolitical reform. The three-year national health plan, drawn up in 1993, reoriented the focus of the Ministry of Health towards primary health care (7). Government services, including health services, have been decentralized to the district level. Accordingly, each district health team prepares an annual work plan and budget which are submitted to its district council for funding from the treasury block grants that the council receives. A cost-sharing plan was introduced, allowing collected funds to be utilized by the health facility concerned. The management of Ministry of Health headquarters has been restructured to be more responsive to the needs of decentralized districts. The health sector's share of the national budget has increased from 1% (1986) to 5.8% (1994), equivalent to a per capita increase from US$1.20 to US$5.00. However, central government health expenditures still remain considerably less than those in most sub-Saharan African countries (8).
During development of the three-year plan, a recurrent finding was poor management of hospitals and health services. In selecting activities to be financed under the World Bank's Second Health Sector Loan to Uganda, improving the quality of care was made a priority. A national quality assurance programme was launched in March 1994, and its first task was to assist health teams in managing their decentralized districts. The methods used built on the experience of a quality assurance pilot project carried out in Kabarole and Bundibugyo districts in Uganda by the German Agency for Technical Cooperation (GTZ) and UNICEF.
Evolution of quality improvement methods
Quality improvement methods were introduced in manufacturing industries in the 1930s when it became evident that reliance on inspection was less effective than strengthening the production processes (9). …