J.12_Health_Systems_Assessment_Report.doc

REPORT

Uganda Health System Pre-Assessment 2016

TABLE OF CONTENTS

Figures

Boxes

Tables

ACRONYMS

AHSPR

Annual Health Sector Performance Report

ANC

Antenatal Care

ART

Anti-Retroviral Therapy

ARV

Anti-retroviral

BeMONC Basic Obstetric and Newborn Care

CAP

Common African Position

CeMONC Comprehensive Obstetric and New-born Care

CHEW

Community Health Extension Worker

CPR

Contraceptive Prevalence Rate

CSO

Civil Society Organization

DHIS2

District Health Information System - 2

DHT

District Health Team

DHMT

District Health Management Team

EAC

East African Community

EDPR

Emergency and Disaster Preparedness and Response

EMHS

Essential Medicines and Health Supplies

EmONC Emergency Obstetric and New-born Care

EOC

Emergency Operation Centre

GBV

Gender Based Violence

GDP

Gross Domestic Product

GFTAM

Global Fund for TB, HIV/AIDs and Malaria

GGE

General Government Expenditure

GoU

Government of Uganda

HC

Health Center

HCT

HIV Counselling and Testing

HDP

Health Development Partner

HMIS

Health Management Information System

HPAC

Health Policy Advisory Committee

HRH

Human Resource for Health

HSDP

Health Sector Development Plan

HSSIP

Health Sector Strategic and Investment Plan

HUMC

Health Unit Management Committee

ICT

Information Communication Technology

IDSR

Integrated Disease Surveillance and Response

IHP+

International Health Partnerships Plus

IPT

Intermittent Presumptive Treatment

IRS

Indoor Residual Spraying

ITN

Insecticide Treated Net

KCCA

Kampala City Council Authority

LLIN

Long Lasting Insecticide Net

LRI

Lower Respiratory Infection

MCH

Maternal and Child Health

MDA

Ministries, Departments, Agencies

MDG

Millennium Development Goal

MDR

Multi Drug Resistant

M&E

Monitoring and Evaluation

MOH

Ministry of Health

NCD

Non-Communicable Disease

NCRI

National Chemotherapeutic Research Institute

NDA

National Drug Authority

NDP II

Second National Development Plan

NHA

National Health Accounts

NHP II

Second National Health Policy

NMS

National Medical Stores

NTD

Neglected Tropical Disease

OOP

Out of Pocket

OPM

Office of the Prime Minister

PEM

Protein Energy Malnutrition

PHC

Primary Health Care

PMTCT

Prevention of Mother-To-Child Transmission

PNFP

Private-Not-For Profit

PPPH

Public Private Partnerships for Health

QI

Quality Improvement

RBF

Results Based Financing

RC

Resource Centre

RDT

Rapid Diagnostic Test

RRH

Regional Referral Hospital

RTI/A

Road Traffic Injuries and Accidents

SDG

Sustainable Development Goal

STI

Sexually Transmitted Infection SWAp

Sector Wide Approach

TB

Tuberculosis

THE

Total Health Expenditure

TWG

Technical Working Group

UBOS

Uganda Bureau of Statistics

UBTS

Uganda Blood Transfusion Services

UDHS

Uganda Demographic Health Survey

UHC

Universal Health Coverage

UNAP

Uganda Nutrition Action Plan

UNMHCP

Uganda National Minimum Health Care Package

UNHRO

Uganda National Health Research Organization

UVRI

Uganda Virus Research Institute

VHT

Village Health Team

1. BACKGROUND AND RATIONALE

The 2011-2015 USAID Uganda Country Development Cooperation Strategy (CDCS) hypothesized that a structurally sound, well-resourced, functioning health system supporting access to quality service delivery is essential to ensuring effective utilization of health services and, subsequently, to improving health outcomes (USAID, 2010). Therefore, prior to identifying and planning strategic and sustainable interventions to improve the health and well-being of Uganda’s population, it is essential to understand the elements that comprise Uganda’s national health system, the relationships and interdependencies between these elements, and the fiscal, political, economic, social, and multi-sectoral factors and stakeholders that influence and impact the system’s functionality.

The World Health Organization defines a health system as “all organizations, people and actions whose primary intent is to promote, restore or maintain health,” the purpose of which is to improve access and coverage of responsive, efficient, effective, equitable, and quality-driven health services (WHO, 2000). To this end, a health system is supported by a set of basic building blocks - including human resources, financing, information systems, medical supply chains, governance mechanisms, and service delivery structures - linked to quality assurance mechanisms, all of which serve to uphold the health sector’s responsibility and accountability to both patients and their communities (Figure 1). For diagrammatic purposes, health systems frameworks often present these building blocks as parallel, stand-alone pillars. In practice, however, elements of a health system are mutually derivative and reinforcing.

Figure 1: Core Functions of Health Systems

Adapted from USAID (2015), Vision for Health Systems Strengthening 2015-2019 An analysis that focuses on the six building blocks independently, then, is insufficient to understand the overlapping, multisectoral nature of health systems, and the influence of social, economic, and political actors and contexts upon them.

2. PURPOSE OF THE PRE-ASSESSMENT

This report is a preliminary pre-assessment of Uganda’s national health system. The purpose of the assessment is to catalog, synthesize, and analyze current information and evidence to assist the USAID Health System Strengthening Team as they embark on a further detailed understanding and description of the status of the health system in Uganda. To this end, the assessment also seeks to identify critical information gaps. The assessment will allow the Health Systems Strengthening Team to strategically identify areas of engagement that are within the manageable interests of USAID/Uganda so as to contribute towards improving and sustaining health outcomes in Uganda.

The key questions asked of this assessment were:

· How well are the building blocks of Uganda’s national health system functioning (i.e. governance, financing, service delivery, medical supply chain, information systems, community participation, and human resources)? For each of these building blocks:

· What are the challenges and gaps faced, and how might they be overcome or plugged to increase effectiveness?

· What specific resource issues do each of these building blocks face - such as personnel, budget allocations, polices/procedures and infrastructure - and how have these resource deficits affected quality and access to services?

· What best practices, approaches and lessons learnt have been adopted within and across each of the health system building blocks based on recent investments in the health sector?

· To what extent have recommendations from past assessments been implemented?

· Within each building block, who are the major internal and external actors/stakeholders in health system? What is their area of engagement? How can USAID leverage these stakeholders? What is USAID's comparative advantage?

· How does/does not the health system interact with other sectors, and how do these relationship(s) contribute to the functionality of the system?

· How does Uganda’s political economy influence the outcomes of its health system?

· What opportunities exist for USAID strategic intervention in the health system strengthening?

· What are the data and information gaps and recommended areas for further research?

As will become evident throughout this pre-assessment, there are major data gaps that prevent many of these questions from being answered sufficiently at this time.

3. METHODOLOGY OF PRE-ASSESSMENT

3.1 Pre-assessment Design

The pre-assessment was carried out utilizing a mixed methods approach, using both quantitative and qualitative data collection methods, guided by the “Getting to Know Answer Matrix” (Annex II) and structured thematically according to building blocks/core health systems functions established within the World Health Organization Health Systems Approach’s Framework for Action (2007), an adapted version of which is also used by USAID for its Vision for Health Systems Strengthening (2015).

Adapted from WHO’s Framework for Action (2007)

3.2 Data Collection

Data collection included a document review of key planning, implementation, performance, research and reporting documents, along with an analysis of relevant data sets both at national and local government level. Documents included annual health sector performance reports, health sector investment plans, health budget framework papers, Uganda demographic health surveys, as well as other health system assessments and research conducted by the private sector, universities, civil society, government and donor partners. Additionally, interviews were conducted with key informants at national level.

3.2.1 Sampling

Informants were identified using purposive sampling. These interviews were intended to fill in gaps identified during literature review and data analysis. No interviews were conducted at district and other local government levels, as this is planned for the next phase of this study.

3.2.2 Data Management and Analysis

Quantitative was cleaned and manually edited for any irregularities. Preliminary results of these analyses were presented to the QED and USAID Teams. Qualitative data was processed and analyzed thematically, focusing on major emerging themes and explanatory factors. The analysis of qualitative data was carried out concurrently with fieldwork in a reflexive and iterative process.

Data analysis was carried out using a number of different approaches. New or emerging components of the building blocks have been described in terms of their roles, positioning and functionality. Analysis of existing sector performance monitoring data was undertaken using trend analysis to determine the performance of the health sector over time as well as its current state. Trend analysis included budgetary information in terms of the Government of Uganda’s financial and donor contributions to the health sector. Additionally, comparison between the current status of the health system building blocks and the status of the health system building blocks as per the last assessment of 2011, so as to understand implementation of the 2011 recommendations was also used.

4. STRUCTURE OF THE PRE-ASSESSMENT REPORT

This assessment is structured according to each of the six health systems building blocks described by USAID as core health systems functions: Governance, Health Service Delivery, Health Human Resources, Health Financing, Health Information Systems, and Medical Products and Medical Supply Chain. For each of each of these building blocks, the report sketches the key stakeholders, resource availability, functionality, intra-sectoral interactions, challenges, and data and information gaps encountered with respect to Uganda’s health sector according to the questions put forth in the SOW.

5. UGANDAS NATIONAL HEALTH SYSTEM

5.1 Introduction

In 2014, Uganda was ranked 164th out of 187 countries on the Human Development Index, and categorized by the UNDP as having a low human development category (UNDP, 2013). Nevertheless, the country has made small incremental improvements since 2005, both broadly in terms of its general human development indicators and, more specifically, in terms of its health status indicators, especially over the last five years (Table 2). These improvements can be attributed partly to the country’s overall economic growth and to large-scale overseas development assistance (ODA) provided by Uganda’s development partners, specifically to the country’s health sector.

Table 1: Uganda Health Status Indicators

* HSA 2011

For example, while Uganda is classified by the World Bank as a low income country, Uganda’s poverty head count decreased from 31.1% of the population in 2005, to 19.5% in 2012, while its Gross National Income (GNI) per capita increased from US $0.880 to $1.168 over the same period, with overall GNI more than tripling during this time (UNDP, 2013; World Bank, 2015). The country’s Gross Domestic Product (GDP) Annual Growth Rate, although inconsistent, averaged 6.85% annually between 2006 and 2015, with both life expectancy and mean years of schooling also slowly improving (Trading Economics, 2013; UNDP, 2013). Simultaneously, Overseas Development Assistance (ODA) commitments increased from $1,497.82 million US$ in 2005 to 2,083.68 in 2010 (WHO, 2011). Within this total, health commitments increased from $367.02 million to $498.67 million, with financing skewed toward MDG 6 (HIV/AIDS, malaria, TB) disease-specific programs and with US government assistance representing 59.6% of all ODA for health (WHO, 2011), The combination of these factors – i.e. Uganda’s slow but steady economic growth, and the distortion of health sector ODA toward vertical disease/health condition programs – have had (and will continue to have) major implications for the structure and performance of Uganda’s health sector, and the functionality of the country’s health system.

Presently, the World Health Organization has situated Uganda at the second lowest tier of the epidemiological transition away from conditions recognized by the Millennium Development Goals (MDGs) as the main cause of mortality in resource-poor countries (i.e. those related to infectious disease and maternal, neonatal, and nutrition conditions) toward the sorts of non-communicable and chronic diseases characterizing middle- and upper-income countries. Between 60-70% of years of life lost (YLL) in Uganda can presently be attributed to what has been referred to as MDG-conditions (WHO, 2014). As with many countries in Africa, the burden of AIDS, TB, malaria, vaccine-preventable childhood disease, maternal and neonatal conditions, and complications related to poor nutrition, has necessarily directed the priorities of Uganda’s health system toward evidence-based targeted interventions that have, both in Uganda and elsewhere, led to progress in reducing national mortality and incidence rates. However, there is an increasing recognition by both government and its partners that Uganda will soon be facing the dual burden of both communicable and non-communicable disease, a situation which will require a radical rethinking as to how health systems are financed and organized, and how health services are staffed and delivered. Additionally, government and its partners are also coming to understand that the progress presently being made by targeted interventions will only be sustainable in the long-term if concomitant investments are made to Uganda’s overall health system.

This section of the pre-assessment discusses each of the building blocks of Uganda’s national health system in turn, in order to analyze the status of each block, and the elements that exist both within and between building blocks that may affect, as well as point the way toward, future strategic orientations and interventions.

5.2 Governance

Governance refers to the policies, strategies, plans, guidelines and institutional structures that have been put in place to support partnership, coalition-building, planning and systems design, and regulation, oversight and accountability (WHO, 2015). In Uganda, the primary mechanism underpinning these structures is the Sector Wide Approach (SWAp). Through the SWAp, government, partners, stakeholders and institutions - guided by the IHP+ framework for health partnership – work to coordinate, plan, manage, and oversee all health-sector related resources, programs and activities.

5.2.1 Stakeholders In Uganda, governance and leadership stakeholders exist at multiple levels of the health system, and feed into decisions regarding policy-making, strategic planning, and the creation of oversight and accountability mechanisms. These include:

· Parliament and Parliamentary Committees (e.g. The Parliamentary Committee on Health, The Parliamentary Committee HIV/AIDS and Related Matters)

· Relevant Cabinet Members (e.g. Minister of Health, Minster of State for Health, Minister of State for Primary Health Care), along with other members of the Top Management Committee

· The Ministry of Health, its Senior Management Committee, and its:

· Departments (e.g. Clinical Services, Planning, Finance and Administration, Disease Control, Quality Assurance, Nursing, Community Health)

· Programs (e.g. AIDS Control, Malaria Control, TB Leprosy Control, Expanded Program on Immunization, Sanitation Fund, Guinea Worm Eradication, Jiggers Eradication, Onchocerciasis Control)

· Commissions (e.g. Health Services Commission, Uganda AIDS Commission)

· Affiliated Health Service Bodies (e.g. Uganda Blood Transfusion Service, National Medical Stores, Central Public Health Laboratories, National Drug Authority, Uganda National Health Research Organization).

· Ministry of Finance, Planning and Economic Development

· Development partners (bi- and multi-lateral donors)

· Technical partners (e.g. UN agencies such as WHO, UNICEF and UNAIDS, that provide technical support for policy, strategy, and guideline development)

· Various high- and mid-level institutional forums for government-partner dialogue (e.g. the Inter-Agency Coordinating Committee, the Health Policy Advisory Committee, the Health Development Partner Group, the Joint Review Missions for the Health Sector, the National Health Assembly, the Health Sector Working Group and other technical working groups and sub-committees, Technical Review Meetings, and the Global Fund Country Coordinating Mechanism/CCM)

· Health professional councils (e.g. Uganda Medical and Dental Practitioners, Allied Health, Nurses and Midwives, and Pharmacy)

· Local government executive committees and councils (e.g. Regional Management Committees, District Health Management Teams, Health Unit Management Committees, Village Health Teams)

· Civil society and advocacy organizations; Media

5.2.2 Resource Availability There is presently no known detailed discussion of the financial and/or other resources directed primarily toward strengthening governance and leadership mechanisms in Uganda. Often government, donor or technical support for policy, planning, coordination, or the establishment and maintenance of institutional mechanisms will be included under general budget lines for national or local government “capacity building” or “dissemination.” Similarly, for NGOs and civil society organizations, resources directed toward governance end up being included under “advocacy” or “community mobilization”. A framework for delineating resources currently available for health governance is urgently needed, as is a comprehensive costed needs assessment for the governance building-block.

5.2.3 Functionality

Policy Environment for Health Governance The Ugandan health system is governed by a series of strong, consecutive policy frameworks and strategic plans. The country’s first 10-year National Health Policy (2000/01-09/10) was followed by the Second National Health Policy (2010/11-19/20) that presently extends to the year 2020. The Second National Health Policy highlights four key priority areas for the health system:

1) Strengthening health systems especially via existing mechanisms of decentralization;

2) Reorganizing and improving supervision, monitoring and evidence-based decision-making;

3) Achieving functional integration both within the public sector, and between public and private sectors in health care delivery, training and research;

4) Addressing the human resources crisis.

These National Health Policies have been supported since 2000 by a number of consecutive 5-year strategic plans. These plans include Health Sector Strategic Plans (HSSPs), the most recent of which, the HSSP III (2010/11-14/15) was supplanted by the First National Health Sector Strategic and Investment Plan (HSSIP) (2010/11-14/15) which now serves as a guide to planning and implementation for the health sector. Additionally, to fully integrate the Health Sector with the country’s Second 10-Year National Development Plan (2014/15-19/20), as well as Uganda’s Vision 2040, the first long-term Health Sector Development Plan (HSDP) (2015/16-2019/20) has also been developed.

The National Health Policy, HSSIP, and HDP were formulated by the Government of Uganda in partnership with various health sector development partners, civil society organizations, and private-for-profit (PFP) and private-not-for-profit (PFNP) health delivery stakeholders, in cognizance of national, regional, and international conventions like the 1995 National Constitution, the 1997 Local Government Act, the Abuja Declaration, the Maputo Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa, Article 14: Health and Reproductive Right, the UN Global Strategy for Women and Children’s Health (Every Woman, Every Child), Inter-Parliamentary Union Resolution on Securing Health of Women and Children, as well as the MDGs and Sustainable Development Goals (SDGs). Additionally, a compact for implementation of the HSSIP was made between government and health sector partners (including development, technical, private-not-for-profit, and civil society partners), which committed these partners to technical and financial assistance for the HSSIP implementation. The performance of the compact is monitored annually (MOH, AHSPR 2014/15).

Uganda also has in place a number of guidelines, strategies, policies and road maps establishing frameworks for implementation of programs within the health system (e.g. malaria, AIDS, child health, maternal and neonatal health, adolescent health, immunization, and other critical health problems).

Institutional Environment

Institutional mechanisms for health governance exist at multiple levels of the health system, as outlined in the stakeholder section. Since amendments to both the 1995 Constitution and 1997 Local Government Act, health governance takes place within the context of decentralization in which the governance of the country is devolved from the center to the districts to municipalities, town councils and sub-counties. The number of districts in Uganda has increased rapidly, particularly over the past two and half decades, from 112 in 2010 and 135 in 2015. This also applies to municipalities, which have increased from 23 and 42 over the same period. There are structures at sub-national level, including Regional Management Committees, District Health Management Teams, Health Unit Management Teams, and Village Health Teams, in place to – theoretically - support decentralized planning, budgeting, and service delivery.

Decentralization is meant to empower local government in strategic planning, partnership- and coalition-building, and accountability measures. In reality, however, the degree to which governance is strengthened under decentralized systems is often dependent on the initiative and force of personality of local government leaders. It also depends on whether or not devolution of power extends to major policy and strategy decisions, or just to budgets and service delivery. In Uganda, existing data on the effect of decentralization as it relates specifically to health systems governance is quite outdated, and much of the existing research focuses on the implications of decentralization for health systems financing at district level and for the management of human resources.

There are institutional mechanisms within the Ministry of Health, and between the Ministry of Health and its partners to develop and operationalize policies and strategies, as well as to ensure accountability measures exist across all levels of the health system. These include the Top Management Committee, Senior Management Committee, and other committees and sub-committees within the Ministry of Health through which strategies, plans and policies are reviewed and approved. Such committees do meet regularly; however, it is worth understanding better other indicators of functionality, such as the pace at which policy or institutional change can be achieved, and the levels of bureaucracy through which proposed changes must pass.

Additionally, there are forums for partners (including the PFNP sector) and government to review strategy, engage in planning, target resources, and implement and improve accountability measures. These include the Inter-Agency Coordinating Committee, the Health Policy Advisory Committee, the Health Development Partner Group, the Joint Review Missions for the Health Sector, the National Health Assembly, the Health Sector Working Group and other technical working groups and sub-committees, Technical Review Meetings, and the Global Fund Country Coordinating Mechanism/CCM).

Some of these mechanisms function efficiently. The Auditor General, for example, will present a report to the Joint Review Mission, the National Health Assembly and the Parliament on annual basis. The Annual Health Sector Progress Report, however, judges a number of the existing structures for partnership engagement as moribund, and as failing to provide the needed forums for sector engagement. The functionality of, for example, the Health Policy Advisory Committee (HPAC) is compromised, with its current focus primarily on statutory actions (e.g. endorsing proposals) as opposed to being forum for dialogue. Some partners, therefore, sidestep these structures, and provide support that is not coordinated and harmonized (MOH, AHSPR 2015). There has not yet been an evidenced-based qualitative and quantitative assessment of the AHSPR’s findings on the mechanisms’ perceived value, their achievements, and their impact on health governance.

Uganda also has four Health Professional Councils (Uganda Medical and Dental Practitioners, Allied Health, Nurses and Midwives and Pharmacy) that are responsible for the registration and annual licensing of health workers and the standardization of training and practice (Draft Concepts of Health Professional Authority Bill, 2015). There are plans to have one umbrella council, the Health Professional Authority, in line with East African protocol to strengthen regulation (Katumba, 2015). Health practitioners are, thus, efficiently registered and licensed through the existing structure; however, it is unclear how standards of training and practice are enforced given weak (and frequently nonexistent) performance management systems in the public sector at local government levels, and the lack of capacity to monitor private sector health providers and health training facilities (MOH AHSPR, 2014/15).

For example, a situation analysis of the supervision, monitoring and inspection (SMI) system in the health sector demonstrated inadequate leadership at all levels to demand and enforce regular SMI, and to ensure follow up of the recommended actions. While regional supervisory and monitoring teams exist with funding from the Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM) to monitor GFATM activities, these teams have not yet been integrated to provide broader supervisory support. In the words of one Key Informant: “The health sector has not developed a framework on how these teams can also support other health sector sectors activities. Preferably these teams could be based in the Regional Referral Hospitals for sustainability purposes” (KI Interview, GFATM Official, MOH). District Health Management Teams (DHMT), moreover, do not have adequate resources and skills to visit health units and at times health units can spend a year without support supervision.

Besides the Health Professional Authority Bill (currently still in draft form), there are several regional initiatives to remedy weak supervisory structures. For example, a Health Sector Support Supervision, Monitoring and Inspection Strategy has been finalized and shared within the Sector Monitoring and Evaluation Technical Working Group, to be rolled out in 2015/16. There is also pilot program supported by Swedish Development Agency and Belgium technical Cooperation (SIDA/BTC) to develop a planning structure on the regional level in Fort Portal and Arua that hopefully will be extended to more regions (Swadin, 2013). The State House, meanwhile, has a Medicines and Health Services Delivery Monitoring Unit which directly reports to the President and does investigate instances of misconduct (MOH, AHSPR, 2014/15). District and hospital league tables also exist to serve as a performance management assessment tool.

Institutions that might support demand-side health governance and accountability mechanisms include media and civil society organizations (CSOs). Uganda has two active associations of health journalists – Uganda Health Journalists Alliance and Health Journalists Network of Uganda - who receive training from Makerere University College of Health Sciences on the use of research evidence in health reporting (Semakula and Nsangi, 2016). There is active reporting on health in both print and electronic media, as well as regular meetings for journalists on specific health topics, such as Science Cafés organized by the Global Advocacy for HIV Prevention AVAC to discuss recent advances in HIV/AIDS (KI Interview with Official, Health Journalists Network of Uganda). Media is to a large extent able to openly report on health issues.

While policy and institutional mechanisms for health governance in Uganda, theoretically, provide a framework for incentives to encourage civil society to participate in joint planning, management, and oversight alongside other partners, civil society and voluntary organizations nevertheless remain marginally involved in the making and implementation of public policy. While advocacy mechanisms are an important element of accountability within health governance, the degree to which investments in, and outreach to, both media and civil society impact both the overall health system, and health governance in particular, has not been adequately measured.

5.2.4 Challenges There are a number of challenges to health governance.

· While there is a strong set of policies, strategies and plans in place, too often stakeholders struggle to implement them. Moreover, while there has been a proliferation of institutional mechanisms – committees, working groups, etc. - for health governance, not all of these function as they are supposed to function. There is limited data addressing why this is the case, and the impact of this situation on the health system and on health outcomes in Uganda.

· There is poor generation and use of evidence in policy-making, and inadequate analysis of how to better package and disseminate data in a manner that is useful to policy makers.

· There is a weak overall legislative process. For example, five bills were brought before Parliament in 2011, and still none have been passed. This creates a backlog of legislation within which critical health legislation – such as the Health Professional Authority Bill - gets held up. Not enough resources are directed toward expediting health legislation through the legislative process. .

· District and local health governance units – such as Health Unit Management Committees – are not fully functional. Moreover, there is no immediate means by which to measure functionality and impact of such units. Supervisory and monitoring structures remain weak.

· Even though there is a strategic mandate for partnership the private-for-profit health sector, including traditional and complementary medicine practitioners, civil society, and advocacy organizations, participation in existing governance structures remains poorly coordinated.

5.2.5 Extent of Implementation of Previous Assessment Recommendations

Four recommendations along with sub-recommendations were made during the 2011 Health Systems Assessment with regard to governance. These recommendations focused on improved coordination, strengthening decentralized health systems performance, and building capacity among PFP, PNFP, and civil society stakeholders. Implementation of these recommendations has been mixed:

Recommendation 1: Strengthen MoH capacity to coordinate all health sector stakeholders.

i. Strengthen the Health Policy Advisory Committee (HPAC) and Senior Management Committee.

Extent of Implementation: Both institutions are fully functional and meet regularly.

ii. Make the compact explicit to other stakeholders and honor their respective roles throughout the entire duration of the compact (for example PFP and PNFP sectors should have an opportunity to review the Compact and also come on board as signatories, and there should be greater representation of PFP and PNFP providers in the HPAC).

Extent of Implementation: This recommendation has not been fully implemented. Out 33 members of the HPAC, only 3 (10%) are from PNFP and PHP although the private sector provides >40% of the health services in Uganda (MOH, AHSPR, 2015).

iii. Include private sector representation in all the working groups.

Extent of Implementation: This recommendation has not been implemented. “The inclusion private sector representation in all the working groups was passed by HPAC but has not been implemented. It needs revitalization by leaders of private sector” (KI Interview, Official, HPAC Secretariat).

iv. Support districts to improve coordination at the district level between government and development partners (e.g. to attend Quarterly Review meetings and District Health Management Team meetings).

Extent of Implementation: This recommendation has not been fully implemented, and exists only in pilot phase in two regions: West Nile and Fort Portal (MOH, AHSPR 2015).

Recommendation 2: Create management and administrative efficiencies within the decentralized system by aggregating districts into health regions.

i. Create a Regional Administrative tier (with Regional Health Management Teams with MoH Regional Director) as an extension.

Extent of Implementation: This recommendation has not yet been fully implemented and exists only in pilot stages.

Recommendation 3: Create an enabling environment to strengthen district performance

i. Invest in health infrastructure, particularly in newer districts that lack it (e.g. office accommodation and equipment, transport).

Extent of Implementation: There has not been an earmarked comprehensive approach, but there are plans for this to be done when development funds are available in the budget.

ii. Institutionalize use of district league table indicators for performance at district and facility level.

Extent of Implementation: This has not yet been done at district level, only at national level and done only during writing of the Annual Health Sector Performance Report.

Recommendation 4: Build PFP and PNFP capacity to represent their own constituencies and to actively participate in policy and planning; raise the consumer and civil society voice.

i. Strengthen Civil Society Organizations (CSOs) and Health Unit Management Committees (HUMCs) through additional financing, capacity building, information sharing, and community dialogue to strengthen community voice and oversight.

Extent of Implementation: Civil society is active at the national level (e.g. CSOs attend the HPAC and engage in policy dialogue); however, there has been no earmarked financial support for training sub-national HUMCs and most have not yet been sufficiently strengthened.

ii. Support assistance to the media to improve the amount and quality of reporting on health issues.

Extent of Implementation: There is on-going training of media in health and research reporting, but no specific program support to improve media coordination and capacity to engage stakeholders (KI Interview, Official, Health Journalists Network of Uganda).

iii. Support MoH and private sector efforts to create an umbrella organization representing the entire private health sector.

Extent of Implementation: Uganda Health Care Federation is active, has a secretariat, and is part of the East African Healthcare Federation (Uganda Health Care Federation, 2015).

iv. Strengthen professional associations to represent both public and private perspectives in policy and planning processes.

Extent of Implementation: This recommendation has not yet been implemented.

5.2.6 Intra-sectoral Interactions Governance structures do not operate independently of the other health systems building blocks. Governance structures require functional and substantive Health Information Systems upon which to base evidence-based policy and decision-making. Governance provides the frameworks upon which human resources, supply chain management, and service delivery systems rest, as well as serves to establish and coordinate mechanisms for health financing. Health governance is impacted by nature of Uganda’s development partnerships and the reliance by the Government of Uganda on external financing for its health system. Most importantly, governance structures require a sufficient, motivated health workforce - to manage and administrate, to generate data for decision-making, to implement and act on the policies, strategies, and guidelines being generated.

5.2.7 Data and Information Gaps

While there exists an ample body of policy and strategy documents for Uganda, a number of information gaps exist with regard governance. For example:

· There is little detailed examination– beyond the descriptive information contained within government documents such as the HSSIP and HSDP – as to the various spheres of health governance in Uganda, nor is there analysis of how or why various national, regional, district, and local health governance structures interact, intersect, or influence one another (or not). Similarly, there is no data available on existing resources for health governance, nor is there a costed needs assessment for the governance building-block.

· There is no readily-available detailed stakeholder analysis of actors involved in governance issues in Uganda, their current and historic role in contributing to the country’s policy and institutional environment, or their relative power and position in determining policy process and/or content, and in creating and maintaining existing institutional mechanisms for governance.

· There is no in-depth qualitative research as to how well stakeholders from across the health sector view specific institutional mechanisms for health governance as working (for example, the HPAC, the Joint Review Missions, the Health Partner Development Group), nor has the institutional performance of these different mechanisms been empirically measured or assessed. Discussions of internal Ministry of Health mechanisms – such committees, sub-committees – tend to be purely descriptive, not analytical nor measured against performance. Information is available as to what such mechanisms are supposed to do, where they sit in the overall structure of the Ministry of Health, who participates in them, and whether or not they take place, but less is known about how and whether they achieve, and/or are perceived to achieve, their goals and objectives.

5.3 Health Service Delivery

Health service delivery refers to elements of a system that ensure coverage of and deliver effective, efficient, quality services and interventions to a population. Service delivery, thus, refers to the local, district and central government structures that plan, manage, and provide oversight of health facilities across all levels of the health system, the facility network itself, and the programs, projects and initiatives aimed at promotion, prevention, and palliative care that supplement facility-based treatment.

5.3.1 Stakeholders In Uganda, health service delivery stakeholders are numerous and extend down to the bottom most rung of the primary care system.

· Sub-national and local government management units (e.g. Regional Management Committees, District Health Management Teams (DHMTs), Health Unit Management Committees, Village Health Teams (VHT))

· Public health facilities delivering care from tertiary down to community level, including Village Health Teams (HC I), Health Centers (HC) IIs, IIIs, IVs, General Hospitals, Regional Referral Hospitals (RRH), National Referral Hospitals

· PFNP clinics and hospitals, many of which are church affiliated and operate under the Uganda Protestant Medical Bureau, Uganda Catholic Medical Bureau, the Uganda Muslim Medical Bureau, and the Uganda Orthodox Medical Bureau, or programmatically, under the Inter-Religious Council of Uganda (an umbrella for faith-based providers). PFNP Medical Bureaus have internal implementation structures, including zonal and programmatic coordination bodies within them. Other PFNPs include NGO-based PFNPs such as the TASO network for AIDS/TB services, as well as research institutions such as IDRC, IDI, and Walter Reed that provide health services to patients in the context of research.

· Traditional and complementary medicine practitioners and practitioner umbrellas, most notably THETA (Traditional and modern Health Practitioners Together against AIDS and other Diseases), which has partnered with biomedical researchers on evidence-based traditional medicine provision.

· The Ministry of Health, its Senior Management Committee, Health Services Commission and its AIDS Commission, along with affiliated Health Service Bodies (e.g. Uganda Blood Transfusion Service, National Medical Stores, Central Public Health Laboratories, National Drug Authority, Uganda National Health Research Organization).

· Departments (e.g. Clinical Services, Planning, Finance and Administration, Disease Control, Quality Assurance, Nursing, Community Health)

· Programs (e.g. AIDS Control, Malaria Control, TB Leprosy Control, Expanded Program on Immunization, Sanitation Fund, Guinea Worm Eradication, Jiggers Eradication, Onchocerciasis Control)

· Commissions (e.g. Health Services Commission, Uganda AIDS Commission)

· Development partners (bi- and multi-lateral donors, including Global Fund) providing financing for implementation of services

· Technical partners that provide technical support for specific types of service provision (e.g. WHO, UNICEF, UNFPA)

· Regional implementing partners, overseeing USAID and CDC sub-contracted programs that provide support for AIDS and TB service provision and, increasingly, for integrated health services both at primary level (e.g. the former STAR programs) and at RRH level (SUSTAIN). These have included EGPAF, MJAP, Baylor, JSI, MSH, PLAN, URC and others.

· Various high- and mid-level institutional forums for government-partner coordination for planning and implementing health assistance (e.g. Health Sector Working Groups and other technical working groups and sub-committees, and Technical Review Meetings)

5.3.2 Resource Availability Resource availability for service provision has been organized, in the past, either via the health basket into which development partners such as the UK Government, World Bank, European Commission and others contribute according to the principles of SWAp, or along vertical lines, with service provision for AIDS, TB and Malaria services being supported by, especially, US Government PEPFAR and PMI, as well as subsequent Global Fund rounds. Immunization services related to the Extended Program for Immunization receive resources from GAVI. Increasingly, resources for other key health issues, such as Reproductive, Maternal and Newborn Health, have come available as new global policy windows and programs open up (e.g. Saving Newborn Lives, Saving Mothers Giving Life).

5.3.3 Functionality

Service Functionality While coverage of health services is generally good, and many indicators have slowly been improving, the functionality of service provision is still an issue and varies greatly across categories of service provider, districts, and regions. On one hand, the performance of core output indicators in Uganda in 2014 was generally better than in 2010. For example, OPD utilization is a proxy measure for access to services, and OPD utilization increased from 0.95 in 2010 to 1.2 in 2014. However, even where progress was made, most core service delivery outputs fell short of attaining the HSSIP targets. For example, although the proportion of pregnant women attending four ANC visits increased from 32% in 2010 to 36.6% in 2014, it is still far short of the HSSIP target of 60%. Likewise, the proportion of health facility deliveries increased from 39% to 52.7%, far off the HSSIP target of 90%. The proportion of children vaccinated for measles by one year of age increased from 85% to 90% against an HSSIP target of 95%, while the proportion of pregnant women receiving IPT2 increased from 34% to 53.4% against an HSSIP target of 70% (AHSPR 2014/15).

The inability to meet existing output targets has affected the country’s progress toward health impact, as infant, under-5, and maternal mortality, while slowly decreasing, also all remain off HSSIP target, in particular the maternal mortality ratio (MMR) which at 360/100,000 is far from the target goal of 131/100,000. MMR is, in many ways, also a proxy measure of the soundness of a health system, as large gains in MMR reduction are often related not simply to one or two single high impact vertical interventions (like the gains in mortality reduction that might be achieved by a mass bed net distribution or vaccination campaign), but rather due to a range of initiatives working simultaneously to strengthen all the building blocks of a health system.

Table 2: Performance for health services core indicators

Source:

Services falling under the context of vertical programs have performed significantly better. Uganda’s MoH implemented a comprehensive TB/HIV collaborative intervention package in 2005. Integrated TB/HIV care now follows the “One Stop Centre” model. As a result of improved integration and coordination by the HIV and TB programs, by 2013 the proportion of HIV‐positive population on HAART had increased to 62% (UNDP 2013), with 81.7% HIV positive people screened for TB (Uganda AIDS Commission, 2012). The proportion of HIV‐positive TB patients on co-trimoxazole preventive therapy (CPT) increased from 70.9% in 2008 to 94% in 2012 (Uganda AIDS Commission 2012; WHO 2013). Similarly, the number of children exposed to HIV by their mothers who received the first PCR test increased from 22,705 in 2011 to 70,634 in 2014. This progress has largely been attributed to the sustained efforts at scaling up ART and DOTS/Community-Based DOTS service delivery, including the EMTCT program which has had the active participation of the First Lady of Uganda. (AHSPR 2014/15).

At the same time, systems weaknesses mean that even well-resourced vertical programs still struggle in a number of areas. For example, while Uganda implemented the expanded and enhanced DOTS intervention to all districts in 2010, TB case detection, adherence monitoring via DOTS/CB DOTS, and sample referral for drug sensitivity testing all suffer from health systems issues related to the human resources crisis, weak referral networks, and poor information systems.