healthrightsadvocate

Recruit More Healthworkers this financial year

2011-03-25T01:08:00.000-07:00

According to the Ministry of Health, Human Resources for Health Recruitment Plan
(2011-2020),the health sector is currently grossly understaffed with nearly half of the approved positions being vacant. A deeper analysis of the current staffing reveals yet another dimension of this problem in that majority of the staff in post are either support or administrative staff. Qualified health workers including doctors, midwives, nurses and allied health professionals are in shortage and more especially in hard to reach rural districts and the new districts. This situation seriously compromises the performance of the sector and particularly in its contribution to national development. According to the trend analysis of the performance of the health related indicators done in the National Development Plan, it is unlikely that the MDG targets of these indicators will be met if the same trend continues. Infant mortality needs to improve from 76 to 41 while under five mortality needs to improve from 137 to 60 and maternal mortality ratio from 435 to 131 by 2015/1016 which is just 4 years away. Further according to the 2009/10 health sector performance report 7 out of the 8 HSSPII PEAP indicators fell short of the set targets. The percentage of deliveries in health facilities were at 33% against the HSSPII target of 50%. The % of approved positions filled by qualified health workers was at 53% at the end of HSSPII falling short of the 65% HSSPII target. Inadequate number of skilled personnel to deliver the Uganda National Minimum Health care package especially of mother and child health, communicable, non communicable and nutrition services was one of the key challenges highlighted in the performance report. The need to urgently address the current HRH crisis that the sector faces is therefore a high priority agenda. The gross understaffing is partly attributed to insufficient recruitment in all local governments for close to four years due to limited wage bill ceilings. Even when wage ceilings provided for recruitment, the funding for the DSC was not adequate to cover the recruitment costs leading to under utilization of the wage bill. Difficulty in attracting certain cadres of staff especially medical officers, dispensers, lab technicians and anesthetic officers has also posed a major challenge to previous recruitment efforts. It is no wonder therefore that even in districts which have relatively higher proportions of their approved posts filled, the major positions filled are those of support staff with low proportions of qualified health workers.

The districts currently have on average only 52% of the staff they need to work (this reduced from 53% after the creation of new districts). In real terms the sector needs approximately 49,000 staff in the district health systems excluding the national and regional referral hospitals but has only 25,000 staff are in post currently. This means that for the sector to be fully functional and perform according to expectations there is need to recruit at least 24,000 more health workers.

Additionally the limited motivation and retention packages given to health workers has contributed to poor performance, absenteeism and even inability to retain critical cadres even where health workers have been recruited. Currently, health workers receive a meager consolidated Duty Facilitation Allowance
(DFA) of Uganda shilling 90,000/- for senior consultants and other senior staff and 45,000/- for the lower level staff. This amount has remained the same for the last five years.

The health sector wage bill has remained constant at 178.07 billion, yet the costing of the HSSIP indicates that in 2011/2012, 688.02 billion will be required to recruit a sufficient number of health workers as per the current staffing norms. The health sector BFP indicates there are plans to recruit an additional 1000 health workers in 2011/2012 but requires an additional 1.8 billion.

Proposal: CSOs cognizant of the constrained resources recommend the recruitment of at least 5000 staff in the next financial year (FY 2011/2012). The cadres to be recruited would comprise mainly qualified health workers i.e. doctors, midwives, nurses and allied health professionals. According to the Human Resources for Health Recruitment plan, this translates in a total wage need of 34 billion and 2 billion to cater for recruitment costs incurred by the DSCs. it would be cost effective to allocate 2 billion to recruit 5000 than 1.8 billion to recruit 1000 health workers. Currently the health sector wage bill is 178.07 bn and increase of this by 34bn would bring the total sector wage bill to 212.07 bn. In order to retain existing healthworkers, and to attract skilled applicants to the positions, we propose additional motivation and retention packages in the form of increasing the DFA based on performance for all cadres of health workers from a minimum of 45,000/- and 90,000/ to 200,000/= and 400,000/- respectively.

If this is done the staffing level would move to 65% and if the trend is continued in subsequent years the NDP target of 85% staffing level would be met by 2014/2015 and subsequently this would have a positive effect on the national development goals. Payment of increased DFA based on performance will have a positive effect on motivation, and increase the capacity of the health system to retain all cadres of qualified health workers.

Urgently fill the key technical positions at the Ministry of Health,

2011-03-24T00:32:00.000-07:00

There is saying that when the elephants fight, the grass suffers. I am writing to express concern about the prolonged delays in filling key technical leadership positions at the Ministry of Health (MoH). When there are leadership gaps, the health system and ultimately health consumers suffer. According to the World Health Organisation, “A health system is the sum total of all the organizations, institutions and resources whose primary purpose is to improve health.” A health system needs not only staff, funds, information, supplies, transport, communications but also overall guidance and direction from people with key technical expertise. The MoH in Uganda has not had a Permanent Secretary (PS) since 2009 and Director General of Health Services (DGHS) since early 2010. When Ms. Nanono was suspended from the position of Permanent Secretary in 2009, the DGHS was appointed to act as the PS. When the then DGHS retired in early 2010, the Director, Clinical and Community Services (C& C), Dr. Nathan Kenyamugisha was appointed to act as both the DGHS and the PS. This went on for about eight months. Then the position of Deputy PS was created in late 2010 and Dr. Lukwago Asuman was appointed to fill this position and to act as the PS. However, the position of DGHS was never been filled and the Director (C & C) has been acting in this position for over 12 months as well as filing his own position. Dr. Kenyamugisha (with all due respect) is expected to handle the job of the DGHS in an acting position efficiently for prolonged periods of time yet this amounts to work overload if he is still the Director (C & C). The Ministry of Health has suffered a technical leadership gap for far too long. Yet, the political leadership is filled with three ministers and a presidential adviser on health. Additionally, there is a parallel monitoring system in the names of Medicines and Health Services Delivery Monitoring Unit under the Office of the President which is performing the work which should partly be done by the health professional councils and support supervision by MoH officials.
No explanation has been provided why these key positions have not been filled and why the positions of PS and DGHS have to be filled by acting persons for over 12 months. Are there no competent people for these positions? To appoint someone in an acting position should be a temporary solution while steps are being taken to fill the position permanently. The professional councils and the support supervision system need to be strengthened instead of creating parallel structures and increasing costs of public expenditure. The concern authorities should take steps to appoint competent persons to these positions instead of increasing the number of political appointees. We need a strong ministry of health with competent leadership to provide overall guidance and direction in order to improve health outcomes.

Government should increase budgetary allocation for ART, PMTCT and other Essential Medicines,

2011-03-24T00:30:00.000-07:00

The overall resource envelope available has grown by about 5% from 7,552 billion in 2010/2011 to 8,004.1 billion for 2011/2012. However, budgetary allocations for the majority of the sectors including health have not changed from last financial year. Infact, the health Sector Budget Framework paper indicates that the health budget will remain at 660 billion in 2011/2012. The Ministry of Health has internally increased the budgetary allocation for Essential Medicines from 201.73 billion to 204.43 billion. This will contribute to ensuring that health facilities receive adequate stocks of essential medicines and health supplies. However, the percentage of the budget allocation to health (including donor support) has gone down from to 8.7% to 8.2%. Government has once again failed to meet the Abuja target of 15% to which Uganda committed in 2001

Domestic investment in Essential Medicines and Health Supplies (EMHS) particularly for Anti Retroviral Therapy (ART) and Prevention of Mother to Child Transmission (PMTCT) in particular remains very low compared to the needs. Funding for EMHS/National Medical Stores (NMS) will remain at 201billion in 2011/2012. Of this allocation, 90 billion is support from the Global Fund. Although there has been a slight increase in availability of medicines since Vote 116 giving NMS autonomy was enacted in August 2009, owing to the funding gap, the supply of EMHS still does not match the current need.

According to the Ministry of Health STD/ACP, a total of 578, 860 PLHIVs (by January 2011) in Uganda required ART but only 263, 154 on ART. Of these, 99, 170 are children but only 19, 903 are on treatment. According to Uganda’s proposal to Global Fund Round 10, to reach the treatment target to provide for 50% of the PLHIV, at least 2443 patients have to be put on treatment in 2011. To reach the treatment target of 61%, at least 92, 756 people have to be put on treatment in 2012. Bearing in mind that Uganda’s proposal to the GFTAM Round 10 (HIV) was unsuccessful, there is need to increase domestic investment in HIV treatment and PMTCT scale up.

The costing of the HSSIP indicates that to address the EMHS need would require 877 billion in 2011/2012, yet only a less than quarter of this has been allocated (201 billion). Moreover, Uganda largely relies on donor funds (PEPFAR, GFTAM, CHAI and other partners) for ART and PMTCT supplies. Of the 201 billion allocated, 90 billion is support from GFTAM Round 7 and 60 billion from GoU for ARVs and ACTs, and only 50 billion has been allocated for other EMHS.

Furthermore in 2010, the Government introduced the BASIC KIT system which supplies a pre determined set of EMHS to HC IIs and IIIs. The KIT does not contain all drugs on the Essential Medicines list of 2007 but also some critical EMHS like panadol are supplied in minimal quantities. For example, Essential medicines for mental health and epilepsy were introduced into the essential medicines list in 2007, however, there is still a critical shortage of mental health drugs. According to BASIC NEEDS, an organisation working to advocate for increased access to mental health services, health centres (HC) IIIs receive only one tin of chlorpromazine (25mg) and one tin of Phenobarbital (30mg) for uncomplicated epilepsy. In effect the HC can only treat 1 or 2 adults with schizophrenia or bipolar affective disorder and 3 children with epilepsy every two months. “There is now a danger of over 99% of those who had already started treatment relapsing (experiencing symptoms again) due to limited supply of medicines, the ripple effect of which will be the reversal of the gains made in reducing the treatment gap for mental disorders and epilepsy.” Insufficient supply of EMHS limits the ability of health workers to deliver the Uganda National Minimum Health care package especially for maternal and child health, communicable, non communicable and services.

There is need for additional domestic investment in the procurement of cotrimoxazole, anti-tuberculosis medicines, diagnostic and monitoring equipment and medicines for mental health and priority essential health commodities. GoU must increase the budgetary allocation for ARVs, and other EMHS especially those provided in the BASIC KIT and allocate a budget for PMTCT to cover the treatment gap. In addition to the 201 billion, an increased allocation to of an additional 100 billion, with a focus on scaling up domestic investment in ART, PMTCT, cotrimoxazole, anti-tuberculosis medicines, diagnostic and monitoring equipment and doubling the supply of EMHS in basic KIT (HC II & III) in order to reach the goals described in the NDP and HSSP III. Increasing financing for EMHS will ensure that essential, efficacious, safe and good quality and affordable medicines are available, which will contribute to strengthening the management and organisation of the national health system

Opening Remarks at Civil Society Consultative Meeting on HSSP III

2010-04-23T11:47:00.000-07:00

Representatives from MoH
Representatives from CSO on HPACs;
Representatives from CSO
Distinguished Guests,
Ladies and Gentlemen,

Welcome to this Civil Society Consultative Meeting on the Draft Health Sector Strategic Plan (HSSP III).

Thank-you for honoring our invitation and we hope that we shall continue this partnership. This meeting has been organized by AGHA and UCOBAC. AGHA is a health rights advocacy organization, recently appointed the CSO representative on the IHP+ Taskforce. UCOBAC focus on vulnerable children and mobilizes communities to participate in health related decision making.

This is a historic day for all of us! For the first time, we as CSOs have organized ourselves together to strategically review and provide input into a key policy document in the health sector.

This meeting builds on a meeting organized on March 10th 2010 for the same purpose for a select group of CSOs that reviewed the first draft of the HSSP III from a health and human rights perspective. While some of the recommendations of the last meeting have reflected in the New Draft of HSSP III, the majority have not. There is still opportunity to influence the development of this policy document especially because next week on the 26th and 27th, the MoH had organized a TRM which will be attended by our representatives on HPAC and its TWG.

Three points I want to communicate in these opening remarks.

1. To the Ministry of Health particularly, CS is not a homogenous entity. CSO are diverse, have varying mandates and modes of working. Some CSOs are in direct service delivery, others are involved in capacity building activities for communities, others are in advocacy, and others involved in monitoring. It is imperative for MoH to understand and appreciate the diversity within CSO bearing in mind their different roles and unique contribution to the sector. Important to remember is that CSOs represent you and me, in organized groups and form an important resource for M & E, and for promoting public accountability in the use of public resources. Civil Society represents the voice of the communities, the public and even the very civil servants who work in MoH who cannot voice their concerns publicly.

2. To the CSOs gathered here today-lets us participate actively. We have been provided an opportunity to review HSSP III and provide strategic input. Please let us make the best of the day. Ask questions to MoH officials and to our representatives on HPAC and the TWGs. As we deliberate throughout the day, let us bear in mind our differences and respect diversity in skills, knowledge, capacity and ability to engage. This meeting is also meant to support and strengthen the capacity of CSOs to understand and engage in Policy process. Our differences should enrich and add value to the discussions. HSSP III is our document, and MoH is merely playing a stewardship role in putting it together. At the end of the day we want this document to reflect our voices and the voices of the people we represent and not the thoughts of a Consultant.

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3. As CSOs, we need to step up efforts to get coordinated so we can work better with Government. We need to build our mutual capacity to participate in and engage in policy processes. In the new IHP + arrangement, we as CSO will have specific roles to play in holding Government and HDPs accountable if they fail to fulfill their obligations. Let us become very well versed with the Content of HSSP III, today and after it has been approved and endorsed by Government, so that in future we shall be equipped to play our monitoring role and effectively promote mutual accountability between Government and Donors.

With these few words, you are welcome once again to this meeting.
I wish you fruitful deliberations.

Health Trends in Uganda This Quarter

2010-04-16T07:00:00.000-07:00

This quarter was both good and bad. The health sector Budget Framework Paper F/Y 2010/2011 reveals a decline in the budget from F/Y 2009/2010 by about 17 billion Uganda shillings. This is a result of a drop in donor funding. DANIDA, a major supporter to the health sector will from December 2010 be transferring to the water sector, leaving a gap in the Technical Support to the planning department, financing for Essential Medicines and Health Supplies, among others. The already under funded sector, particularly the financing of EMHS will suffer next FY if the funding gap is not covered.

Also this quarter, the newspapers were filled with stories of drug stock-outs and arrests of health workers for purportedly stealing drugs. These arrests were initiated by the Medicines and Health Service Delivery Monitoring Unit (MHSDMU). Most outstandingly was the arrest of the Programme Managers of the Malaria Control Programme in the Ministry of Health. Although mismanagement of public resources is an offence and must be prosecuted, these arrests are creating a perception that drug stock-outs are being solely caused by health workers. Even with the revision of the drug distribution system with the National Medical Stores having autonomy and control over distribution of drugs, stock-outs are still rampant. It is therefore important that in fulfilling its mandate, the MHSDMU must repackage its message to convey to the public that drug stock-outs are being caused by a multitude of including low funding, problems with supply chain, and the capacity of NMS to deliver drugs in a timely manner.Other stories reflect that National Medical Stores is making efforts to address shortages.

Maternal health issues next dominate the media.There is a cry in the media for men to be involved in maternal health issues.

THE BLOOD SHORTAGE HAS CONTINUED.

After a long wait, the Global Fund to fight AIDS, Tuberculosis and Malaria (GFTAM) fulfilled some commitments to the people of Uganda. Under Round 7, GFTAM has given Shs 170 billion Uganda to fight malaria. The money, according the State Minister for Primary Health Care, Mr James Kakooza, is meant to buy 17.5 million mosquito nets to be distributed free-of-charge to Ugandans, especially pregnant mothers and children who are more vulnerable.

The Minister of Health, Dr. Stephen Mallinga signed the global International Health Partnerships (IHP+) compact in February 2009. Efforts are now being taken to develop a country compact. AGHA was appointed to represent non facility based civil society organisations on the International Health Partnerships (IHP+) Taskforce. The IHP+ has been described as the translation into practice of the Paris Declaration on Aid Effectiveness for achieving the health-related MDGs through better aid coordination and a focus on results.

The Global Aid Architecture for Health: Road Map for achieving MDGs?

2010-04-16T06:50:00.000-07:00

It is 2010, five years left to 2015- the timeline set for achieving Millennium Development Goals (MDGs). There is a sudden rash by actors in the global and national health system to step up efforts to improve maternal, newborn and child health, and to combat malaria, TB and stop the spread of HIV/AIDS. Sub-saharan African (SSA) countries like Uganda have committed to reach the MDGs, and created the Abuja target of 15% of public spending going to health. Developed countries committed to reach 0.7% of GDP going to Official Development Assistance (ODA). Africa has the highest disease burden, yet the lowest level of financing on health. 41 SSA governments allocate less than 15% to health. Out of Pocket Spending (OOPs) dominates private financing in most countries. In Uganda for example, the per capita expenditure on health is US $ 10, of which half is provided by government and the other half if OOPs.

In the recent past, many initiatives including PEPFAR and the Global Fund to fight AIDS, Tuberculosis and Malaria (GFTAM) have come up to fast track the race to achieve the MDGs. Others include the International Health Partnerships and related initiatives including, the Harmonization for Health in Africa (AHA), the Catalytic Initiative, (CI), the Providing for Health (P4H) Initiative, GAVI’S Health System Strengthening (HSS), the Global Fund-National Strategy Applications, The Health Metrics Network, (HMN), the Global Health Workforce Alliance (GHWA), MDG Africa Initiative. Other initiatives include the Millennium Challenge Corporation (MCC) and Millennium Challenge Account (MCA).

In 2008/2009, the High Level Taskforce on Innovative health financing (HLTIF) chaired by UK Prime Minister Gordon Brown and World Bank President Robert Zoellick supported the global advocacy for more funding to strengthen health systems for MDGs 1,4,5 and 6.The HLTIF Identified a menu of innovative financing mechanisms to complement traditional aid and bridge the financing gaps which compromise attainment of the health-related Millennium Development Goals (MDGs). Now the World Bank, GAVI and GFTAM are proposed yet another platform for Health Systems Strengthening. Moreoever, new ODA commitments have been announced:
• A US$1 billion expansion of the International Finance Facility for Immunization (IFFIm)
• US$360 million worth of debt conversions – Global Fund's Debt2Health Initiative
• The launch of a VAT tax credit pilot scheme called De-Tax, expected to raise up to US$220 million a year in VAT resources
• A new mechanism for making voluntary contributions when buying airline tickets, expected to raise up to US$3.2 billion by 2015
• US$515 million for results-based funding programs for health (RBF)
To crown it all, the United States Government has introduced a new legislation, the Global Health Act, to “establish a strategy to coordinate health-related US foreign assistance, to assist developing countries in improving delivery of health services, and to establish an initiative to assist developing countries in strengthening their indigenous health workforces.”

But how do these initiatives translate to the national level? Who is really benefiting? Is aid the solution to Africa’s problems?To some extent, aid has contributed to the health of people in SSA and Uganda in particular. PEPFAR and GFTAM are primary funders of ART. PEPFAR providing $38.6 million for ARVs. Uganda has scaled up ART for approximately 170,000 adults, including 16,000 children. However, more than 350,000 people (including 50,000 children) are in urgent need of treatment. There have been some successes scored for child health. However in terms of Maternal Mortality, progress is very slow. MMR in Uganda has been stagnant at 435/100,000 for the past decade.
However, aid must not be viewed in isolation. What countries like Uganda require is increased and better allocated domestic for strengthening their national health systems in order to achieve the MDGs. Aid is not the solution to Africa’s problems. Most resources should come from countries’ contributions. There is therefore need for domestic advocacy to raise attention to national budgeting processes and channel private spending into risk pool in avoid over spending by individuals. It is therefore importance for external aid to be only catalytic and temporary with a focus on results and efficiency gains. SSA countries need to grow economically in order to have higher GDPs that will enable them take care of the health of their people. What SSA countries need are free markets to sell their cotton, coffee, tea, and other products. The discussion of the global health architecture must not be in isolation, but in the broader context of economic development and growth.

Uganda MUST do more about Global Fund

2010-02-05T21:23:00.000-08:00

According to the Global Fund to Fight Tuberculosis, Malaria and
HIV/AIDs (GFTAM), an estimated 150,000 Ugandans die from AIDS, Malaria
or Tuberculosis each year. There are almost 14 million people
affected by these three deadly diseases in Uganda and yet they are
also highly preventable. The Global Fund is a multi-billion dollar
international financing mechanism established in 2002 that aims to
combat these diseases by providing financial grants to countries in
need. The GFTAM also now has a window for health systems strengthening
which is an opportunity for countries like Uganda to receive funding
to address broader weaknesses in the country’s health system.

Clearly, Uganda’s health crisis fits the criteria for this type of
assistance yet local politics are hindering our capacity to receive
funding and fight these diseases. Currently 95% of all funds for
ARVs/TB medications comes from either GFTAM/or PEPFAR. When GFTAM
didn’t make a disbursement last March, Uganda experienced a serious TB
drug shortage.

In the eight years the Global Fund has been in existence, Uganda has
applied for and been approved for money in six rounds out of the nine
(round five was not successful, round eight proposal was not submitted
and in November 2009 round nine was not approved). A total of $343
million has been committed yet less than half $158 million has been
disbursed to date. Why?

Quite simply, the Government of Uganda’s lackadaisical approach to
fighting corruption and mending the errors of our previous ways is
affecting our ability to secure vital health care funding from the
international community.

In 2005, Uganda received publicity when the Global Fund decided to
suspend five grants worth $213 million because of mismanagement of
funds. While the Government of Uganda acted quickly and spent a lot
of money to set up a commission to look into the mismanagement, they
have failed to prosecute the people implicated and have yet to come up
with a long term plan to ensure this type of corruption does not
happen again. In fact, while an estimated 300 people were accused in
the mismanagement, only four have been prosecuted. As recently as
2008, the Global Fund acknowledged that Uganda had not done enough to
guarantee the safety of the money. We have not received a grant from
the Global Fund since then. Coincidence? Unlikely.

Of course the international community is hesitant to dole out more
money to Uganda when they lack assurances that the funds will actually
go to the people in need.

The time is long overdue for Uganda’s government to address issues of
corruption and recognize the effects this type of poor management has
on the lives of real Ugandans. President Yoweri Museveni has declared
a war on corruption. If President Museveni is really serious about
fighting corruption, this is an opportune time to deal with the people
who were in senior leadership positions and mismanaged GFTAM monies –
people whose indiscretions are costing Uganda millions of dollars. The
people with the greatest responsibility for mismanagement of GFTAM
monies must be prosecuted and the money returned to the people of
Uganda. The diversion of attention from the real criminals by
punishing a few small fish as scapegoats is totally unacceptable. It
is a sign of political hypocrisy and illustrates a lack of commitment
to the people of Uganda.

Most importantly, Uganda needs to figure out a sustainable approach to
providing transparency and accountability in how health care funds are
spent to mitigate any potential other losses of funds. Ultimately, we
must create a system where corruption is not tolerated and the health
of Ugandans is the utmost priority for all.

Closing Remarks by Civil Society at 15th Ministry of Health, Uganda Joint Review Missions (JRM)

2009-12-02T04:05:00.000-08:00

Closing Remarks by Civil Society at 15th Ministry of Health, Joint Review Missions (JRM) November 26th 2009

The Hon. Minister of State for Hea,
Permanent Secretary, Ministry of Health
Director General of Health Services,
Officials from the Local Governments,
Members of Parliament,
Representatives from our Development Partners,
Representatives from CSOs,
Distinguished Guests,
Ladies and Gentleman,

Good Evening. My name is Sandra Kiapi, I work with Action Group for Health, Human Rights and HIV/AIDS (AGHA)-U, a health rights advocacy organisation based in Uganda. I speak on behalf of civil society organizations working in the health sector in Uganda. CSOs appreciate their involvement in the Joint Review Mission as well as the general planning, budgeting, implementation and monitoring process in the sector.

Over the past four days we have been reviewing progress, identifying problems, proposing solutions, and strategies to improve the performance of the health sector. There are indicators that we have scored some progress.

We commend the Government and our development partners for the increase in financing. Our per capita expenditure on health has increased from US $ 7.84 to 10.4. The Government of Uganda budget allocation to the health sector (excluding donor support) increased from Uganda shillings 242 billion in 2006/07 to 375.38 billion in FY 2008/2009. There has also been a consistent and steady annual increase in the financing of medicines. There have been efforts to revise the drug distribution mechanism in a bid to eliminate drug stock—outs.

There have been steps taken to mainstream human rights into the sector through a health and human rights desk. There are also efforts to promote the Paris Principles on Aid Effectiveness as well as the Accra Agenda for Action through the signing of the Global compact of International Health Partnerships (IHP+) as well as the implementation of the Joint Assessment Framework (JAF). We also have developed key policy documents like the Retention Strategy which is implemented can go a long way in achieving our goals.

However, year after year, we are still discussing some of the same problems-drug stock-outs, health worker shortages, inadequate financing and mismanagement of public resources. Our progress is very slow.

Currently, only 8.3% of the national budget is allocated to the health sector - way off target from the Health Sector Strategic Plan estimate of 13.2%. The per capita expenditure on health is a third of what is needed to achieve national and international health targets. Our minimum health package – the basic package of services that we believe all Ugandans should be able to access – is not fully funded, which leaves gaps in primary health care for many Ugandans. Levels of funding for EMHS are still at a record low of USD 0.93 compare to the projected costing of 5.86 per capita.

At the NHA, we still heard about serious audit queries in the use of funds within the sector. Weaknesses in the procurement process at the central MoH; doubtful delivery of drugs to Soroti, and overpayment of contractors to a tune of over 600 million -a figure which is greater than the PHC wage bill of at least 10 districts in Uganda. We need money for health, but we must also deliver more health for the money we have available. We must promote a policy of zero tolerance for mismanagement of our limited resources.

We learnt yesterday that the health system is the least staffed in the Local Governments. We are still challenged by the inadequate numbers of health professionals to meet the needs of our communities, as we lose health professionals to better salaries and improved working conditions outside of the public sector and sometimes even outside the country. Currently, the approved staffing levels are at an average of 56%. But some districts still lag behind at a level of 38%, and the percentage is much lower at Health Center II Level-22%. Even where funds available for recruitment, the sector has failed to attract staff. The WB and MFPED study revealed that the issue absenteeism has become chronic stands at 40%. Furthermore, poor leadership and management have been identified as factors inhibiting performance in the sector.

Many heath facilities still suffer from stock-outs of essential medicines, despite the considerable effort that the Government of Uganda and the Ministry of Health have put into improving drug procurement and distribution systems. Only 26% of sampled health units had continuous availability of all indicator medicines.

CS organizations make a great contribution to the sector through service delivery, advocacy, as well as monitoring performance. While there are formal structures for CS involvement in decision making at the MoH, at the districts, CS involvement remains weak and sometimes uncoordinated. CS is making efforts to improve this coordination, but this effort needs to be backed with strong proactive support from MOH, also to be reflected through DHO’s office and the local governance structures. The MoH should support the efforts of CSOs by building their capacity to participate in planning, budgeting, monitoring, fundraising for the sector.

We are hopeful that things can get better if we all commit ourselves to playing our roles in the rightful manner. Next year, we will roll into NHP II and HSSP III. It is an opportune time for change. The past four days have revealed a multiplicity of glaring issues which must be addressed. However, some issues must be emphasized.

(a) We MUST promote strong leadership, good management and governance practices in the sector. We need to identify the right people, with the right skills, qualifications, and right personal attributes-people with vision and inspirational qualities- to manage the sector; we need to move away from political appointments to transformative leadership. The MOH must take steps to improve the quality of leadership and management at all levels, and as a matter of urgency develop a strategy put an end to absenteeism.

(b) The sector needs additional resources to meet health needs and fill the financing gap. GoU, Development Partners, CSOs must partner to find ways of filling financing gaps especially for essential medicines and health supplies. A comprehensive, health financing strategy must be developed and additional innovative methods of financing such as SHI should be urgently looked into.

(c) The role of oversight structures at all levels-right from the Parliament, Boards of autonomous health instititutions, RRH, DDHS, as well as HUMC must be strengthened in order to provide oversight on the use of limited resources. In the context of EMHS, Parliament must provide close oversight and monitor the financial and operational performance of NMS.

(d) It is imperative that the GOU, MOH and partners devote sufficient priority and resources to address the HRH crisis as whole. Through a multistakeholder approach, we MUST make a deliberate effort address the issue of attracting and retaining health workers particularly in the hard to reach areas. Increasing health worker compensation and providing additional motivational benefits such as appropriate staff housing will provide health workers the incentive to accept positions particularly in underserved areas.

(e) We MUST promote collaboration between departments, sectors and all stakeholders. The PPPH policy must be finalized and operationalised so that the Public and Private and CSO can collaborate to improve the sector. In developing our new NHP, HSSP III, we must make the linkage between health and its underlying determinants including access to food, sanitation & clean water, and health related information.

(f) In the spirit of a Right Based Approach, we MUST promote access for more vulnerable and disadvantaged groups particularly PWD, people in under served regions like Karamoja as we develop and roll out the NHP II and HSSP III. We need greater emphasis on community participation in order to combat the disease burden at household level. This calls for strengthening and scaling up the existing structures such as VHTs.

(g) Timely, accurate and consistent quality data collection is critical at every level of the sector. Data must be compiled and analyzed regularly and used for planning and decision making.

(h) Future NHA/JRM should allocate time and space for all partners-especially CSOs to engage in more rigorous presentations and discussions.

Let us continue the cooperation between the public and private spheres. We know where we want to go, but we need to work with a renewed energy and with a stronger commitment to achieve progress at a faster pace.

Thank-you for listening to me.

AGHA represents Ugandan CS in International Health Partners Meeting (IHP+) in Bamako

2009-07-09T02:07:00.000-07:00

Action Group for Health, Human Rights and HIV/AIDS (AGHA) Uganda represented Ugandan Civil Society at the International Health Partnerships and Related Initiatives (IHP+) Second Annual Inter-Agency Country Health Sector Teams Meeting which took place in Bamako Mali between June 15-16 2009.

In September 2007, 26 signatories including the 8 major international organizations for health and 18 multilateral and bilateral donor governments, 7 countries, signed a global compact for achieving the health Millennium Development Goals (MDG). Central to the IHP + is the Global Compact which defines its purpose and serves as a mutually binding agreement between signatories at the global level. The signatories agreed to be held politically accountable for cooperating more effectively and with renewed urgency at both the global and country level so as to strengthen health systems and scale up health services and produce health results. The governments of the 8 initial IHP + partner countries agreed to cooperate by implementing their national health plans efficiently, strengthening health management information systems, tackling misuse of resources, and working with NGOs. The Paris Declaration on Aid Effectiveness of 2005 provides the basis for the IHP+ and describes how development partners should reform the ways in which they deliver and manage aid through among other things better alignment with national priorities, systems and procedures; integrating aid with recipient countries broader development agendas, promoting collaboration between donors; harmonizing programmes to reduce fragmentation and duplication of donor aid and lessen transaction costs and improve the predictability and increasing the time frame for funding commitments. The objectives of the Bamako meeting were to:

- Provide an overview of the progress made to date on the Global Compact as well as on national compacts;
- Share lessons learned from IHP+ activities since the Lusaka (2008) meeting;
- Share lessons from countries that are in the process of preparing a country compact and/or are in the process of implementing their compact;
- Review progress made on improving harmonization and alignment of donor aid

Since the 2008 meeting in Lusaka more partners have signed the global compact including Uganda, and Rwanda in February 2009. A high-level task force on Innovative health financing completed its work. This involved exploring innovative ways to fund health services, raising required funding and estimating required funding to meet MDGs. However, of concern was the finding that 45% of health funding at a global level is spent on TA.

Given the fact that Uganda signed up to IHP+, there is need to start discussions at the country level to see how the process can be moved forward. While Uganda signed the Global compact in February this year, no concrete steps have been taken to develop a country compact.

The Ministry of Health in Uganda currently has a sector wide approach (SWAp) to developing the National Health Policy and Health Sector Strategic Plans. This seeks to promote harmonization and alignment of funds in line with the Paris principles. Planning, implementation, assessment and review is jointly carried out by development partners, the Ministry of health, NGOs, and other line ministries like Finance, Planning and Economic Development. The joint review missions are evidence of joint planning and assessment. The Ministry of Health has in place Health Management Information Systems (HMIS)indicators which ideally should generate data that guides decision making for all stakeholders

However, not all stakeholders in the health sector are compliant with the existing framework. Some support to the health sector by some donors remains off budget, and thereby fragmenting donor support and misaligning sector priorities which have jointly been agreed upon. Uganda also has a framework for coordination of development assistance for health which has never been implemented or finalized. Some stakeholders have various indicators or and tools for measuring progress in the health sector, and therefore there is still no compliance to one M & E framework. In practice therefore the framework for application of IHP+ principles exists in Uganda through the SWAp. The greater challenge for Uganda is to put the existing policies, tools and strategies into practice as a country compact rather than developing a new country compact.

Civil Society Groups call upon High Level Taskforce to strengthen domestic revenue base of developing countries

2009-07-09T01:56:00.000-07:00

At the UN High Level Event in New York on 25 September 2008, world leaders called for an additional US$30 billion to save 10 million lives – 3 million mothers and 7 million children. Thereafter, a High Level Taskforce on Innovative International Financing for Health Systems (Taskforce) was announced. The Taskforce is chaired by UK Prime Minister Gordon Brown and World Bank President Robert Zoellick and is focused on ways in which innovative financing mechanisms can be used to strengthen health systems in the poorest countries in the world.(See http://www.internationalhealthpartnership.net/taskforce.html)The objectives of the Task force are:

1. To make recommendations on the mix of innovative international financing mechanisms needed to deliver extra resources required;
2. To promote international support for these recommendations to ensure they are implemented.

Two Working Groups (WGs) were put together to achieve the objectives of the Taskforce: Working group 1 is supposed to foster a better understanding of the key elements of a well functioning health system and analyze existing financing gaps including the volumes and types of funding required. It was to identify the main constraints to scaling up interventions in support of the health MDGs and suggest ways to address these constraints. Working group II was charged with the duty of analyzing the existing innovative financing instruments to respond to health system constraints identified in WG I’s report. It was to make recommendations on instruments that are ready for expansion and examine possible new or complementary approaches.

On March 5 2009, a consultative meeting for Civil Society Organisations (CSO) largely from the north and a few from the south was held in London to review the work of the 2 WGs. During the London meeting, CS organizations requested the Taskforce to hold consultative meetings in the global south. Two consultative meetings were organized: between May 14-15 in Johannesburg, South Africa and May 25-26 2009 Abuja, Nigeria. AGHA Uganda represented Ugandan CS both in London and Abjua. Other CS organizations came from Ethiopia, Ghana, Nigeria, Malawi, Cameroon, Burundi, Burkina Faso.

At the Abuja meeting, CS groups recognized that the two Working Groups of the Task Force have conducted a great deal of valuable work. WG1 in particular has provided a useful analysis of the challenges of health systems financing and strengthening.

However, there are also several deficiencies and gaps with both reports. Moreover, the process of consultation and discussion has been inadequate and incomplete. CS has been consulted in a piecemeal manner and national governments not consulted at all.

CS groups also emphasized the importance of domestic sources of revenue for the health sector within their individual countries. They pointed out that domestic resource mobilization for health systems was not given adequate attention by the Task Force and its Working Groups. Developing countries have substantial domestic resources that are currently being lost to health investment. Ineffective and inefficient tax systems, coupled with capital flight, unfair trade, natural resource exploitation and corruption make too many countries over-dependent on external aid. CS groups therefore requested the Task Force to catalyze a serious global effort, involving low and middle income country governments and civil society, to strengthen the domestic revenue base of developing countries. In a statement sent to the Taskforce Secretariat, CSOs stated:

“Domestic financing systems must contribute to equitable health systems performance and community empowerment, and should be given priority and greater consideration. We recommend the Task Force, the WHO and other actors to support sustained regional and country-level consultations on the development and improvement of domestic health financing arrangements.”

CSO also recognized that financing for health systems cannot be looked at in isolation from greater issues relating to trade and fiscal policies. Less Developed Countries have an unfair place in international trade and debt burdens are great, and therefore they have a smaller Gross Domestic Product (GDP) and inevitably a small resource basket which limits their ability to allocate greater resources to the health sector. Additionally, many fiscal policies place inappropriate constraints on national budgets and therefore on public health expenditure. New rules and policies on fiscal space and macro-economic governance, at both the global and country levels, are required.

These, among other are issues that have been inadequately addressed by both Working Groups.

Efficient Use of Resources is key this Financial Year

2009-06-24T06:24:00.000-07:00

The Action Group for Health, Human Rights and HIV/AIDS (AGHA) Uganda commends the Government of Uganda (GoU) for the prioritization of the health sector as a key element of human development. We support the increments in the budget allocations to the health sector from Uganda Shillings 628.46 billion in 2008/2009 to 784.4 billion for 2009/2010, especially the allocation of 47% (300.9 billion) of the health sector budget to Essential Medicines and Health Supplies (EMHS), and the 128 billion allocation to monitoring and quality assurance.

The FY 2008/2009 witnessed chronic stock-outs of essential medicines in districts and hospitals owing to mismanagement of supplies, deficiencies in the procurement process and lack of funding. The increased allocation pharmaceutical supplies and the proposed measure to build the capacity of planners to forecast and quantify the need for EMHS is welcome. The challenge is ensuring that money allocated is put to intended use.

AGHA however expresses concern over the Government’s consistent failure to honour the Abuja commitment of 2001. Despite the increase in health sector allocation, the percentage out of total national expenditure has in reality gone down. While total revenue in 2008/2009 was 5858.67 billion, the revenue for 2009/2010 has gone up to 7000.2 billion. Even with external support, the budget allocation for the health sector in 2008/2009 was at 10.7% and will be 10.2% in 2009/2010. In 2001, African Heads of State made a commitment to allocate 15% of their annual domestic budgets to health during the special summit on AIDS, TB and Malaria held in Abuja. The Abuja commitment was to exclude external support. The budget allocations have been 9.3%, 9.0%, 10.7%, and 10.2% in 2006/2007, 2007/2008, 2008/2009, 2009/2010 respectively. Although the GoU budget support has gone up by 2.5 billion this fiscal year, the Abuja commitment of 15% has never been met, and the percentage allocated to health has decreased this financial year.

While recognising that the Global Financial Crisis has had an impact on domestic revenue as well as on donor contribution to budget and project support and that the revenue basket is limited and must be divided among competing priorities, we still wish to remind the Government of Uganda that health is about life. Health service delivery in most cases depends on resource availability. All the sectors of the economy depend on it. It is a healthy individual that goes to school, invests, produces and makes decisions. What priority can compete with human life? Who would use the roads if the population is sick? Who would go to school if their health was not attended to? Therefore sectors such as Works and Transport, Education, Security, cannot compete with the health sector whose effectiveness determines if people live or die.

Uganda ranked third most corrupt country in the 2009 Corruption Barometer by Transparency International. The health sector is yet to recover from the effects of the gross mismanagement of money from the Global Fund for AIDS, Tuberculosis, and Malaria (GFATM). Yet the budget for accountability mechanisms including the Inspector General of Government, the Auditor General, Parliament, the Directorate of Public Prosecutions, and the Ministry of Ethics has been cut by Uganda shillings 82 billion. With the limited resource basket, efficient use of resources is key to attaining optimal results. What the country needs more then ever is the strengthening of monitoring and accountability mechanisms to ensure that resources are effectively utilized. Allocating enough resources to that cause is the first and the most important step.

We therefore call upon the Government of Uganda to:
1. Ensure that resources for the health sector are put to the right purpose--which is the delivery of healthcare and not the private enrichment of individuals. Money intended for health must be channeled for healthcare.
2. Take a proactive role in strengthening the watchdog role of accountability mechanisms such as the Parliament, IGG, DPP, and Civil Society (CSOs) by meaningfully involving them in decision making and monitoring the delivery of health care and use of resources for health.
3. Allocate resources based on needs and current data and not political decisions. Resources must be placed where the greatest need is which in experience has shown is EMHS, and strong mechanisms for monitoring resource use and fostering accountability.

Uganda still Off Target from Abuja Commitment of 15%

2009-06-05T04:38:00.000-07:00

The budget for next financial year 2009/2010 will be read on June 11, 2009. Figures released ahead of the budget reading indicate that the budget allocation to the health sector has gone up from 628.46 billion in 2008/2009 to 636.90 billion for 2009/2010. However, calculating the percentage out of total expenditure, Uganda figures have gone down. While total revenue in 2008/2009 was 5858.67 billion, the revenue for 2009/2010 has gone up to 6, 268.85 billion. Even with external support, the budget allocation in 2008/2009 was at 10.7% and will be 10.1% next financial year. Yet in 2001, African Heads of state made a commitment to allocate 15% of their annual domestic budgets to health during the special summit on AIDS, TB and Malaria held in Abuja. This was to exclude external support.

The World Health Organization’s Commission on Macroeconomics and Health (CMH), estimated that a basic package of health services costs US$34 per capita (the so-called “CMH target”). However, current per capita spending on health is lower in sub-Saharan Africa than in any other region at $23, and would need to increase by 68 percent to provide the CMH package. Current spending in Uganda is at US $ 25 (50,000) of which the Government is providing half and other half is private out of pocket. The health sector is therefore under-funded by 50%.

Fiscal planners at the ministry of Finance, Planning and Economic Development have made the argument that the revenue basket is very small amidst competition priorities. Despite the commitment the Government of Uganda made in 2001, fiscal planners argue that 15 percent of the domestic budget cannot be allocated to health because roads, works, and education are equally important sectors that need substantial budget allocations. Fiscal planners look at health as just one of the sectors, yet this is not the case.

Health is about life and death of human beings. Health service delivery in most cases depends on resource availability. Resources are needed for procurement of essential medicines and health supplies; for payment of health workers, for maintaining facilities and so on.

Uganda has a growing population and high disease burden. The fertility rate is 7.1, one of the highest in the world. The population of Uganda is growing at 3.5% per annum. Current statistics from the Uganda Bureau of statistics (UBS) indicate that the current population is about 31,000,000. Yet resources allocation for the health sector does not much the population growth trends. About 100,000 children are HIV infected and 50,000 in need of Anti Retroviral Therapy (ART), but only 26 percent of those in need receive ART. As of February 2009, about 160,000 patients had been initiated on ART which represents only 50 percent of those that are eligible for treatment. Neonatal and maternal conditions constitute the highest percentage of the burden of disease in the country at 20.8 percent.31% of the population live on less than a dollar a day and cannot fend for themselves. Greater resources than available are needed to deal with the ever increasing population and high disease burden particularly for those who cannot afford to pay for health services out of their pockets.

What priority can compete with human life? Who would use the roads if the population is sick? Who would go to school if their health was not attended to? Therefore sectors such as Works and Transport, Education, Security, cannot compete with the health sector whose effectiveness determines if people live or die.

Equally important is the way available resources are utilised. The Government of Uganda must ensure that resources for the health sector are put to the right purpose--which is the delivery of healthcare and not the private enrichment of individuals. Money intended for health must be channelled for healthcare. The Government must take a proactive role in involving communities in decision making and monitoring the delivery of health care and use of resources for health.

Furthermore, priorities for resources use must be informed by health trends, and data. Resources must be placed where the greatest need is. Focus must be placed not on dealing with symptoms of disease but prevention. This calls for greater use of Health Management Information Systems Indicators for decision making.

Greater emphasis is needed on ensuring external assistance helps to build the overall health system in addition to channeling aid into specific diseases and interventions.

New and innovative sources and approaches such as community and social health insurance offer promise for improving efficiency & equity if implemented equitably and in view of current needs.

The Government of Uganda must live by its commitment and invest greater resources in the health sector and therefore the health of her people. We need health children, healthy mothers, and healthy workers. We need the Government of Uganda to allocate 15% of its domestic budget on health.

Uganda Must Act on Zimbabwe

2009-05-07T13:24:00.000-07:00

Last december, while facilitating a training on monitoring the right to health organized by Action Group For Health, Human Rights and HIV/AIDS (AGHA) Uganda, I met a medical student from Zimbabwe whose school has been shut down. As many reports have indicated, (http://physiciansforhumanrights.org/library/report-2009-01-13.html) teaching hospitals have closed due to the lack of stability and complete collapse of the country’s heath system. What does the future hold for this young man and many others in his situation? He has no other choice but to remain in his country. He cannot attend another medical school, yet he has no idea when the school and teaching hospital will reopen again. He has not lost hope though because he knows that there are people out there like you and me who will fight for him.
Uganda, which as been elected to occupy a non-permanent seat of UN Security Council in the 2009-10 term, must use its regional influence to work the Zimbabwe situation through the Southern African Development Community. http://www.theeastafrican.co.ke/news/-/2558/509860/-/item/1/-/x8qfrj/-/index.html
However, Uganda’s former permanent representative to the United Nations, Mr. Francis Butagira objects to UN involvement: “The issue of Zimbabwe does not have an international security dimension and thus does not warrant intervention by the Security Council.” http://voteforhumanity.org/2009/01/15/uganda-begins-term-on-un-security-council/
I couldn’t disagree more. People in Zimbabwe are dying, not because of armed conflict or aggression, but because of the adamancy of their leader who is putting personal interests before the lives of his people. For me, this is an issue of human security, human rights and breach of peace. Absence of war or armed conflict does not imply the presence of peace. The Mugabe regime has destroyed the health-care system, as it has devastated virtually every other sector of public life, with its ruinous mix of corruption, mismanagement, violence and human rights violations.

What kind of future is he creating for the generations of people in Zimbabwe? Are the people of Zimbabwe living in peace? Is there peace when people cannot obtain basic services like healthcare, water and proper sanitation? Don’t the people of Zimbabwe have a fundamental right to these services?

And let’s not forget what history has taught us. African Union peacekeepers failed to maintain the peace and stop the conflict in Darfur. Even the African Mission in Sudan has been ineffective in protecting civilians in Darfur. The forces have a limited mandate, are poorly equipped, underpaid with no morale due to lack of logistics, and are operating in a road less dessert terrain only accessible by air. Instead African Union troops have become part of the victim group.

The U.N Security Council is notorious for pushing the interests of the permanent members with veto power. It does not always have to be this way. Uganda can make a difference. Moreover, its time that the Security Council serve the actual purpose for which is formed- to serve member states as a whole, and not the interests of the permanent members. The Security Council must act in accordance with the principles and purposes of the UN Charter.

Let us not go on record for always wanting African solutions for African problems while our people continue to die. What will we tell the future generation that we did for our continent? How shall we explain to our children that Mugabe let his people die, and we allowed him to do that?

What is Causing Drug Shortages in Uganda?

2009-05-07T12:54:00.000-07:00

Uganda is having problems getting the right type of medicines to the right people at the right time. There are essential medicines out of stock, documented expiry of large quantities prior to utilization, unqualified personnel at the prescription/dispensing window, and self medication or medication unto others (child). What has been the consequence? Pain, increased or chronic ill health, under-doze or over-doze, treatment failure, emergence of drug resistance, socio-economic consequences, and in some cases, death. When essential medications are out of stock especially in remote villages where the communities do not have an alternative solution, then patients blame the health workers who in most cases have no control over the medicine supply chain. The Uganda National Minimum Health Care Package (UNMHCP) obliges the government to make essential drugs available to the population including drugs for TB, malaria and infectious diseases.

However, medicines are often out of stock and several factors are to blame including: the inadequate funding for Essential Medicines and Health Supplies (EMHS); bureaucy associated with procurement at the National Medical Stores (NMS); the hoarding of medicines by communities; problems at the district including the health worker shortage, lack of skills in medicines forecasting, under spending of the budget line for EMHS; and poor selection and quantification of medicines and lack of prioritization.

The health sector is under funded and medicines are no exception. Budgets FY 2004/05 and 2005/06, were 9.6% and 10.6% of the Uganda national budget respectively both less than Abuja Declaration by African Heads of State to spend 15% of the national budgets on health. Uganda spends US $ 7.84 per capita on health, yet to meet the UNMHCP, at least US$ 28, and 40 are needed when ARVs are included. Health Sector needs US $ 6.5-8 per capita to cover EMHS. In 2006/2007, only US $ 0.72 was availed by GOU: donors topped up to US $ 4.06 On a positive note in FY 2008/2009 60 billion allocated to procurement of ARVs and Arteminsin Based Combinations. With the population growth rate of 3.4% p.a, the medicines needs continue to grow especially among the 10,000,000 (UBS, 2008) people that live below the poverty line.

At a workshop on Health Sector Transparency and Accountability organized by Action Group for Health, Human Rights and HIV/AIDS (AGHA) Uganda (www.aghauganda.org) which took place between 21-22 January 2009 for health sector leadership and civil society organizations working in health related activities in the Soroti district, it was revealed that co-Artem, fancida and chloroquine are no longer in stock in the district. As a result, malaria was being treated by quinine in many of the facilities.: “Quinine for children is not available, so we have to break the medicines so as to have the right dosage.” One official from Soroti district health office stated, “We received Tuberculosis (TB) medications which will be expiring in three months time.” He went on to say:

“Stock outs have also led to resistance among patients most especially the TB patients. They start the course of the treatment and some where in the course of treatment the drugs are out of stock causing resistance in the body.”

Some of the participants at the workshop blamed the communities for the drug stock-outs. It was reported that when a new supply of essential drugs arrives in the Health Centers, many community members flock to the unit to get drugs which they store for future use in case of stock-outs. Health workers are dispensing drugs to communities, without an accurate prescription. One healthwork

“Stock outs have created an over whelming turn up of patients at the hospitals when malaria drugs and pain killers like panadol arrive at the hospitals. When the drugs arrive, patients pour in at once to get their share of the drugs for storage due to the fear that the drugs are going to run out soon. The stock outs have made hospital work lag behind because then they can not run the hospital with out drugs.”

However, much of the blame for the drug stock-outs was placed on the bureaucracy of the National Medical Stores (NMS). NMS was set up in 1993 with the mandate to ensure the efficient procurement, storage, sale and marketing of quality medical drugs and other supplies. Districts can procure drugs either through the conditional grants from their Primary Health Care (PHC) or through District Medicines Credit Line System. In some cases, under spending of the PHC budget line for EMHS in some districts may cause drug shortages.

Through the credit line system, districts can procure essential drugs from NMS on credit, and funds will be paid directly to NMS from the Ministry of Health. However sometimes NMS may take 60 days instead of 30 to process and deliver an order to the district.

Delays in procurement of medicines are caused by among other things the procedural requirements under the Public Property and Disposal of Assets (PPDA) Act. At a capacity building workshop organized by the Medicines Transparency Alliance (MeTA) for civil society organizations, from April 26-30 2009, the General Manager (GM) of NMS, Mr. Moses Kamabare explained to the participants the problems caused by the PPDA law. Under this law which is the regulatory framework for procurement of public assets including medicines, the procurement process is governed by prolonged procedures requiring the approval of bids and contracts not only the GM, but also a Contracts Committee within a prescribed number of days. The process involves public advertising and approval of bidders hence the delays.

The NMS is now seemingly putting on a new image. Where orders have been delivered, NMS advertises the deliveries in the Newspaper. (See NEW VISION, April 28th 2009) In the past, drugs which have not been ordered are supplied to the districts in replacement of those which are out of stock. Where drugs are not available, NMS was required to issue a certificate of non-availability so that districts can procure the essential medicines from elsewhere especially the Joint Medical Stores (JMS). However, NMS in most cases failed to issue these certificates even when the drugs are out of stock making it difficult for the districts to order drugs from elsewhere hence the frequent stock-outs.

However, in some cases, district planners are to blame for the shortages. One health worker stated: “One of the major causes of the stock outs is poor management. The people in charge of procurement make the drug orders late.” Equally important is the shortage for human resources for dispensing medicines, and in some health workers lack skills in medicines forecasting.(AGHA, Promise Unmet, 2007). In a research carried out by Dr. Mshilla of Gulu Medical School in 2007, it was revealed that of all cadres of health workers, the shortage is greatest amongst pharmacists and dispensers.
A combination of things will eliminate stock-outs in Uganda:

1. Increased funding for the health sector particularly EMHS to meet the funding gap;
2. Increased support supervision to districts in areas of medicines quantification, forecasting and selection;
3. Amendment of the PPDA Law to reduce on the procedural requirements necessary for the procurement of medicines;
4. Sensitization of communities on the dangers of hoarding medicines;
5. Maintaining and increasing transparency in the drug procurement and supply mechanism at National Medical Stores;

Is Uganda Ready for a National Health Insurance Scheme?

2009-05-05T15:13:00.001-07:00

The Ministry of Health (MoH) in Uganda is proposing to put in place a National Health Insurance Scheme. On April 15, 2009 Action Group for Health, Human Rights and HIV/AIDS (AGHA) Uganda in concert with the Uganda Coalition for Social Security and Pension Reform Organised a Public Dialogue on the proposed scheme in Uganda.

This scheme is being introduced against the background that the 1999 National Health Policy requires the Government to promote sustainable alternative health financing mechanism and the 1995 Constitution obliges the Government to take all practical measures to ensure the provision of basic medical services to the population. According to the MoH, the purpose of the scheme is to:
a) To diversify and strengthen health care financing and make a contribution to bridging the financing gap in the sector;
b) To stimulate providers to avail good quality, accessible and affordable healthcare and
c) To increase welfare gain in healthcare through financial risk protection

The scheme will be designed in such a way that initially, it will target the public sector, then the formal private sector, organized informal sector and subsequently national coverage. The proposed scheme is to be administered by a parastatal body: The Uganda Health Insurance Corporation with a mandate to collect the compulsory contributions from the employer and employees. The contribution proposed is at 8% with 4% from the employee and 4% from employer. The scheme will be run by a body corporate, independent of the Ministry of Health, perpetual succession with power to sue and be sued just like the National Social Security Fund (NSSF). According to Dr. Francis Runumi, Commissioner Health Services/Planning, the Scheme will also be financed from member and employer contributions, but also supplemented by gifts, grants, donations, loans and possibly other credible sources. The funds would be subject to all rules applicable to public funds, audited by the Auditor General and reported to Parliament. The Board of Directors will submit the audited accounts to the Ministry of Health, and the reports and accounts will be presented to the Cabinet. The introduction of the scheme has had mixed reactions from the public most of whom think it will be disastrous after the NSSF funds’ mismanagement commonly known as Temangalo.

The endeavor to raise domestic finance for the health sector is very welcome and overdue. Since 2003, there has been a funding gap that is widening because of little funding for the health sector from tax revenue. The current financial crisis has not made things any better. Consequences of this funding gap are Human Resources for Health (HRH) attrition, low stocks of Essential Medicines and Health Supplies (EMHS), failing infrastructure, and increased use of traditional medicine. Tax revenue currently accounts for only 13% and Donor aid 40% of Uganda’s GDP. In 2001, African heads of state made a commitment to spend at least 15% of their national budget on health. Currently, Uganda spends 9.6% of its national budget on health way off target from the Health Sector Strategic Plan (HSSP) target of 13%, and the Abuja Commitment of 15%. The trend is down from two years ago when the percentage was at 11%. Uganda spends US $ 7.84 per capita on health, yet to meet the Uganda National Minimum Health Care Package, (UNMHCP), at least US$ 28, and 40 are needed when ARVs are included. The health sector needs US $ 6.5-8 per capita to cover Essential Medicines and Health Supplies (EMHS). In 2006/2007, only US $ 0.72 was availed by GOU: donors topped up to US $ 4.06. The health sector has largely been left for donor support, which is not sustainable especially when donors fail to honor commitments. Innovative ways of domestic financing are therefore welcome and much needed in Uganda.

The Question that Ugandans are asking is: Is the proposed health insurance scheme a worthwhile endeavor? Is it the Right time for Uganda to impose an additional tax on the population?

The Ministry of Health argues that the scheme is aimed at stimulating providers to avail good quality, accessible and affordable healthcare. However, the reality is that at the moment, health services in the country do not meet the required standards of accessibility, affordability, acceptability and quality. If Ugandans have to pay for services they must have value for money. Many health facilities are still ill equipped and having frequent drug stock-outs. There are still issues of health worker shortages. At the Local Government, the staffing levels are at 38.4%. Why should the population pay an additional tax for services yet the 30% tax they pay as P.A. Y.E cannot provide them even with the most basic services such as essential drugs?

The MoH has argued that services under the scheme for members will be available at any facility that has been accredited by the parastatal whether it is Private or Private Not for Profit (PNFP) or public facility. The purpose of accreditation in all sectors is to promote competition which will in turn motivate manager to improve their quality of service in order to gain accreditation. However, if issues of motivating health workers in public facilities are not addressed, how will health workers be committed enough to serving the population? Besides raising resources, how will the MoH promote good governance, and leadership in facilities? How will the body ensure that money is being put to optimal use in public facilities?

What about the issue of equity? The scheme is premised on the presumption that people have money to pay for health. What about the poor? A rights based approach requires a focus on the poor and vulnerable. Resources should be directed to those with the greatest need. According to the Uganda Bureau of statistics, 31% of the populations live on less than a dollar a day. They cannot fend for themselves and therefore the Government is obliged to provide for them. However the proposed scheme does not address the issue of equity in access. What assurance does the Ministry of Health have for those with no income? Will they be able to access services? In Ghana, the national health insurance scheme has increased national coverage as of 2008 to 55%; access to health services has increased almost three-fold. However, challenges include undue delays in re-imbursements; the poor still suffer – no clear definition of the poor in the law, and children whose parents do not register are denied their right to access. Uganda must learn from this.

Moreover, the Ugandan public has not had ample opportunity to participate in the development of the law that is supposed to govern the scheme. A rights based approach (RBA) to decision making promotes participation so as to enhance transparency and accountability. The committee on the Economic, Social and Cultural rights, under Comment No.14 has reiterated that an important requirement for fulfillment of the right to health is participation of the population in decision making in matters of heath concerning them. Not much consultation has been done nationally on the proposed law as illustrated by the lack of basic awareness among the public about some key issues in the proposal law. Such a crucial decision to introduce a national health insurance scheme must be designed in consultation with the population that will be affected by this undertaking.

The April 15th 2009 Public Dialogue with over 200 members of Civil Society, the media and other stakeholders clearly revealed that the MoH has not regained credibility in the public eye. Many of the questions showed that the public worried about corruption and mismanagement of the funds. Cases cited included the mismanagement of the money from the Global Fund for TB, HIV/AIDS and Malaria in 2005 where over US $ 367 was regrettably not put to purposeful use as revealed by the audit of the PricewaterhouseCoopers confirmed by the 2006 Commission of Inquiry led by Justice Ogoola that found evidence of inflated figures. Three years down the road, only 2 persons of lower ranks have been prosecuted. Subsequently, any attempt by the Ministry of Health to raise public sources of finance will be suspect in the public health. There is therefore need for the Ministry of Health to build credibility before any form of public financing for the health sector is solicited.

From the Private Sector, Dr. Ian Clarke, of the International Hospital Kampala (IHK) argued that we need to look at what the expectations of this Scheme are and the probability that they will be met. He also argued that this is the wrong time to enact this Scheme because of the global recession that affects both Uganda and all of East Africa. The tax base is decreasing, while the population is increasing, and this will increase taxes. Uganda has about 31 million people, but only about 500,000 pay taxes directly and 85% of the population is rural. Employees currently pay 30% PAYE and 5% NSSF, and employers have many extra costs, including maternity and vacation leave, sick days, public holidays etc.
The proposed Scheme leaves many questions unanswered. Namely, a) how will medical personnel be paid for there services, either as fee for service or capitation? B) How will the government ensure the funds are not embezzled or used corruptly? C) How will this Scheme affect liberalization and the free market economy? Dr. Clarke argued that the Ugandan economy has grown the last 20 years due to the private sector, but this Scheme would take money away from the private sector, give it to the government, only to return it to the private sector.

Mr. Alfred Nuwamanya from the Non Governmental Organizations Forum (NGO) Forum who made a presentation on behalf of civil society recommended that
a) the management structure of the Scheme should reflect modern corporate governance practices so that it is transparent, accountable, independent and liberal regulatory body;
b) review the relevance of the scheme to the current socioeconomic situation in Uganda, including factors like the extended family and HIV/AIDS;
c) cooperate with the NSSF scheme by creating a comprehensive social protection law, instead of a separate health sector law
d) carry out an actuarial study to ensure this Scheme is sustainable, and
e) improve the public image of current social insurance schemes through a comprehensive sensitization programme.

Whereas domestic financing is welcome effort to bridge the funding gap, there still remains a lot to be done before the scheme can be introduced. Moreover, the introduction of the scheme must not be a means by which government will avoid commitments already made such as spending 15% of the national budget on the health sector. The Ministry of Health must therefore:

1. Address the issue of equity in access to healthcare within the Proposed National Health Insurance Scheme
2. Promote public participation in the development of the law on the scheme by holding nationwide consultations
3. Take practical measures to build its credibility and image so as to promote public confidence in the proposed scheme
4. Take measures to strengthen the health system in public facilities before the scheme is introduced
5. Explore the possibility and feasibility of having a single scheme for social protection