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.
Wednesday, December 2, 2009
Thursday, July 9, 2009
AGHA represents Ugandan CS in International Health Partners Meeting (IHP+) in Bamako
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.
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
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.
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.
Wednesday, June 24, 2009
Efficient Use of Resources is key this Financial Year
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.
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.
Friday, June 5, 2009
Uganda still Off Target from Abuja Commitment of 15%
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.
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.
Thursday, May 7, 2009
Uganda Must Act on Zimbabwe
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?
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?
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;
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;
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