AID EFFECTIVENESS AND HEALTH:
THEORY AND REALITY……
PERSPECTIVES FROM CIVIL SOCIETY
IN UGANDA
Dr Lorna B Muhirwe
Uganda Protestant Medical Bureau
Berlin 2009
Overview of presentation
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Background of UPMB
Budget financing and health sector SWap in
Uganda
Budget financing: Challenges and opportunities
Role of civil society
Paris declaration and implications for civil society
participation
Conclusions
UPMB – Background information

National umbrella organization
Not a mini-ministry of health
 No direct jurisdiction
 A moral authority drawn from the corporate legal owners


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The respective religious denominations – CoU and other churches
One of the oldest civil society organizations in
Uganda

The voice at the centre (Kampala) of the over 260 health
facilities and health training institutions

Especially those in the remotest areas of the Country
UPMB - Structure
The UPMB Secretariat
(NATIONAL LEVEL)
Zonal Coordinating Committees (9)
(REGIONAL LEVEL)
Diocesan health services (31)
(DIOCESE LEVEL)
Member units (264)
(HEALTH UNIT/FACILITY LEVEL)
The health sector in Uganda

Key Actors
 Public
health
 Private not for profit sector: Facility based and nonfacility based
 Private Health providers
 Traditional and complementary medicine practitioners
About the PNFP sub sector
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The PNFP Health sub-sector is an old and important feature of the Uganda
Health System
Largely faith based and juridically (legally) private entities
Operating out of social concern →
Enshrined in the constitution of each of these units are important principles
 They are meant to serve the people of Uganda

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Without discrimination of ethnicity, religion, gender, socio-economic status
They are to align as far as possible with the Government policies in
health
They are meant to give priority to the poor
PNFP subsector cont…

85% located in rural environment

Substantial capital/infrastructural investment in static
health units

Have some meaningful voluntary component e.g.
provisions for subsidies of fees

33% of health sector workforce in Uganda

Experience in providing healthcare under economic
constraints
Public-private partnership in health

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PPP-H dates since 1956: between the Ministry of
Health and the facility based PNFP sector
In 1997, government of Uganda reinstated
financial and drug subsidies to private health
providers
Key feature of the National health policy and
health sector strategic plans I & II
SWap (officially launched Aug 2000) greatly
facilitated partnership at national level
Budget financing and health sector
Swap in Uganda

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Uganda health sector signed first Swap MOU in 2000
The five year health sector strategic plan I was developed in
parallel with the lead-up to the Swap
The Swap agreements rapidly resulted in increased budget
financing as opposed to sector support from donors
Ministry of finance was able to assume a stronger role in
determining priorities.
Budget (medium and long term) ceilings were set per sector within
the framework of the PEAP
Budget financing –
challenges and opportunities
Opportunities created by budget
financing

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Longer term commitments from donors enable
countries to develop longer-term plans.
Considerable potential to improve aid effectiveness:
—
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Harmonisation
 Streamlining donor regulations
 One format for reporting / accountability
 Consolidated Audit
Ownership - respect for Policies of recipient countries
Alignment with national strategies, institutions and procedures
Managing for Results – monitor all interventions transparently (Document
and share information, Joint Review Missions)
Mutual Accountability – both donor and southern governments
Challenges with budget financing

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Budget financing strengthens the recipient government’s role
and responsibility, therefore:
 Effectiveness depends on the quality of the national
development strategies to be financed in the recipient
countries.
Difficulty in holding governments accountable – not to
donors, but to the citizenry
Participation of civil society depends heavily on
 Level of maturity of democratic process in a given country
 Capacity and strength of civil society
Significant challenges therefore exist in either poorly
governed countries or where civil society is as poor (or weak)
as the majority of the population
The role of civil society
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A significant provider of basic services for the poor:
health, education, water and sanitation
An important player in limiting pervasive powers of
the state
Specifically for aid effectiveness:
 Important
network of facilities: implementing partners
 Often an effective channel for funding to the poor
 Important partners in determining “national” priorities
and ensuring allocative efficiency of funding
The Paris declaration(2005) and
implications for civil society
participation
At the national level
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Currently the Paris declaration is silent on the roles of civil
society
In Uganda dialogue around sector budgets at sector level is
now ineffective in guiding allocative priorities of the health
sector.
WHY?

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Budget –related dialogue occurs between MoFPED and
multilaterals & bilaterals rendering Swap structures of the health
sector quite ineffective
Civil society forced to seek most funding from government

Limits creativity, advocacy role and accountability to constituents
….especially important for “watchdog” CSOs
At the institutional level

Funding directly from civil society in developed
countries to CSOs in developing countries has
decreased markedly in the past four(4) years
 Governments
of developed countries channeling more
support directly to governments of developing countries
leaving northern CSOs less able to access funding
 Large international NGOs pooling funds into common
(but not government) basket

E.g CSO basket fund for HIV/AIDS in Uganda
Allocations
of Gov.t Funds
PNFP health
sector
Trends in government
of to
Uganda
support
to PNFP
20.00
Hospitals
Low er Level Units
Health Training Schools
Drugs
Total
20.85
B Ug Sh
16.00
20.07
19.90
19.93
10.77
10.91
10.91
10.87
5.08
5.40
5.23
4.9
3.25
3.13
3.13
3.53
0.63
0.63
0.63
0.63
16.03
12.00
11.86
10.41
8.00
4.00
3.03
1.07
1.00
1.00 0.07 1.00
2.02
1.01
10.40
7.04
6.07
0.00
19.73
4.75
4.04
5.08
3.24
3.00
2.03
0.37
0.58
0.67
0.30
97/98 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08
At the institutional level

Direct donor funding now largely constituted by
disease specific projects
 Limits
flexibility and responsiveness of CSOs
 Access to funding very competitive: Limited access as
many local and remote CSOs lack capacity in proposal
writing and information management
Decreased government and external support
→ scale down services or turn to user fees
→ decreased access to /utilization of services

 The
poor are ultimately affected
Financing structure of the PNFP health sector
AIDS and GI
related funding
30%
Traditional Donors
9%
GoU
22%
Fees
39%
Financing structure of the PNFP health sector July 2007
Improving aid effectiveness in the
health sector (1)

SWap mechanisms in Uganda have provided good
lessons on how aid can effectively be managed and
equitably distributed.

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If these mechanisms are supported and allowed to function!
Recognition and involvement of civil society
organisations
In Sub saharan Africa, 30 – 70% of health infrastructure is
held by faith based organisations.
 This recognition both by parent governments and donor
governments

Improving aid effectiveness in the
health sector (2)

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Refocus on health and community system strengthening
in order to achieve primary health care for all
Strengthening the health system will reduce waste and
ensure:
Equitable distribution of HR, medicines
 Functional health infrastructure
 Functional HMIS to facilitate decision making
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Ensure better design of global funding initiatives
Avoiding verticalisation, creation of parallel structures
 Addressing additionality to government resources
 Making these initiatives more responsive to needs of
beneficiaries

Recommendations (1)
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Review global aids effectiveness agendas and
principles as they apply to the recognition of the
roles of CSOs
Northern CSOs should form strategic partnerships
with southern CSOs beyond funding to include
advocacy, sharing information and mutual learning
Northern CSOs have a greater role to play in
international level advocacy to influence decisions in
the EU and global forums that Southern CSOs have
limited access to
Recommendations (2)
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Embrace more innovative and proactive funding
solutions that foster sustainability on both sides
Keep the door open for direct support that nurtures
the growth of civil society in developing countries to
avoid introducing imbalances in power.
THANK YOU FOR YOUR KIND ATTENTION!