Interaction between GHI and
Health Systems
Experience of Uganda
Nelson Musoba
Ministry of Health, Uganda
Presentation Outline
• Background and Reforms in Uganda’s
Health System
• Examples of interactions between GHIs
and Health Systems in Uganda
• Challenges will be highlighted as we go
along
Key Reforms
• 1986-1987: Sector Collapsed, Any help was welcome.
• 1986-1989: Health Policy Review Commission –
consolidation of existing services and re-orientation to
PHC
• 1995/96 – 2000/01 process of development of the new
National Health Policy (NHP) and Health Sector
Strategic Plan (HSSP).
• Poverty Eradication Action Plan (PEAP) 1997, with
updates 2001, 2004; (Poverty Reduction Strategy
Papers in other countries) & now
• National Development Plan 2009-2013
• All closely aligned to the Millennium Development Goals.
• Examples of other reforms;
– Decentralisation
– National Governance Reforms
– Public Service Restructuring
Partnership Principles
• Government of Uganda:
– To seek donor support only for programs in the agreed
framework
– To develop comprehensive, costed, prioritized sectorwide programs covering the entire budget, so that
government speaks with one voice.
• Donors:
– To ensure all support is fully integrated into sector-wide
programs and is fully consistent with sector priorities
– To end individual parallel country programs and stand
alone projects
– To increase level of delegation to country offices
• These Partnership Principles were formulated under the
leadership of government (MoFPED, OPM) and in
discussion with the highest in country donor & Civil
society representation.
SWAp Processes & Structures
SWAp structures
– Health Policy Advisory Committee – and its technical
Working Groups
– Joint Review Missions and National Health Assembly
– Health Development Partners Group
• Tools for SWAp management
– National Health Policy and Health Sector Strategic
Plan
– Memorandum of Understanding
– Aide Memoires
– Annual Health Sector Performance Report & Mid
Term Review Report
• SWAp tools and structures are intended to
facilitate Joint prioritisation, joint planning,
monitoring and evaluation
SWAp
• One of the most significant achievements of
the SWAp during the period under review was
the successful conclusion of negotiations with
both GAVI and GFATM towards increased
alignment of their support with the health
SWAp and agreeing common working
arrangements.
• Agreement was reached with GFATM on the
Long Term Institutional Arrangements (LTIA)
for improved alignment of Global Health
Initiatives (GHI) support to the sector
SWAp
• The GFATM CCM into an expanded
Health Policy Advisory Committee (HPAC),
• The AIDS CCM into the AIDS Partnership
Committee (PC),
• Rationalizing the composition of HPAC,
and streamlining and revitalizing the
Technical Working Groups, including the
absorption of the various technical
programme Inter-agency Coordinating
Committees (ICCs) into the respective
Technical Working Groups (TWGs).
Interactions I
• Built trust and openness between
government and development partners
and progressively Civil Society
• Planning and Budgeting Process –
became more transparent and consultative
– Medium Term Expenditure Framework –
credible presentation of all public resources
(GoU & donor) over a 3 year period
– Brings together
• Government & Development Partners
• Central and District Levels
• Public and Private partners
Interactions II
• Improved the sector supervision, monitoring
and evaluation framework:
– The strategic plan includes agreed indicators for
monitoring health sector performance
– Annual Joint Review Mission (involving GoU – central
& Local, donor, private, civil society) – replaced very
many review missions by donors
– An Annual Health Sector Performance Report
produced every year for presentation at the JRM,
• Provides a bird’s eye view of sector performance;
• Includes a District League Table comparing and ranking
performance among districts
• Modest increase in Health Sector Public
Resource Envelope
• Most donors have switched to budget support
Health Facilities by Level and Ownership 2004 and 2006
OWNERSHIP
Level of
Facility
GOVT
PNFP
Private
Total
2004
2006
2004
2006
2004
2006
2004
2006
Hospital
55
57
42
46
4
8
101
111
HC IV
151
155
12
12
2
1
165
161
HC III
718
762
164
186
22
7
904
955
HC II
1055
1332
388
415
830
261
2273
2008
Total
1979
2301
606
659
858
277
3443
3237
Physical Access
• Access to health services is measured by 5 Km
walking distance to a health facility (public/PNFP)
and is computed from the Health facilities maps,
and stood at 72% at the beginning of 2006.
Current need is to;
• Rehabilitate existing secondary and tertiary health
facilities
• Strengthen HI management including maintenance
• Provide medical equipment
There are several sources of funding for the construction of
health facilities, many of which it is not possible to have prior
information of for planning purposes.
Human Resources for Health
• The ever widening gap between the affordable
and the optimal HRH requirements. The limited
HRH funding for recruitment, salaries and
wages, has resulted in recruitment levels being
lower than planned;
• There is still inequity in the distribution of staff
with only 12 of the 80 districts achieving the
agreed minimum staffing level of 80%. Related
challenges include: Insecurity and remoteness in
some parts in the country; and migration of
health workers between the sub sectors making
recruitment in one result into attrition in another.
HRH II
• The time requirements of the HRH
management processes – the spread of
HRH functions between different
stakeholders leads to a lengthy
recruitment process including delays in
accessing the payroll leading to some
prospective applicants withdrawing before
taking up the positions;
• Low output of some cadres from training
institutions e.g Laboratory & Pharmacy
Technicians, Medical officers & specialist
doctors;
Trends of patients on ART
Trend of patients on ART (Children <14 yrs Vs. Total: 2003 - 2007
120,000
No. on ART
100,000
80,000
60,000
40,000
20,000
0
2003 Dec
2004 June
2004 Dec
2005 June
Total on ART
2005 Dec
2006 June
Children <14yrs
2006 Dec
2007 April
Essential Medicines
• Challenges are at the various levels including the
national level in terms of medicines procurement
and logistics management at the NMS.
– inadequate cash flow;
– inadequate staffing for medicines management at
MoH and local governments;
– poor quantification and late ordering by the health
facilities and local governments; and
– managing the third party items.
• The availability of medicines has continued to be a
major challenge, at less than 35% in against an
annual target of 55% and the HSSP II target of 80%.
• There is marked under funding of medicines
especially EMHS with less than 30% of requirement
for the UNMHCP currently provided for.
Maternal Mortality Ratio
527
505
435
1995
2000-01
2006
How does Infant Mortality in Uganda Compare t
other Countries?
101
Mozambique 2003
86
Rwanda 2005
Ethiopia 2005
77
Kenya 2003
77
Malawi 2004
76
Uganda 2006
76
68
Tanzania 2004-05
Eritrea 2002
2006 UDHS
48
Deaths per
1,000 live
births
Trend in Ownership of
Mosquito Nets
% of households
with at least one
mosquito net
34
26
13
2006 UDHS
2000-01
2004-05
2006
LLIN coverage targets based on availability of nets from GF & partners
120
Percentage (%)
100
80
60
40
20
0
2009
2010
2011
2012
2013
2014
2015
Mosquito Net Indicators
Indicator
HHs with at least 1 mosquito net (treated or
untreated)
HHs with at least 1 Insecticide Treated Net
(ITN)
Children <5 who slept under a mosquito net
the night before the survey
Children under 5 who slept under an
Insecticide Treated Net (ITN)
Pregnant women age 15-49 who slept under a
mosquito net
Pregnant women age 15-49 who slept under
an Insecticide Treated Net (ITN)
2000-01
2006
12.8
34.3
3.2
15.9
7.3
21.6
-
9.7
6.6
24.5
0.5
10.1
Health Sector Budget Allocations by Source FY 2004/05 – 2008/09
700
Billion Ug. Shs.
600
500
400
300
200
100
0
2004/05
2005/06
GoU Budget (incl. Donor Budget Support)
Total MTEF Budget
2006/07
2007/08
2008/09
Donor Project Budget
HSSP II Adjusted Costing
LLIN Coverage
• Current coverage with LLINs in Uganda is estimated at
40% according (Net mapping report, 2008; Malaria
Consortium model, 2007).
• LLIN distribution is the mainstay of the country’s
prevention strategies. Coverage is expected to
drastically increase with Round 7 support which was
approved and which will start implementation in
2009/2010.
• Under Round 7 a total of 17 million nets will be brought
into Uganda and universal coverage is expected by
2011.
• However, after 2011, attrition of nets and population
growth will reduce coverage with LLINs in the population
to approximately 84%, falling to 68% in 2013 and 38% in
2014 (see Figure above).
• Need for “keep-up” of nets in 2012 and 2013 in order to
maintain coverage at 100%. Mass replacement of nets
required for 2014 will be requested in a subsequent
round pending distributions of Round 7.
Uganda’s Population Trends, 1900-2050
120
100
81.4
80
53.7
60
36.8
40
20
2
2.5
2.8
3.6
5
6.5
9.5 12.6
16.7
22.0 24.7
0
19
00
19
11
19
21
19
31
19
48
19
59
19
69
19
80
19
91
20
00
20
02
20
15
20
25
20
40
20
50
Population (millions)
103
Year
Challenges
• Financial
- more efficiency (resource
allocation & use)
- increased investment i.e. new
and additional funding
• Considerable amounts of resources
still managed outside the SWAp
• Population growth
– High fertility rate
– High unmet need for family planning