HEALTH SECTOR REFORMS IN
UGANDA
Reform Model in the Context of Post Conflict National Reconstruction
A presentation to All Party Committee of Parliament,
By Dr. Francis Omaswa, (formerly, DGHS, MOH, Uganda)
Special Adviser, WHO, Geneva
9th May 2006, London.
Outline of Presentation
• Background & Context
• Reforms
– Across Government
– Health Sector
• Achievements
• Challenges
• Lessons
Background & Context
• Population 2006: 27m., Growth rate: 3.4%
• Population Distribution: 80% Rural, 50%<15 yrs
• GDP 2005 - $ 250 pc, Economic Growth 6%, Inflation
6%.
• Proportion of people below the poverty line:
1992 1997 2000 2003
56%
44% 34% 38%
BACKGROUND AND DEVELOPMENT MILESTONES
• Political upheavals - Several coups 1966,1971,1979,
1985, still some unrest in parts of the country.
•
Prior to upheavals 1970s -1980s, country had best
performing health sector in the region.
• Period of decline resulted in reversal and total collapse
of all sectors including health.
• Opportunity of a new effort and new thinking with new
leadership in mid 1980s.
250
200
150
100
50
00
20
95
19
91
19
88
19
80
19
69
19
59
19
48
0
19
infant deaths per 1000 live births
Infant Mortality Rate in Uganda 1948 to 2000
(indirect estimates)
Health Statistics – 1988 to 2002
Indices
1988
1995
2000
2002
UDHS
UDHS
UDHS
Census
IMR
122
97
88
83
Under 5 Mortality
203
147
152
MMR
550
506
504
Life expectancy
54
48
Fertility Rate
6.9
51
6.9
Reforms – across government
1. The Long term development vision – Vision 2025
2. New National Constitution 1992 - 1995
3. The Strategic Poverty Eradication Action Plan
(PEAP/PRSP)
4. Public Sector Restructuring and Decentralisation of
service delivery
5. New Public Sector Financial & Procurement
Regulations
6. Other Governance Reforms: IGG, Human rights,
Environment, Gender
Reforms – across government
PEAP Pillars
1. Framework for Economic Growth and
Transformation
2. Ensuring Good Governance and Security
3. Directly increasing the ability of the poor to raise
their incomes
4. Directly increasing the quality of Life of the Poor
–
–
–
–
Improving the quality of education
improving the quality of Health care
Improving access to and equity of Water and
Sanitation
Reforms – Across Government
PEAP Partnership Principles
• Government of Uganda:
– To seek donor support only for programs in PEAP
– To develop comprehensive, costed, prioritized sector-wide
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
Reforms – Health Sector
• 1986-1987: Sector Collapsed, donors came with free
hand. Any help welcome.
• 1986-1989: Health Policy Review Commission –
consolidation of existing services and re-orientation to
PHC
• 3–year Rolling Plans and Donor Projects
• 1996 – 2000: development of new National Health
Policy (NHP) and Health Sector Strategic Plan (HSSP).
Reforms – Health Sector
SWAp Processes & Instruments
• Government, NGOs, CSOs and DPs prepared the
National Health Policy and Health Sector Strategic Plan
facilitated by WHO Country Office.
• HSSP1 was developed within the framework of the
Poverty Eradication Action Plan (HSSP2 to revised
PEAP and MDGs)
Reforms – Health sector
• SWAp structures
–
–
–
–
–
–
–
MoH and District Management Structures
Health Policy Advisory Committee – and its technical Working Groups
Joint Review Missions and National Health Assembly
Health Development Partners Group
Health Sector Working Group
Interagency Coordination Committees
Annual Meeting of District Directors & Hospital Managers
• Tools for SWAp management
–
–
–
–
–
National Health Policy and Health Sector Strategic Plan
Memorandum of Understanding
Aide Memoirs of Joint Reviews
Quarterly Performance Reports (Centre & Districts)
Annual Health Sector Performance Report & Mid Term Review Report
Other Reforms - Health Sector
• Strengthened Regulatory Framework:
– Professionals Councils
– Health Services Act (Health Services Commission)
– National Drug Authority & Medical Stores
• Restructuring of the MoH & District Services
• Improving Access and Quality of Care
– Continuous quality improvement, service standards,
equipment/infrastructure rehabilitation, health promotion
and community mobilisation
• Burden of Disease/Cost effective Study as basis for
Minimum Health Care Package (1995)
Achievements - Process
• A clear vision for the sector: Minimum Health Care
Package technically sound
• Trust built between GoU, DPs, NGOs based on
openness, mutual respect and patience.
• Mechanisms for dialogue, monitoring and managing
threats, weakness and strengths
• Improved ownership, commitment & capacity of districts
• Planning and Budgeting Process
– transparent and consultative,
– Result-oriented, Integrated Annual, Central and District
Work plans;
– Bottom up - from lower levels upwards given
decentralisation.
Achievements - Process
Strengthened sector supervision, monitoring and
evaluation:
• The strategic plan with indicators for monitoring health
sector performance
• Annual Joint Review Mission : GoU – Central & Local,
donor, private, civil society – replaced multiple donor
missions
• Institutionalised Support Supervision from the centre to
the districts and lower levels
• An Annual Health Sector Performance Report discussed
at the JRM. Annual District League Table
Resources Available to fund the HSSP I to II
(2003/04 prices)
700.00
Billions Uganda Shillings
600.00
500.00
400.00
300.00
200.00
100.00
0.00
97/98
Govt Total
NGOs
98/99
99/00
00/01
01/02
02/03
Donor Project
Resource Envelope
03/04
04/05
05/06
User Fees
06/07
Government of Uganda Budget Expenditure
for District Primary Health Care Activities
1997/98 to 2006/07
Proportion of GOU Health Sector Budget spent at the
different levels 1999/00 to 2006/07
60%
50%
40%
30%
20%
10%
0%
Central services
District Health Services
Central hospitals
Regional referral Hospitals
120
100
80
60
40
20
0
19
97
/98
19
98
/99
19
99
/00
20
00
/01
20
01
/02
20
02
/03
20
03
/04
20
04
/05
20
05
/06
20
06
/07
19
99
/0 0
20
00
/0 1
20
01
/0 2
20
02
/0 3
20
03
/0 4
20
04
/0 5
20
05
/0 6
20
06
/0 7
billion Ug. Shs
140
Achievements - Inputs
• Human Resources for Health
– Recruited over 3,200 primary health care workers resulting
in improved staffing levels of trained health workers – from
33% in 2000 to 68% in 2005.
• Health Infrastructure
– Constructed over 400 PHC units and upgraded others
resulting in increased access to basic health services from
49% in 2000 to 72% by end of 2004, by 2005 to 84%.
• Essential Medicines and Health Supplies
– Increased per capita essential medicine funding from $0.8
in 2000 to $1.8 per capita in 2005
.
per capita new OPD attendance
New OPD attendance at public and PNFP health
facilities during the HSSP I
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0.9
Abolition of
User Fees
0.72
0.79
0.7
0.6
0.4
0.43
1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 HSSP I
Target
.
pentavalent 3 infant coverage
Pentavalent Vaccine 3rd dose Coverage
in infants during the HSSP I
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
84%
83%
2002/03
2003/04
89%
85%
63%
48%
41%
1999/00
2000/01
2201/02
2004/05
HSSP I
Target
proportion mothers delivering
in health facilities
Proportion of expected mothers delivering in
public and PNFP health facilities for the HSSP I
40%
35%
35%
30%
25%
20%
25%
24.40%
22.60%
19%
25%
20.30%
15%
10%
5%
0%
1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 HSSP I
Target
Prevalence (%)
35
30
Nsambya
Rubaga
Mbarara
Jinja
Tororo
Mbale
25
20
15
10
5
0
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
Challenges
• Leadership and Management capacity for Health
Services (centre and districts)
– Human resources – recruitment, retention and deployment
– Capacity of autonomous bodies still weak
• Intersectoral collaboration
• Sustaining partnership and trust
– High turn-over of Development Partner staff
– Sustaining level of commitment and mutual respect
• Global Initiatives
– Resurgence of vertical programmes
• Low and stagnating (recent past) health sector public
resource envelope
– Macro-economics and Health
Resources Available to fund the HSSP I to II
(2003/04 prices)
700.00
Billions Uganda Shillings
600.00
500.00
400.00
300.00
200.00
100.00
0.00
97/98
Govt Total
NGOs
98/99
99/00
00/01
01/02
02/03
Donor Project
Resource Envelope
03/04
04/05
05/06
User Fees
06/07
Lessons
• Government Leadership (Stewardship and
Accountability) is critical determinant.
• Reforms across government provide a positive enabling
environment.
• Comprehensive health sector planning with instruments
for managing implementation essential.
• All elements of the health systems are interlinked and
synergistic and need simultaneous development.
Lessons
• Need for critical mass of committed individuals to trigger
and champion the reform process.
• Trust, Openness and mutual respect between
government officials and DPs need to be nurtured.
• WHO as a credible member state body can effectively
facilitate health sector development at country level