Review of Governance Leadership and Partnerships in the Health
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REVIEW OF GOVERNANCE LEADERSHIP AND PARTNERSHIPS IN THE HEALTH SECTOR HIV/AIDS RESPONSE Draft Report Prepared by Denson Nyabwana A. Dabtience Tumusiime Fred Wabwire-Mangen For The STD/AIDS Control Programme/Ministry of Health With Support From WHO, UNFPA and CDC Atlanta November 2010 i TABLE OF CONTENTS TABLE OF CONTENTS .................................................................................................................... ii LIST OF TABLES............................................................................................................................. iv LIST OF FIGURES........................................................................................................................... iv ACKNOWLEDGEMENTS ................................................................................................................. v ACRONYMS/ABBREVIATIONS ...................................................................................................... vi OPERATIONAL DEFINITIONS ...................................................................................................... viii EXECUTIVE SUMMARY ................................................................................................................. ix 1.0 INTRODUCTION AND BACKGROUND .......................................................................... 1 1.1 Overview of the Building Block Assessment .................................................................................. 2 1.2 Rationale for the Building Block in the National Health System ..................................................... 2 1.3 Terms of Reference ....................................................................................................................... 3 1.4 Understanding the Terms of Reference ......................................................................................... 4 1.5 Objectives of the Building Block Assessment ................................................................................. 5 2.0 METHODOLOGY ........................................................................................................... 6 2.1 Overview of the Methodology ....................................................................................................... 6 2.2 Description of the data Collection process .................................................................................... 7 2.3 Qualitative Methods of Data Collection......................................................................................... 8 2.4 Quantitative Methods of Data Collection ...................................................................................... 8 2.5 Analytical Framework and Questions ............................................................................................ 9 2.6 Data Analysis, Triangulation and Interpretation ............................................................................ 9 3.0 CHALLENGES/LIMITATIONS DURING THE STUDY ..................................................... 11 4.0 FINDINGS OF THE STUDY ........................................................................................... 12 4.1 Findings of the District Response ................................................................................................. 12 4.1.1 District (central) Level ............................................................................................................ 13 4.1.1.1 Background characteristics of the respondents...................................................................... 13 4.1.1.2 Awareness of the national plans ............................................................................................. 15 4.1.1.3 District HIV plan ...................................................................................................................... 16 4.1.1.4 District AIDS Taskforce ............................................................................................................ 16 4.1.1.5 Legal frameworks .................................................................................................................... 17 4.1.1.6 Policy Development & Management ...................................................................................... 17 4.1.1.7 Planning, regulatory frameworks and Monitoring and Evaluation ......................................... 19 4.1.1.8 Mainstreaming of HIV and AIDS into district activities. .......................................................... 21 4.1.1.9 Resource Mobilisation and budgeting: ................................................................................... 22 4.1.1.10 Partnerships Coordination and Participation .......................................................................... 23 4.1.1.11 Strategic Information .............................................................................................................. 25 4.1.1.12 Research and coordination ..................................................................................................... 25 4.1.1.13 Decentralisation ...................................................................................................................... 26 ii 4.1.1.14 4.1.2 4.1.3 4.1.4 Transparency and accountability ............................................................................................ 27 Health Facility Level ............................................................................................................... 29 Community Level .................................................................................................................... 29 Other Providers (PNFPs, PHPs, FBOs, COE and uniformed services) ..................................... 29 4.2 Findings of the National Response .............................................................................................. 30 4.2.1 National Facilities ................................................................................................................... 30 4.2.2 National stakeholders and Providers ..................................................................................... 31 4.2.2.1 Background characteristics of the respondents...................................................................... 31 4.2.2.2 Views on current trend of HIV/AIDS in Uganda ...................................................................... 32 4.2.2.3 National policies and frameworks........................................................................................... 37 4.2.2.4 MACA, Mainstreaming, Coordination, Partnerships and Synergy (health sector) .................. 37 4.2.2.5 Mainstreaming ........................................................................................................................ 40 4.2.2.6 Oversight and guidance role of ACP-MoH as seen by parliament .......................................... 41 4.2.2.7 Decentralisation and capacity of ACP-MoH to manage the response ..................................... 43 4.2.2.8 Legal Framework ..................................................................................................................... 45 4.2.2.9 Policy development and management ................................................................................... 45 4.2.2.10 Resource mobilisation and allocation and funding mechanisms ............................................ 46 4.2.2.11: Stewardship role of the ACP in the HIV/AIDS response .......................................................... 46 4.2.2.12 Transparency, accountability and corruption ......................................................................... 47 4.2.2.13 Interventions that MoH should introduce .............................................................................. 49 4.2.2.14 Community involvement/participation .................................................................................. 49 4.2.2.15 Human rights, gender, GIPA and MIPA principles ................................................................... 51 4.2.3 Other providers (PNFPs, PHPs, COE and uniformed services) ............................................... 53 4.3 Summary of Findings ................................................................................................................... 53 4.3.1 Strengths................................................................................................................................. 53 4.3.2 Weaknesses ............................................................................................................................ 54 4.3.3 Opportunities .......................................................................................................................... 56 4.3.4 Threats .................................................................................................................................... 56 5.0 CONCLUSIONS ............................................................................................................ 58 5.1 By Assessment Objectives ........................................................................................................... 58 5.2 Key Emerging Messages .............................................................................................................. 59 6.0 RECOMMENDATIONS ................................................................................................ 61 6.1 Policy Level Recommendations ................................................................................................... 61 6.2 Programme level recommendations ............................................................................................ 63 6.3 Interventions for key stakeholders .............................................................................................. 66 6.3.1 Policy level stakeholders ........................................................................................................ 66 6.3.2 Programme level stakeholders ............................................................................................. 67 6.3.3 International level stakeholders ............................................................................................ 67 6.3.4 The non-public sector (CSOs, FBOs, NGOs, etc) ..................................................................... 68 7.0 BIBLIOGRAPHY/REFERENCES..................................................................................... 75 8.0 APPENDICES ......................................................................................................................... 77 8.1 National Data Collection tools ...................................................................................................... 77 8.1.1 National Data Collection tools: Quantitative ........................................................................ 77 8.1.2 National Data collection tools: Qualitative ........................................................................... 95 8.2 District Data collection tools...................................................................................................... 132 8.2.1 District Data collection tools: Quantitative ......................................................................... 132 8.2.2 District Data collection tools: Qualitative ........................................................................... 149 iii LIST OF TABLES Table 1 Background characteristics (Respondents and facilities that were visited) ............ 13 Table 2: Comparison of per capita expenditure on general against expenditure on HIV/AIDS services............................................................................................................................ 30 Table 3 Background characteristics of the respondents from the health sector ................ 31 Table 4 Background characteristics of the respondents from parliament ......................... 32 Table 5 Health sector views on the current trend of HIV/AIDS prevalence in Uganda ....... 32 Table 6 Views of parliament on the trend of HIV/AIDS prevalence in Uganda and reasons33 Table 7 Ranking of reasons for the reversal of HIV/AIDS by parliament and health sector 34 Table 8 Staff norms, annual output and registration status of professional staff ............. 35 Table 9 Mainstreaming, Coordination, partnerships and synergy ................................... 41 Table 10 Views of Parliament on ACP-MoH capacity for guidance and oversight of the HIV/AIDS response ........................................................................................................... 42 Table 11 Health sector views on ACP/MoH and mainstreaming and decentralization ........ 44 Table 12 Sex distribution of decision makers in the Public Service..................................... 51 Table 13 What Ugandans demand for 2011 elections to address ....................................... 69 Table 14 Details of qualitative tools as applied at national level and participation ............ 72 LIST OF FIGURES Figure 1: Functions that the health system performs (Source: WHO, 2001) .................... 3 Figure 2: Conceptual framework for interaction between Partner health initiatives and country health systems. ................................................................................................... 65 Figure 3: Village Health Team Strategy, Institutional Framework/Linkages .................. 74 iv ACKNOWLEDGEMENTS The team would like to express heartfelt appreciation to the Ministry of Health for having thought about the idea of having this review done and for giving us this opportunity to serve; our thanks next go to World Health Organisation United Nations joint Programme on HIV/AIDS United Nations Population Fund and Centres for Disease Prevention and Control Atlanta for offering the funds that supported the process Great thanks go to the technical working group under guidance of the AIDS Control Programme Manager MoH, Dr. Akol Zainab and Dr. Nsubuga Peter for the background work that got this review started and eventually kept it on track; Dr. Beatrice Crahay did a great job in making sure that most of the reference documents that were not available at the MoH were got somehow Thanks also go to the external consultants, Dr. Michael Friedman (CDC/Atlanta) Dr. Ogori Taylor (WHO/Nigeria) and Dr. Okoro Chijioke (CDC/Atlanta) for the technical support and concerted efforts to ensure the quality of this review Special thanks go to the respondents at the district level particularly the District Health Officers and the national level particularly the permanent secretaries, heads of departments and agencies who either participated as respondents or gave permission to their officers or staff to avail time for this review Finally we give special thanks to the members of the administrative support, data entry, data analysis and coordination teams for the tremendous work done to get this review to a successful end; the statisticians did much work to support the data analysis and interpretation exercise To all of you and those that we may have forgotten to mention due to human error thank you once again and God bless you abundantly for this service to humanity v ACRONYMS/ABBREVIATIONS ACP AIDS Control Programme AIC AIDS Information Centre AIDS Acquired Immune Deficiency Syndrome APRM African Peer Review Mechanism ART Anti-retroviral Therapy ARV Anti-retroviral CDC Centres for Disease Control and Prevention CHAI Community-Led HIV/AIDS Initiatives CHCT Couples HIV Counselling and testing CRS Catholic Relief Services CSF Civil Society Fund DAC District AIDS Committee DAT District AIDS Taskforce DHO District Health Officer DDHS District Director of Health Services FBO Faith Based Organisation GBS General Budget Support GFATMP Global Fund to fight AIDS Tuberculosis and Malaria HBC Home Based Care HCT HIV Counselling and Testing HFA 2000 Health For All by the Year 2000 HIV Human Immunodeficiency Virus HPAC Health Policy Advisory Committee HSG Health Systems Governance HSHASP Health Sector HIV/AIDS Strategic Plan HSS Health System(s) Strengthening HSSP Health Sector Strategic Plan IEC Information Education and Communication IT Information Technology JCRC Joint Clinical Research Centre LGDP Local Government Development Programme MHO Municipal Health Officer MoFPED Ministry of Finance Planning and Economic Development MoH Ministry of Health NAP National AIDS Policy NDA National Drug Authority NDP National Development Plan NEPAD New Partnership for African Development NGO National Drug Authority NMS National Medical Stores NPAP National Priority Action Plan for the National Response to HIV and AIDS 2008/09 – 2009/10 NSP National HIV/AIDS Strategic Plan 2007/08 – 2011/12 NTLP National Tuberculosis and Leprosy Programme NUMAT Northern Uganda Malaria, AIDS, TB PACE Programme for Accessible health, Communication and Education PAHO Pan American Health Organisation PC Partnership Committee PEPFAR U.S. President’s Emergency Fund for AIDS Relief vi PHC PHIs PHPs PMTCT PNFPs PPU RM&E SAC SAT SCE TCs TCMP UAC UNDP UNCST UNHRO UNICEF USAID WHO VCT VHC VHT Primary Health Care Partner Health Initiatives Private Health Practitioners Prevention of Mother to Child Transmission of HIV Private Not For Profit Policy and Planning Unit Research Monitoring and Evaluation Sub-county AIDS Committee Sub-county Taskforce Self Coordinating Entity Transaction costs Traditional and Complementary Medicine Practitioners Uganda AIDS Commission United Nations Development Programme Uganda national Council for Science and Technology Uganda National Health Research Organisation United Nations Children’s Education Fund United States Agency for International Development World Health Organisation Voluntary Counselling and Testing Village Health Committee Village health Team vii OPERATIONAL DEFINITIONS AIDS Competencies: Ability of all elements of society, individuals, families, communities, and institutions to recognise the reality of HIV/AIDS, analyse its causes and effects and take action to prevent it’s spread and mitigate its effects External mainstreaming: Adapting the core work and functions of an organisation or programme to the causes and effects of HIV and AIDS Complementary Partnerships: Refers to organisations focussing on their strengths while linking actively with other agencies that can address other aspects of the HIV/AIDS epidemic where they (the latter) have comparative advantages Health System(s) Strengthening: Any array of initiatives and strategies that improves one or more of the functions of the health system and that leads to better health through improvements in access, coverage, quality, or efficiency (Health Systems Action Network 2006) HIV/AIDS Mainstreaming: A process that enables development actors to address the causes and effects of HIV/AIDS in an effective and sustained manner, both through their usual work and within their work places (UNAIDS) Health economy: All resources devoted to health ie from the public sector, private sector and households or the community Internal mainstreaming: Changing organisational Policies and practices to reduce susceptibility to HIV infection and vulnerability to effects and impacts of AIDS Output Oriented Budgeting: A budgeting activity that uses the established outputs to determine the resource allocation; it requires the determination of costs of the respective activities that need to be undertaken to achieve the desired outputs Partnerships: Honest relationships between equals based on mutual respect, understanding and trust, with obligations and responsibilities for each partner Primary Health Care: Essential Health Care based on practical scientifically sound and socially acceptable methods made universally accessible to individuals, families and the community through their own participation and a cost that the individuals families the community and the nation can afford at every stage of their development in the spirit of self reliance and self determination Results Oriented Management: A management system that seeks to optimise the use of resources through clearly defining the purpose of the organisation, the service it provides, the activities to be undertaken/outputs to be achieved and the indicators for measuring the organisation’s performance viii EXECUTIVE SUMMARY Introduction This review of Governance, leadership and Partnerships under the Health sector was done as part of the Review of The Health Sector HIV/AIDS Response in Uganda; the other components of the review were Health Management Information Systems, Human Resources for Health, Health Financing, Medical Products, Laboratories and Health Services Delivery. The review was therefore expected to contribute to information and recommendations from the other building blocks for purposes of improving on the draft Health Sector Strategic Plan III, the National Health Policy II and the Health Sector HIV/AIDS Strategic Plan (HSHASP) II; it was expected to contribute to improvement of the effectiveness and efficiency of the health sector HIV/AIDS response and its contribution to the national/multi-sectoral HIV/AIDS response. Objectives The purpose was to review the national strategic frameworks to confirm provisions for effective coalition building oversight regulation and attention to system design and accountability for the Health Sector HIV/IDS Response. Specifically the review sought to assess the level of engagement of stakeholders in development implementation and monitoring of the HSHASP, organisation of the AIDS Control Programme Ministry of Health (ACP-MoH), as a component programme of the Ministry of Health (MoH), the lead ministry of the health Sector, in relation to its national roles of coordinating the overall Health Sector HIV/AIDS Response, and the stewardship roles of ACP-MoH regarding priority setting for research and donor support projects including funding. Methodology The review was done using qualitative and quantitative methods of data collection; they included document review, Key Informant Interviews, Group Interviews, Focus Group Discussions (FGDs), Round table discussions and field visits. Data Collection was done at National, sector, district, sub-district and community levels. We focussed on the national policy level, health sector policy level and health sector senior administration and then other partners in the non-public sector. At district level we focussed on political leadership, the District Health Team (DHT), the District Technical and Planning Committee (DTPC), district based Civil Society Organisations (CSOs) or Non-Governmental Organisations (NGOs), health facilities for the public sector, health facilities for Private Not For Profit organisations (PNFPs), Faith Based Organisations (FBOs), Private Health Practitioner organisations (PHPs) and Uniformed Services. The districts were selected basically as urban/rural, high prevalence/low prevalence and conflict/non-conflict affected, Northeast and North-central etc. At sub-county level the focus was on communities mainly through Health Unit Management Committees (HUMCs) and Village Health Teams (VHTs), including People Having HIV/AIDS (PHAs). Limitations There were various levels of limitations including: Limited numbers of Research Officers for the review Some data collection tools were relatively long leading to delay in transcribing Limited funding for field work particularly at national level The quality of tapes, we had to change; leading to loss of some work Low transcribing standards of some RAs; thus review of tapes took longer than planned Number of informants at national level was big but necessary ix Findings There is general concurrence that the HIV/AIDS situation in Uganda has worsened; most respondents believed the new infections rate outstrips the response Political commitment is currently strong at the presidency but needs to trickle down all levels up to the grass roots ( Presidency to ministers permanent secretaries district level etc) Emphasis has been shifted from prevention to treatment; treatment is doing fairly well Focus on MARPs is still grossly inadequate; it requires revision of the prevention strategy The Multi-sectoral AIDS Control Approach (MACA) is still a best practice; the partnership is big but fragmented with relatively ineffective coordination; complementary partnerships are hard to form and the power of partnerships and synergy has therefore been lost Mainstreaming is being done by many partners; it isn’t well coordinated; it lack resources Decentralisation is still a best practice but the speed needs to be matched with capacity and an effective SWAp strategy; CSOs are not fully effective yet partly for internal reasons Capacity of the ACP-MoH is too low especially with its current position in the MoH structure; coordination of the health sector HIV/AIDS response is thus difficult to manage There are Long Term Institutional Arrangements (LTIA) for management of HIV/AIDS in Uganda along with LTIA for management and coordination of Global Health Grants but they are not yet put to effective use especially at district level Most respondents believe Coordination between the UAC and ACP-MoH/MoH and subsequently among the sectors leaves a lot to be desired Knowledge and understanding of the HSHASP, HSSP and NSP is low; linkage between them is not clear to many; and so is linkage between budgets and plans even in ACP-MoH Lack of an AIDS law plus an overarching National AIDS Policy and some subordinate policies like the Public-Private Partnership for Health Policy is frustrating a lot of AIDS work particularly that related to human rights for both the infected and vulnerable unaffected Most subordinate policies/regulatory frameworks are in place but are not effectively disseminated and this has a lot of negative implications for implementation and enforcement Government has moved to increase funding (60 Billion in 2009) but it is still below expectation (at least 15% of government budget); over 80% of funding for the Health Sector HIV/AIDS Response is still from donor funds; this is demotivating to donors; but government is moving to implement output based budgeting which may improve resource mobilisation; but rapid creation of districts reduces level of resources mobilised both at national and decentralised level as capacity to run the districts does not much the speed of growth Districts have low capacity for mobilisation and the belief that HIV/AIDS has a lot of money compared to other programmes reduces the urgency to mobilise funds for HIV/AIDS The response is generally human rights based but the AIDS law is needed for full effect; the gender perspective is not effectively addressed yet There is general support for integration of HIV/AIDS into other programmes but with some aspects remaining vertical HIV/AIDS being a priority disease Most partners work with communities but the VHT strategy of 2001 is still at about 50% functionality because most partners have established their own, or are using, other versions A lot of research is going on but research priorities are largely driven by funding agencies Currently ACP-MoH has capacity for coordinating HIV/AIDS research and project identification; but much of its capacity may be temporary as the personnel are seconded Transparency accountability and corruption were noted by all respondents to be a serious problem that may be discouraging potential funding partners; this also effects motivation of current DPs to harmonise their systems with the national health system or align their funding to approved funding mechanisms; the review noted that government has established robust systems to correct the situation but public sector staff involvement in the vice is a set back There is no integrated M and E system for the health sector HIV/AIDS response into which all partners can fit and the framework developed with the NSP is not fully operational yet x Recommendations Policy level recommendations Political commitment should be revitalised and monitored at all levels from the presidency to the grassroots; have and monitor relevant out puts for a known service chain Top and senior level positions at the MoH should be filled and kept filled to provide a conducive environment for the ACP-MoH to operate efficiently and effectively The AIDS law, National (overarching) AIDS Policy, and Public-Private-Partnership for Health Policy be finalised, disseminated and monitored forthwith to ensure and guide operationalisation The number of districts should be held at the current number till capacity is built up to at least all HC IIIs with 80% staffing as had been planned for the period of HSSP II The health sector HIV/AIDS Partnership should be reviewed to make it relevant to the current status of the HIV/AIDS epidemic; it should now include Cultural leaders/institutions, the forum of professional Associations and the religious leaders or their forum The position of the ACP-MoH at the UAC in the multi-sectoral response should be made clear with clear roles and responsibilities for the two institutions known by all partners; have a desk officer for ACP-MoH at the UAC like there is one for the decentralised response SCE The IHP+ should be owned and used by government to motivate international partners into harmonising their systems with the national health system and aligning their funding to nationally approved mechanisms Government should adopt and implement relevant components of the Ouagadougou Declaration on PHC in the African region to enhance integration of HIV/AIDS into other health services/programmes; in the meantime selected components should be applied by MoH A deliberate effort should be made to address the issue of HRH; this should include strengthening and implementing the motivation strategy, task shifting and remuneration etc Prevention should be reinstated as the mainstay of the MACA for Uganda; a prevention policy and strategy should be finalised and implemented; if a separate policy for them is not possible then the MARPs should have a customised focus within the prevention strategy Since HIV/AIDS is a disease and 70 to 80% of the multi-sectoral response is the mandate of MoH, the status of the ACP-MoH in the MoH structure should be raised and its capacity built so as for it to take full and effective control of the health sector HIV/AIDS response Programme recommendations The ACP-MoH should review and internalise the HSHASP, HSSP and NSP and ensure the linkages (including that with the PEAP and NHP) are understood by all the team members for effective dissemination to partners particularly the key sectors, CSOs, and districts ACP-MoH should convene health sector HIV/AIDS partnership meetings so as to harmonise policies on management and funding; customised attention should be paid to major funders of HIV/AIDS as a priority programme and those that have mainstreamed it Multi-sectoral collaboration for the health sector HIV/AIDS response (/health) should be strengthened and sustained; this includes strengthening inter-sectoral collaboration with key public sectors (eg the SDS, LG, ES), HDPs, ADPs, key CSOs (eg Umbrella NGOs, FBOs and CSOs), cultural institutions, professional associations and the community ACP-MoH should spearhead Joint Planning with sectors and partners in the health sector HIV/AIDS response, then carry out joint support supervision with the selected key sectors ACP-MoH should spearhead HIV/AIDS mainstreaming in MoH and the LMSCE entities Disseminate and popularise the VHT strategy so that it is used by all partners as they involve communities and support community-led HIV/AIDS initiatives The ACP-MoH should work out a robust integrated M and E framework for the health xi sector HIV/AIDS response in collaboration with UAC to ensure its linkage with that in the NSP International partners should jointly identify priority areas of the health system that make the health sector HIV/AIDS response responsive, efficient and effective A deliberate effort should be made to have the issue of transparency, accountability and corruption addressed as a matter of urgency High level regular bilateral coordination meetings should be encouraged between the ACP-MoH and the UAC for effective collaboration and guidance of other partners International partners International partners should jointly agree on areas requiring funding support for the health sector HIV/AIDS response within the health sector basing on comparative advantages Step up support for the ACP-MoH and build its capacity so that it can carry out effective coordination and control of the health sector HIV/AIDS response Give deliberate support to the IHP+ process along with ADPs/HDPs/GHIs so as to give full effect to the Paris Declaration in relation to the health sector HIV/AIDS response The UN family should continue supporting sectors in mainstreaming and development of their strategic plans; the mainstreaming model used by the family could be used as prototype The non-public sector (CSOs/NGOs/FBOs/private sector) To work towards strengthening own partnership so as to fit fully into partnership with the health sector HIV/AIDS response Establish a peer review mechanism so as to strengthen the way NGOs/CSOs/NGOs do business with the health sector HIV/AIDS response/government xii 1.0 INTRODUCTION AND BACKGROUND Uganda embraced the multi-sectoral approach to HIV/AIDS control in early 1990s and this enabled the country bring down HIV prevalence from above 18% before 1992 to now 6.3% in 2010. By December 2007, an estimated 1.1 million persons were believed to be living with HIV and over 350,000 needed antiretroviral therapy. In addition, the number of people who are not aware of their HIV status continues to be high despite increased efforts to scale-up HIV prevention through counselling and testing. Prevalence continues to vary by geographical locations with central region having the highest at 8.5%, northern at 8.2% through to 2.3% in the West Nile region. Newer predisposing factors to transmission, survival and disease progression have been identified over the years and these have implication on aligning the health sector response to match the trends of development. Following description of the first country case in 1982 in Rakai, the epidemic rapidly spread throughout the country resulting into a mature and generalized epidemic with heterosexual contact as the main route of transmission later on evolving into a heterogeneous epidemic affecting different population subgroups and resulting into multiple and diverse epidemics with different transmission dynamics. The diversity of the populations calls for greater and more complex responses and interventions that are heavily dependent on the population sub-type and impact of the disease on the macro and micro economic situations. The introduction of antiretroviral therapy (ART) in 2003 created newer dimensions to the HIV/AIDS response. Over the years, various drivers have fuelled the epidemic and they included mobile populations, commercial sex workers, armed and uniformed forces, internally displaced persons, among others. In addition, the peak population at risk has lately shifted from the young and unmarried to the old and married persons and this culminated in the need for more appropriate and diverse approaches to HIV/AIDS control in Uganda. On the other hand, the long years of the Lord’s Resistance Army (LRA) insurgency in the north and Allied Democratic Forces (ADF) in the west resulted in creation of internally displaced persons’ (IDP) camps that in turn developed into newer epicentres for stable transmission in the affected areas. Uganda in 1987 created the health sector HIV/AIDS response coordination unit that later was transformed into the AIDS Control Program (ACP). The country HIV/AIDS response has continued to centre around the principles of the “three ones” namely One agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners; One National AIDS Coordinating Authority, with a broad-based multi-sectoral mandate; and One agreed country-level Monitoring and Evaluation System(2). In line with this, the Uganda AIDS Commission (UAC) was created by an act of parliament in 1992 to oversee the national multi-sectoral and all-embracing response to the epidemic. Increased funding for HIV/AIDS control in the health sector led to emergence of vertical programs and this further complicated governance of the national response. Review of Governance Leadership and Partnerships in the Health Sector HIV/AIDS Response in Uganda was carried out as part of the overall assessment that covered a total of seven building blocks including six WHO Building Blocks used for health systems strengthening and the laboratories building block which was added basing partly on the critical role laboratories play as a gateway to accessing comprehensive HIV/AIDS care particularly Antiretroviral therapy. Health systems governance, an intrinsic aspect of which is accountability, refers to management of relationships between various stakeholders in health including individuals, households, communities, governments, non-governmental 1 organisations, private firms and other entities which have the responsibility to finance, monitor, deliver and or use the health services (World Bank 2004). 1.1 Overview of the Building Block Assessment Ensuing from endorsement of the U.N. social goal, for everyone to live a socially and economically productive life, it became clear that an optimal level of health was a prerequisite to its attainment. The Alma Ata Declaration on PHC as a strategy for attaining Health For All by the year 2000 HFA 2000) was meant to, among other things, guarantee a minimum standard of quality of health care in terms of reach-ability (physical access), affordability (economic access) and acceptability (socio-cultural access) but this did not come to pass. Next the millennium summit of 2000 enumerated eight Millennium Development Goals (MDGs), three of which are health MDGs, to direct interventions towards attainment of the same U.N. social goal. The Poverty Eradication Action Plan (PEAP) 2004/5 – 2007/8 has been the framework for attaining the MDGs in Uganda. The four main thrusts of the PEAP, revised to cover the period up to launching of the National Development Plan (NDP) 2010/11 – 2014/15, included creating an environment for sustained economic growth, improved governance and security, actions to help the poor increase their incomes and actions to improve the quality of life (eg primary education and health). The PEAP recognises that optimal health is critical for realisation of the MDGs and eventually the U.N. social goal. Out of acknowledgement that health systems that can deliver an optimal quality of health care equitably and efficiently are critical to achievement of the MDGs, a number GHIs like Global Fund and others have since 2000 been making health systems strengthening part of their support agendas; this created need for a definition of health systems that can deliver the desired outputs, outcomes and impact. Ensuing from the above therefore, World Health Organisation (WHO) established the WHO health-systems framework the purpose of which was to promote a common understanding of what a health system is and what to address when considering health systems strengthening. The framework consists of six health systems building blocks namely: i Leadership and governance ii Health Information iii Health workforce iv Health financing v Medical products (including vaccines and technologies) and vi Health service delivery Although these building blocks help to clarify the essential functions of health systems and expectations from each component, efforts to address health systems and their strengthening are expected to recognise the interdependence of the blocks or parts of the health system. Review of the health sector HIV/AIDS response was therefore based on the six WHO health systems building blocks with laboratories separated to create a seventh block partly because of the importance of laboratories as an entry point to comprehensive HIV/AIDS care, particularly antiretroviral therapy. 1.2 Rationale for the Building Block in the National Health System Significant progress has been made in delivery of interventions that have addressed HIV/AIDS and various other Primary health care Goals. It is now noted that the so far registered achievements can not be sustainable without appropriate investment in the governance of health systems; any gains that are realised from investment in health service 2 delivery are therefore unlikely to be sustained over the long term without addressing health systems governance (Lancet 2009; 373: 2137-69). Health systems governance has become critical because of the increased demand for accountability and demonstration of results arising out of increased funding, among other things. It is realised, while considering governance, that implementation of any programme requires a conducive environment which includes legal and regulatory frameworks, appropriate policies or policy guidelines along with strategic and operational plans all of which need customised and practical organisational structures and an effective M and E framework to provide, among other things, information for decision making. Review of governance, leadership and partnerships within the health sector HIV/AIDS response was done partly to assess the extent to which the above environment existed during implementation of the HSHASP. Governance is one of the four main functions of any health systems but it is cross-cutting in nature and therefore has a bearing on each of the other building blocks as illustrated in figure 1 below: Figure 1: Functions that the health system performs (Source: WHO, 2001) Stewardship (Oversight) Creation of resources (investment and training) Delivering services (Provision) Financing (Collecting pooling and purchasing) 1.3 Terms of Reference Assess and document the following: Strategic policy frameworks and implementation plans; and examine the extent to which they are combined with effective oversight, coalition-building, regulation, attention to system-design and accountability. 1.3.1 Policy design and oversight: Engagement of stakeholders in the development, Implementation, through annual workplans, and monitoring of the HSHASP Linkage of HSHASP with NSP, HSSP II etc Analyse the coordination mechanisms at MoH level for the implementation of the HSHASP and their effectiveness The role, structure of, and relevance of membership in the coordinating Bodies: what have the coordinating bodies achieved/produced? How are their actions guided? What are their monitoring and reporting mechanisms? Coordination mechanisms at the Health Sector level for implementation of HSHASP and their effectiveness Systems for development, approval and dissemination of policies, guidelines etc 3 1.3.2 Organisational Structures: The role of the ACP-MoH in the decentralised process of HIV/AIDS service delivery, coordination of ACP-MoH with district level and regional level hospitals The relationship between the UAC and ACP; How could their roles and relationship be better defined? Communication and coordination mechanism? The relationship and coordination between the ACP and other Programs/Units in the MOH. Analyze the organizational structure of the MoH and where the ACP sits, relative to the ACP’s roles and responsibilities. Assess the extent to which the ACP is able to fulfil its mandate within the existing structure. Assess the coordination and communication mechanisms within the ACP. Assess the coordination mechanisms with the partners 1.3.3 Leadership: ACP-MoH Leadership with regard to guiding partnerships with GHIs, ADPs, HDPs, FBOs etc, coordination of research and Global Fund Proposal writing etc The way in which research priorities are defined and studies coordinated. The role of the ACP in the Global Fund proposal writing and implementation. The mechanism for approval of new health projects being proposed by partners The role of the ACP in the Partnership Committee. The role of the ACP in the implementation and monitoring of the NSP. 1.4 Understanding the Terms of Reference The health sector was the overall coordinating authority for the national HIV/AIDS response since 1986 until 1992 when Uganda AIDS Commission was established, by Statute number 2 of 1992, and also Uganda started to implement the policy of decentralisation. Whereas the mandate of UAC was and still is to coordinate the multi-sectoral response, the health sector remained the core technical arm of the national/multi-sectoral HIV/AIDS response controlling 70–80% of the response making it key. The health sector response is guided by the HSHASP that was formulated to operationalise cluster three of the HSSP II. The health sector retains coordination of the health sector HIV/AIDS response, which makes 70-80% of the multi-sectoral response, even after the UAC took overall coordination of the response. Therefore according to the National Health Policy, the mandate of controlling HIV/AIDS in Uganda is the responsibility of the MoH/Health sector through cluster three of HSSP II. 1.4.1 Tasks The general task under Governance, Leadership and partnerships was to assess the national strategic frameworks and document, the presence or absence of evidence that the frameworks provide the basis for formulation and implementation of an effective health sector HIV/AIDS response; and establish if a basis for effective coalition building exists to ensure effective oversight regulation with attention to system-design and accountability. Specifically the assessment should: Establish the extent to which stakeholders have been engaged in development implementation and monitoring of the HSHASP, implementation being through subordinate but HSHASP-linked strategic and annual plans; Assess the role of the MoH in the decentralized process of HIV/AIDS service delivery with particular focus on coordination of ACP-MoH with district level and regional referral hospitals and other partners like CSOs, FBOs etc that are key actors in the process of decentralisation; 4 Assess and document the Role of ACP-MoH in the business of each of the three major players in the multi-sectoral HIV/AIDS response like the GHIs, ADPs, HDPs, FBOs etc. ACP-MoH is therefore the programme of MoH delegated with the responsibility of Coordinating the health sector HIV/AIDS response. The strategic frameworks are supposed to provide a conducive environment for the ACP-MoH/health sector to engage stakeholders in development, implementation and monitoring and evaluation of the HSHASP, manage the decentralised response through effective coordination and provide stewardship for activities of key partners in key areas like coordination of research and writing of proposals for funding. 1.5 1.5.1 Objectives of the Building Block Assessment General objective: To review the national strategic frameworks and document the extent to which they provide for effective coalition-building and are combined with effective oversight regulation and attention to system design and accountability. 1.5.2 Specific objectives: 1.5.2.1 System design and oversight: Assess the extent of engagement of stakeholders in the development implementation, through annual workplans, and monitoring of the HSHASP 1.5.2.2 Organisational structures: Assess the role o f MoH in the decentralised process of health service delivery focussing on coordination of ACP with district level and regional level referral hospitals and other partners like FBOs, CSOs, CBOs, private sector etc 1.5.2.3 Leadership: Assess and document the role of ACP-MoH coordinating activities of major stakeholders like the GHIs, ADPs, HDPs, FBOs focussing on coordination of research and Global Fund proposal writing etc 5 2.0 METHODOLOGY The methodology under this block took note that governance is the most complex but crucial aspect of any health system (WHO, 2009); it is also the least well-understood component of most health systems and is least often evaluated although it is critical to attainment of the health MDGs in particular. The assessment adopted methods and approaches used for overall health systems in general with focus on the peculiarities of ACP. References were made to WHO’s domains of stewardship initially, the World bank’s six basic aspects of governance, UNDP’s principles of good governance and the Pan American Health Organisation’s essential public health functions. Because Uganda adopted the Alma Ata Declaration on PHC, we referred to the strategy particularly the three of the four pillars of PHC namely Political Commitment, Community participation and Inter-sectoral Collaboration while taking note of the elements of the Multi-sectoral AIDS Control Approach particularly the need to involve everyone from top political level through all intermediate levels to the grassroots. The review was undertaken by a team of two national consultants initially, one supervisor initially, one research officer for national level data collection and two research assistants for district level data collection with inputs from two external consultants. Ten rules based and six output based indicators were adopted from the WHO Health Systems Building Blocks Tool kit for review of governance. All components of governance were addressed; but in view of the maturity and heterogeneity of the epidemic coupled with the current move towards HBC, the team focused a lot on the extent to which communities are involved in planning, implementation oversight and advocacy for participation; the team also laid emphasis on planning and coordination within the multi-sectoral response in view of the complexity of managing the epidemic through wide ranging partnerships that comprise thousands of stakeholders with different core mandates. Finally the methodology took into account current thinking at the U.N. and the African Union/NEPAD regarding handling HIV/AIDS as a vertical programme vis a vis its integration into other programmes. Since governance is cross-cutting, some of its indicators were expected to be applicable to other building blocks. 2.1 Overview of the Methodology The review involved two phases, district and national level data collection and analysis. The district level data collection preceded the national level with data collected from the former providing support to completion of the assessment. Review of Governance Leadership and Partnerships was carried out as a contribution to the overall review of the health sector HIV/AIDS response in Uganda and it was national in scope. The review employed both qualitative, mainly, and quantitative data collection methods. As part of quality assurance, the review team members went through a number of meetings, discussions and eventually training before finalising the process of developing and pre-testing of the data collection tools. Due to the complexity and scope of the review, some adjustments to the methods and tools were made along the process. On qualitative methods, adjustments were made in the process of administration of interviews especially where saturation of responses was being reached. Quantitative tools were adjusted after analysis of district level data. The data collection methods and tools included: 2.1.1 Document review using a document review guide: the documents reviewed included those proposed by ACP-MoH, the TWG members, and those proposed by the review 6 team at the start and during the review process and specific documents included legal and policy frameworks strategic and operational plans, reports and minutes of meetings among others. Document review was done prior to field visits to the districts to inform the methodology and enrich data collection tools; it continued to the district level as part of data abstraction to obtain the required secondary data. 2.1.2 Key informant interviews using key Informant interview guides; selection of key informants was done before the data collection exercise started but with room for others who were added during the exercise where the need arose. At district headquarter level the focus was on holders of strategic posts, as defined by the MoLG, members of the DTPC, DHT, and DHMT; at HSD level the focus was on personnel directly responsible for managing service delivery while at Sub-county and community level the focus was on personnel that would help the teams capture information on community involvement and participation. 2.1.3 Focus Group Discussions using Focus Group Discussion guides; these were intended to capture information related to community involvement and human rights. 2.1.4 Round Table Discussions using round table discussion guides; these focussed mainly on capturing information from a number of key personnel that could not fit into focus group discussions due to their status’ and those with limited time. This was required to obtain information on key and strategic issues not addressed by other methods. 2.1.5 Observations using an observation checklist; these were meant to capture specific information like presence or display of reference documents or IEC materials respectively, presence of items like condoms in strategic positions etc 2.1.6 Collection of quantitative data using semi-structured questionnaires; this was done to increase the number of respondents contributing to the review both at district and national level. Two tools were administered at district level one to top district executives and technical personnel all of whom had a role to play in management of the epidemic and facility personnel that were directly related to service delivery. Another two tools were administered at national level one for health sector personnel and partners and the other for law makers who have an oversight role to play. 2.2 Description of the data Collection process Review of health systems governance relied on qualitative data and expert views and experiences with quantitative data collected to compliment the qualitative data. The quantitative approach was also a strategy for involving as many respondents/stakeholders as possible. Data was collected from four levels national, district, facility and community levels. Data collection in each district started with an introductory meeting at the DHO’s office where a consultant introduced the review and review team members; this was followed by declaration of the officials to be met by the various teams after a guided sampling exercise. At district level our target was top political and administrative personnel including technical staff; selection thus included representation from the district political leadership, technical leadership from the DTPC and DHT and the non public sector namely representation from district NGO forum/CSOs/FBOs etc.; the other target was facility level personnel basing on the facility definition by the MoH namely regional referral hospitals, district/general 7 hospitals, HC IVs, HC IIIs and HC IIs with representation from the public sector including uniformed services a separate entity, PNFPs and PHPs; we also targeted the community through members of HUMCs, VHTs and community groups like PHS groups. Our target at national level was representation from national and MoH law/policy makers, senior and mid-level officers of MoH, key sectors as identified in HSSP II, UAC, ACP-MoH,the civil society, centres of excellence, Umbrella organisations, NGOs, FBOs, UN agencies, ADPs, HDPs, academic and research institutions, Parastatals, semi-autonomous institutions of MoH etc, International partners/donors, Uniformed services, key personnel in the national HIV/AIDS partnership and human rights institutions and organisations. The district phase included most of the data collection methods. Key Informant interviews at this level were intended to gather information from holders of strategic posts that were relevant to governance at district level; these included district political leaders like the RDCs, LC V Chairpersons, the CAOs and members of the DTPC, members of the DHT and DHMT. At HSD level the KIIs were intended to capture information from officers responsible for managing health service delivery at that level including support supervision of lower level health units. Focus Group Discussions were carried out to capture information from definable groups or communities using FGD guides with members of HUMCs, Sub-county structures and VHTs. A few FGDs were carried out at national level to capture information from PHAs and human rights advocates and institutions. One Round Table Discussion was arranged for at least one DHMT/DHT and two at national level one for leaders of professional associations and the other for leaders of FBOs. At national level, meetings were held with key stakeholders like the ADPs, the PEPFAR coordination team and others; these meetings were followed by introductory letters written by the Team Leader for all the consultants and their Research Officers. Governance data collection at national level required an elaborate system of making appointments and cancelling them before an interview eventually took place. 2.3 Qualitative Methods of Data Collection This took the form of document reviews, key informant interviews, Focus Group Discussions and Round table meetings and observations. Key Informant interviews were done at both district and national levels for Key informants selected prior to the data collection exercise and those selected as the need arose out of the initial interviews, after FGDs, after observations or after analysis of quantitative data from both district and national level; the observations made were on selected key issues during qualitative data collection. 2.4 Quantitative Methods of Data Collection Quantitative methods of data collection were also used both at national and district levels for purposes of capturing information from an extended number of respondents among others things. At district level, one semi-structured questionnaire was prepared for district level officers focussing on the strategic posts as identified by the MoLG plus other members of the District DTPC and DHT. The respondents of interest were among the personnel reflected in the LTIA for management of HIV/AIDS in Uganda and the LTIA for Management and Coordination of Global Health Grants in Uganda. Most of the questionnaires at district level were filled in presence of the governance or other block review team members. 8 2.5 Analytical Framework and Questions Analytical framework questions were based on the generic components of governance and reference was also made to the framework for assessing governance of health systems in developing countries. The questions focused on legal and policy frameworks, policy development and management, decentralisation, mainstreaming, planning, resource mobilisation and budgeting, coordination and participation including partnerships, M and E frameworks, strategic information, research coordination, human rights and transparency accountability and corruption. Information was sought on institutional arrangements, TORs for relevant bodies, dissemination, operationalisation/functionality, reviews, what was planned in the period 2007-1010, what was achieved; then identification of strengths and weaknesses and opportunities and threats or challenges relating to the response. 2.6 Data Analysis, Triangulation and Interpretation Handling of the data and subsequent information from quantitative and qualitative data collection methods was done as presented below. Quantitative data at district level One tool was used to capture data mainly from holders of strategic posts, as named by the MoLG, namely top political and administrative personnel including members of the DHT, DTPC and DHMT. The second tool collected data from facility level officials mainly heads of the facilities and chairpersons of the HUMCs. The data was checked by supervisors on returning from the field and counterchecked by the administrative coordinator before being passed over to the consultant and the block R.O for quality assurance checks and then submission to the statistician for data management. Analysis was done using Epi-data soft ware; frequencies of key variables were produced and tabulated. Qualitative data at district level Four tools were used, as earlier indicated, to capture responses from district level political and administrative officials including members of the DHT, DHMT and DTPC, facility level respondents and communities including chairs of HUMCs and VHTs. All interviews were taped and then transcribed verbatim by the responsible R.Os and R.As. All taped materials were handled by the supervisors who were responsible for quality checking and ensuring they were properly transcribed before handing the transcripts to the review coordinators. For qualitative content analysis, the unit of analysis was the interview narratives. The manifest content analysis technique (computer aided) was used. The typed transcripts were read through carefully and then logged into ATLAS.ti v 5.2 qualitative data management software to systematically extract meaningful pieces of data based on the objectives of the review governance components and key areas of concern. Emerging themes were also identified depending on the study objectives. Query reports were run and then carefully read to summarize key messages that guided report writing. Key observations from quantitative data analysis were sorted in relation to questions arising from the analytical framework and triangulation was done with observations from qualitative analysis to explain the key issues that were addressed and answer the review questions; findings from document review were used to explain or clarify issues that were not covered by the information from primary data. 9 Quantitative data at national level One semi-structured questionnaire was used to capture data from health sector level respondents including respondents from sectors that have been identified in the HSSP II as key partners for inter-sectoral collaboration; the definition of the national health system was also used to select other crucial respondents. A similar tool was used to capture data from law makers. The forms in each case were checked by the R.O. and some by the consultant for quality assurance. The analysis process was similar to that applied in the case of district data. Qualitative data at national level The architecture of the national HIV/AIDS partnership, maturity and heterogeneity of the epidemic coupled with the findings from district level necessitated a big number of respondents to be interviewed to cover selected areas of concern. A total of eighteen tools were used for KIIs, group interviews, FGDs and round table discussions that involved national and MoH policymakers, mid- and senior managerial staff of the MoH or its component departments, CSOs, FBOs, PHA-networks, ADPs, HDPs, GHIs, academic and research institutions, media culture and arts personnel and direct community representatives particularly PHAs. Analysis of the qualitative and quantitative data from national level and triangulation of the findings was done as for the district level. Eventually the district and national findings, including findings from document review and observations, were compared and contrasted to come out with a summary of findings. 10 3.0 CHALLENGES/LIMITATIONS DURING THE STUDY There were various levels of limitations including: This being the first time governance is being reviewed specifically, some data collection tools tended to be relatively long and this made transcribing a challenge in terms of time and cost Limited funding for field work was a big set back especially at national level; a need arose to interview more respondents in order to improve on credibility dependability and transferability of findings but the necessary funding could not be secured The quality of the initial tapes was poor and this resulted in loss of very valuable recordings; extra costs had to be incurred to buy the correct tapes through a MISR expert; but still some stop executive respondents could not be interviewed a second time. The standard of transcribing of some of the personnel used was relatively low such that more time was spent reviewing the tapes so as to correct grammatical and other mistakes Most health sector personnel and partners over-delayed to return the filled tool 12 and this disorganised the order of interviewing and increased the time for data management The tools 12 for law makers were delivered when parliamentarians were starting their campaigns and many failed to fill the tools or delayed to return them even up to the deadline for handing in draft reports; the exercise had to be halted when parliament was also suspended due to lack of quorum 11 4.0 FINDINGS OF THE STUDY This section presents findings from the national and district level review. In developing the framework for this HSG review a number of contemporary governance issues were reviewed including the role of the state versus the health market noting that the largest proportion of the national per capita expenditure on health is out of pocket, the role of the MoH/health versus other ministries/sectors noting that HSSP II earmarks four sectors as key sectors for inter-sectoral collaboration, the role of actors in governance at national level particularly the public sector noting its primary responsibility for development of policies and overseeing policy implementation, private sector, civil society, dynamic versus static health systems and health reforms versus human rights based approaches to health care. It was noted that the health sector is managed at basically two levels national and district. The WHO identifies four functions for the health sector that can ensure an effective health system. The deliverables of good stewardship by the MoH include creation of resources, human physical and financial all of which can then be applied to deliver essential health services. A number of respondents in this review acknowledged that the MACA to management of the national HIV/AIDS partnership of 12 SCEs representing partner entities far in excess of 4000 must acceptably be complex. 4.1 Findings of the District Response Introduction ACP-MoH is the programme of the MoH that is charged with implementing the HIV/AIDS component of cluster 3 of HSSP II; it therefore takes the responsibility for national coordination of the health sector (core function) component of the NSP. Up to 1992 the ACP-MoH/health sector coordinated all the components of the national HIV/AIDS response. It started the role of covering only the health component when the UAC came into being to to take charge of overall coordination of the multi-sectoral response. Then the district health system took over the health service delivery component of the health sector but operating under the line authority of local governments (Uganda Constitution 1995 and Local Government Act 1997) to which administrative authority was devolved. The roles that the health sector passed over to the district health system on behalf of the health sector included: Health service delivery Recruitment and management of personnel for District Health Services in collaboration with the Health Service Commission (HSC) Passing by-laws related to health, and Planning, budgeting, additional resource mobilisation and allocation for health services. The activities of all health sector partners in the district are supposed to be reflected in the district health sector strategic plan, which is part of the rolling District Development Plan. The NHP established the health sub District as a functional subdivision or service zone of the district health system to bring quality essential care closer to the people, allow for identification of local priorities, involve communities in the planning and management of health services and increase responsiveness to local needs. Whereas the DHO (previously DDHS) retained, through the DHT, functions of planning, budgeting, coordination resource mobilisation, and monitoring of overall district health sector performance, the HSD, created with decentralisation, took on the responsibility of direct service delivery (HSSP II). The future of the HSHASP was noted not to be very bright as 12 it was noted that poor logistics, inadequate staffing, weak management capacity and poor working conditions had been cited as the main factors that were going to dictate the pace and general effectiveness of the policy change from central control of health service delivery to district health officers’ control (HSSP II). In the period covering implementation of HSHASP, the plan was to give priority to capacity development of DHTs based on needs assessment in areas of human resource development and management, logistics and working environment. Public-Private-Partnership in health care delivery was a priority strategy even during HSSP I and it was planned that in the period covering HSHASP (2007 – 2010) the DHT was to be expanded to include district representatives of CSOs, PNFPs, FBOs, CBOs and other CS service providers that were expected to be active in each district. Review of Governance Leadership and partnerships relating to the health sector HIV/AIDS Response in the districts was undertaken with the foregoing in the background. The review sought to assess the extent to which selected principles of governance, reflected earlier, had been applied during district implementation of the HSHASP to answer related questions. Selection of respondents took into account the new placing of district based governance actors in the response namely district (central) level, HSD level, Sub-county level and community level. District level findings are presented in this section as follows. 4.1.1 District (central) Level 4.1.1.1 Background characteristics of the respondents Table 1 Background characteristics (Respondents and facilities that were visited) Distribution of respondents by districts Mbarara Katakwi Kiboga Arua Tororo Kamwenge Kamuli Gulu Pader Kampala Total Freq Percent 10 3 11 2 8 9 7 7 2 7 66 15.2 4.6 16.7 3 12.1 13.6 10.6 10.6 3 10.6 100 21 18 2 25 66 31.8 27.3 3 37.9 100 Type of the facility (as per MoH definition) Hospital HC IV HIV/AIDS care centre (e.g TASO) HC III Total 13 Ownership of the facility Public Private not for profit(PNFP)/NGO Private for profit Total 42 18 6 66 63.6 27.3 9.1 100 39 2 1 42 92.86 4.76 2.38 100 7 8 1 1 2 1 4 24 29.2 33.3 4.2 4.2 8.3 4.2 16.7 100 Type of administration for the public facilities MoH UPDF Uganda Police Force Total Name of organization (non-public/private) FBO/COU FBO/Catholic FBO/Muslim TASO Individual/private clinic HIPS Private hospital Total Designation of respondent Freq Percent Medical Superintendent Director of Health Services Medical Officer I/C In-charge HC IV In-charge HC III Director Chair HUMC Program Manager Administrator ART clinic focal person District Health Inspector Acting In-charge Midwife Senior Nursing Officer Health Assistant Division medical Officer Total 10 2 6 7 16 1 9 1 3 3 1 2 1 2 1 1 66 15.2 3 9.1 10.6 24.2 1.5 13.6 1.5 4.6 4.6 1.5 3 1.5 3 1.5 1.5 100 Qualification of respondents Doctor 19 28.8 14 Clinical officer Nurse/Midwife Teacher BBA(management and marketing) Administration Social Worker Priest/Reverend Father Environmental Health officer Lab assistant Lab Technologist None medical Missing Total 15 16 2 1 1 1 1 1 1 1 6 1 66 22.7 24.2 3 1.5 1.5 1.5 1.5 1.5 1.5 1.5 9.1 1.5 100 Table 1.0, shows distribution of respondents and facilities according to the district of review. The respondents were evenly distributed except for Pader, Arua and Katakwi districts with 2, 2 and 3 respondents each respectively (Table 1.0) The biggest proportion of health facilities surveyed (37%) were HC III followed by Hospitals (31%); the least reviewed were HIV/AIDS care centres (3%). This could be because these centres are not common in many rural districts (Table 1.0,). Regarding ownership of facilities, majority (64%) were public, 27% were PNFP and PHPs made only 9% which is typical of many districts in Uganda (Table 1.0,). Administratively, majority of the public health facilities (93%) belonged to MoH; UPDF and UPF only administered 7% of the public health facilities. Most of the privately owned facilities (33%) belonged to the Catholic Church followed by 29% for COU and 17% for PHPs (Table 1.0). Of the private/non-public sector facilities, the biggest proportion belonged to the Catholic/FBOs, followed by Church of Uganda then muslims etc (Table 1.0). The biggest proportion of respondents at health facility level were in-charges of HC III (24%); this could have been due to the fact that there are more health centre IIIs than hospitals and HC IVs in all the districts sampled besides the whole country. Next 15% were medical superintendents (Table 1.0). In terms of professional qualifications, the biggest proportion of respondents in the health facility survey (29%) were doctors, then 24% nurse/midwife, and 23% clinical officers (Table 1.0). The spectrum of cadres indicates that almost all the respondents at health facility level would be expected to handle some governance related responsibilities. 4.1.1.2 Awareness of the national plans 15 There are three reference strategic documents for health sector interventions at district level (HSSP II, NSP and HSHASP). Health facility respondents were most aware (64%) 42 of the HSSP II and least aware 52%(34) of the HSHASP. Also respondents were most likely to have read HSSP II and least likely to have read HSHASP. When we engaged district officials, they were also most aware 90.1%(64) of the HSSP II but least aware 69%(49) of the NSP; they were most likely 54%(34) to be involved in reviewing HSSP II and least likely 42.9%(21) for the NSP. Thus both health facility and district office officials were most associated with HSSP II out of the three documents; otherwise district (central) officials appeared to be more associated with HSHASP than the health facility based officers. Most district level officials were members of the DTPC on which the health facility officials may not be sitting. It would also appear that district officials get more involved with health sector documents. District level staff who responded to the semi-structured questionnaire include political leaders, district health technical staff and district non-health technical staff; we desegregated them accordingly for clarity and found that still both health and non-health respondents were most associated with HSSP II. This shows that all respondents across the board were more conversant with HSSP II than the other two plans. There was no response recorded from representatives of CSOs, FBOs and others. All the political leaders were aware of the plans particularly the NSP. It should be noted however that HSSP II is dated earlier (2005/06 – 2009/10) than both HSHASP (2007-2010) and NSP (2007/08 – 2011/12). A good number of key informants expressed concern about presence of too many plans but at the same time appeared confused by the three plans; respondents from CSOs were more concerned about alignment of individual organisational plans with national level plans which they were not clear about. This was an indication that it was not clear to many as to which plans they were supposed to align theirs. CSOs tended to be more conversant with the NSP rather than the other two plans. This indicates that dissemination of the plans needs to be comprehensive so that the various partners can act the same way for purposes of effective coordination. 4.1.1.3 District HIV plan Availability of a district HIV/AIDS plan is essential for guiding the HIV/AIDS response interventions in the district. Health facility respondents were asked about availability of a district HIV/AIDS plan in their districts and the majority 62%(41) agreed to having a district HIV/AIDS plan. Majority 32(78%) were not sure when the HIV/AIDS plan had been developed and 71% were not sure how often it was being or was supposed to be reviewed. Regarding involvement in development and review of the plan, the biggest proportion (65%) mentioned that the district health office had been involved; a significant number mentioned 22(45.1%) community representatives/PHAs as also having participated. The district officials were aware that the plan was reviewed every year. On linkage between the annual budget and action plan and the district plan, majority 58% were not sure of the relationship while 35% mentioned that the three were linked. However district central staff were aware of the linkage between the documents both health staff 80%(28) and non-health staff. 4.1.1.4 District AIDS Taskforce 16 According to the LTIA for management of HIV/AIDS in Uganda, the District AIDS Taskforce (DAT) is responsible oversight of all the HIV/AIDS activities in the district and therefore also oversight of coordination of the health sector HIV/AIDS response in the district. Respondents were asked whether there was a DAT and if it was an active DAT and 31(46.9%) said that they had an active DAT and this met quite often, but 48.4%(32) were either not sure of its existence or they said the DAT was not active. A significant number of the respondents 22.7% mentioned the DHOs and the district HIV/AIDS focal persons as responsible for convening most the DAT meetings. On dissemination of minutes the of meetings, 5(16.1%) mentioned that they were disseminated through DHT meetings; this could reflect confusion between the DATs and DACs. Similarly district (central) officials were asked if a DAT existed and if it was active. Findings showed that all the political leaders (100%) said that the task force existed in their districts but only 33% said that it was active. On the other hand, 33(94%) of the district health workers said that it existed but only 51% observed that it was active. This was followed by 88% of the district non-health technical staff who said that it existed and 69% who observed it to be active. This means that though there are district HIV/AIDS task forces, they are not fulfilling their mandate as required by the LTIA. We sought to get information on what the reasons could be; responses ranged from effects of complacency, inadequate funding from government; some respondents attributed the problem to political commitment. (..”the system has lost steam and enthusiasm has dwindled even from the highest levels; for example we used to have annual meetings of RDCs and issues would be articulated and problems ironed out but RDCs no longer meet; DATs and DACs have various problems and yet SATs and SACs could have done a good job especially at community level” (KI, law maker) 4.1.1.5 Legal frameworks Not many issues came out at district level; but CBOs expressed concern over lack of protection for young girls and women. Where a national law exists, the district can use the law to enact a district bye law for operationalising the national law at district level. Districts are slow on many issues; for example you see a man who is clearly sick taking on a young girl and poor thing needs money and has to accept, the districts are empowered to pass byelaws to protect those; even women being inherited; if there was a national law some of our organisations would come in” (KI, district human rights advocacy CSO). Apart from the AIDS law some people expressed dissatisfaction with delays like that on the domestic relations bill sighting HIV/AIDS related domestic issues like women being beaten for coming home to share HIV/AIDS test results. 4.1.1.6 Policy Development & Management A number of issues arose around policies particularly around dissemination, implementation and enforcement. 4.1.1.6.1 Involvement in Policy Development and management Various stakeholders reported that they are involved in the formulation of policies and plans (like the HSHASP). They reported being invited to attend the planning meetings and being consulted along the road to policy formulation. 17 “The process of developing policies and plans is supposed to be as usual, all involving. They should come down to the district get our priorities and those of other stakeholders which has been ongoing or has been done. The ministry of health has done a wonderful job in this area because it is their role” (KI, DHO) However some key informants outside the health sector in the districts reported that they felt not fully involved in the policy development process. From quantitative data analysis respondents were more likely to be involved in reviewing than the development stages, hence the need for effective dissemination for implementation. “It is participatory but some sectors are not well involved. Some sectors are neglected. The people from the health sector think that HIV/AIDS is only a health issue and it should only be handled by them” (KI, District Planner). It should be noted that the district planner is supposed to be central in development of district plans and a statement like the previous one reflects a problem at district level; the health sector needs to resolve what is stated here as the planners should be a closer partner in planning, implementation including oversight and M and E. National level responses and quotes reflected that there was inadequate intersectoral collaboration even among the key sectors identified in HSSP II. The frameworks in place currently, provide for deconcentration of authority and responsibilities within sectors from the national to district level even up to sub-county level; therefore decentralisation would benefit greatly from effective collaboration among sectors both at national and district levels. 4.1.1.6.2 Challenges to policy development and implementation Some Key Informants reported that there is a problem with proper policy dissemination to the lower level staff much as most of the policies needed are well developed and existing. Some reported that they were not aware of the policy on HIV/AIDS yet they are in the health sector. Other respondents expressed concern about limited funding for implementation of the policies already designed as a challenge. “When you look at the documents...the policies are very excellent; when we talk about funds people are wise, they say the government will commit funds but does the government in the long run bring those funds? The challenge is with implementation” – (KI, DHO). Lower level health managers noted that only district (central) level staff knew when policies were launched as they ‘attended launch ceremonies and took away the copies for themselves’. Many district level staff and those at lower levels indicated they often did not participate even in development of policies 4.1.1.6.3 Existence of workplace HIV/AIDS policies and others Workplace policies are expectedly the results of mainstreaming specifically the stage of the internal mainstreaming component. If well implemented, workplace policies enhance scaling up of the multi-sectoral HIV/AIDS response particularly in the workplaces, where workers spend most of their life time, leading to several benefits for immediate families of direct beneficiaries of those workplaces. There was general lack of knowledge about mainstreaming, but many key informants reported having workplace HIV/AIDS policies where they worked. However many of those policies appeared to have been recently developed and not fully operational yet. A number of institutions/districts follow the national policy on HIV/AIDS and the world of work but don’t have those specific for themselves. 18 SCEs and sectors can be crucial in rolling out mainstreaming policies but dissemination and implementation of the policies has been poor; lack of comprehensive understanding at the central/MoH level may have affected the level of implementation. Mainstreaming would be enhanced if the ACP-MoH/MoH level was effectively guiding the process as a model. Other policies that were mentioned as lacking included the PPP-H policy and one specific for MARPs which some CSOs, FBOs and CBOs said would be guiding them especially “where things tend to be unclear”. Many health professionals and other respondents in the districts were uncomfortable with what they called “quack practitioners” for whose control necessary instruments were not in place. It should be noted that byelaws that the districts are mandated to enact are usually based on specific national instruments which need to be there first; one of the instruments currently being awaited is the policy to regulate traditional and complementary practitioners. 4.1.1.7 Planning, regulatory frameworks and Monitoring and Evaluation 4.1.1.7.1 What guides in planning Key informants were asked about the planning processes in their areas of work. Some of the respondents reported they used the National Health Policy, others the Health sector Strategic Plan, the MoH guidelines on managing HIV/AIDS, and PMTCT to help in guiding their planning at institutional/district level. DHT and DHMT officials, however, tended to be more conversant with the planning frameworks, including HSHASP, than other respondents. Some key district based partners were also not sure of what was supposed to guide their planning. 4.1.1.7.2 Comments on the current ACP-MoH Structure and its placement in MoH Key informants stated that it was good to have everyone in every sector perform some role in the Health sector HIV/AIDS response but emphasised that the partners needed to be well coordinated and harmonised in order for them to play their role(s) effectively. They all submitted that ACP-MoH had to spearhead the coordination role. To the above effect, placement of the ACP in the MoH structure drew mixed reactions from respondents. The strongest views included raising the programme to division or department level. A proposal to give ACP just authority to carry out its responsibilities effectively was also made. ACP managers in other sectors already include directors and commissioners. “I think we have already mentioned that, you know, placement is not satisfactory because you know when you have e.g. CAO at district level, you know he goes down and there are structures that give him control up to the sub-county level, and even parish; but if you have an institution which is at the top only and its job is to monitor, mobilise, etc and yet it does not have branches at lower levels and it is not reflected there… like people keep hearing about ACP at the top level, then it may not be as effective. It must be felt; it must be part of the leadership at various levels” (KI, RDC). It was noted as awkward for the manager ACPMoH to mentor DHOs who are at a higher rank, ACHS, than his/hers. On support from ACP, some respondents reported that ACP technical support to the partners and districts is not frequent and that it needed strengthening and support to be able to play its role effectively. There is need to re-organise it and re direct its line of work because issues keep changing over time. Some key informants reported that they had not had ACP support to the districts at all. “They drop like rain, but they do come. I would be lying if I say they come in this and this time. Someone just gives us a call that they are coming” (FGD, Health centre/HUMC). 19 “the AIDS Control Program (ACP) itself I have not seen them and like I said they only come at the district and usually they come once a year; actually there is that gap compared to the past years. At least they could come twice a year but for the last three years you can find that they came twice in 2 years, once a year, which is really very slim” (KI, RDC) However, a few other respondents reported that they had got monthly supervision from ACP. They reported getting guidelines that helped them in implementing priorities of the districts and institutions. It appeared that the support supervision and visits from ACP-MoH had not been standardised for all partners as the mixed reactions portrayed. ACP-MoH is delegated the responsibility of coordinating the health sector HIV/AIDS response nationally and service delivery is basically at the district level. It was expected that the programme had been providing effective stewardship for the response at the decentralised level. The respondents expressed concern that MoH had no structure at the district level and referred to, for example, the CAO who has structures up to the community level. Proposals have been made by a significant number, including parliament, to recentralise recruitment for at least part of the district health services. For example the DHO, or the whole DHT, could be recruited by the centre as has been done for the CAO’s post; this can give room for staff to be moved where the need is identified to be most crucial; also staff can know of different alternatives available for them to move should they feel like moving rather than the current situation where there is usually no hope of moving even when opportunities for possible advancement arise in other districts or at the centre. Challenges to decentralisation were foreseen even before the HSSP II took off (MoH, 2005); this review indicates a need for retaining some functions at the centre and continuing with decentralisation for those that have been successful. 4.1.1.7.3 Existing frameworks providing a basis for effective response for HIV Most key informants reported that the frameworks existing are ably providing for an effective HIV/AIDS response because service providers and people in care know what to do as provided for by the guidelines. It was noted however that many respondents lacked comprehensive knowledge of the frameworks. 4.1.1.7.4 Oversight and regulation of health services of FBOs in the district The district review sought to find out the status of oversight and regulation of services provided by FBO facilities in districts. According to health facility officials, government of Uganda was seen to be performing its role of oversight and regulation of faith based and Private Health Practitioners’ facilities as seen by 74.2% of the respondents. Also, majority of the respondents 48(72.7%) mentioned that there was a procedure in place in the district for community members to provide feedback on health services and majority 31(64.6%) mentioned periodic meetings with community leaders/community health teams as the most used means of providing feedback followed by suggestion/feedback box at the health facilities. Other feedback mechanisms commonly mentioned were community health management information systems, through health unit management committees and radio talk shows. However, 54% reported that only some of the community members knew about these mechanisms and 35% said most but not all knew about the mechanisms. It was further mentioned that the mechanisms were being used in the community 42(87.5%). 20 The findings showed that when a positive feedback was received, the individual was praised and given an award as seen by 43.8% followed by 25% who noted that the person who performed well was given other responsibilities. Regarding negative feedbacks, a big proportion respondents (33.3%) could not think out off hand what was done; but 18% said that the culprit was reprimanded and removed from service. The MoPS has developed an incentive scheme that is supposed to be rolled out by all ministries and recommends modes of reward for good performance and sanctioning for non compliance. It should be noted that speed of compliance has been low although some ministries have moved ahead of others. It is also to be noted that MoPS initiated a scheme for ministries to develop a client charter each as a result of which MoH also developed one that has but delayed to be disseminated till around now when it has been overtaken by the Patients’ Charter that was spearheaded by the Uganda National Health Consumers’ Organisation but finally also endorsed and or eventually owned by the MoH. 4.1.1.7.5 Procedures to monitor AIDS/health services and give feedback to health facilities Monitoring of HIV/AIDS/health services is essential for effective implementation of the HIV/AIDS response. Majority of the respondents 53(80.3%) acknowledged there were procedures in place for monitoring HIV/AIDS/health services and providing feedback to the health facilities that provide the services. Among the procedures of monitoring the one mentioned most was periodic support supervision visits to health facilities by DHO staff (81.1%) followed by health service assessments or facility visits by Ministry of Health in collaboration with the district health office (57%). Over 50% of the respondents said that the district staff had made a supervisory visit to their health facility within the previous three months and the visit had covered all the health care provision issues in the district. Regarding national level supervision, less than half of the respondents 31.8% and 33.3% said that the supervision team from ministry of health had come in the last three months and 3-6 months respectively. The topics covered during visits included HIV prevention/testing, HIV care, TB, laboratory services, general health services, malaria and family planning. About 50% indicated that an expert from a donor /national organization had visited the district within the previous three month (48.4%) and the issues discussed were mainly concerning HIV care 64.2% and HIV counselling and testing 62.3% and TB 40.4%. It should be noted that whereas all respondents acknowledged presence of feedback procedures, for both district officials and the community, there were fewer people who acknowledged utilisation of the procedures an issue that could be related to lack of clear knowledge about their presence. According to the principle of the three ones, one would expect one monitoring and evaluation framework for the district but this review could not confirm its presence; a number of the respondents actually sounded the need for it. The need was sounded by respondents from both public and private sectors who agreed that one such framework would be good for even quality assurance. 4.1.1.8 Mainstreaming of HIV and AIDS into district activities. Most district key informants reported some level of mainstreaming of HIV and AIDS in district activities; they mentioned there was sensitisation of staff among other things. On further inquiry the review confirmed involvement of other sectors apart from health, in HIV 21 planning and implementing; they indicated there was an effort to ensure that most activities, including those of partners outside the health sector like road construction, included an HIV component in them. “Even if it is national celebrations guiding messages are not left aside. Even in institutions like schools or activities of production like NAADS you find an element of sensitization of people; in production they definitely talk about HIV/AIDS. When you look at women’s activities, if the people go for social mobilization one of the other things that is put in the program is something to do with HIV/AIDS. I think that it has been mainstreamed in activities of government and also non government sector activities.” (KI, RDC) Some however reported that although it is mandatory, HIV is not yet fully mainstreamed in all district activities. It is only in a few activities like education. In other districts, although it appears in the planning phase, it is lost when implementing activities because of lack of funds to meet the added costs. “Yes, it has been mainstreamed in planning, but implementation is another issue. Implementation is different. For the paperwork it is there because every year under LGDP assessment they are to come and see how you have integrated HIV issues in the development plan and may be what is lacking now is to have the reality on the ground, to assess our interventions which are put in the development plan because now we are assessing the planning we are not assessing the implementation; once they come and look at the planning, are the implementations there?.. then they give you a tick” (KI, Senior CDO) It should be noted that the purpose of the National Policy on Mainstreaming of HIV and AIDS was “to compel all sectors to mainstream HIV and AIDS in their planning and budgeting” (Uganda AIDS Commission, 2008); mainstreaming is one of the strategies for effectively scaling up the HIV/AIDS response. Analysis of quantitative data on mainstreaming, including the policy, in the district showed that most of the respondents 35(53%) were not sure whether their districts had the mainstreaming policy or not but 6.1% said the policy was not there; only 25(37.9%) said that they had the mainstreaming policy or plan for HIV/AIDS. Thus a lot still needs to be done for the mainstreaming process to take effective root. 4.1.1.9 Resource Mobilisation and budgeting: Government spending on health from domestic sources is an important indicator of a government’s commitment to the health rights of its people and is essential for sustainability of health programmes and should be the focus of good governance which should also be able to mobilise additional resources from other stakeholders. Under decentralisation districts are empowered to raise funds for district based programmes and this review therefore looked at resource mobilisation and budgeting at district level. 4.1.1.9.1 Support from partners Key informants reported that there was support from the MoH and partners (donors and NGOs) to the districts and health centres specifically. They reported a number of partners that support the districts and health units; these included United Nations Fund for Population Activities (UNFPA), Centres for Disease Control (CDC), the African Medical and Research Foundation (AMREF) Uganda, Programme for Accessible Health Communication and Education (PACE) - formerly PSI, among others. 22 4.1.1.9.2 Comments on the current funding arrangements: A few key informants reported that the current donor vis a vis national policy on funding and disbursement makes it hard for small organisations to compete with big organisations for funds as requirements are almost always hard to meet. Others complained of lack of transparency in the current funding arrangements and that was why, according to many of them, funds end up being misused. There were also complaints about the erratic funding of activities with particular activities being funded and not others. Respondents felt much of the money was being spent on less useful aspects of the programmes like meetings and seminars and not for actual direct benefits to the people who need the support (care). This quote highlights the view further, …” I am gland you called me, I think we’ve talked much and not done much, we need to get working” (KI, CEO of a big CSO). “To me I am not very comfortable with the arrangements because the money comes once in a while. More of workshops and seminars, may be HIV testing kits only; it does not have the money for actual or direct monitoring by political leaders who actually have the plat-form every day.” (KI, LC5 chairperson) “The other issue of funding would be may be when we look at the budget for example when you have 100 shillings how much has gone directly into what is the main objective of the program. Like for the AIDS Control Program, how much goes directly into what the main objective is, that is controlling the disease; the biggest complaint of some of us has been that most of this money is spent in seminars a lot of workshops a lot of nice vehicles running around the city but how much reaches the man who is affected or the person whom we want to help such that he does not get infected.” (KI, RDC). Current funding is likely to lead to heightening of transaction costs; current funding mechanisms are not followed by the major HIV/AIDS donors; but the IHP+ may be moving towards resolving this to an extent. Findings from the district level showed that there is poor linkage of budgets to plans in most districts as the principle of the three ones is not effectively in place yet. Delays in transfers of resources such as Graduated Tax Compensation from the centre were referred to as among the constraining factors. Generally it was noted that mobilisation for HIV/AIDS control at district level was low; some districts even reduced health budgets on grounds that health already had a lot of money from HIV/AIDS. Studies have also shown that development assistance for health through the public sector has a negative effect on government allocations for health (Chunling Lu et al, 2010). 4.1.1.10 Partnerships Coordination and Participation 4.1.1.10.1 Comments on the three ones Respondents viewed the principle of the three ones as a very good idea because it helps in streamlining activities and working together among partners/stakeholders. However most of them reported that although the principle is good, its implementation is limited because of various issues such as poor coordination of activities. They reflected its implementation as a best practice if coordination was improved to make complementary partnerships a reality. 23 “I think if the 3 ones was adopted it can still work, I think it would help a lot for example we or all partners we have the joint Plan and M&E, AMREF and World Vision are all implementing that is we have a component in HIV, IDI is known for VCT so any person who comes with HIV comes at IDI and we give them ARVs for adults, AMREF mobilizes, World Vision provides ARVs to children.” (KI, Partner) 4.1.1.10.2 Coordination role of ACP AIDS control Programme was reported to be helpful in coordinating implementation of the HSHASP, monitoring and evaluation and support supervision, but most of the key informants suggested it needs to be strengthened to play its role better. Some reported having meetings and workshops with ACP technical staff and submitting reports to them who then help to determine funding. “The AIDS Control Programme has played its role. For example the routine area team monitoring. I usually see the program manager in the planning meetings and monitoring of new partners in the district. Whenever new partners want to work with the district always the AIDS Control Program verifies whether the partner is looking at our priorities or not or whether we need the partner” (KI, DHO) There were cases reported where partners are doing similar things in the same geographical location because the coordination was not strong enough. “ACP also provides guidelines and policies, which guide the response. However, more is needed in coordination; coordination or it needs to be improved. We need to know who is doing what to avoid duplication of services for example in Mulago all of us are doing the same things. Why not be clear on what different stakeholders can do in order to have all work as per their comparative advantages” (KI, Kampala) 4.1.1.10.3 Participation in Decision Making and coalition building Most respondents were happy about the participation of Stakeholders as a partnership in decision making concerning HIV issues given that it’s a national problem cutting across sectors. They reported that NGOs (like Catholic Relief Services, AMREF, etc) and projects (Baylor, EGPAF, etc) working in the districts were involved in collaboration with the districts. Respondents commented positively about national coalition building. They argued that the partnerships help in sharing experiences and ideas among implementers. “… its good because you get views from all the implementing partners and share experiences, challenges and see how you can fill the gaps for example we have the NGO forum here and it is responsible for all civil societies in the district; so we all come out and share our experiences and challenges and distribute resources in all sectors.” (KI, DHO) 4.1.1.10.4 Donors' or International organizations' intervention in district health activities Majority of the respondents 62(93.9%) were aware of some donors or international organizations working in their districts and 32(51.6%) observed that donors sought opinions and tried to understand priorities of the community before developing their district activities or programs. Also, 56.5% said that donors routinely make them aware of their district visits and 61.3% noted that donors updated them on their health programs in the district unlike 43.6% who reported otherwise. We noted that majority 53.2% of the respondents were not sure whether donors transferred funds to the district budget; only 32% said that donors transferred funds to the district budget. On the donors supporting HIV/AIDS services, the most commonly mentioned was UNICEF, by 31.6%, and BAYLOR 26.1%; other donors mentioned included EGPAF, Baylor, AVSI, CDC, AMREF, Global Fund, IBFAN, IDI, Italian 24 Cooperation, JCRC, NUMAT, Plan International, PREFA, STAR-EC, TB-CAP, Stride, UNAIDS, UNICEF, UPHOLD, UNEP, USAID, World Vision, TASO etc. Many respondents (42.4%) mentioned that donors influenced their health priorities and or helped to create new district and or subordinate HIV/AIDS/health policies. Most of the respondents 36(54.6%) observed that they had a workplace policy in place. It was also observed by 48(72.7%) and 42(63.6%) that they were implementing the public service and national HIV/AIDS policy respectively. On mainstreaming of HIV and AIDS, majority of the respondents 51(77.3%) agreed that they had generally mainstreamed HIV/AIDS into their planning and budgeting. 4.1.1.11 Strategic Information 4.1.1.11.1 Dissemination of Information concerning HIV services to the people Information to potential clients is channelled through the media (radios, newspapers, Television), IEC posters, community meetings, and gatherings like village meetings, and in places of worship. People are informed of the places where they can get HIV services in case they need them. There is also a good working relationship with the NGOs working in the health sector as they recruit volunteers at different levels for mobilising the communities. NGOs such as World Vision, AMREF, TASO and PACE were mentioned. “As an LC3 chairperson we have council where parish councillors meet and the health centre has the in-charge who always attends the meeting and if he is not around/in his absence he delegates. Also in a council the religious leaders attend the meetings. Even in our local village meetings we do disseminate HIV/AIDS related messages to the people.” (FGD, Health Unit Management Committee) There are laid down institutional arrangements through which communities and clients could receive information and also give feed backs; but we learned that there was the challenge of functionality. HUMCs in many places were reported to be non-functional because of not being facilitated; we learned that meetings were regular during the time of user fees but after that no money is available to convene meetings as the central government payments to replace losses from user fees and graduated tax either come too late don’t come or are diverted at district level. A network leader noted if the HC IIIs, SATs and SACs were functional PHA groups would get crucial information and the same groups could find a way of accessing drugs from HC IIIs which many respondents proposed be made fully functional. The system failure was partly blamed by key informants on rapid creation of districts which led to severe capacity constraints. 4.1.1.11.2 The role of non public sector partners in managing strategic information This review noted that several non-public sector partners namely CSOs, NGOs, FBOs and others exist and most work with communities all over the country and have several comparative advantages that used to manage strategic information. NGOs like PACE and its network REACt can be handy filling in some information gaps that the public sector may have challenges addressing. 4.1.1.12 Research and coordination 4.1.1.12.1 Identification of research priorities The few key informants that reported carrying out research said that identifying research priorities was dependent on funding availability and which agency was funding. Other district key informants reported that they identify priorities with the help of NGOs and CSOs 25 and PHAs, while others generate ideas from complaints and recommendations resulting from activities conducted in the district. Sometimes ACP identifies the research priorities Some key informants from districts reported that they did not do research citing limitations in funding, capacity of human resources, skewed resources distribution; they felt there was generally lack of institutional capacity to take up studies. “...but I think the main challenge has been, if you look back at It, that these researches tend to be over concentrated in some areas may be because of funding or other reason; you hear of research done in Rakai and all in one area; it is not cross-cutting. I hear that we are going very soon to develop areas called research districts because all the researches are done in one area. I think those people must be getting fed up with different researches. I do not know why because AIDS is now across the country, why should the researches always be put in one region; I think that one is building the capacity of some people of that area at the expense of the others.” (KI, DHO, Western Uganda) “I have told you the problem is funding these people know; I do not want to doubt the competence of my DHO to carry out research but if he has no funding how can she/he engage in writing proposals. Let the ministry put research as a key activity to be carried out and they find it in their annual work plans.” (KI, CAO, central Uganda) 4.1.1.12.2 Who else is involved in research coordination? A few respondents reported that research was coordinated through Uganda National Council for Science and Technology, National Drug Authority and ACP. Some key informants from PNFP organisations reported that they had ethical committees that they consult when carrying out research and who help in guiding how the protocols should be arranged 4.1.1.13 Decentralisation Key informants reported that decentralisation had been effective in implementation of the health sector HIV/AIDS response. They reported that the services are now closer to the people than before and decisions could be made at the lower levels compared to the situation that existed before. “we have got the sub-county local governments and all have got some components relating to HIV/AIDS activities in their budgets; and of course the powers have been taken down to those lower levels of government they do not have to refer anywhere for decision making; the decisions are made at those levels. With decentralization usually government sends a bulk of money and people see what they can spend it on; the priorities on which they can spend the money for sure include the HIV/AIDS programs.” (KI, RDC) “Decentralization has helped by way of setting up structures that are closer to the people, HIV communities are among those responsible for coordination at district and sub-county levels. It has also allowed partners to come in directly and support different local governments; decentralisation has actually brought services down to the people because originally the ministry of health would determine services up there.” (KI, DHO) Many key informants reported that decentralisation in ideal terms would have been very helpful to the districts and would have brought services effectively closer, but because of resource limitations, it is not effective in implementation of HIV activities. They felt the districts still depended on the centre for HIV funding and therefore had less power to make independent decisions on use of resources. Other activities are being implemented by NGOs and agencies which many times are driven by the priorities of their funders. 26 “You know decentralization in health still has a lot of gaps because even now they are saying they need to recentralize; therefore we are still on the receiving end we do not participate effectively because we have budget allocations but we do not say we are putting this, there are conditions on grants, we do not have non conditional grants on health, paying salaries and those other few things don’t do much. I do not think decentralization has done a big job on HIV/AIDS. Yes here is a focal person and something but not properly decentralized.” (KI, DHO) On factors limiting the health sector HIV/AIDS response, respondents reported a number of factors that limit the health sector HIV/AIDS response. Funding limits the response because it controls the employment of skilled personnel and their motivation and the execution of activities on the ground. Ultimately the lack of enough skilled personnel to handle HIV related activities is another big limitation. They also reported the limited number of health centres with HIV services being fully offered and the limitations of space in the health facilities where private counselling and other services requiring privacy can be offered. 4.1.1.14 Transparency and accountability 4.1.1.14.1 Ability to track and account for resources disbursed for HIV/AIDS interventions in the district Respondents observed that donors had in place systems to follow reporting requirements within which they were able to track and get accountability for resources disbursed to implementers of interventions funded by them. This information did not come out clearly for the districts; the view was that districts aren’t able to track and account for all resources disbursed to district based implementers. 4.1.1.14.2 Mechanisms in place to address corruption tendencies Most of the PNFP key informants reported that there were procurement units that deal with supplies and pre qualified firms to supply the commodities. There were also auditors in place to verify supplies requested by the procurement before they are used. Products were also delivered first before payments are given to the suppliers. Many also ordered the drugs from Joint Medical Store except where such drugs were not available. There were also various reports at different time periods being written and sent to accounting authorities (monthly, quarterly and annually) Some District Key informants who answered this question also said they procured from National Medical Stores who had arrangements to deliver commodities to the districts to reduce corruption. 4.1.1.14.3 Avenues for clients to give feedback and express grievances Most Key Informants reported that avenues indeed existed in the plans for consumers of the services to give feedback to the service providers in some districts and health facilities. This was confirmed also in Focus Group Discussions at health facilities. Information was received from health centres and posters displayed, also announcements on radios and in gatherings like places of worship and in local newspapers were utilised. They also reported that some clients channelled their complaints through the councillors at Sub-County and other elected leaders and also sometimes they reported to members of Health Unit management committees who later took up their grievances to the in-charges. Another avenue reported was the use of suggestion boxes at the health centres/facilities where clients can drop their written messages of complaints or compliments. “Yes actually we have what we call the district; we have just succeeded in implementing the giant efficient client charter where we are supposed to give like their responsibilities and 27 their roles and one of them is to give a feed back and they can do that through the in-charges of the units; they can also give their elected leaders; they can also give them through the members of Health Unit Management Committees. They can give them through those who are supposed to work like a link and even their political representatives like the RDCs” (KI, DHO) “They normally report to the political leaders for example a few months back there was a stock out of ARVs and most of the people living with HIV/AIDS died and they got scared and decided to face the LC5 chairman to do something. He called the minister of health and the drugs were then sent to the district within a week.” (FGD, PHAs). However some respondents reported that although avenues were existing, at the lower levels they were not very effective and often did not reach the higher levels because of various limitations like lacking staff who are trained in HIV/AIDS management and resources to provide for the complaints. This quotation highlights this point; “It is happening at the national level because I see some key HIV activists in full swing but I have not seen them connecting with these small branches in the district and sub-county level to have their grievances put at national level. Most of the sub-counties have come up with networks and networks are supposed to push up those grievances but now when they push them they can only do that to their network and then it stops there. The networks of people living with HIV/AIDS formed are based at each sub-county and those networks are there but where are they sending their complaints? I am saying I am not seeing them sending their grievances to national level and even to health centres because let us go back to the challenges at the health centres how many people are we having that are trained in HIV/AIDS issues that is issues of counselling this is a person who does not have time to look at even that one carefully and critically; he is overwhelmed by the number/line that is looking at him and he is worried ‘when will I finish these ones’, so there is that gap” (KI, Senior Community Development Officer). This quotation form a network leader emphasises the point ..”As a network we have a lot of issues at local level, because our members actually die ….it would help if SATs and SACs were active and given some support and HC IIIs functioning.” (KI, network leader). 4.1.1.14.4 Public versus Private facilities accountability They reported that private facilities tend to be more accountable because they are for profit and have to ensure the clientele are satisfied. Public sector facilities did not have to account so much to clients because they were just delivering services without profit in the end. 4.1.1.14.5 Suggestions to improve on accountability Whereas the respondents emphasised the need for government to ensure a steady supply of AIDS drugs to limit stock outs they also noted some challenges to be addressed simultaneously. The remuneration of health workers should also be enhanced to reduce the temptations to steal drugs. There should also be deliberate efforts towards empowering of the communities to be able to demand for the services that they are entitled to. “Empowering the community is step number one; let the communities know what they are supposed to get such that they can demand for the services; let us create a situation where communities demand for services demand for accountability. But once we go around thinking that we are giving them a favour right from politics, politicians think giving these people a service is a favour we miss it; so it is empowering them and may be we need much 28 more sensitizations much more interactions, so that we empower them to come out; me I like this idea of the Barazas.” (KI, District Information Officer). There is a client charter developed in line with MoPS guidelines but that was not well publicised for consumers of services to know how to go about demanding for their rights; also the UMDPC has a guiding document on complaints against doctors and protection of society, the code of conduct for public service and the HSC code of conduct and ethics for health workers. Also the medical professional associations’ forums have made proposals on how they can work with councils and MoH to improve accountability of health workers while guiding government on how to handle issues of remuneration, motivation and others for their members. A significant number of respondents had feelings that unethical behaviour of some health workers was because their remuneration or compensation for services rendered did not give them enough to cover even the minimum requirements for daily living. PHA network leaders supported the idea of revitalising Community-Led HIV/AIDS initiatives (CHAIs) which they said can be instrumental in bridging the gap between health facilities and their members especially with regard to accessing ART/ARVs including protecting those drugs from pilferage. Another respondent (in charge of the presidency) gave testimony as to how effective CHAIs funded under the World Bank Funded project of 2000, the UACP, had been in serving the communities and improving accountability by them acting as watch dogs. 4.1.2 Health Facility Level At health facility level, issues included concerns about facilities not being staffed with the required staff and skills apart from infrastructure and steady supply of drugs especially ARVs; it was emphasised that whereas other drugs can be found in drug shops, and even ordinary shops, the ARVs are not expected in those places especially in rural areas. Proposals revolved around making HC IVs and HC IIIs functional, making SATs and SACs active and supporting community led initiatives. Drugs were found to be a top priority among the priorities that the communities all over Uganda wanted the government that will rule after 2011 elections to address (New vision, August 16, 2010). 4.1.3 Community Level At community level the review found that communities were happy with decentralisation as it, in their view, took services nearer to them. Presence of HUs near the people was referred to by many, even with knowledge of regular absence of HWs and drugs; a good number of the respondents thought those latter issues could be handled referring to CSOs like NUMAT that went sponsoring training of health professionals if personnel with suitable minimum requirements could be found. Decentralisation was seen as a best practice by the APRM and also the communities. According to the interview with the decentralised response SCE it was noted that effective collaboration with the ACP-MoH/MoH/health sector was essential so that the SCE could mobilise communities while the MoH would ensure presence of services with skilled manpower in facilities and thus a functional referral system. 4.1.4 Other Providers (PNFPs, PHPs, FBOs, COE and uniformed services) There was acknowledgement that with a heterogeneous epidemic and 90% population in the rural areas CSOs, FBOs, NGOs are essential to the response as they operate closer to the consumers of services. Respondents noted HBC as money saving because it saves on things like transport, food while you travel to a far health facility to access treatment and it even cuts out much of the unofficial/out-of-pocket fees paid at many of the facilities for or to the 29 inconsiderate or unethical health workers. The partners also acknowledged the need to sort the CSOs and NGOs out and “remain with those that are committed to serving communities”. They acknowledged that a lot more is spent on managing HIV/AIDS than is spent on general management of other conditions; document review also indicates a similar picture (see table 3). Anything that makes physical accessibility better would improve on fiscal accessibility. There was a view that some socio-cultural accessibility issues could be dealt with if partnership of CDOs and mobilisers with communities could be strengthened; “this could lead to faster improvement in socio-cultural accessibility than any other means”. Table 2: Comparison of per capita expenditure on general against expenditure on HIV/AIDS Malawi FY 2003 Rwanda FY 2002 Tanzania FY 2003 Zambia FY 2002 FY 2005 FY 2006 FY 2006 FY 2006 Spending (US $) General Population 1.82 1.81 2.85 7.66 5.05 5.57 9.19 16.74 PLWHIV 2.14 3.42 10.16 9.78 11.92 9.75 53.78 20.67 Difference 18% 89% 257% 28% 136% 75% 485% 23% FY = Fiscal year Per person out-of-pocket spending for the general population and for people living with HIV/AIDS (PLWHIV) 4.2 Findings of the National Response Introduction The national level phase of the review was done after the district level phase for strategic reasons and here the focus was national and MoH policymakers, policy makers from key sectors that were already identified by the MoH, senior and mid-level managers of MoH and component departments and ACP-MoH staff, national level CSOs, FBOs, PHA-networks, ADPs, HDPs, GHIs, academic and research institutions, media culture and arts personnel and human rights advocacy institutions and direct community representatives including PHAs. Entities that had district components were favoured as case studies of how the centre has been relating with the district or the decentralized response. Two quantitative tools were used and up to eighteen qualitative tools. Findings from quantitative analysis were triangulated with those from qualitative analysis with appropriate reference to findings from document review and observations before final interpretation. This section presents the national level findings below. 4.2.1 National Facilities Universal access particularly to secondary health care entails presence of a chain of functional health facilities ranging from HC II where contact of communities with the health system begins with referrals from VHTs to HC IIs, then from HC IIs to HC IIIs for the health sub-county, from HC IIIs to HC IVs for the health sub-district, from HC IV to HC V/District general hospital for the health district, from HC V to the regional hospital for the health region and from the regional hospital to the national hospital for the health nation level. The review found that due to lack of facilities at lower levels, national facilities were not functioning the way they should and were handling patients that should have been handled at lower levels; for example Mulago hospital was handling patients that were meant for regional or district level facilities. Efforts were noted towards solving this problem but the speed was a challenge; for example Naguru hospital was being constructed as the district level hospital for Kampala district but had been on the drawing board for 5 to 10 years. Most respondents proposed faster actions so that the national facilities can handle their expected 30 functions that included tertiary care teaching medical sciences and support supervision for regional level referral facilities and mentoring. One major challenge was funding and HRH. 4.2.2 National stakeholders and Providers 4.2.2.1 Background characteristics of the respondents 4.2.2.1.1 Background characteristics of the respondents from the health sector Respondents to the semi-structured questionnaire for the health sector were mainly from the ministry of health and a few from other components of the national health system. The majority 14(58%) were males and 10(41.7%) were female (see table 3.0). It is indicated that 8(33.3%) were staff of the Ministry of Health (MoH), 1(4.2%) from a semi-autonomous institution and 16(66.7%) were working within MoH on specific assignments but not on the pay roll of MoH; 7(29.2%) were programme officers (see table 3.0). Table 3 Background characteristics of the respondents from the health sector SEX Male Female Total DEPARTMENT NDC Ministry of Health (MoH) ACP Other (seconded) Total POSITION/DESIGNATION Head of semi-autonomous unit Manager Statistician Consultant Behavioural scientist PMTCT coordinator Program Officer SMO Project Officer Data/ System analyst Head of section in ACP Technical advisor Project coordinator Missing Total Freq. 14 10 24 Percent 58.3 41.7 100.0 1 6 1 16 24 4.2 25.0 4.2 66.7 100.0 1 2 1 1 1 1 7 2 2 1 1 1 1 3 25 4.0 8.0 4.0 4.0 4.0 4.0 28.0 8.0 8.0 4.0 4.0 4.0 4.0 12.0 100.0 4.2.2.1.2 Background characteristics of respondents from Parliament Majority of the respondents 17(81%) were Constituency MPs and 3(14.3%) were either district or municipality MPs. Regarding their specific roles in parliament, 7(33.3%) were members of the Parliamentary Committee on Social services followed by 3(14.3%) members of the Parliamentary Accountants Committee and the rest belonged to other committees; one was also a minister (see also table 4.0). Though efforts were made to include as many of 31 them as possible, females members of parliament constituted only about 30% of the respondents from parliament. Background characteristics of the respondents from parliament Title Freq. District MP 1 Municipality MP 2 Constituency MP 17 Missing 1 Total 21 Membership to committee Parliamentary Committee on Social services 7 Parliamentary Committee on HIV/AIDS 2 Parliamentary Accountants Committee 3 Finance 1 Legal and Parliamentary Affairs 1 Tourism, Trade and Industry 2 Internal Affairs and Defence 1 Minister 1 Missing 3 Total 21 Table 4 Percent 4.8 9.5 81.0 4.8 100.0 33.3 9.5 14.3 4.8 4.8 9.5 4.8 4.8 14.3 100.0 4.2.2.1.3 Background characteristics of Key informants, FGD and Round Table Discussants A total 46 respondents participated in various qualitative data collection sessions as key informants, focus group discussants, group interviewees or round table discussants. Majority 52.3% were females and they included a variety of personnel from the public and private sectors; two of the key informants were cabinet ministers. The public sector respondents were 45.2% while 12.2% were from the U.N. family and the others GHIs, umbrella CSOs, human rights institutions or advocacy groups (see also table 14). 4.2.2.2 Views on current trend of HIV/AIDS in Uganda 4.2.2.2.1 Views on current trend of HIV/AIDS in Uganda and reasons (health sector) Respondents were asked about the trend of HIV infection in Uganda and majority 22(88%) observed that it was increasing; 2(8%) said that it was neither increasing nor decreasing; one respondent could not commit himself due to, in his words, “lack of a baseline figure”. On the factors that could have accelerated the infection, majority of the respondents 16(64%) mentioned governance at national level followed by health financing 14(56%) and human resources for health and health service delivery (13(52%) respectively. The least mentioned factor was laboratories 1(4%). Table 5 Health sector views on the current trend of HIV/AIDS prevalence in Uganda Views on status of the HIV/AIDS Trend Number of new cases increasing Numbers are neither increasing nor decreasing No measure of baseline for new cases Total Freq 22 2 1 25 Percent 88.0 8.0 4.0 100.0 32 Factors responsible for the above trend Governance at national level Health Financing Human Resource for Health Health Service Delivery Governance at Health sector level Medical Products Health Information systems Laboratories 4.2.2.2.2 16 14 13 13 10 9 4 1 64.0 56.0 52.0 52.0 40.0 36.0 16.0 4.0 Views of Parliament on the trend of HIV/AIDS in Uganda and reasons The largest proportion of the respondents (42.9%) observed that the HIV/AIDS situation in Uganda was worsening while 6(28.6%) mentioned that it was neither improving nor worsening. On the other hand some 6(28.6%) thought it was improving; this could have been based on the ART scale up. The factors mentioned as responsible for the current HIV/AIDS situation in Uganda included, Health Information management (66.7%), Health/HIV/AIDS Financing (55.6%) and Medical Supplies and their management (55.6%). Unlike responses from the health sector respondents, governance at health sector level, rather than governance at national level, was the one mentioned as the major factor by members of parliament (55.6%). Also whereas health sector ranked medical products low, the parliamentarians ranked it as number two at 55.6%. Parliamentarians added more factors to the causes of reversal of the trend (see 6.0). They also proposed areas that needed immediate improvement, to make the response effective; they included, in order of importance, Health Information management, governance at health sector level, human resource for health and health financing (table 6.0) We tried triangulation over he difference in opinion, over contribution of medical products to the HIV/AIDS situation, between health sector respondents and parliamentarians and found that when Ugandans were asked, in a study prior to heightening of 2011 political activities, what they demanded of political leaders for the 2011 elections, health was voted number one and when probed for what was crucial in health they also singled out medical drugs (New Vision, Monday August 16, 2010), thus concurring with the views of parliament on drugs. (see also table 13). Table 6 Views of parliament on the trend of HIV/AIDS prevalence in Uganda and reasons REACTION ON HEALTH SECTOR HIV/AIDS RESPONSE The situation is worsening The situation is improving The situation is neither improving nor worsening Total Factors responsible for the worsening HIV/AIDS situation Health Information management Health/HIV/AIDS Financing Freq 9 6 6 21 Percent 42.9 28.6 28.6 100.0 6 5 66.7 55.6 33 Medical Supplies and their management Governance at Health Sector Level Health Service Delivery Laboratory services Human Resource for Health Governance at national level Laxity by the population Complacency/Self-satisfaction Attitudes and cultural practices Factors for the improvement Human Resource for Health Health Information management Health/HIV/AIDS Financing Laboratory services Governance at national level Table 7 5 5 4 3 2 2 1 1 1 55.6 55.6 44.4 33.3 22.2 22.2 11.1 11.1 11.1 2 5 2 1 2 33.3 83.3 33.3 16.7 33.3 Ranking of reasons for the reversal of HIV/AIDS by parliament and health sector Ranking by health sector Governance at national level Health Financing Human Resource for Health Health Service Delivery Governance at Health sector level Medical Products Health Information systems Laboratory services 1 2 3 4 5 6 7 8 Ranking by parliament Health Information systems Health Financing Governance at health sector level Medical products Health service delivery Laboratory services Human resource for health Governance at national level Laxity by the population Attitudes and cultural practices Complacency/self satisfaction 1 2 3 4 5 6 7 8 4.2.2.2.3 Views on the trend of HIV/AIDS in Uganda and reasons according to Key informants The same questions, as above, were raised in KIIs, FGDs and round table discussions. Responses from qualitative data, (senior government officials, program managers and parliamentarians) also revealed that the infection rates of HIV infection had gone up. They reported various governance related factors that they thought were responsible for this trend including reduction in political commitment over time at all levels, a fragmented multisectoral response, change of focus from prevention to treatment, political interference in the technical work of technocrats especially at the district levels and others. “but in my view what I think is happening is that the kind of political commitment we have is no longer the one we had when there was a decline because by political commitment in my view, it is not only the presidency; political commitment would entail that you have political and technical leaders fully involved in the struggle; for example at ministry level, you must secure political commitment of the political leaders who are ministers and you must secure 34 the commitment of the heads of the technical teams the permanent secretaries, commissioners and under secretaries; but …and when you go down even at the district, you must get that political commitment so that it is a full spectrum of political commitment at all levels. But where we remain only with serious commitment at presidency level, then you can’t get it because the problem is wide spread. Then two, on multi-sectoral approach again I am a strong believer, that for us to make an impact, every body at these very levels individually and collectively must get involved; but unfortunately again when you look at the involvement, okay there have been efforts to get every sector on board, but this one has not been translated into practice in many ways in issues of capacity, resources, people, finances etc (KI, policy level, sector) They also observed that monitoring, supervision and evaluation had been negatively affected. Senior managers in MoH observed that the ability and will for implementing officials to follow instructions and implement programs clearly following them to the dot and as leaders ensure that those people they are leading are following them, were lacking hence weakening of the oversight role. “No, unresolved issues really I wouldn’t call them serious issues, its ability and will for somebody to pick these documents which are very clear and follow them to the dot and if you’re a leader ensure that those people you are leading are following them. You must be evaluating them to see how the work is done, and how the reporting is also done. You must be interested in both technical and financial accountability in a given and agreed time frame. In other words the proper execution of any work plan for the activity that has been identified for funding. Now at the moment the oversight role is weak. Then all those long term Institutional Arrangements just fall on the way side and you get people coming back with excuses and explanations on why things didn’t happen the way were supposed to happen” (KI Policy Level, key sector official). But a very large majority of respondents all levels including top and senior level key sector respondents saw this and coordination as crucial as it may explain the inadequate collaboration among the key sectors and the private sector. Various respondents noted the situation was further compounded by poor staffing at different levels; but it was noted by many that Uganda did not have to import human resources but only to recruit, train and retain the available pool of health professionals and workers; “………..The health systems are not optimally delivering for so many reasons; one the inadequate capacity to function optimally; the patient health worker ratio in Uganda; we have more than enough technical competence in the country but until we be begin the issues of absorption, recruitment of staff where they are needed and motivating them to stay so that we absorb … the issues of retention ..Unlike other countries like Botswana, Swaziland who have to import staff we do not need to import but just get our priorities right and make sure that we are absorbing the staff that we have (KI ..U.N. family). According to the Public sector strategic plan on motivation and capacity less than 50% of health professionals that are registered by the professional councils are included in the public sector norms (see table 8.0); but also about 50% of those appearing in the norms have actually not been recruited yet. Table 8 Cadre Nurses Midwives Staff norms, annual output and registration status of professional staff Norm Output/year Total registered 11,149 5,166 1,031 372 28,297 35 Allied Health 6,826 941 9,299 Pharmacists 74 54 450 Doctors 1,552 324 4,018 Source: Capacity Project 2009 Different respondents in this review expressed concern that every year a lot of money for recruitment of staff is returned to MoFPED as the financial year is ending; but an interview with MoFPED indicated that the problem was with communication among the three sectors concerned health, public service and finance and that the money in question can be made use of improved communication. Qualitative findings also showed that there were problems of maintaining constant supplies of commodities like condoms which are critical to prevention of HIV/AIDS. The key informants also reported the reduction of focus from prevention to management of HIV, whereby more resources are being channelled into care, plus lack of guidance for CSOs in the HIV response implementation such that they and also partners tend not to follow already identified priorities especially when their funds are not from government. The following quote clearly shows this case. “Health financing has a role to play and it goes hand in hand with governance at the highest level like MoH, U.A.C and the civil society. Due to the fact that our governance is very poor we are left with no option but saying ’thank you for the support you are giving us’ to the donors. We need to come up with strong governance structures under MoH, U.A.C and civil society and say, “Yes we have priorities as a country and we want to see these priorities go through”. And we will be very grateful to development partners to come in and support our priorities instead of us supporting their priorities which are not ours as a country”. (KI from National NGO). This review noted that a lot of efforts are on to get the IHP+ to be implemented and if successful could efforts to have donors and the country get concurrence on the priorities that should be followed by all including government and DPs/funders. 4.2.2.2.4 Views of Key informants on Status/performance of the multi-sectoral response When we sought to get specific views of key informants and discussant on the status and or performance of the response, we received several versions of responses but all pointing in the same general direction as below: “We have no response, …I mean you have WHO or the UN family as an organised partner with a disorganised client in a disorganised environment (KI, Key sector) ”particularly I see a very big problem at the National level because for me I see fish rots – when it rots from the head, then it doesn’t matter how the tail looks like; it goes ..it dies some how; ……I see a jumbled up kind of response, responding by emergency ……we have not envisioned a long term kind of response …we normally act by emergency; ...I think at government level, if our coordination, our structures were really right, I don’t think we would really have a problem (KI, Network leader)”. “ ..the health sector is not in control (KI, GHI)” 36 Uganda has relegated its responsibility….the one who blows the piper dances the tune! (KI, national NGO) … am glad you called me, I think we’ve talked much and not done much, we need to get working (KI, media) The assessment is timely; we cannot afford to see a thousand new infections, a high rate of twenty two thousand children being infected and HIV prevention interventions sitting on the shelves and yet we can move the system. Within the multi sectoral system the health sector has about 70 or 80% role to play towards he HIV/AIDS response; ……because the bio medical interventions are with in the control of the health sector and it’s the service sector to the other non medical sectors that are engaged in the response, to provide technical guidance but also quality assurance in all that they (the other sectors) do. The multi sectoral intervention evolved out of need; but the other sectors were not prepared and it is not wholly within their mandate to address such a devastating health hazard (KI, International partner). 4.2.2.3 National policies and frameworks Views were sought on strategic/policy frameworks. The health sector respondents (senior government and program managers) observed that the national policy frameworks provide a basis for an effective national/health sector HIV/AIDS response. This was mentioned by majority 16(64%) of the respondents. When the respondents were asked whether Health Sector HIV/AIDS policies are based on up-to-date and relevant information, majority 17(68%) agreed and 8(32%) strongly agreed. The respondents also agreed 16(64%) that the national frameworks allow for effective coalition building for collective decision making and oversight for the Health sector HIV/AIDS response. Majority of the respondents 16(64%) also agreed with the view that the National Health Policy (1999) covers the national priorities as reflected in the PEAP. Most of the respondents 15(60%) concurred with the view that the annual/operational plans for national level HIV/AIDS activities are aligned to the NSP and NPAP. But it was also noted a number of respondents were not sure if annual plans adhered to HSHASP. It was noted that most respondents had not internalised the HSHASP, almost all levels. At district level the HSSP II was the most known while at national level respondents appeared more conversant with the NSP except for direct health sector partners. On the whole managers at district level and those at national level should be conversant with all the three as they are inter-related and all are frameworks relevant to attainment of the PEAP, NEPAD and Millennium Development Goals. 4.2.2.4 MACA, Mainstreaming, Coordination, Partnerships and Synergy (health sector) The national HIV/AIDS response is supposed to be implemented through a partnership with all stakeholders for a concerted effort and avoidance of duplication of services hence the MACA. Respondents were therefore asked about partnerships in the HIV/AIDS response; they were also asked whether Self Coordinating Entities have been appropriate in coordinating the health sector HIV/AIDS a response and slightly more than half 13(52%) agreed. This implies that the coordination has not been to its best (Table 9.0). Regarding the multi-sectoral HIV/AIDS control approach, policy makers noted that the approach was good for coordination and best for the country but that implementation of its activities along the way had met with challenges. 37 “First of all the principle is very good; multi-sectoral approach is a very good strategy; but in Uganda, I don’t think it has been very successful. As we speak, we don’t even know how the other ministries apart from ministry of health are doing in the fight against HIV/AIDS. I don’t think there has been a monitoring and evaluation exercise to determine their performance; and therefore, while the principle is very good, it is very difficult to tell whether this policy has been successful in Uganda. So until we evaluate the performance of this policy, then we may not say much about it” (KI, Policy Maker). Inter-sectoral collaboration is critical to success of the response; but the above quotation casts some doubt performance of the LMSCE. Poor coordination among the sectors was the concern of many and it was blamed for the problems facing the health sector HIV/AIDS response; this came from both the public and private sector respondents as it affected state business. On whether HPAC is an effective policy organ of the MoH, majority 17(68%) agreed. But 15(60%) said they were not sure whether the Legislation Task Force/policy analysis unit was an effective policy organ for MoH. Less than half of the respondents 11(44%) reported that annual plans were adhered to during implementation of the HSHASP. A big range of respondents were asked whether they/their organizations participated in development of HSHASP and 12(48%) agreed while 16% strongly agreed that they/their organizations participated. Coordination between ACP-MoH and UAC was also seen as an issue of concern in the HIV/AIDS response. The review found out that 32%(8) agreed and another 32%(8) disagreed that coordination between ACP-MoH and UAC is effective but 28%(7) were not sure while 4%(1) strongly agreed and the same proportion 4%(1) strongly disagreed (table 9.0). This means that there is more likely to be a problem of coordination than not between ACP and UAC in the response against HIV/AIDS. Concerning the partnerships and synergy, most policy makers and senior MoH officials mentioned that there was conflict between the ACP-MoH and the UAC. CSO informants also reported that the linkage between different partners has been difficult to forge or implement and as a result complementary partnerships and synergy could not be realised. Various other key informants were asked about synergy between the ACP-MoH and UAC as a starting point for complementary partnerships and synergy among other partners but there was a general view in the negative; for example one large network leader was asked to comment on the level of synergy between the two and the response was as indicated below “…… I don’t see the synergy, I am sorry …. I don’t see. You really see two people in their parallel lines, I don’t see the synergy. They seem to be parallel.. (KI, CSO) Partnership in Uganda has been described as breath-taking (Rogger Riddell and Katarina Kotoglou, 2008); with Uganda government handling 50 DPs and above it is reported that transaction costs are very high implying that if partnership of the more than 4000 partners in the HIV/AIDS response has to be efficaciously managed, then the two major players on government side (UAC and ACP-MoH) must be very close with almost daily contact before looking at coordination of the partners; when UAC and ACP-MoH collaborate effectively this will then be cascaded to the key sectors so that there can be clear division of labour as governance of the response moves to coordinate with the larger group of the HIV/AIDS partnership namely the non-public sector which is even more complex already (CSF, 2007). The head ACP-MoH would therefore need to be closer in rank/status/position to the head of 38 the UAC than currently and possibly be a deputy; handling the partnership particularly its coordination can be better done then. On whether the internal coordination within MoH is effective, 9(36%) disagreed while 6(24%) strongly agreed. This means that coordination within the ministry of health may be lacking or having challenges. The question was asked again and 9(36%) were not sure whether coordination between ACP-MoH and other departments of the Ministry is effective while 6(24%) felt that the coordination between ACP-MoH was not effective (Table 9.0). However, the findings show that coordination between ACP-MoH and the various development partners is effective; this was observed by 14(56%) who agreed with the view that MoH coordination with other partners was effective. Coordination was also reported to be effective between ACP-MoH and the other sectors (Table 9.0). But this could not be corroborated with findings from other respondents; a number CSOs in advocacy also had concerns about lack of effective coordination among key sectors. On whether coordination between ACP-MoH and PNFPs was effective, the biggest proportion of respondents 44% (11) were not sure; but 32% (8) strongly agreed and 20% (5) agreed that coordination was effective (9.0). This was not the view from the district and some national level PNFPs; they felt the collaboration with CSOs generally could be improved even with them. Most of the respondents 12(48%) were not sure whether coordination between ACP-MoH and PHPs was effective while 2(8%) said that coordination was not effective. Officials of PHPs think a lot needs to be done. When respondents were asked whether coordination between ACP-MoH and the various organizations of PHAs was effective, about half, 48% (12) agreed but 8(32%) disagreed. This means that there has been some coordination between ACP-MoH and various organizations of PHAs or it is much better than with other partners. The review noted that PHAs are generally happy with progress in provision of ARVs and are more likely to keep close to the MoH than other stakeholders. On whether coordination between ACP-MoH and the districts was effective, majority of the respondents 15(60%) disagreed and only 6(24%) agreed. This view had already been expressed at district level by various respondents. Challenges to coordination with districts had been foreseen at the beginning of the HSSP II. 3.2.2.5 The principle of the three ones The principle of the three ones is supposed to guide partnerships in the multi-sectoral response as a coordination tool. When asked whether the principle of “The three ones” has been practiced among all stakeholders or partners implementing the health sector HIV/AIDS strategic plan (HSHASP 2007-2010), about 40% (36%) were not sure, 8(32%) disagreed and 4(16%) strongly disagreed. This implies that the principle of the three ones has not been effectively implemented. Most respondents among key informants reported that the principle of the three ones is wonderful because it can reduce confusion among players. However they acknowledged that the implementation of it was hard at all levels. They felt there was need to know who should take the lead in coordinating particular issues. Some key informants were actually not aware of this principle at all as exemplified by one respondent who when asked to what extent the principle of the three ones was being applied exclaimed 39 “……What is that…….” (KI, law maker on an oversight committee) and another who, on being asked the same question, asked, “can you please first explain that then continue recording ” (KI, top manager in one of the key SWAp sectors). A number of KIs were generally aware of the principle but thought commitment to implement the principle was still lacking; a comment from one KI is reflected below. “For better results I think we need commitment. We need both political and technical commitment at the national level. We must lead by example. If we are doing poorly, if we have failed to implement this wonderful principle at the national level, there is no way it can trickle down. So first and foremost, commitment,…at the national level; and when I talk at the national level, I mean both commitments from the political leaders and commitment from the technical people.” (KI, Policy Maker) 4.2.2.5 Mainstreaming Mainstreaming is a strategy, of international origin (UNGASS Declaration of Commitment No. 38, 2001), for scaling up the HIV/AIDS response by ensuring that partners participate according to their comparative advantages and the partnerships are complementary with minimal or no duplication and or conflict. The national HIV/AIDS mainstreaming policy guidelines of 2006/07 were timely; this was soon after the United Nations General Assembly High-Level Meeting , on AIDS, where world leaders committed to scaling up to universal access by 2010 (WHO, UNAIDS, UNICEF, 2007). When asked, some key informants reported that HIV/AIDS had been mainstreamed in their entities; those that had already mainstreamed or started the process included sectors like the education sector, local government sector and social development sector. Others included the UN agencies, local governments and Umbrella NGOs etc including AMICAALL, the Uganda Red Cross and others. It was noted that the health sector had not carried out the mainstreaming within itself. Most key informants from the sectors which have mainstreamed HIV/AIDS reported resource constraints eg in terms of personnel, skills, finances and structures to provide backstopping to those officials supposed to implement the mainstreamed activities. Limited technical support from MoH-ACP was noted as another area of concern. It was noted that the lack of financial resources was despite instructions from MoFPED to accounting officers to budget for the process since 2006/07; at least two circulars from MoFPED were seen to the effect. A number of respondents felt funds for mainstreaming should not have been an issue as there was a policy with guidelines. “……this time I don’t think we should be arguing about resources. Resources ...we were advised to put it in and in most cases they may be putting it in their budget but implementing it becomes a problem and all they do is, they do the simple ones. Money is put in the budget and all they do is to help those who are already affected – giving them the treatment but what about those who are not known, who need awareness sessions, who need to be counselled. So that group tends to be left behind – So that is why we are having that reversal; you concentrate on those who are already affected, give them treatment but then you are not encouraging others to open up and to be helped until when the situation becomes so bad and somebody is not working and of course that affects performance” (KI, Policy maker). The main deliverable of internal mainstreaming is a workplace HIV/AIDS policy; an inquiry was made to many respondents on this. Written workplace policies were reported to be existing in key sectors; according to the review observation checklist, at least ten copies were recovered including those from the key sectors identified in the HSSP II. A number of CSOs also had policies in place. However the MoH did not have a work place HIV/AIDS policy at the time of the review and this short coming was acknowledged. 40 Health sector views on mainstreaming, Coordination, partnerships and synergy Performance item Response SA A Not sure D f % f % f % F The SCEs have been appropriate in 5 20 8 32 8 32 0 coordinating the health sector HIV/AIDS Coordination between ACP-MoH and the 1 4 6 24 3 12 1 districts is effective 5 Internal coordination within MoH is effective 6 24 6 24 3 12 9 Coordination between ACP-MoH and the 2 8 14 56 2 8 7 various development partners is effective Coordination between ACP-MoH/Health 9 36 7 28 9 36 0 Sector and other sectors is effective Coordination between ACP-MoH and other 1 4 8 32 9 36 6 departments of the Ministry is effective Coordination between ACP-MoH and UAC is 1 4 8 32 7 28 8 effective Coordination between ACP-MoH and PNFPs is 8 32 5 20 1 44 1 effective 1 Coordination between ACP-MoH and PHPs is 0 0 5 20 4 16 1 effective 2 Coordination between ACP-MoH and the 1 4 12 48 4 16 8 various organizations of people living with HIV/AIDS is effective Coordination between ACP-MoH and other 0 0 12 48 5 20 8 NGOs is effective I/my organization/department participated in 4 16 12 48 2 8 3 the formulation of the HSHASP HIV/AIDS has been mainstreamed in all the 1 4 8 32 4 16 9 programmes under the department of NDC and the MoH Table 9 % 0 SD F 0 % 0 60 0 0 36 28 1 0 4 0 0 0 0 24 1 4 32 1 4 4 0 0 48 2 8 32 0 0 32 0 0 12 0 0 36 0 0 4.2.2.6 Oversight and guidance role of ACP-MoH as seen by parliament According to the parliamentarians, findings indicate that ACP-MoH officials have been adequately prepared when responding to questions and issues on HIV/AIDS presented to them by Parliament in the last 3 years. This was observed by majority of the respondents 16(76.2%). It was also revealed by majority of the respondents 15(71.4%) that ACP-MoH or MoH has been adequately prepared when presenting a health/HIV/AIDS related Bill/policy to Parliament in the last 3 years. The respondents were asked whether, in their view, MoH was doing enough to ensure that the codes of conduct and ethics are adhered to and practiced by health professionals and majority of the respondents 14(66.7%) disagreed. Also majority of the respondents 12(57.2%) observed that MoH was not doing enough for constructive engagement of the professional associations in enforcing codes of conduct and ethics or standards of their members. This could be the cause of misconduct among health workers in the health sector in Uganda that has resulted into unethical behaviour like corruption and misuse of office. Professional associations are supposed to advocate for the welfare of their members on one hand and hold their members accountable for any unethical behaviour; almost 100% of the providers must be health professionals of one cadre or another. 41 We have done our best as a forum of professional associations to see that we contribute to improving the quality of health professionals because we can advocate for them; but we can also counsel and mentor them. However, the ministry does not seem to see us as a complementary partner; for example we think we should be represented on the TWG for human resources but we are not……(KI, representative of professional association) A significant section of Key informants reported that ACP had not fully played its stewardship role in helping other agencies and partners in the response. Others noted that the linkage between the AIDS Control Programme and Uganda AIDS Commission was not very effective and that they were conflicting in some ways. “As a chairperson of this committee on ……., stewardship in my view is not yet there. That’s why we still have a lot of issues. I know people have been talking about inadequate resources for HIV and AIDS activities; but even the little that is available is not efficiently and effectively put to use.” (KI, law maker) “By far the ACP has played very little and it is as a result of not wanting to step beyond their boundaries or not understanding their mandate or partly because of the blanket cover of decentralization. A number of policies are not being reviewed. It has not been able to do the HMIS, data management. They have left it with the mandate of districts. ACP needs to sit back and look at its mandate”(KI, National NGO) To understand more deeply the question on the stewardship/coordination role of ACP-MoH we widened the spectrum of respondents that we thought could contribute on the environment within which the ACP-MoH is supposed to operate in carrying out its stewardship role. Another respondent made the contribution below: “…..I think the Ministry of Health has tried its level best but apparently there seems to be a problem in that there is so much to be achieved by the ministry and yet there is no capacity to monitor, to supervise those programs and I think there is need for internal cohesion, the structure itself of Ministry of Health could also be contributing to that, they need to rationalize the key result areas and leadership. I think leadership has been kind of not stable in the Ministry and that is contributing to the problem in terms of not providing strategic direction” (KI, policy maker). Table 10 Parliament views on ACP-MoH capacity for guidance and oversight of the HIV/AIDS response Performance item Yes f Do you think that ACP-MoH officials have been adequately 16 prepared when responding to questions and issues on HIV/AIDS presented to them by Parliament in the last 3 years? Do you think that ACP-MoH or MoH has been adequately prepared 15 when presenting a health/HIV/AIDS related Bill/policy to Parliament in the last 3 years? Do you think that MoH as the lead ministry for the Health Sector 10 has fulfilled its roles regarding the Health Sector HIV/AIDS response in the last 3 years? Do you think that MoH is doing enough for the CSOs/NGOs/ 6 media/Private sector to play their roles in influencing important policy decisions that affect health? Do you think that MoH is doing enough for ensuring that the codes 3 % 76.2 Response No f % 3 14.3 Not sure f % 1 4.8 71.4 1 4.8 4 19.1 47.6 10 47.6 1 4.8 28.6 10 47.6 4 19.1 14.3 14 66.7 4 19.1 42 of conduct and ethics are adhered to and practiced by health professionals? Do you think that MoH is doing enough for constructive 2 engagement of the professional associations in enforcing codes of conduct and ethics or standards of their members? 9.5 12 57.1 4.2.2.7 Decentralisation and capacity of ACP-MoH to manage the response Most respondents 13(52%) agreed with the view that decentralization enhanced service delivery at the health facility/community level; 20%(5) were not sure (see table 11.0). Key informants were also asked to give their views about decentralisation as a strategy for taking services nearer to the people; many agreed that the principle was good. “I think the issue for decentralizing HIV/AIDS services was a very good idea and I do believe the Self Coordinating Entities were also a good idea. However my challenge is the linking between the two if the districts where the decentralization has been put to and the self coordinating entities that are there to support, if there was a strong organisation that could bring them together eventually by far we would be making a lot of progress in the response to the HIV and AIDS epidemic right at the decentralized level but together with the self coordinating entities. HIV/AIDS should still be housed in Uganda AIDS Commission but I think we need a stronger UAC and stronger leadership at the decentralized level in terms of the bonding between the Self Coordinating Entities and the decentralized response to make the partnership work.” (KI, Civil Society organisation) But key informants felt that decentralisation was not preceded or immediately followed by the needed capacity building and this was having negative effects on the services it was meant to improve. For example many PHAs felt if decentralisation had gone “up to Subcounty with the DATs and SATs working to support PHAs the policy would have benefited the communities better. Key informants noted that many fruits have been realized like building health centers at lower levels. The challenges in implementation were because the capacities of districts were not built on time; as a result health centres that had been constructed had few staff, not enough equipment and they largely lacked drugs and supplies to function normally for their respective levels. “Yes I do appreciate the decentralization system and I think to some extent, it has helped a great deal because you can’t expect the centre to be doing everything. But in as far as provision of health facilities are concerned, I think we need HC IVs we need them. We need the HC IIIs also. My biggest worry is what we observed when we visited the field. Health centre IIs have been put in place but they are not facilitated. So I think if we put more HC IVs and HC IIIs, well facilitated, well equipped with staff, good staff houses, I think we shall have done a good job, than having so many health centre IIs without equipment and staff; so I think having more HC IIIs will be better.”(KI Policy Maker) “Well I think there is a good move as far as the decentralized response of government is concerned, because I think the local government is bringing all stakeholders in form of the districts together to address their concerns. And that is far much better. ”(KI. MoGLSD) One key informant however felt that decentralization had created a problem in human resource. He thus said; “But with this decentralization where each district is almost a government of its own, you cannot transfer anybody, you cannot influence recruitment etc. So may be talking about all those I have mentioned, the issue of human resource at all levels is extremely crucial” (KI, top policy maker) 43 7 33.3 Decentralization, adopted in Uganda in 1993, is entrenched in the 1995 Constitution and further stipulated in the Local Governments Act, Cap 243 (amended). This legal framework provides for the transfer of political, financial and administrative power to local governments. Local Governments have made considerable progress in identifying, prioritizing, planning, implementing and managing service delivery, but still face several constraints which hinder their ability to adequately deliver services to their constituents. The Government of Uganda continues to deepen decentralization as stated in the Local Government Sector Investment Plan 2006-2016 (LGSIP). One such effort includes the introduction of citizen satisfaction surveys to establish views and satisfaction levels of the citizens with local services across the country. (Get ref for the 2008 citizen Sat. survey) Also the biggest proportion of respondents 11(44%) disagreed and 3(12%) strongly disagreed with the view that MoH has a clear strategy for better involvement of the Private Health sector in implementation of HSHASP both at national and district levels. On whether lower level stakeholders in the Health Sector HIV/AIDS response have the capacity to implement the response, the majority 16(64%) were either not sure or disagreed. The findings indicate that the respondents were not sure whether there was greater adherence to registration of health practitioners to-date than during implementation of HSSP-I. This was observed by 13(52%) of the respondents. On whether MoH has an HIV/AIDS work place policy, most respondents were either not sure or disagreed; only 10(40%) mentioned that MoH is implementing an HIV/AIDS Workplace Policy and 9(36%) were again not sure. The study showed that HIV/AIDS had not been mainstreamed in all the programs under the department of NDC and the MoH (Table 11.0) except in the NTLP. An earlier organisational capacity assessment of ACP-MoH had revealed inadequate understanding of the mainstreaming process and mainstreaming itself. Table 11 Health sector views on ACP/MoH and mainstreaming and decentralization Performance item Response SA A f % f Decentralization Policy enhances service 2 8 13 delivery at the health facility/community level MoH has a clear strategy for better 0 0 7 involvement of the Private Health sector in implementation of HSHASP Lower level stakeholders in the Health Sector 1 4 7 HIV/AIDS response have the capacity to implement the response Lower level stakeholders in the HIV/AIDS 0 0 13 response have been effective in delivering HIV/AIDS services There is greater adherence to registration of 0 0 9 health practitioners to-date than during implementation of HSSP-I MoH has a Workplace/HIV/AIDS Policy in place 1 4 5 % 52 Not sure f % 5 20 D f 3 % 12 SD f 2 % 8 28 4 16 11 44 3 12 28 8 32 8 32 1 4 52 2 8 10 40 0 0 36 13 52 3 12 0 0 20 11 44 5 20 1 4 44 MoH is implementing an HIV/AIDS Workplace 2 Policy All staff have job descriptions and roles related 0 to HSHASP that are understood The principle of “The three ones” is practiced 0 among all key stakeholders or partners who are implementing the Health Sector HIV/AIDS Strategic Plan (HSHASP) (2007 – 2010) 8 10 40 9 36 2 8 2 8 0 10 40 5 20 10 40 0 0 0 4 16 9 36 8 32 4 16 4.2.2.8 Legal Framework Most key informants including policy/law makers acknowledged that the country has no law on HIV/AIDS. Several Key informants raised concerns that an HIV/AIDS law should have been put in place first in order to guide the multi-sectoral AIDS control strategy, but it was still at the bill stage. District level respondent had the same view and expressed a worry that many human rights related cases will remain unresolved if the law cant be put in place. One human rights institution that provides legal aid services had its hands tied and could not resolve a number of cases that came its way. 4.2.2.9 Policy development and management Key informants expressed concern that there is no overarching HIV/AIDS Policy for the country. They acknowledged that subordinate policies to address specific HIV/AIDS issues were generally adequate in the country; but implementation and enforcement still posed big challenges. They also reported that the dissemination of policies is not well done in the whole country generally. “There are a number of policies that have been developed and one of them is the condom policy but the challenge is, have they been widely disseminated? Because even if they disseminated them, we have gotten many changes in the civil society, institutions and also in local governments as well. If you look at the time these policies were developed we have had elections, we have had new changes, have they been disseminated? Are they reviewed? Are they evaluated? Are they still working? On top of that the attention worsens the status quo because we have got new leaders new managers in these institutions so it should be an on going process, they should be reviewed as well to make sure they are relevant given the dynamics of the epidemic”(KI, Local Government sector). There was frustration that some good strategies are developed but remain on the shelves. Concerning participation in policy development, most of the key informants noted that some of the partners are involved in the development of policies. A number of civil society organizations, professional associations among others, reported having been consulted along the process of developing polices. However, this took the form of being invited to attend meetings rather than initiation of the policies. “We are privileged to have been contacted in the beginning and we had one or two of our staff at senior management level join the team that was coming up with the draft of the strategic plan. Partly in terms of providing information right from the field, of what the issues are, what the challenges are in terms of being able to make services accessible in terms of information among others”. (KI, Civil Society organisation) Respondents noted a problem regarding priority policies; for example several respondents noted the challenge of managing a partnership of over 4000 partners in the private sector without a Public-Private-Partnership policy. This was expressed as a serious concern by the law makers who expressed an urgency to have the policy in place sighting confusion in the 45 field. A number of respondents at district level also expressed the above need as they foresaw some problems operating without a specific guiding policy especially in the nonpublic sector. On workplace policies respondents noted they were good for scaling up the response as they served as an avenue for bringing all workers on board sighting a big indirect benefit for the populations that interact with the workers at their workplaces. The worry was delays in implementing the national policy on mainstreaming of HIV and AIDS in Uganda. 4.2.2.10 Resource mobilisation and allocation and funding mechanisms Government spending on health from domestic sources is an important indicator of that government’s commitment to the health and rights of its people and is essential for sustainability of the country’s health programmes and the global health community has recognised that public spending on health in developing countries is essential for meeting the MDGs, reducing poverty and fighting major killer diseases like HIV/AIDS, TB and malaria (Chunling Lu, et al, 2010). Government is therefore expected to mobilise resources from domestic sources and only augment them with development assistance for health. This review noted that government has been increasing resources mobilised for HIV/AIDS control from domestic sources on top of resources from DPs both ADPs and HDPs etc. Most respondents were concerned however that over 90% of funding for HIV/AIDS in Uganda is still from external sources as the status quo reflects a big challenge for sustainability of the response programmes. District level findings noted that districts tended to defer allocations to HIV/AIDS control on grounds that HIV/AIDS already had a lot of funds. Document review also noted the relatively negative effect that development assistance to health through government has on domestic allocations compared to development assistance to health through the non public sector. Most of respondents (60%) agreed that the ministry of health adherers to financial and administrative rules when allocating and disbursing resources for the health sector HIV/AIDS response. Most of the respondents 52%(13) were not sure whether donor funding and disbursing mechanisms for the HIV/AIDS response are aligned to the country/national financial management systems and processes while 16%(4) agreed. This shows lack of understanding on funding mechanisms for the fight against HIV/AIDS in the country. The respondents 12(48%) were also not sure whether funding for the HIV/AIDS response that is outside budget support is handled appropriately. 4.2.2.11: Stewardship role of the ACP in the HIV/AIDS response Over 70% of the national multi-sectoral HIV/AIDS response falls under the mandate of the MoH and the ACP-MoH was delegated this responsibility (HSSP II). ACP/MoH is supposed to play a stewardship role in implementation of the health sector HIV/AIDS response. Respondents were asked whether ACP-MoH has more capacity and resources (technical, human, financial) to enforce health laws and regulations to-date than during implementation of HSSP-I and 28%(7) agreed; but 24%(6) disagreed. 46 Majority of the respondents 68%(17) mentioned that ACP-MoH disseminates relevant information on the Health Sector HIV/AIDS response more to-date than during implementation of HSSP-I; 44%(11) of the respondents however, mentioned that the MoH has slowed down in providing pertinent information on the epidemic to the public. The findings above indicated that the MoH, including all personnel handling HIV/AIDS currently, had some capacity to over see implementation of the health sector HIV/AIDS response but probably only at national level as observed by majority of the MoH level respondents (56%)14 who agreed and 4(16%) who strongly agreed. It was noted that the current capacity at the MoH level includes personnel, about 50%, that are not formal employees of the MoH; the capacity referred to here should therefore be considered as emergency or temporary and therefore not sustainable in the long term. This view is also supported by findings from districts and a number of key informants at national level. A work load analysis of the ACP-MoH is necessary to elucidate the actual facts about the capacity referred to. Less than 40% of the respondents strongly agreed that the position of ACP within MoH is appropriate for implementation of HSHASP; 32%(8) agreed. Respondents from key sectors didn’t think ACP-MoH had the capacity .… apart from other challenges they (ACP-MoH) are thin on the ground. (KI, key sector). The respondents were also asked whether terms of reference for all the units under the ACP-MoH line of authority are clear to all staff and 10(40%) agreed while another 10(40%) were not sure and 3(12%) strongly agreed with the view. The respondents were asked whether ACP guides the process of identifying research priorities effectively and 36%(9) agreed while another 36% disagreed. This means that ACP’s role in identifying research priorities may be relatively ineffective. On further questioning, (36%) said that stakeholders in the fight against HIV/AIDS are involved in identifying research priorities. Most of the respondents, 14(56%) mentioned that ACP has the capacity to determine priorities for HIV/AIDS funding. A number of respondents indicated that much of the research going on is initiated by funders and usually ACP-MoH may not have an opportunity to influence such research; this was the view advanced by majority of respondents at district level. (Most of the research work we do here in Uganda Dr. ……is – if I can call it- donor driven (KI, Research and academia). 4.2.2.12 Transparency, accountability and corruption Respondents were asked on transparency in implementation of the HIV/AIDS response particularly in the area of funding. Less than 50%(10) agreed with the view that the funding mechanisms and resource allocations for the HIV/AIDS response are transparent; 28%(7) were not sure. There was concern from various respondents across the board as reflected here “… there is no transparency”. (KI, development partner). The respondents were asked whether MoH provides financial accountability to the public for government spending on HIV/AIDS and 11(44%) of them agreed with the view but 8(32%) were not sure while 6(24%) disagreed. 47 Of those who responded to the questionnaire, 10(40%) disagreed with the view that MoH has mechanism for the general public to report cases of absenteeism, corruption, substandard performance, and mismanagement. However most of the respondents 14(56%) agreed that there is more pressure from the districts and other partners for ACP-MoH to account to them regarding its mandate in implementation of HSSP-II than during implementation of HSSP-I; some 7(28%) were not sure of this. On presence of an up-to-date national policy and plan on drug procurement in Uganda, most of the respondents 13(52%) were not sure and 6(24%) disagreed with the view. Majority of the respondents 15(60%) observed that in their view drug procurement practices always adhere to the national drug procurement policy. It was also mentioned by 12(48%) of the respondents that key health sector documents are published and disseminated regularly for consumption of the general public and civil society. The findings revealed that the respondents were not sure whether HIV services have a greater level of accountability than other health services. Most of those who participated in this review submitted that there were still big issues with transparency accountability and integrity/corruption. This situation was being compounded by the fact that there are so many independent sources of funding. In general the health sector can no longer effectively monitor and supervise the various implementing partners. It was noted that government was not in a position to supervise the private sector effectively; for example it was reported that the Auditor General can not audit the private sector the way he audits the public sector although over 80% of the funding for HIV/AIDS currently goes through the private sector. Several respondents had concerns on the subject as partly reflected below. “Definitely lack of integrity results into many problems because I would like to relate this to the issue of the global fund. We know very well the intention of the global fund – what it was. And when you compare how much money was lost, how much of the global fund was lost in the hands of those without integrity, in the hands of corruption, you realize we have a problem. And if that money was not lost, don’t you think it would have contributed a great deal” (KI Policy maker). From key informants it turned out that the country was still suffering from the post-global fund effects; funds from various GF rounds still cant be used yet though the HIV/AIDS response still lacks funding. There was concern about absenteeism of health workers especially in the public sector compared to PNFP and PHP institutions; this had serious human rights implications as most health workers are from the public sector. “We visited one of the health centres and these people affected by HIV/AIDS were telling us that for the days they were given, whenever they go there, they don’t find the health workers to give them drugs. You see!! So we don’t know whether the problem is that the drugs are not there or the health centres (health workers) who should give them the drugs are there” (KI, leader of a network). Respondents reported that PHAs die out of lack of ARVs. When asked, many key respondents did not know about the Client Charter. The key informants who knew the client charter revealed that they had only heard of the client charter but they had not read it. One of the key informants thus said; “I have heard about it but I have not read it to internalize it; but I will give my view of course now there are lots of changes because people are now more knowledgeable and more educated because if you prescribed the wrong drug the person will go to the internet unlike 48 in the past where somebody walked into your clinic and surrendered life to you. You can see the trend of debate on the HIV/AIDS bill the way it is going that people have the right not to accept or to accept treatment or be treated; people know that before you administer anything you must tell them and they choose. My view is that if people are well sensitized about it, it might improve” (KI, CSO). Review of documents revealed that a client charter was originally an initiation of the Ministry of Public service and all ministries were supposed to produce a client charter for their clients. The MoH produced a client charter that should have coincided with the HSSP II and HSHASP period; however most respondents seemed not to know about it. Other documents like the guidelines for complaints against doctors were produced by the professional councils but the communities did not know of their existence. One CSO spearheaded formulation and production of a patient charter which the MoH eventually adopted on top of the client charter. Both the two charters enumerate the roles and responsibilities of the authorities, the service providers and the patients or clients and could have served to inform the community about what to expect and their role in demanding for transparency and accountability as a way to fight corruption. The problem of dissemination of documents by the health sector had also been brought up during district interactions. The African Peer Review Mechanism (APRM) has done in-depth work on transparency accountability and corruption and noted the gravity of the problem as reflected by respondents in this study; APRM noted that that participation of government officers in corruption involved even senior public sector personnel. It was noted that government has put several measures to improve transparency accountability and the fight against corruption. One respondent in a public sector PPU referred to corruption as a system problem; another respondent was frustrated by “the cover public sector personnel put up when some officials are implicated”. The Aide memoire’ signed between Global Fund Geneva and Government of Uganda sought to have LTIA that would ensure focus on accountability by accounting officers. 4.2.2.13 Interventions that MoH should introduce Respondents were asked for interventions that they suggested for improving the way the ACP-MoH should manage the response. The top five proposed interventions in order of preference were to: Provide motivation to staff (27.8%) Improve information sharing (22.2%) Improve staff appraisal (22.2%) Provide clear job description to staff (16.7%) Timely release of funds/better funding Others included creation of desks for partner coordination, institution of performance audit meetings and capacity building. 4.2.2.14 Community involvement/participation Community participation in planning, implementation, M and E and providing oversight is a pillar of PHC and is implied in element one of the MACA; but it is a best practice for a heterogeneous epidemic whose management is said to be most effective through HBC. It is also strongly advocated for by PHA networks as part of MIPA. PHAs have invested a lot in formation of PHA groups through which they believe costs of managing HIV/AIDS clients would be drastically reduced if community involvement is combined with presence of functional HC IIIs with ARVs constantly in stock. 49 It is noted that GHIs have been instrumental in building various capacities in the non public sector including improvement of community participation in governance of community health (WHO, 2009) Respondents were therefore asked questions relating to community involvement in management of HIV/AIDS and health services in general including feedback mechanisms available for reporting on proper health sector service delivery or its absence in terms of absenteeism of staff, stock outs of drugs and out-of-pocket/unofficial fees/payments among other things. The most frequently mentioned feed back mechanism was periodic meetings with community leaders/community health teams 11(64.7%), Newspaper or radio reports on community views of health services 7(41.2%) and others. On whether community members knew about the feedback procedures, about 50% said that some, but not all community members knew the procedures; another 23%(4) said that none or very few knew about the feedback mechanisms. VHTs/VHCs are expected to be the first link between the community and health facilities or care providers. Respondents indicated the link as not operational thus leading to heads of networks starting to move around the country looking for ARVs that should be in designated places; this reflected a loss of focus of the decentralisation policy. Majority of the respondents mentioned that MoH is not doing enough for the district officials to monitor health services and provide feedback to health facilities. The respondents were also asked about monitoring and feedback procedure(s) that are operational in their districts and most of the respondents 70.6%(12) mentioned Periodic support supervision visits to health facilities by DHO/MHO staff followed by meetings to review HMIS data trends with health facility leaders (47.1%) and visits by Ministry of Health officials in collaboration with the district health office (41.2%). Gender sensitive community participation and empowerment has been accorded high priority since the HSSP I and this continued during HSSP II. The plan was to establish a VHT or similar structure that was gender balanced in every village to be responsible for: Identifying the community’s health needs and taking appropriate measures; Mobilisation of additional resources and monitoring of utilisation of all resources for their health programs including the performance of health centres; Mobilisation of communities using gender specific strategies for health programs such as immunisation, malaria control, sanitation and construction, and promoting health seeking behaviour and lifestyle. Selection of Community Health Workers while maintaining a gender balance; Overseeing the activities of the Community health Workers; Maintaining a register of members of households and their health status and Serving as the first link between the community and health providers and facilities. The VHT strategy has been a priority for making health services physically, fiscally and socioculturally accessible. Through document review we found that active VHTs can only be found in about 50% of the intended locations. During the district phase of this review we still found VHTs having problems of sustainability. Of the several partners in the districts, many were establishing other structures and hence creating potential for duplication and conflict. The hospital based structures supposed to support the VHT systems like Community Health Departments (CHDs) were not in place in a number of the places visited; a number of the HUMCs also meant to offer support to VHTs were not in place. Most partners in the district supported the strategy; but the issue of their remuneration had not been resolved. Many key informants supported their facilitation. 50 4.2.2.15 Human rights, gender, GIPA and MIPA principles The most fundamental human right is the right to life; the right to health, which is a prerequisite, is guaranteed by the Constitution of Uganda article 51. The human rights based approach to health/HIV/AIDS care implies that services are available, affordable and accessible (Uganda Human Rights Commission, 2008). Good governance also implies protection of the rights of all especially the marginalised and minorities. We sought to establish to what extent the health sector HIV/AIDS response is human rights based and gender sensitive and to what extent there was greater and meaningful involvement of people having HIV/AIDS in the period under review. Many respondents thought the area of human rights and gender had improved to an extent from what it was before the period of HSHASP. We looked at records on women who held positions of decision making before the plan period (see table 12.0) and noted some positive changes had taken place; also at international level 60% of people receiving ARVs by 2008 were noted to be women representing 50% of those in need (WHO, UNICEF, UNAIDS, 2009). A number of respondents acknowledged there were measures to prevent stigma and discrimination against PHAs in health care settings. Generally various respondents also had different views. But also there was a view that many people still don’t understand the meaning of human rights; there was also a problem with understanding of the term gender. There was consensus that gender is still an issue in the HIV/AIDS response and failure to involve men will continue to be an obstacle to service access by and rights of women. Whereas women in urban areas particularly Kampala can declare themselves HIV positive and get meaningful involvement in HIV/AIDS management, the situation is different in the rural areas just as it is in terms of availability of services; the quotation below throws some light on the issue: “…… for example in many rural areas a woman can not dare declare her status to her husband, she will be bartered or thrown out of the house, properties will be taken away from her” (KI, Consumers’ Organisation”). Table 12 Sex distribution of decision makers in the Public Service Category of service Percentage Women Government ministries 16 Judicial service 22 Foreign service 11 Education service 12 Prisons service 5 District public service 11 RDCs 18 Average 12 Source: MoPs, MoLG, NRM Secretariat** Percentage men 84 78 89 88 95 89 82 88 4.2.2.16 Integration of HIV/AIDS into other health programmes (mainstreaming etc) Most respondents supported integration of HIV/AIDS into other health programmes but with selected areas maintaining a vertical element to keep momentum against the disease, among other reasons. Development of the LTIA for management and coordination of Global health grants by Ministry of health (MoH, 2009) on top of the LTIA for management of HIV/AIDS in Uganda (UAC, 2005/6) was a step in support of integration. 51 To confirm if there was a case for integration of HIV/AIDS into other health programmes or services we reviewed literature on PHC, the MACA and the MDGs. We found on assessment that PHC had a lot of similarities with the MDGs and the MACA such that if well implemented PHC strategy would effectively deliver the HIV/AIDS response as an integrated component the strategy. Below we present excerpts from what was available to illustrate that what we want done regarding HIV/AIDS has actually been the business of Ministry of health or the health sector, especially after the SWAp was introduced, and it can still be done. Principles of PHC a. Universal access (physical, fiscal and socio-cultural) b. Equity c. Community participation d. Inter-sectoral collaboration e. Appropriate technology Components of PHC i Education on prevailing health problems and control and prevention mechanisms ii Promotion of food supply and proper nutrition iii Adequate supply of safe water and basic sanitation iv Maternal and child health care, including family planning v Immunisation against the major infectious diseases vi Prevention and control of locally endemic diseases vii Appropriate treatment of common diseases and injuries viii Provision of essential drugs Pillars of PHC Political Commitment Inter-sectoral collaboration Community participation Appropriate technology Bamako initiative on PHC, 1987 (the four areas of emphasis) NB: The main objective behind the initiative was to ensure access to essential health services by the majority of the population Promotion and implementation of a minimum package of services Access to drugs at affordable cost Cost-sharing between government and the users Effective participation of the community in local management of the health system The Millennium Development Goals (Millennium Summit 2000) The eight United Nations Millennium Development Goals, agreed upon by United Nations Member States in 2000, commit countries and development partners to achieve the following by 2015: 1 eradicate extreme poverty and hunger; 2 achieve universal primary education; 3 promote gender equality and empower women; 52 4 reduce child mortality; 5 improve maternal health; 6 combat HIV/AIDS, malaria and other diseases; 7 ensure environmental sustainability; and 8 develop a global partnership for development. NB: In appendix five we selected some components of the Ouagadougou Declaration on PHC in the African region and indicated benefits of their implementation to integration and how the recommendations can be applied in our situation to benefit HIV/AIDS through the PHC approach. 4.2.3 Other providers (PNFPs, PHPs, COE and uniformed services) According to the definition of the national health system, PNFPs, PHPs from the non-public sector and the uniformed services from the public sector are relatively critical providers within the health sector. The review noted that within the non-public sector PNFPs provided the biggest proportion of services; in major urban areas most services were being provided by PHPs at different levels. The uniformed services though part of the public sector provide services to a significant proportion of MARPs (UN Security council resolution 1308). The numbers of uniformed officers were noted to quite big of recent due to the growth in numbers of private security agencies; the occupational hazards, habits and life styles of these groups tend to be similar. Respondents confirmed that these partners were more effective in taking services to communities than the public sector institutions. On the other hand some communities like uniformed personnel are relatively hard to reach and hard to serve; they are also vulnerable on top of being MARPs. Respondents submitted that PNFPs and PHPs can do a lot more work if given more than the current support. Respondents also agreed that uniformed services needed to be given more recognition and roles in the response including representation on HPAC based on the role they can play in getting services to uniformed services and the communities that surround the various difficult environments they usually operate in. 4.3 Summary of Findings Governance is a crosscutting function among the four identified by the WHO and therefore acts as a spring board for the other three; its handing therefore determines the success or failure of any programme. The findings presented in the previous sections have been revisited here in form of a SWOT analysis so as to inform the way forward for improving governance in the ACP-MoH in particular and the health sector in general in view the fact that the health sector is eventually answerable for performance of the ACP-MoH. 4.3.1 Strengths 4.3.1.1 Legal, Policy and regulatory frameworks: Presence of policy analysis and planning unit in MoH; Most policies and regulatory frameworks are in place; Presence of the Local Governments Act and decentralisation policy; Political commitment at the health sector level; Political commitment is strong especially at the presidency which is critical; ion as well as standards are in place and adequate; ACPMoH/MoH is in or on top structures of the HIV/AIDS partnership. 53 4.3.1.2 Mainstreaming and decentralisation: There is a policy and guidelines in place for mainstreaming; the health SWAp strategy is in place and MoFPED has interest in having the mainstreaming policy and decentralisation implemented, several respondents supported mainstreaming and decentralisation and many understand the two, the VHT strategy is gradually taking root. 4.3.1.3 Coordination, participation and partnerships: LTIA for management of HIV/AIDS in Uganda was put in place since 2005/06; there are HIV/AIDS partnership structures in place that group partners into constituencies for ease of identification and coordination; ACP-MoH has formed partnerships with many stakeholders who support implementation of HSHASP; 4.3.1.4 Planning: HSHASP is in place to cover cluster 3 of the HSSP II; linkage of HSHASP with HSSP II and the NSP; presence of an active planning unit in MoH; presence of an operational health SWAp 4.3.1.5 Resource mobilisation and budgeting: There is an elaborate resource mobilisation and budgeting cycle in place, the health SWAp mechanism has structures and is operational; Presence of resource mobilisation and budgeting guidelines for districts; presence of LTIA for management and coordination of Global health grants in Uganda is in place; 4.3.1.6 M and E framework: There is an M and E unit within ACP-MoH and one for the MoH, the MoH has an IT department to assist the health sector in information management, there is an M and E framework that was developed along with the NSP to guide partners in the multi-sectoral response which the M and E framework under HSHASP should feed into; MDAs have got information scientists that are meant to work with their policy and planning units (PPUs). 4.3.1.7 Research coordination: ACP-MoH has capacity to identify research priorities with its current strength; recent enactment of a legal instrument for the UNHRO is likely to improve capacity of the ACP-MoH to handle research coordination relating to the health sector HIV/AIDS response. 4.3.1.8 Transparency accountability and corruption: There are instruments to address the transparency accountability and corruption in the public sector; also government has invited civil society organisations to partner with the public sector in for example fighting corruption. 4.3.2 Weaknesses 4.3.2.1 Legal, Policy and regulatory frameworks and their implementation: Delays in passing the laws for example the Local Governments Act was enacted in 1997 five years after implementation of decentralisation had started; the AIDS Bill has not been enacted yet; the Overarching HIV/AIDS Policy is still at cabinet level, the PPP-H policy has not been finalised and this could have implications for managing the partnerships as noted by many key informants; dissemination or communication of the laws and policies has challenges and those responsible for their implementation can not act in darkness; financial implications of introducing laws/policies may not be well addressed during formulation; implementation and enforcement of policies and laws is not carried out as expected or is not timely and therefore the target populations can not enjoy the benefits for example the National Policy on mainstreaming of HIV and AIDS in Uganda was meant to enhance or 54 facilitate scaling up of the multi-sectoral response by 2006/07 but you find some key or crucial sectors have not implemented the policy and so the intended resource mobilisation through this policy can not be exploited, political commitment at the presidency level is not effectively cascaded down the levels to reach the grass roots. 4.3.2.2 Mainstreaming and decentralisation: Understanding of mainstreaming is not uniform to all stakeholders; there are still some stakeholders that either do not understand decentralisation or do not favour its implementation; enforcing mainstreaming and decentralisation is weak, capacity for mainstreaming and decentralisation is still low and budget provisions are low or advice on the proposed approaches is not followed; there are severe challenges with transparency accountability and integrity/moral uprightness in both public and private sectors 4.3.2.3 Coordination, participation and partnerships: LTIA for HIV/AIDS and Global Health grants not yet internalised; capacity for coordination still low for the MoH and for ACP-MoH there is a problem of sustainability of the seconded HRH capacity of ACP-MoH; coordination of some partners is a challenge especially where funding is not from the public sector one wishes to effect a specific change, inter-sectoral collaboration among public sectors is poor and therefore the public sectors can not effectively guide partnerships within the private sector; involvement of communities in decision making and planning is low as the VHT strategy has even not covered the whole country yet; some respondents submitted that many times what we call community involvement is eventually exploitation like using them to get supplies or funds which are eventually shared; partnership structure not reviewed to bring it in line with new findings and as a result cultural institutions are not on board and so are the forum for health professional associations, unformed services have no representation on HPAC. 4.3.2.4 Planning: Relatively many key stakeholders are not aware of HSHASP; many stakeholders didn’t participate in development of HSHASP except those in MoH or close to MoH; plan not reviewed annually, operational plan not aligned to the strategic plan; planning at national level is not well linked with the grass root processes; most of the plans with partners were more likely to be based on the NSP rather than the HSHASP. 4.3.2.5 Resource mobilisation and budgeting: Sectors appear not very keen at resource mobilisation; SWAp is seen by some in public sector as cumbersome; sectors are not implementing SWAp effectively; failure to budget for VHTs; rapid increase in number of districts without the necessary resources reduces funds that would facilitate service delivery 4.3.2.6 M and E framework: Not all partners in the health sector HIV/AIDS response have M and E frameworks, M and E frameworks for those with them are not systematically linked to one integrated M and E framework; failure to disseminate the client and patients charters means you miss useful feedback information on services 4.3.2.7 Research coordination: Lack of resources for research means ACP-MoH can not influence choice of research priorities at the moment; much of the research done now is not known to ACP. 4.3.2.8 Transparency accountability and corruption: 55 Enforcement of provisions against the three has challenges; most ministries and sectors have not appointed disciplinary committees that could help address non compliance 4.3.3 Opportunities 4.3.3.1 Legal, policy and regulatory frameworks: Political commitment at the highest level of government; presence of the Local Governments Act and decentralisation policy; discussion of AIDS Bill is in advanced stages; National AIDS Policy has gone through cabinet level; strong international and JLOS support for the rule of Law in Uganda; recognition of MACA as a best practice by the APRM. 4.3.3.2 Mainstreaming and decentralisation: The UN family and other international agencies are supportive and are supporting both; many international partners are willing to support the VHT strategy to enhance decentralisation; recognition of decentralisation as a best practice by the APRM. 4.3.3.3 Coordination participation and partnerships: Planned meetings by the presidency to improve collaboration and synergy between UAC and ACP-MoH/MoH; there are more partners than the country needs only needing coordination; presence of the Uganda HIV/AIDS partnership; number of DPs and ADPs has been going up. 4.3.3.4 Planning: The current team at the ACP-MoH have the necessary capacity for planning; many key partners are willing to support the HSHASP, HSSP II and the NSP/NPAP. Presence of the IHP+ to harmonise joint planning between government and DPs so that once done the plan will be binding for all. Presence of Joint Planning between MoH, MoFPED and ADPs. 4.3.3.5 Resource mobilisation: An increase in funding by government recently makes political commitment a reality, the increase in number of donors during the period of HSSP II and HSHASP (over 60 with over 66.7% of them being bilateral), the economic situation in the country is improving. 4.3.3.6 M and E framework: The health sector M and E framework is expected to feed into the M and E Framework for the PEAP; all major partners including the ADPs have capacity and have invested in robust M and E frameworks through their performance based projects. 4.3.3.7 Research coordination: Enactment of an instrument to cover health research; many of the partners in the Health sector response have carried out various studies whose findings are guiding decision making in rural areas and in their own systems. 4.3.3.8 Transparency accountability and corruption: Commitment by the presidency and international/donor community to zero tolerance to corruption, many CSOs are in place to assist with monitoring; strengthening IGG’s department and the AG’s office, the approach that the agency handling the civil society fund has adopted is a good model. 4.3.4 Threats 4.3.4.1 Legal and policy frameworks: 56 International partners may withdraw their support if the country does hurry to put the needed legal policy and regulatory frameworks; due to the global economic down turn international partners may reallocate shift support to other priorities; if crime continues the rights of vulnerable groups will continue to be denied. 4.3.4.2 Mainstreaming, integration and decentralisation: A few international partners are not supportive; economic situation may reduce partners that support the processes; rapid increase in number of districts without capacity may reduce the effect of decentralisation; some funders still favouring vertical programmes. 4.3.4.3 Coordination, participation and partnerships: Too many partners that MoH cannot handle due to the multiplicity of funding sources; inadequate synergy between UAC and ACP-MoH/MoH; poor inter-sectoral collaboration among the key sectors identified by the MoH. 4.3.4.4 Planning: Many international partners are likely to maintain vertical plans especially if they suspect lack of transparency; 4.3.4.5 Resource mobilisation: Failure of government to redirect local resources to prevention when external donors insist on funding treatment and care may have a negative effect on prevention; failure of local governments to allocate funds to HIV/AIDS on grounds of it having too much from elsewhere; DPs may reduce funding if the fight against corruption doesn’t succeed; rapid increase in number of districts raises the funds needed to run districts by a big margin and may affect direct funding for interventions (martin Odiit, David Kaweesa, Charles Nkolo et al, 2006) 4.3.4.6 Monitoring and evaluation: Too many unlinked M and E systems threaten the expected framework that generates information for decision making using common indicators; the GHIs especially have robust M and E systems that they can not abandon before an equivalent and efficient alternative is in place on the side of the public sector. 4.3.4.7 Research coordination: Continued practice of partners to evade guidelines for research coordination and implementation in the health sector. 4.3.4.8 Transparency accountability and corruption: Community sometimes doesn’t see any problem there and some CSOs are said to be promoting some vices; DPs may reduce support if these vices are not addressed effectively. 57 5.0 CONCLUSIONS There was concurrence that the trend of HIV/AIDS in Uganda is currently worsening with new cases of HIV infection outstripping both the number of deaths and also the number of clients being enrolled on ART annually; respondents also acknowledged that there was positive progress on the side of antiretroviral therapy. All acknowledged the number of partners in the response was excessive but the response was fragmented; a significant number questioned if the response actually needed all the partners. There is concurrence that the response can only succeed if the focus is returned to prevention with customised attention to the MARPs. 5.1 By Assessment Objectives The national strategic frameworks were noted to provide an adequate basis for effective implementation of the health sector HIV/AIDS response; they provide for effective coalition building with relevant stakeholders, oversight, regulation and attention to system design and accountability. The national health policy covers the national priorities as laid out within the PEAP, 2004/05 – 2007/08. Key stakeholders were involved in development of the HSHASP and others like the HSSP II and the NSP to which the HSHASP is linked. A number have been involved in development and implementation of annual or operational work plans including Monitoring and ongoing Evaluation of the HSHASP. Respondents at district level were more likely to be aware of HSSP II than NSP and HSHASP implying challenges with dissemination of HSHASP; those at national level were more likely to know the NSP than HSSP II and HSHASP including key partners of the health sector. Some but not all stakeholders knew about the linkage between HSHASP and the other plans. Coordinating mechanisms at MoH level were found to be lacking in a number of aspects and this affected their effectiveness. There is an elaborate array of coordinating bodies that are reflected in the LTIA but they have not been reviewed for sometime; Their actions needed more guidance for maximum performance. Monitoring and reporting mechanisms of the coordinating bodies exist but needed regular follow up in a complex partnership like the one for the multi-sectoral response. There is a system for development approval and dissemination of policies and guidelines and the review found that many were in place. However there were a number of policies that lacked and for some there were plans for their develop as early as the period of the HSSP I; and many of those that were in place had not been effectively disseminated. Respondents were critical of policy launches as means of disseminating policies and guidelines saying it was not effective beyond publicity. There was general consensus that the relationship between UAC and ACP-MoH did not provide the conducive environment necessary for an effective response. Respondents thought the roles of the two entities their and relationships needed regular review and redefinition and or whenever necessary and so did their coordination and communication mechanisms. The need for synergy between the two was voiced by the majority in view of the fact that over 70% of the multi-sectoral response fell under the mandate of ministry of health; this was seen as critical for effective stewardship of a large and complex partnership as that for HIV/AIDS in Uganda. The relationship and coordination between ACP-MoH and other programmes or units in the MoH needed nurturing and strengthening to improve on prospects for integration of HIV/AIDS into other health programmes. 58 Regarding the organisational structure of the MoH and where the ACP-MoH sits relative to its roles and responsibilities respondents had several views; these were related to the extent to which the ACP-MoH could deliver on its mandate within the current structure. It became clear that the position of ACP-MoH in the structure was disadvantaging. Respondents noted that heads of ACPs in related key public sectors particularly those identified by MoH were either commissioners directors or undersecretaries who sit on the top management committees in their their sectors or ministries. Respondents noted that the head ACP-MoH had the crucial role of mentoring the health sector heads in the districts and giving them skills; but the rank of DHOs whom he/she sould mentor was found to also be higher than that of the head of the ACP-MoH. The coordination and communication mechanisms within ACP-MoH were satisfactory. But with most ACP-MoH staff not being on the pay roll of MoH there was concern over the relationships particularly with other formal MoH structures; another concern was on how long the non-MoH staff would remain to handle the current responsibilities hence the concern about sustainability of the status quo. Respondents noted that ACP-MoH in its present status had inadequate capacity to provide stewardship for coordination of research and identification of priorities for new projects but most of the current capacity was to be viewed as temporary since most of the staff of ACPMoH were not regular employees of MoH for the time being as noted above. The roles of ACP-MoH in the PC were not very clear because according to the LTIA the manager acts through the relevant working group(s) and issues then go to senior management before going to HPAC which then gets selected issues to be presented to the PC. ACP-MoH had a lot of stake monitoring the NSP as the bulk of AIDS work covered in the plan falls under the mandate of the health sector. 5.2 Key Emerging Messages The epidemic is growing faster than the response and Uganda may not meet the deadline for halting and reversing the spread of HIV infection; the mode of transmission is still predominantly heterosexual at about 80% but the MARPS are not appropriately targeted. The political commitment that led to reversal of the HIV/AIDS in the 1990s is now mainly at the presidency and is no longer replicated through all the structures to the grass roots as it was then. The AIDS control focus has been diverted from the policy of prevention to treatment and care; the action required to correct this mistake has not been timely. Respondents concurred that what is needed to reverse the incidence of HIV infection in Uganda is largely all available; only return of focus to prevention will cause the reversal that Uganda urgently needs. A prevention strategy with customised focus on MARPS is needed now. The MACA is still a best practice for Uganda, and so is decentralisation; but both have challenges. The number of partners that we have is in excess but the level of coordination across the Uganda HIV/AIDS partnership poses a very big problem to the ACP-MoH the MoH and the sector as a whole and even the UAC; this makes the numbers of partners relatively irrelevant as the complementary partnerships and synergy needed can not be forged. Respondents were of the view that there has been decreased ownership and stewardship of the response. The position of the ACP-MoH in the MoH structure is highly disadvantaging; the programme has grossly inadequate capacity to lead the response and is therefore not effectively in 59 control; the ACP-MoH and UAC are not collaborating enough to keep partners under control and guidance; there has been inadequate or no effective inter-sectoral collaboration though it is critical if the public sector has to lead other stakeholders. There is urgency for the ACP-MoH to be given the capacity needed to lead the response in close collaboration with the UAC; two alternatives include giving the ACP-MoH the necessary authority to manage the response, which may be tricky, or to upgrade the ACP-MoH to either division or department level. Whereas it is understood that domestic spending on health from domestic sources is an indicator of a government’s commitment to the health, and therefore human rights, of its people and that public spending on health in developing countries is essential for fighting major diseases like AIDS, TB and malaria, reducing poverty and meeting the MDGs, the greatest proportion of funding for HIV/AIDS in Uganda, about 90% and above, is still from development assistance (DAH) with less that 10% from domestic sources. Government contribution still remains below the expected minimum contribution to health namely 15% of the national budget and about 2% of collections from taxes and there is therefore room for increased government contribution to HIV/AIDS control. The review noted the concern of DPs and other key stakeholders over transparency accountability and corruption and the fact that this affects the commitment of partners to increase funding assistance towards AIDS control and health services in general meaning that efforts to fight the vices must be kept highest on the priority list(s). 60 6.0 RECOMMENDATIONS Governance remains a most complex but critical function of the health system though difficult to measure; without appropriate investment in HSG any investments in health service delivery may not be sustained over the long term. Below we present recommendations that arose from findings of this review. 6.1 Policy Level Recommendations 6.1.1 MoH and UAC should work with JLOS and parliament to finalise, enact and cause dissemination and enforcement of the AIDS law and the National AIDS Policy. As of now human rights institutions that offer legal aid can not help especially in the areas of human rights; several key informants complained of failing to assist citizens in the cases that regularly require a reference law. 6.1.2 Political commitment should be revitalised; the review found that this was currently more at the presidency and was not trickling down the administrative/political ladder effectively as the case was when Uganda scored a decline. A minister of state for HIV/AIDS may be helpful in assuring continuity of the process by ensuring politicians accounting officers the UAC the ACP-MoH/health sector and the districts/district health sector practically deliver on related outputs that make the response effective. 6.1.3 Consider raising capacity of the current number of districts, about 112, to 80% first if more have to be created; this was the target for the period covering HSSP II and therefore HSHASP though the review found the level was still at around 50%. Universal ART access currently has a lot to do with presence of functional referral systems and respondents in this review (especially PHAs/the community) prayed for facilities/HUs that function efficiently up to HC III level. 6.1.4 Compel all sectors to put in place an effective mainstreaming process, according to the national policy on mainstreaming of HIV and AIDS in Uganda, beginning with formulation and implementation of workplace policies. The UN family model of mainstreaming and division of labour could be used as reference. The prevention strategy being developed should be in place to guide creation of complementary partnerships that will guarantee synergy and therefore efficient delivery of the response. 6.1.5 Finalise and cause dissemination of the Public-Public-Private Partnership Policy; this will pave way for coordination of partners and make provisions for holding partners accountable for their actions; ACP-MoH should advocate for establishment of the post of a senior level Desk Officer for Coordination and Partnerships at the health sector/ACP-MoH level 6.1.6 Revisit engagement with the non-public sector and rationalise the partnerships with the sector while taking care of PHPs for their potential. The review noted that respondents from CSOs, NGOs, FBOs wanted this done to “make a distinction between the civil society that is just following the money and he civil society that will help..” to deliver the response. 6.1.7 The policy governing Memoranda Of Understanding (MOUs) should be reviewed with the view of streamlining engagement of non public sector partners in health sector HIV/AIDS work 61 6.1.8 Have all policies reviewed to ensure that all of them have an element of HIV/AIDS according to the National Policy on Mainstreaming of HIV and AIDS in Uganda; this action should ensure that the prevention strategy benefits MARPs towards universal access. 6.1.9 Review the PHC strategy/policy and strengthen the environment for meaningful entrenchment of HIV/AIDS into all components of the PHC strategy. This will pave way for enhancing integration of HIV/AIDS into other programmes and services (ref. mainstreaming). 6.1.10 Review the HRH policy and integrate WHO/World Bank/PEPFAR/UNAIDS issues as recommended by the high level consultations on task shifting; the review noted top management and senior management officials of MoH were part of the consultations. The policy should create room for development of the comprehensive nurse cadre so that MoPS can absorb them; the aim should be to end the acute shortage of HRH in a country whose registers show presence of enough professionals for the response and health services in general. The review noted training of comprehensive nurses continues but no absorption yet. 6.1.11 Revisit and review the current Motivation Strategy/Scheme, Client Charter and the Patients’ Charter to address further the HRH challenges; there should be a communication strategy that can augment dissemination and implementation. This review noted that meaningful involvement of the professional associations eg through legal recognition and allocation of roles, could add value to this process; their forum indicated keenness to have the HRH situation in the country improved towards perfection if possible. 6.1.12 Consider the recommendation by the parliamentary committee on social services (supported by the forum of Kings and Cultural Leaders) regarding partial recentralisation of recruitment and deployment of senior medical professionals especially the hard to get; the review noted that hard to get cadres don’t respond to district adverts and districts have several challenges including filling a number of other strategic posts and this results in loss of focus on health. 6.1.13 Review the MACA and the National HIV/AIDS Partnership through which the MACA should be delivered using the principle of the three ones; the review should confirm the key challenges that may have derailed the response in view of the current evidence base; particularly the review should consider introducing a SCE for the Forum of Professional Associations, another for Cultural leaders and or Institutions and religious leaders. 6.1.14 MoH or government should consider giving legal recognition and allocation of specific roll to the Uganda Medical Association, or the professional associations, with emphasis on professional conduct and ethics; the review learned that this was done for the Law society which currently can hold even high profile personnel to account for their acts; the review also found that for example many medical practitioners even at MoH headquarters may not be doing the required registrations as required by law. 6.1.15 Review the status of the ACP-MoH within the current structure of MoH and act to ensure its status is upgraded to a level commensurate with the roles and responsibilities given to the programme. This study found out that the head ACP-MoH is delegated the duty of leading the health sector HIV/AIDS response and according to its mandate the sector shoulders about 70-80% of the multi-sectoral response. The ACP-MoH should lead the process of attracting donors to the health sector but the status of the head of the ACP-MoH doesn’t fit this vital action. The review noted decisions or recommendations of the manager ACP-MoH on business of the programme always have very long to go before a final version 62 can be moved out of the MoH/health sector; for example discussions beginning at the subcommittee of the CDC division then to the Minimum Health Care Package TWG before reaching SMC and eventually HPAC which has to get clearance from the TMC before eventually reporting to the CCM may disappear along the way and this may frustrate major partners like the GHIs who find it better to avoid GBS processes or public sector processes in favour of the private sector where performance based approaches work faster and, to them, better. The review noted that managers of ACPs in key public sectors are either heads of departments (Commissioners), directors or undersecretaries and therefore sit on their MDA’s top management committees and this allows them to move their HIV/AIDS agendas. The review proposes ACP-MoH to be upgraded to either a division, or a department if not a directorate; this will improve communication with donors, collaboration with UAC and facilitate speedy resolution of HIV/AIDS issues. 6.1.16 The relationship between ACP-MoH and UAC: It was noted that 70-80% of the national/multi-sectoral response falls under the mandate of MoH and must have been reason for formulation of the HSHASP; the ACP-MoH is delegated the role of coordinating the health sector HIV/AIDS response at national level but this review found out that the business that ACP-MoH and UAC do together does not reflect this fact and most respondents both through quantitative and qualitative methods reported that there was inadequate synergy between the two to guide other partners. A number of proposals are made to policy makers for improving HIV/AIDS business: a. Creating a position of Desk Officer for the ACP-MoH/Health Sector at UAC; this review found there was an officer designated as Desk Officer for the Decentralised Response b. If the ACP-MoH is raised to the status of directorate, can the head of ACP-MoH can also operate as Deputy DG-UAC c. If a and b. cant apply then one can have two deputy DGs, a deputy DG responsible for Health Sector issues and a deputy DG responsible for non-health sector issues d. If the head ACP-MoH is a head of department then he or she could also hold the responsibility of Assistant DG-UAC. The review heard that the Minister of Health deputises the Chair of the CCM to maintain a reflection of the critical role of the health sector in the response NB: A desk officer for non-health sector issues would ensure close collaboration with the health sector on issues to be covered by for example the SDS, LGS, ES, JLOS etc. 6.1.17 The health sector should deliberately popularise the IHP+ for implementation to ensure that there is, as a policy, one point for originating all proposals for funding in the health sector; the desk officer IHP+ should share IHP+ progress reports and reports of the Prime Minister’s Office on “Progress in implementation of the Paris Declaration” with all top and senior management officials, TWGs and HPAC officials. 6.2 Programme level recommendations State business is supposed to be led by the public sector; a peep at the public sector strategic plan shows this relationship. Establishment notice No. 1 of 2007 requires each ministry/sector to have a focal point and the UAC expects an ACP with a manager to lead it. This review found all the sectors identified in the HSSP II as key sectors for inter-sectoral collaboration had sector ACPs and had evidence of a mainstreaming process in place with even elaborate strategic plans, based on the NSP, and workplace policies but little evidence of effective collaboration with the health sector and yet had interventions that fall within the mandate of the health sector. There was a lot of room for synergy. The mainstreaming 63 policy expects an ACP in each MDA but interventions are based on comparative advantages and mandates of the different MDAs 6.2.1 Ministries should continue to have focal points/managers for their ACPs. Sectors should continue to have coordinators for HIV/AIDS activities spearheaded by the focal point/managers mentioned. 6.2.2 All sector coordinators and focal points/managers of ACPs in the MDAs should be purposefully selected and then inducted at the start of their assignments. They should be trained and should internalise the contents of the NSP, HSSP and the HSHASP; their SPs should be aligned to the HSHASP and HSSP (II) and NSP depending on the mandates of their MDAs/sectors. The ACP-MoH/health sector should guide their actions in collaboration with the social development sector. All should mainstream and have HIV/AIDS embedded in their annual appraisals as recommended in the mainstreaming policy. The health sector should hold regular spaced meetings with the key sectors to ensure their actions are constantly guided and they should attend all implementers’ meetings that the health sector plans to start convening. 6.2.3 Government should ensure that all strategic management posts at the centre and at the district health sector level are filled at all times if possible; there are provisions in both the constitution and public service which can be invoked to avoid having long vacuums in strategic posts. The review found critical posts at MoH remained unfilled for long and it affected the environment in which a lot of the health sector’s programmes eg ACP-MoH operate. 6.2.4 Capacity of the ACP-MoH should be built in order to guarantee good governance of the health sector HIV/AIDS response which is critical to overall success of the MACA. The following are proposed: 6.2.4.1 A workload analysis should be done to establish the minimum number of officers required to run the health sector HIV/AIDS response countrywide; currently ACP-MoH has control over about hundred and above personnel but the majority are not on the MoH pay roll; This scenario should be a pointer as to what could be the norms for the ACP-MoH. There should be norms for the ACP-MoH. 6.2.4.2 All posts identified in 6.2.4.1 should be filled as soon as they are identified and a plan should be put in place to manage the change; public service should be approached to create any posts identified that may not already be in the structure of MoH. 6.2.4.3 With one hundred plus staff, ACP-MoH should be upgraded to a department; which will mean the manager/head becomes a member of top management; in this position she or he should be able to discuss at per with big donors and also call those who err to order. Also she or he will be in position to mentor DHOs who will now be a step below (Assistant Commissioner level). This level puts her in position to guide coordinators in the key health related sectors; the team that runs a department should ably coordinate partnerships at national level and at the district health sector. 6.2.4.4 No of units in ACP to be reviewed and put under definable groupings/divisions (see the units as at 1995): i Management: (to be in charge) Finance and Administration ii Prevention: (to be in charge) IEC; Condom; HCT;PMTCT; STD; ICU 64 iii Information for decision making: (to be in charge) HMIS; ICT for HSD; IDSR/M&E; HR &D etc; this could also be named ‘M and E’ instead of ‘information for decision making’ to reflect the importance of M and E in management of the response. iv Rx, care & support: (to be in charge) HBC; nutrition. The ACP-MoH should then implement, or guide implementation of, the principle of “the three ones” by having a unit and head for planning, a unit and head for Coordination and partnerships and a unit and head for M and E. 6.2.4.5 Based on the workload analysis results a skills or competence package should be defined and skills training done to ensure AIDS competence for all team members in the ACP-MoH and, with time the DTPC and DHT; the review found that DPs were willing to fund skills capacity building for the response. 6.2.4.6 The ACP-MoH/health sector should lead a process to review the HSHASP with key partners in the Health sector HIV/AIDS response. This forum should provide a conducive environment for interactions with key stakeholders in the health sector HIV/AIDS response. Figure 2 below presents a conceptual framework that can be followed to guide interactions with funding partners to reach a workable funding arrangement. The review should focus on the WHO building blocks for systems strengthening and identify areas where different partners have comparative advantages; the process will also identify areas of possible synergy in particular. One output of this forum is concurrence on priorities that the next HSHASP should or must address. The implication is that once the priorities are agreed on, then the ACP-MoH can keep this document as reference for all potential and current partners. If any partner(s) are unable to offer funding through GBS they can still address the laid down priorities which should then be appearing as gaps to define additionality of donor funds in the HSHASP. Governance Partner Health Initiatives Financing Health workforce Country Health Systems Health service delivery Health outcomes Health information systems Supply management systems Figure 2: Conceptual framework for interaction between of PHIs and country health systems The key sectors that the health sector has identified for close inter-sectoral collaboration should be part of this interaction for purposes of identifying areas where the said sectors can work together for efficiency gains. For example the MoGLSD has structures whose business is community mobilisation for community development and yet the health sector 65 also does community mobilisation for health under the health promotion and Education division. The review saw it as very possible that CDOs (from GLSD), AHEs (from MoH/district health sector) and LCs (from LG) can move together and deliver meaningful messages as one package to the community rather than each one going alone which may even confuse the communities. The MoH can discuss with the other partners how best the VHT strategy can be operationalised here without duplication; thus all partners should support the same model of VHT. The framework in Figure 2 above should be adopted for all sizes of partners. 6.2.5 Implement guidelines on integration of HIV/AIDS into other programmes; focus on DTPCs and DHMTs, the district NGO forum and in charges of HUs etc; the division of health promotion and education in MoH is critical in ensuring universal access to prevention messages; the review discovered a very good document for Health Promotion and Education for communities. 6.2.5.1 There should be regular and timely integrated support supervision to ensure sustained quality assurance through competency based in service training as soon as the need is noted. This intervention is necessary due to the relatively uncontrolled movement of health professionals and workers plus the rapid change in knowledge relating to HIV/AIDS care and management; the review found that there was potential for synergy between the health sector and the health related sectors like MoGLSD on one hand and the non-public sector partners. 6.2.5.2 Monitoring and Evaluation: The head of the M and E unit should be an expert in M and E but M and E should be within the competency package for the ACP-MoH management team. ACP-MoH should be supported to develop a robust integrated M and E framework for the HSHASP but which at the same time feeds into the HSSP and NSP. M and E framework should ensure that relevant indicators in the HSSP II the NSP and the NPAP are covered. 6.3 Interventions for key stakeholders 6.3.1 Policy level stakeholders Political commitment should be revitalised and monitored at all levels from the presidency to the grassroots; have and monitor out puts for a known service chain Top and senior level positions at the MoH should be kept filled to provide a conducive environment for the ACP-MoH to operate effectively; this review found all top officials were holding more than one post during application of the selected qualitative tools The AIDS law, National (overarching) AIDS Policy, the Public-Private-Partnership for Health should be finalised, disseminated and monitored forthwith for operationalisation The health sector HIV/AIDS Partnership should be reviewed to make it relevant to the current status of the HIV/AIDS response; proposed for inclusion are Cultural leaders/institutions, the forum of professional Associations and religious leaders The position of the ACP-MoH at the UAC in the multi-sectoral response should be made clear with clear roles and responsibilities for the two institutions known by all partners but especially key partners. There should be a desk officer for the ACP-MoH at the UAC as there is for the decentralised response SCE. The IHP+ should be owned and used as policy by government to motivate international Partners Into harmonising their systems with our health system and aligning their funding to nationally approved mechanisms; the focus should be on harmonising planning funding and M and E and reducing TCs incurred by partners at the expence some vital interventions. Government should adopt and implement relevant components of the Ouagadougou 66 Declaration on PHC in the African region to enhance integration of HIV/AIDS into other health services/programmes Since HIV/AIDS is a disease and 70 to 80% of the multi-sectoral AIDS Control Approach is the mandate MoH/the health sector, raising the status of the ACP-MoH in the MoH structure should be given the priority it deserves so that its capacity is built fast enough for it to take full and effective charge/control of the health sector HIV/AIDS response immediately Uniformed services should be represented on HPAC judging by the value that they can add to coverage and efficiency of the health sector HIV/AIDS and other programmes; the review noted that uniformed services were previously represented on the CCF for the GF A deliberate effort should be made to address the issue of HRH; this should include strengthening and implementing the motivation strategy, task shifting and remuneration A deliberate effort should be made to have effective policies to address the issue of transparency, accountability and corruption; all ministries should appoint members to their disciplinary committees to address the issues that can be handled internally, eg monitoring and support supervision and administration of internal sanctions, to discourage escalation of the problem beyond the MDAs; the review noted a significant level of frustration among DPs 6.3.2 Programme level stakeholders The ACP-MoH team heads should review and internalise the HSHASP, HSSP and NSP and ensure that the linkage, (including that with the PEAP and NHP), is understood by all the team members for proper dissemination to partners particularly the key sectors, CSOs, and districts ACP-MoH should convene health sector HIV/AIDS partnership meetings so as to harmonise understanding of policies on management and funding; customised attention should be paid to major funders of health or health related programmes Multi-sectoral collaboration for health sector HIV/AIDS response (/health) should be strengthened and sustained; this includes strengthening inter-sectoral collaboration with key public sectors (eg the SDS, LG, ES), HDPs, ADPs, key CSOs like Umbrella NGOs, FBOs and CSOs), cultural institutions, professional associations and the community ACP-MoH should spearhead Joint Planning with sectors and partners in the health sector HIV/AIDS response, then carry out joint support supervision with selected key sectors ACP-MoH should spearhead HIV/AIDS mainstreaming in MoH and the LMSCE to prepare for or allow for efficient and effective cascading downwards to through all levels to the grassroots ACP-MoH to disseminate and popularise the VHT strategy so that it is used by all partners as they involve communities and support community-led initiatives The ACP-MoH should work out a robust integrated M and E framework for the health sector HIV/AIDS response in collaboration with UAC to ensure its linkage to that in the NSP; in the transition period a mechanism should be found to collect the current M and E reports or data from the different active stakeholders and produce a usable overall form out of them and share it for use by all partners ACP-MoH should develop mechanisms to discourage issues relating to transparency, accountability and corruption within the health sector HIV/AIDS response 6.3.3 International level stakeholders International partners should jointly identify priority areas of the health system that need support to make the health sector HIV/AIDS response responsive, efficient and effective and get concurrence from the health sector on the selected areas International partners should jointly agree on areas requiring funding support basing on Comparative advantages The UN family should continue with supporting sectors in mainstreaming and 67 development of their strategic plans The UN family should give support to ACP-MoH to be able make out one M and E document from the different versions referred to earlier or those being used by the various stakeholders currently A deliberate effort by international partners to assist government deal with issues relating to transparency, accountability and corruption; this should include technical support, training and support to CSOs or advocacy organisations fighting the same problem The UN family and selected partners should work hard to build the country’s capacity for timely receipt and efficient use of financial assistance; this should include similar support to the non-public sector 6.3.4 The non-public sector (CSOs, FBOs, NGOs, PHPs etc) Non-public sector (CSOs/FBOs/NGOs/CBOs/cultural institutions/religious leaders’ forum) to review own partnership and appropriateness of entry point to the health sector HIV/AIDS response (ie through HPAC) Establish a peer review mechanism that can critically assess the way the partnership does business; the review noted findings from robust studies that DAH through the nonpublic sector is more likely to lead to increased domestic allocations to health spending than DAH through the public sector/government. Establish a mechanism for complementary partnership to for assisting government/the health sector to deal with issues to do with transparency accountability and corruption Establish an M and E system that can be aligned to the integrated M and E framework for the health sector HIV/AIDS response 68 Table 13.0 What Ugandans demand candidates for 2011 elections to address 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Table 13: What all Ugandans demand the 2011 Elections to address Issue % Health 97.4% Road network & transport means availability 96.6% Education 96.5% Child related issues 95.1% Employment 94.4% Personal security 93.6% Agriculture and food security 92.9% Poverty alleviation 92.6% Business 92.2% Water and sanitation 91.1% Environment 90.6% Small business activities 90.2% Land 90.1% Media (Newspapers, Radio, TV) 89% Domestic violence 86.6% Sports 84.2% Energy/ Fuel use 82.2% Traditional leaders 67.1% National security 62.2% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 `15 16 17 18 19 Major issues that Ugandans in Western region want addressed at 2011 Health 100% Education 98.9% Road network & transport means availability 98.5% Employment 97.7% Business 97.7% Media (Newspapers, Radio, TV) 97.3% Small business activities 96.9% Child related issues 95.8% Poverty alleviation 95.8% Personal security 95.0% Agriculture and food security* 93.9% Water and sanitation* 92.7% Land 92.4% Environment 91.9% Sports 90.1% Domestic violence 86.4% Energy/ Fuel use 75.9% National security 58.0% Traditional leaders 51.9% 69 1 2 3 4 5 6 7 8 9 10 11 12 13 14 `15 16 17 18 19 Major issues that Ugandans in Northern region want addressed at 2011 Health 97.6% Road network & transport means availability 97.1% Agriculture and food security 96.7% Education 96.6% Child related issues 96.2% Environment 94.8% Land 93.1% Employment 92.7% Business 92.3% Personal security 90.7% Poverty alleviation 90.4% Small business activities 89.4% Sports 88.8% Water and sanitation* 87.9% Media (Newspapers, Radio, TV) 86.8% Energy/ Fuel use 85.9% Domestic violence 84.9% National security 69.4% Traditional leaders 62.0% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 `15 16 17 18 19 Major issues that Ugandans in Central region want addressed at 2011 Employment 96.4% Health 95.4% Personal security 95.3% Child related issues 95.0% Education 94.8% Road network & transport means availability 94.8% Energy/ Fuel use 92.5% Water and sanitation 92.3% Business 92.2% Poverty alleviation 91.3% Agriculture and food security* 87.8% Domestic violence 87.5% Environment 87.4% Small business activities 86.0% Media (Newspapers, Radio, TV) 85.3% Land 84.9% Traditional leaders 80.5% Sports 76.4% National security 66.2% 70 Major issues that Ugandans in Eastern region want addressed at 2011 1 Health 97.1% 2 Road network & transport means availability 96.7% 3 Education 96.2% 4 Agriculture and food security 95.7% 5 Child related issues 93.4% 6 Poverty alleviation 92.5% 7 Land 92.3% 8 Personal security 91.9% 9 Water and sanitation 90.6% 10 Environment 89.5% 11 Employment 89.1% 12 Small business activities 88.9% 13 Domestic violence 87.3% 14 Media (Newspapers, Radio, TV) 86.3% `15 Business 85.5% 16 Sports 83.9% 17 Energy/ Fuel use 71.1% 18 Traditional leaders 71.1% 19 National security 54.5% th Source for table 13: New Vision 16 August 2010 71 Type of interaction Meetings held (%) No. of participants Table 14 Details of qualitative tools as applied at national level and participation 7). Director NAFOPHANU, Director NACWOLA, National Coordinator NGEN+ and selected formal groups/groups of individual PHAs. FGD 1(3.0) 1 8). Registrars of Medical Practitioners and Dentists Council, Uganda Nurses and Mid wives Council, Allied Health professionals council, Law society council, etc 9). President of UMA, UNANM, Pharmaceutical society of Uganda, Counselor’s Association, Private midwives association, Allied professional association, Association of surgeons of Uganda, Association of physicians of Uganda, Law society of Uganda, Professional centre of Uganda etc. KII 1(3.0) 1 KII 1(3.0) 1 10). Chair parliamentary committee of social services, Chair parliamentary committee on HIV/AIDs (including the last chair), Clerk to National assembly, Chairs sect oral committees, the Head of opposition in parliament, head of the ruling party in parliament. 13). Head of civil service/Secretary to cabinet, Deputy Head of civil service/Head civil service reform, PS Public service, Chair Health service commission. 14). Senior MoH including ACP-MoH, National Hospitals and a few selected others. 15). Coordinator AMICAALL, Director URC, Director TASO, Director AIC, Director World Vision Uganda, Director UNASO, Director UHMG, etc. 16). WHO, UNAIDS, UNICEF, WFP, and UNFPA. KII 4(12.0) 4 KII 3(9.0) 4 KII 2(6.0) 2 KII 2(6.0) 2 FGD 2(6.5) 5 17). Country Director World Bank, Coordinator PEPFAR, Coordinator GFATM, Coordinator GAVI, Country Director DFID, Coordinator USAID, Irish AID, IHP+ Country/Desk Officer. 18). PS- Health, DGHS, DG-UAC, Director NPA CHS /Director Planning MoH, Accounting officer accountability sector, MoH-PHC. FGD 3(9.0) 4 KII 3(9.0) 3 Nil 0 3(9.0) 8 Nil 0 KII 1(3.0) 1 KII 3(9.0) 3 Tool number and intended target group 19). NDA, UBTS, UVRI, NMS, managers of the programmes in MoH (MCH, NTLP, S and RH, UNEPI) etc. FGD 20). Chairs for SCEs, selected umbrella/National NGO reps, PHA groups, SWAp -TWG chairs in sectors and uniformed services (UPDF, UPF, UPS, etc.) 21). JCRC, IDI, Mild-May International, etc. 22). Director MISR, The Dean MU School of Health services, Director MJAP Dean MUSPH, Director UNHRO, etc. 23). Public sector, Public Administration, JLOS, Social Development, Security, Legislature and Local Government, ACP managers in line 72 ministries. 24). Major News papers (New vision and Monitor etc.), UTV programmes, UBC, President Straight Talk Foundation, head of most widely read News paper in district and or District information officer. KII 1(3.0) 1 25) Selected informants/institutions/sectors (R.O/Consultant to decide) at the beginning or during the process of data collection according to circumstances) Observat ion(s) - - 27). The chairperson UHRC, ED UNHCO, ED AGHA, ED FHRI (U). FGD 3(9.0) 7 33 46 Total Figure 2: Conceptual framework for interaction between Partner Health Initiatives and country health systems Governance Partner Health Initiative s Country Health Systems Financing Health workforce Health service delivery Health outcomes Health information systems Supply management systems Figure 2: Conceptual framework for interaction between Partner Health Initiatives and country health systems 73 Figure 3: Village Health Team Strategy, Institutional Framework/Linkages Political LCV LC IV LC III LC II Administrative DHC HSD Committee SCHC P.D.C, NGOs, CBOs LC I Technical DHT HC IV(HSD) HC III HC II VHT/HC I HOUSEHOLD 74 7.0 BIBLIOGRAPHY/REFERENCES 1. APRM (2008), APRM Country Review Report No. 7; Republic of Uganda January 2009. Chunling Lu, Mathew Schneider, Paul Gubbins et al. Public Financing of health in developing countries: a cross-national systematic analysis. Lancet April 9, 2010; www.thelancet.com Martin Odiit, David Kaweesa, Charles Nkolo et al. LQAO Monitoring Report. Evaluation of the impact of interventions on HIV/AIDS-related knowledge, practices and coverage in 12 districts of Uganda. Uganda HIV/AIDS Control Project(MAP)< September 2006). Medical and Dental Practitioners’ Council, 2007; Guidelines in respect of Complaints against Medical and Dental Practitioners, “To protect society and guide the profession”. Ministry of Health; 2010: Village Health Team Strategy. Ministry of Health, 2001: Operationalisation of Village Health Committees in Uganda; September 2001. Ministry of Public service (2005): Public Service Reform Programme Strategic Framework (2005/6-2009/10); Steering Rapid Economic Growth and Poverty Eradication; July 2005. MoFPED; Budget call circular 2006/7, 2007/8, 2008/9 and 2009/10. MoH, 2005. Health Sector Strategic Plan II 2005/06 – 2009/10, Volume 1. 2005, Kampala Uganda New Vision, Monday August 16, 2010: What Ugandans demand for 2011. New Vision, Tuesday August 17, 2010: Museveni best, say polls. OAU, 2001. Abuja Conference on OAU and Partnerships with Civil Society Organisations; Abuja, June 2001. Parliament of Uganda. Report on the field visits by the Sessional Committee on Social Services on the Performance of the Health Sector; Office of the Clerk to Parliament; May 2009. Republic of Uganda. The Uganda gender Policy; MoGLSD, 2007. Republic of Uganda; United Nations General Assembly Special Session (UNGASS), Country Progress Report; Uganda, March 2009. The Republic of Uganda. The Code of Conduct and Ethics for the Uganda Public Service; Ministry of Public Service. The Village Health Team Strategy and Operational Guidelines; Health Education and Promotion Division, March. UAC 2006, Accelerated HIV Prevention, The roadmap towards Universal Access to Prevention, Uganda, Kampala Uganda. UAC 2006, A rapid assessment of the drivers of the HIV/AIDS epidemic and effectiveness of the prevention interventions, Kampala Uganda UAC 2008, National HIV and AIDS Strategic Plan for Uganda, 2007/08 – 2011/12, Kampala, Uganda 2007 Uganda Human Rights Commission (2008); Human Rights Based Approach Guidelines to National Development Planning/Programming UNAIDS (2007) Joint UN Programme of Support for AIDS in Uganda 2007-2012 Wabwire-Mangen F., M. Odiit, W. Kirungi, D. Kaweesa Kisitu (2008), Modes of Transmission Study, Analysis of HIV Prevention Response and Modes of Transmission, The Uganda Country Synthesis Report, GoU/UNAIDS/UAC 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 75 24. 25. 26. 27. WHO, 2007; Strengthening Management in Low Income Countries: Lessons from Uganda. WHO/HSS/health systems/2007.4; Working Paper No. 11 WHO Maximising Positive Synergies Collaborative group (2009). An assessment of interactions between global health initiatives and country health systems; Lancet 2009: 373: 2137-69. WHO/PEPFAR/UNAIDS: Task shifting; rational redistribution of tasks among health workforce teams. Global Recommendations and guidelines.2010. WHO, UNAIDS and UNICEF (2009), “Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector”; Progress report, 2009. 76 8.0 APPENDICES Appendix I 8.1 National Data Collection tools 8.1.1 National Data Collection tools: Quantitative TOOL 11: Semi-structured questionnaire for members of Parliament Informed consent Good morning/ afternoon. This tool is presented on behalf of the Ministry of Health. This questionnaire is on a review to assess governance, leadership and partnerships in regard to the Health Sector HIV/AIDS Response/programs. You are requested to kindly answer questions on the issues mentioned. The information you give will be treated with a high level of confidentiality. Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. You are free to ask any question about the study. Now, given the information given to, you do you accept to participate in the review? Respondent accepts to participate in the review. . . . . . …………......1 Respondent does not want to participate in the review ……………...2 (terminate interview) THANK YOU. I. IDENTIFICATION CODE SEX Male ……………………….……………1 Female …………………………………..2 Title District MP……………………………………………………………....1 Municipality MP …………………………………………………… ..2 Constituency MP……………………………………………………...3 Special Group MP……………………………………………………..4 Member of the Parliamentary Committee on Social services….…..…...1 Member of the Parliamentary Committee on HIV/AIDS…………….…..…2 Member of Parliamentary Accounts Committee ……………………………..3 Other Specify…………………………....….…………………………………………..…....4 DISTRICT OF MP ……………………………………………………………………………… INTERVIEW STARTED AT:___________AM/PM INTERVIEWER CODER DATA ENTRANT NAME ____________ NAME ___________ NAME __________ CODE: _______ CODE: _______ CODE: _______ DATE ____________ DATE ____________ DATE ___________ **RESULT CODES 1. COMPLETED 2. PARTLY COMPLETED- GIVE REASON ________________________________ 77 3. OTHER SPECIFY ________________________________________________ COMMENTS ________________________________________________________ Governance, Leadership and Planning at National Level Please complete this questionnaire as completely as you can. If any of the questions, responses or choices are not clear to you, please ask a research team member to clarify before answering. Most of the questions are in the yes/no/not sure category. For these questions, please circle the one answer that is most correct and in case the question does not apply to you for example considering the answer from the previous question, put N/A for not applicable. Some questions have multiple answer choices; for these, circle as many of the options as you know to be true. If you are not sure of any of the options, please do not circle that answer. Thank you for your time. We will provide you feedback on your answers once all the information is collected and reviewed, and recommendations for improving the health sector response to HIV can be articulated. QUESTION RESPONSE CODE SKIP No. 1. 1Uganda is recognized for having .controlled the HIV/AIDS epidemic 1between 1992 and the early 2000s, but there is now a worry that the trend/situation is changing; what is your view? 2. 1What factors could be responsible .for the worsening? 2 3. 1What factors could be responsible .for the improvement? 3 4. 1Are you familiar with the Long term .Institutional Arrangements (LTIA) for 4management of HIV/AIDs in Uganda? The situation is worsening………..1 The situation is improving………..2 The situation is neither improving nor worsening………....3 If 2 go to 1.3 A. Human Resource for Health B. Health Information management C. Health Services Delivery D. Health/HIV/AIDS Financing E. Medical Supplies and their management F. Laboratory services G. Governance at national Level H. Governance at Health Sector Level Other (specify)…………………………………… A. Human Resource for Health B. Health Information management C. Health Services Delivery D. Health/HIV/AIDS Financing E. Medical Supplies and their management F. Laboratory services G. Governance at national Level H. Governance at Health Sector Level I. Other (specify) ………………………………… YES ………………………….1 NO……………..……………2 NOT SURE ……………….3 78 5. 1Are you familiar with the long term .Institutional Arrangements (LTIA) for 5management of Global Health Funds in Uganda? 6. 1Are the roles and responsibilities of .the Health Sector in the context of 8the National response to the HIV/AIDS epidemic in Uganda clear to you? 7. 1Are the roles and responsibilities of .the MoH in the context of the 7National response to the HIV/AIDS epidemic in Uganda clear to you? 8. Are the roles and responsibilities of the ACP-MoH in the context of the National response to the HIV/AIDS epidemic in Uganda clear to you? 9. 1Are the roles and responsibilities of .the Uganda AIDS Commission in the 9context of the National response to the HIV/AIDS epidemic in Uganda clear to you? 10. 1Are the roles and responsibilities of .the ACP-MoH in the context of the 1National Policies relating to 0HIV/AIDS in the country clear to you? 11. 1Are the roles and responsibilities of .the MoH in the context of the 1National Policies relating to 1HIV/AIDS in the country: Clear to you? 12. 1Are the roles and responsibilities of .the Health Sector in the context of 1the National Policies relating to 2HIV/AIDS in the country clear to you? 13. 1Are the roles and responsibilities of .the Uganda AIDS Commission in the 1context of the National Policies 3relating to HIV/AIDS in the country clear to you? 14. 1In your view, have policies Strategies .and plans relating to HIV/AIDS been 1disseminated to all stakeholders? 4 15. 1In your view do you think absence of .a national HIV/AIDS policy affects 1the national response to the 5epidemic? 16. 1In your view, has decentralization YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 Yes to some……………………….1 Yes to all……………………….……2 Not at all …….…………………...3 Not sure……….………………..….4 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 79 17. 18. 19. 20. 21. 22. 23. .been effective in taking HIV/AIDS 1services closer to the people? 8 1Are you aware of the Uganda Health .Sector HIV/AIDS Strategic Plan 2(HSHASP) 2007 - 2010? 1 1Are you aware of the National .HIV/AIDS Strategic Plan (NSP) 22007/08-2011/12? 2 1Are you aware of any National .HIV/AIDS policy for the country? 2 3 1If yes, which year was it presented .to Parliament for discussions? 2 4 1Are you aware of the National Policy .on mainstreaming of HIV and AIDS 2in Uganda? 5 1If yes, has HIV/AIDS been .mainstreamed into planning and 2budgeting processes of parliament 6as a Self Coordinating Entity (SCE)? 1a. Does Parliament have a specific .HIV/AIDS workplace policy? 2 7b. If yes to a, are you implementing any workplace policy? c. If no to a. or b., do you see a use in parliament having a workplace policy? 24. 1Do you think that ACP/MoH officials .have been adequately prepared 2when responding to questions and 9issues on HIV/AIDS presented to them by Parliament in the last 3 years? 25. 1Do you think that UAC officials have .been adequately prepared when 3responding to questions and issues 0on HIV/AIDS presented to them by Parliament in the last 3 years? 26. 1Do you think that ACP-MoH or MoH .has been adequately prepared when 3presenting a health/HIV/AIDS 1related Bill/policy to Parliament in NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 Name of Policy: _____________ Year presented: -____________ YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 80 27. 28. 29. 30. 31. 32. the last 3 years? 1Do you think that MoH as the lead .ministry for the Health Sector has 3fulfilled its roles regarding the 3Health Sector HIV/AIDS response in the last 3 years? 1Is there a District HIV/AIDS Strategic .Plan specifically for your district? 3 4 1If yes, are you aware if it is aligned .with HSHASP 2007-2010? 3 5 1When was the district plan .developed? 3 6 1How often is it reviewed and .modified as required? 3 7 1Who was involved in developing it? . 3 8 33. 1Who was involved in reviewing it? . 3 9 34. 1Is the district annual/operational .HIV/AIDS plan/budget closely linked 4with the district HIV/AIDS Strategic 0Plan? 35. 1a. Do you think that the health .sector is adequately funded by 4government? 1b. Do you think that the National response to the HIV/AIDS epidemic is adequately funded by government? 36. 1Do you think that the Health Sector .HIV/AIDS Strategic Plan (HSHASP) is 4adequately funded by government? 2 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 2005 or before……………...1 2006-7…………………….…... 2 2008-9 ………………………....3 Not sure………………………..4 Never ……………………..………. 1 Only when required….……… 2 Every 2 years ……………….…..3 Every year…………………………4 A. Yourself/self B. District Health Office staff C. Community representatives D. Hospital representatives E. Persons living with HIV/AIDS (PLHA networks) F. Others_______________________ A. Yourself/self B. District Health Office staff C. Community representatives D. Hospital representatives E. Persons living with HIV/AIDS (PLHA networks) F. Others_______________________ YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 81 37. 1If not adequate, what action has .parliament taken to address the 4inadequacy? 3 38. 1Do you think that the health .professionals that manage the 4health facilities in the country have 4the requisite administrative and organizational management capabilities to implement HSHASP? 39. 1Do you think that the ACP-MoH or .MoH has had adequate 4enforcement capacity to ensure 5compliance with minimum standards, policies, guidelines, codes of conduct and ethics etc by the service providers in the last 3 years? 40. 1Do you think that MoH is doing .enough to regulate or oversee the 4health services of the Faith-Based 7Organisation(s), clinics hospitals etc within the country? 41. 1Do you think that MoH is doing .enough to regulate or oversee the 4health services of the private/PHP 8clinics/hospitals within the country? 42. 1Do you think that MOH is doing .enough for community members to 4provide feedback on health /HIV 9services? 43. 1Which of the following feedback .procedures are operational in your 5district? 0 44. 1Does the community in your .constituency/district know about 5this feedback procedure? 1 45. 1Do you think that MoH is doing .enough for the district officials to 5monitor health services and provide 2feedback to health facilities? YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 A. DHO/MHO provides specific time to meet community members B. CAO/Town Clerk provides specific time to meet community members C. Suggestion/feedback box at the health facilities D. Periodic client exit interviews at health facilities E. Periodic meetings with community leaders/community health teams F. Newspaper or radio reports on community views of health services G. Other: _____________________ Yes, most do ………………..….…..1 Yes, some do ………………………..2 None/very few know ……….…..3 Not sure…………………………..……4 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 82 46. 1Which of the following monitoring .and feedback procedure(s) are 5operational in your district: 3 47. 1Do you think that MoH is doing .enough for the NGOs/ media to play 5their roles in protecting people’s 4health rights and needs? 48. 1Do you think that MoH is doing .enough for the CSOs/NGOs/ 5media/Private sector to play their 5roles in influencing important policy decisions that affect health? 49. 1Do you think that MoH is doing .enough for ensuring that the codes 5of conduct and ethics are adhered 6to and practiced by health professionals? 50. 1 .Do you think that MOH is doing 5enough for constructive 7engagement of the professional associations in enforcing codes of conduct and ethics or standards of their members? A. Periodic support supervision visits to health facilities by DHO/MHO staff B. Surprise health facility checks/visits by DHO/MHO staff C. Meetings to review HMIS data trends with health facility leaders D. External health service assessments by donors/technical experts which actively involve district staff E. Health service assessments of facilities F. Visits by Ministry of Health in collaboration with the district health office etc. G. Other: ________________________ YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 YES.……………….…….…….1 NO……………………..………2 NOT SURE…………...…….3 Thank you very much 83 TOOL 12: Semi-structured questionnaire for ACP-MoH and other health sector personnel INFORMED CONSENT Good morning/ afternoon. This questionnaire is being presented on behalf of the Ministry of Health. We are on a review to assess governance, leadership and partnerships in regard to the Health Sector HIV/AIDS response/programs. We request you to kindly answer questions on the issues mentioned. The information you give us will be treated with a high level of confidentiality. Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. You are free to ask any question(s) about the study. Now, given the information we have given you do you accept to participate in the study? Respondent accepts the interview . . . . . . ………………......1 Respondent does not want to be interviewed ... . . . . . . 2 (terminate interview) THANK YOU. 84 ASSESSMENT OF GOVERNANCE, LEADERSHIP AND PARTNERSHIPS I. IDENTIFICATION SEX MALE …………………………….1 CODE FEMALE ………………………..2 DISTRICT: _________________________ EMPLOYER Government …….1 Department ________________________ Uniformed service …………..…..2 NGO ..…………………………………..3 PHP ………………….….…………..4 FBO/PNFP ………….................…5 Others (Specify).……………….6 POSITION PS …………….…………………………………….………..1 Director …………………………………………….….…..2 Commissioner/Asst. commissioner …… ……..3 Head of a semi-autonomous Unit ………….…..4 Manager ……………………………………….……....….5 PPU(Leg. Task Force)………………….………….....6 Other (specify) …………………..…………….……...7 LOCATION ______________________ How long have you served in this position? Less than 1 year ………………………….1 1 to 3 years …………………………………2 More than 3 years ………………………3 **RESULT CODES 4. COMPLETED 5. PARTLY COMPLETED- GIVE REASON ________________________ 6. OTHER SPECIFY ________________ COMMENTS ________________________________________________________ INTERVIEW STARTED AT:______AM/PM INTERVIEWER CODER DATA ENTRANT NAME ____________ NAME _________ NAME __________ CODE: _______ DATE ____________ QUESTION No. CODE: _______ DATE ____________ CODE: _______ DATE ___________ CODE CODING CATEGORIES 85 01 02 03 04 05 06 07 08 09 What is your view about the current trend Number of new cases increasing…1 of the HIV/AIDS epidemic in Uganda? Number of new cases declining…..2 Not sure………………………………………3 What do you think is responsible for the A. Governance at national level above trend? (Multiple answers allowed) B. Governance at Health sector level C. Human Resource for Health D. Health Financing E. Health Information systems F. medical Products G. Laboratories H. Health Service Delivery The national policy frameworks provide a Strongly Agree……….………..1 basis for an effective national HIV/AIDS Agree……………………..……….2 response Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Health Sector HIV/AIDS Policies are based Strongly Agree……….………..1 on up-to-date and relevant information Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 The national frameworks allow effective Strongly Agree……….………..1 coalition building for collective decision Agree……………………..……….2 making and oversight for the Health sector Not sure……………...…...…….3 HIV/AIDS Response Disagree………………..…....….4 Strongly Disagree………..…..5 The National Health Policy (1999) covers Strongly Agree……….………..1 the national priorities reflected in the Agree……………………..……….2 PEAP Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 An annual/operational plan for national Strongly Agree……….………..1 level HIV/AIDS activities is aligned to the Agree……………………..……….2 NPAP and NSP Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 The provisions in the HIV/AIDS partnership Strongly Agree……….………..1 structures are understood by stakeholders Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 The SCEs have been appropriate in Strongly Agree……….………..1 coordinating the health sector HIV/AIDS Agree……………………..……….2 response Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 86 10 11 12 13 14 15 16 17 18 19 Decentralisation Policy enhances service Strongly Agree……….………..1 delivery at the health facility/community Agree……………………..……….2 level Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Coordination between ACP/MoH and the Strongly Agree……….………..1 districts is effective Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Internal coordination within MoH is Strongly Agree……….………..1 effective Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Coordination between ACP/MoH and the Strongly Agree……….………..1 various development partners is effective Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Coordination between ACP/MOH and other Strongly Agree……….………..1 departments of the Ministry is effective Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Coordination between ACP/MoH/Health Strongly Agree……….………..1 Sector and other sectors is effective Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Coordination between ACP/MoH and UAC Strongly Agree……….………..1 is effective Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Coordination between ACP/MoH and Strongly Agree……….………..1 PNFPs is effective Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Coordination between ACP/MoH and PHPs Strongly Agree……….………..1 is effective Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Coordination between ACP/MoH and the Strongly Agree……….………..1 various organizations of people living with Agree……………………..……….2 HIV/AIDS is effective: Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 87 20 21 22 23 24 25 26 27 28 29 Coordination between ACP/MoH and other Strongly Agree……….………..1 NGOs is effective Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Understanding of objectives of the HSHASP Strongly Agree……….………..1 is good within the Health Sector Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 MoH has a clear strategy for better Strongly Agree……….………..1 involvement of the Private Health sector in Agree……………………..……….2 implementation of HSHASP Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Lower level stakeholders in the Health Strongly Agree……….………..1 Sector HIV/AIDS response have the capacity Agree……………………..……….2 to implement the response Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Lower level stakeholders in the HIV/AIDS Strongly Agree……….………..1 response have been effective in delivering Agree……………………..……….2 HIV/AIDS services Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Performance of the ACP/MoH in Strongly Agree……….………..1 Agree……………………..……….2 coordinating the Health Sector HIV/AIDS Not sure……………...…...…….3 Response is optimal Disagree………………..…....….4 Strongly Disagree………..…..5 The funding mechanisms and resource Strongly Agree……….………..1 allocation for the HIV/AIDS response are Agree……………………..……….2 transparent. Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 The ministry of health adherers to financial Strongly Agree……….………..1 and administrative rules when disbursing Agree……………………..……….2 and allocating resources to the HIV/AIDS Not sure……………...…...…….3 response Disagree………………..…....….4 Strongly Disagree………..…..5 Donor funding and disbursing mechanisms Strongly Agree……….………..1 for HIV/AIDS response are appropriate Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Donor funding and disbursing mechanisms Strongly Agree……….………..1 for the HIV/AIDS response are aligned to Agree……………………..……….2 the country/national financial management Not sure……………...…...…….3 systems and processes Disagree………………..…....….4 Strongly Disagree………..…..5 88 30 31 32 33 34 35 36 37 38 39 Funding for the HIV/AIDS response that is Strongly Agree……….………..1 outside budget support is handled Agree……………………..……….2 appropriately Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 MoH has more capacity and resources Strongly Agree……….………..1 (technical, human, financial) to enforce Agree……………………..……….2 health laws and regulations to-date than Not sure……………...…...…….3 during implementation of HSSP-I Disagree………………..…....….4 Strongly Disagree………..…..5 There is greater adherence to registration of Strongly Agree……….………..1 health practitioners to-date than during Agree……………………..……….2 implementation of HSSP-I Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 There is greater adherence to registration, Strongly Agree……….………..1 accreditation and licensing of health facilities, Agree……………………..……….2 clinics, pharmacies, laboratories to-date than Not sure……………...…...…….3 Disagree………………..…....….4 during implementation of HSSP-I Strongly Disagree………..…..5 MoH is monitoring the protection of rights Strongly Agree……….………..1 of clients that receive Health sector HIV/AIDS Agree……………………..……….2 services to-date than during Not sure……………...…...…….3 Disagree………………..…....….4 implementation of HSSP-I Strongly Disagree………..…..5 Give reasons justifying your responses indicating optimal/sub-optimal _______________________________ performance of the MoH in coordination MoH disseminates relevant information on the Health Sector HIV/AIDS response more to-date than during implementation of HSSP-I Strongly Agree……….………..1 Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 MoH provides financial accountability to Strongly Agree……………..1 the public for government spending on Agree……………………..…….2 HIV/AIDS more to-date than during Not sure……………………….3 Disagree……………………….4 implementation of HSSP-I Strongly Disagree………...5 MoH has mechanism for the general public to report cases of absenteeism, corruption, sub-standard performance, and mismanagement more to-date than during implementation of HSSP-I Strongly Agree……….………..1 Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 The public is holding MoH accountable for Strongly Agree……….………..1 the Health Sector HIV/AIDS response more Agree……………………..……….2 to-date than during implementation of Not sure……………...…...…….3 89 HSSP-I 40 41 42 43 44 45 46 47 48 49 There is more pressure from the districts and other partners for ACP-MoH to account to them regarding its mandate in implementation of HSSP-II than during implementation of HSSP-I Disagree………………..…....….4 Strongly Disagree………..…..5 Strongly Agree……….………..1 Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 My overall rating of governance or Strongly Agree……….………..1 (stewardship) of MoH for HSSP-II is lower Agree……………………..……….2 Not sure……………...…...…….3 than for HSSP-I Disagree………………..…....….4 Strongly Disagree………..…..5 MoH has a Workplace/HIV/AIDS Policy in Strongly Agree……….………..1 Agree……………………..……….2 place Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 MoH is implementing an HIV/AIDS Strongly Agree……….………..1 Agree……………………..……….2 Workplace Policy Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 If yes to 1.43, State which one ………………………………………………………………… ………………………………………………… The MoH has slowed down in providing Strongly Agree……….………..1 pertinent information on the epidemic to Agree……………………..……….2 Not sure……………...…...…….3 the public Disagree………………..…....….4 Strongly Disagree………..…..5 MoH policies for internal communication and Strongly Agree……….………..1 flow of information are in place and are Agree……………………..……….2 Not sure……………...…...…….3 effectively used Disagree………………..…....….4 Strongly Disagree………..…..5 Strongly Agree……….………..1 HPAC is an effective policy organ of the Agree……………………..……….2 MoH Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 The Legislation Task Force is an effective Strongly Agree……….………..1 Agree……………………..……….2 policy organ of the MoH Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Understanding of objectives of the HSHASP Strongly Agree……….………..1 is good within the sector Agree……………………..……….2 Not sure……………...…...…….3 90 Disagree………………..…....….4 Strongly Disagree………..…..5 50 51 52 53 54 55 56 57 58 Policies for operationalizing the HSHASP are Strongly Agree……….………..1 adequate and are adhered to during Agree……………………..……….2 planning and implementation of activities Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Policies are adhered to during planning and Strongly Agree……….………..1 implementation of activities in MoH Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 An Operational plan for implementing HSHASP is Strongly Agree……….………..1 made annually Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Annual plans are adhered to during Strongly Agree……….………..1 implementation of the HSHASP Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 MoH should be more involved in Strongly Agree……….………..1 implementation instead of strategic Agree……………………..……….2 guidance and monitoring only Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 I/my organization/department participated Strongly Agree……….………..1 in the formulation of the HSHASP Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Many of the key stakeholders participated Strongly Agree……….………..1 in formulation of the HSHASP: Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 ACP/MoH was involved in development of Strongly Agree……….………..1 the policy documents/frameworks that Agree……………………..……….2 HSHASP it is aligned to Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Policies in the MoH are formulated basing Strongly Agree……….………..1 on evidence from monitoring and Agree……………………..……….2 evaluation: Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 91 59 60 61 62 63 64 65 66 67 68 The ministry of health has capacity to over Strongly Agree……….………..1 see implementation of the health sector Agree……………………..……….2 HIV/AIDS response Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 All nationally approved essential ARVs Strongly Agree……….………..1 appear in the National essential medicines Agree……………………..……….2 list/policy for Uganda Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 There is an up-to-date national policy and Strongly Agree……….………..1 plan on drug procurement in Uganda: Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Drug procurement practices always adhere Strongly Agree……….………..1 to the national drug procurement policy Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 There is a national policy/strategy for Strongly Agree……….………..1 TB/HIV Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 HIV/AIDS has been mainstreamed in all the Strongly Agree……….………..1 programmes under the department of NDC Agree……………………..……….2 and the MoH Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 The key health sector documents are Strongly Agree……….………..1 published and disseminated regularly for Agree……………………..……….2 consumption of the general public and civil Not sure……………...…...…….3 society Disagree………………..…....….4 Strongly Disagree………..…..5 HIV services have a greater level of Strongly Agree……….………..1 accountability than other health services Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 There is a formal mechanism for Strongly Agree……….………..1 accountability within the PHP and PNFP Agree……………………..……….2 sectors Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Suggest three priority interventions that ………………………………………………………………… MoH should put in place to improve on ………………………………………………………………… this aspect of governance ………………………………………. (accountability) 69 The position of ACP within MoH is Strongly Agree……….………..1 appropriate for implementation of HSHASP Agree……………………..……….2 92 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Strongly Agree……….………..1 Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Strongly Agree……….………..1 Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Strongly Agree……….………..1 Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Strongly Agree……….………..1 Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Strongly Agree……….………..1 Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Strongly Agree……….………..1 Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 70 Terms of reference for all the units under the ACP-MoH line of authority are clear to all staff. 71 The way staff are organized in ACP facilitates work, information flow, and decision-making 72 All staff have job descriptions and roles related to HSHASP that are understood 73 The scheme used for rewarding high performers is meaningful and effective 74 Work environment in MoH encourages staff to work for high performance, improvement and excellence 75 Staff appraisals include assessment of staff involvement in HIV/AIDS work 76 Suggest three priority interventions that MoH should do to improve performance of the ACP-MoH _______________________________ 77 ACP guides the process of identifying Strongly Agree……….………..1 research priorities effectively Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 Stakeholders in the fight against HIV/AIDS Strongly Agree……….………..1 are involved in identifying research Agree……………………..……….2 priorities Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 ACP coordinates research activities that are Strongly Agree……….………..1 aimed at addressing the HIV/AIDS epidemic Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 78 79 93 80 81 82 83 84 85 ACP has the capacity to determine Strongly Agree……….………..1 priorities for HIV/AIDS funding. Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 The Aid liaison office in the MoFPED Strongly Agree……….………..1 participates in processes for approval of Agree……………………..……….2 new projects. Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 All stakeholders/partners responsible for Strongly Agree……….………..1 achieving and sustaining health in Uganda Agree……………………..……….2 are familiar with the Health Sector Strategic Not sure……………...…...…….3 Plan (HSSP) II (2005/06 – 2009/10) Disagree………………..…....….4 Strongly Disagree………..…..5 All stakeholders/partners responsible for Strongly Agree……….………..1 achieving and sustaining good health in Agree……………………..……….2 Uganda are familiar with the Health Sector Not sure……………...…...…….3 HIV/AIDS Strategic Plan (HSHASP) (2007 – Disagree………………..…....….4 2010) Strongly Disagree………..…..5 The principle of “The three ones” is Strongly Agree……….………..1 practiced among all key stakeholders or Agree……………………..……….2 partners who are implementing the Health Not sure……………...…...…….3 Sector HIV/AIDS Strategic Plan (HSHASP) Disagree………………..…....….4 (2007 – 2010) Strongly Disagree………..…..5 All stakeholders/partners who are implementing the (HSHASP) (2007 – 2010) have a designated officer for each of the following functions below: a. Planning Strongly Agree……….………..1 Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 b. Coordination Strongly Agree……….………..1 Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 c. M and E Strongly Agree……….………..1 Agree……………………..……….2 Not sure……………...…...…….3 Disagree………………..…....….4 Strongly Disagree………..…..5 THANK YOU VERY MUCH 94 8.1.2 National Data collection tools: Qualitative TOOL 7: Guide for Focus Group Discussion/In-depth interviews for PHAs and PHA Organisations of different levels Welcome! Moderator welcomes participants, introduces him/her self and members of the research team. Explains the purpose of the study and the significance of their contribution. Introductions: Participants are encouraged to introduce themselves (preferably by first names) and the organizations and their position in the national network. Solicit and respond to any questions. Explain and get permission if you intend to use recording devices. Start the group discussion or interview. QUESTIONS: I will like to begin by asking 1. How are PLWHA generally treated in Uganda? a. Do PLWHA still experience stigmatizing behaviours from people? Probe for any personal experiences with family members, colleagues or peers, healthcare providers, international development partners, government officials, community members, any other b. Have there been any changes in the stigma/discriminatory experiences of PLWHA in the last 5 years? 2. How are PLWHA groups organized at the national level in the country? a. What are the different networks that exist at the national level and who are the members (please list any other networks eg women support groups if mentioned) b. Is this the umbrella organization for all PLWHA support group?, if yes how many members do you have?, if no mention all other umbrella PLWHA bodies at the national level c. Is membership voluntary and free for all support groups?, are there any eligibility requirements for membership? If yes name a few 3. What institutional structures do you have in place currently? a. Are you registered according to the law of Uganda, b. Please indicate which of these are in place i. a national board, ii. national management team, iii. office secretariat, staff members, iv. a written constitution or bye law? c. If governing bodies (board and management team) are in place, do they each play their roles? Please mention some of the roles of the board and management d. Do you have an organogram that defines clear communication lines in the organization and is this understood by members? 95 e. Do you have job descriptions that delineates responsibilities of the board, management team and staff members? f. Do you have defined values and norms that are known by all members? g. How are the leaders of your support group/network elected/appointed? Is the process democratic and participatory? 4. I will ask you some questions about the performance of the mandate of this body. a. Do you have a written mandate/mission that is understood by all members?(site/see copy of written mandate), what is your mandate? b. Do you have strategic and operational plans that guide the activities of this body? (site copy of plans) c. How was this plan developed, were members involved in the development of this plan? d. What are the responsibilities of the network to its members i. ii. iii. iv. e. Do you have designated staff members whose job responsibility is to carry out this mandate at the secretariat? If yes how many staff members and do they have the skills necessary to perform their duties? 5. Role of the network in the HIV/AIDS response at the national level a. What do you see as the role of this body in HIV/AIDS response at the national level? (please indicate and explain all that apply) i. Education of member organizations ii. Public Education iii. Advocating for better conditions for PLWHA iv. Building technical skills and capacity amongst members v. Participating in developing national policies and strategies vi. Partnering with international agencies for service delivery vii. Raising funds for member organizations viii. Seating on the board of Ugandan AIDS Commission (UAC) ix. Any other please specify___________________________ b. Did you or any other officer of this body participate in developing the Uganda National Strategic/ or Annual plans for HIV/AIDS plan? If yes, how did you get involved, were you invited by authorities organizing the event or did you advocate for inclusion? Probe for role in the development of the plan. c. How would you describe the relationship between this network and the following stakeholders i. AIDS Control Programme Unit, Ministry of Health ii. Uganda AIDS Commission iii. Centers for disease control and prevention 96 iv. v. vi. vii. viii. ix. x. World Bank USAID Global Fund GTZ DFID SCE-PHA Any other___________________________ 6. How does this body perform the coordination function in this era of decentralization? For example how do you as an umbrella body relate with smaller networks at the district level? 7. How effective is the PHA representative on the CCM, PC, HPAC, CSF? Does he/she consult and bring feedback to your organization? What needs to be done to improve on PHA representation? 8. What are the strengths and weaknesses in the roles of these structures in relation to PHAs, ACP-MoH, UAC, PC, HPAC, CCM 9. To what extent do you think the GIPA and MIPA principles are being implemented by ACP-MoH and UAC and what should the way forward be? 10. Are there any policies, legislations or guidelines that you feel MOH-ACP should put in place to address PHA concerns in the national response to HIV/AIDS? 11. Going forward, what roles can PLWHA Network play at the national level to advance HIV/AIDS services? 12. To what extent are HIV/AIDS issues mainstreamed in all your departments/activities? 13. Do you have a workplace HIV/AIDS policy in your organization? Please don’t forget the observation checklist THANK YOU VERY MUCH 97 TOOL 8: Key Informant Interview Guide for (Health) Professional Councils (heads) 1. Please comment on the current situation of HIV/AIDS in Uganda and the direction it is taking. To what extent do you think the governance/stewardship by MoH is responsible for reversing trends in the health related components of the national response? 2. To what extent are health professionals adhering to the Professional Code of Conduct and Ethics for health workers as laid out in the health service Commission Act? How can the councils and the Professional Associations work together to improve the situation for better quality HIV/AIDS services? (Probe for roles and responsibilities of the two and any areas of possible improvement or synergy). 3. What are the current activities and responsibilities of the council in terms of: a. Licensing and registering individual nurses/physicians b. Accreditation of nursing and medical schools/health facilities c. Tracking the nursing and medical workforce numbers in Uganda d. Addressing task shifting as a human resources for health issue e. Addressing other nursing and medical policy issues 4. How are the council board members selected and how accountable are they to the members? How regularly does the council meet and what is the level of participation of the members? 5. Do you think that the councils are doing enough to help MoH in regulating the public and private health practitioners? Are there adequate legislation, policies and guidelines set by MoH to support the council to carry out their activities? What needs to be done to strengthen the council? 6. Does the council operate independently of MoH? Do they have strategic plans, Annual work plans, M and E system, clear roles and responsibilities of the board and secretariat, annual performance report and audits? What needs to be done to strengthen them? 7. How are the operational costs of the council financed? a. MoH funding? b. Donor funding? c. Licensing/registration fees? d. Accreditation fees? e. Other: 8. Besides funding support for routine operations, how is the council working directly with donors and their partner organizations here in Uganda? What activities or capacity building efforts are being funded by donors/partners? Is there more that could be done in your opinion? 9. To what extent are HIV/AIDS issues mainstreamed in all your departments/activities? 10. Do you have a workplace HIV/AIDS policy in your organization? 98 11. Uganda Nurses and Midwives Council What is the council doing to support HIV education/training among nurses and doctors? a. Is HIV education/training required to graduate from medical/nursing school? If yes, how do you enforce this? b. Are there plans to require that all nurses/physicians undertake a certain number of continuing education training hours per year. If so, what is holding this up? 12. Does the council leadership have an opinion on pay for performance type schemes here in Uganda? (note: describe what a pay for performance incentive scheme is if they don’t already know). 13. Are there any policies, legislations or guidelines that you feel ACP-MoH or MoH should put in place to address the concerns of Professional Councils? 14. Are there any policies, legislation or guidelines that you feel MoH should put in place to improve effectiveness on the Health Sector response to HIV/AIDS? 15. To what extent are HIV/AIDS issues mainstreamed in all your departments/activities? 16. Do you have a workplace HIV/AIDS policy in your organization? Please don’t forget the observation checklist THANK YOU VERY MUCH 99 TOOL 9: Key Informant Interview Guide for (Health) Professional Associations 1. The APRM recently recognised the Uganda MACA as a best practice and the President for his stewardship role in the HIA/AIDS fight between 1992 and early 200s; but now there is a worry that the trend is changing; What are your views about the trend; worsening/new infections going up or improving/new infections reducing ? To what extent is governance the issue? (Probe for other components of the health system ie HMIS, HRH, HF, Health products and supplies, HSD and laboratory services) 2. Are you implementing any HIV/AIDS policy for your members? If yes, which one? (Probe for a customised policy, the National Policy on HIV and AIDS and the world of work? If not, probe for importance of having one). 3. From the NGO perspective, what is your comment on view of the CSOs and community regarding service availability and affordability, staffing levels, drug supplies, unofficial fees among others in public vs private health facilities? (Probe for comparative or contrasting views between private and public domains) 4. Comment on corruption as one of the factors frustrating the multi-sectoral AIDS Control Approach (MACA); which areas do you think need addressing? (Probe for procurement procedures and instances of punitive action so far taken). 5. Comment on accountability within the PHP, PNFP sectors vis a vis the public sector? 6. What are you/is your organisation doing to assist government in the area of accountability, fighting corruption, adherence to the codes of conduct and ethics (Probe for use of the professional codes, the Health Service Commission code and any best practice that can be copied) 7. Are the national medicine regulatory authorities doing enough to enforce existing international guidelines to prevent dumping of donated medicines? What is you experience regarding expiry of drugs in Uganda? (Probe for donated supplies, and those not on the essential medicines list, and their quality; and the role of associations in this). 8. To what extent has ACP-MoH helped all stakeholders and partners to know and perform their roles and responsibilities in the health sector HIV/AIDS response? Do you think ACP-MoH understands its roles and responsibilities in guiding partners in the Health sector HIV/AIDS response? (probe for a policy that guides dissemination) 9. Are there provisions in the policy/strategies/plans for consumers of HIV/AIDS services to forward their grievances for action? What are they? Are the consumers effectively utilising this option? (Probe for utilisation of the Client Charter and document on complaints against doctors etc) 10. What oversight roles does ACP play in relation to the HIV/AIDS activities of your organisation and other partners and stakeholders in the health sector HIV/AIDS response? How can this role be more effective? (probe for visits documents and M and E) 100 11. How does ACP coordinate with your organization/facility in relation to the health sector HIV/AIDS response? How effective has the coordination been? (Probe for structural relationships, coordination meetings, technical support) 12. How often do you get technical support supervision visits form ACP? 13. To what extent has your organization been involved in the development of proposals for funding for HIV/AIDS activities eg Global fund? 14. To what extent are HIV/AIDS issues mainstreamed in all your departments/activities? Please don’t forget the observation checklist THANK YOU VERY MUCH 101 TOOL 10: Interview guide for Chairs of selected Parliamentary committees and few from the 10 districts (studied) 1. Recently Uganda’s MACA has been recognised by the APRM as a best practice in control of HIV/AIDS between 1992 and early 2000s and so was the President for his stewardship role; but there are now fears, and many currently believe, that the trend is reversing. To what extent could governance account for the current trend? 2. To what extent do you think the principle of “The three ones” is being implemented by all stakeholders in the HIV/AIDS response? How best can it be implemented for maximum benefits? (Probe for view on the principle operating at at least all major levels ie UAC, ACP-MoH, Sectors, Donor agencies, Districts etc) 3. Please comment on (ACP’s)/MoH’s stewardship role in Implementation of the health sector HIV/AIDS response. How best can the roles of the ACP-MoH and UAC be better defined to ensure synergy? (Probe for views on dual allegiance of UAC and its status at MoH and ideas on the possible way forward) 4. How does the responsible/your committee carry out its oversight functions on MoH with particular reference to HIV/AIDS? What steps were taken by ACP-MoH and/or UAC to empower the members of the committee so that they could effectively carryout their work? (Probe for dissemination of strategies coordination and mentoring etc) 5. Does the decentralization policy enhance service delivery at the Health facilities? Should there be more HC-IV and HC-IIIs established (when those that exist do not always have medicines, doctors, staff houses with some not functioning at all etc)? If yes, what should be done to make the policy effective? (Probe for views on carrying on with only what is so far approved/there) 6. What does the responsible/your committee do in order to ensure that legislation, policies and strategies put in place for HIV/AIDS are implemented by ACP-MoH and other key stakeholders in the health sector? 8. To what extent has MoH played its stewardship roles in providing the necessary legal, policy or regulatory support to stakeholders for enhancing their health sector HIV/AIDS response? 9. What needs to be done by MoH in order to ensure that the necessary resources are allocated and disbursed for health related HIV/AIDS activities at the national, sector, district, facility levels? 10. Do you think that the professional councils are doing enough to help MoH in regulating the private health practitioners? Are there adequate legislation, policies and guidelines set by MoH to support the councils to carry out their activities? What needs to be done to strengthen the councils? 11. To what extent are HIV/AIDS issues mainstreamed in all your departments/activities? 12. Do you have a workplace HIV/AIDS policy in your organization? Thank you very much 102 TOOL 13: Key Informant Interview Guide for the Heads of civil service and Public service 1. To what extent do you think that the public sector ministries are playing their roles in addressing HIV/AIDS? To what extent does MoH empower the permanent secretaries and public sector staff to play their pivotal roles in addressing HIV/AIDS in their ministries and sectors? (Probe for the National Policy on Mainstreaming HIV and AIDS in Uganda etc) 2. Has the inter-ministerial coordination committee that was set by UAC/MoH been effective in the coordination of HIV/AIDS activities? 3. There is evidence that most of the policies/frameworks needed to support the Multisectoral response are in place but implementation, a responsibility of the public sector workers/civil servants is a setback; What could the problem be regarding implementation? (Probe for use of the Code of Conduct and ethics for Public service, Code conduct and ethics for health workers both of which are in place) How far has public service followed operationalisation of Client Charters by sectors (including guidelines for complaints from communities against public servants/doctors). 4. Based on your experience in the last three years, what are the challenges that MoH has to address in developing policies that relate to the health sector response to HIV/AIDS? What are some other areas that MoH need to develop policies and laws on? (Probe for view on a strategy for communication of policies etc) 5. To what extent do you think MOH has been adhering to the government policies that affect delivery of health services? 6. What do you see as the best entry point for civil servants into the fight against HIV/AIDS in Uganda? (probe for LMSCE or decentralisation to sectoral levels) 7. Comment on Task shifting, supported by appropriate training, as one of the strategies for addressing the critical/chronic shortages of the Human Resources for health and or improving HIV/AIDS and health services delivery in Uganda. (Probe for views on employment of retired civil servants on contract especially eg nurse and midwives) 8. To what extent are HIV/AIDS issues mainstreamed in all your departments/activities? 9. Do you have a workplace HIV/AIDS policy in your organization? Please don’t forget the observation checklist THANK YOU VERY MUCH 103 TOOL 14: KI uide for MoH/ACP-MoH Officials and a few selected others 1. To what extent could governance (vis a vis other components of the health system) be a factor in the negative trend in the HIV/AIDS epidemic in the country? 2. To what extent are you satisfied with the policy organs of MoH in providing stewardship and strategic direction to the health sector, and particularly, national health sector HIV/AIDS response? 3. To what extent is HPAC functioning (composition, schedule of meetings, agenda, attendance of meetings, decisions, roles/responsibilities) etc as stipulated? To what extent are you satisfied with the line of communication between MoH and members of HPAC? 4. To what extent is CCM functioning (composition, schedule of meetings, agenda, attendance of meetings, decisions, roles/responsibilities) etc as stipulated? To what extent are you satisfied with the line of communication between HPAC, UAC-PC, MoFPED (Principal Recipient), Price Waterhouse Coopers (Local Fund Agency) and Geneva? What governance shortcomings have contributed to the poor performance of GFATM in Uganda that can be attributed to MoH? 5. To what extent are you satisfied with the organization of the TMC, SMC and ACP-MoH as means of providing strategic leadership to the implementation of HSHASP? What needs to be done to improve? 6. Do you think that there is a harmonious working relationship (team spirit, trust, confidence etc) between the political, administrative and technical arms of the SMC, TMC and ACP-MoH at MoH? 7. Do the major structures of MoH work effectively e.g. SWG, TWGs in providing strategic guidance to HSHASP and HSSP II? 8. In which areas do we now need urgent laws, policies and guidelines for supporting implementation of HSSP and HSHASP e.g. DNA parenthood testing, in-vitro fertilization, etc 9. To what extent are you satisfied with the organization (agenda, invitation, attendance, management, reporting , feedback etc) of the Area teams, AHSPR, JRM, TRM and NHA as a means of providing strategic leadership and monitoring implementation of the HSHASP? What needs to be done to improve? 10. To what extent are you satisfied with the organization of the DHOs and directors of hospitals as a means of providing strategic information to MoH-ACP in relation to implementation of the HSHASP? What needs to be done to improve? 11. What is your comment on the role of ACP-MoH in coordinating implementation of HSHASP within MoH and with all relevant stakeholders? (probe for mechanisms in place for the coordination and any challenges to the ACP-MoH ) 12. Is the linkage between policy, planning, budgeting, allocation, implementation, supervision and monitoring understood and adhered to with respect to HIV/AIDS activities under HSHASP? (Probe for capacities of ACP-MoH staff etc) 104 13. Has the MoH come out with transparent criteria for resource allocation to hospitals that is linked to expected outputs under HSHASP? Does your facility receive the resources as stipulated by SWGs? And does your facility/entity spend according to the budget? 14. What is your comment on the current placement/position of ACP-MoH within the MoH organizational structure? How does this placement/position influence the activities of ACP-MoH as far as the Health sector HIV/AIDS response is concerned? Can upgrading of ACP/MoH to division, department or directorate improve on delivery of its mandate? 15. Does the current organizational structure of Ministry of health support effective implementation, coordination and monitoring of the health sector HIV/AIDS response? (probe for reporting mechanisms and functions). 16. Do you think that the professional councils are doing enough to help MoH in regulating the work of health practitioners? Are there adequate legislations, policies and guidelines set by MoH to support the councils to carry out their activities? What needs to be done to strengthen the councils? 17. To what extent are HIV/AIDS issues mainstreamed in all your departments/activities? 18. Do you have a workplace HIV/AIDS policy in your organization? Please don’t forget the observation checklist THANK YOU VERY MUCH 105 TOOL 15: Key Informant Interview Guide for Umbrella Organisations National NGOs & CSOs 1. The APRM recently recognised the Uganda MACA as a best practice and the President for his stewardship role in the HIV/AIDS fight between 1992 and early 2000s; but now there is a worry that the trend is changing. To what extent is governance by the MoH contributing to this? (Probe for other components of the health system ie HMIS, HRH, HF, Health products and supplies, HSD and laboratory services) 2. How does rapid growth in number of CSOs/NGOs/CBOs affect the national HIV/AIDS response? Comment on Community-Led HIV/AIDS Initiatives in Uganda and Community Health insurance as sustainability options; can the presence of so many NGOs and CSOs as stakeholders in the multi-sectoral HIV/AIDS response be exploited to initiate and or enhance strategies for sustainability?; if so how? 3. To what extent is coordination through SCEs and decentralization to sectors consistent with the policy of decentralized health/HIV/AIDS services delivery as a strategy for taking services where people live? 4. Comment on the principle of “the three ones” in implementing the multi-sectoral HIV/AIDS response. Is it being effectively applied in the context of health sector HIV/AIDS response? Any proposal(s) for improvement? 5. From the NGO perspective, what is your comment on views of CSOs and the community regarding service availability and affordability, staffing levels, drug supplies, unofficial fees among others? (Probe for comparative or contrasting views between private and public domains) 6. How did you participate in formulation of the HSHASP? (Probe for other, major, stakeholders and partners that were involved). To what extent has ACP-MoH helped all stakeholders and partners to know and perform their roles and responsibilities in the health sector HIV/AIDS response? What guides you/your organization in the health sector HIV/AIDS response to develop your own strategic plans? Probe for the NSP or the HSHASP or the HSSP II 7. Are the national medicine regulatory authorities doing enough to enforce existing international guidelines to prevent dumping of donated medicine? What is you experience regarding expiry of drugs in Uganda? (Probe for donated supplies, and those not on the essential medicines list, and their quality). 8. How does accountability of HIV/AIDS services compare with other health services? (Probe for any best practices that can be copied). Comment on accountability within the PHP, PNFP sectors vis a vis public sector? What mechanisms do you thinking MoH has put in place to address corruption in the area of procurement and distribution of pharmaceuticals particularly for ART? (Probe for the practice of procurement procedures and instances of punitive action so far taken). 9. To what extent has ACP-MoH helped all stakeholders and partners to know and perform their roles and responsibilities in the health sector HIV/AIDS response? What coordination role does ACP-MoH play in relation to the HIV/AIDS activities of 106 other partners and stakeholders in the health sector HIV/AIDS response? How can this role be more effective? 10. Has HIV/AIDS been mainstreamed in all your core functions? Have you received appropriate guidance regarding this and from who? (Probe for the stewardship role of ACP-MoH in this) 11. To what extent are formulated policies/strategies/plans for implementation of the health sector HIV/AIDS response disseminated to all relevant stakeholders? (probe for a policy that guides dissemination) 12. Are there provisions in the policy/strategies/plans for consumers of HIV/AIDS services to forward their grievances for action? What are they? Are the consumers effectively utilising this option? (Probe for utilisation of the Client Charter and document on complaints against doctors etc) 13. How does ACP coordinate with your organization/facility in relation to the health sector HIV/AIDS response? How effective has the coordination been? (Probe for structural relationships, coordination meetings, technical support supervision). 14. Do you have a workplace HIV/AIDS policy in your organization? Please don’t forget the observation checklist THANK YOU VERY MUCH 107 TOOL 16: Interview guide for UN agencies and some select ADPs or agencies 1. Recently Uganda’s MACA has been recognised by the APRM as a best practice for controlling HIV/AIDS between the 1990s and early 2000s as was the president for his stewardship role. But there are now fears, and many currently believe, that the trend is reversing. To what extent could governance be responsible and what do you see as the way forward? (Probe for national governance, HSG and the other six components of the health system) 2. There were Long Term Institutional Arrangements (LTIA) for Management of HIV/AIDS in Uganda since late 2005 and now there are LTIA for Management and coordination of Global Health Funds; how helpful have these arrangements been towards the multisectoral and Health Sector HIV/AIDS response; do you see any serious problems? If yes; how best can the problem be addressed? (Probe also for the status’ of UAC including its dual allegiance and ACP-MoH) 3. What are your views about the Uganda HIV/AIDS Partnership, the health SWAp and decentralisation with regard to the Uganda health sector HIV/AIDS response? 4. Can you comment on the contribution that Uganda makes towards funding the fight against HIV/AIDS compared to other stakeholders; is it in line with the national HIV/AIDS mainstreaming policy? To whom should the status quo be attributed, what should the way forward be? (probe for possible focus on sustainability of the national response) What policy changes are needed with regard to funding health sector HIV/AIDS response for public and private sector?. (Probe for consensus on the best mechanism) 5. To what extent do you think the principle of “The three ones” is being implemented by all stakeholders in the HIV/AIDS response? How best can it be implemented for maximum benefits? (Probe for views on a person for each of planning, Coordination and M and E for each establishment carrying out HIV/AIDS activities starting with ACP-MoH) 6. Please comment on ACP’s stewardship role in implementation of the health sector HIV/AIDS response at national, district/sector and community levels. (probe for views on ACP-MoH/MoH roles and responsibilities vis a vis its positioning in the MoH structure) 7. What are the challenges faced in implementation of MOU (i) between development partners and MoH and (ii) between development partners and UAC? 8. WHO has proposed raising the cut off point for starting ARVs against the fact that 50% and above of those currently in need of ARVs cant have them; Comment on the above and the fact that most of the programmes that are in place have no predicatable sustainability plan; should Uganda focus on sustainability or covering the un-met need for ARVs? (probe for views about the recent problems whereby life saving programmes that started as emergency programmes have been closing and clients on ARVs are abandoned to government/ACP-MoH which also had no take over plans). 9. To what extent can the Ouagadougou Declaration on Accelerating implementation of the PHC strategy, if effectively implemented, improve on community involvement in planning, implementation, decision making, oversight/regulation and advocacy for 108 reform? (Probe for possible enhancement of implementation of the Paris Declaration on Aid Effectiveness) 10. Are there any policies, legislation or guidelines that you feel MoH should put in place to improve effectiveness on the Health Sector response to HIV/AIDS? 11. To what extent are HIV/AIDS issues mainstreamed in all your departments/activities? 12. Do you have a workplace HIV/AIDS policy in your organization? Please don’t forget the observation checklist THANK YOU VERY MUCH 109 TOOL 17: KII guide for International donor agencies or GHIs including international NGOs. 1. Recently Uganda’s MACA has been recognized as a best practice for control of HIV/AIDS between 1990s and early 2000s. But there are now fears, and many currently believe, that the trend is reversing. To what extent could governance be responsible?. (Probe for contribution the other blocks may have contributed or any other factors) 2. There are increasing calls for good HSG because of increased health services funding and demand for results and accountability. To what extent do you think a conducive environment exists for good HSG in relation to the Health Sector HIV/AIDS response? (Check the internal and external environments) 3. What are your views about the Uganda HIV/AIDS Partnership and its structures, the LTIA, the health SWAp and decentralisation with regard to the Uganda Multi-sectoral HIV/AIDS response? (probe for clarity on relations between ACP-MoH and UAC and their roles and responsibilities and proposals for improvement) 4. A lot has been done towards harmonising funding by Global Health Initiatives and national health systems. To what extent do you think efforts in this direction may help improve funding mechanisms for the national/health sector HIV/AIDS response? (probe for the pressure that GHIs put on HSGs and its effect on government planning and programming, the varying planning and budgeting cycles; get concrete proposals for the way forward etc) 5. To what extent is there coordination and synergy in the planning, resource allocation, implementation and M&E etc of PEFPAR, GFATM and the CSF? (Probe also in relation to other donor funded non-HIV programs). For PEPFAR, what is stopping Uganda from participating in the PEPFAR Framework? For GFATM, what are the current challenges in the CCM and PR? 6. In terms of value for money which funding mechanism do you see as most appropriate for Uganda? What policy changes are needed to achieve that scenario?. 7. Can you comment on the contribution that Uganda Government makes towards funding the fight against HIV/AIDS compared to other stakeholders; is it in line with the national HIV/AIDS mainstreaming policy? To whom should the status quo be attributed and what should the way forward be? (Probe for views on statements that government action is influenced by the lots of money from other/non-government sources especially in districts and the way forward for sustainability) 8. WHO has proposed raising the cut off point for starting ARVs against the fact that 50% and above of those currently in need of ARVs cant have them; Comment on the above and the fact that most of the programmes that are in place have no predicatable sustainability plan; should Uganda focus on sustainability or covering the un-met need for ARVs? (probe for views about the recent problems whereby life saving programmes that started as emergency programmes have been closing and clients on ARVs are abandoned to government/ACP-MoH which also had no take over plans yet). 9. To what extent do you think the principle of “The three ones” is being implemented by all stakeholders in the HIV/AIDS response? How best can it be implemented for 110 maximum benefits? (probe for proposals at national, district/sectoral and community levels) 10. Comment on Community-Led HIV/AIDS Initiatives in Uganda and Community Health insurance as sustainability options; can the presence of so many NGOs and CSOs as stakeholders in the multi-sectoral HIV/AIDS response be exploited to initiate and or enhance strategies for sustainability?; if so how? 11. GFATM: What are the current challenges and weakness of the structures of the funding mechanism viz CCM, HPAC, PC-UAC, Principal Recipient, Local Fund Agency? What needs to be done to improve on performance of GFATM in Uganda from the perspective of MoH? 12. To what extent do you think government is doing enough to ensure accountability and value for money for the support given through PEPFAR., GFATM, Civil society Fund etc. What needs to be improved? (Probe for views about mistrust between government and some partners) 13. Are there any policies, legislation or guidelines that you feel MoH should put in place to improve effectiveness on the Health Sector response to HIV/AIDS? 14. To what extent are HIV/AIDS issues mainstreamed in all your departments/activities? 15. Do you have a workplace HIV/AIDS policy in your organization? Please don’t forget the observation checklist THANK YOU VERY MUCH 111 TOOL 18: Key informant Interview Guide for Policy level MoH officials etc 1. Recently APRM recognised the president for his stewardship role in the fight against the HIV/AIDS epidemic; also Uganda’s MACA has been recognised as a best practice in the control of HIV/AIDS between 1990s and early 2000s. But there are now fears and many currently believe, that the trend is reversing. To what extent could our health system governance be responsible? (Probe for national governance also, HMIS, HRH, Health financing, Medical products and HSD) 2. There were Long Term Institutional Arrangements (LTIA) for Management of HIV/AIDS in Uganda since late 2005 and now LTIA for Management and coordination of Global Health Funds. How helpful have these arrangements been towards the multi-sectoral HIV/AIDS response? Are there still unresolved issues to be addressed? If any, which ones and how can the problem be addressed? (Probe views about the Uganda HIV/AIDS Partnership, the health SWAp and decentralisation with regard to the Uganda health sector HIV/AIDS response). 3. A lot has been done towards harmonising funding by Global Health Initiatives and national health systems; but the GHIs have issues they need to be addressed first. To what extent do you think efforts in this direction may help improve funding for the multi-sectoral HIV/AIDS, response and the health sector HIV/AIDS response in terms of value for money? What Issues has the Health sector still to address; what about the national level? (Probe for results oriented views about corruption, refer to the code of conduct and ethics by public servants and health professionals) 4. Decentralisation is facing a number of challenges at district level; communities are not yet effectively on board though the policy exists on CHDs HUMCs, VHTs, DACs, DTFs HIV/AIDS, Focal Points etc. What are the constraints and what is the way forward? To what extent is increasing the number of districts part of the solution? (Probe why districts can not mobilise substantial amounts of funds at local level etc ) 5. Can you comment on the contribution that Uganda government makes towards the fight against HIV/AIDS compared to other stakeholders and the urgency with which sustainability measures are needed; what must be done to correct the situation? (Probe for implementation of the national mainstreaming policy, SWAp and decentralisation without increasing the number of districts) 6. To what extent do you think the principle of “The three ones” is being implemented by all stakeholders in the HIV/AIDS response? How best can it be implemented for maximum benefits? (Probe for different scenarios of implementation focusing on capacity at all strategic levels) 7. To what extent has the planned involvement of communities in planning, implementation and evaluation and decision making been realised and how can the issue be addressed with urgency? (Probe CHDs in hospitals, HUMCs and VHTs and their supporting policies and why nothing moves) 8. Please comment on ACP’s stewardship role in Implementation of the health sector HIV/AIDS response in view of its present positioning in the MoH Organizational Structure? Could upgrading of its position significantly improve its 112 performance/national coordination role? (probe for any set backs especially at district level and HPAC). 9. How far has implementation of workplace/HIV/AIDS Policies gone and how effective is it in supporting the quest for universal access to HIV/AIDS services? (Probe for administrative support or stigma in high administrative levels; probe for which policy is more in place of the national policy on HIV/AIDS and the world of work or the Public Service version) 10. To what extent are you satisfied with the Policy advisory unit and Legislation Task Force in MoH in carrying out its work with particular reference to HIV/AIDS? How can parallel policy development process (initiation, data collection, participation, technical guidance, resource use, harmonization, production, dissemination etc) in MoH-ACP be streamlined with the LTIAs and activities of the Legal Task Force and Policy Analysis Unit? 11. To what extent has the inter-ministerial committee supported MOH in ensuring that the HSHASP is implemented in a coordinated manner? 12. Are there any conflicts in the roles and responsibility of UAC and MOH/ACP in the governance and stewardship of the national response to HIV/AIDS? What needs to be done to address these concerns? 13. Are there any policies, legislation or guidelines that you feel MoH should put in place to improve effectiveness on the Health Sector response to HIV/AIDS? 14. To what extent are HIV/AIDS issues mainstreamed by all actors in the fight against HIV/AIDS? Please don’t forget the observation checklist THANK YOU VERY MUCH 113 TOOL 19: KII Guide for MoH Semi-Autonomous Institutions Programme Managers 01. Comment on the recognition by the APRM of the MACA for bringing down the HIV prevalence in the 1990s up to early 2000s and the President for his stewardship role vis a vis the current trend of HIV/AIDS in Uganda. To what extent could governance (vis a vis other components of the health system) be a factor in the negative trend of this HIV/AIDS epidemic in the country? 02. To what extent are you satisfied with the policy organs of MoH in providing stewardship and strategic direction to the health sector, and particularly, national health sector HIV/AIDS response? 03. To what extent is HPAC functioning (composition, schedule of meetings, agenda, attendance of meetings, decisions, roles/responsibilities) etc as stipulated? To what extent are you satisfied with the line of communication between MoH and members of HPAC? 04. To what extent is CCM functioning (composition, schedule of meetings, agenda, attendance of meetings, decisions, roles/responsibilities) etc as stipulated? To what extent are you satisfied with the line of communication between HPAC, UAC-PC, MoFPED (Principal Recipient), Price Waterhouse Coopers (Local Fund Agency) and Geneva? What governance shortcomings have contributed to the poor performance of GFATM in Uganda that can be attributed to MoH? (Probe for views on the best way forward) 05. To what extent are you satisfied with the organization of the TMC, SMC and ACP as means of providing strategic leadership to implementation of the HSHASP? What needs to be done to improve? 06. Do you think that there is a harmonious working relationship (team spirit, trust, confidence etc) between the political, administrative and technical arms of the SMC, TMC and ACP at MoH? 07. Do the major structures of MoH work effectively e.g. SWG, TWGs in providing strategic guidance to HSHASP and HSSP II? 08. In which areas do we now need urgent laws, policies and guidelines for supporting implementation of HSSP and HSHASP e.g. DNA parenthood testing, in-vitro fertilization, etc 09. To what extent are you satisfied with the organization (agenda, invitation, attendance, management, reporting , feedback etc) of the Area teams, AHSPR, JRM, TRM and NHA as a means of providing strategic leadership and monitoring of the implementation of HSHASP? What needs to be done to improve? 10. To what extent are you satisfied with the organization of the DHOs and directors of hospitals as a means of providing strategic information to MoH-ACP in relation to the implementation of HSHASP? What needs to be done to improve? (Probe for views on challenges and the way forward) 114 11. What is your comment on the role of ACP-MoH in coordinating implementation of HSHASP within MoH and with all relevant stakeholders? (probe for mechanisms in place for the coordination and any challenges to the ACP-MoH ) 12. Is the linkage between policy, planning, budgeting, allocation, implementation, supervision and monitoring understood and adhered to with respect to HIV/AIDS activities under HSHASP? (Probe for capacities of ACP-MoH staff etc) 13. Has the MoH come out with transparent criteria for resource allocation to hospitals that is linked to expected outputs under HSHASP? Does your facility receive the resources as stipulated by SWGs? And does your facility/entity spend according to the budget? (Probe for the far OOB has gone in the sectors/MoH). 14. What is your comment on the current placement/position of ACP-MoH within the MoH organizational structure? How does this placement/position influence the activities of ACP as far as the Health sector HIV/AIDS response is concerned? Can upgrading of ACP/MoH to division, department or directorate improve on delivery of its mandate? 15. Does the current organizational structure of Ministry of health support effective implementation, coordination and monitoring of the health sector HIV/AIDS response? (probe for reporting mechanisms and functions). 16. Do you think that the professional councils are doing enough to help MoH in regulating the work of health practitioners? Are there adequate legislations, policies and guidelines set by MoH to support the councils to carry out their activities? What needs to be done to strengthen the councils? 17. To what extent have HIV/AIDS issues been mainstreamed in your division and all other divisions/departments/activities? 18. Do you have a workplace HIV/AIDS policy in your entity/organization? (Probe for which one and if none discuss the importance) 19. To what extent is the ACP-MoH able to monitor or give support supervision for mainstreamed activities within the Health Sector and selected others? (probe for the WHO building block requirements). NB Apply the skip pattern to cater for specific issues of different entities. Please don’t forget the observation checklist THANK YOU VERY MUCH 115 TOOL 20: Guide for round table meetings with reps of various stakeholders Respondents: Chairs for SCEs, select Umbrella/National NGOs, Reps PHA groups, SWAp TWG chairs in sectors and uniformed services (UPDF, UPF, UPS, etc) 1. Recently Uganda’s MACA has been recognised as a best practice for control of HIV/AIDS between 1990s and early 2000s; and the president for his Stewardship role. But there are now fears and many currently believe, that the trend is reversing. To what extent could governance be responsible? (probe for other components of the HS). 2. There were Long Term Institutional Arrangements (LTIA) for Management of HIV/AIDS in Uganda since late 2005 and now LTIA for Management and coordination of Global Health Funds. How helpful have these arrangements been towards the Health Sector HIV/AIDS response? Do you see any problem in them and if any how can the problem be addressed? 3. What are your views about the Uganda HIV/AIDS Partnership, the health SWAp and decentralisation with regard to the Uganda health sector HIV/AIDS response? (Probe for any preferences and why; also check on the relationship between and roles and responsibilities of UAC and ACP-MoH and proposals for the way forward) 4. Can you comment on the contribution that Uganda government makes towards funding the fight against HIV/AIDS compared to other stakeholders; to what extent could mainstreaming of HIV/AIDS into planning and budgeting processes improve funding for HIV/AIDS in Uganda? 5. To what extent do you think the principle of “The three ones” is being implemented by all stakeholders in the National HIV/AIDS response? How best can it be implemented for maximum benefits? (probe for views about the principle at the various levels ie national, sector and district or village/Community etc) 6. Please comment on the stewardship role of ACP-MoH in implementation of the health sector HIV/AIDS response including its role in determining research priorities and priorities for funding of new proposals (probe for views on enhancement of ACP’s performance). 7. What are the strengths and weaknesses of SCEs in the coordination of HIV/AIDS activities? To what extent has ACP-MoH been an active participant in the LMSCE and the decentralized Response SCE? What roles has it played in supporting other SCEs such as PHAs, FBOs, etc? 8. What are the strengths and weaknesses of the UAC-PC, CSF-Steering Committee, HPAC and CCM on which some members of the SCE sit? What needs to be done to improve coordination of Health sector HIV/AIDS response at national, district and lower levels? 9. Comment on the perception among different officials especially at district level, that health is already a well funded sector in relation to fears, that funds for health may be reallocated to other sectors? Could this be part of the reasons why there is very low mobilization of funds for health/HIV/AIDS services at district level? (Probe implementation of the Fiscal Decentralisation Strategy) 10. For Uniformed series, to what extent is there coordination in HIV/AIDS and health programs between programmes of government and private security agencies? 116 11. To what extent are HIV/AIDS issues mainstreamed in all your departments/activities? 12. Do you have a workplace HIV/AIDS policy in your organization? Please don’t forget the observation checklist THANK YOU VERY MUCH 117 TOOL 21: Key Informant interview guide for Centres of excellence etc 1. The APRM has recently recognized Uganda’s MACA as a best practice and it also recognized the president for his stewardship role; this was in relation to the declines recorded between the 1990s and early 2000. But currently the HIV/AIDS situation in the country seems to be taking a reverse trend! What is your comment on this (include increase or reduction in incidence? What factors could account for this in as far as management of the response is concerned? To what extent could governance be a factor in this trend? (probe for views on HMIS, HRH, HF, Health Products etc, Laboratories and HSD) 2. Comment on the Uganda HIV/AIDS partnership and its coordination structures, including relations between the roles and responsibilities of UAC and ACP-MoH? To what extent do you think the Long Term Institutional Arrangements (LTIA) for management of HIV/AIDS in Uganda are enhancing effectiveness of the multi-sectoral response and the health sector HIV/AIDS response? Did you receive a copy of the LTIA? (confirm presence of the copy and reflect closely on proposals for UAC and ACP synergy) 3. Did your organization participate in formulation of the HSSP-II, NSP, HSHASP and PPPH in any way? To what extent are your activities guided by these three strategic plans? (Probe if currently participating in the development of PPPH, HSSP-III and NHP-II? 4. How effectively has the ACP related to your organization in relation to MoH’s mandate in the context of HIV/AIDS? Has your sector attended any meetings with the ACP-MOh? Have you received guidelines from the ACP on management of HIV/AIDS for your organization? 5. Does your organization participate in any of the ACP-MoH TWGs? To what extent is the NMHCP TWG doing its work effectively and does it provide feedbacks from SMC and HPAC regularly? How can the functionality of the TWG be improved (composition, frequency of meetings, agenda setting, etc? (Probe for views on the structures and UAC synergy) 6. To what extent has your organization participated in the activities of the SelfCoordinating Entity established by UAC? How effective has the coordination mechanism through the self-coordinating entities and partnership committee been? To what extent is coordination through SCEs and decentralization to sectors consistent with the policy of decentralized health/HIV/AIDS services delivery? 7. How do you as an organization at national level relate/coordinate with district HIV/AIDS activities? What is your role in District HIV/AIDS work? What needs to be done by ACPMoH or UAC to improve on the status quo? (probe also views on the HRH situation in districts) 8. Comment on HIV/AIDS Mainstreaming as strategy for scaling up the multi-sectoral response. To what extent do you think MoH has carried out HIV/AIDS mainstreaming within the health sector? Is there a way the strategy can be improved? 9. Are you implementing any workplace/HIV/AIDS policy? (Probe for the ILO protocol, the National Policy on HIV/AIDS and the world of Work etc) 118 10. What makes your organization to be called a centre of excellence in comparison with others (especially local NGOs) involved in HIV/AIDS response? What does MoH need to do/have in place so that more indigenous organizations become centres of excellence? 11. What policies, strategies and legal framework need to be put in place by MOH in order to enhance the work of your organization? Please don’t forget the observation checklist THANK YOU VERY MUCH 119 TOOL 22: Key Informant interview guide for Academia, research and Science etc 1. The APRM has recently recognized Uganda’s MACA as a best practice and it also recognized the president for his stewardship role; all this was in relation to the declines recorded in the 1990s up to early 2000s. But currently the HIV/AIDS situation in the country seems to be taking a reverse trend! To what extent could governance be a factor in this trend? (probe for views on HMIS, HRH, HF, Health Products etc, Laboratories and HSD) 2. To what extent does the strategic plan of your organization address HIV/AIDS mainstreaming? (Probe if organization also has and is implementing any HIV/AIDS work place policy in relation to National policy on HIV/AIDS and the world of work or Establishment Notice No. 1 of 2007 from the Public Service). 3. How effectively has the ACP related to your organization in relation to MoH’s mandate in the context of HIV/AIDS? Has your sector attended any meetings with the ACP-MoH? Have you received guidelines from the ACP-MoH on management of HIV/AIDS for your organization? (probe for dissemination of policies, plans etc) 4. Does your organization participate in any of the MoH-ACP TWGs? To what extent is the TWG doing its work effectively and does it provide feedback from SMC and HPAC regularly? How can the functionality of the TWG be improved (composition, frequency of meetings, agenda setting, etc 5. To what extent has your organization participated in the activities of the SelfCoordinating Entity established by UAC? How effective has the coordination mechanism through the self-coordinating entities and partnership committee been? To what extent is coordination through SCEs and decentralization to sectors consistent with the policy of decentralized health/HIV/AIDS services delivery? 6. How are HIV/AIDS research priorities reached by your organization? Whom do you coordinate such activities with between ACP-MoH and UAC to ensure that your scientists or research experts address priority research concerns for responding to the HIV/AIDS epidemic? (probe for coordination meetings on the same) 7. To what extent have MOH and UAC played their roles in ensuring that the academic programmes and extra-curricular activities in research and higher institutions of learning are responsive to HIV/AIDS? 8. What coordination mechanisms exists or needs to be put in place between UNHRO, NARO and UNCST for enhancing strategic research and research on cross-cutting concerns in relation to health and HIV/AIDS in particular? 9. What role does your organization play in building the capacity of other partners in operational research, policy research and monitoring and evaluation etc in order to generate strategic information for planning and guiding national, sectoral, district and local response to HIV/AIDS? 120 10. What policy or legal frameworks need to be put in place to ensure that research findings are disseminated to the relevant stakeholders as soon as possible by scientists? 11. To what extent are HIV/AIDS issues mainstreamed in all your departments/activities? 12. Do you have a workplace HIV/AIDS policy in your organization? Please don’t forget the observation checklist THANK YOU VERY MUCH 121 TOOL 23: Key Informant Interview Guide for Selected Sectors other than health 1. The APRM has recently recognized Uganda’s MACA as a best practice and the president for his stewardship role in controlling HIV/AIDS between the 1990s and early 2000s. But the HIV/AIDS situation in the country seems to be taking a reverse trend from the declines recorded in the 1990s. To what extent could governance be a factor in this trend? (probe the role of other components of the HS) 2. What is your comment on the national strategic policy/frameworks (The Constitution, the PEAP, the National Development Plan, NHP) in relation to the fight against HIV/AIDS? Do these frameworks adequately provide a basis for an effective response to the epidemic? 3. How effective have the coordination structures and mechanisms put in place under the auspices of UAC been? To what extent does ACP-MoH link up with the structures for coordination of the multi-sectoral response viz SCE-LMs, SCE-DR, SCE-PHA, SCE-FBO etc? To what extent is coordination through SCEs and decentralization to sectors consistent with the policy of decentralized health/HIV/AIDS services delivery? (Probe for views on the number of districts further or no further increase in view of the speed at which facilitation is being provided to districts) 4. To what extent is your sector involved in the SWAp mechanism put in place by UAC/ACPMoH in the context of HIV/AIDS e.g. TWGs? (Probe HIV/AIDS priority setting at sector level, is there a genuine problem or what is it and what needs to be done) 5. To what extent did your sector participate in formulation of the NAP, HSSP, NSP and HSHASP? Which partners are you aware of as having participated also; and is your sector involved in implementation of the HSHASP? (Probe for partners/stakeholders that must be involved to ensure effective coalition building) 6. Has HIV/AIDS been mainstreamed in your sector? If yes, have you met any challenges in the process? If any, what were or are they? (Probe for action at sector level cascading down to all sector institutions and lower levels) To what extent has ACP-MoH provided technical guidance to your sector in context of mainstreaming HIV and AIDS? 7. Do you have an HIV/AIDS workplace policy or are you implementing any? What role did ACP-MoH play in developing the policy? (Probe for a customized policy or national policy on HIV/AIDS and the World of Work) 8. Do you have an HIV/AIDS strategic plan for your sector? What role did ACP-MoH play in developing this plan? 9. To what extent has ACP-MoH and/or UAC empowered your sector in operationalizing the International principle of “The three ones”? How have you approached it in your sector? 10. Did you think that ACP-MoH has been effective in carrying out its mandate in relation to your sector HIV/AIDS response? What broad changes within the Ministry of Health or the Government of Uganda in general are urgently needed in order for ACP-MoH to fulfill its mandate and function at its maximum capacity? Please don’t forget the observation checklist THANK YOU VERY MUCH 122 TOOL 24: Key Informant Interview Guide for mass media 1. Comment on the current situation of HIV/AIDS in Uganda and the direction it is taking; What do you say about the feeling that the trend is reversing? What could have happened? To what extent could governance have been responsible? (Probe for National governance, HSG, HMIS, HRH, HF, HSD, Laboratories, decentralization etc) 2. What is the role of the media and your establishment in the multi-sectoral HIV/AIDS response and the health sector HIV/AIDS response? What challenges do you face in your day to day work? Probe for possibilities of limitation to freedom of the press. 3. How easy/difficult has it been to get access to important health data? a. When was the last time you or your staff were invited to a meeting designed to disseminate new health information to the public/key stakeholders? b. How easy/difficult is it to get health information from the following: i. Ministry of Health/ACP ii. UAC iii. Donors iv. National level NGOs/CSOs v. UN agencies/WHO vi. District government vii. Academic institutions c. Give me one example of a time when you or your staff had difficulty getting access to important health information. d. Have you been provided with HSSP-II, HSHASP, NSP and NPAP? e. In the last three years, were you ever provided by ACP-MOH any policies or guidelines on HIV/AIDS developed by ACP-MoH/MoH? 4. Comment on the Uganda HIV/AIDS partnership and its structures for delivering the multi-sectoral response? To what extent do you think it is strategically placed for the fight against HIV/AIDS in Uganda. What challenges does it face and how best can they be addressed if any. (Probe extent of harmonization or synergy in coordination of the HIV/AIDS response between UAC and ACP-MoH and what needs to be done to improve on it if the need is there; probe coalition building through the partnership, the extent to which partners are consulted and if it guarantees effective involvement of partners in decision making, oversight/regulation and advocacy for reform or improvement at national, district and community levels). 5. How effective is the SCE-media that was put in place by UAC? How often does it meet? Do the members know their roles and responsibilities? What are its major challenges in context of implementing the HSHASP? How helpful has the ACP-MoH been in enhancing the work of this SCE? (Probe for collaboration on information to the public though mass media and guidance on formulation of messages to the public) 6. What mechanism is in place for effective oversight over and regulation of the service providers in government health units? To what extent is the community and media able to report cases of malpractice and demand for effective remedial measures? Are there any watchdog organizations that you know of in the fight against malpractices? Is there a way the situation can be improved? 123 7. To what extent do you think the ACP-MoH is able to coordinate the activities of the Health sector HIV/AIDS response? What challenges have you observed so far and how can the situation be improved? (Probe for involvement of various stakeholders including the mass media) 8. Comment on the extent to which the media has contributed to the multi-sectoral and the health sector HIV/AIDS response? Any proposals for improvement of the capacity of the media in the fight? Probe legal, institutional, financial, policies, etc 9. Has HIV/AIDS been mainstreamed by all registered mass media entities? (Probe for awareness and presence of copies of the National Policy on Mainstreaming HIV and AIDS in Uganda; if not done then probe for knowledge of importance of it to the MACA) 10. Are you and other mass media implementing any Workplace/HIV/AIDS Policy? (Probe for a customized policy,” The National Policy on HIV/AIDS and the World of Work” or the Public service HIV/AIDS Policy; if not probe for knowledge of its importance) Please don’t forget the observation checklist THANK YOU VERY MUCH 124 TOOL 25: Checklist for key documents, reports, guidelines and minutes of key meetings relevant to the Health sector HIV/AIDS response since HSSP I and NHP I Please check and confirm availability of the following documents, reports, guidelines, MoUs, item eg condom(s) and any other not mentioned but relevant to the Governance block. Yes means you were told a document or item is available and seen means you have seen the document or item physically and ensured recovery where needed. Different items will need to be confirmed at different times as they become relevant Reports, guideline documents, minutes of meetings Availability Yes/Seen No Poverty Eradication Action Plan (PEAP) 2004/5 – 2007/8 National Health Policy (NHP) 1999 National AIDS Policy (NAP) Listing in chronological order of officers who held key offices that matter to HIV/AIDS management in MoH since HSSP I and NHP I to date Hand over report for last ACP-MoH Manager (Dr. Madra Elizabeth) to the current ACP-MoH Manager (Dr. Akol Zainab) MoH Structure/Norms at start of the current HSSP (II) MoH Structure/Norms after Mid-term review of the current HSSP (II), (if any revision was made) Job description of the Head of division of the CDC division MoH Job description of the ACP-MoH Manager (and Job title) Job Schedules for the ACP-MoH Manager (if differing from the Job description) Staff list for ACP-MoH as it appeared in the MoH staff list at start of the current HSSP (II) 2005/06 – 2009/10 Total Staff list for ACP-MoH (including MoH and Seconded staff) as it appeared at start of the current HSSP (II) 2005/06 – 2009/10 Staff list for ACP-MoH as it appeared in the MoH staff list after Midterm review of the current HSSP (II) 2005/06 – 2009/10 (report dated ?2007/08) Total Staff list for ACP-MoH (including MoH and Seconded staff) as it appeared after Mid-term review of the current HSSP (II) 2005/06 – 2009/10 (report dated 2007/08) Job description of the head of planning for ACP-MoH (and the Job title) Job description of the head of Coordination for ACP-MoH (and the Job title) Job description of the head of M and E for ACP-MoH (and the Job title) Job descriptions of all MoH heads of units for ACP-MoH (and their Job titles) Job descriptions of all Seconded heads of units for ACP-MoH (and their Job titles) Job Schedules of all Seconded heads of units for ACP-MoH (if differing from their Job descriptions) Job Schedules for the ACP-MoH, MoH staff (if differing from the Job description) Health Sector Strategic Plan (HSSP) 1 2000/1 – 2004/5 125 End of term review of HSSP I Mid Term Review Report of the Health Sector Strategic Plan 2000/012004/05. April 2003 Health sector Strategic Plan (HSSP) II 2005/06 – 2009/10 Mid-term review of HSSP II 2005/6 – 2009/10 Guidelines for Mainstreaming HIV and AIDS in Planning and Budgeting Processes at National and District Levels MoFPED/UAC 2007 National Policy on Mainstreaming of HIV and AIDS in Uganda 2008 National Priority Action Plan (NPAP) 2007/08 – 2008/09 Long Term Institutional Arrangements (LTIA) for management of HIV/AIDS in Uganda (2005/06 Guidelines for National Referral Hospital Management Boards List(ing) of members of the National Referral Hospital Management Board Minutes of Quarterly meetings of NRH Management Boards (esp 4th qtr) Guidelines for Regional Referral Hospital Management Boards List(ing) of members of the RRH Management Board Quarterly reports from the Department of NDC to HPAC Quarterly reports from the Sector Budget Working Group on budget performance Minutes of Quarterly meetings of RRH Management Boards (esp 4th qtr) Guidelines for District/General Hospital Management Boards List(ing) of members of the D/GH Management Board Minutes of Quarterly meetings of D/GH Management Boards (esp 4th qtr) Guidelines for Health Unit Management Committees (HC 1V, HC III, HC II) List(ing) of members of the HUMC (HC 1V, III, II) Minutes of Quarterly meetings of HUMCs (HCs 1V, III, II) (esp 4th qtr) Guidelines for management of Village Health Teams/Committees List(ing) of members of the VHT/VHC Minutes of Quarterly meetings of VHTs/VHCs (esp 4th qtr) Aide memoire signed by between GF Geneva and Uganda at lifting of Uganda GFATM activity suspension November 2005 Long Term Institutional Arrangements (LTIA) for management and coordination of Global Health Funds National Health Policy* National HIV/AIDS Strategic Plan (NSP) 2007/8 – 2011/12 Health Sector HIV/AIDS Strategic Plan (HSHASP) 2007 – 2010 National Drug Policy/Strategy/Procurement Plan* National Essential Medicines list (Updated in the last 5 years)* National Policy/Strategy/Plan on Tuberculosis and Leprosy* National Policy/Strategy/Plan on Malaria* National Policy/Strategy/Plan on Sexual and Reproductive Health* National Policy/Strategy/Plan on Child health* Reports of Policy/Strategy/Plan dissemination Workshops Minutes of Policy/Strategy/Plan dissemination Workshops Client Charter 2007/08 Health Sector HIV/AIDS Annual/Operational Plan (HSHAOP) 2006/07 126 Quarterly Support supervision visit reports by DHO’s office 2006/07 Quarterly reports by CAO to MoLG, President’s office etc 2006/07 Quarterly Support supervision visit reports by Regional hospital 2006/07 Quarterly Technical Programme support supervision reports of ACPMoH 2006/07 Quarterly reports from the Sector Budget Working Group on budget performance 2006/07 ACP-MoH staff list for FY 2006/07 (Compare with ACP-MoH staffing norms) District health staff list for FY 2006/07 (Compare with district staffing norms) District HIV/AIDS Forum report 2006/07 Quarterly Area Team CQI Reports 2006/07 (4) Report on “Completion of the UNGASS National Composite Policy Index Questionnaire for HIV/AIDS” 2006/07 (also 2007/08/09/10 if possible) Joint Annual HIV/AIDS Review (JAR) 2006/07 National HIV/AIDS Partnership Forum 2006/07 Aide memoire signed at end of Forum 2006/07 Annual Health Sector Performance Report 2006/07 Joint Review Mission 2006/07 National Priority (HIV/AIDS) Action Plan 2007/08 – 2008/09 Health Sector HIV/AIDS Annual/Operational Plan (HSHAOP) 2007/08 Quarterly Support supervision visit reports by DHO’s office 2007/08 Quarterly reports by CAO to MoLG, President’s office etc 2007/08 Quarterly Support supervision visit reports by Regional hospital 2007/08 Quarterly Technical Programme support supervision reports of ACP 2007/08 Quarterly reports from the Sector Budget Working Group on budget performance 2007/08 ACP-MoH staff list for FY 2007/08 (Compare with ACP-MoH staffing norms) District health Staff list for FY 2007/08 ( Compare with district staffing norms) District HIV/AIDS Forum report 2007/08 Quarterly Area Team CQI Reports 2007/08 (4) Report on “Completion of the UNGASS National Composite Policy Index Questionnaire for HIV/AIDS” 2007/08 Joint Annual HIV/AIDS Review (JAR) 2007/08 report National HIV/AIDS Partnership Forum 2007/08 Report Aide Memoire signed at end of Forum 2007/08 Annual Health Sector Performance Report 2007/08 Joint Review Mission 2007/08 report Health Sector HIV/AIDS Annual/Operational Plan (HSHAOP)2008/09 District Health sector Strategic Plan (D-HSSP) II 2005/06 – 2009/10 District HIV/AIDS Strategic Plan (DSP) District Health Sector HIV/AIDS Strategic Plan (D-HSHASP) District HIV/AIDS Annual/Operational Plan (DSP) 200 D-Health Sector HIV/AIDS Annual/Operational Plan (D- 127 HSHAOP)2006/07 Health Sector HIV/AIDS Annual/Operational Plan (HSHAOP) 2008/09 Quarterly Support supervision visit reports by DHO’s office 2008/09 Quarterly reports by CAO to MoLG, President’s office etc 2008/09 Quarterly Support supervision visit reports by Regional hospital 2008/09 Quarterly Technical Programme support supervision reports of ACP 2008/09 Quarterly reports from the Sector Budget Working Group on budget performance 2008/09 ACP-MoH staff list for FY 2008/09 (Compare with ACP-MoH staffing norms) District staff list for FY 2008/09 (compare with District norms) District HIV/AIDS Forum 2008/09 Quarterly Area Team CQI Reports 2008/09 (4) Report on “Completion of the UNGASS National Composite Policy Index Questionnaire for HIV/AIDS” 2008/09 Joint Annual HIV/AIDS Review (JAR) 2008/09 National HIV/AIDS Partnership Forum 2008/09 Report Aide memoire signed at end of Forum 2008/09 Annual Health Sector Performance Report 2008/09 Joint Review Mission 2008/09 Guidelines to Implementation of the SWAp strategy Guidelines for making complaints against doctors Code of Conduct and Ethics; Uganda Medical Practitioners and Dentists’ Council Code of Conduct and Ethics for health workers; Health Services Commission Act Annual Health Sector Performance Reports 2001/02 – 2008/9 HIV/AIDS Monitoring and Evaluation, a guide to the districts, revised January 2007 Annual operational plan ACP District strategic plan Synthesis report-annual assessment of local governments 2008/09 Report of the Prime Minister’s office on “Progress on Implementation of the Paris Declaration on Aid Effectiveness” Minutes of the HIV/AIDS Partnership Committee monthly meetings Minutes of meetings for Line Ministries Self Coordinating Entity (LMSCE) Minutes of the Quarterly Meetings of the UAC Board Minutes of Quarterly Meetings of Self Coordinating Entities (12) Minutes of the Quarterly Meetings of the District AIDS Taskforce Minutes of the Quarterly Meetings of the District AIDS Committee Minutes of Quarterly Meetings for the ACP 2006/07 – 2008/09 Minutes of monthly meetings for the Division of Communicable Disease Control, MoH Minutes of monthly meetings for the Department of National Disease Control, MoH Client charter 2008/009-2010/2011 HIV/AIDS Monitoring and evaluation guide for districts 128 Ministerial policy statement 2007/2008 District HIV/AIDS Strategic Plans covering (2007 – 2010) District Annual/Operational Plans (2007, 2008, 2009) DHO’s Office Staffing norms for each district visited and Job descriptions District Health Staffing norms for districts visited and Job descriptions Staff lists for all Health Units visited Listing of the HUMC/Board members for Regional Hospitals visited Minutes of quarterly Board meetings of Regional hospitals visited (’07– ’09) Listing of the HUMC members for District Hospitals visited Minutes of quarterly HUMC meetings of District hospitals visited (’07 – ’09) Listing of the HUMC members for HC 1V, HC III and HC IIs visited Minutes of quarterly HUMC meetings of HC 1V, HC III, HC Iis visited (’07–’09) Listing of the VHT members for Regional, District, HSD, HS-C Units visited Minutes of quarterly VHT meetings for VHTs around hospitals or HUs visited (’07 – ’09) Minutes of CHD meetings in Regional and District Hospitals with VHTs Health Sector Strategic Plan 2005/06 – 2009/10, Mid-term Review Report; MoH, October 2008 Annual Health Sector performance Report, Financial Year 2006/07; October 2007 Annual Health Sector performance Report, Financial Year 2007/08; October 2008 Annual Health Sector performance Report, Financial Year 2008/09; October 2008 Scaling up HIV/AIDS Strategic Planning at Local Government Level in Uganda; Report of the workshop to launch the HIV/AIDS Strategic Planning process in Non-UACP Districts, 1-3 March 2006; March 2006 NB: Notes on recoveries made should be made in report for each visit accomplished; this checklist is relevant for districts also items picked depending on circumstances agreed 129 TOOL 26: Inventory of tools prepared for national level qualitative data collection indicating maximum number of respondents expected (Transferred to appendix III to the report indicating actual number interviewed) TOOL 27: Key Informant Interview Guide for Human Rights and Health Advocacy Institutions 1. There is a worry now that the trend of HIV/AIDS in Uganda is reversing. What is your comment on this, is the trend reversing stagnating or is it improving? What could be the explanation for the problem if any? (is it Governance at national level, governance within the MoH/Health Sector, HMIS, HRH, HF, Health products and supplies, HSD and laboratory services) 2. Comment on Community-Led HIV/AIDS Initiatives (CHAIs) in Uganda; Can the presence of so many NGOs and CSOs as stakeholders in the multi-sectoral HIV/AIDS response be exploited to support or enhance strategies for sustainability of the fight against the AIDS epidemic?; if so how? 3. To what extent is the National/Health Sector HIV/AIDS response “Human Rights based and Gender Sensitive? Are the rights of vulnerable groups and minorities well observed without discrimination? 4. Do you see “Greater and Meaningful Involvement of People with HIV/AIDS” in matters relating to the National/Health Sector HIV/AIDS response? If not, what can you propose to improve the situation? 5. From the human rights perspective, what is your comment on views of the CSOs and community regarding decentralisation and service availability and affordability, staffing levels, drug supplies, unofficial fees among others? (Probe for comparative or contrasting views between private and public domains) 6. How did you participate in formulation of the HSHASP? (Probe for other, major, stakeholders and partners who were involved). To what extent has ACP/MoH helped all stakeholders and partners to know and perform their roles and responsibilities in the health sector HIV/AIDS response? What guides you/your organization in the health sector HIV/AIDS response to develop your own strategic plans? (Probe for the HSSP, NSP or the HSHASP) 7. To what extent has ACP/MoH helped all stakeholders and partners to know and perform their roles and responsibilities in the health sector HIV/AIDS response? What coordination role does ACP-MoH play in relation to the HIV/AIDS activities of other partners and stakeholders like you in the health sector HIV/AIDS response? How can this role be more effective? (Probe the importance of a critical path/service chain, known outputs and close monitoring with inbuilt sanctions for non compliance) 8. To what extent are formulated policies/strategies/plans on the implementation of the HIV/AIDS response disseminated to all relevant stakeholders? (probe for a policy that guides dissemination or a communication strategy) 9. Are there provisions in the policies/plans for consumers of HIV/AIDS services to forward their grievances for action? What are they? Are the consumers effectively utilising this 130 option if any? (Probe for utilization of the Client Charter, Patients Charter and the document on complaints against doctors etc) 10. Has HIV/AIDS been mainstreamed in your core functions? Have you received appropriate guidance regarding this (mainstreaming) and from who? (Probe for the stewardship role of ACP in this) 11. Do you have a workplace HIV/AIDS policy in your organization/establishment? Please don’t forget the observation checklist THANK YOU VERY MUCH 131 Appendix II 8.2 District Data collection tools 8.2.1 District Data collection tools: Quantitative TOOL 5: Semi-structured questionnaire for District Administration Officials (general) INFORMED CONSENT Good morning/ afternoon Sir/Madam/Dr./Prof………………………………………… Hon. My name is ______________________________ and I am here on behalf of the Ministry of Health. I am here on a study to assess governance, leadership and partnerships in regard to HIV/AIDS programs. I request you to kindly answer questions on the issues mentioned. The information you give us will be treated with a high level of confidentiality. Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. You are free to ask me any question about the study. Now, given the information I have given you sir/madam can I proceed to interview you? Respondent accepts the interview . . . . . . …………….......1 Respondent does not want to be interviewed ... . . . . . . 2 (terminate interview) THANK YOU. 132 ASSESSMENT OF GOVERNANCE, LEADERSHIP AND PARTNERSHIPS I. IDENTIFICATION CODE DISTRICT: _________________________ POSITION ………………………………………………………. LOCATION ______________________ **RESULT CODES 7. COMPLETED 8. PARTLY COMPLETED- GIVE REASON ________________________ 9. OTHER SPECIFY ________________ COMMENTS ________________________________________________________ INTERVIEW STARTED AT:______AM/PM INTERVIEWER CODER DATA ENTRANT NAME ____________ NAME ___________ NAME __________ CODE: _______ CODE: _______ CODE: _______ DATE ____________ DATE ____________ DATE ___________ Notes on filling the Health Governance, Leadership and Partnerships questionnaire 1. Please fill this questionnaire as completely as you can. If any of the questions or response choices are not clear to you, please ask the assessment team member to clarify. 2. Most of the questions are in the yes/no/not sure category. For these questions, please circle the one answer that is most correct in your set up/district. Some questions have multiple answer choices. For these, circle as many of the options as you know to be true. If you are not sure, do not circle that answer. Thank you for your time. We will provide you feedback on your answers once all the district or study information is collected and reviewed, and recommendations for improving the Health Sector HIV/AIDS response. 133 1.0 POLICIES /STRATEGIES/ PLANS No. 1.01 1.02 QUESTION Are you aware of the Health Sector Strategic Plan (HSSP) II 2005/06 – 2009/10? Have you read it? Did you participate in a HSSP dissemination meeting? 1.03 Were you involved in developing the plan? If yes: describe your role: CODING CATEGORIES Yes ………………………….1 No……………………………2 Yes ………………………….1 No……………………………2 ________________________ ______ 1.05 How else are you involved in reviewing ________________________ progress on HSSP objectives/goals ___ 1.06 Are you aware of the Uganda HIV/AIDS Health Sector Strategic Plan (HSHASP)? 1.08 1.09 2.00 2.01 Did you participate in a HSHASP dissemination meeting? Were you involved in developing the plan? Describe your role Have you been involved in any HSHASP review meetings? Yes No If 2 go To 1.06 None of it ………….…..1 Yes, part of it…..……..2 Yes, all of it……….…….3 Have you been involved in any HSSP review meetings? Have you read it: Skip Yes……………….……….1 Y No………………….……..2 e Not sure………………..3 s 1.04 1.07 CODE Yes ………………………….1 No……………………………2 If 2 go To 2.02 Yes ………………………….1 No……………………………2 None of it ……………....1 Yes, part of it……….…..2 Yes, all of it…………..….3 Yes ………………………….1 No……………………………2 Yes ………………………….1 No……………………………2 ________________________ ____ Yes ………………………….1 No……………………………2 134 2.02 How else are you involved in reviewing progress on the HSHASP objectives/goals: 2.03 Are you aware of the National HIV/AIDS Strategic Plan (NSP) 2007/8 – 2011/12? 2.04 2.05 2.06 2.07 Have you read it: Did you participate in a NSP dissemination meeting? Were you involved in developing the plan? Describe your role 2.08 Have you been involved in any NSP review meetings? 2.09 How else are you involved in reviewing progress on the NSP objectives/goals: 3.00 Is there a district HIV/AIDS plan specifically for your district? 3.01 When was the district plan developed? ________________________ ____ Yes…….………….……….1 No………………..………..2 Not sure……….………..3 None of it ……..…..…..1 Yes, part of it…………..2 Yes, all of it……..……….3 Yes ………………………….1 No……………………………2 Yes ………………………….1 No……………………………2 ________________________ ______ Yes ………………………….1 No……………………………2 ________________________ _______ Yes…….……………….1 No…………….………..2 Not sure……………..3 2005 or before ……………1 2006-7 ………………………..2 2008-9 …………………..……3 Not sure ………………………4 3.02 How often is it reviewed and modified as required? Never ………………..……...1 Only when required….. 2 Every 2 years …………..…3 Every year ………………….4 Not sure …………..………..5 3.03 Who was involved in developing it and/or reviewing it periodically? A. Yourself B. District health office staff C.Community representatives D.Hospital representatives E. Persons living with HIV/AIDS (PLHA networks) F. Others: ____________ 3.04 Is the district annual HIV budget and action plan closely linked to this district plan? Yes…………………..….1 No…………….....……..2 Not sure……….……..3 Yes………………..…….1 No……………….……...2 Not sure……………...3 3.05 a. Is there a District AIDS Taskforce (DAT)? If 2 go To 3.00 If 2 go To 3.04 135 b. If yes, Is it active? 3.06 3.07 3.08 3.09 4.00 4.01 4.02 When was the last time it met? Who convenes these meetings? How are the minutes of the meeting and decisions made disseminated to the people of the district? Is there a specific district HIV mainstreaming policy or plan (or a section within the district HIV plan that addresses mainstreaming of HIV activities into broader health sector programs and structures)? Does the district do anything to regulate or oversee the health services of the faithbased clinics/hospitals within the district? Does the district do anything to regulate or oversee the health services of the private clinics/hospitals within the district? Is there a procedure in place within the district for community members to provide feedback on health services? Yes………………..…….1 No……………….……...2 Not sure……………...3 DD…….MM……..YY………….. Don’t know ……………………98 ________________________ ________________________ ________________________ ________________________ Yes…….……………….1 No…………….………..2 Not sure……………..3 Yes…….……………….1 No…………….………..2 Not sure……………..3 Yes…….……………….1 No…………….………..2 Not sure……………..3 Yes…….……………….1 No…………….………..2 Not sure……………..3 4.03 Which of the following feedback procedures are in place in your district? A. DHO open visiting hours for community members B. CAO open visiting hours for community members C. Suggestion/feedback box at the health facilities D. Periodic client exit interviews at health facilities E. Periodic meetings with community leaders/community health teams F. Newspaper or radio reports on community views of health services G. Other: _____________ 4.04 Does the community know about this feedback procedure? Yes, most do………………..1 Yes, some do………………. 2 None/very few know…..3 Not sure…………….……….4 136 4.05 4.06 4.07 4.08 4.09 Is the procedure being utilized? Which of the following were actively done in the past 3 years when the district received positive feedback from one or more community members? Which of the following were actively done in the past 3 years when the district received negative feedback from one or more community members? Are there any procedures in place within the district for officials to monitor health services and provide feedback to health facilities? Which of the following monitoring and feedback procedure are in place in your district: Yes…….…………………..…….1 No………………………………..2 Not sure……………..………..3 A. Individual staff was praised (as part of performance appraisal) or giving an award B. Entire health facility was given an award C. Health budget was increased at that facility D. Additional work or responsibility was given to that person/health facility E. Health facility was visited to better understand why they are doing a good job F. Can’t think of anything that was done A. Individual staff was reprimanded (as part of a performance appraisal) B. Individual staff were removed from service (terminated or transferred) C. The entire health facility was reprimanded D. The health budget of that facility was decreased E. Work or responsibility was taken away from that person/health facility F. Health facility was visited to document the poor performance and better understand how to fix this G. A plan to fix the problem was formally developed and acted upon H. Can’t think of anything that was done Yes…….……………….1 No…………….………..2 Not sure……………..3 A. Periodic supportive supervision visits to health facilities by DHO staff 137 B. Surprise health facility checks/visits by DHO staff C. Meetings to review HMIS data trends with health facility leaders D. External health service assessments by donors/technical experts which actively involve district staff E. Health service assessments or facility visits by Ministry of Health in collaboration with the district health office. F. Other: _____________ 5.00 5.01 5.02 Are the procedures being fully utilized in your district? Yes…….……………….1 No…………….………..2 Not sure……………..3 Which of the following were actively done in the past 3 years when the district received positive feedback from one of the above supervisory monitoring procedures? A. Individual staff was praised (as part of performance appraisal) or giving an award B. Entire health facility was given an award C. Health budget was increased at that facility D. Additional work or responsibility was given to that person/health facility E. Health facility was visited to better understand why they are doing a good job F. Can’t think of anything that was done Which of the following were actively done in the past 3 years when the district received negative feedback from one of the above supervisory monitoring procedures? A. Individual staff was reprimanded (as part of a performance appraisal) B. Individual staff were removed from service (terminated or transferred) C. The entire health facility was reprimanded D. The health budget of that facility was decreased E. Work or responsibility was taken away from that person/health facility F. Health facility was repeatedly visited to 138 document the poor performance and better understand how to fix this G. A plan to fix the problem was formally developed and acted upon H. Can’t think of anything that was done 5.03 5.04 5.05 5.06 5.07 5.08 5.09 Are you aware of any donors or international organizations working in the district? Did the donors or their representatives seek your opinions and understand your priorities before developing their district activities/programs? Do the donors or their representatives routinely make you aware of their district visits? Do the donors or their representatives routinely update you on their HIV/AIDS or health activities? Have the donors or their representatives asked you to help review or monitor their HIV/AIDS/health programs/activities? Have the donors or their representatives actually transferred funds to the district budget? Have the donors influenced your HIV/AIDS or health priorities or helped to create new district HIV/AIDS/health policies? 5.10 Do you have an HIV/AIDS workplace policy for your place of work? 5.10 Are you implementing the public service HIV/AIDS Policy? 5.12 Are you implementing the national policy on HIV/AIDS and the world of work? Yes…….……………….1 No…………….………..2 Not sure……………..3 Yes…….……………….1 No…………….………..2 Not sure……………..3 Yes…….……………….1 No…………….………..2 Not sure……………..3 Yes…….……………….1 No…………….………..2 Not sure……………..3 Yes…….……………….1 No…………….………..2 Not sure……………..3 Yes…….……………….1 No…………….………..2 Not sure……………..3 Yes…….……………….1 No…………….………..2 Not sure……………..3 Yes………………….….1 No………………………2 Don’t know………..3 Yes……………….…….1 No…………….………..2 Don’t know…….…..3 Yes…………………..….1 No……………………….2 Don’t know………...3 INTERVIEW ENDED AT……………..AM/PM THANK YOU 139 TOOL 6: Semi-structured questionnaire for Health Facility Officials INFORMED CONSENT Good morning/ afternoon Sir/Madam/Dr./Prof………………………………………… My name is ______________________________ and I am here on behalf of the Ministry of Health. We are on a study to assess governance, leadership and partnerships in regard to HIV/AIDS programs. We request you to kindly answer questions on the issues mentioned. The information you give us will be treated with a high level of confidentiality. Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. You are free to ask me any question about the study. Now, given the information I have given you sir/madam can I proceed to interview you? Respondent accepts the interview . . . . . . ………………......1 Respondent does not want to be interviewed ... . . . . . . 2 (terminate interview) THANK YOU. 140 ASSESSMENT OF GOVERNANCE, LEADERSHIP AND PARTNERSHIPS I. IDENTIFICATION CODE DISTRICT: _________________________ NAME OF HEALTH FACILITY _____________________ TYPE OF FACILITY Hospital ………………………………………………….1 HC IV……………………………………………..………..2 HIV/AIDS Care centre (e.g TASO)………….….3 HC III ……….………..……………………………..……..4 OWNERSHIP OF THE FACILITY Public …………………………………….………………….1 Private not for profit (PNFP)/NGO …………....2 Private For Profit …………………………….…………3 IF PUBLIC, UNDER WHAT ADMINISTRATION MOH…………………………………………………………..1 UPDF…………………………………..……………………..2 Uganda Prisons Service (UPS)……………………..3 Uganda Police Force (UPF)………………….………4 IF PRIVATE, NAME THE ORGANIZATION/COMPANY FBO/COU…………………….……..……………………..1 FBO/Catholic……………………………………………..2 FBO/Muslim……………………….……………………..3 FBO/Orthodox……………………………………………4 FBO/SDA…………………….………….…………………..5 IDI ……………………………………………..……..………6 JCRC ………………………………………….…..……….…7 Mildmay ……………………………….……….…….……8 TASO ………………………………….……………..………9 AIC ………………………………………………….…………10 URC …………………………………………………..……….11 AMICAALL …………………………………..…….……….12 Other specify _______________________ DESIGNATION OF THE RESPONDENT Medical Superintendent ……………………………...1 Director of health Services …………………………..2 Medical officer 1/c …….…………………….…………..3 In-Charge HC IV………………………………….. ………..4 In-Charge HC III………………………………….. ………..5 Director…………………………………………….…………..6 Chair Hospital Board ……………….…………………….7 Chair HUMC ………………………………………………….8 Program manager …………………………..……………..9 Others Specify ….……………………………...………...10 QUALIFICATION Doctor ……………………………..……….1 Clinical officer ……………….………….2 Nurse/Midwife …………………………3 141 **RESULT CODES 10. COMPLETED 11. PARTLY COMPLETED- GIVE REASON ________________________ 12. OTHER SPECIFY ________________ COMMENTS ________________________________________________________ INTERVIEW STARTED AT:______AM/PM INTERVIEWER CODER DATA ENTRANT NAME ____________ NAME ___________ NAME __________ CODE: _______ CODE: _______ CODE: _______ DATE ____________ DATE ____________ DATE ___________ Notes on filling the Health Governance, Leadership and Partnerships survey questionnaire 3. Please fill this questionnaire as completely as you can. If any of the questions or choices are not clear to you, please ask the assessment team member to clarify. 4. Most of the questions are in the yes/no/not sure category. For these questions, please circle the one answer that is most correct in your set up/district/Facility. Some questions have multiple answer choices. For these, circle as many of the options as you know to be true. If you are not sure, do not circle that answer. Thank you for your time. We will provide you feedback on your answers once all the district or study information is collected and reviewed, and recommendations for improving the health sector HIV/AIDS response are made. QUESTION No. 1.01 1.02 1.03 Are you aware of the Health Sector Strategic Plan (HSSP) II 2005/06 2009/10? Have you read it? 1.05 Did you participate in a HSSP dissemination meeting? Were you involved in developing the plan? If yes: describe your role: 1.06 Have you been involved in any HSSP 1.04 RESPONSE CODE YES ………………………….…….1 NO ………………………………..2 SKIP IF 2 GOTO 1.06 YES …………………………………………1 YES, PART OF IT ………………………2 NO ……………………………………….….3 YES …………………………………….……1 NO……………………………………………2 YES ………………………………….………1 NO……………………………………………2 ________________________ YES ………………………………….…………1 142 review meetings? How else are you involved in reviewing progress on the HSSP objectives/goals: NO……………………………..………………2 1.08 Are you aware of the Uganda Health sector HIV/AIDS Strategic Plan (HSHASP) 2007 -2010? YES ………………………………………………1 NO…………………………………….…………2 NOT SURE …………………………….……..3 1.09 If yes have you read it? 1.10 Did you participate in a HSHASP dissemination meeting? Were you involved in developing the plan? If yes: describe your role YES ………………………………..…………….1 YES, PART OF IT……………………….……2 NO ………………………………………….……3 YES ……………………………………….………1 NO…………………………………………………2 YES ……………………………………….………1 NO…………………………………………………2 1.07 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 Have you been involved in any HSHASP review meetings? How else are you involved in reviewing progress on HSHASP objectives/goals? YES ……………………………………….………1 NO…………………………………………………2 Are you aware of the National HIV/AIDS Strategic Plan (NSP) (2007/8 – 2011/12)? If Yes, have you read it: YES ……………………………………….………1 NO…………………………………………………2 Did you participate in a NSP dissemination meeting? Were you involved in developing the plan? If yes: describe your role: Have you been involved in any NSP review meetings? How else are you involved in reviewing progress on NSP objectives/goals: _________________________ Is there a district HIV plan specifically for your district? If yes, when was the district plan developed? IF NOT 1 GOTO 1.13 IF 2 GOTO 1.22 YES ……………………………………………….1 YES, PART OF IT………………………….…2 NO ………………………………………….……3 YES ……………………………………….………1 NO…………………………………………………2 YES ……………………………………….………1 NO…………………………………………………2 YES ……………………………………….………1 NO…………………………………………………2 YES ………………………………………..………1 NO……………………………………….…………2 NOT SURE ………………………………….…..3 2005 or before ……………………………….1 2006-7 ………………………………………..….2 2008-9 ……………………………………..…….3 Not sure …………………………………..……..7 IF 2 GOTO 1.18 143 1.24 How often is it reviewed and modified as required? 1.25 Who was involved in developing it and/or reviewing it periodically? 1.26 Is the district annual HIV budget and action plan closely linked to this district plan? Is the district AIDS taskforce (DAT) active? 1.27 1.28 1.29 If yes, when was the last time it met? : Who convenes these meetings? 1.30 How are the minutes of the meeting and decisions made disseminated to the people of the district? 1.31 Is there a specific district HIV mainstreaming policy or plan (or a section within the district HIV plan that addresses mainstreaming of HIV activities into broader health sector programs and structures)? Does the Uganda government do anything to regulate or oversee the health services of the faith-based clinics/hospitals within the district? Does the Uganda government do anything to regulate or oversee the health services of the private clinics/hospitals within the district? Is there a procedure in place within the district for community members to provide feedback on health services? If Yes which of the following feedback procedures are in place in your district: 1.32 1.33 1.34 1.35 Never ……………………………………….…….1 Only when required …………………….…2 Every 2 years ……………………….………...3 Every year ………………………………..…….4 Not sure ………………………………….………7 Yourself ……………,,,,,,,,,,,,,,,,,,,,,,,,………1 District health office staff………………..2 community representatives…………….3 hospital representatives……………..…..4 Persons living with HIV/AIDS (PLHA networks)…………………………………………5 Others: __________________ YES ……………………………………………..……1 NO………………………………………….…………2 NOT SURE …………………………….…………..3 YES ……………………………………………………1 NO………………………………………..……………2 NOT SURE ……………………………..…………..3 DD ………….MM…………………….YY ……….. YES ……………………………………….………1 NO…………………………………………………2 NOT SURE …………………………………….3 YES ……………………………………….………1 NO…………………………………………………2 NOT SURE …………………………………….3 YES ……………………………………….………1 NO…………………………………………………2 NOT SURE …………………………………….3 YES ……………………………………….………1 NO…………………………………………………2 NOT SURE …………………………………….3 A. DHO open visiting hours for community members B. CAO open visiting hours for community members C. Suggestion/feedback box at the health facilities 144 1.36 Does the community know about this feedback procedure? 1.37 Is the procedure being utilized? 1.38 Which of the following were actively done in the past 3 years when the district received positive feedback from one or more community members? 1.39 Which of the following were actively done in the past 3 years when the district received negative feedback from one or more community members? 1.40 Are there procedures in place within the district for officials to monitor HIV/AIDS/health services and provide feedback to health facilities? If YES, Which of the following monitoring and feedback procedure are in place in your district: 1.41 D. Periodic client exit interviews at health facilities E. Periodic meetings with community leaders/community health teams F. Newspaper or radio reports on community views of health services G. Other __________________ YES Most do …………………………..…….1 Yes, Some do .……………………………...2 None/very few Know …………………..3 Not sure ……………………………………...7 YES ……………………………………….………1 NO…………………………………………………2 NOT SURE …………………………………….3 A. Individual staff was praised (as part of performance appraisal) or giving an award B. Entire health facility was given an award C. Health budget was increased at that facility D. Additional work or responsibility was given to that person/health facility E. Health facility was visited to better understand why they are doing a good job F. Can’t think of anything that was done A. Individual staff was reprimanded (as part of a performance appraisal) B. Individual staff were removed from service (terminated or transferred) C. The entire health facility was reprimanded D. The health budget of that facility was decreased E. Work or responsibility was taken away from that person/health facility F. Health facility was visited to document the poor performance and better understand how to fix this G. A plan to fix the problem was formally developed and acted upon H. Can’t think of anything that was done YES ……………………………………….………1 NO…………………………………………………2 NOT SURE …………………………………….3 A. Periodic supportive supervision visits to health facilities by DHO staff B. Surprise health facility checks/visits by DHO staff C. Meetings to review HMIS data trends with health facility leaders D. External health service assessments by 145 1.42 When was the last time district staff made a supervisory visit to your facility? 1.43 What topics did they address? 1.44 When was the last time a national level Ministry of Health staff made a supervisory or technical assistance visit to your facility? 1.45 What topics did they address? 1.46 When was the last time a technical expert from a donor or national organization visited your health facility? 1.47 What topics did they address? donors/technical experts which actively involve district staff E. Health service assessments or facility visits by Ministry of Health in collaboration with the district health office. F. Other _____________________ Within last 3 months ……….1 3-6 months ago ……..……..2 6-12 months ago……..………..3 >1 year ago ……………………....4 Never ………………………………..5 A. HIV care B. HIV prevention/testing C. Malaria D. Family Planning E. TB F. Maternal Health G. Child health H. Laboratory I. general management J. Finance Within last 3 months …………..….1 3-6 months ago …………………..2 6-12 months ago…………….………..3 >1 year ago ……………………………..4 Never ……………………………….……..5 A. HIV care B. HIV prevention/testing C. Malaria D. Family Planning E. TB F. Maternal Health G. Child health H. Laboratory I. general management J. Finance Within last 3 months ……….1 3-6 months ago …………..2 6-12 months ago……………..3 >1 year ago …………………..4 Never ………………………..5 A. HIV care B. HIV prevention/testing C. Malaria D. Family Planning E. TB F. Maternal Health G. Child health H. Lab I. general management J. Finance 146 1.48 Which of the following were actively done in the past 3 years when the district received positive feedback from one of the above supervisory monitoring procedures? 1.49 Which of the following were actively done in the past 3 years when the district received negative feedback from one of the above supervisory monitoring procedures? 1.50 Are you aware of any donors or international organizations working in the district? If yes, did the donors or their representatives seek your opinions and understand your priorities before developing their district activities/programs? Do the donors or their representatives routinely make you aware of their district visits? Do the donors or their representatives routinely update you on their health activities? Have the donors or their representatives asked you to help review or monitor their health programs/activities? Have the donors or their representatives actually transferred funds to the district budget? If Yes so, which donors and projects: 1.51 1.52 1.53 1.54 1.55 1.56 1.57 Have the donors influenced your health priorities or helped to create A. Individual staff was praised (as part of performance appraisal) or giving an award B. Entire health facility was given an award C. Health budget was increased at that facility D. Additional work or responsibility was given to that person/health facility E. Health facility was visited to better understand why they are doing a good job F. Can’t think of anything that was done A. Individual staff was reprimanded (as part of a performance appraisal) B. Individual staff were removed from service (terminated or transferred) C. The entire health facility was reprimanded D. The health budget of that facility was decreased E. Work or responsibility was taken away from that person/health facility F. Health facility was repeatedly visited to document the poor performance and better understand how to fix this G. A plan to fix the problem was formally developed and acted upon H. Can’t think of anything that was done YES ……………………………………….1 NO………………………………..………2 NOT SURE …………………………….3 YES ……………………………………….1 NO………………………………..………2 NOT SURE …………………………….3 YES ……………………………………….1 NO………………………………..………2 NOT SURE …………………………….3 YES ……………………………………….1 NO………………………………..………2 NOT SURE …………………………….3 YES ……………………………………….1 NO………………………………..………2 NOT SURE …………………………….3 YES ……………………………………….1 NO………………………………..………2 NOT SURE …………………………….3 YES ……………………………………….1 NO………………………………..………2 147 1.58 new district HIV/AIDS/health policies? Do you have a workplace Policy for this facility? 1.59 Are you implementing the Public Service HIV/AIDS Policy? 1.60 Are you implementing the National Policy on HIV/AIDS and the world of Work? Has HIV/AIDS been mainstreamed into your planning and budgeting? 1.61 NOT SURE …………………………….3 YES ……………………………………….1 NO………………………………..………2 NOT SURE …………………………….3 YES ……………………………………….1 NO………………………………..………2 NOT SURE …………………………….3 YES ……………………………………….1 NO………………………………..………2 NOT SURE …………………………….3 YES ……………………………………….1 NO………………………………..………2 NOT SURE …………………………….3 INTERVIEW ENDED AT……………..AM/PM THANK YOU 148 8.2.2 District Data collection tools: Qualitative TOOL 1: Key Informant Interview Guide for District Administration Officials 1. Comment on the trend the HIV/AIDS epidemic is taking in Uganda to day and the factors that might have contributed to it? To what extent could governance be a factor in this trend? 2. What is your comment on the process through which policies, strategies/plans that guide the implementation of the health sector HIV/AIDS response go? Are there any loop holes in this process? What are they? 3. To what extent are stakeholders and partners involved in national decision making and oversight in activities of the HIV/AIDS response? Is their participation effective? 4. How has decentralization helped in the implementation of the health sector HIV/AIDS response? How effective do you think the practice has been in the response? 5. What do you comment on the role of ACP in the coordination of implementation of the HSHASP within MoH? (probe for mechanisms for coordination and any challenges in coordination by ACP) 6. Does the ACP-MoH come to your district for technical support supervision of other partners/stakeholders? 7. What do you comment on the current financing and disbursement mechanisms (probe for transparency, alignment to budget, quantity, handling of funding outside budget support etc). 8. To what extent is the ACP/MoH placed to keep track of and account for resources injected into the country for health sector HIV/AIDS response work? 9. To what extent has HIV/AIDS been mainstreamed in all the activities in your district? 10. Are there measures for consumers of HIV/AIDS services to forward their grievances for action? What are they? Are the consumers effectively utilising this option? 11. What factors limit/constrain you in implementation of the health sector HIV/AIDS response? How can these challenges be addressed? 12. What is your comment on the current placement/position of ACP within the MoH organizational structure? How does this placement/position influence the activities of ACP as far as the Health sector HIV/AIDS response is concerned? 13. Comment on upgrading ACP to enhance performance: to Division, Department or Directorate; if not these propose an alternative 14. How are research priorities on HIV/AIDS identified in your district? What role is played by ACP in identifying HIV/AIDS research priorities in your district? Is there coordination and involvement of stakeholders in this? 149 15. What challenges are there in determining HIV/AIDS related research priorities? How can these be addressed? 16. Is there a District HIV/AIDS Workplace Policy for your District? If yes probe for implementation, If not comment on the importance of having one. 17. Has HIV/AIDS been mainstreamed into district Planning and Budgeting? Do not forget the observation check list! THANK YOU VERY MUCH 150 TOOL 2: Focus Group Discussion guide for communities on accountability and planning 1. What can you say about the situation of HIV/AIDS in your area and the country? How do you get information about HIV/AIDS service delivery in your district/HSD/Sub-county or community? (Probe the types, sources, frequency, timeliness, adequacy of information regarding services in public and private health units) 2. What role do you play in planning and implementation of HIV/AIDS services at your nearest government health unit? Have you and/or other members of the community ever participated in decision-making regarding service delivery by this health facility? (Probe how participation was done. If no participation, probe why there is no participation. What factors influence participation or lack of it?) 3. Regarding the nearest government health unit, what mechanism is in place for (a) the medical staff in-charge (b) Health Unit Management Committee, (c) VHT to educate you on their roles and responsibilities regarding health/HIV/AIDS service delivery? (Probe the extent to which these office bearers have used these mechanisms to account to the communities. How was in-action and poor performance by the office bearers handled?) 4. What mechanism is in place for reporting cases of absenteeism, corruption, illegal payments, sub-standard performance, and mismanagement by service providers in government health units, including VHTs? (Probe the extent to which the community has used this mechanism and how effective it has been. What needs to be done to improve?) 5. What mechanism is in place for reporting cases of exorbitant payments, substandard performance, and misuse of drugs by service providers in non-government health units including clinics and drug shops? (Probe the extent to which the community has used this mechanism and how effective it has been. What needs to be done to improve?) 6. How does service delivery by government in HIV/AIDS and health in general compare with that government provides in (a) education and (b) agriculture? Why are they better or worse? What needs to be done to improve on services delivery in HIV/AIDS and health in general from the perspective of planning, management, accountability? 7. Is the health facility that serves you implementing an HIV/AIDS Policy? If yes probe which policy (Health facility, district, public service or national; also find out how the respondent benefits) if not, let respondent comment on the importance of a policy) for the facility. 8. Does the facility include HIV and AIDS in their planning and budgeting processes/activities? PLEASE THANK THE RESPONDENTS 151 TOOL 3: Key Informant Interview Guide for Umbrella Organisations National NGOs and CSOs 1. Comment on the Uganda HIV/AIDS partnership and its structures in relation to the Multi-sectoral response to the HIV/AIDS epidemic in Uganda. 2. Comment on the trend the HIV/AIDS epidemic is taking in Uganda to day. What factors could account for this trend? To what extent could governance be a factor in this trend? 3. Do you believe existing frameworks adequately provide a basis for an effective response to the HIV/AIDS epidemic? Comment. 4. What is your comment on national coalition building to ensure that all stakeholders and partners are consulted and subsequently participate in national policy and planning decision making in all matters related to the HIV/AIDS response in the country? 5. What guides you/your organization in the health sector HIV/AIDS response to develop your own strategic plans? (Probe for NSP, HSSP II, HSHASP, NPAP) 6. How did you join the HIV/AIDS partnership? (Probe for SWAp and decentralisation mechanisms in relation to the multi-sectoral HIV/AIDS response) 7. To what extent is coordination through SCEs and decentralization to sectors consistent with the policy of decentralized health/HIV/AIDS services delivery? 8. How has decentralization helped in the implementation of the health sector HIV/AIDS response? How effective do you think the practice has actually been in the response? 9. Comment on the principle of “the three ones” in implementing the multi-sector HIV/AIDS response. Is it being effectively applied in your organization/facility? Any proposal(s) for improvement? 10. What are your views on the current donor vis-vis national policy on funding disbursement mechanisms (probe for transparency, views on or prospects alignment to approved mechanisms). and for 11. To what extent is your organisation able to keep track of and account for resources injected into it for health sector HIV/AIDS response work? 12. To what extent do other stakeholders like community members have a chance to participate in your planning, implementation, M&E for the HIV/AIDS response? 13. What mechanisms are in place to address corruption in the area of procurement of pharmaceuticals in your organisation? (Probe for the practice of procurement procedures and instances of punitive action so far taken). 14. Comment on mechanisms of accountability for all HIV/AIDS/health services provided by your organisation vis-avis those of PHPS, public sector and other PNFPs? 152 15. How does accountability of HIV/AIDS services compare with other health services? 16. How were you involved in the formulation of HSHASP? (Probe for other stakeholders and partners who were involved). 17. Who is involved in the implementation of the HSHASP? To what extent has ACP helped you and other stakeholders and partners to play their roles and responsibilities? 18. Has HIV/AIDS been mainstreamed in all your activities? 19. To what extent are formulated policies/strategies/plans on implementation of the HIV/AIDS response disseminated to all relevant stakeholders and partners? 20. Is there a policy/Strategy on communicating policies/Plans that are formulated for the HIV/AIDS response or other matters? 21. Are there provisions in the policy/strategies/plans for consumers of HIV/AIDS services to forward their grievances for action? What are they? Are the consumers effectively utilising this option? 22. What challenges in terms of policy design and linkages limits/constrains you in the implementation of the health sector HIV/AIDS response and how can these challenges be addressed? 23. What coordination role does ACP-MoH play in relation to the HIV/AIDS activities of other partners and stakeholders in the health sector HIV/AIDS response? How can this role be made more effective? 24. How does ACP coordinate with your organization/facility in the health sector HIV/AIDS response? Has the coordination been effective? 25. Comment on effectiveness of ACP in coordinating the health sector HIV/AIDS response in general. 26. How often do you get technical support supervision visits form ACP-MoH? 27. What is your comment on the current placement/position of ACP-MoH within the MoH organizational structure? How does this placement/position influence the activities of ACP-MoH as far as the Health sector HIV/AIDS response is concerned? 28. Does the current organizational structure of Ministry of health support effective implementation, coordination and monitoring of the health sector HIV/AIDS response? (probe for reporting mechanisms and functions). 29. What challenges/constraints/limitations in terms of organizational structure affect/constrain ACP-MoH in fulfilling its mandate in the HIV/AIDS response and how can they be addressed? 30. Are the TORs for your HIV/AIDS workers clear to them? What about those of ACPMoH? 153 31. Do your staff appraisals include assessment for HIV/AIDS work? 32. What is your comment on upgrading the ACP-MoH to Division, department or directorate level to improve on delivery of the ACP-MoH mandate? 33. How are your research priorities on HIV/AIDS identified? What role is played by ACP in the process? 34. Other than ACP-MoH is there another channel that you use to get approval of your research projects? If yes how? 35. What role has ACP-MoH played in coordination of research activities on HIV/AIDS? 36. To what extent has the ACP-MoH been involved in the development and approval of proposals for HIV/AIDS funding eg Global fund? 37. What are the mechanisms for approval of new HIV/AIDS/health projects? What role does ACP-MoH play in this? (probe for projects whose funding is not provided for in the MTEF or sector budget ceilings). THANK YOU VERY MUCH 154 TOOL 4: Key informant interview guide for major mass media/news paper officials 1. Comment on the current situation of HIV/AIDS in Uganda and the district and the direction it is taking. What do you say about the feeling that the trend is reversing? 2. What is the role of the media and your establishment in the multi-sectoral response and the health sector HIV/AIDS response? What challenges do you face in your day to day work? (Probe for possibility of limitation to freedom of the press) 3. Comment on the Uganda HIV/AIDS partnership and its structures for delivering the multi-sectoral response? To what extent do you think is strategically placed for the fight against HIV/AIDS in Uganda? What challenges does it face and how best can they be addressed if any. 4. What mechanism is in place for effective oversight over and regulation of the service providers in government health units? To what extent is the community and media able to report cases of malpractice and demand for effective remedial measures? Are there any watchdog organizations that you know of in the fight against malpractices? Is there a way the situation can be improved? 5. To what extent do you think the ACP-MoH is able to coordinate the activities of the Health sector HIV/AIDS response? What challenges have you observed so far and how can the situation be improved? 6. Comment on the extent to which the media has contributed to the health sector HIV/AIDS response? Any proposals for improvement of your capacity in the fight? 7. Do you have an HIV/AIDS Workplace Policy where you work? If not please discuss the importance of having an HIV/AIDS Workplace Policy. 8. Does your employer include HIV/AIDS in planning and budgeting processes/activities? (If not probe for views about the importance of mainstreaming HIV/AIDS issues into core functions of institutions) THANK YOU VERY MUCH 155 Appendix III Table 15.0 what Ugandans demand candidates for 2011 elections to address 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Table 13.0: What all Ugandans demand the 2011 Elections to address Issue % Health 97.4% Road network & transport means availability 96.6% Education 96.5% Child related issues 95.1% Employment 94.4% Personal security 93.6% Agriculture and food security 92.9% Poverty alleviation 92.6% Business 92.2% Water and sanitation 91.1% Environment 90.6% Small business activities 90.2% Land 90.1% Media (Newspapers, Radio, TV) 89% Domestic violence 86.6% Sports 84.2% Energy/ Fuel use 82.2% Traditional leaders 67.1% National security 62.2% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 `15 16 17 18 19 Major issues that Ugandans in Western region want addressed at 2011 Health 100% Education 98.9% Road network & transport means availability 98.5% Employment 97.7% Business 97.7% Media (Newspapers, Radio, TV) 97.3% Small business activities 96.9% Child related issues 95.8% Poverty alleviation 95.8% Personal security 95.0% Agriculture and food security* 93.9% Water and sanitation* 92.7% Land 92.4% Environment 91.9% Sports 90.1% Domestic violence 86.4% Energy/ Fuel use 75.9% National security 58.0% Traditional leaders 51.9% 156 1 2 3 4 5 6 7 8 9 10 11 12 13 14 `15 16 17 18 19 Major issues that Ugandans in Northern region want addressed at 2011 Health 97.6% Road network & transport means availability 97.1% Agriculture and food security 96.7% Education 96.6% Child related issues 96.2% Environment 94.8% Land 93.1% Employment 92.7% Business 92.3% Personal security 90.7% Poverty alleviation 90.4% Small business activities 89.4% Sports 88.8% Water and sanitation* 87.9% Media (Newspapers, Radio, TV) 86.8% Energy/ Fuel use 85.9% Domestic violence 84.9% National security 69.4% Traditional leaders 62.0% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 `15 16 17 18 19 Major issues that Ugandans in Central region want addressed at 2011 Employment 96.4% Health 95.4% Personal security 95.3% Child related issues 95.0% Education 94.8% Road network & transport means availability 94.8% Energy/ Fuel use 92.5% Water and sanitation 92.3% Business 92.2% Poverty alleviation 91.3% Agriculture and food security* 87.8% Domestic violence 87.5% Environment 87.4% Small business activities 86.0% Media (Newspapers, Radio, TV) 85.3% Land 84.9% Traditional leaders 80.5% Sports 76.4% National security 66.2% 157 Major issues that Ugandans in Eastern region want addressed at 2011 1 Health 97.1% 2 Road network & transport means availability 96.7% 3 Education 96.2% 4 Agriculture and food security 95.7% 5 Child related issues 93.4% 6 Poverty alleviation 92.5% 7 Land 92.3% 8 Personal security 91.9% 9 Water and sanitation 90.6% 10 Environment 89.5% 11 Employment 89.1% 12 Small business activities 88.9% 13 Domestic violence 87.3% 14 Media (Newspapers, Radio, TV) 86.3% `15 Business 85.5% 16 Sports 83.9% 17 Energy/ Fuel use 71.1% 18 Traditional leaders 71.1% 19 National security 54.5% th Source for table 13: New Vision 16 August 2010 158 Meetings held (%) No. of people Details of qualitative tools as applied at national level and participation Type of interaction Table 16.0 7). Director NAFOPHANU, Director NACWOLA, National Coordinator NGEN+ and selected formal groups/groups of individual PHAs. FGD 1(3.0) 1 8). Registrars of Medical Practitioners and Dentists Council, Uganda Nurses and Mid wives Council, Allied Health professionals council, Law society council, etc 9). President of UMA, UNANM, Pharmaceutical society of Uganda, Counselor’s Association, Private midwives association, Allied professional association, Association of surgeons of Uganda, Association of physicians of Uganda, Law society of Uganda, Professional centre of Uganda etc. KII 1(3.0) 1 KII 1(3.0) 1 10). Chair parliamentary committee of social services, Chair parliamentary committee on HIV/AIDs (including the last chair), Clerk to National assembly, Chairs sect oral committees, the Head of opposition in parliament, head of the ruling party in parliament. 13). Head of civil service/Secretary to cabinet, Deputy Head of civil service/Head civil service reform, PS Public service, Chair Health service commission. 14). Senior MoH including ACP-MoH, National Hospitals and a few selected others. 15). Coordinator AMICAALL, Director URC, Director TASO, Director AIC, Director World Vision Uganda, Director UNASO, Director UHMG, etc. 16). WHO, UNAIDS, UNICEF, WFP, and UNFPA. KII 4(12.0) 4 KII 3(9.0) 4 KII 2(6.0) 2 KII 2(6.0) 2 FGD 2(6.5) 5 17). Country Director World Bank, Coordinator PEPFAR, Coordinator GFATM, Coordinator GAVI, Country Director DFID, Coordinator USAID, Irish AID, IHP+ Country/Desk Officer. 18). PS- Health, DGHS, DG-UAC, Director NPA CHS /Director Planning MoH, Accounting officer accountability sector, MoH-PHC. FGD 3(9.0) 4 KII 3(9.0) 3 Nil 0 3(9.0) 8 Nil 0 KII 1(3.0) 1 KII 3(9.0) 3 Tool number and intended target group 19). NDA, UBTS, UVRI, NMS, managers of the programmes in MoH (MCH, NTLP, S and RH, UNEPI) etc. FGD 20). Chairs for SCEs, selected umbrella/National NGO reps, PHA groups, SWAp -TWG chairs in sectors and uniformed services (UPDF, UPF, UPS, etc.) 21). JCRC, IDI, Mild-May International, etc. 22). Director MISR, The Dean MU School of Health services, Director MJAP Dean MUSPH, Director UNHRO, etc. 23). Public sector, Public Administration, JLOS, Social Development, Security, Legislature and Local Government, ACP managers in line 159 ministries. 24). Major News papers (New vision and Monitor etc.), UTV programmes, UBC, President Straight Talk Foundation, head of most widely read News paper in district and or District information officer. KII 1(3.0) 1 25) Selected informants/institutions/sectors (R.O/Consultant to decide) at the beginning or during the process of data collection according to circumstances) Observat ion(s) - - 27). The chairperson UHRC, ED UNHCO, ED AGHA, ED FHRI (U). FGD 3(9.0) 7 33 46 Total Figure 2: Conceptual framework for interaction between Partner Health Initiatives and country health systems Governance Partner Health Initiative s Country Health Systems Financing Health workforce Health service delivery Health outcomes Health information systems Supply management systems Figure 2: Conceptual framework for interaction between Partner Health Initiatives and country health systems 160 Figure 4: Village Health Team Strategy, Institutional Framework/Linkages Political LCV LC IV LC III LC II Administrative DHC HSD Committee SCHC P.D.C, NGOs, CBOs LC I Technical DHT HC IV(HSD) HC III HC II VHT/HC I HOUSEHOLD 161
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