UGANDA HEALTH SYSTEM ASSESSMENT 2011 Health Systems 20/20 is USAID‟s flagship project for strengthening health systems worldwide. By supporting countries to improve their health financing, governance, operations, and institutional capacities, Health Systems 20/20 helps eliminate barriers to the delivery and use of priority health care, such as HIV/AIDS services, tuberculosis treatment, reproductive health services, and maternal and child health care. April 2012 For additional copies of this report, please email info@healthsystems2020.org or visit our website at www.healthsystems2020.org Cooperative Agreement No.: GHS-A-00-06-00010-00 Submitted to: Scott Stewart, AOTR Health Systems Division Office of Health, Infectious Disease and Nutrition Bureau for Global Health United States Agency for International Development Recommended Citation: Ministry of Health, Health Systems 20/20, and Makerere University School of Public Health. April 2012. Uganda Health System Assessment 2011. Kampala, Uganda and Bethesda, MD: Health Systems 20/20 project, Abt Associates Inc. Abt Associates Inc. I 4550 Montgomery Avenue I Suite 800 North I Bethesda, Maryland 20814 I P: 301.347.5000 I F: 301.913.9061 I www.healthsystems2020.org I www.abtassociates.com In collaboration with: I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane University School of Public Health and Tropical Medicine UGANDA HEALTH SYSTEM ASSESSMENT 2011 better systems, better health Ministry of Health Kampala, Uganda Makerere University School of Public Health Kampala, Uganda April 2012 This publication was produced for review by the Ministry of Health, Uganda and the United States Agency for International Development. It was prepared by the Ministry of Health, Health Systems 20/20, and Makerere University School of Public Health. DISCLAIMER The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development (USAID) or the United States Government. FOREWORD There is global consensus, among both developing and developed nations, that strong health systems are essential to the effective delivery of health services and improved health outcomes. Understanding the current status of the health system of Uganda is therefore critical, in order for the Ministry of Health, other government agencies, development partners, the private sector, NGOs, and others to be able to develop, implement, and monitor health system strengthening programs and deliver health services to the people of Uganda, as well as to achieve the government‟s priority objectives as specified in the Uganda Health Sector Strategic and Investment Plan (HSSIP) 2010/11–2014/15. This Health System Assessment is a snapshot of the health system of Uganda in 2011. It is based on a methodology that has been applied in more than 25 countries, and was adapted to the Ugandan situation. The approach focuses on the six building blocks of the health system, as defined by the World Health Organization: Governance; Health Financing; Human Resources for Health; Service Delivery; Medical Products, Vaccines, and Technologies; and Health Information Systems. There are interrelationships among these six building blocks of the health system, which the assessment addresses. The assessment identifies the strengths in the health system of Uganda and also the challenges that the Ministry of Health, with development partners, the private sector, and civil society, will need to address. System strengths include the participatory nature of health sector governance, the use of evidence generated locally and internationally to inform policy-making, improved collaboration between government and development partners, and the increase in the number of potential service delivery points across the country. Some of the challenges are: relatively high vacancy levels, particularly at lower-level health facilities; coordinating all actors in the health sector; tapping the large private health sector; and limited capacity in many districts for informed planning and implementation of health programs. This health system assessment for Uganda was carried out during the first year of implementation of the HSSIP. Its findings, therefore, serve as a benchmark of the health system. By doing a similar assessment towards the end of HSSIP implementation, we will be able to gauge the progress made in the health system over the period covered by the plan. It is my hope that health workers, development and implementing partners, the private sector, civil society, and policymakers in Uganda and beyond will use this Health System Assessment report to identify ways in which they can further strengthen Uganda‟s health system so that it can deliver quality services to people in Uganda. I would like to thank all the numerous stakeholders who gave their time and other resources to support this assessment. I would particularly like to thank: USAID, through the Health Systems 20/20 project, implemented by Abt Associates, for the funding and technical assistance provided; Makerere University School of Public Health, for being on the ground for the assessment at the country level and for developing the capacity to do these kinds of health system assessments; and development partners, including the World Bank, the World Health Organization, the Centers for Disease Control and Prevention, and the UK‟s Department for International Development, for reviewing different assessment concepts and draft reports. Within the Ugandan government, I would like to thank the staff of the Ministry of Finance, Planning and Economic Development and the Ministry of Public Service for providing relevant information for this assessment. Finally, and most dear to us in the Ministry of Health, I would like to thank the staff of the Ministry of Health, and particularly those in the Supervision, Monitoring, Evaluation, and Research Technical Working Group, chaired by Dr. Henry Mwebesa, for steering the process on behalf of the Ministry. The people of Uganda are grateful to all of you, for all your contributions. Dr. Asuman Lukwago Permanent Secretary, Ministry of Health UGANDA HEALTH SYSTEM ASSESSMENT 2011 V CONTENTS Acronyms xi Acknowledgments xv Executive Summary xvii Introduction and Methodology xxiii 1. Background and Country Overview 1 1.1 Demographic Information and Population Growth 1 1.2 Mortality 3 1.3 Top Causes of Morbidity and Mortality 3 1.4 Reproductive Health Indicators 4 1.5 HIV, Tuberculosis, and Malaria 5 1.6 Nutrition, Sanitation, and Hygiene 5 1.7 Immunization 5 1.8 Business and Macroeconomic Environment 6 1.9 Service Delivery Organization 6 1.10 Governance of the Health Sector 7 1.10.1 National Planning, Policy, and Regulatory Frameworks . 9 1.10.2 Decentralization 9 1.11 Uganda National Minimum Health Care Package 9 1.12 Health Development Partner Coordination 9 2. Health Governance 11 2.1 Key Governance Indicators 12 2.2 Governance Structures 15 2.3 Health Sector Policies, Planning, and Implementation 17 2.3.1 State-District Relationships: Resources and Oversight . 18 2.3.2 Expanded Decentralization and its Implications 19 2.3.3 Decentralization and Decision Space 19 2.4 State-Provider Regulation 20 2.4.1 Private Sector Regulation 21 2.4.2 Supervision 22 2.4.3 Accountability and Transparency 22 2.5 Government and Health Development Partner Relationships 24 2.6 Service Provision, Information, and Lobbying 25 2.6.1 Service Provision 25 2.6.2 Information 25 2.6.3 Lobbying 26 2.7 Client Power and Voice 26 2.7.1 Media Participation in Governance 27 2.8 Summary of Findings: Health Governance 27 VI UGANDA HEALTH SYSTEM ASSESSMENT 2011 3. Health Financing 29 3.1 Overview 29 3.2 Resource Mobilization 30 3.3 Resource Flows and Management 33 3.4 Resource Allocation 34 3.4.1 Health Budget Formulation and Alignment to Medium- Term Expenditure Framework 34 3.5 Resource Pooling 36 3.5.1 Social Health Insurance 37 3.5.2 Community-Based Health Insurance 37 3.5.3 Private Commercial Health Insurance 37 3.6 Financial Management 37 3.6.1 Financial Reporting 37 3.6.2 Auditing 38 3.6.3 Effectiveness and Efficiency in Resource Allocation and Utilization 38 3.6.4 Equity in Financing of Health 39 3.7 Purchasing and Provider Payment 39 3.7.1 Contracting 39 3.8 Institutional Capacity Building for Financial Functions 40 3.9 Summary of Findings: Health Financing 40 4. Human Resources for Health 43 4.1 Overview 43 4.1.1 Overall Number of Health Care Workers in Uganda 44 4.1.2 Geographic and Facility Distribution of Health Care Workers 45 4.1.3 HRH Availability by Facility Type 46 4.1.4 Availability of Data on HRH in the Public, Private, and Private Not-for-Profit Sectors 47 4.1.5 Labor Market Dynamics 47 4.1.6 Productivity of the Existing Workforce 48 4.2 Human Resource Policy 49 4.2.1 Existing HRH Strategy and Policy 49 4.2.2 HRH Coordination Mechanisms 49 4.2.3 HRH Policy Implementation 50 4.2.4 Human Resource Management Within the MoH 50 4.3 Financing Workforce Costs 50 4.4 Performance Management 52 4.5 Training, Education, and Licensing 52 4.5.1 Workforce Licensing and Regulation 53 4.5.2 Cost of Training Programs 54 4.5.3 Quality of Training 54 4.6 Summary of Findings: Human Resources for Health 55 UGANDA HEALTH SYSTEM ASSESSMENT 2011 VII 5. Service Delivery 57 5.1 Overview and Health Indicators 57 5.2 Organization of Service Delivery 60 5.2.1 Integration 63 5.2.2 The Referral System 64 5.3 Availability and Coverage of Services 64 5.4 Service Utilization 66 5.5 Quality Assurance 67 5.6 Community Participation 69 5.7 Summary of Findings: Service Delivery 69 6. Medical Products, Vaccines, and Technologies 71 6.1 Overview of the MMP Sector 71 6.2 Policies, Laws, and Regulation 73 6.2.1 Policies 73 6.2.2 Legislation 74 6.2.3 Regulation 75 6.3 Financing 76 6.4 MMP Human Resources 78 6.5 Local Production of MMP 78 6.6 Management of MMP 80 6.6.1 Selection of MMP 80 6.6.2 Inventory Management 81 6.6.3 Public Procurement of Medicines at the National Level 83 6.6.4 Storage and Distribution 83 6.6.5 Distribution of Medicines to Health Facilities 85 6.7 Appropriate Use of Medicines 86 6.8 Summary of Findings: Medical Products, Vaccines, and Technologies 86 7. Health Information Systems 89 7.1 Overview, Structure, and Relationships 89 7.2 Policies and Regulations 92 7.3 Data Sources 92 7.3.1 Routine Health Service Statistics 93 7.3.2 Data Collection by Village Health Teams 93 7.3.3 Population and Survey Data Sources 94 7.4 Data Management Systems 96 7.4.1 Electronic Medical Records and the District Health Information System 97 7.4.2 Data Storage 98 7.5 Data Quality and Availability 98 7.5.1 Data Quality Assessment 100 7.5.2 Data Burden at the Health Facility Level 101 7.6 Human Resources for Health Information Systems 101 VIII UGANDA HEALTH SYSTEM ASSESSMENT 2011 7.7 Dissemination and Use of Data 102 7.8 Summary of Findings: Health Information Systems 103 8. Cross-Cutting Findings and Recommendations 105 8.1 Cross-cutting Findings and Recommendations 105 8.1.1 Improve Efficiency throughout the System to Reduce Costs 107 8.1.2 Invest in Needed Policies, Tools and Systems To Improve Quality Across All Sectors 108 8.1.3 Tap into Uganda‟s Private Health Sector to Increase Access to Health Care 109 8.1.4 Strengthen Coordination of All Health Stakeholders to Integrate the Health System 109 8.1.5 Harnessing Consumer Power to Advocate for Better Health Care 110 8.2 Recommendations by Technical Building Block Modules 111 8.2.1 Health Governance 111 8.2.2 Health Financing 113 8.2.3 Human Resources for Health 115 8.2.4 Service Delivery 117 8.2.5 Medical Pproducts, Vaccines, and Technologies 119 8.2.6 Health Information Systems 120 8.3 Priority Recommendations Identified by Stakeholders 122 Annex A. Stakeholder Resource Persons and Interviewees . 125 Annex B. District League Table 2010/11 129 Annex C. Funding on Health by Development Partners 135 Annex D. Proposed Indicators for Monitoring Health Systems 137 Annex E. Uganda Health System Assessment Dissemination, Validation, and Prioritization Workshop Participants, March 13–14, 2012 141 Annex F. References 144 [...]... implementation arrangements UGANDA HEALTH SYSTEM ASSESSMENT 2011 XXIII FRAMEWORK FOR THE HEALTH SYSTEM ASSESSMENT APPROACH The assessment approach was adapted from USAID‟s Health Systems Assessment Approach: A How-To Manual (Islam 2007), the use of which has been documented in more than 25 developing countries The Health Systems Assessment Approach is based on the WHO health systems framework of six building... this assessment Dr Asuman Lukwago Permanent Secretary, Ministry of Health UGANDA HEALTH SYSTEM ASSESSMENT 2011 XV EXECUTIVE SUMMARY This Health System Assessment (HSA) was carried out to identify strengths and challenges of the Ugandan health system, and to make recommendations for interventions to strengthen the system It has three specific objectives: First, it provides a baseline for monitoring health. .. in 2010/11, and led the Uganda HSA in collaboration with Health Systems 20/20 In addition, technical support and guidance was provided by Health Systems 20/20 HSS specialists The core Uganda HSA assessment team comprised:  Health Systems 20/20 team leader  Health Systems 20/20 team coordinator  MakSPH leads and research assistants for each building block module HEALTH SYSTEM ASSESSMENT PROCESS The... Management Information System Health Metrics Network Health Policy Advisory Committee Human Resources for Health Human Resources Management Health System Assessment Health Service Commission Health System Strengthening Health Sector Strategic and Investment Plan UGANDA HEALTH SYSTEM ASSESSMENT 2011 XI HSSP HTI HUMC IDSR IFMS IMNCI IPT IRS ITN JMS LIC LMIS MakSPH MCC MDG MEEPP MMP MoFPED MoH MTEF NCD... Strengthening Uganda s health system requires an understanding of its unique strengths and weaknesses This Health System Assessment (HSA) will provide an overview of key system functions organized around six technical modules, which are aligned with the World Health Organization‟s (WHO‟s) health system building blocks: Governance; Health Financing; Service Delivery; Human Resources for Health (HRH);... sectors 2 The Government of Uganda refers to for-profit health care businesses as “Private Health Practitioners” (“PHP”) This assessment report uses the terms private for-profit health care providers (PFP) and commercial health care providers to refer to those health care service providers, labs, pharmacies, etc., that operate on a for-profit basis 1 UGANDA HEALTH SYSTEM ASSESSMENT 2011 7 FIGURE 1.4: ORGANIZATION... strengthening the Ugandan health system These are listed and summarized here at a high level only In Chapter 8, the recommendations are organized around short-term (next 12 to 18 months) and medium-term to longterm (next 12 to 36 months), to help planning and implementation UGANDA HEALTH SYSTEM ASSESSMENT 2011 XIX A RE-ALIGN HEALTH SECTOR RESOURCES TO FOCUS ON THE POOR Cross-cutting finding: The health system. .. and planning XXII UGANDA HEALTH SYSTEM ASSESSMENT 2011 INTRODUCTION AND METHODOLOGY As the global community continues to scale up health interventions for HIV/AIDS, tuberculosis (TB), malaria, and other priority areas, it is essential to understand the state of the health systems in which these services are being delivered Good health systems should deliver effective, safe, quality health services to... 7.2: Summary of Findings: Health Information Systems 103 UGANDA HEALTH SYSTEM ASSESSMENT 2011 IX LIST OF FIGURES Figure 1: Conceptual Framework for Health Systems Performance xxiv Figure 1.1: Map of Uganda 1 Figure 1.2: Proportion of Cases Among Leading Causes of Morbidity, 2010/11 3 Figure 1.3: Top 10 Causes of Hospital-Based Mortality (All Ages) in Uganda, 2010/11 ... Indicators World Health Organization Yellow Star Program UGANDA HEALTH SYSTEM ASSESSMENT 2011 XIII ACKNOWLEDGMENTS Multiple organizations and individuals contributed to this health system assessment, from its inception to the production of this report All their contributions are hereby acknowledged Special thanks go to Makerere University School of Public Health, which is the main author of this assessment . Ministry of Health, Health Systems 20/20, and Makerere University School of Public Health. April 2012. Uganda Health System Assessment 2011. Kampala, Uganda and Bethesda, MD: Health Systems 20/20. Findings: Health Information Systems 103 X UGANDA HEALTH SYSTEM ASSESSMENT 2011 LIST OF FIGURES Figure 1: Conceptual Framework for Health Systems Performance xxiv Figure 1.1: Map of Uganda. Commission HSS Health System Strengthening HSSIP Health Sector Strategic and Investment Plan XII UGANDA HEALTH SYSTEM ASSESSMENT 2011 HSSP Health Sector Strategic Plan HTI Health Training