Interaction between GHI and Health Systems Experience of Uganda

Interaction between GHI and Health Systems

Experience of Uganda

Nelson MusobaMinistry of Health, Uganda

Presentation Outline• Background and Reforms in Uganda’s

Health System

• Examples of interactions between GHIs

and Health Systems in Uganda

• Challenges will be highlighted as we go

along

Key Reforms• 1986-1987: Sector Collapsed, Any help was welcome.• 1986-1989: Health Policy Review Commission –

consolidation of existing services and re-orientation to PHC

• 1995/96 – 2000/01 process of development of the new National Health Policy (NHP) and Health Sector Strategic Plan (HSSP).

• Poverty Eradication Action Plan (PEAP) 1997, with updates 2001, 2004; (Poverty Reduction Strategy Papers in other countries) & now

• National Development Plan 2009-2013• All closely aligned to the Millennium Development Goals.• Examples of other reforms;

– Decentralisation– National Governance Reforms – Public Service Restructuring

Partnership Principles• Government of Uganda:

– To seek donor support only for programs in the agreed framework

– To develop comprehensive, costed, prioritized sector-wide programs covering the entire budget, so that government speaks with one voice.

• Donors:– To ensure all support is fully integrated into sector-

wide programs and is fully consistent with sector priorities

– To end individual parallel country programs and stand alone projects

– To increase level of delegation to country offices• These Partnership Principles were formulated under the

leadership of government (MoFPED, OPM) and in discussion with the highest in country donor & Civil society representation.

SWAp Processes & Structures SWAp structures

– Health Policy Advisory Committee – and its technical Working Groups

– Joint Review Missions and National Health Assembly– Health Development Partners Group

• Tools for SWAp management – National Health Policy and Health Sector Strategic

Plan– Memorandum of Understanding– Aide Memoires– Annual Health Sector Performance Report & Mid

Term Review Report • SWAp tools and structures are intended to

facilitate Joint prioritisation, joint planning, monitoring and evaluation

SWAp• One of the most significant achievements of

the SWAp during the period under review was the successful conclusion of negotiations with both GAVI and GFATM towards increased alignment of their support with the health SWAp and agreeing common working arrangements.

• Agreement was reached with GFATM on the Long Term Institutional Arrangements (LTIA) for improved alignment of Global Health Initiatives (GHI) support to the sector

SWAp • The GFATM CCM into an expanded

Health Policy Advisory Committee (HPAC),

• The AIDS CCM into the AIDS Partnership Committee (PC),

• Rationalizing the composition of HPAC, and streamlining and revitalizing the Technical Working Groups, including the absorption of the various technical programme Inter-agency Coordinating Committees (ICCs) into the respective Technical Working Groups (TWGs).

Interactions I• Built trust and openness between

government and development partners and progressively Civil Society

• Planning and Budgeting Process – became more transparent and consultative– Medium Term Expenditure Framework –

credible presentation of all public resources (GoU & donor) over a 3 year period

– Brings together • Government & Development Partners • Central and District Levels • Public and Private partners

Interactions II• Improved the sector supervision, monitoring and

evaluation framework:– The strategic plan includes agreed indicators for

monitoring health sector performance – Annual Joint Review Mission (involving GoU – central

& Local, donor, private, civil society) – replaced very many review missions by donors

– An Annual Health Sector Performance Report produced every year for presentation at the JRM,

• Provides a bird’s eye view of sector performance;• Includes a District League Table comparing and ranking

performance among districts

• Modest increase in Health Sector Public Resource Envelope

• Most donors have switched to budget support

Level of Facility

OWNERSHIP

GOVT PNFP Private Total

2004 2006 2004 20062004

20062004

2006

Hospital 55 57 42 46 4 8 101 111

HC IV 151 155 12 12 2 1 165 161

HC III 718 762 164 186 22 7 904 955

HC II 1055 1332 388 415 830 2612273

2008

Total1979

2301 606 659 858 2773443

3237

Health Facilities by Level and Ownership 2004 and 2006

Physical Access• Access to health services is measured by 5 Km

walking distance to a health facility (public/PNFP) and is computed from the Health facilities maps, and stood at 72% at the beginning of 2006.

Current need is to;• Rehabilitate existing secondary and tertiary health

facilities • Strengthen HI management including maintenance • Provide medical equipmentThere are several sources of funding for the construction of

health facilities, many of which it is not possible to have prior

information of for planning purposes.

Human Resources for Health• The ever widening gap between the affordable

and the optimal HRH requirements. The limited HRH funding for recruitment, salaries and wages, has resulted in recruitment levels being lower than planned;

• There is still inequity in the distribution of staff with only 12 of the 80 districts achieving the agreed minimum staffing level of 80%. Related challenges include: Insecurity and remoteness in some parts in the country; and migration of health workers between the sub sectors making recruitment in one result into attrition in another.

HRH II• The time requirements of the HRH

management processes – the spread of HRH functions between different stakeholders leads to a lengthy recruitment process including delays in accessing the payroll leading to some prospective applicants withdrawing before taking up the positions;

• Low output of some cadres from training institutions e.g Laboratory & Pharmacy Technicians, Medical officers & specialist doctors;

Trend of patients on ART (Children <14 yrs Vs. Total: 2003 - 2007

0

20,000

40,000

60,000

80,000

100,000

120,000

2003 Dec 2004 June 2004 Dec 2005 June 2005 Dec 2006 June 2006 Dec 2007 April

No. o

n AR

T

Total on ART Children <14yrs

Trends of patients on ART

Essential Medicines• Challenges are at the various levels including the

national level in terms of medicines procurement and logistics management at the NMS. – inadequate cash flow; – inadequate staffing for medicines management at

MoH and local governments; – poor quantification and late ordering by the health

facilities and local governments; and – managing the third party items.

• The availability of medicines has continued to be a major challenge, at less than 35% in against an annual target of 55% and the HSSP II target of 80%.

• There is marked under funding of medicines especially EMHS with less than 30% of requirement for the UNMHCP currently provided for.

Maternal Mortality Ratio527

435

505

1995 2000-01 2006

How does Infant Mortality in Uganda Compare to How does Infant Mortality in Uganda Compare to other Countries?other Countries?

48

68

76

76

77

77

86

101

Eritrea 2002

Tanzania 2004-05

Uganda 2006

Malawi 2004

Kenya 2003

Ethiopia 2005

Rwanda 2005

Mozambique 2003

2006 UDHS

Deaths per 1,000 live births

2006 UDHS

Trend in Ownership of Trend in Ownership of Mosquito NetsMosquito Nets

13

26

34

2000-01 2004-05 2006

% of households with at least one mosquito net

0

20

40

60

80

100

120

2009 2010 2011 2012 2013 2014 2015

Per

cent

age

(%)

LLIN coverage targets based on availability of nets from GF & partners

Mosquito Net Indicators Indicator 2000-01 2006

HHs with at least 1 mosquito net (treated or untreated)

12.8 34.3

HHs with at least 1 Insecticide Treated Net (ITN)

3.2 15.9

Children <5 who slept under a mosquito net the night before the survey

7.3 21.6

Children under 5 who slept under an Insecticide Treated Net (ITN)

- 9.7

Pregnant women age 15-49 who slept under a mosquito net

6.6 24.5

Pregnant women age 15-49 who slept under an Insecticide Treated Net (ITN)

0.5 10.1

0

100

200

300

400

500

600

700

2004/05 2005/06 2006/07 2007/08 2008/09

Bil

lio

n U

g.

Sh

s.

GoU Budget (incl. Donor Budget Support) Donor Project Budget Total MTEF Budget HSSP II Adjusted Costing

Health Sector Budget Allocations by Source FY 2004/05 – 2008/09

LLIN Coverage• Current coverage with LLINs in Uganda is estimated at

40% according (Net mapping report, 2008; Malaria Consortium model, 2007).

• LLIN distribution is the mainstay of the country’s prevention strategies. Coverage is expected to drastically increase with Round 7 support which was approved and which will start implementation in 2009/2010.

• Under Round 7 a total of 17 million nets will be brought into Uganda and universal coverage is expected by 2011.

• However, after 2011, attrition of nets and population growth will reduce coverage with LLINs in the population to approximately 84%, falling to 68% in 2013 and 38% in 2014 (see Figure above).

• Need for “keep-up” of nets in 2012 and 2013 in order to maintain coverage at 100%. Mass replacement of nets required for 2014 will be requested in a subsequent round pending distributions of Round 7.

Uganda’s Population Trends, 1900-2050Uganda’s Population Trends, 1900-2050

2 2.5 2.8 3.6 5 6.5 9.5 12.6 16.722.0 24.7

36.8

53.7

81.4

103

0

20

40

60

80

100

120

Year

Po

pu

lati

on

(m

illi

on

s)

Challenges • Financial - more efficiency (resource allocation & use) - increased investment i.e. new

and additional funding• Considerable amounts of resources

still managed outside the SWAp• Population growth

– High fertility rate– High unmet need for family planning