uganda experience by dr tonny tumwesigye, upmb

Uganda Protestant Medical Bureau

Decentralization/Devolution of healthcare- Experiences from

Uganda 7th Biennial ACHAP Conference 22ND-26TH February 2015

Dr. Tonny Tumwesigye

EXECUTIVE DIRECTOR

www.upmb.co.ug Health in Totality

Decentralization

• Formal transfer of power from central government to lower levels in a political-administrative and territorial hierarchy

• Transfer of “locus of decision making to regional or local governments

• Transforming local institutional infrastructure to handle new responsibility

• Allowing for participation of people and local governments

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Health Reforms in Uganda- Drivers

• Over-centralization of power

• Overburdened state

• Excessive bureaucracy

• Lack of responsiveness to local needs

• Lack of accountability to local population

• Poor service quality

• Inequity in resource allocation


Health reforms in Uganda

• Uganda adopted a “devolution” type of decentralization

– where district has absolute powers for management of district resources

• Prior to 1990s, Uganda had highly centralized healthcare system with considerable differences in health services standards between urban & rural areas

• 1986: Creation of Resistance Councils (Later changed to Local Councils (Village, Parish, Subcounty, District)- Political decentralisation

• 1993: Formalisation of Political and Administrative and Fiscal Decentralisation

– Local Government Statute 1993

– Local Government Finance and Accounting Regulations 1995, amended in 1997


Health reforms in Uganda

• 1994: Uganda adopted a structural adjustment program (SAP) in two phases.

• 1997: Decentralization policy introduced under Local Government Act of 1997 that has since undergone several amendments.

• Policy inherently decentralized service delivery institutions and their governance in order to improve access to services for rural poor.


Uganda Health System & Organisation of Care

Community level

HC II

General hospital

RR hospital

Referral system

National hospital

HC III

HC IV

HC IIIHC III

Gen. Hosp.

RRH

NH

Referral system

Referral system

Ugandan health system organisation WHO health district concept and organisation

UrbanHC III

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Structural levels of decentralisation in Uganda

Formal decentralisation structure

• National

• District

• County (weak – no accounting authority)

• Sub-county

• Parish

• Village

Health Sector levels

• National (MoH) – Policy, Standard setting, Monitoring

• Regional (RRH, Regional Teams for supervision)

• District (DHT, Hospital) – Political decision, planning, implementation, monitoring

• Health Sub-district (County) – HC IV / Hospital – Planning, implementation

• Sub-county (HC III), Planning, implementation

• Parish (HC II) – Planning, implementation

• VHT (Community Extension Workers)

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Structure of Local Governments

Rural

Sub county

Parish

Village

Town

Ward

Cell/zone

District

Urban

Municipality

Division


Role of MOH in decentralized system Considerable changes in the management and delivery of health services.

• Separation of policy from operations- after decentralization, central government, through MOH is responsible for;

• Resource allocation and hospitals

• Policy formulation,

• Setting of service standards and

• Quality assurance,

• Provision of training and Human resource guidelines,

• Technical supervision,

• Responses to epidemics and other disasters, and

• Monitoring and evaluation of health services.


Devolution in Uganda

• MOH headquarters divested all service provision to regional & national hospitals and was significantly reorganized & reduced in size.

• All staff, except those at the national & regional hospitals, have been transferred to 112 districts

• Semi-autonomous district & hospital boards- devolved much responsibility of operating lower health units, such as health centers and dispensaries, to lower levels of local government under Ministry of Local Government


Health worker remuneration in Uganda

• HWs remuneration still a component of the wage bill as an earmarked grant within a decentralized system where local governments also employ HWs.

• Uganda also receives support towards its wage bill from development partners.

• Salary scales and payroll are still set and managed centrally by the Ministry of Finance, Planning and Economic Development and the Ministry of Public Service.


Financing of local governments

• Currently, LGs in Uganda obtain their finances from four main sources:

• Locally generated revenue, such as market dues, trading licenses, rent, and rates;

• Government grants;

• Donor and project funds for specified activities; and

• Fund-raising from well-wishers.

• LGs depend heavily on subventions from the central government.

• Central government transfers to LGs account for 30 to 37% of national budget and constitute about 95% of LG revenue


Financing of LGs cont’d

• Government formulated the Fiscal Decentralization Strategy (FDS) that allowed local governments some flexibility and/or discretion to reallocate resources between and within sectors during planning and budgeting process and aims to improve resource allocation, planning, budgeting and budget execution.

• Disadvantage: high percentage of earmarked funds has reduced the discretionary autonomy of local governments over the use resources in areas where need is most felt.


PNFP Facilities across Uganda (DHIS2 – GIS – Over 70 facilities missing from this map)


Historical feature of Uganda’s PNFPs


PNFP sub-sector in devolved system

– Health facilities run by faith-based organizations, constitute 40% of health sector outputs, perceived to offer better services than non-faith-based facilities

– 29 PNFP facilities are Health sub district headquarters

– PNFPs operate effective decentralized structure

– Uganda has policy on public-private partnership and the operating mechanisms are documented.

• Institutional mechanisms were set up to enable the participation of facility based private-not-for-profit (PNFP) institutions as appropriate.

• Districts are main public partners in health service delivery & are principle actors in dialogue with faith-based PNFP representatives in process of improving health care


PNFP sub-sector as national player

• At central level, the Joint Review Mission, Health Policy Advisory Committee and Public Partnership in Health working groups are prominent part of sector wide approach processes (SWAp) & provide fora for partnership dialogue.

• Joint Review Mission analyzes financial, technical and institutional progress in the sector on a bi-annual basis and agree on the outputs and resource allocation for the year by both the GoU and its development partners


Contribute to all health system building blocks and levels of care


60%

50%

46%

43%

35% 37%

32% 34% 33%

31%

35% 33%

39% 38% 41% 41%

0%

10%

20%

30%

40%

50%

60%

70%

97 98 98 99 99 00 00 01 01 02 02 03 03 04 04 05 05 06 06 07 07 08 08 09 09 10 10 11 11 12 12 13

Hospital Recurrent Cost Recovery Rate (Median in PNFP Hospitals as example)

When government subsidy was highest

Reducing government

subsidy


Financing of PNFP Facilities – 2013/14 (From UCMB and UPMB data)

Proportions vary at local level e.g. between facilities or between dioceses

60 – 80% of donor funds are for HIV/AIDS, TB and Malaria


Successes

• Were objectives of Decentralization/Devolution achieved? – equity in services and improving health status of the poorer, increasing community participation (decision making and participating in health, increasing accountability)

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Successes

Mixed picture among different objectives and districts

• Objectives largely met but implementation has given rise to new challenges which need to be progressively addressed.

• General increase in patient attendance in hospitals, although in some cases decline.

• Prescribing patterns varied, with improvement in some indicators, while others showed no change or even worsened

• Decentralization was lauded with improved HWs supply & distribution

• Salary payments more predictable salary payments with some possible improvements in motivation & retention

• Some HWs also preferred to work in areas of origin which increased retention although could promote discrimination among HWs


Successes

• Experience – 2001 - 2004 : Districts are indeed able to better plan and use resources to plug in key holes.

• E.g. Nebbi district was able to improve without additional resources from being 56th /56 on district league table in 2001 to the 6th / 56 in 2003.

– Participatory allocation and re-allocations of resources

– Improved accountability (Political, Financial, Administrative)

– More availability of medicines and medical supplies

– Increased staff availability and skill mix and therefore better performance (Redistribution)

– Facilities better equipped for Maternal Health services

– More immunisation outreach stations targeting poorly covered areas

– Increased confidence in population and increased usage of services

– Increased SWAp at district level

– More targeted interventions e.g. Construction of new health facilities

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– human resource management and development,

– planning and resource allocation,

– policy analysis and formulation,

– financial management,

– unfair balance in allocation of funds to Local Governments vis- a- vis the devolved responsibilities,

-local revenue decline, management and sustainability of social investments,

-little focus on Local Economic Development by Local Governments,

-unique issues for conflict areas in the North and North East and,

-mainstreaming of the Cross cutting issues like Environment, and Gender in LG plans and programs.

Challenges-Manifested in the Areas of;


Challenges 1

• Uganda still heavily dependent on external support, with insufficient local resources to health sector; has dire sustainability implications

• Faced with competing priorities in other sectors, health budget considerably low, actual total resources allocated to sector inadequate.

• MOH system no longer nationally unified, district health officials no longer have the same geographic mobility and access to promotion, making it significantly more difficult for poorer rural districts to attract qualified personnel.


Challenges 2

• Different levels of resources & prioritization of health sector tend to lead to non-uniformity in training and capacity of district health personnel.

• Wealthier urban districts provide better amenities, as well as more opportunities for complementary private sector employment.

• Creation of new poorly resourced districts a major challenge

• Hiring and firing decisions are susceptible to tribalism which contributes to a deterioration in staff quality.

• Decentralization potential not fully tapped, health seen as a technical issue rather than a social or political one. System more sensitive to views of health professionals than service users

• Overall, decentralization of health services has not resulted in greater participation of ordinary people & accountability of service providers to community.


Challenges 3

• Mismatch between administrative levels and Health sector levels

Anders Jeppsson

“In the health sector, failure to achieve one’s goals is generally perceived as a personal failure for those involved in planning. In areas other than health, as, for example, in the social or political sciences, an implementation failure is seen as an issue requiring further research rather than a human weakness”. (Decentralisation and National Policy Implementation in Uganda – a Problematic Process March 2004)

– This phenomenon has created various types of conflicts at district level – especially between politicians and technocrats – sometimes used to get rid of an officer who sticks too much to policies and principles

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Challenges 4

• The change in “Who has more power” between technical officers and political leaders has often affected priority settings – E.g. Political heads want to construct more health facilities

– There is also temptation of politicians to divert some health funds to road and other constructions.

– (to be able to show to the electorate)

– Technocrats want to consolidate services in existing facilities and do more careful expansion of infrastructure

• This requires a well prepared and assertive technocrat to lead the sector at each level – Be able to technically convince the politicians

– To gain respect of the politicians

– To manoeuvre between conflicting interests


Challenges 5

• Financial constraints:

– Political and Administrative decentralisation occurred faster than fiscal decentralisation

– Inability of many District Local Governments to raise enough of their own / local revenues • Especially after abolition of the Graduated Tax and scrapping of User fees in government

health facilities in 2000

– Heavy dependence on central government transfers / subventions which are to some extent earmarked. • Limited fungibility e.g. Use 50% for medicines, other prescribed %s for other things (e.g.

salaries), development grants for specifics.

– All these reduce Local Governments’ ability to exercise full autonomy in making decisions on priorities


Challenges 6

• Human Resources

– This affects the new, and especially poorer districts most.

– Health workers are less attracted to these districts

– Mal-distribution and poor skill mix between the rich and poor districts

– Quite often the new district health leaders and managers are less qualified or far less inexperienced in the new job.

– “Apparent” Limited opportunity for promotion and further education

• Current agitation to recentralise recruitment and management of health workers


Challenges 7

• Apparent “decentralisation of corruption”

– Decentralised leaders fear to make some difficult / unpopular decisions for fear of losing the next election

– Awarding service tenders to political supporters and relatives of local government leaders (and those who pay kickbacks)

• Tendency to view decentralisation as opportunity to localise everything e.g. job creation for local community, awarding tender to local community etc.


Challenges 8

• Prolonged absence of a PPPH Policy (passed in 2012) affected implementation of SWAp at district level

– Depending more on understanding of individual political and technical leaders

– E.g. While Religious Medical Bureaus (UCMB, UPMB, UMMB, UOMB) collaborated well with MoH, this often was not smooth in districts

• No systematic continuous assessment of the functionality of the decentralised system


Opportunities to consolidate the Gains

Depends on the success factors

• A strong District Health Team

• Public Health knowledge and skills – Management Competency

– Assertiveness

– Positive collaboration between political and technical players in districts

• Ability of MoH officials to support / backstop the district technical staff

• Willingness & ability of DHT to strengthen &work with lower level structures

• PNFP’s (mainly faith-based) relative better performances are largely due to decentralised nature of function – With Medical Bureaus doing central coordination, policy guidance, systems strengthening etc.

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Opportunities • Although decentralization has hitherto been primarily associated with

service provision, experience suggests that it is essential to link it to poverty reduction to make a real difference in overall wellbeing.

• Experiences of implementation of decentralization policy indicates that it is insufficient to strengthen institutions & to increase access to services if this is not accompanied by increases in people’s incomes

• Decentralization an instrument for shifting attitudes, developing, deepening skills, competencies, & engaging multiple stakeholders in the development process.


References

1. Anokbonggo WW, Ogwal-Okeng JW, Obua C, Aupont O, Ross-Degnan D. Impact of decentralization on health services in Uganda: a look at facility utilization, prescribing and availability of essential drugs. East Afr Med J. 2004 Feb;Suppl:S2-7.

2. Bashaasha, B., Mangheni, MN and Nkonya, E. 2011. Decentralization and Rural Service Delivery in Uganda. IFPRI Discussion Paper 01063 February 2011. Development Strategy and Governance Division

3. Fanaka Kwa W: Uganda health sector: an overview. Policy paper on health sector financing in Uganda. Fanaka Kwa Wote Newsletters 2008, 1:1. http://www.kwawote.org.

4. Lirri E: Decentralisation blamed for poor health services. The Daily Monitor Online 2008, http://www.monitor.co.ug/artman/publish/regional-special.

5. Lutwama et al.: A descriptive study on health workforce performance after decentralisation of health services in Uganda. Human Resources for Health 2012 10:41

6. Matsiko, CW 2010. Positive Practice Environments in Uganda: Enhancing health worker and health system performance. For the Positive Practice Environments Campaign

7. Saito F Decentralization in Uganda: Challenges for the 21st Century

http://www.kwawote.org/


The Future is Bright-Thank you

uganda experience by dr tonny tumwesigye, upmb

Documents

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totality health reforms

health district concept

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health services standards

uganda drivers

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