uganda national academy of sciences proceedings/13th annual scientific conference...13th annual...

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UGANDA NATIONAL ACADEMY OF SCIENCES

Proceedings of the 13th Annual Scientific Conference of UNAS

“Some Ingredients of Social Transformation for Uganda”

THEME:

OCTOBER 2013

13th Annual Scientific Conference Proceedings

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Uganda National Academy of SciencesA4 Lincoln House

Makerere UniversityPO Box 23911

KampalaUganda

Tel: +256-414-53 30 44Fax: +256-414-53 30 44E-mail: [email protected]

Website: www.ugandanationalacademy.org

© Uganda National Academy of Sciences, March 2014.

ISBN: 978-9970-26-003-4

Support for this work was provided by the African Science Academy Development Initiative (ASADI) of the U.S. National Academies, Washington, DC.

All rights reserved. Except as otherwise permitted by written agreement, no part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopying, recording, or otherwise without the prior permission of the copyright owner, the Uganda National Academy of Sciences.


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The Uganda National Academy of Sciences (UNAS) is an autonomous, honorific and service organization comprising of a diverse group of scientists from the physical, biological, social and behavioural sciences. It was founded in 2000 and was granted a Presidential Charter to operate as the National Academy of Uganda in January 2009. Our vision is to improve the prosperity and welfare of the people of Uganda through science by generating, promoting, sharing and using scientific knowledge and giving evidence-based advice to government and society.

The organizational structure of UNAS consists of the General Assembly, Council, Standing Committees and the Secretariat.

The membership includes Founding members, Fellows of the Academy, Foreign Fellows and Honorary Fellows. As of March 2014, there were 56 Fellows and 60 Members.

COUNCIL MEMBERS

Prof. Nelson K. Sewankambo President

Prof. Patrick R. Rubaihayo Vice-President

Prof. Edward K. Kirumira Treasurer

Prof. Justin Epelu-Opio Secretary General

Prof. Frederick I.B. Kayanja Member

Prof. Livingstone S. Luboobi Member

Prof. Julius Y. K. Zake Member

Prof. Elly N. Sabiiti Member

Prof. David J. Bakibinga Member

Prof. John R. Stephen Tabuti Member

Prof. Mary J.N. Okwakol Member

Dr. David R. Mutekanga Executive Secretary (Ex-Officio)


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ACKNOWLEDGEMENTS

The Uganda National Academy of Sciences (UNAS) wishes to express her warm-est appreciation to the individuals and organizations who gave valuable time to provide information through their participation in the Annual Scientific Confer-ence of 2013.

The Academy wishes further to appreciate Prof. Patrick R. Rubaihayo for review-ing the whole document to ensure that it meets the minimum UNAS document publication requirements. The Academy also wishes to acknowledge the UNAS staff in organizing the conference and production of this conference report.

Special thanks go to the individual paper reviewers who volunteered their time to provide candid and critical comments to ensure that the report is accurate, ef-fective and credible.

Gratefully acknowledged are the sponsors US National Academies who provided financial support for this activity.

The views presented in this conference report are those of the individual authors and not those of the Uganda National Academy of Sciences.

Professor Nelson K. Sewankambo PRESIDENT, Uganda National Academy of Sciences; Principal College of Health Sciences, Makerere University


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ACKNOWLEDGEMENTS

The Uganda National Academy of Sciences (UNAS) wishes to express her warmest appreciation to the individuals and organizations who gave valuable time to provide information through their participation in the Annual Scientific Conference of 2013.

The Academy wishes further to appreciate Prof. Patrick R. Rubaihayo for reviewing the whole document to ensure that it meets the minimum UNAS document publication requirements. The Academy also wishes to acknowledge the UNAS staff in organizing the conference and production of this conference report.

Special thanks go to the individual paper reviewers who volunteered their time to provide candid and critical comments to ensure that the report is accurate, effective and credible.

Gratefully acknowledged are the sponsors US National Academies who provided financial support for this activity.

The views presented in this conference report are those of the individual authors and not those of the Uganda National Academy of Sciences.

Professor Nelson K. Sewankambo PRESIDENT, Uganda National Academy of Sciences; Principal College of Health Sciences, Makerere University


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REVIEWERS

All presenters at the conference have reviewed and approved their respective sections of this report for accuracy. In addition, this conference summary was reviewed in a draft form by independent reviewers chosen from their diverse perspectives and technical expertise, in accordance with procedures approved by the Uganda National Academy of Sciences (UNAS) Council. The purpose of the independent review is to provide candid and critical comments that assist UNAS in making the published report as sound as possible and to ensure that the con-ference summary meets institutional standards, including those for objectivity and evidence. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

The Uganda National Academy of Sciences thanks the following individuals for their participation in the review process.

Prof. Emeritus Patrick R. Rubaihayo, FUNAS Department of Agricultural Production College of Agricultural and Environmental Sciences, Makerere University Kampala, Uganda

Prof. William B. Banage, FUNAS Retired Professor of Zoology, College of Natural Sciences Makerere University Kampala, Uganda

Prof. David Serwadda, FUNAS School of Public Health, College of Health Sciences Makerere University Kampala, Uganda


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PREFACE

Uganda National Academy of Sciences is committed to providing an autonomous forum through which scientists can exchange ideas, knowledge and experiences aiming at generating, promoting, sharing and using scientific knowledge and giv-ing evidence-based advice to Government and society.

This is done annually through various mechanisms such as Annual Scientific Conferences. UNAS has held Scientific Conferences since 2001. The themes for these conferences have ranged from Sciences for Sustainable Development, Sci-ence Education for Development, Biotechnology for Development and Impact of Climate Change to National Development.

The 13th Annual Scientific Conference was held on 25th October, 2013 at Grand Imperial Hotel, Kampala Uganda. The Guest of Honour was Rt. Hon Amama Mbabazi, SC.MP The Prime Minister of the Republic of Uganda. The conference was attended by over 100 participants and among these were government offi-cials, academicians, researchers, young scientists, and various stakeholders.

The theme for the conference was, “Some Ingredients of Social Transformation for Uganda.” Under this theme, three subthemes were selected from three sec-tors of the economy that is, Agriculture, Health and Environment. These are: (1) Transforming Subsistence Agriculture to Commercial Agriculture in Uganda by 2040: What will it take? (2) Ownership and Accountability for Health Outcomes in Uganda: the role of Stewardship and leadership: Looking 30 years back and 30years forward, and (3) Overview of the Environment Management in Uganda. These subthemes were presented by individual experts from the selected fields.

This conference report is made up of two sessions:

Session 1: “Annual Scientific Conference”, it is important to note that; the views presented in this part are those of the individual authors, and not necessarily those of the Uganda National Academy of Sciences.

Session 2: Presents the profiles of Fellows who were inducted into the Academy in the year 2013


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TABLE OF CONTENTS

ACRONYMS AND ABREVIATIONS......................................................viii1.

WELCOME REMARKS................................................................................12.

GUEST OF HONOURS SPEECH.................................................................33.

SESSION 1:

TRANSFORMING SUBSISTENCE AGRICULTURE TO COMMERCIAL 4. AGRICULTURE IN UGANDA BY 2040.WHAT WILL IT TAKE .............6

Introduction..........................................................................................6a.

Key Challenges to Achieving Agricultural Transformation...............10b.

Actions required to achieve Transformation......................................19c.

Concluion...........................................................................................23d.

References..........................................................................................25e.

OWNERSHIP AND ACCOUNTABILITY FOR HEALTH OUTCOMES 5. IN UGANDA: THE ROLE OF STEWARDSHIP AND LEADERSHIP: LOOKING 30 YEARS BACK AND 30YEARS FORWARDS...................28

Introduction........................................................................................28a.

Concepts of Health and Health Outcomes.........................................29b.

Stewardship and Leadership..............................................................35c.

Health Sector Reforms in Uganda 30 years back..............................43d.

Looking 30 years Forward.................................................................68e.

References..........................................................................................72f.

OVERVIEW OF ENVIRONMENTAL MANAGEMENT IN UGANDA...746.

Introduction........................................................................................74a.


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Evolution of Environmental Management in Uganda........................75b.

The state and trends of Environmental resources in Uganda c. and the challenges being faced...........................................................78

Conclusions and Recommendations...................................................89d.

References..........................................................................................91e.

SESSION 2:

INDUCTION OF NEW FELLOWS.............................................................957.

APPENDIX8.

Conference Programme......................................................................98a.

List of Participants............................................................................101b.


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ACRONYMS AND ABREVIATIONS

ACF: Agricultural Credit Facility

ACHEST: African Centre for Global Health and Social Transformation

ACODE: Advocates Coalition for Development and Environment

ACTs: Artemisinin-Combination Therapies

ADB: Agricultural Development Bank

AHSPR: Annual Health Sector Performance Report

APHRH: African Platform on Human Resources for Health

ARVs: Antiretroviral drugs

ATAAS: Agricultural Technology and Agribusiness Advisory Services

BOD: Biochemical Oxygen Demand BoU: Bank of Uganda CAADP: Comprehensive Africa Agriculture Development Programme CAOs: Chief Administrative Officers CBOs: Community Based Organizations CBR: Centre for Basic Research CCF: Country Coordination and Facilitation CICS: Competitive and Investment Climate Strategy CMR: Clinical Microbiology Reviews CO2: Carbon dioxide DEC: District Environment Committees DEO: District Environment Officer DFIs: District Farm Institutes DFM: Diploma in Farm Management DGHS: Director General of Health Services DPs: Development Partners DSIP: Development Strategic and Investment Plan DWD: Directorate of Water Department ECA: Economic Commission for Africa ECN: Enrolled Comprehensive Nurse ECSA: East, Central Southern African EPRC: Economic Policy Research Centre EU: European Union FAO: Food and Agricultural Organisation FOWODE: Forum for Women in Democracy


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FY: Financial Year GAVI: Global Alliance for Vaccination Initiative GDP: Gross Domestic Product GFATM: Global Fund to Fight AIDS, Tuberculosis and Malaria GHI: Global High Income Fund GNI: Gross National Income GoU: Government of Uganda H.E: His Excellency HIPCs: Heavily Indebted Poor Countries HIV/AIDS: Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome HPAC: Health Policy Advisory Committee HRPIs: Health Resource Partnership Institutions HRS: Human Resource for Health HSC: Health Service Commission HSSIP: Health Sector Strategic and Investment Plan HUMC: Health Unit Management Committee HWF: Health Workforce IFPRI: International Food Policy Research Institute IGG: Inspector General of Government IHP+: International Health Partnership IISD: International Institute for Sustainable Development IMF: International Monetary Fund IMR: Infant Mortality Rate JRM: Joint Review Mission KTDA: The Kenya Tea Development Authority LC: Local Council LVEMP: Lake Victoria Environment Management Project LVFO: Lake Victoria Fisheries Organisation MAAIF: Ministry of Agriculture Animal Industry and Fisheries MDGs: Millennium Development Goals MFIs: Microfinance Institutions MFPED: Ministry of Finance Planning and Economic Development MMR: Maternal Mortality Rate MNR: Ministry of Natural Resources MOES: Ministry of Education and Sports MOH: Ministry of Health MOPS: Ministry of Public Service MSCL: Microfinance Support Centre Limited MTEF: Medium-Term Expenditure Framework MWE: Ministry of Water and Environment


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NAADS: National Agricultural Advisory Services NARO: National Agricultural Research Organisation NDA: National Drug Authority NEAP: National Environmental Action Plan NEMA: National Environment Management Authority NFA: National Forestry Authority NGO’s: Non Governmental Organisations NHP: National Health Policy NIDA: National Irrigation Development Board NMS: National Medical Stores NPA: National Planning Authority NRM: National Resistance Movement OECD: Organisation of Economic Co-operation and Development OPD: Out Patient Department PAF: Poverty Action Fund PEAP: Poverty Eradication Action Plans PHC: Primary Health Care PMA: Plan for Modernization of Agriculture PNFP: Private Not for Profit PS: Permanent Secretaries PSA: Prosperity for All PWC: Price Waterhouse &Coopers QA: Quality Assurance RCN: Registered Comprehensive Nurse RRH: Regional Referral Hospitals SACCOs: Savings and Credit Cooperative Organisations SAMSS: Sub-Saharan African Medical Schools Study SAPs: Structural Adjustment Programmes SCOUL: Sugar Corporation of Uganda SMC: Senior Management Committee SOER: State of Environment Reports SWAPS: State Wide Approaches T&V: Training and Visit System TB: Tuberculosis TMC: Top Management Committee UBOS: Uganda Bureau of Statistics UCA: Uganda Cooperative Alliance UCRA: Uganda Cooperatives Regulatory Authority UDHS: Uganda Demographic and Health Survey UHC: United Health Care


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UN: United Nations UNAIDS: United Nations Programme on HIV and AIDS UNEP: United Nations Environmental Programmes UNFCC: United Nations Framework Convention on Climate Change USAID: United States Agency for International Development USD: United States Dollar UWA: Uganda Wild life Authority VHT: Village Health Team WHA: World Health Assembly WHO: World Health Organisation WHR: World Health Report. WPS: Working Paper Series


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WELCOME REMARKS

Professor Paul Edward MugambiPresident Uganda National Academy of Sciences

Introduction

I welcome you all to this 13th Annual Scientific Conference. I also take this op-portunity on behalf of UNAS to welcome the Chief Guest, the Rt. Hon. Prime Minister of Uganda who has been of great support to UNAS.

The UNAS Annual Scientific Conferences have been held every year for the last 12 years and each year a different theme has been addressed.

This year’s theme “Some ingredients of Social Transformation for Uganda” is very important, and certainly needs being addressed now in light of the deadline of the end of the period for the current Millennium Development Goals (MDGs) in 2015.

The Uganda National Academy of Sciences (UNAS)

UNAS was established 13 years ago to provide evidence based advice to govern-ment and society on various issues. In the most recent past, UNAS has provided advice to government on Vaccines and Immunization and this support is continu-ing. UNAS has also been involved and continues to work in collaboration with the AIDS Commission on research in the fields of HIV AIDS. New programs are also beginning on climate change and its impacts at various levels.

The 13th Annual Scientific Conference

The theme of this year’s conference will be focusing on three major elements: Agriculture, Health and Environment. For each of these the presenters will be highlighting among other things the major challenges these elements are facing which are causing them to fail in contributing to socio-economic development. Hopefully they will also show some of the impacts so far the elements have had on socio- economic transformation in Uganda.

This year a major emphasis has also been placed on inviting young scientists to this meeting as part of the program for UNAS to mentor the young scientists and encourage them to think of ways of identifying means to bring about an increased pace to national transformation and achieving the National Vision 2040.


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Soon a meeting of Young Scientists will be held to formally incorporate them into the activities of UNAS.

Distinguished guest, today’s presenters are very experienced and highly regarded individuals in their profession and expertise here in Uganda and internationally and I particularly welcome them and thank them for agreeing to come and participate in this conference.

I wish you very good deliberations.


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SPEECH BY THE GUEST OF HONOUR

Rt. Hon Amama Mbabazi, SC. MP, The Prime Minister of the Republic of Uganda

Senior Researchers, Professors and distinguished Members of the Uganda National Academy of Sciences:

Prof. Apolo R. Nsibambi, Former Prime Minister of• Republic of Uganda

Prof. Emmanuel Tumusiime-Mutebile, Governor Bank of Uganda•

Prof. Mary J.N. Okwakol, Vice Chancellor Busitema University•

Prof. Jack H. Pen Mogi-Nyeko, Vice Chancellor Gulu University•

Prof. Frederick I.B. Kayanja, Vice Chancellor Mbarara University•

Prof. Livingstone S. Luboobi, Former Vice Chancellor Makerere •University

Researchers and Lecturers from Institutions of Higher Learning;

Scientists and researchers from various Research Institutions;Ladies and Gentlemen.

1. On behalf of the Government of Uganda I salute you all and warmly welcome you to the 13th Annual Scientific Conference of the Uganda National Academy of Sciences (UNAS).

2. I am delighted to have been given this opportunity to preside at this Annu-al Scientific Conference. The theme of this conference – “some ingredients for social transformation for Uganda” – is relevant to our National Vision 2040: “a transformed Ugandan society from a peasant to a modern and prosper-ous country within 30 years”.

3. Building our national capacity in Science, Technology and Innovation (STI) is imperative for the sustainable socio-economic growth and transforma-tion of Uganda. Government recognizes the strategic role that STI plays in fos-tering research and development, and in building the human capital that Uganda requires for a knowledge-based and competitive economy.


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4. Government is indeed actively tackling the strategic national challenge of low application of science and technology in the development process of the country. Strategic measures to address this challenge are well articulated in our National Development Plan which focuses on “Growth, Employment and So-cio-Economic Transformation for Prosperity”. One of the eight strategic ob-jectives of the National Development Plan is promotion of science, technology, innovation and ICT to enhance competitiveness. In pursuit of this strategic objective, Government expects to use science, technology and innovation to con-tribute to the following benefits for our people:

Increased share of exports with high technology content,(i)

Strengthened institutional capacity, (ii) Increased capacity for Research and Development (R&D),(iii) Increased capacity, access and use of Information and (iv) Communications Technology, and;Increased number of Science, Technology and ICT professionals.(v)

5. Government is focused on strengthening the policy, legal and institutional framework to support the development of Science, Technology and Innovation (STI). This indeed is the basis for the Science, Technology and Innovation Policy of August 2009. This policy is building national capability to generate, transfer, and apply scientific knowledge, skills and technologies that ensure sustainable utilization of natural resources for the realization of Uganda’s development ob-jectives.

6. Government is implementing national science, technology and innova-tion policies with steady progress under the National Biotechnology and Bio-safety Policy, Research Registration and Clearance Policy, Agricultural Research Policy and Act, Copyright Law and Patents Act, National Guidelines for Re-search involving Humans as Research Participants, the National Environment Regulations.

7. President Yoweri Museveni has demonstrated real leadership in support-ing Science, Technology and Innovation through the “Presidential Science, Technology and Innovation’s Award” to young scientists every year.

8. The President also granted a Charter in 2009 to the Uganda National Academy of Sciences (UNAS) in recognition of the role UNAS played in im-proving the prosperity and welfare of the people of Uganda through science by generating, promoting, sharing, using scientific knowledge and giving evidence based advice to Government and Civil Society.


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9. To support the Presidential Charter, I am pleased that efforts are under-way in the Ministry of Finance, Planning and Economic Development to develop legislation to firmly establish UNAS. I have also noted the need for a permanent home for UNAS since it is temporarily housed at Makerere University. I will direct the Minister of Finance, Planning and Economic Development to brief me on matters relating to the institutional development of UNAS so that alternatives can be explored and expedited.

10. Government of Uganda is aware and fully acknowledges the role of UNAS in the growth and development of the country. UNAS has supported and advised the Ministry of Health and related agencies on Immunization, Manage-ment of Malaria and Research on HIV/AIDs; UNAS has advised Ministry of Education and Sports on Science Education; and UNAS has also provided advice to Government on Nutrition and Agriculture.

11. The topics for discussion today on Health, Agriculture and Environment attest to the positive contribution you are making in bringing evidence for stra-tegic decision making for national development. These topics are pertinent for Uganda which is facing strategic challenges in provision of healthcare, protec-tion of the environment and modernization of agriculture.

12. Government has always supported and encouraged such fora for strategic debate on development issues. I am therefore pleased that UNAS has taken the initiative to bring together national, regional and international actors to advance ways of promoting scientific awareness on developmental issues.

13. I am informed that UNAS won the bid to host, here in Uganda, the 10th Annual Meeting of Academies of Sciences of Africa (AMASA 10) in November 2014. This meeting is of great significance as African scientists will be looking at the new global development agenda after the end of the Millennium Develop-ment Goals (MDGs).

14. I am confident that the deliberations today will be a resounding success and I am therefore happy to note that Government is looking forward to receiving strategic recommendations from this Conference.

15. It is with great pleasure that I now declare the 13th Annual Scientific Conference of the Uganda National Academy of Sciences open.

For God and My Country

I thank you.


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SESSION 1:

Transforming Subsistence Agriculture to Commercial Agriculture in Uganda by 2040: What will it take?

Professor Joseph K. Mukiibi, Fellow of the Uganda National Academy of Sciences

1. Introduction

1.1 In the beginning

Subsistence agriculture is a form of farming in which nearly all the crops or livestock raised are used to maintain the farmer and his/her family, leaving lit-tle surplus for sale or trade. (http://www.merriam-webster.com/dictionary/sub-sistence%20farming). It is characterised by low productivity and low income. Transformation from this system entails commodity specialisation in order to raise productivity of land, labour and capital by shifting from self-sufficiency to depending upon markets for one’s daily needs (Johnson and Kilby 1975).

Before 1900, Uganda practiced a pure form of subsistence agriculture like all pre-industrial communities throughout the world did. Following the introduction of cash crops such as cotton, coffee and tobacco (Uganda Protectorate 1912), Uganda started moving away from traditional subsistence farming towards com-mercial farming. The emergence and growth of urban centres throughout Uganda and the East African region, created market opportunities for food commodi-ties and Ugandan farmers started producing considerable surpluses of crop and livestock products, beyond their families’ needs, for sale and trade. Therefore, Agriculture in Uganda ceased to be subsistence farming, sensu stricto. Today it consists of a monetary in addition to a non-monetary (subsistence) sector.

The non-monetary sub-sector has been steadily declining over the years. During the period 2007-2011, non-monetary agriculture accounted for just about 40 per cent of total Agricultural GDP on the average as shown in Table 1. The Forestry and Food Crops non-monetary subsectors accounted for 54 and 52 percent re-spectively while the Fisheries and Livestock non-monetary subsectors accounted for about 3 and 20 per cent respectively.


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Table 1: Monetary and Non-Monetary Agriculture GDP

Sub-sector Monetary Non-Monetary2007-2008 2010-2011 2007-2008 2010-2011

Agriculture –Total 60.6% 60.5% 39.4% 39.5%Food crops 47.6% 47.6% 52.4% 52.4%Livestock 80.2% 80.1% 19.8% 19.9% Forestry 39.7% 45.1% 60.3% 54.9%Fisheries 97.6% 97.1% 2.4% 2.9%

Source: MFPED (2013)

While Agriculture is no longer wholly subsistence, it is still characterised by features of subsistence farming such as:

Dominance of small holdings and therefore absence of economies of scale,

A wide range of crops and animals i.e. lack of specialisation,

Low productivity of land, labour and capital; and

High poverty levels among smallholder farmers who constitute two thirds (NPA 2010) of the national workforce.

Because of these features and the absence of a strong industrial sector, the econo-my of Uganda is still regarded as a peasant economy and a major concern among development practitioners.

1.2 Where we want to go

The Government of Uganda has recently launched a new development vision dubbed “Vision 2040” entitled “Transformed Ugandan Society from a Peasant to a Modern and Prosperous Country within 30 years” (NPA 2010). While launch-ing this vision President Museveni emphasised that “Uganda will become a Low-er Middle-income Country by 2017; and an Upper Middle-income Country by 2032.” (New Vision 20 April 2013). To conform to Vision 2040, MAAIF (2010) formulated its guiding mission to read “To transform subsistence farming to com-mercial agriculture”.


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Therefore Government development paradigm has shifted from focusing on the peasant as has been over the last 50 years to a new paradigm of creating a farmer of the future who will do farming as a business and will be connected to the do-mestic, regional and international markets and not as a way of life. The farmer of the future will be more educated and will demand from Government productivity enhancing services as well a policy and regulatory regime that promote market efficiency.

1.3 Where we are

While Uganda’s economic performance has been impressive judging by where the country was in 1986 at the end of the Bush War, and it is projected to grow by 7 per cent per annum over the next 30 years, the country is starting from a low level to climb to upper middle class status by 2032 as the President fore-casts. Uganda’s economy is dominated by near subsistence workers: farmers, merchants, artisans and even civil servants whose productivity is generally low. Uganda’s GNI of ($560) per capita per annum (World Bank 2012) is well below the bracket of (USD1,036 - 4,085) for Lower Middle Income, and far below (USD4,086 -12,615) which is the bracket for Upper Middle Income countries. At the projected growth rate of 7 per cent per annum, it would take the country ap-proximately 10 years to reach Lower Middle Income status (USD1,050) and ap-proximately 30 years to attain Upper Middle Class status (5,000) on a business-as-usual working mode. Should Uganda’s economic rate of growth move up to an average 10 per cent per annum over the same period, then it would take 7 years to reach Lower Middle Income Status and approximately 22 years to reach Upper Middle Income Status; close to the President’s prediction.

Over the last 20 years, the agricultural sector output grew at an average of 2.5 per cent per annum (UBOS 2012) through expansion of cultivated land and not through increased productivity. This rate of growth in agricultural output is quite below Uganda’s population growth (3.15%) and very much below the 6 per cent p.a. recommended in the CAADP framework. While 77 per cent national labour force is in agriculture (ACODE 2009), it produces only 22 per cent of GDP in-dicating that labour productivity in the sector is very low compared with other sectors of the economy. While the GDP share of the sector has been declining, the number of subsistence farmers and poverty levels in rural areas has been increasing (ACODE 2009). For the transformation of agriculture from subsis-tence to commercial to happen and in order to avoid extreme income disparities between urban and rural, most of the economic growth in future would have to take place in agriculture. Herein lays the real challenge and the real opportunity for change.


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1.4 Opportunities and challenges

Government intends to create a brave new world of commercial farmers in the space of 30 years i.e. within two generations. This dream is realizable because Uganda is gifted by nature. The country has:

A favourable climate for Agriculture

A Government committed to transformation

A state of peace and security

An expanding entrepreneurial class of young people

Discovered reasonable amounts of oil and gas (non-renewable resources) which will soon be exploited to yield revenue for investing in renewable resources such as Agriculture

An expanding local market for staple food and other agricultural com-modities

Further opportunities will arise from the growing market for fresh and processed agricultural products in the East Africa Community, the Great Lakes region, the Middle East and beyond. Additionally, due to the high labour costs in the rich nations of the world, those countries may, in future, find it more economical to import food from cheap-labour countries like Uganda than to continue to subsi-dise production in their countries.

There are also challenges to be overcome for Uganda’s agriculture to transform from subsistence to commercial. They include:

Policy Constraints

Institutional constraints

Market constraints

Productivity constraints

Constraints revolving around cross cutting issues like land tenure.

Competition from countries similarly endowed

“Gifted by nature” as Uganda prides itself, carries the connotation that all is well and has resulted in complacenceWidespread corruption


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2. Key Challenges to Achieving Agricultural Transformation

The challenges facing the agricultural sector in Uganda have been reviewed ex-tensively in many publications (ACODE 2009, USAID 2010, NPA 2010, MAAIF 2010, Bategeka et al 2013). This paper will only deal with a few of them which the author considers critical for transformation to take place and which are often overlooked or understated.

2.1 Lengthy Policy Visioning Process

Uganda Vision 2025 (http://openlibrary.org/books/OL145026M/Uganda_vision_2025) was published in 1998 after long and costly consultations and dis-cussions throughout the country and beyond. It was never implemented; Govern-ment and development partners behind its formulation offered no explanation for its disappearance. Then, in 2007, Cabinet authorised the formulation of Vision 2040. It was published in 2010; three years after authorisation and was launched this year – three years after publication. Thus it has taken the Government bu-reaucracy 18 years (1995 -2013) to come up with a national vision. What hap-pened or did not happen in the interregnum and why, could be a subject of study and reflection by the Academy.

Further to date, there is no evidence that Government has launched a vigorous sensitisation exercise and that Government departments, Local governments, Parastatal agencies, Political parties, Faith based organisations, NGO’s, CBO’s and the private sector are planning and working towards achieving Vision 2040. The time for achieving stated targets is short. It is only 4 years left to achieve the President’s goal of Lower Middle Income status by 2017 and 19 years (2032) to attain Upper Middle Income status i.e. GNI per capita of USD9,500 starting from the low GNI of USD560 pc/pa and this is clearly an uphill task.

2.2 Agriculture accorded low priority

The most important constraint in my opinion is policy inconsistency or ambigu-ity with respect to the place of Agriculture in the National Economy vis-à-vis budget allocations to the sector. Kiwanuka (2013), the Minister responsible for Finance in her Budget Speech 2013/14 states in paragraph 91 “Agriculture con-tinues to play a critical part in our economy, employs 66 % of Uganda’s labour force and has great potential to transform the economy” and Agriculture accounts for more than 50 per cent of exports. But in paragraph 92 she states “Agriculture is a private sector activity, for which Government will continue to provide sup-port towards its further development in research, seed multiplication and certifi-cation, and disease control.” The impression given in the 2013/14 budget speech


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is that Agriculture is a primary concern of the private sector and only a secondary concern to Government.The agricultural sector,

is the cash cow of the economy, has the potential to transform the co untry from a Low Income Country to a Middle Income Country or even higher,is populated by poorest people in the country.

It is clearly a sector of strategic and fundamental importance in Uganda for which the Government must bear full responsibility. As the economic lifeline of Ugan-da, it seems a serious contradiction to expose the sector, almost fully, to the tur-bulence of the global market place knowing full-well that agriculture is heavily subsidised in countries where farm populations are less than 2 percent of total population.

With such a mind-set at the centre of Government, it is of little surprise that Agriculture is ranked low in terms of budgetary allocations (Tibaidhuka 2011, PWC 2012). Over the last 10 years Agriculture share of the budget has been 3.8 per cent well below the 10 per cent stipulated in the Maputo Declaration. Alloca-tion to the sector 2013/14 financial year is UGX403.6Bn below UGX 455.9Bn in the MTEF ceiling and quite below UGX 581.9Bn suggested in DSIP for year 2013/14. Further, in most years budget releases from MFPED to MAAIF is 60-70 per cent of the budget approved by Parliament.

Table2. Uganda Budget Allocations by Sectors for the financial year 2012/13.

PRIORITY SECTOR PERCENTAGE1. Transport 15.22. Education 14.93. Energy and Minerals 14,94. Administration 13.65. Security 8.56. Health 7.87. Accountability 5.48. Justice, Law and Order 4.89. Agriculture 3.510. Water and Environment 3.311. Others 8.1

TOTAL 100.0 Source: www.pwc.com/ug


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seen that during that fiscal year Agriculture was priority number 9 with a budget share of 3.5 percent. During this fiscal year 2013/14, the allocation dropped to 3.08 percent (http://devanalyst.com/?p=601). Therefore budget allocations to the agricultural sector do not seem to be consistent with public pronouncements that Agriculture is the backbone of the economy of Uganda and its engine of growth. For as long as:

governments ambivalence towards the agricultural sector prevails and

in the absence of significant economic stimuli for the rural sector, the journey “towards socio-economic transformation for Uganda” (which is the theme of the 2013/14 budget speech) may begin with fault starts.

2.3 Lack of an Indigenous Development Model

Every country has a development model (written or not) which serves its eco-nomic, social and political interests. During the pre-independence period, Britain operated a model (as she did in all other colonies) for extracting raw materials from Uganda to support British industries. That the natives got cash for their la-bour was a secondary consideration intended as a bait. Thereafter and up to the early 1980’s successive governments of Uganda more or less unwittingly con-tinued to implement that colonial model believing that it would primarily benefit Ugandan citizens.

From the early 1980’s up to now Development partners (most of them former co-lonial masters) introduced an era of Structural Adjustment Programmes (SAPs) in many developing countries including Uganda. These programmes were con-ceived, managed and monitored by Development partners with client countries playing the role of guided implementers with little local analysis and apprecia-tion of outcomes of the programmes. Mkandawire and Soludo (1999) captured this situation when they stated thus: “The tragedy of Africa’s policy making and policy implementation in the last several years is the complete surrender of na-tional policies to the ever-changing ideas of international experts” and “the first important thing Africans can do is to reassume responsibility for plotting the paths of development in their respective countries”.

With Privatisation, Liberalisation, Democratisation and Decentralisation as hall-marks, this era introduced sweeping reforms in all the economic and social sec-tors of Uganda’s economy including agriculture. With more than 20 years of implementing SAPs, there is little evidence for a causal relationship between these reforms and economic growth of recipient countries (Collier and Gunning 1999, Easterly 2005). In fact, in Uganda, statistics show (UBOS) that agricultural


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growth during the SAP era has been stagnant. Further, several reports show that these reforms may have had benign or negative effects on agriculture generally (Boussard 1992, Opio 1996, Schatz 1994, Ansah 2006, Bertow and Schultheis 2007, Bategeka et al 2013) and in Uganda may have caused institutional instabil-ity as is discussed later.

Whether or not SAPs implemented in Uganda have sustainably put more money in the hands of poor farmers in the agricultural sector rather than in the hands of speculators or the corrupt; both local and foreign; would be an interesting topic for UNAS to study with a view of providing “merit-based advice” on de-velopment models suitable for the long term economic and political interests of Uganda.

2.4 MAAIF Architecture

The dismembering of the sector ministry of Agriculture started in the 1970’s with the transfer of the planning function of the ministry to the Ministry of Finance and later to the Bank of Uganda to form the Agricultural Secretariat. Currently the functions of the ministry are spread over several ministries e.g. Water & En-vironment, Trade and Industry, Education, Finance and Local Government. Even though the Plan for Modernisation of Agriculture (PMA) and National Agricul-tural Advisory Services (NAADS) are nominally under MAAIF effective control of these important agencies is vested in the ministry of Finance. The extension function is statutorily under NAADS, but the Ministry’s Extension department was never abolished resulting in a double spine extension system. Coordination of the sector activities which are dispersed in so many ministries will inevitably constitute a challenge in the efficiency in the transformation process.

2.5 Institutional instability

The institutional reform programmes were accompanied by a considerable degree of institutional instability which is still on-going. With regard to extension, Gov-ernment operated the remnant of the colonial “command” extension system. The reforms brought in the Unified Extension System which was a modification of the Training and Visit (T&V) system formerly practised in India. The system seemed to be working well for 5 years. But without documenting the lessons learned from the new Unified Extension System, yet another new system, NAADS, was introduced. NAADS was supposed to be a “demand driven, client oriented, and farmer-led extension system targeting the poor”; an idealistic objective which has proved difficult to realise in the prevailing socio-political context (Rwakakamba et al 2011).


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Although it has been evaluated well by development partners and government of-ficials, it has attracted a lot of criticism judging by press reports and reactions of farmers. The President of Uganda has castigated the programme and suspended NAADS several times and he has threatened to scrap it all together (Wesonga 2013). In the state in which NAADS finds itself today, it does not seem to be a suitable instrument for agricultural transformation as envisaged in Vision 2040.

Similarly, the research arm of MAAIF has suffered the same fate. Established during the colonial era, it remained a colonial model until the institutional re-forms when it was re-configured as the National Agricultural Research Organisa-tion (NARO). NARO appeared to be working well and was considered a system worth adopting by some African countries. But without scientifically document-ing successes and failures in its implementing, NARO was subjected to a reform process that lasted 5 years. The reforms of the agricultural extension and research system was originated externally and were conditions for Uganda receiving do-nor money (most of it borrowed) for undertaking extension and research services. Institutions which are in a state of perpetual change lose focus and are unlikely to deliver agricultural transformation.

These two programmes are now supposed to be implemented under a new um-brella programme known as Agricultural Technology and Agribusiness Advisory Services (ATAAS) which was launched in 2011. In practice they operate in-dependently with little practical coordination. The ATAAS Programme was de-signed to build on “the accomplishments of the NAADS programme recently completed”. But in actual fact the accomplishments of the NAADS programme are questionable (Bategeka et al 2013).

2.6 Low capacity for implementation, monitoring and evaluation Uganda is credited with having good policies and programmes but faulted on im-plementation, monitoring and evaluation. Programmes are implemented without enforcing performance indicators rigorously. Major programmes under MAAIF are financed, monitored by donors and evaluated either by the donors themselves or by their appointed agents. For reputational purposes evaluation reports of do-nor funded projects can be expected to be and are almost always positive. It is not clear that Government carries out independent value-for-money audits on completed government projects; whether donor funded or not. A clear example is the PMA whose mission was “to transform subsistence agriculture to commercial agriculture”. It is not clear as to what extent this mission was accomplished. Fur-ther, Government of Uganda does not enforce performance or service contracts


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in any of its departments or agencies. In the absence of a rigorous implementa-tion, monitoring and evaluation regime and transparent value for money audits, it is difficult to forecast that agricultural transformation will be achieved in the set time frame.

2.7 Market institutions and value addition African farmers in Uganda early in the 20th century could not realise the full bene-fits from farming because they went through opportunistic middlemen in order to market their produce. They therefore, braving colonial government obstructions, established their own cooperatives to market and add value to their commodities (Kyazze 2010, CBR 2013). By the time of independence several strong Coopera-tives had been established in Mengo, Lango, Teso, Masaka, Bugisu, Bunyoro, Ankole, Busoga and elsewhere. These cooperatives flourished and grew stronger in the period immediately following independence to the extent of establishing the Uganda Cooperative Development Bank in 1964 (UCA 2003). However po-litical interference gradually eroded their independence and the economic and political turmoil between 1971 and 1986 further threatened their existence. Nev-ertheless the cooperative unions as well as the Cooperative Development Bank survived until the SAP reforms of the late 1980s and early 1990s when they were privatised or abolished (Bategeka and Okumu 2010).

The cooperatives in their time provided inputs including credit, facilitated mech-anisation, bulked and processed produce (added value) and handled local and in-ternational marketing. They also provided loans for school fees and constructing of houses for members. In many ways cooperatives operated a warehouse receipt system (currently being rediscovered). Their disappearance created a lacuna for opportunistic local and international business people to exploit unorganised or poorly organised farmers. Gone too, is the cooperative spirit of mutual trust along with the institutional memory accumulated over many years.

It is interesting that today NAADS, Uganda Cooperative Alliance (UCA) and various NGOs are encouraging farmers to form producer groups, area coopera-tive enterprises and Savings and Credit Cooperatives (SACCOs), a development stage that had been attained especially by coffee farmers in the 1950s. Neverthe-less, the UCA model seems to have the most potential for reviving a cooperative movement that will create the farmer of the future. This model is experiencing many problems including financial mismanagement (Kyazze 2010, CBR 2013). Also the model lacks an appropriate institutional and regulatory framework which can protect the interests of the co-operators.


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2.8 Dependence on rain-fed agriculture

Drought affects agricultural production in Uganda and elsewhere in Sub-Saharan Africa almost every year. Yet drought episodes alternate with rainy seasons and this is a well-known fact. These episodes can be managed in the same way winter is managed in the temperate zones. While the temperate zones people have learnt to cope with prevailing weather patterns, Africans have shamefully failed to cope with weather variability and especially to manage drought. Even though Africa is endowed with abundant freshwater resources, Sub-Saharan Africa has failed to harness this enormous irrigation potential in the continent.

In Uganda there are plenty of opportunities for irrigation (Carruthers 1970, MWE 2011). Land suitable for irrigation is 7.6MHa and 2.4MHa for upland and low-land crops respectively. Land currently irrigated is 9,150Ha which is about 0.1 percent of cultivated land. Pressure on freshwater resources due to irrigation in Uganda is 0.18% while in Kenya it is 7.05%, Egypt 102% and Libya 512% (FAO Aquastat 2012. The irrigation schemes developed many years ago are not being utilized fully. For example only 500 acres at Mubuku are being utilized out of a total of 2000 acres. If all the irrigable land in Uganda cold be utilized, Uganda would feed the rest of East Africa given the fact that there are 2 rainy seasons a year and irrigation would only be required to tide the crops over relatively short dry spells in most years.

Without exploiting the enormous irrigation potential of the country the problem of unpredictable rain patterns will continue constraining farmers and will certain-ly frustrate the transformation of agriculture from subsistence to commercial.

2.9 Expensive Agricultural Finance

The most critical non-biophysical factor constraining commercial small and me-dium farming enterprises in Uganda today is expensive agricultural finance (Mu-nyambonera et al 2012). As can be seen in Table 3 Government has launched several initiatives intended to avail farmers with affordable agricultural finance. None of these initiatives have been a notable success. Causes of failures ranged from weak institutional frameworks, inadequate financing, weak regulatory frameworks, limited access, narrow outreach, political interference, loans not eq-uitably distributed and credit market distorting.


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Table 3. Agricultural Financing Initiatives and Implementation Problems

N/S INITIATIVES IMPLEMENTATION PROBLEMS

1. Endandikwa-1996 Weak institutional framework for implementation

2. The medium term competi-tive and Investment strategy (CICS)

Inadequate financing

Narrow outreach

Weak institutional framework for coordination and implementation

3. Rural financial services programme of 2005-2008

Weak regulatory framework for MFIs and SACCOS

4. Prosperity for all (PSA)-2008

Limited access

Government failure to allocate resources in time

Political interference5. The National Agricultural

Advisory Services (NAADS)-2001

Weak institutional framework for coordination, financing and implementation

Inadequate financing to cover a good number of farmersPolitical interference

6. The Microfinance Support Centre Limited (MSCL)-2005

Loans not equitably distributed in all zones

The MFIs and SACCOs shift ed from the initial objective of low

credit provision to purely trade at rates competing with commercial banks and some times higherLack of effective regulation, monitoring and supervision


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7. Agricultural Credit Facility (ACF)-2009

Biased credit facility to agro pro-cessing and value addition for medium and large scale farmers

Did not cover production inputs such as fertilisers, fungicides and pesticides which are important for small holder productivity gains

The facility is blamed for being credit market-distorting

Source: Munyambonera et al 2012

It is clear from these and other examples that issues relating to agricultural fi-nancing did not receive careful consideration before being launched. This needs to be done. Munyambonera et al (2012) recommend the establishment of a rural or agricultural development bank that prioritises agricultural financing.

2.10 Inappropriate land tenure systems

In 1900, the colonial administration engineered a treaty with Buganda which per-manently altered the traditional land tenure system in use before then. Under the traditional system, land was held by the King in trust for all his subjects. No one, including the King himself, till then had exclusive ownership in perpetuity of any piece of land in the kingdom. For reasons beyond the scope of this paper, the British allocated land to some 3,000 chiefs (in reality civil servants of the King– and to the sovereign King who was at that time an infant. For the first time in the history of Buganda, farmers were dispossessed of land and they became tenants or squatters on land they previously farmed without any hindrance. Today, more than 110 years later, land has been severely fragmented through inheritance and or selling as well as a continuous influx of immigrants in most high potential farming districts. As a result, there is a growing class of landless people who need farm land.

The abolition of the 1975 Land Reform Decree and the enactment of the 1998 Land Act in effect created a situation of overlapping land rights. This situation is already causing (sometimes severe) civil unrest in Central Uganda and the Mid-west. In other parts of the country where land is believed to be communally owned, disputes between communities are rampant (Rugadya 2009).


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The land tenure system is made worse by the haphazard settlement pattern of Ugandans. For although currently cultivated land constitutes 36 per cent of all land suitable for cultivation indicating that Uganda is still land-rich, the 64 per cent of apparently free land, is scattered haphazardly between human settlements making it unavailable for large scale farming. The present toxic land tenure sys-tems coupled with the absence of a land policy conducive to the emergence of modern farming may well hinder the transformation from subsistence to com-mercial agriculture.

2.11 Gender Inequity

Challenges faced by women in agriculture have been extensively documented (MAAIF 2010, FOWODE 2012). Nationwide, 72% of all employed women and 90% of all rural women work in agriculture. In addition to challenges faced by all small scale farmers women are further constrained by limited land rights, child bearing and child care obligations, domestic chores, and disease viz. malaria, HIV/AIDS. Although the Land Act 1998 as amended provided a framework for enhanced security of tenure, implementation has been a challenge particularly with regard to women.

A study by Peterman et al (2010) showed that the productivity of female owned plots and female-headed households in Uganda is lower than men’s. In addition women’s role in agriculture is traditionally confined to producing food crops and their role in the production and marketing of cash commodities such as coffee, cotton, fish and cattle is limited. These findings partly explain the low productiv-ity of the agricultural sector overall since women dominate farming in Uganda; and the significant disparities between men and women in sharing benefits from agricultural production.

3. Actions Required to Achieve Transformation

From the foregoing account and from a lot more literature not cited in this paper, it is clear that a lot of effort and thinking out of the box will be needed in order to successfully address challenges and opportunities, relating to the process of transforming Ugandan agriculture from subsistence to commercial. Interventions will have to be prioritised, phased and sequenced. This author is proposing the following actions for purposes of discussion:


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3.1 Deepening understanding and ownership of Vision 2040

Vision 2040 as presented by the President is the ideological guiding star for all people living and working in Uganda whether they are Ugandans or not. No les-son can inspire young people more than the promise of a better life such as is embodied in Vision 2040. Further Vision 2040 creates, perhaps, the first political opportunity for Ugandans to have and to cherish a Common Symbol of National Unity. It is the essence of patriotism.

Therefore government should take immediate steps to:

Mount a vigorous and carefully planned awareness campaign for all min-isters, all members of Parliament and local councils, all civil servants in the Central and Local administrations, all security personnel, all universi-ties, schools and other educational institutions, all leaders of Faith Based organisations and CBO’s, all leaders of cultural institutions and all lead-ers of private sector institutions.

Require all government departments and agencies to align their pro-grammes and activities with Vision 2040 and to draw up performance contracts for all employees showing clearly how their activities will con-tribute to the attainment of Vision 2040.

Require all schools to make 2040 part of an examinable subject at O and A-levels

Require all local and international NGO’s to align their programmes with Vision 2040

In short Vision 2040 must become the Bible /Qur’an of the Government of the Republic of Uganda, in all sectors, for the next 30 years.

3.2 Policy Formulation

One of the reasons for poor implementation and follow-up is policy conceptuali-sation of policies and programmes that are generally done overseas by persons who (however bright and well-intentioned) have book knowledge of the country. Ugandan politicians and professionals are co-opted later for purposes of securing local endorsement. Originators of concepts are much more likely to retain memo-ry and ownership of concepts than co-opted persons. When these thought leaders go away and their co-opted nationals retire or change jobs, institutional memory is easily lost. So it is important for nationals to be in the driver’s seat both as thought leaders and implementers. This consideration is especially important for location-specific challenges such as are found in Agriculture.


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Government should therefore identify indigenous thought leaders through a transparent process to lead policy conceptualisation and formulation

3.3 Agricultural transformation

The agriculture will continue to be, over the life span of Vision 2040, the domi-nant sector of the economy of Uganda and will also drive Vision 2040 because of the number of poor people in that sector. Moving the country from Low Income to Upper Middle Income Status will be determined by what happens or what does not happen in the agricultural sector. The country needs a deliberate policy which recognises this fact and therefore Government should:

Develop a New Policy which places Agriculture and Rural Development at the centre of Uganda’s Economic Development

3.4 Land Tenure

Land is an important and essential factor of production and needs to be accessed without hindrance by all those who want to use it for farming. Uganda has com-plex land tenure systems and land law and these are increasingly becoming dis-incentives to rural development. Government should:

Amend the 1995 Constitution and the Land Act to create a more uniform and/or simpler land tenure system throughout the country paying particu-lar attention to gender equity.

3.5 Agricultural Cooperatives

Cooperatives have played a critical role in promoting agriculture and community welfare and development in many countries the world over. In Uganda they were important in creating economic awareness and were an important avenue for eco-nomic empowerment of rural people for most of 20th century until they were phased out during the implementation of the structural adjustment programmes; leaving the rural areas without a community based development framework. Government has been talking for a long time about reviving cooperative unions. The Kenya Tea Development Authority (KTDA) which is a successful farmer owned institution as well as cooperatives of tea growers in Uganda should serve as useful templates.

Government should revive farmer owned agricultural cooperatives as a matter of urgency.


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3.6 Establishing Institutions that will service the Farmer of the Future

President Barrack Obama on his first official visit to Africa stated that “Africa doesn’t need strong men, it needs strong institutions: Get your act together”. Uganda needs to establish institutions that will lubricate the wheels of transfor-mation from subsistence to commercial agriculture. The following institutions which have been mentioned in various publications as essential should be estab-lished:

National Irrigation Development Board (NIDA)

Uganda Cooperatives Regulatory Authority (UCRA)

Agricultural Development Bank (ADB)

3.7 Agricultural education

Farmers and service providers in the agricultural sector will require training in key areas that will drive the transformation process, such as basic and applied sciences, the social sciences and specific soft skills. The farmer of the future will require practical farming skills and access to information on farming locally and globally.

Agricultural faculties traditionally offer courses in agricultural sciences usually covering production aspects. University level agricultural education and training will now have to extend its reach beyond production and productivity to cover whole commodity chains from production to consumption. Modern Agriculture goes beyond milking cows and picking coffee berries. So new curricular will have to be designed to service the famer of the future. Agricultural Colleges of the 1950’s and 60’s such as Arapai and Busitema have become universities and abandoned the practical skills that they used to teach in the past. While these colleges produced mid-level extension staff, the farmer of the future who will not be an amateur but a full time professional farmer will need to be equipped with skills through formal training. Farmers without formal education emerging from subsistence to commercial farming (such as we have today) will also need training on the job. This kind of training was in the past offered at District Farm Institutes (DFIs) before they were phased out following SAPs of the World Bank. Agricultural transformation will call for new approaches to agricultural educa-tion and training and Government:

Require all university level agricultural institutions to overhaul their cur-ricular to embrace the whole-commodity-value chain approach for mana-gerial type graduates and scientists


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Establish Regional Agricultural Colleges (e.g. Kabale Teso, Busoga, Kar-amoja, Bugisu etc.) offering Diplomas in Farm Management (DFM- not degrees) to farmers of the future

Re-establish District Farm Institutes (DFI’s) to train emerging commer-cial small holders in practical farm management and farm business skills all districts.

3.8 National Professional Bodies

Vision 2040 offers and opens a unique opportunity for academia and intellectuals to offer (or to demand to offer) their services to their country. The government should also seize the opportunity of using the services of its own experts who have been trained at great cost to the same government and whose expertise is either used by foreign or are lying unutilised. It would cut costs, build national capacity and institutional memory. Therefore

All National professional bodies should align their mission statements, objectives and activities with Vision 2040

UNAS as an eminent body of Scientists offering independent merit-based advice for the prosperity of Uganda, should organise a scholarly con-ference to review progress made by each sector (Agriculture, Health, Education, Geology, Energy, Transport etc.) during the first 50 years of independence so as to provide Government with merit-based advice on what worked, what did not work and why; and lessons learnt which can guide the match to Vision 2040

GOU should require that all donor funded projects must involve the participation of Ugandan consultants selected on a competitive basis.

4. Conclusion

This paper is a brief review of the challenges and opportunities in transforming Agriculture in Uganda from a near-subsistence form of farming to commercial Agriculture leading to wealth and job creation especially in rural areas and it has suggested some actions necessary to bring about that transformation. In conclu-sion the paper is suggesting that the Government of Uganda adopts the following as drivers of a home grown Green Revolution moving to Vision 2040:

Crafting and implementing home-grown policies that target agricultural and rural transformation

Operationalization of the Irrigation Master Plan already developed in 2010


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Increase investment in Innovations, Technology Development and Dissemination

Professionalising farming by establishing Farm Schools and Colleges

Expediting the development of the fertiliser industry in Uganda and East Africa

Promoting the development of Agro-processing and Value addition infrastructure in every sub-county

Promoting a marketing and agricultural financing infrastructure based on producer owned cooperatives


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Bategeka L and L. J. Okumu (2010). Banking Sector Liberalisation in 5. Uganda: Process, Results and Policy Options . Research Report. SOMO; pp43

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Boussard, JM (1992). The impact of structural adjustment on small hold-7. ers. FAO Economic and Social Development Paper No103; pp81

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FOWODE (2012). Gender Policy Brief for Uganda’s Agriculture Sector 13. pp18


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MFPED (2013). Government Outlays Analysis Report FY 2010/2011; 19. pp48

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Munyambonera (2012). Access and Use of Credit in Uganda: Unlocking 22. the Dilemma of Financing Small Holder Farmers. EPRC Policy Brief No 25; pp4

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Ownership and Accountability for Health Outcomes in Uganda: The Role of Stew-ardship and Leadership: Looking 30 years back and 30 years forwards.

Prof. Francis Omaswa, Executive Director, ACHEST

Introduction 1.

I want to start by thanking the Uganda Academy of Science for inviting me to speak at this Annual event for the Academy. I should have spoken last year but there was a scheduling conflict which has proved to be a blessing in disguise because this paper is presented during a new and more hopeful time within the Health Sector in Uganda and globally. The Mid-term review is taking place, new Ministers have been appointed and the opportunities for up-take of the contents of this paper appear to have a better chance.

African Centre for Global Health and Social Transformation (ACHEST)

The African Centre for Global Health and social Transformation (ACHEST) is an independent Think-Do tank whose mission is to develop, test and promote evidence-based and technically sound policies and strategies and to apply these to build professional and institutional capacity for program implementation that are owned and driven by African populations themselves. Our vision is that of Africa as a people driven continent enjoying the highest attainable standard of health and quality of life. We undertake studies and apply the results in two ar-eas namely Health systems governance, leadership and management and health workforce education, training and retention. We have a team of 20 staff at our office in Kampala and another 7 Faculty of medical education leaders based in seven universities across Africa. We are the Secretariat of the APHRH and of Ashgovnet.

The material that I will be presenting in this paper is based largely on the work that has been done by ACHEST and include studies on Health Sector Reforms in Uganda, Leadership development, Tracking Health Workers, Strong Ministries for Strong Health Systems and Health Resource Partner Institutions in five Afri-can countries (HRPIs)

The purpose of the paper

This paper has been developed at the request of the UNAS and is intended to stimulate dialogue on the health sector in Uganda at a time when a new political leadership has been installed and a time when there is restlessness in the popula-tion on the state on health services provided by the public sector.


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The paper attempts to be objective and makes specific and concrete recommen-dations for action.

Frame of the paper

The paper discusses:

The concepts of health and health outcomes, its production and owner-•ship as distinct from health care

Accountability for Health Outcomes•

Functions of stewardship/governance for health•

Players and their roles •

Performance review of Health sector reforms over past 30years and •

Recommendations for immediate action and the future•

Concepts of Health and Health Outcomes2.

Health:

The WHO Constitution states that health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, and that the enjoyment of the highest attainable standard of health is one of the funda-mental rights of every human being without distinction of race, religion, political belief, economic or social condition. It is enshrined in the Universal Declaration of Human Rights acknowledges that everyone has the right to a standard of liv-ing adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. These two key positions were adopted by the international community immediately af-ter the Second World War. It was also the vision and message of the historic Alma Atta Declaration in 1978 and re-examined and reaffirmed as still valid by WHO during the 30th Anniversary of the Alma Atta Declaration in 2008. It has been now reinforced by the Report of the WHO Commission on Social Determinants of Health.


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The key point to note here is that health as defined by WHO and the UN Hu-man rights Declaration is broader than absence of disease. It is about wellbeing; mental, physical and social that goes with access to basics of life such as food, shelter, security and medical care. During this discussion, I will be arguing that most of the current approaches that purport to ensure access of populations to the highest attainable standard of health as defined by WHO have missed the point. They have focused too much on disease and its prevention but not on proactively creating the conditions that enable individuals and populations to remain healthy as they were created.

Health is made at home

“Health is made at home and only repaired in health facilities when it breaks down. Be clean, eat well, and do not share accommodation with animals. This is a message from the Director General of Health Services”.

In 2000, as Director General of Health Services in Uganda, I had this statement recorded and played several times a day in different radio stations in the country until I left the job in mid-2005. Our starting point is that 94% of human beings are born completely normal and healthy, devoid of birth defects and can live in good health for long periods of time until old age without losing their health and without needing medical care to restore it. Indeed the human body is designed in such a way that it is capable on its own of making highly informed choices on how to maintain well- being and defend itself from health risks. In physiology, we are taught about Homeostasis by which the body’s internal environment is maintained in a steady state through very complex feed-back mechanisms. For example, when it is hot, we sweat so that the sweat evaporates and cools us; when it is cold, we shiver to generate heat, when we are short on water, we feel thirst and when we have too much water in the body, the kidneys produce urine to get rid of excess water and other unwanted metabolites … and so on and on. Effort-lessly day in day out, month in month out, year in year out; the body’s state of well-being is maintained through these in-built mechanisms.

It is therefore evident that the primary responsibility, ownership and account-ability for maintaining uninterrupted healthy life through the life course i.e. from the womb to the tomb rests on the shoulders of individuals, households, families and communities. The mothers, fathers, clan, other cultural and religious leaders, and local administrators are the faces of the key actors. Each individual should not take their health for granted but should appreciate and celebrate the fact that they have health and are working hard to protect it and support the body’s own internal homeostatic mechanisms and ensure that their healthy status is not taken


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away or lost. A key role of the health system should be to ensure that individuals continue to remain healthy and do not lose their health and will not need avoid-able health care. This can be achieved by promoting and embedding awareness also known as health literacy, and health seeking behaviour into the routine of life of the population, identifying and highlighting health risks and either removing them or facilitating behaviour that favours health.

However, there is a catch; even when individuals know what to do or what to eat, they still need access to the healthy food, clean water, adequate housing, educa-tion and other key determinants of health or they will not be able to realize their full health potential. To address these needs, it is the governments that are called upon to shoulder the ultimate responsibility for assuring the conditions in which people can be as healthy as they can.

We face another challenge and another catch. The pressures to society and gov-ernments to pay more attention to the needs of repairing and restoring lost and broken individual and community health are stronger than those to promote and protect existing health. An injured person has to be attended to immediately, a baby must come out and be born now, a child convulsing from an attack of ma-laria has to be rushed to a health facility straight away as does a middle aged man who has had an attack of intestinal obstruction. An epidemic in one country puts the whole world on alert. As a result, this drama of providing health care is the more easily visible face of the health system receiving more attention and more resources than the movement to promote and maintain individual and population health.

There is also encouraging news. The movement in support of encouraging popu-lations to jealously protect and promote their inborn health is taking root albeit with fits and starts. It was envisioned at the creation of the WHO Constitution, it is enshrined in the Universal Declaration of Human Rights, it is the vision and message of the historic Alma Atta Declaration in 1978 and was reaffirmed is still valid by WHO during the 30th Anniversary of the Alma Atta Declaration in 2008. It has now been reinforced by the Report of the WHO Commission on Social Determinants of Health.

In order to get the balance right between health care and preserving and maintain-ing existing population health and well-being, it takes leadership, exceptional and visionary leadership to ensure that national health action is focused on enabling individuals, families and communities to make health in their own homes and communities and reducing the need for avoidable repairs through health care. It calls of concerted, consistent cross-sectoral, cross-cultural, community, national,


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regional and global action. This action in turn calls for leadership that will ensure that the governance and management of society at all the above levels has the health of the population at the center.

Fortunately, African populations do not need convincing that their health is im-portant to them. According to Participatory Poverty Assessment Studies carried out in Uganda, when the poor are asked what causes their poverty, the most cited answer is poor health (67%). When the question is reversed to “what is the most likely effect of poverty to you?”; the most frequently cited answers were “poor health and death”. Yet effective and educated demand for better health services from the general Ugandan population is weak. It takes mobilization for families to immunize children fully, attendance at ante natal clinics for the four recom-mended visits is poor, diseases are reported late and worse still patients do not demand for quality health care. They will visit a clinic, find no health workers and no drugs and just shrug their shoulders and go home and seek other remedies. They do not stand up to demand an explanation as to why the services are not provided.

The Rio Declaration on Social Determinants of Health (5) acknowledges the cen-trality of governance and leadership in achieving the objectives of the declaration by calling upon the international community to:

- Adopt improved governance for health and development; - Promote participation in policy-making and implementation; - Further reorient the care delivery system towards promoting health and reduc-ing health inequities; - Strengthen global governance and collaboration; - Monitor progress and increase accountability.

Health and sustainable development: Do we have to prove that health is important?

In private conversations with all types of leaders and during funerals and other social gatherings, no one argues against the prime position of health as a prereq-uisite for everything; economic productivity, school attendance and indeed hap-piness itself. However when it comes to allocation of resources for making, pro-moting and restoring health, health gets relegated and classified as a consumptive and non-productive sector; low in priority! Inexplicably we have to work very hard to justify the need to invest in the health of the people.


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Fortunately, there is change in the horizon. The post 2015 development agenda is being debated at a time when sustainable development is in the political fore-ground. While the first draft of the Rio + 20 outcome document was disappoint-ing, health is relatively well reflected in the final version of “The Future We Want”. In this document, there is recognition of the fact that healthy people have stronger cognitive and physical capabilities and, in consequence, make more pro-ductive contributions to society; health policy contributes to poverty reduction through the financial protection inherent in universal health coverage. Changes in population growth rates, age structures and distribution of people are also closely linked to national and global development. In addition, health is also a potential beneficiary of policies in a wide range of other sectors such as transport, energy and urban planning. And health metrics can measure progress across the eco-nomic, social and environmental pillars of sustainable development.

Health outcomes can be defined precisely and are measurable, and health con-cerns are immediate, personal and local. Measuring the impact of sustainable development on health can generate public and political interest in a way that builds popular support for policies that have more diffuse or deferred outcomes (such as reducing CO2 emissions)1. Similarly, health is an important component of other “holistic” approaches to development that seek to replace or supplement GDP as the main indicator of economic progress.

Ownership of Health Outcomes

Country ownership in this context means that governments recognise and ac-cept that they are accountable for the health of their populations and have the ultimate responsibility to do all in their power, on their own, and with the active participation of the people and in collaboration with external partners as needed. The foundation that makes country ownership an imperative is the thesis that sustainable change is endogenous and must come from within the country, the community and the people who benefit from the change. ‘Only that change that comes from the communities themselves is sustainable.’3 Due to a variety of fac-tors such as economic collapse, poor governance, the cold war, and devastating epidemics and famine, Africa has become a continent for global pity and deemed not to be able to take care of itself and in need of outside help for both resources and worse still for ideas and solutions as well. This is what we need to change, to make Africans regain confidence in themselves and know that it is up them to lead and cause the change that they desire. Friends and partners from outside only come to help.


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The challenge of realising and demonstrating country ownership has three sets of actors. The first are African governments. African political leaders collectively through the African Union and sub-regional groupings have demonstrated com-mitment reflected in the several summits they have held on Africa’s health. Ex-amples include several Abuja summits on HIV and other infectious diseases, on malaria and recently the Neonatal, Child and Maternal Health summit in July in Kampala; there is also now an African Union Health Strategy. However, there is a huge implementation gap for those many resolutions and declarations and Afri-can health indices are not good with only a few countries on target to achieve the MDGs. Stronger governments are essential for Africa to transform. The second actor is African Civil Society. The demand side for good governance and better health systems needs to come from the people so that these issues become the ones against which elections are lost and won and against which accountability by governments can be monitored and enforced. It is not in the interest of most governments to have strong civil society that hold them to account but good governments should be prepared to support and fund civil society and human rights activists in their countries as partners and not adversaries. The third actor is the international community. The last decade has seen most developed countries supporting country ownership as evidenced by principles in Swaps, the Paris and Accra declarations, and IHP+. The government of the USA through the Global Health Initiative now embraces shared responsibility and country ownership as a central tenet of its foreign policy. There is a large and active movement of in-ternational civil society organisations that are active in African health. Some of these acknowledge and support country ownership. Unfortunately we are strug-gling with others who see African counterparts as enclaves to extend their own missions and are very patronising. The encouraging global movement in support of country ownership should provide Africans with the space that we have been clamouring for to demonstrate that we care about our people and are accountable to them. This is an opportunity which African governments, civil society, and our global partners should take full advantage to generate and entrench internally generated and sustained transformation in the way we govern ourselves and en-joy the highest attainable standard of health like other people in the world.

Accountability for Health Outcomes

A practical approach to defining accountability is to present the accountability framework that was developed by Working Group on Accountability for Results of the UN Commission on Information and Accountability for Children and Women’s Health in 2011. It consists of three separate but related activities. First, is monitoring which means acquiring data to find out what is happening, where, and to whom.


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Second is Analysis and Review: to establish whether pledges, promises, and commitments been kept by all stakeholders The third element of accountability is Action or Remedy on what needs to be done to put things right or maintain and accelerate progress? This cyclical process of monitoring, review, and action publicly recognizes success, draws attention to good practice, identifies short-comings, and recommends what needs to be done. This framework applies at all levels, individual, community, government, country stakeholders and the interna-tional community. According to Charles Boelen the following constitute the do-mains of Social accountability: relevance to ensure that the priorities of societal needs are met, quality to ensure that the interventions are achieving objectives, cost effectiveness to ensure that there is value for money and finally equity to ensure that no one in society is left behind. Metrics are at the centre of account-ability which means that countries need to have robust and effective Information Systems for health and that relevant indicators need to be agreed and used both for health status and as coverage that are segregated to address the equity domain of accountability.

Stewardship and leadership3.

Definitions of stewardship, leadership and governance

Stewardship of Outcomes

According to the Oxford dictionary definition, a steward is one who is entrusted with the management of things belonging to another or acts as a supervisor or administrator of the finances, property for another or others. This designates the role of government as protector of the public interest and, in a unique sense not applicable to non-governmental entities, responsible to the public for its actions.

The ministry of health as a steward must do more than ensure that care is deliv-ered. It must work effectively across government—with ministries of finance for resources; with ministries of education on health professions training and health education in schools with ministries of economic development, water, ag-riculture, housing and transportation, as well as with those ministries effecting decisions on centralization and decentralization of government and civil service reform and with parliament to gain political support for healthy policies. Minis-tries in some countries must also relate to specialized parastatal agencies often created to perform government functions such as those that regulate drug quality; conduct and commission research; perform disease surveillance functions; and operate health care services among others In this complex environment, govern-ment cannot meet its responsibilities alone, and health ministries must also work


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effectively with an increasing number of non-governmental actors-- civil society, business, philanthropy, professional associations, academia, donors, academies of medicine and science, the public and with regional and international organiza-tions.

GovernanceThe expanded number of actors that must be involved in assuring conditions for health has led to the increasing use of the term “governance”. There are multiple definitions of this term but most reflect, at the simplest level, the alignment of multiple actors and interests to promote collective action towards an agreed upon goal. As a good steward, ministries of health must be able to lead and participate in effective systems of governance to assure the best use of resources for health.

Though there are evolving international standards for effective government, “governance” is almost always context specific, because it must reflect the ways in which all stakeholders interact with one another in a particular set of societal circumstances in order to influence the outcomes of public policies. Therefore, of necessity, actions needed to strengthen leadership and management for this increasingly complex role will vary from country to country.

WHO combines the use of stewardship and governance and states “Steward-ship, sometimes more narrowly defined as governance, refers to the wide range of functions carried out by governments as they seek to achieve national health policy objectives. In addition to improving overall levels of population health, objectives are likely to be framed in terms of equity, coverage, access, quality, and patients’ rights.

Stewardship is a political process that involves balancing competing influences and demands. It will include: maintaining the strategic direction of policy de-velopment and implementation; detecting and correcting undesirable trends and distortions; articulating the case for health in national development; regulating the behaviour of a wide range of actors - from health care financiers to health care providers; and establishing effective accountability mechanisms. Beyond the formal health system stewardship means ensuring that other areas of govern-ment policy and legislation promote - or at least do not undermine - peoples’ health. In countries that receive significant amounts of development assistance, stewardship will be concerned with managing these resources in ways that pro-mote national leadership, contribute to the achievement of agreed policy goals, and strengthen national management systems.


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While the scope for exercising stewardship functions is greatest at the national level, the concept can also cover the steering role of regional and local authorities. “ http://www.who.int/health-systems-performance/sprg/hspa06_stewardship.pdf

LeadershipLeadership entails scanning the environment to create a vision and strategy fol-lowed by inspiring and aligning all stakeholders for a common vision and shared action.

ManagementManagement is about getting the work done by making plans

Definition of Health systems

WHO states that “a health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. This includes ef-forts to influence determinants of health as well as more direct health-improving activities. A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services.

It includes, for example, a mother caring for a sick child at home; private provid-ers; behaviour change programmes; vector-control campaigns; health insurance organizations; occupational health and safety legislation. It includes inter-sec-toral action by health staff, for example, encouraging the ministry of education to promote female education, a well known determinant of better health.

An effective health system ensures that the following four components are ad-dressed:

(i) Personal and family health care services, (ii) public or population health ser-vices, (iii) health research and (iv) health streamlined into all the policies of other sectors.

The WHO has identified six health system building blocks which can be used as the more specific action areas needed to address the above four health system components. These are: service delivery, health workforce, information, medical products, vaccines & technologies, financing and leadership and governance.


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Figure 1: Country Health Systems

The role of National Governments

Governments in all countries have ultimate responsibility and accountability for population health which cannot be delegated. Most international agreements, conventions and treaties assume that it is the governments that are responsible for assuring the health of their populations and that compliance with international health regulations are responsibility of national governments. That is why for example, the United Nations, the World Health Organization, the African Union, is run by governments as constituent member states.

In terms of providing health services, most constitutions have some language on the right of citizens to basic health services and it is the constitutional responsi-bility of the government to fulfil that obligation either by providing the services directly or ensuring that other agencies do so. This is referred to as the steward-ship role of government in which the state has a responsibility to act on behalf of the public and as a protector of the public interest. It is the government that has the responsibility to ensure that arrangements to provide basic health services are in place and that other conditions that enable people to be as healthy as possible prevail in the country. These arrangements are what are commonly known as the health system.


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determinants of health as well as more direct health-improving activities. A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services. It includes, for example, a mother caring for a sick child at home; private providers; behaviour change programmes; vector-control campaigns; health insurance organizations; occupational health and safety legislation. It includes inter-sectoral action by health staff, for example, encouraging the ministry of education to promote female education, a well known determinant of better health. An effective health system ensures that the following four components are addressed:

(i) Personal and family health care services, (ii) public or population health services, (iii) health research and (iv) health streamlined into all the policies of other sectors.

The WHO has identified six health system building blocks which can be used as the more specific action areas needed to address the above four health system components. These are: service delivery, health workforce, information, medical products, vaccines & technologies, financing and leadership and governance.

Figure 1: Country Health Systems

The role of National Governments Governments in all countries have ultimate responsibility and accountability for population health which cannot be delegated. Most international agreements, conventions and treaties assume that it is the governments that are responsible for assuring the health of their populations and that compliance with international health regulations are responsibility of national governments. That is why for example, the United Nations, the World Health Organization, the African Union, is run by governments as constituent member states.

Effective health systems strengthening requires attention to all four of these dimensions in order to achieve balanced health investments that can more effectively promote and protect health. Ministers and ministries of health must have the capability to play their appropriate role in these four prior-ity areas.


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Managing efficient and effective Ministries requires certain leadership character-istics and it is leadership and governance that we are discussing here. It is by far the most important as all the others depend on leadership and governance. It is unfortunately also the most neglected topic in health systems strengthening. To champion the health agenda among the general population, to negotiate with vari-ous interest groups, with other government sectors for funds, personnel and space and visibility is complex. It is country and context specific being rooted in local history, culture, power balances and resource base. It calls for vision, courage and perseverance, and skill sets in communication, advocacy; in the generation, inter-pretation of data and evidence and its dissemination to the right audience at the right time. It calls for leadership from the top echelons of government; the head of state and government, the Prime Minister, the political party all supporting the Minster of Health. It calls for strong technical leadership from techno-profes-sional leaders across government and the support of the HRPIs. Marshalling and aligning all these multiple actors and interests to achieve common goals in health is what are known as health system governance. The leadership for this, in most countries, rests with the Minister and Ministry of Health. In some countries the leadership is under the office of the Prime Minister but in these cases too, driving the actions remains with the Ministry of Health.

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Evidently strong Ministries of Health are critical to the achievement of national health goals. Properly prepared, equipped and supported Ministers of Health who coordinate and drive the action are central as are competent and motivated technical personnel who work with the Minister of Health. The circle is complet-ed by the willingness and ability of the Ministry of Health to work with HRPIs. There is evidence to show that it is the countries with strong, confident and clear local leadership that are able to stay the course in implementing home-grown policies, and are also making the most progress towards achieving the MDGs. Their stories are part of this work and this book.

Despite the central role ministers and ministries of health play in these processes, they are currently overlooked when investments are being made and initiatives are being designed to strengthen health systems. On top of this, the turnover rate of Ministers of Health is high with short tenure periods averaging, 3.9 years on the job and many come without any preparation for the onerous leadership roles expected from them. Among the ministers and stakeholders interviewed for the Strong Ministries for Strong Health Systems study, there was significant support for the specific proposals for an executive leadership development program for new ministers, leadership support for sitting ministers, and the establishment of a virtual information resource centre on health systems stewardship and gover-nance. There is a need to build awareness among politicians, policy makers, and the public, of the importance of stewardship and governance in strengthening health systems, and the critical role of ministers and ministries of health.

Individuals who manage efficient and effective Ministries of Health require cer-tain leadership characteristics that include vision, strong communication skills, ability to inspire, win trust and align all actors to achieve agreed results. Selection of such individuals and their motivation are often the source of failure of African health leadership. Tools and opportunities for their induction and for them to discharge their functions effectively should be made available to them. Executive leadership development programs need to be grounded and well contextualized for Africa and individual countries by those with hands-on experience in working in Africa and with the international community.

The role of Health Partner Resource Institutions (HRPIs)

While governments cannot delegate the responsibility for stewardship of health systems, government action alone is insufficient. Governments need to work closely with an ever increasing array of other actors in health. These include NGOs and civil society, advocacy groups, private sector


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and business, academia and think tanks, professional associations, me-dia, parliaments and development partners. These are described as Health Partner Resource Institutions (HRIPs) in the Strong Ministries for Strong Health Systems study report. From the study on supporting Ministries of Health Leadership and its report “Strong Ministries for strong health systems”, interviews with ministers of health and other country based as well as international health leaders strongly pointed out the importance of organisations both in and outside of government that can provide needed expertise and resource to ministries of health.

The study noted that every country needs to cultivate and grow a critical mass of individuals, groups and institutions that interact regularly among themselves and with their governments, parliaments, and civil society as agents of change, holding each other and their governments to account, as well as providing support and collectively ensuring that the visibility of the national health agenda remains prominent in the national psyche and culture. The HRPIs are well positioned to and can support govern-ment in several ways in enhancing people’s health; policy formulation and implementation, health service provision, and enhancing governance and stewardship. These institutions can also work with ministries to cre-ate a culture of evidence based policy and practice and hold each other accountable for results. HRPIs comprising the knowledge and think tanks sub-sector can provide information and evidence for accountability of extent to which the leadership is effectively, efficiently, equitably, and quality of executing the defined stewardship/governance functions to en-able production and ownership of good health outcomes.

African governments and ministries are therefore encouraged to marshal and collaborate with HRPIs as health resources that are available to and at the disposal of MOHs. A key recommendation from the study report states: “That countries develop effective governmental and non-govern-mental Health Resource Partner Institutions to support the health system stewardship and governance functions of the ministries of health”.

A mapping study in five countries in Africa, Kenya, Malawi, Mali, Tanza-nia and Uganda, by ACHEST found that these institutions are active in all the countries and are ready to partner with their governments. Similarly, the government in those countries expressed willingness to work with the HRPIs.


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The role of techno-professionals

The leaders of the HRPIs and government officials are the techno-professionals who are knowledgeable but often do not demonstrate the bold leadership that should make them stand out as change agents in their societies and communi-ties. They generally watch and tolerate wrong things in their midst and fear or fail to speak out on the side of the people and the common good. Leadership is largely left to politicians some of whom have the legitimacy of holding elective positions while others are aspiring to be elected and both groups have vested personal interest. I want to argue that the technocrats and professionals have let Africa down. Why? These policies and resolutions adopted by political leaders are crafted by techno-professionals and implementation strategies are designed by them. It is the techno-professionals who understand how the technologies work and monitor implementation success or failures round the world. They at-tend many meetings all over the world on health issues but most go back home to business as usual. They have the statistics on mortality and morbidity rates and can interpret the significance of these in terms of suffering, deprivation, and pre-mature death, including the economic and social ramifications. Yet the sense of urgency and the outrage the situation calls for is nowhere to be seen or heard. The absence of leadership and complacency of the techno-professionals is disturbing. Many have left Africa for greener pastures.

I would like to see the growth of professionals associations and institutions in Africa as the protectors of the common good and custodians of standards and quality. Individuals within the professions are best placed to judge and police each other on behalf of the public for the common good.

Partnerships for Health development

The relationship between Africa and its development partners has gone through many phases ranging from encounters with adventurous explorer Europeans to religious missionaries and to traders and the colonialists. Following indepen-dence, there was a cautious relationship at the background of which was the cold war. Then Africa suffered economic collapse, already described and became a beggar. During the beggar period, African countries accumulated debts which became unbearable and earned these countries the derogatory title of Highly In-debted Poor Countries (HPICs). During this phase, there has been chronic ten-sion between the donors and the aid recipients. Donors inserted themselves into government offices of African countries to make sure that the aid was used to the satisfaction of the donors. Priority setting was generally prevailed over by the donors and resulted in the disempowerment syndrome, misunderstandings and


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frustrations that has been described already. It was Africans who pushed for a new way of managing aid which led in to a series of conferences in Monterrey, Rome and culminated in the crafting of the Paris Declaration on Aid Effective-ness in which Africans made an effective contribution. Credit also goes to the leadership of the OECD countries who were active supporters of the develop-ment of the new partnership principles enshrined in the Paris Declaration on Aid Effectiveness.

Health Sector Reforms in Uganda 30 years back4.

Historical background

The African Centre for Global Health and Social Transformation (ACHEST) was commissioned to carry out the study by the Ministry of Health and partners facilitated by a financial grant from the USAID. The documentation and analy-sis contributes to building the knowledge base for policy development, initiates proactive review of implementation constraints of the HSSIP and provides a real time model for identifying actions to ensure the implementation of HSSIP is on track.

This study is a retrospective review and analysis of health sector reforms in Ugan-da from 1978, when the historic Alma Ata Declaration on PHC was adopted, and spans the period between 1978 up to 2010, just prior to the launch of the NHP and HSSIP (20111 – 2015). The Study documents the interventions and experiences, successes and achievements, challenges and lessons of health sector reforms as well as other reforms outside the health sector that impact on the health of the people in Uganda. The expectation is that the findings will contribute to further improvements in the HSSIP 2010-2015 during its implementation and planned review processes.

The study was overseen by a Steering Committee led by Professor Raphael Owor and included stakeholders from the government ministries, districts, pro-fessional associations and academia. The methodology included Semi structured interviews (using a combination of questionnaires and verbal interactions) with key informants supplemented the systematic review of literature. Key informants included past and current policy-makers as well as implementers, professional organizations, the academia, the private sector, development partners, and con-sumers of health services.


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Findings were subjected to a combination of policy analytic approaches for poli-cy process and policy content. Comprehensiveness and quality of methodological processes as well as reality checks and validation of findings all benefitted from broad, regular stakeholder consultations for consensus building at various stages of the study and the major output of the study is a Synthesis review document on health system reforms in Uganda. The report was completed in August 2011 and was formally launched by the Minister of Health in April 2013.

For the purposes of the paper, the findings of the report that pertain to leadership, ownership and accountability will receive more attention and all the key recom-mendations will be discussed. These are presented in three phases over the 32 year period namely:

Leadership and governance

Situation analysis of the leadership functions in the period of 1978 – 1985The study period commences in 1978, the time of the global promulgation and adoption of the Alma Ata Declaration on Health for All by the year 2000 through the Primary Health Care (PHC) approach. Between 1978 – 1985 Uganda enthu-siastically embraced the PHC principles and a White Paper was published by the MoH in 1982. However, due to the instability in the country at the time, the leadership, both political and technical was not able to implement the recom-mendations of the White Paper. During this period, the country experienced three civil wars in succession: to dislodge in series, the governments of Idi Amin, Tito Okello and Milton Obote. There was a huge exodus of health professionals and health facilities were destroyed and looted resulting in total collapse of the health services (Cole Dodge ed. 1981). Thirty years down the road, WHO (2008) has revalidated PHC principles and has focused on four reform areas namely: Lead-ership reforms to make the authorities more reliable, service reforms to be people centred public policy reforms to protect the health of populations and universal coverage reforms to promote equity. The participation of the populations them-selves in the reforms continues to be central to the reform process. It is helpful at this point to make a distinction between PHC and Primary care. PHC is an ap-proach or a philosophy for achieving health outcomes of a population. Primary Care is the health services provided at the first point of contact between the com-munity and the health system.


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Situation analysis of the leadership functions in the period of 1986 – 1995The NRM government came to power and the leadership created a hopeful en-vironment and provided an opportunity for new thinking and a new effort in all aspects of the country’s development. In the stewardship and governance of the health sector, a Health Policy Review Commission under chairmanship of Pro-fessor Raphael Owor, was established and deliberated during the period 1987 – 1989. The key governance recommendations included restructuring of the MOH and separating technical and administrative leadership roles, establishment of the Health Services Commission, village health committees, NDA and NMS among others. Some of these were implemented piece meal over the ensuing years.

There were other major reforms across government at this time: a new national constitution was promulgated, roles of the central and local governments were redefined with decentralization of service delivery to district local governments; leaving central ministries with residual roles of policy, standard setting, resource mobilization and supervision.

The MoH established the Quality Assurance Program with the primary role of supporting districts to take over decentralized health services. This program worked closely with a decentralization secretariat located in the Ministry of Lo-cal Government. District political and administrative leaders were provided with training support by the QA program with tools to take over management of health services under the decentralized arrangements. The level of ownership of ser-vices delivery will prove to be a major challenge to the quality of health services provided at district level. In another study by ACHEST commissioned by USAID on Capacity building for leadership in Uganda, it was found that while CAOs were knowledgeable and well qualified for their jobs, they were having difficul-ties with district politicians especially councillors whose basic education levels were not prescribed by law. There were challenges of nepotism and corruption for which their management training had not prepared them.

It is important to note that this period followed several devastating civil wars that impoverished the whole country. Government had no money; essential com-modities were scare with long queues for everything. Health services were not spared and were equally decimated with damaged and looted health facilities, lacking water, power and suffering a massive brain drain. Under the circum-stances, the international community played a major role in the recovery of the country. Initially government favoured leftist partners such Cuba and North Ko-rea espousing barter trade but soon turned round to partner with the West and the Bretton Woods institutions. Without the country’s own money, bilateral partners, the World Bank and IMF played leading roles in shaping approaches to health


46

development including the selection of and implementation of the recommenda-tions from the Owor commission of inquiry and PHC principles.

Global thinking at the time was also heavily influenced by President Ronald Rea-gan and Prime Minister Margaret Thatcher where development was looked at primarily through the money lens and the role of government was considered peripheral. It is interesting to note that the role of the World Health Organization in policy dialogue during this period was not prominent apart from providing a few scholarships for training and providing technical assistance to Makerere University.

There was a high turnover of Ministers of Health with four Ministers serving during this period. This was also the period when the HIV and AIDS epidemic received exceptional attention and leadership from the new government with H E the President himself acting as Chair of the first national HIV committee and the establishment of the first global HIV department in the world. This was so suc-cessful that there was a dramatic decline of prevalence from an average of 18% in 1990 to 6% in 1993. This was achieved primarily through a massive national awareness campaign led by H E the President and followed by other leaders, re-ligious, cultural and professional.

It was during this period that important laws governing health professionals were enacted. These included The Medical and Dental Practitioners Act, the Nurses and Midwives Act and the Allied Health Professionals Act. These are the basis for the existence of respective Health Professionals Councils which have key roles to play in the governance and leadership of health professionals and the health system.

Achievements during this period can be summarized as follows

The Health Policy Review Commission into the health services in •Uganda

Development partners engaged after the wars•

Three year rolling health plans•

Demonstrated leadership on HIV and AIDS Introduction of •Decentralization of health services delivery

Establishment of the Quality Assurance Program for supportive •supervision and standard setting


47

Health Professionals Acts passed and Councils established•

New National Constitutions adopted.•

Constraints

Weak human resource and institutional capacity•

Dilapidated infrastructure•

Local governments learning to take over services delivery•

Lessons and Implications for NHPII and HSSIP

Strong political leadership contributed to the developments that took •place during this period. This was also matched by strong technical lead-ership and translating political direction into technical interventions. It also demonstrates the advantages of broad national dialogue and consen-sus as opposed to restricted individual disease or issue specific dialogue and interventions.

The weakened state from a series of wars and without an explicit health •policy provided the environment for outside forces to sideline the imple-mentation of the Owor commission report in respect to the implementa-tion of PHC. This influence led to the emphasis on user fees, and vertical disease programs to the detriment of health system development.

Recommendation

Health sector reforms work best where there is wide participation and consulta-tion. While HSSIP discusses inter-sectoral collaboration, there are no specific interventions that have been provided for achieving this. It is therefore recom-mended that a high level structure be established under the leadership of the Rt. Hon Prime Minister to coordinate multi sector engagement in health. An Ad-ditional structure at technical level should also be established under the Head of the Civil Service.

Situation analysis of the leadership functions in the period of 1996 – 2000

This period was extremely busy for the health sector and government as a whole. The country started to assert overall policy leadership in respect to development partners and development assistance now moving from rehabilitation and recon-struction to development planning.


48

The provisions of the new national constitution were being rolled out. Constitu-tional institutions with implications for the health sector were set up such as the IGG, Human Rights Commission, NEMA and districts were learning how to run all decentralized services including health services while central line ministries were being restructured and equally adjusting to play the new roles of policy formulation, standard setting, and supervision and monitoring and resource mo-bilization for respective sectors.

The Ministry of Finance Planning and Economic Development under strong po-litical and technical leadership envisioned a Comprehensive National Develop-ment Framework with a document for Vision 2025 and the Poverty Eradication Action Plan (PEAP) to be implemented through Sector Wide Approaches (Swaps) by all sectors. International agencies were also undergoing change. New Global Health Initiatives such UNAIDS and GAVI, Global Stop TB partnership and the Global Fund to Fight Aids TB and Malaria were being negotiated. Uganda was very closely associated with these negotiations and gave leadership to these ini-tiatives. The World Bank continued to of health professionals maintain strong engagement with the Ugandan reforms including the health sector. A new WHO Country Representative had arrived and made an effective contribution as a go between the government and development partners in health. Key reforms are:

The Restructuring of the Public ServiceMajor restructuring of government ministries was undertaken during this period. Although the MoH was part of this exercise, the outcome was not considered satisfactory by the MoH. An additional internally led restructuring was therefore carried out. It was this overall restructuring exercise that led to the creation of the office of the DGHS in order to fulfil a constitutional requirement for “a technical head of health services” to be in place in the event that the health of the head of state needed to be evaluated within the provision of the constitution. However, there is also a cabinet minute to the effect that the Ministry of Health like other technical ministries needed to be headed by a technically qualified individual. In spite of all this a post of Permanent Secretary was created for the MoH separate from that of the DGHS. This later became a source of conflict and remains an issue whose implications have been pointed out in the Key Informant interviews and midterm reviews of HSSP I and II. Experience has also shown that other departments in the MoH are not performing optimally and need a review of their mandates. An example is the management of health information which is frag-mented and not streamlined for distribution in a user friendly manner.


49

The Health Services Commission was one of the Constitutional Commissions that were operationalized through the Health Services Act. Its first job was to ap-point the DGHS and to interview and appoint all staff in the MoH Headquarters during the early part of 1999. According to Key informant interviews, this Com-mission has not performed to expectations as it has concentrated more on making appointments and much less overseeing the health work force development and determining the conditions of service of health professionals.

NHP 1, HSSP1 and Swaps

Following national elections of 1996, a new Minister of Health was appointed and was in post until 2001. The NHPI and HSSPII and the Swap arrangements were negotiated simultaneously through very wide and laborious consultations that started 1997 leading to the adoption of the NHPI in 1999 and the launch of HSSPI in 2000. Swaps structures and instruments were put into place and the overall outcome of this process was that a clear vision for the health sector was achieved and trust had been built between GoU, DPs, NGOs based on openness, mutual respect and patience. Mechanisms for dialogue, monitoring and managing Swaps were established and there was evidence of demonstrated national own-ership and commitment (JRM statement Aid memoir). The capacity of districts was growing around implementing the Planning and Budgeting Process that was transparent bottom-up and consultative for result-oriented and integrated Annual Work plans. This has been described as the golden era of the Health Sector in Uganda and the reforms implemented have been copied by many other develop-ing countries. A large number of foreign delegations were coming on study tours of these reforms.

Impact of SAPsUDHS of 2000/2001 report was released that showed a stagnation in health indi-ces especially, IMR, CMR and MMR. While this was seen as surprise by some development partners, it was easy to explain on account of the negative impact of the SAPs with the recruitment ban, staff attrition resulting in high vacancy and a low morale among health workers that had characterised that period. The MoF-PED instituted and investigation which was led from that sector.


50

Table 1: Health Outcomes in the period 1988 to 2000 (Source UDHS 2000)1

The major findings of this investigation were to show that the stagnated health indicators was an expected result of the policies and interventions that preceded the DHS and further that funding for health services was grossly inadequate. Fur-ther it made a direct link between health interventions and health indices; a point that is sometimes lost.

Achievements

Swaps working arrangements were successfully negotiated and • intro-duced and were functioning well with strong donor coordination through guidelines developed with MOFEP, - JRMs;

A clear sector vision was created and trust was built between GoU, DPs, •NGOs based on openness, mutual respect and patience;

Mechanisms for dialogue, monitoring and managing Swaps were in •place;

Ownership status improved;•

Commitment and capacity of districts built for Planning and Budgeting •through a transparent and consultative process that was in addition result-oriented with integrated Annual Work plans.

Health S

Indices

IMR

Under 5 M

MMR

Life Exp

Fertility R

HIV Prev

Statistics-19

Mortality

ectancy

Rate

valence

88 to 2000

1988

122

203

550

54

20%

1995

97

147

506

48

6.1

2000

88

152

505

6.9

6.1


51

The HSC was established and new appointments made in the MOH with •a new DGHS, and all staff interviewed.

Constraints

The effects of the SAPs characterized by the three year recruit• ment ban for health workers who were qualifying from publicly sponsored health training institutions and were not being recruited,

Down-sizing of the civil service with retrenchment health work• ers, re-moval of allowances etc further demoralized the health workforce.

The impact was low morale among health workers, massive mi• gration of health workers and increase in vacancy rates in the health services.

The DHS report for this period showed stagnation of health indices•

Negotiating NHPI, HSSPI and Swaps was a labour intensive undertaking •but provided good preparation for roll out of these tools later.

Lessons

The critical value of strong country leadership in mobilizing inter-sec-•toral actors, civil society and DPs for common action in agreeing NHPI, HSSPI and the Swaps

Strengthened sector supervision, monitoring and evaluation is possible•

Need to build a critical mass of committed individuals to trigger and •champion the reform process

In order to build and nurture trust, openness and mutual respect between •government officials and DPs is needed.

Recommendation

While HSSIP underscores the importance of multi-sector action, it is silent on practical steps to implement Inter-sectoral collaboration: It is therefore recom-mended that strong action and leadership is required in order to promote inter-sectoral action by establishing coordinating structures at various levels i.e. Politi-cal/Cabinet under the Rt. Hon Prime Minister, Technical under the Head Civil Service, District under the Chief Administrative Officer, Sub county under the Sub county chief.


52

Situation analysis of the leadership functions in the period of 2001 to 2005

This period saw the launch of several Global Health Initiatives in which the coun-try provided leadership and with significant implications for the health sector in Uganda. These included the Global Stop TB Partnership and the Global Fund to Fight Aids TB and Malaria. In the year 2000, H E the President had participated at the Children’s Summit in New York. He returned from there and convened a meeting with District LCV Chairpersons to discuss immunization coverage and this resulted in strengthened ownership by district leaders of this program and a rapid improvement in immunization coverage across the country. The Paris Declaration on Aid Effectiveness was negotiated and adopted at the beginning of 2004 and again Uganda was an active participant in its adoption. Indeed the Uganda development assistance model including Swaps and budget support were used as a foundation for the articles of the Paris declaration.

The roll out of the HSSP I under Swaps arrangements continued to make good progress. Input, process and output indicators were showing rapid and sustained improvements such as immunization coverage, utilization of health facilities, staffing norms and personnel recruitment. Funds transfers to PHC were gradually increasing. One indicator was not improving namely the attendance of skilled health workers during deliveries and this became the subject of a special study commissioned by the MoFPED. The policy to cap funding of hospitals at this time has later proved to have been carried on for too long and has had negative implications.

Table 2: Achievements - Outputs of HSSP-I implementation (Source AHSPR 2005.)2

Achievements-Outputs

Indicator 00/01 01/02 02/03 03/04 04/05 2005 Target

OPD new attendees

0.43 0.60 0.72 0.79 0.9 0.70

DPT 3 Coverage

48% 63% 84% 83% 89% 85%

Deliveries in units

22.6% 19% 20.3% 24.4% 25% 35%

Filledstaff positions

40% 42% 66% 68% 68% 52%

HIV sero-prevalence

6.1% 6.5% 6.2% 6.2% 6.5% 5.0%


53

Figure 1: New OPD attendance for HSSP-I (Source AHSPR 2005.)ii

Figure 2: Pentavalent Immunization Coverage for HSSP-I (Source AHSPR 2005.)ii

.New OPD attendance at public and PNFP health facilities during the HSSP I

0.4 0.43

0.60.72

0.790.9

0.7

00.10.20.30.40.50.60.70.80.9

1

1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 HSSP ITarget

per

cap

ita

new

OP

D a

tten

dan

ce

Abolition of User Fees


41


Figure 3: HSSP-I - Expected mothers delivering in health facilities (Source AHSPR 2005.)ii

Situation analysis of the leadership function in the period of 2006 - 2010

This period saw new leaders being appointed in the health sector; namely three Ministers, the Permanent Secretary, the DGHS, two Directors of Health Services and Under Secretary among

Proportion of expected mothers delivering in public and PNFP health facilities for the HSSP I

25%

19% 20.30%24.40% 25%

35%

22.60%

0%

5%

10%

15%

20%

25%

30%

35%

40%

1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 HSSP ITarget

prop

ortio

n m

othe

rs d

eliv

erin

g in

hea

lth fa

cilit

ies

Pentavalent Vaccine 3rd dose Coverage in infants during the HSSP I

41%48%

63%

84% 83%89% 85%

0%10%20%30%40%50%60%70%80%90%

100%

1999/00 2000/01 2201/02 2002/03 2003/04 2004/05 HSSP ITarget

pent

aval

ent 3

infa

nt c

over

age


54



This period saw new leaders being appointed in the health sector; namely three Ministers, the Permanent Secretary, the DGHS, two Directors of Health Services and Under Secretary among others. There were also new appointments at the Health Services Commission. According to the report of the midterm review for HSSP II and statements from respondents to Key Informant interviews, there were strains between the leadership at both political and technical level at the MOH Headquarters. The arrival of a large team of new leaders, the scandals over GFATM and GAVI led to suspicions that adversely affected the performance of the sector. There was a manifest decline in input, process and output indicators during this period


41




This period saw new leaders being appointed in the health sector; namely three Ministers, the Permanent Secretary, the DGHS, two Directors of Health Services and Under Secretary among

Proportion of expected mothers delivering in public and PNFP health facilities for the HSSP I

25%

19% 20.30%24.40% 25%

35%

22.60%

0%

5%

10%

15%

20%

25%

30%

35%

40%

1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 HSSP ITarget

prop

ortio

n m

othe

rs d

eliv

erin

g in

hea

lth fa

cilit

ies

Pentavalent Vaccine 3rd dose Coverage in infants during the HSSP I

41%48%

63%

84% 83%89% 85%

0%10%20%30%40%50%60%70%80%90%

100%

1999/00 2000/01 2201/02 2002/03 2003/04 2004/05 HSSP ITarget

pent

aval

ent 3

infa

nt c

over

age


55

Table 1: Falling Core Performance Indicators for HSSP II Implementation

There was change in staffing norms by MOLG1.

This analysis excludes availabilityof coartem which is procured 2. through the Global fundANC surviellence data 20083.

The UDHS of 2005/06 showed improved health indices. This is attributable to the success achieved during the roll out of HSSP I and the demonstrated improve-ment in input, process and output indicators during HSSPI. At the international level, WHO and the World Bank were signed to implement the International Health Partnership (IHP+) and Uganda became a signatory to an IHP+ compact during the later part of this period. This compact was a reaffirmation of the MoUs that Uganda had signed with the development partners’ way back in 2000 at the launch of HSSPI and were indeed largely copied from this MoU.

AchievementsSigning of the IHP+ Compact•Development and negotiation of NHPII and HSSIP.•

ConstraintsInternal conflicts among the leadership•Low resource base due to suspension of GHI funds•Loss of trust from Partners and community•

others. Treport ofinterviewMOH HeGAVI lemanifest

Table 1:

1. T2. T

fu3. A

The UDHachievedoutput insigned toto an IHPMoUs thHSSPI an

AchieveSD

There were af the mid- tews, there wereadquarters. ed to suspicdecline in in

Falling Co

There was chThis analysisund

ANC surviel

HS of 2005d during the ndicators duo implement P+ compact

hat Uganda hnd were inde

ements igning of the

Development

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also new apperm review fre strains beThe arrival

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ore Perform

hange in stas excludes a

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5/06 showedroll out of H

uring HSSPIthe Internatduring the l

had signed weed largely c

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nnual Scienti

pointments afor HSSP II etween the l

of a large tdversely affs and output

mance Indica

affing normavailabilityo

2008

d improved HSSP I and tI. At the intional Healthlater part of

with the devecopied from

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at the Healthand stateme

eadership atteam of newfected the pt indicators d

ators for HS

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health indithe demonstternational l

h Partnershipthis period.

elopment parthis MoU.

PII and HSS

nce Proceed

h Services Coents from ret both politic

w leaders, theperformance during this p

SSP II Impl

Gwhich is pr

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rtners’ way b

IP.

dings

ommission. espondents tcal and teche scandals oof the sect

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lementation

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s attributablvement in in

O and the Wd Uganda beact was a reaback in 2000

According tto Key Inforhnical level aver GFATMtor. There w

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ough the G

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World Bank ecame a signaffirmation o0 at the laun

42

to the rmant at the

M and was a

lobal

uccess s and were

natoryof the nch of


56

LessonsLosing trust is easy but Building and Sustaining trust not easy•

Negative consequences of leadership gaps•

Recommendations:

In response to the recommendations of midterm reviews of HSSP I and II, •and the findings from Key informant interviews, there is need to redefine the roles at all levels for accountability: TMC, PS/DGHS,SMC, HPAC; VHT, HUMC, Regional Tier, RRH oversight of services

There is need to review NHP II and HSSIP to harmonize & align poli-•cy, strategy and investment focus as well as edit Executive Summary to match content of the main document.

Health Workforce

Health workforce reforms

The Health Workforce embraces all persons with or without formal training who contribute to the protection, maintenance and improvement of health (WHO). The definition of health workforce implies three interlinked aspects of availabil-ity, competence and management at operational level. The health workforce is the driving force of health care delivery systems and is the main determinant of quality of health care. A well performing workforce is one that acts in ways that are responsive, fair and efficient to achieve the best health outcomes given avail-able resources and circumstances. There should be adequate numbers of skilled, supported and motivated workforce, well distributed with the required tools to perform in order to contribute positively to the success of the health system.

The world is experiencing a global health workforce crisis characterized by widespread shortages, maldistribution and poor working conditions. The world health report of 2006 identified 57 countries that currently have critical shortages of health workforce. The proportional shortfall is greatest in sub-Saharan Africa with 36 including Uganda and Asia with 12 countries. In order to address this crisis, the international community has undertaken several studies and convened global consultations which have led to the promulgation of good practice guide-lines in health workforce education and training, retention and management.


57

Figure 2: Countries with critical HWF Shortages (Source: WHR 200632)

A global movement, under the Global Health Workforce Alliance, that I served as founding Executive Director, has emerged that has clearly linked the HWF crisis to the achievement of the MDGs and country health outcomes.

Whereas Uganda has developed a National HRH Policy and Strategy and the HSSIP includes a good situation analysis, there is no reference to the new global directions that the global community is taking in this important field This discus-sion links the Uganda HWF plans with the new global directions as the country is one of those identified as having a critical HWF shortage (WHR 2006).

Availability of health workforce includes the absolute numbers, their distribu-tion and their skill mix. Availability is influenced by policy, organization, by at-traction retention and absorptive capacity of the health system, by attrition and brain drain and by changes in epidemiology and medical technology.

Competence includes technical skills, interpersonal skills, patient centred atti-tude and professionalism. To develop these skills and characteristics, good edu-cation, training and socialization are essential. The quality of medical education in low income countries is suffering and continued professional development and in-service training are under developed. If competent HRH are available in the health service then their motivation and behaviour will still be dependent on working conditions organizational context and management.


58

The management of health workforce deals with administrative tasks and with human relations. It aims at optimizing health workforce contribution to organiza-tional performance by motivation, commitment and staff development. In many low income countries, especially sub-Saharan Africa HRH problems are chronic and have to do with all the above factors. In some the problems are worsening, with increasing imbalances in all dimensions and inadequate regulation of train-ing institutions leading to problems in quality.

New Global Directions in Transformative Health Professionals Education and Training to strengthen health systemsEducation System is a critical entry point into building strong health systems and there is strong evidence linking professional education and health outcomes. Health Training institutions are like factories; a good factory will produce good products while a bad factory will produce poor quality health workers. A recent WHO report states “Insufficient collaboration between the health and education sectors as well as weak links between educational institutions and health systems can create a poor match between medical education and the realities of health service delivery. The inseparable linkage between service, teaching and research as part of knowledge, skill and attitude transfer in professional development has received overwhelming endorsement. These systemic constraints perpetuate skill flow away from underserved communities that bear the burden of poor health and force institution to choose between global excellence and local responsiveness in skills and competence of medical trainees” (WHO Scaling up Medical and Nurs-ing and Midwifery Education 2011). Two other global study reports highlight the critical need for close collaboration between the education systems and the health systems namely; , the Sub-Saharan African Medical Schools Study - SAMSS, points out the emerging role played by the private sector in HWF education and the need for closer supervision by both sectors working in tandem and the study on Social Accountability of Medical Education 3 (Charles Boelen 2010) promote the inculcation of attitudes and skills to enable graduates to work in their own communities as professionals that has defined the social accountability of medi-cal schools as “the obligation to direct their education, research and service activ-ities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public”. Social Accountability Partnership Pentagram.

Embedded in the WHO definition of social accountability, the Partnership Pen-tagram reflects the five-way collaborative relationship that must exist for those involved in providing a health system based on people’s needs.


59

In Uganda this is an opportune moment to embrace these new directions in HWF education and training.

Figure 4: The complex interactions between Education and the Health Systems. (Source: Health Professionals for a New Century: Lancet 2010)


47


Figure 4: The complex interactions between Education and the Health Systems. (Source:Health Professionals for a New Century: Lancet 2010)

Country Coordination and Facilitation (CCF)

In response to the global health workforce crisis, the Kampala Declaration and Agenda for Global Action, endorsed at the first-ever Global Forum on Human Resources for Health held in 2008 in Kampala, Uganda, sets out areas for action over the next decade by all partners. However, translating these complex and over-arching nature of the human resources for health arena and the wide variety of stakeholders involved. To address the need for country


47


Figure 4: The complex interactions between Education and the Health Systems. (Source:Health Professionals for a New Century: Lancet 2010)

Country Coordination and Facilitation (CCF)

In response to the global health workforce crisis, the Kampala Declaration and Agenda for Global Action, endorsed at the first-ever Global Forum on Human Resources for Health held in 2008 in Kampala, Uganda, sets out areas for action over the next decade by all partners. However, translating these complex and over-arching nature of the human resources for health arena and the wide variety of stakeholders involved. To address the need for country


60

Country Coordination and Facilitation (CCF)In response to the global health workforce crisis, the Kampala Declaration and Agenda for Global Action, endorsed at the first-ever Global Forum on Human Resources for Health held in 2008 in Kampala, Uganda, sets out areas for ac-tion over the next decade by all partners. However, translating these complex and over-arching nature of the human resources for health arena and the wide variety of stakeholders involved. To address the need for country coordination, GHWA has developed a tool that facilitates the participation of all stake holders in every country in the training, retention and management of the HWF known as the CCF.

In September 2009, GHWA held a conference in Ghana where a delegation from the Uganda MOH, MOES, MOPS, MOFEP and the PNFP sectors were repre-sented to disseminate this tool. The country is in a good position to implement the tool which is not mentioned in the HSSIP.

Pre-service training and Skill MixIn the period 1978-1986 There was no explicit Human Resources for Health pol-icy and plan to guide the production and management of human resources for health. The realty was that despite the already existing establishment norms the staffing ratios varied enormously among hospitals and district Medical Offices. There was little correlation between the number of staff in place and the estab-lishment norms, or hospital bed numbers or even patient workloads

( Owor 1987, HRH survey 1991 Oscar Gish 1993).

Basic training in Uganda was under the Ministry of health undertaken by Gov-ernment and non-government institutions. During the upheavals of the seventies and early eighties training institutions were looted and damaged. The training curricula were curative based but with the declaration of Alma-Ata which recom-mended the adoption of Primary Health Care and utilization of suitably trained health teams of health workers that should include doctors, nurses, midwives, auxiliaries and community health workers the various curricula required orienta-tion to Primary Health Care(Alma-Ata 1978).

The entrants to health training institutions were primed by career guidance includ-ing visits and talks by health professionals and besides having the basic academic requirements had to undergo a physical interview in which the understanding of the candidate of what he/she was going in for and attitudes could be judged. Public sector reforms recommended transfer of training institutions to Ministry


61

of Education and Sports for better integration within the national educational policies, strategies and plans and retention of the in-service training institution. While the restructuring report states that the Ministry of Health is expected to work closely with Ministry of Education and Sports to ensure that the interests and concerns of Ministry of Health are accommodated in the operations of the institutions, the specific roles and responsibilities appear to be an impediment (Turyamuhika report 1998).

Decisions concerning human resource development in the education sector should be effectively guided by requirement for health policies and plans. Training of health workers shows mismatch between the burden of disease and health service requirements on the one hand and training outputs on the other hand. Employers are especially concerned about the poor quality or lack of practical training of recently qualified candidates. The root cause of the training problems appears to be the un-resolved key issues relating to the transfer of the health training schools to the education sector (HRH Strategic Plan 2007).

Liberalization of education sector led to mushrooming of private health training institutions with deterioration in the quality of training. Whereas the shifting of the basic health training institutions to Ministry of Education where this core function lies, the operational arrangements to take care of the interests of many other stakeholders have not worked as expected.

The Registered Comprehensive Nurse (RCN) and Enrolled Comprehensive Nurse (ECN) training programs started in Uganda in 1994 and 2003 respectively. Prior to that Enrolled Nursing, Enrolled Midwifery, Registered Midwifery, Registered Nursing were conducted as independent courses. RCN and ECN programs aimed at producing skilled health professionals with competencies in general nursing, midwifery public health, psychiatry, paediatrics and management. It was envis-aged that the multipurpose nurse would be deployed to primary health care posts and be able to meet the majority of health needs in the rural communities.

However there has been growing concern over the quality of training and com-petencies of RCN and ECNs. Many of the RCN and ECN graduates have not been absorbed in Government health facilities due to lack of clarity over their status in relation to the establishment structures. The report of the evaluation of RCN and ECN training program June 2011 finds that the programs are still rel-evant but found deficiencies in the curricula design, implementation and capacity of training institutions. Some of the recommendations include re-training of the graduates in midwifery and mental health, review of curricula content and imple-mentation arrangements.


62

Uganda is still faced with critical health workforce problems related to absolute numbers, skills mix, recruitment and retention, remuneration, motivation and management which require to be addressed by all stakeholders. There is a criti-cal and urgent need for effective coordination of all stakeholders. Coordination mechanisms in some countries have produced good results for the health work-force.

The Role of the Health Services Commission: Recruitment and RetentionThe Health Service Commission was enshrined in the Constitution Chapter 10 articles 169 and 170. One of its mandates is to review the terms and conditions of service, standing orders, training and qualifications of the members of the health service and matters connected with management and welfare and make recom-mendations to government. Evidence from key informant interviews pointed out that the HSC has concentrated mostly on recruitment and not the other core func-tions of addressing conditions of service and health workforce development in general.

Recruitment, deployment and management of district health workers is decen-tralized to the districts and though districts were trained to manage district health services, the area of health workforce management remains weak.(HRH Strategic Plan, 2007). Instances of corruption, political interference and other vices such as sectarianism have led to appointment of unqualified persons instead of trained health workers. Examples of wrongfully employed persons include drivers and cleaners occupying posts for qualified health workers were quoted (Key infor-mant interview: ACHEST Study to track newly qualified doctors in Uganda).

Where are the Doctors?

Health S

Indices

IMR

Under 5 M

MMR

Life Exp

Fertility R

HIV Prev

Statistics-19

Mortality

ectancy

Rate

valence

88 to 2000

1988

122

203

550

54

20%

1995

97

147

506

48

6.1

2000

88

152

505

6.9

6.1


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The minimum Health Care Package stipulated the basic range of services that is expected to be provided at various levels of the health care system. HSSP I established minimum staffing norms for the various levels of the health system based on the package to be provided at that level. Inadequate staffing to coordi-nate various activities, especially midwives, doctors, anesthetists and laboratory technicians at health center IV was noted.

Human Resources for Health reforms implemented under HSSP 1 resulted in marked improvement with an increase in proportion of approved posts filled by qualified health workers from 33% in 1999/2000 to 69% in 2004/2005. However, a reduction of proportion of posts filled by trained health workers from75% in 2005/2006 to 38.4% in 2006/2007 was noted in subsequent reviews. There after an improvement was again noted to 79% in 2007/2008. (AHSPR 2004/2005; 2006/2007; 2007/2008; 2008/2009; 2009/2010) HRH biannual report Oct 2010-March 2011 shows that at the end of June 2010, only 25 districts out of the old 80 districts had a health worker staffing status above the HSSP 11 target of 65%. 26 districts had a staffing status ranging from 50 – 64%. Another 26 districts were in the range of 31 – 49% while 3 districts were 30% and below. There were marked staffing status variations ranging from 123% in Kampala to 20% in Maracha-Terego district.

The salaries of health workers in the country are still low compared to those in the countries in the region. A newly qualified doctor in Uganda has earns 788,988 as compared to his counterpart in Kenya with an Equivalent of 2,088,000. A senior doctor at consultant level in Uganda earns 2,358,323 as compared to his counterpart in Kenya with an equivalent of 6,142,200(HSC). This scenario is a recipe for disaster. Health workers continue to trickle out to greener pastures in the region and beyond. Some health workers have abandoned the health sector and turned their attention to other gainful activities.

Financing“A good health financing system raises adequate funds for health, in ways that ensure people can use needed services, and are protected from financial catastro-phe or impoverishment associated with having to pay for them. It provides incen-tives for providers and users to be efficient,” (WHO 2007).

One of the leading challenges facing the health system in Uganda is inadequate funding and the absence of a nationally agreed framework for raising, pooling and paying for health care. The public health system depends on taxes and donor money and allocates approximately $10 per capita for health which is far less that


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the $35 per capita recommended by the WHO Commission on Macroeconomics and Health excluding ARVs and ACTs. Further, the National Health Accounts show that out of pocket expenditure by the population accounts for 60% of health expenditure.

The international community is currently engaged in active discussions on health financing. The WHA2011 passed a resolution on Universal Health Coverage as did the ECSA Health Community at the Ministerial conference in October 2010 in Harare. Uganda in an effort to raise adequate funds for health in a fair and socially supportive manner that protects against financial catastrophe of its population, has been actively discussing modalities for addressing the significant financing gap. However, the discussion has not been broad and deep enough to include all key stake holders. In the light of global interest in this matter, this is a good time for Uganda to engage the population and stakeholders.

The fight to eradicate poverty was the country’s response to SAP. Key financing reforms introduced the pooling of funds for health to execute a common invest-ment program for health development called SWAp and in addition resulted in the abolition of user fees. Another important reform was the introduction of di-rect transfers to districts for PHC implementation and the establishment of Pov-erty Action Fund (PAF) at the centre with special budget support funding from the HPIC initiative of the World Bank.

Achievement

Health Financing Strategy development initiated - A health fi• nancing strategy was tabled and discussed to guide the Swaps effort – While a broad consensus failed to emerge, it proved useful in going forward.

Budget reforms were initiated; AG office Strengthened; budget • and finan-cial management procedures Strengthened;

Matching of donor disbursements to domestic commitments • piloted through projects

Fiscal decentralization through PHC grants to district was established •Increased allocation to health through Poverty Action Fund

Capacity was built for policy dialogue to support resource mobilization •to the sector

Studies to review alternative financing and introduction of Health Insur-•ance were conducted (Harvard University Group and University of Han-nover Group)


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Constraint

Key constraints included the slow progress towards consensus on policies •during a period of falling utilization rates of health services and a low capacity to implement reforms. The structuring of exemption mechanism for the poor also failed to work in practice.

Lessons

Reform negotiation requires a long time of building trust•

Reform negotiation capacity is built interactively in practice • over a long time of engagement with stakeholders

Reform consensus requires more than technical soundness of •interventions.

A health financing strategy is a useful framework to guide fi• nancing reform negotiation and

Implementation.•

Recommendations

Urgently review previous health financing strategies for reforms to •enhance system revenues to support health service delivery.

Comprehensively re-appraise implications of available studies on Health •Insurance

Studies that explored the impact on health service utilization and catastrophic health expenditures using data from National Household Surveys undertaken in 1997, 2000 and 2003 showed that utilization among the poor increased much more rapidly after the abolition of fees than beforehand. Unexpectedly, the inci-dence of catastrophic health expenditure among the poor did not fall, a finding at-tributed to the continuing underfunding especially of drugs and commodities 42; 43; 44. The reforms established “pools” for health financing through implemen-tation of a Swaps in the health sector. This greatly improved domestic support to the health sector and the financing envelop grew significantly in the first part of this period of 2001 to 2005. The parallel implementation of vertical programs for priority intervention by global financing mechanisms had a negative effect on the initially positive outcomes of the Swaps financing reforms. Subsequently,


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the institutional capacity for financial management, oversight and accountabil-ity were overwhelmed resulting allegations of corruption. These negative effects have been accompanied with a falling resource envelope and reversals of health outcome growth trends as occurred during SAP reforms in the health sector. An extensive review of the health financing situation was conducted in 2009 and the findings have in part been used in the HSSIP, but there are aspects of previous studies of alternative health financing options in Uganda that may further need to be taken into account. A key short-coming of the analysis however, is the tra-ditional approach adopted for that analysis and review. Reference could be made to the approach introduced by Joe Kutzin (Kutzin J., 2001), that is possibly more robust to guide thinking and planning for health financing reforms at country level 46. Kutzin’s framework focuses on the functions of a health care financing system, namely:

The revenue collection function (the sources)

The function of pooling of funds and,

The function of purchasing of services

This framework is useful in assisting to guide detailed discussions about how to design each aspect or function of the financing system to achieve specific ob-jectives, taking account of the country-specific context. It leads to a more com-prehensive consideration of the full range of system elements and interactions between the different health care financing functions and in this way provides an important basis for more effective design and implementation of health care financing policy reforms.

The framework of the health financing review of the previous national financ-ing strategy in NHP I, focused upon maximizing returns on the pooling function of health financing through the Swaps. This was because the infrastructure and institutions for alternative pooling mechanisms (such as social health insurance) were weak and needed to be built as a pre-requisite.) The organization of the pur-chasing function and institutions for revenue collection also needed much work before roll out of reforms. Given the limitation of the approach for the Uganda health financing review of 2009, a comprehensive discussion of the functions is not presented in both the review report and the NHP-II/HSSIP. For example the three financing scenarios discussed in the HSSP broadly state that the mecha-nisms for financing the services set out in the HSSIP to implement the NHP-II shall not raise adequate funds for health services under any of these settings but the scenarios are based upon contentious input assumptions and with little dis-cussion of expected productivity.


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In particular limitations to the current pooling (SWAp) arrangements need to be considered along with alternative pooling mechanisms as well as alternative collection and purchasing options before narrowing down to a particular choice. Further still, no explicitly practical social marketing approach is articulated to gain concurrence on the proposed reforms. These short comings are in part also noted by the AHSR report of 2000/2010 and the JANS report on the HSSIP con-ducted by partners in 2010.

AchievementsA Health Financing Strategy was partially implemented and SWAp successfully established.

Health resource envelope positively grew with the resource pooling reforms un-der the SWAp.

Budget reforms were implemented

Constraints

Weak oversight and financial management capacity•

An over stretched under-performing institutional capacity led to possible •corruption, loss of trust, and a declining resource envelope

Health system output and outcome growth trends begun to show a down-•ward reversal

LessonRe-introduction of heavily funded vertical intervention based programs has had consistent negative effects on health system performance core indicators and health outcomes.

Recommendations for health financing

Urgently expedite work to develop a health financing strategy as part of •the HSSIP.

Conduct a more realistic financing range of scenarios based upon a more •complete discussion of the varying options of basic financing functions

Initiate a dialogue process for a social strategy to agree financing reforms •with stakeholder across the country.


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Explore options for building further the institutional capacity for the core •health financing functions.

Explicitly articulate a migration plan to mitigate impact of existing and •future vertical financing program operations whenever required.

Explicitly articulate measures to mitigate low capacity for financial man-•agement, oversight and accountability.

Conclusion

We have explained that “Ownership and accountability for health outcomes” takes place at several levels namely; (i) individual, family and community. (ii) government: central, district and sub-district including village level, (iii) HRPIs i.e. civil society, NGOs, professional associations, academia, research institu-tions, think tanks etc., (iv) international/global level. We will now discuss how Uganda can put all this into practice on a long term basis.

Looking 30 Years Forward5.

Initiating National Dialogue on Health

The first step is to bring everyone on board through an open dialogue. Health re-forms that deliver results and are sustainable in democratic societies are achieved through broad national consensus. Examples include the NHS, Thailand led by civil society with encouragement from the King and the current Obama care to name but a few. Once the consensus is gained, they also need to be implemented consistently over a long period of time usually a minimum of 30 years for them to get entrenched in the laws, society and in institutions. This is the way Uganda needs to go and such dialogue is normally led at the highest political level and results in a social and political compact between the government and the popula-tion. In Uganda, while the HSSIP acknowledges the need for a national compact and multi sector action, practical steps for its achievement are not articulated. Health is currently viewed as treating and preventing diseases by the Ministry of Health and not as a way of life that is at the centre of the governance of society.

It is recommended that the Hon Minister of Health should with immediate ef-fect take leadership and work to engage HE the President, the RT Hon PM and other government sectors, parliament, professional associations, civil society, academia and think tanks and development partners to kick off this dialogue. This dialogue should culminate in the passing by Parliament of a new Health Act that contains provisions for ensuring that the various levels of ownership and accountability for population health outcomes in Uganda are provided for in the new Health Act.


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Strengthening Stewardship and Governance of HealthThe second key step is to strengthen the stewardship of the health sector at all levels. For this to happen, it is first necessary to address issues around the techni-cal leadership of the Ministry of Health. The midterm review reports for HSSP-I and HSSP-II as well as information from Key Informant interviews have pointed out the difficulties that have arisen from the current structure of the offices and governance structures at the MOH headquarters. The difficulties experienced in-clude conflicts between officers and departments, overlap of roles and delays in decision making.

These have contributed to significant shortcomings in performance over the years. Further, there is evidence to show that the recommendations and decisions taken during the Restructuring exercise of 1998/99 were not fully implemented with respect to leadership roles in this highly technical ministry. Further and very important, the 1995 constitution provides for the role of the “technical head of medical services” with an important role in assessing and determining the fitness of the head of state to govern on medical grounds. To discharge this constitu-tional role such technical head of medical services needs to be independent and not under the direction of any other person. Who is that person today? Is it the DGHS or the PS? It had been recommended that this ministry like other technical ministries should be led by a technically qualified individual. There is a need to stream-line the decision making processes and redefining roles of various offices and organs in the MOH: Offices of PS / DG; Planning / QA; Resource Cen-tre / Disease surveillance; HR development and Personnel; TMC, SMC, HPAC, NHA/JRM for more effective stewardship and governance of the health sector

It is therefore recommended that the Hon MoH takes the lead with immediate ef-fect in undertaking a review to streamline roles of the key offices and governance organs at the MoH headquarters.

Political and Technical oversight of HealthPolitical and Technical oversight and supervision of services delivery is critical to ensuring that the quality of health services meet populations expectations and that there is value for the money. The midterm reviews and the Joint Assessment of HSSIP have noted that Uganda has established service standards for delivery of the minimum health care package of services by level including implemen-tation arrangements. For example, health centres I, II, III and IV have clearly defined roles yet most have not received the required minimum inputs and the political and technical support to enable them to perform in accordance with their defined roles and to meet public expectations.


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There is need to review and agree service standards by level, mobilize neces-sary resources for inputs needed for compliance with the standards and establish mechanisms for ensuring that the required capacity is developed for sustainable performance according to the agreed service standard. Further, the Annual Health Sector Performance Report of 2009/2010 recommended the revival of consultant outreach program of supervision, and the reactivation of various supervision and QA practices. There is need for review and institutionalization of a Systems ap-proach to Supervision and oversight of services delivery including the use of con-tinuous performance improvement approaches such as Quality Assurance tools, leadership and management capacity development, negotiation and communica-tion skills, routine self-assessment etc.

It is therefore recommended that the Top Management of the Ministry of Health works with the Ministries of Local Government, Finance to review of health care service standards with a view to:

agree and update existing service standards by level,•

develop a health financing strategy to facilitate mobilization of the neces-•sary resources to

support delivery of the agreed service packages and in compliance agreed •service standards;

establish regulatory or legal mechanisms to facilitate oversight in ensur-•ing compliance and,

Build capacity at all levels for oversight of implementation of the services •package and

Eliminate corruption.•

It is further recommended that in addition to other measures to strengthen health sector governance, a review is conducted of quality assurance procedures, tools and, supervision manuals already developed by the Ministry, so as to update and institutionalize them for immediate use, as tools for improvement of health ser-vices delivery.

Human Resources for HealthHuman Resources for Health are a critical input in all efforts to improve the performance of health systems in all countries. There is unanimity in the reviews of HSSP I and II and Annual Health Sector Performance Reports that the both the health and education systems are facing serious challenges in training and


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education, recruitment and retention and in incentives provided to the health workforce. At the global level, much attention has been applied to developing global good practice guidelines in health professionals training and management. These span the areas of skill mix planning, education and training that links the education and health systems, rural retention and incentive packages. A number of African countries have established the Country Coordination and Facilitation (CCF) framework that creates a platform for all stakeholders to jointly plan for national health workforce that is responsive to country health needs.

It is recommended that The Hon Minister of Health and the Chairperson of the Health services commission should with immediate effect convene stakeholders in Uganda to establish an effective CCF.

Whereas the constitution and HSC Act provide a key role for the HSC to manage all aspects of the health work force and in light of persisting health workforce is-sues noted above, it is recommended that the scope of work of the HSC be evalu-ated and measures put in place to facilitate HSC to fulfil the broader mandate.

Financing Strategy for Universal Access to Health Services

The UN and the rest of the international community have embraced the principle of Universal Health Coverage and Uganda has been a signatory and participant in global resolutions on UHC at regional and global level. Health Financing in Uganda is a matter that calls for urgent attention and should be part of the na-tional dialogue discussed in 1 above. In the light competing national priorities for the limited resources from the tax base, the country should look to accessing and better manage the 60% health expenditure currently born by households. The government budget per capita expenditure at about $10 is well below the $45 recommended by the WHO Commission on Macroeconomics and Health. Over the years a number of studies and efforts have been made to establish a national health insurance plan for Uganda but due to weak stewardship of the process by the MoH no conclusive arrangements have been reached. In the face of this, all neighbouring countries have already established health financing strategies and there are leading countries in the continent with advanced schemes from which Uganda can learn.

It is recommended that the Hon Minister of Health should review previous work and include the discussions on health financing as part of the national dialogue on health. This should result in a national health financing strategy that is home grown and broadly owned and is consistent with the national resource base other national priorities


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References

ACHEST, (August 2011): A Study of Health Sector Reforms in Uganda: 1. Lessons for the Health Sector Strategic and Investment Plan (HSSIP) 2010/2015.

Charles Boelen, (2010): The study on Social Accountability of Medical 2. Education

Dodge CP et al (1981): Crisis in Uganda - The Breakdown of Health 3. Services - edited by Cole P. Dodge and Paul D. Wiebe.

Francis Omaswa, (2010): Strong Ministries for Strong Health Systems 4. study report

George Washington University School of Public Health and Health 5. Services (2010): The Sub-Saharan African Medical Schools Study (SAMSS).

Kirunga-Tashobya, C.; Ssengooba F.; and Cruz, V.O. (editors-2006): 6. Health Systems Reforms in Uganda: processes and outputs. Institute of Public Health, Makerere University, Uganda, Health Systems Devel-opment Programme, London School of Hygiene & Tropical Medicine, UK., Ministry of Health, Uganda, ISBN: 0 902657 77 1, 117 pp.

Kutzin J (2001): A descriptive framework for country-level analysis of 7. health care financing arrangements. Health Policy

Ministry of Health – Uganda (1993): The Three Year Health Plan Frame, 8. 1993/94 – 1995/96.

Ministry of Health – Uganda (1993): White Paper on Health Policy Up-9. date and Review of 1993

Ministry of Health – Uganda (1999): National Health Policy September 10. 1999

Ministry of Health – Uganda (2000): Health Sector Strategic Plan 11. 2000/01 – 2005/05

Ministry of Health – Uganda (2000): Health Sector Strategic Plan 12. 2005/06 – 2009/2010


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Ministry of Health Uganda (2007): HRH strategic Plan13.

MoH and Prof Owor (1987): Report of the Health Policy Review Com-14. mission.

Nabyonga J, Desmet M, et al (2005): Abolition of cost-sharing is pro-15. poor: evidence from Uganda. Health Policy Plan 2005; 20: 100–08.

World Health Organization (2008): The World Health Report 2008 - pri-16. mary Health Care (Now More Than Ever

World Health Organization (2007): Everybody’s business: strengthen-17. ing health systems to improve health outcomes: WHO’s framework for action.

World Health Organization (2006): The World Health Report 2006 - 18. Working together for health

Xu K, Evans DB, et al (2006): Understanding the impact of eliminating 19. user fees: Utilization and catastrophic health expenditures in Uganda; Social Science & Medicine 62 (2006) 866–876


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Overview of Environmental Management in Uganda

Prof. Frank Kansiime, Makerere UniversityCollege of Agriculture and Environmental Sciences

1. Introduction

Ever since the 1972 Stockholm UN conference on the Human Environment, which established a link between underdevelopment and environmental integrity, environmental issues have gained attention (UNEP, 1999). Awareness has been generated so as to minimise degradation of environment and uncontrolled exploi-tation of natural resources therein. The threat to fauna, flora and ecosystems in general and the security of the human being has created institutions and organiza-tions whose primary goals and objectives are to preserve and protect the environ-ment. Furthermore, the 1992 UN conference on Environment and Development, otherwise known as the “Earth Summit” which was held in Rio de Janeiro in Brazil generated an action plan for sustainable development in the 21st century, which has become the policy instrument that drives environmental management programs in many countries, Uganda inclusive (Ngategize et al, 2000). At this summit emphasis was put on sustainable development which was considered as the ability of the present generation to meet its needs without compromising po-tentials of the future generations to meet theirs. Furthermore, principle 3 of the Rio Declaration provides that “the right to development must be fulfilled so as to equitably meet developmental and environmental needs of the present and future generations”.

However, due to the need to develop via industrialization, developing countries like Uganda are constrained to pursue the same development models without im-pacting on the environment. Developing sustainably without compromising the integrity of the environment constitutes a major challenge to environmental man-agement in Uganda. Environment can be considered as the interactions and inter-relationship of all living and non-living things (Sandeep, 2003). Its management known as “environmental management”, are actions that industries, companies and individuals undertake to regulate and protect the health of the environment or the natural world. In most cases, it does not only involve managing the envi-ronment itself, but rather the process of taking steps and promoting behaviours that will have a positive impact on how environmental resources are used and managed sustainably.

Uganda has a high natural resource potential on which more than 90% of the country’s population depends directly for their livelihood (UBOS, 2006). Like-wise, the country’s development process and opportunities mainly depend on the natural resource base with a GDP growth rate of about 6% (World Bank, 2002).


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Natural resource exploitation will continue to form the basis for livelihoods of the majority in the foreseeable future (Lubega, 2006). However, the resources are facing tremendous pressures from rapidly expanding population, economic activities and in some cases increasing degradation by users. Uganda has con-tinued to experience environmental degradation manifested by different forms of problems some of which are directly linked to the health and well-being of natural resources (wetlands, forests and water). The Government of Uganda ac-cord high priority to the protection of environment and natural resources and has developed a number of laws and regulations to that effect. This protection drive dates back to 1986, when the National Resistance Movement came to power and put hold to the degradation of environmental resources until policies regulating their use were put in place.

2. Evolution of Environmental Management in Uganda

Environmental management can be traced back to the pre-colonial era where ac-cess to environmental goods and services (natural resources) was governed by a democratic system of communal tenure under which all members of society had equal access rights over forests, pastures and water resources (Akello, 2007). The governing ‘policy’ then was that it was an indisputable right of every member of the community to have access rights to those resources in addition to full owner-ship of the products of one’s labour (Kamugisha, 1993). However, Colonialists came with protectionist perception in which resource users were seen as problem makers. This perception guided the establishment of protected areas where access to resources was restricted. In the 1960s to 1980s, local people looked at Game Rangers as their enemies since they denied them access to hunt animals for food, skins and hides, horns, etc. (UWA, 2005). The total restricted areas comprise ap-proximately 8% of Uganda’s total land (Green, 1995).

Two relatively recent developments have influenced the environmental regime in Uganda. First, as international environmental concerns attract global atten-tion; Uganda is a signatory to important conservation conventions. Second, a new constitution that was promulgated in 1995, clearly stipulates that environ-mental issues form one of the important matters of the state and the people of Uganda (MFPED, 1999). Even before that, the National Environment Manage-ment Policy had been put in place in 1994 to promote sustainable economic and social development that enhances environmental quality. The constitution also acknowledges decentralization as one of the major efforts for state building after a long period of civil war and social turmoil especially from the middle of 1970s to 1980s. It should be noted that before this time, governance and environmental management used a top-bottom approach.


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The processes of decentralization were accelerated in the early 1990s. This was done to ensure that environmental management is brought to the people as close as possible. The local council (LC) system, which is a hierarchy of councils and committees, became an important forum for local people to interact with authori-ties. The LC system has five levels ranging from district (LC5), county (LC4), sub county (LC3), parish (LC2) and village (LC1). The political leaders of each level are elected into office and with decentralization, LCs are responsible for overall planning and implementation of development activities, including envi-ronmental management. The LC system has a local autonomy though they are dependent on the centre for financial resources which inevitably affects their au-tonomy (Saito et al, 2003).

Section 15 of the National Environment Act, Cap 153 mandates the establish-ment of the District Environment Committees (DEC). The DEC is supposed to ensure that environmental concerns are integrated into activities carried out by each district in accordance with the national environmental policy. In most of the districts, there is a District Environmental Officer (DEO), who is responsible for overall planning and management of environmental issues. The tasks of the DEO include creating environmental awareness, incorporating environmental activi-ties in schools, monitoring economic activities which may have adverse impacts on the environment, building data bases on environmental issues in each district and supporting implementation of environmental actions within the district. At the grass root levels, the LC system is a valuable forum for consultation. At this level, there is no legal requirement for establishing environmental management committees, but in some limited areas, these committees have been formed.

As aforementioned, the structure of decentralized environmental initiative is in place, but the question now is how to turn the structure into effective manage-ment. Even if a significant degree of decentralization has been implemented in Uganda, central authorities still retain controls over environmental regulations, primarily when they are related to national parks, forest and game reserves. The main problem is to secure institutional links between authorities and the LC sys-tems. Even if there have been some attempts to promote collaboration between conservation authorities and the LC system, there has not been a clear link estab-lished between those two. Thus quite often, collaboration is based on personal ties rather than institutional arrangements. As of recent, environmental matters have attracted attention of many Ugandans right from politicians, academicians, non-governmental organizations, and community based organizations to ordi-nary citizens. This has been attributed to wide spread environmental awareness programs, environmental education and communication and community com-parison of current and past environmental trends especially by communities who


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are occupying unsafe areas (low lying areas like wetlands, unstable hills and mountains, etc).

The national environment action plan (NEAP) led to formulation of the Environ-ment Management Policy in 1994 which was a landmark output of the NEAP. The NEAP process also pressurized government to formulate laws and regulations and institutions to govern the use of environmental resources. The laws and regula-tions that have been formed include: The constitution of the Republic of Uganda of 1995 is the supreme law and provides for environmental management; Nation-al Environment Act, cap 153; Uganda Wildlife Act, 1996; National Environment (Minimum Standards for Discharge of effluents into Water or Land) Regulations, 1996; Local Governments Act, 1997; National Environment Impact Assessment Regulations, 1998; National Environment (Audit) Regulations, 2009; Land Act, 1998; National Environment Water Act, 1998; National Environment (Waste Management) Regulations, 1999; National Environment (Wetlands, Rivers banks and Lakeshores Management) Regulations, 2000; National Environment (Mini-mum Standards for Management of Soil Quality) Regulations, 2001; National Environment (Noise Standards and Control) Regulation, 2002; Investment Code, 1991; National Environment Mining Act, 2003; National Environment Forestry and Tree Planting Act, 2003; National Environment Hilly and Mountainous Ar-eas Regulations, 2000. In addition the Government of Uganda is a signatory to many International conventions like the Ramsar Convention (1971) on wetlands of international importance, Rio Declaration (1992) on Environment and Develop-ment, Kyoto protocol (1997) of United Nations Frame Work on Climate Change, Montreal protocol (1987) on Substances that Deplete the Ozone Layer, among others. The NEAP also tasked government to gazette environment institutions which brought about the creation of a fully fledged Ministry of Environment and Natural Resources now called the Ministry of Water and Environment (MWE) and the National Environment Management Authority (NEMA) whose role is to coordinate, supervise and monitor environmental issues though local communi-ties and all resource users have a key role to play in the protection and sustainable use of natural resources.

Of recent many Ugandans have become environmentally friendly as revealed by establishment of many locally initiated nongovernmental organizations in the environment sector, community based organizations and individual groups that lobby against environment degradation. The relationship between forest rangers and the local people living near forest reserves in the past has improved and now the locals inform the rangers in case any person invades forest reserves (NFA, 2007). If this current relationship (community based natural resources manage-ment) persists, conservation efforts are likely to yield greater results.


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3. The state and trends of environmental resources in Uganda and the challenges being faced

3.1 Wetland Resources

Uganda’s wetlands range from those fringing the equatorial lakes to those in the Afromontane regions of Mt. Elgon and Rwenzori. This large expanse of wetland resources is explained by a climate of high rainfall and the general topography of the country. In 1964, the total area of wetlands was estimated at 32,000 km2 but by 1999, it had decreased to 30,000 km2 which is about 13 percent of the total area of Uganda (SOER, 2000/1). The National Forestry Authority (NFA) (2008) reported that Uganda’s wetlands cover which was estimated in 2005, had reduced to 26,308 km2, or 11 percent of total land area in 2008.

Uganda loses approximately 15% of its Gross Domestic Product (GDP) due to the destruction of its natural resources. Wetlands destruction alone costs Uganda nearly 2 billion shillings annually and contamination of water resources which is partly caused by reduced buffering capacity provided by wetlands costs Ugan-da nearly 38 billion annually (Aryamanya-Mugisha, 2011). The key underlying cause of wetland loss is human encroachment. People are converting wetlands for infrastructural development and as dumping sites for wastes especially in urban areas, agriculture, settlement and commercial purposes like overharvesting wetland products for sale. This has been worsened by high levels of poverty and the rapid population growth which has created increased demand for food and settlement. For example in Eastern Uganda, most of the wetlands are being used for rice cultivation while vegetables are cultivated in the Central and Western regions of Uganda. The highest loss of wetlands has been recorded in Eastern Uganda (Table 1). Unsustainable use of wetland catchments has led to siltation of wetlands, rivers and lakes.


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Table 1: Total wetland area (km2) and area converted by district, Uganda (Source, SOER, 2000/1)


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Industrial development and human settlements have largely led to degradation of urban wetlands. For Kampala City which has lost over 80% of its original wet-land area most of which buffer Lake Victoria. This has led to polluted water being discharged into the lake. As a result problems associated with eutrophication and eventual anoxic conditions of L. Victoria will be exacerbated. The Kabale wetland reclamation decade of 1970-1980 and the Bushenyi district scramble for wetlands farms remain the work of NEMA and other relevant Institutions to restore these habitats sooner than later. The recent conversion of valley environ-ments in the greater cattle corridor zone of Nyabushozi, Kashari, Ssembabule into banana plantations has also been a problem through formation of pseudo-lake after heavy rains due to lack of water percolation and bare ground; (a pseudo lake is created when rain water accumulates in a depression on a bare ground and stagnates there for a long time); the Nshara Pseudo- lake, the Kyazanga Pseudo- lake and the Ntusi Pseudo lake in Ssembabule are indicators of valley environ-ment degradation. This should stop to avoid further environmental upheavals in form of floods. If the vegetation is restored, percolation and rain water absorption will be enhanced and this will support direct and indirect attributes of environ-ment.

Despite these challenges in wetland resource management, Uganda as a country and a contracting party to the Ramsar Convention has taken some measures with the aim of bringing about a positive change such as; designating some wetlands as Ramsar sites (currently 11 from 1 in 1988), evicting encroachers on wetlands and eventually restoring them to their original status, publishing wetland resources use guidelines. In order to reduce wetland loss and degradation, all stakeholders should be included in the management of wetlands and awareness rising so that wetlands benefit us all. Demarcating and inventorying of all wetlands should be done and followed by strict enforcement of the existing laws and regulations and strengthening wetland institutions and policies.

3.2 Forest resources

Forests in Uganda occur as gazetted areas (forest reserves), protected areas (na-tional parks) and constitute 30 percent of the forest cover while the remaining 70 percent is on private and ungazetted public land (NEMA, 2007). Forests are habitats of rare plants and animals and constitute unique ecological systems. The forests on public and private land are largely being degraded, while those in Na-tional Parks have restricted access. Generally, the size of Uganda’s forest cover declined by 25 percent between 1990 and 2000, Figure 1.


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Figure 1: Trends in Forest cover since 1990 (Source, SOER 2006/7)

The driving forces behind forest loss include among others: high population growth rate which has resulted into increased demand for food, energy and land for settlement. For example about 90 percent of Uganda’s population in rural ar-eas directly depend on fire wood for their energy needs and generally, 92 percent of Uganda’s source of energy is fuel wood (NEMA, 2007). Encroachment on for-est reserves, weak laws and institutions, and over harvesting of the forest prod-ucts are the other forces and these were at their peaks between 1970 and 1980 as a result of the civil war. Currently, it is estimated that 800,000 m3 of logs are cut each year, a rate of timber harvesting that exceeds sustainable cutting levels by a factor of four (NEMA, 2007). The most recent forces have been urbanization and establishment of a business industrial park like one in Namanve near Kam-pala. The Uganda Cabinet is still debating the issue of 7,100 hectares of Mabira Central Forest Reserve which is supposed to given to the Sugar Corporation of Uganda (SCOUL). Since tropical forests like these ones are known to be good carbon sinks, their continued loss lead to release and accumulation of carbon to the atmosphere thereby increasing trends of global warming and climate change as green house gases in the atmosphere will continue to accumulate.

The positive trends taken by the government in the forest sector include among others; carrying out voluntary and forceful evictions of people encroaching on Central Forest Reserves, planting of trees on formerly encroached forest reserves (however a number of exotic trees like pines, eucalyptus- the South Africa type with high evapotranspiration rates have been planted without experimental trials to assess their negative impacts), sensitizing political, civic leaders and encroach-


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ers on local radio stations and establishment of institutions, policies, and laws and regulation governing the use of forest resources. However, since the majority of Uganda’s population live in rural areas and entirely depend on biomass as the source of energy, forest loss and degradation in such areas will only be reduced by providing alternative sources of energy like hydropower. Forest reserves near urban areas should be protected from encroachment by industrial and other in-frastructural development through strengthening corresponding laws and regula-tions, policies and institutional frameworks.

3.3 Land resources

Of Uganda’s 241, 500 square kilometres total area, the land area covers 236,000 sq km (UBOS, 2006). Uganda has 7.2 million hectares of arable land under per-manent crops and is one of the least urbanized countries in Africa with close to 84 percent of its population practicing pastrolism or subsistence agriculture (ECA, 2005). Despite Uganda being endowed with favourable climate compared to the rest of sub-Saharan Africa, its land under cultivation has fluctuated considerably over the past years (NEMA 1998). There was a sharp rise in the area under culti-vation between 1960 and 1979 from around 3.3 to 3.5 million hectares. This was followed by a sharp fall between 1979 and 1980 from 5.7 to 3.5 million hectares. This fall was primarily due to the civil war which was prevailing at that time. The period between 1980 and 1984 registered a slight increase in the cultivated area followed by yet another decline between 1984 and 1985 following another civil war. Since then, there has been a steady increase in the area under cultivation due to improved security, macroeconomic stability and law and order (MFPED, 1998, UBOS, 2000, BOU, 1983).

The use and management of land resources in Uganda has been mainly affected by land tenure systems. During the colonial period, various policies and laws relating to ownership and management of land tended to favour individualiza-tion but without alienating the need for customary tenure. Perhaps the most fun-damental change in tenure was introduced in the Land Reform Decree in 1975 (NEMA, 2001). The law repealed all previous tenure systems except lease hold. Here, all communal areas became public lands, potentially available for lease by any interested party. As a result of this, several areas originally gazetted as forest or wildlife reserves, were degazetted hence frustrating environment management efforts.

In 1998, the Land Reform Decree was replaced by the Land Act (1998). The Act recognizes four tenure systems; customary, freehold, mailo and leasehold. This Act provides for environmental protection. In particular, section 44 of the Act requires a person who owns/occupies land to manage and utilize it in accordance


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with the National Environment Act, cap 153. As of now, most of Uganda’s land is under customary tenure, meaning communal utilization. In some areas, par-ticularly within rangelands there is open access in which no control is exercised in determining where, when, how or who utilizes the land and has been the major cause of land degradation in Uganda (Kisamba-Mugerwa, 1992).

Uganda’s soils were once among the most fertile in the tropics, however, many its fertility has declined because of many challenges: nutrient depletion, erosion, overgrazing and others forms of land degradation are increasing. Many tradi-tional systems such as shifting cultivation that were sustainable 50 years ago have been abandoned. In the most highly populated areas in the country, farmers use greatly shortened fallow periods and practice continuous cultivation without resting the soil. Consequently, the soils are systematically mined and their natural fertility has disappeared (UNEP/IISD, 2005). Soil erosion is the most serious and extensive form of land degradation and is especially severe in Kotido, Moroto, Mbarara, and Luwero districts where overstocking and grazing have degraded the vegetation cover (UNEP/IISD, 2005). Soil erosion is also severe in the highland districts of Mbale, Kabale, Kabarole, Kapchorwa, Bundibugyo and Kasese which are more favourable agricultural areas (Nkonya et al, 2002). With Uganda’s two growing seasons a year, the depletion rates of crucial nutrients such as nitro-gen, phosphorus and potassium are among the highest in Africa (NEMA, 2001). Agro-chemical input to overcome soil nutrient loss, bush burning and dumping of wastes have polluted the land. The restoration of contour ploughing bands with strict band sizes in hilly places of Kabale, Rwenzori, Bugisu to avoid envi-ronmental land degradation, floods, landslides, mass wasting and further siltation of streams, rivers and lakes should be carried out. A settled system of life from a sedentary life of pastoralists must be enforced urgently.

Uganda has taken a number of interventions in land management. The soils and soil management programme of National Agricultural and Research Organi-zation (NARO) together with other collaborative institutions have undertaken on-station and on-farm research activities aimed at curbing land degradation trends and improve people’s livelihoods. These encompass participatory iden-tification of environmental problems, understanding the underlying causes, sen-sitizing stakeholders about these problems, identification and experimentation with different potential solutions on addition to establishment of institutions, policies, and laws and regulations pertaining the use and management of land resources. Adopting proper farming methods, control and monitoring of poten-tial land pollution sources and adopting an inclusive land management strategy which involves land users, owners and authorities will help to reverse the cur-rent land degradation trends.


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3.4 Water Resources

Water resources in Uganda comprise, ground water, rain water and open wa-ter bodies including lakes, rivers and streams, constituting about 15 percent of Uganda’s total area. Lakes alone in Uganda cover one fifth of the total area of the country. NEMA (1996) reported that on a regional basis, 39.1% of water bodies are found in central, 30.3% in eastern, 3% in northern and 8% in west-ern regions showing greater disparities in the availability of water. The whole of Uganda lies in the Upper Nile catchment consisting of numerous rivers and streams flowing into principal lakes such as Victoria, Kyoga, Edward and Al-bert. Ground water resources have sustained a gradual decrease in water lev-el and has been attributed to increased abstraction for boreholes ndsprings. The quantity of surface water varies from season to season. The water levels in lakes, rivers streams and ponds recede during the dry season and increase during the wet season. The current major areas of concern in water resource manage-ment are poor watershed management, inadequate water accessibility and quan-tity, poor water quality, inadequate institutional capacity and international water rights all of which affect the quality and quantity of water available for use.

The quality of Uganda’s water resources has been declining over time. The major problems associated with the decline of water quality include; heavy siltation of rivers and dams, untreated domestic sewage and industrial effluent discharges, mining activities, poor solid waste management and other non-point sources of pollution. Water resources in Uganda and indeed in many African countries are prone to degradation mainly because they are traditionally a common property, utilized by anybody but in practice owned by nobody. In addition to these, water environments occupy the lowest topography in a given area where agents of envi-ronmental degradation often expose them to degradation. Consequently manage-ment of aquatic resource in Uganda has not been effective at safe guarding the water environment and fisheries resources from the resultant threats. Various hu-man activities notably poor land use practices, dumping excessive nutrients and toxic wastes (pollution) into water has resulted into excessive growth of algal blooms in Lake Victoria. Exotic species introduction and over fishing have also threatened many lakes in Uganda (Bugenyi, 2001). DWD (2006) reported that 72 percent of Lake Victoria’s pollution is contributed by urban centres, 13 percent by industries and 15 percent by fishing villages (Figure 2)


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Figure 2: Pollution loading from point sources of Lake Victoria (Source, SOER 2006/7)

Pollution of water for example Lake Victoria, Africa’s biggest fresh water lake and source of water for millions of people in the region implies poor health for the water users or incurring high costs of water treatment to attain recommended water quality standards (NEMA, 2004). In some rural areas of Uganda, scarcity of water is being experienced due to drying of wells, springs and decline of water levels in boreholes which force women and children to move long distances in search for water (DWD, 2008).

Uganda has overtime established policies, laws and regulations and institutions to manage water resources. The Water Action Plan of 1995 and Water Statute of 1995 are the cornerstones of water resources management in Uganda by provid-ing measures for sustainable management and incorporating legislation for water resources. To address water pollution, proper waste management measures have been put in place. For example effluent discharge regulations of 1999, point out the need for efficient collection and disposal of solid wastes by city and mu-nicipal/town authorities through the public-private initiatives, pre-treatment of liquid wastes prior to disposal and involving all stakeholders in cleaner produc-tion practices in addition to protection of water sources from abuse by users. Furthermore, there is need for establishment of buffer zones along water bodies to minimize pollution of Uganda’s fresh waters. This intervention will also re-duce hypoxic and anoxic conditions that have seen Uganda lose fish stocks in the past.


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3.5 Fisheries Resources in Uganda

Uganda has about 18% of its surface covered by lakes, rivers and swamps which are important sources of fish. The most important fishing grounds include Lakes Victoria, Kyoga, Albert, Edward and George, Rivers Victoria Nile and Albert Nile. Others include small Lakes like Wamala, Nabugabo, Kwania, Koki, among others. Fishing in these areas is open access where one can join or leave at any time of convenience, (NEMA, 2006/7).

The management of Uganda’s fisheries resource has passed through several phas-es. The key management issue during the early days of subsistence fishing was mainly catching fish using rudimentary gear as fish were in plenty. In 1920’s, however, localized overfishing became a reality. From then onwards, the overrid-ing management issue became how to contain the over-exploitation of fisheries resources (MNR, 1994). As a result of the findings of the survey of Lake Victoria, Graham in 1929, made four principal recommendations with regard to the future management: prohibiting the use of gill-nets with a mesh size of less than 127mm (5 inches) when stretched; instituting sustained research on the fisheries resourc-es; setting up fisheries statistics collection to monitor the fishery; and establish-ing a lake wide authority to oversee the collection of statistics and enforcement fishery regulations. Before Graham’s study, the management of Uganda’s fisher-ies resource was the responsibility of the Game Department. It employed Fish Guards whose duties were primarily the compilation of catch statistics, general control and limited experimental investigations involving the use of gill-nets.

Today, the management of Uganda’s fisheries resources rests in powers of two organizations, one dealing with research (National Fisheries Resources Research Institute), responsible for research on the country’s fisheries, and the other deal-ing in administration (The Fisheries Department), charged with monitoring the fisheries resources and enforcing regulations. Uganda’s fisheries resources are crucial in its economic development being the second export earner after coffee between 2002 and 2005, contributing about 2.2 percent of the country’s GDP (UBOS, 2006). In terms of employment, about 5.3 million people are engaged in fishing as their livelihoods (Fisheries Department, 2010)

Despite the above economic benefits accruing from the fisheries resources and existence of institutions to guide the exploitation of the fisheries resources, Ugan-da’s fisheries resources have faced a number of challenges over time. Over fish-ing and indiscriminate indigenous species decline, pollution of water sources and poor coordination in the management of shared fisheries resources are among the major challenges.


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Increase in population growth and urbanization has resulted into increased de-mand for fish as a source of high quality animal protein locally and internation-ally. This has resulted into use of poor fishing methods like under sized gill-nets and poisoning to increase on the volume of the catch so as to sustain the demand. This has been exacerbated by easy access to markets due to the improvement in the transport sector.

Pollution of water bodies has become more pronounced in the recent days than in the past. Agriculture, industrial activities and indiscriminate dumping of wastes by fisher folk communities are the major factors contributing to pollution of water bodies. Discharge of industrial effluents and run-off from agricultural fields has caused eutrophication of water bodies. The invasion of water bodies by aquatic weeds (specifically water hyacinths) is a rising concern. In addition to polluting water resources, the weed is able to perforate extremely fast and is able to double its population every 5 to 15 days under favourable temperatures and high concen-trations of nitrogen and phosphorus nutrients (UBOS, 2006)

Decline of indigenous species of fisheries resources especially in Lakes Victoria, Kyoga and Nabugabo has been attributed to the introduction of the Nile perch into the lake which is predating on the indigenous species (NEMA, 2004/5). For example, prior to the 1960s, Lake Victoria boasted of fish species diversity similar to that of lakes Malawi and Tanganyika with about 400 species of fish. However, current observations from commercial catches indicate that the species composition of Lake Victoria stocks has been reduced to three main species of Nile perch, Rastroneobala argentea (mukene) and Oreochromis niloticus with indications showing 20 species depleted in the lake in only the past 40 years (LVFO, 2005).

Coordination in the management of fisheries resources traversing international boundaries is another concern. Take for example Uganda sharing Lake Victoria with Tanzania and Kenya, Lakes Albert and Edward with the Democratic Re-public of Congo, poses a major problem when it comes to resource management. Uganda’s efforts in the sustainable management of these resources are sometimes frustrated by the other parties. However, much as these challenges exist a number of interventions have been put in place by the government to counter them. The government, through the Ministry of Agriculture Animal Industry and Fisheries (MAAIF) is implementing programs for improved fish management, research and development; fish Beach Management Units have been put in place. Through Lake Victoria Environment Management Project (LVEMP), the East African es-tablished the Lake Victoria Fisheries Organization (based in Jinja-Uganda), to ensure improved productivity of Lake Victoria. The Aquatic Research and Devel-opment Institutes have also been put in place


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Other government interventions include provision of resources to strengthen Uganda National Bureau of Standards and the Inspectorate Section of the Fish-eries Department, introduction of a number of courses related to the fisheries sector at higher institutions of learning, providing resources to upgrade landing sites and quality control laboratories, employing fisheries officers at local gov-ernments, among others.

3.6 Atmosphere

The state of the atmosphere governs the viability of agriculture and the health of the human population and other living organisms. The issues of concern in Uganda are climate change and variability and pollution. Although Uganda is a net sink for green house gases (due to its forest cover and other ecosystems like wetlands), the country cannot ignore the potential impact of climate change since atmospheric gases have no national boundaries and the impacts are global. According to Ottichilo (1991), climate change is expected to have far reaching impacts on both existing and potential development activities by affecting bio-productive system on which most economic investments in Africa are based. The impacts of increased temperature and decreased rainfall will cause shifts in vege-tation zones as plants which cannot tolerate high temperatures will be eliminated (UNEP 1993). This will in turn affect various sectors including agriculture, tour-ism, energy, industry and commerce especially as a result of prolonged droughts. Already Uganda’s rainfall has become irregular both in amount and distribution, impacting heavily on rain-fed agriculture practiced by the majority farmers of the country (FAO, 2000).

Of particular emphasis now is atmospheric pollution. According to UNEP (1991), atmospheric pollution has emerged as a problem in many African countries in the past few decades. The impact and severity is still largely unknown, although it is believed that vegetation, soils and water in some areas have been adversely affected. The main sources of atmospheric pollution in Uganda are bush fires, vehicle emissions, industry and mining. The major industrial sources include diesel power generators, ferro-alloy works, steel works and cement plants. Af-rica’s emission from vehicles is expected to continue increasing if the projected growth of demand for vehicular transport is to be met (World Bank, 1992). This is because of the aging vehicles used in Africa, most of which are more than 15 years old (World Bank, 1995). Uganda’s vehicles on the roads in 1971 were 44,510 and by 1999, the number had increased to 186,244, a fourfold increase in less than 30 years. On the other hand petroleum consumption decreased from 536,610 m3 in 1970 to 192,269 m3 in 1982 and then increased to 503, 083 m3 in


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1999 and numbers of registered vehicles in 2011 were 635,656. This increase in the number of vehicles is attributed to financial and political stability being experienced in Uganda. Lack of awareness and limited traffic and road signs; warnings and signals are the leading causes of increased fuel consumption due to traffic congestion.

The main issues related to atmospheric pollution in Uganda include; inefficient utilization of fuels, poorly planned modes of transport, poorly serviced vehicles, inefficient cook-stoves and fire places, rudimentary kilns and stoves in industries, charcoal production, bush burning and importation of equipment that contain chlorofluorocarbons. Importation of second hand cars and auto-mobiles also con-tribute to atmospheric pollution.

Uganda has taken some positive steps to address atmospheric pollution, including being a signatory to, and ratifying the United Nations Framework Convention on Climate Change (UNFCC), adopting energy efficient practices and formulation of air quality standards. To reduce on atmospheric pollution, Uganda should re-strict importation of used and inefficient vehicles, encourage use of public means of transport including buses and trains, promote other forms of energy like hy-dropower, prohibit use of leaded fuels, and emphasize environmentally friendly industrial production processes. Efforts should also be made to plant more trees which will help to absorb atmospheric green house gases.

4. Conclusions and recommendations

Since poverty and environment are related in one way or the other, there is need for the government to create alternative sources of livelihoods for the majority poor. Other sources of renewable energy like hydropower, solar, wind, biogas should be promoted to reduce dependence on firewood as a source of energy for cooking. There is need to educate the public on good soil and land conserva-tion practices and provide alternative sources of income rather than entire de-pendence on natural resources. Environmental management in Uganda has pro-gressed on well though many new emerging issues are being encountered like climate change which will pose new environmental challenges. Other challenges like deforestation, overexploitation of resources, land and soil degradation, high population growth rate, implementation of laws, among others, have remained and now needs the efforts of every Ugandan since environmental management is a collective responsibility of every citizen.


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Environmental laws should be strengthened and enforced to punish environmen-tal degraders reasonably. Coordination in relevant environment agencies and line ministries will help ease implementation of environmental policies and projects. There is however a need to put a good communication strategy in place. The government should upwardly revise its funding to the environment sector since it contributes a considerably high amount to the country’s gross domestic product (GDP) either directly or indirectly.

Environment being the interaction between man and the living and the nonliving things, man is crucial in the success of environmental management. The manage-ment should begin at household level, move through institutions up to policy makers; who should have played their role at household level. Through this hi-erarchy, awareness raising and environmental education are key to the success of efforts towards environmental management. We need to talk less and use the available information and act. We also need to lead by example. We ourselves should think of basic environmental actions like minimising the generation of wastes, by reusing and recycling of waste at household level. We should be cau-tious bearing in mind that the actions we take now might affect us and our future generations. As we strive for better environmental management, through aware-ness and environmental education, there is need to carefully and appropriately package our messages to our household members and policy makers. Scientists should pass over information that make policy makers appreciate the importance of environment and thereafter hope that they take right and informed decisions.


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SESSION 2:

INDUCTION OF NEW FELLOWS:

Prof. Livingstone S. Luboobi the Chairperson of the Fellows and Membership Committee of the UNAS Council presented the following nominees to the presi-dent for induction into the UNAS Fellowship:

Prof. Noble Ephraim Banadda 1. Prof. Denis Karuhize Byarugaba2.

Prof. Harriet Mayanja-Kizza3.

Professor Noble Ephraim Banadda

Prof. Banadda holds a PhD in Chemical Engineering (2006) as well as M.Sc. Processing Engineering (2001) of the Katholieke Universiteit Leuven (Belgium) and has previously been a post doctoral Cochran Fellow (2007) at Massachusetts Institute of Technology (USA) in bioprocessing and biosystems engineering with a bias in Process Control, Monitoring and Optimization. He was recently fast tracked to the rank of Professor making him one of the youngest professors to have ever graced the 90-year history of Makerere University (Uganda). Noble is currently the Chair of the Department of Agricultural and BioSystems En-gineering at Makerere University. He is actively involved in research in water, wastewater and bioprocessing Engineering with focus on mathematical model-ing, monitoring and control. He also carries out research in solid waste man-agement, reactor design and optimization and development of alternative energy sources and food Engineering. He has also taught and supervised a number of postgraduate students (M.Sc. and PhD) carrying out research in Engineering. He is currently keen in areas of renewable energy with interest on resource recovery and optimization from wastewater. He is a member of the Global Young Acad-emy and has published over 60 peer reviewed papers in reputable international journals and reports on water quality, waste-water treatment and modeling, food processing and Engineering, and renewable Energy recovery. He has coordinated and undertaken several projects as a team leader in the domain of bioprocessing especially water modeling and bio-energy funded by International organizations like the European Union, Swedish International Development Agency- Swedish Agency for Research Cooperation (SIDA-SAREC), VLIR-UOS, Infectious Dis-ease Research Collaboration (IDRC) to mention but a few.


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Noble has also carried out consultancy in the domain of food engineering, water and sanitation, product development and quality control as well as systems de-velopment. He recently won recognition from the Inter-University Council for East Africa for Outstanding Performance in a project focusing on modeling of non-point source pollution in the Lake Victoria (Uganda, Rwanda and Tanzania). He enjoys good and cordial working relationships in a network of universities around the world not limited to Makerere University (Uganda); Ghent Univer-siteit (Belgium); Katholieke Universiteit Leuven (Belgium); Massachusetts Insti-tute of Technology (USA); Sokoine University of Agriculture (Tanzania); Iowa State University (USA); Swedish University of Agricultural Sciences (Sweden); University of Dar-se-Salaam (Tanzania); Busitema University (Uganda); Univer-sity of Zimbabwe (Zimbabwe); Chinhoyi University of Technology (Zimbabwe); University of Zambia (Zambia); National University of Rwanda (Rwanda); Jomo Kenyatta University of Agriculture and Technology (Kenya); Ain Shams Uni-versity (Egypt); China Agricultural University (China); University of Fort Hare (South Africa) to mention but a few. He joined the category of Agricultural Sci-ences of the Uganda National Academy of Sciences

Professor Denis Karuhize Byarugaba

Prof. Byarugaba graduated with Bachelor of Veterinary Medicine, a Master of Science and holds a PhD in Microbiology. He is an Associate Professor of Mi-crobiology at Makerere University in the College of Veterinary Medicine, Ani-mal Resources and Biosecurity. He developed and sourced funding that set up two BSL-2 Emerging Infectious Diseases Laboratories which he directs under Makerere University Walter Reed Project that have been instrumental in the re-sponse towards influenza pandemics and he ensures that they are run under Good Clinical Laboratory Practice (GCLP) standards. He is currently involved in re-search on influenza viruses and other highly pathogenic pathogens with poten-tial for causing pandemic threats and antimicrobial resistance. He is a principal investigator on a number of grants and he has undertaken several consultancies in various areas for a number of organizations including Food and Agriculture Organization of the United Nations (FAO), Centre of Agricultural Bioscience In-ternational (CAB) International, Development Alternatives Incorporated (DAI) and others. He has been a visiting scientist at several institutions including (a) the WHO Reference Centre on the ecology of Animal Influenza Viruses at St Jude Children’s Research Hospital in Memphis (b) University of Copenhagen, Denmark, working on Molecular Ecology of Poultry Gut micro flora. He is a recipient of several awards including (a) A National Institute of Health / National Institute of Allergy and Infectious Diseases (NIH/NIAID) fellowship award for scientific visit to the NIH/NIAID Centres of Excellence for Influenza Research


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and Surveillance (CEIRS) in the USA (b) American Society for Microbiology/ United Nations Educational Scientific and Cultural Organisation (ASM/UNES-CO) Fellowship for a scientific visit to CABI Bioscience, UK, (c) a World Bank/ The Association for Respiratory Technology and Physiology (ARTP) fellowship to the Royal Veterinary College, University of London working on DNA Vac-cines. He is Ambassador for the American Society of Microbiology in Uganda and President of the Alliance for the Prudent Use of Antibiotic Uganda Chapter. He is author/co-author of over 50 publications in peer-reviewed journals, book chapters and proceedings of international meetings. He led the team that pro-duced over 60 complete influenza A and B genomes, the first of such extensive description in Sub-Saharan Africa. He is also senior editor of a book on Antimi-crobial resistance in developing countries published by Springer. He is has been working at Makerere University for the last 20 years. He joined the category of Veterinary Sciences of the Uganda National Academy of Sciences.

Professor Harriet Mayanja-Kizza

Prof. Mayanja-Kizza is an internist and immunologist trained at Makerere Uni-versity, Uganda and Case Western Reserve University, Cleveland, Ohio, USA. She is the Dean of the School of Medicine at Makerere University College of Health Sciences. Honorary Lecturer, Case Western Reserve University, Cleve-land, Ohio, USA. (Adjunct appointment). She is a holder of a Master of Science (MS) Immunology/Pathology, Case Western Reserve University, USA, (1999); Master of Medicine, (Med) Internal Medicine, Makerere University (1983); Bachelor of Medicine and Bachelor of Surgery (MBChB), Makerere University (1978). She is a Professor of internal Medicine and immunology at the College. Her research focuses on HIV and Tuberculosis co-interaction, immunopathogen-esis, and immune-modulation treatment among patients with HIV and Tubercu-losis. Other areas of research include clinical trials of new anti-TB treatments and TB vaccines in endemic country sites, and improved ways of diagnosis, pre-vention, and management of tuberculosis with and without HIV infection. She has conducted research specific projects in the area of cytokine and chemokine regulation in HIV/ TB interaction. Currently Prof. Mayanja-Kizza is conducting epidemiological trials in adolescents and infants in preparation for tuberculosis vaccine clinical trials in Uganda. She is a World Health Organisation Advisor in the area of TB and HIV immunopathogenesis and clinical research for the study of TB vaccine candidates. She joined the category of Health and Medical Sci-ences of the National Academy of Sciences.


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APPENDIX: A

CONFERENCE PROGRAMME

13TH ANNUAL SCIENTIFIC CONFERENCE OF THE UGANDA

NATIONAL ACADEMY OF SCIENCES [UNAS]

THEME: Some Ingredients of Social Transformation for Uganda.

VENUE: Grand Imperial Hotel, Kampala

DATE: Friday 25th October 2013

PROGRAMME:

MASTER OF CEREMONY: Prof. Justin Epelu-Opio [Secretary General UNAS]

08: 30H09:00 Registration of Participants

SESSION 1 [CONFERENCE]

CHAIRPERSON: Prof. Patrick R. Rubaihayo, FUNAS

09:00H09:10 Opening Remarks: Prof. Paul Edward Mugambi [President UNAS]

09:10H09:40 Guest of Honour: Rt. Hon. Amama Mbabazi [The Prime Minister of Uganda]


PROCEEDINGS OF THE 13TH ANNUAL SCIENTIFIC

CONFERENCE OF UNAS

THEME:

“Some Ingredients of Social Transformation for Uganda”

OCTOBER 2013


99

09:40H10:05 Prof. Joseph Mukiibi [Presenter]: Transforming Subsis-tence Agriculture to Commercial Agriculture in Uganda by 2040: What will it take?

10:05H10:20 Dr. Kisamba Mugerwa [Discussant]

10:20H10:35 Discussion [Plenary]

10:35H10:50 HEALTH BREAK

MODERATOR: Prof. Edward K. Kirumira, FUNAS, Principal CHUSS Makerere University

10:55H11:20 Prof. Francis Omaswa [Presenter] Ownership and Accountability for Health Outcomes in Uganda: The role of stewardship and leadership: Looking 30years back and 30years forward

11:20H11:35 Ms. Diana Kizza [Discussant]


MODERATOR: Prof. Elly N. Sabiiti, FUNAS

11:50H12:15 Prof. Frank Kansiime [Presenter]: Overview of the Envi-ronment Management in Uganda

12:15H12:30 Prof. Dominic Byarugaba [Discussant]



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SESSION: 2

[INDUCTION OF NEW UNAS FELLOWS].Presentation, Induction and Acceptance Remarks by the new FellowsMODERATOR: Prof. Livingstone S. Luboobi, FUNAS12:45H13:00 Dr. Denis Karuhize Byarugaba

(Veterinary Sciences)

Introduction by the nominator • Prof. Francis Ejobi (3minutes),

Oath taking by the Inductee (• 3minutes)Signing of the register by the Inducted Fellow, •the Nominator and the Seconder(4minutes)Acceptance remarks by the Inducted Fellow •(5minutes)

13:00H13:15 Prof. Noble Ephraim Banadda (Agricultural Sciences)

Introduction by the nominator •Prof. Elly N. Sabiiti (3minutes)

Oath taking by the Inductee• (3minutes)

Signing of the register by the Inducted Fellow, •the Nominator and the Seconder(4minutes)Acceptance remarks by the Inducted Fellow •(5minutes)

13:15H13:30 Prof. Harriet Mayanja-Kizza (Health and Medical Sciences)

Introduction by the nominator • Prof. Livingstone S.Luboobi (3minutes),

Oath taking by the Inductee (• 3minutes) Signing of the register by the Inducted Fellow, •the Nominator and the Seconder (4minutes) • Acceptance remarks by the Inducted Fellow (5minutes)

13:30H14:30 LUNCH & CLOSURE OF THE CONFERENCE.


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APPENDIX: B

List of Participants

Abdu B.K. Kasozi (Prof.) Uganda National Academy of Sciences

David R. Mutekanga (Dr.) Uganda National Academy of Sciences

Adam Keith MC Royal College of Physicians

David Kitara (Dr.) Gulu University

Aggrey Kigongo College of Agricultural and Environmental Sciences Makerere University

Anorld NtungwaBuganda Road Primary School

Diana Kizza Mugenzi (Ms.) Sabin Vaccines Institute

Antonia Nyamukuru Makerere University

Dominic Byarugaba (Assoc Prof.) Mbarara University of Science & Technology (MUST)

Apolo R.Nsibambi (Prof.) Uganda National Academy of Sciences

Drota Asile James National Curriculum Development Centre- Kyambogo

Arthur Munanura Makerere University

Edmund E.M. Bukenya (Prof.) University of Rwanda

Babu Talik Makerere University

Edward K. Kirumira (Prof.) Makerere University

Catherine Kansiime African Center for Global Health and Social Transformation

Elly N. Sabiiti (Prof.) Makerere University/ Uganda National Academy of Sciences

Celia Nalwadda (Ms.) Uganda National Academy of Sciences (UNAS)

Elsie Kiguli-Malwadd African Center for Global Health and Social Transformation

Chale Judith (Ms.) Makerere University

Emmanuel Ekuru Makerere University

Denis K. Byarugaba (Prof.) Makerere University


102

Charity Nantume Makerere University

Emmanuel Tumusiime-Mutebile (Prof.) Bank of Uganda

Charlotte Nyamungu Makerere University

Emmanuel Ngolobe Makerere University

Clare Isingima (Ms.) Katwe Geothermal Power Project Limited

Epelu KevinMakerere University

David J. Bakibinga (Prof.) Makerere University

Epelu-Opio Justin(Prof.) Uganda National Academy of Sciences

Felix B. Bareeba (Prof.) College of Agricultural &Envi-ronmental Sciences Makerere UniversityFelix Oketcho Fox Magazine

Flavia Kabeere (Dr.) Uganda National Academy of Sciences

Francis Ejobi (Prof.) Makerere University

Joseph Mukiibi (Prof.) Uganda National Academy of Sciences

Frank Kansiime (Prof.) Makerere University

Judith Sempa Makerere University

Frederick I.B Kayanja (Prof.) Mbarara University of Science & Technology

Julius Y.K Zake (Prof.) Uganda National Academy of Sciences

Grace Kobusingye Makerere University

Louis Javuru (Mr.) Uganda National Academy of Sciences

Ham Mukasa Mulira (Dr.) Office of the President

Livingstone S. Luboobi (Prof.) Makerere University

Ezra MasolakiMakerere University

Jonathan Baranga (Prof.) Mbarara University of Science & Technology

JonathanTumusiime Makerere University


103

Hannington Oryem-Origa (Prof.) Makerere University

Lucy Ampumuza(Ms.) Uganda National Academy of Sciences

Harriet Nanfuma (Ms.) Uganda National Academy of Sciences Ibrahim Mayanja Makerere University

Michael Mugisha National Forestry Authority

Isaac Ezaati (Dr.) Ministry of Health

Michael Bamuwanye Ministry of Health National Crops Research InstituteMoses A. Barisigara Ministry of Education and Sports

James Boogere (Mr.) Gulu University

Moureen Basalirwa Kyambogo University

James P.M Ntozi (Prof.) Uganda National Academy of Sciences Jane Ruth Aceng (Dr.) Mnistry of Health

Noble Banadda (Prof.) Makerere University

John Patrick Amama Mbabazi (Rt. Hon.) Prime Minister of the Republic of Uganda

Salome Mukwaya African Center for Health and Social Transformation

Omaswa Francis (Prof.) African Center for Global Health and Social Transformation

Samuel Kyamanywa (Prof.) Makerere University

Patrick Mwesigye Makerere University

Sarah Mawerere Uganda Broadcasting Cooperation Radio

Patrick Ochapet (Mr.) Uganda National Academy of Sciences

Matovu Derrick Makerere University

Nelson K. Sewankambo (Prof.) Makerere University

Stephen Baguma (Mr.) Uganda National Academy of Sciences


104

Patrick R. Rubaihayo ( Prof.) Uganda National Academy of Science /Makerere University

Stephen Sekiranda National Agricultural Research Organisation

Paul E.Mugambi (Prof.) Uganda National Academy of Sciences

Swaleh Bakole

Nile FM

Peter Eriki (Dr.) African Center for Global Health and Social Transformation

Teddy Nantongo Makerere University

Peter N. Mugyenyi (Prof.) Joint Clinical Research Centre

Tom Otiti (Prof.) Makerere University

Ralph Atwooki Nyakabwa (Mr.) Katwe Geothermal Power Project Limited

Victoria Bukirwa African Center for Global Health and Social Transformation

Robert Kiggala Makerere University

Wilberforce Kisamba Mugerwa (Dr.) National Planning Authority

Robinah Nannungi Makerere University

William B. Banage (Prof.) Uganda National Academy of Sciences

Ronald Semyalo Kampala University

Ziraba R. Bukenya (Prof.) Makerere University

Weere Stephen Makerere University

Rebecca M Nyonyitono (Prof.) Makerere University


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Uganda National Academy of SciencesFlat A4 Lincoln House, Makerere University

P. O. Box 23911 Kampala, UgandaTel: +256-414-533 044, Fax: + 256-414-533 044

E-mail: [email protected], www.ugandanationalacademy.org

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