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The Health Sector in Ugandaand the Work of CUAMM

Dr. Peter LochoroCountry Representative

Doctors with Africa CUAMM Uganda

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General issues• Democratic government, stable country and more

peaceful• Population estimated to be 30.1 million (87% rural) in

2008/09 doubling every 20 years owing to a very high population growth rate of 3.3% TFR 6.9

• GDP/Capita of US$ 453 growing at an average of 6.5% per annum since 1990

• Human Development Index 0.581 (2007) cf. Italy 0.945 • poverty level down from 56% in 1992 to 31% in 2005.

Poverty in north 70% Karamoja 82%

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Health Financing and Budget 2007/08

• Health Budget budget in 2007/08 Ush 418.48 Billion (246.02 Million USD)

• Government of Uganda component Ush 277.36 Billion (163.06 Million USD)

• Donor Projects in Health Ush 141.12 Billion or 82.96 Million USD (i.e 34% of Health Budget)

• Total Public Expenditure per capita Ush 13,949 (USD 8.2)

• Total Health Expenditure per capita USD 25 (in 2006)

• Health Budget as % of GoU Budget 9.6%

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USAID50%

WHO 3%

UNICEF2%

DANIDA3%

JICA3%

UNFPA0%

SIDA1%

(CAP) For humanitarian response

6%

GFATM27%

ITALIAN5%

Donors to Uganda Health Sector 2007/08

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Consequences of Funding

• Severely underfunded with only about a third of the US$ 28 needed to provide the minimum health package

• Shown in perennial shortages of drugs and supplies, poor health infrastructure and shortage and de-motivation of human resources.

• Constraints magnified for the northern region.

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Development Strategy• PEAP development framework and MDG

Uganda development framework emphasises poverty eradication and economic development for social transformation.

• Now government developing a National Action Plan to replace PEAP

• Off-track in achieving MDG goals with exception of HIV/AIDS reduction. See table below

• Poor health indicators contribute to the low life expectancy of 50.4 years

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Health indicators & MDG TargetsIndicator 1990 2000 2006 Target

2009 MDG target

2015

Life Expectancy 50.4 (2007)

Infant Mortality Rate (IMR deaths/1,000 live births)

122 88 76 68 31

Under 5 MR (deaths/1,000 live births)

180 152 137 103 56

Maternal Mortality Rate (MMR deaths/100,000 live births)

527 505 435 354 131

Supervised deliveries (%) 38 38 42 85

Stunting in children under five years of age (Chronic Malnutrition)%

38 38.5 32 28

Children Fully Immunized % 31(1991)

38 (2001) 46.2 90

HIV/AIDS prevalence (ANC HIV prevalence)

30% 6.2% 6.4% (2005)

5% 1.7%

Disability Rate 3.5% (2002)

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The Trend for Health MDGs

180152 137

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527505

435

1316.2%

1.7%

30.0%

6.4%

0

100

200

300

400

500

600

1990 2000 2006 2011 20150.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

U5MRMMRHIV/AIDS

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General Health Problems

• Over 75% of life years lost in Uganda are due to ten preventable diseases/conditions including:– maternal and perinatal conditions (20.4%),– malaria (15.4%), – acute lower respiratory tract infections (10.5%),– AIDS (9.1%) and – diarrhoea (8.4%). – Others include tuberculosis, malnutrition and trauma.

• minimum health package address this conditions

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Uganda Health System

HSD

District Health Services HQ

National Referral HOSP

Referral Facility (Public or NGO)(HC IV or HOSPITAL)

HC II HC II

HOUSEHOLDS / COMMUNITIES / VILLAGES

Regional Referral

HOSPITALS

HC II HC II HC II

HC IIIHC IIIHC III

MOH Headquarters

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Uganda Health System 2• Ministry of Health and other National Level

Institutions• National Referral Hospitals (30 Million)• Regional Referral Hospitals (2,000,000

population)• District Health Services (District level,

500,000 population)• Health Sub-District (Functional Zone of district)

– Referral Facility General Hospital (District level - 500,000 pop) or Health Centre IV (County level - 100,000 pop)

– Health Centre III (Sub-country level - 20,000 population)– Health Centre II (Parish Level – 5,000 population)– Health Centre I (Village Health Team - 1,000 population)

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Health Units and staff

• Uganda health services are implemented through 80 districts, 214 HSD, 114 hosp (46 PNFP, 8 PFP)

• Staff about 30,000 in Public and PNFP• Mal-distributed eg 60% drs in the central

region.

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Public Private Partnership• A key principle guiding the implementation of the

HSSP2 is to further strengthen the broader health partnerships, esp with PNFP.

• The PNFP health units currently are responsible for 30% of the publicly oriented sub-sector (PNFP and Government). Higher % in the north.

• Some of the PNFP health units are even charged with health sub-district management functions of supervision, planning, logistical responsibilities and coordination for the whole zone including government owned units.

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Doctors with Africa CUAMM in Uganda

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The Presence of CUAMM 2008/09

CUAMM Districts Populations

Total 4,901,761

0-5 Years 990,156 40%

Women CBA 990,156

Pregnant Women

245,088

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Karamoja a key focus area for CUAMMComparative Humanitarian and Development Indicators National Karamoja

Estimated Population [UBOS] 28.9 million 1.1 million

Life expectancy [UNDP 2007] 50.4 years 47.7 years

Population living below poverty line [World Bank 2006, OCHA/OPM 2008] 31% 82%

Maternal mortality rate (per 100,000live births) [UDHS 2006, WHO 2008] 435 750

Infant mortality rate (per 1,000 live births [UNICEF/WHO 2008] 76 105

Under five mortality rate (per 1,000 live births) [UNICEF/WHO 2008] 134 174

Global Acute Malnutrition (GAM) rate [UNICEF/WHO 2008] 6% 11% and rising

Immunization (children 12 to 23 months, fully immunized) [UDHS 2006] 46% 48%

Access to sanitation units [MoH 2007, OCHA/OPM 2008] 59% 9%

Access to safe water [UDHS 2006] 67% 43%

Literacy rate [UNDP HDR 2006, UDHS 2006] 67% 11%

HIV/AIDS prevalence rate [HSBS 2005, WHO 2008] 6.4% 3.9%*

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CUAMM in Uganda• CUAMM has been in Uganda since 1959

now 50 years of presence!• One of the first places of CUAMM was my

village hospital – Matany an oasis in the middle of no where

• My inspiration as a child from CUAMM doctors in that hospital

• Uganda is a major country for CUAMM programmes in Africa

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CUAMM Strategy

Support to Service DeliveryInputs,

Proceses

Support to Districts/HU

management

Central advocacy and policy

Community actions

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CUAMM in Uganda 2• At a district level,

– Strengthening district health systems management by providing technical assistance and other relevant input, currently working with 6 district health systems.

• At rural hospitals level, – Supporting 6 hospitals, providing staff, training,

equipment and management support.• At community primary health care level,

– Supported prevention, service improvement and community based services currently in disability, primary eye care and inputs to improve service delivery at primary care health units in 15 districts.

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CUAMM in Uganda• Health training and research:

– Trained in basic and postbasic medical personnel in professional schools and in service and supported health systems research. Currently it is supporting 1 University and 1 nursing school.

• Specific service areas:– Special attention to mother-and-child healthcare, TB,

HIV/AIDS, Eye care, Malaria and other infectious diseases.

• Restoration:– Physical and functional restoration, of services

destroyed by wars, natural disasters or neglect• Emergencies:

– When essential survival needs have to be faced, or in conditions of extreme social and health crisis

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CUAMM Uganda Projects now• Reproductive health Oyam 2007/2010, € 2.24 Million• Hospital Water and Sanitation Project Oyam, 2009/10

€150,000• Karamoja districts support project 2009/2010, € 627,600• Primary Eye care, 2009, € 20,000• Moroto Hospital support, 2009, € 40,000• Disability West Nile, 2009, € 80,000• West Nile Dioceses health system, 2007/2010, € 1.25

Million• Nkozi University 2008/2010, € 1.4 Million• Naggalama Hospital and Lugazi Diocese 2007/2010, €

1.2 Million• HIV/AIDS Lugazi 2009, € 20,000• Matany Hospital and Nursing School 2009/2011, € 1.26

Million

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Some Results 2008 CUAMM hospitals

• Hospital Beds 1,113 Beds• 185,844 Outpatient visits• 54,252 admissions• 27,475 Antenatal visits• 8,362 Deliveries• 81,661 Immunizations

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Where we work

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Matany Hospital

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Improving Maternal Health Care

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Enhancing outreach services

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The First Cesarean Section Kotido HC IV

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New staff accommodation in remote health centers – Lotome HC III

Odaga John, Uganda Martyrs University 30

Uganda Martyrs University

• Owned by the Uganda Episcopal Conference• A Young University

– first academic year opened on October 1993 • … and small

– Student body of about 3000; about 800 on campus

• International in character– Great lakes region, Sudan, southern Africa, W. Africa,

parts of Europe

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The Faculty of Health Sciences (FHS)

– May 2001 as a dept; Faculty late 2004– 7 full-time staff– 1 teaching assistant– 4 visiting lecturers

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Why Dept/FHS was established

• Growing concern for effective management as a strategy for strengthening the health system– ↑ resource inflow (local & donor aid) to public &

private systems • … the management of the resources is sometimes taken for

granted– Changing policies

• Decentralisation, PPPH, financing mechanisms (SHI, CBHIS), Pull system of drugs supply

– Hence need for competent managers in the health system

• Planning, budgeting, accounting, understanding of policies, management of contracts

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Why Dept/FHS was established

– Current ‘managers’• only have basic qualifications in clinical fields• Others are auxillary staff—no formal training• The curriculum of health workers in Uganda do not

give adequate emphasis on management

– Management is only taught at postgraduate level;

• Even then as an adjunct to those studying public health

• Few, get better paying jobs, mainly private sector

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Why Dept/FHS was established

• Acute shortage of competent managers– Over 3000 health facilities in need of trained managers– Only about 50 of 214 (23%) are headed by doctors with some

management background– The district Health Services– At the MoH, a small cadre of highly qualified people at the planning

level– Non-facility based NGOs & CBO– The Catholic Health services were most affected (25% of HU, 75 of

training schools, & 30% of all services)

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Why Dept/FHS was established

• Hence the reason focusing on training in management of health services– UMU was the first to start health services-focused

management training

– Brain child of the UCMB

– Of the 14 registered Unis in Uganda, only 2 or 3 others have started other management-related courses

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Mission

• To form health managers with the integrity, knowledge, managerial skills, and competencies needed to provide good quality health services to the Ugandan population.

– We want to transfer attitudes in addition to knowledge.

– Goal: to have a critical mass of managers with the above qualities

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What we do• Teaching

– Formal training– Short (thematic) courses

• Research– Individual– Student support– Needs-based (UCMB, Districts, MoH, CUAMM, etc)

• Limited Consultancies – Management/policy related

• Technical assistance & CME to hospitals and districts

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1. TeachingWhat we do

Health Services Management

Health Promotion & education

Proposed

Master level Yes M Med

Diploma Yes Yes

Certificate Yes Yes*

Short-courses Yes Yes

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1. Teachinga. Participants

– come from • the Ministry of health, • health programmes• districts and Health

Sub-districts, • hospitals and health

centers

– They include • Ugandans & non

Ugandans• Government, NGO &

private sector

– Type of programme• Full time, part-time,

selected modules

What we do

Number of students in each course over the years

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Intake of students in the FHS by type of course in the last 10 Academic Years

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Course Number of student per each Academic Year Total

99-00

00-01

01-02

02-03

03-04

04-05

05-06

06-07

07-08

08-09

10 yrs

Master in HSM 3 4 11 15 14 12 14 19 22 29 143

Diploma in HSM

9 14 14 11 11 19 17 20 9 11 135

Diploma in HPE

0 0 0 0 14 19 43 18 13 12 119

Certificate in HSM

0 0 0 0 0 20 18 19 19 18 94

Certificate in HPE

0 0 0 0 0 0 25 0 0 0 25

All courses 12 18 25 26 39 70 117 76 63 70 516

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Financial bases

• Fees• Donation

– CUAMM (Italian coop, Bassano group, CEI, MPS)

– CORDAID

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What we do with the money

• Paying staff• Equipment • Sponsoring of students

– Fees– Personal laptops– Research

• Books • Constructions • Transport

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Who are our customers?

• Various Dioceses and UCMB• The Ministry of Health • The districts and Health Subdistricts• Other Medical Bureaus• The World Health Organisation• Other NGOs involved in Health Services

delivery

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Are we making a positive impact on the Health system?

• Are we on track with our mission?• Are our customers satisfied• How can we tell?

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Are we making a positive impact …?

• Anecdotal evidence – Spontaneous positive feedback

• from past students• Stakeholders (esp. MoH, WHO, UCMB)

– Increasing demand for the courses• Increasing number of application• Requests (especially from the MoH) to increase the size of

our classes• Sponsoring of students by the MoH

Are we making a positive impact …?

• Anecdotal evidence – Utilisation of our research findings for decision

making• Dioceses, Hospitals, MoH, UCMB

– Technical assistance to hospitals• Provision of tools for management

– Increasing requests for collaboration• Training Institution (ITM, KIT, Keele, etc.)• International Organisations (e.g. WHO)• Professional Networks (HEPNet Africa, etc)

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Are we making a positive impact …?

• Limited empirical evidence: similar findings– Tracking studies of past students, – stakeholders, – labour market

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Challenges • Size of the staff: small compared to the tasks• Structure of the courses: only full time, making it

expensive• Location of the University: 80 kms from the city,

– hence no evening programs, – all students have to pay for ‘hotel services, further

increasing the cost• Fees: not affordable by the average Ugandan,

who are the majority

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Levels of Subsidies

CourseAve Cost per student (US $)

Fees per student (US $) Subsidy

MSc. HSM 10,095 3,158 70%

Dip HSM 5,506 2,105 68%

Dip HPE 4,383 2,105 60%

Overall 6,913 68%