AFRICAN DEVELOPMENT FUND

AAPPPPRRAAIISSAALL RREEPPOORRTT

SUPPORT TO HEALTH SECTOR STRATEGIC PLAN

PROJECT II (SHSSPP II)

UGANDA

HUMAN DEVELOPMENT DEPARTMENT June 2006

TABLE OF CONTENTS

Page PROJECT INFORMATION SHEET, CURRENCY AND MEASURES, LIST OF TABLES, LIST OF ANNEXES, LIST OF ABBREVIATIONS, PROJECT MATRIX, EXECUTIVE SUMMARY i - x

1. ORIGIN AND HISTORY OF THE PROJECT 1

2. THE HEALTH SECTOR 2

2.1 Health Status 2 2.2 Health Sector Policy 3 2.3 Decentralization Policy 3

2.4 Organization of Health Services 4 2.5 Human Resources 4 2.6 Health Care Financing 5

2.7 Main Sector Challenges 6 2.8 Donor Support to the Health Sector 8 3. THE SUB-SECTORS 10

3.1 Health Sector Strategic Plan II 10 3.2 Maternal Health 11 3.3 Mental Health 13

4. THE PROJECT 14

4.1 Project Concept and Rationale 14 4.2 Project Area and Beneficiaries 16 4.3 Strategic Context 17 4.4 Project Objectives 17 4.5 Project Description 17 4.6 Detailed Description of Components and Activities 18 4.7 Environmental Impact 22 4.8 Project Costs 23 4.9 Sources of Financing and Expenditure Schedule 24

5. PROJECT IMPLEMENTATION 26

5.1 Executing Agency 26 5.2 Institutional Arrangements 27 5.3 Supervision and Implementation Schedules 28 5.4 Procurement Arrangements 28 5.5 Disbursement Arrangements 32 5.6 Monitoring and Evaluation 33 5.7 Financial Reporting and Auditing 33 5.8 Aid Coordination 33

6. PROJECT SUSTAINABILITY AND RISKS 34

6.1 Recurrent costs 34 6.2 Project Sustainability 35 6.3 Project Assumptions and Risks 35

7. PROJECT BENEFITS 37

7.1 Socio-Economic impact 37

8. CONCLUSIONS AND RECOMMENDATIONS 38

8.1 Conclusions 38 8.2 Recommendations 38

This report was prepared by Mrs. B. BA, Principal Health Analyst and two consultants following their appraisal mission to Uganda in 14 to 26 May, 2006. Any further questions relating to the report may be addressed to Mr. T. B. Ilunga, Manager, OSHD.3 (2117) or Ms. A. Hamer, Director, OSHD (2046).

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AFRICAN DEVELOPMENT FUND

TEMPORARY RELOCATION AGENCY B.P. 323 1002 TUNIS BELVEDERE

Tel: (216) 71 333511 Fax: (216) 71 351933 e-mail: afdb@afdb.org

PROJECT INFORMATION SHEET Date : May 2006

This information given hereunder is intended to provide some guidance to prospective suppliers, contractors, consultants and all persons interested in the procurement of goods and services for projects approved by the Boards of Directors of the Bank Group. More detailed information and guidance should be obtained from the Executing Agency of the Borrower. 1. COUNTRY: Republic of Uganda 2. NAME OF PROJECT: Support to Health Sector Strategic Plan Project II (SHSSPP II) 3. LOCATION: Districts of Mbarara, Isingiro, Kiruhura, Ibanda Ntungamo, Bushenyi, Kabale, Rukungiri, Kanungu, Kisoro

Regional Mental Health Units : Lira, Moroto, Mbale, Jinja, Mubende, Masaka, MBarara

4. BORROWER Government of Uganda 5. EXECUTING AGENCY: Ministry of Health P.O. Box 8096 Kampala-Uganda Tel: + 256 41 534025/533481/554261 Fax: + 256 41 530701 e-mail: hsrp@imul.com 6. PROJECT DESCRIPTION: The project will consist of the following components: i) Improvement of the delivery of Maternal Health Services ii) Expansion of the delivery of Mental Health Services iii) Project Management 7. TOTAL COST: UA 22.22 million i) Foreign Exchange UA 15.28 million ii) Local Costs UA 6.94 million 8. Bank Group Financing ADF Loan UA 20.00 million 9. OTHER SOURCES OF FINANCE: GOU UA 2.22 million 10. PLANNED DATE OF APPROVAL: November 2006

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11. ESTIMATED STARTING DATE: January 2007 PROJECT DURATION: Five Years 12. PROCUREMENT Procurement of goods and services would be undertaken in accordance with the following Bank Group’s rules of procedure: International Competitive Bidding (ICB) Civil works for health facilities, medical equipment and special furniture National Competitive Bidding (NCB) General Furniture, delivery kits, learning and training materials National Shopping (NS) Equipment for Project Management Unit, Reproductive and Mental Health Divisions in MOH Direct Purchase or Negotiation (DS) Long and short term training, sensitization for mental health by staff of MOH and VHTs, NACME facilitation for procurement of medical equipment and specialized furniture Shortlisting Professional Services, technical assistance, auditors, PMU staff, sensitization for Maternal health (NGO), baseline study, midterm evaluation and end of project evaluation. Operating costs Logistical support to MOH and Village Health Teams for community awareness raising on maternal and mental health issues. 13. CONSULTANCY SERVICES REQUIRED Consultancy services will be required for design, construction and supervision of civil works; project management; auditors for project accounts; conducting of baseline, midterm evaluation, end of project evaluation and sensitization.

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CURRENCY EQUIVALENTS

(May 2006)

National Currency Uganda Shilling 1 UA USH 2627.40 1 UA USD 1.47106

WEIGHTS AND MEASURES

1 kilometre (km) 0.62 miles 1 meter (m) 3.28 feet 1 hectare (ha) 2.47 acres

FISCAL YEAR

1st July to 30th June

LIST OF TABLES Page Table 2.1 Health Facilities by Level and Ownership in Uganda 4 Table 2.2 Govt. Funding and Budget Performance (2001-2005) 5 Table 2.3 Present national health indicators as compared to MDG’s targets 6 Figure 2.4 Resource Projections for HSSP II (2003/4 prices) 9 Table 3.1 Selected RH indicators for the East African Countries 11 Table 4.01 Dist.of the MH component direct project beneficiaries by type and dist. 16 Table 4.1 Summary of project cost estimates by component 24 Table 4.2 Summary of project cost estimates by category of expenditure 24 Table 4.3 Source of financing 25 Table 4.4 Sources of Finance by category of expenditure 25 Table 4.5 Expenditure schedule by component 25 Table 4.6 Expenditure schedule by category and Source of Finance 26 Table 5.1 Procurement Arrangements 29 Table 5.2 Other Modes of Procurement Arrangements 30

LIST OF ANNEXES Annex I Map of Uganda Annex II Project Formulation Process Annex III Current numbers of Human Resources for Health (Governt.- Private Not For Profit) Annex IV Donors contribution to the Health Sector in Uganda Annex V Summary of Bank Group Portofolio of on-going and newly approved

Projects/Programmes/Studies in Ugandainterventions in Uganda Annex VI Progress towards meeting Millenium Development Goals Annex VII List of proposed Health Centre IIIs and IVs to be rehabilitated/remodelled Annex VIII Summary of Environmental and Social Management Plan (ESMP) Annex IX List of Goods and Services Annex X Organization Chart of MOH Annex XI PMU organogram Annex XII Implementation Schedule Annex XIII Table of contents of the project implementation document

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LIST OF ABBREVIATIONS

ADB African Development Bank ADF African Development Fund AHSPR Annual Health Sector Performance Report ARI Acute Respiratory Infections BEmOC Basic Emergency Obstetric Care CEmOC Comprehensive Emergency Obstetric Care DDHS District Director Health Services EPI Expanded Program on Immunization ESIA Environmental Social Impact Assessment GDP Gross Domestic Product GFATM Global Fund for AIDS/TB/Malaria GPN General Procurement Notice GoU Government of Uganda HDP Health Development Partners HMIS Health Management Information System HPAC Health Policy Advisory Committee HSD Health Sub District HSSP Health Sector Strategic Plan HSWG Health Sector Working Group IMCI Integrated Management of Childhood Illnesses IMR Infant Mortality Rate JRM Joint Review Mission LCA Local Currency Account LGA Local Government Act LTEF Long Term Expenditure Framework MCH Maternal and Child Health MDGs Millennium Development Goals MMR Maternal Mortality Rate MoFPED Ministry of Finance, Planning and Economic Development MOH Ministry of Health MTEF Medium Term Expenditure Framework NACME National Advisory Committee for Medical Equipment NCD Non-Communicable Disease NEPAD New Partnership for Africa Development NGO Non-Governmental Organization NHA National Health Assembly NHP National Health Policy OPD Out-Patient Department PEAP Poverty Eradication Action Plan PPPH Private Public Partnership for Health PLWHA People Living With HIV and AIDS PMTCT Prevention of Mother to Child Transmission PNFP Private Not for Profit PSC Project Steering Committee RFP Request for Proposal SHSSPP Support to the Health Sector Strategic Plan Project SRH Sexual and Maternal Health and Rights SWAp Sector Wide Approach TASO The AIDS Support Organization TSC Technical Sub-Committee UBTS Uganda Blood Transfusion Services UDHS Uganda Demographic and Health Survey UNMHCP Uganda National Minimum Health Care Package

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EXECUTIVE SUMMARY, CONCLUSIONS AND RECOMMENDATION 1. PROJECT BACKGROUND

Despite achievements in the health sector, some key challenges remain. These include the evident lack of progress in improving maternal and child survival, with stagnating Maternal and child health indicators. The Maternal Mortality Ratio is 505 maternal deaths per 100 000 live births (Africa: 661) and Infant Mortality Rate (IMR) is 88 per 1000 live births (Africa : 80.6). Furthermore, in spite of near universal first attendance at antenatal clinics, the proportion of women who reach the national target of 4 attendances per pregnancy has not improved, nor has the rate of deliveries in a designated health facility, which is around 38% only. Access to emergency obstetric care, the main determining factor for improved maternal and neonatal survival remains poor, and the unmet need currently stands at 87%. The total fertility rate remains among the highest in Sub-Saharan Africa at 6.9 children per woman (Africa : 4.9). The prevalence of mental health problems is high and is on the increase with the baseline survey indicating the following: 29.3% have moderate to severe depressive symptoms; 17.4% have symptoms of alcohol abuse. Mental health care continues to be a major Public health issue in Uganda. The Support to Health Sector Strategic Plan Project II (SHSSPP II) will expand nationwide mental health services funded under the latest Bank health intervention, “Health Sector Strategic Plan Project (SHSSPP)”. The proposed project is aligned with the HSSP II priorities. The current project has made significant contributions to the HSSP priorities, especially in the area of mental health services. It is expected that the proposed project will consolidate the contributions of the SHSSPP as well as address new and emerging challenges. 2. PURPOSE OF THE LOAN The ADF loan of UA 20 million (90%) of total cost will finance 100% of the foreign costs and part (68%) of the local costs. The Government counterpart will finance 32% of the local costs. 3. PROJECT OBJECTIVE The objective of The Support to the Health Sector Strategic Plan II (SHSSPP II) under ADF financing is twofold (i) to contribute to the reduction of Maternal mortality in selected districts in Uganda, and (ii) to contribute to the reduction of mental Health disorders in Uganda. 4. BRIEF DESCRIPTION OF THE PROJECT

In order to achieve these objectives, the project will comprise the following components: (i) Improvement of the delivery of Reproductive Health Services ; (ii) Expansion of the delivery of Mental Health Services and ; (iii) Project Management.

5. PROJECT COSTS

Total project cost including contingencies is estimated at UA 22.22 million. 6. SOURCES OF FINANCE The project will be financed by ADF and GOU. The ADF loan of UA 20 million will finance 100% of the foreign cost and part of the local costs, while the GoU counterpart of UA 2.22 million will

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finance part of the local costs. The grant will finance technical assistance, part of civil works, equipment, office furniture, consultancies, training and part of operating costs. The GOU counterpart contribution will finance part of the civil works, and operating costs. 7. PROJECT IMPLEMENTATION

The project will be implemented over a period of 5 years. The executing agency of the project will be the Ministry of Health (MOH).

8. CONCLUSIONS AND RECOMMENDATION The proposed Project aims to contribute to the reduction of the maternal mortality in selected districts in Uganda and reduction of mental health disorders in Uganda. Project beneficiaries include women of childbearing age, persons with mental illnesses, health personnel and the communities. The proposed project is in line with the HSSP II, the GOU broad policy framework for poverty eradication (PEAP), the Uganda Joint Assistance Strategy (UJAS) and the ADB health policy. Therefore, the activities under the proposed project are expected to contribute significantly to poverty eradication targets as envisioned in the PEAP as well as attainment of the MDG (especially MDG 3 : reduce maternal mortality by three quarters by 2015 and MDG 4 : reduce infant mortality to 31 per 1,000 live births). The Project is expected to have significant health and socio-economic impacts that will accrue as a result of the planned intervention. These include: community empowerment and mobilisation for health and increased utilization of reproductive health services; improved access to quality health care for rural populations; and increased access to comprehensive mental health care. In addition, socio-economic impacts include: reduction of the burden of ill-health and increasing population productivity, construction jobs created for the local population and savings for rural people who will not have to travel far in search for better health. The project is technically sound, economically viable and sustainable. It is recommended that an ADF loan not exceeding UA 20 million be granted to the Government of the Republic of Uganda for the purpose of implementing the Project.

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Year Uganda AfricaDevelo-

pingCountries

Develo-ped

CountriesBasic Indicators Area ( '000 Km²) 241 30 061 80 976 54 658Total Population (millions) 2003 25.8 849.5 5,024.6 1,200.3Urban Population (% of Total) 2003 14.3 39.2 43.1 78.0Population Density (per Km²) 2003 107.1 28.3 60.6 22.9GNI per Capita (US $) 2003 250 704 1 154 26 214Labor Force Participation - Total (%) 2003 47.8 43.3 45.6 54.6Labor Force Participation - Female (%) 2003 47.6 41.0 39.7 44.9Gender -Related Development Index Value 2002 0.487 0.476 0.655 0.905Human Develop. Index (Rank among 174 countries) 2002 146 n.a. n.a. n.a.Popul. Living Below $ 1 a Day (% of Population) 1992 36.7 46.7 23.0 20.0

Demographic IndicatorsPopulation Growth Rate - Total (%) 2003 3.2 2.2 1.7 0.6Population Growth Rate - Urban (%) 2003 5.8 3.8 2.9 0.5Population < 15 years (%) 2003 52.1 42.0 32.4 18.0Population >= 65 years (%) 2003 2.6 3.3 5.1 14.3Dependency Ratio (%) 2003 111.2 86.1 61.1 48.3Sex Ratio (per 100 female) 2003 98.9 99.0 103.3 94.7Female Population 15-49 years (% of total population) 2003 21.3 24.0 26.9 25.4Life Expectancy at Birth - Total (years) 2005 47.0 50.7 62.0 78.0Life Expectancy at Birth - Female (years) 2003 48.1 51.7 66.3 79.3Crude Birth Rate (per 1,000) 2003 50.4 37.0 24.0 12.0Crude Death Rate (per 1,000) 2003 16.1 15.2 8.4 10.3Infant Mortality Rate (per 1,000) 2005* 88.0 80.6 60.9 7.5Child Mortality Rate (per 1,000) 2005* 143.4 133.3 79.8 10.2Maternal Mortality Rate (per 100,000) 2005* 506 661 440 13Total Fertility Rate (per woman) 2005* 6.9 4.9 2.8 1.7Women Using Contraception (%) 2005* 23.0 40.0 59.0 74.0

Health & Nutrition IndicatorsPhysicians (per 100,000 people) 2005* 4.0 57.6 78.0 287.0Nurses (per 100,000 people) 2005* 27.6 105.8 98.0 782.0Births attended by Trained Health Personnel (%) 1995 38.0 44.0 56.0 99.0Access to Safe Water (% of Population) 2002 56.0 64.4 78.0 100.0Access to Health Services (% of Population) 2005* 72.0 61.7 80.0 100.0Access to Sanitation (% of Population) 2000 75.0 42.6 52.0 100.0Percent. of Adults (aged 15-49) Living with HIV/AIDS 2005* 6.2 6.4 1.3 0.3Incidence of Tuberculosis (per 100,000) 2000 130.4 109.7 144.0 11.0Child Immunization Against Tuberculosis (%) 2003 96.0 81.0 82.0 93.0Child Immunization Against Measles (%) 2005* 83.0 71.7 73.0 90.0Underweight Children (% of children under 5 years) 2005* 23.0 25.9 31.0 …Daily Calorie Supply per Capita 2002 2,409.6 2 444 2 675 3 285Public Expenditure on Health (as % of GDP) 1998 1.9 3.3 1.8 6.3

Education Indicators Gross Enrolment Ratio (%) Primary School - Total 2004* 141.0 88.7 91.0 102.3 Primary School - Female 2004* 139.0 80.3 105.0 102.0 Secondary School - Total 2004* 22.0 42.9 88.0 99.5 Secondary School - Female 2004* 20.0 41.3 45.8 100.8Adult Illiteracy Rate - Total (%) 2003 30.2 36.9 26.6 1.2Adult Illiteracy Rate - Male (%) 2002 21.3 28.4 19.0 0.8Adult Illiteracy Rate - Female (%) 2003 39.6 45.2 34.2 1.6Percentage of GDP Spent on Education 2005* 3.9 5.7 3.9 5.9

Environmental IndicatorsLand Use (Arable Land as % of Total Land Area) 2003 25.3 6.2 9.9 11.6Annual Rate of Deforestation (%) 1995 0.9 0.7 0.4 -0.2Annual Rate of Reforestation (%) 1981-90 … 10.9 … …Per Capita CO2 Emissions (metric tons) 1998 0.1 1.2 1.9 12.3

Source : Compiled by the Statistics Division from ADB databases; UNAIDS; World Bank Live Database and United Nations Population Division.Notes: n.a. Not Applicable ; … Data Not Available. * Latest Figures obtained from GoU Health and Education Statistics

COMPARATIVE SOCIO-ECONOMIC INDICATORSUganda

Infant Mortality Rate ( Per 1000 )

0

20

40

60

80

100

120

1995

1996

1997

1998

1999

2000

2001

2002

2003

uganda Africa

GNI per capita US $

0100200300400500600700800

1995

1996

1997

1998

1999

2000

2001

2002

2003

uganda Africa

Population Growth Rate (%)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

1995

1996

1997

1998

1999

2000

2001

2002

2003

uganda Africa

111213141516171

1995

1996

1997

1998

1999

2000

2001

2002

2003

uganda Africa

Life Expectancy at Birth (Years)

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UGANDA SUPPORT TO MATERNAL AND MENTAL HEALTH SERVICES LOG FRAME ** Nota bene : A baseline survey will be conducted

Narrative Summary Expected Results Reach (Target population) Performance Indicators**

Sources

Indicative targets and time frame

**

Assumptions and Risks

1. Sector Goal To reduce morbidity and mortality from the major causes of ill-health and the disparities therein.

Longer term outcomes Ugandan population live longer and healthier

General population Infants Women in childbearing age Women in childbearing age

Indicators Life expectancy Infant mortality rate Maternal mortality rate Fertility rate Sources Uganda Demographic and Health, Survey. (UDHS)

By the year 2010 - 2015 Life expectancy at birth increaaed from 47 to 55 years Reduce Infant Mortality rate from 88 to 68 deaths per 1,000 live births MMR is reduced from 505 to 354 maternal deaths per 100 000 live births. Reduction of the Total fertility Rate from 6.9 to 5.4 children per woman.

2. Project Objectives 2.1. To contribute to the reduction of maternal mortality in 10 districts in Uganda

Medium term outcomes Maternal deaths are significantly reduced.

Women in childbearing age in the project districts (Bushenyi, Kabale,Kanungu, Kisoro, Mbarara, Kiruhura, Isingiro, Ibanda, Ntungamo, Rukungiri)

Indicators Number of maternal deaths at the health facilities constructed/rehabili-tated by the project (Mbarara hospital, 13 HC IV and 26 HC III) Proportion of births attended by skilled attendants in South Western Region

By the year 2015 Reduction of maternal deaths in Mbarara Hospital by 25% (from 1130 per 100,000 live births to 848) Reduction of maternal deaths in the 13 HC IV and 26 HC III rehabilitated and equipped by the project by 25% from baseline data Reduction of maternal deaths by 25% in prroject districts/communities by 25% from baseline data Percentage of assisted

Assumption Government to meet all recurrent cost requirements as well as project counterpart contribution Risk indicator :low Mitigation measures :

i) MOH budget increases from 9.7% to 15% to reach the Abuja target

ii) GOU is implementing alternative financing; methods such as Social Health insurance and Community Based Health Insurance schemes; iii) the Development partners have committed themselves to support the MOH in the funding and implementation of the HSSP II Commitments from Development partners; iv) GOU put an emphasis on the

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Narrative Summary Expected Results Reach (Target population) Performance Indicators**

Sources

Indicative targets and time frame

**

Assumptions and Risks

deliveries by trained personnel in project areas increased from 38% to 50%

2.2. To contribute to the reduction of mental health disorders in Uganda

Better Mental Health of population

Population of Uganda Prevalence of Mental Health Sources Uganda Demographic and Health, Survey. (UDHS) Butabika hospital, PMU Regional hospitals

Prevalence of mental health disorders reduced from 29% to 15% in Uganda

3. Project Activitie/Inputs - Rehab/equip the Mbarara Regional Hospital and the equipping of 13 HCIV 26 HCIII and 8 district hospitals and recruitment of health staff by GOU; - Support on the job training of health staff in emergency obstetric care (EmOC) and other RH issues; - Support regular supervision mission of RH activities at national, regional & district levels; - Adapt, print and disseminate EmOC guidelines - Apply norms and procedures related to the implementation of RH activities - Provide the RH Division with Technical Assistance, office equipment, monitoring & evaluation tools and 1 vehicle for supervision - Train Traditional Birth Attendants and involve them in community sensitization activities - Equip health facilities with ambulances and strengthen their communication system -Strengthen outreach and adolescent awarenss activities of one Adolescent Reproductive Centre in the South Western region; -Enhance Family Life Education Programme in schools; -Develop and implement a multi-media campain strategy;

Short term Outputs 1) Access to quality maternal health services improved 2) Pregnant women with complications are timely referred to a health facility

Women of child bearing age (15-49 years) Traditional birth attendants (TBA) Pregnant women Adolescents Communities NGOs

Indicators Caesarian section rate in project area

Number of TBA trained or contacted

Number of pregnant women with complications referred to a health facility

Abortion rate

Adolescents’ knowledge and utilization of RH services

Contraceptive prevalence rate

% of women having partner’s approval of the use of family

By year 2011 Caesarian section in project area increased by 30% (in facilities where it is very low) from baseline data % of trained TBA increased by 20% Number of timely referred pregnant women with complications increased by 30% Reduction in abortion among female youths(15-24 years) from 15%-23% to 10-18% Adolescent’s knowledge in and utilization of RH services increased by by 40% from baseline data Contraceptive prevalence rate increased from 23% to 35%

% of women having partner’s approval of the use of family

efficiency and good performance of the health sector. Assumption There is peace in the Northern Region Risk indicator: high Mitigation measure The best solution is that sustainable peace comes back in the northern region. However waiting for this situation, to mitigate this risk, under the previous SHSSP project, project staff, contractors and suppliers have tried, during 2005-2006, a strategy that has worked. They met directly with the communities living around the project sites and had open discussion with them on the project objectives and put the emphasis on the different benefits the populations will gain from the project activities. Now the populations have showned stronger ownership of the project. The same strategy will be adopted during the design and the implementation of the project.. . Assumption There is improvement of rural transport Risk indicator : moderate Mitigation measures i)GOU with partners to develop road infrastructures ii) project to procure ambulances, stregthen communication and sentizes community for early patient referral; iii)GOU to improve intersectoral collaboration; Assumption Staffing levels is adequat Risk indicator High

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Narrative Summary Expected Results Reach (Target population) Performance Indicators**

Sources

Indicative targets and time frame

**

Assumptions and Risks

-Develop & disseminate IEC/Advocacy materials; -Develop and implement a community mobilization strategy; -Revitalize male involvement programme on Reproductive Health (RH); -Construct & equip seven mental health units in Mbale, Mbarara, Lira, Moroto, Masaka, Jinja and Mubende. -Train health personnel in the selected districts -Conduct a survey to assess the prevalence and the geographical distribution of specific mental health problems such as epilepsy, schizophrenia -Monitor and Evaluate mental health activities in the field -Develop and implement community mobilization action plan for improving MH services Project Costs by Category Category in UA (millions) A. Goods 4.95 B. Works 12,60 C. Services 3.87 D. Op. Costs 0.80 Total 22.22

3)Adolescent and community awareness to quality reproductive health services improved 4) Ugandan Mental health disorders are adequately addressed Project coordination team in place

Project beneficiaries and target populations

planning

Number of visits/inhabitant per year for mental health issues

Percentage of Health facilities having integrated mental health into PHC

Sources National Health Information system Govertment budget Supervision reports Project Mid-term review, PQPR

planning increased from 48% to 60% Number of visits per 10 000 inhabitants increased by 30% from baseline data Number of health facilities Having integrated mental health into PHC increased by 20% Project coordination staff recruited Operating costs made available

Mitigation measures i) the project minimizes the recruitment of staff; ii) GOU allocate more ressources to recruitment of required staff

ORIGIN AND HISTORY OF THE PROJECT 1.1 In Uganda (see attached MAP in Annex I), despite achievements in the health sector, some key challenges still during this period remain. These include the evident lack of progress in improving maternal and child survival, with stagnating Maternal and child health indicators. The Maternal Mortality Ratio is 505 maternal deaths per 100 000 live births (Africa: 661) and Infant Mortality Rate (IMR) is 88 per 1000 live births (Africa : 80.6). Furthermore, in spite of near universal first attendance at antenatal clinics, the rate for delivery in a designated health facility, which is estimated at 38% only, has not improved. Access to emergency obstetric care, the main determining factor for improved maternal and neonatal survival remains poor, and the unmet need currently stands at 87%. The total fertility rate remains among the highest in Sub-Saharan Africa at 6.9 children per woman (Africa : 4.9). 1.2 According to the World Health Organisation, mental illness now accounts for about 12.3% of the global burden of disease. This will rise to 15% by the year 2020, by which time, depression will disable more people than AIDS, heart disease, traffic accidents and wars combined. (World Health Organisation, World Health Report 2001 Geneva: WHO, 2001, p.250). In Uganda, the prevalence of mental health problems is high and is on the increase with the baseline survey indicating the following: 29.3% have moderate to severe depressive symptoms. 1.3 In order to resolve these health constraints, the GOU, within the Sector Wide Approach (SWAP) and within the Health Sector Strategic Plan II (HSSP II) framework, has requested the assistance of the development partners including the Bank. In October 2004, the GOU requested funding from the Bank for a new health project. An ADB mission was fielded in Uganda in August 2005 to identify the new Support to Maternal and Mental Health Services Project. The GOU official request for funding the health sector was submitted to the Bank Group in December 2005. The Bank considered to finance the project and fielded the preparation and appraisal missions in December 2005 and May 2006, respectively. Annex II indicates the project formulation process. 1.4 The Support to Health Sector Strategic Plan Project II (SHSSPP II) is complementing the past Support to the Health Sector Strategic Plan Project (SHSSPP). The SHSSPP II will be the 7th Bank Group operation in the sector. The total amount committed to date is UA 92.31 million. Mbale Hospital Rehabilitation Project (UA 3.52 million, ADF) and the Mulago Hospital Rehabilitation Study (UA 0.59 million, ADF) were approved in 1987. The Health Services Rehabilitation Project (UA 25.33 million, ADF; UA5.00 million; NTF and UA 3.78 million, OPEC) was approved in 1990. The Second Health Services Rehabilitation Project (UA 22.57 million, ADF) and Health Sector Studies (UA 2.80 million, TAF) were approved in 1993. Savings from the Health Sector Studies were used to sensitize the public about the HSSP launched in July 2000. The Support to the Health Sector Strategic Plan Project (SHSSPP) was approved in September 2000 (ADF Loan : UA 30 million and UA 2.5 million, ADF Loan. The PIU of the SHSSPP, that was the same executing agency for past health projects provided invaluable technical input to the successful implementation of past and present health projects. As with the past SHSSPP, the proposed project is closely aligned with the HSSP II priorities. The current project has made significant contributions to the HSSP priorities, especially in the area of mental health services. It is expected that the proposed project will consolidate the contributions of the SHSSPP as well as address new and emerging challenges.

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2. THE HEALTH SECTOR

2.1 Health Status

2.1.1. The health sector is slowly recovering from the general decline in social services witnessed during the periods of economic and political instability in the 70s and 80s. Furthermore, health outcomes have shown little or no progress in the 1990s, while some have worsened. The stagnation of health outcomes in the 1990s is largely attributed to the underlying poverty with deprivation not only in nutrition, housing, water, sanitation and education but also to the high burden of communicable and non-communicable diseases. While the HIV/AIDS pandemic that peaked in the 1990s is being effectively contained, its social and economic impacts are being felt, most notably the decrease in life expectancy of Ugandans. 2.1.2. Preparatory work for the HSSP II entailed an intensive process of analysis of the past five years. This included examination of the Annual Health performance reports, the report of the Mid-term Review (2003), the various monitoring and supervision reports, special studies undertaken during HSSP I, and detailed discussions within and between Working Groups. This analysis has confirmed the findings of the Uganda Demographic and Health Survey (DHS) of 2000 , which recorded the infant mortality rate (IMR) at 88 deaths per 1,000 live births, under five mortality at 152 deaths per 1,000 live births and the maternal mortality ratio at 505 deaths per 100,000 live births. There are also socio-economic differences in the health outcomes with the IMR at 60.2 deaths per 1,000 live births for the highest socio-economic quintile compared to 105.7 deaths per 1,000 for the lowest socio-economic quintile. Similarly, the under five mortality rate for the lowest quintile is twice as high as that for the highest quintile. The prevalence of mental health problems is high and there is need therefore to build capacity to handle such emerging problems. 2.1.3 According to the Burden of Diseases study done in Uganda in March 1996, over 75% of life years lost due to premature deaths are due to ten preventable diseases. Peri-natal and maternal conditions 20.4%, malaria 15.4%, acute lower respiratory tract infections 10.5%, HIV/AIDS 9.1%, and Diarrhoea 8.4% together account for over 60% of the disease burden. The common non-communicable diseases include hypertension, diabetes, cancer, mental illness, chronic and degenerative disorders and cardiovascular diseases. Women and children bear a disproportionate amount of the burden of ill-health. There are also significant variations between regions in Uganda and within regions. Other diseases responsible for a significant proportion of morbidity and mortality include: Mental Health, Tuberculosis, Malnutrition, Anaemia, Intestinal infestations, Trauma/accidents, Skin infections, cardiovascular diseases and other non-communicable diseases. The large regional disparity between the north and the south also has consequences for the differential in mortality and morbidity figures. 2.1.4 Furthermore, high adult illiteracy rates (39.6% for women and 21.3% for men) contribute, amongst others, to the high levels of prenatal and maternal related deaths. Poor sanitation (only 13% of the population has proper sanitation) and malnutrition, which affects about 23% of children also contribute to ill health. Finally, the low level of gender awareness and the existing inequality between men and women have an adverse effect on the health of women and children.

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2.2 Health Sector Policy 2.2.1. Since the late 1990s, Government has been undertaking a series of health reforms. These reforms were designed to shift spending towards areas of greatest effectiveness including increased resource allocation for PHC activities, abolition of user fees in public facilities in March 2001, expansion of rural health facilities, provision of subsidies to the Private Not for Profit (PNFP) sub-sector, the introduction of Health Sub-Districts structure, recruitment of qualified health workers and increases in the volume of essential drugs purchased for the health centers. 2.2.2 The goal set for the health sector under the National Health Policy (NHP), is to reduce morbidity and mortality from major causes of illness. This is operationalised through the Health Sector Strategic Plan (HSSP). The first HSSP covering the period 2000/01 – 2004/5 was aimed at achieving the delivery of theUganda National Minimum Health Care Package (UNMHCP) to all Ugandan households. Interventions in the package were chosen to target the most common diseases using the most cost effective interventions. The achievement of the UNMHCP is however not yet affordable in its entirety. 2.2.3 The Ugandan Constitution (1995), the Local Authorities Act (1997) and the 2001 Local Governments Act (as amended), the NHP (1999) and the PEAP (2004) provide the policy basis for Uganda’s second Health Sector Strategic Plan (HSSP II) that has been developed to provide a common strategic framework for the new plan period covering 1st July 2005 to 30th June 2010 and a framework that will guide all interventions by all parties at all levels of the national health system (section 3.1 provides more details on the HSSP II).

2.3 Decentralization Policy 2.3.1 The Constitution of Uganda 1995 and the Local Governments Act 1997 (LGA) provide for devolution of powers, functions and resources from the central government to the districts / local authorities. The district health system comprises of a well defined population living within a clearly delineated administrative and geographic boundary which includes all actors in the recognized spheres of health within the district. It is expected that the activities of the diverse partners are reflected in the District Health Sector Strategic Plan, which in turn is an integral part of the rolling district development plan. LGA provides for the central roles to be restricted to policy formulation, standard setting, resource mobilization, technical support and capacity development; and monitoring. The districts/local authorities are charged with service provision and implementation of national policies and standards. The GoU has decentralized financial ressources at district level. 2.3.2 The local authorities therefore, make operational plans and by-laws to implement policies and to address local problems. In theory and of relevance to maternal mortality, the districts are to provide health services including promotion of family planning and maternal health services among others. In practice however, some of the services are not provided and others have become worse over time. Thus, while the principle of decentralization is good, lack of capacity and resources, and lack of genuine community mobilization and participation have undermined its virtues in Uganda.

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2.4 Organization of Health Services 2.4.1. The health sector comprises the Ministry of Health (MOH), NGOs, private and community providers, and various partners. The MOH promotes better health outcomes through the monitoring and provision of preventive and curative health services. Its responsibility stretches not only to the public provision of services but also to the supervision of the private sector, which provides a very significant proportion of health care in Uganda. The delivery of primary health care services in Uganda is the responsibility of the districts. These services are provided through a network of facilities that are categorised, in order of increasing capacity and designated, as Health Centres I to IV. This categorisation is in line with the administrative division of the country. The Health Centre I facilities are the initial points of entry to the health system and be staffed by an auxiliary nurse. However the concept of Village health teams (VHT) is being introduced to work at the community level and replacing the physical HC I. The VHT serve as the first link between the community and the formal health providers. 2.4.2 Health Centre II facilities exist at the parish level and serve populations of about 5,000 people. These facilities are staffed by nurses, and provide outpatient services. The Health Centre III facilities are at the sub-county level. They serve populations of about 20,000 people and provide both outpatient as well as inpatient (including maternity) services (8-bed units). At the apex of the district primary heath facilities are the Health Centre IV facilities which are established at the county level and expected to servea population of up to 100,000. These are 12-bed facilities with theatre units, headed by a medical officer, and expected to provide a full range of services. In most districts, this network of facilities is complemented by a hospital. General hospitals are located at district level. Regional and national referral hospitals provide services at regional (serve a population up to 2,000,000) and national (the whole population) levels respectively. The number, level and ownership of health facilities in Uganda is shown in table 2.1. 2.4.3 Health care is delivered by the private sector, including commercial units and NGO or religious facilities, as well as by Government. In Uganda, the majority of consultations are with private facilities (including NGO facilities that may be publicly subsidized). However, the poor are proportionately more likely than the non-poor to use the public sector. In 2002, for instance, of households in the poorest quintile who consulted a health facility, 44% used a public facility, whereas only 19% did so in the top quintile.

Table 2.1: Health Facilities by level and Ownership in Uganda

Level of Facility Ownership Government NGO Private Total

Hospital 55 42 4 101 Health Center IV 151 12 2 165 Health Center III 718 164 22 904 Health Center II 1055 388 830 2273

Total 1979 606 858 3443 Source: Health Facilities Inventory, MOH Infrastructure Division (October 2004)

2.5 Human Resources

The HSSP II cleary states that availability of human resources is one of the most critical limiting factors for the delivery of the minimum package. In addition to the MOH,

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other stakeholders include other Ministries and private not for profit health providers. A human resource policy and strategic plan is essential to guide the various stackholders. One of the specific objectives of the HSSP II is to provide and maintain a policy and strategic framework to guide the human resources process by 2006. The total number of staff in the public health sector, including the private not for profit (PNFP) is 27 487 (ref. Annex II for more details). Of these 53% are in Government health centers and general hospitals, 30% at PNFP health facilities while the rest (17%) are in Regional and National Referral Hospitals and the Ministry of Health headquarters. The work of professional health workers is being complemented by Village Health Team members. Annex III indicates the current numbers of Human resources for Health (Government and Private not for profit).

2.6 Health Care Financing

2.6.1 At the time of developing the National Health Policy (NHP) and HSSP I, stakeholders in the health sector agreed to a SWAp whereby all stakeholders in the sector agreed to one programme of work (HSSP) and the point of involvement of the various players. The same approach has been taken for HSSP II, and ADB works closely with other Health Development Partners (HDPs) within the framework of the SWAp having agreed on one programme of work and how the different players can contribute to it optimally. The Government of Uganda and Development Partners have updated a Memorandum of Understanding indicating the different roles and responsibilities of the different players under HSSP II. The stakeholders in the sector include: government, development partners, the private sector, and the consumers. Table 2.2 indicates GoU funding and budget performance during 2001-2005.

Table 2.2 : Government funding and budget performance from 2001-2005 FY GOU

Funding Billion of Ugshs

Per Capita Expenditure in USD

GOU health Expenditure as a % of total government expenditure

Budget performance for GOU (Disbursed budget divided by Planned Budget)

Increase on the previous year in GOU allocation

2000/1 124.23 5.9 7.5 82.8 37%2001/2 169.79 7.5 8.9 96.2 15%2002/3 195.96 7.3 9.4 96 6%2003/4 207.80 7.7 9.6 95.4 5%2004/5 219.56 8.0 9.7 92.8 -

Source: Ministry of Health; Annual Health Sector Performance Report – Financial Year 2004/2005 2.6.2 Over the HSSP I period, GoU budget performance improved from 83% in FY 2000/01 to about 95% for the rest of HSSP I. However, the FY 2004/05 shows a relative decline to 92.8% budget performance compared to the previous two years, and this poor performance has been attributed to poor wage budget performance. However, the Health budget as a percentage of the national budget has been increased continuously from 7.5% in 2001 to 9.7% in 2005. This increase in the budget demonstrates the government’s commitment to reaching the Abuja target of 15% by 2010. For instance, the GOU has started covering drugs costs from its budget and an illustration of this effort is that during the appraisal of the present project the mental health drugs that were planned to be procured by the ADF Loan will be now procured under the GOU budget.

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2.6.3 Besides the GOU financing, patients used to pay user fees for cost sharing of minimum package services in GOU health units. However, in order to increase attendance rate, the Government abolished user fees in 2001 except in private wards in urban hospitals. As a result countrywide data has shown a dramatic increase in the consumption of minimum package services, especially by poor people. Thus from 2001 to 2004, the number of new outpatient attendances in Government and Private Not for Profit Health Units has increased from 9.6 million to 20.2 million. In addition, a Social Health Insurance (SHI) is being designed and Community Based Health Insurance Schemes are being implemented on a small scale (about 11 schemes countrywide).

2.7 Main Sector challenges

2.7.1 The main challenges facing the health sector can be summarized as follows : (i) the burden of diseases and other health problems; (ii) inadequate human resources; (iii) low health coverage; (iv)inadequate maintenance of health infrastructure and medical equipment (v) financial resource constraints and; (vi) low community mobilisation for positive health action. 2.7.2 Burden of diseases and other health problems:Communicable diseases such as Malaria (case fatality rate in-patients under five : 4%), Tuberculosis (TB death rate : 6.2%) and HIV/AIDS (prevalence rate : 6.2%) continue to be the leading cause of morbidity and mortality among the Ugandan population (with a high population growth of 2.5%) in spite of the efforts made by the Government. Table 2.3 below includes present national health indicators as compared to the MDGs targets. Table 2.3 : Present national health indicators as compared MDG’s targets

Health indicators 2005 indicators MDGs targets Infant mortality 88/1,000 live births 41/1,000 live births Under five mortality 152/1,000 live births 60/1,000 live births Maternal mortality rate 505/100,000 live births 131/100,000 live births Stunting rate in under five 38,5/100 children under five 19/100 children under five

2.7.3 The above table shows that infant, under five and maternal mortality as well as malnutrition rates are not only very high but are not on track to meet the Millenim Development Goals (MDG) targets. The direct causes and underlying factors of maternal mortality can be summarized as abortion, anemia, eclampsia, hemorrhage, obstructed labor, and puerperal sepsis; and indirect causes include malaria, HIV/AIDS, viral hepatitis, tuberculosis and heart diseases. Harmful traditional practices cause pregnancy-related complications such as pelvic inflammatory disease, infertility, ectopic pregnancy and obstetric fistula. Other factors include: high total fertility rate (6.9 children per woman) coupled with short birth intervals; high teenage pregnancies; poor quality, inaccessible and unusable health structures; harmful and negative culture on reproduction, food/nutrition, gender relations, health-seeking behavior, hygiene and sanitation; insufficient community mobilization to ensure demand for services at the local level. 2.7.4 Mental health remains a challenge to the health sector. The funds for mental health activities as well as the availability of trained service providers remain inadequate. There is an information gap in the mapping of specific mental health problems in order to determine the magnitude as well as the geographical distribution. In addition there are still low levels of

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community appreciation of the existing and potential magnitude of the mental health burden. Community empowerment and mobilisation for health, through the Village Health Team Strategy offers an opportunity for communities to participate in ameliorating the mental illness burden at community level. 2.7.5 HSSP I strengthened the expansion of implementation of major health reforms. The National Health Policy provided strategic direction for implementation through a sector Wide Approach (SWAp). There was a shift to Primary Health Care activities and services were brought closer to populations. The Government has made significant progress in addressing the burden of diseases. Indeed many of the HSSP I output targets were reached. The combination of improved quality of care and removal of the major financial barrier for the poor have resulted in a dramatic rise in utilization of health services. New outpatient attendance rose from 0.4 visit per person per year in 2000 to 0.9 in 2005. With the strengthening of the Expanded Programme on Immunization, coverage for DPT 3 rose from 55% to 89% during the same period. In addition, proven and cost-effective interventions for the prevention and control of Malaria and HIV/AIDS are being implemented. HIV/AIDS epidemic continued to be contained at 6.2% percent (compared to about 25% a decade back). Furthermore the GoU has made significant efforts to almost reach the complete coverage of antenal clinic (91%). However there has been similar improvement in access to Emergency Obstétric Care. 2.7.6 Human resource constraints: Availability of adequate qualified staff remains a big constraint. The total number of staff in the public health services including the private non for profit services (PNFP) is about 27,487, of whom 53% are in Government health centers and general hospitals, 30% in the PNFP and 17% in public hospitals and in the Ministry of Health headquarters. In addition, there is an unequal distribution of the staff and inappropriate skills mix. Section 2.5 provides more details on the workforce. The limitation in skills not withstanding, the Village Health Team members can serve as a supplementary health human resource. GoU has made efforts in improving overall staffing especially at district level facilities which attained 68% compared to the revised HSSP I target of 52% of established posts filled by trained health personnel. 2.7.7 Low health coverage :The GOU, with the assistance of development partners, has reached 72% of health coverage (geographic accessibility) within 5km radius. However there are still underserved populations (28%) and large disparities between regions and districts. For instance, Kampala has 100% coverage while other regions have much less. Although the health coverage is better than in many African countries the quality of health services has not improved correspondingly mainly because some of the health structures are not operational due to lack of staff or equipment. In addition, there is a high turn over of staff due to, among others, lack of decent accommodation. The GoU, with donors’support, has made an important investment in health infrastructure development within the framework of both the HSSP I and HSSP II. 2.7.8 Inadequate maintenance of health structures and medical equipment: The maintenance of health infrastructures and equipment is inadequate and is not prioritized during the budgetary process. Existing Regional maintenance workshops provide limited services. Maintenance of health infrastructure and medical equipment remained a major challenge in HSSP I. In HSSP II, there is a target of devoting 5% of all non wage PHC budget in districts to infrastructure maintenance. The GOU assured the Bank that this target is likely to be achieved during the implementation of the HSSP II. District and Regional

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Hospital Engineers, backed up by the Ministry of Health Infrastructure Division, are responsible for maintenance of health units in districts and the regional referral hospitals, respectively. The regional maintenance workshops back up regional hospitals and health units in catchment districts for maintaining medical equipment. 2.7.9 Financial constraints : Inadequate financing remains one of the key constraints of the health sector. The current public funding of USD 8 per capita falls below the estimated requirement of USD 28, as defined by the Uganda Health Financing Strategy. Only 30% of the Health Sector Strategic Plan was funded. Increase in funding of the health sector has been hampered by macroeconomic concerns and rigid sector ceilings. Furthermore, a financial gap exists also under the costing of the HSSP II. Indeed, the required funding for 2009/10 is Ushs 1,216.67 billion, while the financial commitments for the Government and development partners are estimated at Ushs 659 billion with a gap of Ushs 557.67billion (46%). Closing the financial gap requires examining ways of maximizing efficiency as well as mobilizing additional resources within the prevailing context of macroeconomic considerations, which includes: a) Growth in the Government of Uganda Budget; b) Improving efficiency; c) Research/analysis and advocacy; and d) Exploitation of intersectoral collaboration. 2.7.10 Communities therefore have to be empowered and mobilised towards health promotion and disease prevention, so that the limited financial resources can be targeted at a reduced disease burden. The concept of a village health team is being established in every village to be responsible among others, for the following : (i) identifying the community’s health needs and taking appropriate measures; (ii) mobilising additional ressoures and monitoring of the utilisation for their health programs including the performance of health centers; (iii) mobilising communities for health activities; (iv) selection of community health workers while maintaining a gender balance ad overseeing the activities of these latter and ; (v) maintaining a register of members of households and their family status and serving as the first link between the community and health providers. The current status is that at least 10,000 villages have operational health teams.

2.8 Donor Support to the Health Sector 2.8.1 The SWAp was developed as a mechanism, which addresses the health sector as a whole in planning, management and in resource mobilization and allocation. The revised MOU spells out the obligations of the main parties and describes the structures and procedures established to facilitate the functioning of the partnership. The Health Development Partners are responsible for their own coordination through the health development group, which provides a forum for information sharing, consensus building and collating and coordinating responses to government. It is intended to reduce transaction costs for all parties. 2.8.2 Despite health sector budget increases during these last six years, there is still a significant mismatch in the funding requirements of the HSSP (US $28 per capita) and the available resources (US$ 9 per capita). However, an important feature of the SWAp is that alternative mechanisms of donor funding are accepted (e.g. general support, TA, projects with donor control), thus ensuring continuing active participation of all the major HDPs in the SWAp process. There is now much greater predictability of both government and donor funding of the sector, after taking into account the average disbursement rate of donor funds (around 65%). The pattern of funding has also changed, with GoU contribution (including donor budget support) now accounting for the greater part. As a number of donors have

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moved to general budget support, the contribution of donor projects to the overall resource envelope has decreased from 55% in 2000/1 to 42% in 2002/3. 2.8.3 As aforementioned, the SWAP arrangements provide for both budget support and project support. Given the SWAp and in line with the MOU there have been efforts during HSSP I for development partners to use the government budget as the preferred mechanism for funding HSSP I. However, a number of donor projects still exist with some development partners providing both the budget and donor project support. Donor support (projects and global initiatives) during the period 2001 to 2005 has increased from Ugs billion 114 to Ugs b 146.74. Sector allocations are made within the Mid Term Expenditure Framework (MTEF), and recently long term projections have been made in the Long Term Expenditure Framework (LTEF). At this stage, it is difficult to make a projection with accuracy of the volume of financing available for HSSP II, given the unpredictable nature of some of the key financing mechanisms to the sector. Figure 2.4 below shows negligible growth in the health sector financing over the period of the next MTEF. In the longer term, however, the LTEF figures suggest an improvement in health sector financing which will result in a 40% real increase in the resource envelope (FY 2005/06 to 2009/10) by the end of HSSP II.

Figure 2.4: Resource Projections for HSSP II (2003/04 prices)Using MoFPED's LTEF Projections

0

100

200

300

400

500

600

700

97/98 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10

Bill

ions

of S

hilli

ngs

Total Resources MTEF Envelope Other Sources GoU Budget Donor Projects

40% increase

2.8.4. The status of donor supported projects/ programs in Uganda during the first three years planned for HSSPP II (as indicated in Annex IV). As far as the project components are concerned, there are few Health Development Partners funding the Maternal Health, and ADF remains the main donor for the Mental Health component. Data are not complete because some donors have not yet confirmed their full financial support to the HSSP II. Among about eighteen (18) health development partners, six are doing budget support only (EU, Belgium, Ireland, France, Italy, Norway), seven (07) are supporting projects only (USAID, Japan, ADB, WHO, UNICEF, UNFPA, WFP) and four (04) are dealing with both projects and budget support (UK, Sweden, Denmark (DANIDA), Netherlands and World Bank). Budget support is of two types: (i) earmarked health sector support (Belgium, France and Italy) and ; (ii)

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general budget support to the Treasury not specific to any sector and within the framework of the General Poverty Action Fund, concerned by other above mentioned donors dealing with budget support.

3. THE SUB-SECTORS 3.1 The Health Sector Strategic Plan (II) 3.1.1 HSSP II forms the basis for : (i) developing the Long and Medium Term Expenditure Frameworks (MTEF) and the annual budget framework paper (BFP) for the health sector; (ii) guiding investment by the health development partners, including project support; (iii) developing and implementing the respective operational plans of the Departments, Divisions and Units of the central Ministry of Health, the District and Health Sub-District Plans, and Community health action. HSSP II has been developed through an intensive and iterative process (2003-2004) that involved all key stakeholders in health development in Uganda. The SWAP approach initiated during the HSSP I has been also decided for the HSSP II. 3.1.2 Compared to HSSP I, the new strategic plan document is constructed to reflect more clearly, the maxim that the primary purpose of the National Health System (NHS) is to achieve improved health of the people. The program overview has therefore been amended to demonstrate that implementing the UNMHCP is the main approach for achieving the sector program goal and development objective. The universalisation of the Village Health Team Strategy to all the villages of Uganda by 2010 is a key target in HSSPP II. The conceptual framework and elements of the UNMHCP have been restructured to illustrate more clearly, how the various clusters (maternal and child health, prevention and control of communicable and non communicable diseases including Mental Health, health promotion, disease prevention and community health initiatives) will contribute to the HSSP development objective and key program outputs, as well as to foster improved operational coordination and integration. 3.1.3 The overall goal of the health sector remains “the attainment of a good standard of health by all people in Uganda, in order to promote a healthy and productive life”. HSSP II also retains the same program development objective as for HSSP I, i.e.: “Reduced morbidity and mortality from the major causes of ill-health and premature death, and reduced disparities therein” – to be attained through universal delivery of the UNMHCP. The overriding priority of HSSP II will be the fulfillment of the health sector’s contribution to the PEAP objectives of reducing maternal and child mortality and to reducing the burden of HIV/AIDS, Tuberculosis, Malaria, other communicable diseases and non communicable diseases. 3.1.4 The HSSP II programme objectives are as follows : (i) have a health care delivery system that is effective, equitable and responsive; (ii) strengthen the integrated support system; (iii) reform and enforce the Legal and Regulatory Framework and; (iv) have an evidence-based, programme, planning and development in place. The HSSP II targets vis à vis the PEAP by 2010 includes the following: (i) reduce Maternal Mortality Ratio from 505 to 354 per 100,000 live births; (ii) reduce Infant Mortality Rate from 88 to 68 per 1,000 life births; (iii) reduce under five mortality from 152 to 103 per 1,000 births; (iv) reduce Total Fertility Rate from 6.9 to 5.4; (iv) increase Contraceptive Prevalence Rate from 23% to 40%; (v) reduce HIV prevalence at ANC sentinel sites from 6.2% to 5%; reduce stunting in

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children under 5 years from 38.5% to 28%. The delivery of the UNMHCP under the HSSP II will focus on the improvement of child and maternal health, the prevention and control of communicable and non communicable diseases such as mental health. Thus the focus of the project will be on maternal health and mental health because they are part of the HSSP II and also because the Bank will expand mental health activities started in the SHSSPP.

3.2 Maternal Health

3.2.1 The single most important factor underlying high maternal mortality is the health care system. It is regarded as a tracer condition for the health system. Maternal health falls under the ambit of Reproductive Health. The main factors contributing to high maternal mortality rates in Uganda include among others:- high and unregulated fertility as well as short birth intervals; high rates of teenage pregnancy and abortion; low and persistent stagnant levels of supervised delivery resulting in high rates of default in recognizing life-threatening complications of pregnancy and labor for timely referral and effective action; high disease burden (e.g malaria, HIV/AIDS); high prevalence of protein/calorie malnutrition and micronutrient deficiencies; poor quality, inaccessible and unusable health services; poor transport facilities; negative attitudes of health services providers; harmful and negative culture on reproduction, health-seeking behavior hygiene and sanitation; insufficient mobilization to ensure demand for services at local level as well as low level of male involvement in maternal health and rights; and unaccountability of civil and political leaders and lastly poor transport. Most maternal deaths are avoidable with proven technical interventions such as access to basic surgery for caesarian sections, blood supplies for haemorrhage, and drugs for eclampsia and infection can avert a large proportion of maternal deaths, and yet, provision of these technical emergency interventions remains wanting. 3.2.2 In Uganda, Maternal and mental health are both GoU priorities included in the HSSP I and HSSP II. Maternal health (MH) is a state of complete physical, mental and social well-being and not merely the absence of disease, in all matters relating to the Maternal system. Reproductive Health problems such as early and unwanted childbearing, HIV and other sexually transmitted infections, pregnancy-related illness and death account for a significant part of the burden of disease among adolescents and adults in developing countries. Table 3.1 presents an overview of the RH situation in East Africa.

Table 3.1: Selected RH Indicators for the East African Countries

Index Uganda Kenya Tanzania Total Fertility Rate Contraceptive Prevalence Rate (%)

Infant MortalityRate/1000live births Under 5 Mortality Rate /1000

Maternal Mortality Ratio / 100,000 Delivery under skilled personnel (%) HIV Prevalence (%) Life Expectancy (years) Income per capita ($)

6.9 23 88 152 505 38 6.1 45 330

4.7 39 59 98 414 42 10 49 360

5.6 25 108 111 504 36 11 51 270

Source: DHSs and survey reports

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3.2.3 In Uganda access to and utilization of Maternal health services is low as reflected in the low skilled attendance at childbirth (38%) and high unmet need for Emergency Obstetric Care (EmOC) at 86% among others. Despite the knowledge on contraception being very high at 96%, the contraception prevalence rate only increased from 5% in 1989 to 23% in 2001, with only 48% of the married women having spousal approval of the use of family planning. Knowledge on contraception among adolescents aged 15-19 years is 92% for girls and 96% for boys. Despite this, the contraceptive prevalence among girls in this age group is only 9%. By age 15, 14.2 percent of women 15-19 years were already sexually active. Overall, the most commonly cited reasons for not using contraception are difficulty in becoming pregnant (23 percent), side effects (18 percent), and desire to have children (11 percent). 3.2.4 Uganda has several initiatives focusing on young people. However, there is still limited access to adolescent sexual and maternal health information and services. Social, economic and cultural factors still play a significant role in influencing the behavior practices of young people. Teenage pregnancy rate of 31% remains one of the highest in Sub-Saharan Africa, contributing to maternal mortality and morbidity, including obstetric fistula. All pregnant women, face some level of maternal risk. According to the WHO, about 40% of pregnant women will experience delivery complications, while about 5% need obstetric care to manage complications which are potentially life threatening to the mother and the infant. Despite the importance of antenatal care to predict and prevent some complications, many are sudden in onset and unpredictable. The prevailing high rates of fertility (6.9 births per woman), in an environment of poor access to quality maternal and neonatal care, have continued to expose Ugandan mothers and infants to a high risk of death from pregnancy related causes, with an estimated 1 woman in 10 dying from maternal causes in Uganda. 3.2.5 Unsafe abortion is a major problem in Uganda currently estimated to contribute to between 20% to 35% of maternal deaths and a much higher proportion of Maternal health morbidity. Adolescents are at a high risk of unwanted pregnancy and, as there are no legal abortion services, an unsafe abortion may follow. Approximately 15-23% of female youths (15-24 years of age) who had ever been pregnant had an abortion. A large number of women seek Ante Natal Care (ANC) but yet do not deliver with a trained attendant. In Mbarara, nearly all women (91%) attended antenatal care but more than half (56%) delivered at home. 3.2.6 The decision making power of women seeking health services during pregnancy is limited in many ways. Decisions are mostly taken by their relatives and husbands. The Bank’s gender profile in Uganda (January 2005) has highlighted some of these issues. Societal and familial expectations often influence women’s choices to seek care, and may lead to delays in seeking essential professional care. In order to better address the Reproductive Health issues outlined above, the key areas of policy interventions to reduce infant and maternal mortality rates, among others, include the following ; (i) quantity and quality of health care; (ii) family planning and; (iii) community mobilization and development. Under the country’s Strategy to improve RH (2005-2010) and the HSSP II, specific targets set to reduce Maternal deaths can be summarized as follows : (i) increase the proportion of deliveries by skilled attendants from 38% to 50%; reduce the unmet need for EmOC from 86% to 40%; increase the contraceptive prevalence rate from 23% to 40%; increase the attendance for 4 visits per pregnancy from 42% to 50%; reduce the percentage of teenage pregnancy rates from 37% to 20%. Core interventions related to RH issues are being implemented. And coordinated by the RH Divisionwithin the MOH.

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3.3 Mental Health 3.3.1 Mental Health is not merely the absence of mental disorder or illness but also includes a positive state of mental well-being. It describes the capacity of an individual for social adaptation, to fulfill their social roles and responsibilities. It also describes the capacity to handle frustrations and enjoy life and the capacity to cope with most of life’s daily challenges. Following the formulation of the National Health Policy and Health Sector Strategic Plan (2000-2005), Mental Health was included in the Basic Minimum Health Care Package of Health Services to be provided at all levels. A policy of decentralization and integration of mental health services was adopted to ensure improved access to primary health services supported by quality referral services. The policy also provides for ensuring a continuum of care to include rehabilitation and reintegration of consumers of mental health services (patients) in their communities. 3.3.2 A Mental Health Policy and guidelines for mental health services implementation were developed in 2005 and include: planning guidelines for mental health; in-service training manual for operational level health workers; clinical management guidelines; a monitoring tool for mental health workers; essential drug list for mental health drugs; training manual for management of mental health effects of war and violence; guidelines for management of mental health complications of HIV/AIDS; and review of the mental health act initiated; pre and in-service training/capacity building initiated. Policy development for mental health programmes is still in its infancy and some of the interventions still underway include: development of alcohol and substance abuse control policy, addressing gender-based violence, implementation of the framework convention on tobacco control, and the mental health act, which is awaiting cabinet approval. 3.3.3 Most of the aforementioned interventions were achieved with the support of SHSSPP. The guidelines have been integrated into the health sector strategies. A baseline study carried out in 2004-2005 by the NGO “Basic needs UK in Uganda ”found the following elements as perceived causes of mental health : (i) socio-economic factors : drug and alcohol use and abuse, pressure to succeed, poverty, HIV/AIDS, broken and unstable relationships, unemployment; (ii) political factors : war and conflict; (iii) cultural factors : curses, family spirits and guilt. 3.3.4 Although the policy and guidelines are in place, there is need to integrate them at all levels of care with special emphasis on primary care. It is notable that only 2.3% of the population in the baseline survey (financed under the ADF-GOU SHSSP I Project) area were getting treatment for depression in modern health clinics, while the rest were going to religious and traditional healers. Capacity for Mental Health care is still very inadequate due to previous historical neglect at all levels. The aforementioned study also noted that “most districts have some form of Mental Health Programmes but which are not well developed and beset with problems such as poor or no infrastructure, severe understaffing, and low prioritisation of mental health during planning and budgeting” (SHSSPP Baseline Survey Report, 2004). The study also noted that most communities still hold negative and false beliefs about the nature, causation and course of mental illness. There is therefore need to intensify public education on mental health to change the negative attitudes of the communities to mental illnesses and increase utilization of available mental health services. 3.3.5 The Mental Health coordinator at the Ministry of Health has the responsibility to ensure that the mental health policy and guidelines are implemented in the complex

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multisectoral and multidisciplinary context. To fully coordinate and facilitate the above processes, and to better supervise and build capacities of district level managers and local leaders in planning and integrating mental health into district health programmes, it is very critical that the Mental Health Coordinator at MOH be supported. In addition, the Village Health Team (VHT) Strategy provides an institutionalised avenue to address community perceptions about mental illnesses and mental health, to mobilise mentally ill patients to seek appropriate care, and to follow-up mentally ill patients who are on treatment in the community. 4. THE PROJECT 4.1 Project Concept and Rationale 4.1.1 The MOH has launched the second HSSP (2005/06-2010/11) and has developed the SWAp as a mechanism to address the health sector as awhole in planning, management and in resource mobilisation and allocation. The overall health care development in Uganda retains the same overall goal and development objectives as the first HSSP. The overriding priority of HSSP II will be the fulfilment of the health sector’s contribution to the PEAP and the MDG related goals. The proposed project fits within the HSSP II that includes Maternal and mental health as major health problems to be tackled and has been designed after a wide consultation with development partners in conformity with the SWAPs approach. The Health Policy Advisory Committee (HPAC) and the Health Sector Working Groups, structures put in place under the SWAp have both approved the present project. The preference of the GOU for this ADF Loan is project support. This decision is also related to the satisfaction with the ongoing Support to Health Sector Strategic Plan Project (SHSSPP) that uses this modality and the fact that the Bank is the major donor financing Mental Health. The predictability of funding availability and the urgency of improving maternal health in particular are considered as key advantages associated with this modality. The HSSP II clearly states that donor project funding will continue to be crucial. Accordingly, the Bank’s support will be channelled through the project funding modality under the MTEF. It will expand mental health services financed under the Bank’s “Support to Health Sector Strategic Plan I Project” and will contribute to the improvement of the Maternal health (MH) services by contributing to the reduction of the maternal mortality ratio (MMR) in selected districts of Uganda. 4.1.2 The Bank funded SHSSP project has accomplished the following outputs: (i) the capacity of Butabika National Referral Mental Health Hospital developed to meet the priority needs of the nation, and ii) functional and sustainable mental health services built at six regional hospitals. Butabika Mental Hospital is comprehensibly rehabilitated in order to fulfil its role as the national referral hospital for diagnosis and management of mental disorders and epilepsy. The hospital serves as the main training centre for mental health professionals. Six regional referral mental units are built within six regional hospitals (Arua, Fort Portal, Gulu, Hoima, Kabale and Soroti) to provide regional, district and community mental health services. These MH facilities are the only well established units in the country. The SHSSP has also support community activities. In support of mental health, Maternal health and other elements of the Uganda National Minimum Health Care Package (UNMHCP), the present project will also extend the SHSSPP I community empowerment and mobilisation activity of implementing the Village Health Team (VHT) strategy and mobilising leaders for health through Sub-county and District Health Assemblies in the 10 new project districts. School Health will also be addressed in the context of supporting mental health and Maternal health interventions.

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4.1.3 Quality integrated RH services are one of the major strategies for reducing IMR (including neonatal mortality), MMR and fertility. In Uganda, RH indicators remain an issue of concern. MMR and total fertility rates are still high. Furthermore, the PEAP targets for reducing infant, child and maternal mortality have not been achieved. This is exacerbated by poor access and poor quality of care, lack of (qualified) staff and shortage of drugs, especially in the remote areas. In addition Mental health services were identified as a critical gap in health care delivery in Uganda in the context of the legacy of civil strife and HIV/AIDS trauma. In its HSSPI and HSSP II, the GOU considers Mental Health as amongst the most pressing health needs in the country and intends to address the heavy burden of mental illness in the country. 4.1.4 The Bank Group has approved for Uganda 59 loans and 32 grants amounting to UA 856.38 million to finance 82 operations. Of these , 61 have been completed, while 5 loans and 1 grant were cancelled. Annex V indicates a Summary of Bank Group Portfolio of On-going and Newly-approved Projects/Programs/Studies in Uganda. The implementation of the Bank’s portofolio has been hampered by, among others, the following constraints. : (i) ) delays in Parliamentary ratification of loans; (ii) insufficient field supervision and monitoring visits; (iii) long delays in processing procurement and disbursement matters; (iv) insufficient training of project staff. ; (iv) delayed accountability for project funds by some districts; (v) irregular and inadequate Government counterpart funding for projects, (vi) inadequate and/or slow staffing of some PIUs by the Government. However, there is some improvement in portofolio management since the establishment in May 2004 of the Uganda Country Office. Specifically, concerning the last health sector SHSSPP closed on 30 June 2006, its implementation has been satisfactory and was completed within the planned schedule at appraisal. Additional project outputs were achieved for civil works and training, that exceeded the targets at appraisal. The main objective of strengthening the provision of health services, with special attention to mental health and primary health care in selected districts, has been achieved. However, the following problems were raised by Bank’s PCR mission: (i) shortage of mental health drugs during the life of the project ; (ii) delays in staff deployment to the project health facilities; (iii) failure in the implementation of community income generation activities financed under the project; (iv) insufficient follow up of some of the already trained health staff.

4.1.5 These lessons and others drawn from other Bank financed projects have been taken into account in the design of the SHSSPP II as follows: (i) the approach adopted has been participatory and the number of conditions prior to first disbursement was limited to one in order to build GOU ownership and to expedite the project commencement; (ii) the GOU and the Uganda country office were involved in the project design and will facilitate the availability of conterpart funds; in addition the Bank has been assured that counterpart funds for 2006/2007 fiscal year have been included in the Medium Term Expenditure Framework; (iii) activities that will require dirbursement of resources to the health districts have been reduced to a minimum (i.e. support to supervision and outreach activities, VHT activities) in order to minimise the problem related to the delay in the submission of accountability for project funds by health districts; (iv) the project will be dealing mostly with rehabilitation of existing facilities in order to reduce the number of new staff to be recruited; (v) the project does not include income generation activities as the Ministry of Health does not have any comparative advantage in managing such activities; (vi) most of the targeted health staff to be trained under the project will be civil servants and the training activities are on the job in

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order to minimize the brain drain challenge and ; (vii) the project will scale up mental health activities initiated successfully under the concluded SHSSP Project.

4.2 Project Area and Project Beneficiaries 4.2.1 The project coverage is countrywide, with the main thrust on Maternal health and mental health initiatives such as IEC and Advocacy programmes, as well as production of Emergency Obstetric Care (EmOC) guidelines and protocols benefiting the national population, which is currently projected to be 25.6 million (Projected from 2002 Census). Mental Health Units will be built within seven regional hospitals (i.e. Mbarara, Lira, Moroto, Mbale, Jinja, Mubende and Masaka). Six regional mental health units were already built under the SHSSP I. Maternal health component in particular targets the women of Maternal age, especially, in the Western Region of Uganda, which has a total population of 6,400,000 people (27% of the total population) and a high population growth rate of 2.8% per annum (2002 Census). Within the ten districts that will benefit substantially from the project activities, the direct beneficiaries living in the ten targeted districts are about 3,358,259 persons (14% of the country total population) and are presented below.

Table 4.01: Distribution of the Maternal Health component direct project beneficiaries by type and district

District Adolescents & young

adults (10-24 years) Youths (18-30 years)

Women of Maternal age (15-49 years)

Total Population

Bushenyi 264,008 155,146 165,006 731,392Kabale 166,738 97,775 108,304 458,318Kanungu 71,710 44,543 46,433 204,732Kisoro 78,547 43,621 52,106 220,312Greater Mbarara including Kirihura, Isingiro & Ibanda

379,079 249,093 1,088,356

Ntungamo 134,739 82,068 87,243 379,987 Rukungiri 99,253 56,548 62,227 275,162 TOTAL 1,194,074 731,181 770,412 3,358,259

4.2.2 The present project will focus mostly on the South-Western region for the following reasons : (i) it will scale up some of activities implemented in the Northern and Eastern regions under the past SHSSP project: (ii) the poor health situation in general, particulary poor Maternal health in the region; (iii) the lack and/or inadequacy of health infrastructures in the South-Western in general and in Mbarara Regional Teaching Hospital and its catchment area in particular; and (iv) it will strengthen the referral system within the region. The status of buildings in Mbarara Hospital are poor and lack appropriate equipment, yet the occupancy rate is high due to lack of alternative health facilities in the region. Mbarara Regional referral hospital effectively serves as a district hospital for Mbarara district and also serves as the regional referral hospital for the districts of Mbarara, Kiruhura, Isingiro, Ibanda, Bushenyi, Ntungamo and Rukungiri. In addition some referrals are coming from western parts of Rakai, western parts of Masaka districts, Kabale, Kisoro and Fortportal districts. The Mbarara hospital catchment population is estimated at 2,207,259 people. With regards to maternal health, the caesarean section rate (CSR) was 22.6% in 2004 higher than the WHO recommendation of 5%. This high CS-rate is attributed to the fact that some of the obstetric emergencies reach the hospital very late. The institutional maternal mortality ratio (MMR) was 1,130 maternal deaths per 100,000 live births, more than double the national figure of

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505 per 100,000 live births. Although the MMR is still high, it is an improvement from the MMR of 1,781 experienced in the year 2000.

4.3 Strategic Context 4.3.1. The project has been prepared in the context whereby the GoU has adopted a health sector wide approach and the following key policy and strategic documents are already available and have facilitated the design of this ADF intervention: i) Poverty alleviation document (PEAP 2005-2008) ; (ii) implementation and evaluation of the HSSP I (2001-2005) ; (iii) Uganda Joint Assistance Strategy (UJAS) ; (iv) HSSP II has a main priority of fullfiling the health sector’s contribution to the PEAP and MDGs. Successive Participatory Poverty Assessment reports have identified ill-health as a leading cause and effect/result of poverty in Uganda. Health, therefore, continues to be an important element of the Human Development Pillar of the PEAP. Following in-country consultations with the government, development partners and civil society, supplemented by internal reviews within the ADB, the UJAS was endorsed by the ADB Board of Directors on 19 December 2005. Subsequently, the process of implementing the UJAS has started off very well under the stewardship of the Local Development Partners Group (LDPG) in collaboration with the Government of Uganda. The operational focus of the Bank Group strategy are the two PEAP pillars of “Enhancing Production, Competitiveness and Incomes” (Pillar 2) and “Human Development” including Health and Education (Pillar 5). The Health sector goal is to reduce morbidity and mortality from the major causes of ill-health and the disparities therein. 4.3.2 The project is in conformity with the above mentioned documents as well as the Bank’s Health Policy. In addition, the present project will contribute towards the MDGs (particularly MDG 3 and 4 related to the reduction on maternal and infant mortality). With regards to its efforts towards achieving the MDG, Uganda: (i) will probably eradicate extreme poverty; (ii) will potentially reduce hunger; (iii) is unlikely reduce maternal by three quarters and and infant mortality to 31 (unless there are more efforts from GOU and development partners); (iv) has already reached the targets related to HIV/AIDS and Malaria; (v) will probably reach the targets related to gender promotion and equity, universal primary education and environmental sustainability. Mental health issues are not stated as an MDG target. However, the reduction in mental health morbidity will contribute to MDG one (eradicate poverty) as the persons recovered from mental health disorders will increase their productivity. Annex VI of the report provides more details on the status of the MDGs in Uganda.

4.4 Project Objective The objectives of the project are to contribute to the reduction of maternal mortality in selected districts and to contribute to the reduction of mental health disorders in Uganda. 4.5 Project Description 4.5.1 The project consists of the following three components: i) Improvement of the delivery of Maternal Health Services ii) Expansion of the delivery of Mental Health Services iii) Project Management

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4.5.2 The project outputs per component are as follows: Component I : Improvement of the delivery of Maternal Health Services

Output 1: Access to quality maternal health services improved Output 2: Pregnant women with complications are timely referred to a health facility

Output 3 : Adolescent and community awareness to quality RH services improved Component II: Expansion of the delivery of Mental Health Services Output 4: Mental Health disorders are adequately adressed nationwide

4.6 Detailed description of components and activities Component I: Improvement of access to quality Maternal Health Services 4.6.1 Under this component, the project aims at improving access to quality maternal health services as well as the timely referral of pregnant women with complications. A collateral benefit will be the reduction of neonatal mortality. In addition, the project will strengthen adolescent and community awareness to quality Reproductive Health (RH) activities. Specifically, the project will finance the remodeling/new construction and equipping of selected regional and district health facilities including antenatal structures, blood Banks, obstetric blocks and delivery rooms. The guiding principals in rehabilitating/equipping health facilities are the following: (i) ensure the continuity of quality services by improving health facilities at all levels; (ii) improve the health facility as the whole not only the ones related directly to maternal and mental health considering that the services are related and that clients come to the health facility for many health issues (i.e. the pregnant woman come for neonatal care, child care, malaria etc.). The project will support staff and community representatives training related to maternal health. Particular attention will be on community/adolescent awareness and use of RH services. 4.6.2 The details of categories of expenditure under the component are as follows: (A) Goods 4.6.3 Furniture will be provided for Mbarara Regional and Teaching Hospital, 26 Health Centre IIIs and 13 Health Centre IVs. This will include specialized medical furniture especially for Mbarara Regional and Teaching Hospital. 4.6.4 Medical equipment will be purchased for Mbarara Hospital, 4 Government owned district hospitals, 4 Private Not for Profit district hospitals, 26 Health Centre IIIs and 13 Health Centre IVs including equipment for 7 theaters for HC IVs. Other types of equipment to be purchased include 22 Ambulances for 8 district hospitals for referrals and counter-referrals, 13 HC IVs and Mbarara hospital, 2 cinema vans, audio visual equipment for the adolescent centres, and a 4x4 vehicle for the supervision of maternal health activities by the Reproductive Division of the Ministry of Health. 4.6.5 Delivery kits numbering about 400,000 will be made available to pregnant women, preferably through a revolving system, to encourage them to deliver in Health Centres. Learning and Training materials will be procured to facilitate training under Component I.

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(B) Works 4.6.6 The upgrading of facilities will boost the capacity of MOH and NGOs to deliver Maternal Health services with community participation in 10 districts. In addition, the MOH strategy for rolling out Emergency Obstetric Care Services calls for hospitals and HC IVs to provide comprehensive EmOC services and for HC IIIs to provide basic Emergency Obstetric Care Services. Accordingly, one regional referral and teaching hospital, 13 HC IVs, and 26 HC IIIs will be fully rehabilitated. Mbarara Regional and Teaching Hospital will be upgraded through remodeling of some existing buildings and new construction. Staff Housing will also be made available as well as facilities for ancillary services. Twenty six (26) existing Health Centre IIIs and 13 Health Centre IVs will be upgraded through a combination of remodeling of existing buildings and new construction. Surveys will be carried out at each of the selected Health Centre IIIs and IVs to determine the exact nature of intervention in each health centre. The list of health centres to be rehabilitated/remodelled in included in Annex VII. C) Services 4.6.7 At Mbarara Hospital, a firm of consultancy services (60 months) for both Architectural and Engineering will be needed for buildings to be remodeled and newly designed. With regards to the 26 Health Centre IIIs and 13 Health Centre IVs existing MOH standard designs of the Health Infrastructure Development Plan (HIDP 2002) will be adapted to the various sites. After tendering and selection of contractors carried out by the PMU, post-contract services and site supervision will be carried out by consultants until completion of the project. The consultants will apart from regularly visiting the sites also maintain their various clerk of works for day-to-day supervision for the duration of the contracts. 4.6.8 Technical Assistance in the Reproductive Health Division will be provided for a period of 48 person/months to assist the Maternal Health Unit of the Ministry of Health. The Technical Assistance will cover areas of intervention including training and the design of Maternal Health activities. An NGO will be subcontracted to help increase access and utilization of quality contraceptive method mix among underserved population, as well as strengthen the youth programme in the South Western Uganda. Technical Assistance will further be required in conducting a Baseline Survey to help establish appropriate benchmark data and help to monitor and evaluate programme performance. 4.6.9 On the job-training will be provided in Emergency Obstetric Care for doctors and midwives in Health Centre IVs and also for one doctor and one midwife in district hospitals (27 doctors and 27 midwives drawn from 27 HC IVs and district hospitals). A total of 88 Nurses in the Health Centres and 5 health staff in Mbarara hospital will be trained in Adolescent-Friendly Services to enable them impart Adolescent knowledge on Maternal Health. A total number of 88 midwives from HC IIIs will be trained in basic Post Abortion Care (PAC) and Life Saving Skills (LSS) to ensure that they provide related services at the respective health facilities. Training will also be carried out at community level to strengthen the skills of VHTs and Community Health Workers in Maternal Health. In addition, the project will support training of health staff at national, regional and district levels in Health Management Information System, planning and financial management to facilitate the smooth functioning and management of health facilities. Complementary reproductive training will be financed by United Nations Fund for Population Activities.

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4.6.10 In collaboration with WHO, UNFPA, UNICEF who have already developped a number of a number of maternal health Guidelines and Protocols the project will finance the adapting, the printing and the disseminaion of these documents including the following : Managing Complications in Pregnancy and Childbirth; Pregnancy, Childbirth and Newborncare; Life Saving Skills Modules; Maternal Death Review Guidelines; Safe Motherhood in the Community; Decision-Making Tool for Family Planning Clients and Providers; Counseling Booklet for Pregnant Women; The Partograph in Uganda: A Practical Guide for Health Workers; Management of Hypertensive Disorders in Pregnancy; and Emergency Obstetric Care Protocols. Appropriate IEC and Advocacy materials and Job Aids for RH will also be developed and disseminated. 4.6.11 An Adolescent Maternal Health Centre in the South Western region will be strengthened with the support of an NGO (with the support of adolescent peer educators) to provide young people with appropriate and accurate information on Maternal health as well as youth friendly services. This is an appropriate response to the high teenage and unwanted pregnancies, most of which lead to unsafe abortions, obstetric fistulae and maternal mortality. In collaboration with the District Health Management teams and NGOs, the Family Life Education Programme in schools will be strengthened and revitalized in the South-Western region. 4.6.12 The Health sub districts will be supported to eliminate stock-outs and wastage of FP commodities and supplies at service delivery points. This will be achieved through training of the supervising officers and support supervision by the District Technical Teams. The districts will be further supported to establish data bases to track the use of FP commodities and supplies at the health centre level. 4.6.13 The project will support revitalization of male involvement programmes on Maternal Health. This will entail sensitization seminars organized for men as well as peer educators among men. The peer educators will be trained on male involvement in Maternal Health and will be facilitated to reach out to men. 4.6.14 The project will finance the implementation of the Maternal Health component of the National Health Communication Strategy. To operationalize this, the Village Health Teams (VHTs) will be established and supported to empower communities to enable them to play a larger role in the promotion of health in the community. (D) Operating Costs 4.6.15 Running costs of 1 vehicle, 2 cinema vans and office supplies to be used in promoting Maternal health activities will be financed by the project. The project will support per diem and fuel allowances of Regional Technical Team and District Technical Teams to provide on-job performance improvement and enhancement skills on a quarterly basis in the South Western region. In addition the project will contribute to the financing of supervision of Maternal Health services by the Ministry of Health. Component II: Expansion of Mental Health Services 4.6.16 The project will aim at addressing adequately the issues of mental health disorders by expanding and complementing the activities financed by the Bank under the SHSSP project. Therefore it will finance the construction and equipping of 7 Mental Health Units. In addition

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Mental health professionals will be trained to build capacity towards the delivery of adequate mental health care to women, men and children with psychotic disorders, stress-related disorders such as depression, anxiety, substance and alcohol abuse and epilepsy. Public education through radio, television, newspaper articles and other IEC materials will be used by health workers and Village Health Teams to seek to change negative attitudes and false beliefs about the nature and causes of mental illness. 4.6.17 The details of the categories of expenditure under the component are as follows: (A) Goods 4.6.18 Furniture and medical equipment will be provided for the 7 Mental Health Units to be constructed on the premises of selected 7 referral hospitals. In addition, a 4x4 vehicle, 2 laptops and a photocopier will be procured for the Mental Health Division in order to better coordinate the implementation of Mental Health activities to be financed under this component. For sustainability reasons, the Government will procure all drugs including the ones for mental health by using its recurrent budget. (B) Works 4.6.19 Works under this component will consist of the construction of 7 new Mental Health Units on the premises of existing Regional Referral Hospitals in Mbale, Lira, Moroto, Masaka, Jinja and Mubende. Each mental health unit will consist of the following: Out Patient Department, Pharmacy, 4 side rooms, Staff toilets, Servery, male/female wards/Dining, Male/Female Private Rooms, Washrooms/Store Therapy/Stores, Duty Station/Relatives Accommodation and Staff Houses. (C) Services 4.6.20 The 7 Mental Health Units to be constructed need to be adequately staffed. In addition new staff will have to be recruited to provide services at the District level. The project will support the training of the following categories (trainees are selected from civil servant staff): 50 Psychiatric Clinical Officers (24 months), 12 Master of Medicine in Psychiatry (36 months), 4 Psychiatric Social Workers (24 months) and 6 Clinical Psychologists (24 months). 4.6.21 In addition, 11 Regional and 40 District Training of Trainers workshops will be organized and coordinated by the Ministry of Health to improve on capacity building through inservice training at the national, regional and district levels on mental health delivery. 4.6.22 The project will seek to strengthen community participation in mental health delivery through the existing Village Health Teams. Public education by radio, TV spots, Newspaper Articles, Posters and Leaflets on mental health will be supported to change the negative attitudes and false beliefs about the nature, causes and treatment of mental illness. Village Health Team members in the 40 districts will be sensitized on mental health issues to promote and to raise awareness at grassroots level. The school health programmes will also promote mental health awareness and practices. In addition the project will finance consultancy services to finalize the mental health policies and guidelines such as the alcohol and substance abuse control policy, the framework convention on tobacco control.

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(D) Operating Costs 4.6.23 The project will finance operating costs of mental health delivery including vehicle running costs, support supervision as well as learning and training materials for various workshops Component III: Project Management 4.6.24 The project will finance the provision of goods and services necessary for project implementation and coordination. 4.6.25 The details of categories of expenditure are as follows: (A) Goods 4.6.26 Three project vehicles (4x4) will be purchased by mid-project life to replace the existing old vehicles under SHSSPP. These vehicles will allow PMU Staff to supervise the project activities implemented in remote areas located in different districts of the country. Printers, photocopiers and computers will also be procured under this component to facilitate project co-ordination and management. (C) Services 4.6.27 The core staff of the Project Management Unit staff will undergo training in ADF procedures. Technical Assistance for PMU (Architect, Quantity Surveyor, Engineer, Public Health Specialist, Procurement Specialist and Accountant, will be provided for 60 months duration of the project. The Project Manager and the Monitoring and Evaluation Specialist will be seconded to the project from the Ministry of Health and salaries and allowances will be paid to them by the GoU and ADF resources respectively. In addition, Technical Assistance (6 person months) will be utilized for the procurement of medical equipment and furniture through the National Committee for Medical Equipment facilitation (NACME). Provision has been made for external auditing of project accounts to be carried out during the project duration. A Firm or an Institution will be recruited to conduct a baseline survey at the beginning, a midterm evaluation and an end of project evaluation/project completion report (a total of 6 person-months). Some MOH staff will be trained in planning, financial management and health information systems. (D) Operating Costs 4.6.28 The operational costs of the PMU in carrying out the administration, co-ordination and procurement activities necessary for the successful completion of the project will be met for the 60 months of implementation. These include vehicle running costs, telecommunications expenses, supervision and civil servants indemnities. 4.7 Environmental Impact 4.7.1 The project is classified in category 2 according to the Bank’s environmental guidelines. In carrying out civil works, the environment will be protected by the preservation of existing trees and the planting of new ones. Any destruction of vegetation resulting from excavations will be mitigated by replanting after the completion of civil works. Appropriate

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drainage systems will also be constructed to rapidly evacuate waste water into soakaway pits and also storm water to prevent soil erosion. Mbarara Hospital 4.7.2 The Support to Health Sector Strategic Plan Project II will be an undertaking involving expansion of the existing hospital infrastructure, improved health care facilities and increased hospital capacity to handle a larger patient population. This will result in an increase of patient numbers, generation of more healthcare waste, waste water and general solid waste of great quantity and complexity than ordinary waste. These will translate into extra pressure on the surrounding environment. Under such circumstances GoU requires an Environmental and Social Impact Assessment (ESIA) to identify the likely negative environmental impacts to ensure that construction and operation of the facility after expansion will comply with national environmental, occupational health & safety and public health regulations. 4.7.3 The main objectives of the ESIA will be to identify and assess potential environmental impacts, recommend mitigation measures and prepare an Environmental and Social Management Plan (ESMP). Specific terms of reference will include: (i) assessment of potential impacts of the proposed expansion of infrastructure and increase of equipment at the hospital; (ii) identification and assessment of the nature, magnitude and duration of the impacts; (iii) conduct public consultations among stakeholders to identify their views and build consensus; (iv) identify significant negative environmental impacts and develop a mitigation plan for the adverse impacts identified; (v) propose mitigation measures and present them to the other consultants i.e., the Architect, Land Surveyor, Civil Engineer, Mechanical & Electrical Engineers for incorporation in the Preliminary & Final Designs. In conducting this assessment, the ESIA Consultant(s) will analyze technical, social and ecological issues related to the proposed expansion. This will be done through use of regulatory guidelines, site assessments, literature reviews and interviews with stakeholders. Health centers IVs and health centers IIIs 4.7.4 Renovation of these Centres will be limited in scope and will not be expected to cause major environmental impacts. However, a study will be carried out which will include, but not limited to: (i) screen for positive & negative environmental and social impacts of each of the project sites and ; (ii) identify significant negative environmentaland social impacts. Boreholes will be dug to guarantee the availability of potable drinking water on all sites. Solar panels will be installed to provide power on sites where electricity is unavailable. Ventilated improved pit latrines will also be constructed on all designated sites to ensure the safe disposal of human excreta. Facilities like placenta pit and incinerators would also be provided at all health centres to facilitate the disposal of medical waste where necessary. The Bank summary of Environmental and Social Management Plan (ESMP) is included in Annex VIII. 4.8 Project Costs 4.8.1 The total cost of the project, net of taxes and customs duties, is estimated at UA 22.22 million (USD 32.68 million) of which UA 15.28 million is in foreign exchange and UA 6.94 million is in local currency. Most of the costs information are obtained from the MOH, the on-going SHSSPP and the Ministry of Finance. All items have been priced in USD and

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converted into UA at the exchange rate applicable in the Bank for the month of May 2006. A summary of project cost estimates is given below in Table 4.1 by component and in Table 4.2 by category of expenditure. 4.8.2 The cost estimates for civil works, furniture and equipment are based on data obtained from the PMU. Physical contingencies are set at 5% of base costs for all categories of expenditure. Price contingencies are estimated at 3.5% inflation per year for both local and foreign currency costs since the project is priced in USD. The List of Goods and Services can be found in Annex IX.

Table 4.1

Summary of Project Costs by Component USD million UA million

COMPONENT F.E. L.C. Total F.E. L.C. Total % of Total

Component I 16.81 5.16 21.97 11.43 3.51 14.93 67.2% Component II 2.50 2.10 4.60 1.70 1.43 3.13 14.1% Component III 0.51 1.74 2.25 0.35 1.18 1.53 6.9%

Base Costs 19.82 9.00 28.82 13.47 6.12 19.59 88.2% Physical Contingencies 0.99 0.45 1.44 0.67 0.31 0.98 4.4% Price Contingencies 1.66 0.76 2.42 1.13 0.51 1.65 7.4%

22.48 10.21 32.68 15.28 6.94 22.22 100.0% TOTAL COSTS 68.8% 31.2% 100.0% 68.8% 31.2% 100.0%

Table 4.2 Summary of Project Costs by Category of Expenditure (UA million)

USD million UA million CATEGORY F.E. L.C. Total F.E. L.C. Total

% of Total

Goods 5.55 0.87 6.42 3.77 0.59 4.36 19.6% Works 11.98 4.37 16.35 8.14 2.97 11.11 50.0% Services 2.19 2.80 4.99 1.49 1.90 3.99 15.3% Operating Costs 0.10 0.94 1.04 0.07 0.64 0.71 3.2% Base Costs 19.82 9.00 28.82 13.47 6.12 19.59 88.2%

Physical Contingencies 0.99 0.45 1.44 0.67 0.31 0.98 4.4% Price Contingencies 1.66 0.76 2.42 1.13 0.51 1.65 7.4% TOTAL COSTS 22.48 10.21 32.68 15.28 6.94 22.22 100% 68.8% 31.2% 100.0% 68.8% 31.2% 100.0%

4.9 Sources of Financing and Expenditure Schedule

4.9.1 The project will be financed jointly by the ADF Loan (UA 20.00 million) and the Government of Uganda (UA 2.22 million) as shown in Table 4.3 below. The ADF’s contribution will finance 90% of the total project cost and will comprise UA 15.28 million in foreign exchange representing 68.8% of the total project costs and UA 4.72 million in local costs which is 21.2 % of the total project costs. The ADF will cover 100% of all foreign exchange costs and 68.0% of local costs. The Government will finance 32.0% of local costs estimated at UA 2.22 million which represents 10% of the total project costs. In addition, the Government will finance all taxes and duties.

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Table 4.3

Sources of Finance (UA million) SOURCE F.E. % L.C. % TOTAL % of Tot ADF 15.28 100.0 4.72 68.0 20.00 90.0 GOVERNMENT 0.00 0.0 2.22 100.0 2.22 10.0 TOTAL 15.28 6.94 22.22 100.0

68.8% 31.2% 100.0%

Table 4.4 Sources of Finance by Category of Expenditure (UA million)

TOTAL ADF LOAN GOVERNMENT CATEGORY

Amount % of Tot. Amount % of Tot. Amount % of Tot. Goods 4.95 22.3% 4.95 24.8% 0.00 0.0% Works 12.60 56.7% 11.25 56.3% 1.35 60.8% Services 3.87 14.0% 3.50 17.5% 0.37 16.7% Operating Costs 0.80 7.0% 0.30 1.5% 0.50 22.5% TOTAL 22.22 100.0% 20.00 100.0% 2.22 100.0%

4.9.2 Tables 4.5 and 4.6 below show expenditure schedule by component and by category of expenditure and source of financing respectively.

Table 4.5 Expenditure Schedule by Component (UA million)

COMPONENT 2007 2008 2009 2010 2011 TOTAL Goods 0.08 1.13 1.54 1.48 0.17 4.40 Works 0.06 2.62 4.15 3.53 0.10 10.46 Services 0.45 0.49 0.50 0.46 0.12 2.02 Operating Costs 0.00 0.02 0.02 0.01 0.01 0.06

TOTAL COMPONENT 1 0.59 4.26 6.21 5.48 0.40 16.94 Percentage 3.5% 25.1% 36.7% 32.3% 2.4% 100%

Goods 0.00 0.14 0.17 0.16 0.00 0.47 Works 0.06 0.27 1.13 0.58 0.10 2.14 Services 0.00 0.30 0.30 0.22 0.06 0.88 Operating Costs 0.01 0.01 0.01 0.01 0.01 0.05 TOTAL COMPONENT 2 0.07 0.72 1.61 0.97 0.17 3.54 Percentage 2.0% 20.3% 45.5% 27.4% 4.8% 100%

Goods 0.03 0.03 0.02 0.01 0.00 0.09 Services 0.17 0.23 0.22 0.22 0.13 0.96 Operating Costs 0.14 0.13 0.13 0.13 0.15 0.69 TOTAL COMPONENT 3 0.34 0.39 0.37 0.36 0.28 1.74 Percentage 19.5% 22.4% 21.3% 20.7% 16.1% 100%

TOTAL PROJECT 1.00 5.37 8.19 6.81 0.85 22.22 Percentage 4.5% 24.2% 36.9% 30.6% 3.8% 100%

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Table 4.6 Expenditure Schedule by Category and Source of Finance (UA million)

ADF LOAN 2007 2008 2009 2010 2011 Total Goods 0.11 1.49 1.64 1.55 0.16 4.95 Works 0.12 2.30 4.88 3.85 0.10 11.25 Services 0.45 0.97 0.98 0.87 0.22 3.50 Operating Costs 0.22 0.03 0.01 0.01 0.14 1.05 Total 0.90 4.79 7.43 6.26 0.62 20.00 Percentage 4.50% 23.95% 37.15% 31.30% 3.10% 100.0%

GOVERNMENT 2007 2008 2009 2010 2011 Total Works 0.02 0.40 0.57 0.36 0.00 1.35 Services 0.04 0.07 0.08 0.09 0.09 0.37 Operating Costs 0.04 0.11 0.11 0.10 0.14 0.50 Total 0.10 0.58 0.76 0.55 0.23 2.22

Percentage 4.5% 26.1% 34.2% 24.8% 10.4% 100.0% TOTAL 2007 2008 2009 2010 2011 Total Goods 0.11 1.49 1.64 1.55 0.16 4.95 Works 0.14 2.70 5.45 4.21 0.10 12.60 Services 0.49 1.04 1.06 0.96 0.31 3.87

Operating Costs 0.26 0.14 0.04 0.09 0.28 0.80 Total 1.00 5.37 8.19 6.81 0.85 22.22 Percentage 4.5% 24.2% 36.9% 30.6% 3.8% 100.0%

5. PROJECT IMPLEMENTATION

5.1 Executing Agency 5.1.1 The Ministry of Health (see organigramme in Annex X) will be the Project executing agency and it will be coordinated through a Project Management Unit (see organigramme in Annex XI). The PMU (under the completed SHSSPP) was performing satisfactorily and therefore some of the staff will be will be retained in accordance with Bank’s rules and procedures in procuring services and strengthened to supervise the proposed project. A Project Coordinator seconded by the MOH and coordinating the past health project, will be responsible for the overall co-ordination, management and supervision of the project’s activities. He will be assisted by a team comprising a Health Specialist, Monitoring and Evaluation Specialist who will be seconded by the MOH to the PMU (the M & E Specialist who is a member of the Health Sector Working Group (HSWG) will facilitate the coordination of the project with other donors interventions), Engineer, Architect, Quantity Surveyor, Accountant, Procurement Officer, Senior Secretary/Administrative Assistant, Accounts Assistant, Internal Auditor, Secretary and four drivers. Administratively, the Project Coordinator will report to the Permanent Secretary of the Ministry of Health or any designated senior health officer by him. The Project Coordinator will work closely with all other relevant MOH programs at the central level, regional referral hospitals and district levels. He will participate in the RH Inter-Agency Coordination Committee (ICC) meetings to ensure synergy with other on-going work on Reproductive Health. 5.1.2 The current Project Steering Committee (PSC) has been effective to provide strategic and policy guidance to the PMU, review project progress and approve annual work-plan(s) presented by the PMU. The Committee which will meet quarterly and when there is need, will determine policy, decide on financial allocations and assess progress of project implementation against quarterly work-plans. The Chairman of the PSC shall in turn, keep the MOH’s top and senior management and HPAC informed on the progress of the project.

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The PSC will comprise of the Permanent Secretary, MOH, as Chairperson; the Director General Health Services as the alternate Chairperson; the Project Coordinator as the Secretary, the Director of Butabika Hospital; the Director of Planning and Development; the Director (Clinical and Community Health); the Commissioners of Health Services responsible for Planning, Community Health and Clinical Services; the Assistant Commissioners for Health Infrastructure, for RH and HP/E; the Principal Medical Officer (Mental Health); a Representative of the Ministry of Finance; the Director of Mbarara Hospital; a Representative from the Ministry of Justice and Constitutional Affairs; a Representative of the Civil Society; and a District Representative. The PSC will invite other experts stakeholders, including UNFPA, as observers to meetings as appropriate. The steering committee will have three (3) technical subcommittees (TSC), namely, the Maternal Health & Mental Health TSC, the Health Infrastructure TSC and Medical Equipment TSC (which will utilise the current National Advisory Committee on Medical Equipment/NACME). The TSC will review the project work plans, provide technical guidance, and monitor / support project implementation.

5.2 Institutional Arrangements

5.2.1 The project will be implemented by using as much as possible the mechanisms and tools put in place under the SWAPs (see details on section 5.8). The project involves a substantial civil works component, and since the MOH infrastructure division is understaffed, it is expedient that the PMU be staffed with the relevant expertise to supervise contractors involved in the civil works financed under the project and will assist the MOH on similar activities. Overall supervision for the project will be handled by the Steering Committee which is headed by the Permanent Secretary of the MOH. In addition to strengthening harmonisation, integration and sustainability of activities at national level, the project will work closely with the MOH health planning department, and the divisions of Health infrastructure, Maternal Health, Mental Health and Health Education / Promotion. Three technical sub-committees, namely; the Maternal Health & Mental Health TSC, the Health Infrastructure TSC and Medical Equipment TSC will work closely with both the steering committee and the PMU to enhance project co-ordination and implementation. 5.2.2 At the district level, District Health Management Teams (DHMT) will be responsible for implementation of project supported activities in close collaboration with community representatives in line with the project objectives and such activities will be included in districts health plans. The line MOH programs, the PMU and the district leaders will routinely supervise and monitor implementation of the activities in the districts. The District Directors of Health Services will prepare activity reports and records that will be submitted to the PMU quarterly. 5.2.3 At community level, the Village Health Teams and NGO will facilitate the collaboration between the populations and the health staff and will be responsible for the community mobilization and sensitization with regards to the project maternal and mental health activities and to the maintenance of the health facilities. These activities will focus on measures to be taken by the communities in order to avoid maternal deaths and stigma on mental health problems and to care for their patients. 5.2.4 The existence of the Bank Uganda Field Office will facilitate the implementation of the project. In conformity of the Bank Group Presidential Directive PD n° 02/2005 concerning delegation of authority on project administration to field offices’s staff, The

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UGCO will ensure, during all stages of the project cycle, that the Borrower understand the importance and relevance of the procurement and disbursement provisions to be stipulated in the Protocol Agreement. Details on the delegation of authority and procurement and disbursement to the field offices are included in the above mentioned PD.

5.3 Supervision and Implementation Schedules

The project will be implemented during a period of 5 years (60 months). Detailed implementation schedule is presented in Annex XII and summarized below. The project implementation document outline is indicated in Annex XIII. ACTIVITY RESPONSIBLE TARGET DATE AGENCY Administration Board Approval ADF November 2006 Loan Signature GoU/ADF October 2006 General Procurement Notice ADF/GoU January 2007 Loan Effectiveness GoU/ADF January 2007 Project Launching ADF/GoU January 2007 Supervision ADF/GoU Twice a year Midterm Review GoU/ADF June 2009 Borrowers PCR GoU July 2012 ADB PCR ADF October 2012

5.4 Procurement Arrangements 5.4.1 Procurement arrangements are summarized in Table 5.1 below. All procurement of civil works, goods and acquisition of consulting services financed by the Bank will be in accordance with the Bank’s Rules of Procedure for Procurement of Goods and Works or, as appropriate, Rules of Procedure for the Use of Consultants, using the relevant Bank Standard Bidding Documents. There will be Advance Action for the acquisition of Consultancy Services (AAA).

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Table 5.1 Procurement Arrangements (UA million)

CATEGORIES ICB NCB SHORTLIST OTHER TOTAL 1.0 WORKS 1.1 Construction of Mbarara Hospital 3.951[2.633] 3.951[2.633] 1.2 Construction of 26 Health Centre IIIs 3.581[3.581] 3.581[3.581] 1.3 Construction of 13 Health Centre IVs 2.923[2.923] 2.923[2.923] 1.4 Construction of 6 Mental Health Units 2.143[2.143] 2.143[2.143] 2.0 GOODS 2.1 Furniture incl.Specialised Mbarara 0.347[0.347] 0.347[0.347] 2.2 Furniture for 26 Health Centre IIIs 0.131[0.131] 0.131[0.131] 2.3 Furniture for 13 Health Centre IVs 0.075[0.075] 0.075[0.075] 2.4 Furniture for 7 Mental Health Units 0.081[0.081] 0.081[0.081] 2.5 Equipment for Mbarara Hospital 0.838[0.838] 0.838[0.838] 2.6 Equipment for 8 District Hospitals 0.200[0.200] 0.200[0.200] 2.7 Equipment for 26 Health Centre IIIs 0.640[0.640] 0.640[0.640] 2.8 Equipment for 13 HCIVs 0.444[0.444] 0.444[0.444] 2.9 Equipment for 7 theatres HCIVs 0.320[0.320] 0.320[0.320] 2.10 Equipment for 7 Mental Health Units 0.340[0.340] 0.340[0.340] 2.11 Equipment for Maternal Sensitization 1.088[1.088] 1.088[1.088] 2.12 Equipment for Mental Health Sensitization 0.033[0.033] 0.033[0.033] 2.13 Equipment for Project Management 0.085[0.085] 0.085[0.085] 2.14 Delivery kits for 10 Districts 0.316[0.316] 0.316[0.316] 2.15 Learning and Training Materials 0.011[0.011] 0.011[0.011] 3.0 SERVICES 3.1 Design and Supervision of Mbarara Hosp. 0.395[0.084] 0.395[0.084] 3.2 Supervision of HCIIIs and HCIVs 0.855[0.855] 0.855[0.855] 3.3 Supervision of 7 Mental Health Units 0.107[0.107] 0.107[0.107] 3.4 Training of Doctors, Nurses, VHTs 0.296[0.296] 0.296[0.296] 3.5 Training of Mental Health Personnel 0.499[0.499] 0.499[0.499] 3.6 Training of PMU staff 0.023[0.023] 0.023[0.023] 3.7 Training in fin. Management, HIS 0.039[0.039] 0.039[0.039] 3.8 Baseline study 0.077[0.077] 0.077[0.077] 3.9 Technical Assistance Maternal Health 0.115[0.115] 0.115[0.115] 3.10 NACME facilitation for procurement 0.004[0.004] 0.004[0.004] 3.11 External Auditing 0.034[0.034] 0.034[0.034] 3.12 Internal Auditing 0.012[0.012] 0.012[0.012] 3.13 Maternal Health Sensitization 0.320[0.320] 0.320[0.320] 3.14 Implementation Maternal sens. By NGO 0.035[0.035] 0.035[0.035] 3.15 Environmental Impact Assessment 0.024[0.024 0.024[0.024 3.16 Technical Assistance PMU 0.749[0.749] 0.749[0.749] 4.0 MISCELLANEOUS 4.1 Mental Health Sensitization 0.274[0.274] 0.274[0.274] 4.2 Operating Costs Component I 0.061[0.061] 0.061[0.061] 4.3 Operating Costs Component II 0.050[0.050] 0.050[0.050] 4.4 Project Management 0.648[0.098] 0.648[0.098] TOTAL 15.727[14.409] 0.614[0.614] 2.699[2.388] 3.160[2.589] 22.220[20.000]

Shortlist applies to the use of consulting services. ** Others may be International or National Shopping or Direct Purchase ***Figures in brackets are financed by ADF [ ]

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Table 5.2 Other Modes of Procurement (UA million)

Procedure Goods Max per Contract Max in Aggregate

International Shopping Maternal Health Sensitization 2 Minibuses 0.055 0.055 2 Cinema vans 0.056 0.056 4x4 vehicle for Technical Support 0.023 0.023 National Shopping 4x4 Vehicle (MH) 0.023 0.023 3 (4x4) vehicles for PMU 0.070 0.070 Equipment for PMU (excl. vehicles) 0.015 0.015 Equipment for Maternal H. sensitization 0.200 1.088 Equipment for Mental Health sensitization 0.033 Direct Negotiation Training of doctors, nurses, VHTs 0.296 Training of mental health personnel 0.499 Training of PMU Staff 0.023 Training fin. Management, HIS 0.039 Mental Health Sensitization 0.274 NACME facilitation for procurement 0.004

Civil Works

5.4.2 Procurement of civil works will be carried out under International Competitive Bidding (ICB) procedures. One (1) contract will be awarded for civil works at Mbarara Hospital, and valued at UA 3.951 million. Three (3) contracts (UA 1.193 each, or UA 3.581 million in total) will be awarded for the civil works for 26 Health Centre IIIs. Two (2) contracts (UA 1.461 million each, or UA 2.923 million in aggregate) will be awarded for the civil works for 13 Health Centre IVs. Two (2) contracts (UA 1.071 million each, or UA 2.143 million in total) will be awarded for the construction of 7 Mental Health Units. The list of Health centers to be rehabilitated/remodelled in indicated in Annex X.

Goods 5.4.3 The following items of goods (valued in total at UA 3.055 million) will be procured through International Competitive Bidding procedures. These include one (1) contract for the supply of equipment to Mbarara Hospital (valued at UA 0.838 million) and for 8 district hospitals (UA 0.200 million); one (1) contract for supply of equipment to 26 Health Centre IIIs (UA 0.0.640 million); one (1) contract for supply of equipment to 13 Health Centre IVs (UA 0.444 million); one(1) contract for supply of 22 ambulances (UA 0.593 million) and 7 Mental Health Units (UA 0.340 million). 5.4.4 The following supply items (valued in total at UA 0.961 million) will be awarded through National Competitive Bidding (NCB) procedures. These include one (1) contract for furniture including specialised to be supplied to Mbarara hospital (valued at UA 0.347 million); one (1) contract each for furniture to be supplied to 26 Health Centre IIIs (UA 0.131 million); for 13 Health Centre IVs (UA 0.075 million); and for the 7 Mental Health Units (UA 0.081 million); delivery kits (UA 0.316 million); and learning and training materials (UA 0.011 million) NCB has been chosen because the goods are of such value or quantities or character that their supply could not possibly interest suppliers from outside Uganda, and there are local suppliers sufficiently qualified and in number sufficient to ensure competitive bidding. 5.4.5 Vehicles for Maternal health including 2 minibuses (UA 0.055 million) and 2 cinema vans (UA 0.056) million will be procurered through International Shopping (IS) because they are standard specification commodities and cannot be purchased locally.

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5.4.6 Equipment for PMU valued at UA 0.015 million, maternal health sensitization valued at UA 1.088 million, mental health sensitization valued at UA 0.033 million and five (5) 4x4 vehicles (UA 0.116 million) will be procured through National Shopping (NS), because the items are readily available off-the-shelf goods that can be purchased locally. Consulting Services and Training 5.4.7 In order to speed up project execution, there will be Advance Action for the Acquisition of architectural Consultancy Services for the Mbarara Hospital Redevelopment (valued at UA 0.395 million). The relevant safeguards of the Bank Group will be applied. 5.4.8 Three (3) contracts, including consultancy services for Design and Supervision of Mbarara Hospital (valued at UA 0.395 million), supervision of Health Centre IIIs and IVs (UA 0.855 million) and supervision of Mental Health Units (UA 0.107 million) will be procured through shortlisting of firms. The selection procedures will be based on the technical quality and price consideration. Long and short-term training for Maternal Health Staff (valued at UA 0.296 million), Mental Health Staff (UA 0.499 million), training of PMU staff (UA 0.023 million), training in Planning and financial management (UA 0.039 million), will be procured through Direct Negotiations with Makerere University, because it has adequate capacity, experience, expertise, as well as the track record for such training. 5.4.9 Technical Assistance for PMU (valued at 0.749 million) and the development of the Maternal Health Sensitization/IEC tools (UA 0.115 million), will be procured through shortlisting of individuals experts. Technical assistance for implementation of maternal health sensitization by firms including NGOs (valued at UA 0.350 million), will be procured through shortlisting. The selection procedure will be based the technical quality with price consideration. Technical Assistance for the baseline study (valued at UA 0.077 million), external auditing of project accounts for 3 years (valued at UA 0.034 million) will be procured through shortlisting of firms. The selection procedure will be based on the comparability of technical proposals and selection of the lowest financial offer. NACME facilitation for procurement (valued at UA 0.004 million) will be extended to the PMU, through Direct Negotiation procedures. The capacity, expertise, experience, and track record of these institutions have been found to be acceptable Miscellaneous 5.4.10 Logistical support (valued at UA 0.274 million) will be provided by the PMU to MOH and Village Health Teams for Mental Health Sensitization. National Procedures and Regulations 5.4.11 Uganda’s national procurement laws have been reviewed and found to be acceptable. Executing Agency 5.4.12 The MOH through the PMU be responsible for the procurement of goods, works, consulting services and training. The resources, capacity, expertise of the Project Management Unit are adequate to carry out the procurement.

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General Procurement Notice 5.4.13 The text of a General Procurement Notice (GPN) will be agreed during negotiations and will be published in the UN Development Business, upon approval by the Board of Directors of the Loan Proposal. Review Procedures Prior Review 5.4.14 The following documents are subject to review and approval by the Bank before promulgation:

• Specific Procurement Notice; • Prequalification Invitation Documents; • Tender Documents or Requests for Proposals from Consultants; • Tender Evaluation Reports or Reports on Evaluation of Consultant’s

Proposals, including recommendations for Contract Award; • Draft contracts if these have been amended from the drafts included in the

tender documents.

Post Review 5.4.15 Given the large number of contracts of small value, there will be procurement Post Review procedures for items below the following thresholds, viz.: UA 100,000 [for Works]; UA 50,000 [Goods]; and UA 30,000 [Consultancy].

Safeguards for Advance Action for the Acquisition of Consultancy Services

5.4.16 The Borrower shall be fully aware that: • AAA is taken at its own risk and it in no way obliges the Bank to award a

loan or grant for the study in question; • for AAA to be eligible for Bank financing, it shall be carried out in accordance

with the Bank’s procedures; • announcements in the case of AAA should mention that, the Borrower has

requested for a loan or grant from the Bank and that the contract award will be subject to approval of the loan or grant by the Bank.

5.5 Disbursement Arrangements

5.5.1 The Special Account (SA) method and the Direct Payment (DP) method will be used for disbursement. Funds for the operating costs of the Project Management Unit, workshops, travels and project audits would be disbursed through the special account method from which the PMU would make payment for expenditures approved by ADF. 5.5.2 GOU will open one (1) Special Account (SA) in foreign currency to receive the ADF Loan, and one (1) Local Currency Account (LCA) in a bank acceptable to the ADF to receive GOU’s counterpart contribution. The ADF will replenish the SA when the precedent advance has been utilized and justified up to at least 50% of the funds paid into the Account and that all previous advances have been fully justified. The PMU will maintain records at all times of all disbursements made by the Bank and GOU. The opening of the SA and the LCA will be a

33

condition precedent to first disbursement of the Loan. 5.6 Monitoring and Evaluation

5.6.1 At start of the project implementation, a baseline survey will be conducted by an institution/firm to set baseline indicators on maternal and mental health services (indicators highlighted in the project log-frame) in the project areas. The results of the baseline will provide guidance to the PMU in decision making. In addition, a mid-term evaluation and an end of project evaluation (including the project completion report) which will be conducted by the same above mentioned firm, will be part of the M&E. In addition the PMU will be strengthened with the services of a Monitoring and Evaluation Specialist who will be a member of the Health Sector Working Group and seconded from the Ministry of Health. 5.6.2 In terms of reporting, the project management will submit to ADF quarterly project progress reports (QPPR) in accordance with the established format covering all aspects of the project, within 30 days following the end of each quarter. The QPPR will cover progress measured against indicators in the project matrix. As part of the preparation of QPPR, the Project Coordinator will ensure the development of a Project Progress Chart, indicating percentage of disbursement against implementation status of each component of the project. The project management will also prepare and submit a project completion report in accordance with the format recommended by ADF. Additional reports and clarifications will be submitted to the Fund as required. The UGCO as well as the project task managers will assist the PMU staff in the supervision and providing guidance whenever necessary. 5.6.3 Under the Sector-wide approach, the Bank will participate in joint supervision missions with other development partners. In addition the Bank will take part in key meetings (National Health Assembly, annual Review, health sector working group, etc.) which strenghthen partnership and coordination with other health actors. Furthermore, a mid-term review will be carried out at a time and on the basis of terms of reference to be agreed between the Bank and GOU. ADF will be responsible for undertaking the review in collaboration with the Ministry of Health.

5.7 Financial Reporting and Auditing

The Executing Agency will maintain the project’s accounts by category of

expenditure and source of funding and put in place a system of internal control to ensure prompt recording of transactions, timely production of accounts and reports and safeguard project assets. Financial records will be maintained in accordance with internationally acceptable accounting procedures and standards. The PMU will prepare monthly financial statements that will be consolidated into quarterly financial statements to be included as a section of the Quarterly Progress Reports. An independent audit firm acceptable to the Bank and to the Auditor General of Uganda will audit the financial statements of the project annually. The PMU will submit the audit report to the Fund for review and comments within six months after the end of each financial year. An allocation has been made in the project budget to cater for the costs of engagement of an independent external auditor.

5.8 Aid Co-ordination 5.8.1 At the macro level the Commissioner Aid Liaison Department, in the Ministry of Finance, Planning and Economic Development (MOFPED) is responsible for aid

34

coordination. With regards to health interventions, the Directorate of Planning within the Ministry of Health is in charge of the coordination of health activities. The Health policy and the Health Sector Strategic Plan are implemented through the framework of the Health Sector Wide Approach with the leadership of the MOFPED that is responsible for the performance of the HSSP. The GOU has signed a Memorandum of Understanding with health development partners (including the Bank) to define their respective roles, responsibilities, relationships and contributions to the health sector. 5.8.2 Under the SWAPs in order to strengthen aid coordination, the MOH, with the assistance of Development Partners have put in place the following structures and processes: (i) the Health Policy Advisory Committee (HPAC) and its working groups for overall policy guidance to the sector; (ii) the annual Government of Uganda/Development Partners Joint Review Missions that facilitate the joint monitoring of the sector performance; (iii) the Health Sector Working Group (established under the auspices of the MOFPED) deals with budget cycle and managing the approval and alignment of project inputs to the sector; (iv) the National Health Assembly (NHA) convened once a year to provide an annual forum for the broader health partnership (central and local governments, civil society, and development partners to review sector policy, plans and performance; (v) the Health Development Partners Group that is a forum of partners to coordinate donor assistance; (vi) a central Public-Private Partnership Health Office established within the MOH to strengthen the relationship between the two sub-sectors ; (vii) the strengthening of Intersectoral Collaboration to better assess the inter linkages with other sectors that impact on the health of the population (i.e. education, agriculture, infrastructure, water and sanitation, etc). All these mechanisms are operational and the Project design and implementation has taken into account these structures and processes. 5.8.3 The Uganda Country Office, established since May 2004, is responsible for the coordination of the Bank portfolio in Uganda as well as the coordination with other development partners. The Office will participate in meetings called by the different structures highlighted in paragraph 5.8.2. The Bank’s representation in Uganda has been invaluable to the improvement of the design and implementation of Bank’s interventions in Uganda. In addition, it has helped the Bank in addressing some of the key constraints facing the portfolio and harmonization with other donors. 6. PROJECT SUSTAINABILITY AND RISKS

6.1 Recurrent Costs 6.1.1 The additional recurrent cost generated by the project upon its completion are based on the assumption that all the civil works on the facilities will be completed within the 5 year project implementation period and will become operational in 2012. The proposed project will affect the recurrent budgets of Mbarara Hospital, the 39 Health Centre IIIs and IVs, and the 6 Mental Health units. The new construction and upgrading will lead to increases in the recurrent budget as more health workers, as well as other supplementary input, are put in place for service delivery in all the facilities. The total district recurrent budget for financial year 2005/6 was estimated at Uganda Shs 40,98 billion and projected to be Uganda Shs 190.0 billion in 2011/2012. With the provision of new staff for each of the upgraded Health Centres and the newly constructed mental health units, the recurrent budget for the project districts is expected to rise from Uganda Shs 12.9 billion in 2005/6 to Uganda Shs 20.0 billion in

35

2011/12. Thus the total incremental recurrent cost generated by the project amounts to Ushs 7.1 billion. It represents 2.5% of the MOH total recurrent budget estimated at Ushs 285 billion in 2012. 6.1.2 The Medium Term Expenditure Framework for the health sector has made projections on the staff increase by 2012 in the Regional Hospital and consequently the increased recurrent expenditure of the 39 Health Centre IIIs and IVs, and the 6 Mental Health units. All recurrent costs due to the project will be financed by the GOU (i.e. MOH recurrent budget and other resources raised from alternative health care financing such as health insurance. 6.2 Project Sustainability 6.2.1. The principal key to sustainability of the project will lie on the low level of recurrent costs and the ability of the project to bring about community participation in the running of the facilities. The mobilization and empowerment of the communities, including universal functioning of Village Health Teams, and support for the effective functioning of health unit management committees at all levels will facilitate their involvement in planning and management of the services. This would make the community members to use the facilities in a responsible manner, help to make workers more accountable to the community and contribute to the sustainability of the project. 6.2.2. By improving the functioning of the health facilities (rehabilitating and equipping health facilities, availability of trained staff, etc.) and by raising population’s awareness on maternal and mental health issues, the project will facilitate utilization of health services by the community. As resources generated through alternative financing mechanisms such as social health insurance are ploughed back into the health recurrent budgets the project’s sustainability will be strengthened. In addition, the GOU will provide all drugs required under the project. It is expected that GOU will continue to generate increased levels of financial resources to sustain the project in line with its policy statement to match all development investments to resources available for recurrent costs. Routinely maintained health infrastructure, medical and communication equipment will be another key determinant to the sustainability of the project. Paragraph 2.7.8 provides more details on the maintenance of health infrastructures and medical equipment. In HSSP II, there is a target of devoting 5% of all non wage PHC budget in districts to infrastructure maintenance.

6.3 Project Assumptions and Risks

6.3.1 Identifiable project risks to the implementation of the proposed SHSSP Project II are as follows: (i) limited budgetary provisions for recurrent expenditures and risk for not meeting the project counterpart contribution; (ii) insecurity in the Northern Region; (iii) no improvement in rural transport to health facilities equipped to provide Emergency Obstetric Care; (iv) inadequate staffing. 6.3.2 Limited budgetary provisions for recurrent expenditure and risk for not meeting the project counterpart contribution : this project assumes that government will continue to generate increased levels of financial resources to sustain the project. However, limited budgetary provisions for recurrent expenditures appear to be a frequent problem affecting many government services. Concerns have been raised by the Bank that the budgetary provisions for recurrent expenditures especially government ministries only cover salaries,

36

with minimal provision for non-salary operational activities. Budgetary constraints, if any, will thus impact negatively on the timely implementation of SHSSPP II and may therefore delay utilization of the SHSSPP products. The mitigation measures can be summarized as follows : (i) the Government has committed itself to meet the Abuja target in increasing its allocated budget to the MOH to 15% (present budget is 9.7%); (ii) the GOU is implementing alternative financing mechanisms (social health insurance and community-based health insurance schemes, etc); (iii) the development partners have committed themselves to support the MOH in the funding and implementation of the HSSP II; iv) GOU put an emphasis on the efficiency and good performance of the health sector. 6.3.3 There are pockets of insecurity in the Northern Region : The best solution is that sustainable peace comes back in the northern region. However waiting for this situation, to mitigate this risk, under the previous SHSSP project, project staff, contractors and suppliers have tried, during 2005-2006, a strategy that has worked. They met directly with the communities living around the project sites and had open discussion with them on the project objectives and put the emphasis on the different benefits the populations will gain from the project activities. Now the populations have showned stronger ownership of the project. The same strategy will be adopted during project implementation. 6.3.4 No improvement in rural transport to health facilities equipped to provide Emergency Obstetric Care : The poor accessibility and lack of transport, roads, communication and money for fares are known to be a major source of delay faced by women in reaching the facility. Therefore, this issue has to be adequately addressed as it can negatively impact on the project outcomes with regard to Maternal health component. In order to mitigate this risk the following measures will be taken : (i) GOU with partners to develop road infrastructures ii) project to procure ambulances, strengthen communication and sensitize community for early patient referral; iii) GOU to improve intersectoral collaboration. GOU and the local government, with the assistance of development partners, have developped the road infrastructures in the country including in the project areas. As an illustration, under the Area-Based Agricultural Modernisation Project, the Bank and IFAD financed feeder roads in the greater Mbarara (Project area). In addition the GOU has requested the Bank to use the uncommitted funds on this project to rehabilitate new sets of feeder roads within the project areas. Furthermore the Local Government Development Fund financed by the World Bank and the Non-Sectoral Conditional Grants are some times used to finance opening up and rehabilitation of feeder roads once they are prioritized by the District. The MOH has committed itself to strengthen sectoral collaboration with other sectors such as those in charge of road infrastructues. Furthermore the project will strengthen the communication between health facilities to expedite the referral process, will sensitize communities including traditional birth attendants to do early referrals and procure ambulances to refer patients promptly. 6.3.5 Inadequate staffing: This is currently a constraint to the effective implementation of the UNMHCP including project activities. To mitigate this risk, budgetary allocations for new staff have been made for the HSSP II. In addition, the project will minimize the recruitment of staff as the main activities are related to already existing infrastructures (1 regional hospital and 39 health centres). There is an ongoing nationwide recruitment of health workers and government has prioritised enhancement of salaries of health workers.

37

7. PROJECT BENEFITS

7.1 Socio-Economic Impact 7.1.1 Reducing maternal mortality depends on a number of factors, the key being improved quality of maternal health care. The high fertility, especially when childbearing begins early and is thinly spaced, plays a major role in maternal mortality. Adolescent girls often lack decision-making power and access to Maternal health services. Universal access to Maternal health care including family planning; care in pregnancy, during and after childbirth; and emergency obstetric care would reduce unwanted pregnancy, unsafe abortion and maternal death, saving women’s lives and the lives of their children. In addition to these issues of health care supply, addressing women’s empowerment will enable women to address the social conditions endangering their health and lives. 7.1.2 The rehabilitation of Mbarara hospital will ensure an improved referral system for emergency cases in the concerned communities. This activity is expected to contribute to the reduction of maternal deaths due to a better management of emergency obstetric cases. In addition, by strengthening mental health services, the project will contribute to improving access to mental health services, particularly in the western and northern parts of the country. Consequently, the economic situation of the family is likely to improve as rehabilitated patients are able to participate gainfully in the household workforce and in the same vein improved mental health services will contribute to the reduction of their poverty. Both the maternal health and the mental health components will contribute to decongest the Mulago and Butabika hospitals respectively with the Community Mobilization intervention. It is expected that end-users will increasingly use the services provided and demand for better quality services. This activity will contribute to ensure the sustainability of the project. 7.1.3 Maternal health care, particularly family planning, enables couples to achieve smaller family size, improving household situations. Therefore the project will revitalize the male involvement programme on reproductive health. Poor families often want more children compared to wealthier families, however, they also have more children than they say they want. Moreover, while it is often believed that poor families are willing to trade off higher consumption from having more children for future gain (e.g., economic inputs, old age support), emerging evidence demonstrates that poor families do not benefit financially or materially from the birth of additional children. In contrast, the ability to control the number, timing, and spacing of births prevents the dilution of and competition for already scarce resources within households. Smaller families have more opportunities to increase household savings, to invest more time and resources in each child, and increase each family member’s “human capital”. 7.1.4 Sexual and Maternal health programmes could constitute a targeted, “pro-poor” investment with huge benefits for those who need it most. Among all human development indicators, those for sexual and Maternal health show the starkest inequities between the rich and poor (both within and between countries). The World Bank estimates that if 99 per cent of women had access to professionally delivered interventions, up to 74 per cent of current maternal deaths could be averted. The poorest will gain the most from investments in Maternal health, but are the least able to access these services more often than not. The project intervention will enable the population in the South Western Region access these services, hence avert maternal deaths in the region. In addition the economic impact of mental illness entails direct treatment costs, lost employment and income and reduced

38

productivity among persons with mental illness, their caregivers and families. This imposes endless economic costs in terms of transport, medication, food, accommodation, and opportunities foregone to care for the sick relative. 8. CONCLUSIONS AND RECOMMENDATIONS 8.1 Conclusions 8.1.1 The proposed Project aims to contribute to the reduction of the maternal mortality in selected districts in Uganda and reduction of mental health disorders in Uganda. Project beneficiaries include women of childbearing age, persons with mental illnesses and the communities. The proposed project is in line with the HSSP II, the GOU broad policy framework for poverty eradication (PEAP), the Uganda Joint Assistance Strategy (UJAS) and the ADB health policy. Therefore, the activities under the proposed project are expected to contribute significantly to poverty eradication targets as envisioned in the PEAP as well as attainment of the MDG (especially MDG 3 : reduce maternal mortality by three quarters by 2015 and MDG 4 : reduce infant mortality to 31 per 1,000 live births). 8.1.2 The Project is expected to have significant health and socio-economic impacts that will accrue as a result of the planned intervention. These include: community empowerment and mobilisation for health and increased utilization of reproductive health services; improved access to quality health care for rural populations; and increased access to comprehensive mental health care. In addition, socio-economic impacts include: reduction of the burden of ill-health and increasing population productivity, construction jobs created for the local population and savings for rural people who will not have to travel far in search for better health. The project is technically sound, economically viable and sustainable.

8.2 Recommendations 8.2.1. It is recommended that the Fund consider extending an ADF loan not exceeding the sum of UA 20 million for the GOU as described in this proposal, subject to the following conditions:

A. Conditions Precedent to Entry into Force of the Loan Agreement 8.2.2. The Loan Agreement shall enter into force on the date of signature by the Borrower

and by the Fund.

B. Conditions Precedent to First Disbursement of the Loan 8.2.3. Prior to first disbursement of the Loan, in addition to the Entry into force, the GOU shall have:

i) Provided written evidence that one (1) Special Account (SA) and one (1) Local Currency Account (LCA) are opened in a Bank acceptable to the Fund. The SA will be used to receive part of ADF resources, while the LCA will receive GOU counterpart contribution (paragraph 5.5.2).

MAP OF UGANDA WITH THE NEWLY CREATED DISTRICTS Annex I

. Project sites are written on the MAP. This map was provided by the African Development Bank exclusively for the use of the readers of the report to which it is attached. The names used and the borders shown do not imply on the part of the Bank and its members any judgment concerning the legal status of a territory nor any approval or acceptance of these borders.

Annex II

PROJECT FORMULATION PROCESS ACTIVITY DATE 1. Reception of GOU request

December, 2005

2. Project Identification Mission

12 August-26 August, 2005

3. Project Preparation Mission

4 December-21 December, 2005

4. Internal Working Group (IWG) Meeting

3 May, 2006

5. Inter-Departmental Working Group Meeting

12 May, 2006

6. Project Appraisal Mission

14 May- 26 May, 2006

7. Internal Working Group (IWG) Meeting

6 July 2006

8. Inter-Departmental Working Group Meeting

20 July 2006

9. Senior Management Committee Meeting

7 August 2006

10. Loan Negotiations

9-10 August 2006

11. Board Presentation

November 2006

Annex III Current numbers of Human Resource for Health GOU- PNFP

Staff Districts

DDHS Total Districts

Regional Hospitals

Mulago

Butabika

Total GOU

PNFP

Total

Clinical Medical Midwives Nursing

1,319 308 1,635 2,542

53 50 18 34

1,372 358 1,653 2,576

168 164 312 758

91 111 147 1,114

7 15 35 86

1,638 648 2,147 4,534

436 305 914 1,915

2,074 953 3,061 6,449

Total Medical/clinical

5,804 155 5,959 1,402 1,463 143 8,967 3,570

12,537

Nursing Assistants Diagnostic Pharmacy Other medical related Other staff

4,165 356 76 988 1,627

21 4 22 161 245

4,186 360 98 1,149 1,872

175 79 29 63 462

123 75 25 144 433

3 6 5 79

4,484 517 158 1,361 2,846

2,005 358 43 126 3,052

6,489 875 201 1,487 5,898

Total 13,016 608 13,624 2,210 2,263 236 18,333 9,154

27,487

Source: Health Sector Strategic Plan II (2005/06-2009/10), Volume I, MOH

Annex IV

Donor contribution to the health sector in Uganda

DONOR INTERVENTION TITLE 2006/07 2007/08 2008/09 US$ M US$ M US$ M

ADB Support to maternal and mental health project 1.2 6.8 10.4

China HR support to Jinja Hospital

DANIDA HEALTH SECTOR PROGRAM SUPPORT 9.6 10.0 10.0

DFID HEALTH PLANNING UNIT PROJECT(TA) 2.1

DFID Support to Maleria Control and Prevention 0.4 0.2

DFID PARTNERSHIP FUND PROJECT

EU Sexual and Maternal health

Germany STI Project / HIV Prevention, Phase II (Kfw) 0.1

Germany STI Project / HIV Prevention, Phase III (Kfw) 2.2

Germany District Health programe (Kfw) 0.2

Global Fund Global Fund HIV round 1 11.4

Global Fund Global Fund Malaria round 2 6.7

Global Fund Global Fund T.B round 2 1.3

Global Fund Global Fund HIV round 3 11.8

Global Fund Global Fund Malaria round 4 15.7

Ireland Partnership funds 0.1

Ireland HIV/AIDS Uganda Aids Commission TA

Italy Health sector strategic plan 4.2

Italy Integrated Public Private Partnership in health

IDA NUTRIT.CHILD DEV

Japan EPI Revitalisation

Japan Rehabilitation health facilities Eastern Region 4.0 Japan Vector Control through School, Health and Community mobilisation.

Japan Improvement of Health Infrastructure Development & Mgt. 0.1

Japan Support to Soroti Hospital

Netherlands Oret Project (Imaging and Equipment to Ministry of Health 1.6 1.6 1.6

Sweden Technical Assistance to Ministry of Health 0.5 0.5 0.5

Sweden Policy Development 0.8 0.8 0.8

UNFPA Maternal Health Services 1.0

UNICEF Rights to Health and Nutrition

UNICEF HIV/AIDS &Rights to self protection

WFP Support the fight against HIV/AIDS and TB (Basic Activity III) 3.9 4.3 5.9

WFP Promoting early childhood development through Maternal Child Health and Nutrition (Basic Activity II) 2.9 3.1 3.4

WHO WHO Support to the Health Sector 7.4 3.7

ADB Support to Maternal and Mental Health Project 1.5 5.8 7.3

IDA HIV/AIDS Control Project 2.6

Norway Uganda Aids Commission 0.1 2.8

EU Blood Transfusion Service Phase III

91.2 34.1 42.7 Source: Macro Economics Department, Ministry of Finance, Planning and Economic Development (April, 2006)

Summary of Bank Group Portfolio of On-going and Newly-approved Projects/Programs/Studies Annex V (Page 1 of 2) Country: UGANDA Date of Update: 06 May 2006

1 15/12/99 20/11/00 18/05/01 nil 17.60 nil nil 17.60 4.06 23.1% 31/12/07 0n-going

2 13/09/00 30/05/01 14/11/03 nil 9.67 nil nil 9.67 3.47 35.9% 31/12/06 0n-going

3 12/06/02 14/11/02 9/5/2003 nil 22.00 nil nil 22.00 0.70 3.2% 31/01/08 0n-going

4 04/12/02 02/06/03 12/4/2004 nil 23.74 2.80 nil 26.54 1.58 5.9% 31/12/08 0n-going

5 29/09/04 18/01/05 Not yet nil 31.57 9.85 41.42 0.00 0.0% 31/12/10 not effective

117.23 9.80 8.4%

6 13/09/00 30/05/01 19/07/01 nil 15.00 nil nil 15.00 8.18 54.5% 30/06/06 On-going

7 27/04/0515/05/05&19/05/05 15/09/05 nil 27.01 1.49 nil 28.50 0.00 0.0% 31/12/10&31/

12/07 not effective

43.50 8.18 18.8%

8 24/11/04 18/01/05 13/06/05 12.26 6.15 18.41 0.72 3.9% 31/12/08 ongoing

9 19/12/05 23/01/06 40.00 40.00 0.00 0.0% 31/12/10 not effective

58.41 0.72 1.2%

10 24/11/99 29/05/00 23/02/01 nil 13.10 1.84 nil 14.94 9.01 60.3% 31/12/07 on-going

11 13/09/00 30/05/01 30/08/01 nil 30.00 2.50 nil 32.50 23.09 71.1% 30/06/05 on-going

12 21/12/00 30/05/01 18/06/01 nil 20.00 2.38 nil 22.38 19.76 88.3% 31/12/05 on-going

13 19/12/05 23/01/06 20.00 20.00 0.00 0.0% 31/12/11 not effective

89.82 51.87 57.7%

Rural Water Supply & Sanitation programme

Support to ESIP (Education II)

Water and Sanitation - Sub total

D. SOCIAL

Rural Microfinance Support Project

Support to Health Sector Strategic Plan Project

Transport - Sub Total

C. WATER AND SANITATION

Small Towns Water Supply & Sanitation Project

B. TRANSPORT

Roads Sector Support Project

Roads Maintenance & Upgrading Project

National Livestock Productivity Improvement Project (Educ I

Farm Income Enhancements & Forestry Cons. Project

Agriculture - Sub Total

Effective Date

ADB ADF Loan

Signature DateProject Description Approval

Date

Deadline for Last

Disbursement

Fisheries Development Project

Approved Amount UA million

ADF Grant

Northwest Smallholder Agricultural Development

Support to PPE and Training Project (Educ. III)

Social - Sub Total

Status, completed,on

going,etc

A. AGRICULTURE

Area-based Agric.Modernization Programme

Net Commit.UA million

Amount Disbursed UA

millionDisbursed (%)

NTF

Serial No.

Summary of Bank Group Portfolio of On-going and Newly-approved Projects/Programs/Studies Annex V (Page 2 of 2) Country: UGANDA Date of Update: 06 May 2006

14 17/11/04 18/01/05 14/03/05 9.00 9.00 0.75 8.3% 31/12/08 0n-going

9.00 0.75 8.3%

15 29/09/04 18/01/05 18/01/05 5.35 5.35 0.04 0.7% 31/12/10 0n-going

5.35 0.04 0.7%

323.31 71.36 22.1%

16 22/10/03 04/03/04 04/03/04 1.65 1.65 0.29 17.8% 31/12/07 On-going

17 08/12/04 19/05/05 30/12/05 6.55 0.24 nil 6.79 0.31 4.5% 31/12/11 effective

8.44 0.60 0.7%

18 18/09/02 20/11/02 06/05/03 6.02 6.02 6.02 100.0% 31/12/03 disbursed

6.02 6.02 100.0%

337.77 77.98 23.09%

Status, completed,on

going,etc

E. MULTI-SECTOR

Net Commit.UA million

Amount Disbursed UA

millionDisbursed (%)

NTF

Serial No. Project Description Approval

Date

Deadline for Last

Disbursement

Approved Amount UA million

ADF Grant

Institutional Support Project for Good Governance

Mineral Resources Man. & Capacity Building Project

GRAND TOTAL FOR PUBLIC SECTOR OPERATIONS

Multi Sector - Sub total

F. INDUSTRY

Effective Date

ADB ADF Loan

Signature Date

Industry - Sub total

Private Sector Operation - subtotal

GRAND TOTAL INCLUDING MULTI NATIONAL AND PRIVATE SECTOR PROJECTS

Multi National Projects - Sub Total

H. PRIVATE SECTOR OPERATION

Sheraton Kampala Hotel

G. MULTINATIONAL PROJECT

Sustainable Tsetse and Trypanosomiasis Free Areas

Lakes Edward & Albert Fisheries Pilot Project

Annex VI

UGANDA: TOWARDS MILLENIUM DEVELOPMENT GOALS

MDG MDG Target GOU Target

Chances of Attaining goals

1. Eradicate extreme poverty

Reducing poverty headcount from 56% (1990 estimate) to 28% by 2015

Reduce to less than 10% the number of people living in poverty by 2017

Probably

2. Reduce hunger

Halve the proportion of underweight under-five year olds by 2015

Target not yet met. 23% of under 5 are under weight in 2005

Potentially

2. Reduce maternal mortality

Reduce maternal mortality by ¾ by 2015

Reduce MMR from 505 in 2006 to 354 by 2015

Unlikely

3. Reduce infant mortality

Reduce, by two thirds, the under 5 mortality rate by 2015

Reduce infant mortality from 88 to 68 deaths per 1,000 live births

Unlikely

4. HIV-AIDS, Malaria

Halt and begin to reverse the spread of HIV/AIDS by 2015

Target met in 1996

Target already met

5. Promote gender equality

Eliminate gender disparity in primary and secondary education, preferably by 2005, and at all levels by 2015

Target almost met (141 for male and 139 for female since 2004)

Potentially

6. Achieve universal primary education

Achieve 100% enrolment of 6-12 year old children into primary school by 2015

Target met since 2004 (141)

Probably

7. Ensure environmental sustainability

Integrate the principles of sustainable development into country policies and programmes and reverse the loss of environmental resources Halve by 2015, the proportion of people without access to safe drinking water Provide safe drinking water to 62% of the rural population by 2015 Achieve by 2020, a significant improvement in the lives of at least 100 million slum dwellers. This includes sanitation

Provide safe drinking water to 100% of the urban population by 2010, and 100% of the rural population by 2015

Potentially Probably Probably

Annex VII (Page 1 of 2) PROPOSED HEALTH UNITS TO BE REMODELLED

Annex VII

No. District County Sub-

county

HCIV HC III

Rugando Kinoni HC IV

Bugamba Bugamba HC IV

Rwampara

Nyakayojo Nyakayojo HC

1. Mbarara

Kashari Bukiiro Bukiiro HC

Birere Nyamuyanja

HC IV

Isingiro

Masha Nyarubungo HC

Endinzi Endinzi HC

2. Isingiro

Bukanga

Ngarama Rwekubo HC

IV

Kenshunga Kiruhura HC IV

Kanyaryeru Kanyaryeru HC

Nyabushozi

Kikatsi Kikatsi HC

3. Kiruhura

Kazo Rwemikoma Rwemikoma HC III

Ishongororo Ishongororo HC IV

4. Ibanda Ibanda

Rukiri Rukiri HC III

Ruhaama Ruhaama HC III

Rweikiniro Rweikiniro HC III

Ruhaama

Ntungamo Butare HC

5. Ntungamo

Kajara Nyabihoko Rwashamaire

HC IV

Annex VII (Page 2 of 2) Igara W Kyabugimbi Kyabugimbi HC IV

Kyeizooba Kyeizooba HC III

Igara E

Bumbaire Kabushaho HC III

Sheema South Shuuku Shuuku HC IV

Sheema North Kagango Kihunda HC III

. Bushenyi

Bunyaruguru Katunguru Katunguru HC III

Hamurwa Hamurwa HC IV Rubanda

Muko Bufundi HC III

Buhara Buhara HC III Ndorwa

Kamuganguzi Kamuganguzi HC III

Rukiga Bukinda Bukinda HC III

7. Kabale

Rubaya Bufundi Butanda HCIII

Kebisoni Kebisoni HC Rubabo

Nyakishenyi Nyakishenyi HC

Buhunga Buhunga HC

Nyakagyeme Nyakagyema HC

Rweshama HC

8. Rukungiri

Rujumbura

Bwambara

Bikurungu HC

Kihiihi Kihiihi HC IV Kinkizi W

Mpungu Mpungu HC III

9. Kanungu

Kinkizi E Rugyeyo Rugyeyo HC III

10. Kisoro Covered Covered

Total 13 26

Annex VIII

ENVIRONMENTAL AND SOCIAL MANAGEMENT PLAN SUMMARY Project Title: Support to Maternal and Mental Health Project Project Number:

Country; UGANDA Department: ONSD Division: ONSD 2

a) Brief Description of the Project and Key environmental and social components • New construction and rehabilitation at Mbarara Referral and Teaching Hospital • New construction and rehabilitation at 39 selected HCIIIs and HCIVs • Construction of 6 Mental Health Units

b) Major environmental and social impacts Positive Impacts

• Improved safe drinking water at the health centres; • Improved sanitation facilities through the provision of ventilated latrines, medical waste pits; • Reduced incidence of water-borne diseases like cholera, malaria, gastro-intestinal disorders, etc;

Potential Negative Impacts: • New construction and rehabilitation at the existing sites will lead to de-vegetation, soil erosion, dust emission and

noise • Slight risk of pollution of ground water and soil contamination • Functioning of Mbarara hospital and the health centres will generate dangerous medical and other waste Enhancement and mitigation program

An Environmental Impact Assessment will be carried out by the National Environmental Management Authority and cleared by the Bank before commencement of the physical implementation of the project. The following mitigation measures represent the main outline of the ESMP and will form an integral part of the project:

• An incinerator, VIP latrines, placenta and medical waste pits will be built at Mbarara and in the health centres to provide for proper disposal of medical waste;

• To avoid the contamination of water resources, the water points will be designed and constructed in such a way as to ensure proper drainage of waste water so as to prevent any possibility of water stagnation, which may pose the risk of groundwater contamination and development of breeding grounds for mosquitoes, flies and other insects. Such care will minimise the transmission of water-borne diseases and malaria;

• Existing trees on hospital and health centre sites will be preserved to protect the soils, provide shade and serve as wind shields

c) Monitoring program and complementary initiatives • The National Environmental Management Authority, MOH and PMU will follow up on all the issues relating to

protection of the environment in the hospital and all the health centres; • Bank supervision missions will follow up the implementation of the ESMP. d) Institutional arrangements and capacity building requirements • The PMU, under the guidance of NEMA and the Ministry of Health will direct all consultants to adhere to

guidelines designed to safeguard and improve physical environments _________________________________________________________________________________________________

e) Public consultations and disclosure requirements • The PMU, guided by the Ministry of Health, will occasionally organise events to publicise project activities • The project is designed to operate in a participatory approach manner where all activities will be implemented in

close collaboration with local communities to increase their sense of ownership of the improved facilities to provide under the project.

f) Estimated Cost • US$..35,000 for EIA and monitoring for 5 years g) Implementation schedule and reporting

The environmental management and monitoring plan will be implemented on the basis of the project implementation schedule, as all activities are mainstreamed in the project design. Problems which will be reported in the quarterly project progress reports should be promptly addressed by the project management and the Bank.

ANNEX IX (Page 1 of 2) PROVISIONAL LIST OF GOODS AND SERVICES

USD (million) UA (million) CO-FINANCIERS Category F.E. L.C. Total F.E. L.C. Total ADB GoU WORKS Construction of Mbarara Hospital 3.661 1.465 5.126 2.489 0.996 3.485 2.297 1.188 Construction of 26 Health Centre IIIs 3.021 1.624 4.645 2.054 1.104 3.158 3.158 Construction of 13 Health Centre Ivs 3.272 0.520 3.792 2.224 0.353 2.578 2.578 Construction of 7 Mental Hospitals 2.026 0.755 2.781 1.377 0.513 1.890 1.890 GOODS Furniture for Mbarara Hospital 0.319 0.131 0.450 0.217 0.089 0.306 0.395 Furniture for 26 Health Centre IIIs 0.040 0.130 0.170 0.027 0.088 0.116 0.204 Furniture for 13 Health Centre IVs 0.000 0.096 0.096 0.000 0.065 0.065 0.131 Furniture for 7 Mental Health Units 0.000 0.105 0.105 0.000 0.071 0.071 0.143 Equipment for Mbarara Hospital 1.087 0.000 1.087 0.739 0.000 0.739 0.739 Equipment for 8 District Hospitals 0.255 0.000 0.255 0.173 0.000 0.173 0.173 Equipment for 26 Health Centre IIIs 0.830 0.000 0.830 0.564 0.000 0.564 0.564 Equipment for 13 Health Centre IVs 0.577 0.000 0.577 0.392 0.000 0.392 0.392 Equipment for 7 theatres 0.415 0.000 0.415 0.282 0.000 0.282 0.282 Equipment for 7 Mental Units 0.441 0.000 0.441 0.300 0.000 0.300 0.300 Equipment for Maternal Health sensitization 1.418 0.000 1.418 0.964 0.000 0.964 0.964 Equipment for Mental Health sensitization 0.043 0.000 0.043 0.029 0.000 0.029 0.029 Equipment for Project Management 0.110 0.000 0.110 0.075 0.000 0.075 0.075 Delivery kits for 10 Districts 0.000 0.410 0.410 0.000 0.279 0.279 0.557 Learning and Training Materials 0.015 0.000 0.015 0.010 0.000 0.010 0.010 SERVICES Design and Supervision of Mbarara 0.358 0.154 0.512 0.243 0.105 0.348 0.033 0.236 Supervision of 26 HCIIIs, 13 HCIVs 0.547 0.561 1.108 0.372 0.381 0.753 0.600 Supervision of 7 Mental Health Units 0.095 0.044 0.139 0.065 0.030 0.094 0.183

ANNEX IX (Page 2 of 2)

PROVISIONAL LIST OF GOODS AND SERVICES

USD (million) UA (million) CO-FINANCIERS Category F.E. L.C. Total F.E. L.C. Total ADB GoU SERVICES Training of Doctors, Nurses, VHTs 0.212 0.172 0.384 0.144 0.117 0.261 0.378 Training of Mental Health Personnel 0.226 0.428 0.654 0.154 0.291 0.445 0.736 Training in management and HIS 0.050 0.000 0.050 0.034 0.000 0.034 0.034 Training of PMU staff 0.030 0.000 0.030 0.020 0.000 0.020 0.020 T.A. Maternal Health 0.150 0.000 0.150 0.102 0.000 0.102 0.102 T.A. NACME facilitation-procurement 0.005 0.000 0.005 0.003 0.000 0.003 0.003 Baseline study 0.100 0.000 0.100 0.068 0.000 0.068 0.068 External Auditing 0.045 0.000 0.045 0.031 0.000 0.031 0.031 Internal Auditing 0.000 0.007 0.007 0.000 0.005 0.005 0.010 Environmental Impact Assessment 0.000 0.030 0.030 0.000 0.020 0.020 0.041 Maternal Health sensitization (NGO) and TA 0.207 0.258 0.465 0.141 0.175 0.316 0.491 Mental Health sensitization 0.165 0.191 0.356 0.112 0.130 0.242 0.372 Technical Assistance for PMU 0.000 0.957 0.957 0.000 0.650 0.650 0.650 MISCELLANEOUS Operating Costs Component I 0.013 0.066 0.079 0.009 0.045 0.054 0.099 Operating Costs Component II 0.018 0.046 0.064 0.012 0.031 0.044 0.075 Operating Costs Project Management 0.069 0.840 0.909 0.047 0.572 0.618 0.085 0.533 BASE COST 19.820 9.000 28.820 13.473 6.118 19.591 17.638 1.957 Physical Contingencies 0.991 0.450 1.441 0.674 0.306 0.980 0.882 0.098 Price Contingencies 1.665 0.756 2.421 1.132 0.514 1.646 1.482 0.164 TOTAL COST 22.476 10.206 32.682 15.279 6.938 22.220 20.000 2.220

ORGANIGRAMME OF THE MINISTRY OF HEALTH Annex X

OFFICE OF THE MINISTER

OFFICE OF THE MINISTER

PERMANENT SECRETARY

PERMANENT SECRETARY

HEALTH SERVICES COMMISSION

HEALTH SERVICES COMMISSION

POLICY ANALYSIS UNIT

POLICY ANALYSIS UNITRESOURCE

CENTRE RESOURCE

CENTRE

DIRECTORATE OF CLINICAL AND COMMUNITY

HEALTH SERVICES

DIRECTORATE OF CLINICAL AND COMMUNITY

HEALTH SERVICESDIRECTORATE OF PLANNING

AND DEVELOPMENT

DIRECTORATE OF PLANNINGAND DEVELOPMENT

DEPARTMENT OF NATIONAL

DISEASE CONTROL

DEPARTMENT OF NATIONAL

DISEASE CONTROL DEPARTMENT

OF COMMUNITY HEALTH

DEPARTMENT OF COMMUNITY

HEALTH

DEPARTMENT OF CLINICAL

SERVICES

DEPARTMENT OF CLINICAL

SERVICES

DEPARTMENT OF

PLANNING

DEPARTMENT OF

PLANNING DEPARTMENT OF QUALITY ASSURANCE

DEPARTMENT OF QUALITY ASSURANCE

DEPARTMENT OF FINANCE ANDADMINISTRATION

DEPARTMENT OF FINANCE ANDADMINISTRATION

DIRECTOR GENERAL

DIRECTOR GENERAL

National Level Institutions National Drug Authority National Medical Stores Uganda Health Research Organization Uganda Virus Research Institute Uganda Cancer Institute National Referral Hospitals National Blood Transfusion Services National Public Health Laboratory Services Natural Chemotherapeutic Research Laboratory

Professional Councils Medical & Dental Practitioners Council Nurses & Midwives Council Pharmacists Council Allied Health Professionals Council

COMMISSIONER NURSING

COMMISSIONER NURSING

GOU/MOH

Project Streering Committees

Permanent Secretary

Project Coordinator

Technical Sub-Committees

Project Engineer

Health Specialist

Health Specialist

Project Accountant

Architect ProcurementOfficer

Quantity Surveyor

Health Specialist

Assistant Project Accountant

ORGANIGRAMME OF THE PROJECT MANAGEMENT UNIT

Annex XI

IMPLEMENTATION SCHEDULE Annex XII

ACTION BYM J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J

ADF/GoUADFADF/GoUADF/GoUADFADF/GoUADF/GoU

PIU/GoU/ADFADFCON/GoU/ADFCONTRACTORGoU

GoUGoU

GoU

CONSULTANTGoUCONSULTANTNGOCONSULTANTGoUGoUCONSULTANTCONSULTANTCONSULTANT

ADF/GoUADF/GoUADF/GoUADF/GoUADF/GoU

M J J A S O N D J F M A M D J A S O N D J F M A M D J A S O N D J F M A M D J A S O N D J F M A M D J A S O N D J F M A M D J A S O N D J F M A M J

2009

Tenders for other equipment

Fourth Supervision Mission

YEARSMONTHS

2006 2007

ACTIVITY

ADMINISTRATIONAppraisalBoard ApprovalGrant SignatureGrant EffectivenessProject LaunchingMid-Term ReviewProject Completion Report

WORKSTendering exerciseADF ApprovalContract signatureConstruction worksDefects Liability Period

GOODSTenders for medical furn. & equip.Delivery/Installation of medical..

Delivery/Installation

SERVICESDesign/Supervision of civil worksTraining of Medical Staff/VHTsReproductive Health Activities

Technical Assistance for Log./EmOCTraining of Mental Health StaffMental Health Activities

Technical Assistance by NGO

Training of PMU StaffT.A. for Medical Equipment/Furn.Baseline/endline studyAuditing

PCRs

2006 2007

SUPERVISION MISSIONS

Third Supervision Mission

First Supervision MissionSecond Supervision Mission

2012

2008 2009 2010 2011 2012

2010 20112008

Annex XIII

OUTLINE OF THE PROJECT IMPLEMENTATION DOCUMENT

1 THE PROJECT 1.1 Project scope and objectives 1.2 Project outputs 2 PROJECT DESCRIPTION 2.2 Project cost and financing 3 PROJECT IMPLEMENTATION 3.1 Executing Agency 3.2 Institutional Arrangements 3.3 Implementation Plan 3.4 Procurement Arrangements 3.5 National Procedures and Regulations 3.6 General Procurement Notice 3.7 Review Procedures 3.8 Disbursement Arrangements 4 MONITORING AND EVALUATION 4.1 Project reporting 4.2 Financial Reporting and Auditing Annex 1 Implementation Schedule Annex 2 Structure of Project Management Unit Annex 3 Job Description of key staff Annex 4 List of Equipment Annex 5 Project Matrix Annex 6 Project Detailed Costs