1. Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane University’s School of Public Health Training Resources Group By Suzann e N. Kiwanuka, Christine Kirunga Tashobya, Freddie Ssengooba. Makerere University College of Health Sciences, School of Public Health Department of Health Policy Planning and Management HEALTH SYSTEM GOVERNANCE: A CASE STUDY OF UGANDA

2. What is governance?

3. Defining governance “Ensuring strategic policy frameworks exists and are combined with effective oversight, coalition building, regulation paying attention to system design and accountability ” (WHO 2007). “The process of competently directing health systems resources, performance and stakeholder participation towards the goal of saving lives and doing so in ways that are transparent, accountable, equitable and responsive to the needs of the people” (USAID 2006).

4. 4 Governance and health systems

5. Good health governance Responsiveness to public health needs and clients/citizens preferences. Responsible leadership to address public health priorities. The legitimate exercise of clients ’ /citizens ’ voice. Institutional checks and balances with Clear and enforceable accountability Transparency in policymaking, resource allocation, and performance and Evidence-based policymaking. Efficient and effective service provision arrangements, regulatory frameworks, and management systems.

6. Objective and Methods To assess Uganda’s health system governance performance Document Review Key Informant interviews 4 District visits (KIs)

7. Donors MA MA- Mutual accountability

8. DIRECTIVES TRANSPARENCY AND ACCOUNTABILITY MANDATEPERFORMANCE DIRECTIVES Policies and structures are in place for evidence based service delivery. TMC, SMCs the Health Policy Advisory Committee (HPAC), Technical Working Groups, and the Health Assembly (enhance accountability and participatory decision making but not performing). Uganda’s performance on directives globally is moderate (TI, 2005). Perception of corruption in health sector high/enforcement low. Implementation of strategies and policies is poor.

9. The State’s Role in Governance: RESOURCES MANDATEPERFORMANCE Resources UNMHCP founded on principles of equity and efficiency. Resources allocated to health too few therefore most spending is private. Ear marked funding limits decision making space (Public and HDP). Budget leakages have been reported Providers struggle to provide quality care. Clients choose to bypass facilities.

10. Results: REGULATION AND OVERSIGHT MANDATEPERFORMANCE Regulation and Oversight MOH too limited to provide regular necessary supervision under staffed to meet multiple districts needs Professional councils under funded/under staffed Pharmacy council lacks policy Private sector growth rapid and un (poorly) regulated. Local government not fully under taking supervisory role. Supervisory visits are cursory.

11. Results: RESPONSIVENESS MANDATEPERFORMANCE RESPONSIVENESS Improved access (geographical)- functionality questionable! Spending grossly inadequate (drugs and HRH).

12. Results: SERVICE PROVISION, INFORMATION LOBBYING ROLE / RESPONSIBILITYPERFORMANCE SERVICE PROVISION Geographical access not matched by staffing and resources Incentives to provide quality services poor (except 4 HDPs). INFORMATION No room to use data at local level for planning/earmarks. Parallel systems threaten data reliability. LOBBYING Districts leaders with lobbying skills are able to engage with state for their needs eg. Bugiri got additional HR. Others lose out.

13. Decentralization Districts increased from 17 in 1962 to 114 in 2011

14. Decentralization Oversight of the decentralized service delivery is the direct mandate of the local authorities with the guidance and oversight of MOH. Devolution intended to provide wide powers and decision space for these authorities to deliver essential health services not commensurate with resources.

15. RESULTS Allocative efficiency thwarted Districts grants 80% to 90% earmarked - very little decision space to address local priorities (Okwero Peter, Ajay Tandon et al. 2009). Dependence on the central level is nearly absolute. Less than 5% of the districts provide more than 5% of locally generated revenue to district health programs.

16. Results LG face severe capacity constraints limiting the effectiveness of decentralized service delivery. Materials and equipment needed to carry out work in short supply. HRH Shortages hamper service delivery (World Bank, 2001). New districts are performing equally well. Three new districts were ranked among the top 10 performing districts (AHSPR 2009/10).

17. HDPs influence on governance 2002-2007 DAH ($1.422 million) between 40% and 60% of total health expenditures (Nirmala, Paul et al. 2009). Complex conditionalities, interests and a distortion of power and legitimacy of the governance structures (Buse and Walt 1997; Elsey, Kilonzo et al. 2005; Oliveira-Cruz 2007). Lack of HDP trust in government structures due to corruption, lack of transparency, lack of harmonization of plans and systems (sustainability issues?????)

18. Progress on COMPACT

19. Client Voice and Power

20. CLIENT POWER AND VOICE MANDATEPERFORMANCE Technical input and Oversight CSOs are part of decision making at central level. Media role active and crucial. HUMCs under (not ) performing/ lack information to make decisions. Power imbalance between clients and providers- fear of victimization. Clients are wiling to act as overseers but are not well informed or empowered of their rights. Vote with their feet ( bypass facilities with perceived poor quality). Client satisfaction now health indicator. Suggestion boxes not valued/used.

21. Information asymmetry, mis-information Providers believe “….the people do not need information…they need drugs… The state is not providing drugs in adequate quantities!! The people believe …….. “Government is providing drugs but providers are stealing them”

22. Politicization of health issues The perception of health as political issue inhibits action and progress on key issues.

23. Recommendations 1. Strengthen structures - Coordinate multiple stakeholders (HDPs/PPP) - Community oversight CSOs and HUMC skills development and information sharing - Decision making at local levels 2. Decentralization: -Create regional (local) structures/teams. -Improve district level performance quarterly district review meetings. - Health facility performance (creation of facility league tables). - Provider community dialogues 3. Accountability and transparency- A nnual audits of ALL funds received in the health sector (under budget or not) -Central government, HDPs, local government leaders, providers Use the media

24. Recommendations Improve and expand district level performance through establishment and strengthening of quarterly district review meetings with stakeholders in order to promote health facility performance (creation of facility league tables). Empower existing oversight structures to aggressively investigate and enforce rule of law to mitigate corruption at ALL levels in the sector. Institute annual audits of ALL funds received in the health sector (under budget or not) for both government and HDPs. The state needs to support health workers rather than victimize them.

25. Proposed SMART indicators Proportion of HDP funding aligned with government budget (alignment/harmonization). Proportion of functional HUMCs per district per quarter (technical input). Proportion of client satisfied with services (client oversight). Number of support supervisory visit reports submitted per facility per quarter for MOH (month- local government) (MOH/LG oversight). Number of facilities/districts/parastatals broadcasting funds received and used per quarter (transparency and accountability). Proportion of health sector public office abuse cases reported media (prosecuted-courts of law) (enforcement).

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