HEALTH SECTOR POLICY ISSUES PAPER FINANCIAL YEAR 2014/15. Local Government Regional Budget workshops for financial year 2014/15

Key thematic focus areas in FY 2014/15 agreed in the 19 th JRM: Leadership / Governance Health Investments Human Resources for Health Medicines and Health Supplies Information and Research Quality and Safety Service Delivery 2

Health Sector MTEF- 2014/15( External Financing EF may change substantially Health Sector MTEF 3

Leadership / Governance) Health sector Reforms: The sector shall Expedite the health sector reform process through redefinition of the roles of the different levels of care and central level institutions in FY 2014/15. The sector shall Finalize and disseminate the implementation guidelines for PPPH to all Local Governments Revamp and functionalize all the Health sector leadership / governance structures at District Levels through Institutional capacity building Reactive the inter-sectoral committees at central and district levels Further strengthen systems for accountability and efficient use of resources through formulation of additional controls and guidelines in line with the existing regulations 4

Human Resource for Health In order to eliminate ‘quack medical workers’ Health Professionals shall register annually with the respective professional councils – validation to be carried. Develop and operationalize guidelines for the reward and sanctions committees at all levels and focus on attraction, retention and motivation of staff Develop a monitoring framework for tracking conditions under which health workers provide care in private, public, PNFP, Institutions such as army, police, schools etc, including traditional healers/herbalists. In the next two years,MOH shall focus on training adequate midwives and critical medical cadres who were not recruited during the last recruitment exercise The policy on nursing assistants is that no more recruitment of NA will be carried, the NA shall be phased out through ; allowing them to grow and retire or other ways of attrition e.g. Death, upgrading in recognised nurses training institutions etc. 5

Human Resource for Health MOH shall Operationalize the performance agreements in a phased manner to all levels of health facility to improve staff performance The Health sector shall collaborate with MOES to streamline operations of the private health training institutions to eliminate fake Health training schools. The policy on TBAs is that active TBAs are encouraged to work within the VHT system and arrangement. otherwise TBA’s in the health system have been phased out. Mentorship of Health workers on the use and maintenance of newly supplied medical equipments shall be carried in all Health facilities under the UHSSP project. 6

Resource Allocation Primary Health Care (PHC) Non wage The formula has the following components: _Fixed amount (F) to cater for administration and as correction factor for districts with small population sizes which provide services at high unit costs. _Allocation for eventuality factors (ft) eg allocation for districts in PRDP area _Allocation of balance (a) to the following factors: a)_Proportion of balance for population (s) b)_Proportion of balance for infant mortality rate (1-s), or to avert infant deaths 1._Vote Allocation = F + £ft + (pi/P/)as + (di/D)a(1-S) Where: _pi = ith District population _P = Total population of Uganda (£pi) _di = Number or deaths in the ith district between birth and first birthday anniversary _d = Total deaths in Uganda between birth and first birthday anniversary (£di) 7

Medicines and health supplies ordering and supply LGs are advised that Orders submitted by facilities should be aligned to the procurement plans.NMS therefore serves orders taking into account the submitted orders with a variation of + 20 % of the quantities indicated in the procurement plan. NMS performance on the order fulfillment should be judged against the extent to which orders submitted by facilities have been aligned to the procurement plan submitted and served or not served by NMS. Even after aligning orders to the procurement plan there is still a constraint to get the needed supplies in time because of the PPDA Act.NMS presented its case to have flexibilities in the regulations. The amendment were made in the PPDA Act but are awaiting to be gazetted to have them operational. 8

Medicines and health supplies ordering and supply The value of medicines and medical supplies on dispatch notes/invoices of each consignments should be deducted by the health facilities from the indicative figures provided to the them at the beginning of the financial year in order to ascertain the balance in the custody of NMS after every delivery. MOH recommend reconciliation between the figures as per the health facilities ledgers and those provided by NMS at the end of every quarter. Government to train and support clinicians to prescribe medicines according to the patient need both in type and quantity. Government plans to allocate funds for laboratory reagents and chemicals since the donors who have been providing funds have since significantly reduced on the funds made available for this purpose. 9

Medicines and Health supplies Indicative planning figures (CREDIT LINES per annum) for Health facilities FY 2013/ /15 -General Hospitals- 366,497,131 -Health centre IV’s- 44,648,044 -Health Centre III’s- 19,793,131 -Health centre II’s= 6,502,540 10

Medicines and Health supplies 2 Regional hubs (Mbarara & Mbale) shall be established next FY for storage of life saving items, heavy volume but low value cross docked items and tracer drugs) Last mile delivery systems shall further be decentralised to reduce on lead time, gain Local acceptability and better coordination with the community Budget line for handling emergencies has been established and shall be enhanced in FY 2014/15 11

Medicines and Health supplies Procurement requests should be confined to the procurement plans approved at the commencement of the FY. NMS shall only honour request for items planned for within the budget limits allocated to each facility The value of the medicines and medical supplies on delivery notes of each consignment shall be deducted by the facilities from the IPFs provided to the facilities at the beginning of the FY in order to ascertain the credit balances in the custody of NMS after every delivery. MOH shall make timely communication to LGs in case of budget cuts during budget execution. As a policy, health facilities should adhere to the initial approved procurement plans at the beginning of the FY. 12

Information and Research Review the quality assessment tools and indicators for all health facility levels Establish the number of staff per level of care to enable assessment of performance Conduct regular data validation exercises which are coordinated by the MoH Resource Centre. Disseminate the DHIS2 to all Local Governments and continue to revise the reporting tools. 13

Service Delivery HIV/AIDS control program –LGs shall focus on the prevention aspects of HIV/AIDS than curative in the medium term. LGs shall Scale up the Maternal Prenatal Death Notification and Audit as a Quality Improvement Tool and ensure integration in the existing health facility Quality Improvement initiatives LGs shall Map and implement targeted Reproductive Health interventions in districts/localities that are performing poorly. Involvement of Anthropologists/social scientists in MNCH is very critical. MOH shall functionalize more HC IVs in the next 2 years LGs should disseminate and implement Male involvement Strategy in RMNCH services. MOH shall Scale up User training for medical equipment and maintain up to date medical equipment inventories Support all Local Governments with vehicles for supervision and administration of health service delivery under GAVI and GOU funding. 14

Health infrastructure LGs shall Focus on staff accommodation, functionality of ambulances for referral and maintenance of medical equipments Priority shall be Functionality of existing health facilities.Construction of new facilities at all levels or upgrading facilitates shall be approved where there is an assessed need. An accreditation/standards for each health facility level is being revised so that each facility can have an identification number from FY 2014/2015 Hospital beds and mattresses shall be procured and distributed to some general hospitals this financial year and next financial year. 15

Health investments Analyse cost of delivering the UNMHCP at each PHC level in order to inform and guide sector budget requirements taking into consideration SUO. Track off budget and on budget funding in the health sector to enhance planning for sustainable financing through National Health Accounts study. A revised resource allocation formula for medicines and grants will be developed taking into consideration actual service delivery outputs A comprehensive health financing strategy is being developed with a view to carry out health financing reforms e.g introduction of RBF and SHI. 16

Quality and Safety Revise, consolidate and disseminate all service delivery standards i.e. health care services, equipment, infrastructure and staffing. Develop and disseminate client charters at all RRHs and GHs/HC IVs Develop and operationalize a comprehensive supervision strategy that promotes integration and coordination of the visits. Local Governments requiring gas cylinders should submit their requests to MOH for purposes ensuring safety of vaccines. Staff uniforms for medical workers shall be procured and distributed effective 2013/14 and all facilities will be covered in 2014/15 17

Budget execution issues Some Local Governments do not submit the quarterly Health sector OBT reports to MOH. The sector will undertake costing of service delivery at each level of care to guide budget allocations in the medium term For purposes of reporting the sector in consultation with OPM will create an output for immunisation services and supplies in the OBT to be used by Local Governments for reporting. The sector shall disseminate the revised health sector planning guidelines and enhance capacity of Local Governments to plan for health services 18

Direct transfers of PHC grants GoU has decided to implement the direct remittance of Grants using Straight Through Processing (STP) of grants to all public and private owned health facilities Under STP arrangement, Government will ensure that the PHC Grants are paid directly by MoFPED to health facilities’ (Spending Centers) Commercial Bank accounts using Electronic Funds Transfer (EFT) Soft and hard copies of the transfers will be sent to accounting officers and the accounting officers shall verify the authenticity of the submissions before it is used for releases The computation of the Grants will continue to follow the formulae specified in the guidelines for the specific grants.The LGs will undertake the expected planning and budgeting process which among others entails the development of an annual workplan for each grant. About 7 districts and 13 Municipalities had not submitted account numbers of their health facilities by 17 th October

Concluding remarks The MOH with support from partners shall organise DHOs meeting/regional health sector planning meetings to further harmonise the health sector plans for FY 2014/15 The objective of the regional planning meeting is to further strengthen Local Government planning and budgeting in the health sector and provide more detailed and focused assessment of key priority areas and poor performance areas The second objective is to strengthen project selection and prioritization in the health sector. 20