ISLAMIC UNIVERSITY IN UGANDA

(IUIU)

YEAR: 1.1

Course: Advanced Diploma in Health Service Management

GROUP 2:

COURSE UNIT: COMMUNITY HEALTH CARE

Lecturer. DR. KAGORO ISMAEL

Question:

1) Write short notes on the following

a) History of health service in Uganda
b) The Uganda health policy
c) The millennium development goals
2) Describe the components of the Uganda national minimum health care
package.

Sn NAME Reg: No

1 MAIGA AYUB HUSSEIN 120-032123-22587

2 MUKYALA ZAINABU 120-032123-22169

3 NAMONYWE ANNAH 120-032123-21951

4 NAMBOZO ROSEMARY 120-032123-21340

5 OYITE DAVID 120-032123-22297

6 WAISANA RICHARD 120-032123-22466

MAGAWA ERINA NABUDE 120-032123-23388

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History of health service in Uganda

Health:  Health is a state of complete physical, mental and social well-being and
not merely the absence of disease or infirmity.

Health services consist of medical professionals, organizations, and ancillary

health care workers who provide medical care to those in need

In 1960s Uganda’s health system was one of the best in the region with well-
equipped and staffed hospitals and a set of connected health units. However,
political turmoil between 1970 -1985 ragged the health system. Uganda covers a
territory of 241,040 square kilo meters; the country has moved from 80 districts to
111 as of 2012.

The increase in number of districts has been referred to as a political patronage

tools by critics (Conroy-Krutz & Logan, 2011). Notwithstanding the political
bickering on the mushrooming districts, there is a risk of fragmenting the health
system and human resource challenges as new districts emerge.

The country is bordered by Kenya, Tanzania, Congo DRC, Sudan, and Rwanda,
Uganda is landlocked. Recent discovery of oil may probably boost Uganda’s
economy and health sector to an unprecedented proportion.

Improving the level of education is observed to be a major goal of the government

according to its policy reports. Under Universal Primary Educating (UPE) enrolls
students for free compulsory education, the program has been extended to selected
public secondary schools as well, purporting great improvement in the education
sector noticed by the United Nations Development report of 2009.
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Much leaves to be done in the tertiary institutions, for instance in medical

institutions all combined (Makerere, Mbarara and Gulu Universities)
approximately 200 physicians are produces annually, however many leave the
country amidst poor and uncompetitive working environment, many end up on
Lesotho, South Africa and Europe.

Information and communication technology (ICT) and media have recently

changed the way of life of households and the health sector at large. ICT will
enhance research and development as well cooperation and exchange of
information among health professionals and patient care on various paradigms.

According to a study by a media group- Audience Scapes, Ugandans in the high

socio economic status (SES) bracket are more exposed to TVs, computer and
internet. Radio access has a 20 percentage point difference between the low SES
and high SES group.

Mobile phones are the most accessible ICT device in Uganda, while television
viewing is increasingly determined by both SES and education levels. Internet
access at home is rare even for Ugandans with the highest SES; internet is more
accessible at cyber café than at home. Therefore the health care system can utilize
the increasing telephone access for telemedicine in Uganda to revitalize
appointment and feedback links to patients and in administration.

Uganda Health system

• Village health teams/community medicine distributors

The first contact for someone living in a rural area would be a medicine distributor
or a member of a village health team (VHT). Each village is supposed to have
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these volunteers using bicycles. They still have no medicine, but they can advise
patients and refer them to health centres.

• Health centre II

• According to the Ugandan government's health policy, every parish is supposed

to have one of these centres. A health centre II facility, serving a few thousand
people, should be able to treat common diseases like malaria. It is supposed to be
led by an enrolled nurse, working with a midwife, It runs an out-patient clinic,
treating common diseases and offering antenatal care.

Health centre III

• This facility should be found in every sub-county in Uganda. These centers

should have about 18 staff, led by a senior clinical officer. It should also have a
functioning laboratory.

Health centre IV/ District Hospital

• This level of health facility serves a county. In addition to services found at

health centre III, it should have wards for men, women, and children and should be
able to admit patients. It should have a senior medical officer and another doctor as
well as a theatre for carrying out emergency operations.

Regional Referral Hospital (RRH)

• There are 10 RRH which should have all the services offered at a health center
IV, plus specialised clinics – such as those for mental health and dentistry – and
consultant physicians.
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National Referral and Teaching Hospital

• At the top of the healthcare chain is the national referral hospital.

This is where some of the best medical brains can be found, often working part-
time at private clinics to supplement their meagre government salaries.

The Uganda health policy

What is a policy?

A policy is law, regulation, procedure and administrative action, incentive or

voluntary practice of governments and other institutions (sometimes even
individual practices)

The Uganda national health policy (2017) seeks to reach everyone in a

comprehensive integrated way to move towards wellness. It aim at achieving
universal health coverage and delivery quality of health care services to all at
affordable cost.

What is the meaning of a national health policy?

Its strategies and plans are essential in defining Uganda’s vision, policy directions
and strategies for ensuring the health of its population.

The national health policy has eight major inclusions/areas beginning with an
introduction.

1. Introduction

The national health policy (NHP) was formed under the national development
programme (NDP) which the overall national development agenda for Uganda

2. The situational Analysis

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Between 1962-1971, Uganda had the best health indices and rural health care
system after in Africa but collapsed between that time and the early 1990.

3. The development context

It’s observed that improvement of people’s health is both an outcome and a cause
of economic development

Under this provision, government also commits itself to revitalize the Health
Development system in order to achieve the millennium development goals
(MDGS).

4. Uganda has a vision, goal, mission, and guiding principles in its health policy.

Vision

A healthy and productive population that contributes to economic growth and

National development

Goal

To attain a good standard of health for all people in Uganda in order to promote a
healthy and productive life.

Mission

To facilitate the attainment of a good standard of health by all people of Uganda in

order to promote healthy and productive life

5. Policy objectives and strategies: Talks about achieving the objectives of the
policy through organization and management of the national health system. e.g.
ensuring health promotion disease prevention and early diagnosis and treatment
(pair of the minimum health care package).
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6. Communication and Dissemination of the National Health Plans

It’s important that different stakeholders (including communities and individuals)

are aware of the policy and their role in the implementation process.

7. NHP Implementation Arrangements

The strategic plans under the NHP shall be operationalized through the
development of integrated work plan developed with input from all stakeholders.

8. Monitoring and Evaluation

A monitoring framework will be developed to monitor attainment of the NHP

objectives.

Priority areas for the national health policy

In addition the NHP shall focus on health systems strengthening, specifically:

i. Strengthening health systems in line with decentralization through training,

mentoring, technical assistance and financial support.

ii. Re-conceptualising and organising supervision and monitoring of health systems

at all levels in both public and private health sectors and improving the collection
and utilisation of data for evidence-based decision making at all levels.

iii. Establishing a functional integration within the public and between the public
and private sectors in healthcare delivery, training and research.

iv. Addressing the human resource crisis and re-defining the institutional
framework for training health workers, including the mandate of all actors.

Leadership and coordination mechanisms, with the aim of improving the quantity
and quality of health workers production shall also be a priority.
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Policy objectives and strategies

Organisation and management of the national health system

In accordance with the Constitution of the Republic of Uganda as amended and the

Local Government Act, the public health sector shall review the management of
decentralisation of health service delivery system. The focus shall be on
strengthening health systems’ capacity to deliver the UNMHCP including health
promotion, environmental health, disease prevention, early diagnosis and
treatment. While decentralisation shall be the focus, RRHs shall be strengthened to
effectively supervise and support health systems at the regional level.

The minimum health care package

The minimum health care package in Uganda shall consist of the most cost-
effective priority healthcare interventions and services addressing the high disease
burden that are acceptable and affordable within the total resource envelope of the
sector.

Supervision, monitoring and evaluation

The policy recognises that effective supervision and monitoring are an essential
aspect of the health system and are critical in improving the quality of health
services and care.

Research

The Government of Uganda prioritises research in order to support evidence-based

policy and intervention formulation, identification of gaps and critical factors for
special needs for vulnerable groups especially women and children. Particular
attention will be given to how research can be used to guide the development and
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implementation of health systems, health promotion, environmental health, disease

prevention and early diagnosis and treatment.

Legal and Regulatory Framework

Appropriate legislation and its enforcement provide an enabling environment for

operationalisation of the policy, and are essential for an effective health service
delivery system.

Health resources

In order to effectively deliver the UNMHCP at all levels, government with support
from development partners, communities and the private sector shall make
available an optimal level of all necessary health resources including human
resources, medicines and other health supplies, health infrastructure and financial
resources.

Partnerships in health

Ministries, government and private health sectors, development partners, and

communities shall play an important role in healthcare, training and research and in

2nd National Health Policy July 2010 this regard the GoU shall foster and sustain
partnerships with all the different relevant institutions, including corporations and
business concerns that are involved in service delivery.

Millennium Development Goals (MDG)

Goal 1: Eradicate extreme poverty and hunger

Goal 2: Achieve universal primary education

Goal 3: Promote gender equality and empower women

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Goal 4: Reduce child mortality

Goal 5: Improve maternal health

Goal 6: Combat HIV/AIDS, malaria and other diseases

Goal 7: Ensure environmental sustainability

Goal 8: Develop a global partnership for development

Eradicate extreme poverty and hunger

Where do we stand? The global mobilization behind the Millennium

Development Goals has produced the most successful anti-poverty movement in
history, according to UN Secretary-General Ban Ki-moon. The MDG target of
reducing by half the proportion of people living in extreme poverty was
achieved in 2010, well ahead of the 2015 deadline.

Achieve universal primary education

Where do we stand? Considerable progress has been made in expanding

primary education enrolment since 1990, particularly since the adoption of the
MDGs in 2000. The global number of out-of-school children has fallen
considerably since 1990, although the pace of improvement has been
insufficient to achieve universal primary enrolment by 2015. Currently, 57
million children of primary school age are estimated to be out of school, down
from 100 million in 2000. Of these, 33 million are in sub-Saharan Africa, and
more than half (55 percent) are girls

Promote gender equality and empower women

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Where do we stand? Much progress has been made towards women’s and girls’
equality in education, employment and political representation, but many gaps
remain. Since 1995, when the Beijing Platform for Action on women’s
empowerment was adopted, the global average proportion of women in
parliament has nearly doubled, growing from 11 per cent in 1995 to 22 percent
in January 2015. Women in parliament have gained ground in nearly 90 percent
of the 174 countries for which data are available for 1995–2015.

Reduce child mortality

Where do we stand? Substantial progress in reducing child mortality has been

made, but more children can be saved from death due to preventable causes.
Focusing on newborns and reducing socioeconomic disparities are critical to
further accelerate progress in child survival. Under- five mortality rate, 1990
and 2015 (deaths per 1,000 live births

Combat HIV/AIDS, malaria and other diseases

Where do we stand? The number of people newly infected with HIV continues
to decline in many regions of the world. Access to antiretroviral therapy has
increased at a remarkable pace, averting millions of deaths. Unfortunately
knowledge of HIV and HIV prevention remains low among young people.
Similarly, increased global attention to the devastating effects of malaria has
produced significant results, and the burden of tuberculosis has declined, thanks
to effective prevention, diagnosis and treatment.

Ensure environmental sustainability

Where do we stand? Deforestation has slowed, but global greenhouse gas

emissions continue their upward trend. In recent years, the net loss of forest area
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has slowed, due to both a slight decrease in deforestation and an increase in

afforestation. Deforestation, forest degradation and poor forest management
release carbon into the atmosphere, contributing to climate change.

A global partnership for development

Where do we stand? Official development assistance to least developed

countries increased significantly over the MDG period. Official development
assistance has plateaued in recent years, after increasing significantly in the first
decade of the new millennium. Imports from developing countries, especially
from least developed countries, increasingly receive preferential treatment from
developed countries.

Greater funding and innovation are crucial to the implementation of the post-
2015 development agenda.

UGANDA NATIONAL MINIMUM HEALTH CARE PACKAGE

Minimum health package represents a health insurance that the state provides its

population (WHO 2000).

To ensure cost-effective service delivery and those interventions that address the
highest disease burden, the National Health Policy defined the Uganda National
Minimum Health Care Package (UNMHCP). This includes

(1) Health promotion, environmental health, disease prevention, and community

health initiatives, including epidemic and disaster preparedness and response;

(2) Maternal and child health (MCH)

(3) Prevention, management, and control of communicable diseases.

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(4) Prevention, management, and control of non-communicable diseases.

The UNMHCP has, however, been consistently underfinanced through the years,
and receives only about 30 percent of the total funding required for its full
provision.

The overriding aim in setting an essential or minimum health care package

(MHCP) is for the state to guarantee free access of its population to a set of health
services it can afford. In essence, the minimum health package represents a health
insurance that the state provides its population (WHO 2000).

The purpose of developing and using the minimum package approach was to assist
in resource allocation in the health sector especially in the face of a huge and
growing health burden that has to be addressed with small public budgets that
characterize developing countries like Uganda.

The aim of establishing MHCP is also to achieve the best possible value for
available resources by allocating them to interventions that have the most benefits
in improving population’s health.

The MHCPs is an explicit rationing of health services by the state. Services that
fall outside the boundaries are not guaranteed to the population and therefore
additional financing (e.g. private insurance or out-of-pocket payments) are needed
(World Bank 1993).

The aim of establishing MHCP is also to achieve the best possible value for
available resources by allocating them to interventions that have the most benefits
in improving population’s health.

Priority setting in health sector

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Sometimes decisions regarding allocation of resources are, based on professional

opinions or on strong lobby groups, political expediency or outright public
hysteria. For example, the most important single determinant of the annual health
budget and its composition, for most districts in Uganda, is the previous year's
expenditure pattern with some marginal additions to compensate for inflation and
budget growth. This basis of allocation creates a financial inertia that perpetuates
the deficiencies and inefficiencies in the system.

The socio-political dimensions of priority setting

Resource allocation is essentially a socio-political process although technical

inputs such as cost effectiveness are important for evidence-based policy making
(Walt 1994). Political expedience tends to drive the package beyond the available
resources due to the distasteful concept of rationing in the political debates
especially due to strong lobby groups such as women and human rights activists
(Tengs 1996, Maynard 1998).

System financing and the minimum health care packages

The MHCP services typically include preventive services such as childhood

immunization, health promotion and education as well as treatment and control of
common and infectious disease such as malaria, HIV/AIDS and TB. The use of
MHCP recquires three main issues:

1) That government has a good estimate of the resources that are going to be
available for health service delivery,

2) That the delivery system has the capacity to deliver the package of services, and
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3) That the costs of the services to be delivered and their benefits to the population
are available.

Mostly due to lack of reliable cost data about interventions effectiveness in

Ugandan context, the selected interventions are of unknown effectiveness in the
local circumstances and have turned out to be beyond the reach of available
resources.

Rationing within the package

Given the inadequacy of the resources to shoulder the MHCP as designed in the
Health Services Support Programme, there is a re-prioritization with an explicit
and implicit rationing process within the package of services and across population
coverage. It is this reprioritization that in part works against quality, equity and
utility of benefit to the users.

Given the infrastructure plan, a comprehensive MHCP is only available from

functional Health Center IV and at hospital levels. Hospital services are by plan
mostly in major urban/township centers.

Rationing quality of services

Although rationing on the basis of quality is ethically unacceptable, it is implied in

the MHCP approach adopted in Uganda. The operational policies have explicitly
sought for low-cost substitutes to health care with clear quality tradeoff.

For example, huge investments were directed into training traditional birth
attendants (TBA) in attempts to bring down maternal mortality while little efforts
were paid to scaling up midwifery training, motivating rural deployment nor
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provider performance incentives (Kyaddondo 2003). At the inception of the TBA

approach, cost-effectiveness was implied (WHO 1982, Hoff 1997).

In the last couple of years, the Ministry of Health has sunk over two billion
shillings "professionalizing" nursing aids as another explicit strategy for
substituting professional cadres in hard to reach areas.
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References

1) Uganda National eHealth Policy November 2016

2) Health Policy and Development Journal, Vol. 2, No. 1, April, 2004,
3) Tashobya, C.K., N. Musoba, and P Lochoro. 2007. Public Private
Partnership for Health in Uganda: Will HSSP II
4) Deliver on the Expectations? Health Policy and Development
5) Torpey, K., et al. 2010. From project aid to sustainable HIV services: a case
study from Zambia. Journal of the International AIDS Society
13:19.Transaid. 2008. Reference forthcoming
6) The second national health policy promoting people’s health to enhance
7) Socio-economic Development July 2010
8) Uganda’s minimum health care package: rationing within the minimum?
Freddie Ssengooba, Lecturer, Institute of Public Health, Makerere
University Medical School, Uganda
9) The Millennium Development Goals Report 2006
10) Uganda health system assessment 2011