AIDE MEMOIRE THEME: ADDRESSING SOCIAL DETERMINANTS OF HEALTH FOR IMPROVED HEALTH OUTCOMES

Transcription

1 THE REPUBLIC OF UGANDA AIDE MEMOIRE 23 RD JOINT REVIEW MISSION FOR THE HEALTH SECTOR 28 th 29 th SEPTEMBER, 2017 THEME: ADDRESSING SOCIAL DETERMINANTS OF HEALTH FOR IMPROVED HEALTH OUTCOMES CONFERENCE HALL, OFFICE OF THE PRESIDENT, KAMPALA 1 P a g e

2 Abbreviations / Acronyms AHSPR CHEW CHS CSO DHO DHT EMS FY HCWM HDP HMIS HPAC HSDP HUMC JRM LG MDA MoFPED MoH MoLG MoPS MPDSR OAG RMNCAH UBTS UHC Annual Health Sector Performance Report Community Health Extension Workers Commissioner Health Services Civil Society Organisation District Health Officer District Health Team Emergency Medical Services Financial Year Health Care Waste Management Health Development Partner Health Management Information System Health Policy Advisory Committee Health Sector Development Plan Health Unit Management Committee Joint Review Mission Local Government Ministries, Departments and Agencies Ministry of Finance, planning and Economic Development Ministry of Health Ministry of Local Government Ministry of Public Service Maternal Perinatal Death Surveillance and Review Office of the Auditor General Reproductive Maternal Neonatal Child and Adolescent Health Uganda Blood Transfusion Services Universal Health Coverage 2 P a g e

3 1 Preamble The Compact for Implementation of the Health Sector Development Plan (HSDP) 2015/ /20 provides, as part of monitoring and evaluation, for the annual Joint Review Mission (JRM) so as to assess sector performance on the policies, strategies, plans and interventions, and capacity needs in line with the HSDP and to dialogue with all stakeholders on future health priorities. The 23 rd Health Sector JRM was organized by the Ministry of Health (MoH) in collaboration with Health Development Partners (HDPs), Civil Society Organisations(CSOs) and the Private sector. The key output of the 23 rd JRM are the priority actions and recommendations for programming and implementation in the 2018/19 financial year (FY), within the available resources and contextual limitations. 1.1 The objectives of the 23 rd JRM 1. To receive, present and deliberate on the sector performance report for FY 2016/ To receive and discuss sector progress in implementation of the 22 nd JRM priority actions. 3. To present and deliberate on key sector innovations to facilitate improved sector performance 4. To discuss and build consensus on the priorities, targets and major inputs required for FY 2018/19, within the resource and contextual constraints faced by the sector. 1.2 Participants This was the 2 nd JRM under the HSDP, and was attended by sector stakeholders, including Ministers, representatives of the Health Committee of Parliament, the related Ministries, Departments and Agencies (MDAs), representatives of Resident District Commissioners, Local Council V Chairpersons, Chief Administrative Officers and Secretaries of Health, HDPs, CSOs, the Private Sector representatives, Directors of National Referral and Regional Referral Hospitals, semi-autonomous institutions, academic institutions, District Health Officers, Municipal Medical Officers of Health and other stakeholders in the sector. The JRM was officially opened by Hon. Dr. Jane Ruth Aceng, the Hon. Minister of Health. The presentations and discussions during the 23 rd JRM focused on country progress towards achievement of the HSDP key performance indicators target and key interventions in the HSDP to embrace Universal Health Coverage (UHC) based on the annual workplans for 2016/17 FY. Presentations from other MDAs also provided an external analytical synthesis of the sector performance especially in the areas of governance and accountability. 3 P a g e

4 rd JRM Program Day one: Official Opening of the 23 rd JRM. Highlights of the Annual Health Sector Performance Report (AHSPR) for 2016/17 FY Progress in implementation of the 22 nd JRM priority actions. Overview of the CHEW Strategy Key note address: Addressing Social Determinants of Health for Improved Health Outcomes Results Based Financing Overview of the framework, institutionalization plan and experience on implementation. Office of the Prime Minister s Delivery Unit progress in implementation of the Human Resource implementation of the performance improvement plan Presentation of the Health Monitoring Unit report 2016/17 Day Two: Health Sector-Budget monitoring report by MoFPED BMAU Highlights of the Auditor General s report for 2015/16 Annual Progress Report for National Medical Stores The Refugee Health and Nutrition Response Plan Presentation on District Health Services The Ministry of Health Call Centre Implementation Plan Draft Aide Memoire of the 23 rd JRM Recognition and reward Closing Ceremony 4 P a g e

5 2 Milestones and Priority Actions This Aide Memoire outlines the desired milestones in relation to the key challenges and recommendations discussed during the JRM. The priority actions are categorized under service delivery, human resources for health, health infrastructure, governance and leadership, health information management, health financing and supervision, monitoring and evaluation. The table below presents the milestones and priority actions generated from the proceedings of the 23 rd JRM. The responsible bodies / persons, time frame, expected outputs/outcomes and means of verification have also been included. This is expected to guide the sector planning, budgeting, implementation and monitoring process for remaining part of the FY 2017/18 and FY 2018/19. The progress will be monitored quarterly during the Health Policy Advisory Committee (HPAC) and quarterly sector review meetings and presented at the 24 th JRM. 5 P a g e

6 Table 1: Agreed Milestones and Priority Actions for the 23 rd Health Sector Joint Review Mission Milestone Priority Actions / Recommendations 1. Service Delivery 1.1 Improve service Implement and monitor delivery to citizens progress of the agreed actions by addressing their in the Strategy for Health key concerns Services Improvement 1.2 Functionalize the Emergency Medical Services (EMS) and Critical Care services 6 P a g e Identify and redesign persistently poorly performing programs with the aim of improving targeting to reach the right people/beneficiaries. Finalize and roll-out EMS policy, guidelines, strategy and tools, including referral and ambulance guidelines Training of frontline workers in emergency medicine and critical care Improve the specialized care, accident and emergencies units of hospitals Responsibility Timeframe Means of Verification PS MoH / PS LGs / CSOs, Private Sector, DPs MoH Heads of Departments MoH - CHS EMS & CHS IC / Partners MOH - CHS EMS & CHS IC / Partners / Health Training Institutions & Universities MoH - CHS IC / Hospital Directors / Medical Superintendents Progress reports & Patient satisfaction surveys June, 2018 Mid-term review Report June 2018 Ongoing EMS Policy, guidelines and strategy No. of health workers trained Well-equipped and Functional Emergency and critical Outcomes / Targets Improved service delivery with improved patient satisfaction Improved service utilization coverages Policy, strategy & guidelines finalized Emergency Unit staff on all RRHs trained on Job All RRHs and hospitals along the high way

7 Milestone Priority Actions / Recommendations 1.3 Improve coverage for indicators that have shown slow progress e.g. high malnutrition, low contraceptive use, high teenage pregnancies, high vaccination dropout rate for maternal and child health services e.g. ANC 4, IPT, high TB, malaria and HIV prevalence Finalize, disseminate and implement the communication strategy for Behaviour Change Communication to strengthen community mobilization, awareness and promote utilization of health services Mobilize resources and implement the revised Sharpened Plan (Investment Case) for RMNCAH Disseminate the revised Maternal Perinatal Death Surveillance and Review (MPDSR) guidelines and forms and ensure mandatory MPDSR are conducted and use findings for improving maternal and neonatal care Scale up community family connect strategy & community mobilization on RMNCAH interventions Responsibility Timeframe Means of Verification care units in the RRHs MoH - CHS HPC & December BCC EH / DHT / 2017 Communicatio Partners / Local n strategy Leaders MoH - CHS MCAH / Partners / DHOs / CSOs / Community MoH - CHS MCAH / Partners / LGs / Private Sector / CSOs / Community MoH CHS MCAH, CHS HPC & EH / Partners / LGs / CSOs / Progress reports based on the M&E framework for the Sharpened Plan Ongoing MDPSR Reports Outcomes / Targets Strategy finalized and disseminated Increased funding for implementation of the sharpened plan and Improved performance as per the targets set in the sharpened plan Improved notification and review of maternal and perinatal deaths June 2018 Reports Increase from pilot districts to al least 30 districts 7 P a g e

8 Milestone Priority Actions / Recommendations Responsibility Timeframe Means of Verification Community Outcomes / Targets Roll out Results Based Financing for RMNCAH services Scale-up interventions in HIV/AIDS Control in areas of further reducing the MoH CHS P / Partners / LGs MoH CHC DPC, PM ACP / LGs / Partners / CSOs prevalence Strengthen TB CB DOTS MoH - CHC DPC, PM NTLP / LGs / Partners / Community Scale-up the Total Market Approach to increase access to priority health products and services e.g. condoms, FP commodities MoH CHC DPC, PM ACP, NTLP, NMCP, CHS MCAH / Partners / Private Sector / LGs / CSOs November 2017 No. of districts implementing RBF Program reports Program reports Ongoing Program reports 40 districts Reduced HIV prevalence from 6.3% to 5% Increased TB treatment success rate Increased CPR and use of condoms 1.4 Improve TB Case detection Improve TB case finding (Xrays, genexpert utilization, capacity building for health workers, contact tracing) Strengthen MDR TB surveillance and management 1.5 Improve health Strengthen the existing working committee on Health MoH PM NTLP / Hospital Directors / DHOs / Partners MoH CHS IC, CHS HI / Partners June 2018 January 2018 Program reports - functionality of X-rays, etc Multi-sectoral working Increase TB case detection rate Proper HCWM practices in health 8 P a g e

9 Milestone Priority Actions / Recommendations care waste care Waste Management and management engage other regulatory (HCWM) bodies to discuss HCWM e.g. NEMA, Ministry of Environment Put in place a comprehensive multi-year health care waste management strategic plan and mobilize resources to support its implementation. Training of all health workers including waste handlers in HCWM Provision of color coded bins and bin liners and safety boxes 1.6 Improved supply of blood 9 P a g e Establish system for accounting for blood at health facility level Generate a list of all potential institutions / organizations to help mobilize blood to expand catchment beyond schools Provide key facts (messages) for leaders and community to mobilize for blood Responsibility Timeframe Means of Verification committee established MoH CHS IC, CHS HI / Partners MoH CHS IC, CHS HI / LGs and Partners MoH CHS Pharmacy / NMS / JMS / PHP UBTS / MoH CHC ICS UBTS / RBB UBTS March, 2018 Ongoing Immediate April 2018 January 2018 January 2018 HCWM Strategic Plan Reports on numbers trained Availability of color coded bins and liners Blood utilization information system List of institutions targeted for routine blood donation Messages developed Outcomes / Targets facilities HCWM strategic plan developed All hospitals 100% facilities on Credit line Blood accounting system in place List of institutions targeted for routine blood donation Key messages developed

10 Milestone Priority Actions / Recommendations Increase resource allocation to Uganda Blood Transfusion Services 1.7 Improved RRHs to supply to General availability of Oxygen Hospitals and HC IVs at HC IVs 1.8 Latrines built according to recommended standards 1.9 Regulate rampant advertising by Traditional Complementary Medicine Procure oxygen gas cylinders and accessories for GHs and HC IVs Implementation of the Kampala Declaration on sanitation Engagement of District leaders in monitoring and reporting; Display of shame lists at all levels of leadership Promote construction of latrines according to standards Strengthen enforcement of the Public Health Act Establish a joint monitoring team for all regulators (UCC, Police, Regulators, MoH) to enforce regulations Responsibility Timeframe Means of Verification MoH Top Management / MoFPED Hospital Directors RRHs CAOs / DHOs / Medical Superintendents / HC IV In-charges MoH CHS HPC & EH Health Inspectors / LC V chairpersons / Secretary for Health / Police NDA / MoH / Ministry of Internal Affairs Outcomes / Targets 2018/19 MPS Increased budgetary allocation June 2018 Reports on oxygen availability Ongoing Reports on % of latrines build according to recommended standards February 2018 Reports All GHs and HC IVs have regular 02 supply from the RRHs All Hospitals & HC IVs oxygen gas cylinders and accessories 76% of household with standard latrines Joint Monitoring Team established 10 P a g e

11 Milestone Priority Actions / Recommendations Practitioners 1.10 Improve Implementation of the CHEWs community strategy engagement for Support training of the CHEWs health (3,000) IP to utilize CHEWs and Village Health Teams instead of 1.11 Increased focus on social determinants of health 1.12 Institutionalization of planning and programming for refugee health 2. Medicines and Health Supplies 2.1. Improved capacity for procurement planning, 11 P a g e creating other structures Advocacy for health-in-allpolicies Active participation in the multi-sector engagements to ensure that policy decisions or other sector plans have neutral or beneficial impacts on the determinants of health. Refugee health intervention plan drafted, marketed, resourced and implemented in a multi-sectoral manner Continuous capacity building in procurement planning, quantification and ordering for all health facilities Responsibility Timeframe Means of Verification MoH CHS HPC & EH / Partners MoH DHS P&D / NPA / LGs / Other MDAs MOH CHC DP&C / HDPs / LGs / NSAs / OPM MOH CHS Pharmacy / GM NMS / Partners / DHOs June 2018 Reports on CHEWs trained and assigned to work Ongoing Reports / Policies December 2018 Final Refugee Health and Nutrition Plan Outcomes / Targets CHEW policy approved by Cabinet. Phase 1 (1,500) CHEWS trained Health issues addressed by relevant sectors Refugee Health and Nutrition Plan finalized and funded Ongoing Reports Proper quantification and timely ordering from all Districts,

12 Milestone Priority Actions / Recommendations quantification and ordering 2.2 Improved availability of medicines and supplies Strengthen the management and supervision of medicines at the districts Regular audit and reporting by the In-charges and DHT Continuous medical education on accountability of medicines Responsibility Timeframe Means of Verification MoH CHS Pharmacy / RDCs / CAOs / Health Consumers / CSOs / Partners DHOs / Incharges Immediate Ongoing Reports on medicines availability at facility level Outcomes / Targets Hospitals and HC IVs Medicines availability at 90% (Basket of 41 commodities) 2.3 Reduced stocks of expired drugs from facilities Develop guidelines / handbook for minimizing expiry of medicines MoH CHS Pharmacy / Medicines TWG April 2018 Guidelines / handbook Guidelines / handbook developed 2.4 Improve the Last Mile Delivery (LMD) of Medicines 2.5 ARVs supplied to all accredited facilities Mobilise resources for disposal of expired medicines PS MoH / PS MoFPED / Partners Enforce the MoU for LMD NMS/ CAOs, / DHOs, Health Facility In-charges / Distributors / JMS/UHMG / Private Sector Continuous accreditation and updating list of all accredited facilities MoH CHC DPC, PM ACP June 2018 Immediate Ongoing Reports DHO reports on LMD List of accredited facilities Budget availed and expired medicines disposed LMD of EMHS improved 100% eligible facilities Provision of ARVs to all MoH - CHC March 2018 % of 100% accredited 12 P a g e

13 Milestone Priority Actions / Recommendations accredited facilities 3. Human Resource for health 3.1 Incentivize health workers for improved HRH attraction, performance and retention 3.2 Improved staffing for critical Human Resource for Health (Anesthetic officers, psychiatrists, DHOs) Provision of housing and social amenities for frontline health workers Absorb contract workers recruited for the sector on request by HDPs by aligning recruitment cycles to availability of recruitment resources to absorb contract staff Progressively improve HW compensation Gaps driven Training/ capacity building Scholarships for critical cadres (Prioritize training anaesthetic officers, Biomedical engineers, dispensers and health assistants) Compile the list of double trained officers and present to Responsibility Timeframe Means of Verification Pharmacy / NMS accredited / MAUL facilities receiving ARVs MoH CHS HI, Hospital Directors / CAOs MoH - CHS HRM / Hospital Directors / CAOs / DSC PS MoPS / PS MoFPED / Parliament MoH - CHS HRM / Partners / CAOs MoH CHS HRM Outcomes / Targets facilities Ongoing Reports Housing provided in hard to reach and hard to stay areas June 2018 Medium Term Ongoing January 2018 HRH Reports on numbers absorbed Remuneration package Number of scholarships awarded Report 100% of contact workers absorbed Improve remuneration package 400 Scholarships awarded Salary structure for all cadres reviewed 13 P a g e

14 Milestone Priority Actions / Recommendations an inter-ministerial forum HSC, MoLG, MoPS and MoFPED for special consideration in remuneration. Review the salary structure of all cadres in line with the job description Establish mechanism for the center to take up critical staff on long term training and allow LGs replace them so as not the disrupt service delivery Recruitment of substantive DHOs and ADHOs 3.3 Improved Human Workforce recruitment and performance Put in place mechanisms for making enforcing requirement of LGs to fill vacant positions in LGs Fast-track recruitment of professional staff within the allocated available budget Revise Staffing norms for RRHs and LGs Work with other stakeholders to complete revision of the Public Service Standing Orders Responsibility Timeframe Means of Verification MoH CHS HRM / HSC / MoPS PS MOH / PS MOLG / CAOs / DSC Outcomes / Targets in line with their job descriptions June 2018 Report Mechanism for catering for staff on long training established Immediate HRH Audit report PS MOLG / CAOs Immediate CAO performance reports HSC / DSC / CAOs / DHOs / Hospital Directors MoH CHS HRM / Hospital Directors / PS MoLG / PS MoPS MoH / MoLG / MoPS Immediate June 2018 Recruitment reports / Wage absorption Staffing norms for RRHs and LGs 80% of DHOs and ADHOs recruited 80% of DHOs and ADHOs recruited 100% wage bill utilized Staffing norms revised June 2018 Revised PSSO PS Standing orders revised 14 P a g e

15 Milestone Priority Actions / Recommendations 2010 Introduce performance contracts for all staff with clear outputs and targets Scale up attendance tracking with automated biometric attendance analysis routinely 3.4 Regular provision of Uniforms for health workers 4. Health infrastructure 4.1 Establishment of HC IIIs in subcounties without 4.2 Improved health infrastructure at HC IVs and IIIs Timely procurement and distribution of uniforms in a phased manner beginning with the RRHs Progressively in a phased manner upgrade HC IIs to IIIs and construct HC IIIs in subcounties without, considering the population Assessment of health facility infrastructure (HC IVs and IIIs) to guide construction and renovation Provide PHC Development Funds for completion of Responsibility Timeframe Means of Verification MoH / Hospital Directors / LGs Hospital Directors / OPM / LGs / Partners MoH PS / CHS Nursing, AC B&F / GM NMS MoH CHS HI, / CAOs / DHOs MoH CHS HI, / CAOs / DHOs Outcomes / Targets June 2018 Reports Performance Contracts signed June 2018 Reports All RRH hospitals & 250 LLUs implementing the automated biometric attendance system Immediate Ongoing January 2018 No. of uniforms procured and distributed No. of HC IIs upgraded or HC IIIs constructed in sub counties without Assessment report No. of HC IVs and IIIs allocated 25,000 uniforms for nurses and midwives 80 HC IIIs PHC Development Funds provided for incomplete structures 15 P a g e

16 Milestone Priority Actions / Recommendations unfinished projects 4.3 Improved asset Prepare, maintain and management in the continuously update asset sector registers at all levels Establish fleet management system for sector fleets at all levels Budgetary allocations to LGs for asset operations and 4.4 Reliable Transport for coordination at the District Health Offices 4.5 Equipment redistributed 4.6 Designs and BOQs for health structures maintenance Provision of vehicles for coordination, monitoring and supervision at the District Health Offices within the available budget. Take inventory of equipment, redistribute which is not in use and disposal of all old equipment Harmonize and disseminate the designs and BOQs for structures in the health sector Responsibility Timeframe Means of Verification funds MoH US / CAOs Ongoing Annual assets / Health Facility register at In-charges national and LG levels PS MoH / PS MoFPED MoH CHS HI / CAOs Medium term April 2018 Fleet management reports Number of vehicles procured for DHTs Equipment inventory report and redistribution and disposal report Outcomes / Targets Updated assets register Fleet management system implemented Subject to availability of funds All redundant equipment at health facilities redistributed. All old equipment disposed of according to the PPDA guidelines MoH CHS HI June 2018 Reports Harmonized designs and BOQs developed and 16 P a g e

17 Milestone Priority Actions / Recommendations harmonized 5. Governance and leadership 5.1 Improved planning, including procurement planning and resource management in the sector Capacity building for evidence based planning, resource allocation, programming and procurement planning at all levels Support individual programs to come up a minimum number of high impact interventions, work out clear indicators & targets against which annual performance can be measured. Participatory multi-sectoral and multi-stakeholder planning and budgeting for health (including OAG) Strengthen the health sector capacity to improve efficiency in procurement and projects execution, to reduce resource wastage Enforce resource and financial management guidelines including value-for-money and Responsibility Timeframe Means of Verification MoH DHS P / MoFPED / PPDA MoH - CHS Planning / Partners MoH CHS P / MoPFED / Partners / CAOs / DHOs MoH PS / Head Procurement / AC Internal Audit / Partners / OAG / BMAU MoH - PS / CAOs / OAG Ongoing December 2018 Capacity building reports Reports Ongoing Minutes / Reports June 2018 Project Implementatio n Reports / Audit reports Outcomes / Targets disseminated All entities use evidence based plans and budgets All programs with annual workplans, indicators and targets against which performance is assessed. Budgeting process is participatory with involvement of all key stakeholders Efficiency in procurement and project execution Ongoing Reports Timely accountability for all resources 17 P a g e

18 Milestone Priority Actions / Recommendations mandatory timely accountability for all deployed sector resources at all levels Reduce leakage and wastage through eradication of theft / corruption (administrative measures, litigation) 5.2 Strengthen the Induction of Hospital Boards performance of the and HUMCs Hospital Boards and Health Unit Finalize and disseminate the Management Hospital Board and HUMC Committees (HUMC) guidelines 5.3 Taxation of nonstate actors harmonized 6. Health Information 6.1 HMIS tools available in health facilities 6.2 Improved quality of data 18 P a g e Support / spearhead multisectoral dialogue on establishing mechanisms to harmonize taxation for nonstate actors to avoid double taxation. Printing and distribution of the HMIS tools on quarterly basis Modify the DHIS2 to have DHOs validate the reports Responsibility Timeframe Means of Verification MoH - PS / CAOs / OAG / HMU Referral Hospitals / CAOs / DHOs / Partners Outcomes / Targets Ongoing Reports Reduced leakage and wastage Ongoing Reports All Hospital Boards and HUMCs inducted MoH CHS ICS April 2018 Revised HUMC Guidelines PS MOTI / PS MoH / Professional Councils / Atomic Agency / NSAs MoH ACHS DHI / GM NMS and IPs March 2018 Progress reports Revised Hospital Board & HUMC guidelines disseminated to all districts Taxation of nonstate actors harmonized Ongoing Reports Availability of HMIS tools at health facilities MoH ACHS DHI June 2018 DHIS 2 rules All reports through the DHIS2 validated

19 Milestone Priority Actions / Recommendations before submission to MoH Revision of the HMIS for inclusion of National Identification Number (NIN) in the patient registration Mentorship for health information assistants 6.3 All functional facilities reporting through the DHIS2 6.4 ehmis connectivity stabilized to enable timely reporting 7. Health financing Review staffing norms and scheme of service to include cadre of Diploma level for Medical Record Management at all levels Disseminate the current Master Facility List Facilitate registration of all functional health facilities into DHIS2 Upgrade capacity of the ehmis servers Work with NITA-U for IT platform integration Disseminate and implement the five-year e-health strategy Responsibility Timeframe Means of Verification MoH ACHS DHI / DHTs / Partners MoH ACHS DHI / DHOs / IPs MoH CHRM / PS MoPS MoH ACHS DHI MoH ACHS DHI /D HOs June 2018 Revised HMIS tools Outcomes / Targets by the DHOs HMIS tools revised to include NIN Ongoing Reports Mentorship undertaken in all districts June 2018 December 2017 Revised scheme of service Revised scheme of service by June 2018 Reports MF List 2016 disseminated to all stakeholders March 2018 DHIS 2 DHIS 2 registered facility list MoH ACHS DHI / Partners June 2018 Reports Stable ehmis PS MoH / NITA-U Immediate Reports IT platform for MDAs integrated MoH ACHS DHI Reports E-Health strategy / HID disseminated, financed and implemented 19 P a g e

20 Milestone Priority Actions / Recommendations 7.1 Increased financing for the health sector sector 7.2 Health Financing reforms, including the NHIS and Results Based Financing implemented 8. Supervision, Monitoring and evaluation 8.1 Monitoring and support supervision 20 P a g e Advocacy for improved domestic financing for the Prioritize deliberate capacity building, resourcing and support to the new districts Fast track the legislation process for establishment of a NHIS Incorporate all stakeholder inputs in formulation of the NHIS Bill. Responsibility Timeframe Means of Verification Outcomes / Targets PS MoH / Ongoing MTEF Increased Partners / CSOs budgetary MoH DHS Planning & Policy / PS MoLG / PS MoFPED / CAOs / Partners MoH CHS P/ PS MoFPED / Parliament MoH CHS P / First Parliamentary Counsel Scale up the RBF program MoH CHS P / LGs / Partners Conduct periodic monitoring and supervision at all levels MoH CHS QAID, Programme Managers / CAOs / IPs allocation to MOH April 2018 Reports Capacity building plan for new districts December 2018 December 2018 Ongoing Progress reports Final NHIS Bill RBF Program reports NHIS Act in place Updated NHIS Bill 15 districts in Rwenzori & West Nile 74 districts under URMCHIP 27 districts URHVP Ongoing Reports All districts and health facilities supervised quarterly

21 Milestone Priority Actions / Recommendations Re-design and roll out a supervisee centered supportive supervision strategy Adopt the DHT cluster system of monitoring and supervision Scale up support supervision by sub county leadership 8.2 Ranking of hospitals reviewed Actively participate in the Community feedback system (Barazas) organized by the OPM Roll out the Regional Joint Review Missions Develop clear targets and performance assessment plan for all Hospital Directors, Medical Superintendents and DHOs Review the formula used for ranking hospitals to take into account their core functions Responsibility Timeframe Means of Verification MoH - CHS QAID March 2018 Supervision Strategy DHOs / CAOs / Sub-county Chiefs MoH CHS HPC&EH / DHTs / IPs MoH CHS Planning / Partners MoH - Director Clinical Services / Hospital Directors / DHOs MoH CHS P/ SMER TWG / Hospital Directors / Partners March 2018 Ongoing August 2018 December 2018 April 2018 Supervision Reports Reports on actions taken Reports Performance assessment plan Annual Health Sector Performance Report Outcomes / Targets New Supervision strategy implemented All Sub-counties Chiefs conducting supervision and monitoring of health service delivery MoH and DHTs involved in the Barazas and act on the feedback. At least 6 Regional JRMs held by August 2018 Performance assessment plan and targets in place Revised SUO formula for hospitals 21 P a g e

22 Proposed dates for the 24 th Joint Review Mission The proposed dates for the 24 th JRM at which the HSDP 2015/ /20 Mid-Term Review report will be presented are 26 th to 28 th September This Aide Memoire has been signed on behalf of Government of Uganda, Health Development Partners, Private-Not-For Profit, Private Sector and Civil Society representatives. 22 P a g e

23 3 Annex OPENING SPEECH FOR THE 23 RD JOINT REVIEW MISSION FOR THE HEALTH SECTOR, OFFICE OF THE PRESIDENT CONFERENCE HALL 28 th SEPTEMBER 2017 Hon. Minister of State for Health (GD) Hon. Minister of State for Health (PHC) BY HON. DR. JANE RUTH ACENG, MINISTER OF HEALTH Dep. Secretary General for EAC, and also our Key Note Speaker Chairperson and Hon. Members of Parliament, Health Committee Chairperson HSC Chair and Head of Health Development Partners All our Development Partners Permanent Secretary, MOH Secretary Health Service Commission Ag. Director General Health Services Director Medicines and Health Service Delivery Monitoring Unit Resident District Commissioners Chairpersons LC Vs Chief Administrative Officers Representatives of Civil Society Organizations and Private Health Providers Ladies and Gentlemen I have the pleasure of welcoming you all to our two day 23 rd Joint Review Mission (JRM) that will take place today and tomorrow. I would like to extend a special welcome to our Guest Speaker, Members of Parliament, Representatives of Health Development Partners, Civil Society Organizations; District Leaders and the Private Health Providers. I thank you for sparing time to be part of this important review. This goes a long way to show your commitment and support to the health sector. Allow me to also to welcome and congratulate Dr. Diana Atwine, who is attending this review for the first time as the PS / MOH. As most of you know, Annual Joint Review Missions (JRMs) bring together important stakeholders in the health sector to review and discuss the sector performance for the previous Financial Year. Against this background, the Annual Health Sector Performance Report 2016/2017 will be presented and discussed, outlining the achievements, lessons learnt and challenges for the previous FY. In addition, we will discuss the implementation status of agreed 23 P a g e

24 priority recommendations in the last Aide Memoir. Furthermore, in line with the JRM objectives, we will identify and agree on the sector priorities for FY 2018/2019; among others. The theme for our 23 rd JRM is Addressing Social Determinants of Health for Improved Health Outcomes. Most of our discussions will therefore be oriented towards this theme. As we review our performance, issues to do with multi-sectoral approach and how the social determinants of health impact on the health outcomes must feature strongly in the discussions. We have amidst us none other than the Deputy Secretary General for the EAC Hon. Christopher Bazivamo, to present a key note speech on this very theme. Once again Hon. Bazivamo, you are welcome to Uganda, and thank you very much for accepting our invitation. Ladies and Gentlemen, as most of you know, during the year under review, the results of the Uganda Demographic and Health Survey (UDHS) 2016 were released. The study indicated significant improvements in most key health impact indicators. For example, over the 5 years between 2011 to 2016, IMR decreased from 54/1,000 to 43/1,000 live births, Under 5 mortality from 90/1000 to 64/1000 live births, and Maternal Mortality from 438/100,000 to 336/100,000. The Contraceptive Prevalence Rate improved from 30% to 39% and the Total Fertility Rate from 6.4 to 5.9. The deliveries attended to by a skilled health work increased from 59% to 74%, to mention but a few. We also released results for the Uganda population HIV Impact Assessment that showed a decline of HIV prevalence rate from 7.3% in 2011 to 6.0% in The same study assessed prevalence of Hepatitis B across the country which showed an overall prevalence of 4.3%. This was much lower than previous studies in 2005 which had showed a prevalence of over 10%. The highest prevalence of 4.6% was in Mid North and lowest in South West at 0.8%. A year earlier, we had received the Malaria Indicator survey results showing a prevalence of Malaria falling from a national average of 43% to 19%. I would like to thank you all, our stakeholders for contributing to these improvements. We all contributed to the achievements the public sector, private sector, partners and civil society. I can only ask you all to work harder for even better results moving forward. You will also be informed in the presentation of the Annual Report that, the HSDP Monitoring outcome indicators also showed good improvements for the last FY. Ladies and Gentlemen, I would like to remind you that alongside our commitments in the HSDP , during this FY, we also developed a guideline on Key Strategic Interventions for Improving Service Delivery in the Health Sector for the period This document is in line with H.E. the President s June 2016 directives on improving service delivery in order to attain the Middle Income Status by The guideline also addresses priorities in the NRM manifesto. These interventions include: 1. We shall focus most of our efforts and resources on disease prevention and health promotion. H.E. the President has often called us the Ministry of Diseases because of our focus on treatment rather than on preventing diseases yet available evidence shows that 75% of our diseases are preventable the communicable and even some noncommunicable diseases. Going forward, our sector plans and budgets will focus on community mobilization and empowerment for disease prevention. We also need to 24 P a g e

25 redesign our health messages accordingly. We are developing a cadre of Community Health Extension Workers (CHEWs) to strengthen our linkages with the community in this regard. The CHEWS will be trained early next year and we expect to post the first group early next FY. 2. Improve transparency, accountability and efficient use of resources to avoid waste and corruption. The vice of illegal charging of patients is still rampant. We need to work together to address this. In particular, I call on local government leaders to help us fight the vice of corruption in our health facilities. This Strategic Guideline outlines our mechanisms for controlling corruption in the sector. It also outlines on how we shall stop shoddy works in construction, procurement malpractices, and procurement of poor quality medical equipment. We are also improving on fleet management. 3. Increase availability of Essential Medicines and Supplies to the people of Uganda. We are aware that quarter 4 of last FY experienced shortages of medicines and supplies. This was mainly due to inadequate funds to NMS arising from foreign exchange fluctuations. We are trying to address this constraint with our colleagues in Ministry of Finance Planning and Economic Development. The document gives clear guidelines on addressing stock outs, medicine thefts, expiry and prompt recording keeping for medicines. 4. Strengthening Human Resources for Health The guideline outlines strategies to address absenteeism and negligence of duty, improving numbers of health workers at facility level, motivation of staff and training of professionals including internship training. I am happy to learn that our staffing levels have reached 73% of the staffing norms, but we need to emphasize whether these staff are actually on the ground delivering services to our people. 5. On health infrastructure development, over the 5 year period our focus will be on construction, equipping and functionalizing HC3s and HC IVs in sub-counties and constituencies with no HC IIIs and HC IVs respectively. Construction of very few general hospitals will be prioritized in districts with poor accessibility and high population. The Uganda Hospital and HC IV survey 2014 found out that Uganda has more hospitals than is recommended by the MOH and that majority are not functioning to capacity. 6. On Service Delivery, MOH is committed to achieving Universal Health Coverage for all Ugandans. In line with this, we are moving forward the National Health Insurance Bill, developing guidelines for an effective referral system, and developing the ambulance policy. 7. You will recall during the just ended FY we undertook a verification and validation exercise of private health facilities receiving government PHC grants. All facilities that did not meet the eligibility criteria were eliminated in line with the Cabinet directive. This process will continue even during this FY. On the other hand, MoH has set up a credit medicine line for PNFP health facilities at the JMS starting this FY. 25 P a g e

26 8. Strengthening Supervision systems is a core priority of the sector and this will be intensified during this period. I would like to ask district leaders and the DHTs to strengthen supervision within your local governments. Ladies and Gentlemen, that is a summary of our Strategic Interventions but I would like to encourage the Commissioner Planning to share with you this guideline because we will need to address these interventions together with you especially local government leaders. It is true some of the interventions above will require additional resources and we will continue to lobby Ministry of Finance for more funds. We thank wholeheartedly all our Partners who continue to support us financially to address our financing gaps. May be I also need to remind you that we recently concluded signing a US $ 140 Million financing from the World Bank to support our revised Maternal and Child Health Investment Case that I intend to launch today. Furthermore, the Global Fund approved a $465 grant for HIV, Malaria and TB. Of course we appreciate the continuous support from all of you partners that have been supporting us every year over the years. I singled out these two because it is financing that was announced during the year under review. During 2016/2017 we were confronted with a few disease outbreaks e.g. Rift Valley Fever in Kabale and the Avian Flue in Entebbe, Wakiso, Masaka and Kalangala which we promptly responded to, largely due to an efficient surveillance system. Let me briefly comment on implementation of our Country Compact because it is very important for our partnership. I note there were regular Health Policy Advisory Committee and Senior Management Meetings although attendance of GoU representatives to HPAC was unsatisfactory (just below 50%). The Technical Working Group meetings were even irregular. I am glad the new PS has taken this challenge head on and this FY we should see better results. Quarterly monitoring of the sector performance was carried out through bi-annual reviews. The Annual Sector Performance Review (the JRM) has been undertaken. The Midterm review of the HSDP is due next year. I would like us to prepare in good time for the Midterm review of the HSDP as you know this is an undertaking in the Compact that we signed with our Partners, CSO and the private sector. On the other hand, failure by the centre to conduct regular supervision of local governments is major source of concern. I am also aware that supervision health facilities by Local Governments is irregular and inadequate. I want all of us to recommit ourselves in this review to improving supervision in the health sector. Ladies and Gentlemen, I want to conclude by thanking all of you once again for the good work that you continue to do in the health sector. I know a lot remains to be done but I am counting on you that together we shall climb any mountain and cross any valley. In a special way, I wish to thank UNICEF and UNFPA who contributed significantly to funding some costs of this JRM. I also thank BTC that organized Regional JRMs for West Nile and Rwenzori regions. Information from those 2 regional meetings has fed into this National JRM. Thank you very much indeed to all of you. This reminds me to ask Partners in other regions to 26 P a g e

27 support local governments undertake regional JRM in your respective regions. Deliberations of the regional reviews can then feed into the national JRM. The example of BTC should be emulated in other regions. At this juncture, let me thank the organizing committee of this JRM, headed by the PS and Ag. DGHS supported by various sub committees for the good organization. The task force that drafted the Annual Health Sector Performance Report 2016/2017 is appreciated in a special way. LADIES AND GENTLEMEN, I NOW HAVE THE PLEASURE TO OFFICIALLY DECLARE THE 23 RD JRM OPEN, FOR GOD AND MY COUNTRY. DR. JANE RUTH ACENG MINISTER OF HEALTH 27 P a g e

28 Opening remarks by Health Development Partners at the 23 rd Health Sector Joint Review Mission (JRM) Honourable Ministers Honourable Members of Parliament Permanent Secretary, MoH Directors and Commissioners of the Ministries and staff of MoH present District Delegates Health Development Partner colleagues Members of the civil society and private sector Distinguished Guests Ladies and gentlemen On behalf of the Health Development Partners, it is my distinct pleasure to present the opening remarks at this 23 rd Health Sector Joint Review Mission under the theme: Addressing Social Determinants of Health for Improved Health Outcomes. We fully embrace this theme. Indeed, this is an opportunity to jointly reflect on how we have performed in the last financial year, identify lessons learnt, and define what we want to do and how we want to do it in the current financial year. It will be important to go through this exercise objectively and with all honesty to ensure real improvements can be attained. As Health Development Partners we recognize the unwavering commitment of the Ministry of Health, and other stakeholders towards improving the health status of the Country and congratulate you upon last year s successes. We commend the cordial working relationship between the Ministry of Health and Health Development Partners that has enabled us to work together to tackle some of the challenges in the sector. Over the past year, we have seen increased efforts by the Ministry of Health s to strengthen the Health Policy Advisory Committee and Technical Working Groups. No wonder that the Ministry of Health emerged the best sector in the recently concluded assessment exercise on Sector Working Groups by the Office of the Prime Minister. We acknowledge the strides that have been made in improving the health status of Ugandans as evidenced in the preliminary results of the UDHS most notably the reduction in Child (Underfive mortality rate from 90 to 64/1,000 live births) and Maternal Mortality (maternal mortality ratio from 438 to 336/100,000 live births); and of the Uganda Population HIV Impact Assessment (UPHIA) (from HIV prevalence 7.3 to 6.0 in the reproductive age group between 2011 and P a g e

29 We also acknowledge the progress made towards National Health Insurance Scheme including getting the Certification of Financial Implication from the Ministry of Finance, Planning and Economic Development. In addition, there have been significant strides towards implementation of the Community Health Extension Workers (CHEWs) Programme. Health Development Partners are committed to supporting to the CHEWs strategy since it provides a framework for strategic investment in the community health program in Uganda. We know that CHEWs will fill an important gap in the human resource for health and will be critical in supporting the provision of promotive and preventive health services at community level; especially in a country where over 75 per cent of the diseases are preventable. However, we urge the Government to do more in the following areas: There is need to increase domestic financing for the health sector. The 6.4 per cent of the national budget for the 2017/18 financial year is still far below 15 per cent Abuja declaration. Further, we need to work together to fast-track the enactment and roll-out of the National Health Insurance Scheme to broaden the health financing base. Increasing financing would contribute to addressing the issue of frequent stock-outs of some basic medicines and supplies; a challenges that has adversely affected health service delivery. As much we are committed to support the CHEWs Programme as a means of increasing access to health promotive and preventive services at the community level, we urge the Ministry of Health to continue pursuing the issue of having the CHEWs as part of the Government s Public Service system to ascertain sustainability of the programme as the honoraria arrangement is implemented in the interim. Furthermore, as we aspire to bring health services closer to the people, we appeal to the Government to reconsider the decision of downsizing Health Centre IIs given that significant primary health care services are provided at health centre II level. For example as 40 percentage of immunization services are provide at HC level. The issue of ensuring physical access to health services is critical as we pursue universal health coverage. We are also concerned about the implementation rates for some of the programmes that development partners support. Funds need to be utilized in the prescribed programme time. This does not only deprive the targeted beneficiaries of the needed services but also adversely affects our resource mobilization efforts. 29 P a g e

30 In addition, we also appeal to the Government to enhance both programmatic and financial accountability mechanisms to ensure that funds are used for the intended purpose and value for money. Considering the common saying that no product, no services we urge the Government of Uganda to ensure timely contribution to the procurement of health commodities and supplies. Unreliability in essential medicines and key commodities including for HIV, Malaria, TB and reproductive health adversely affects the delivery of quality services. Human Resources for Health are critical for driving the health system. We do appreciate the progress made so far in recruitment of additional health workforce. We appeal to the Government to consider what more could be done to improve the remuneration and working conditions for health workers. This will have a significant effect on boosting their motivation, effectiveness and retention, contributing to quality and sustainable health services. Furthermore, we also request the Government to prioritize absorption of contract staff recruited by Development Partners premised on understanding that Government would transition them into Government s pay schemes. Ladies and gentlemen, we note that a lot has been achieved in reducing mortality and increasing the life expectance of the general population. However, maternal mortality ratio (of 336/100,000 live births), neonatal mortality rate (of 27/1,000 live births), teenage pregnancy (of 25 per cent); and modern contraceptive rate (of 35 percent) that has led to high population growth rate of 3 percent. All these remain of a big concern. We need to critically examine the root causes of this status especially social determinants of health that are the core of our theme today and work together to advance approaches that have proved to work including family planning and universal access to emergency obstetric and neonatal care. Finally, with Uganda hosting the largest number of refugees (now over 1.3 million) in Africa, working across sectors to ensure that this protracted crisis doesn t weaken the health system further will be critical. We look forward to a fruitful Joint Review Mission. Thank you. Dr. Edison Muhwezi Chair of the Health Development Partners 30 P a g e

31 OPENING REMARKS OF NON-STATE ACTORS IN THE HEALTH SECTOR 23 RD JOINT REVIEW MISSION The Hon. Minister of Health Hon. Minister of State for Health (General Duties) Hon. Minister of State for Health (Primary Health Care) The Permanent Secretary, Ministry of Health Other Permanent Secretaries The Key Note Speaker, Hon. Christophe Bazivamo, Deputy Secretary General of the East African Community The Director General of Health Services, Ministry of Health Chair, Development Partners and all Development Partners All Non-State Actors (CSOs, FBOs, NGOs, PHPs etc) District Political and Civil leaders All invited guests Ladies and Gentlemen, Hon. Minister, I am Dr. Sam Orach, the Executive Secretary of Uganda Catholic Medical Bureau (UCMB) making this remark on behalf of the Non-State Actors which include the Civil Society Organizations (CSOs), Faith-Based Organizations (FBOs) such as the Medical Bureaus, Non-Governmental Organizations (NGOs), etc. We are happy to participate in this review and to have participated in the health policy engagements, processes of the health service delivery in the country in the period under review and the review process itself. We thank you and others in the Ministry for providing leadership to the sector. The non-state actors in this country make a significant contribution to the health sector through health infrastructure (health facilities, health training institutions), human resource production, direct health service delivery (both facility-based and non-facility based), policy engagement etc. The PNFP alone contribute over 40% of the health infrastructure. Those under the four medical bureaus see about 20% of the outpatients, about 30% of the deliveries and higher proportion of surgery. We have over 30 health training institutions. With the PHP and other PNFPs these proportions are higher. The resources mobilized whether locally or externally, though off Ministry of Health budget is a big contribution to the overall resource availability for the health of Ugandans. 31 P a g e