The Health Sector in Uganda and the Work of CUAMM Dr. Peter Lochoro Country Representative Doctors with Africa CUAMM Uganda 1
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General issues Democratic government, stable country and more peaceful Population estimated to be 30.1 million (87% rural) in 2008/09 doubling every 20 years owing to a very high population growth rate of 3.3% TFR 6.9 GDP/Capita of US$ 453 growing at an average of 6.5% per annum since 1990 Human Development Index 0.581 (2007) cf. Italy 0.945 poverty level down from 56% in 1992 to 31% in 2005. Poverty in north 70% Karamoja 82% 3
Health Financing and Budget 2007/08 Health Budget budget in 2007/08 Ush 418.48 Billion (246.02 Million USD) Government of Uganda component Ush 277.36 Billion (163.06 Million USD) Donor Projects in Health Ush 141.12 Billion or 82.96 Million USD (i.e 34% of Health Budget) Total Public Expenditure per capita Ush 13,949 (USD 8.2) Total Health Expenditure per capita USD 25 (in 2006) Health Budget as % of GoU Budget 9.6% 4
Donors to Uganda Health Sector 2007/08 (CAP) For humanitarian response 6% SIDA 1% GFATM 27% USAID 50% ITALIAN 5% UNFPA 0% DANIDA 3% JICA 3% UNICEF 2% WHO 3% 5
Consequences of Funding Severely underfunded with only about a third of the US$ 28 needed to provide the minimum health package Shown in perennial shortages of drugs and supplies, poor health infrastructure and shortage and de-motivation of human resources. Constraints magnified for the northern region. 6
Development Strategy PEAP development framework and MDG Uganda development framework emphasises poverty eradication and economic development for social transformation. Now government developing a National Action Plan to replace PEAP Off-track in achieving MDG goals with exception of HIV/AIDS reduction. See table below Poor health indicators contribute to the low life expectancy of 50.4 years 7
Health indicators & MDG Targets Indicator 1990 2000 2006 Target 2009 Life Expectancy 50.4 (2007) Infant Mortality Rate (IMR 122 88 76 68 31 deaths/1,000 live births) Under 5 MR (deaths/1,000 live 180 152 137 103 56 births) Maternal Mortality Rate (MMR 527 505 435 354 131 deaths/100,000 live births) Supervised deliveries (%) 38 38 42 85 Stunting in children under five years of age (Chronic Malnutrition)% Children Fully Immunized % 31 (1991) HIV/AIDS prevalence (ANC HIV prevalence) 38 38.5 32 28 38 (2001) 46.2 90 30% 6.2% 6.4% (2005) Disability Rate 3.5% (2002) 5% 1.7% MDG target 2015 8
The Trend for Health MDGs 600 35.0% 500 527 30.0% 505 30.0% 400 435 25.0% 300 20.0% 15.0% U5MR MMR HIV/AIDS 200 100 0 180 152 137 131 6.2% 6.4% 56 1.7% 1990 2000 2006 2011 2015 10.0% 5.0% 0.0% 9
General Health Problems Over 75% of life years lost in Uganda are due to ten preventable diseases/conditions including: maternal and perinatal conditions (20.4%), malaria (15.4%), acute lower respiratory tract infections (10.5%), AIDS (9.1%) and diarrhoea (8.4%). Others include tuberculosis, malnutrition and trauma. minimum health package address this conditions 10
Uganda Health System HOUSEHOLDS / COMMUNITIES / VILLAGES HC II HC II HC II HC II HC II HSD HC III HC III HC III Referral Facility (Public or NGO) (HC IV or HOSPITAL) District Health Services HQ Regional Referral HOSPITALS National Referral HOSP MOH Headquarters 11
Uganda Health System 2 Ministry of Health and other National Level Institutions National Referral Hospitals (30 Million) Regional Referral Hospitals (2,000,000 population) District Health Services (District level, 500,000 population) Health Sub-District (Functional Zone of district) Referral Facility General Hospital (District level - 500,000 pop) or Health Centre IV (County level - 100,000 pop) Health Centre III (Sub-country level - 20,000 population) Health Centre II (Parish Level 5,000 population) Health Centre I (Village Health Team - 1,000 population) 12
Health Units and staff Uganda health services are implemented through 80 districts, 214 HSD, 114 hosp (46 PNFP, 8 PFP) Staff about 30,000 in Public and PNFP Mal-distributed eg 60% drs in the central region. 13
Public Private Partnership A key principle guiding the implementation of the HSSP2 is to further strengthen the broader health partnerships, esp with PNFP. The PNFP health units currently are responsible for 30% of the publicly oriented sub-sector (PNFP and Government). Higher % in the north. Some of the PNFP health units are even charged with health sub-district management functions of supervision, planning, logistical responsibilities and coordination for the whole zone including government owned units. 14
Doctors with Africa CUAMM in Uganda 15
The Presence of CUAMM 2008/09 CUAMM Districts Populations Total 4,901,761 0-5 Years 990,156 40% Women CBA 990,156 Pregnant Women 245,088 16
Karamoja a key focus area for CUAMM Comparative Humanitarian and Development Indicators National Karamoja Estimated Population [UBOS] 28.9 million 1.1 million Life expectancy [UNDP 2007] 50.4 years 47.7 years Population living below poverty line [World Bank 2006, OCHA/OPM 2008] 31% 82% Maternal mortality rate (per 100,000 live births) [UDHS 2006, WHO 2008] 435 750 Infant mortality rate (per 1,000 live births [UNICEF/WHO 2008] 76 105 Under five mortality rate (per 1,000 live births) [UNICEF/WHO 2008] 134 174 Global Acute Malnutrition (GAM) rate [UNICEF/WHO 2008] 6% 11% and rising Immunization (children 12 to 23 months, fully immunized) [UDHS 2006] 46% 48% Access to sanitation units [MoH 2007, OCHA/OPM 2008] 59% 9% Access to safe water [UDHS 2006] 67% 43% Literacy rate [UNDP HDR 2006, UDHS 2006] 67% 11% HIV/AIDS prevalence rate [HSBS 2005, WHO 2008] 6.4% 3.9%* 17
CUAMM in Uganda CUAMM has been in Uganda since 1959 now 50 years of presence! One of the first places of CUAMM was my village hospital Matany an oasis in the middle of no where My inspiration as a child from CUAMM doctors in that hospital Uganda is a major country for CUAMM programmes in Africa 18
CUAMM Strategy Support to Service Delivery Inputs, Proceses Support to Districts/HU management Central advocacy and policy Community actions 19
CUAMM in Uganda 2 At a district level, Strengthening district health systems management by providing technical assistance and other relevant input, currently working with 6 district health systems. At rural hospitals level, Supporting 6 hospitals, providing staff, training, equipment and management support. At community primary health care level, Supported prevention, service improvement and community based services currently in disability, primary eye care and inputs to improve service delivery at primary care health units in 15 districts. 20
CUAMM in Uganda Health training and research: Trained in basic and postbasic medical personnel in professional schools and in service and supported health systems research. Currently it is supporting 1 University and 1 nursing school. Specific service areas: Special attention to mother-and-child healthcare, TB, HIV/AIDS, Eye care, Malaria and other infectious diseases. Restoration: Physical and functional restoration, of services destroyed by wars, natural disasters or neglect Emergencies: When essential survival needs have to be faced, or in conditions of extreme social and health crisis 21
CUAMM Uganda Projects now Reproductive health Oyam 2007/2010, 2.24 Million Hospital Water and Sanitation Project Oyam, 2009/10 150,000 Karamoja districts support project 2009/2010, 627,600 Primary Eye care, 2009, 20,000 Moroto Hospital support, 2009, 40,000 Disability West Nile, 2009, 80,000 West Nile Dioceses health system, 2007/2010, 1.25 Million Nkozi University 2008/2010, 1.4 Million Naggalama Hospital and Lugazi Diocese 2007/2010, 1.2 Million HIV/AIDS Lugazi 2009, 20,000 Matany Hospital and Nursing School 2009/2011, 1.26 Million 22
Some Results 2008 CUAMM hospitals Hospital Beds 1,113 Beds 185,844 Outpatient visits 54,252 admissions 27,475 Antenatal visits 8,362 Deliveries 81,661 Immunizations 23
Where we work 24
Matany Hospital 25
Improving Maternal Health Care 26
Enhancing outreach services 27
The First Cesarean Section Kotido HC IV 28
New staff accommodation in remote health centers Lotome HC III 29
Uganda Martyrs University Owned by the Uganda Episcopal Conference A Young University first academic year opened on October 1993 and small Student body of about 3000; about 800 on campus International in character Great lakes region, Sudan, southern Africa, W. Africa, parts of Europe Odaga John, Uganda Martyrs University 30
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The Faculty of Health Sciences (FHS) May 2001 as a dept; Faculty late 2004 7 full-time staff 1 teaching assistant 4 visiting lecturers
Why Dept/FHS was established Growing concern for effective management as a strategy for strengthening the health system resource inflow (local & donor aid) to public & private systems the management of the resources is sometimes taken for granted Changing policies Decentralisation, PPPH, financing mechanisms (SHI, CBHIS), Pull system of drugs supply Hence need for competent managers in the health system Planning, budgeting, accounting, understanding of policies, management of contracts 33
Why Dept/FHS was established Current managers only have basic qualifications in clinical fields Others are auxillary staff no formal training The curriculum of health workers in Uganda do not give adequate emphasis on management Management is only taught at postgraduate level; Even then as an adjunct to those studying public health Few, get better paying jobs, mainly private sector 34
Why Dept/FHS was established Acute shortage of competent managers Over 3000 health facilities in need of trained managers Only about 50 of 214 (23%) are headed by doctors with some management background The district Health Services At the MoH, a small cadre of highly qualified people at the planning level Non-facility based NGOs & CBO The Catholic Health services were most affected (25% of HU, 75 of training schools, & 30% of all services) 35
Why Dept/FHS was established Hence the reason focusing on training in management of health services UMU was the first to start health services-focused management training Brain child of the UCMB Of the 14 registered Unis in Uganda, only 2 or 3 others have started other management-related courses 36
Mission To form health managers with the integrity, knowledge, managerial skills, and competencies needed to provide good quality health services to the Ugandan population. We want to transfer attitudes in addition to knowledge. Goal: to have a critical mass of managers with the above qualities 37
What we do Teaching Formal training Short (thematic) courses Research Individual Student support Needs-based (UCMB, Districts, MoH, CUAMM, etc) Limited Consultancies Management/policy related Technical assistance & CME to hospitals and districts 38
What we do 1. Teaching Health Services Management Health Promotion & education Proposed Master level Yes M Med Diploma Yes Yes Certificate Yes Yes* Short-courses Yes Yes 39
What we do 1. Teaching a. Participants come from the Ministry of health, health programmes districts and Health Sub-districts, hospitals and health centers They include Ugandans & non Ugandans Government, NGO & private sector Type of programme Full time, part-time, selected modules 40
Number of students in each course over the years 41
Intake of students in the FHS by type of course in the last 10 Academic Years Course Number of student per each Academic Year Total 99-00 00-01 01-02 02-03 03-04 04-05 05-06 06-07 07-08 08-09 10 yrs Master in HSM 3 4 11 15 14 12 14 19 22 29 143 Diploma in 9 14 14 11 11 19 17 20 9 11 135 HSM Diploma in 0 0 0 0 14 19 43 18 13 12 119 HPE Certificate in 0 0 0 0 0 20 18 19 19 18 94 HSM Certificate in 0 0 0 0 0 0 25 0 0 0 25 HPE All courses 12 18 25 26 39 70 117 76 63 70 516 42
Financial bases Fees Donation CUAMM (Italian coop, Bassano group, CEI, MPS) CORDAID 43
What we do with the money Paying staff Equipment Sponsoring of students Fees Personal laptops Research Books Constructions Transport 44
Who are our customers? Various Dioceses and UCMB The Ministry of Health The districts and Health Subdistricts Other Medical Bureaus The World Health Organisation Other NGOs involved in Health Services delivery 45
Are we making a positive impact on the Health system? Are we on track with our mission? Are our customers satisfied How can we tell? 46
Are we making a positive impact? Anecdotal evidence Spontaneous positive feedback from past students Stakeholders (esp. MoH, WHO, UCMB) Increasing demand for the courses Increasing number of application Requests (especially from the MoH) to increase the size of our classes Sponsoring of students by the MoH 47
Are we making a positive impact? Anecdotal evidence Utilisation of our research findings for decision making Dioceses, Hospitals, MoH, UCMB Technical assistance to hospitals Provision of tools for management Increasing requests for collaboration Training Institution (ITM, KIT, Keele, etc.) International Organisations (e.g. WHO) Professional Networks (HEPNet Africa, etc) 48
Are we making a positive impact? Limited empirical evidence: similar findings Tracking studies of past students, stakeholders, labour market 49
Challenges Size of the staff: small compared to the tasks Structure of the courses: only full time, making it expensive Location of the University: 80 kms from the city, hence no evening programs, all students have to pay for hotel services, further increasing the cost Fees: not affordable by the average Ugandan, who are the majority 50
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Levels of Subsidies Course Ave Cost per student (US $) Fees per student (US $) Subsidy MSc. HSM 10,095 3,158 70% Dip HSM 5,506 2,105 68% Dip HPE 4,383 2,105 60% Overall 6,913 68% 52