The panel was a powerhouse of diverse experience and expertise in governance. Prof. Bart Criel from the Institute of Tropical Medicine, Antwerp, Belgium is Head of the Health Policy and Financing Unit of the Department of Public Health. Honorable Dr. Sam Okuonzi is Member of Parliament with extensive prior experience in health policy. Dr. Ruth Nassanga has served Mpigi district as the District Health Officer for over a decade, she has loads of experience managing the subnational health system.
Prof. Bart started off the discussion by saying that governance has everything to do with checks and balances; the effectiveness of which has to do with democracy. Since democracy is not a one man’s game, he added that the checks and balances cannot be fulfilled by one single actor. Others like media, Civil Society Organisations and others play a key role in ensuring this happens.
Talking about stewardship as a key ingredient of governance, he emphasised that this is indeed a critical issue especially at sub-national level. “The function of stewardship is very crucial at district level; a steward is a buffer between the very many programmes, and demands and needs of the people on the other hand. Therefore we need strong people at the district level. They should also be able to adapt local policies to local realities. I am a believer in districts; it gives a face to issues of governance and service delivery at that level”, he said.
Honourable Dr. Sam Okuonzi cautioned against pushing the health sector to the front of implementing universal health coverage, noting that “We don’t think about sectors anymore; welfare is not just about the health sector. Health sector is not the most prominent in determining health; other sectors like water and sanitation, nutrition, education, culture, etc are key determinants. Health comes in only to repair in case of damage. If Universal Health Coverage (UHC) is our social goal, all sectors must agree to align themselves under that goal. Looking at UHC we are thinking of change that is going to be widespread across sectors”.
He noted that other key issues are the inconsistent leadership in the health sector and the lack of clarity on the ground as to where the country wants to go. “As we are talking about UHC, the African Development Bank is working to privatize Mulago Hospital. There is absolutely no clarity and common sense of direction. Most of our work is driven by donor funding which is erratic, unpredictable and with short-term priorities that are not entirely in our hands”.
He also cautioned against setting unattainable expectations regarding universal health coverage and what it can deliver. “It cannot be possible that everyone gets the services they need; we are very poor country and even rich countries cannot do that. Some of the things should be done through the household level. We must organically evolve our own system although we can get and adapt some elements from other countries. Pooling is one of the tools to be used by Uganda to effect UHC. It is important to identify the very cost-effective interventions and these need to be identified by evidence and then decide our priorities”.
Dr. Ruth Nassanga, a veteran sub-national health manager cautioned against using finance figures that appear in official documents since most of the time, they give budget estimates, while actual disbursements are less. The implication of this is that in the process of costing universal health coverage, the district level may be the best to obtain the most accurate financial data. She then requested SPEED to support DHOs to input symposia like this one on UHC and the National Health Assembly with data that can inform presentations, debates and planning. “In terms of finances, even the little they are allocated is not fully provided; water gets cut off, power is disconnected and some facilities use torches to deliver women at night”, she said.
One key development she wanted to point one is that at district level, governance has moved away from a few people to multiple players with political and village community structures like councils and VHTs which is a good development. Districts are also receiving policies, guidelines and standards from the center to support districts to perform. However she hastened to add that more responsibility is being sent down to districts under the guise of decentralization but with limited authority, resources and space for decision making. She also pointed out that community-based structures are voluntary and raise sustainability issues. Planning for universal health coverage therefore may require examining these more critically and their ability to hold the bottom in.
The other matter she brought to the attention of the meeting is the over-dependence on partners for critical activities as well as a weak referral system, both of which present challenges to sustainable universal health coverage.
While effective implementation of universal health coverage depends on, among other things, strong data and evidence, she noted that there are currently challenges related to appreciation of data by some of the stakeholders. “We encourage regular data sharing at district level with politicians but once data discussions begin, politicians leave. You are only sharing amongst yourselves”.