Dr. Elizabeth Ekirapa-Kiracho
The Ministry of Health and its partners held the Health Sector Joint Review mission from the 28th to the 29th of September under the theme “Addressing social determinants of health for improved health outcomes”. This is the second year of implementation of the Health Sector Development Plan that aims at propelling Uganda towards achieving Universal health care coverage (UHC). The sector has made positive progress in several areas for example child and infant mortality and maternal mortality has declined remarkably. Antiretroviral therapy coverage has also improved exceeding the target. Staffing norms have also increased to 73%. However, some areas have remained stagnant or improved only slightly for example neonatal mortality has remained stagnant at 27 per 1000, the contraceptive prevalence rate has improved only slightly and is now 39%. The attendance of four ANC’s has also remained low at 37%.
As I reflected on areas where we have done well and where we still need to change, I identified three over-arching issues.
Firstly I thought that we need to strengthen monitoring, evaluation, performance management and performance assessment at the level of the health facilities and districts. The Ministry of Health ranks the performance of districts, hospitals and health centres and the best performers are applauded for their good performance. The Ministry is indeed commended for taking this action. However, we need to devote more time to understanding and addressing challenges faced by the poorly performing districts. We therefore need to map districts that are performing poorly on specific indicators with their key problems and specific action plans to address these issues so that we can support the poorly performing districts to improve.
Another issue that was very pronounced is the fact that a lot more effort needs to be devoted to preventive and promotive services. More than 75% of the disease burden in the country is preventable. Uganda is planning to implement a community health extension worker strategy that is expected to improve access to preventive services and to promote health promotion. It is expected that this strategy will revamp mechanisms for strengthening community involvement in health by using a multi-sectoral approach so as to address problems such as early marriage that leads to high teenage pregnancies; low latrine coverage and poor newborn care practices among others. The districts don’t have adequate funds to invest in these areas, although several donor programs are trying to address these issues. However, often there is duplication and failure to focus on the most burdened areas. Such donor support needs to be more coordinated and targeted at district level where implementation of these programs takes place.
Challenges and more challenges in service delivery. We need to do things differently! During the meeting, several challenges were highlighted. One of the challenges that were raised was related to the inadequate logistics for support supervision. In the current model the higher level of care has to move to a lower level to supervise it. The health sub district and district offices for example have to send supervisors to the lower level health centres; however the funding available is inadequate for this. As I thought about this I felt that we need to modify the model that we are using so that it provides support while holding the facility and district managers more accountable for performing their roles. This will require that we focus more on building the capacity of the facility in-charges to do their own support supervision, mentorship, self-appraisal, monitoring, and evaluation. District health offices and Ministry of Health supervision teams can then concentrate more on regular performance appraisal and assessment of the facilities and districts identifying problems, gaps and solving these by thinking out of the box. There is a lot of dependence and an overall outcry about the lack of support supervision by the external teams and not as much emphasis on the internal performance management processes, which need to be strengthened.
One of the other challenges was the continuous new districts and sub counties that are sprouting all the time. Uganda currently has 112 districts with 12 more approved, up from 56 districts, and these districts and sub counties are still continuing to grow.
This is making it very difficult for districts and implementers to plan services in a manner that ensures equitable access. As I pondered over this issue, I thought to myself “we are not able to control the ‘birth’ of these new districts and subcounties because they are highly politicized, however we need to think of how to deal with the challenges that are arising out of this. Can we come up with our own carefully planned and mapped health-related boundaries that will not be directly linked with the changing administrative boundaries? We already have health sub districts, we could have lower levels that are aligned to the sub counties and the villages so that if we plan to have for example a health centre III per sub county this does not have to change to three HC III’s because what was originally one sub county now has three sub counties. Or similarly if we have one district health team managing a reasonably sized district we should not need three other district health teams to manage three astonishingly small districts. As I conclude, I congratulate the Ministry of Health and its partners on the numerous positive achievements and developments and I look forward to seeing your suggestions about some of these challenges.
Dr. Elizabeth Ekirapa-Kiracho is a Senior Lecturer at the Makerere University School of Public Health and a Health Economist on the SPEED Project
She can be reached on firstname.lastname@example.org