The session on governance was kicked off by a titillating presentation by Dr. Suzanne Kiwanuka. The presentation focused on what has been happening in the last 10-15 years in health governance and what can be learned from this. It also dwelled a little on the implications/strategies for accelerating the Universal Health Coverage agenda.
To the lay the ground for a flavoured discussion she right away pointed out that good health governance is responsive, exercises legitimacy and transparency in resource allocation and policy making.
Using examples over the last ten years, she illustrated that financial resources for health are so few but also decreasing and not taking into consideration the rapid population growth, e.g. Primary Health care funds to districts are getting less over the years yet the demand for services is increasing. Closely tied to this is the focus on curative care which neglects and defeats preventive care. “With Universal Health Coverage, we have to invest more in keeping people away from hospital, so prevention is the way to go”, she elaborated.
In terms of policy environment, she noted that Uganda has proved prolific in tabling of bills and design of policies but implementation is very poor. This is complicated further by the high turnover of ministers and other senior management in the Ministry of Health and related sectors which has relegated effecting fundamental changes in the health sector to mere table-talk. “Leadership turn-over in Uganda; ministries always in transition making sustainable change complex. Uganda is in the high ministerial turn over category”.
The fact that a good part of governance in Uganda is exercised through committees, technical working groups and similar bodies makes coordination and regular meetings critical for effective governance. However, she noted that evidence shows that attendance of meetings is not consistent and meetings are held irregularly.
She also noted that contrary to the UHC ideal of multi-sectoral collaboration, health development partners’ influence on governance in Uganda is poor. Yet, they contribute a big percentage of financial resources to the sector.
Dr. Kiwanuka was cognizant of the fact that in spite of all the challenges mentioned, there are successes and things going well, many of them providing lessons for UHC. She applauded the technical working groups on including line ministries on committees, although attendance of meetings by representatives from these ministries is still a challenge. She also noted that there is continuous quality improvement and setting targets for annual health sector performance reviews by the Ministry of Health, while the Ministry has put in place structures to monitor its performance as well as putting in place integrated governance systems.
She however noted that gains in these areas are negated by the creation of parallel structures to address the failures of existing ones, which creates power struggles and is a drain on resources.
While more focus on social accountability in the media is a welcome development, she noted that this is more biased on the rights of users with little attention on the obligations.
“However, the need to focus on the obligations of users so that they know they are not only entitled to services but have a role to play in seeing services performed well. Families need to adhere to their obligations. For instance why should families think because government is paying fees for their children under UPE, it should feed them while at school as well?”
Governance in health, multi stakeholder, universal health coverage