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Looking Back and Forward to Speed U

p the ProgressEdited by F. Ssengooba et al.

Universal Health Coverage in Uganda: Looking Back and Forward to Speed Up the Progress is a product of capacity-building efforts to advance health policy analysis and advice at Makerere University to influence national policies and plans for universal health coverage in Uganda and similar countries.

Over the past three decades, Uganda has witnessed major improvements in population health, especially with regard to child survival, care programmes for HIV/AIDS, and epidemic management and control, to mention but a few. In Uganda, like in other developing countries, many studies have been conducted, many service delivery models have been tested and many technical assistance programmes have come and gone. This book provides an in-depth understanding of the policy trade-offs, especially in resource-constrained countries like Uganda. Among others, the book provides useful advice on how to expand the fiscal space for health while leveraging health benefits from other sectors of the economy, and ways to manage the rapidly growing population and the health needs thereof. The key actions for mitigating the escalation of costs associated with scaling up health interventions and boosting service quality are also highlighted.

As the Government of Uganda repositions its policies and strategies towards Sustainable Development Goals by 2030, this book comes at an opportune time for decision-makers in government, in the health sector and in the development community. The book is a must-read for professionals in government concerned with improving health and well-being in Uganda and similar countries.

ISBN: 978-9970-627-00-4

UNIVERSAL HEALTH COVERAGE IN UGANDA Looking Back and Forward to Speed Up the Progress

Edited by Freddie SsengoobaSuzanne N. KiwanukaElizeus RutebemberwaElizabeth Ekirapa-Kiracho

SPEED Project

UNIVERSAL HEALTH COVERAGE IN UGANDA Looking Back and Forward to Speed Up the Progress

Edited byFreddie SsengoobaSuzanne N KiwanukaElizeus RutebemberwaElizabeth Ekirapa-Kiracho

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Makerere University School of Public HealthP.O. Box 7062Kampala

© Makerere University, School of Public Health, 2018

Rights and Permissions

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without the prior written permission of the publisher.

ISBN 978-9970-627-00-4

Editors Freddie SsengoobaSuzanne N. KiwanukaElizeus RutebemberwaElizabeth Ekirapa-Kiracho

The content of this book does not reflect the official opinion of the European Union or the Government of Uganda. The responsibility for the information and views expressed herein lies entirely with the authors.

iii

Contents

Contributors ...............................................................................................................viList of Abbreviations and Acronyms ...........................................................................xiiForewords..................................................................................................................xivAcknowledgements ...................................................................................................xvii

Part ICoverage Reforms ................................................................................................................. 1

Chapter 1 Framing the Determinants of Health and Well-Being for Universal Health Coverage Freddie Ssengooba, Charles Hongoro .................................................................... 3

Chapter 2 Universal Health Coverage and the Social Protection Agenda: Opportunities, Challenges and Policy Considerations for UgandaJohn Ssekamatte, Judith Mutabazi, Aloysius Ssennyonjo ....................................... 24

Chapter 3 How are Developments at Global and Regional Levels Influencing Progress towards UHC in Uganda? Implications for Ensuring Good Health and Well-being Remco van de Pas, Aloysius Ssennyonjo, Bart Criel .............................................. 48

Part IIGovernance ...................................................................................................................... 71

Chapter 4 Governance for Universal Health Coverage in UgandaSuzanne N Kiwanuka, Freddie Ssengooba .......................................................... 72

Chapter 5 The Right to Health in Uganda: Implications and Practical Steps to Achieving Universal Health CoverageRobinah Kaitiritmba, Moses Kirigwajjo, Aloysius Ssennyonjo, Suzanne N Kiwanuka ....................................................................................... 96

Chapter 6 Decentralisation and the Uganda Health System: What can we Learn from Past Experiences to Facilitate the Achievement of Universal Health Coverage? Christine K Tashobya, Vento A Ogora, Suzanne N. Kiwanuka, Aloysius Mutebi, Timothy Musila, Sarah Byakika, Freddie Ssengooba ......................................... 117

Chapter 7 How is the Partnership between the Public and Non-Public Sector Evolving to Strengthen Universal Health Coverage?Phyllis Awor, Harold Bisase, Peter Lochoro, Filippo Curtale ............................... 150

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Part IIIFinancing .................................................................................................................... 169

Chapter 8 Resource Mobilisation in the Context of Moving towards Universal Health CoverageBaine SO, Odokonyero Tonny, Chrispus Mayora Kwesiga Brendan ..................... 170

Chapter 9 Pooling Resources and Health Risks for UHC Advancement in Uganda: An Assessment of Current Mechanisms and Policy OptionsSebastian Olikira Baine, Aloysius Ssennyonjo, Remco van de Pas, Freddie Ssengooba ........................................................................................... 184

Chapter 10 Purchasing Health Care Services for Universal Health Coverage: Policy and Programme Implications for UgandaElizabeth Ekirapa-Kiracho, Chrispus Mayora, Aloysius Ssennyonjo, Sebastian Olikira Baine, Freddie Ssengooba ...................................................... 205

Part IVService Delivery ................................................................................................................. 227

Chapter 11 How Is Physical Health Infrastructure in Uganda Supporting Universal Health Coverage?Elizeus Rutebemberwa, Charles Hongoro .......................................................... 228

Chapter 12 Health Workforce Developments: Challenges and Opportunities to Secure Universal Health Coverage in UgandaFreddie Ssengooba, Suzanne N Kiwanuka ...................................................... 245

Chapter 13 Managing Health Technologies to Advance Universal Health Coverage In UgandaAngela N Kisakye, Simeon Kalyesubula, Sam Wanda, Freddie Ssengooba, Suzanne N Kiwanuka, ................................................................................... 271

Part VPriority Interventions ........................................................................................................ 289

Chapter 14 Health Promotion: The Path to Good Health and Well-being Milly Nattimba, Charles Ssemugabo, Freddie Ssengooba .................................... 290

Chapter 15 Making Family Planning Programmes Accessible to All Under Universal Health Coverage Denis Akankunda Bwesigye, Angela Akol ......................................................... 311

Chapter 16 Non-Communicable Diseases in Low-Income Countries: Implications for Universal Health CoverageRoy William Mayega, Elizabeth Ekirapa-Kiracho, Barbara Kirunda, Francis Xavier Kasujja, Geofrey Musinguzi, David Guwatudde ............................................... 332

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Chapter 17 How Has Outbreak Management Improved over the Years in Uganda? Recommendations to Improve Health System Resilience to Disease Outbreaks in UgandaSteven Ssendagire, Doreen Tuhebwe, Susan B Kayongo, Freddie Ssengooba .......... 352

Chapter 18 Improving Child Survival in Uganda: Trends, Opportunities and Policy Implications for Achieving Universal Health CoveragePhyllis Awor, Lumbwe Chola, Xavier Nsabagasani, Fred Kagwire, Flavia Mpanga, Anthony Mbonye ............................................................................................. 376

Chapter 19 Maternal Health: Towards Universal Coverage with Impact, Equity and Quality of Care in Uganda Peter Waiswa, Doris Kwesiga, Peter Kivunike Mukasa ....................................... 393

Chapter 20 Conclusion Chapter: The Road Map to Universal Health Coverage Freddie Ssengooba ........................................................................................... 413

Index ..................................................................................................... 433

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Contributors

Aloysius Mutebi is a Research Fellow under the Department of Health Policy Planning and Management at the Makerere School of Public Health, Kampala, Uganda. He holds a Bachelor of Statistics and a master’s degree in Public Health. He is a health policy and systems researcher whose work focuses on governance with special interest in human resources for health, leadership and management for universal health coverage.

Aloysius Ssennyonjo is the manager, SPEED Project and a research fellow at the Makerere University School of Public Health. He is a health policy and systems researcher with a keen interest in governance and health financing for universal health coverage. He holds a medical degree (Makerere University), an MSc in Global Health and Public Policy (University of Edinburgh) and a postgraduate diploma in Monitoring and Evaluation (Uganda Management Institute).

Angela Akol, MD, MA, is the Country Director of Uganda for FHI 360, where she serves as the FHI 360 in-country representative and is responsible for leading family planning projects, financial monitoring and resource development.

Angela Kisakye is a Research Fellow at the Makerere University School of Public Health and a Scientific Writer with the African Field Epidemiology Network (AFENET). Angela has a keen interest in health policy with a focus on human resources for health. She holds a Master of Public Health degree from Makerere University.

Anthony Mbonye, PhD has a distinguished work record in public health. Prof. Mbonye served as Acting Director General of Health Services and Director Health Services (Clinical & Community) at MoH. Besides his civil service job, Mbonye works as an Honorary Professor at the Makerere University School of Public Health. He has been a lead investigator of key research work on maternal and child health. He has over 80 publications on different public health threats featured in distinguished journals. Anthony Mbonye is a member of the Faculty of Public Health at London’s Royal College of Physicians.

Barbara Eva Kirunda is an Assistant Lecturer in the Department of Epidemiology and Biostatistics, Makerere University College of Health Sciences, School of Public Health. She is a Swedish International Development Agency (SIDA) Postdoc Fellow at Makerere University. She holds a degree of Philosophiae (PhD) in International Health (University of Bergen, Norway). Her research areas of interests include non-communicable diseases and lifestyle behaviours like nutrition and physical activity.

Bart Criel is a medical doctor by training. He is currently a Professor at the Institute of Tropical Medicine (ITM), Antwerp and is involved in a wide range of activities in the fields of research and service delivery in sub-Saharan Africa and India. He is currently also co-director of the ITM-based MPH course. His main domains of interest are the organisation of health care delivery at the district level and the study of social health protection arrangements.

Brendan Kwesiga currently works at the USAID/Uganda Health Supply Chain, Management Sciences for Health. Brendan does research in health economics and financing. The current

viiContributors

focus is on strengthening pharmaceutical systems to enable increased equitable access to medicines in resource-limited settings.

Charles Hongoro is a Research Director in the Population Health, Health Systems and Innovation Programme. He holds a PhD in Health Economics and Policy from the London School of Hygiene and Tropical Medicine, University of London. His areas of research interest include health systems financing, the economics of HIV/AIDS and other infectious diseases, health systems and policy-oriented research in general, evaluation and impact studies.

Charles Ssemugabo is a Research Associate in the Department of Disease Control and Environmental Health at the Makerere University School of Public Health. He holds a bachelor’s degree in Environmental Health Science (Makerere University) and a master’s degree in Public Health – Health Promotion (Uganda Martyrs University).

Chrispus Mayora is an Assistant Lecturer and a Doctoral Fellow working on the role of the private sector (particularly drug shops) in advancing the universal health coverage agenda, especially. He has been particularly focusing on retail sector drug shops and their potential to improve under-five child health in Uganda. He is a trained economist and health economist. He has a master’s degree in Economics (Makerere University), a Graduate Certificate in Economic Policy (Australian National University) and a Master of Health Economics degree (University of Queensland, Australia).

Christine Kirunga Tashobya is a Postdoctoral Fellow in the Department of Health Policy Planning and Management at the Makerere School of Public Health, Kampala, Uganda. She holds a PhD from the Catholic University of Louvain and the Institute of Tropical Medicine Antwerp, Belgium. Her recent publications have been on health systems performance assessment and relating to the Uganda District League Table.

David Guwatudde, BStat, MSc, PhD, is an Associate Professor of Epidemiology and Biostatistics at MakSPH. His research interests are in the area of non-communicable diseases (NCDs), specifically quantifying the epidemiology of NCDs in Uganda and the neighbouring region, and identifying and evaluating the efficacy of context-relevant interventions to mitigate the effect of NCDs in the general population.

Denis Akankunda Bwesigye, MA, DrPH, is a Post-Doctoral Research Fellow at Makerere University College of Health Sciences. His research centres on maternal and child health within resource-limited settings of the sub-Saharan Africa region.

Doreen Tuhebwe is the Field Coordinator of the Master of Public Health at Makerere University College of Health Sciences, School of Public Health. She holds a bachelor’s degree in Environmental Health Sciences and a Master of Public Health from Makerere University.

Elizabeth Ekirapa-Kiracho is a medical doctor who has specialised in the field of public health and health economics. She holds a doctorate in Health Systems Research, two master’s degrees in Public Health and in Health Economics as well as a bachelor’s degree in Medicine and Surgery. She is a senior lecturer in the Department of Health Policy Planning and Management. She has vast experience in managing, conducting and analysing health-related research in a variety of fields, including health systems, maternal and reproductive health, infectious diseases, health financing and economic evaluation.

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Elizeus Rutebemberwa, MBChB, MPH, PhD, is an Associate Professor in the Department of Health Policy, Planning and Management and Co-PI for the SPEED project. His work focuses on health systems and management, especially the dynamics at the interface between health care systems and communities.

Filippo Curtale is an epidemiologist and public health advisor with a special interest in developing the public-private partnership for the health sector. During the last years of his career, he has provided technical assistance to the MoH in Egypt and Uganda for the development of national health policies and strategic plans. He contributed to the drafting of the National Health Policy on PPPH for Uganda (2012). He holds a medical degree and two postgraduate specialisations in Tropical Medicine and Infectious Diseases (University of Rome “La Sapienza”).

Flavia Mpanga Kaggwa has over 16 years of experience in implementing public health programmes. She currently manages the child health team at UNICEF with the primary responsibility of providing technical, financial and administrative oversight of key policies strategies, to leverage resources for children and women programmes. Dr Mpanga is a member of several health governance structures in Uganda, such as the Health Policy Advisory Committee (HPAC), Health Development Partners group (HDP) and the Country Coordinating Mechanism of the Global Fund.

Francis Xavier Kasujja is a Research Associate at the Makerere University School of Public Health. He is the Coordinator of the SMART2D project.

Freddie Ssengooba is Associate Professor of Health Policy and Systems Management with a doctorate in Public Health Policy from the University of London. He possesses over 20 years of teaching and research in Health Policy and Systems. He is the Chair of the HPPM Department and Director SPEED project. He has provided technical and consultancy services to WHO, DFID, USAID, the World Bank, Ministries of Health, Uganda AIDS Commission and multi-lateral and bilateral agencies and foundations.

Geofrey Musinguzi is a Fellow at the Makerere University School of Public Health in the Department of Disease Control and Environmental Health. He also holds a Post Doc Research position at the University of Antwerp, Belgium. He holds a Doctor of Medical Science (PhD) from the University of Antwerp (2015). His academic and research interest is epidemiology of HIV and cardiovascular disease risk factors in the community, environmental health and preparedness of health systems.

Harold Bisase is a health policy and systems independent researcher with keen interest in governance, public-private partnerships, global health and health financing for universal health coverage. He holds a medical degree (Makerere University), an MSc in Public Health (Institute of Tropical Medicine, Belgium), a master’s degree in Business Administration (ESAMI) and postgraduate certifications in Global Public Health, Health Systems Reforms, Policy Analysis, Health Financing Policy for UHC, Data Management for Clinical Research and Clinical Epidemiology.

John B. Ssekamatte-Ssebuliba is the Manager, Population and Social Sector Planning in the National Planning Authority (Uganda). He is a demographer and M&E specialist with considerable research interest in the areas of fertility and infant and child mortality, as well as the social determinants of health. He holds a bachelor’s degree in social sciences from

ixContributors

Makerere University; a postgraduate diploma in population studies from the University of Ghana (Legon); an M. Phil degree in Demography (Cairo Demographic Centre, Egypt) and a PhD in Demography from Brown University (USA).

Judith Mutabazi is a Project Officer, SPEED and a Planner/Population, Gender and Social Development at the National Planning Authority. She is a social policy analyst whose work focuses on social sector policy and planning for the acceleration of universal health coverage. She holds a BA (SA, SOC), MA (Social Sector Planning and Management), Makerere University and a postgraduate Diploma in Financial Management (Uganda Management Institute).

Kaitiritimba Kitungi Robinah is the Executive Director of Uganda National Health Consumers’ Organisation (UNHCO) and presents experience of 15 years working with the health sector. She is a seasoned expert in the right to health and an authority on the rights-based approach (RBA) and social accountability. She represents civil society on the Health Policy Advisory Committee of MoH among other health governance structures in Uganda and the region.

Lumbwe Chola, PhD, MPhil, BA Econ, is a Senior Health Economist at the University of the Witwatersrand School of Public Health, South Africa. His main interests are in priority setting for the improvement of maternal, newborn and child health. He has led projects to generate the best buys for maternal and child health in South Africa.

Milly Nattimba is a Communications and Research Uptake Specialist. She is currently Head, Communications at the One Health Central and Eastern Africa (OHCEA) Regional Secretariat. She is a trainer in communications, media relations, research uptake and policy influencing. She holds a master’s degree in Communications Studies (University of Leeds, UK) and a Bachelor of Social Sciences (Makerere University, Uganda).

Moses Kirigwajjo Nsaire is currently Programmes Officer with Uganda National Health Consumers /Users Organisation (UNHCO). He has combined experience of 16 years of implementing public health interventions with both local government and non-governmental organisations with a focus on capacity-building, community health systems strengthening and health policy advocacy at community and national levels. He is a holder of a Master of Science in Environmental Health and a Bachelor of Development Studies from Nkumba University, Uganda.

Peter Kivunike Mukasa, MBChB, M.Med (OBS/GYN), Dip SRHR, is the SRH/Maternal Health Analyst with UNFPA/MOH with a keen interest in and passion for policy and system strengthening for Sexual Reproductive Maternal Newborn Child and Adolescent Health.

Peter Lochoro is a public health physician and health manager, he has a medical degree from Makerere University and an MSc HSM from the University of London. He is currently the Country Representative of Doctors with Africa (CUAMM) and previously worked with the Uganda Catholic Medical Bureau where he contributed to development of the current national PPPH policy. He has been a member of several policy and technical working groups at MoH, including the PPPH Working Group and has published three articles on public-private partnership in health.

x Universal Health Coverage in Uganda

Peter Waiswa, MBChB, MPH, PhD, is an Associate Professor at the Makerere University School of Public Health and a Visiting Researcher at Karolinska Institutet, Sweden. He is also the Leader of the Makerere University Centre of Excellence for Maternal, Newborn and Child Health and the INDEPTH Network Maternal, Newborn and Child Health Working Group. He is a health policy, planning and systems researcher with expertise in maternal, newborn and child health in low- and middle-income countries.

Phyllis Awor is a Ugandan Public Health Physician with over 10 years of experience conducting health systems and operational research. She works at the Makerere University School of Public Health as a Senior Researcher, with responsibility for designing, implementing, monitoring and evaluating field programmes improving the quality of care for people in rural communities.

Remco van de Pas, MD, MScIH, is a medical doctor and a public health scholar. He is a researcher at the Institute of Tropical Medicine, Antwerp in the International Health Policy Unit, and a Visiting Fellow at Clingendael, the Netherlands Institute of International Relations. His PhD research focuses on governance for equitable globalisation of the health workforce. He teaches at universities and international courses on global health governance, diplomacy and policy coherence for health, with special attention to health workforce development and migration, health systems and social protection.

Roy William Mayega is a Lecturer in the Department of Epidemiology and Biostatistics at the Makerere University School of Public Health. His research interest is in the area of non-communicable diseases and their interface with the health system and communities in low-income countries. He holds a bachelor’s degree in Medicine and Surgery and a master’s degree in Public Health from Makerere University. He also holds a PhD in Medical Science from Karolinska Institutet, Sweden.

Sam SB Wanda is a retired Assistant Commissioner Health Services (Health Infrastructure) at the Ministry of Health, Uganda. He is a civil engineer with keen interest in health systems strengthening, particularly in synergy between physical infrastructure and medical equipment to enhance the functionality of health facilities and improve health care delivery. He has a wealth of experience in carrying out the above with funding from the government, AfDB, the World Bank, EU, JICA, NDF, GEF and CDC. He has an engineering degree (Makerere University) and an MSc (Loughborough University of Technology), and is a registered engineer in Uganda.

Sarah Byakika is a Public Health Specialist working as the Commissioner Planning and Policy at the Ministry of Health, Kampala, Uganda. She has over 2 decades of experience in the Ugandan health system.

Sebastian Olikira Baine is a Senior Lecturer in the Department of Health Policy, Planning and Management at the Makerere University School of Public Health. He holds a doctorate in Health Economics and Finance. He worked in the health sector for eight years and has been teaching for 24 years. He has researched in the areas of health economics and finance.

Simon Kalyesubula-Kibuuka provides monitoring and evaluation (M&E) technical support for the Laboratory Sub-sector at MoH, and is an M&E specialist for the East African Public Health Laboratory Networking Project (EAPHLNP) at MoH. Simon is an engaged scholar

xiContributors

with interest in health systems strengthening (HSS) and laboratory quality management systems (LQMS) in particular. He is a qualified and practising public health physician with an MBChB (Makerere University), a postgraduate diploma in International Health (Humboldt University, Berlin) and a master’s degree in Public Health (Heidelberg University, Germany).

Steven Ssendagire is currently a Senior Resident Mentor with the Health Policy Planning and Management Department of the Makerere University School of Public Health. Steven has practical experience and research interest in the coordination of outbreak management. He holds a bachelor’s degree in Pharmacy, a master’s degree in Public Health and a master’s degree in Business Administration.

Susan Babirye is a Research Fellow in the Department of Health Policy, Planning and Management at the School of Public Health, Makerere University. She holds a master’s degree in Public Health and a master’s degree in Research and Public Policy. Susan also received additional training in Monitoring and Evaluation from Uganda Management Institute.

Suzanne N. Kiwanuka is a Senior Lecturer at the Makerere University School of Public Health with more than 10 years’ experience in health systems and policy research, with a special focus on human resources for health, governance, maternal health and knowledge management. She holds a degree in Dental Surgery (University of Dar es Salaam), a Master of Public Health (University of the Western Cape) and a PhD (University of Bergen).

Timothy Musila is currently a Principal Health Planner in the Department of Planning in the Ministry of Health of the Republic of Uganda, where he heads the Public-Private Partnership in Health. He qualified as a medical doctor from the Makerere University Medical School and obtained a master’s degree in Health Policy, Planning and Financing from the London School of Economics and Political Science.

Tony Odokonyero is a Research Analyst attached to the Sectoral Department at EPRC. He holds a master’s degree in Economics and a bachelor’s degree in Economics from Makerere University. He also holds a postgraduate diploma in Research Methods and Skills from Maastricht University. Tony has also worked in the financial sector (banking and social security fund).

Vento Ogora Auma is a Health Systems Management Specialist with keen interests in health governance and human resources for health for universal health coverage. She holds a BA degree in Social Works and Social Administration (Makerere University), an MSc in Health Services Management (Uganda Martyrs University) and a Fellowship Award in Health Systems Management (Makerere University).

Xavier Nsabagasani has a PhD, an MA (Development Studies), a BA (SS) and a diploma in Health Research Methods. Currently he is the Research Coordinator Perform 2 Scale Project at the Makerere University School of Public Health. He is also a Research Associate, Child Health and Development Centre, College of Health Sciences, Makerere University. Nsabagasani is a behavioural and policy analyst with multi-sectoral experience in basic research (both quantitative and qualitative), monitoring and evaluation. His main contributions in research have been in the sectors of health, education, natural resource management and livelihood analysis.

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List of Abbreviations and Acronyms

AHSPR Annual Health Sector Performance Report AIDS Acquired Immunodeficiency SyndromeCAO Chief Administrative OfficerCG Central Government CHEWS Community Health Extension WorkersDHIS District Health Information SystemDHMT District Health Management TeamDHO District Health OfficeDLT District League TableDMO District Medical OfficerDS Decentralisation SecretariatDSC District Service CommissionEMHS Essential Medicines and Health SuppliesFDS Fiscal Decentralisation StrategyGAVI Global Alliance for Vaccines and ImmunisationGHI Global Health InitiativesHC Health CenterHIS Health Information SystemHIV Human Immunodeficiency VirusHMIS Health Management Information SystemHPAC Health Policy Advisory CommitteeHSC Health Service CommissionHSD Health Sub-districtsHSDP Health Sector Development PlanHSQIF Health Sector Quality Improvement FrameworkHSSIP Health Sector Strategic and Investment PlanHSSP Health Sector Strategic PlanHUMC Health Unit Management CommitteeJMS Joint Medical StoresKCCA Kampala Capital City AuthorityKCCAA Kampala Capital City Authority Act

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LC Local CouncilLG Local GovernmentLGA Local Government ActLGFAR Local Government Financial and Accounting RegulationsLGFC Local Government Finance CommissionLLG Lower Local GovernmentLMIC Low Middle Income CountriesM&E Monitoring and EvaluationMDG Millennium Development GoalsMoFPED Ministry of Finance, Planning and Economic DevelopmentMoH Ministry of HealthMoLG Ministry of Local GovernmentMoPS Ministry of Public ServiceNHIS National Health Insurance SchemeNHP National Health PolicyNMS National Medical StoresOAG Office of the Auditor GeneralPAF Poverty Action FundPEAP Poverty Eradication Action PlanPHC Primary Health CarePNFP Private-Not-for-ProfitPPDAA Public Procurement and Disposal of Assets ActPPPH Public Private Partnership for HealthPSC Public Service CommissionQA Quality Assurance QI Quality ImprovementRBF Results-Based FinancingRC Resistance CouncilRPMT Regional Performance Monitoring TeamsSDG Sustainable Development GoalsSWAp Sector-wide Approach to Health Development UF User FeesUHC Universal Health CoverageUNMHCP Uganda National Minimum Health Care PackageVHT Village Health TeamYSP Yellow Star Programme

xiv

Forewords

Makerere University

This book is a must-read for professionals in government concerned with improving health and well-being in Uganda and similar countries. The book is a product of capacity-building efforts to advance health policy analysis and advice at Makerere University to influence national policies and plans for universal health coverage in Uganda and similar countries. It is a culmination of numerous capacity workshops held by the SPEED Project over the last three years (2015 – 2017) to bring together academics and policy practitioners and programme experts to reflect on the past 10-15 years of health development in Uganda and advise on the future goals and strategies for advancing universal health coverage within the broad global agenda and commitments for Sustainable Development Goals.

This partnership and the analyses highlighted within this book have inspired the development of the Centre for Health Policy and Systems Development to champion and sustain the work started by the SPEED Project of the University. This book is a tribute to the remarkable accomplishments that partnerships between academia, government and policy-oriented civil society can bring to the field of policy analysis and influence for better health and well-being. Makerere University is proud of this book – a landmark in the field of health policy in Uganda and among communities seeking to advance population health and well-being around the globe.

Prof. Barnabas Nawangwe Vice Chancellor Makerere University, Uganda

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Ministry of Health

As the Government of Uganda repositions its policies and strategies towards Sustainable Development Goals by 2030, this book comes at an opportune time for decision-makers in government, in the health sector and in the development community. There is urgent need for evidence-informed policy advice to scale up health interventions and improve the performance of the health system to support the expanding health needs of the population.

Over the past three decades, Uganda has witnessed major improvements in population health, especially with regard to child survival, care programmes for HIV/AIDS, and epidemic management and control , to mention but a few. In Uganda, like in other developing countries, many studies have been conducted, many service delivery models have been tested and many technical assistance programmes have come and gone. This book provides an in-depth understanding of the policy trade-offs, especially in resource-constrained countries like Uganda. Among others, the book provides useful advice on how to expand the fiscal space for health while leveraging health benefits from other sectors of the economy, and ways to manage the rapidly growing population and the health needs thereof. The key actions for mitigating the escalation of costs associated with scaling up health interventions and boosting service quality are also highlighted.

This book stands out as a tremendous source of policy advice for all colleagues working in government with the goal of advancing the health of Ugandans and populations across the globe. I am confident that many policymakers and health service leaders and managers at national and sub-national levels will find this book very resourceful and a key reference for personal professional advancement and collective improvements of the policies, programmes and implementation arrangements for better health outcomes. I also take pride in the work that the SPEED Project has undertaken in producing this work and the policy analysis capacity built within the team of authors during the production of the book. On behalf of Government, I thank the European Union and Commission for making available resources, both financial and technical, for this work and the leadership of the SPEED Project and Makerere University for a job well done.

Hon. Dr. Jane Ruth Aceng Minister of Health Ministry of Health, Republic of Uganda

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The European Union

In 2014, at the moment of the outbreak of Ebola in West Africa, I was serving as Ambassador of the European Union to Liberia. The country and the whole region faced the deadliest, longest, and most complex outbreak since Ebola first emerged in 1976. I have thus learnt how imperative it is for a country to develop a solid public health system to respond to emergencies and, above all, to prevent their occurrence as well as to cooperate closely with neighbouring countries and with international partners.

Through the Support to Public Health Institutions Programme (SPHIP), the European Union supports actions aimed at improving decision-making capacities and processes of national authorities in low-income countries. This goal will be achieved through enhancement of expertise, knowledge and resources of selected schools and institutes of public health, provision of training and evidence-based policy advice, and improving monitoring of policy implementation. When the SPHIP global call for proposals was launched in 2013, the action proposed by the Makerere University School of Public Health was one of the selected proposals. That is how Supporting Policy Engagement for Evidence-based Decisions–SPEED–came into being.

Therefore, I wholeheartedly congratulate Makerere University for having successfully competed and succeeded in this global call for proposals and having thus demonstrated the capacities of such a renowned Ugandan institution and its partners.

I am particularly pleased by the policy advice that is reflected in this book. It is the result of the policy analysis expertise built within the Makerere University School of Public Health thanks to the enriching partnership, established within the SPEED project, among Ugandan and international public health institutions.

The book addresses the various facets of evidence and themes necessary for policy and programme actions that can accelerate the achievement of Universal Health Coverage and the realisation of the Sustainable Development Goals (SDGs) for good health and wellbeing. Better sector governance, increased policy coherence across sectors, and knowledge generation for evidence-based decisions are central components of public health. All these aspects are very well articulated in several chapters of this book.

I strongly believe that building policy guidance from local experts and institutions, especially schools of public health, is the most sustainable way to build a country’s own systems.

On its part, globally the European Union continues to provide support to broader health system strengthening, health planning, health financing and policy dialogue which will all contribute directly towards Universal Health Coverage.

I congratulate the SPEED project team and leadership, project partners, and all technical assistance that has been provided through the EU Headquarters in making this project a success. I believe that this book will benefit policy makers, programme-level practitioners and researchers both in Uganda and beyond.

Attilio PacificiAmbassador – Head of Delegation

European Union Delegation to Uganda

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Acknowledgements

This book serves as a compendium of reflections and analyses by policy and programme practitioners, academia and civil society on the recent history, state of the art and priority actions for steering health policies and system developments for improving well-being and population health. Although the reflections are based on Uganda’s experiences, many health development practitioners, policymakers and scholars will find this book relevant to their undertakings.

The specific chapters were devised from the perspective of applied policy analysis – where policy problems are analysed from vital perspectives of stakeholders, beneficiaries and systems capabilities. Unlike conventional analyses, policy analysis seeks to explicate the problem within its real-life context. Applied policy analysis was used to clarify and frame the problems for policy actions and innovations. In this process, the authors make attempts to find actions and entry points to resolve the problems within the context of vital stakeholders, resources and institutions. This is vital to identifying the technical and political economy variables that are central to understanding the problem and identifying feasible solutions. The book is a product of capacity -building in policy analysis for those that were involved in its preparation – more importantly, the purpose of the book is to contribute to accelerating universal health coverage programmes by providing fit-for-purpose advice to decision makers in government, development partners, academic and civil society. The central questions that this book set out to address were: 1) Where are the strength and challenges in Uganda’s health system developments? 2) What are the strategic directions for Uganda to address UHC? 3) What changes are necessary for building strong and resilient health systems?

This book is a product of the Support to Policy Engagement for Evidence-based Decisions (SPEED) project – a partnership whose aim is to advance universal health coverage by providing policy analyses and advice to the Government of Uganda and similar countries. The SPEED project is financed by the European Union through its Commission in Brussels as part of the EU initiative to support schools of public health to improve their capacity in health policy analysis and health policy advice to their countries. Dr. Freddie Ssengooba (Associate Professor in Health Policy and Systems Management) led the project team in writing and editing this book with

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Dr. Elizeus Rutebemberwa, Dr. Suzanne N. Kiwanuka and Dr. Elizabeth Ekirapa-Kiracho from Makerere University School of Public Health.

The book was prepared by a multidisciplinary partnership with experts from the Economic Policy Research Centre at Makerere University, the National Planning Authority, Uganda National Health Consumers Organisation and with collaboration with other experts from the government and academia in Uganda and experts from the Human Sciences Research Council in South Africa and the Institute of Tropical Medicines in Antwerp, Belgium. These organisations together with the Makerere University School of Public Health form the partnerships for the SPEED project that aims to advance universal health coverage in Uganda.

The authors are grateful to the many persons who provided technical support, comments, reviews and ideas at the different stages of the preparation of the book. These include Jane Ruth Aceng (Hon. Dr. Minister of Health, Uganda), Barnabas Nawangwe (Professor and Vice Chancellor, Makerere University), Elizabeth Ongom (Senior Advisor, Social Sector EU Mission Kampala), William Bazeyo (Professor and Deputy Vice Chancellor, F&A and former Dean MakSPH), Koot Jaap (Professor and Team Lead – EU Monitoring Facility for SPHIP), Timothy Musila (Dr. Principal Planner Ministry of Health), Julius Ocwinyo (Editor, Fountain Publishers), as well as Mrs Enid Kemari (Coordinator Engagements - SPEED Project) for their overall support during the process of preparing this book.