who country cooperation strategy · the uganda country cooperation strategy is part of a corporate...

WHOCOUNTRY

COOPERATIONSTRATEGY

UGANDA

World Health Organization

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The Uganda Country Cooperation Strategy is part of a corporate effort to develop and improveinstruments for articulating WHO’s strategic agenda in and with countries. This document isthe result of a pilot process intended to contribute to strengthening WHO’s country work inthe context of the Organization’s corporate strategy.

The designations employed and the presentation of the material in this document do notimply the expression of any opinion whatsoever on the part of the Secretariat of the WorldHealth Organization concerning the legal status of any country, territory, city or area or of itsauthorities, or concerning the delimitation of its frontiers or boundaries.

WHO/CCS/2Distribution : GeneralOriginal : English

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1 INTRODUCTION

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Uganda is undergoing rapid reforms in most of its development sectors and in thehealth sector in particular. Recent developments such as the revision of the nationalPoverty Eradication Action Plan, formulation of its Comprehensive DevelopmentFramework and Poverty Reduction Strategy Paper, and the United NationsDevelopment Assistance Framework, all contribute to making a fundamental review ofthe role and work of WHO in the country very timely.

This document - the WHO Country Cooperation Strategy (CCS) - sets out thestrategic directions and medium term (3 to 5 years) agenda of work in and withUganda for the entire WHO Secretariat.

Through the CCS, WHO aims to be more responsive to country needs by being moreselective and focused in its areas of work and the actual functions it performs withinthose areas.

The WHO Corporate Strategy, the AFRO orientations, the Uganda National HealthPolicy and the National Health Sector Strategic Plan inspire the CCS. Within theboundaries defined in the Corporate Strategy and the priorities set by the WHOExecutive Board, the CCS aims to provide an optimum balance between the needsand expectations of the country on the one hand, and the collective priorities andcomparative advantage of WHO on the other, fully taking into account the activities ofother development agencies. WHO will seek to support national capacity buildingand seize every opportunity for maximising synergies and complementarity with otherdevelopment partners.

Introduction

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Health and Development Challenges

2 HEALTH AND DEVELOPMENT CHALLENGES

Continuing the Recovery

Fourteen years after the National Resistance Movement came to power in 1986,Uganda is still recovering from the preceding twenty years of misrule and civil war.Since 1986, the country has been relatively stable. Insecurity remains a concern withcontinuing conflicts in the North and on the border with the Democratic Republic ofCongo (DRC).

The country has undergone major political and economic reforms, includingeconomic liberalisation, privatisation, downsizing of the public sector anddecentralisation. These reforms continue today. The 1990s saw steady andconsistent real economic growth averaging about 7% per annum, with an averageannual inflation rate of 5%. Subsistence agriculture still dominates the economy, withcoffee accounting for 50% of export earnings. As a result, the economy remainsvulnerable to fluctuations in the weather and in international coffee prices.

Despite considerable growth, incomes in this landlocked nation of 22 million peopleremain below 1970 values in real terms, with a per capita GDP of US$ 348 in 1997.Significantly, growth in incomes has been uneven. Whilst absolute poverty has beenreduced from 56% to 44% over the period 1992 to1997, with the central region andcash crop farmers benefiting most, the poorest 20% of Ugandans appear to havebecome even poorer. Urban areas and men did better than rural areas and women. Inthe Human Development Index of 1999, Uganda ranked 158th out of 174.

The three major areas of policy focus for government remain poverty reduction,decentralisation and good governance:

Poverty reduction

Uganda has been implementing a poverty reduction strategy since 1997. The mainfeatures of the strategy are economic growth, macro-economic stability, andinvestment in universal primary education, primary health care, rural access roadsand agricultural extension.

The Poverty Eradication Action Plan (PEAP), which was formulated following twoyears of extensive consultation, has recently been revised and expanded to serveboth as the national development framework and as Uganda’s Poverty Reduction

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Strategy Paper (PRSP). It is expressly linked to the national Medium TermExpenditure Framework (MTEF), within which line ministries negotiate and receiveglobal budgets through a highly transparent and broadly representative budgetframework development process.

A Poverty Action Fund (PAF), initially created to ensure that debt service savingswere used for poverty eradication, is fully integrated into the Government budget. Inaddition to being used to protect priority expenditure areas, it has become the mainconduit for direct budget support. A quarterly meeting of Government, donors andrepresentatives of civil society closely monitors the Poverty Action Fund. For addedtransparency, all releases from the fund are published in the national press.

Decentralisation

The major decentralisation of authority to district councils has its origins in thevisions of the National Resistance Movement and serves primarily political objectives- putting in place a more democratic, accountable and participatory government.A 5-tiered local government structure has been created with the District LocalCouncil 5 (LC5) at the pinnacle, LC4 at county level, LC3 at subcounty, LC2 andLC 1 at parish and village levels respectively. The policy is enshrined both in the 1995Constitution and in the 1997 Local Government Act. Almost all sectors have beenaffected. The district councils now employ most district staff. They receive blockgrants from the recurrent budget, which they allocate as they choose. Councils alsoreceive conditional grants, such as the primary health care grant, whichare strictly earmarked for defined national priorities that are expected to havedirect impact on the welfare of the poor. For the present, the capital budgetremains centrally managed.

So far, the capacity of districts to generate resources locally, and therefore the abilityto contribute significantly to their own budgets, remains very limited and is virtually nilin the country’s poorer districts. In the context of the 2000/2001 national budget,equalisation grants were introduced on a trial basis, the objective being to close thedevelopment gap between richer and poorer districts.

As a means for improving the management and delivery of services, decentralisationin Uganda has yet to fulfil its potential.

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Good governance

The Government of Uganda is introducing strategies to increase accountability,improve gender balance and curb widespread corruption in all institutions. Regardingthe health sector, the 1999 report of the Uganda Participatory Poverty AssessmentProject revealed widespread consumer dissatisfaction with both the quality of serviceand the confusing array of official and unofficial charges being demanded in publichealth facilities. These findings were also highlighted in the National Integrity Survey.

The government’s anti-corruption plan includes strengthening the judiciary andholding public hearings; recruiting more accountants and auditors; undertakingextensive reform of procurement procedures; increasing public awareness throughpublic debates and hot lines; and fostering a free and active media. As a result, notonly have there been several resignations, but senior civil servants and governmentministers have been convicted and jailed for their offences.

The Government also supports financially the constitutionally established UgandaCivil Rights Commission, which is fully independent.

Health Profile

The health status of Ugandans is amongst the worst in the world, in part the legacyof the loss of infrastructure and human resources during the war years, and of theAIDS epidemic. In the World Health Report 2000, Uganda ranks 186th out of 191countries worldwide for level of health. A life expectancy of 42 years, the same as in1960, compares unfavourably with an average of 52 years for sub-Saharan Africa. Theinfant mortality rate is officially estimated at 97 per 1000 live births, almost the sameas it was in 1980, compared with an average of 90 in the region. Estimates ofmaternal mortality differ widely (from 506 per 100,000 live births according togovernment statistics to 1200 according to WHO and UNICEF) but are all very highby any measure. The Uganda Participatory Poverty Assessment Project found illhealth the most consistently cited reason for persisting poverty in Uganda. Childrenand women bear a disproportionate burden of ill health and premature death. The1995 Burden of Disease study estimated that over 60% of life years lost frompremature death could be attributed to five groups of preventable conditions. Manyare associated with poor living conditions. Poor physical access, low quality of health

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care and low utilisation of health services also contribute. There are considerabledifferences between regions and districts, although health inequalities are lessmarked than in other countries in the region.

Peri-natal and maternal conditions

These are estimated to account for 20% of the total disease burden. Multiple factorscontribute: poverty; high fertility; low percentage of attended deliveries and limitedaccess to qualified care in emergencies; low standards in hospitals and a perceivedhigh and unpredictable cost of public services.

Malaria

Malaria is the largest single cause of ill health and highly endemic in 90% of thecountry. It accounts for up to 40% of outpatient attendances and 14% of inpatientdeaths. The rapid spread of chloroquine resistance, fake or unwholesome drugs, andchanging environmental conditions all contribute to the exacerbation of the situation,with frequent occurrence of epidemics.

HIV/AIDS and tuberculosis

AIDS is the leading cause of death in adults and the main cause of falling lifeexpectancy. Encouragingly, prevalence rates now appear to be declining: while HIVsero-prevalence among women attending antenatal clinic in the sentinel sites is 9.7%- a drop from 30% only 5 years earlier -, the overall national rate was estimated in1998 at less than 2%, with a sero-incidence rate of 3.2/1000 person years ofobservation. But rapidly rising rates of mother-to-child transmission are a majorcause for concern. Closely associated with HIV is the rapidly rising number of TBcases, with an estimated incidence of 320 per 100,000 based on current estimates of3% ARTI (annual risk of TB infection). Over 60% of all new cases are associated withHIV/AIDS. Multi-drug resistance is an emerging additional complicating factor.

Diarrhoea, including cholera

Diarrhoeal diseases remain a major cause of mortality and morbidity, particularly inchildren. Recent outbreaks of cholera have attracted much publicity. In 1999, only

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49% of the population were estimated to have access to safe water, compared with85% in the early 60s and only 48% had access to sanitary latrines.

Measles, immunization and malnutrition

Outbreaks of measles epidemics associated with declining immunisation coveragenow occur with regularity. The highest estimated EPI coverage was 60% in 1990. Bythe late 1990s, sample surveys in two districts found coverage of 23% and 34%respectively, compared with routinely reported values of 64% and 83%. The 1999coverage survey report of the MOH indicated that only 44.3% of the target populationwere fully immunised. Although Uganda is among the few countries in the region thatare self-sufficient in food, almost half the under-fives are chronically malnourished,mainly as a result of poor feeding practices and repeated infections.

Non-communicable diseases

Trauma/accidents, and a heavy burden of mental illness resulting from poverty, thecivil wars and AIDS, are rising and being increasingly recognised as significantcauses of morbidity and mortality. Chronic non-communicable diseases related tounhealthy life styles are also on the increase. According to recent surveys, 58% of allyouth are reported as smokers. Substance abuse is on the increase as well.

Health Sector Development

The health sector has faced many challenges since 1986. New health problemshave been added to persistent old ones. Uganda is trying to provide services for alarger and rapidly expanding population with fewer resources than in the 1970s. Thesector has had to respond to the government-wide decentralisation of authority oversector funds and staff to 45 (now increased to 56) elected district councils, and to amajor civil service reform programme with extensive retrenchment of local staff.

Health expenditure accounts for 4% of the GDP (about US$ 14 per capita). However,the public share of total health expenditure remains rather low (approximately US$ 6per capita per annum, including donor funds). This level of total health expenditurecan barely meet the estimated cost of the minimum package alone, as indicated inBetter Health in Africa, despite the fact that the health share of government

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expenditure has risen from 4% in the mid-80s to 10% to 12% over the last few years.By comparison, the defence budget, which has been rising with the recent insecurity,fluctuates between 12-20% of government expenditure.

The principal actors in the health sector are the Ministry of Health (MOH), the localcouncils and the religion-based non-profit organisations. In accordance with theconstitution and local government law, primary health care service delivery has beenfully devolved to the local councils. The MOH is responsible for policy development,regulation, standard setting, supervision and monitoring of performance. It alsoretains responsibility for secondary and tertiary referral hospitals, and for nationalservices, such as epidemic prevention and control, integrated disease surveillanceand national blood transfusion services.

Recent work in formulating the new health policy and strategic plan, andgovernment’s commitment to work with its partners in health development through atransparent sector-wide approach, has clearly demonstrated the determination of thecurrent health leadership to attain a more effective and accountable health system.Nevertheless, considerable efforts will be needed to change the perception that thereis a wide gap between health policy and implementation, and that the sectorperforms poorly overall.

Key challenges to be addressed include:

Improving access and quality

There is low and uneven access to care. Around half the population has no access tomodern health care. Trained health workers are inadequate in numbers, unevenlydistributed, and generally poorly motivated and supervised. Many of the primary carefacilities are grossly understaffed, especially in rural areas where 87% of thepopulation live.

In 1999, only 34% of established posts in the sector were filled by qualified staff, therest being occupied by unqualified nursing aides or remaining vacant. Utilisation ofpublic facilities is low. Outreach services have declined. Amongst the leasteducated, only 23% have a trained attendant at delivery. A large part of the healthphysical infrastructure that exists remains dilapidated and poorly equipped.

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A major subject of debate in the health policy development process has been therelative balance between increasing physical access through additional infrastructureon the one hand, and increasing the utilisation of existing facilities through improvedquality of care on the other. At this stage, strengthening human resources capacityand funding drug supply and other operating costs for existing facilities would seemto be the key to improving performance.

Government health workers: incentives and performance

Salaries and conditions of service for health workers, though improved of late, remainfar from adequate and paying a living wage remains an issue. The consequentproblems related to the widespread diversion of public resources (staff time, drugs,equipment, fees collected), euphemistically referred to as “dual employment” or“survival strategies of health workers”, are among the biggest challenges facing thesector. Staff morale and performance in general remain low.

An additional challenge for the overall coordination of human resources is that healthworkers, except for central appointments, are now hired and managed by DistrictService Commissions. Due to lack of resources, these commissions are barelyoperational in many districts, with the unintended consequence of further widening ofthe staffing gap between districts. The Ministry of Finance recently releasedadditional grants from the Poverty Action Fund to assist the weaker districts inrecruiting staff. So far, there appear to be no effective mechanisms to redistributestaff within or between districts. The National Health Service Commission iscurrently looking into staff performance and related issues.

One area flagged for urgent attention is salaries: getting better information on thewage bill (the central payroll is not disaggregated according to sector), payingsalaries on time, and settling long outstanding and still accumulating salary arrears.

The many and varied private providers

It is generally acknowledged that non-profit providers deliver more efficient servicesthan government facilities. Although only one third of all heath facilities are mission-managed, these institutions provide over 50% of curative care in rural areas. TheMOH increasingly recognises the contribution of these providers and has reversedthe downward trend in government subsidies to them.

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The new health policy and strategic plan place great emphasis on collaboration withthe private sector. In addition to embracing non-profit providers, the plan also providesfor sub-contracting selected functions to private for-profit entities. The policy on thelatter has yet to be put into practice on a significant scale, however.

Except for the large urban areas, private for-profit care is largely unofficial, oftenprovided by public employees, as indicated in the previous section. Registration andother regulatory mechanisms remain weak.

Integrated surveillance

Improving the effectiveness of health services requires timely and accurateinformation on disease incidence and trends. Uganda is prone to natural and man-made disasters and epidemics. Recent outbreaks of cholera, malaria, and latelyEbola Fever, have highlighted the need for a more effective national emergency anddisease surveillance system. The country has been one of the first in the region toadopt an integrated surveillance system. It has been introduced in all districts but isnot yet fully operational.

Strategic planning, the resource envelope and resource allocation

The Health Sector Strategic Plan (HSSP) is organised under five major elements : i)priority diseases and conditions that together constitute the Uganda NationalMinimum Health Care Package, ii) organisation and management of the health caredelivery system, iii) the legal and regulatory framework, iv) support services, and v)policy, planning and information system, research and development.

The Uganda National Minimum Health Care Package is an important part of thestrategic plan, intended to guide investment in district health services. Malaria,common childhood illness, HIV/AIDS/TB, safe motherhood and childbirth,immunisation, and mental health are included. Whilst technical strategies andstandards are available for individual programmes, guidance is needed on how tomake the integrated package operational at facility level.

Following extensive discussions by all development partners, the proposed capitalcosts have now been reduced, significantly narrowing the gap between the cost ofthe plan and the total resource envelope.

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The fact that the development budget, which contains most of the donor funds, hasyet to be decentralised, poses significant challenges to the central programmemanagers in fully transferring implementation responsibilities to the District Directorsof Health who are the legitimate operational managers of the district health services.

Whilst the HSSP is supposed to be a strategic national document with operationaldetails to be worked out by districts, there is a risk both of over-elaboration atnational level, and burdening the already stretched district teams with too muchdetailed planning. It is noteworthy that as many as 27 drafts of the HSSP wereproduced and reviewed over a period of more than two years, before government andits development partners pronounced it to be satisfactory.

As in most countries, resource inputs rather than outputs have been the traditionalfocus of performance monitoring. The recent civil service reform requiring a shifttowards ‘result oriented management’, and ‘output oriented budgeting’ was initiated inthe 2000-2001 financial year. Three indicators have been selected for monitoringhealth sector performance under the poverty reduction strategy, and these are amongthe 20 sector monitoring indicators agreed upon by government and its developmentpartners under the SWAp (see section 3).

Health sector decentralisation

Ensuring implementation of national health priorities has become more complexunder decentralisation. There remains concern about the capacity of districtauthorities to plan and manage service provision, and of the central ministry to play amore strategic and advisory role. Many councils interpret the provisions of theConstitution and the 1997 Local Government Act as giving them total autonomy toplan, budget and expend as they see fit, sometimes in direct conflict with nationalpriorities, and this continues to pose major difficulties. Early experience showed thatdistrict councils had little inclination to spend on health; when they did, they favouredhospitals over primary care. Spending on health dropped by one third during the firstyear of decentralisation to district councils.

In response to this dilemma, central government has progressively increased theconditional grants relative to the discretionary block grants. The districts and someof the development partners see this as “disguised re-centralisation”. As a result ofconditional grants for primary health care, a significant shift in resources for health

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has been experienced, with district health systems (which include district hospitals)taking 69% to 74% of the total health budget starting in July 2000. In contrast, withthe exception of designated national service functions, the budgets of the centreincluding the referral and national hospitals are pegged at current levels, allowing onlyfor inflation-related increases.

There has been a protracted debate as to the level of decentralisation most relevantto primary health care. The question of how best to link local government budgetholders with the appropriate referral and service delivery level for health is now beingresolved, and further work on the role and responsibilities of the sub-district level isunder way.

Health financing

The Ministry of Health has recently begun to tackle the previously neglected issue ofuser fees and health insurance. Out of pocket payments account for nearly two thirdsof total health expenditure. Unofficial public sector user fees have been widespreadfor many years. Cabinet has now approved the MOH proposal on user fees as a firststep to improving their haphazard application. The approval is only in principle,pending clear provisions for protecting the poor and improving accountability.Exploring risk-sharing mechanisms is currently limited to health insurance in theformal sector and pilot community insurance schemes.

With regard to increasing the share of the health sector within the government’soverall expenditure framework, the Ministry of Finance is reportedly ready to investmuch more in the health sector, provided it can demonstrate value for money. Theonus is on the Ministry of Health to make its case.

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Development Assistance

3 DEVELOPMENT ASSISTANCE: AID FLOWS, INSTRUMENTS AND COORDINATION

Overall Trends in Aid

Uganda’s efforts at reforming its national development strategy predate the currentinternational interest in the management of official development assistance andpoverty reduction. Since 1995, the Government of Uganda has been seriouslyengaged in a continuing dialogue with its development partners, with a view toincreasing the effectiveness of its rehabilitation and development programme througha more rational integration of external development assistance with locally generatedresources.

Uganda has adopted a highly pragmatic approach to linking its national efforts andinitiatives with recently devised international instruments for development cooperationand partnership. As indicated earlier, the National Poverty Eradication Action Planserves as Uganda’s Comprehensive Development Framework and Poverty ReductionStrategy Paper for agreements with the IMF and World Bank.

On average, donor support has amounted to almost 10% of GDP since 1986, witharound two thirds provided in the form of grants. About 80% of the Government’sdevelopment budget is donor funded. In its presentation at the Consultative Groupmeeting in April 2000, the Government estimated that after taking into account thelevel of resources it expects to mobilise through taxes and other revenue measures,the anticipated level of debt relief (HIPC1 and 2) and previously agreed donor flows, itwill additionally require approximately US$ 800 millions per annum to fully fund itsdevelopment programme. The Consultative Group endorsed the Government’s plansand committed itself to continue to increase the shift towards sector funding andbudget support.

Towards a Sector-wide Approach for Health Development

In the health sector, donors provide well over half the total resources: they fund 90%of the capital and 33% of the recurrent budget. Until recently, donors have mostlyfinanced primary health care through a variety of projects with varying content, modesof operation and geographic coverage, resulting in a form of “balkanisation” of thecountry, and perpetuating inequities between districts. Duplication co-exists with

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gaps in financial and technical support. This pattern of support imposes a greatburden on an already over-stretched national management capacity. One of the mostimportant recent developments in the health sector is the agreement of thegovernment and its donor partners to support a common programme of actionthrough a sector-wide approach (SWAp). The Memorandum of Understanding (MOU)involves 23 funding and development agencies. Key agencies supporting health arethe African Development Bank, Austrian Agency for International Development,Belgian Co-operation, DANIDA, DFID, the EC, FAO, French Co-operation, GTZ,Ireland Aid, Italian Co-operation, JICA, Netherlands Co-operation, NORAD, SIDA,USAID, UNDP, UNICEF, UNFPA, UNHCR, the World Bank and WHO.

In addition to defining the objectives of the SWAp, the MOU lays out sharedobligations, modalities and structures for cooperation among the partners (planning,monitoring, review and reporting, financial systems, procurement, conflict resolution,inclusion of new partners) and procedures for amendment or termination of the MOUitself. The MOU dictates that all resources available for health be applied within theframework of the sector strategic plan and in accordance with the priorities settherein.

The role of the World Health Organization in these processes has been significant. Ithas been designated as the focal point for health for both the UN and other donoragencies in the PEAP and the budget framework paper development processes.WHO also chairs the joint GOU/Health Partners Consultative Meeting and is a keymember of each of the management and coordination structures of the SWAps.

Within this context, and in addition to their contribution to a common fund, mostdevelopment agencies continue to support specific geographical areas and/or aparticular programme focus. The African Development Bank and the World Bank areinvolved in infrastructure rehabilitation and development. UNICEF is deepening itsfocus on community-level activities and advocacy using the rights based approach.UNFPA and USAID are concentrating on population issues and sexual andreproductive health, with emphasis on gender issues and women’s rights. UNAIDS,WB, USAID and NORAD have major inputs in HIV/AIDS. The ADB is especiallyconcerned with mental health, the EU with human resources, blood transfusion andreproductive health; DANIDA with district capacity building in health servicemanagement, the national medical stores and the health information system. Some

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donors support various types of training and management capacity building. TheWorld Bank, UNDP and DANIDA also work on the broad sector reform and buildingplanning capacity in districts nation-wide. WHO’s current programme of cooperationis presented in section 4.

Coordination Structures

In addition to the fortnightly meetings of the Joint Health Policy Advisory Committee,the GOU/Health Partners Consultative Meetings take place twice a year : the first ofthese is to review the performance of the Partnership and the Health Sector StrategicPlan; the second is to examine the draft detailed annual sector plan and budget forthe following financial year.

There is growing risk of conflict and confusion between these new coordinationstructures and earlier pre-SWAp mechanisms, such as the Social Sector sub-groupof the main donors meeting, which continue to operate in parallel with the newerones.

Result-orientation and Performance Measures

The framework that the Ministry of Finance is trying to introduce involvesperformance-linked contracts for the different sectors. This will take time to develop.The Government and its external partners at times seem to be stuck in a policyformulation and planning process underpinning a sector-wide approach on the onehand, whilst on the other hand, project support and direct assistance to districts stillprevail. The speed and extent of decentralisation compounds some of the difficultiesexperienced in setting up institutional frameworks and management systems.

A key issue is how to help the country move forward with policy action through anenabling institutional environment with adequate incentives and performanceindicators. Agencies have a responsibility in supporting the process throughidentifying performance indicators and benchmarks that constitute incentives forimplementation.

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National Development Framework, Sector Plans andAgency Business Plans

The Government of Uganda has indicated that it wishes all external partners tocontribute to one national development framework at macro level and, within that, toone common programme for each sector. It also wishes to see increasinglycombined approaches to assessing needs and developing strategies, putting an endto multiple and often duplicative efforts of individual or groups of selected agencies.Whilst all agencies’ strategies for cooperation are to feed into common macro andsector frameworks, it is understood that each agency will prepare its own businessplan for approval by its own management in a way that will not unnecessarilycontribute to an already heavy burden of donor coordination and aid management inthe country.

In the case of the United Nations, the CCA (Common Country Assessment) and theUNDAF (United Nations Development Assistance Framework) represent not only aneffort to harmonize the UN’s programme of work, but also an opportunity to articulateand promote the UN’s common value framework in terms of overarching and cross-cutting themes (governance, human rights, gender, HIV/AIDS). Like other agencybusiness plans, the UNDAF is a contribution to the government’s comprehensivedevelopment framework. Its modus operandi is, however, characterized by a projectapproach rather than budget or sector support.

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Current WHO Country Programme

4 CURRENT WHO COUNTRY PROGRAMME

The Changing Pattern of WHO Operations in Uganda

In the second half of the 80s, WHO co-operation with Uganda was very much in linewith the need for rehabilitation and reconstruction after a decade that left the countryin total disarray. This included direct support to the establishment or re-establishment of priority programmes such as GPA, MCH/FP, EPI, the protection ofwater sources, the re-building of capacities in the MoH and the medical schoolsthrough staff and equipment, and even extended to the rehabilitation of physicalinfrastructure.

As national capacity was re-established, the pattern of support shifted towards theformulation/review of policies, strategies and guidelines for priority technicalprogrammes and other key areas such as human resources, managementinformation systems, and overall planning and management. The support alsoincluded execution of projects on behalf of other development partners (e.g. UNDP,UNFPA).

The 1998/1999 biennium saw the finalisation of the National Health Policy and 5-YearHealth Sector Strategic Plan (HSSP), which were approved by Cabinet in October1999. They provide the framework for collaboration in health in Uganda.

Current Areas of Work and Main Functions

Today, in addition to high level advocacy for health within the context of povertyreduction, WHO in Uganda gives broad support to overall health sector development,a key priority for the country, and more specific support to selected technicalprogrammes, projects and initiatives. The WHO programme budget for 2000-2001 inUganda has seventeen areas of work:

? health sector development, including health policy and strategy development,institutional reform and forging partnerships, an area in which both Governmentand the development partners consider WHO to have comparative advantage.This support focuses on the SWAp process currently under way in Uganda andclearly articulated with the broad socio-economic frame of the PovertyEradication Action Plan and medium-term expenditure framework. WHO plays animportant role as a broker between the Government and its external partners andas an adviser on policy issues.

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? health systems development, the second most important area of focus for WHO,with emphasis on support to the formulation of the medium-term national healthinfrastructure development plan; the development of the newly created healthsub-districts, including sub-district planning and implementation, and communityhealth financing; the finalisation and implementation of the human resourcespolicy and plan; the revision and strengthening of the national healthmanagement information system; the coordination of national health research,and studies on impact and comparative cost effectiveness of selected healthinterventions within the minimum package. A significant fellowship programmealso falls under this area of work.

? health in sustainable development, within which WHO provides advocacy both onthe integration of health within the broad development frame and on the centralrole of health in poverty reduction. The Organization also assists in promotingintersectoral action for health, and supports local studies on the health impact ofmacroeconomic policies.

? communicable diseases, with three areas of work: prevention and control,eradication and elimination, surveillance and response. Those address malaria,STD/HIV/AIDS, TB, diseases targeted for eradication or elimination, and selectedendemic diseases such as lymphatic filariasis, onchocerciasis andtrypanosomiasis. Key elements in those areas are: the establishment of anintegrated disease surveillance and response system, the technical review ofpolicies and guidelines, the introduction of new vaccines into EPI, injectionsafety, and operational research.

? sexual and reproductive health, and child and adolescent health. The work ofWHO in these two areas forms part of global projects for the development oftools and technologies. They involve support to policy and strategy development,quality assurance, district capacity building, provision of supplies and equipment,and monitoring.

? protection of human environment, which involves work on the finalisation andoperationalisation of the national environmental sanitation policy and plan, waterquality surveillance, healthy settings and chemical safety.

Under the last six areas of work, WHO supports selected national programmes andregional/global initiatives such as polio eradication, Roll Back Malaria, Safe

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Motherhood - through the mother-baby package1 , EPI, IMCI, safe water andsanitation, healthy schools and healthy cities. WHO also executes projects onbehalf of other agencies.

? emergency preparedness and response, with emphasis on building capacity forsurveillance, risk mapping, and national and district response.

? essential drugs and other medicines, the area of work with perhaps the highestpotential for derailing achievement of the main targets set for the health plan, andthreatening the still fragile SWAp partnership. WHO support is focused on thedevelopment of the national drug policy and regulatory framework, and onstrengthening national and district capacity for drug management, includingprocurement and rational use.

? social change and mental health, substance abuse, disability prevention andrehabilitation, health of the elderly, women’s health. Those areas involve relativelylimited WHO resource inputs (human or financial), e.g. assistance in thefinalisation of the mental health policy, plan and legislative instruments; supportto the Ministry of Gender for data collection with a view to formulating a healthprofile and a national policy for the elderly, generating gender disaggregated dataand formulating the national policies on women and on gender and domesticviolence; and collaboration in the finalisation of the policy and plan on injuries,disability prevention and rehabilitation.

? health information management and dissemination. The information function cutsacross all areas of work, with, among other actions, an effort to further developthe WHO information and documentation center, provide the “blue trunk library” toadditional districts, and avail access to information technology to district healthoffices and key health related agencies of government.

Partnerships

Most of the work programme involves collaboration with other development agencies,for instance: the EU and Ireland Aid on human resources planning and development;DFID, Italian Cooperation, WB, NORAD, UNAIDS, UNICEF and USAID oncommunicable diseases; ADB on mental health; DFID, USAID, UNFPA, UNICEF,EDF on reproductive health; a local NGO on tobacco.

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1 It is not clear in Uganda whether the name should change to «making pregnancy safer» and what actual shifts this would mean.

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WHO is a lead co-operation agency for policy and strategy development in selectedtechnical programme areas and initiatives: reproductive health/family planning,Expanded Programme on Immunization and polio eradication, HIV/AIDS, adolescenthealth, Roll Back Malaria, Integrated Management of Childhood Illness, healthtechnology and pharmaceuticals, mental health, environmental health and TobaccoFree Initiative.

WHO also supports the Ministry of Health in harmonising guidelines and coordinatingthe main actors in the key technical programmes.

As already mentioned, WHO has been assigned the role of co-ordinator of the rapidlyevolving partnership for a SWAp in the health sector, and has also been designatedas a principle source of technical assistance for the health sector within the PEAPand Budget Framework development processes.

Issues Around Current WHO Support

General pattern of cooperation

? the broad support to health sector development makes it necessary tostrengthen the policy advice function of WHO through new expertise in thecountry office and greater inputs from AFRO and HQ.

? has WHO a comparative advantage in executing projects for others?

Funding

? most of the funds to be used at country level are extra-budgetary – partly relatedto specific projects - for supplies and activities (more than US$ 14 millions for2000 and beyond, as per early 2000 estimates, compared to 2.6 millions corefunding for 2001-2001 from WHO regular budget). How does this fit with WHObeing both a technical organisation and a leading agency in the support to thenational SWAp?

? WHO funding is earmarked: how does this fit with the need to be responsive tocountry realities?

Staffing

? there are enormous pressures on the office of the WHO Representative withtasks of different nature and scope, the bulk of which seems difficult to delegatein the current situation of limited senior staffing in the office: participation in

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numerous meetings linked to WHO’s role in the partnership between thegovernment and development agencies, handling “top priority” urgent requestsfrom the government and WHO, collaborating with various types and sizes ofmissions from WHO and other external agencies, providing technical advice onkey health sector issues, either directly or through WHO staff and consultants,and managing the country office.

? in terms of profiles of WHO country staff, how best to balance the ability tounderstand the country context with the ability to bring experiences fromelsewhere? How does this impact on the balance between national andinternational staff?

? should standard WHO programmes remain the organisational principle of theWHO country office, or are there other principles more conducive to coordinationand communication?

? how to retain good national staff with current WHO rates and other conditions ofservice?

Management

? how to reflect better in the programme budget all the actual WHO inputs atcountry level, including staff secondments, inter-country activities involvingUganda, missions and consultants coming from the regional office andheadquarters (around 60 short-term missions over the last biennium,representing about a thousand person days)?

? how to alleviate the administrative burden involved in managing the wide rangeand types of WHO resources that come to bear at country level?

Broader issues

? how to attain an appropriate balance between the need to achieve planned“expected results” against the desired role to support national capacity building?

? how do we reconcile WHO’s very broad constitutional mandate with the need forselectivity and limited scope of our programme of cooperation with countries?

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WHO Corporate Policy Framework

5 WHO CORPORATE POLICY FRAMEWORK: GLOBAL AND REGIONAL DIRECTIONS

Goal and Mission

The goal of WHO remains the attainment, for all peoples, of the highest possible levelof health. Its mission is to make the greatest possible contribution to world healththrough increasing its technical, intellectual and political leadership and on the basisof values and principles articulated in the Primary Health Care strategy and theHealth for All policy.

New Ways of Working

In order to respond effectively to the global challenges, WHO is adopting new ways ofworking which include:? a broader approach to health, focusing on the links between health and poverty

reduction

? establishing wider national and international consensus on health policy,strategies and standards

? triggering more effective action to improve health, and to decrease inequities inhealth outcomes through carefully negotiated partnerships and catalysing actionon the part of others

? creating an organisational culture that encourages strategic thinking, globalinfluence, prompt action, creative networking and innovation.

Strategic Directions: Content Areas and Functions

In order to build healthy populations and communities, and to combat ill health, WHOhas adopted the following strategic directions for its areas of work:? reducing excess mortality, morbidity and disability, especially in poor and

marginalised populations

? promoting healthy lifestyles and reducing risk factors to man

? developing health systems that equitably improve health outcomes, respond topeoples’ legitimate demands, and are financially fair

? developing an enabling policy and institutional environment in the health sector,and promoting an effective health dimension to social, economic, environmentaland development policy based on equity.

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The four strategic directions are inter-related and mutually supportive. They all call fornew and broader partnerships.

The WHO African Region is facing huge health problems with the highest levels ofinfant, child and maternal mortality rates in the world. It has ninety per cent of themalaria and HIV/AIDS morbidity and mortality within the context of frequent wars,instability and natural disasters, weak health systems, social and economichardships and unbearable debt burden. In order to support Member States in theirefforts to meet these challenges, WHO is strengthening its support to Africa. A newregional strategy is being finalised, complementing the key principles for co-operationwith Member States outlined in the AFRO policy framework. The Health-For-Allpolicy for Africa emphasises the necessity to overcome diseases related to poverty,exclusion and ignorance in a context of good governance and performing healthsystems.

Within its areas of work, WHO can perform a whole range of functions, from high-level policy advice to involvement in routine implementation providing knowledge,supporting research and development, or catalysing the adoption of technicalstrategies. Looking at the right balance of WHO’s core functions should providestrong guidance for improving its work in and with countries, taking into considerationWHO comparative advantages.

Priorities

WHO selection criteria for setting priorities include: potential for significant change inburden of disease, health problems with major socio-economic impact and adisproportionate impact on the poor, need for new technologies, opportunities toreduce health inequalities, comparative advantage of WHO and major demand fromMember States. Such criteria have to be adapted, at country level, to the specificcountry situation and needs, and to be balanced by what the other developmentpartners are doing.

Within the priority areas of work adopted globally in WHO, specific priorities in theAfrican region include control of the major communicable diseases (e.g. malaria,HIV/AIDS, tuberculosis and epidemics), improvement of maternal and child health,emergency preparedness and response, as well as reforming/strengthening healthsystems in the broader context of poverty reduction and sustainable development.

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WHO Strategic Agenda For Uganda

6 WHO STRATEGIC AGENDA FOR UGANDA: THE NEXT THREE YEARS

Shifts in General Directions

Over the years to come, WHO will strengthen its advisory and advocacy functions,as well as its role as a broker in support of broad health sector development. We willfocus our traditional technical expertise on initiating or catalysing action to achievethe widest possible coverage with effective delivery of the National Minimum HealthCare Package, while focusing on the needs of the poor and disadvantaged.

The areas of work covered under this strategic agenda have not changed significantlyfrom the current programme of work that is already based on the national healthstrategy. What the CCS does propose, however, is to:

? regroup these areas under five broad components in order to re-focus our thrust,reduce overlaps while fostering synergies, integration and linkages. Thesecomponents are: health sector development; health systems; combating specificdiseases; reproductive, child and adolescent health; healthy lifestyles andenvironment;

? effect shifts in the functions WHO performs while supporting the building ofnational capacity: moving progressively towards the roles of broker, catalyst andconvenor, towards more support to operational research, and away from directsupport to routine implementation;

? change WHO modes of operation accordingly.

Although we will be moving away from a hands-on approach, time-bound efforts likepolio eradication campaigns, revitalisation of routine EPI, and support for acuteemergencies and disease outbreaks will continue to be part of WHO’s work. The keywill be to achieve a sound balance between different functions while retainingsufficient flexibility to respond quickly, when required.

The new arrangements for joint funding and monitoring of the health sector plan setout in the SWAp Memorandum of Understanding offer a unique opportunity for WHOto take a more strategic posture without disruption or leaving any major gaps inpriority programmes it is already involved in.

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Accordingly, the WHO strategic agenda for Uganda is based on the followingprinciples:

? being more selective in deciding which part of the national health programmeWHO will support, while at the same time being more proactive in offering promptremedial support to obstacles in the implementation of the health strategy;

? leaving room for responding to the requests and legitimate expectations ofgovernment and its partners, within clearly defined boundaries;

? looking for the right balance of functions, and getting involved in routineimplementation only in case of critical gaps, and then, only as a transitionalstrategy;

? taking explicitly into account the strategies and activities of other partners,seizing opportunities to increase and strengthen partnerships within the existingnational development frames and aid instruments of external partners;

? building confidence and trust between WHO and Government on the one hand,and within the broader SWAp partnership on the other;

? contributing to the achievement of equity and the reduction of poverty;

? the national stakeholders are the owners, leaders and main implementers of theentire health plan. This implies distinguishing between government’s programme ofwork and WHO’s own role and performance in contributing to selected parts of it.

WHO uses the following typology of functions to describe its action at country level:

F1 supporting routine long-term implementationF2 catalysing adoption of technical strategies and innovations; country-specific

adaptation of guidelines; seeding large-scale implementationF3 supporting research and development; policy experimentation; development of

guidelines, stimulating monitoring health and health sector performance; trendsassessment and anticipation

F4 providing information, sharing knowledge (global, regional, inter-country),advocacy: generic policy options and positions; case studies of good practice;generic guidelines and standards; study tours

F5 providing specific high level policy and technical advice; serving as broker andarbiter; exercising influence on policy, action and spending of government anddevelopment partners

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Overall Goal

The overall goal and purpose of Uganda’s health policy and strategy is “to reducemorbidity, mortality and fertility and the disparities therein, as a contribution topoverty eradication and socio-economic development of the people”. This goal is alsocovered under one of the four pillars of the poverty eradication action plan which aimsat “improving the quality of life of the poor by providing essential services andbuilding human capital through provision of primary health care, water and sanitation,primary education and preserving the environment”.

WHO’s goal is to support the overall national effort through focused action in selectedkey areas that will facilitate the achievement of the national development objectivesand by collaborating in monitoring policy action and health outcomes.

Principal Components

Component 1Health sector: policy analysis, institutional development and partnerships

This component will be a major area of focus for WHO, in view of the need tocontinue to assist in shaping Uganda’s health policy to achieve equitable healthoutcomes. We will help strengthen the capacity of national and local governments toguide and implement health sector action, and to sustain and service the partnershipin support of a sector-wide approach to health development.

This component is central to the sector reform programme and the entire SWApspartnership. WHO will intensify its efforts as advocate, broker and arbiter of thehealth SWAp partnership; help monitor health sector performance and theimplementation of the strategic plan; and provide support for policy analysis to mapout institutional relationships and capacity requirements and to ensure policycoherence.

Supporting the central Ministry of Health: toward effective stewardship

The health sector strategy clearly states that the intended results can only beachieved if effective systems and structures are put in place. It therefore calls forthe “strengthening of the Ministry of Health’s capacity for policy analysis andformulation, planning, monitoring, quality assurance and evaluation”.

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The central Ministry of Health has been extensively restructured and downsized inline with its changed functions and responsibilities. Effective fulfilment of its newrole and functions is a basic prerequisite for a functioning health system at alllevels, within a broader institutional and policy frame with local government as amain channel for implementing the health policy and plan. Similarly, the degree offunctionality of the health-related statutory and regulatory bodies such as theHealth Service Commission, Uganda AIDS Commission, National Drug Authority,the professional Councils, etc. all have a significant bearing on sectorperformance, accountability and credibility. WHO will provide strategic andlogistic support to these institutions.

In particular, WHO will:

? work with the MOH and other development partners in formulating terms ofreference for expert consultants with experience in a variety of relevant settingsto advise on options for addressing institutional issues;

? provide expertise in areas such as policy analysis, regulation, performanceassessment and resource allocation;

? in the context of upcoming global initiatives for targeting the poor, assist in thedesign of mechanisms to improve national absorption capacity - bothgovernmental and non-governmental - and resource utilisation.

Work on institutions in the health sector will be linked with support provided byother development partners for continuing government reform in cross-cuttingareas such as governance, decentralisation, and public management (includingfinancial management, accounting and auditing, procurement of goods andservices, salary and payroll).

Emergency preparedness and risk mapping

The complex and now protracted unrest in the north, the ongoing war in theDemocratic Republic of Congo, insurgency in the western border, the unsettledareas of Karamoja, and the frequent occurrence of various natural disasters havemade Uganda an emergency-prone country. WHO will continue to act as adviserand facilitator to improve risk mapping, surveillance and response to emergenciesat both central and district levels.

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Component 2Health systems development

The national health policy has as an objective to provide “a network of functional,efficient, and sustainable health infrastructure for effective health care delivery closerto the people. The functional status and the linkages between the different levels ofcare, and coordination of the various health care providers will be assured, so as toimprove access and minimize avoidable waste”.

This is a key component of WHO action and support, with the aim of contributingsignificantly to improving access to, and utilisation of, quality health care in anextensively decentralised system. WHO work will involve supportive action in theinvestigation and resolution of selected critical obstacles to effective functioning ofthe decentralised system, including health financing, operationality of the health sub-districts and client satisfaction.

Health sub-district

WHO will focus on supporting the development and institutionalisation of thehealth sub-district concept, particularly in the areas of management, financing,quality assurance, and the pursuit of equity in health. Putting health policy intopractice will depend on achieving fundamental reform of health management atdistrict and sub-district levels, in the context of other local government reforms.Districts will be supported in redefining their role, from an operational to a morestrategic one as called for by the national health policy.

Key challenges will be to bring together different technical programmes thatusually develop their own frameworks, tools and training separately, and toimprove the accountability of services and their interface with the communitiesthey serve.

Human resources

WHO will support information sharing, act as advocate and provide expertise onvarious aspects like the review of systems and plans, curricula and guidelines,staffing norms and performance indicators, and the key issues of staff motivationand accountability (incentives). It will also catalyse large scale implementationthrough providing logistic support and facilitating training locally. The overseasfellowships programme will be adjusted accordingly, taking into account the needto fill crucial gaps.

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Essential drugs and other health supplies

WHO will continue to link operational support to drug management and supply atdistrict level, with policy advice and institutional development at central MoH, thenational Drug Authority, the Department of Pharmacy of Makerere Medical School,and the National Medical Stores. The focus will be on procurement managementand pricing, quality, safety and rational use of drugs and other medicines.

Financing

WHO will support the development of fair financing strategies. This includes furtherdevelopment and wider extension of community-based insurance schemes,coupled with exploration of broader-based national schemes for workers in boththe formal and informal sectors. It also covers the development and evaluation ofan effective strategy to ensure access to health care for the poor.

Each of the major service providers and external partners active in Uganda alsodeals with aspects of this component. WHO is expected to provide high-levelpolicy advice on standards for service delivery.

Component 3Combating disease

A significant part of the national minimum health care package is allocated toprevention and management of common diseases, mainly diseases of poverty. Thehealth sector strategy calls for Government to focus on “demonstrably cost-effectiveinterventions that have the largest impact on reducing mortality and morbidity”. Thehealth policy further states that “the Minimum Health Care Package will comprise ofinterventions that address the major causes of the burden of disease and shall bethe cardinal reference in determining the allocation of public funds and otheressential inputs”.

Communicable diseases

WHO will continue to provide significant support to the fight against malaria, HIV/AIDS and tuberculosis; to the strengthening of the Expanded Programme onImmunization and the eradication of polio; and the control/elimination of selectedtargeted diseases that are of immediate relevance to Uganda, such as sleepingsickness and widespread infestation with various forms of worms. The latter willinvolve support for integrating the control of schistosomiasis and soil-transmittedhelminths with the control of river blindness, while anchoring these to the nationalschool health programme. WHO will focus increasingly on strategy development,

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monitoring and assessment, operational research and policy advice, especiallywithin those initiatives for which WHO has been assigned global or regional leadrole, including its mandate for international certification of diseases targeted foreradication.

Under the umbrella of ‘Massive Effort’, WHO will support government inoperationalising the relevant elements of the Minimum Package, and incollaboration with other stakeholders, devise appropriate mechanisms forchannelling new funds as closely as possible to health action at the householdlevel in order to increase demand for primary health care and to achieve improvedhealth outcomes. WHO will support the central and local governments inimproving their capacity for drawing up and managing performance contracts withNGO, private for-profit and community based groups.

Non-communicable diseases

Greater emphasis will be put on the rapidly increasing problems of non-communicable diseases like cardiovascular diseases (including juvenile rheumaticheart disease), diabetes, cancer of the breast, cervix, and hepatitis B-induced livercancer. The main accent of WHO support will be on developing, promoting andcatalysing implementation of new and innovative strategies for prevention -promoting healthy lifestyles -, diagnosis, and care.

Road traffic accidents as a major cause of severe injury are of great and growingconcern. WHO will support policy and strategy development including legislation;strengthen the national accident and injury epidemiology unit; and help improveinjury care at all levels of the health system.

In the area of mental health, WHO will provide support to policy development,national level management and service reform, with particular emphasis oncommunity and district level primary care, and development of the regional andnational referral network. We will also support research on the psychosocialeffects of the HIV/AIDS epidemic, public health aspects of epilepsy and thegeneration of data and information for advocacy and management.

Component 4

Reproductive, child and adolescent health

WHO will continue to support the development and introduction of new policies,standards, guidelines and best practices, support their adaptation and catalyse

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large-scale implementation. Financial support to routine activities like operationaltraining and supervision will however be discontinued.

Focus on the household

A new thrust of WHO’s work is re-visiting interventions aimed directly athouseholds, and strengthening the capacity of the MOH to work more effectivelyat the community/health facility interface. This will involve operational research,monitoring and information support.

Fostering integrated approaches

The challenges here are to broaden the scope of “traditional” programmes like safemotherhood, adolescent health and IMCI in the light of national dynamics and tomove toward greater integration of work in the three areas, with commonstrategies for community outreach and household level interventions and healthsystems development. Promoting linkages with the areas related to combatingdiseases (especially HIV/AIDS/TB, EPI, and Roll Back Malaria) and to improvingservice delivery, will also receive greater attention.

WHO will increase its advocacy and technical advice functions in the area of fertilityregulation, and maternal and neonatal mortality surveillance. We will also putparticular emphasis on the coordination of the multiple stakeholders, currently a keyissue in this area.

Strong collaboration in this component already exists with the other major actorssuch as UNFPA, UNICEF, WB, DFID, USAID, EU, and DANIDA.

Component 5Environment and healthy lifestyles

One of the objectives of the strategic plan is to: “strengthen and establishcollaborative mechanisms at various levels and with relevant agencies for promotionof safe water and sanitation; promote proper food hygiene and safety, managementof waste and pollution control, occupational health and safety in the workplace;promote public information and education to support community mobilization onenvironmental health matters”.

This component, some aspects of which are relatively new for Uganda, will continueto receive a significant share of WHO efforts as in the recent past. We will act both

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as a catalyst for large-scale implementation of technical strategies (e.g. guidelineson water quality) and as policy adviser and advocate. Here again, efforts will be madeto strengthen collaboration with disease control (e.g. Roll Back Malaria, EPI, masstreatment of parasitic diseases, juvenile rheumatic fever, and epidemic prevention andcontrol), as well as between the departments of health and water.

? WHO will provide support for the development of the tobacco control policy andlegal framework, catalyse the establishment of counselling and support centresfor cessation of tobacco use, and the implementation of a communicationsstrategy for addressing the growing problem of teenage addiction.

? Regarding environment, we will focus our support on hygiene and sanitation withemphasis on healthy cities and schools, as well as standards and surveillancefor water quality.

WHO will work in close collaboration with the ministries of natural resources andeducation, NGOs and relevant development partners.

Conclusion

Uganda is still recovering from a long period of hardships. It is facing enormousdifficulties linked to poverty and weak institutional capacities. The national drive, overthe last 15 years, towards democracy, improved governance, economic growth andsocial development has been impressive. Aid agencies have a responsibility topositively respond to this evolution, and to move from supporting projects tosupporting, in a coherent way, the macro and sector strategies that the governmenthas put in place, in consultation with its partners. Among the major challengesconfronting the partnership is the need to speedily move forward with policy action,putting in place the right incentives for effective performance and accountability, andmonitoring performance.

Over the past few years, WHO has supported the design of broad national strategiesfor the health sector and the related dialogue between the government and itspartners. It has also, on more traditional lines, helped formulate technical strategiesfor various programmes in the country, feeding as well into the development ofapproaches and tools at the global level. However, there are still missing linksbetween the “broad picture” and the “system” approach on the one side, and work onspecific diseases, interventions and population groups, on the other. Fosteringcreative thinking, responsive to country realities within the context of approachesdesigned at the global level, is not always easy. Neither is fostering team work and

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collaboration across programmes, when the managerial incentives are all geared to a“programme” approach. The strategic agenda for the future builds on the actual andpotential strength of the country and of current WHO cooperation, and targets someof the weaknesses of both. It takes into account the overall policy directions of WHO,as well as what other agencies are doing in Uganda.

The main shifts in WHO cooperation with Uganda will be:? more effort on the provision of information and high level technical assistance to

policy analysis, institutional development and sustaining the partnership for thesector

? increased attention to operational research, technical and policy advice on thehealth system, which includes monitoring its operationality and performance

? emphasis on priority health problems related to poverty: selected communicableand non communicable diseases, as well as high levels of maternal and childmorbidity/mortality

? significant move towards research in innovative approaches to community levelaction, institutional development, advocacy and community mobilisation forincreased service demand and utilisation, especially by the poor.

Although the pattern of WHO inputs being brought to bear at country level reflects thecurrent priorities of its co-operation with Uganda, some shifts in staffing and funding,short-term expertise, inter-country activities involving Uganda, and technical backupwill be necessary to support the changes in areas and functions proposed in thestrategic agenda. Epidemiology and control of communicable diseases will requiremore expertise at country level. More emphasis will be put on policy developmentwithin the broader frame of macro-economic policies and poverty reduction,institutional development, health financing and sector performance assessment. Thiswill mean finding ways of actually bringing in high level expertise and lessons learntfrom other countries in a sustained and continuous way. A team of senior staff and/orconsultants – from WHO or other appropriate institutions – could be contracted forproviding such a service on a regular and consistent basis, with a clear commitmentto next steps and follow-up.

The WHO country office will reorganise itself in accordance with the directions of theWHO strategic agenda, looking for more collaboration and coordination in line with theneed to integrate technical interventions. It will systematically look at national expertiseand call upon national resources - institutions and individual consultants - wheneverpossible.

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In line with ongoing developments within the Organization and the SWAp process,there is a compelling need to examine carefully the appropriateness orinappropriateness of WHO’s role as executor of projects for other agencies, and toensure that the CCS is used as the strategic frame for planning all WHO inputs inthe country.

In view of the flexibility built into the CCS, the evolution of development aid in Ugandaand the role of WHO within it, the Organization needs to consider moving towards amore flexible and responsive allocation of its resources to be used at country level,getting funding for its core technical role and showing the way towards some directun-earmarked funding of country priorities.

The case of Uganda has moved international thinking on development co-operationand informed aid instruments; it is thus a good example of the importance of feedingcountry experiences into international debates. Conversely, it is equally important toprovide the country office with the main points and key issues evolving frominternational debates in a timely manner.

The task of accelerating development and achieving equitable health outcomes is aformidable challenge to Uganda’s government and its people. For WHO, it offers agreat opportunity for collaborating with the country and for putting into practice newthinking and ways of working together so as to make a significant difference to thehealth and welfare of all Ugandans. The widest possible consensus has beenachieved on a purposefully pro-poor health policy and plan; and a tightly cohesive andpotentially highly exemplary SWAp partnership is in its early stages of consolidation.All this is occurring in an environment that recognizes the role and functions of WHO.The real challenge now is for WHO to fully live up to the expectations of its partnersand to the principles underlying its own corporate strategy. This Country CooperationStrategy paper aims to provide a sound framework that will guide action towards thatend.

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Sources of InformationUganda CCS

Uganda? Poverty Eradication Action Plan (Vol.1); 1997, Ministry of Finance? Revised Volume 1 of the Poverty Eradication Action Plan (Draft); March 2000,

Ministry of Finance, Planning and Economic Development? Participatory Poverty Assessment Project Report; 1999, Ministry of Finance? Medium Term Expenditure Framework 2000/01-2002/03, Review and Outlook;

March 2000, Ministry of Finance Paper for the Consultative Group meeting? “Making Partnerships Work on the Ground - Experience in Uganda”; August

1999, E. Tumusiime-Mutebile, Permanent Secretary/Secretary to the Treasury? National Integrity Survey; 1999, Office of the Inspector General of Government? National Health Policy; September 1999, Ministry of Health? Health Sector Strategic Plan, 2000/01-2004/05; Ministry of Health? Memorandum of Understanding (Draft) between the Government of Uganda and

its Health Development Partners; April 2000? Burden of Disease and Cost-effectiveness Study; 1995, Ministry of Health? Annual Report of the AIDS Control Programme; 2000, Ministry of Health? Uganda Demographic and Health Survey, 1999? Decentralization and Health Systems Change; Okuonzi and Lubanga

World Health Organization? A corporate strategy for the WHO Secretariat: report by the Director-General,

EB105/3, 10 December 1999? Programme Budget 2002-2003: policy framework? HFA Policy in the 21st Century for the WHO African Region; 2000, AFRO? Policy Framework for Technical Cooperation with Countries; Aug.1995, AFRO? Working in and with Countries: report by the Director-General, EB105/7, 15

December 1999

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Sources of Information

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