Alliance%20 hpsr%20iprq makere_report

Final Report – 6 August 2008
Priority Research Questions Study Makerere Institute of Social Research1
IDENTIFICATION OF PRIORITY RESEARCH QUESTIONS WITHIN THE
AREAS OF: HEALTH FINANCING; HUMAN RESOURCES FOR HEALTH
AND THE ROLE OF NON-STATE SECTOR
Prepared by
Delius Asiimwe
Senior Research Fellow, MISR
Supported by
Alliance for Health Policy and Systems Research

Reproduced with permission

TABLE OF CONTENTS
ACKNOWLEDGEMENTS ....................................................................................................................................... 5
EXECUTIVE SUMMARY........................................................................................................................................ 6
Background....................................................................................................................................................... 6
Study Description and Methods..................................................................................................................... 6
Findings ............................................................................................................................................................. 7
Policy Concerns – Health Financing .......................................................................................................... 7
Policy concerns – Human Resource for Health........................................................................................ 7
Policy Concerns – Non-state Sector .......................................................................................................... 7
Priority Research Questions ....................................................................................................................... 7
ABBREVIATIONS.................................................................................................................................................. 9
1.0 STUDY CONTEXT ................................................................................................................................... 11
1.1 Objectives of the Study ................................................................................................................... 12
2.0 METHODOLOGY ..................................................................................................................................... 12
2.1 Scope.................................................................................................................................................. 12
2.2 Selection of organizations and respondents................................................................................. 12
2.3 Methods of Data Collection............................................................................................................. 12
2.3.1 Literature Search and Review .................................................................................................... 12
2.3.2 Pre-visits........................................................................................................................................ 13
2.3.3 In-depth interviews with Key Informants................................................................................. 13
2.4 Data Analysis..................................................................................................................................... 14
3.0 LITERATURE REVIEW ........................................................................................................................... 14
3.1 Introduction....................................................................................................................................... 14
3.1.1 Health Care Financing ................................................................................................................. 15
3.1.2 Human Resource for Health ....................................................................................................... 16
3.1.3 Non-State Sector.......................................................................................................................... 17
4.0 FINDINGS FROM KEY INFORMANT INTERVIEWS ............................................................................ 19
4.1 Policy Concerns - Health financing ................................................................................................ 19

4.1.1 Budgeting and Resource allocation for the health sector..................................................... 19
4.1.2 Public financing of the private sector........................................................................................ 19
4.1.3 Alternative source of financing................................................................................................... 20
4.2 Research Priority Questions - Health Financing........................................................................... 22
4.3 Policy Concerns – Human Resource for Health............................................................................ 23
4.3.1 Numbers, deployment and attrition .......................................................................................... 23
4.3.2 Record Keeping and Data Management ................................................................................... 23
4.3.3 Human Resource for Health Training........................................................................................ 24
4.3.4 Management of Human Resource for Health........................................................................... 24
4.4 Research Priorities Areas – Human Resource for Health ........................................................... 25
4.5 Policy Concerns – Non-State Sector .............................................................................................. 26
4.6 Research Priorities Areas – Non-State Sector .............................................................................. 26
5.0 DISCUSSION........................................................................................................................................... 27
5.1 Uganda’s Health Policy Environment............................................................................................. 27
5.2 Health Financing............................................................................................................................... 27
5.3 Human Resource for Health............................................................................................................ 28
5.4 Non-State Sector .............................................................................................................................. 28
5.5 Strength of the study Methodology............................................................................................... 29
5.6 Short Comings of the Study Methodology.................................................................................... 29
6.0 REFERENCES .......................................................................................................................................... 30
Annexes:........................................................................................................................................................... 31
1: List of Key Informants .............................................................................................................................. 31
2: Key Informant Tools ................................................................................................................................. 31

Priority Research Questions Study Makerere Institute of Social Research
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ACKNOWLEDGEMENTS
This report was prepared by Makerere Institute of social Research, Makerere University as part of the
collaborative study with Faculty of Arts and Social Sciences, University of Dar es Salaam Tanzania.
The author would like to thank Alliance for Health Policy and Systems Research, WHO, Geneva for
supporting this study. He also wishes to extend his gratitude to Sara Bennett, Manager and Michael
Kent Ranson, Consultant both of Alliance HPSR for their input that shaped the outcome of this study.
I am also grateful for the thoughtful guidance of the Dr. Francis Runumi, Commissioner Health
Service Planning and Dr. Basaaza, Senior Planner, Ministry of Health, Kampala during the preparatory
stages of the study.
On behalf of Makerere Institute of Social Research, I would especially like to thank the informants
that participated in the study – policy makers and program staff from the various government
ministries, leaders of NGOs providing health care and providers’ associations as well as private
providers who freely gave in their time to answer questions and provided reflections on policy
concerns and priority research questions. Special tribute goes to the leadership of the health
consumer and users organization in championing the communities’ voices in health care and hope
that these findings will contribute to improving the health and quality care of the people of Uganda
and the region.

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EXECUTIVE SUMMARY
Background
Uganda is among the twenty poorest countries in the world with a per capita GDP of about $300 with
about 31 percent of Ugandans still living below the poverty line as of 2006. Its economy is
predominantly agricultural where the majority of the population is dependant on subsistence farming
and light agro-based industries.
The government’s significant investment in the social sector since the 1980s has increased the health
sector funding to 13% of the total national budget (7.6% of the GDP as of 2004) from 7% in 1995.
Consistent with the decentralized system of governance much of health care functions and
responsibilities were devolved to a three tier local governments- the district; municipality and Sub-
county/Town council. The central government retained the mandates of making national policies,
setting standards and supervision. In order to improve access to basic services, the delivery of
health care is through a layered system of health units, ranging from national referral hospitals,
regional referral hospitals, district hospitals, health sub-districts to lower level health centre IIIs and
IIs at sub-county and parish levels.
Despite these achievements, the Health sector still has glaring gaps in quality and reliability of
services. Infant mortality stands at 75/1000, maternal mortality ratio is 435/100,000, 38 percent of
children less than five years are stunted and only 44 percent of eligible children complete the full
immunization cycle. There is shortage of manpower, physical infrastructure and inadequate financing
among others to cater for the soaring patient numbers and changing needs in health care in Uganda.
Study Description and Methods
This study is intended to identify priority research questions in Health Financing, Human Resource for
Health and Non-State Sector in the Low and Middle income countries in the Eastern Africa Region.
Following socio-economic reforms of the countries in the region beginning the late 1980s, much has
been done to support their health sectors. However, the planning, financing and delivery of health
care in most countries remain poor. The main purpose of the study therefore, is to ensure that in the
next 5-10 years, generation of information for policy and decision making in three thematic areas is
mainly guided by policy concerns of key stakeholders in health care.
The objectives are: (i) identifying and ranking policy concerns at national and regional levels as
perceived by policy makers and Civil Society in the three thematic areas and; (ii) Identifying and
ranking the emerging national and regional research priority questions in the three thematic areas in
Uganda and Tanzania.
The study was carried out in the public and private sector covering key ministries, Non-Governmental
Organisations (NGOs), private health facilities, Bi/multi-lateral organizations, public and private
provider associations as well as research and consumers’ organizations. A total of 35 strategically
placed policy makers, managers and staff from selected organizations/
agencies/ministries/associations were interviewed.
Data from key informants was collected using qualitative methods of In-depth interview. A set of
tools with each tailored to the roles and responsibilities of the selected informants were used as
guides during the interview.
Secondly, a comprehensive literature search of official documents and grey literature in libraries;
information centers and on the internet was carried out. The search yielded hard and soft copies of
national health policies, strategic plans, partnership policies survey reports and program documents
among others. The key and related literature has been reviewed for purposes of writing this report.
All the literature that has been identified and collected has been capture in a database to be further
developed and packaged by Alliance for Health Policy and Systems Research for wider dissemination.

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Findings
Policy Concerns – Health Financing
The National Health Policy priorities in Uganda focus at ensuring access to the Minimum Health Care
Package. However available data shows that delivery of the Minimum Health Care Package shows a
big resource gap between the requirements of HSSP II and resources available under the current
Medium Term Expenditure Framework (MTEF).1
The informants major concern was that the costing of HSSP II like that of HSSP I remain largely
facility based and applies to only government and Faith Based-NGO facilities excluding private for
profit providers, employers’ clinics and the complementary and traditional medicine sub-sector. These
together underpin the lack of systematic mechanisms needed to ensure adequate financing of the
national health care delivery in Uganda.
Policy concerns – Human Resource for Health
The major human resource problems in Uganda’s health sector were reported as mal-allocation of
human resources; shortage of trained staff in the health sector and; attrition of qualified staff from
private not-for-profit to public facilities and private for-profit practice. In addition, poor remuneration
of health workers and over dependence on untrained personnel in the primary health care facilities,
pose major challenges to effective implementation of health programmes in Uganda.
The absence of adequate information as an input to Human Resource for Health development and
management raise a key policy concern among policy makers. The current information on of HRH is
disjointed, difficult to access and not standardized to provide basis for determining the required
numbers, categories, quality of training and the impact of dual employment as well as attrition of
health workers particularly from the PNFPs to the public health sector and other organisations.
Policy Concerns – Non-state Sector
The Non-State Sector role in health services delivery was widely acknowledged by most informants.
However much of its contribution to the national health care delivery in not well known except for the
facility based PNFPs whose contribution is about 40% of the national health care delivery. In support
to PNFPs, government willingness to spend and the condition that user fees be kept minimal
overrides the basis of what is required to delivery the PNFP services. The inelastic funding from the
public sector tend to force PNFPs to increase user fees rendering their services in accessible to the
very poor that are unable to pay higher fees.
On the other hand, though the PFP and Traditional medicine sub-sectors are recognized as partners
in the health care delivery, they are never provided for in the national health sector strategic
planning creating a gap in planning for services already being expended in the national health
system.
Priority Research Questions
Health Financing
The holistic costing to ascertain a unit cost and the health burden of a country in relation to per
capita GDP of Ugandans was ranked the first priority research question.

1
MTEF is the overall mechanism by which resources are expected from government including donor budget support
allocated to and within sectors. It sets sector and local government spending ceilings within a three year rolling framework
and also links planning and development in budgeting based on the amount of resources available.

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The second was to generated evidence on resources use, application and the cost-effectiveness of
financing the burden of disease in a resource constrained environment.
The third priority research question in health financing was the cost benefit analysis of the National
Social Health Insurance Scheme with regard to information on equity, management and financial
analysis for decision making.
Human Resource for Health
The first priority research question was to assess the human resource for health in national health
care system to help develop a harmonized management system and a consolidated human resource
development plan.
The second is the review of the training curricula in light of the new diseases, changing clients’ health
care seeking patterns, new policies and the occupational issues of health workers.
The third was the assessment of human resources development and deployment synergies between
the public and private sectors. The data generated would address the challenges of building
synergies for effective utilization of human resource between public and private sectors.
Non-State Sector
The first priority research question is the development of Health Management Information System
(HMIS) to capture information from the private sector (PNFP, PFP and Traditional and Complimentary
Medicine) to be reflected in the national official documents for planning and policy making purposes.
The second was to assess the weak/absence of relationships/synergies in the health sector to help
provide strategies to information the partnership among the different sub-sectors in health care
delivery.
The third was the mapping private sector with regard to categories, range and pricing of services,
kind of patients handled by the private health providers, costs and treatment procedure as well as
information made available to patients.
The fourth was a national survey of consumers’ views and value for money audit of health providers
to assess the clients’ satisfaction with health service delivery.
Conclusion
The health financing, human resources for health and Non-State Sector hurdles seem to stem from
the governance and financing regimes. The governance and policy environment for Uganda’s health
sector that is made up of various actors (public, private and donors) requires harmonization of basic
rules, standards as well as information and management systems. The financing regimes need a
system to plan and utilize resources effectively in order to realize cost effective interventions. Priority
setting should be based on information on the overall health sector to help assess cost effectiveness
use of human and financial resources.

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ABBREVIATIONS
ACT Artemesinin-based Combination Therapy
AIDS Acquired Immune Deficiency Syndrome
ARV Antiretroviral
CEO Chief Executive Officer
ENHR Essential National Health Research
FB-PNFP Faith Based Private Not For Profit
FY Financial Year
GAVI Global Alliance for Vaccine Immunization
GDP Growth Domestic Product
HIV Human Immunodeficiency Virus
HMIS Health Information Management Systems
HRH Human Resource for Health
HRHP Human Resource for Health Policy
HSSP I Health Sector Strategic Plan (2000/01-2004/05
HSSP II Health Sector Strategic Plan (2005/06 -2009/2010
HW Health Worker
MDGs Millennium Development Goals
MISR Makerere Institute of Social Research
MoES Ministry of Education and Sports
MoFPED Ministry of Finance Planning and Economic Development
MoH Ministry of Health
MTEF Mid-Term Expenditure Framework
NFB-PNFP Non-Faith Based Private Not For Profit
NGO Non-Governmental Organisation
OPD Out Patients Department
PEAP Poverty Eradication Action Plan
PFP Private For Profit
PHC Primary Health Care

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PPPH Public Private Partnership for Health
SAPs Structural Adjustment Programmes
STI Sexual Transmitted diseases
SWAP Sector Wide Approach
TCM Traditional and Complementary Medicine
UAHPC Uganda Allied Health Professionals Council
UBOS Uganda Bureau of Statistics
UDHS Uganda Demographic Health Survey
UMDPC Uganda Medical and Dental Practitioners Council
UNEB Uganda National Examination Board
UNHS Uganda National Household Survey
UNHRO Uganda National Health Research Organisation
UNMC Uganda Nurses and Midwives Council
UNMHCP Uganda National Minimum Health Care Package
UPC Uganda Pharmacists Council
UPE Universal Primary Education
US$ United States Dollars
USE Universal Secondary Education
WHO World Health Organisation

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1.0 STUDY CONTEXT
Uganda is a Sub-Saharan country with a population of 24.7 million people. Close to 90 percent of
these live in rural areas, and engage in peasant subsistence agriculture (UBOS, 2002). The country
remains among the twenty poorest countries with a per capita GDP of about $300 (UNHS, 2006).
As a strategy to confront poverty, the government launched a series of poverty eradication
Programmes being implemented through the Poverty Eradication Action Plan (PEAP) first drafted in
1997 to provide an overarching framework to guide public action to eradicate poverty. As a result
there has been a reduction in the proportion of Ugandans living in absolute poverty from 56 percent
in 1992 to 35 percent in 2000 and currently estimated at 31 percent (PEAP 2004/5-2007/8).
The government has since late 1980s continued to invest significantly in the improvement of social
and economic infrastructure, such as road and communication networks, education, and health
services with the goal of improving access to basic services, especially for the poor. Health sector
funding has also increased to 13 percent of the total national budget, up from 7 percent in 1995
(MoFPED, 2005) or 7.6 percent of the GDP (2004) (WHO, 2007)2
In order to enhance access, health services have been decentralized to communities through a
layered system of health units, ranging from national referral hospitals, regional referral hospitals,
district hospitals, health sub-districts to lower level health centre IIIs and IIs at sub-county and
parish levels respectively. This arrangement is consistent with the devolving of functions and
responsibilities including health to decentralized three tier local governments - the district;
municipality and Sub-county/Town council. The central government retained the mandate of making
national policies, setting standards and supervision of the services (The Local Government Act,
1997).
Despite the achievements, the country continues to host a big mass of people engulfed by poverty
and disease. The Infant mortality stands at 75/1000, maternal mortality ratio is 435/100,000, 38
percent of children less than five years are stunted and only 44 percent of eligible children complete
the full immunization cycle. HIV prevalence is at 7 percent with high percentage recorded among
women in the reproductive age (15-49 years) (UDHS 2006).
In response the government developed several policies, strategies and programmes to help improve
health status and life of its people. In particular, the National Health Strategic Plan 2005/06 -
2009/10 (HSSP II) as a consolidation and extension of the Health Sector Strategic Plan I (HSSP I)
(2000/01-2004/05 has an overriding priority of contributing to the Poverty Eradication Action Plan
(PEAP) and the Millennium Development Goals (MDGs). The plan emphasizes the role of communities
and households targeting the poor, orphans, children, women, the elderly, refugees and internally
displaced persons among others so as to foster a sense of individual ownership of health services.
However, a number of challenges continue to override the overall objective of the National Health
Policy of reducing mortality, morbidity and fertility, and the disparities therein. Key among them are
the health financing costs required to achieve the policy objectives agreed upon by government of
Uganda and its development partners. The human resource for health that pose a number of
problems such as mal-allocation; shortage and attrition of qualified staff within and outside various
health care delivery points. The fragile relationships between the public and private sector3
that
undermining one of the National Health Policy objective of making the private sector a major partner
for successful scaling up and improvement of health care delivery.

2
Figures are for 2005 from World Health Organisation Statistics, 2007.
3
The Private Sector in health includes: Private Not for Profit Health Providers (PNFP), Private Health Practitioners and, Traditional and Complementary
Medicine Practitioners (TCMP). The PNFP includes Facility Based (FB-PNFP) and are mainly faith-based for example Uganda Catholic Medical Bureau
and; Non-facility based (NFB-PNFP) such as NGOs both local and international.

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1.1 Objectives of the Study
The main purpose of the study is to ensure that in the next 5-10 years, research agendas in the Low
and Middle income countries are driven by policy concerns of the time other than the researchers’
interests and funding sources. The strategy is to identifying research priority questions in the areas of
Health Financing; Human Resources for Health and the Role of the Non-State Sector arising out of
policy concerns/challenges among policy makers and other key stakeholders as well as from the
processed and Grey literature in Uganda, and Tanzania.
The objectives are:
i) Identifying and ranking policy concerns at national and regional levels as perceived by
policy makers and Civil Society in the three thematic areas and;
ii) Identifying and ranking the emerging national and regional research priority questions
in the three thematic areas in Uganda and Tanzania.
2.0 METHODOLOGY
2.1 Scope
This study is an attempt to provide an insight into the existing and/or desired relationship between
policy development and information generated through research in the health sector. The task is
viewed as systematically examining the policy making cycle to help capture the policy concerns and
issues that give birth to priority research questions for national policy agenda setting. These may be
influenced by Global issues and local concerns such as the Millennium Development Goals (MDGs);
combating HIV/AIDS; Human resources and professionalism for health; poverty and ill-health;
immunization; health financing options and public/private health care mix and delivery.
In each country the study covered government ministries, Non-Governmental Organisations (NGOs),
Bi/multi-lateral organizations, research organizations, private health facilities and consumer
organizations.
2.2 Selection of organizations and respondents
The selection of the organizations/agencies/ministries was guided by their roles in the national health
system and health care delivery. The number of respondents from each organization/agency/ministry
was based on its role, coverage of health programmes and activities in health care delivery system.
Consequently the Ministry of Health had the highest number of respondents due to its central role in
health care policy and management in the country but also because of the departmentalized nature
of the activities and programmes in the three thematic areas of the study. A total of 35 strategically
placed policy makers, managers and staff in the selected organizations/agencies/associations in
Uganda were visited to conduct key informant interviews (see Annex: 1).
2.3 Methods of Data Collection
2.3.1 Literature Search and Review
A search strategy for literature to review and develop a data base was three pronged. First was a
search on the internet that enabled the team access to the readily available public and other
documents based on potential sources of critical information. The internet search also helped to
inform the design of search strategy plan and provided benchmark for literature review.
Secondly, literature search was conducted in key libraries and resource centres of organizations,
ministries, universities and research institutions. The target was to collect hard and soft copies of
programme documents as well as survey and evaluation reports on the subject matter.

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Thirdly, in consideration of the practice of poor record keeping prevalent in most middle and low
income countries, personal contact with key stakeholders in organizations/agencies/ministries was
used to access literature (official or grey) before and during the course of the interviews with the key
informants. This part of literature search mainly yielded hard copies of official documents, survey
reports and publications.
The documents (hard and soft copies) and grey literature in the three thematic areas were reviewed
in the light of the study objectives. All the details of documents and literature identified were
captured by region, author, year, type of document (e.g Policy, Strategic Plan etc); thematic area of
the study and country onto which the information mainly focused for the purposes of creating a
completed and edited data base, whose soft copies will be available for wider dissemination.
2.3.2 Pre-visits
In June, 2007 two pre-visits were made to the Ministry of Health, Kampala. The purpose was to seek
guidance and equip the team with information on policies and priority setting in Uganda’s health care
system. In the first visit, the team discussed with the Commissioner, Health Services - Planning while
in the second one the discussion was held with Senior Planner/Health Economist in charge financing
together with a few Health Economists of the health financing section of the ministry. The pre-visits
generated valuable information on the potential areas of investigation and key informants in the
three thematic areas of the study. The information was also used in the planning of the data
collection exercise and the revision of the zero draft study tools.
2.3.3 In-depth interviews with Key Informants
In-depth interviews were conducted with national level public policy makers and heads of selected
sections in three Ministries of Health, Finance, Planning and Economic Development and Local
Government. The heads of Special Health Programs such as HV/AIDS, Immunization and Clinical
Services in the Ministry of Health were also interviewed. In the private sector interviews were held
with heads of Private Health Facilities (Pharmacies, Hospitals and Clinics), heads of NGOs involved in
delivery and supporting of Health care as well as members of various health workers’ Associations.
Others were program heads of Bilateral and Multi-lateral Organizations, head(s) of public and private
Research Organizations/Agencies that engage in health related research and health user and
consumer organization.
The tools for various categories of key informants were designed to elicit information on policy
processes, current and future policy concerns and the research questions that could address the
raised concerns. Others focused on the research agendas, programme activities and support in
relation to health policy concerns in the three thematic areas of the study (see Annex: 2).
Interviews with policy makers helped to provide insight into the policy environment within which
health services are delivered. The existing and perceived policy concerns, challenges to
implementation and partnerships as well as research questions to inform policy were also raised.
Interviews with Heads of selected sections and Heads of Special Health Programs yielded data on
experiences of delivering health services with a key focus on both their program and policy in the
study thematic areas. In addition, the impact of current policies on quality and quantity of services
and challenges and recommendations of managing services were also explored.
Similarly, interviews with Heads of Private Health Facilities and Faith-Based health NGOs as well as
health workers associations generated data on realities of delivering health services within in the
national health system. The working experiences, financing mechanisms, partnerships with public
sector and impact of current health policies in the delivery of health care were explored and a
number of research priority questions identified.
The interviews with Bilateral and Multi-lateral organizations focused on their key activities and
concerns regarding national health policy and system. In the research organizations the relationships

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between the organizations’ research agendas in relation to national health sector activities and
priorities were explored. In both cases, the interviews were used to assess their perspectives and
identify key research priority questions for future health policy making and programming.
2.4 Data Analysis
Content Analysis was used to analyze the generated qualitative data on the basis of emerging themes
and sub-themes in line with the study objectives. Descriptive summaries and use of quotes was
utilized. This analysis was useful in identifying the major issues for each of the thematic areas with
regard to policy concerns and priority research questions. It also facilitated comparisons and
contrasts of views of informants from different organizations.
The data collected through document reviews was used to assess historical, current and emerging
policy concerns in the three thematic areas. The same set of data was used to draw up generalization
on the regional level on the emerging health policy concerns and priority research questions in the
three thematic areas. The soft copies from the internet, libraries and offices have been systematically
captured and listed while a detailed list of hard copies has been developed for the purposes of
creating a data base of the generated literature.
Finally, the analysis of the data enabled triangulation of data from key informant interview and
literature review on two specific issues of emerging policy concerns and priority research questions
pertaining in the country.
3.0 LITERATURE REVIEW
3.1 Introduction
The Uganda’s National Health Policy, 1999 (for a period 1999-2009) focuses on health services that
are demonstrably cost-effective and have the largest impact on reducing mortality and morbidity.
Consequently the major contributors to the burden of disease at all levels that include malaria,
STI/HIV/AIDS tuberculosis, diarrheal diseases, acute lower tract infections and maternal conditions
attributable to high fertility and poorly spaced births, vaccine preventable childhood illnesses,
malnutrition, injuries, and physical and mental disability were not given highest priority. The overall
objective of the National Health Policy, 1999, was to reduce mortality, morbidity and fertility, and the
disparities therein with efforts focused at ensuring access to the minimum health care package4
. The
policy further provides objectives and guidelines specific to health care financing, human resource for
health, and private health sector in general. The exception in the National Health Policy was stating
the objective of Complementary and Traditional Medicine Practitioners but not providing specific
guidelines.
The actions lined up to achieve the overall objective of the National Health Policy with regard to the
three thematic areas are clearly stipulated in the health policy as:
• Provision of additional resources for Primary Health Care (PHC) in the form of conditional
and equalization grants or similar mechanisms with increased funding specifically on
immunization as a component of public health (HSSP 2000/01 – 2004/05.
• Clarifying the relationship between the key stakeholders, notably health related line
ministries, the Health Service Commission, the Local Governments, Donors, Private
Practitioners, NGOs, and Traditional Practitioners within the decentralized system.

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The minimum health care package comprises interventions that address the major cause of burden of disease. This is
taken to be a cardinal reference in determining allocation of public funds and other essential inputs in the health sector. The
minimum health care package involves control of communicable diseases (malaria), STI/HIV/AIDS, and Tuberculosis);
integrated management of childhood illness; Sexual and reproductive health and rights; and other public health
interventions.

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• Implementing the organization and management reform of the Ministry of Health in line
with its new roles and responsibilities.
In 1990, when the country embraced the concept of Essential National Health Research (ENHR),
efforts were made to set a health research agenda in Uganda. To achieve this objective, policy
makers, researchers and civil society were to be called upon to participate at various stages in the
evolution and development of research. The activities that included wider consultations and workshop
to draw-up a health research plan were carried out in second half of 1990s.
Available literature shows a Health Research and Development brochures (1999) listing research
priority areas for the period 1997-20015
and updated for the period 2005-20106
. The research
priorities were reportedly identified in consultation with district health officers at their regional
meeting, a few representatives of research institutions and senior officers of the Ministry of Health.
In this case the district officials verbally gave their research priorities mainly based on their
experience. Moreover, the proposed research priorities (2005-210) are over 75 sub-topics under 9
topics such as maternal child health and nutrition; HIV/AIDS; Malaria; Drug use studies and; non-
communicable diseases rather than priority research questions.
Among the steps taken to support the implementation of health research was the formation of an
indigenous organization called Uganda National Health Research Organisation (UNHRO)7
intended to
develop, coordinate, promote and strengthen health research which is essential for the health and
development of the people of Uganda. However, UNHRO is not yet not legally established, is limited
in consultations, does not have data base due to lack of funding and have no information on the
kinds and nature of much of health research that has been done in the country.
3.1.1 Health Care Financing
Uganda like Kenya and Tanzania has had a tradition of using government treasury resources to
finance health care. For example, Uganda and Tanzania health care financing was mainly run by the
government funds to ensure that citizens accessed all health care services free of charge. The non-
profit sector participation in health services delivery was with a heavy level of government subsidy to
ensure affordability (Ashington Ngigi and Daniel Macharia, May 2006). Though, health care
financing is increasingly being done by both the government and the private sector, the government
through the Ministries in charge of health is still the major financier and provider of health care
services in the three countries.
The three countries have also had a gamble on alternative financing options. In Uganda for example
the fee for service (sometimes referred to as cost-sharing) has been introduced, abolished or re-
introduced (formally and informally) and health insurance is planned. The common factor being the
governments’ inability to provide unlimited free care because of budgetary allocations that are
insufficient to meet rising health costs (Asiimwe D., Mwesigye F., McPake B., and Streefland
P., 1997; HSSP II, 2005/06-2009/2010).
Uganda’s Health Sector Strategic Plan (HSSP I) 2000/01 – 2004/05 provides indicative cost analysis
for the HSSP I of a total cost of US$ 954 million for the five year period of the plan. The annual total
costs are US$ 159 million in year one; US$ 179 million in year two; US$207 million in year three; US$
209 million in year four; and US$ 201 million in year five. A number of challenges remained, key
among these being under funding with current level of public funding of about US$8 per capita falling

5
Uganda National Health Research organization (UNHRO), 1997-2001, (Brochure 1999), UNHRO, Entebbe
6
A brochure of Uganda National Health Research organization (UNHRO) Research Priorities 2005-210, UNHRO,
Entebbe
7
UNHRO is health research organization owned by government with Research institutions of government not directly
supervised by UNHRO and Private practitioners/ private researchers as affiliates (see also UNHRO, Bill 2006)

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far below the estimated requirements (US$ 28 per capita). In effect only 30% of HSSP I was
funded excluding the activities and financing of private for profit providers, employers’ clinics and the
traditional sector. The percentage of the government of Uganda budget that is allocated to the
health sector declined from 10.8% in FY 2004/05 to 8.9% in 2005/06 against the target of 11.1%.
The percentage of the government expenditure on health as a percentage of total government
expenditure also declined from 9.75% in FY 2004/05 to 8.3% in FY 2005/06 (MoH, October 2006).
In development of HSSP II, when the inputs for the delivery of the Minimum Health Package were
identified, quantified and costed, there was a big resource gap between the requirements of HSSP II
and the resource available in the current MTEF. The medium term costing scenario that scales down
the inputs to be more inline with the MTEF was therefore proposed. In the light of this, emphasis of
HSSP II is to concentrate effort and resources on a limited set of evidence–based, cost-effective
intervention under each of the elements of the Uganda National Minimum Health Care Package
(UNMHCP) (HSSP 2005/06 – 2009/10).
Like in HSSP I, costing methodology8
of HSSP II remains largely facility based except for the
estimated costs at central level. Furthermore the costing applies to only government and Faith
Based-NGO facilities and like HSSP I, HSSPII does not cover the private profit providers, employers’
clinics and the complementary and traditional medicine sector. As pointed out in the Draft Policy on
Public Private Partnership, 2006, limited national awareness of the potential contribution of the
private sector to national health care delivery and apparent absence of a national policy on
partnership and financing in Uganda are major impediments to inadequate support to the
Complementary and Traditional Medicine and Private Health providers.
Upon a review of the existing documents one can deduce critical issues around financing health
services in the country. These include:
• The public/ Private Mix in health care financing
• Costing delivery of health services
• Alternative Health financing mechanisms including health insurance
• Accessibility, equity and affordability of non-state sector health services especially the poor
and vulnerable groups
• Sustainability in financing health care in public and private domains
3.1.2 Human Resource for Health
The National Health Policy (1999) and Draft National Policy on Public Private Partnership in Health,
2006, point out three major human resource problems in Uganda’s health sector. These are: (a) mal-
allocation of human resources with 54% of the health workers concentrated in hospitals; (b)
shortage of trained health workers in the health sector and; (c) attrition of qualified staff from private
not- for- profit practitioners to public facilities and private practice. These together with poor
remuneration of health workers pose major challenges to effective implementation of health
programmes in Uganda.
In response, the Ministry of health attempted to address the major constraints of inadequate
numbers and inappropriate distribution of trained health personnel. The HSSP I aimed to attain at
least 75% of the minimum staffing norms at each level of the district health system. This was revised
to 52% of all the approved posts to be filled by appropriate trained staff. The recruitment of health
workers during HSSP I raised the proportion of approved posts filled with trained health workers from
33% to 68%. However, in HSSP II it is noted that though the numbers of qualified health workers
improved, it is still constrained by unequal distribution and inappropriate skills-mix with nursing
assistants constituting the bulk of the health workers at all levels of health care.

8
This costing methodology is detailed on pages 81 – 85 of the HSSP I and Page 76 of HSSP II

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In a related effort, the Human Resource for Health Policy (HRHP), 2006 was developed with the
main rationale of providing a framework and guidance for effective and efficient implementation of
the National Health Policy. The HRHP policy goal is to develop and maintain a health workforce that
is appropriately sized, structured, skilled, well balanced, distributed, resourced, committed and
performing efficiently and effectively in order to provide all Ugandans with equal access to a
minimum health care package, sufficient to meet Uganda’s health development targets within
affordable resources.
The objectives of the Human Resource for Health Policy are to ensure that:
• planning for human resource for health is rational and financing is adequate, education and
training of HRH is relevant to the health needs and health personnel requirements of
Uganda,
• management of HRH is improved at all levels;
• standards and rights of health professionals and clients are upheld;
• information and research on HRH are strengthened;
• partnership among public, private not for profit and private stakeholders in HRH is
promoted;
• benefits of globalization are reaped and its ill-effects mitigated; the institutional framework
for HRH functions is strengthened.
The strategy is to attain the right HRH numbers and skills mix to populate the health sector taking
into account recurrent budget constraints. The plan target is that the total health workforce in the
public and private sectors will increase by 66% from a current level of 59,000 to 98,000 for the
period 2005-2020 compared with a population growth rate of 60% giving a slightly improved health
worker to population ratio (MoH, June 2007).
The human resources needs, development and deployment raise a number of issues (MoH, June
2007; Uganda AIDS Commission, April 2007; MoH, April 2006; HSSPII 2005/06 –
2009/2010; The World Bank, 2003)
The philosophical tenets informing the Human resource policy making process
. Employment/labor laws, statutory environment and their relationships to effective health
care services delivery
. Rules and regulations concerning human resources in the health sector including
remuneration structures, motivation, retention and development
. Health workers preferences between Urban and rural areas; and public and private health
sector
. Capacity building standardization of skills training for effective health services delivery
. Professional organizations and their role in ethical practice maintenance.
. Commercialization vs professionalization in the growing private health sector
. Human resources budgeting for health services provision
. Market competitiveness for health related human resources and job security
3.1.3 Non-State Sector
For a long period since independence, the health services financing and provision in Uganda
remained largely the province of the government with substantial government subsidies to the non-
profit organizations in the three countries. It is in the post Structural Adjustment Programmes that
these countries formally invited the non-state profit oriented and non-profit making organizations to

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participate in the financing and provision of health care services9
. For example in Uganda non-state
sector role in financing and provision of services were formally recognized as late as 1998. (Kiyonga
C.W.B., (1997; MoH, 1998).
The National Health Policy (1999) recognizes existence of insufficient collaboration between the
public and the ‘private sector’10
and Traditional Health providers. The major objective is to make the
private sector a major partner in Uganda’s national health development by encouraging and
supporting its participation in all aspects of the national health programmes.
The draft National Policy on Public Private Partnership in Health (PPPH), 2006, provides a general
framework for effective partnership between the Ministry of Health and the Private Not-for Profit;
Private Health Practitioners, Traditional and Complementary Medicine Practitioners as key actors that
form the private health sector. The purpose for the framework is to institutionalize and guide the
implementation of the partnership between government and the private health providers.
It also encourages registration of providers with their respective councils such as; the Uganda
Medical and Dental Practitioners Council (UMDPC), the Uganda Nurses and Midwives Council (UNMC),
the Uganda Pharmacists Council (UPC), and the Uganda Allied Health Professionals Council (UAHPC).
The policy further provides policy makers and other stakeholders with guidelines of identifying and
addressing partnership concerns when taking policy decisions.
A number of issues to be observed with regards to the role of the non-state sector arise out of the
fact that it is now a major player in health services financing and delivery and these may include,
inter alia:
. Size and coverage of the private sector in the health care system including referral
. Type of services rendered by the private health sector
. Regulatory framework, supervision and quality assurance for private health care provision
. Investment and consumer choices in terms of meeting standards of quality, safety,
quantity, utilization and value for money with increased private sector participation
. Incentives or disincentive and state-based mechanisms to ensure increased role of the non-
state sector with an assurance of equity of social and geographical dimension of access or
distribution of services
. Training of professionals such as physicians, nurses and technicians for the private sector
. Intra and extra mural participation by publicly employed professionals (parallel working) in
the non-state sector and its impact on health care delivery.

9
Peter Berman and Ravindra Rannan-Eliya, October 1993, Factors affecting the development of private health care in
developing countries: Review of Concepts and Literature and Preliminary Field Design, Health Financing and
Sustainability Project, Montgomery, USA.
10
The Private Sector in health includes: Private Not for Profit Health Providers (PNFP), Private Health Practitioners and, Traditional and Complementary
Medicine Practitioners (TCMP). The PNFP includes Facility Based (FB-PNFP) and are religious based for example Uganda Catholic Medical Bureau
and; Non-facility based (NFB-PNFP) such as NGOs both local and international.

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4.0 FINDINGS FROM KEY INFORMANT INTERVIEWS
4.1 Policy Concerns - Health financing
4.1.1 Budgeting and Resource allocation for the health sector
The budgeting process for the health sector seemed very clear to majority senior policy makers. As
reported by one of the informants from Ministry of Finance, the Medium Term Expenditure
Framework (MTEF) is the overall mechanism by which resources are expected from government,
including donor budget support and allocated sectors. The MTEF sets sector and local government
spending ceilings within a three year rolling framework. The sectoral ministries through Sector Wider
Approach (SWAP) then decide on spending within available resources in the context of their strategic
plans such as HSSP II of the Ministry of Health. This is expected to link planning and development in
budgeting based on the amount of resources available.
The majority of policy makers particularly in planning department and financing section of the
Ministry of Health reported that though the budgetary resource allocation to the health sector had
increased over the period of HSSP I from 7.6% of the government budget in 2000/01 to 10.3% in
2003/04, the sector is still grossly under funded. As clearly expressed by one informant, in reality the
money got from all the three sources (government, donors and user fees) can just be US$ 18-20 per
person per year but only US$ 9 per person per year is available in the budget of the Ministry of
Health. Again this is considered far less compared to Uganda’s unit cost estimated at US$ 30 per
person per year and the World Health Organisation (WHO) minimum requirement of US$ 30-40 per
year per year excluding bed nets, ARVs, ACT and some vaccines for children.

A senior policy maker in charge of Ministry of Health planning alluded;
In 2002/2004 the health sector budget was about 220 billion shillings and rose to 242 billion shillings in 2007/2008
instead of the expected - over 430 billion. …. In real terms the budget being used is just for 8 million people to
provide health services to the population of about 27 million people. (Senior Policy Maker, Planning, MoH)
The under funding of the health sector raises a number of policy concerns reflecting the continuing
colonial legacy. The major source of funding for the health sector remains the tax base system
supported by donor funds with limited health insurance and user fees. Though user fees were
retained in private wings in public referral hospitals and Private Not-For-Profit (PNFPs) facilities after
they were abolished in 2001, they do not cover a full cost recovery component at any point of service
delivery. On the other hand health insurance remains limited to a few corporate bodies and
companies that make specific arrangements for their staff with private health providers. A senior
public officer hinted on the implications of inadequate national resource envelope:
Ministry of Finance Planning and Economic Development does not envisage massive resources coming into the
national budget, Therefore review of current funding priorities may be needed to encourage reallocation of resources
or look for efficiency savings within the sectors (Principal Officer, MoFPED, Kampala)
4.1.2 Public financing of the private sector
The PNFPs contribution to health service delivery in Uganda was reported to be of close to 40% by
most policy makers and leaders of PNFPs. For example 37% OPD services and; 35% of delivery of
mothers is by PNFPs. Despite this sizeable contribution, government financial support to PNFPs is
very low. Currently government contributes only 22% with 38% covered by user fees and 40% from

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donations. Yet PNFPs are by law bound to provide Primary Health Care service (PHC) such as
immunization of children and mothers that is at 29% coverage. In addition, public policy makers
acknowledge that hardly any support was being extended to non-facility based PNFPs until the global
initiatives that are pushing for more focus in that direction using GAVI and the Global funds.
The misconception by government that PNFPs get a lot of external funding from international organizations should be
corrected. The external grants are not even regular in the way they come. (Head/Programme Officer, Faith Based
NGO Medical Bureau, Kampala)
The PNFPs further reported experiencing problems related to inelastic funding from the public sector.
Key among these is the exodus of health workers from PNFPs to government sector, which is
providing better pay and employment motivation such as various allowances, shorter working hours
and career development opportunities.
The PNFPs are said to have responded by increasing user fees to raise funds to sustain their services.
They have also resorted to using part time doctors, employing clinical officers and nursing assistants
instead of highly trained nurses. This tends to breed overload of staff resulting into general poor
quality of services provided because fewer staff can not give patients enough time. These combined
are reported to discouraged many people who are not able to pay more from seeking health services
as well as low trust in the quality services and performing capacity of health facilities.
Few patients tend to seek services due to the low trust they develop. The quality of health care is down below
average. So as a way of survival PNFPs tried to increase user fees to sustain qualified health workers
(Head/Programme Officer, Faith Based NGO Medical Bureau, Kampala)
Generally small facilities do not attract any good funding but rely on user fees. The impact of user fees has been the
reduction of clients seeking services in faith based facilities (Head, Faith Based NGO Medical Bureau, Kampala)
4.1.3 Alternative source of financing
The proposed National Health Insurance Scheme is considered one of the key alternative sources of
financing the sector. The policy makers reported that the scheme which is derived from the National
Health Policy of 1999, expects everybody to pay for health services. The piloting of the scheme
expected to start with the formally employed in both public and the private sector plans government
contribution of 50%, employer 10% and the beneficiary 40% to raise 2.5% of the health budget in
about five years. The informants from the public sector raised a number of concerns related to the
scheme. The first was the concern on the financial implications on employers business as they
contribute to the scheme. Second was how to get everybody (unemployed and informal sector) into
the scheme and make it affordable to most people. Others are the mechanisms of collection and
disbursement of funds and; lack of credible institutions to run the scheme given Uganda’s past
experience with poor management of provident funds.
Employers are skeptical about financial implication of the scheme on their businesses. The requirement that
employers contribute to the scheme is what is causing the controversies. The national health insurance policy is very
sensitive because it touches on the private money. (Senior Policy Maker, Planning, MoH , Kampala)
The informants in the public and private sector further expressed doubt on the implementation of the
national social insurance scheme when it eventually becomes law. The non-governmental key
partners in health care delivery such as PNFPs and PFPs are reluctant to enter the national health
scheme because the government has not studied and determined costs and mechanisms of taking up
contractual arrangements. The costing of services remains very complex with apparent lack of

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adequate data that can be immediately and effectively utilized by the scheme. The implementation
of the scheme is not in the foreseeable future with the MoH envisaged to concentrate on setting up
institutions and management systems of the scheme during the period of HSSP II.
Private –not- for- profit health care providers are reluctant to enter the national social health insurance scheme
because it has not been studied to determine cost of contracting arrangements and mechanisms of taking up
contractual arrangements. There is no information or financial analysis to guide decision making (Head, Faith Based
I have not seen the costing of health service delivery in Uganda. … Yet we are now going for the National Social
Health Insurance Scheme. Since government does not have any costing strategy, either the service provider or client
is going to be cheated (CEO, Faith Based NGO Medical Bureau, Kampala)
The unit cost of delivering services should be established so that the decision remains on the individual. We cannot
cost health services in isolation of traditional and PFP providers who are currently not brought on board (Senior
Planner, MoH, Kampala)
The informants from the private sector envisage that the scheme might negatively impact on the
rural poor who are the majority of Uganda’s population. They assert that leaving out majority rural
population can negatively affect health indicators because of high dependence syndrome in a country
like Uganda.
In addition this may create high expectations in a situation where there is no adequate financing for
its implementation. It is also suspect to introducing inequity at service delivery points because those
insured and those not insured may have different fees thus denying the latter access to health
services.
The second policy concern on health financing relate to funds that are never captured in the national
budgets rendering it very difficult to plan and predict its impact on health care delivery. This happens
because some partners continue to put aside resources to directly fund projects in districts and for
others that prefer to fund specific activities of their interest even after the Sector Wide Approach
(SWAP) developed in 2002 to pool all the funds to cover agreed activities and avoid duplication of
services in a few areas among development partners. The policy makers in the ministry of health
acknowledge the challenges of weak systems and poor transparency in the management of funds
that force some donors to pull out of the SWAP arrangement at anytime.
The dominant role of donor support to the health budgets is distorting funding of the health sector components. This
is because donor initiatives are project based and thus distort the funding of the health sector.(Head, Faith-Based
The challenge of donor funding is that it is driven by their interests. Secondly the process of fund acquisition is
stringent, so the funds come late and delays activities. Donor funding does not cater for human resource component.
(Medical Coordinator, HIV/AIDS Service NGO, Kampala)

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4.2 Research Priority Questions - Health Financing
The holistic costing of the health strategy rather than costing of health service delivery
based on available resources was identified as the first priority question. The assessment
should provide answers regarding the health burden of a country, the cost in relation to
per capita GDP of the Ugandans and the health standards to be adopted in the delivery of
health care.
The informants particularly from the MoH and MoFPED were emphatic on determining of a unit cost
of delivery of services rather than the Minimum Health Package to guide assessment the staffing
levels and stocking of health facilities with drugs and equipment. The informant from the MoFPED
argued that while, they may know that the health sector needs additional human resources and
funding for drugs, they lack critical information for determining the numbers of health workers and
amount and categories/kinds of drugs needed. A senior planner in the MoH, noted that the total cost
of health care delivery is important in directing priorities towards certain areas.
Another informant from a multi-lateral organization asserted that costing of health services should be
based on a system that can help guide in gauging services delivered and setting realistic
interventions.
The need to track cost effectiveness of resources allocated to the Ministry of Health was
ranked the second priority research area in the health sector. The shared reason, invariably
stated by key policy makers in the MoH and MoFPED as well as informants in NGO and Multilateral
organizations was the need to assess the value for money that is currently allocated to the health
sector.
Needles to say an informant from MoFPED, reported that Uganda as a low income country which
does not envisage massive financial resources coming into the national budget. In such a case the
optimum as well as evidence-based prioritization in the use of the limited resources becomes an
obvious option. The majority of the informants agreed that this research area calls for examination of
the priority activities to which resources are spent and identification of factors responsible for non-
improvement of health indicators in Uganda over a period of time. This research was seen to be
helpful in generating evidence to support review of the current funding, programs, reallocation of
resources and priority setting.
There is need to track cost effectiveness of resources allocated to the Ministry of Health to find out whether resources
are spent on priority activities. … Ideally, we need research to track movement of resources allocated and how they
have improved the health indicators (Principal Officer, MoFPED, Kampala)
The cost-benefit analysis of the health sector to support the proposed health insurance
scheme in analyzing the situation was proposed as the third priority research area.
Among the issues are mechanisms of collection of money and disbursement, accrediting
institutions to provide health services and inclusion, equity and affordability issues in the
scheme.
Costing of health interventions should be based on a system; because it’s a system which can guide in gauging how
services can be delivered and helps in the process of setting realistic interventions. Planning should as well be based on a
comprehensive required system or intervention rather than planning being driven by isolated significant problems like
HIV/AIDS and Malaria. ( Health Specialist, Multi-lateral Organization , Kampala)

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The National Social Insurance Scheme, now a bill before the cabinet was viewed by policy makers
as an alternative source of financing the health sector. Almost all the informants in the public and
private sectors were skeptical regarding the implementation of the scheme. They foresee problems
related to access and equity in service delivery, discrimination in costs of services, absence
managerial arrangements and skills among others. There were calls for the information to address
issues of policy, implementation, financing and management of the scheme across the board.
4.3 Policy Concerns – Human Resource for Health
4.3.1 Numbers, deployment and attrition
According to the public policy makers, the numbers, deployment and skills mix of health workers in
health facilities present a puzzle regarding developing and managing human resource for health in
Uganda. The presence of health workers in the public health units is said to be skewed towards
urban areas with the majority in big hospitals despite efforts of by government to ensure equitable
distribution during deployment.
The problem of staff deployment was closely related to that of retaining of staff hired by the public
sector. The informants from the Human Resource Department of MoH, reported that most health
workers do not want to work in ‘hard to reach areas’ where they are deployed. They also leave the
public to private sector or the health sector all together due to low salaries, workload and poor
incentives.
The attrition of health workers extends to the private sector. This was reported to have started in
2003/2004 when government selectively increased the salaries and conducted a massive recruitment
exercise to fill the 6000 positions of health workers in the in public service. The private health
workers mainly in the PNFPs were attracted to the public sector since PNFPs were already paying
lower salaries. There was considerable concern among PNFPs that the human resources in their units
may further be depleted due to government ear-marked salary increment in year 2008 and the
dishonoring of PNFPs’ proposal to government requesting for an increase in subsidies to raise health
workers salaries.
In 2003/2004, Uganda Protestant Medical Bureau lost over 2000 health workers, 71% of these were clinical officer.
About 40% of those that left PNFPs went to government. (CEO, Faith Based NGO Medical Bureau, Kampala)
Salaries in the public sector are higher than in the private not for profit sub-sector, so our problem is to find a way of
retaining staff because these providers serve the most rural areas not served by government (Senior Policy Maker,
Human Resource Dept., MoH, Kampala).
The ministries of health and public services acknowledge the apparent lack of proper mechanisms for
tracking staff deployment including those on normal transfers and those that go outside the country
for various reasons such as studies. The regulation and code of conduct of health workers is also said
to be very poor that even when there are numbers and skills mix, the poor work ethics override
them.
4.3.2 Record Keeping and Data Management
The poor record keeping in the public sector was reported as one of the serious problems. Though
the HRH information exists, it is found to be disjointed, difficult to access and not standardized
sometimes creating contradictions in sets of data such as the pay roll and the general register of
health workers. For example the MoFPED urged that they may know that the health sector needs

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additional human resources but lack aggregated information for decision making on the numbers
and categories of staff needed.
Only one person based in the ministry of health manages data with a lot of secrecy. 0ne time we were in a planning
workshop and we wanted information from MoH but we couldn’t get it because the person managing the data was
sick and admitted at Mulago national referral hospital. The computer had to be taken to him in hospital and he was
so protective in not wanting others to see the password (Senior Policy Maker, Human Resource Dept., Ministry of
Public Service, Kampala)
The policy makers reported that currently there is no information on different categories,
specializations and health staff ratios such as nurses and doctors at health centers, regional and
district hospitals. There are also no standards required to develop a skills mix formula to be applied
to provide proportionately required numbers for the various health facilities.
There is need to study the existing human resource status to establish numbers skills mix and related strategies for
human resources development (Advisor, Human Resource Dept., MoH, Kampala)
4.3.3 Human Resource for Health Training
The quality of training health workers is another major concern expressed by most informants. In
Uganda all medical training schools were hurriedly transferred to Ministry of Education and Sports
(MoES) from that of Health without streamlining the management of the institutions and relationship
between the two ministries. The controversy was reported to be wide spread to include ownership,
management and conflict of roles between the two ministries. For example, while the Nurses and
Midwives Council is mandated by law to set examination for medical students, UNEB under the MoES
is also mandated to set examinations for the same medical students such that some nurses who
didn’t do examinations set by the Medical Council in the previous years had not been registered by
time of interview.
The conflict was reported to have considerable devastating impact on human resource training.
Three informants from human resource department of the ministry of health and one from the
ministry of public service reported that the problems range from losing focus on human resource
development aspect, lack/inadequacy of teaching materials like gloves to low quality of training of
health workers.

The shifting of medical schools to MOE has revealed the poor coordination between MoES and MOH … Both MoES and
the Nurses and Midwives Council have exercised their mandates and given nurses contradicting examinations. ( CEO,
Faith Based NGO Medical Bureau, Kampala)
4.3.4 Management of Human Resource for Health
Another key concern identified by the informants in public and private sector is the management of
the current human resource for health. In Uganda’s decentralized system of governance, Health
service delivery is decentralized to local governments. The informants in the public sector reported
that every district recruits and keeps their staff which the MoH is not mandated to supervise and
transfer. Moreover the districts health staff are not answerable to human resource Development
department, of the MoH which makes districts independent in their health workforce operations.
Even in situations where some district health services have been poorly managed, MoH reported that
it was unable to intervene and discipline the decentralized staff or easily apply sanctions such as
refusing to fund those districts. For example some districts have recruited District Medical Officers of
low caliber since much of the recruitment in local government is characterized with nepotism.

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In addition, some staff seconded to PNFPs could go for further studies without MoH’s consent, while
some became difficult to manage by their bosses in PNFPs claiming allegiance to MoH, which in
essence doesn’t have any control over them. This forced the Ministry of Public Service to abolish the
seconding of health workers to Private Not-for-Profit (PNFP) facilities.
A related concern was that of dual employment of public health workers reported to greatly affect
the performance of the public sector. The dual employment of public health workers has implications
on quality and management of health care delivery such as indiscipline, time loss and poor work
ethics. The tendency is for the health workers valuing job security and addresses from the pubic
sector that make them even more recognized in their private practice.

The President of the Republic Uganda directed us up to come up with a figure to pay staff and stop dual employment
but it is still a difficult thing to do due to lack of data on the cost efficiency of the health sector ( Senior Policy Maker,
Human Resource Dept., Ministry of Public Service, Kampala)
4.4 Research Priorities Areas – Human Resource for Health
The absence of a harmonized human resource management system and a consolidated human
resource development data creates a need for a Human Resource for Health systems study.
The first priority research area was an assessment of the current recruitment,
deployment and management systems of health workers in the public health sector. The
study is intended to review the current system to identify the strength and weaknesses
and develop a monitoring and evaluation system for existing HRH.
The policy makers in charge of human resource in Ministries of health and public service expressed
the need for information on the number of staff and their categories in public and private health
sectors, their qualifications and distribution in the service as the second research area. For example
the lack of this kind of data continue to make it difficult to calculate and process pensions of retiring
staff, determine the number of staff recruited at certain time, assess the workload and future human
resource needs.
The research question was the study on the number, categories and length of service of
public and private health workers. In this study an assessment of the skills mix was also
considered important to help in developing a skills mix formula/strategy that can
proportionately provide required numbers for various health facilities.
The third research question was to review the training curricula to address the health
sector needs in light of the new diseases, changing health care seeking patterns, new
policies and the occupational issues of health workers. The increasing workload for health
workers and the emerging issues such as task shifting where doctors should be able to shade off
some tasks to nurses require re-examination of the training curricula.
The challenges of building synergies for human resources between the sectors to address problems
of dual employment, staff specializations and training discussed earlier presented a fourth research
area. The research question is the need to examine the relationship with regard to human
resources deployment and development between the two sectors and the impact on
performance of the public and private health sectors.

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4.5 Policy Concerns – Non-State Sector
The public and private sector have had a lot of informal collaboration dating back in 1960s. However,
public and private informants reported that the partnership between government and the PNFP sub-
sector was still weak. The government stills gives PNFPs little money amidst considerable
contribution. In addition both government and PNFPs have different focus and objectives in health
care delivery.
The general situation is that there are weak partnerships between government and the PNFP sub-sector and lacking
in the PFP and Traditional sub-sectors.(Senior Policy Maker, Public Private Partnership, MoH, Kampala)
The reports from private providers indicated that there was hardly any meaningful relationship
between the government, PFP and Traditional sub-sectors. They complained of being unrecognized
by government with the traditional sub-sector being considered informal and not legally recognized.
However, the private sector pay taxes, employ health workers and make services readily available to
communities apart from being required to provide immunization and ARV services free of charge.
Private for-Profit (PFP) providers are taken as people out there just making money yet PFPs are providing highly
required and specialized services such as heart surgery (Chief Executive Officer, Private Hospital, Kampala)
This hospital is actually spending about Uganda Shillings 1.5 million monthly to pay for the delivery of free public
services (Medical Director, Private Hospital, Kampala)
4.6 Research Priorities Areas – Non-State Sector
The first priority research question is to develop a comprehensive Health Management Information
System (HMIS) to generate information from the private sector (PNFP, PFP and Traditional and
Complimentary Medicine). The data generated should be reflected in the national official documents
for planning and policy making purposes.
The second important research question is to provide an account for the weak/absence of
relationships/synergies in the health sector. The information is intended to provide strategies to
improve and establish desired collaboration among the different sub-sectors in health care delivery.
The third should be a national mapping of the private health facilities and providers, categorize them.
The study should also generate data on pricing of services, kind of patients handled by the private
sector, costs and treatment procedure as well as information made available to patients by providers.
The fourth would be a national survey on consumer satisfaction. The survey would help bring out
consumers’ views regarding improving service delivery and establish the value for money audit from
the health consumers.

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5.0 DISCUSSION
5.1 Uganda’s Health Policy Environment
The health sector policy development process is considered to be interactive involving key
stakeholders addressing particular areas. These initiate policy ideas that are brought to the attention
of the ministry of health or the ministry itself can initiate policy development process.
In each case a concept policy paper has to be developed by MoH in collaboration with representative
of stakeholders. When agreed upon and endorsed by the Minister responsible it then becomes a
policy guidelines paper. It is a committee working closely with implementers that develops a draft
policy. Finally when a policy is enacted it becomes a living document and can be reviewed to address
some emerging issues.
This tends to imply that the policy development is harmonious and all inclusive exercise where policy
ideas of most key players in the national health system are usually considered and acted upon.
However, the study results show that that some critical players such as PFPs and traditional medicine
have always been merely recognized but not streamlined in the health policy making process. The
abundance of policy concerns among public policy makers, private providers, and representative of
public providers and users/consumers of health care point to limited consultations in the health policy
environment. The financing mechanisms applied by MoFPED, proposed National health insurance
scheme, lack of data on most aspects of human resource for health and weak/absence of relationship
between public and much of the private sector are a few examples that show limited involvement of
key stakeholders in health policy making.
5.2 Health Financing
The costing and allocation financial resources for health emphasize minimum health care package to
ensure universal access to health services by all people. The health resource allocation criteria do not
only greatly vary across providers but is based on few factors. For example in the public sector the
allocation of resources to district health services are based on factors such as population size in the
district; levels of poverty using the human poverty index provided by Ministry of Finance Planning
and Economic Development; level of development of the district in terms of road network, access to
electricity and health infrastructure. For the PNFPs that access public funding consideration has been
given to facility based units on the basis of number of beds and level of the unit. For the other key
players such as the PFPs and Traditional medicine has not any known basis upon which they access
or may access public financing.
The practice of costing and allocation of public financial resources appeared to be driven by limited
resources of the health sector. This means that priority setting and adequate health care delivery is
likely to remain a formidable challenge even with the available resources.
The holistic costing of health care delivery that was identified and ranked number one of the priority
research question thus become critical in generating information to help setting priorities in a
resource constrained country like Uganda.

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5.3 Human Resource for Health
The Human Resource for Health Policy (HRHP), 2006 and the strategic plan 2005-2020 have clearly
identified the major problems but not the factors responsible for the key problems with regard to
Human Resource for Health. Anecdotal evidence indicates that these problems are a result of a
combination of factors the main ones being poor remuneration, conditions of services as well as lack
of harmonized human resource development and management system in the national health system.
With current information on HRH disjointed, difficult to access and not standardized, majority of
health workers have been known to take advantage and engage in dual employment to earn
additional income11
default on deployment or migrate in search of better conditions of service.
Attaining the desired goals and standards of the Human Resource for Health Policy may need major
overhaul of government human resource management systems, revised conditions of service and
clearly developed human resource deployment arrangements between the public and private heath
sectors. These actions will require information on most attributes as well as the development and
management systems of human resource in the health sector.
5.4 Non-State Sector
The Non-State sector is large and widespread. By comparison to the public sector, private health
facilities are relatively abundant and much closer to the majority of the population and present to
users a wide variety of types and levels of services.12
The role and contribution of the Non-State sector in health care delivery is as varied as the players.
For example, the role of faith based PNFPs provide health care as a social services to the public
targeting the vulnerable people. The PNFPs health services extend to the very remote areas where
government services are not existent. Available data shows that PNFPs cover 36% of fixed facilities
offer 7800 beds compared to 9500 beds of the government. In that respect, the public and private
sectors are considered ‘natural’ partners in health care delivery. The non-state sector is recognized as
a key stakeholder in HSSPI and II as well as in the proposed National Social Health Insurance
Scheme.
However, weak partnerships between the government and the PNFP sub-sector. The most significant
factors fostering current partnership between government and PNFP is basically that NGOs have
structures that government finds easier to deal with; as opposed to the private for profit (PFP) and
traditional sub sectors. On the other hand, any partnership hardly exists between government, the
Private for profit and Traditional sub-sectors. The PFP were considered by policy makers to be much
disorganized during policy development meetings even in instances where they have an association
while traditional Spiritualists’ shied away from policy development process because they could not
meet the modern religious spiritualists.
The funding methodology or unit costing to private sector continue to based on the capacity of the
health facilities in terms of the number of beds and level of the health unit. Consequently the support
has been limited to facility based PNFPs leaving out the majority of private sector providers. Even
then government total funding has since 2004 remained stagnant despite the increase in the number
of PNFPs sharing the fund. The contributions of PFPs and Traditional Medicine providers are not
reflected in any national documents and no systematic support has been extended to them from the
public sector. Consequently, the generation of comprehensive data on numbers, categorize and

11
Asiimwe D., Mwesigye F., McPake B., and Streefland P., (1997), Informal Health Markets and formal Health Financing Policy in Uganda, Final
Report, Makerere institute of Social Research, Kampala.
See also: Jitta J. and van der Hiejden, T., (1993) , Economic Survival Strategies of Health workers in Uganda, Study Report, Child Health Development
Centre, Makerere University, Kampala
12
Delius Asiimwe (1999), The Current Private Health Care delivery System in Uganda, Makerere Institute of social
Research , Kampala

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range of services and their costs and contribution remain critical in development of harmonized
health system.
The proposed National Social Health Insurance Scheme is derived from the National Health Policy of
1999, out of the need for a financing strategy and system to generate own funding to supplement
government resources. In a situation where the employer together with the beneficiary contributes
50%, a number of controversies and challenges arise to make national health insurance policy a very
sensitive issue. Its piloting is proposed to start with the formally employed in both public and the
private sector making it accessible and affordable to just a few people. The mechanisms of collection;
disbursement of funds and accrediting of institutions to provide health services are not current
feasible in a situation where the Uganda government is ridden with corruption and bad experiences
of management of provident funds. These and other challenges make employers and beneficiaries
skeptical about financial and management implications of the scheme requiring that the government
revisits the proposed bill of the scheme.
5.5 Strength of the study Methodology
The focus on policy makers as informants, the majority in the health sector enabled using interview schedules
with relatively similar questions to deal with issues related to the study objectives. This made the analysis easy
when it came to drawing similarities and differences in the data from various respondents.  The interview with
such knowledgeable respondents also permitted exploring in detail a wide range of issues as well as sharing of
experiences on the three thematic areas under study.
The other strength was the factor that the study utilized a wide range of literature from official document,
surveys, reports and publications that were collected from the varied sources such as internet, libraries and
offices of key policy makers. This method was helpful in collecting documented data that formed a basis for
follow‐up questions and supplemented the data from key informants.
These two together presented a comprehensive assessment of the priority research questions from the
available key sources of information in the country.
5.6 Short Comings of the Study Methodology
The selection of the key informant interviews was subjective in that the knowledge and experience on issues
under study was linked to the position held by the individual in the targeted organization. In a few cases
where individuals were not conversant with much of the subject matter and never suggested alternative
source, less valuable information was obtained.
The focus on policy makers as informants meant generating information mainly on questions and issues
affecting their planning and implementation processes. This left out much of the information on concerns and
questions of most health providers and users of the health services in the country.
The study assumed a coherent and vibrant non‐state sector. However, Uganda’s non –state health sector is
highly fragmented and efforts to interview a cross‐section of informants did not yield much valuable data.  The
lack of knowledge regarding government plans and policies and the non‐state sector exclusion from
mainstream development processes as well as poor record keeping in both sectors  limited the information
being sought.

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6.0 REFERENCES
1. Ashington Ngigi and Daniel Macharia , Health Sector Policy Overview Paper, May 2006, IT Power East Africa
(http://www.enable.nu/publication/D_1_7_Kenya_Policy_Overview.pdf) (accessed 30/07/07)
2. Asiimwe D., Mwesigye F., McPake B., and Streefland P., (1997), Informal Health Markets and formal Health
Financing Policy in Uganda, Final Report, Makerere institute of Social Research, Kampala.
3. Draft National Policy on Public Private Partnership in Health Care, (PPPH) 2006.
4. http://www.who.int/countries/uga/en/ (accessed 29/01/08)
5. Kiyonga C.W.B (1997), Minister of Health, Health Policy Statement 1997/98, Ministry of Health, Entebbe
6. Magnus Lindelow, Ritva Reinneka and Jakob Svensson (2003), Health care on the Frontlines: Survey
Evidence on public and private providers in Uganda, African Region Human Development Working Paper
Series, The World Bank, Washington D.C
7. Ministry of Finance, Planning and Economic Development: Budget Speech, Financial Year 2005/2006, June
2005, Kampala.
8. Ministry of Health (October 2006), Annual Health Sector Performance Report, Financial Year 2005/2006,
Kampala
9. Ministry of Health, Draft Health Policy, 1998, Entebbe
10. Ministry of Health, Human Resources for Health Policy, April 2006, Kampala
11. The Health Sector Strategic Plan (HSSP) 2000/01 – 2004/05
12. The Health Sector Strategic Plan (HSSP) 2005/06 – 2009/2010
13. The Republic of Uganda, The Local Government Act, 1997
14. The Republic of Uganda , Poverty Eradication Action Plan 2004/5 – 2007/8, Ministry of Finance, Planning
and Economic Development, Kampala, December, 2004
15. The Republic of Uganda, National Health Policy, September 1999, MoH, Kampala
16. Uganda AIDS Commission, (April 2007); Accelerating HIV Prevention: The Road Map towards Universal
Access to HIV Prevention in Uganda, Uganda HIV/AIDS Partnership Committee, Kampala
17. Uganda Bureau of Statistics and ORC/Macro, August 2007, Uganda Demographic and Health Survey 2006,
Entebbe: Bureau of Statistics, and Calverton, Maryland: ORC/Macro.
18. Uganda Bureau of Statistics and ORC/Macro: 2002 Uganda Population and Housing Census, 2002, Entebbe
19. Uganda Bureau of Statistics, Uganda National Household Survey, 2006

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Annexes:

1: List of Key Informants
2: Key Informant Tools

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LIST OF KEY INFORMANTS
NAME TITLE ORGANISATION/INSTITUTE
MINISTRY
1. Dr. Naomi Kyobutungi Assistant Commissioner, Health Services (Human
Resource Department)
Ministry of Health
2. Mr. Moses Arinaitwe Assistant Commissioner, Human Resource Development Ministry of Health
3. Dr.  J.H. Kyabaggu Technical Advisor, Human Resource Department Ministry of Health
4. Dr. Eddie Mukooyo  and Mr. Amos Nzabarita   Assistant Commissioner, Health  Services (In‐charge of
Resource Centre) and Principal Bio‐Statistician
Ministry of Health
5. Dr. Robert Basaaza Senior Planner / Health Economist   Ministry of Health
6. Dr. Grace Mulindwa Head, Health Financing Section Ministry of Health
7. Dr. Francis Runumi Commissioner, Planning Ministry of Health
8. Dr. Nathan Kenya‐Mugisha representing Director
General, Health Services
Director, Clinical Services and Community Medicine Ministry of Health
9. Ms. Jane Mwesiga   Assistant Commissioner, Human Resource Development Ministry of Public Service
10. Mrs. Elizabeth Imagara representing
Commissioner, Planning
Principal Policy Analyst Ministry of Local Government
11. Mr. Laban Mbulamuko Principal Economist, Budget and Evaluation Department Ministry of Finance Planning Economic Development
(MoFPED) – Medium Term Expenditure Framework
Email: laban.mbulamuko@finance.go.ug
SPECIAL HEALTH PROGRAMS
12. Dr. Jacinto Amandua Commissioner, Clinical Services   Ministry of Health
13. Dr. Elizabeth Madraa Program Manager AIDS Control Program, Ministry of Health
14. Dr. Nelson Musooba Assistant Commissioner, Public Private Partnership   Ministry of Health

15. Mr. Elly Mugumya Executive Director Family Planning Association of Uganda (FPAU)
Email: emugumya@fpau.org
16. Prof. John Rwomushana Director, Policy and Research Uganda AIDS Commission

33
33
NAME TITLE ORGANISATION/INSTITUTE

17. Dr. Possy Mugyenyi representing Program
Manager, EPI

Deputy Manager, Expanded Program on Immunization Uganda National Expanded Program on Immunization
BI/MULTILATERAL ORGANISATIONS
18. Dr. Peter Okwero Health Specialist World Bank
19. Mr. Dan Ahimbisibwe Programme Officer, HIV/AIDS USAID
20. Dr. Juliet Nabyonga  and Dr. William Mbabazi National Professional Officers, Health Economics /
Surveillance
World Health Organisation (WHO)
Email: mbabaziw@ug.afro.who.int ;
nabyongaj@ug.afro.who.int
RESEARCH INSTITUTES & ORGANISATIONS
21. Dr. Simon Peter Rutabajuuka Executive Director Centre for Basic Research, Uganda
Email: srutabajuka@cbr‐ug.org
22. Dr. Grace Nambatya Executive Director Traditional & Complementary Medicine Laboratory,
Uganda
23. Prof. Ralph Owor Director Uganda Health Research Organisation (UNHRO)
PRIVATE FOR PROFIT HOSPITAL
24. Dr. Ian Clarke Chief Executive Officer International Hospital Kampala (IHK)
Email: iclarke@img.co.ug
PRIVATE CLINIC
25. Dr. Henry Kasozi Medical Director KADIC Hospital
Email: henry_kasozi@yahoo.co.uk
PHARMACEUTICAL OUTLET
26. Mr. Crescent Muhumuza Pharmacist Friecca Pharmacy
NON GOVERNMENTAL ORGANISATIONS (NGOs)
27. Dr. James Tamale Secretary The Pharmaceutical Society of Uganda
28. Ms. Mary Namusisi Branch Programmes Coordinator Uganda Private Midwives Association
29. Dr. Geoffrey Mulindwa and Vanessa
Tremamunno representing Executive Director
Medical Service Coordinator and Public Relations and
Advocacy Manager
AIDS Information Centre (AIC)
Email: byaruhanga@aicug.org ; akellov@aicug.org
30. Dr. Jennifer Kavuma   General Secretary Uganda Medical Association (U.M.A)
31. Ms. Robinah K. Kaitiritimba National Coordinator Uganda National Health Users/Consumers’
Organisation
32. Dr. Christine Nabiryo Lwanga representing
Executive Director
Director, Projects and Planning The AIDS Support Organisation (TASO)
Email: nabiryoc@tasouganda.org
FAITH BASED ‐ PRIVATE HEALTH FACILITIES

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