Health Financing for Equitable Access to Maternal, Newborn and Child Health

Health Financing for Equitable Access
to Maternal, Newborn and Child Health:
A means to ending preventable deaths in Uganda.
Health Financing Report
August 2012
By WorldVision Uganda
Child Health Now Campaign

Report prepared by:
Nathan Nshakira, Emmanuel Rukundo, Stella Settumba
Edited by: Dr. Christine Nabiryo,
FARST Africa
Editor: Davinah Nabirye
OurVision
Our vision for every child, life in all it’s fullness;
Our prayer for every heart, the will to make it so.
Mission Statement
WorldVision is an international partnership of Christians whose mission is to follow our
Lord and Saviour Jesus Christ in working with the poor and oppressed to promote human
transformation, seek justice and bear witness to the good news of the Kingdom of God.

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Health Financing Report - August 2012
Table of Contents
Foreword.......................................................................................................................................................................4
Acknowledgements.................................................................................................................................................... 5.
Glossary........................................................................................................................................................................6
Abbreviations and Acronyms .................................................................................................................................7
Executive Summary...................................................................................................................................................10
1. STUDY OVERVIEW.........................................................................................................................................16
2. METHODOLOGY...........................................................................................................................................18
3. FINDINGS..........................................................................................................................................................19
3.1 Impact of decentralization on financing the delivery of health services.......................................13
3.2 Policy gaps in financing malaria and malnutrition programs in Uganda.........................................28
3.3 Uganda government 2005-2010 health expenditure, trends analysis.............................................34
3.4 Effects of out-of-pocket expenditure on utilization of MNCH care services..............................38
4. CONCLUSIONS AND RECOMMENDATIONS......................................................................................41
4.1 Key Conclusions......................................................................................................................................41
4.2 Recommendations..................................................................................................................................42
ANNEXES..................................................................................................................................................................47
Annex 1: Study Conceptual Framework......................................................................................................47
Annex 2: Key Informants List.........................................................................................................................50
Annex 3: Coverage of key rights related to health in international and national instruments.......52
Annex 4: Progress on selected indicators on maternal, newborn and child health...........................53

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Foreword
As the world counts down towards 2015, there continues to be slow progress towards attaining
millennium development goals (MDGs) 4 and 5; aimed at reducing under-five mortality rate by two-
thirds and maternal mortality ratio by three quarters respectively especially in developing countries
including Uganda.
Therefore, an immediate concerted action is needed by key players such as Ministry of Health, donors,
civil society organisations if Uganda is to make significant strides in realizing MDGs as well as improve
the health system.
In 2010, the United Nations Secretary-General, Ban Ki-moon launched the ‘EveryWoman Every Child’
initiative to mobilize and intensify global action to improve the health of women and children around
the world. Over 60 countries including Uganda made commitments to step up efforts to improve
women and children’s health.
For the past 50 years, World Vision International has sought to transform the lives of children and
the communities in which they live with a vision for every child to enjoy life in its fullness. One of
WorldVision’s aspirations is to see that children enjoy good health.The organisation also ensures that
government leaders deliver on their commitments to reduce child mortality by two-thirds.
In line with the UN Every Woman Every Child strategy and MDG target 4,World Vision launched its
first global advocacy ‘Child Health Now’ campaign in 2009 to eliminate six million deaths of children
under five - the ones we know are easily preventable - by getting governments to do more, so that
children have enough nutritious food and clean water, and access to community-based health services.
In Uganda, one of the strategic focus areas of the campaign is to influence policy and decision making
to ensure long term and predictable funding for maternal, newborn and child health. If government
rebalances health spending, it would ensure provision of such low-cost, simple interventions as better
nutrition, bed nets and skilled birth attendants; this would annually save close to 141,000 under five
deaths in the country.
In 2011,World Vision Uganda commissioned a research on ‘Health financing for equitable access to
maternal, newborn and child health’ to generate evidence for the campaign.This report presents an
analysis of the impact of decentralization on financing the delivery of health services; Identifies policy
gaps related to supporting and financing child health programme in Uganda; analyzes the trends of
Uganda government health expenditure over the five years between 2005 and 2010 and examines the
effects of out-of-pocket expenditure on utilization of maternal, newborn and child health care services
in public health services.
By addressing policy recommendations in this report; the district health teams, Health Financing and
Planning, and human rights monitors, I believe the under-five morbidity and mortality rates in Uganda
will greatly reduce.
I extend my sincere appreciation to all the people and entities that contributed to the findings in
this report; Government Officials, the donor community, civil society organisations, District local
Governments, communities of served and WorldVision staff.
Albert Siminyu
Interim National Director
WorldVision Uganda

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Acknowledgements
It has been great honor and privilege to undertake this study on behalf of World Vision Uganda. Let
me extend my sincere appreciation to Rudo Kwaramba (former National Director- World Vision
Uganda (WVU) for her leadership and guidance towards this operation. I am also highly thankful for
the technical guidance from the other staff including: Njeri Kinyoho- Advocacy and Justice for Children
AdvisorWorldVision EastAfrica Regional Office, James Kintu-Associate DirectorAdvocacyWVU and
Robert Kanwagi- Associate Director Health WVU.
I would like to take this opportunity to express my humble gratitude to the different key informants
from the Ministry of Health, Ministry of Finance, different Civil Society Organisations and the District
local Governments of Nakaseke,Arua, Kalangala and Soroti.Your consent to share vast knowledge and
experiences made this report what it is and helped us to accomplish this assignment. I am also grateful
for my team from FARST Africa, without whom I would not have executed this study.
I am highly thankful to my project internal guide Richard Dickens Kintu- Child Health Now Campaign
CoordinatorWVU for steering this process rightly,coordinating all the actors,resources and constantly
tightening the loose ends.
Nathan Nshakira

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Glossary
Resource flow: effective and timely movement of funds and inputs for health service
delivery, within and outside the health system.
Efficiency: how well the available resources are deployed in the health system so as to
achieve the ‘best possible’ desired outcomes from the given resource level1
.
Effectiveness: ensuring that planned outcomes and objectives are achieved as a result of
implementation of planned interventions and activities as intended.
Accountability: political justification of decisions and actions, and managerial answerability
for implementation of agreed tasks according to agreed criteria of performance.
Allocative efficiency: matching of public services to local preference.
Social Health insurance: health financing mechanism whereby costs of health services is
recovered through mandatory pre payment contributions to a health fund operating on a
principle of society risk pooling,as all individuals and households share the financing of total
healthcare costs.
Community health Insurance: health financing mechanism whereby households in a
community (the population in a village, district or other geographical area, or a socio-
economic or ethnic population group) finance or co-finance the current and/or capital costs
associated with a given set of health services while at the same time participating in the
management of the community financing scheme and the organization of the health service2
.
Decentralization: The policy of government decentralization in Uganda, as described in the 1993
Decentralization Act (Cap 243), provides for four main elements: (i) fully fledged local governments
with elected political leadership, planning, financing and legislative powers; (ii) strengthened
administration through enhanced capacity and mandate of deployed administration staff,and greater
participation and accountability to the people; (iii) an expanded service delivery mandate, together
with a public service management framework to ensure this; and (iv) critical oversight, support and
guidance from central government through Resident District Commissioners,the Local Government
Finance Commission, Ministry of Local Government, and sector line ministries.
1 James C. Carrin G. Savedoff W. Hanvoravongchai P (2005) Clarifying Efficiency-Equity Tradeoffs Through Explicit Criteria,With a Focus on
Developing Countries Health Care Analysis,Vol.13. No. 1. March 2005 DOI: 10.1007/s 10728-005-2568-2
2 http://www.who.int/health_financing/documents/tmi-community_insurance.pdf

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Abbreviations and Acronyms
ACHPR African Charter on the Human and People’s Rights
ACRWC African Charter on the Rights and Welfare of Children
ACT Artemisinin Combination therapy
AIDS Acquired Immune Deficiency Syndrome
BOD Burden of Disease
CAO Chief Administrative Officer
CBHIS Community Based Health Insurance Scheme
CBO Community Based Organization
CDO Community Development Officer
CRC Convention on the Rights of the Child
DDP District Development Plan
DHMT District Health Management Team
DHO District Health Office
DTPC District Technical Planning Committee
ECD Early Childhood Development
EPI Expanded Program on Immunization
FDS Financial Decentralization Strategy
GAVI Global Alliance forVaccination and Immunization
GHOSP General Hospital
HC Health Centre
HIPC Highly Indebted Poor Countries
HRH Human Resources for Health
HSD Health Sub-District
HSC Health Service Commission
HSSP Health Sector Strategic Plan
HSSIP Health Sector Strategic and Investment Plan
HUMC Health Unit Management Committee
ICESCR International Covenant on Economic, Social and Cultural Rights
ITN Insecticide Treated Nets
LG Local Government
MCH Maternal and Child Health
MDGs Millennium Development Goals
MFPED Ministry of Finance, Planning and Economic Development

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MGLSD Ministry of Gender, Labour and Social Development
MNCH Maternal and Neonatal Child Health
MOH Ministry of Health
NCC National Council for Children
NDP National Development Plan
NGO Non-Governmental Organization
NHA National Health Accounts
NHIS National Health Insurance Scheme
NO National Office
OOP Out of Pocket Expenditure
OVC Orphans andVulnerable Children
PEAP Poverty Eradication Action Plan
PEPFAR Presidential Emergency Plan for AIDS Relief
PER Public Expenditure Reviews
PFP Private for Profit
PHC Primary Health Care
PMTCT Prevention of Mother to Child Transmission
PNFP Private Not for Profit
TB Tuberculosis
TBA Traditional Birth Attendants
UCRNN Uganda Child Rights NGO Network
UNCESCR United Nations Committee on Economic, Social and Cultural Rights
UDHR Universal Declaration of Human Rights
UHRC Uganda Human Rights Commission
UNCA Ugandan National Children Authority
USPA Uganda Service Provision Assessment
UFNP Uganda Food and Nutrition Policy
VHT Village Health Team
WASH Water Sanitation and Hygiene
WVU WorldVision Uganda

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In order to contribute to a two-thirds reduction in
child mortality by 2015,World Vision International
initiated a five-year campaign called the Child
Health Now (CHN) in 2009.The campaign focuses
on 30 low-income countries that have the highest
rates and numbers of child deaths.The goal of CHN
campaign in Uganda is to contribute towards the
reduction of the under-five child mortality from
137 deaths to 56 deaths per 1000 live births by
2015 through addressing preventable deaths such
as malaria and malnutrition at the household,
community and national levels. Progress reports
on the Millennium Development Goals (MDGs)
indicate slow progress especially on health-related
goals and targets.3
Factors that underlie the slow progress include:
limited Government investment to strengthen
health systems, insufficient or poorly coordinated
donor resources, lack of agreement on effective
technical strategies,limited scale-up of interventions
that work; and limited analysis of how and why
national health policies achieve less than expected,
perform differently from expected, or even fail.4
The CHN campaign in Uganda focuses on three
main action strategies:
• Influencing policy and decision making to
ensure long term and predictable funding for
maternal and child health.
• Addressing barriers (financial, social-cultural,
and geographic) to accessing basic healthcare
services by families and communities.
• Building capacity of families and communities to
adopt healthier attitudes and practices aimed at
disease prevention,seek,and demand for health
services from duty bearers.
3 For example: Uganda Ministry of Finance, Planning and Eco-
nomic Development (2010) Millennium Development Goals
Report for Uganda 2010: Accelerating progress towards im-
proving maternal health; United Nations (2008)Achieving the
Millennium Development Goals in Africa: Recommendations
of the MDG Africa Steering Group June 2008; and United Na-
tions Millennium Campaign and Overseas Development In-
stitute (2010) Millennium Development Goals Report Card:
Learning from progress
4 United Nations (2008) Achieving the Millennium Develop-
ment Goals in Africa: Recommendations of the MDG Africa
Steering Group June 2008; and Buse K, Dickinson C, Gilson L
(2007) How can the analysis of power and process in policy-
making influence health outcomes? ODI Briefing Paper #25.
World Vision Uganda commissioned this research
with a goal to generate and profile evidence for the
CHN campaign in Uganda. The specific objectives
of the operational research were to:
a) Examine the impact of decentralization on
financing the delivery of health services;
b) Identify policy gaps related to supporting and
financing malaria and malnutrition programs in
Uganda;
c) Analyze the trends of Uganda government
health expenditure over the five years between
2005 and 2010;
d) Examine the effects of out-of-pocket
expenditure on utilization of maternal,newborn
and child health care services in public health
services.
The study was premised on a rights-based
framework that connects 4 elements that underpin
health services: (i) health as a universal human
right, and an entitlement for all Ugandan citizens;
(ii) government policies, strategies and legislation
to provide a mechanism for delivery of the right
to health; (iii) health financing as the means to
enable implementation of health care policies
and strategies; and the health system that actually
delivers services and its operation, including
measurement and reporting on provision and
results from health services.
The research was conducted as a cross sectional
descriptive study, primarily using qualitative
methods of data collection and analysis. Primary and
secondary data was collected at national level and in
four districts (Arua,Kalangala,Nakaseke and Soroti).
Analyzed data was validated through a national
level workshop, attended by representatives from
all 4 study districts and national-level respondents
including official from the Ministry of Health and
the social services parliamentary committee .
Triangulation between primary and secondary
data and with discussions at the national validation
workshop was done to inform this report.
Executive Summary

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Key findings
A: Child health rights:
• Uganda is party to all international and regional
commitments to human rights in general, and
specifically the right to health; and has put in
place a number of mechanisms and systems to
support their realization
• Government has established national level
mechanisms to ensure and monitor realization
of the right to health for all; and specifically for
children – as an integral element in child rights
• District and community level stakeholders
have some awareness about the constituent
elements of child health rights,and the key duty
bearers for their realization.
• Realization of the right to health in general and
child health rights and entitlements as specific
elements therein, is constrained by: (a) weak
mechanisms for ensuring and monitoring this,
(b) inadequate dissemination and popularization
of the specific elements and implications of
these rights, and (c) limited translation of the
rights into policy commitments and action
strategies for their realization.
B: Policies in support to child health
• Successive health policies and strategies since
1999 are appropriately focused and committed
to provision of child and maternal health
services
• Policies and strategies for other social and
development services are supportive of
realization and protection of child health
• The 4 key stages of the policy cycle are not fully
realized for most policies relevant to child and
maternal health; only the policy writing stage is
most completed.
• Realizationofthehealth-relatedpolicyintentions
in decentralization has been constrained by:
weak health planning and management systems
at district, health-sub-district and facility levels;
and inadequate human and financial resources.
• The policy processes for ensuring maternal
and child health are primarily based in
central government; largely de-linked from
the decentralized local governments and
with limited participation from the broader
community.
• Existing opportunities for local government and
community contribution to the policy process
are not fully utilized.
• Respondents in the districts made specific
policy recommendations focused on three main
issues: human resources for health; a multi-
sectoral approach to delivering and managing
improvements in child health; and greater
involvement of community representation
structures in policy advocacy and service
delivery.
C: Financing child health:
• High achievements in financing for planned
health services in the early 2000s were not
sustained in the later years; and have continued
on a downward trend.
• Despite Uganda’s commitment to a systems
approach to health service delivery; financing
for health primarily focuses on a few elements
of the health system.
• The Ugandan health financing framework
continues to be primarily focused on public
health facilities,with limited integration of other
elements in the health system (private health
facilities, community and home-based services,
non-facility services of NGOs, etc.).
• Decentralization is appreciated as a useful
framework for participatory planning and
management of primary health care services,
but is currently perceived as not adding value to
financing of child health services in the districts
covered by the study.
• Out-of-pocket spending on health care seeking
from public health facilities continues to be a
policy issue of concern; and a major worry for
health consumers.
• Efforts at mobilization and pooling of user
contributions for health financing have not yet
succeeded in making health insurance a viable
and sustainable option for the majority of
health service users.
• Although efficacious interventions have been
prioritized to attain child health; systems for
their delivery are constrained by poor planning,
inadequately resourced health facilities and

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communities that lack necessary empowerment
for effective participation in maternal and child
health services.
• Mis-match between health strategies and
allocated resources; weak health management
systems (personnel, supplies and information);
and limited consideration of the private
sector in decentralized health planning are key
constraints to efficiency.
• Thereishighpublicinterestandgrowingdemand
for government accountability to citizens; but
existing legal and institutional mechanisms to
ensure and enforce this have not been fully
utilized for extensive public benefit.
D: Planning and delivery of district health
services
• Physical access to public health facilities has
improved, but quality of services in these
facilities remains inadequate.
• There are mixed experiences in realization of
the six child health services examined in this
study; with more appreciated provision with
respect to immunization, maternal care and
malaria services; and expressed concern with
respect to diarrhea, pneumonia and nutrition
services.
• There is limited systematic and comprehensive
planning for health services in general (and
specific to maternal and child health services)
across the different levels of the decentralized
district health system.
• The consistent policy commitments to a
decentralized health system have not been
translated into necessary empowerment and
operational support to the decentralized health
management system at different levels.
E: Measuring progress in child health
• The overall picture is of slow progress to realize
the health-specific goals (MDG 4, 5 and 6); and
the health-supportive goals (MDG 1, 2 and 7).
• Slow progress in attaining the MDG is
reflection of stagnation on many of the service
interventions that underpin realization of
MDGs.
• There are numerous gaps in data and
information management at visited health
facilities and health management offices;
and limited utilization of available data and
information to improve services.

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Key recommendations
Building blocks Key actions
1. Governance and
leadership
The Government through its line ministries should fast truck the
implementation of its commitments in the UN strategy for women and
children’s health.
Civil society should initiate and coordinate stakeholder mobilization for
re-vitalized focus and support for the district health system as the key
vehicle for realizing child and maternal health within the framework of
MDGs 4& 5 and the UN strategy for women and children’s health.
Civil society should work closely with the UHRC, NCC; MOH and other
relevant government Ministries, Departments and Agencies to revive and
scale up rights and policy based planning for district health systems.
Parliament should fast track legislation to pass the Food and Nutrition Bill,
2008 into law, as an important guiding framework for realization of the
right to health.
District councils should institutionalize inter-sectoral and participatory
processes to develop district multi-year health strategies based on the
HSSIP and the intentions of NHP II.
District councils should establish and use district health assemblies as
annual forums for health partnership mobilization, good practice sharing
and public accountability; with necessary collaboration across districts to
enhance cross-learning and joint health development initiatives.
Districts should ensure that communities, CSOs and private sector
partnerships are fully engaged is a governance and leadership role and
responsibility for health rights realization.
2. Health financing
MOH should work with districts, PNFP medical bureaus and other
stakeholders to develop and implement an integrated health financing
framework that mainstreams user contributions with a focus on appropriate
pre-payment schemes in line with a national economy that remains largely
informal; and user fees for selected secondary level services with in-built
mechanisms for subsidy and exemption to those unable to pay.
MOH and development partners should support districts to develop
and institutionalize district health accounts and efficiency monitoring; to
provide baseline and monitoring information on resource mobilization and
utilization in implementation of the district multi-year health strategies.
Please include (15% commitment of GDP to health, committing to the
Abuja declaration).
3. Human resources for
health
MOH and MOPS should support districts to develop capacity and
institutionalize systems for health workforce planning and monitoring.
Central government and donors should increase investment to strengthen
national, district and facility-level mechanisms for planning, management,
retention and motivation of human resources for health.

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4. Medicines and tech-
nologies
MOH should support districts to develop capacity and institutionalize
systems for quantifying, projecting and monitoring requirement and supply
of medicines and other medical technologies in the entire district health
system.
Health rights advocates should support districts to monitor, report and
institute measures to ensure and improve availability, utilization and quality
of medicines and other medical technologies.
5. Service delivery
DHOs should revitalize the expanded DHMT and its operation,inclusive of
all actors in health service delivery and health development in the district
(government, PNFP and private health facility operators, and providers of
non-facility based health services).
Expanded DHMTs should plan and manage delivery of integrated and
effective health services that progressively reach all communities, families
and individual in accordance with their needs.
Civil society should work through current operating mechanisms at
national, district and community levels to support empowerment and
sustained mentoring of local government development and health planning
systems to ensure quality health services through health assemblies.
DHOs should support lower local governments and health facilities to: (a)
reorient the health service delivery system to a community partnership
approach; (b) undertake annual integrated health and development
planning; working through existing structures for community development
and social service delivery (PDCs,VHTs, etc.); and (c) build the capacity of
community leadership and mobilization structures; community groups and
families to participate in personal and community health development to
demand and utilize necessary health and development services.
6. Health information
and research for health
UHRC should collaborate with civil society and other stakeholders to
undertake periodic, comprehensive and decentralized measurement of
progress in realizing the right to health; to inform improvement planning:
monitoring, reporting, dialogue, and action planning.
MOH should support districts to develop and institutionalize an integrated
community and health-facility based health information system as an
integral element in the district health system.
Civil society should support family and community empowerment for
measurement and accountability with respect to realization of health
for all mothers and children through: (a) maintenance and processing of
community health records by VHTs; and (b) annual community health
planning and accountability forums at parish level; based on plans, records
and service results at community level and health facilities.

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In order to contribute to a two-thirds reduction
in child mortality by 2015, World Vision
International initiated a five-year campaign
called Child Health Now (CHN) in 2009.The
campaign focuses on 30 low-income countries
that have the highest rates and numbers of
child deaths.WorldVision works with partners
and communities in 22 of these countries to
increase access to essential health services,
especially at the community level, and advocate
for increased focus and spending on maternal,
newborn and child health. The goal of CHN
campaign in Uganda is to contribute towards
the reduction of the under-five child mortality
from 137 deaths to 56 deaths per 1000 live
births by 2015 through combating malaria and
malnutrition at the household, community
and national levels. The strategic focus of the
campaign in Uganda is three-fold:
• Influencing policy and decision making to
ensure long term and predictable funding
for maternal and child health.
• To address barriers (financial, social-cultur-
al, geographic) to accessing basic healthcare
services by families and communities.
• To build capacity of families and communities
to adopt healthier attitudes and practices
aimedatpreventingmalariaandmalnutrition,
seek, and demand for health services from
duty bearers.
Global progress reports on the Millennium
Development Goals (MDGs) indicate slow
progress especially on health-related goals and
targets.5
5 For example: Uganda Ministry of Finance, Planning and
Economic Development (2010) Millennium Development
Goals Report for Uganda 2010: Accelerating progress towards
improving maternal health; United Nations (2008) Achieving the
Millennium Development Goals in Africa: Recommendations
of the MDG Africa Steering Group June 2008; and United
Nations Millennium Campaign and Overseas Development
Institute (2010) Millennium Development Goals Report Card:
Learning from progress
Factors that underlie the slow progress
include: limited investment in weak health
systems, insufficient or poorly coordinated
donor resources, lack of agreement on
effective technical strategies,limited scale-up of
interventions that work; and limited analysis of
how and why national health policies achieve
less than expected, perform differently from
expected, or even fail.6
In 2011, World Vision Uganda commissioned
this operational research to generate and profile
evidence for the CHN campaign in Uganda; with
specific focus on campaign goal 2 – reviewing health
system strengthening. The specific objectives of the
operational research were to:
a) Examine the impact of decentralization on
financing the delivery of health services;
b) Identify policy gaps related to supporting and
financing malaria and malnutrition programs in
Uganda;
c) Analyze the trends of Uganda government
health expenditure over the five years between
2005 and 2010;
d) Examine the effects of out-of-pocket
expenditure on utilization of maternal,newborn
and child health care services in public health
services.
The study conceptual framework used to address
these objectives is attached (Annex 1).
6 United Nations (2008)Achieving the Millennium Development
Goals inAfrica:Recommendations of the MDGAfrica Steering
Group June 2008; and Buse K, Dickinson C, Gilson L (2007)
How can the analysis of power and process in policy-making
influence health outcomes? ODI Briefing Paper #25.
1. STUDY OVERVIEW

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The research was conducted as a cross sectional
descriptive study, primarily using qualitative
methods of data collection and analysis. The study
sites at national level included government offices,
civil society organizations, development networks,
international development agencies, and research
andtraininginstitutions. Fourdistrictswereincluded
in the study; Arua, Kalangala, Nakaseke and Soroti.
Available documentation and records on public
health financing were identified and gathered for
review at national, district and health facility levels.
Key Informant (KI) interviews were conducted at
national,district,lower local government,and health
facility levels (Annex 2). Focus group discussions
were done with Village Health Team (VHT)
members and parents of children below 5 years.
Exit interviews were conducted with a sample of
parents attending services at visited health facilities.
All data collected was entered into computer
using the Microsoft office software package. A
manual approach was used to analyze data. Simple
spreadsheet analysis based on Microsoft Excel
was used to process numerical data. Integrative
and comparative analysis was conducted across
data sets from the different levels and categories
of respondents. Analysis generated from collected
data was validated through a national level
workshop, attended by representatives from all
4 study districts and national-level respondents.
Triangulation between primary and secondary
data and with discussions at the national validation
workshop was done to inform this report.
Data quality was assured through selection and
contracting of data collection supervisors and data
collection assistants with the necessary training
and work experience. Study tools were developed
and pre-tested before actual use in data collection.
The data collection team was trained for 5 days,
to internalize the research design and primary
interest, and to master the data collection process
and tools. The training also included actual trial of
the data collection process in one community. All
data collected was reviewed and edited by the lead
investigators to ensure completeness, validity and
consistency, before final analysis and report writing.
This synthesis report captures the main study
findings and recommendations; structured around
the study objectives and the five key research
questions covered in the operational research to
analyze government health financing as a means to
attain equitable access to MNCH in Uganda.
2. METHODOLOGY

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The survey findings are summarized below by study
objectives and as drawn from information gathered
using the research questions.
3.1 Impact of decentralization on
financing the delivery of health
services
Findings were that decentralization is
appreciated as a useful framework for
participatory planning and management of
primary health care services, but is currently
perceived as not adding value to financing of
child health services in the districts covered
by the study.
3.1.1 Impact of fiscal devolution on health
financing
The focus of this study as regards
decentralization was on fiscal devolution and
how it relates to financing of health services.
It is noted that key decisions on expenditures
for decentralized health services are made
within central government. For example
purchase and distribution of medicines and
other supplies; payments to health workers
and funding for the main disease control
programs such as immunization, AIDS,
malaria and TB. Many health expenditures
decisions, have been re-centralized after
an initial period of decentralization, for
reasons that include: inadequate capacity at
local government level (few staff and limited
skills of both staff and elected leaders) and
instances of district‘mis-use’ of the delegated
responsibility.
Respondents in the districts noted that
commitment to decentralized planning has
been undermined by perennial underfunding
(resulting in limited implementation of
plans made); and limited investment in
the structures that are meant to lead and
manage the local planning processes (e.g.,
HSD, and VHTs). Although more donors
and non-government implementers of health
programs have adopted a local focus (e.g.,
on districts and health facilities) as a result
of decentralization, most of them retain
decision-making responsibility and only
make occasional consultations with local
governments and communities.
Analysis of the health related decentralization
experiences based on the ‘decision space’
framework described by Bossert (1998)7
provides further insight to status of
decentralization in financing health. The
analysis showed that there was: limited
space for local governments to raise and
manage health financing for public health
services; limited decision space with regard
to management of human resources for
health (especially with regard to terms and
conditions of service, and staff attraction and
retention in locations considered difficult
for long-term professional service amongst
other factors related to health services
delivery.
3.1.2 Access and quality of the
decentralized health services
Study findings show that whereas physical
access to public health facilities has improved
as a result of decentralization, the quality of
services in these facilities remains inadequate.
Improvements are most notable in expansion
of the network of health facilities across the
country and the framework for management
of decentralized health services (through
increased number of district health offices,the
health-sub district concept, and community
participation in health management through
health unit management committees and
village health teams). This has resulted in
increased access to health facilities; with
the population living within 5Km to a health
facility (public or PNFP) rose from 49% in
1992 to 72% by 2005, where it remained
till 2010. Between 2004 and 2010, public
health facilities increased by 48%;while PNFP
facilities increased by 24% over the same
period.
7 Bossert, 1998 and Bossert & Beauvais, 2002; ibid
3. FINDINGS

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This multiplication of health facilities was
acknowledged and appreciated in all study
districts. The process to develop these
facilities has included participation at all levels
of the health system. Community members’
voices were noted as evident through:
demanding accessible services, making
available land for hosting facilities, willingness
and lobby to serve as support staff, nursing
assistants,and training as health professionals
for local deployment.
Local governments at sub-county and
district levels played key roles in funding and
managing construction of health facilities.
It was acknowledged in all 4 districts that
inadequate financing for health facility
construction was the main factor behind the
lack of vital structures such as maternity units,
staff housing, water and sanitation facilities,
fencing, at most of the new facilities all of
which are essential for improved delivery of
quality health services in general, maternal
and child health services, in particular.
In general, the quality of services in health
facilities is constrained by poor infrastructure,
inadequate medicines and other health
supplies, and by shortage and low motivation
of human resources.8
Local government leaders in the study
districts indicated that they have limited
mandate to address these gaps, especially
since the re-centralization of key decisions
on procurement and supply of medicines,
and on staff deployment and remuneration.
The assessment of health service provision
done nationally in 2007 found only 63% of
health facilities providing the three basic child
health services (care for the sick, routine
immunization and growth monitoring). This
proportion was even lower (at 55%) at
the lowest and most accessible level of the
health care system, the Health Centre II.
Only 9% of assessed facilities had in place the
requirements to provide quality immunization
services and 10% had full capacity to provide
quality out-patient care for children.
8 Second National Health Policy 2010; sec 2.4 pg 5 and sec
2.8.3 pg 8
3.1.3 Efficiency of decentralized health
services delivery
It was further noted that there is a mis-match
between health strategies and allocated
resources; weak health management systems
(personnel, supplies and information); and
limited consideration of the private sector
in decentralized health planning as key
constraints to efficiency.
Allocative efficiency was noted as lacking,with
respect to health and development strategies,
and the mechanisms for re-allocations in
circumstances of mismatch between planned
and available resources. Documents reviewed
and respondent interviews further pointed to
limited operational and technical efficiency,as
evident in weak health management systems,
limited staff supervision and motivation; and
ineffective mechanisms for ensuring timely
and adequate supplies.
“My best example of our inefficiency
is the way we spent so much money
to build health facilities;to ensure that
everybody lives within 5 km from a
health centre. Now we have them but
they have no staff no medicines and
therefore no services.” [Key Informant;
National level]
Expiry of medicines and other medical
supplies at different levels in the health
system was pointed out as a frequent
experience and a good pointer to inefficiency.
A similar indicator of inefficiency in broader
government resource management was
allocated and often disbursed resources
that remain unused at the end of each
financial year. Records reviewed at national
level revealed that for the FY 2009/10 33
districts and 2 municipal authorities returned
a total UGX 3.295 billion in unspent dues.
This therefore highlights challenges around
absorptive capacities at local government
levels and this has an implication on financing
of health services within the decentralized
governance context.
Furthermore, results from the 2004 NHA
showed that the average technical efficiency
score for all the districts was 70%; meaning

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that on average they could produce 30% more
output without increasing inputs.9 National
and district-level respondents pointed out a
number of factors that continue to constrain
technical efficiency, including: delays in
delivery of medical supplies, prolonged
recruitment processes, a high number of
recruited staff that decline offered postings;
and high levels of absenteeism among health
staff. Absenteeism was indeed noted to range
between 37% and 52% in different studies at
public health facilities; and estimated in the
2008 PER to have cost government up to
UGX 45 billion in FY 2006/07 alone.
Respondents in districts also mentioned the
importance of private-for-profit facilities
such as drug shops and maternity homes,
which are widespread in many communities
and provide services for many children and
mothers. However, these are not considered
when planning for district and health
facility services, or in the community-based
services of VHTs. Respondents in one
district welcomed a recent initiative to make
medicines for malaria cheaper and more
available in drug shops as a step in the right
direction.
Finally,as regards monitoring efficiency,it was
noted that the accountability mechanisms in
most use (e.g., audits within government and
through donor or civil society expenditure
tracking) primarily focus on money and less
on the service outputs and outcomes. They
provide limited space for public access,
understanding and debate on the results; and
often come long after the investments and
losses have been incurred, and needed child
health services missed.
3.1.4 Decentralized health service delivery
Planning
In addition, it was noted that there is limited
systematic and comprehensive planning for
health services in general (and specific to
maternal and child health services) across the
different levels of the decentralized district
9 MOH (2004) Financing Health Services in Uganda 1998/1999
- 2000/2001: National Health Accounts Final Report. Kampala:
Ministry of Health
health system. This then directly affects the
financing of these services and realization
of the health policy intentions through the
decentralized health system. Constraints
noted include: (a) limited strategic outlook
in planning of district health services (largely
restricted to annual activity plans, rather
than comprehensive multi-year strategies);
(b) inadequate cross-sectoral integration of
health and other social service/development
interventions (e.g through District
Development Plans and the DistrictTechnical
Planning Committees); (c) health sub-
district systems that remain under staffed
and largely non functional; and (d) limited
integration of the private sector actors into
the government-coordinated district health
systems (e.g. through the functioning of the
expanded district health management teams).
Although all study districts had DDPs with
specific commitments for health service
development in the medium term (3-5 years);
there was limited alignment between these
documents and the actual health services
experienced in the districts. Allocated
resources from central government (based
on the district annual budgets and available
funds in the national government treasury);
and off-budget donor funding were noted as
more directly influencing the experienced
reality. Illustrative analysis of the DDP for
one of the study districts is presented in the
text box below.
The Health Sub-District (HSD) was conceived
as a mechanism to aggregate management of
a set of health facilities and the communities
they serve at a level below the district; to
be based (as an additional responsibility) in
a HC IV, a government General Hospital or
a PNFP hospital. However, realization of
the HSD function has been constrained by
inadequate dissemination and understanding
of the idea, half-hearted implementation in
districts where resistance to loss of power as
a result of further decentralization was high;
absence of a corresponding local government
structure at the same level to buttress its
realization; and limited human and financial

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resources.10,11
The rapid subdivision of
districts between 2005 and 2010 turned
most of the envisaged HSDs into districts.
“The decentralization policy was
intended to bring services closer
to people, it was good, but it was
politicized. Every small county has
become a district but it is financially
unviable and incapable of providing
MNCH services”. Even the idea
of HSDs is now forgotten.” [Key
Informant; National Level]
It was noted that weak strategic planning
within local government systems limits
the possibility and effectiveness of policy
processes that are locally initiated. It was
indicated that the LG planning systems are
mainly focused on annual planning at the
different levels (village, Parish, sub-county,
district), and quarterly and annual planning
at health facilities. This consumes too much
time and resources, and limits focus on a
long-term/policy perspective.
“We spend all the time making
annual plans which never get funded
and implemented.” If you cannot
implement activities for just one year,
why waste time thinking about policy,
which will take even longer to finish
and put in practice.” [Key Informant,
HealthWorker, Soroti]
Some respondents, especially at sub-county
level and in health facilities pointed out that
they lack motivation and encouragement to
initiate policy processes. They attributed this
to the perspective in government that their
primary role is policy implementation.
Theotherfactormentionedbyhealthworkers
10 Lukwago JC. Et al (2009) Effects of decentralization on health
service delivery in Uganda. Kampala: Ministry of Health
11 Murindwa G.,Tashobya C.K.,Kyabaggu J.H.,et al.(2006) Meet-
ing the challenges of decentralized health service delivery in
Uganda as a component of broader health sector reforms. In
Tashobya C.K., Ssengooba F., CruzV.O. (Eds.) Health Systems
Reforms in Uganda: Processes and Outputs. Institute of Public
Health, Makerere University, Uganda/Health Systems Devel-
opment Programme, London School of Hygiene & Tropical
Medicine, UK/Ministry of Health, Uganda.
was the multiple layers of government above
them, which show limited interest and
support to any policy innovations at health
facility level.
There is no systematic planning for health
services taking place at health facility or
community levels, either. In the few settings
where VHTs were trained; their role was
largely restricted to community health
education, encouraging health care seeking,
participation in health service delivery, and
keeping household health records. None of
theVHT members participating in focus group
discussions indicated that they are mandated
(or have conducted any health planning
activities at community level or in liaison
with health facilities. Development planning
forums at parish and sub-county levels were
acknowledged as taking place annually, but
attracting very limited participation of VHTs,
or health workers at health facilities. The
only health-related planning acknowledged
as taking place in such forums was the
construction and other forms of capital
support for health facilities. The planning
and management operations in HSDs were
noted as largely limited, due to inadequate
staffing and lack of funds to facilitate review
and planning activities at health facilities and
consolidation of plans at HSD level.
Acknowledged effort and progress in bold
and far-reaching health decentralization in
Uganda during the 1990s was not sustained;
especially with respect to: full mandate to
local governments for management of all
health resources; extensive representation
of all actors in health care in the expanded
District Health Management Teams; and
evidence-based medium and long-term
district health plans. 12
The experience of
using Burden of Disease (BOD) information
in health planning was noted as particularly
useful in highlighting the importance of
accurate and dis-aggregated data as a basis
for meaningful planning.
12 Kapiriri L, Norheim OF, Heggenhougen K.(2003) Using burden
of disease information for health planning in developing
countries: the experience from Uganda. Soc Sci Med. 2003
Jun; 56(12):2433-41. Okuonzi, S.A., and F. X. K. Lubanga. 1997.
“Decentralization and Health Systems Change in Uganda.”
Ugandan Ministry of Health,Entebbe,and Ugandan Ministry of
Local Government, Kampala.

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The BOD results were vital in informing
development of the 1999 national health
policy and in defining the contents of the
national essential health care package.
However, their use for operational planning
at district level was constrained by:
poor understanding of the methodology,
inadequate in-depth data on disease patterns;
low involvement of stakeholders;and inability
of the methodology to capture key non-
economic parameters. 13
A similar initiative in Tanzania was more
effective in causing radical and effective
changes in district health planning and
resource allocation;partly because it involved
elaborate but inexpensive data collection
through sentinel surveillance system, and
use of structured tools to enable districts
generate and apply critical information in
the planning process.14
Evaluation of the
Bamako Initiative in Benin and Guinea also
attributed success to a dynamic process
of local and participatory problem solving
approaches;including monitoring of coverage,
identification of problems and micro-planning
of solutions.15
In another initiative in Niger
between 1996 and 2003, a combination
of diverse initiatives was undertaken to
facilitate effective access to health services
including:16
(a) increasing demand for services
by establishing health committees that
negotiated health care coverage plans and
fees for emergency evacuation; (b) increasing
uptake of services through additional and
better managed health centres;
13 Jeppsson, Anders, Agatre Okuonzi, Sam, Per-olof Ostergren,
and Bo Hagstorm. 2004.“Using burden of disease/cost effec-
tiveness as an instrument for district health planning: experi-
ence from Uganda.” Health Policy.
14 Neilson S. & Smutylo T. (2004) The TEHIP Spark: Planning and
managing health resources at the district level. A report on
TEHIP and its influence on public policy
15 Levy-Bruhl D. et al (1997) The Bamako Initiative in Benin and
Guinea: improving effectiveness of primary health care. Inter-
national Journal of Health Planning and Management; 12(S1):
S49-79
16 WHO (2005) World Health Report 2005: Make every
mother and child count. Geneva:World Health Organization
; and Bossyns P., Abache R. Abdoulaye S. Van Lerberghe
W. (2005) Unaffordable or cost-effective?: introducing an
emergency referral system in rural Niger Tropical Medicine
and International Health vol. 10 (9): 879–887 Sep 2005
and (c) improving case management in the
health centres and at hospitals.
3.1.5 Impact of decentralization on MNCH
services delivery
Study findings are that consistent policy
commitmentstoadecentralizedhealthsystem
have not been translated into necessary
empowerment and operational support
to the decentralized health management
system at different levels. All national health
policies and strategic plans since 2000 have
firm commitment to establish, strengthen
and enable effective and efficient operation
of the decentralized health system. This
commitment is most concretely expressed
in HSSP I in the costing of delivery of the
minimum health care package at different
levels of the district health care system (Table
1 below).

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Table 1: Unit costs for different levels of district health system in HSSP I – US Dollars FY
2000/01
Facilities HC I HC II HC III HC IV GHOSP DHMT
RECURRENT COSTS 248 12,823 39,335 94,502 363,288 84,404
Clinical Personnel 2,168 4,938 12,440 100,583 50,679
Drugs 8,250 18,500 44,000 102,600
Hospital Beds/Hotel Costs 2,769 4,077 25,385
Laboratory supplies 3,846 6,231 8,354
X-ray supplies 12,615
Office supplies 14 22 71 180 1,197 624
Travel expenses 409 714 1,804 2,395 6,242
Utility 175 598 1,536 7,692 538
Maintenance 20 565 3,425 10,809 58,784 10,619
Support staff 562 2,201 5,597 19,151 11,745
Supervision allowances 136 357 902 1,197 3,121
IEC and social marketing 64 192 934 4,647 4,647
In-service training costs 108 217 494 1,244 15,091
National Management support 42 127 488 1,035 3,597 836
CAPITAL COSTS 80 27,458 122,627 199,841 1,041,523 33,052
Facilities 21,333 74,000 83,705
Furniture, Beds & Medical Equipment 3,333 40,000 77,778 950,000
Refrigerators, Coolers 935 935 1,950 1,950 1,950
Communication Equipment 1,000 1,000 2,500 1,000
Vehicles (Inc. motor cycles and bicycles) 80 80 80 22,080 22,000 22,000
Initial training 1,777 6,612 13,328 65,073 8,102
TOTAL 328 40,281 161,962 294,343 1,404,811 117,456
Source: HSSP I document

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It is notable that the HSSP I costing
framework was specific in providing for
necessary management support to districts
by the central MOH; and also paid specific
attention to the community level operations
of Village Health Committees. Some national
level respondents in this study noted that
this investment in VHC development was
an important foundation for the successful
initiative for Home-Based Management
of Fever (HBMF) implemented across the
country between 2003 and 2006.
Respondents at national level and in the
districts acknowledged that financing based
on this costing was vital in establishing and
operational support to the large number of
health facilities and HSDs over the HSSP I
period.
“The best example of effective
community-based health intervention
in this country was the treatment of
malaria in children with HOMAPAK,
dispensed by community medicine
distributors. Many children were
saved from suffering and death; until
the initiative was killed off by the
policy change to ACT as the first line
treatment for malaria.” [Key Informant,
National Level]
This commitment to financing community
level health activities is evident in HSSP II
(largely as financing medicines for community-
level distribution); and in HSSIP as the largest
element in the budget for health promotion.
However, it is acknowledged in HSSIP that
the 100 percent HSSP II target for VHT
establishment and operation across the
country was not realized, largely because of
limited funding. Only 60 of the 112 districts
(54%) in 2010 reported having started VHT
training; and only 31% of districts reported
that VHTs had been trained in all villages.
Respondents at different levels in study
districts noted that the VHT program (in
the form as experienced in the study) was
a recent undertaking, most of teams formed
and trained in the previous 2 years.
In general, reported VHT support activities
were led by NGOs, with limited district
involvement.

“The VHT idea has been in the system
but has not been operationalized; you
never see it mentioned in any of the
sector reports. This is where you find a
problem in the priorities of the health
sector. They do not allocate money to
the base of the pyramid; how do you
expect the pyramid to stand.”
[Key Informant, National level]
The key roles that trainedVHTs have played in
the visited communities include: sensitization
of households about health promotion and
care; arranging and participating in outreach
services; referral to health facilities; and
necessary follow up of families on adherence
to treatment instructions. Some VHTs had
received registers and were keeping a range
of family health and demographic records.
The only experience reported in study
communities of recent or current stocking
of medicines for household level dispensing
was in relation to home-based AIDS care
(Co-trimoxazole prophylaxis).
It was further noted that realization of
the health-related policy intentions in
decentralization has been constrained by:
weak health planning and management
systems at district, health-sub-district and
facility levels; and inadequate human and
financial resources.
3.1.6 Other forms of health financing
The tax based public health financing system
supported by donor contribution through
budget support are the main forms of health
financing in decentralized governance system
in Uganda. Other forms of health financing
are yet to become widely operational
within decentralized systems. For example,
efforts at mobilization and pooling of user
contributions for health financing have
not yet succeeded in making social health
insurance a viable and sustainable option for
the majority of health service users within
both the national and decentralized health
care system. The proposed national socialHOMAPAK is a pre-packed sulfadoxine/pyrimethamine (sp) and
chlorozuine for children between 2 months- 5years of age.

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health insurance was discussed at length
by national level respondents, especially
about the weaknesses in the process of its
development and introduction. Respondents
pointed out that to-date there has been
no publically available document describing
details on the proposed scheme; and no
systematic engagement with all stakeholders
about the scheme and its main elements,
and its implications with respect to service
provision, service access and the true cost
of services involved. It was noted that
absence of such dialogue was indicative of a
poorly conceptualized process; inadequate
thinking and elaboration on critical aspects
of the scheme; and limited value attached
to comprehensive participation by all
stakeholders.
“The most critical issue to think about
is actually translating this money into
direct health services. Where are the
institutions that are going to provide
these facilities? You want to leave it as
a voluntary scheme; this will retain the
incentive for health service providers
to make available quality services
for the contributors.” [Key Informant,
National Level]
In addition It was emphasized that key
elements that will enhance effectiveness
of the scheme include: implementing it as
an independent initiative from the existing
social security system; and delivering it as a
voluntary undertaking, and marketing it well
so that people buy into it for what it is worth.
Respondents at national level (and a few
in the districts) discussed the experiences
from a number of community-based health
insurance schemes that have been tried in
different parts of the country. A number of
them were noted to have been sustained
over time, but continue to depend on a
combination of member contributions and
external support. Some research reviewed on
these schemes point to them being a relevant
policy option for financing health services and
raising the quality of health care in both public
and private health units; and community-
based services. However, understanding of
the activities and implications of the schemes
is largely limited to health managers with
direct experience with their operations.
One of the health facilities visited in this
study had an operational community health
insurance scheme, as described in the text
box below.
A number of them were noted to have
been sustained over time, but continue
to depend on a combination of member
contributions and external support. Some
research reviewed on these schemes point
to them being a relevant policy option for
financing health services and raising the
quality of health care in both public and
private health units; and community-based
services. However, understanding of the
activities and implications of the schemes
is largely limited to health managers with
direct experience with their operations.
One of the health facilities visited in this
study had an operational community health
insurance scheme, as described in the text
box below.

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COMMUNITY-BASED HEALTH INSURANCE SCHEME - KIWOKO
HOSPITAL
Kiwoko Hospital is a private not for profit hospital located in Kikamulo sub-county,Nakaseke
district. The hospital is one of the few health facilities that run a community based health
insurance scheme locally termed as“Munno mubulwade”(loosely translated as“a friend during
sickness”).The community-based health insurance was launched in 1999 with funding from
Centre for International Development and Research (CIDR). The scheme is registered under
Save for Health Uganda (SHU), an amalgamation of community solidarity groups for health
financing and maternal care, operating in Nakaseke, Luweero, Bushenyi and Nakasongola.
According to the respondent interviewed at the hospital, the scheme currently has over
12,000 members associated with it. Under the scheme, people pay an agreed amount of
premium (UGX 3,600), which is renewed, on an annual basis and when they are faced with
health costs, they pay only a small percentage (about 10%) of the total cost of the treatment.
Services covered under this scheme include deliveries and other complications and illnesses
which are thought to have a heavy financial burden on the patients.
The respondent highlights that one of the reasons why the scheme has succeeded has
been efforts to strike a balance in service provision without making profits while remaining
commercially viable (not operating in a loss). He also says that the scheme has been able
to build client confidence in such a way that when they come to the facility, they can find all
the services they require. However, it was indicated that the scheme is not yet self-sufficient
and still receives financial support in form of donations. It was acknowledged that current
government support to the hospital through the PHC grant is a useful complement to the
schemes in meeting the hospital costs. However, the flow of PHC funding is unpredictable
and never fully realized as budgeted.
“At the moment we cannot tell how much PHC grant actually gets disbursed for
the hospital. We are only told to pick some amount from the district; and this
keeps reducing every time. The performance is just scandalous. Our wish is that
the ministry should publish the amount of money released and make clear how
that money gets to us.” [Key Informant, National Level]

According to the respondent, the proposed national health insurance scheme will do a
great deal in buffering health care costs. Nevertheless, challenges are foreseen in form of:
limited understanding of the scheme by most stakeholders, inadequate capacity to manage it
effectively; and the number of poor people who might not have the capacity to contribute.
“I think the National Health Insurance Scheme is a good initiative, but I am still
at a loss about how it would work. It has been delaying meaning that legislators
do not understand it well.Given the number of people who pay the tax (very few)
and the enormous poor people,it would be hard to work.” [Key Informant,National
Level]
The respondent emphasized that there are other models and opportunities for public-private
partnership in health financing that need to be tried out in Uganda. He mentioned options
for establishment and running of model rural health facilities with good management systems
as private institutions;and the possibility to involve non-government agencies in management
of public health facilities.

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3.2 Policy gaps in financing malaria
and malnutrition programs in Uganda
Uganda is party to all international and
regional commitments to human rights in
general, and specifically the right to health;
and has put in place a number of mechanisms
and systems to support and monitor their
realization. The study shows that Uganda
has policies in place for financing malaria
and malnutrition program interventions but
there are gaps that have led to compromising
of the impact of these policies.
3.2.1 Uganda’s commitment to rights and
conventions relating to child health
The main global commitments to human
and child rights, including the 1948 Universal
Declaration of Human Rights; the 1966
International Covenants on civil and political
rights; and on economic, social and cultural
rights; and the 1989 Convention on the
Rights of Children, and these have been
ratified and domesticated in Uganda. The
rights elaborated by respondents in this study
focused primarily on three areas considered
relevant to child health the right to health;
the right to food and the right to clean safe
water. The respondents indicated the right to
education and the right to access information
as key determinants of the ability of citizens
as right holders to know and demand for
all other health-related rights. Coverage of
key health rights and entitlements due to
children as human beings in key international
and national instruments of commitment is
summarized in Annex 3.
Other Social and Development policies &
strategies supportive of child health
Other Policy documents with stated linkage
to child health support and realization
include: the national OVC policy (2004),
the two national strategic program plans of
implementation for OVCs (2005/-10/11) and
2011/12-15/16), the 2003 Uganda Food and
Nutrition Policy (UFNP), the 2005 National
Food and Nutrition Strategy, the 1999 water
policy, the 2010-15 National Development
Plan (NDP) and the 2011-16 Nutrition
Action Plan. In general, these policies are
based on national and global commitments
to ensure maternal and child health, and
reflect progressive recognition and focus on
realization of child health as a right. They all
make grand commitments to put in place
mechanisms to ensure realization of key
elements of child and maternal health rights.
Uganda government recognizes the right to
health as inclusive of timely and appropriate
medical care,and the underlying determinants
of health such as safe water and adequate
sanitation, food and nutrition, and health-
related information.17
It also recognizes
and provides for participation of citizens in
health-related decision making at all levels
(community, health facilities, and different
levels of local and central government).18
The key elements in the obligation to pro-
vide for the right to health; and the core
roles of the state in this regard (as presented
in Table 3 below) are generally accepted in
Uganda as standards to strive for.
17 As described in: Hunt P, Backman G (2008) Health Systems
and the right to the highest attainable standard of health.
Health and Human Rights: An International Journal 10: 1
(2008):40-59
18 Based on the 2008 Report of the UN Special Rapporteur
on the right of everyone to the enjoyment of the highest
attainable standard of physical and mental health,A/HRC/7/11,
31 January 2008

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Table 3: Key elements in the right to health and obligations of the state in its realization
Key elements Obligations of the State
Availability of adequate health
facilities trained personnel
essential medicines.
Accessibility to health facilities,
goods and services,for everyone
without discrimination.
Acceptability with regard
to respect of medical ethics,
cultural appropriateness, and
sensitivity to gender and life-
cycle requirements.
Quality products and processes
in line with scientific and medical
standards.
1. A Comprehensive health plan: for development of
a health system that is all-inclusive accommodating the
public, private, traditional health care sectors.
2. Progressive realization: with the reality that the
right to health cannot be realized for all citizens at
once define a minimum package of health services as a
beginning point and a road-map (with indicators) to its
progressive realization.
3. Non-discrimination: ensuring access to all especially
disadvantaged individuals, communities and populations
including effective outreach where there is need.
4. Equitable distribution: of the health system and its
services to ensure fair balance of health-related services
and facilities (rural, urban, regional, etc.).
5. Accountability: through effective, transparent,
accessible and independent mechanisms in relation to
all duties arising from the right to health.
Source: UN Committee on Economic, Social and Cultural Rights, General Comment No. 14;Aug 2000
3.2.2 Appropriateness of policies for universal
access to Child health
The study examined whether current policies
and strategies in Uganda are specific and
appropriate to ensure child health as a right for
all. It was noted that successive health policies
and strategies since 1999 are appropriately
focused and committed to provision of
child and maternal health services. This was
elicited from key policy documents from
health and other sectors that were reviewed
and discussed with respondents in this study.
The policy documents reviewed include: the
national health policies (1999 and 2010), the
health sector strategic plans for 2000/01-04/05
and 2005/06-09/10, the health sector strategic
investment plan (2010/11-14/15), and the 2009
Patients’ Charter.
The 1999 health policy commits to ensure
access to the minimum health care package
(with emphasis on poor women and children)
through a decentralized health system based
on three main pillars: (a) the District Health
Office as the main policy implementation and
service management unit (b) the Health Sub-
District (HSD) as functional subdivision of
the district health system aimed at further
decentralization of the management of routine
health service delivery and (c) a network of
health facilities; efficient, coordinated and
functional in delivering effective and sustainable
health care closer to the people.
The focus and service priorities in the 2010
second national health policy are largely based
in the 1999 first policy, and are closely aligned
with the National Development Plan 2010/11-
14/15.The policy includes a stated commitment
to promotion of health and nutrition as a
fundamental human right (in line with NDP
commitments) and the right to the highest
attainable level of health as a key social value
(sec 4.4.1 pg 11). However,this commitment is
not evident in the stated principles of the policy,

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or in the specific objectives and strategies
therein (beyond awareness creation as a
policy strategy, stated in sec 6.2.2b). For
example, the legal and regulatory framework
for the policy (pg 20-21) is entirely focused
on operational elements of the health system,
and does not address the justice ability of the
right to health.
The HSSP I period (2000/01-04/05)
largely focused on re-orienting focus in
service delivery to PHC, decentralization
of service management to districts and
HSDs, and abolition of user-charges
in all government health facilities to
enhance access to services for the poor.
The overriding priority over the HSSP II
period (2005/06-10/11) was the fulfillment
of the health sector’s contribution overall
national development and poverty reduction
by improving child survival,reducing maternal
mortality,fertility and malnutrition decreasing
the burden of HIV/AIDS, Tuberculosis and
Malaria and reducing disparities in health
outcomes among the lowest and highest
income quintiles. Health rights were most
directly addressed in HSSP II with reference
to sexual and reproductive health, and with
regard to mental health. The unique needs
of children related to their dependency and
vulnerability are discussed as part of the
interventions to enhance equitable access
to health for the vulnerable. These include
the poor, the elderly and orphans and
communities in conflict and post-conflict
situations (especially in northern and north-
eastern Uganda. The third health sector
strategic investment plan (HSSIP 2010/11-
14/15) is well aligned to delivery of child
health services as evident in the stated
service delivery investment priorities (sec
6.1pg 131): sexual and reproductive health,
child health, health education and control of
HIV, malaria and TB.
Collaboration between government and civil
society in 2009todevelopthePatients’Charter
was one notable effort to bring health rights
to the fore. Government considers the
charter as a key basis for realizing the right
to health as a framework for health worker
education and training and a means for
raising public awareness on health rights. The
objectives of the patients’ charter are to: (i)
empower health consumers to demand high
quality health care (ii) enhance community
participation in health and empower
individuals to take responsibility for their
health and (iii) improve the capacity of health
providers in provision of high quality care
The Uganda Constitution provides for
establishment and functioning of a Human
Rights Commission (Articles 51-55) to
oversee the promotion and protection of
all human rights including restitution awards
in cases of human rights abuse, and periodic
reportingonthestateofhumanrightsinUganda.
The Uganda Human Rights Commission
(UHRC) has been in place since 1997, and
established a Right to Health Unit in 2006.
UHRC has since initiated engagement with
health sector stakeholders in dialogue and
planning to enhance a rights-based approach
in health planning and service delivery and
has included a section on the right to health
in its annual reports to parliament.
3.2.3 Monitoring performance of policies
A comprehensive framework for
monitoring realization of the right to
health was published by UHRC in 2009.
The framework is based on 5 key steps: (i)
the government commitments under national
and international law that are relevant to
the right to health (ii) government policies
and programs and their appropriateness
and adequacy to fulfill the obligations (iii)
the health system and the extent to which
it adequately implements interventions to
realize the right to health and health care for
all citizens (iv) the extent to which the health
status of different social groups and the
population as a whole reflects progression
or regression in their right to health and
health care and (v) practical manifestations
of denial of the right to health in the country.
Compared to the conceptual framework
used in this study, the framework does not
include financing for health as a key step.

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Coordination of the national effort to
meet the rights of children was vested
in the National Council for Children
(NCC), responsible for planning,
monitoring and documenting progress, and
advocating for gaps that need to be filled.
The Council is mandated to produce and
coordinate implementation of a periodic
National Plan of Action for Children and to
periodically carry out studies and produce
reports on the situation of children in Uganda.
Key Informants at national level underscored
the importance of the National Council
for Children (NCC), as the government
framework for coordinating and supporting
efforts to ensure realization of all child rights
through sector-based programs.
3.2.4 Awareness about child health rights,
and responsible duty bearers
Respondents at all levels in the districts
(local government leaders, health workers,
VHT members and parents) were able to
articulate three key aspects of child health
rights:
• Right to be healthy: primarily based in
family care (such as appropriate nutrition and
feeding, parental love and care) and disease
prevention using services as provided by
the health system such as immunization and
mosquito nets.All categories of respondents
acknowledged that household poverty and
limited rights awareness are the current
constraints to realization of this right
• Right to access services: for prompt
management of illness based on early care-
seeking (from the right source),and availability
of quality health care ‘within reach’. Cost of
accessing services (both direct and indirect
costs such as transport) was highlighted as
a key constraint, especially byVHT members
and parents. Respondents at all levels agreed
that the poor quality of services in public
health facilities is largely a reflection of
limited inputs and support from higher levels
and less attributable to local weaknesses.
• Rights that enhance health: also seen as
indirect health rights including the right to
education for mothers and for children of
school-age and the right to work and earn
household income; a critical factor in family
capacity to provide for health.
Parents were acknowledged as the
primary duty bearers for child health rights
responsible for the right to be healthy (access
to food and nutrition, care and love) and the
right to access timely health care. However,
the respondents also pointed out that some
parents are lazy and reluctant to look after
the children (e.g. those who drink alcohol
in excess). They underscored the need
for planning at household level, balancing
between resource opportunities and income
for self development on one hand, and family
size and the requirements to provide fully
for all members on the other hand. Tension
was recognized between work outside the
home for food production, income and the
childcare demands on mothers as well as
fathers.
“Families must plan well to ensure child
health and well being. Some mothers
do not have time to look after their
children because they are busy fending
for the family.” [Focus Group Discussion,
VHT members - Nakaseke]
Multiple layers of actors in government were
discussed as actors in child health rights less
explicitly as duty bearers with an enforceable
obligation. Three main categories of
government actors were discussed with
different roles in ensuring realization of child
health rights:(a) health workers as providers
of health services also educating parents
and planning for health services (b) local
government leaders - educating community
members on health rights (to the extent
that they know enough and have the means
to educate (skills, resource materials, ability
to move around) and (c) higher government
(central government) leaders in making laws
and policies to protect child health rights
largely focused on ‘prevention and response
to abuse of child health rights, and less on
policies, strategies and financing to ensure
realization of the health rights due.
“The health rights of children are a
collective responsibility of everyone
such as the health assistants at the

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village level, councillors who move
around in the villages encouraging the
women to immunise their children,and
the parents themselves.” [Focus Group
Discussion, Parents - Soroti]
In essence therefore, the address of the economic
status of communities has a bearing on financing
of child health care. Furthermore, government
financing of the health care system helps to ensure
that the necessary services for child health are
in place by enabling the duty bearers e.g health
providers do their work.
3.2.5 Child and Maternal health Policy gaps
A common weakness across all reviewed
and discussed policies was failure to follow
through the respective policy process to
cover the different stages of the policy cycle
(as illustrated below). Policy making in its
fullness (the policy cycle) includes four critical
elements as illustrated: (i) Evidence-based
strategic thinking to understand the problem;
(ii) Developing solutions within a policy
framework (iii) Communicating solutions and
putting them into effect, (iv) Testing success
andmakingitstick, allwithin anorganizational,
political and wider public context.
In most of the cases reviewed, policy
development is the most accomplished stage,
largely dominated by technocrats in central
government and political endorsement
by relevant central government organs. In
spite of stated government commitment to
decentralization, participation of actors in
local government and community members
in the reviewed policy processes was largely
limited.
Although the need for and benefits from
comprehensive policy reforms are well
appreciated, factors that encourage an
incremental approach to policy making
in Uganda and other contexts include:
(a) Limited time and information: available
to policy makers, (b) Institutional design
of political system which disperse power
and the capacity for policy development to
different branches and levels of government;
each branch representing and accountable to
different constituencies, and (c) Limited fiscal
capacity of government to take on additional
responsibilities.
Figure 3:The Policy Cycle
National level respondents also bemoaned
the fact that there are many good national
policies that are not implemented. This was
attributed to: inadequate resources, limited
involvement of different stakeholders in the
policy process, and particular weaknesses
in local governments responsible for policy
implementation.
“We have excellent policies, strategies
and laws; the problem is with
implementation and enforcement.
The local governments are everywhere;
as the responsible arm of government
for policy implementation. But many
of them are just in name; they lack
qualified staff, and their systems are
very weak.” [Key Informant, National
Level]
“Government does its best to align
policies with the international treaties
and declarations. However, rights must
be aligned with resources available.
There is no way we as a country, can
realize rights in a state of poverty.”
[Key Informant; National Level]
Civil society respondents at national level
emphasized that participation in the policy

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process by all levels of stakeholders is not
only an integral element in the rights-based
approach to development,but also in keeping
with government policy of decentralization.
However, it was also pointed out that
effective participation must be accompanied
by necessary information and appropriate
facilitation as may be required (e.g. by
children, less educated community members
and the elderly).
Again, it was noted that there are mixed
experiences in realization of the six child
health services examined in this study with
more appreciated provision with respect
to immunization, maternal care and malaria
services and expressed concern with respect
to diarrhea, pneumonia and nutrition
services.
“If the health system was working
properly, we would be seeing less people
dying of preventable diseases and fewer
malnourished children. At the moment,
we still have too many mothers dying
in pregnancy, childbirth and children
continuing to die before their first
birthday.” [Key Informant; National level]
Amongst key health services to children,
EPI stands out as most ‘available’ especially
noted to be the only outreach service in
all district settings visited, and evident in
reported immunization coverage (illustrated
below). Multiple factors explain this good
performance with respect to EPI.There is high
community awareness and concern about the
risk of immunizable diseases (especially polio
and measles),and extensive integration of EPI
into the training of health professionals at all
levels and health volunteers at community
level.
This integration is also evident in funding of
health services;e.g.the inclusion of funding for
outreach services (largely for immunization)
as a recognized expenditure line for central
government grants for Primary Health Care.
Table 4 below illustrates allocations to
outreach immunization services from the
PHC grant in one of the study districts.
Although there is consistent allocation to
outreach immunization services across the
three financial years;the proportion allocated
reduces from 19% in FY 2008/09 to 13% in
FY 2010/11.

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Table 4:Allocations for outreach services from PHC grant
Allocation FY 2008/09 FY 2009/10 FY 2010/11
HSD 1 outreach allocation 8.16% 6.81% 5.16%
Total allocation for outreach 19.14% 17.26% 12.80%
Total PHC grant (UGX) 244,586,915 291,459,528 327,591,947
Respondents in the districts made specific policy recommendations focused on three main issues:
human resources for health; a multi-sectoral approach to delivering and managing improvements in
child health and greater involvement of community representation structures in policy advocacy and
service delivery. All these recommendations have financial implications for their implementation. In
general the survey revealed that realization of child health rights and entitlements is constrained due to
inadequate financing amongst other causes.
3.3 Uganda government 2005-2010 health expenditure, trends analysis
The study sought to establish trends in health spending and whether current plans and provisions for
health financing are adequate to meet the minimum package of quality health services for all under-fives.
It was noted that though there were high achievements in financing for planned health services in the
early 2000s in Uganda, these were not sustained in the later years and have continued on a downward
trend. The HSSP I period (2001-2005) was outstanding with regard to government commitment to
health financing,as evident in full funding of the whole strategy budget (ranged between 94% and 106%)
the landmark decision to abolish user fees in general public health services and in a number of robust
well delivered programs that met specific child health needs (immunization, essential drugs supply and
malaria control). However, the commitments were not sustained in the HSSP II period 2006-2010 or
in the current HSSIP period 2011-2015 (Table 5).
Table 5: Health financing trends – Uganda 2000 to 2010
Finan-
cialYear
GoU Donor Total
% alloca-
tion to
districts
Per
capita
(UGX)
Per
capita
(US $)
% total
Gov
Exp.
HSSP
Budget
(UGX)
HSSP
Budget %
total Gov
Exp
% HSSP
Budget
realized
2000/01 124.23 114.77 239.00 17.3 10,349 5.9 7.5 244.38 7.7 97.8
2001/02 169.79 144.07 313.86 25.9 13,128 7.5 8.9 312.39 8.9 100.5
2002/03 195.96 141.96 337.92 28.6 13,654 7.3 9.4 358.41 10.0 94.3
2003/04 207.80 175.27 383.07 27.5 14,969 7.7 9.6 360.93 9.0 106.1
2004/05 219.56 146.74 366.30 34.2 13,843 8.0 9.7 349.84 9.3 104.7
2005/06 229.86 268.38 498.24 25.8 26,935 14.8 8.9 783.82 14.0 63.6
2006/07 242.63 139.23 381.86 34.5 13,518 7.8 9.3 934.94 22.8 40.8
2007/08 277.36 141.12 418.48 34.1 14,275 8.4 9.0 1021.31 22.0 41.0
2008/09 375.46 253.00 628.46 25.0 20,810 10.4 8.3 1110.87 14.7 56.6
2009/10 435.80 301.80 737.60 24.3 24,423 11.1 9.6 1216.67 15.8 60.6
2010/11 569.56 90.44 660.00 27.4 20,765 9.4 8.9 2191.25 29.5 30.1
Source: HSSP documents and MOH Annual Reports

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Over the period between 2000 and 2010,
the proportion of national budget allocated
to health was stable between 8% and 10%
over the period against a commitment to
allocate at least 15%. It is notable that the
HSSP II budget projections (based on costed
estimates of required resources) were close
to the 15% target in the Abuja declaration
a reflection that realizing the commitment
in Uganda would be close to the true
requirements in the health sector.
There is general recognition that resource
flows into health services have increased
over the years but continues to remain less
than what would be required (both in terms
of the plans and budgets made and with a
view to the ideal provision to meet the right
to health for all).
“Human resource is a big problem so
most of the services are integrated. For
example,in antenatal clinics,the same
staff has to do all the antenatal tasks,
then include PMTCT, and in addition
do all the tasks and follow up on early
infant diagnosis. The same hands are
the one managing it and it becomes
too much and the hands are short.”
[Key Informant, LG Leader - Arua]
Concern was expressed by many respondents
and in a number of documents about the
consistent disparity in plans and budgets;
and the reality of available resources. The
risks noted in such circumstances include
limited and often inappropriate adjustments
of service activities in response to resource
gaps (often compromising both effectiveness
and efficiency). There is also limited evidence
of a strategic approach to realize systematic
and progressive growth in services;to keep in
step with available (and hopefully increasing)
resources. This works against progressive
realization of the right to health.
The biggest problem is we often do
not have the full information and
participation we need. Whenever
there is a budget cut, the first thing
to go is movement and consultation.
You cannot move around or bring
people together without money; yet
we know it is a very fundamental input
in planning.” [Key Informant; LG Leader -
Kalangala]
Despite Uganda’s commitment to
protection of the rights to health and
a systems approach to health service
delivery; financing for health primarily
focuses on a few elements of the health
system.Uganda is fully committed to health
systems strengthening, based on the 6 core
elements recommended by WHO and
presented in the text box below, as the
preferred approach to achieving equitable,
sustainable and quality health care.
Health Systems Strengthening: Core
elements
Leadership, governance and stewardship:
ensures strategic policy frameworks, effective
oversight, regulation and ascertains planning
monitoring and accountability.
Sustainable health financing & social
protection: raising adequate funds for health
while protecting users from financial catastrophe
and impoverishment due to health-related
payments and providing incentives for providers
and users to be efficient.
Well-performing health workforce: sufficient
and competent staff, fairly distributed, organized
and managed to ensure productivity (efficient,
responsive and adaptable).
Essential medical products: medicines,vaccines
and technologies of assured quality,safety,efficacy
and cost-effectiveness.
Good health services: medical and public
health; including personal and non-personal
interventions that are effective, safe and high
quality; efficiently reaching those in need, where
and when most needed, with minimum wastage.
Well-functioning health information system:
ensuring timely production,analysis,dissemination
& use of adequate reliable data and information
on health status & determinants of health system
performance.
However, the budget element in the health
sector budget specifically categorized
as ‘health system development’ covers
infrastructure investments at health facilities
and the bulk of the health budget is allocated
to pharmaceuticals and other health supplies,
district and referral hospital services (Table
6) with over 60% of the allocation to district

36
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health services dedicated to staff wages. Similarly 68% of the FY 2008/09 budget for a Regional Referral
Hospital in one study district was allocated to staff wages.
Table 6:Allocation of health budget – Percent FY 2008/09 to 2011/12
Budget line item FY 2008/09 FY 2009/10 FY 2010/11 FY 2011/12
Pharmaceuticals and other supplies 53.0 47.2 38.4 34.9
District health services 25.1 24.8 22.7 23.4
Referral Hospital services 15.8 20.9 19.9 19.9
Health system development 2.3 1.8 13.4 14.1
MOH (Central functions) 3.8 5.3 5.6 7.7
Total 100.0 100.0 100.0 100.0
Source: Ministry of Health BFP FY 2009/10
This therefore shows that there are
gaps in ensuing resource allocation to
support effective implementation of health
services including malaria and malnutrition
programs.
3.3.1 Impact of government expenditure on
MDGs and MNCH indicators
The overall picture is of slow progress to
realize the health-specific goals (MDG 4,5 and
6);and the health-supportive goals (MDG 1,2
and 7).Results from reviewed documents and
discussions by respondents are in agreement
about commendable progress attained on a
number of interventions towards realizing
MDGs relevant to child health especially on:
provision of immunization services, maternal
and newborn care,treatment of sick children,
HIV prevention treatment and care, formal
education especially for girls, and access to
safe drinking water and improved sanitation.
Similarly, there is consensus about slow
progress with respect to other important
interventions most notably on:child nutrition
and household food security, child retention
in primary school and transition to secondary
education, quality and consistently available
care for sick children, HIV prevention,
treatment and care specific for children
and quality maternal and newborn care (in
pregnancy, at birth and in post-natal period).
Slow progress in attaining the MDG is
reflection of stagnation on many of the service
interventions that underpin realization of
MDGs. Stagnation with respect to a wide
range of health indicators is evident in health
status and service utilization indicators at
national level, the service delivery and output
measurements in districts and health facilities.
Study respondents attributed this stagnation
to inadequate government financing for
health and other services (concurrent with
losses in the system through corruption and
inefficiency) poorly developed health planning
and management in the decentralized health
system, inadequate community mobilization
and participation (including managed and
sustained financial contribution to health
services).
“It is not realistic to expect Uganda
to achieve MDGs on health when
the government funding to the
health sector has at best remained
stagnant (as a percent of GDP). Our
achievement is a reflection of our
investment.” [Key Informant; National
Level]
“It pains me that even the little that
government puts into health never
reaches the people. A lot is stolen
by politicians and technocrats in
MOH; while the mothers and children
continue to die.”[Key Informant;Local
Government Leader - Soroti District]

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At one HC IV visited in the study,the number of children treated who had measles dropped from 25 in
FY 2006/07 to 5 in 2007/08 and 4 in 2008/09. However, utilization of maternal care services dropped
at the same facility over this period; with full ante-natal attendance (4 or more visits) falling from 12%
through 5% and to only 1%; with only 22%, 29% and 5% of the same mothers respectively reached with
two doses of medicine for preventive malaria treatment.It was difficult to access full records in most of
the health facilities visited to assess similar trends in service delivery. One hospital where such records
were accessed and analyzed reflected a similar trend; as presented in Table 7 below.
Table 7:Trend of MNHC service outputs – Regional Referral Hospital
Service indicator FY 2007/08 FY2008/09 FY 2009/10 FY 2010/11
Full ANC attendance (4+ visits) - percent 47.8 29.6 27.2 25.4
IPT (2 doses Co-trimoxazole) - percent 67.8 68.7 56.5 62.2
Post-natal attendance (percent of deliveries) 22.4 22.4 28.0 28.2
Maternal mortality ratio (hospital births & deaths) 372 473 236 450
Proportion deliveries of HIV+ mothers - percent 4.8 6.0 6.5 6.2
HIV+ mothers given ARVs for PMTCT - percent 99.5 110.0* 94.0 100.0
Observed ARV administration for PMTCT - percent 83.2 78.2 94.0 98.6
HIV exposed babies given ARVs for PMTCT - percent 89.1 89.6 94.0 102.4**
* Includes mothers who received ARVs but did not deliver at the hospital
** Includes two sets of twins born to HIV+ mothers
Source: Hospital records – Regional Referral Hospital
3.3.2 Focus in Health financing
The Ugandan health financing framework
continues to be primarily focused on public
health facilities, with limited integration of
other elements in the health system (private
health facilities, community and home-based
services, non-facility services of NGOs, etc.)
Historically,the financing of health and health
care in Uganda has been shared across
three main sectors: government financing
from public revenue and donor funding, the
faith sector as major providers of facility-
based and non-facility services and user
contributions in moving to seek care at health
facilities and paying for some or all elements
of service received. The establishment of
the Uganda Catholic and Protestant Medical
Bureaus by government in 1955 was an effort
to enhance coordinated access to grants
from the colonial government, and pooled
procurements of equipment and medicines
for the voluntary health care sector.19
This
formalized partnership was re-activated in
1997, as part of the effort to expand delivery
of primary health care services; accessible at
no cost to consumers,or at heavily subsidized
prices that are affordable for most families.20
However, granting mechanisms to PNFP
health facilities by government and global
health financing initiatives were noted to
be fragmented, inconsistent and inefficient.
Surveys between 2004 and 2006 found that
16% to 21% of PHC grants to PNFP health
facilities did not reach the point of allocation.
21
19 UCMB (1999) Mission statement and policy of Catholic
health services in Uganda. Kampala: Uganda Catholic Medical
Bureau
20 Orach S.O (_) Is religion relevant in health care in Africa in
the 21st Century? The Uganda experience. Kampala: Uganda
Catholic Medical Bureau
21 Merotto D. (2009) Uganda A Public Expenditure Review
2008 With a Focus on Affordability of Pay Reform and Health
Sector,World Bank

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