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LESSONS FROM UGANDA

WHO/HSS/healthsystems/2007.4

WORKING PAPER No. 11

Available in this series:

Working paper 1 Strengthening Management in Low Income Countries (Also available in French) Working paper 2 Working with the Non-state Sector to Achieve Public Health Goals (Also available in French) Working paper 3 Improving Health System Financing in Low-Income Countries (Forthcoming) Working paper 4 Opportunities for Global Health Initiatives in the Health Systems Action

Agenda Working paper 5 Improving health services and strengthening health systems: Adopting

and implementing innovative strategies - An exploratory review in twelve countries

Working paper 6 Economics and financial management: What do district managers need to know? (French version forthcoming)

Working paper 7 Renforcement de la Gestion sanitaire su Togo: Quelles leçons en tirer? Working paper 8 Managing the Health Millennium Development Goals - The challenge of

management strengthening: Lessons from three countries Working paper 9 Aid effectiveness and health

Working paper 10 Towards Better Leadership and Management in Health: Strengthening Leadership and Management in Low-Income Countries

The reference to the "WHO/HSS/healthsystems" series replaces the original "WHO/EIP/healthsystems" series.

© World Health Organization 2007

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MAKING HEALTH SYSTEMS WORK: WORKING PAPER No. 11 WHO/HSS/healthsystems/2007.4

STRENGTHENING MANAGEMENT IN

LOW-INCOME COUNTRIES: LESSONS FROM UGANDA

A CASE STUDY ON MANAGEMENT OF HEALTH SERVICES DELIVERY

Dominique Egger Elizabeth Ollier

Prosper Tumusiime Juliet Bataringaya

Department for Health Policy, Development and Services Health Systems and Services

WHO, Geneva

MAKING HEALTH SYSTEMS WORK _______________________________________

STRENGTHENING MANAGEMENT IN LOW-INCOME COUNTRIES: LESSONS FROM UGANDA ii

ABOUT THE 'MAKING HEALTH SYSTEMS WORK' WORKING PAPER SERIES

The 'Making Health System Work' working paper series is designed to make current thinking

and actual experience on different aspects of health systems available in a simple and

concise format for busy decision makers. The papers are available in hard copy and on the

WHO health systems website.

Working paper 11:

Strengthening Management in Low-Income Countries: Lessons from Uganda

A Case Study on Management of Health Services Delivery

This case study is part of three country studies conducted by the Health Policy, Development

and Services Department of WHO/HQ. The purpose was to gather evidence on the situation

with service delivery management in low-income countries. This paper reviews and

summarizes service delivery management at district level in Uganda using a core technical

framework developed by WHO for analysis and evaluation of management strengthening

actions.

The paper was written by Dominique Egger (WHO/HQ), Elizabeth Ollier (HLSP UK), Prosper

Tumusiime (WHO/AFRO) and Juliet Bataringaya - Wavamunno (WHO, Uganda). It incor-

porated feedback from the Uganda Health Sector Technical Review Meeting in April 2006

and from the WHO Country Office. It was reviewed and edited by Delanyo Dovlo (WHO/HQ)

and Catriona Waddington (HLSP UK).

Further comments and information

Those wishing to give comments, or interested in finding out more about activities outlined in

this paper, should contact Dominique Egger ([email protected]) or Delanyo Dovlo

([email protected]).

For more information on the work of WHO on health systems, please go to:

www.who.int/healthsystems


STRENGTHENING MANAGEMENT IN LOW-INCOME COUNTRIES: LESSONS FROM UGANDA iii

TABLE OF CONTENTS

ABBREVIATIONS .................................................................................................... iv

EXECUTIVE SUMMARY ............................................................................................. v

1 STUDY OVERVIEW......................................................................................... 1

2 BRIEF COUNTRY CONTEXT AND BACKGROUND ............................................... 2

3 WHO ARE THE MANAGERS AT DISTRICT LEVEL? ............................................. 3

4 HOW ARE MANAGERS' SKILLS DEVELOPED?.................................................... 4

4.1 Management development approaches used in Uganda............................. 4

4.2 Sources of Management Training ............................................................ 4

4.3 Other capacity building approaches ......................................................... 6

5 DO CRITICAL SUPPORT SYSTEMS FUNCTION WELL? ....................................... 7

5.1 Planning systems ................................................................................... 7

5.2 Health management information systems (HMIS) ..................................... 8

5.3 Monitoring the health sector strategic plan............................................... 8

5.4 Financial management ........................................................................... 9

5.5 Human resource management and planning ............................................ 9

5.6 Medicines management........................................................................ 11

5.7 Quality assurance, supervision and monitoring ....................................... 11

6 WORK CONTEXT AND ENVIRONMENT OF DISTRICT MANAGERS..................... 13

6.1 Managers' roles and responsibilities....................................................... 13

6.2 Management practices changes at district level ...................................... 15

6.3 Health service outputs and management ............................................... 16

7 CONCLUDING REMARKS .............................................................................. 18

Annex 1. References and Bibliography ................................................................. 19

Annex 2. Summaries: District case studies............................................................ 20

Annex 3. Summary: Management development interventions................................. 22

Annex 4. Persons met and interviewed................................................................. 24

Annex 5. Other examples of district performance measures ................................... 27


STRENGTHENING MANAGEMENT IN LOW-INCOME COUNTRIES: LESSONS FROM UGANDA iv

ABBREVIATIONS AISPO Assiciazone Italiana per la Solidarieta tra I popoli AMREF African Medical and Research Foundation AVSI Associazione Volontari Per Il Servizio Internazionale (International Service Volunteers Association) CAO Chief Administrative Officer CARE A private international relief and development organization CIDA Canadian International Development Agency CORAID Catholic Organization for Relief and Development CUAMM Centro Universitario Aspiranti Medici Missionari (University College

for Aspirant Doctors and Missionaries) DANIDA Danish International Development Agency DDHS Director of District Health Services DFID Department for International Development (UK) DHMT District Health Management Teams DHS District Health Systems DISH Delivery of Improved Services for Health DSC District Services Commission EDF European Development Fund EU European Union FDS Fiscal Decentralization Strategy GFATM Global Fund against AIDS, TB and Malaria HC II to IV Health Centre II or IV HIV/AIDS Human Immune Deficiency Virus/Acquired Immuno-Deficiency Syndrome HMIS Health Management Information System HR Human resources HSD Health sub-districts HSSP Health Sector Strategic Plan ICMI International Christian Medical Institute IPH Institute of Public Health JHU Johns Hopkins University LSHTM London School of Hygiene and Tropical Medicine MO Medical Officer (at HSD level) MoF Ministry of Finance MOFPED Ministry of Finance Planning and Economic Development MoH Ministry of Health MoLG Ministry of Local Government MPH Master of Public Health (Degree) MTEF Medium Term Expenditure Framework MUST Mbarara University of Science and Technology NGOs Nongovernmental Organizations NMS National Medical Stores (NMS) PHC Primary health care PNFP Private not for profit QAP Quality Assurance Project SCF-UK Save the Children UK SWAp Sector-wide Approaches TB Tuberculosis UHSSP Uganda Health Sector Support Program UMI Uganda Management Institute UNAIDS The Joint United Nations Programme on HIV/AIDS UNISA University of South Africa UPMB Uganda Protestant Medical Bureau USAID United States Agency for International Development WHO World Health Organization


STRENGTHENING MANAGEMENT IN LOW-INCOME COUNTRIES: LESSONS FROM UGANDA v

EXECUTIVE SUMMARY Study overview Weaknesses in managerial capacity in health, especially at local levels, have been widely cited as a constraint to scaling up health services and achieving the Millennium Development Goals (MDGs). In Uganda, decentralization of district health services management to local governments has re-emphasized a need for strengthened local management capacity because of a rapid increase in the number of districts and the creation of health sub-districts (HSDs). In an initiative to collate experiences on management development in low resource settings, WHO carried out case studies in South Africa, Uganda and Togo to explore management development approaches in use and how these impacted on managerial and service delivery performance. Specific objectives of Uganda's case study were to review:

1. the scope, scale, and duration of health sector management development approaches implemented during the last five to seven years;

2. changes in management capacity at district level in the public sector; 3. changes in management performance at district level in the public sector; 4. other contextual changes that may have independently affected management

performance; 5. trends in health service delivery outputs and determine whether these are linked to

effects of management development. Methodology

The study involved a desk review of country documentation (Annex 1) followed by a country visit for an in-depth exploration using key informant interviews (Annex 4) and direct observations of management practices at national and sub-national levels. Information was sought in relation to:

• changes in the numbers, recruitment and retention of health managers; • changes in developing their management competences; • changes in critical management support systems; • changes in context and work environment of managers.

Five district health management teams selected for their prior involvement in management strengthening activities were visited for in-depth observation and discussions (Busia, Jinja, Masindi, Mpigi, and Mukono districts).

Data and documentation on health management programs and service delivery were generally lacking, and information obtained was mainly qualitative, based on respondents' perceptions and experiences. However, several clear themes emerged helping the case study to provide a “snapshot” of the service delivery management situation in Uganda. National context Uganda is a low-income country which has had positive economic growth since the late 1980s though some 38% of the population still lives below the poverty line. Malaria is the largest single cause of ill health and AIDS is the leading cause of death in adults though the initial generalized heterosexual HIV epidemic now shows significant decline.

The Local Government Act of 1997 mandated the decentralization of many sectoral functions to local authority in municipalities and districts. In the health sector, the central ministry of health (MoH) only retains responsibility mainly for policy formulation and national standards setting. The new "District Council Administrations" are headed by a "Chief Administrative Officer" to whom all sectors report to.


STRENGTHENING MANAGEMENT IN LOW-INCOME COUNTRIES: LESSONS FROM UGANDA vi

A new national health policy adopted in 1999 was followed in 2000 with a sector strategic plan which introduced a minimum health care package and redefined the care delivery system. However, health sector problems including several management-related ones such as centralized decision making, low morale, and motivation remain identified as constraints.

Managers at district level Two types of managers are found at the district level. A "district director of health services" (DDHS) leading a district health management team (DHMT) and a "medical officer" (MO) who heads a "health sub-district" and is responsible for managing actual service delivery. MOs are usually recently qualified doctors with little or no management training while DDHS are mostly physicians with an MPH. There is good retention of DDHS but there is significant attrition of MOs for reasons that include a lack of a career pathway and emigration.

Main findings

Developing managers Significant effort has gone into developing managers using long and short courses and placing "technical advisers" with DHMTs. A key feature in Uganda, however, is the multiplicity of training programs compounded by the lack of a national management competency framework. Moreover, management institutions have identified the absence of a specific MoH focal point for management policy as a problem.

Critical management support systems Uganda has developed fairly sophisticated planning, budgeting, information and financial management systems that function quite well though at times they seem overly complex. For example, the Health Management Information System (HMIS) requires several forms to be filled in daily by busy clinic and HSD staff and often local priorities tend to be neglected as districts try to conform to strict national planning formats. Monitoring and supervisory systems demonstrate good practice especially in being well structured and having a supportive format. However, human resources management systems still seemed weak especially in the areas of performance management and staff discipline.

Context and environment A good framework of policies and regulations are in place starting with Uganda's 1995 constitution which assures basic health services for the population and forms the basis of the national health sector policy and plan. In terms of management accountability, there seems to be a genuine understanding of the need for public accountability with information on district performance available in the national press, for example.

Managers' motivation is linked to the perceived status of the position and its accompanying career enhancement opportunities. However, the lack of career opportunities remains to be a concern for managers despite their having a relatively good salary compared to other public servants.

Changes in management practices Annual performance indicators need to be improved to help establish performance trends and monitor management performance. However, persuasive circumstantial evidence suggests that management had improved in a number of areas:

• Team-work in districts was reported to be much more effective with improved coordination with local government units.

• A strong planning process now exists but needs better linkage between plans and budgets, and activities and actual expenditures.

• A good supportive supervision system exists which advises on issues important to managers and is not just a performance check.

• Medicines management has improved significantly with fewer "stock outs". • Health services delivery is more accountable to communities and coverage

performance information is widely circulated.


STRENGTHENING MANAGEMENT IN LOW-INCOME COUNTRIES: LESSONS FROM UGANDA vii

Analysis of the districts' performance illustrated a number of factors:

• Newly created districts perform less satisfactorily than older districts; • Distance between a district and an urban centre correlated with reduced

performance (the islands generally performing less sufficiently well); • The war and civil unrest in parts of northern Uganda seemed to correlate with

generally poorer performance though with some notable exceptions.

Conclusions Uganda has made tremendous efforts at improving service delivery coverage and quality through improved management and filling of most critical management positions (e.g. DDHS posts). Opportunities exist for managers to develop appropriate skills but courses need to be better designed to produce the essential competencies needed. A health sector competency framework for managers will provide common performance objectives and standards in the sector. Uganda does very well with its management support systems and has a good supervisory system. However, its detailed prescriptive planning formats could result in local priorities and decision making getting lost in the process. The allegiance that district managers hold to both the local government and the national health system appears to be evolving and the role conflicts and dichotomy are likely to improve with time.


STRENGTHENING MANAGEMENT IN LOW-INCOME COUNTRIES: LESSONS FROM UGANDA viii


STRENGTHENING MANAGEMENT IN LOW-INCOME COUNTRIES: LESSONS FROM UGANDA 1

1 STUDY OVERVIEW Weaknesses in managerial capacity in health, especially at local levels, have been widely cited as a constraint to scaling up health services and achieving the Millennium Development Goals (MDGs). In Uganda, the decentralization of district health services management to local governments has re-emphasized the need to strengthen management. Major challenges have also been tackled in developing local capacity partly because of a rapid increase in the number of districts (almost doubled since 1997) and the creation of new health sub-districts (HSDs) in 2000. Workforce planning done in preparation for the HSD concept did not take the supply and demand for managers into consideration.

WHO, as part of a wider program of work, has started an initiative to improve the knowledge base on management development in low resource settings. As a first step, rapid qualitative assessments were conducted using multi-country case studies from South Africa, Uganda and Togo. These case studies explored the range of management development approaches in use, and assessed if these had resulted in improved managerial and service performance. The aim was to get an overview of critical management problems in service delivery and the methods used to address them.

Objectives The specific objectives of the Uganda case study were to review:

1. The scope, scale, and duration of the main management development approaches implemented during the last five to seven years;

2. Changes in management capacity at district level within the public sector; 3. Changes in management performance at district level in the public sector; 4. Other contextual changes that may have independently affected management

performance; 5. Trends in health service delivery outputs and determine whether these are linked to

effects of management development.

Methodology

The first step involved a desk review of available country documents and data. This was followed by a country visit for an in-depth exploration of various approaches based on key informant interviews and direct observations of management practices at national and sub-national levels. This review of service delivery management used a core technical framework that was being developed by WHO as the basis for analysis and evaluation of management strengthening efforts. The framework proposes that for good leadership and management, there has to be a balance between four dimensions described as follows:

• Having adequate number of managers deployed to defined posts where needed; • Managers with appropriate competences (knowledge, skills, attitudes and behaviors)

and the means of acquiring these; • Critical management support systems that function well (to manage finances, staff,

information, supplies, etc.); • An enabling working environment (organizational context, rules, supervision,

incentives and motivators, relationships with other actors).

The study collected information (when available) on management strengthening in relation to the areas mentioned above and also evaluated trends (where possible) in changes related to recruitment and retention of managers, management competence development, critical support systems and work context, and incentives of managers. It examined various management programs that may have contributed to improved service results and possible constraints that may have produced adverse effects. In Uganda, in-depth interviews were held with key informants from the ministry of local government, ministry of health, the local



government finance commission, various development partners (including the WHO Country Office) and institutions providing management and public health training. Five district health management teams, selected for their prior involvement in management strengthening activities, were visited (see Annex 2 for a summary of visits made to Busia, Jinja, Masindi, Mpigi, and Mukono districts).

Limitations and constraints

The study focused on public sector health services at district level, though it did examine some interactions between the public and private sectors. Time was a major constraint as the entire case study was carried out in less than two weeks. Five dispersed districts and their sub-districts were visited as well as several national departments and stakeholders. It was difficult to get documentation on evaluations of past management programs and to track data over time in order to analyse trends. Inevitably, much of the information obtained was qualitative and, to some extent, were subjective perceptions and experiences. However, several clear themes had emerged that suggested general applicability of issues raised by respondents. Therefore, the case study does not claim to provide hard evidential data but uses the sample districts selected to provide a “snapshot” of the situation in Uganda.

2 BRIEF COUNTRY CONTEXT AND BACKGROUND Uganda is a low-income country which has had positive economic growth from the late 1980s through the present. However, the proportion of the population living below the poverty line, which had been declining (52% in 1992 to 1993 to 35% in 2000), has risen slightly to 38% in 2003.

1 Poverty, though a largely rural phenomenon (96% of the poor lived in rural areas in

2000),2 has began to show a disproportionate rise in urban areas.

3 Malaria is highly endemic

in 90% of the country and is the largest single cause of ill health accounting for up to 40% of outpatient attendances. AIDS is the leading cause of death in adults and the main cause of falling life expectancy in Uganda. However, the generalized heterosexual HIV epidemic of this country now shows significant decline. The MoH, Uganda's HIV/AIDS sero-behavioural survey (2004-2005) showed an HIV prevalence of 6.4% among 15 to 49 year-olds.

Major political and economic reforms, including economic liberalization, privatization, public sector downsizing and decentralization, have taken place. The Local Government Act of 1997 mandated the decentralization of many functions to local authority entities such as municipalities and districts. In the health sector, the central MoH retained responsibility for policy formulation, national standards setting, quality assurance, resource mobilization and national coordination of services such as epidemic control. It provides technical support to district health authorities and most importantly, carries out monitoring and evaluation of overall sector performance. At district level, health management teams have been re-designed to focus on core management and technical support roles, with responsibility for local resource mobilization, planning of services, supervision and coordination of HSDs. The direct management of service delivery is delegated to the HSDs which have a primary referral facility (for population of about 100 000 people) and is headed by a medical officer who is responsible for planning, implementing, monitoring and supervising service delivery in the area. Other service delivery units that require managers are the hospitals (three types: national and regional referral, district/rural/general hospitals). Referral hospitals are managed

1 National Household Survey 2003. Kampala, Ministry of Finance, Planning and Economic Development, Uganda.

2 Poverty Status Report 2000. Kampala, Ministry of Finance, Planning and Economic Development, Uganda.

3 Poverty Eradication Action Plan 2004/5-2007/8. Kampala, Ministry of Finance, Planning and Economic Development, Uganda.



independently of the districts where they are situated, but district/rural/general hospitals are designated as HSDs in their respective districts. An ongoing public service reform has re-structured the local government to align its functions with newly devolved responsibilities and to create better accountability for services delivery. The new district council administrations are headed by a "Chief Administrative Officer" (CAO) who has the rank of "Commissioner" in the public service (equivalent to the head of a central ministry department) and is required to have a master's degree in public administration. All decentralized departments (including health) report to the CAO. A new national health policy was adopted in 1999 and was followed in 2000 by a new health sector strategic plan which introduced a minimum health care package and re-defined the care delivery system. A second health sector strategic plan (2005/06-2009/10) is now being implemented. Many of the health sector problems identified were said to be management- related and included remnants of centralized management decision-making, staff mal-distribution and low morale, weak supervision and poor public and private partnership.

3 WHO ARE THE MANAGERS AT DISTRICT LEVEL? This section examined the availability and typology of managers at district level. Unfortunately, the human resource (HR) information system listed health workers according to their original professional qualification and so it could not tell us how many played management roles and were qualified to do so. However, there is policy clarity as to who managers are and what roles they play at district level. Also, almost all DDHS posts were filled with persons meeting the official criteria.

Two types of managers are found at the district level in Uganda. A "district director of health services" (DDHS) leads a district health management team (DHMT) and supervises the health sector in the entire district. DHMTs may have "focal persons" who are responsible for technical programs and are appointed on the basis of their technical background (not managerial experience). Since 1997 all DDHS were required to have a medical qualification and a master's degree in public health (MPH). All district DDHS posts are currently filled and retention is not seen as a problem. Each district has up to four "health sub-districts" (HSD). A health sub-district is led by a "medical officer" (MO) who is responsible for managing service delivery and supervising other (minor) health centers (II and III) in the sub-district area. The HSDs medical officer is based either in a "health center 4" or a general hospital. Each sub-district is now required to have two MOs to reduce the workload by separating their managerial and clinical roles. However, MOs are usually recently qualified doctors with little or no management training and though in theory they are also expected to hold an MPH, few have this qualification. The high retention of DDHS is countered by significant attrition of HSD medical officers. The two MOs in each sub-district have to compete for the very few DDHS posts that have become vacant. The high turnover and financial constraints to their employment pose a challenge to filling MO posts and emigration was also said to affect their retention. The criteria for managerial appointments at district level (beyond the academic qualifications) are unclear and appear to be based on years of service rather than prior managerial training, experience or competency. Candidates from local communities in a district tend to have an advantage and are likely to be chosen over proven managers coming from elsewhere in the country. While this may favor retention, it can constrain the taking of unpopular managerial decisions. Key Issues • Senior district level management posts are currently confined to doctors because of the

required academic qualifications. • The career path of district managers is limited by lack of promotion opportunities beyond

the DDHS position and this also limits the opportunities available for MOs serving in HSDs.



• Motivation: Isolation, lack of accommodation, lack of opportunities for income augmentation and inclement working hours are other factors said to affect retention of MOs.

• Managers who hail from the locality may tend to stay on in their communities but their willingness to take unpopular decisions may well be compromised.

• Selection criteria for managers do not go beyond academic qualifications and are not based on candidates having other desirable managerial attributes.

4 HOW ARE MANAGERS' SKILLS DEVELOPED? Do district managers in Uganda have the appropriate competencies and how are these acquired? While it was difficult to do a competency assessment as part of the study, the team reviewed the criteria for selecting the managers and the types, methods and content of the training they receive, to see whether these matched with their role expectations. As with many other countries, health managers in Uganda are mostly clinicians (the majority are doctors) who have been promoted into management roles. Management training is therefore, essential to provide the required skills and competencies. Significant effort has gone into developing district managers using long and short courses (including distance learning) and the placement of "technical advisers" to support DHMTs and to transfer skills.

A key feature of management development in the last decade or so has been the multiplicity of activities in this area. This situation was compounded by the lack of a national competencies framework to guide the training of health managers. Indeed, institutions providing management training identify the absence of a specific MoH focal point for coordinating management policy as a factor in having multiple courses and materials that may not have met the sector's needs.

4.1 Management development approaches used in Uganda

Two broad types of management development were found in Uganda.

4.1.1 Training programs for individual managers. Significant local training takes

place and several institutions run either specific management programs or courses with management aspects. Most courses appear to be "knowledge- based" rather than "competency-based", though some have used problem- solving and work-based learning approaches. The MPH degrees that are required of all DDHS were at the time of the review only offered by Makerere University. Some current managers (nine during this review) were taking distance learning MPH courses based outside Uganda. Donors have also funded external full-time long and short courses.

4.1.2 Team strengthening initiatives. There are several decentralization support

initiatives, often part of special projects that have management strengthening aspects. These projects train the entire DHMT and have been supported by a range of international, regional and local agencies. Many such projects have since ended but it was difficult to find formal evaluations and it is doubtful whether lessons from such experiences have informed current practices.

Details of various management development approaches that were identified from key informant interviews are summarized in Annex 3.

4.2 Sources of Management Training

Three groups of management training providers were identified in Uganda. These were university academic programs, non-university organizations and government or MoH training programs. The main providers are described below.



University-based providers

Institute of Public Health, Makerere University, Kampala The Institute runs an MPH program which is taken either as a two-year full-time course or by distance learning. The last revision of the curriculum was in 1999 but a new review is expected shortly. Its students are attached to districts and use problem-based approaches for public health training (not for the management aspects). The course is focused on clinical and epidemiological skills and though participants in the past have mainly been doctors, recent intakes have seen an increasing number of nurses.

The Uganda Martyrs University (UMU), Nkozi The faculty at UMU is supported by an Italian Christian nongovernmental organization (NGO), Centro Universitario Aspiranti Medici Missionari (CUAMM), now called "Doctors with Africa", and the Catholic Organization for Relief and Development (CORAID). The following courses are run at the UMU: • Diploma in Health Services Management: This one-year course targets mid-level

managers ranging from district managers, hospital administrators, diocesan health coordinators, health centers in-charge to senior nursing managers and wards in-charge. Student intake is limited to 15 per course and majority of recent participants (34/51) have been female. Its 13 modules include a four-week field-based section.

• MSc in Health Services Management: This 12-month course is said to be aimed at

developing managerial competencies with analytical and critical skills. The course content is based on needs identified from reports of the Catholic Medical Bureau and has a curriculum developed independently of the MoH. However, participants are exposed to the experiences of MoH officials, national and international organizations and institutions through attachments. It has 10 compulsory modules designed with learning objectives aimed at improved understanding of key management issues and providing practical skills such as computer use, presentations and writing skills. Emphasis on "soft" skills (e.g. advocacy, negotiation, team building and management behavior) is rather weak. A key feature is the mentoring provided by former students to new graduates. The course fees of 6.3 million Ugandan Shillings compare unfavorably with MOs starting salary of USh5 millions per annum. Majority of participants (42/52) are male (2001-2004).

• Certificate courses of five weeks duration are also run but these are "on-demand"

ad hoc programs run as extra-mural courses procured by clients (e.g. Rakai district purchased programs in 2003 and 2004).

Uganda Protestant Medical Bureau (UPMB)/International Christian Medical Institute (ICMI)/Uganda Christian University, Mukono UPMB was established in 1957. It is a private, non-profit organization representing over 160 faith-based health service organizations. It runs the International Christian Medical Institute (ICMI) which has since 1993 offered a diploma (aimed at mid-level managers) and a degree (for senior managers) in health administration (awarded by the Uganda Christian University). The diploma course originally run with donor support is now self-financing with a joint Ugandan and Canadian faculty. The courses use various adult learning methods with small interactive classes. A comprehensive evaluation said to have been conducted was however not available for review. The MoH is represented on the Bureau’s Advisory Board.

Non-university providers

Uganda Management Institute (UMI) The UMI was established in 1969 as the Institute of Public Administration and transformed in 1992 into a semi-autonomous degree-awarding body with a remit beyond the public service. It currently generates most of its income but receives a



subvention of about 10% of its income from government. It offers a repertoire of long and short management courses, and tailors special programs on request. Several specialist short courses (e.g. finance and planning) are run for health managers and a new course is aimed at developing mentoring skills for public sector managers at district level. The curriculum is comprehensive and appears to reflect international good practices. Emphasis is placed on building competencies of its staff in modern teaching methods and staff exchanges have taken place with institutions in South Africa, UK and USA. The courses use group work, action learning and problem solving and have a multi-disciplinary approach to studying. Evening programs have been created to assist students who work full-time and an e-learning program has also been started to cater for students living outside Kampala. Manpower Development Centre, Mbale This centre was formerly a public service (MoH) in-service training facility that in the past had provided courses mainly in clinical skills and was funded by CIDA through AMREF. Its recent programs have focused on developing skills at district level for training needs assessments and it also runs a distance learning course for district level managers. The centre’s current position, accountability and roles are not very clear as government funding only covers salaries and not development and delivery of courses.

Government-run programs

Ministry of health short courses WHO has supported the development of a training manual and three-week short courses on organization, and planning and management of health services in health sub-districts. The courses were run with facilitators from MoH, WHO and Mbarara University of Science and Technology (MUST) for core HSD teams (MO, health inspector, data assistant and chief nursing officer).

Ministry of local government short courses The ministry of local government has capacity building programs for its personnel in planning, budgeting, resource management, administration, etc. Twenty six modules developed and approved in 2004 are used for the courses. It is funded by the World Bank and targets only local government staff, but it is not very clear if district health managers benefited from these programs.

4.3 Other capacity building approaches

Mentoring

District managers who were interviewed felt they had many benefits from coaching and mentoring received from more experienced managers, especially in terms of the “political” skills acquired. Peer mentors or “buddies” were specifically identified by new MOs as valuable sources of support which gave them the opportunity to explore difficult problems in a safe and confidential environment. However, mentoring and coaching approaches need to be well understood, organized and coordinated to be fully beneficial.

Technical advisers Technical advisers have been attached to various district projects to provide support over the years but there is little evaluation or feedback on the success, or otherwise, of this approach. Sometimes, advisers have been drawn into direct service activity when under pressure to produce quick results as compared to the rather slow skills transfer and developmental roles expected from them. A much cited problem is the lack of sustainability when projects end and advisers leave.



Management in Disease Programs: Priority disease programs (e.g. AIDS, TB, and malaria) often provide training courses with management aspects. The likely duplication that this entails may result in conflicting messages on managers' roles and functions especially when a national competency framework is not available.

Key issues:

• A multiplicity of management training/development initiatives covering similar ground but at times using different methods, suggest a lack of national coordination. When previous experiences are not built upon, it has cost implications for both the MoH and district managers as each new course entails high development costs to repeat the program design, materials and tools.

• MPH courses are not management qualifications (the management modules are optional) and so may not deliver effective managerial competences. Potential managers should be required to take the management modules in order to qualify for posts.

• Soft skills' training (e.g. negotiation and advocacy) is needed but requires methods that are not found in many formal courses. Mentoring and coaching approaches need to be harnessed to provide these skills and the public sector mentoring skills development program run by UMI is a commendable program that can be incorporated into other programs.

• A nationally-agreed management competency framework is needed to ensure training content consistency and coordination and to assure that core standards are met. The MoH should also clarify responsibilities for management development strategy and training coordination.

• Technical assistance used for management development must be reviewed to minimize sustainability problems when projects end.

5 DO CRITICAL SUPPORT SYSTEMS FUNCTION WELL? A third dimension of management capability is the systems and tools that facilitate management functions (e.g. planning, human resources, supplies, management information, etc.). Management effectiveness depends on well functioning support systems and in Uganda, decentralization to local government and the presence of some level of dual reporting and supervisory expectations may place a burden on the effectiveness of support systems. This section reviews the status of selected support systems at district level and how they impact on managers' functions.

5.1 Planning systems

All district departments operate under strict local government finance and accounting regulations. Efforts have been made to streamline different planning processes and provide coherent guidance to districts and HSDs. New national guidelines have been issued, training provided, and support visits paid to districts. Districts have been grouped and assigned a designated planner at the MoH as the focal point for planning support M a move that has strengthened planning and budgeting processes. However, the planning guidelines were seen as quite complex and the activities took too much of a manager’s time (often months). Other problems include delayed issue of annual planning frameworks, unanticipated changes in budget allocations, delayed planning support visits and data difficulties. The process requires the filling of three different forms: a "budget framework" submitted to the local government; an "annual estimates of revenues and expenditures" also for local government; and an "annual health plan" submitted to the MoH (after agreement with the district health committee).

In practice, it appears that budgets are drawn by adding a percentage to the previous year’s figures. The planning framework is quite prescriptive and may restrain local priorities from being adequately reflected. There is poor information on timing of activities of centralized disease control programs, NGOs and development partners.



The 2003 medium term review (MTR) had recommended new central planning guidelines to assist the disease programs in identifying core central functions of resource prioritization and technical coordination in order to streamline their activities into the established planning processes.

5.2 Health Management Information Systems (HMIS)

The HMIS was rolled out in all districts to collate information as a requirement of the annual planning process. However, despite attempts at harmonization, many disease programs still demand information parallel to the agreed HMIS. HMIS information requirements are very comprehensive which may be a bit unrealistic in view of staff shortages and lack of computing capacity to facilitate data collation and transmission. For example at clinic level, eleven separate A4 pages of documentation are to be filled each day (one clinic said it took eight hours). Despite these problems, timeliness and completeness of district reporting improved from 15.60% to 70% between 1999 and 2002.

District managers clearly understood the need for information though the perception from this review is that the information is primarily collected for the central MoH and not much of it is used locally. The planning process produces trend data which were regularly displayed in offices and public places. A lack of data culture meant that many managers interviewed could not back discussions with hard figures on their districts. Managers are assessed on completed and timely returns and not on how or if data is used. In addition, district managers cannot question overall HMIS data to compare information collated from their districts with those of others. Figure 1 (below) illustrates the performance of the districts visited in terms of HMIS submissions as compared with the average for Uganda. Three of four districts with data available performed above average.

Figure 1. HMIS performance at district level (No 2002/03 data available for Mpiji)

Sources:

1. Ministry of Health, Annual Health Sector Performance Report FY 2002/03



5.3 Monitoring the health sector strategic plan

A number of indicators have been established to assess achievements in implementing the national health sector strategic plan, a process which operates in conjunction with agreed quality standards in all institutions. Indicators are set for both national and district levels with the results benchmarked in league tables that illustrate how well or poorly districts are performing. The selected indicators (which include both output and

Percentage of health units submitting complete

HMIS reports to district

0

20

40

60

80

100

120

2002/03 2003/04 2004/05

Jinja

Mpigi

Busia

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Uganda Average



process indicators) have agreed targets, and baseline data have been established against which performance is measured. This system covers only the public sector and faith-based NGO services and excludes the private-for-profit sector.

5.4 Financial management

Decentralization of financial management to districts was initiated with district "block grants" in 1993, followed by a "conditional grants" system for NGO hospitals in 1997. Currently the country is implementing a fiscal decentralization strategy (FDS) whereby local governments in districts receive full budget grants (including capital budget) for each sector, 10% of which (non-wage) can be re-allocated locally between sectors. This virement seems to affect the health sector negatively which could be due to a perception that the sector is well endowed compared to others and often attracts additional donor resources.

District health budgets are based on 4 core criteria: (a) geographical size, (b) poverty index, (c) "health need" calculated from infant mortality, and (d) population. Districts receive "budget ceilings" in advance on some items, and certain other funds are earmarked from national level for specific activities. Despite decentralization, DHMTs directly control only the relatively small amounts of money in their "operational" budget which cover staff allowances, meetings and supervisory visits; maintenance; fuel; and stationery costs. Other recurrent budget items (e.g. salaries, drugs, supplies) and development (capital) funds are centrally controlled and have fixed ceilings. However, unlike the public sector, faith-based NGO institutions that operate in collaboration with the MoH are allowed to generate and retain income from user fees. Salaries, once discussed with the CAO, are transferred directly from the ministry of finance (MOFPED) to the local government and virement is not allowed. It was reported that with payroll responsibility now at district level salaries were usually paid on time (albeit at middle of the following month). Previous problems with salary delays were said to have damaged morale and affected retention. Each year, districts open a bank account for receiving the budget and it is closed after reconciliation at the end of the year. Financial control is done by reconciling bank statements and cash books with the agreed workplan. No financial expenditure can be made outside of the workplan so in practice, the DDHS only exercises true financial management over very minor local purchases. A local government accountant (directly responsible to the CAO) provides financial administration support to the DDHS though he is not usually involved in the planning and budgeting process. Feedback received indicated that release of funds is often not timely. For example, 6 weeks after the financial year started, allocations had not been received from the MOF by any of the district teams visited even though districts should normally receive an automatic release of funds for the first month of the financial year. Funds channeled through the local government are also delayed before being transferred into district health bank accounts.

5.5 Human resource management and planning

The decentralized human resource management is characterized by poor local capacity to undertake certain tasks (e.g. recruitment) and HR management functions at the central MoH level are somewhat constrained by a lack of collated data from decentralized units that will enable national strategic HR planning. A number of ongoing programs have been initiated to strengthen HR information with support from the EU and USAID.

The HR information system does not track managers as a component of the health workforce and apart from "hospital administrators", management posts are not formally identified and included in the data. For example, information on district managers’



profiles, recruitment, attrition and turnover rates, etc., which can be used to determine future needs, are absent. Recruitment Employment is done by the "Health Service Commission" for the national MoH and referral hospitals. Districts have a "District Service Commission" (DSC) for all local government departments which are made up of a mix of political appointees and representatives of the specific sector requiring staff. Recruitment is a lengthy process which was partly re-centralized when many districts did not have the funds to advertise, arrange interviews and pay DSC members. Established posts are only filled when funds are assigned from the ministry of finance after which the District Service Commission advertises the post and manages the selection process with the DDHS as a "technical" adviser. The districts visited during the review estimated "staff at post" to "established post" ratios at a maximum of 50%. However, national average figures from the MoH gave 68%. Districts reported that they could now in theory vary their skill mix locally using the authority vested in the DSC upon advice from the DDHS. Staff appraisal and performance management A new public sector appraisal system was introduced in 2003 and district managers were trained to use it. Some were concerned about the amount of time the appraisal process took but it appears to be good for developing managers' skills in conducting staff performance appraisals. The review recognized a number of features that reflected good practice including the requirement of joint staff and supervisor identification of annual objectives linked to the district workplan, requirement for staff self assessments and their involvement in documenting work details and in planning future activities. Staff are appraised against a generic framework of critical competences (see Table 1 below). However, these competences may not be appropriate for all types of staff but are clearly relevant for managers. Adding assessments of "self management" and incorporating personal development planning will be good enhancements.

Table 1. Generic staff performance assessments Staff performance generic criteria : • Ability to apply professional/technical knowledge and skills • Knowledge of job • Planning and organizing • Decision making • Leadership • Management of financial and other resources • Communication • Loyalty • Integrity • Ability to achieve desired outputs

Maintaining staff discipline The ultimate responsibility for staff discipline is vested in the DSC with well documented procedures available. However, there are still reports that major disciplinary actions often failed because the appropriate procedures were not followed and formally recorded. This was thought to be due to managers' reluctance to take unpopular decisions in what is often a small community. Managers interviewed however mentioned an interesting and potentially more powerful disciplinary system that arises from the professional associations and can result in having one's registration suspended for incompetence or misconduct. The lack of effective



disciplinary authority frustrates attempts to get optimal performance from staff and provide little incentive for people to improve.

5.6 Medicines management

Medicine procurement is financed from PHC recurrent budget, credits established with the National Medical Stores (NMS), the Joint Medical Stores (JMS) and, to a lesser extent, user fees from faith-based NGO institutions. MoH guidelines require that at least 50% of districts' non-wage budget is spent on medicines at Health Centres II to IV, and 30% in hospitals but in practice, wide variations exist. When medicines are unavailable at the National Medical Stores (a common occurrence), districts are permitted to procure from the Joint Medical Stores and if this is not feasible, then from private sector sources. Stock outs appear to have decreased significantly when "credit lines" were introduced, but problems still exist about medicines actually reaching patients. A wide variation in expenditure on medicines exists between districts for which there seems no rational explanation. It ranges from a low of 11% to a very high 200% (possibly carried forward from previous years, or inclusive of medications from other sources and programs, e.g. GFATM) of recurrent budget.

5.7 Quality assurance, supervision and monitoring

The health sector's supervisory system is well institutionalized and integrated at district and sub-district levels. The system was originally introduced in 1994 as part of a quality management process led by a "Quality Assurance Department" in the MoH. It is now an integral part of the health system and has survived the changes brought about by decentralization. However, decentralization has perhaps made it even more important as this process has become the key link between district health offices and the central MoH. It is the main channel for delivering national support to DHMTs and for exchanging good practices and experiences between districts.

Its attributes include: • It is designed to be a supportive and non-punitive process where supervisors are

trained to establish trust with the units they supervise. • The process has integrated routine service delivery monitoring with priority program

assessments during the same visit and it is part of the annual workplan with specific time and budget allocated for it.

• Supervision cascades from national level to districts and sub-districts, and has become a core responsibility of district health teams since 2001.

• It enrolls all senior MoH staff into 10 multi-disciplinary teams, each with responsibility for supervising an assigned cluster of districts. Teams include staff with finance, planning, management, and engineering backgrounds. Some visits include local government officials and program specialists which enhances its inclusiveness.

• While certain critical items are monitored every six months (e.g. finance, planning), other areas (malaria, child health, etc.) are selected in rotation and the appropriate technical staff are added to the core team.

• The district teams get immediate verbal feedback after each visit and later summary reports highlight key issues and suggest actions requiring national intervention.

Some weaknesses do exist: • Possibly due to staff shortages and high transaction costs, the cascade of

supervision to the sub-district has not been fully implemented. • Review of visitor’s books suggests that members of the supervisory teams changed

frequently which may affect the building of good links between supervisors and the receiving teams.

• Despite integration attempts, some separate vertical program supervision visits still occur.



• Teams reported that little time was available to adequately carry out other support activities such as coaching.

• The impact of integrated supervision on actual quality of care has not been systematically assessed.

On balance, the impact of the integrated supervisory system has been quite positive on management at district level.

Key Issues

Planning

• Clear improvements have been achieved in the planning and budgeting process which needs to be sustained.

• Planning is well supported by the central level but there are complaints that may not be as timely as needed.

• The planning guidelines are rather prescriptive and thus local priorities may be insufficiently reflected in the final product.

• Managers tended to spend an inordinate amount of time on planning activities and training workshops and this raises the transaction costs of the planning process.

HMIS

• The rather sophisticated HMIS system is likely to be too complicated for current district level capacity. Some simplification may be needed.

• The planning system is in theory driven by information. However, managers interviewed did not appear to appreciate and internalize the core local data needed for decision-making. The information culture is weak and appears driven mainly by national level needs. Some managers could not give the data underlying certain basic service decisions when asked.

• Collecting the required data is very time-consuming for staff, and returns are frequently late and/or incomplete.

Monitoring

• There is a good high level tool used to monitor progress towards the sector's strategic goals. This tool is designed to recognize achievements as well as areas needing greater effort.

• An increased number of districts and a high staff turnover seem to have significantly increased the costs of monitoring.

• Quality assurance of data from monitoring seems minimal and this is detrimental to the recognition of local priorities. Some indicators also measure things that are beyond the control of the districts (e.g. medicine stock outs may reflect supply issues at the National Medical Store) and the weighting given to indicators may not reflect the true source of difficulties.

Financial

• Despite decentralization, there is relatively little financial autonomy at district health level. The authority of local government under the fiscal decentralization strategy is not fully used and may even go against health sector interests as DDHS usually has little negotiating power with district councils.

• Budgets allocated to districts do not adequately reflect some of the local priorities identified from the planning process.

• Faith-based facilities’ authority to retain user fee revenue has enabled true financial management to occur. Public sector facilities could benefit from having similar authority.

HRH

• Core HR management systems are in place and managers have received training in their use. One difficulty however is that delayed release of finances creates difficulties for staff recruitment.



• The national HR information system currently lacks data on the numbers, deployment and qualifications of health sector managers.

• The local government system has an appraisal form which is quite comprehensive and incorporates excellent features such as a generic competence framework for managers. It can be adapted for health sector use though it is complex, which may limit its use to senior managers only.

• A key observation is the suggestion that managers were reluctant to use staff disciplinary procedures effectively due to a variety of cultural and other reasons.

6 WORK CONTEXT AND ENVIRONMENT OF DISTRICT MANAGERS

An enabling work environment is one in which managers know exactly what is expected of them from well communicated policies, job descriptions and technical guidelines supported with good performance management. These provide clarity of roles and enable the use of authority with responsibility and without fear. This section examines influences of the work context and environment on the district health manager's work in Uganda.

6.1 Managers' roles and responsibilities

Policies and regulatory frameworks. The 1995 constitution enjoined the state to provide basic health services to the population and this forms the basis for Uganda's "Minimum Health Care Package" derived from the national health sector policy and plan adopted in 1999 and 2000, respectively.

During the 5 years prior to this review, efforts had been made to streamline sector funding and operations through various modalities including sector-wide approaches (SWAp), donor budget support and an integrated planning and supervision process. Several national and local guidelines were developed for planning, budgeting, expenditure control and staff management. Furthermore, service delivery norms and standards have been published and are in use at operational level. However, formal job descriptions had not been developed at the time of this review.

Statutory documents such as the National Constitution (1995), the Local Government Act (1997) and the National Health Policy (1999) clearly define the structure and roles of decentralized units and district health managers. Operational guides such as the MoH draft manual on "Organization, Planning and Management of Health Services in the Heath Sub-District" (2001) and the "Report on Review and Restructuring of the Local Governments and Staffing Levels by the Ministry of Public Service" (2003) have helped in the design of district management functions.

The restructuring processes that created independent district health offices in 1997 separated hospital management from the routine district health management and clarified specific management responsibilities of various units. Also, the creation of HSDs enabled delegation of direct service provision and got district health teams to focus firmly on their core management responsibilities.

Roles and responsibilities however, remain unclear in a number of areas. The relationship between local government and DHMTs, and between regional referral hospitals and HSDs remain to be grey areas. Management and links with some technical areas such as school health (Ministry of Education); water and sanitation (Ministry of Water, Lands & Environment); and HIV/AIDS (Uganda AIDS Commission) also require better clarification and coordination. District managers tend to feel that decentralization had limited their links with the national MoH and their inputs into national health strategy development. At the same time, though recognizing the benefits of decentralization, many also felt there were limits to their influence on local government especially in gaining an understanding of the budget needed to maintain health. Overall, the decision space of district health



managers is quite limited and may have shrunken further with the fiscal decentralization policy. Local government also carries out many management functions on behalf of all sectors at district level which reinforces to some extent perceptions of health managers that they lacked authority and influence. Management processes such as hiring and firing are handled by the DSC and the district personnel officer. Procurement of goods and services is effected by a "district tender board." Accountability for service delivery: There is a genuine understanding of the need for health services to be publicly accountable, and information on the performance of services is made available in the national press (picture below) and at other forums. The monitoring and supervisory systems enhance a sense of accountability for service targets. However, this has not quite translated into enhanced customer focus for service delivery.

Figure 2. District epidemiology and surveillance reports in newspapers

The sub-title reads: "Ministry of Health: Maternal and neonatal tetanus elimination surveillance and routine immunization performance indicators in 2005"

The Yellow Star Programme: This programme evolved from the Quality Assurance project and was designed to give incentives when quality benchmarks were achieved. Though it is not an accreditation system, it monitors district performance against 35 standards M full compliance to which could qualify for an award of a plaque, which comes with significant recognition and publicity. This scheme (originally initiated with USAID support) is now active in 47 districts and managers take pride in displaying a yellow star on their facility.

The programme focuses on a few key standards and this may well affect the attention given to other critical issues that are sometimes of higher local priority. Furthermore, districts that are performing poorly do not receive much support and there is a need to invest in building better communication and trust between local facilities and national supervisory levels.

Incentives that drive managers: A manager's incentives are only partially about remuneration. It is also linked to the perceived status of the position, the degree of



autonomy managers have and career enhancement opportunities that are available. Both the appraisal and supervision systems recognize good performance but do not lead to any financial incentives for individual managers. Salary increments are administrative events that appear unlinked to performance and are limited to a specified number of increases (per annum) until the top scale is reached.

Senior health sector posts are comparatively reasonably well paid and salary levels exceed other public sector services (e.g. education, finance, armed forces and police).

4

The DDHS position is reasonably well rewarded and they are said to have significant status in the community. However, career progression beyond this position is limited and managers may have to remain in the same posts until retirement. The only real option, that of joining the national MoH, is quite limited and jobs are reportedly rarely advertised. Local government career posts such as Chief and Assistant Chief Administrative Officers require post-graduate qualifications that are not normally required in the DDHS training. Some DDHS do feel they should get appointed to CAO posts based on their management experience. Many district health managers are appointed to work in their home areas suggesting that many districts prefer to hire "sons of the soil." However, having strong social links locally may, for example, constrain the taking of hard decisions which affect relatives. Alternatively, it may foster good relationships with local opinion leaders as a key to success. Other possible incentives are the training courses many managers attend although currently, training budgets are consolidated with local government finding funds for training much more competitive. Indeed, many DDHS and MOs pay for courses leading to promotion qualifications themselves. The cost of an MPH (the basic requirement to be a DDHS and HSD MO) can take about a third of their annual take-home pay. Staff on long term training have at times been removed from the payroll. However, allowances and other remuneration received when attending short courses could mean that managers spent a considerable amount of time in training workshops. Uganda holds national health assemblies in which District Health Committee chairpersons, Chief Administrative Officers, District Secretaries for Health, the DDHS and selected health unit managers participate. These assemblies serve as a forum to solicit local government support for health plans. Based on the assessment of performance of the various districts, good performers receive plaques of recognition which have served as powerful incentives to improve rankings. While some teams found the plaques rewarding, others are cynical, and feel that receiving tangibles like transport or computers would have been real incentives.

Key Issues:

• Salaries are relatively attractive compared to similar public sector positions and the social status of local health managers is quite good.

• There are limited forums for peer-to-peer exchanges between DDHS and to help articulate common concerns. Having health managers' newsletters, for example, can help to reinforce status and provide updates on good practice.

• Decentralized appointments mean that managers have limited career options and little opportunity to be posted in other districts.

• There are few financial incentives although supervision and monitoring systems clearly recognize good performance.

• The tendency of districts to recruit natives of the area, while having some advantages, may also have distinct disadvantages.

6.2 Management practices changes at district level

It was difficult to obtain accurate quantitative data which demonstrated whether sustained improvements had taken place in management practices. It is generally

4 It is reported however, that some DDHS and MOs operate private practices after official hours or even during

working hours.



difficult in any case to attribute improved service delivery and health status changes to management development. However, annual performance indicators currently in use by the health sector may, with some refinement, help to establish trends that can demonstrate changes better. Interviews with district managers did give persuasive circumstantial evidence that management functions had improved in a number of areas, notably:

• Team-work in the districts visited was reported to be much more effective with improved coordination with other local government units.

• A strong planning process now exists despite somewhat tenuous links between plans and budgets, and activities and actual expenditures.

• A good supportive supervision system has been established that relates to issues important to managers and is not just a performance check.

• Medicines management improved significantly with fewer "stock outs" due to the new "pull" system and better planning.

• There is more accountability of health services delivery in communities served with performance information widely circulated in facilities and through the media.

As the five districts visited were selected on the basis of having benefited from certain management development programs, efforts were made to look at whether these districts also showed improvements in certain management functions and outcomes in quantitative ways. One selected indicator is illustrated below while others are displayed in Annex 5. Clearly, more accurate data including inputs, timings and results are needed to even begin to make a link but the graph below (Figure 3) gives an example of how such indicators may point to performance trends. Some management-related indicators showed mixed results in comparison to the national average but there are a number of downward trends over the past couple of years that need further investigation. Generally, only one of the four districts with data was persistently below the national average.

Figure 3. Expenditure as a proportion of agreed budget

(No data available for Masindi. Busia may have leveraged additional funds from its

local government.)

Source: Annual Health Sector Performance Report FY 2003/04. Kampala, Ministry of Health, Uganda.

6.3 Health service outputs and management

This study avoided linking management improvement interventions and health service coverage as it is a difficult task given the multiple factors that influence service coverage. The core indicators of the 2003-2004 Uganda health sector review showed significant variation in districts' performance but poor and rural districts were not necessarily the bad performers. Available analyses of the districts' performance illustrated a number of factors:

Percentage of PHC funds disbursed that are expended in 2003-2004

0 20 40 60 80

100 120 140

Jinja Mpigi Busia Mukono Masindi Uganda Avg

Series1



• The newly created districts perform less well than the districts that had been in existence for some time.

• Distance between a district and urban centres correlated with reduced performance M the islands generally performing less well.

• The war and civil unrest in parts of northern Uganda, as expected, also seemed to correlate with generally poorer performance though surprisingly one or two districts in this area (e.g. Gulu) were said to have persistently been top performers, a possible result of sterling DHMT leadership.

The study had planned to examine data trends over a five-year period but a general lack of data restricted trend data mainly to between 2002 and 2004. Composite service performance indicators (2002-2003) taken from the monitoring system showed two of the four districts were at or above national average (Figures 4) and the overall national ranking of three of the five had improved between 2002-2003 and 2003-2004 with Jinja, often a highly ranked district, declining slightly. The study was unable to determine if the falls in coverage found in these districts simply mirrored countrywide trends.

Figure 4. District monitoring composite indicators and ranking

Total District Score 02/03Composite of key indicators

010203040

5060708090

2002/03

Jinja

Mpigi

Busia

Mukono

Masindi

Uganda Avg

(Data for Mpigi unavailable. Top score = 100)

Source: Annual Health Sector Performance Report FY 2002/03. Kampala, Ministry of Health, Uganda.

Sources:

1) Annual Health Sector Performance Report FY 2002/03. Kampala, Ministry of Health, Uganda.

2) Annual Health Sector Performance Report FY 2003/04. Kampala, Ministry of Health, Uganda.

Districts Ranking 2002-2003 & 2003-2004

(range 1st to 50th)

0

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Key issues:

• Health service managers spend 65% to 80% of their time preparing plans, writing reports, and attending workshops, leaving little time for supporting implementation of health activities in the district.

• Little true prioritization takes place at local levels aimed at tackling the main health issues related to the locality.

• Local strategies are based on following national guidelines than on creative thinking and developing locally relevant approaches.

• DDHS are still not sufficiently empowered to carry out their roles and responsibilities M there is a tendency to just carry out instructions. Being answerable to both the MoH and the local government may have caused split loyalties and some confusion.

7 CONCLUDING REMARKS

Uganda has made tremendous efforts at improving service delivery coverage and quality through improved management processes, systems and skills. Most critical management positions are filled (e.g. DDHS posts) and managers are well retained with little attrition except at the more operational level of HSD. Better efforts are needed to understand the trends in the management workforce and determine strategies to sustain the gains made.

Several opportunities exist for managers to develop appropriate skills and acquire needed qualifications. However, courses need to be designed to include essential soft skills and to use methods that enable these competencies to be gained. A health sector competency framework for managers will greatly enhance having common objectives and standards across various courses and ensure that the sector gets the right management competencies developed. Uganda does very well with its management support systems especially in the area of planning, budgeting and financial management. The supplies system has improved and a good supervisory system is in place. However, the need to set up structured national systems have suffered setbacks due to time spent on detailed planning, for example, and the likelihood that local priorities and decision-making were overlooked in the process. Data use for local decision making must be strongly encouraged for communities to reap more benefits from the decentralization process. District managers serve in a rather fluid environment of allegiance to both a local government and a national health system. The situation appears to be evolving and is likely to improve with time. Attention needs to be paid to the non-financial motivators that encourage good management performance and to the factors of local recruitment that may discourage the same. Overall, these five districts showed service performance near or above national average. Whether these results reflect management effectiveness cannot really be determined but the overall impression has been one of improved systems with qualified managers in the critical district posts. However, other areas such as the way management competencies are developed and how managers are motivated by their work environment need to be improved.



Annex 1. Bibliography

1. Health sector strategic plan (2000/01-2004/5): Midterm review report. Kampala, Ministry of Health, Uganda, 2003.

2. Annual health sector performance report: Financial year 2003/04. Kampala, Ministry

of Health, Uganda, 2004.

3. World development indicators. Washington, D.C., World Bank, 2005. 4. Local government statute. Kampala, Government of Uganda, 1993.

5. Local government act of 1997. Kampala, Government of Uganda, 1997.

6. Health sector strategic plan 2000/01 – 2004/05. Kampala, Ministry of Health, Uganda,

2000.

7. Owarwo V, Murindwa G, Erickson S. Providing support to district health services under decentralisation and sector-wide approaches. A pre-workshop draft synthesis paper on experiences in Uganda. 2002.

8. Health sector guidelines for preparing annual workplans for district health services.

Kampala, Health Planning Department, Ministry of Health, Uganda, 2004.

9. Health budget framework paper for health sector. 2004/05 to 2006/07. Kampala, Health Planning Department, Ministry of Health, Uganda, 2004.

10. Final report on the review and restructuring of the local governments and staffing

levels. Kampala, Ministry of Public Service, Uganda, 2003.

11. Guidelines for health sector conditional grant 2004-05. Kampala, Ministry of Health, Uganda.

12. Annual health sector performance report: Financial year 2002/03. Kampala, Ministry

of Health, Uganda, 2003.

13. Area team reports: March-April 2004, Sept-October 2004, March-April 2005. Kampala, Ministry of Health, Uganda.

14. Makerere University. Programme Handbook: Masters in Public Health 2003/04.

15. Uganda Management Institute Prospectus 2005/2006.

16. Pearson M. DFID Uganda country health briefing paper. 2000.

17. Organization, planning and management of health services in the health sub-district.

Kampala, Ministry of Health, Uganda, 2001.

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Annex 2. Summaries: District case studies

District

Who are the managers?

Competency development

& systems strengthening?

Changes in management

practice & management

systems?

Changes in work

environment?

Lessons learnt:

Masindi with Buruli

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ble

[s

ee

H

ea

lth

Se

cto

r P

erf

orm

an

ce

Re

po

rt

20

02

/03

]

DH

MT

:

• D

DH

S (

9 m

on

ths

), H

ea

lth

V

isit

or;

He

alt

h E

du

ca

tor;

H

ea

lth

In

sp

ect

or;

As

sist

an

t H

ea

lth

In

sp

ect

or

for

Dru

gs

;

S

r N

urs

ing

Off

ice

r •

Fo

ca

l p

oin

ts:

HIV

/AID

S

(als

o D

ep

. D

DH

S);

T

B/L

ep

ros

y; M

ala

ria

C

on

tro

l; H

MIS

; E

pid

. S

urv

eill

an

ce

; D

ista

nc

e

Le

arn

ing

(A

MR

EF

).

• D

HM

T m

em

be

rs w

ith

MP

H;

ad

v d

iplo

ma

in

Pu

blic

He

alth

•

Mo

H w

ork

sh

op

s &

se

min

ars

(m

os

t re

ce

nt

VC

T c

oo

rdin

ati

on

) •

WH

O/N

OR

AD

pro

jec

t o

n

SD

HS

. H

SD

wit

h t

oo

l fo

r s

itu

ati

on

an

aly

sis

& p

lan

nin

g +

in

fo-b

as

ed

pri

ori

ties.

U

S$

10

0 0

00

in

20

04

fo

r im

ple

me

nta

tio

n.

• P

lan

nin

g im

pro

ved

in

th

e l

ast

fe

w y

ea

rs (

be

tte

r in

fo u

se

d

fro

m H

MIS

). P

lan

nin

g w

as

la

te

as

ne

w f

isc

al y

ea

r st

art

ed

in

J

uly

(m

ore

th

an

1 m

on

th).

•

Su

b-d

istr

ict

fee

ls s

up

po

rt

rec

eiv

ed

fro

m W

HO

/NO

RA

D

pro

jec

t a

llow

ed

in

no

vati

ve

str

ate

gie

s (

e.g

. e

sta

blis

h

co

mm

un

ity

su

pp

ort

gro

up

s a

t s

ub

-co

un

ty le

vel

to p

rom

ote

A

NC

se

rvic

es

& h

igh

ris

k d

eliv

eri

es

in

he

alth

fa

cilit

ies.

• E

ac

h D

HM

T m

em

be

r s

pe

nd

s a

vera

ge

of

60

wo

rkin

g d

ays

o

n w

ork

sh

op

s a

nd

se

min

ars

, (u

su

ally

by

Mo

H

de

pa

rtm

en

ts.)

•

Na

tio

na

l le

vel

vis

its f

req

ue

nt,

(e

sp

ec

ially

te

ch

nic

al

pro

gra

ms

).

• S

up

erv

isio

n &

su

pp

ort

we

re

no

t re

gu

lar

bu

t a

pp

rec

iate

d,

(es

pe

cia

lly p

lan

nin

g v

isit

).

• W

HO

/NO

RA

D S

DH

S p

roje

ct

ga

ve e

qu

ipm

en

t, (

so

lar

pa

ne

ls,

an

d c

om

pu

ters

) fo

r h

ea

lth

ce

ntr

es.

• G

oo

d s

itua

tio

n a

na

lys

is &

ca

refu

l se

lec

tio

n

of

str

ate

gie

s e

sse

nti

al t

o s

uc

ce

ss.

• C

on

tin

uin

g e

xt.

su

pp

ort

, i.e

. m

en

tori

ng

an

d

co

ac

hin

g u

se

ful.

•

Ow

ne

rsh

ip o

f p

rob

lem

s a

nd

so

lutio

ns

- k

ey

to a

ctio

n a

nd

ch

an

ge

. •

In

fo/p

lan

nin

g -

go

od

bu

t ta

ke

s u

p a

lo

t o

f th

e

DH

MT

's t

ime

.

Mpigi district: Mawokota

South health sub-district

• M

pig

i: p

oo

r ru

ral

dis

tric

t,

in s

ou

thw

es

tern

Ug

an

da

•

Po

pu

lati

on

: 4

15

00

0

• S

ub

-dis

tric

ts:

4

• O

ne

of

the

10

be

st

pe

rfo

rme

rs o

n L

ea

gu

e

Ta

ble

[H

SR

20

02

/03

].

Ma

wo

ko

ta S

ou

th s

ub

-d

istr

ict

• P

op

ula

tio

n:

10

0 0

00

•

Ca

tho

lic H

os

pita

l: 1

00

b

ed

s

• H

SD

He

ad

is a

lso

th

e

Ho

sp

ita

l Su

pe

rin

ten

de

nt.

•

Co

re H

SD

te

am

ca

rrie

s o

ut

Ho

sp

ita

l & P

HC

fu

nct

ion

s.

• T

ea

m:

De

p.

Me

d.

Su

pt.

, S

r.

Nu

rsin

g o

ffic

er,

Ho

sp

. A

dm

inis

tra

tor

& H

os

p.

Acc

ou

nta

nt

• H

SD

in

ter-

su

b-c

ou

nty

te

am

: i

nc

orp

ora

tes

he

ad

s o

f o

the

r h

ea

lth u

nits

, h

ea

lth

ins

pe

cto

rs &

fo

ca

l p

oin

ts f

or

PH

C,

inje

ctio

n s

afe

ty,

ma

lari

a &

imm

un

iza

tio

n

• M

oH

wo

rks

ho

ps

ma

inly

on

d

ise

as

es

mg

mt.

•

No

mg

mt

tea

m m

em

be

r e

nro

lled

on

ava

ilab

le d

ista

nc

e

lea

rnin

g

pro

gra

mm

e.

• 3

HS

D s

taff

att

en

de

d 3

-we

ek

c

ou

rse

on

he

alt

h s

ub

-dis

tric

ts

(20

02

/03

).

• W

HO

/NO

RA

D p

roje

ct

on

S

DH

S.

HS

D w

ith

to

ol f

or

sit

ua

tio

n a

na

lysi

s &

pla

nn

ing

+

info

ba

se

d p

rio

riti

es

.

US

$1

00

00

0 i

n 2

00

4 f

or

imp

lem

en

tati

on

. •

Mo

tiva

tio

n b

y Y

ello

w S

tar

Pro

gra

mm

e

• P

lan

nin

g w

ith

da

ta u

se

im

pro

ved

& w

as

re

su

lts-

ori

en

ted

.

• S

erv

ice

co

vera

ge

in

fo

dis

pla

yed

in

fa

cilit

ies

to

mo

tiva

te s

taff

. •

Fin

an

cia

l mg

mt:

lo

ca

l u

se

r fe

es

us

ed

if f

un

ds

are

de

laye

d

(us

ua

lly i

n P

NF

P u

nits

on

ly).

•

Su

pe

rvis

ion

& s

up

po

rt d

on

e

reg

ula

rly

as

a t

ea

m.

•

Wo

rk w

ith

in

tern

atio

na

l & l

oc

al

NG

Os

(4

NG

Os

in H

SD

) in

ten

sifi

ed

(in

co

mm

un

ity-

ba

se

d H

IV/A

IDS

se

rvic

es

, N

GO

s p

rovi

de

te

stin

g k

its &

fi

na

nc

ial i

nc

en

tive

s fo

r vo

lun

tary

co

un

se

lors

.

• G

ov'

t fu

nd

s f

or

Ho

sp

ita

l PH

C

co

nd

itio

na

l gra

nts

d

ec

rea

se

d.

•

Th

e P

NF

P h

os

pit

al s

ala

rie

s p

aid

ou

t o

f th

eir

gra

nts

&

top

pe

d u

p w

ith

ho

sp

ital-

us

er

fee

s.

• H

SD

bu

dg

et

is a

pp

rox

10

%

of

ho

sp

ital g

ran

t b

ut

ge

ts 5

%

to c

ove

r e

xpe

ns

es

(3

ite

ms:

a

llow

an

ce

s,

Eq

uip

me

nt,

s

tati

on

ery

fu

el,

ma

inte

na

nc

e,

•

Wa

ge

& d

rug

s b

ud

ge

t is

c

en

tra

lize

d.

• P

lan

nin

g:

Th

e H

SD

te

am

s

pe

nd

s 2

0 d

ays

pre

pa

rin

g

pla

ns

. •

Dis

tric

t s

up

erv

iso

ry v

isits

w

ere

in

fre

qu

en

t b

ut

ap

pre

cia

ted

.

• U

nc

oo

rdin

ate

d N

GO

& H

SD

pla

nn

ing

re

su

lts i

n d

up

lica

tio

n &

inc

on

sis

ten

cy

in

se

rvic

es

(e.g

. V

CT

, te

sti

ng

, P

MC

T).

•

Th

e H

ea

lth

Un

its M

an

ag

em

en

t C

om

mitt

ee

s

are

mu

ch

le

ss a

ctiv

e a

nd

in

volv

ed

sin

ce

u

se

r fe

es

ha

ve b

ee

n a

bo

lish

ed

. •

Hig

h s

taff

tu

rno

ver

wh

en

PN

FP

an

d g

ov'

t s

ala

rie

s a

re d

iffe

ren

t.

• U

sin

g i

n-d

ep

th s

itua

tio

n a

na

lys

is

(WH

O/N

OR

AD

pro

ject

) w

as

"e

ye o

pe

ne

r" o

n

rea

l s

erv

ice

co

ns

tra

ints

).

Mukono health district

• E

st.

Po

pu

latio

n:

83

0 0

00

•

He

alt

h f

ac

iliti

es

: 7

2

• (

49

go

vern

me

nt

& o

the

rs,

PN

FP

) •

(5

Ho

sp

ita

ls,

4 H

ea

lth

Ce

ntr

e I

Vs,

24

HC

III

s

an

d 3

9 H

C I

Is)

Financial systems

• D

istr

ict

"co

llec

tio

n a

cco

un

t"

for

ce

ntr

al

bu

dg

et

fun

ds

be

fore

allo

ca

tio

ns

to

se

cto

rs.

• D

istr

ict

he

alt

h c

are

acc

ou

nt

ha

s E

xec

Off

ice

r- A

cco

un

ts

bu

t a

cco

un

tab

le t

o t

he

LG

C

AO

.

Information systems

• S

taff

re

ce

ive

d H

MIS

tra

inin

g

(co

llect

ion

/ in

terp

reta

tio

n).

•

Dis

tric

t re

gis

try

to h

an

dle

fa

cili

tie

s d

ata

.

• I

n 2

00

2/3

Mu

ko

no

su

bm

itte

d

81

% o

f in

form

ati

on

on

tim

e.

10

0%

in

20

03

/4.

Factors identified as

strengthening management

• M

oti

vati

on

(p

aym

en

t o

f s

ala

rie

s o

n t

ime

, s

up

erv

isio

n,

tra

inin

g,

ma

na

ge

me

nt

too

ls/

sys

tem

s, r

ec

og

nit

ion

of

go

od

p

erf

orm

an

ce

)

Problems faced by

managers

• L

ow

mo

tiva

tio

n o

f p

ers

on

ne

l &

hig

h a

ttri

tio

n

• D

em

an

ds

of

vert

ica

l p

rog

ram

s

Key issues

• M

uk

on

o im

pro

ved

sig

nifi

ca

ntl

y in

p

erf

orm

an

ce

be

twe

en

20

03

/4 a

nd

20

04

/5.

• T

he

Dis

tric

t h

as

cle

arl

y b

ee

n m

oti

vate

d t

o

imp

rove

an

d h

as

fou

nd

th

e n

ati

on

al

lea

gu

e

tab

les

a s

pu

r to

me

etin

g t

arg

ets

.

MAKIN

G H

EALTH S

YSTEM

S W

ORK

_______________________________________

ST

RE

NG

TH

EN

ING

MA

NA

GE

ME

NT

IN

LO

W-I

NC

OM

E C

OU

NT

RIE

S:

LE

SS

ON

S F

RO

M U

GA

ND

A 21

District

Who are the managers?

Competency development

& systems strengthening?

Changes in management

practice & management

systems?

Changes in work

environment?

Lessons learnt:

Mukono health district

• T

ota

l o

f 7

HS

Ds,

in

clu

din

g o

ne

on

Bu

vum

a

Isla

nd

s o

n L

ak

e V

icto

ria

Financial systems

• S

tan

da

rd f

ina

nc

ial t

oo

ls

us

ed

(vo

te b

oo

k,

ca

sh

b

oo

k,

ba

nk

sta

tem

en

ts,

an

d

rec

on

cili

ati

on

, q

ua

rte

rly

rep

ort

s).

•

DH

MT

th

inks

th

at

"co

llec

tion

acc

ou

nt"

u

nn

ec

ess

ary

bu

rea

uc

rac

y.

• B

ud

ge

t w

as

7 w

ks l

ate

fo

r th

e f

ina

nc

ial y

ea

r.

•

Re

qu

ire

me

nt

to c

los

e o

ld

ac

co

un

ts &

op

en

ne

w o

ne

s

ea

ch

ye

ar

ha

s m

ajo

r tr

an

sa

ctio

n c

os

ts.

Information systems

•

Qu

alit

y c

he

cks

are

pa

rt o

f s

up

erv

iso

ry v

isits

. D

ata

are

c

olle

cte

d d

aily

& r

ep

ort

ed

w

ee

kly

/mo

nth

ly.

• T

he

re a

re a

lso

se

pa

rate

d

ise

as

e s

urv

eill

an

ce

re

po

rts

, e

.g.

ac

ute

fla

ccid

pa

raly

sis

.

• T

B,

HIV

/AID

S,

RH

ha

ve s

pe

cia

l d

ata

fo

rms.

•

Fin

an

ce

s o

f ve

rtic

al

pro

gra

ms

a

re n

ot

we

ll c

ap

ture

d.

•

Fe

ed

ba

ck

in N

ew

sp

ap

er,

Mo

H

qu

art

erl

y, a

nd

at

an

nu

al

dis

tric

t re

vie

ws

•

In

dic

ato

rs (

PE

AP

), i

n 2

00

2/3

M

uk

on

o w

as

46

th i

n t

he

n

ati

on

al

lea

gu

e t

ab

le b

ut

by

20

04

/5 i

t h

ad

imp

rove

d t

o 1

2th

.

Research

• S

ma

ll re

se

arc

h b

ud

ge

t (U

sh

s 6

m

illio

n p

er

yea

r).

Factors identified as

strengthening management

• T

ec

hn

ica

l su

pp

ort

na

tio

na

l T

As

& v

ert

ica

l p

rog

ram

s

• I

mp

rove

me

nt

on

in

form

ati

on

in

-se

rvic

e t

rain

ing

dis

tan

ce

e

du

ca

tio

n

• S

ett

ing

of

sta

nd

ard

s f

or

ou

tpu

ts s

up

po

rt s

yste

ms

like

p

ers

on

ne

l a

dm

in,

wo

rks

, e

tc.

in M

oL

G

• R

es

ult

-ori

en

ted

mg

mt

to

ols

: in

tro

du

ce

d i

n 2

00

2

• P

olit

ica

l in

terf

ere

nc

e i

n

ma

na

ge

me

nt/

rec

ruitm

en

t •

In

ab

ility

to

ad

dre

ss

co

mp

ete

nc

e g

ap

s T

arg

et

bu

dg

et

wa

s U

sh

s1

4 m

illio

n)

Jinja district

• P

op

ula

tio

n:

42

6,6

45

•

4 s

ub

-dis

tric

ts,

3

ho

sp

ita

ls (

tota

l: 5

0

fac

iliti

es

)

• R

ate

d 2

nd

be

st d

istr

ict

in

20

03

/4

• D

HM

T i

de

nti

fie

d

pro

ble

ms

as

fu

nd

ing

&

HR

re

so

urc

es.

Human resource

challenges

• E

xce

ss

of

sta

ff a

bo

ve n

orm

in

20

03

/4 b

ut

a p

erc

ep

tio

n

of

sh

ort

ag

es

•

Re

al

co

nc

ern

s a

bo

ut

the

d

em

oti

vati

ng

eff

ec

t o

f s

imila

r p

ost

s i

n r

eg

ion

al

ho

sp

ita

ls a

nd

dis

tric

t p

os

ts.

Ho

sp

ita

ls r

ec

eiv

ed

sa

lari

es

o

n t

he

22

nd

of

ea

ch

mo

nth

b

ut

dis

tric

t st

aff

did

no

t g

et

pa

id u

nti

l th

e 1

0th

of

the

fo

llow

ing

mo

nth

.

• F

un

din

g o

f tr

ain

ing

s is

c

on

ten

tio

us

. S

taff

se

lf- f

un

d

MP

Hs

at

66

0,0

00

US

h p

er

se

me

ste

r.

Enabling environment

Finance

• F

isc

al

De

ce

ntr

aliz

ati

on

Sc

he

me

c

om

pri

se

d 1

0%

of

the

he

alt

h

bu

dg

et

rea

lloc

ate

d t

o L

G?

•

Fu

ng

ibili

ty o

f G

FA

TM

fu

nd

s

• E

xpe

nd

itu

re o

n u

tilit

ies

ris

ing

.

Total budget $4 per head

• D

istr

ict

sta

ff s

ee

le

ss f

un

ds

rec

eiv

ed

on

ce

pe

rfo

rma

nc

e

imp

rove

s (

e.g

. p

er

die

ms

for

su

pe

rvis

ion

). T

he

re is

ve

ry g

oo

d

us

e o

f fin

an

cia

l sys

tem

s, e

.g.

co

st c

od

es,

qu

art

erl

y e

lec

tro

nic

re

po

rts

to

Mo

F,

etc

. Decentralization

• C

on

ce

rns

ab

ou

t lin

k w

ith

Mo

H &

p

erc

eiv

ed

is

ola

tio

n c

om

pa

red

to

R

eg

. h

os

pita

l. A

s a

re m

on

itore

d

by

the

Mo

H b

ut

ma

na

ge

d b

y L

G

at

Dis

tric

t

Factors contributing to

improved performance

• S

tro

ng

pe

rfo

rma

nc

e a

ttri

bu

ted

to

su

pe

rvis

ion

& m

on

ito

rin

g

sys

tem

, c

om

mo

n v

isio

n &

p

rio

riti

es.

•

Str

en

gth

en

ed

lin

ks w

ith

dis

tric

t c

olle

ag

ue

s.

• S

kill

s g

ain

ed

in

ne

go

tia

tion

, in

flu

en

cin

g u

se

ful.

Re

su

lt o

f m

en

tori

ng

; g

oo

d t

rain

ing

o

pp

ort

un

itie

s &

en

co

ura

ge

d

pe

rso

na

l d

eve

lop

me

nt

Problems experienced

• L

ac

k o

f e

lect

rici

ty,

po

or

co

mm

un

ica

tio

n (

e.g

. ra

dio

n

etw

ork

) •

Po

or

sta

ffin

g l

eve

ls

• H

ea

lth

ce

ntr

es

no

t fu

lly

eq

uip

pe

d

• M

oH

su

pp

ort

fo

cu

se

d o

n

HS

Ds

an

d r

ed

uc

ed

to

th

e

DH

MT

Key issues

• G

oo

d w

ork

ing

re

lati

on

s w

ith

lo

ca

l go

v't

ad

min

istr

ati

on

Min

imu

m i

nte

rfe

ren

ce

•

Im

pro

ved

pe

rfo

rma

nc

e d

ue

to

pla

nn

ing

p

roc

ess

, s

up

erv

isio

n,

targ

ets

•

Dis

tric

t o

ffic

ers

re

lati

vely

dis

ad

van

tag

ed

c

om

pa

red

w

ith

ho

sp

ita

l d

oc

tors

•

Pro

jec

ts e

.g.

Ru

ral W

ate

r &

Sa

nita

tio

n

(RU

WA

SA

) a

nd

DIS

H s

ucc

ess

ful

in

imp

rovi

ng

pe

rfo

rma

nc

e

• H

R t

rain

ing

in

sta

ff m

an

ag

em

en

t &

a

pp

rais

als

he

lpfu

l

MAKIN

G H

EALTH S

YSTEM

S W

ORK

_______________________________________

ST

RE

NG

TH

EN

ING

MA

NA

GE

ME

NT

IN

LO

W-I

NC

OM

E C

OU

NT

RIE

S:

LE

SS

ON

S F

RO

M U

GA

ND

A

22

Annex 3. Summary: Management development interventions

Nature of Intervention

Beneficiaries

Provider

Duration

Evaluation

Surveys?

Funder(s)

Comments

1. Management programmes for individual managers

Long Courses/Masters programs

Ma

ste

rs c

ou

rse

s:

He

alt

h

po

licy,

pla

nn

ing

an

d f

ina

nc

e (

a

pa

rt o

f D

HS

pro

gra

m,

se

e

be

low

)

Ma

inly

Mo

H s

taff

N

uff

ield

Le

ed

s

Yo

rk U

niv

. L

SH

TM

Pe

rio

d b

tn 1

99

6-2

00

1

1 y

ea

r N

o

Wo

rld

Ba

nk

Ma

ste

rs in

Pu

blic

He

alt

h

(MP

H)

All

DD

HS

& n

ow

ext

en

de

d t

o

MO

s a

t H

SD

leve

l. A

lso

a

vaila

ble

to

oth

er

se

nio

r m

an

ag

ers

IPH

, M

ak

ere

re

Tw

o y

ea

r c

ou

rse

an

d

an

on

go

ing

pro

gra

m

D

eve

lop

me

nt

Pa

rtn

ers

, L

G

tra

inin

g f

un

ds

&

se

lf fi

na

nc

e

MP

H i

s re

qu

ire

d t

o b

e D

DH

S.

(On

ly 3

/21

mo

du

les

co

ver

ma

na

ge

me

nt.

)

Dip

lom

a,

Ma

ste

rs i

n H

ea

lth

Se

rvic

es

Ma

na

ge

me

nt

Mid

& s

en

ior

leve

l se

rvic

es

m

an

ag

ers

F

ac

ult

y o

f H

ea

lth

Sc

ien

ce

s,

Ug

an

da

Ma

rtyr

s

Un

iv,

On

e y

ea

r fo

r b

oth

c

ou

rse

s

No

C

ath

olic

Ch

urc

h

CU

AM

M

CO

RA

ID

Se

e t

ext

be

low

Short Courses/certificate programs

Sh

ort

co

urs

es

: h

ea

lth

po

licy,

p

lan

nin

g,

fina

nc

e (

DH

S

pro

gra

mm

e)

Ma

inly

Mo

H s

taff

N

uff

ield

Le

ed

s

Yo

rk U

niv

. L

SH

TM

Pe

rio

d b

tn 1

99

6-2

00

1

1 y

ea

r N

o

Wo

rld

Ba

nk

A

bs

en

ce

of

loc

al m

an

ag

em

en

t c

ou

rse

s a

t th

e t

ime

Sh

ort

co

urs

e f

or

ho

sp

ita

l m

an

ag

ers

M

ed

ica

l S

up

ts.

Dis

tric

t A

dm

inis

tra

tors

N

urs

ing

Off

ice

rs

Ug

an

da

M

an

ag

em

en

t In

stit

ute

2 w

ee

ks

sta

rte

d i

n

20

05

Mo

H /

De

pt

of

Clin

ica

l Se

rvic

es

S

ee

te

xt b

elo

w

Me

nto

rin

g s

kills

co

urs

e

Se

nio

r lo

ca

l g

ov'

t o

ffic

ers

U

ga

nd

a

Ma

na

ge

me

nt

Inst

itu

te

20

05

S

ee

te

xt b

elo

w

Ma

na

ge

me

nt

an

d p

ub

lic

ad

min

istr

ati

on

co

urs

es

M

idd

le l

eve

l lo

ca

l go

v't

off

ice

rs

inc

lud

ing

he

alth

pe

rso

nn

el

Pro

test

an

t M

ed

ica

l B

ure

au

1

99

7-p

res

en

t

Init

ial 5

-yr

Ca

na

dia

n s

up

po

rt

No

w M

oH

, lo

ca

l g

ov'

t &

fe

es

Hig

h o

n o

rga

niz

ati

on

al

be

ha

vio

r, e

tc.

Acc

red

ite

d b

y U

ga

nd

a C

hri

stia

n U

niv

.

2. Management development for teams

Short courses: managerial

& clinical topics

Ind

ivid

ua

ls a

nd

te

am

s a

t d

istr

ict

leve

l M

inis

try

of

he

alt

h

Va

rio

us

N

ot

ava

ilab

le

Inte

rna

l/ W

HO

an

d

oth

er

de

velo

pm

en

t p

art

ne

rs

Mu

ltip

le s

ho

rt c

ou

rse

s -

wid

e r

an

ge

of

top

ics

. T

ak

es

mu

ch

tim

e b

ut

no

t b

as

ed

o

n n

ee

ds

as

se

ssm

en

ts

Short courses on

managerial and technical

issues

Ind

ivid

ua

ls a

nd

te

am

s a

t d

istr

ict

leve

l M

inis

try

of

loc

al

go

vern

me

nt

Va

rio

us

N

ot

ava

ilab

le

No

t k

no

wn

Development partner

support to district

strengthening

DH

S P

roje

ct

(in

all

dis

tric

ts)

a)

De

velo

pm

en

t o

f in

teg

rate

d

sys

tem

s

b)

Lo

gis

tics

su

pp

ort

c

) C

ap

ac

ity b

uild

ing

in

p

lan

nin

g

d)

Po

st-g

rad

mg

mt

tra

inin

g

e)

Intr

od

uct

ion

of

QA

D

ep

art

me

nt

Min

istr

y o

f H

ea

lth

an

d D

istr

icts

M

oH

M

oH

sta

ff

DD

HS

M

oH

UK

in

stit

uti

on

s

IPH

, M

ak

ere

re

19

96

-20

01

Y

es

W

orl

d B

an

k

MAKIN

G H

EALTH S

YSTEM

S W

ORK

_______________________________________

ST

RE

NG

TH

EN

ING

MA

NA

GE

ME

NT

IN

LO

W-I

NC

OM

E C

OU

NT

RIE

S:

LE

SS

ON

S F

RO

M U

GA

ND

A 23

Nature of Intervention

Beneficiaries

Provider

Duration

Evaluation

Surveys?

Funder(s)

Comments

We

st N

ile H

ea

lth P

roje

ct,

D

istr

ict-

ba

se

d a

dvi

se

rs,

Ca

pa

cit

y b

uild

ing

wit

h

MP

H &

S

tud

y to

urs

Aru

a,

Ne

bb

i, Y

um

be

, A

dju

ma

ni,

Mo

yo

Te

ch

nic

al

Ad

vis

ers

(C

UA

MM

, S

CF

-U

K)

19

96

-20

02

Y

es

E

U

UH

SS

P (

Ug

an

da

He

alt

h

Se

cto

r S

up

po

rt P

rog

ram

) D

istr

icts

in t

he

No

rth

: In

itia

lly 3

E

xte

nd

ed

to

17

AM

RE

F,

AV

SI

an

d C

UA

MM

1

99

7 t

o

>2

00

1

DA

NID

A

Dis

tric

t-b

as

ed

TA

fo

r re

form

ag

en

da

&

intr

o o

f b

as

ic P

HC

pa

ck

ag

e

Dis

tric

t S

up

po

rt P

rog

ram

me

s

DH

MT

s i

n M

as

ind

i an

d M

pig

i d

istr

icts

A

dvi

se

rs f

rom

W

HO

co

un

try

tea

m

20

03

up

to

pre

se

nt

No

t k

no

wn

W

HO

S

up

po

rt D

HM

Ts

’ mu

tua

lly a

gre

ed

a

cti

viti

es

Dis

tric

t D

eve

lop

me

nt

Pro

ject

K

um

i an

d s

ep

ara

tely

Kib

og

a

an

d K

iba

ale

T

A (

AIP

SO

) A

MR

EF

No

t k

no

wn

Ir

ela

nd

AID

1

exp

at

ad

vis

er

an

d 1

Ug

an

da

n

Dis

tric

t s

up

po

rt

Kit

gu

m,

Pa

de

r, K

aro

mo

ja,

We

st N

ile

TA

(A

VS

I a

nd

C

UA

MM

)

No

t k

no

wn

It

alia

n c

oo

pe

rati

on

De

live

ry o

f Im

pro

ved

Se

rvic

es

for

He

alt

h (

DIS

H)

12

dis

tric

ts (

ce

ntr

al

an

d s

ou

th

we

st)

J

HU

No

t k

no

wn

U

SA

ID

Dis

tric

t s

up

po

rt p

rog

ram

me

(F

ive

dis

tric

ts)

Dis

tric

t a

nd

su

b-d

istr

ict

sta

ff

AM

RE

F,

AV

SI,

C

UA

MM

No

t k

no

wn

D

AN

IDA

T

hre

e U

ga

nd

an

TA

s.

Fo

cu

s o

n p

lan

nin

g

an

d im

ple

me

nta

tio

n

Ku

mi d

istr

ict

he

alth

pro

jec

t D

istr

ict

leve

l

CA

RE

No

t s

ee

n

DF

ID

Su

pp

ort

: 1

exp

at

Pro

ject

Dir

ec

tor

+ 3

U

ga

nd

an

TA

s

Ug

an

da

n F

am

ily H

ea

lth

P

roje

ct

(4

dis

tric

ts)

Dis

tric

t st

aff

C

AR

E

N

ot

se

en

D

FID

S

up

po

rt:

3 e

xpa

t a

dvi

se

rs +

2 U

ga

nd

an

T

As

Ru

ral

He

alt

h P

rog

ram

(1

2 d

istr

icts

in

SW

) D

istr

ict

sta

ff

Mo

LG

an

d M

oH

No

t s

ee

n

ED

F

I e

xpa

t a

dvi

se

r a

nd

2 U

ga

nd

an

TA

s

MAKIN

G H

EALTH S

YSTEM

S W

ORK

_______________________________________

ST

RE

NG

TH

EN

ING

MA

NA

GE

ME

NT

IN

LO

W-I

NC

OM

E C

OU

NT

RIE

S:

LE

SS

ON

S F

RO

M U

GA

ND

A

24

Annex 4. Persons met and interviewed

NAME

DESIGNATION

INSTITUTION

(1) Ministry of Health / KAMPALA

D

r F

ran

cis

Ru

nu

mi

Mw

es

igye

C

om

mis

sio

ne

r H

ea

lth

Se

rvic

es

Pla

nn

ing

M

inis

try

of

He

alth

HQ

, P

lot

6 L

ou

rde

l R

d N

ak

es

ero

P

.O.

Bo

x 7

27

2,

Ka

mp

ala

, U

ga

nd

a

D

r G

eo

rge

Ba

ga

mb

isa

A

ss

ista

nt

Co

mm

issi

on

er

Pla

nn

ing

F

orm

er

DD

HS

M

inis

try

of

He

alth

HQ

K

am

pa

la,

Ug

an

da

Mr

Ch

arl

es

Ma

tsik

o

HR

H D

ep

t M

inis

try

of

He

alth

HQ

K

am

pa

la,

Ug

an

da

Mr

Mo

se

s A

rin

ait

we

P

rin

cip

al P

ers

on

ne

l O

ffic

er

Min

istr

y o

f H

ea

lth

Ka

mp

ala

, U

ga

nd

a

D

r H

en

ry G

. M

we

be

sa

A

ss

ista

nt

Co

mm

issi

on

er

He

alth

Se

rvic

es

(Q

ua

lity

Ass

ura

nc

e),

&

P

roje

ct M

an

ag

er,

Su

pp

ort

to

He

alt

h S

ec

tor,

Str

ate

gic

Pla

n P

roje

ct

(SH

SS

PP

)

Min

istr

y o

f H

ea

lth H

Q

Ka

mp

ala

, U

ga

nd

a

D

r C

hri

stin

e K

iru

ng

a T

as

ho

bya

P

ub

lic H

ea

lth

Ad

vis

or,

DA

NID

A H

ea

lth

Se

cto

r P

rog

ram

me

Su

pp

ort

M

inis

try

of

He

alth

HQ

Local Government

M

r L

aw

ren

ce

Ba

nyo

ya

Co

mm

issi

on

Se

cre

tary

L

oc

al

Go

vern

me

nt

Fin

an

ce

Co

mm

issi

on

T

he

Wo

rke

rs B

uild

ing

, P

.O.

Bo

x 2

31

4,

Ka

mp

ala

(2) Training Institutions and Organizations

M

r D

avi

d M

. S

erw

ad

da

D

ire

cto

r In

stit

ute

of

Pu

blic

He

alt

h,

Ma

kere

re U

niv

ers

ity

P.O

. B

ox

70

72

, K

am

pa

la

M

r G

eo

rge

W.

Pa

riyo

A

g.

He

ad

, D

ep

art

me

nt

of

He

alt

h P

olic

y P

lan

nin

g a

nd

Ma

na

ge

me

nt

Ins

titu

te o

f P

ub

lic H

ea

lth

M

ak

ere

re U

niv

ers

ity

D

r O

lico

-Oku

i D

ep

art

me

nt

of

He

alt

h P

olic

y P

lan

nin

g a

nd

Ma

na

ge

me

nt

Ins

titu

te o

f P

ub

lic H

ea

lth

M

ak

ere

re U

niv

ers

ity

D

r L

ule

Ko

nd

e

Dis

tan

ce

Le

arn

ing

MP

H P

rog

ram

me

H

ea

d o

f E

pid

em

iolo

gy

an

d B

ios

tatis

tics

De

pa

rtm

en

t In

stit

ute

of

Pu

blic

He

alt

h

Ma

ke

rere

Un

ive

rsity

M

r E

no

ck

Mu

gye

nyi

D

ep

uty

Dir

ect

or

Ug

an

da

Ma

na

ge

me

nt

Ins

titu

te

Plo

t 4

4-5

2 J

inja

Ro

ad

, P

.O.

Bo

x 2

01

31

Dr

Jo

hn

Od

ag

a

De

pu

ty D

ea

n,

Fa

cult

y o

f H

ea

lth S

cie

nce

s

Ug

an

da

Ma

rtyr

s U

niv

ers

ity

(in

Nk

ozi

) P

.O.

Bo

x 5

49

8,

Ka

mp

ala

Dr

Eg

un

e

He

ad

M

an

po

we

r D

eve

lop

me

nt

Ce

nte

r, M

ba

le

S

r P

ris

cilla

Ma

np

ow

er

De

velo

pm

en

t C

en

ter,

Mb

ale

Dr

Ed

wa

rd M

uk

oo

za

Pro

gra

mm

e C

oo

rdin

ato

r In

tern

ati

on

al

Ch

ris

tian

Me

dic

al I

ns

titu

te (

ICM

I).

UP

MB

Bu

ildin

g,

Plo

t 8

77

, B

alin

tum

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d.

Me

ng

o

P.O

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x 4

12

7 K

am

pa

la

MAKIN

G H

EALTH S

YSTEM

S W

ORK

_______________________________________

ST

RE

NG

TH

EN

ING

MA

NA

GE

ME

NT

IN

LO

W-I

NC

OM

E C

OU

NT

RIE

S:

LE

SS

ON

S F

RO

M U

GA

ND

A 25

NAME

DESIGNATION

INSTITUTION

(3) Development Agencies and Organizations

D

r R

os

am

un

d L

ew

is

Ac

tin

g W

HO

Re

pre

se

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an

k B

uild

ing

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O B

ox

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57

8 .

Ka

mp

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Ju

liet

Ba

tari

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a-W

ava

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o

NP

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ea

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Sys

tem

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eve

lop

me

nt

WH

O

D

r J

ulie

t N

ab

yon

ga

N

PO

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alt

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con

om

ist

WH

O

M

r K

las

Ra

sm

us

son

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irs

t S

ec

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ry

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ba

ss

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de

n,

24

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mu

mb

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, N

ak

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ro,

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ox

22

66

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Ka

mp

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Mr

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ed

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SID

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P.O

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78

22

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he

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H

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n

M

r C

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nd

ah

l C

on

su

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nt

SID

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we

de

n

M

s E

lisa

be

th O

ng

om

EU

Dr

Pe

ter

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Pe

tit

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er,

EU

Pro

jec

t:

De

velo

pin

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um

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Re

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urc

es

for

He

alt

h (

DH

RH

) P

roje

ct

K

iso

zi H

ou

se

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oo

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loc

k B

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nd

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.O.

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78

56

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76

1,

Ka

mp

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(4) Masindi District

D

r J

oh

n T

ury

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aru

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ire

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alt

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alth

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tric

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ak

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nio

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urs

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ch

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mu

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itia

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sin

di

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spit

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uru

li H

ea

lth S

ub

-Dis

tric

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(5) Mpigi District

M

s R

ita

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zin

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DH

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igi

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r G

od

fre

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ea

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urv

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ce

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cal

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int

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Off

ice

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pig

i

MAKIN

G H

EALTH S

YSTEM

S W

ORK

_______________________________________

ST

RE

NG

TH

EN

ING

MA

NA

GE

ME

NT

IN

LO

W-I

NC

OM

E C

OU

NT

RIE

S:

LE

SS

ON

S F

RO

M U

GA

ND

A

26

NAME

DESIGNATION

INSTITUTION

Meeting in Mawokota South health sub-district

D

r M

art

in S

se

nd

yon

a

Me

dic

al

Su

pe

rin

ten

de

nt

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dic

al

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ice

r in

ch

arg

e o

f th

e H

ea

lth S

ub

-Dis

tric

t N

ko

zi H

osp

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l, P

.O.

Bo

x 4

34

9,

Ka

mp

ala

S

r E

liza

be

th N

alu

ma

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i S

en

ior

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rsin

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spit

al

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s F

lore

nc

e L

ind

a N

as

sali

En

rolle

d M

idw

ife

, T

ea

m P

HC

Co

ord

ina

tor

Nk

ozi

Ho

spit

al

S

r J

ose

ph

ine

Na

lab

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H

os

pita

l A

cc

ou

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nt

Mr

De

sir

e M

ug

erw

a

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co

rd A

ssi

sta

nt

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ozi

Ho

spit

al

M

s J

os

ep

hin

e-J

ac

kie

Ka

zag

a

Se

cre

tary

N

ko

zi H

osp

ita

l

(6) Jinja District

D

r D

.W.

Kit

imb

o

DD

HS

D

r S

ara

Bya

kik

a

De

pu

ty D

DH

S

Dr

Fe

lix O

nzi

ma

M

ed

ica

l O

ffic

er

Mr

Bo

nif

ac

e N

falo

D

.H.E

.

M

r C

hri

s W

ag

ole

re

DH

I

Dr

Ma

rtin

Ru

hw

eza

M

PH

Off

ice

r

M

r C

hri

sto

ph

er

Ms

ub

ura

D

PP

PH

C

Dr

Isa

ye M

us

ing

izi

DD

HE

M

rs J

oyc

e I

sik

o

D.H

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Mr

Gilb

ert

Ba

raye

nd

a

D.V

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. ,

Ma

lari

a f

oc

al p

ers

on

M

s J

.E.

Lu

ma

la

SN

O/D

SF

P

Mr

Gis

on

M.

Gid

ud

u

P.H

.I.

/ J

MC

(7) Mukono District - Meeting at District Level

M

r Y

os

sa

Ka

zim

oto

D

.H.I

.

M

s S

ara

h K

atu

mb

a

Dis

tric

t N

urs

ing

Off

ice

r

D

r A

nto

ny

KK

on

de

i/

c M

uk

on

o N

ort

h H

SD

(8) Busia District - Meeting at District Level

D

r G

.B,

Ou

nd

o

DM

O

Mr

Ma

low

a C

ha

rle

s K

ud

ech

i C

ha

ir P

ers

on

Sta

nd

ing

Co

mm

itte

e f

or

He

alth

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uc

ati

on

& S

oc

ial S

erv

ice

s

M

s J

ud

ith

Ma

ry A

gu

ttu

M

em

be

r -

He

alt

h,

Ed

uc

atio

n &

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cia

l S

erv

ice

s C

om

mit

tee

M

s H

op

e A

ko

ng

o

Se

cre

tary

fo

r G

en

de

r &

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cia

l Se

rvic

es

M

r M

arg

eri

e D

.A.

Mu

dik

o

Me

mb

er,

Dis

tric

t H

ea

lth

Co

mm

itte

e

Ms

Ch

ris

tin

e I

ch

uu

m

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tric

t W

om

en

Co

un

cill

or

Ms

An

na

Ma

ry N

ab

wir

e

Dis

tric

t W

om

en

Co

un

cill

or

Dr

Od

do

ba

Wa

nyo

ng

a

Se

nio

r M

ed

ica

l O

ffic

er

Mr

Ro

be

rt M

uzi

mb

a

DV

CO

M

r A

lex

Og

wa

l D

HI

M

r J

os

ep

h B

wir

e

HM

IS

Dr

Ibra

him

Kir

un

da

M

PH

Off

ice

r

M

s M

on

ica

Eg

es

sa

h

Re

gis

tere

d N

urs

e



Annex 5. Other examples of district performance measures

The following charts are derived from national health statistics/indicators to compare the performance of districts visited with the national averages.

A. Other management and district indicators

Percentage of approved post filled with trained staff5

Proportion of PHC funds spent on drugs5

5 Annual Health Sector Performance Report FY 2002/03, 2003/04, 2004/05. Kampala, Ministry of Health, Uganda.

0

20

40

60

80

100

120

140

160

2002/03 2003/04 2004/05

Jinja Mpigi Busia Mukono Masindi Uganda Average

0.0

20.0

40.0

60.0

80.0

100.0

120.0

2002/03 2003/04 2004/05




B. Service delivery/Coverage performance indicators

Proportion of TB cases notified compared to expected6

Percentage of pregnant women received 2nd dose Fansidar for IPT7

Percentage of children <1 who received 3 doses of DPT according to schedule8

6 Ibid. 7 Annual Health Sector Performance Report FY 2002/03, 2003/04. Kampala, Ministry of Health, Uganda.

8 Annual Health Sector Performance Report FY 2002/03, 2003/04, 2004/05. Kampala, Ministry of Health, Uganda.

0

50

100

150

200

250

300

2002/03 2003/04 2004/05


0.0 5.0

10.0 15.0 20.0 25.0 30.0 35.0 40.0

2002/03 2003/04


0.0

20.0

40.0

60.0

80.0

100.0

120.0

140.0

2002/03 2003/04 2004/05

Jinja

Mpigi

Busia

Mukono

Masindi

Uganda Average



Total government and NGO OPD utilization per person per year9

9 Ibid.

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

2002/03 2003/04 2004/05

Jinja

Mpigi

Busia

Mukono

Masindi

Uganda Average

World Health Organization Geneva

http://www.who.int

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