Thursday, December 22, 2011


By Senfuka Samuel
WRA Uganda

Kabale district is found in south western Uganda about 500km from Kampala. It is one of the two districts White Ribbon Alliance for Safe Motherhood Uganda (WRA Uganda) selected to advocate for recruitment, motivation and retention of health workers through a ‘Teaming Up’ approach. This was based on a human resource assessment by WRA Uganda indicating inadequate staffing especially for maternal health.

Budgeting for health workers
16th December 2011 was a Budget Conference day for Kabale District Local Government which is the basis for the preparation of a budget and work plan for Financial Year (FY) 2012/13 and a time when the district presents the performance of the ending FY and the local governments (Sub-counties) present their budget proposals to be integrated into the district budget.
The outcome is a district Budget Framework Paper (BFP) which is submitted to the central government for consideration; the BFP can be passed back and forth until agreed upon before the national budget is passed. 

Members of the District Council, sub-county chiefs partners and other leaders attending the
District Budget Conference at Rukiko Hall, Kabale

In his report to the District Council, Sub county leaders and other stakeholders, the Chief Administrative Officer (Head of Civil Service) indicated an improvement in the level of health workers staffing from 30% to 57% over the last six months (June-November 2011). This is 8% below the recommended minimum staffing level of 65% by WHO/MoH. The teaming up members who were in attendance including myself had a smile on their faces because the six months referred to is the time we found the Director of Health Services with over 178 recruited health workers who were not deployed because of the wage bill! 

Collaborative Efforts and Successes
Through collaborative efforts, WRA Uganda members petitioned key decision makers including Ministry of Finance, Director of Planning at Ministry of Health, area Members of Parliament over the urgent need to release funds and post the staff to respective health facilities, the response was positive. The number of midwives increased from 12 to 36, and nurses from 76 to 128 among other categories. In addition the number of women who delivered under skilled care increased from 37.9% (April-June 2011) to 46.9% (July-Nov 2011).  Most of the recruited nurses have undergone Comprehensive Training in schools and can deliver both nursing and midwifery services wherever they are deployed. 

The district is also refocusing on Health Centre (HC) IIs at parish level for managing deliveries with a valid justification that it is more accessible to the communities in terms of distance as compared to HC IIIs at Sub-County level, HC IVs at County and Hospital at District level. Midwives have been deployed at these facilities. Kabale District targets to have 74% HC IIs offering quality and focus oriented ANC and PMTCT by end of June 2012. However, it may not be enough to deploy midwives at this level of care without addressing the system issues that are currently impacting negatively on maternal and newborn health (MNH) service delivery. 

Strengthening Health Systems
By design, HC IIs are supposed to deliver mothers and have a midwife post in the approved Public Service Staffing Structure. However, HC IIs have huge issues in attracting and retaining critical cadres of MNH staff due to the location of these health facilities. Most of the HC IIs are located in hard to reach, hard to stay and hard to work rural areas and face chronic shortages of staff. 
Staff motivation is low due to unmet needs; they have unfavorable working conditions with significant lack of staff accommodation and basic diagnostic/maternity equipment. Some centers lack the necessary basic infrastructure like maternity wards. Local Governments will need a lot of support to overcome the operational challenges in order to deliver MNH services that are close to women and well equipped in order to positively change the quality of life of women, newborns, children and families. 

There are problems with decreasing visits of women to antenatal care services with some attributing it to the harvesting season where a number of women could miss ANC appointments due to competing priorities at home. There is a need to make services more easily accessible to women particularly at these times of the year.

Notwithstanding the achievements in the short term, the sector still faces perennial challenges which at times make the hope fade for the low hearted ones!  A one-on-one with the District Director of Health Services Dr Tusiime Patrick reveals more about the health system and services in the district. His major concern and challenge is motivating and retaining those who have been recruited. He cites the problems faced by health workers such as salaries not even matching the cost of living as the main priority.

Dr Tusiime Patrick on left during the interaction

 “The solution is known, central government must increase financing to the health sector based on total surface area of a district and population, the Hard-to-reach, Hard-to-Stay and Hard-to-work nature of a district.The generic resource allocation can not address the individual district challenges. Ministry of Health, Ministry of Finance and Ministry of Public Service should work out a system and establish how much money is required to provide services at each level of care." Dr. Tusiime recommends

It should be noted that Central Government decentralized the responsibilities and duties to Local Governments (LGs) without matching it with financial resources to execute their mandates. Nearly 90% of LGs funding comes from the centre and the biggest percentage comes as conditional funds. Over 70% of the district budgets across the country cover wage bills leaving a paltry 30% for activities and service delivery! Districts are also given ceilings within which they must plan and budget.

About 70% of Ministry of Health budget remains at the ministry headquarters and only 30% is appropriated among 112 districts where the bulk of health service delivery is based. This is worsened by the inefficiencies in collecting internal revenues to augment income from the centre. For instance Kabale district collects about 28% of its target internal revenues (District performance report 2011/2012). Given this situation and the competing district priorities, it makes the budgeting process more of a ritual than a process aiming at enhancing service delivery.
Paradoxically remuneration of one Member of Parliament pays about 20 doctors. The Ministry of Finance has commissioned a review of Local Government financing which is hoped to adequately address the financial discrepancies to enable LGs perform better.
Dr. Tusiime and other hardworking Officers are quite frustrated by the perennial challenges. He further cites the ambulance system which is functional but with operational challenges such as repair and maintenance of all vehicles at all levels of care, inadequate fuel for the ambulances to refer patients and lack of allowances for overtime work by the staff.  

“A Health Centre IV like Kamwezi is about 2hrs drive from the referral hospital with a bad road. It requires about 40 liters of diesel for one referral but the health centre is allocated only UGX 650,000 (Approx USD 260) per month for all routine operations including purchase of fuel and other maintenance costs for the ambulance” He explains. 

At about 22:50hrs as the discussion went into the night; Dr. Tusiime received a phone call from one of the health centres that a mother had complications and needed transport to be referred to Kabale Regional Referral Hospital. This is the only referral health facility which can manage complications because the other seven Health Centre IVs do not have a single doctor so their theatres are non-operational. When I asked Dr Tusiime why there are no doctors the answer was obvious. They all left for better working conditions and even when jobs are advertised there is little response. To partly address the lack of doctors and referrals he suggests task shifting of Clinical Officers by retraining them in surgery to be able to carry out C-Sections.

Dr Tusiime called a driver to go and get the ambulance to pick the mother but the driver needed money to get a motorcycle from his home to where the ambulance was parked. This meant that Dr Tusiime had to pay the bill himself.

Looking forward
Some have called for a review of the user fees and perhaps reinstatement to meet operational costs, as promised access to free services without adequate planning and budgeting for it from the government has placed heavy strain on the health services. Dr. Tusiime suggested:

“Our leaders and other partners should sensitize Community members and make them aware that they have a role to play in saving their lives. They should be made to understand the benefit of contributing to their health.”

A couple of years ago government tabled in Parliament the National Health Insurance Bill but it was later shelved for unclear reasons. The passing of the Bill into an Act may go a long way to address this challenge as it has worked in neighbouring countries like Rwanda.
These are some of the issues which make the existence of WRA more relevant particularly using a teaming up approach to tackle them through advocacy, awareness and mobilization of stakeholders. In order to execute this Teaming Up members were trained in advocacy and communication skills before the budget conference.

In addition, the Teaming Up members prior to the district budget conference met and engaged the district executive council members and district counselors on the key interventions for achieving the national maternal health targets as described and guided in the Road Map where LGs are key implementing institutions. We also lobbied them on the critical core budgeting areas as they discuss the planning and budgeting for FY 2012/13.  

Ms Beebwajuba Mary Kabale District Vice Chairperson addressing the District Executive members, Counselors, technical representatives during a pre district budget meeting organized by WRA members in Kabale.

During the budget conference leaders emphasized focusing on interventions aimed at enhancing service delivery and one of their strategic priorities for the FY 2012/13 is to increase access to quality social services including health. We hope this does not remain rhetoric. It is every one’s responsibility to ensure that these pledges are translated into actions where the leaders deliver to the community members’ expectation.

The Central Government should be bold enough and allocate more resources to the health sector in FY 2012/13. After all, it pledged in the Abuja Declaration (2001) to increase it to 15% of the national budget. For the past decade it has been oscillating between 7-10% of the national budget.
Mr Barusya Julius, Media Rep WRA Kigezi region presenting during a pre budget meeting with district executive and  counselors organized by Teaming Up members

A district woman Counselor making a strong submission in support of budget increase for maternal health
Members prioritizing advocacy issues during the advocacy and communication training

Robert Muhereza Kabale based Daily Monitor Journalist presenting group work during advocacy training

Some of Teaming Up members pose for a group photo after training

Chief Administrative Officer giving a district performance report during the budget conference as the district chairperson and District Council Speaker look on

Some Teaming Up members in attendance during the budget conference at Rukiko Hall

The District Chairperson on left and District Council Speaker

Secretary for health (on left), Senfuka Samuel (centre) and Barusya Julius chatting after the district conference 

From left: Secretary for health, Senfuka Samuel, Barushya Julius, David Ssebugwawo and the district Planner discussing after the budget conference


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