Health Service Delivery Needs Financing

”The budget framework papers indicate a number of unfunded priorities which will significantly affect quality healthcare. As a country, we have not been successful in increasing financing for the health sector”

By Peter Eceru

The Covid-19 pandemic has not only painfully exposed the gaps in the health systems and infrastructure, but also the high levels of vulnerabilities of individuals, and households. Most poor and vulnerable people in Uganda have limited resources to cope with the economic and health impacts of the pandemic. Ugandans at the base of the pyramid who are majorly women, experience enormous hardship when out-of-pocket payments, formal or informal, are high in relation to households’ ability to pay for health care. As a result, lack of financial protection reduces access to health care, therefore, undermining the health status and exacerbating health and social-economic inequalities.

With the aim of ensuring access to affordable quality health and reduce out of pocket cost for Ugandans several initiatives have been enforced including the elimination of user fees in 2001 The user fees at health facilities were used as an additional source of revenue to fund health care. Unfortunately, over the last 10 years, government contribution towards health care as a percentage of the national budget has reduced from 8.9% in 2010/11 to 6.1% in 2020/21 and this burden has been shifted to the donor community and households. Similarly, government contribution as a percentage of the national health budget reduced from 74.2% to 57% over the same period. This clearly demonstrates that the health of citizens is being gradually scaled down in terms of government prioritisation. What is even more worrying is that of the 57% government contribution towards the health budget, 53% is spent on recurrent expenditure such as salaries, oils and fuels, allowances and only 4% is spent on capital expenditure.

In the budget Framework Paper for the financial year 2022/23 that was laid before parliament on the 21st of December, 2021, it is evident that there will be no significant change. The budget framework papers indicate a number of unfunded priorities that will significantly affect the quality of health care. The unfunded priorities include; wage enhancement is unfunded to the tune of 47.9Bn, procurement and maintenance of equipment to the tune of 12.3 Bn, the Phased establishment of the national ambulance service- 20.8Bn shillings among others. This means that the health care system will still deal with challenges of unmotivated staff, inability to kick start the national ambulance service, 

The World Health Organisation recognises that there are 3 inter-related domains that are fundamental to achieving and maintaining universal access to health care- raising sufficient funds for health care, reducing financial barriers to access by pooling funds in a way that prevents out of pocket costs and allocating funds in a way that promotes quality, efficiency and equity. Over the last ten or so years government has failed on all the 3 domains. As a country, we have not been successful in increasing financing to the health sector as a percentage of the national budget. The World Health Organisation argues that for a country to be able to achieve Universal Health Coverage, it must allocate about 15% of its budget towards health. Uganda has for most of the last 10 years allocated less than half of that. To be able to achieve our health targets as set out in the NDPIII Uganda, the programme Implementation Plan for Human Capital Development projects an expenditure of more than 9 trillion shillings in the 2021/22 FY. However, in the same financial year, the government allocated only 2. 7 trillion shillings leaving a funding gap of 6.3 trillion shillings.  In terms of pooling resources, parliament passed the National Health Insurance Scheme Bill in 2021, but this was not assented to by the President and in accordance with the ruling of the Speaker of parliament, this was one of those bills that abetted. As a result, out-of-pocket expenditure on health is over 40% which is more than twice the World Health Organisation recommended.

Maternal, reproductive and new-born health is a key determinant of the opportunities that women and their children have in life. The budget must therefore ensure that pregnant mothers are capable of accessing a doctor regardless of where she is, be able to access blood whenever she needs it during childbirth among others. Women should have a right to safely bear children and to freely decide whether to have them, how many to have and when to have.

Peter Eceru is a Programme Coordinator-Advocacy, Health and Human Rights Advocacy at Center for Health, Human Rights and Development (CEHURD)

A version of this article was published in the Daily Monitor Newspaper on Wednesday 2nd January 2022.

Press Statement: Medical Interns Issue Notice to Sue Over Ministry of Health Directive

Kampala – Uganda. Center for Health, Human Rights and Development (CEHURD) on behalf of the Uganda Medical Association (UMA) and the Federation for Uganda Medical lnterns (FUMI), has issued a notice of the intention to sue in response to the Ministry of Health’s directive for medical interns to vacate hospital premises. UMA and FUMI are exercising a constitutional right to carry out industrial action geared at resolving the challenges faced in the day-to-day execution of their work, training, service delivery and welfare. The challenges range from lack of proper supervision, lack of accommodation, poor remuneration and poor working environment, among others.

By virtue of their appointment by the Ministry of Health, medical interns play a vital role as frontline workers in this era of the Covid 19 pandemic. It is therefore inconceivable that the Ministry of Health has resorted to illegally denying the medical interns their constitutional right to practice their trade and complete their medical training.

On 9th August 2021, His Excellency The President of Republic of Uganda following a meeting with the leadership of UMA, directed that the Government addresses the challenges of UMA and FUMI by, among others, enhancing the remuneration of the medical interns.

Unfortunately, instead of fast-tracking the implementation of the presidential directives aimed at resolving the grievances that led to the strike, the Ministry of Health has resorted to irregular, unorthodox and unconstitutional means of resolving a lawful industrial action. Directing medical interns on strike to vacate the hospital premises within one week is not only unacceptable and unjustifiable in a free and democratic society like Uganda, it is also a callous decision.

In light of this, we point out that the directive does not only undermine constitutionally guaranteed fundamental rights and freedoms of medical interns, it also offends the Directive/ Guidance by His Excellency the President of the Republic of Uganda. These actions are also irregular, illegal, arbitrary, high handed and certainly challengeable in the Civil Courts of Law.

Call to action
We call upon the Ministry of Health to recall the directive to the medical interns to leave their stations within two days or else we risk creating a crisis in the delivery of health services.

For more information contact: info@cehurd.org and copy in kenganzi@cehurd.org or call +256 778 723 449

Find the press statement and a copy of this letter attached here.

There is an urgent need to prioritise access to health care and services for survivors of sexual gender-based violence

Despite government’s initiatives and programmes to facilitate the utilisation of SGBV services in Uganda, there is still evidence of barriers and several gender disparities which persist in access to sexual and reproductive health services for survivors of sexual gender-based violence. 

By Judith Nakalembe

As we mark the 16 days of activism campaign against Gender Based Violence (GBV), we appreciate the Government of Uganda through the Ministry of Gender, Labour and Social Development, and Ministry of Health for the tremendous effort in policy and programme development and implementation with regard to prevention and response to GBV. This is reflected in the enactment of several legislation such as the Domestic Violence Act 2010, The Prohibition of Female Genital Mutilation Act, 2010, Trafficking in Persons Act 2010. This is in addition to policies such as the Uganda Gender Policy 2007, The National Policy on Elimination of Gender Based Violence in Uganda 2016, the Guidelines for Establishment and Management of Gender Based Violence Shelters in Uganda. The recent directive to prohibit health service providers from soliciting funds from survivors of sexual and gender based violence is also of note. These policies, directives, laws and guidelines provide the legal context within which programmes on prevention and response to GBV occur, foster zero tolerance environment, provide comprehensive response and care and support services to survivors as well as eliminate impunity by the abusers. Article 33 of the 1995 constitution of the Republic of Uganda government has an obligation to protect women and girls from any form of violence, which is why these 16 days are important, as they give us an opportunity to assess how we are doing on that front, and in achieving the sustainable development goals (SDGs), particularly SDG 3.

As civil society, we complement government efforts in prevention and response to SGBV. Despite government initiatives and programmes to facilitate the utilisation of SGBV services in Uganda, there is still evidence of barriers and several gender disparities which persist in access to sexual and reproductive health services for survivors of sexual gender-based violence.

Ms Nakalembe is a Programme Officer in the Community Empowerment Programme, CEHURD.

The 2021 Annual Police Crime Report and an assessment by Center for Health, Human Rights and Development (CEHURD) of cases reported before and during the pandemic in various districts,indicate an increase in sexual offences reported. When faced with SGBV, survivors are advised to report to public health facilities urgently as a referral mechanism for medical examination and management and to fill in Police Form 3 appropriately. However, in the course of our interventions we have observed that some health facilities are not survivor centred, and lack appropriate good quality care for survivors of sexual violence. Survivors are also unable to access services 24 hours a day, as most health service providers work half day and are hardly available over the weekends. We have had to contend with unethical health service providers who solicit funds at a fee of Shs50,000 from survivors for medical examination and the form. A majority of survivors cannot afford it and end up only reporting the cases to police without seeking medical attention yet sexual abuse can lead to numerous health adverse health conditions. These include disability due to injury, HIV/Aids, sexually transmitted infections (STIs), unintended pregnancy, unsafe abortions, mental health outcomes, including posttraumatic stress disorder, anxiety and depression, and an increased risk of ideated or attempted suicide, among others.

During the Generation Equality Forum, an international initiative in favour of gender equality, held in Paris on June 30 to July 2, 2021 the government of Uganda committed to eliminating GBV by scaling up comprehensive, accessible, and quality services for survivors. The commitments included;

  1. Supporting the collection of forensic evidence on GBV, violence against children (VAC), especially capital offences reported through the media, GBV special courts and shelters, Sauti 116, Police, Health Facilities, NGOs and LCs to inform court processes.
  2. Effective implementation of GBV/VAC legislation with adequate resourcing and budgets.
  3. Provision of timely medical services including Emergency Contraceptives (EC), Post Exposure Prophylaxis (PEP) and STI treatment etc. to GBV/VAC survivors for increased access to timely, comprehensive and quality medical services to GBV/VAC survivors.
  4. Development of a national guideline for health service providers on identification and Management of victims/survivors of GBV, including roles, responsibilities and referral pathways and socialization to health providers at all levels and related stakeholders on the National guideline
  5. Training health facility staff to handle GBV/VAC cases including collecting of forensic evidence for Improvement in the quality of forensic evidence and service delivery to GBV/VAC survivors.
  6. Establishment of additional 20 shelters across the county to handle issues GBV/VAC survivors.
  7. Provide training and support to all service providers within the Criminal Justice systems dealing with GBV/VAC matters (including police, prosecutors, magistrates, intermediaries, court preparation officers, health care providers and policy makers) to strengthen victim-centric survivor focused services and prevent any forms of secondary victimization.
  8. Programs for counseling and psychosocial support to young girls that got pregnant during COVID 19 lockdown established.
  9. Ensuring that victims and survivors’ rights are fully protected through formal Justice systems and perpetrators are brought to justice by enhancing the capacities of the policing and prosecution institutions to ensure GBV survivors are able to access quality justice services; accessible, responsive and gender inclusive to ensure GBV survivors are able to access efficient and sensitive criminal justice that is quick and inclusive.
  10. Mechanisms put in place for survivors/victims who seek legal redress as well as whistleblowers who provide information in-order to protect them from reprisals and further harm. 
  11. Put in place interventions to respond to specific barriers that victims may face in accessing information and services, addressing the unequal and inequitable spread of victim services.

As we commemorate these 16 days of activism (from November 25th to December 10th), we call upon the Government of Uganda to fulfill these commitments, and end gender-based violence.

A version of this article was published in the Daily Monitor on 1st December 2021.