REVIEW OF GOVERNANCE LEADERSHIP AND PARTNERSHIPS IN THE HEALTH SECTOR HIV/AIDS RESPONSE
Draft Report
Prepared by
Denson Nyabwana A.
Dabtience Tumusiime
Fred Wabwire-Mangen
For
The STD/AIDS Control Programme/Ministry of Health
With Support From
WHO, UNFPA and CDC Atlanta
November 2010
TABLE OF CONTENTS
TABLE OF CONTENTS
LIST OF TABLES
LIST OF FIGURES
ACKNOWLEDGEMENTS
ACRONYMS/ABBREVIATIONS
OPERATIONAL DEFINITIONS
EXECUTIVE SUMMARY
1.0INTRODUCTION AND BACKGROUND
1.1Overview of the Building Block Assessment
1.2Rationale for the Building Block in the National Health System
1.3Terms of Reference
1.4Understanding the Terms of Reference
1.5Objectives of the Building Block Assessment
2.0METHODOLOGY
2.1Overview of the Methodology
2.2Description of the data Collection process
2.3Qualitative Methods of Data Collection
2.4Quantitative Methods of Data Collection
2.5Analytical Framework and Questions
2.6Data Analysis, Triangulation and Interpretation
3.0CHALLENGES/LIMITATIONS DURING THE STUDY
4.0FINDINGS OF THE STUDY
4.1Findings of the District Response
4.1.1District (central) Level
4.1.1.1Background characteristics of the respondents
4.1.1.2Awareness of the national plans
4.1.1.3District HIV plan
4.1.1.4District AIDS Taskforce
4.1.1.5Legal frameworks
4.1.1.6Policy Development & Management
4.1.1.7Planning, regulatory frameworks and Monitoring and Evaluation
4.1.1.8Mainstreaming of HIV and AIDS into district activities.
4.1.1.9Resource Mobilisation and budgeting:
4.1.1.10Partnerships Coordination and Participation
4.1.1.11Strategic Information
4.1.1.12Research and coordination
4.1.1.13Decentralisation
4.1.1.14Transparency and accountability
4.1.2Health Facility Level
4.1.3Community Level
4.1.4Other Providers (PNFPs, PHPs, FBOs, COE and uniformed services)
4.2Findings of the National Response
4.2.1National Facilities
4.2.2National stakeholders and Providers
4.2.2.1 Background characteristics of the respondents
4.2.2.2Views on current trend of HIV/AIDS in Uganda
4.2.2.3National policies and frameworks
4.2.2.4MACA, Mainstreaming, Coordination, Partnerships and Synergy (health sector)
4.2.2.5Mainstreaming
4.2.2.6Oversight and guidance role of ACP-MoH as seen by parliament
4.2.2.7Decentralisation and capacity of ACP-MoH to manage the response
4.2.2.8Legal Framework
4.2.2.9Policy development and management
4.2.2.10Resource mobilisation and allocation and funding mechanisms
4.2.2.11:Stewardship role of the ACP in the HIV/AIDS response
4.2.2.12Transparency, accountability and corruption
4.2.2.13 Interventions that MoH should introduce
4.2.2.14Community involvement/participation
4.2.2.15Human rights, gender, GIPA and MIPA principles
4.2.3Other providers (PNFPs, PHPs, COE and uniformed services)
4.3Summary of Findings
4.3.1Strengths
4.3.2Weaknesses
4.3.3Opportunities
4.3.4Threats
5.0CONCLUSIONS
5.1By Assessment Objectives
5.2Key Emerging Messages
6.0RECOMMENDATIONS
6.1Policy Level Recommendations
6.2Programme level recommendations
6.3Interventions for key stakeholders
6.3.1Policy level stakeholders
6.3.2 Programme level stakeholders
6.3.3International level stakeholders
6.3.4The non-public sector (CSOs, FBOs, NGOs, etc)
7.0BIBLIOGRAPHY/REFERENCES
8.0 APPENDICES
8.1 National Data Collection tools
8.1.1National Data Collection tools: Quantitative
8.1.2National Data collection tools: Qualitative
8.2District Data collection tools
8.2.1District Data collection tools: Quantitative
8.2.2District Data collection tools: Qualitative
LIST OF TABLES
Table 1 Background characteristics (Respondents and facilities that were visited)
Table 2: Comparison of per capita expenditure on general against expenditure on HIV/AIDS services
Table 3 Background characteristics of the respondents from the health sector
Table 4 Background characteristics of the respondents from parliament
Table 5 Health sector views on the current trend of HIV/AIDS prevalence in Uganda
Table 6 Views of parliament on the trend of HIV/AIDS prevalence in Uganda and reasons
Table 7 Ranking of reasons for the reversal of HIV/AIDS by parliament and health sector
Table 8 Staff norms, annual output and registration status of professional staff
Table 9 Mainstreaming, Coordination, partnerships and synergy
Table 10 Views of Parliament on ACP-MoH capacity for guidance and oversight of the HIV/AIDS response
Table 11 Health sector views on ACP/MoH and mainstreaming and decentralization
Table 12 Sex distribution of decision makers in the Public Service
Table 13 What Ugandans demand for 2011 elections to address
Table 14 Details of qualitative tools as applied at national level and participation
LIST OF FIGURES
Figure 1:Functions that the health system performs (Source: WHO, 2001)
Figure 2:Conceptual framework for interaction between Partner health initiatives and country health systems.
Figure 3: Village Health Team Strategy, Institutional Framework/Linkages
ACKNOWLEDGEMENTS
The team would like to express heartfelt appreciation to the Ministry ofHealth for having
thought about the idea of having this review done and for giving us thisopportunity to
serve; our thanks next go to World Health Organisation United Nations joint Programme
on HIV/AIDS UnitedNations Population Fund and Centres for Disease Prevention and
Control Atlantafor offeringthe funds that supported the process
Great thanks go to the technical working group under guidance of the AIDS Control
Programme Manager MoH, Dr. Akol Zainab and Dr. Nsubuga Peter for the background work
that got thisreview started and eventually kept it on track; Dr. Beatrice Crahay did a great job
inmaking sure that most of thereference documents that were not available at the MoH
were got somehow
Thanks also go to the external consultants, Dr. Michael Friedman (CDC/Atlanta) Dr. Ogori
Taylor (WHO/Nigeria) and Dr. Okoro Chijioke (CDC/Atlanta) for the technical support and
concerted efforts to ensure the quality of this review
Special thanks go to the respondents at the district level particularly the District Health
Officers and the national level particularly the permanent secretaries, heads of departments
and agencies who either participated as respondents or gavepermission to their officers or
staff to avail time for this review
Finally we give special thanks to the members of the administrative support, data entry,
data analysis andcoordination teams for the tremendous work done to get this review to a
successful end; thestatisticians did much work to supportthe data analysis and
interpretation exercise
To all of you and those that we may have forgotten to mention due to human error thank you
once again and God bless you abundantly for this service to humanity
ACRONYMS/ABBREVIATIONS
ACPAIDS Control Programme
AICAIDS Information Centre
AIDSAcquired Immune Deficiency Syndrome
APRMAfrican Peer Review Mechanism
ARTAnti-retroviral Therapy
ARVAnti-retroviral
CDCCentres for Disease Control and Prevention
CHAICommunity-Led HIV/AIDS Initiatives
CHCTCouples HIV Counselling and testing
CRSCatholic Relief Services
CSFCivil Society Fund
DACDistrict AIDS Committee
DATDistrict AIDS Taskforce
DHODistrict Health Officer
DDHSDistrict Director of Health Services
FBOFaith Based Organisation
GBSGeneral Budget Support
GFATMPGlobal Fund to fight AIDS Tuberculosis and Malaria
HBCHome Based Care
HCTHIV Counselling and Testing
HFA 2000Health For All by the Year 2000
HIVHuman Immunodeficiency Virus
HPACHealth Policy Advisory Committee
HSGHealth Systems Governance
HSHASPHealth Sector HIV/AIDS Strategic Plan
HSSHealth System(s) Strengthening
HSSPHealth Sector Strategic Plan
IECInformation Education and Communication
ITInformation Technology
JCRCJoint Clinical Research Centre
LGDPLocal Government Development Programme
MHOMunicipal Health Officer
MoFPEDMinistry of Finance Planning and Economic Development
MoHMinistry of Health
NAPNational AIDS Policy
NDANational Drug Authority
NDPNational Development Plan
NEPADNew Partnership for African Development
NGONational Drug Authority
NMSNational Medical Stores
NPAPNational Priority Action Plan for the National Response to HIV and AIDS 2008/09 – 2009/10
NSPNational HIV/AIDS Strategic Plan 2007/08 – 2011/12
NTLPNational Tuberculosis and Leprosy Programme
NUMATNorthern Uganda Malaria, AIDS, TB
PACEProgramme for Accessible health, Communication and Education
PAHOPan American Health Organisation
PCPartnership Committee
PEPFARU.S. President’s Emergency Fund for AIDS Relief
PHCPrimary Health Care
PHIsPartner Health Initiatives
PHPsPrivate Health Practitioners
PMTCTPrevention of Mother to Child Transmission of HIV
PNFPsPrivate Not For Profit
PPUPolicy and Planning Unit
RM&EResearch Monitoring and Evaluation
SACSub-countyAIDS Committee
SATSub-countyTaskforce
SCESelf Coordinating Entity
TCsTransaction costs
TCMPTraditional and Complementary Medicine Practitioners
UACUganda AIDS Commission
UNDPUnited Nations Development Programme
UNCSTUganda national Council for Science and Technology
UNHROUganda National Health Research Organisation
UNICEFUnited Nations Children’s Education Fund
USAIDUnited States Agency for International Development
WHOWorld Health Organisation
VCTVoluntary Counselling and Testing
VHCVillage Health Committee
VHTVillage health Team
OPERATIONAL DEFINITIONS
AIDS Competencies:Ability of all elements of society, individuals, families, communities, and
institutions to recognise the reality of HIV/AIDS, analyse its causes and effects and take
action to prevent it’s spread and mitigate its effects
External mainstreaming: Adapting the core work and functions of an organisation or
programme to the causes and effects of HIV and AIDS
Complementary Partnerships:Refers to organisations focussing on their strengths while
linking actively with other agencies that can address other aspects of the HIV/AIDS
epidemic where they (the latter) have comparative advantages
Health System(s) Strengthening: Any array of initiatives and strategies that improves one or more of the functions of the health system and that leads to better health through improvements in access, coverage, quality, or efficiency (Health Systems Action Network 2006)
HIV/AIDS Mainstreaming:A process that enables development actors to address the causes
and effects of HIV/AIDS in an effective and sustained manner, both through their usual work
and within their work places (UNAIDS)
Health economy: All resources devoted to health ie from the public sector, private sector
and households or the community
Internal mainstreaming:Changing organisational Policies and practices to reduce
susceptibility to HIV infection and vulnerability to effects and impacts of AIDS
Output Oriented Budgeting: A budgeting activity that uses the established outputs to
determine the resource allocation; it requires the determination of costs of the respective
activities that need to be undertaken to achieve the desired outputs
Partnerships: Honest relationships between equals based on mutual respect, understanding
and trust, with obligations and responsibilities for each partner
Primary Health Care: Essential Health Care based on practical scientifically sound and
socially acceptable methods made universally accessible to individuals, families and the
community through their own participation and a cost that the individuals families the
community and the nation can afford at every stage of their development in the spirit of self
reliance and self determination
Results Oriented Management: A management system that seeks to optimise the use of
resources through clearly defining the purpose of the organisation, the service it provides, the
activities to be undertaken/outputs to be achieved and the indicators for measuring the
organisation’s performance
EXECUTIVE SUMMARY
Introduction
This review of Governance, leadership and Partnerships under the Health sector was done as part of the Review of The Health Sector HIV/AIDS Response in Uganda; the other components of the review were Health Management Information Systems, Human Resources for Health, Health Financing, Medical Products, Laboratories and Health Services Delivery. The review was therefore expected to contribute to information and recommendations from the other building blocks for purposes of improving on the draft Health Sector Strategic Plan III, the National Health Policy II and the Health Sector HIV/AIDS Strategic Plan (HSHASP) II; it was expected to contribute to improvement of the effectiveness and efficiency of the health sector HIV/AIDS response and its contribution to the national/multi-sectoral HIV/AIDS response.
Objectives
The purpose was to review the national strategic frameworks to confirm provisions for effective coalition building oversight regulation and attention to system design and accountability for the Health Sector HIV/IDS Response. Specifically the review sought to assess the level of engagement of stakeholders in development implementation and monitoring of the HSHASP, organisation of the AIDS Control Programme Ministry of Health (ACP-MoH), as a component programme of the Ministry of Health (MoH), the lead ministry of the health Sector, in relation to its national roles of coordinating the overall Health Sector HIV/AIDS Response, and the stewardship roles of ACP-MoH regarding priority setting for research and donor support projects including funding.
Methodology
The review was done using qualitative and quantitative methods of data collection; they included document review, Key Informant Interviews, Group Interviews, Focus Group Discussions (FGDs), Round table discussions and field visits. Data Collection was done at National, sector, district, sub-district and community levels. We focussed on the national policy level, health sector policy level and health sector senior administration and then other partners in the non-public sector. At district level we focussed on political leadership, the District Health Team (DHT), the District Technical and Planning Committee (DTPC), district based Civil Society Organisations (CSOs) or Non-Governmental Organisations (NGOs), health facilities for the public sector, health facilities for Private Not For Profit organisations (PNFPs), Faith Based Organisations (FBOs), Private Health Practitioner organisations (PHPs) and Uniformed Services. The districts were selected basically as urban/rural, high prevalence/low prevalence and conflict/non-conflict affected, Northeast and North-central etc. At sub-county level the focus was on communities mainly through Health Unit Management Committees (HUMCs) and Village Health Teams (VHTs), including People Having HIV/AIDS (PHAs).
Limitations
There were various levels of limitations including:
Limited numbers of Research Officers for the review
Some data collection tools were relatively long leading to delay in
transcribing
Limited funding for field work particularly at national level
The quality of tapes, we had to change; leading to loss of some work
Low transcribing standards of some RAs; thus review of tapes took longer than planned
Number of informants at national level was big but necessary
Findings
There is general concurrence that the HIV/AIDS situation in Uganda hasworsened;most
respondents believed the new infections rate outstrips the response
Political commitment is currently strong at the presidency but needs to trickle down all
levels up to the grass roots ( Presidency to ministers permanent secretaries district level etc)
Emphasis has been shifted from prevention to treatment; treatment is doing fairly well
Focus on MARPs is still grossly inadequate; it requires revision of the prevention strategy
The Multi-sectoral AIDS Control Approach (MACA) is still a best practice; the partnership is big but fragmented with relatively ineffective coordination; complementary partnerships are hard to form and the power of partnerships and synergy has therefore been lost
Mainstreaming is being done by many partners; it isn’t well coordinated; it lack resources
Decentralisation is still a best practice but the speed needs to be matched with capacity and an effective SWAp strategy; CSOsare not fully effective yet partly for internal reasons
Capacity of the ACP-MoH is too low especially with its current position in the MoH structure; coordination of the health sector HIV/AIDS response is thus difficult to manage
There are Long Term Institutional Arrangements (LTIA) for management of HIV/AIDS in Uganda along with LTIA for management and coordination of Global Health Grants but they are not yet put to effective use especially at district level
Most respondents believe Coordination between the UAC and ACP-MoH/MoH and subsequently among the sectors leaves a lot to be desired
Knowledge and understanding of the HSHASP, HSSP and NSP is low; linkage between them is not clear to many; and so is linkage between budgets and plans even in ACP-MoH
Lack of an AIDS law plus an overarching National AIDS Policy and some subordinate policies like the Public-Private Partnership for Health Policy is frustrating a lot of AIDS work particularly that related to human rights for both the infected and vulnerable unaffected
Most subordinate policies/regulatory frameworks are in place but are not effectively disseminated and this has a lot of negative implications for implementation and enforcement
Government has moved to increase funding (60 Billion in 2009) but it is still below expectation (at least 15% of government budget); over 80% of funding for the Health Sector HIV/AIDS Response is still from donor funds; this is demotivating to donors; but government is moving to implement output based budgeting which may improve resource mobilisation; but rapid creation of districts reduces level of resources mobilised both at national and decentralised level as capacity to run the districts does not much the speed of growth
Districts have low capacity for mobilisation and the belief that HIV/AIDS has a lot of money compared to other programmes reduces the urgency to mobilise funds for HIV/AIDS
The response is generally human rights based but the AIDS law is needed for full effect; the gender perspective is not effectively addressed yet
There is general support for integration of HIV/AIDS into other programmes but with some aspects remaining verticalHIV/AIDS being a priority disease
Most partners work with communities but the VHT strategy of 2001 is still at about 50% functionality because most partners have established their own, or are using, other versions
A lot of research is going on but research priorities are largely driven by funding agencies
Currently ACP-MoH has capacity for coordinating HIV/AIDS research and project identification; but much of its capacity may be temporary as the personnel are seconded
Transparency accountability and corruption were noted by all respondents to be a serious problem that maybe discouraging potential funding partners; this also effects motivation of current DPs to harmonise their systems with the national health system or align their funding to approved funding mechanisms; the review noted that government has established robust systems to correct the situation but public sector staff involvement in the vice is a set back
There is no integrated M and E system for the health sector HIV/AIDS response into which all partners can fit and the framework developed with the NSP is not fully operational yet
Recommendations
Policy level recommendations
Political commitment should be revitalised and monitored at all levels from the
presidency to the grassroots; have and monitor relevant out puts for a known service chain