Uganda struggles with the challenges that come with delivering an efficient health service system to her citizens. Addressing these challenges is one of the country’s goals in trying to fit into the Abuja Health declaration that set a road map to guide African nations’ targets on health.
In April 2001, the African Union countries met and pledged to set a target of allocating at least 15% of their annual budget to improve the health sector. Uganda’s health challenges include; under funding, under staffing, poor waste management, lack of commitment and underutilization of resources. Despite these roadblocks, the country continues to make significant progress thanks to a team of dedicated officials.
Last month, the current Permanent Secretary at the Ministry of Health, Dr. Diana Atwine made three years in office following her appointment to the Wandegeya based Ministry in November, 2016. In this article, she shared with our reporter some of the strides that have been made under her watch and the challenges that remain.
Q: Congratulations On Making 3 Years. How Was Your Appointment Received At The Ministry, what things did you do to set the ball rolling?
DIANA: Thank you. On assumption of office, I started on the process of bringing reforms to the Ministry of Health. Reforms in areas of Human Resource Management, Financial Management, Inventory Management, Fleet Management, Health promotion, digital health and infrastructure development, among other key areas of general health service delivery.
As you may be aware, prior to my appointment to the ministry of Health, I had been traversing the whole country monitoring health services. That experience accorded me a better understanding of the challenges that faced the sector. This informed my approach and the subsequent introduction of the reforms in the Ministry of Health.
Q: What have you done to address the common challenge of absenteeism at different levels of health service delivery?
DIANA: Prior to assuming this office, I had noted that absenteeism was a big problem not only in the Local Governments but also at the Centre. In cases where there was no absenteeism, there was ‘presentism’’ this a case where health workers report for duty, but do not do any work at all. I am glad that one of my first activities at the Ministry of Health was the installation of biometric system at Ministry of Health headquarter and affiliated offices, where everybody is expected to log in and log out.
Q: Was this embraced by the staff?
DIANA: No! Like all new changes, at the beginning, this was not accepted widely and therefore it was difficult to assess the attendance. However, later in the subsequent years, this became the basis of the performance indicators for appraisal, where we would assess everyday attendance for a year. Although this has not been fully accepted by all, but largely many have embraced it. I am glad to report that the level of absenteeism now stands at 8.09%, compared to 46.9% in 2016. This model has also been rolled out to Regional Referral Hospitals.
Q: How has that reflected in the performance of employees at the ministry?
DIANA: In order to effectively execute performance management at the Ministry of Health, we put in place a detailed performance contract process whereby at the beginning of each year, the staff from the rank of the Program Managers and above are required to sit with their respective supervisors and develop individual and departmental performance targets. This becomes the basis for the appraisal of staff at the end of the year. I continue to see that this becomes the culture of assessing performance.
In addition, I noted that although the sector is under – funded, one of the biggest impediments to performance was the mindset of some health workers. This related to the quality of work as well as their attitude to work and work ethics. As a solution to this issue, I sourced for funding from Johnson and Johnson through The University of Cape-Town. Subsequently, through an implanting agency, we have started training the health managers on mindset change, with the Pilot project covering 10 Districts we plan to spread to the whole country. We emphasize the culture of excellency with the little we have to deliver the required results.
Q: Your job’s mainstay is accountability, what is the experience like the past three years, encouraging accountable practices at the ministry.
DIANA: The initial challenge that I met was to build confidence of the development partners and win the them back to support the sector, namely; UNICEF which had stopped disbursing funds for two years prior to my coming because of lack of accountability. GAVI had likewise suspended support because of lack of the same.
However, through my effort, together with my team, we worked hard to ensure that we recover funds from staff that had misused it both at headquarters and through local governments.
We have encouraged staff to follow strict financial management from both at the headquarters and through local governments.
I can gladly state that, during my stay at the Ministry of Health, there has been remarkable increase in the absorption of Government of Uganda funds. As a result, the MOH rarely returns money to the consolidated funds. The challenge remains on the externally funded projects that have lengthy and numerous processes that delay timely implementation
Q: The ministry has in the past come under attack for misuse of ministry property by employees. It was almost common to see government vehicles loaded with people’s personal staff. Is there any effort being put to stop that?
DIANA: Yes. One of the major tasks I undertook when I assumed the role was to have all the ministry vehicles validated. Like you mention, many vehicles had been registered with NGO-like numbers and diverted for personal use while other units did not have any vehicles at their disposal.
However, we have set up a Fleet Management Assessment Committee together with the ministry of works and as a result, a fresh and up-to-date inventory was established. We have been able to recover 10 cars that had been stolen by individuals.
We have also implemented an in-house vehicle service centre to cut down on wastage. Previously, the ministry was paying shs700, 000 to service each car, however, that has been reduced to between 150k to 300k per car.
Q: The health ministry is a service delivery based unit. However, it has come under attack from mainly the opposition about the not so deserving delivery. Share your experience on service delivery in the last three years.
DIANA: In order to address the question of service delivery, we have come up with a support supervisory strategy that will soon be rolled out. Under this, reward and sanctions will be implemented at both the center and local governments.
We are also working on strengthening our referral system that’s why we have set functionalization of Health Center IV Theatres as one of the priorities to ensure that minimal referrals are sent to the national hospitals. This is helping in bringing quality services closer to our people most especially in rural areas.
Q: What are some of the challenges you have experienced?
DIANA: Understaffing at the ministry headquarters and other hospitals remains a challenge. Many Hospitals have failed to even attract staff despite repeated advertisement for jobs, something that is hampering service delivery.
In addition, underfunding of the ministry has also proved a big challenge according with some facilities lacking the necessary equipment and increased utility bills such as power and water that slow work.
Unfulfilled Financial commitments especially of counterpart funding of big projects, has led to sky rocketing interests’ accumulation and in some instances has led to litigation that has made government to pay heavily.
Waste management, stalling of works and low absorption in externally funded projects (stringent requirements in some projects put up by funders like the World Bank causing slow disbursement), continue to plague the ministry.
Q: What measures are in place to scale down on these challenges?
DIANA: We are doing a lot. We continue to engage both technical and political leaders of districts to actively participate in health promotion at all levels. This will continue until we see improvement. It goes a long way in spreading the message about what we are doing so we can be more accountable to the public.
In our digitization strategy, my vision is to ensure that this digitization does not stop at big hospitals but trickles down. Our target is to cover 18 hospitals initially and then we roll out as funds are secured.
We are training more specialists for deployment to our health facilities to cover the big gap. Also at the center, we are undergoing a recruitment process aimed at filling all vacant position in the new structure that was recently reviewed to cover key technical areas of health services delivery.
We are also currently upgrading all health center 2s into HC3s with a goal of having every parish with at least one HC3. This will help bring critical services closer to the people.
Qn: What are your last remarks for all Ugandans out there who rely on you for better health care?
DIANA: I encourage all Ugandans to appreciate the fact that health is made at home and only repaired in the hospital. This means that focus should be put more on not falling sick. Our resource envelope can never be enough to treat every disease but we can reduce numbers seeking treatment in our facilities by prevention of diseases, doing regular check-ups and avoiding risky behaviors.