Document of
The World Bank
FOR OFFICIAL USE ONLY
Report No: 53 15 1-UG
PROJECT APPRAISAL DOCUMENT
ON A
PROPOSED CREDIT
IN T E AMOUNT OF SDR 85.7 MILLION INCLUDING SDR 19.8 MI PIL T
CRW RESOURCES
(US$130 MILLION EQUIVALENT)
TO THE
REPUBLIC OF UGANDA
FOR A
UGANDA HEALTH SYSTEMS STRENGTHENING PROJECT
April 27, 2010
Human Development 1
Country Department AFCE 1
Africa Region
This document has a restricted distribution and may be used by recipients only in the
performance of their official duties. Its contents may not otherwise be disclosed without World
Bank authorization.
CURRENCY EQUIVALENTS
(Exchange Rate Effective as of March 3 1, 2010
Currency Unit = Uganda Shilling Shs.
Shs.2085 = US$]
US1 = SDR0.6586
FISCAL YEAR
July 1 - June30
ABBREVIATIONS AND ACRONYMS
ACT Artemisinin-based Combination Treatment MIS Management Information System
AtDB African Development Bank MMR Maternal Mortality Rate
AHSPR Annual Health Sector Performance Report MOFPED Ministry of Finance, Planning and Economic Planning
ANC Antenatal Care MOH Ministry of Health
APL Adaptable Program Loan MOU Memorandum of Understanding
BCC Behavioral Chang Communication MSI - U Mane Stopes International Uganda
~
CAS Country Assistance Strategy MTEF Medium-Term Expenditure Framework
CFAA Country Financial Accountability Assessment MVA Manual Vacuum Aspiration
CPI Country Portfolio Index NACME National Advisory Committee on Medical Equipment
CPR Contraceptive Prevalence Rate NDP National Development Plan
csos Civil Society Organizations NMS National Medical Stores
DAH Development Assistance for Health ORET Development-Related Export Transactions Programme
DALYs Disability Adjusted Life Years PACE Programme for Accessible health, Communication and Education
DANIDA Danish International Development Agency PDE Procurement and Disposal Entity
DHS Demographic and Health Survey PDO Project Development Objective
DHSP District Health Services Pilot and Demonstration PDU Procurement and Disposal Unit
Project
DPT Diphtheria, Pertussis and Tetanus PEAP Poverty Eradication Action Plan
EmONC Emergency Obstetric and Neonatal Care PEFA Public Expenditure and Financial Accountability
EMP Environmental Management Plan PEPFAR USG President's Emergency Program For AIDS Relief
ESAMl Eastern and Southern Africa Management Institute PER Public Expenditure Review
ESlA Environmental and Social Impact Assessment PETS Public Expenditure Tracking Survey
FlNMAP Financial Management Accountability Program PMTCT Preventing Mother-to-Child-Transmission of HIV
GFATM Global Fund for AIDS Tuberculosis and Malaria PNFP Private-not-for-profit Providers
GAVl Global Alliance for Vaccines and Immunization PPDA Public Procurement and Disposal of Public Assets Act
GOU Government of Uganda PRSCIJBSO Poverty Reduction Support Creditlloint Budget Support Operation
GHs General Hospitals PPP Public Private Partnership
HClV Health Center Type Four PRSP Poverty Reduction Strategy Paper
HCWMP Health Care Waste management Plan PER Quality Enhancement Review
HGSAP Health Governance Strategy and Action Plan RBF Result Based Financing
HMlS Health Management Information System RHU Reproductive Health Uganda
HNP Health Nutrition and Population ROM Results-Oriented Management
HPAC Health Policy Advisory Committee RRHs Regional Referral Hospitals
HRH Human Resources for Health SCM Supply Chain Management
HSSP Health Sector Strategic Plan SIL Sector Investment Loan
ICT Information, Communication. and Technology SoE Statement of Expenditure
IDA International Development Association STlP Sexually Transmitted Infections Project
IEC Information, Education, and Communication SURE Securing Uganda's Right to Essential Medicines
IFMIS Integrated Financial Management Information Systems SWAP Sector Wide Approach
IMF International Monetary Fund TA Technical Assistance
IMR Infant Mortality Rate TB DOTS Directly Observed Tuberculosis Treatment
IPT Intermittent Preventive Treatment TFR Total Fertility Rate
ITN Insecticide Treated Net TOR Terms of Reference
IUD Intrauterine Contraceptive Device UACP Uganda AIDS Control Project
IFMlS Integrated Financial Management Information Systems UBOS Uganda Bureau of Statistics
IMR Infant Mortality Rate UHSSP Uganda Health systems Strengthening Project
I PT Intermittenl Preventive Treatment UNFPA United Nations Population Fund
ITN Insecticide Treated Net UNMHCP Uganda National Minimum Health Care Package
IUD Intrauterine Contraceptive Device l!JAS Uganda Joint Assistance Strategy
LTlA Long-Terin Institutional Arrangeinentc l!PSPEP Uganda Public Sector Performance Enhancement Project
1.GMSDP I oca1 Cob1 Management and Fervice Deliver) VHT Village Health Teams
Prograin
MDG Millennium Development Goal VOlP Voice Over Internet Protocol
-
V i c e President Obiageli Katryn Ezekwesili
C o u n t r y Director John Murray Mclntire
S e c t o r Director Tawhid Nawaz
S e c t o r Manager Eva Jarawan
Task Team Leader Peter Okwero
FOR OFFICIAL USE ONLY
UGANDA
Uganda Health Systems Strengthening Project
CONTENTS
Page
I. STRATEGIC CONTEXT AND RATIONALE .................................................................. 1
A . Country and sector issues ................................................................................................... -1
B . Rationale for Bank involvement .......................................................................................... 5
C . Higher level objectives to which the project contributes .................................................... 6
I1 . PROJECT DESCRIPTION .................................................................................................. 7
A . Lending instrument ............................................................................................................. -7
B . Program objective and Phases ............................................................................................. 7
C . Project development objective and key indicators .............................................................. 7
D . Project components.,............................................................................................................ 8
E. Lessons learned and reflected in the project design .......................................................... 13
F. Alternatives considered and reasons for rejection .................... :........................................ 14
111. IMPLEMENTATION ..................................................................................................... 15
A . Partnership arrangements .................................................................................................. 15
B. Institutional and implementation arrangements ................................................................ 15
C. Monitoring and evaluation (M&E) of outcomeshesults ................................................... -16
D. Sustainability ..................................................................................................................... 17
E. Critical risks and possible controversial aspects ...................................................... ........17
F. Loadcredit conditions and covenants ............................................................................... 19
IV . APPRAISAL SUMMARY .............................................................................................. 19
A . Economic and financial analyses (see Annex 9) ............................................................... 19
B . Technical .......................................................................................................................... -20
C . Fiduciary............................................................................................................................ 21
D . Social ................................................................................................................................. 23
E. ...................................................................................................................... 23
Environment
F . Safeguard policies .............................................................................................................. 24
G . Policy Exceptions and Readiness ...................................................................................... 24
I I
This document has a restricted distribution and may be used by recipients only in the performance of
their official duties . Its contents may not be otherwise disclosed without World Bank authorization .
Page
Annexes
Annex 1 : Country and Sector or Program Background ................................................................. 25
Annex 2: Major Related Projects Financed by the Bank and/or other Agencies .......................... 30
Annex 3: Results Framework and Monitoring .............................................................................. 31
Annex 4: Detailed Project Description .......................................................................................... 39
Annex 5: Project Costs .................................................................................................................. 49
Annex 6: Implementation Arrangements ...................................................................................... 52
Annex 7: Financial Management and Disbursement Arrangements ............................................. 56
Annex 8: Procurement Arrangements ........................................................................................... 65
Annex 9: Economic and Financial Analysis .................................................................................. 76
Annex 10: Safeguard Policy Issues ................................................................................................ 80
Annex 1 1 : Health Governance Strategy and Action Plan ............................................................. 82
Annex 12: Project Preparation and Supervision ............................................................................ 89
Annex 13: Documents in the Project File ...................................................................................... 91
Annex 14: Statement of Loans and Credits ................................................................................... 92
Annex 15 : Country at a Glance ..................................................................................................... 94
Annex 16: Maps ............................................................................................................................. 96
List of Tables and Figures
Table Al-1: Health Outcome Indicators 1989 . ...............................................................
2006 25
Table A1-2: Trends in Health PEAP Indicators (2000/01 - 2008/09) ....................................... 26
Table A2- 1 : Major Health Related Projects in Uganda ............................................................. 30
Table A3-1: Results Framework ................................................................................................ 35
Table A3-2: Arrangements for Results Monitoring ................................................................... 37
Table A4- 1 : Proposed Renovation List of Selected General Hospitals and Health Centre IVs 42
Table A5-1: IDA Financing Table by Category (US$ million) ................................................. 49
Table A5-2: IDA Financing Table by Component (US$ million) ............................................. 49
Table A5-3: Foreign Exchange (US$ million) ........................................................................... 50
Table A5-4: UHSSP Project Costs by Subcomponent (US$ million) ....................................... 51
Table A7-1: Financial Management Risks and Mitigation Measures ........................................ 57
Table A7-2: Financial Management Action Plan ...................................................................... 63
Table A8- 1 : Procurement Action Plan ...................................................................................... -70
Table A9- 1 : Calculations of waste in the health sector FY 2005-06 ......................................... 78
Table A9-2: Fiscal Space for Health Projections Based on Economic Growth, 2007-15 .........79
Table A1 0-1 : Health Governance Strategy and Action Plan - Monitoring Indicators ................86
UGANDA
UGANDA HEALTH SYSTEMS STRENGTHENING PROJECT
PROJECT APPRAISAL DOCUMENT
AFRICA
AFTHE
Date: April 27, 2010 Team Leader: Peter Okwero
Country Director: John McIntire Sectors: Health (100%)
Sector ManagedDirector: Eva Jarawan Themes: Health system performance (1 00%)
Project ID: P115563 Environmental category: Partial Assessment
Lending Instrument: Specific Investment Loan Joint IFC:
Joint Level:
Project Financing Data
[ ] Loan [XI Credit [ ] Grant [ 3 Guarantee [ ] Other:
Source Local Foreign Total
BORROWEWRECIPIENT 14.31 0.00 14.31
International Development Association 89.62 40.38 130.00
(IDA)
Total: 103.93 40.38 144.3 1
Borrower:
The Republic of Uganda
Responsible Agency:
Ministry of Health
Plot 6 Lourdel Road
P.O. Box 7272
Uganda
Tel: (256-41) 434-0874 Fax: (256-41) 434-0887
info@health.go.ug
2Y 11 12 j 13 14 15
4nnual 2.90 47.40 1 34.40 29.50 15.80
2umulativeI 2.90 I 50.30 1 84.70 I 114.20 1 130.00 I
Proiect imulementation ueriod: Start Mav 25.201 0 End: Julv 3 1. 201 5
Expected effectiveness date: August 2, 2010
Expected closing date: July 3 1, 201 5
Does the project depart from the CAS in content or other significant respects?
[ ]Yes [XINO
Ref:PAD I.C.
Does the project require any exceptions from Bank policies?
Ref: PAD IKG. [ ]Yes [XINO
Have these been approved by Bank management? [ ]Yes [ I N 0
Is approval for any policy exception sought from the Board? [ ]Yes [XINO
Does the project include any critical risks rated "substantial" or "high"?
[XIYes [ ] N o
Ref:PAD IIL E.
I
.
Does the project meet the Regional criteria for readiness for implementation?
[XIYes [ ] N o
Ref:PAD IKG.
I
.
Project development objective Ref: PAD II.C., Technical Annex 3
The project development objective is to deliver the Uganda National Minimum Health Care
Package (UNMHCP) to Ugandans, with a focus on maternal health, newborn care and family
planning. This will be achieved through improving human resources for health; physical health
infrastructure; and management, leadership and accountability for health service delivery.
Project description [one-sentence summary of each component] Ref: PAD ILD., Technical
Annex 4
The project comprises four components, namely: (a) improved health workforce development
and management; (b) improved infrastructure of existing health facilities; (c) improved
management, leadership, and accountability for health service delivery; and (d) improved
maternal health, newborn care and family planning services. The choice of subcomponents and
activities was guided by the need to both achieve results during the project's life span, and also
promote reforms that would sustain service delivery in the long run, whilst complementing on-
going efforts by other development partners.
Which safeguard policies are triggered, if any? Ref: PAD IKF., Technical Annex 10
The project includes renovation of health facilities and provision of health care, which may have
potential adverse environmental impacts. As such, the project needs to comply with
environmental assessment requirements under the Uganda National Environment Act (1 9 9 9 ,
National Environmental Impact Assessment Regulations 13/1998, other Ugandan environmental
regulations, and the World Bank safeguard policy OP 4.01 on Environmental Assessment. The
Environmental and Social Impact Assessment (ESIA) including the EMPs and the Health Care
Waste Management Plan dated April 13,2010 (HCWMP) have been disclosed at the country
level and in the InfoShop. The ESIA suggests that there are no involuntary resettlement issues
associated with this project and that OP 4.12 is not triggered.
Significant, non-standard conditions, if any, for:
Ref: PAD III. F.
Board presentation:
None
Loankredit effectiveness:
(a) The Recipient has prepared the Annual Work Plan for the first year of Project
implementation;
(b) The Recipient has recruited the Accounting, Procurement and Monitoring and Evaluation
Specialists; and
(c) The Recipient has adopted the Project Implementation Manual.
Covenants applicable to project implementation:
(a) The Project Implementation Manual will include the following: (i) an institutional set-up
for the management of the Project, (ii) financial management and accounting procedures
annexes; (iii) detailed arrangements for the overall carrying out of the Project; (iv) guidelines
for the preparation of Annual Work Plans; (v) internal control systems to be followed during
Project implementation; (vi) detailed guidelines and procedures for the implementation of the
ESIA in connection with the carrying out of the Project; (vii) the guidelines for Project
monitoring and evaluation; and (viii) guidelines for implementation of the Health
Governance Strategy and Action Plan;
(b) By April 15 of each year, an annual work plan and budget (the Annual Work Plan) shall
be developed, including: (i) the Project activities to be carried out during the next twelve
months; (ii) the procurement plan and disbursement schedule; (iii) the annual budget for the
Project; (iv) annual training plan; and (v) the amount of counterpart funds to be provided by
the Recipient to carry out the Project activities during such period.
(c) The Project shall be carried out in accordance with the provisions of the Anticorruption
Guidelines;
(d) The Project shall be carried out in accordance with a Health Governance Strategy and
Action Plan, in form and substance satisfactory to the Association, including, inter alia: (i)
anticorruption prevention measures; (ii) mechanisms to improve the impact of Project
activities; and (iii) procedures to enhance the transparency of Project transactions;
(e) The external audit shall be carried out by the Auditor General of Uganda, within 6
months after the end of each fiscal year and include action plans to improve performance
and/or correct any shortcomings and/or deficiencies;
(0 The Project shall be implemented in accordance with the provisions of the Health Care
Waste Management Plan and the Environment Management Plan;
(g) Project progress reports shall be provided quarterly no later than forty-five days after the
end of the period, and shall include progress on the Key Performance Indicators;
(h) Procurement audits of the project shall be carried out annually.
I. STRATEGIC CONTEXT AND RATIONALE
A. Country and sector issues
1. Over the last two decades, Uganda has registered impressive economic performance.
Average GDP rate grew at an average of over 6 percent per annum and poverty levels were
reduced from 44 percent to 3 1 percent between 1992 and 2005/06. Nonetheless, Uganda remains
one of the least developed countries. GDP per capita in 2007 was estimated at US$320. In 2008
the population was estimated at 28 million people with a growth rate of 3.2 percent and a
dependency ratio of 1.12, both among the highest in the world. Per capita income is estimated to
have grown only by 0.6 percent per year in the past decade'.
2. The global economic crisis threatens short-term prospects. In 2008/09, GDP grew at 7.1
percent, but growth rate is expected to decrease to 5 percent in 2009/10, falling short of projected
performance in both years. At the outset of the global financial crisis, Uganda was shielded
against the first round effects, with the exception of instability in the foreign exchange market.
However, secondary effects later became apparent, with a slowdown in growth on account of
reduced demand for Uganda's traditional exports, tighter liquidity conditions, and a resultant
slowdown in economic activity. Both the current and capital account balances deteriorated, and
the shortfall in fiscal revenue resulted in modest expenditure cuts, while inflationary pressures
continued through 2008/09 and the first half of 2009/10. In the health sector, the increased
prices for drugs and medical supplies have reduced availability of critical health commodities.
3. Uganda has registered improvements in Health Nutrition and Population (HNP)
outcomes, but the improvement in outcomes remains poor compared to other countries in
the region. The Maternal Mortality Rate (MMR) is estimated at 435 deaths per 100,000 live
births2, while the Infant Mortality Rate (IMR) is estimated at 76 deaths per 1,000 live births;
stunting in children under five is estimated at 32 percent. Communicable diseases contribute over
50 percent of disability adjusted life years (DALYs) lost3. HIV prevalence dropped from 18
percent in the early 1990s to 6.4 percent, where it has remained since 2002. With the exception
of Millennium Development Goal (MDG) 6 on combating communicable diseases, Uganda is
unlikely to achieve MDGs 4 and 5 related to reducing child mortality and improving maternal
mortality. In comparison with other African countries, Uganda has similar outcomes to Kenya
and Tanzania in infant mortality, but is higher than both countries in mortality in children under
5 years. In maternal mortality, Uganda has slightly better outcomes than Kenya and Tanzania.
The status of key HNP outcomes is outlined in Table Al-1 in Annex 1.
4. While over 72 percent of the population resides within 5 kilometer radius of a health
facility, this has not translated into effective utilization and coverage for key interventions4.
Interventions targeted at HIV/AIDS and Malaria Control Programs registered marked progress
since 2004/05. Coverage of (a) children under five who receive effective treatment for fever
within 24 hours increased from 60 to 71 percent; (b) pregnant women who receive intermittent
preventive treatment (IPT) for malaria during pregnancy increased from 34 to 47 percent; and (c)
' As measured in [IS$
MMR for 2008 is 352 according to the latest Lancet paper.
' The last Burden of Disease study was in 2002.
4Health Sector Strategic Plan 2005106 - 2009/10. Midterm Review Report, MOH, October 2008.
households with at least one insecticide treated bed net (ITN) increased from 15 to 42 percent
between 2004/5 and 2008/9. It is estimated that 190,000 out of 350,000 eligible persons are
receiving antiretroviral treatment. With the introduction of artemisinin-based combination
treatment (ACTS), malaria, a leading cause of morbidity registered a 39.3 percent decline in the
,total outpatient cases. Utilization of other key services have stagnated or deteriorated and their
coverage remains low. Outpatient utilization is estimated at 0.9 visits per capita, deliveries under
skilled care at 41 percent, contraceptive prevalence rate (CPR) at 24 percent and percentage of
women attending at least four antenatal care (ANC) visits at 58 percent. While the percentage of
children under one year reported to have received three doses of diphtheria, pertussis and tetanus
inoculations (DPT) is high (90 percent), the proportion of fully immunized children is low (46
percent). Similarly, while all districts report having adopted community based directly observed
treatment of tuberculosis (TB DOTS), the proportion of TB cases reported remains low at 57.4
percent compared to the target of 70 percent. The TB cure rate is estimated at 75 percent against
a target of 85 percent. Table A1-2 in Annex 1 illustrates the trends in major HNP indicators.
5. The goal for health in Uganda is to reduce morbidity and mortality from the major
causes of illness by delivering the Uganda National Minimum Health Care Package
(UNMHCP). The package includes cost effective interventions which primarily target major
communicable diseases, as well as maternal and child health. The objective is to improve access
to, and utilization of, essential services, including basic surgical and obstetric care. These
objectives are highlighted in the Poverty Eradication Action Plan (PEAP)6 under Pillar 4 on
improving human development. The plan's emphases are on mobilization and efficient
utilization of funding; recruitment and better deployment of the health workforce; improvement
in supply, distribution and rational use of essential drugs; and strengthening public private
partnerships for improved health services.
6. Uganda's health reforms are generally regarded as successful in terms of structural
changes, although outcomes have been mixed. Despite acknowledged underfunding,
improvements were observed, especially during Health Sector Strategic Plan I (HSSP I), in
programming of the Government portion of the budget; rationalization of financing of essential
medicines and supplies through the Drug Credit Line;' partnership and financing of the private-
not-for-profit providers (PNFPs); recruitment of qualified health workers in Government health
facilities; and in the renovation and upgrading of primary health care facilities and provision of
staff accommodation. Since 2004/05, bottlenecks have emerged which impede health system
performance. These include the misalignment of external development assistance with national
priorities and systems; weak procurement and supply chain management; generally weak
management capacity; and issues related to recruitment, deployment, and management of the
health workforce, especially in remote and hard to reach areas8 Compounding the low funding
level is the limited allocation of discretionary funds and restricted availability of operational
funds largely due to the earmarking of the budget through the wage bill, project support, and
conditional grant transfers.
' National Health Policy ( 1 999 - 2009) & Health Sector Strategic Plans (2000101 -2004105 and 2005106 - 2009110)
Poverty Eradication Action Plan of 2000 and revised in 2004; the equivalent to the Poverty Reduction Strategy Paper (PRSP).
'According to the Essential Drug List of Uganda.
Fiscal Space for Health in Uganda May 20, 2009 - Contribution to the 2008 Uganda Public Expenditure Review.
2
7. Improving maternal health remains a challenge. Major causes' of maternal deaths can
be prevented if women deliver with the assistance of skilled health personnel and have access to
quality emergency obstetric care. While the percentage of women who deliver with the
assistance of doctors or nurse/midwives increased from 38 percent in 1988 to 42 percent in 2006
and the use of antenatal care increased from 87 to 94 percent in the same period, emergency
obstetric and neonatal care (EmONC) is still not widely accessible. Health Centre IVs facilities
were designed to provide comprehensive EmONC, but only 16 percent have functional theatres
and 45 percent have a medical officer at the post." Providing EmONC services does not
necessarily mean that women will utilize them. According to the 2006 Demographic and Health
Survey (DHS), 81 percent of women indicated they had difficulty accessing health services: 65
percent could not afford treatment; 54 percent indicated long distance to the health facilities; 49
percent have difficulty obtaining transport; and 46 percent were concerned that drugs are not
available at the health facilities.
8. The status of maternal health is a good predictor of the functioning of the health
system. The maternal health Millennium Development Goal is perhaps the one most dependent
upon a well functioning health system (including the availability of facilities, medicines,
supplies, staff, and a functioning referral system), so there are synergies in focusing on health
systems strengthening and maternal/reproductive health in parallel.
9. The total fertility rate (TFR) is the fifth highest in the world and has virtually
remained unchanged for two decades (6.9 births per woman in 1988 versus 6.7 in 2006).
The use of modem contraceptives among married women is low (24 percent), and Uganda has
the highest unmet need for contraceptives in the world (41 percent). As a result, many women
resort to induced abortions with an estimated 300,000 performed annually. The average desired
family size of 5.0 (as opposed to TFR of 6.7) indicates that the need for family planning services
in Uganda is high. Only 46 percent of public health facilities provide family planning services
and there is limited availability of community based family planning services. The private sector
is the major source of contraceptives as 43 percent of women obtain contraceptives from private
sector, as opposed to 32 percent from public health facilities. The Government has prepared a
Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity
(2006 - 2015), and a Reproductive Health Commodity Security Strategic Plan (2010/11 -
201 411 5 ) , which addresses these concerns in a systematic way, including appropriate emphasis
on the use of existing private sector providers.
10. Uganda is under considerable pressure to increase spending for health. This is driven
by the rapidly growing population and the need to adopt more effective health technologies and
service standards to combat the high disease burden. Most hospitals in Uganda were built
between 1930 and 1970 and no longer conform to current demands and service standards. Over
the years, insufficient attention was paid to their maintenance; and the majority are dilapidated
and in poor physical condition. Existing management systems for hospitals have become
outdated and misaligned with current reforms underway in the country. Poor alignment of
Hemorrhage. abortion complications. sepsis. obstructed labor and pregnancy induced hypertension.
I"Uganda has a seven-tier public health care system: Health Center I (serves villages with a population of 1,000 or less); Health
Center I I (parishes with a population of 5.000): Health Center I l l (sub-countries with a population of 20,000); Health Center IV
(counties with a population of 100.000): General Hospital (districts with a population of 500.000): Regional Referral Hospitals
with a population of 500.000 population); and the National Referral Hospital,
3
various public sector reforms (procurement, decentralization, restructuring of line ministries and
agencies, etc.) to health sector needs, coupled with proliferation of districts that lack resources
and capacity to execute their mandates, have both complicated management of health service
delivery and rendered the existing management, supervision mechanisms, and accountability
frameworks ineffective. Abuse, waste, and inefficiency are recognized as major problems in the
sector. In particular, absenteeism represents a major source of inefficiency and waste. The
Global Fund for AIDS Tuberculosis and Malaria (GFATM) and Global Alliance for Vaccines
and Immunization (GAVI) suspended their support in 2005 citing mismanagement of their
grants. Although the suspensions have since been lifted, grant disbursements have not fully
recovered.
11 . The Government recognizes the challenges and is committed to improving efficiency
and effectiveness of public spending by strengthening the overall public financial
management and procurement system." Starting in 2009/2010, implementing agencies
receiving external funds were required to provide detailed work plans, including procurement
plans, and ensure the availability of counterpart funds during the preparation of the Budget
Framework Paper. The health sector, as a major recipient of external funds, is strengthening its
institutional capacity to manage grants under GFATM in line with the newly developed
framework for the management of development partner projects, the Long-Term Institutional
Arrangements (LTIA). The LTIA describes processes and measures to align programming and
management of external funds to national processes and systems. The Government, with the
support of partners under the Joint Budget Support Framework, is working on strengthening
service delivery by addressing cross cutting constraints. The Joint Budget Support Framework
brings together partners providing general budget support and is coordinated by the Ministry of
Finance, Planning and Economic Development (MOFPED) and the Office of the Prime Minister.
Public sector management has been singled out for improvement, with a focus on improving
personnel management and accountability for service delivery. In the health sector, in particular,
this will involve strengthening personnel management functions, rolling out implementation of
Results-Oriented Management (ROM) and Client Charters and developing an incentive scheme
to attract and retain health workers in remote and hard to reach areas. To address the bottlenecks
in the sector, the Ministry of Health (MOH) has developed a Master Plan for Accelerating
Performance in the Health Sector (April 2008). This plan underscores the need to address
bottlenecks in health infrastructure, human resources for health, and essential medicines and
supplies.
The Republic of Uganda, Budget Speech, Financial Year 2009110 and National Budget Framework Paper FY 2008109 -
20 1211 3.
'* Long Term Institutional Arrangements for Management and Coordination of Global Health Grants in Uganda; Operational
Manual, August 2008.
4
B. Rationale for Bank involvement
12. Health systems strengthening has generally received insufficient support from
development partners. The Government of Uganda (GOU) wishes to address these issues by
strengthening the health system, specifically in the areas of improving existing health
infrastructure, human resources for health and management of the health sector. In addition, it
would like to improve the quality and availability of services for maternal and newborn care as
well as family planning. These areas receive considerably less support from other development
partners. The main sources of external funding to Uganda are from the Global Health
Initiatives, GFATM, GAVI and USG President's Emergency Program For AIDS Relief
(PEPFAR), and are directed to prevention of HIV/AIDS, malaria, tuberculosis, and other
immunizable diseases. The Government views the World Bank as a key development partner
able to mobilize the scale of funding needed to tackle health systems bottlenecks and to provide
the necessary technical expertise.
13. Health system bottlenecks require actions involving Government-wide engagement.
The World Bank is uniquely positioned to facilitate such a multisectoral response given the
scope of its engagement with the GOU across sectors, as well as its experience and available
expertise. The Bank already has a number of ongoing operations with a multisectoral reach,
including the series of the Poverty Reduction Support Credit/Joint Budget Support Operation
(PRSCIJBSO), the Uganda Public Sector Performance Enhancement Project (UPSPEP), and the
Local Government Management and Service Delivery Program (LGMSDP). A key priority
under the PRSCIJBSO is to improve service delivery. While support under the PRSC/JBSO
arrangement will tackle broad policy reforms, the proposed project will complement these
activities by deepening their implementation within the health sector. In addition, the project
will strengthen laboratory infrastructure and services in the renovated health facilities, thereby
complementing efforts of the proposed East Africa Public Health Laboratory Networking
~
P r ~ j e c t . 'The project will focus on physical health infrastructure; human resources for health;
and management, leadership, and accountability for health service delivery. These priority areas
currently represent the chief constraints to effective health services delivery. By addressing them,
the project will contribute towards improving service delivery at the frontline, and making
providers accountable for services delivered to clients.
14. The recent changes in the aid architecture for health have led to increased calls for
the World Bank to concentrate on strengthening health systems. The project is consistent
with both the Bank-wide and Africa Region HNP' Strategie~,'~ which stress the Bank's
comparative advantage in addressing health system bottlenecks. The specific actions selected
under the project are therefore in line with the Bank's core competences.
j 3 This is a regional project with the aim of strengthening capacities for the diagnosis and surveillance of TB and other
communicable diseases through the establishment of a network of efficient, high quality, and accessible public health
laboratories. Proposed for joint submission to the Board with this project on May 25, 2010.
l 4 The World Bank Strategy for Health, Nutrition, and Population Results, April 2007; and Improving Health, Nutrition, and
Population Outcomes in Sub-Saharan Africa: The Role of the World Bank. December 2004.
5
15. The Bank's current approach to support the health sector was prepared jointly with
other partners providing budget support, and is elaborated in the Uganda Joint Assistance
Strategy (UJAS 2005-09). The UJAS is aligned to the Poverty Eradication Action Plan (PEAP),
and although it did not explicitly provide for a separate investment operation for health outside
the PRSC, the proposed project is consistent with both UJAS and PEAP objectives, and several
of the health systems bottlenecks were earmarked for action. Improving health infrastructure,
human resources for health, leadership, and management functions, will contribute to
strengthening health service delivery. The Government recently approved a five-year National
Development Plan (NDP) to replace the PEAP. The theme of the NDP is "growth, employment,
and prosperity for socio-economic transformation". It underscores the importance of human
capital formation and places emphasis on the expansion of the delivery of the essential health
package and strengthening the existing health systems and leadership in the health sector. The
project is included in the new Country Assistance Strategy (CAS) under preparation, which will
be submitted to the Board on the same date as the project.
16. The proposed operation also takes into account the impact of the global economic
slowdown on the Ugandan health sector. Secondary effects have now become apparent, with a
slowdown in growth on account of reduced demand for Uganda's traditional exports. In 2009/10
the current account balance improved, but Foreign Direct Investment and other short-term
foreign inflows have remained weak. The Ushs/US$ exchange rate, which depreciated by over
17 percent in 2008/09, is expected to depreciate more moderately by 4.6 percent in 2009/10.
From 5.8 months of import cover recorded by end of 2007/08, the international reserve position
is still a comfortable 5.6 months cover. However, a continued weakening in aggregate demand
through 2009/10 is expected to reduce GDP growth to 5.6 percent, slow imports, reduce tax
revenues, and support a further deceleration in inflation, from 14.2 percent year-on-year in
2008/09 to 7.0 percent by the end of 2009/10. In the health sector sustained inflationary
pressures have led to increased prices of commodities, a majority of which are imported. To this
end, supplementary resources provided under the Crisis Response Window will help the
Government to counteract the negative effects of the crisis by sustaining current investment
levels in the health sector and to ensure availability of health commodities under component four
of the project on improving maternal health, newborn care and family planning.
C. Higher level objectives to which the project contributes
17. The project contributes towards reduction of morbidity and mortality. The project
is designed to contribute to the achievement of the HSSP I1 objectives of reducing morbidity and
mortality from major causes of ill-health, premature death and disparities therein. The project
will also contribute towards the attainment of the goals and objectives of the new National
Development Plan of improving growth and creating employment and prosperity for socio-
economic development through improving human capital development.
18. Maternal and child mortality remain high in Uganda, yet many of the causes are
avoidable. The project will therefore also help to make operational the 2006-2015 Uganda Road
Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity and
contribute to strengthening Uganda's national capacity to deliver maternal and child health
services. In doing so, the project will contribute towards the achievement of MDGs 4 and 5
6
which aim to reduce child mortality and improve maternal health as outlined in the National
Development Plan (NDP). page 254.
11. PROJECT DESCRIPTION
A. Lending instrument
19. The project will be financed through a Sector Investment Loan.
B. Program objective and Phases
20. Not Applicable
C. Project development objective and key indicators
21. The project development objective (PDO) is to deliver the Uganda National
Minimum Health Care Package (UNMHCP)" to Ugandans, with a focus on maternal health,
newborn care, and family planning. This will be achieved through improving human resources
for health; physical health infrastructure; and management, leadership and accountability for
health service delivery.
22. The project will place emphasis on expanding coverage and improving the quality of
maternal health and newborn care, and family planning services. Maternity care, in
particular, is influenced by the degree to which the health system is functioning. Hence, in
addition to addressing major (cross-cutting) gaps in the achievement of the MDGs, a focus on
maternity services should provide an additional indication of the success of the project's efforts
at strengthening health systems.
23. Achievement of the project development objective will be measured using the
following key performance indicators (KPJs)'~:
Deliveries taking place in Government and Private-not-for-Profit (PNFP) health facilities
(YO).
Pregnant mothers attending at least four antenatal care (ANC) visits (%).
Contraceptive Prevalence Rate (CPR) (%).
People with access to basic package of health, nutrition or population services (number).
Direct Project Beneficiaries (number) of which female (%)I7.
I s The UNMHCP is a set of essential cost effective interventions identified to respond to the most important causes of disease
burden in Uganda. The UNMHCP is organized around four clusters: (a) integrated maternal and child health services; (b)
prevention and control of major communicable diseases: (c) prevention and control of non communicable diseases; and (d)
crosscutting areas of health promotion, community health initiatives, environmental health. school health, as well as gender and
health.
I` Newborn care will be addressed through improved care during the ante natal period and delivery. In this regard no specific
PDO indicator will be provided for newborn care. Instead the indicators on deliveries and ante natal care will cover newborn
care.
l 7 Defined as patient visits in renovated health facilities - out and in patient visits.
7
D. Project components
24. The project comprises four components. This include: (a) improved health workforce
development and management; (b) improved infrastructure of existing health facilities; (c)
improved management, leadership, and accountability for health service delivery; and (d)
improved maternal health, newborn care, and family planning services. The choice of
subcomponents and activities was guided by the need to both achieve results during the project's
life span, and also to promote reforms that would sustain service delivery in the long run, while
complementing ongoing efforts by other development partners. While some activities are being
undertaken at the national level because of the need to address systemic sector-wide issues, the
core set of interventions in each of the first three components will focus on a selected number of
districts (see Annex 4 for the criteria used in selecting facilitieddistricts), with a view to rolling
out these core interventions to other districts in the future. The project renovation interventions
are primarily directed at public facilities, but will to a limited extent equip PNFP training
institutions.
Component One: Improved health workforce development and management (US$5 million).
25. The objective of this component is to improve development and management of the
health workforce. Emphasis will be placed on improving Human Resources for Health (HRH)
to address maternal and neonatal care. The project will support: (a) consolidation of central level
HRH functions at the MOH; (b) strengthening human resource management functions in the
sector; (c) improving staff retention in remote and hard to reach areas; and (d) improvement in
pre-service and in-service training. Specific aspects of HRH will also be addressed in other
project components.
26. Consolidate central level Human Resources for Health functions. The Government
intends to strengthen and consolidate central level HRH functions in MOH. Specific activities
will include the funding of two long-term advisors, rolling out of an HRH Management
Information System (MIS), and providing logistical support to the four professional councils.'*
27. Strengthen human resource management functions. To minimize recruitment delays
and reduce the high cost of advertisements, the project will support: creation of a Central Job
Bureau in the MOH, short-term training of personnel officers (designated officers) including
hospital administrators and other health managers in relevant areas of personnel management,
and provide equipment and technical support for HRH MIS in selected district^'^, including
hospitals.
28. Improve staff retention in remote and hard to reach areas. The Ministry of Public
Service is in the process of developing an incentive-based framework to support recruitment and
retention of personnel in hard to reach areas. The project will support the implementation of this
framework and the motivation and retention strategy repared by MOH. Also, since students
from remote areas are likely to stay in their districts?'the project will provide scholarships for
Medical and Dental Practitioners, Nurses and Midwives, Pharmacists and Allied Health Professionals Councils.
l9 WHO and USAID Capacity Project will support HRH MIS in other districts.
2o MOH, Uganda Health Workforce Study: Satisfaction and Intent to Stay Among Current Health Workers, April 2009.
8
students from hard to reach areas who would be expected to return to the areas after their
courses.
29. Improve pre-service and in-service education. This subcomponent will improve pre-
service education for selected health cadres in short supply by providing scholarships for high
priority cadres and teaching materials. For in-service training, the project will provide
scholarships for postgraduate training in clinical disciplines with major vacancies; support the
accreditation of courses for continuing professional development; and support the development
of a system of internship and clinical mentorship for selected cadres.
Component Two: Improved infrastructure of existing health facilities (US$SS million).
30. The objective of this component is to improve infrastructure of existing health
facilities. Emphasis will be placed on providing minimum quality standards of health care
services, especially in the areas of maternal and child health, through (a) renovation of selected
health facilities; (b) provision of medical equipment; (c) improved capacity for operations and
maintenance; and (d) strengthening the referral system.
3 1. Renovation of selected health facilities. Under this subcomponent, the Government
proposes to renovate 17 general hospitals (GHs)~'and 27 Health Centers Type IV (HC I V S ) ~ ~
and upgrade two general hospitals into regional referral hospitals ( R R H s ) ~ ~ proposed list of
(the
health facilities are listed in Annex 4, Page 42 in Table A4-1). The final list will be agreed after
completion of studies on the detailed designs and cost of the works. The health facilities for
renovation were selected based on remoteness of location; the state of dilapidation; proximity to
major highways prone to road traffic accidents; catchment population; and the need to promote
an effective referral system. The infrastructure works also will include construction of
incinerators; provision of HIVIAIDS clinics and obstetric theatres; expansion of laboratory and
delivery suites; completion of operating theatres; and the constructiodcompletion of staff
housing. Depending on identified needs, the project will connect health facilities to reliable
sources of water, power, sewerage, transport, and Information Communication and Technology
(ICT) services. The specific activities that will be carried out under this subcomponent include
the following:
(a) Six GHs dating back to the 1930s will require fundamental replanning and replacement
of some buildings to align them to the revised standards. This will involve construction of
staff houses as the lack of housing is a major constraint to the recruitment and retention
of key hospital staff.
(b) The two GHs selected for upgrading to RRHs are located in remote areas and are among
the hospitals built before the 1950s.
(c) The GHs built between 1969 and 1973 will not require major replanning. Renovation
works are anticipated to include re-roofing, replacement of water and sewerage systems,
*' General hospitals have a capacity of 100 beds, serve a catchment population of about half a million people and are staffed by
four to six medical officers.
22 Health Centers Type IV are upgraded Health Centers started under HSSP 1 to bring emergency surgical and obstetric care
closer to the communities. They are staffed by one or two a medical officers and serve a catchment population of 100,000 people.
23
In addition to services provided by general hospitals. regional referral hospitals provide specialist services in surgery,
pediatrics. obstetrics. internal medicine. and ophthalmology and serve a population of about two million people.
9
window replacement, and provision of solar lighting in the wards. Some additional works
will include construction of incinerators, provision of HIV/AIDS clinics and obstetric
theatres, as well as expanding space for the laboratories and the delivery suites.
(d) Work on HC IVs will involve completion of operating theatres and doctor's houses and
construction of some additional staff housing. Patient privacy and improved infection
control, especially for HIV/AIDS and TB patients, will be addressed during replanning.
32. Provision of medical equipment. The renovated facilities will be supplied with
appropriate types of medical equipment, with priority given to essential medical equipment for
diagnostics, surgery, and obstetric care.
33. Improved operations and maintenance. This subcomponent will strengthen capacity
for proper operations (maintenance, repairs, and replacements) of health facility assets:
buildings, medical equipment, and vehicles. The project will assist GOU to develop policies and
procedures for procurement and maintenance of medical equipment; support existing policies for
maintenance; review options for managing and financing Regional Medical Equipment
workshops including exploring Public Private Partnership (PPP) options; and support
implementation of an inventory system developed through the Danish International Development
Agency (DANIDA).
34. Improved referral system. The project will provide ambulances depending on need to
selected hospitals and a general purpose vehicle for each renovated health facility so that the
ambulances are reserved for emergency transfers rather than general purpose use. In addition,
the project will support MOH to develop policy guidelines on ambulances and a strategy for
using ICT to improve referrals. The procurement of vehicles will be guided by the Government
instructions on engine capacity. Activities under this subcomponent will be implemented under
close collaboration with component four on reproductive health.
Component Three: Improved Leadership, Management, and Accountability for health service
delivery ( U S 10 million).
35. The objective of this component is to strengthen management, leadership, and
accountability for health service delivery. Priority will be placed on (a) implementing
performance-based management approaches; (b) professionalizing and strengthening the
management of hospitals; (c) developing and rolling out implementation of the hospital policy
framework; and (d) procurement, logistics, and supply chain management (SCM).
36. Performance-based management approaches. The Ministry of Public Service has
instituted Result-Oriented Management (ROM)24 and Client Charters2' as part of a
comprehensive integrated performance management system aimed at improving performance
monitoring for results and productivity in delivery of public services. The project will assist
24 ROM is aimed at enhancing performance and accountability of implementing agencies, which are required to prepare annual
performance plans that reflect their performance output targets as a basis for the appraisal of the performance of the agency and
staff.
2 5 Client Charters spell out the service standards and the commitment to service delivery that clients and stake holders should
expect from an implementing agency. The Client Charters are intended to enhance transparency, performance, and
accountability.
10
MOH in customizing and rolling out the implementation of ROM and Client Charters;
strengthening Performance Appraisal and systems for Recognition, Reward, and Sanctions; and
initiating application of Performance Contracts in the sector. Further, the project will support the
scaling up of social accountability mechanisms like the citizens report card at community level
for health service delivery.
37. Hospital policy framework. The project will support the new MOH hospital policy by
assisting in the development and roll out of guidelines for developing individual hospital plans,
reviewing options for management of RRHs and developing a rational financing mechanism for
public hospitals. In addition, the project will support the MOH to develop a hospital
accreditation system and internship policy to guide practical skills development for essential
health cadres.
38. Professional management of health facilities. The Government has plans to
professionalize the management of hospitals, and has requested Uganda Martyrs University,
Nkozi26 to develop a two-year Masters program in hospital management. The project will
support MOH to implement this training program, as well as, programs to upgrade staff already
in management positions.
39. Procurement, logistics, and supply chain management. Under this subcomponent, the
project will build capacity in the pharmacy division to monitor activities of National Medical
Stores (NMS); review relevant procurement regulations (Public Procurement and Disposal of
Assets and Local Government Acts) to suggest amendments and develop guidelines where
necessary; and provide complementary SCM support to selected districts in close collaboration
with the new USAID-financed SURE project27.
40. Strengthening delivery of health services at the district level. With the proliferation of
districts, the Health Sub-district concept is no longer able to meet its original intended objectives
in terms of appropriate supervision of health services.28The project will provide short-term TA
to examine the options for addressing this by reviewing the viability of the Health Sub-district
concept, the suitability and capacity of the regional hospitals, and the administrative and
management capacity at the district level to support health service delivery.
41. Project Management. This subcomponent will support costs related to the operations
and management of the project, including specific TA in the areas of project management,
financial management, procurement, and other areas. Consistent with the use of government
systems, these consultants will work as part of the relevant functional units.
Component Four: Improved maternal, newborn and family planning services (US$30 million).
42. The objective of this component is to improve access to, and quality of, maternal
health, newborn care, and family planning services. This component will: a) expand and
26 Uganda Martyrs University is already running courses in health services management.
27 The USAID SURE project is supporting 45 districts in medicines logistics management.
28 The subdistrict concept involved delineation of catchment areas and upgrading of selected health centers to provide emergency
obstetric and surgical care. The health subdistrict was headed by a medical officer.
11
improve quality of reproductive health and newborn care; and b) increase the availability and
demand for family planning services. While some activities under this component will be
implemented on a national scale, others will be implemented in selected districts based on
specific criteria. The project will finance key Emergency Obstetric and Neonatal Care (EmONC)
equipment, contraceptives, and training and capacity building activities to expand coverage of
maternal health, newborn care, and family planning services. Consistently with the objective of
rapid disbursement of CRW resources, procurement of EmONC equipment and commodities,
including contraceptives, under this component will be front-loaded. This should allow the
buildup of buffer stocks which will guard against future stock-outs, allowing normal
Government procurement of contraceptives to maintain adequate inventory levels.
43. Expanding and improving quality of maternal and newborn care. This
subcomponent will: (a) finance development and dissemination of maternal and newborn care
guidelines and protocols; (b) provide hands-on training and mentorship on Emergency Obstetric
and Neonatal Care (EmONC); (c) provide basic and comprehensive EmONC lifesaving
procedures and delivery services, including the purchase of major EmONC equipment, essential
EmONC medicines and supplies; (d) augment the provision of post-abortion care through the
purchase of manual vacuum aspiration kits and provision of related training; (e) strengthen the
referral and communication system through the provision of protocols and guidelines,
ambulances with basic resuscitation equipment, a boat ambulance for the Kalangala district29,
and ambulances (bicycle, motorcycle, or tricycle) for hard to reach communities to increase
utilization of maternal and newborn care services3'; and ( f ) expand and strengthen maternal and
perinatal death reviews.
44. Increasing the availability of and demand for family planning services. This
subcomponent will expand the provision of family planning services through: (a) expanding and
improving the quality of facility-based family planning services; (b) expanding the provision of
long-term and permanent methods (LTPM) through NGOs and private providers (e.g., midwives
and private practitioners); (c) providing community-based distribution of family planning
services; and (d) generating demand for services. The project will procure additional IUDs and
implants to meet the needs of NGOs that are providing such services, and to make LTPM more
accessible at the public facilities. The MoH will partner with these NGOs to provide hands-on
training to nurses and clinical officers (for IUD and implant insertion and removal) and to
medical doctors at the HCIV health facilities and hospitals (to perform female sterilization).
Family planning equipment will be procured for the public health facilities, including mini-
laparatomy kits, vasectomy kits, implant insertion and removal kits, and IUD insertion kits. The
project will train and support community-based distributors to provide condoms and oral
contraceptive pills and to refer and follow-up clients using injectable contraceptives, implants, or
IUDs. The project will support the 2009- 14 Uganda Reproductive Health Commodity Security
Strategic Plan by filling gaps to ensure the continuous availability of the full range of
contraceptives (taking into consideration contributions .from US AID and the United Nations
Population Fund [UNFPA]).
29Made up op small islands in Lake Victoria.
30
The equipment will be procured as part of Component 2 for an estimated cost of $3.2 million in addition to the funding for this
component.
12
E. Lessons learned and reflected in the project design
45. Previous IDA Projects. The project design benefitted from lessons learnt by the earlier
IDA projects3' other development partner projects in Uganda, and the Bank study on contracting
for Primary Health Care in Uganda3*, which assessed performance-based contracting as a means
of delivering primary health services through private not for profit health facilities. These lessons
are consistent with findings from other countries.
46. Project Development Objective (PDO) and Result Framework. Both the DHSP and
STIP had broad PDOs and weak monitoring frameworks. As a result, monitoring the
achievement of the development objectives and implementation progress was less than
satisfactory. Accordingly, efforts have been made to elaborate a realistic PDO for which the
project can be accountable, and to develop a clear result framework with baseline data at the
outset. In doing so, special attention was paid to existing capacity, with a premium placed on
avoiding an overly complex project design.
47. Focus on reforms for which there is already commitment. Reform processes tend to
be protracted, especially if they are too broad and commitment, and/or a champion, is absent.
The project was specifically requested by the GOU (and hence there is clear ownership) and it
has been designed on the basis of existing government programs, and to the extent possible,
avoids introducing new reforms. The project will target selected areas of reform for which there
is both Government-wide and development partner commitment, and ongoing complementary
operations, especially in regard to reforms which require cross-sectoral actions.
48. Ensure synergy and complementarity with other ongoing programs. The World Bank
is unique in Uganda because of the complementary operations which it has on the ground. These
include the PRSC, UPSPEP, and LGMSDP. The project, in its design of Components 1 and 3,
takes these operations into account and will deepen implementation of reforms under these
programs in the health sector. While the other operations are focused on broad Government
reforms, the project will deepen implementation of these reforms within the health sector.
49. The benefit of analytical work. The project design greatly benefits from analytical
work in the sector. Prior to project preparation, the Bank and GOU undertook a study on
realities of fiscal space for health in Uganda.33The Bank also undertook a study on governance
and political economy of the health sector in Uganda.34These studies and those by the USAID-
financed Capacity Project3' have provided valuable input to Components 1 and 3, and were
instrumental in helping GOU to look beyond health infrastructure challenges towards the major
binding constraints affecting health sector performance.
" Sexually Transmitted Infections Project (STIP), District Health Services Project (DHSP) and Uganda HIVIAIDS Control
Project (UACP).
3 2 Unpublished Report, World Bank. Contracting for Primary Health Care in Uganda, February 2007.
Fiscal Space for Health In Uganda, May 2009.
l4 Final Draft Report; Governance and Political Economy Constraints for Development Effectiveness in Uganda's Health Sector;
August 2009.
35 MOH, Uganda Health Workforce Study: Satisfaction and Intent to Stay Among Current Health Workers, April 2009; Uganda
Health Workforce Turnover Study, February 2009.
13
50. Managing cost escalation. This project involves considerable work on infrastructure.
Experience from previous African Development Bank (AfDB) health infrastructure projects, as
well as IDA'S road projects, show that substantial cost escalation often occurs. To mitigate
against this, the feasibility and architectural design studies (including costing) will be completed
early so that adjustments can be made to the implementation plan before the contracting process
begins. In addition, the financing of Component 2 will be capped at US$85 million.
51. Building on successes of earlier projects. To mitigate the logistical challenges of
distributing medical equipment from the national level, the (IDA-funded) District Health
Services Project and Dutch funded Development-Related Export Transactions Programme
(ORET), both consigned medical equipment directly to health facilities. In addition, seven year
maintenance contracts were included under ORET for expensive equipment. The Government
has incorporated the lessons learned from these projects into the project design.
52. Bonding staff and performance contracts. Several attempts by Government and
development partners to bond staff in the health sector proved ineffective in the past. Similarly,
the performance-based bonus scheme experiment36 did not have a discernible impact on the
production of health care services provided by PNFP facilities. Instead, it appears that facility
autonomy in financial decision making had a positive impact on health care production.
Cognizant of this, the project will introduce scholarship schemes and focus on. strengthening
management functions at the health facility level, in line with responsibilities already devolved to
the health facilities under the decentralized arrangement.
53. Governance and Accountability. In 2005, the GFATM and GAVI suspended their
support to Uganda citing mismanagement of the grants. The Bank undertook a study on the
governance and political economy of the Uganda health sector in August 2009 findings which
that study have been incorporated into the design of the institutional, fiduciary, and monitoring
arrangements. The report highlights challenges in areas of fiduciary management, sector
stewardship, and proliferation of districts lacking sufficient capacity to implement their
mandates. The issues are elaborated in Annexes 7, 8 and 1 1.
F. Alternatives considered and reasons for rejection
54. Lending instruments. The following two alternatives were considered: (a) an adaptable
program loan (APL); or (b) a stand-alone sector investment lending (SIL) operation. While the
value of ensuring long-term engagement and commitment to policy reforms in the sector could
potentially be realized under an APL, this instrument was rejected mainly because of the absence
of a current sector plan to anchor the operation over most of the period of project execution.
GOU is currently in the process of developing a new health sector strategic plan and an overall
National Development Plan. Once this plan is developed and approved, an APL instrument
could be considered for any follow-on operation.
55. Including a specific focus on nutrition. In light of the significant problem of
malnutrition in Uganda, the option of incorporating nutrition interventions into the project was
explored. However, it was felt that since malnutrition is currently being addressed by GOU
36 Unpublished Report, World Bank, Contracting for Primary Health Care in Uganda, February 2007.
14
(including some external assistance), and there are already a number of complexities in the
project, adding another major area of focus beyond reproductive health was not feasible,
although nutrition interventions related to maternal and child health may be explored in the
future.
56. Incorporating Results Based Financing (RBF) into the project interventions. RBF
was also considered as an option. It was felt that RBF should be explored once project
implementation is more advanced, rather than incorporating this into the initial project design,
since many of the project interventions in leadership, management, and human resources will
help facilitate RBF. However, these elements need to be in place for RBF to work effectively,
and thus a sequential approach was therefore felt to be the most appropriate.
111. IMPLEMENTATION
A. Partnership arrangements
57. The project will be implemented under the Uganda health sector wide approach
(SWAP) arrangement governed by the Memorandum of Understanding (MOU) between
the GOU represented by the MOH and the development partners. While the MOU is not a
legal document, it reflects the commitment of all parties towards implementation of the Health
Sector Investment Plan under principles which foster strong collaboration and partnership. In
addition, the project will be implemented in a complementary manner to the USAID supported
Capacity Project and Securing Uganda's Right to Essential Medicines (SURE) project, both of
which are particularly relevant to the interventions included under this project.
B. Institutional and implementation arrangements
58. The project will be implemented under the newly created framework for the
management of the development partner projects, the Long-Term Institutional
Arrangements (LTIA). This framework describes processes and measures to align and
mainstream programming and management of development partner projects to national processes
and systems, thus ensuring coordination and sustainability of programs. The PS of the MOH
will serve as the "Accounting Officer" for the project, assuming overall responsibility for project
funds. The PS will delegate the day-to-day management of the project to a Project Coordinator
who will be a senior officer within the MOH and will be supported by Component Coordinators.
These Coordinators are heads of departments/divisions directly involved in project
implementation: Health Infrastructure; Human Resources for Health; Reproductive Health;
Curative and Clinical services; Quality Assurance, Procurement and Finance. Component
coordinators may appoint focal persons to lead implementation in their respective
departments/sections.
59. This project will be among the first to use the new framework. A manual to make
operational the LTIA was developed and endorsed by partners. In support of this approach,
technical advisors/specialists will be provided under the project to assist with capacity building
and other project implementation activities in, inter alia, Financial Management, Procurement,
Monitoring and Evaluation, Human Resources for Health (HRH Policy Advisor and HRH
Management System Strengthening Advisor), Health Infrastructure (Quantity Surveyor and
15
Architect) and Reproductive Health (RH Advisors). The Project Coordinator will be supported
by a Deputy Project Coordinator and a Project Officer. Where consultants are recruited, they
will be accountable and report to the respective heads of departmentskomponent coordinators to
which they are assigned. Coordination of policy issues arising from the implementation of this
project will be through the respective Technical Working Groups. The Project Coordinator will
be responsible for providing periodic reports to Senior Management and Top Management
Committees as well as the Health Policy Advisory Committee (HPAC), where partners and
Government meet together. This arrangement will ensure coordination and harmonization of
policy proposals and decisions which affect the implementation of the project specifically and
the health sector generally. The Permanent Secretary will ensure that all the above positions
including focal persons are assigned to lead project implementation in their respective
sections/departments. The structure for the institutional arrangement for the project, principles
governing project institutional arrangements and the detailed job descriptions for the project
coordinator, component coordinators, focal persons and suggested TAs are outlined in Annex 6,
and elaborated in detail in the project implementation manual.
60. The project will concentrate its activities in districts with facilities under renovation.
Implementation of activities under Components 1, 3, and 4 will be targeted to districts with
health facilities under renovation to demonstrate the impact of a comprehensive health systems
approach to improving service delivery. By clearly showing the success of the approach, the
potential for further roll-o'ut to other districts with either Bank or other development partner
funds would be enhanced. In order to ensure local government ownership, districts will
participate in all the phases of renovation. The districts will be expected to approve and certify
the architectural designs and works under the project.
C. Monitoring and evaluation (M&E) of outcomes/results
61. The results framework is informed by current advances in M&E thinking in the
Bank, and is consistent with MOH's overall M&E framework. The result framework focuses
on accountability for results by placing a strong emphasis on intermediate outcomes. The data
will be collected from a combination of sources such as the routinely collected health
information systems and sample-based surveys, including beneficiary surveys to evaluate user
satisfaction conducted by the Uganda Bureau of Statistics. The Department of Quality
Assurance will have the primary responsibility for coordinating M&E activities under the
project. An M&E specialist will be recruited to work in the Department of Quality Assurance. In
support of the project objective, and consistent with the activities being financed, five outcome
indicators and 16 intermediate indicators were selected for which the project will be held
accountable. These, however, are not the only indicators that will be tracked by the project, or
that will be needed to successfully demonstrate the results chain in support of the outcome
indicators. The following IDA- 15 indicators applicable to this project are included in the core set
of project indicators: (a) Health personnel receiving training (number, in-service, pre-service);
(b) Health facilities constructed, renovated, and/or equipped (number); (c) Pregnant women
receiving antenatal care during a visit to health provider (number); (d) Direct Project
Beneficiaries (number) of which female (%); and (e) People with access to a basic package of
health, nutrition and population services (number). The indicator: patient visits in renovated
health facilities - out and in patient visits - will be used as a proxy measure for Direct Project
16
Beneficiaries (number - female and male). The detailed description of the result framework
including the matrix is in the Annex 3.
D. Sustainability
62. The project will address health systems bottlenecks and improve effectiveness of the
health sector. By improving management of human resources for health and strengthening
management functions in the sector, the project will directly contribute towards the sustainability
of the sector. Emphasis on addressing system-wide constraints will ensure reproductive health
activities become more sustainable. The financial impact of the project on Government's health
spending will be felt mainly in terms of additional resources for maintenance of renovated
facilities and repairs and replacements of medical equipment. These costs will require a
commitment by Government if the project's benefits are to be sustained beyond the project's life
span. The project is part of the broader Government program under the SWAP and it is included
within the Government's Medium-Term Expenditure Framework (MTEF). Under the optimistic
scenario, Government per capita health expenditure is projected to double between 2007 and
2015 (from UGShs 19,453 to UGShs 41,214), rising from 3.13 percent to 4.08 percent of GDP.
Using projections based on a much more prudent scenario, per capita expenditure is anticipated
to increase to UGShs 3 1,582. With this projected increase in health spending, Uganda should be
able to absorb the recurrent costs into its budget. This will however depend on continued
development partner support, Government commitment to health, and increased emphasis on
reducing waste in health spending.
E. Critical risks and possible controversial aspects
63. The overall project risk rating is substantial.
64. Provision of operational funds for maintenance. The poor state of the physical health
infrastructure is largely due to inadequate budgetary allocations towards operational costs,
including maintenance. There is a risk that Government will continue to provide inadequate
budgetary allocation for such costs. The MOH has agreed to create a credit line for medical
equipment; establish a budget line under the hospital vote to finance replacement of basic
medical equipment and undertake renovations and repairs of their assets; and include
maintenance contracts during procurement of large ticket items. The Bank will continue
working with Government to: (a) ensure that adequate budgetary allocations are made towards
maintenance in the MTEF; (b) establish a viable maintenance program including making
operational the credit fund/line for essential equipment for which Government and partners have
already reached agreement; and (c) operate the new inventory system.
65. Capacity to implement the project. The MOH has previously relied on project
implementation units to execute large development partner projects. For this project, it intends to
use the newly developed framework for the management of development partner funded
projects. To mitigate the risks associated with the move to the new implementation
arrangements, a detailed assessment of the implementation as well as fiduciary arrangements was
conducted, and agreement reached with the MOH to provide additional consultants who will
have the dual roles of helping to carry the burden of project implementation and building
17
capacity within the MOH to effectively carry on such activities on an ongoing basis. In addition,
the team will undertake rigorous monitoring of the project during implementation. Further, at
the suggestion of the Quality Enhancement Review (QER) panel, the Bank team will pay
specific attention to the civil works component through the following steps: (a) retaining the
services of an independent architect to review the designs and costing when the report of the
consultants contracted under the PPA is available and (b) conducting semi-annual internal audits
as well as value-for-money audits under the project.
66. Sustained interest for reform. Project activities under Components 1 and 3 demand
sustained commitment of Government, especially that of the Ministry of Public Service, towards
reforms in areas of management of human resources for health and strengthening management of
health facilities. These reforms may take time, resulting in a loss of interest by Government. In
order to mitigate against this risk, the project will target a few selected areas of reform for which
there is Government wide and development partner commitment, as well as complementary to
ongoing Bank operations. For example, the team will engage in the PRSC process and continue
to work with the UPSPEP team to build and maintain broad commitment to the agreed reforms
especially with the Ministry of Public Service. Emphasis on Information, Education and
Communications (IEC) and Behavioral Change Communications (BCC) in an effort to change
the mindset will promote sustainable change regarding acceptance of RH services.
67. Governance Challenges. GAVI and GFATM both at one time suspended their grants to
Uganda citing irregularities with the way the grant funds were being used. A detailed project
implementation manual is being developed with the roles of key entities involved in the project
implementation clearly defined. Measures to ensure effective oversight and fiduciary control
have been considered, including appropriate covenants in the financing agreement, Le.,
semiannual internal audits and value-for-money audits. Management of fiduciary risks will be
built into the project design including: (a) prior review of large contracts; (b) random reviews of
statements of expenditures (SOEs) during implementation; (c) financial management reporting
linking performance to financial costs; (d) random audits of small executing entities; and (e)
financial audits of all large executing agencies. During project implementation, FM (and
procurement) will be given emphasis during supervision with respect to monitoring agreed
mechanisms and conditions. In addition, a Health Governance Strategy and Action Plan has
been agreed with Government. This will also be monitored during project implementation
(Annex 1 1, Health Governance Strategy and Action Plan). Guidelines on preventing and
combating Fraud and Corruption in projects financed by IBRD Loans and IDA Grants" dated
October 15,2006 shall apply to the project.
68. National Elections. National elections are scheduled for February 201 1. This may result
in attempts to exert political influence in established project decision making processes.
Processes and principles promoting transparency in the project decision making were agreed
during preparation and have been clearly elaborated in the project implementation manual. In
addition, health facilities for renovation were ranked and selected in accordance to the agreed
criteria at project preparation. Clear criteria, broad stakeholder involvement, and detailed
documentation of decision making processes (including the selection of facilities for
rehabilitation) should help to minimize political interference, by increasing the leverage of the
project to argue in support of agreed activities/ interventions.
18
F. Loadcredit conditions and covenants
69. Credit Effectiveness:
(a)The Recipient has prepared a satisfactory Annual Work Plan for the first year of Project
implementation.
(b)The Recipient has recruited the accounting, procurement and monitoring and evaluation
specialists.
(c)The Recipient has adopted the Project Implementation Manual. The manual will include
financial management, procurement, monitoring and evaluation annexes.
70. Project Execution:
(a) The Project Implementation Manual will include the following: (i) an institutional set-up
for the management of the Project, (ii) financial management and accounting procedures
annexes; (iii) detailed arrangements for the overall carrying out of the Project; (iv) guidelines
for the preparation of Annual Work Plans; (v) internal control systems to be followed during
Project implementation; (vi) detailed guidelines and procedures for the implementation of the
ESIA in connection with the carrying out of the Project; (vii) the guidelines for Project
monitoring and evaluation; and (viii) guidelines for implementation of the Health
Governance Strategy and Action Plan;
(b) By April 15 of each year, an annual work plan and budget (the Annual Work Plan) shall
be developed, including: (i) the Project activities to be carried out during the next twelve
months; (ii) the procurement plan and disbursement schedule; (iii) the annual budget for the
Project; (iv) annual training plan; and (v) the amount of counterpart funds to be provided by
the Recipient to carry out the Project activities during such period.
(c) The Project shall be carried out in accordance with the provisions of the Anticorruption
Guidelines;
(d) The Project shall be carried out in accordance with a Health Governance Strategy and
Action Plan, in form and substance satisfactory to the Association, including, inter alia: (i)
anticorruption prevention measures; (ii) mechanisms to improve the impact of Project
activities; and (iii) procedures to enhance the transparency of Project transactions;
(e) The external audit shall be carried out by the Auditor General of Uganda, within 6
months after the end of each fiscal year and include action plans to improve performance
and/or correct any shortcomings and/or deficiencies;
(f) The Project shall be implemented in accordance with the provisions of the Health Care
Waste Management Plan and the Environment Management Plan;
(g) Project progress reports shall be provided quarterly no later than forty-five days after the
end of the period, and shall include progress on the Key Performance Indicators;
(h) Procurement audits of the project shall be carried out annually.
IV. APPRAISAL SUMMARY
A. Economic and financial analyses (see Annex 9)
19
71. Health status is a major determinant of individual wellbeing and a good indicator of
a country's level of development, particularly for developing countries. Public investment in
health care is justified because of: (a) its public goods nature; (b) uncertainty surrounding illness
(in terms of occurrence), severity, and cost of treatment; (c) asymmetry of information regarding
medical interventions; and (d) the need to correct existing inequ8lities. The public sector will
continue to play a significant role in Uganda for a number of reasons: the private health
subsector is underdeveloped and poorly regulated; the population is largely rural; and there is a
high burden of communicable diseases primarily affecting mothers and children for which cost-
effective interventions exist. In addition, Uganda as a country is witnessing a rapid rise in
household out-of-pocket expenditures on health and catastrophic illnesses.
72. The project focuses on critical bottlenecks imp.eding sector performance. In addition
to health infrastructure, the project will focus on addressing critical health system bottlenecks, as
they relate to, in particular, maternal, child health, and family planning services. These
bottlenecks are responsible for significant waste in the sector. To mitigate contingent liabilities
arising from health infrastructure related works, expansion of existing facilities and construction
of new facilities will be discouraged.
73. Uganda will continue to experience optimal growth prospects in the near and
intermediate period. The economy is anticipated to continue to grow by 6 to 7 percent per year
in real terms for the next 5 to 7 years. Similarly, as previously noted, it is anticipated that health
spending will double over the same period. On the basis of this projected growth, Uganda should
be able to realize considerable spending in the sector. The impact of the increase, however, will
critically depend on a number of factors: the sustainability of funding from global initiatives, the
extent to which domestic resources can be mobilized to substitute funding from Global Health
Initiatives if the latter become unavailable, and on the extent to which Uganda can improve
efficiency of health spending and address drivers of increased health spending.
74. The fiscal space study revealed significant waste in the health sector, primarily
because of weak management o f (a) human resources for health; (b) health facilities; (c)
procurement and logistics; and (d) development assistance for health. The project will address
gaps in some of the areas under Component 1 and 3 and contribute to reducing waste in the
sector.
B. Technical
75. The project aims to improve functionality of the existing health facilities. The choice
of project subcomponents and interventions has been guided by the need to address the most
pressing health system bottlenecks and to improve functionality of existing health facilities, in
particular to deliver maternal and child health services which represent a major source of disease
burden in the population. Poor management of human resources for health, weak overall
logistics management and inadequate management capacity at the health facility level are among
the most pressing challenge^.^^ While some project activities will have a national focus, project
implementation will be targeted to the districts with health facilities under renovation, in order to
maximize the synergistic impact of a comprehensive health systems approach to improving
" Fiscal Space for Health in Uganda. Contribution to the 2008 PER. May 2009
20
health service delivery. The selection of the preliminary list of health facilities for renovation
was based on remoteness of location, state of dilapidation, proximity to the major highways
prone to road traffic accidents, catchment population, and the need to promote an effective
referral system.
76. Uganda's high population growth rate is driven primarily by the high total fertility
rate. The total fertility and population growth rates are among the highest in the world and are
putting a big strain on the capacity of Government to deliver social services, especially in areas
of education, health care, and employment. Investing in reproductive health care, especially
family planning will not only release the strain on Government budget for social services but
also improve the health of mothers and children and the overall welfare of households.
C. Fiduciary
Procurement
77. The national legislation on public procurement as laid out in the Public
Procurement and Disposal of Public Assets Act (PPDA), 2003 is generally in line with the
World Bank's Guidelines. Some of the exceptional provisions are currently being addressed as
part of the PRSC. The exceptions are listed in Annex 8 of the PAD. The major country
procurement risks are the limited compliance with the Act, as indicated in PPDA's Audit
Reports. This risk will be mitigated for the project by the IDA'S monitoring through prior review
and post review of contracts and supervision missions. Procurement for the proposed project
would be carried out in accordance with the World Bank's "Guidelines: Procurement under
IBRD Loans and IDA Credits," dated May 2004, revised October 2006, and "Guidelines:
Selection and Employment of Consultants by World Bank Borrowers," dated May 2004, revised
October 2006.
78. Procurement for the project will be implemented by MoH and NMS. The key issues
and risks concerning procurement for implementation of the project are: (i) staff capacity gaps in
the MoH Procurement Disposal Unit (PDU), particularly the lack of experience of the PDU staff
in IDA financed procurement management; (ii) inadequate staff numbers and technical skills mix
in the Health Infrastructure Division to supervise consultants and contractors; (iii) the workload
for the PDU, (iv) Inadequate procurement planning, (v) Inadequate procurement record keeping,
and insufficient space in PDU and (vi) inefficiency in procurement processing partly attributed to
lack of understanding of roles and responsibilities between user departments and PDU. The risk
to project procurement management by MoH to project is Substantial. The details on the
procurement arrangements are indicated in Annex 8.
79. The corrective measures to mitigate the overall risk as agreed upon are: (a) Recruit a
Procurement Specialist to provide hands-on coaching, mentoring of PDU staff and User
Departments, (b) PDU staff to attend courses in procurement of works and goods and selection
of consultants at ESAMI, (c) PDU to delegate to user departments the micro-procurement
function or to use framework contracts for common items, (d) MoH to establish an acceptable
MIS for procurement tracking and an acceptable procurement filing and record keeping system,
(e) MoH to recruit one Architect, one Quantity Surveyor and 5 Clerks of Works, ( f ) PDU to
21
prepare a procurement plan for the first 18 months in coordination with the user departments, and
( f ) Prepare Procurement Manual to clarify roles and responsibilities of staff. The procurement
plan was agreed between the Borrower and the Project Team on April 1, 2010 and endorsed
during the negotiations.
80. The results of the assessment indicate that the procurement management overall risk
rating for the project is Substantial.
Financial Management
8 1. The project's financial management transactions will be mainstreamed within the
MOH with the Permanent Secretary as the overall accounting officer. Daily operations will
be handled by the Accounting Department headed by the Assistant Commissioner (Accounts).
Due to the already existing work load, additional accounting staff will be recruited under the
project. The GOU accounting policies and procedures documented in the Government's Treasury
Accounting Instructions issued under the Public Finance and Accountability Act 2003 will be
used for the project. This will be supplemented with additional guidance on Bank project
requirements regarding external auditing and financial reporting, as documented in the Financing
Agreement. Semiannual internal reviews will be carried out by the Internal Audit Department of
the MOFPED, and at least two Value-for-Money audits will be commissioned by the Auditor-
General during the life of the project. The funding for these activities will be provided through
the project. The project's accounts will be handled using Navision accounting software pending
configuration of the Integrated Financial Management Information Systems (IFMIS) currently
being rolled out by the MOFPED to handle preparation of project accounts. The Ministry has
adequate internal audit arrangements, and the internal auditors within the Ministry will include
the project activities in their work plan. The project's financial statements will be audited by the
Auditor General in accordance with statutory requirements, and Terms of Reference will be
developed. The GOU will name at least three designated signatories for Withdrawal Applications
and will name at least two individuals designated to act for the Accounting Officer, the Project
Coordinator, and the Component Coordinators when absent. The GOU will further state a
procedure in the project implementation manual that will automatically delegate, authority to the
Acting Accounting Officer, Project Coordinator and Component Coordinators as required.
82. The results of the assessment indicate that the Financial Management overall risk
rating for the project is substantial after mitigating measures. Appropriate mitigating
measures have been identified and incorporated in project design. Actions outlined in the
Financial Management Action Plan will be undertaken by MOH to strengthen the financial
management system. In order to ensure that the project is effectively implemented, MOH will
ensure that appropriate staffing arrangements are maintained throughout the life of the project. In
conclusion, the proposed financial management arrangements put in place by the project meet
the Bank's minimum requirements for project financial management as per OP/BP 10/02 and
therefore adequate to provide, with reasonable assurance, accurate and timely information on the
status of the project required by IDA. The implementing entities are compliant with the Bank's
financial management requirements and there are no overdue audit reports and interim financial
reports from these entities.
22
D. Social
83. The project will contribute towards improving service delivery at the frontline and
making providers accountable for services delivered to the clients, as well as providing
opportunity for both male and female users to provide feedback on the same services. This
will promote the social development outcomes of inclusion and cohesiveness for improved
health services delivery. Further, the project activities include the rehabilitation of known
existing general hospitals and HCIV health facilities including staff housing. However, the
Environment and Social Impact Assessment (ESIA) undertaken in January 201 0 that included
visits to all sites has confirmed that there is no need for additional land for project activities, and
MOH and the relevant facilities have acceptable proof of ownership of the available land and
there are no disputes over this land. The ESIA suggests therefore that there are no involuntary
resettlement issues associated with this project and that OP 4.12 is not triggered. Individuals,
who are staff of the health facilities with non-health related activities like gardening on the
facility land will be given notice and a date for their departure or relocation will be set prior to
the start of civil works. Construction related social impacts have been covered under the site
specific EMPs. It is agreed that employer rules affecting activities employees can exercise on
their work premises are not subject to the Association's resettlement policy.
E. Environment
84. The rehabilitation/expansion of basic health infrastructure and construction of staff
houses and other facilities on the grounds of existing hospitals and health centers may have
localized adverse environmental impacts associated with civil works. To manage these, the
project will have to comply with environmental assessment requirements under the Uganda
National Environment Act (1 995), National Environmental Impact Assessment Regulations
13/1998, other Ugandan environmental regulations, and the World Bank safeguard policy OP
4.01 on Environmental Assessment. Environmental due diligence for the major civil works was
carried out through preparation of an Environmental and Social Impact Assessment (ESIA),
which includes an Environmental Management Plan. There are no environmental or social issues
which cannot be addressed through routine mitigation measures and good construction practices
and funded within the overall level allocated for civil works activities.
85. The project will enhance and expand provision of health services, thus contributing
to increased generation of medical waste. To manage the environmental aspects of medical
waste management, the project will promote implementation of the National Health Care Waste
Management Plan for 2009/2010 - 201 1/2012 that was recently completed and disclosed. The
project will also promote implementation of the existing injection safety policy. Following the
HCWMP, the project will fund construction and use of suitable medical waste incinerators for
the various levels of health facilities. The final selection of waste incineration technology was
determined with environmental (air pollution) as well as operating (cost and sophistication)
considerations in mind. It was agreed that the approved HCWMP (April 13, 2010) will apply to
the project throughout the duration of the project, unless agreement is reached to adopt an
updated or revised version of the HCWMP.
23
F. Safeguard policies
Safeguard Policies Triggered by the Project Yes No
Environmental Assessment (OP/BP 4.0 1) [XI [I
Natural Habitats (OP/BP 4.04) [I [XI
Pest Management (OP 4.09) [I [XI
Physical Cultural Resources (OPIBP 4.1 1) [I [XI
Involuntary Resettlement (OP/BP 4.12) [I [XI
Indigenous Peoples (OP/BP 4.10) [I [XI
Forests (OP/BP 4.36) [I [XI
Safety of Dams (OP/BP 4.37) [I [XI
Projects in Disputed Areas (OP/BP 7.60)* [I [XI
Projects on International Waterways (OP/BP 7.50) [I ' [XI
G. Policy Exceptions and Readiness
86. No policy exceptions are required. The project implementation plan has been
completed and a project operations manual is being prepared. Further, activities have started
under the Project Preparation Advance to develop detailed environmental assessments for each
facility and to conduct detailed architectural, engineering, and costing work. Once completed,
this should allow the project to quickly move into tendering and implementation of the civil
works, which represent a large proportion of total project costs.
* By supporting the proposed project. the Bank does not intend to prejudice the final determination of the parties' claims on the
disputed areas.
24
Annex 1: Country and Sector or Program Background
Uganda: Uganda Health Systems Strengthening Project
87. Uganda has over the last two decades registered impressive economic performance.
GDP rate grew at an average of over 6 percent per annum and poverty levels were reduced from
44 percent to 3 1 percent from 1992 to 2005/06. Nonetheless, Uganda remains one of the least
developed countries. GDP per capita in 2007 was estimated at US$320. In 2008 Uganda's
population was estimated at 28 million people with a growth rate of 3.2 percent with a
dependency ratio of 1,12, both among the highest in the world. Income per capita is estimated to
have grown by 0.6 percent in US$ terms in the past decade.
88. Uganda's HNP outcomes remain by and large poor. MMR is estimated at 435 deaths
per 100,000 live births, IMR at 76 deaths per 1,000 live births and stunting in children under five
at 32 percent. HIV prevalence dropped from 18 percent in the early 1990s to 6.4 percent in
2002, where it has since remained. With the exception of MDG 6 on combating communicable
diseases, Uganda is unlikely to achieve MDGs 4 and 5 related to reducing child mortality and
improving maternal mortality. Communicable diseases contribute over 50 percent of disability
adjusted life years (DALYs) lost. The status of HNP outcomes are exemplified in Table 1.
Table A I - I : Health Outcome Indicators 1989- 2006.
Infant mortality 119 97 88 16
Under five mortality I80 147 I52 137
Infant Immunization Rate 31% 47% 38% 46.5%
Maternal mortality 523 506 505 43 5
Deliveries supervised by skilled health providers 38% 38% 38% 41%
Total Fertility Rate 1.3 6.9 6.9 6.1
Contraceptive Prevalence Rate 5yo 15% 18% 23.1%
Stunted children (chronic malnutrition) 43% 38.8% 38% 32%
Source: Uganda Demographic Health Surveys 1989, 1995,2000. and 2006
89. Improved physical access to health facilities (72 percent of the population resides
within 5 kilometer radius) is not resulting in high utilization and effective coverage of key
interventions. Interventions targeted to HIV/AIDS and Malaria Control Programs - programs
receiving large inflows of funding from Global Health Initiatives - registered marked progress
between 2004105 and 2006/07. Coverage of (a) children under five who receive effective
treatment for fever within 24 hours increased from 60 percent to 71 percent; (b) pregnant women
who receive IPT increased from 34 percent to 42 percent; and (c) households with at least one
ITN increased from 15 percent to 42 percent. To date, it is estimated 190,000 out of 350,000
eligible persons eligible are on antiretroviral treatment. With the introduction of ACTS, malaria,
a leading cause of morbidity, registered a 39.3 percent decline in the total outpatient cases from
16.3 million cases in 2005 to 9.9 million cases in 2006. However, utilization of other key
services have stagnated or deteriorated and their coverage remains low. Outpatient utilization is
estimated at 0.9 visits per person, health facility deliveries at 32 percent, contraceptive
prevalence rate at 24 percent and women attending 4 ANC visits at 58 percent. While the
proportion of children under one year reported to have received DPT3 is high (90 percent), the
25
proportion of fully immunized children is low at 46 percent. Similarly, while all districts report
adopting community based directly observed treatment of tuberculosis (TB DOTS), the
proportion of TB cases reported remains low at 57.4 percent against the target of 70 percent. The
TB cure rate is estimated at 75 percent against the target of 85%. Table 2 illustrates the trends in
major HNP indicators.
Table A1-2: Trends in Health PEAP Indicators (2000/01 - 2008/09)
Indicator 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 Target
Pop coverage 5 57% NA NA 72% 72% 72% NA 75% NA 80%
km Radius -
Outpatient 0.43 0.60 0.72 0.79 0.9 0.9 0.9 0.9 0.8 0.9
Utilization
DPT Vaccine 48 % 63% 84.1% 83 % 89% 89% 87% 90% 85% 90 %
Coverage
Deliveries in 22.6% 19% 20.3 % 24.4 % 25% 29 % 32% 40% 41 % 60%
Facilities
% Qualified 40 % 42 % 56 % 68 % 68 % NA 68% *51% 53% 85%
Workers
HIV- Prevalence 6.1% 6.5% 6.2% NA 6.4% NA 6.4% 7.4% NA 5%
HCs without drug NA NA 33 % 40 % 35 % 27 % 35 % 28 % 26 % 60 %
stock-outs
Latrine Coverage NA NA 55.6% 55.9% 57% 58 % 58.5% 63% 64 % 65 %
Couple Years of NA NA 210,839 212,089 234,259 309,757 357,021 361,080 549,594 325,407
Protection
Coverage IPT 8.6% NA 20 % 27 % 34 % 37% 42% 46 % 47% 50%
Household with 17.6% NA NA 15% 25.9% 34 % NA NA 40 % 70 %
Nets
TB Cure Rate 50% 52% 60% . 65% 67% 70.5% NA 68.4% 75.1% 80%
Source: MOH. Annual Health Sector Performance Report 2006107, 2007108 and 2008109,
* The staffing norms were changed.
DPT - includes pentavalent vaccine for children.
IPT - intermittent preventive treatment i.e., malaria prophylaxis treatment given to pregnant mothers to prevent malaria.
NA Not Available
90. The goal for health in Uganda is to reduce morbidity and mortality from the major
causes of illness by delivering the Uganda National Minimum Health Care Package
(UNMHCP) to all Ugandans under a sector wide approach (SWAP). Interventions are
primarily targeted to major communicable diseases and mother and child health with the
objective of improving access and utilization of essential services as well as basic surgical and
obstetric care. This is captured in the Poverty Eradication Action Plan (PEAP), the equivalent to
the Poverty Reduction Strategy Paper (PRSP) under Pillar 4 on improving human development.
The main reforms were on mobilization and efficient utilization of funding; recruitment and
better deployment of the health workforce; improvement in supply, distribution and rational use
of essential drugs; and strengthening public private partnerships for health.
91. Uganda has had a long track record with implementing health reforms. These
reforms however have not led to the desired improvements in health outcomes. The pace of
reforms slowed down during the HSSP I1 period. During the HSSP I period, improvements were
observed in programming of the Government portion of the budget, rationalization of financing
of essential medicines and supplies through the Drug Credit Line, partnership and financing of
the private-not-for-profit providers (PNFPs), recruitment of qualified health workers in
26
Government and PNFP health facilities and renovation and upgrading of primary health care
facilities as well as provision of staff accommodation. However, several health systems
bottlenecks have prevailed upon the health sector to impede its performance.
92. Low Resource Base Coupled with Inefficiency and Pressure to Increase Spending.
Although cost-effective interventions exist for the majority of diseases affecting the population,
Uganda is inadequately resourced to adopt and implement the interventions to scale.38
Earmarking through the wage bill, project support, and conditional grant transfers has greatly
limited allocation discretion and restricted availability of funds for operations. In face of low
funding, Uganda is also under considerable pressure to increase spending for health, driven
primarily by the rapidly growing population and the need to adopt more effective-but
expensive-health technologies and service standards to combat the high disease burden.
Uganda derives a large share of its health financing from external sources, a large portion of
which are off-budget and skewed to a few programs, notably HIV/AIDS, which make it difficult
to effectively program these resources. In addition, overall management of these funds is weak.
93. Health Workforce. The health workforce represents a major source of waste in the
health sector and is characterized by low motivation, mal-distribution, high rates of attrition and
absenteeism, and difficulties with attraction and retention of health workers in remote and hard
to reach districts. Personnel management is especially poor and is characterized by delays in
recruitment, payroll entry, confirmation, appraisals and promotion, and is associated with high
staff turnover. Because of relatively better salaries in Government, the PNFP facilities are losing
their staff to Government employment, depleting the PNFP subsector and undermining the entire
health sector. Despite the challenges, studies by the USAID-financed Capacity Project reveal
several opportunities: (a) few significant differences among health worker profiles in remote and
non-remote areas; (b) greater job stability and intent to stay among public sector employees -
over 53 percent having stayed in current organization at least 10 years; (c) desire mainly by
PNFP health workers to migrate internally, but remain working in the sector; (d) low desire by
nurses and allied health workers to leave the country (10 percent); and (e) a strong desire,
particularly by health workers from the north, to serve their communities. The studies also reveal
that physicians, especially PNFP physicians, were most likely to express desire to leave their
jobs or migrate out of the country and that salary was a significant predictor in reducing odds of
leaving.
94. Health Infrastructure. Hospitals in Uganda were built between 1930 and 1970 and no
longer conform to current demands and service standards. Over the years, little attention was
paid to their maintenance, and generally, the majority are dilapidated and in poor physical shape.
Most Health Centers Type IV upgraded under the Health Subdistrict concept, which underpinned
the sector reform agenda, remain incomplete and not fully functional. The current system for
maintaining medical equipment through the Regional Medical Equipment workshops is not
functioning adequately. In addition, existing management systems for hospitals have become
outdated and misaligned to current reforms underway in the country. The referral system is poor
and availability of equipment is low with only 50 percent of equipment estimated to be in good
working condition. Staff accommodation is grossly inadequate. It is estimated that only 30
38
Out of the estimated US$ 28 per capita, only about US$ I O per capita is available to the public sector to finance its health
program.
27
percent of eligible staff have institutional accommodation. The lack of accommodation is cited
as a major reason for the inability to attract staff to remote areas, late coming and high rates of
absenteeism. This has been recognized and with support of JICA, six hospitals were renovated
and equipped in the last three years. In addition to revising the essential equipment list and
maintenance policy and plan, plans are underway to establish a credit line for minor equipment.
95. Inadequate availability of essential medicines and supplies is a major constraint.
Although Government established a drug credit line and developed a rolling three-year
comprehensive procurement plan for medicines and supplies, coordination of the procurement of
third party commodities and overall logistics management continues to be problematic across all
levels. Drug shortages are common. In 2006/7, 65 percent of health facilities reported running
out of one or more of the six tracer drugs. While this is partly because of a limited drug budget,
it is believed that inadequate capacity for planning and management is also contributing to the
shortages. Few districts are able to spend their drug budgetary allocations. In 200617, out of the
,
US$ 2.40 per capita that was needed for essential drugs, only US$ 0.72 was made available for
essential medicines and health supplies, excluding ARVs, vaccines, and ACTS.
96. Impact of various Government reforms on the sector. Uganda has undergone several
public sector management reforms including procurement, decentralization, liberalization, etc.
Poor alignment of the reforms to the health sector needs coupled with proliferation of districts
that lack resources and the capacity to execute their mandates have complicated management of
health service delivery and rendered the existing management and supervision mechanisms, as
well as accountability frameworks, ineffectual. Although recognized, inter-sectoral collaboration
has proved challenging in several areas including, sanitation, environmental health, and
reproductive health.
97. There is a growing understanding to improve efficiency of health spending and to
address system bottlenecks. Growth in health funding is projected to be modest and Uganda's
opportunities for improving health service delivery will depend on improving value for money
and efficiency of health spending. Government has committed to improving efficiency and
effectiveness of public spending by strengthening overall public financial management and
procurement. Starting 2009/20 10, implementing agencies receiving external funds will provide
detailed work plans, including procurement plans, and ensure availability of counterpart funds
during the preparation of the Budget Framework Paper. The health sector, a major recipient of
external funds, is strengthening institutional capacity to manage grants under the Global Fund for
AIDS Tuberculosis and Malaria (GFATM) in line with the newly developed framework for the
management of the development partner projects: Long-Term Institutional Arrangements
(LTIA). The LTIA describes processes and measures to align programming and management of
external funds to national processes and systems. The Government, with support of partners
under the Joint Budget Support Framework, is working on strengthening service delivery. Public
sector management has been singled out for improvement with a focus on improving the
accountability framework for service delivery. In the health services, this will involve
strengthening personnel management functions, rolling out implementation of Result Oriented
Management (ROM) and Client Charters, and developing an incentive scheme to attract and
retain health workers in remote and hard to reach areas, among others. The project will facilitate
implementation of these Government-wide reforms in the sector. To address the key problems in
28
the sector, the MOH developed a Master Plan for Accelerating Performance in the Health Sector
(April 2008). The plan underscores the need to address bottlenecks in health infrastructure,
human resources for health, and essential medicines and supplies.
98. Improving maternal health remains a challenge. The major causes of maternal deaths
(hemorrhage, abortion complications, sepsis, obstructed labor, and pregnancy induced
hypertension) can be prevented if women deliver with the assistance of skilled health personnel
and have access to quality emergency obstetric care. The percentage of women who deliver with
the assistance of doctors or nurse/midwives increased from 38 percent in 1988 to 42 percent in
2006, while use of antenatal care increased from 87 percent to 94 percent in the same period.
Emergency obstetric and neonatal care (EmONC) is not widely accessible. Health Centre IVs
facilities are expected to provide comprehensive EmONC, but only 16 percent have functional
theatres and 45 percent have a medical officer at post. Providing quality EmONC does not
necessarily mean that women will access them. According to the 2006 DHS, 81 percent of
women indicated they had difficulty accessing health services: 65 percent could not afford
treatment; 54 percent indicated long distance to the health facilities; 49 percent have difficulty
obtaining transport; and 46 percent were concerned that drugs are not available at the health
facilities. The total fertility rate (TFR), the fifth highest in the world, has virtually remained
unchanged in two decades (6.9 births per woman in 1988 versus 6.7 in 2006). The use of modern
contraceptives among married women is low at 24 percent. Uganda has the highest unmet need
for contraceptives in the world at 41 percent. As result, some women resort to induced abortions
to achieve their fertility desires with about 297,000 induced abortions performed annually. The
average desired family size of 5.0 (as opposed to TFR of 6.7) indicates that the potential need for
family planning services in Uganda is high. Indeed, 65 percent of women of reproductive age not
using contraceptives intend to use in future. The potential demand for family planning is not
being met considering that only 46 percent of health facilities provide family planning services
and community-based family planning services is virtually non-existent. Moreover, the private
sector is the major source of contraceptives: 43 percent of women obtain contraceptives from
private hospitals or clinics as opposed to 32 percent from Government hospitals or clinics. The
Government has prepared a Road Map for Accelerating the Reduction of Maternal and Neonatal
Mortality and Morbidity (2006 - 201 5) and Reproductive Health Commodity Security Strategic
Plan (2010/11 - 2014115.
29
Annex 2: Major Related Projects Financed by the Bank and/or other Agencies
UGANDA: Uganda Health Systems Strengthening Project
Table A2-1: Major Health Related Projects in Uganda
ProjectProgram Title Objectives Coverage Total Project Development
Cost partner
Contribution
Ongoing projects
AfDB. Support to the To improve access to aualitv 10 districts in SW UA 22.2 M UA20 M
Health Sector Strategic Reproductive Health Servicks in Uganda for RH and 7
Plan Project I1 South Western Uganda and Regional Hospitals for
expand Mental Health Services in mental health
Uganda
JICA: The Rehabilitation To upgrade and improve quality 6 General Hospitals in US$13.5 M
of Hospitals and Supply of health care services at selected Central Uganda
of Medical Equipment in health facilities through the
the Central Region in refurbishment. expansion and the
Uganda supply of equipment.
GAVl Construct staff houses; train and Countrywide US$41.38 M US$19 M
equip 5,000 Village Health Teams
in poorly performing districts; and
train and equip 100 private health
facilities to deliver immunization
services
IDA: Uganda Public Transform public service so that it Ministry of Public US18.8 M
Service Performance is affordable. efficient and Service
Enhancement Prqject accountable in the use of public
resources and improve policy.
institutional and regulatory
environments in targeted areas for
sustainable growth and service
delivery.
USAID: SURE Project To strengthen logistics 45 districts US45 M
management for medicine
15 districts US$50 M
USAID: STRIDES FP Expand FP services
Project
Projects under
preparation
Belgium: Institutional To strengthen the capacity for MOH at the center, 2 Euro 6.5 M
Capacity Building Prqject planning. management. and regional hospitals and a
leadership in the health sector few general hospitals
and HC IVs
IDA: East Africa Public To strengthen capacities for Regional Project US$3.3 M
Health Laboratory diagnosis and surveillance of TB covering four countries: (Uganda)
Networking Project and other communicable diseases Uganda, Kenya,
by establishing a network of Tanzania and Rwanda
public health laboratories
30
Annex 3: Results Framework and Monitoring
UGANDA: Uganda Health Systems Strengthening Project
A. Introduction
99. The results framework for this project is informed by current advances in M&E
thinking in the Bank and is consistent with the MOH's overall M&E framework. The
results framework focuses on accountability for results and places emphasis on intermediate
outcomes. To avoid parallel data collection, the project will utilize the routine Health
Management Information System (HMIS) and statistical records from the Uganda Bureau of
Statistics (UBOS).
100. A key principle underpinning the project design is to ensure that the systems
investments are directly linked geographically to the infrastructure investments. The
selected districts where infrastructure related works will take place will also be targeted with
interventions in other components (human resources, drugs distribution, etc.). The coordinated
approach in improving buildings, equipment, human resources as well as availability of drugs is
to ensure functionality of service delivery units, whether at hospitals or health centers.
101. A large part of the project is devoted to financing infrastructure (civil works and
equipment). Such operations are usually procurement heavy. As such, there is a tendency to
focus on tracking procurement (i-e., inputs) during supervision rather than the achievement of
results (Le., outcomes). For this reason, specific attention will be paid to tracking the
outcomes/results that the project intends to achieve.
B. Monitoring and Evaluation Design
102. Selection of Indicators. The PDO is to deliver the Uganda National Minimum Health
Care Package to Ugandans, with a focus on maternal health, newborn care and family planning.
In support of this project objective, and consistent with the activities being financed, 5 key
performance indicators and 16 intermediate outcome indicators were selected for which the
project will be held accountable (Table A3-1). These, however, are not the only indicators that
will be tracked in the project, or that will be needed to successfully demonstrate the results chain
in support of the outcome indicators. As such, an additional set of project-level indicators
(disaggregated by component) will be tracked by the project team.
103. Consistency with Bank Core indicat01-s.~~ following core indicators applicable to
The
this project are included in the core set of project indicators: (a) Health personnel receiving
training (number, in-service, pre-service); (b) Health facilities constructed, renovated, and/or
equipped (number); (c) Pregnant women receiving antenatal care during a visit to health provider
(number); (d) Direct Project Beneficiaries (number) of which female (%); and (e) People with
access to a basic package of health, nutrition and population services (number). Patient visits in
renovated health facilities (out and in patient visits) will be used as a proxy measure for (d) and
(e) i.e., access and direct beneficiaries.
39 OPCS. 2009. Core Sector Indicators and Definitions - Health. OPCS, World Bank, Washington, DC.
31
104. Level of indicator^.^' The indicators are a combination of output and outcome
indicators. Specifically, the indicators are mainly Level I11 pertaining to capacity, and Level I1
pertaining to service delivery functioning, as per the agreed upon Africa Sector Results Chain for
Health.
105. Definition of indicators. The denominator and numerator for each indicator have been
clearly specified to ensure that definitions do not change over time. None of the project
interventions target a specific target group; thus, there is no specific target group identified in the
definition of the indicators.
106. Disaggregation of data. The infrastructural investments have a geographic focus, while
many of the system-level investments (human resources and drug distribution) may have impacts
beyond these geographic areas. For this reason, the indicators that have been identified will be
associated with national averages, but will allow for district level disaggregation. This should
allow for a closer link to be made with the district level activities.
107. Data sources. The data source for each of the indicators is clearly defined. Data sources
are a combination of HMIS and sample-based surveys conducted by the UBOS. Further
clarification on data quality, data collection methodologies, responsibility for data collection was
done at appraisal.
108. Attribution. There are two ways to think about attribution: (a) attribution of a change in
outcome relative to the inputs that the Bank financed; versus (b) attribution of a change in
outcome relative to the program that the Bank supported (together with financing from
Government, other development partners, etc.). The latter is the way that attribution will be
considered in this project. While no formal impact evaluation has been envisaged for the project,
informal efforts will be used to allow for the assessment of attribution (albeit imperfectly). For
example: (a) data will be collected from the intervention districts as well as the non-intervention
district^;^' (b) strong efforts will be made to construct the results chain to link the inputs, outputs
and intermediate outcomes with the project outcomes. The latter is also consistent with the point
made in paragraph 103 that in addition to the core set of indicators, additional project-level
indicators will also be collected.
109. Baseline data. To the extent possible, the proposed results framework uses existing
indicators and data to measure the progress-not only for efficiency, but also to build on and
strengthen existing data collection mechanisms. Baseline data are available for almost all
indicators. Preliminary baseline data and targets were established for the following indicators:
(a) people with access to a basic package of health, nutrition and population services (number),
(b) Direct Project Beneficiaries (number) of which female (%) and (c) health workers receiving a
salary within two months from reporting to work (YO). These will be confirmed after the baseline
survey in September 2010 using the project preparation advance.
40AFTHE. 2009. Results Chains for HNP.
41
While these districts will not be formally treated as control districts because no formal matching is possible, it will be
important to see how progress differs across these districts.
32
1 10. Targets for the indicators. The indicator targets and reporting arrangements were
agreed upon and finalized at appraisal. Particular attention was given to the basis on which the
targets were set as well as the realism and feasibility of their achievement.
C. Planning for Monitoring and Evaluation Implementation
1 1 1 . Data collection. A key determinant of successful M&E implementation is the quality of
data planning during the project preparation and the resources and responsibility for data
collection and analysis.42 To this end, a detailed data collection plan has been developed that
identifies for each indicator:
(a) The source of the data or data collection mechanism;
(b) The frequency of the data collection;
(c) An assessment of the quality of the data collection mechanism;
(d) Where necessary, some comment on the concerns about data collection methodology
especially where a non-standardized data collection mechanism is used;
(e) Responsibility for data collection and analysis (where an external source has been
identified, the contact within the MOH is listed);
(f) Level and source of resources available for data collection.
112. The methods of data collection include a combination of HMIS and surveys. As far
as possible, standardized data collection methods will be used. Most of the indicators will be
collected annually, and any survey-based indicators will be collected at baseline, at mid-term and
in the last year of project implementation. Where survey methods are being used, as in the case
of CPR, a formal statistical sampling will be applied to ensure representativeness of the results.
113. Primary responsibility of M&E. The Department of Quality Assurance in the MOH
will have the primary responsibility to coordinate M&E activities of the project. This will
include: coordination of data collection processes, reviewing consultant reports or analytical
products for M&E, and preparing periodic progress reports. An M&E specialist will be recruited
to work in the Department of Quality Assurance.43 This person will serve a quality assurance
role for the project's M&E, and be expected to solicit expert opinion as necessary.
114. Resources for M&E. Costs related to M&E have been included in the costing of the
project .
D. Planning for Monitoring & Evaluation Use
1 15. The implementation of the M&E framework will be tracked during implementation,
and will be a central part of project supervision. In this regard, the mid-term review will
provide an opportunity to assess fundamental M&E design issues, and make adjustments if
necessary. There will be a strong results-orientation during supervision, with adequate attention
devoted to progress on data collection, data quality and the actual use of data in tracking project
42 Uribe-Vilar. 2009. Assessmenf o f M and E wi HA'P operatcons, 1997-2009, Background Paper, HNP Evaluation, IEG. World
Bank, Washington, DC.
4 3 While this person may not have a dedicated responsibility for this role, agreements have been reached with the relevant
authorities to second the identified individuals. This is fully consistent with the LTIA principles that the project is implementing,
Le.. using the Government systems.
33
implementation in Aide Memoires. The M&E specialist will also be responsible for providing
periodic and annual reports on the progress of M&E implementation and usage, as well as any
design changes that may be proposed. One of the supervision's missions will coincide with the
MOH's annual review meetings in October each year.
E. Country level M&E systems and capacity building strategies
116. M&E capacity. The majority of the project indicators are already being collected
through the HMIS at the MOH and the UBOS. Data collection is therefore unlikely to pose a
serious challenge. As previously noted, it was agreed at appraisal to recruit an M&E Specialist in
the Quality Assurance Department to support the various teams to provide periodic reports on an
inter alia basis.
34
Table A3-1: Results Framework
PDO - Project Development Project Outcome Indicators Use of Project Outcome
Objective and Outcomes Information
To Deliver the Uganda National 1. Deliveries taking place in To assess impact of the project in
Minimum Health Care Package Government and PNFP Health improving access and quality of
(UNMHCP) to Ugandans, with a Facilities (%).44 health services.
focus on maternal health,
newborn care, and family 2. Mothers attending at least 4
planning. antenatal care (ANC) visits (YO).
3. .Contraceptive Prevalence Rate
(YO).
4. People with access to a basic
package of health, nutrition and
population services (number)45.
5. Direct Project Beneficiaries
(number) of which female (%)46.
Intermediate Outcomes by Intermediate Outcome Indicators Use of Intermediate Outcome
Project Component Monitoring
Component 1 : Improved Health Workforce Development and Management
Improved availability of human 6. Health personnel receiving To monitor capacity for personnel
resources for health training (number).47 management to recruit and deploy
health workers.
Improved Performance of the 7. Approved positions filled by
Health Workforce qualified health workers (%). 48
8. Health workers receiving a salary
within two months from reporting to
work. (YO).
Component 2: Enhanced Existing Health Infrastructure
Improved Availability of Health 9. Health facilities constructed, To monitor project progress
Infrastructure. renovated and/or equipped (number).49 towards improving functionality
of physical health infrastructure.
10. HC IV and Hospitals renovated
Improved Availability of according to agreed standards
Essential Equipment (Number).
1I . H C IV and Hospitals with
functioning minimum Essential
Improved Referrals of Patients Equipment (number)50 To monitor effectiveness of the
44 This is a national-level indicator. The denominator for estimated pregnancies is 5 percent the estimated population size.
" Shall use a proxy indicator: patient visits in renovated health facilities - in and out patients (number)
46 Shall use a proxy indicator: patient visits in renovated health facilities - in and out patients (number)
47 Cadres are nurses, anesthetists and clinical officers.
'* This indicator monitors approved positions by Government, which are funded according to their particular level.
49 Government plans to renovate HC IV and Hospitals according to agreed standards
50 Essential Equipment consists of: Theatre Equipment, Laboratory Equipment, Delivery Beds and Patient Beds in Maternity and
Ward, per facility.
35
referral system and functionality
12. HC IVs performing caesarian o f H C IVs.
sections (number).
13. Health facilities with functional
ambulances and communication
systems (number)."
Component 3: Improved Management and Accountability
Improved Hospital Management 14. Hospitals with medical To assess project progress
superintendents trained in health towards building management
managementihospital administration capacity to deliver health services.
(%),52
To assess whether improvements
Improved Responsiveness to 15. Health Facilities with Client in capacity are translating into
Clients Charters (YO). improved service delivery.
Improved Procurement and 16. Health facilities without stock- To assess how responsive Health
Logistics Management for outs of tracer medicines and supplies Facilities are towards their
Medicines and Supplies (%).53 Clients.
17. Drug orders processed timely by
NMS f%154
Component 4: Improved maternal, newborn, and family planning services
Expanding and improving 18. Hospitals and HC IVs offering To monitor the project's progress
quality of maternal and newborn comprehensive emergency obstetric in improving access to maternal
care care (YO), and neonatal care services
19. HC IV facilities conducting
maternal and perinatal death audits
(YO).
Increasing the availability and
demand for family planning 20. Pregnant women receiving
services antenatal care during a visit to a health
provider (number)
21. Couple years of protection
IcYP\.55
This measures the number of functional ambulances and general purpose vehicles in the sector per level of health facility.
'*A qualified manager is defined as a manager with graduate or postgraduate training in health services management or hospital
management and administration.
51
This is measured on the basis of six tracer medicinesisupplies i.e.. the absence of any of the tracer medicines.
" N M S supplies for orders received on time reaching recipient district within 21 days of receiving order.
55
This indicator measures the sum of Couple Year Protection by type of Family Planning commodity for all FP commodities
dispensed or offered during the year.
36
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Annex 4: Detailed Project Description
UGANDA: Uganda Health Systems Strengthening Project
1 17. The project comprises four components, namely. (a) improved health workforce
development and management; (b) improved infrastructure of existing health facilities; (c)
improved management, leadership, and accountability for effective health service delivery; and
(d) improved maternal health, newborn care, .and family planning services. The choice of
subcomponents and activities was guided by the need to both achieve results during the project's
life span, and also promote reforms that would sustain service delivery in the long run, while
complementing ongoing efforts by other development partners.
Component One: Improved health workforce development and management (US$S million).
118. The objective of this component is to improve development and productivity of the
health workforce. Under this component, the project will support: (a) consolidation of central
level HRH functions at the MOH; (b) strengthening personnel management in the sector; (c)
improve staff retention in remote and hard to reach areas, and (d) pre-service and in-service
training. Specific aspects of HRH will also be addressed in other project components.
119. Consolidate central level HFW functions. The Government intends to consolidate
central level HRH functions in the MOH. At the moment, these functions are housed in different
sections of the Ministry and are poorly coordinated. The project will strengthen and consolidate
HRH functions in HRM and HRD Divisions of the MOH to develop policies, oversee
management of the health workforce in general, and to liaise with other Government agencies on
personnel related matters. The project will place two long-term consultants (HRH Policy Advisor
and HRH Management System Strengthening Advisor) in the newly created department, and will
provide logistical support to the four professional councils. Councils will be assisted in assessing
their capacities to discharge their mandates, through inter alia, the development of sound
business plans. In addition to this, the project will also support the rolling out of the HRH MIS,
which was developed with assistance from the USAID-financed Capacity Project. The HRH
MIS is linked to the existing HMIS in the ministry, as well as those of other relevant
Government agencies including the professional councils.
120. Strengthen human resource management functions. Personnel management in the
sector is characterized by delays in recruitment, payroll entry, confirmation, appraisals and
promotion, and is associated with high staff turnover largely on account of decentralized
recruitments. To minimize recruitment delays and reduce high costs of advertisements, a Central
Job Bureau will be created in the MOH. Districts and hospitals will be able to advertise staff
openings with this Bureau, while job seekers (including recent graduates) will be able to register.
This information will be relayed to the Health Service Commission and District Service
Commissions on a regular basis, and made available to the general public. The project will
provide short-term technical assistance to create the Central Job Bureau, and funding to furnish
and equip the bureau on creation. At the district level, the project will build capacity for
personnel management through training of designated officers including hospital administrators
and other health managers in relevant areas of personnel management and provide equipment
and technical support for HRH MIS. Each district will designate personnel officers or other
39
existing staff where personnel officers are in short supply to work for the health department.
Other support will include support to the Health Service Commission and selected District
Service Councils, with high vacancy rates, to recruit health workers.
121. Improve staff retention in remote and hard to reach areas. Staff turnover and
vacancies are highest in remote and hard to reach areas, among lower level health facilities and
the PNFPs. The Ministry of Public Service is in the process of developing an incentive-based
framework to support recruitment and retention of personnel in hard to reach areas. This
framework is underpinned by a motivation and retention strategy for health workers prepared by
the MOH. The project will support the implementation of this framework. Several districts are
implementing diverse retention schemes with varying degrees of success; these are under review
by the Ministry of Public Service in order to come up with a Government wide policy for hard to
reacwstay areas. In addition to documenting existing schemes, the project will assist to
institutionalize mechanisms for routinely collecting data on the use and effectiveness of the
schemes as part of the overall HRH MIS process. As previous attempts to bond staff after
training has proved futile; the project will set up a scholarship scheme to support training of
health workers to serve in remote areas. The MOH will prepare guidelines for managing the
scholarship program in the project implementation manual.
122. Improve pre-service and in-service education. This subcomponent will improve pre-
service education for selected health cadres in short supply. Both Government and not for profit
(PNFP) training institutions will receive support to improve quality and the numbers of their
graduates. Priority will be given to: laboratory technicians, radiology technicians, tutors,
pharmacy technicians, and store keepersAogistics assistants for medicines through the provision
of scholarships, as well as purchasing teaching materials including, anatomical models and
charts, teaching videos and CDs, and other educational materials. For in-service training, the
project will provide scholarships for postgraduate training in clinical disciplines where
established, but vacant positions exist and support the accreditation of courses for continuing
professional development. Since students from remote areas are likely to stay in their districts,
the project will provide scholarships for students from hard to reach areas who would be
expected to return to the areas after their courses. With liberalization of training, many private
initiatives are involved in training health workers. The project will support the Government to
develop a system of internship and clinical mentorship for selected cadres. In Health Center IVs,
for example, newly graduated medical doctors will receive hands-on training, through
mentorship programs, to ensure they can perform Caesarian deliveries, and manage EmONC.
Component Two: Improved infrastructure of existing health facilities (US'S85 million).
123. The objective of the component is to improve infrastructure of the existing health
facilities in order to provide minimum standards of quality health care services, especially
in the areas of maternal and child health, through: (a) renovation of selected health facilities;
(b) provision of medical equipment; (c) improved capacity for operations and maintenance; and
(d) strengthening the referral system.
124. Renovation of selected health facilities. Poor maintenance has been the main cause for
the poor status of both physical health infrastructure and medical equipment. The current system
40
for maintaining medical equipment through the Regional Medical Equipment workshops is not
functioning adequately, with more than 50 percent of medical equipment in health facilities
reported out of order. The MoH proposes to renovate 17 general hospitals (GHs) and 27 Health
Centers Type IV (HC IVs), and to upgrade two general hospitals into regional referral hospitals
(RRHs). See Table A4-1 below for the proposed list of facilities selected for renovation.
Selection of the preliminary list of health facilities for renovation was based on remoteness of
location, the state of dilapidation, proximity to the major highways prone to road traffic
accidents, catchment population, and the need to promote an effective referral system. The final
selection of health facilities and the works will be made after completion of feasibility and
design studies currently underway. The choice of design will take into account the need for
efficiency and the future recurrent cost implications of the investments and the contractors will
be required to carefully plan the phasing of construction works in such a way that hospital
operations are maintained throughout the construction perioda5* Specific activities that will be
carried out under this subcomponent include the following:
(a) Six general hospitals dating back to the 1930s will require fundamental replanning and
replacement of some buildings to align them to the revised standards and construction of
staff houses as they were originally built without them. The lack of staff housing is a
major constraint to the recruitment and retention of key hospital staff.
(b) The two GHs selected for upgrading to RRHs are located in remote areas and are among
the hospitals built before the 1950s.
(c) The GHs built between 1969 and 1973 will not require major re-planning. Renovation
works is anticipated to include re-roofing, replacement of water and sewerage systems,
window replacement and provision of solar lighting in the wards. Some additional works
will include construction of incinerators, provision of an HIV/AIDS clinic and obstetric
theatre, as well as expanding space for the laboratory and the delivery suite.
(d) Work on HC IVs will involve completion of operating theatres and doctor's houses and
construction of some additional staff houses. Patient privacy and improved infection
control, especially for HIV/AIDS and TB patients will be addressed during re-planning.
Depending on identified needs the project will connect health facilities to reliable sources
of water, power, sewerage, transport, and ICT services.
5 8 As previously noted the Government is using the Project Preparation Advance (PPA)[note: PPA not in acronym list] to prepare
detailed architectural designs and costs the proposed works. The current cost estimates are based on market rates of similar works
being undertaken by the Government and other partners.
41
Table A4-1: Proposed Renovation List of Selected General Hospitals and Health Centre IVs
25 Ngoma
26 Budondo
27 Kikamuro
125. Provision of medical equipment. The renovated health facilities will be supplied with
appropriate types of medical equipment in accordance with identified needs, based on the
medical equipment policy and standard equipment list (disaggregated by level of facility).
Priority will be given to essential medical equipment for diagnostics, surgery, and obstetric care.
In addition, incineration facilities will be constructed or repaired where absent or out of order in
accordance to NEMA recommendations. An assessment carried by NEMA and the MOH will
guide the selection of the type of incinerators to be purchased and installed.
126. Improved Operations and Maintenance. This subcomponent will strengthen capacity
for proper operations (maintenance, repairs and replacements) of health facility assets: buildings,
medical equipment and vehicles. The MOH has agreed to create a credit line for medical
equipment and establish a budget line for capital expenditure under the hospital vote. This should
ensure that hospitals are able to both finance the replacement of basic medical equipment, and
undertake renovations and repairs of their assets. Maintenance contracts will be provided for
expensive and large ticket items (such as medical equipment and communication infrastructure).
The project will enhance the MOH's capacity to replace and maintain medical equipment by: (a)
42
strengthening procurement capacity for medical equipment, especially with regard to
specifications; (b) support policies for maintenance, including reducing the number of brands of
medical equipment that health facilities can acquire; (c) explore the Public Private Partnership
model, whereby health facilities can readily access private maintenance firms; (d) review options
for managing and financing Regional Medical Equipment workshops; and (e) operate an
inventory system developed through DANIDA.
127. Improved referral system. The project will provide ambulances on an as needed basis
for selected hospitals, and a general purpose vehicle for each renovated health facility. This
arrangement should ensure that ambulances are reserved for emergency transfers rather than
general purpose use. There has been a marked expansion in ICT coverage in Uganda.
Ambulances or specific persons, for example, will have phones that communities can call.
Partnership with mobile phone companies will be explored to provide toll free numbers for
communities to contact health personnel or request an ambulance. Ambulance drivers will be
trained in the referral guidelines and will be required to keep log books on the use of
ambulances. The MOH is in the process of determining where ambulances will be placed and
how the operating and maintenance costs will be funded. In addition to this, the project will
support the MOH to develop a strategy for using ICT (and possibly e-health) to improve referrals
and roll out its implementation.
Component Three: Improved Leadership, Management, and Accountability for health service
delivery (US$I 0 million).
128. The objective of Component 3 is to strengthen management, leadership, and
accountability for health service delivery. Priority will be placed on (a) implementing
performance based management approaches, (b) professionalizing and strengthening existing
management of hospitals; (b) developing and rolling out implementation of the hospital policy
framework; and (c) strengthening procurement, logistics and supply chain management.
129. Hospital Policy Framework. The MOH recently prepared a new hospital policy aimed
at strengthening management of hospitals. A cabinet paper has been developed and a bill drafted
on the organization and governance of tertiary hospitals. The cabinet paper sets out the
Government's vision on granting autonomy to tertiary hospitals. The project will support the
MOH to develop and roll out guidelines for developing individual hospital plans, hospital
accreditation system, review options for autonomy of RRHs and develop a rational financing
mechanism for public hospitals. As part of the hospital accreditation system, the project will
support the MOH to develop a mentorship policy to guide practical skills development for
essential health cadres.
130. Performance based management approaches. The Ministry of Public Service has
instituted Result-Oriented Management (ROM) and Client Charters as part of a comprehensive
integrated performance management system aimed at improving performance monitoring for
results and productivity in the public service. The project will assist the MOH in customizing
and rolling out the implementation of the ROM and Client Charters; strengthening Performance
Appraisal and systems for Recognition, Reward, and Sanctions, and initiating application of
Performance Contracts in the sector. Based on public service-wide guidelines, districts, hospitals
43
and unit managers will be required to develop institutional and individual plans for use during
performance assessment and introduction of performance based contracts at MOH Headquarters,
RRHs and Districts. Close collaboration with the Ministry of Public Service will be maintained
during the process. In addition, the project will support the scaling up of social accountability
mechanisms like the citizens' report cards at community level for health service delivery. Both
service users and providers will get an opportunity to provide feedback on the performance of
service points and agree on actionable plans to address identified constraints.
13 1 . Professional Management of Health Facilities. The Government is planning to
professionalize management of hospitals and has requested Uganda Martyrs University to
develop a two-year Masters program in hospital management. The project will support the MOH
to implement this training program, as well as upgrading programs for staff already in
management positions. The Government has agreed to create positions for senior management
cadre within the overall hospital establishment, with clearly defined competencies,
qualifications, roles and abilities to fill these positions. The project will support the MOH to
develop the plan for the transition and finance the actual training program of selected trainee
managers. Two options are under consideration. In the first option, all staff holding positions of
medical superintendents will take an initial introductory course, followed by a course-work
component of the hospital management program offered through distance learning or part-time
study. The staff will be given a maximum allowable time to complete the course and those who
do not complete mandatory training within the stipulated time would be removed from their
positions. In the second option, a select number of potential staff would undergo training on a
full-time basis. As such, they will finish their training more quickly. It is anticipated that new
candidates appointed to these positions would need to have the necessary management training
qualifications. Hence persons without the required qualifications would be disqualified from
holding these positions.
132. Logistics and Supply Chain Management. Under this subcomponent, the project will:
(a) strengthen the capacity of the pharmacy division to coordinate procurement planning,
monitor logistics and supply chain management and develop and monitor the performance
agreement with the National Medical Stores; (b) review regulations (Public Procurement and
Disposal of Assets and Local Government Acts) governing procurement of essential medicines
and equipment, suggest relevant recommendations for amendments, and develop appropriate
guidelines where necessary; and (c) provide complementary supply chain management support
to selected districts including expandinghenovating storage facilities for medical supplies and
pharmaceutical in the hospitals undergoing renovation. This support will be conducted in close
collaboration with the new USAID-financed program that is also aimed at improving various
aspects of supply chain management. Districts will be responsible for designating pharmacy
assistants who will be trained in logistics management for medicines. This will ensure that they
have the skills needed to coordinate the quantification and ordering of medicines and supplies.
In addition, the project will procure distribution vehicles to improve capacity of the National
Medical Stores.
133. Strengthening delivery of health services at the district level. The Health Subdistrict
concept has encountered several challenges and is no longer able to meet its original intended
objectives. With the proliferation of districts, most districts no longer have the requisite capacity
44
needed to manage health services delivery. The MOH is overstretched in its supervisory role and
is increasingly relying on regional hospitals to supervise district programs. The project will
provide support to review suitability and capacity of the regional hospitals in this regard. In
addition, the project will review the viability of the Health Subdistrict concept as well as the
administrative and management capacity at district level to support health services delivery.
Arising from this, viable options for addressing current problems will be proposed.
134. Project Management. This subcomponent will support costs related to the operations
and overall management of the project. While the details need to be discussed and agreed, this
component will include specific technical assistance in the areas of project management,
financial management, procurement, and other areas. Consistent with the LTIA, consultants (in
areas such as Quantity Surveying, Architecture, M&E, Procurement, and Accountancy) will
work as part of the relevant functional units. The numbers, duration, and duties of these
consultants will be defined and elaborated in the project implementation manual. Apart from
this, key activities under this subcomponent include: the collection of baseline data, coordination
and implementation of the mid-term and end-of-project evaluation of all project components, and
annual financial audits.
Component Four: Improved maternal, newborn, and family planning services (US$30 million)
135. The objective of this component is to improve access to and quality of maternal
health, newborn care, and family planning services. Improved access to family planning
services is an important factor in reducing the risk of complications in pregnancy and childbirth,
including better birth spacing, delayed pregnancy in young women, and averting maternal
deaths. This component will support: (a) expanding and improving quality of maternal health and
newborn care, and (b) increasing the availability and demand for family planning services.
136. Expanding and improving quality of maternal health and newborn care. This
subcomponent will draw on the lessons learned from the WHO supported Making Pregnancy
Safer Initiative and the UNFPA supported Rural Extended Services and Care for Ultimate
Emergency Relief (RESCUER) Project piloted in Soroti and Iganga districts respectively. It will
involve: (a) disseminating maternal and newborn care guidelines and protocols; (b) providing
hands-on training and mentorship on EmONC; (c) ensuring the provision of basic and
comprehensive EmONC lifesaving procedures and delivery services; (d) augmenting the
provision of post-abortion care; (e) strengthening the referral and communication system; and ( f )
expanding and strengthening maternal and perinatal death reviews.
137. Maternal health and newborn care guidelines and protocols. Guidelines and protocols
will be adapted to improve and standardize maternal and newborn care. This will include the
following: use of partograph, management of second and third stages of labor, neonatal
resuscitation, newborn care (including early breastfeeding and Kangaroo Mother Care59),
managing preterm/low birth weight babies, postnatal care, antibiotic treatment schemes,
management of major obstetric complications (antepartum hemorrhage, postpartum hemorrhage,
59
Technique to encourage new mothers to practice "skin-to-skin" contact with their newborns, especially pre-term babies, like a
kangaroo mother keeps her baby in her pouch.
45
severe pre-eclampsideclampsia, sepsis, obstructed labor), post-abortion care, including use of
manual vacuum aspiration (MVA) kits, and indications for Cesarean sections. Printed and
laminated copies of guidelines and protocols will be disseminated to both public and private
health facilities.
138. Providing hands-on training and mentorship on EmONC. Midwives, clinical
officers, and medical officers will receive appropriate hands-on training based on developed
protocols and guidelines. The Reproductive Health Division will determine the modes of training
with workshops outside the work places of health personnel reduced to the minimum. UNFPA
plans to constitute regional teams (comprising of an obstetrician, a midwife, and a public health
nurse) to provide training and mentorship to health personnel at district hospitals and health
centers. Given that in the past, commitment of regional teams have been patchy, the Kayunga
District hospital currently has an arrangement whereby specialists visit the hospital on specific
days of the month (at 140,000 Uganda Shillings, Le., US$72 per day) to both attend to patients
and train staff. This approach is working well, and could be scaled up, and used to supplement
the efforts of regional teams. New graduate medical doctors will undergo mentorship prior to
being posted to HC IVs to ensure that they can perform Cesarean deliveries, and anesthetist
assistants will also be trained to work at Health Center IV.
139. Provision of basic and comprehensive EmONC lifesaving procedures and delivery
services. Under this subcomponent, an attempt will be made to ensure that health centers and
district hospitals are appropriately staffed; in particular, Health Centers should have midwives to
perform delivery services and HC IVs should have medical officers who can perform Cesarean
deliveries. Based on the maternal and neonatal assessment which will be conducted prior to
project implementation, health facilities will be designated as Basic or Comprehensive EmONC.
Considering that only 16 percent of Health Centers IV have surgical theatres, not all Health
Centers IV will be able to provide comprehensive EmONC as expected. Major EmONC
equipment and supplies (such as autoclave and general anesthetic equipment) and minor
equipments (such as manual vacuum aspiration (MVA) kits) will be procured, an equipment
maintenance plan developed, and training in equipment use provided under Components 2 and 3.
Further, blood transfusion services will be strengthened to curb maternal deaths due to
hemorrhage (antepartum, postpartum or abortion complications).
140. Augmenting the provision of post-abortion care. Post-abortion care (treatment of
abortion complications with manual vacuum aspiration, post-abortion family planning
counseling, and appropriate referral where necessary) deserves special attention since it requires
both emergency care and family planning. Nearly 300,000 induced abortions are performed
annually, with about 85,000 resulting in complications which require treatment. Medical doctors
and midwives will be trained in the use of the MVA for managing abortion complications and
MVA kits will be procured for use in HC IVs and hospitals.
141. Strengthening the referral and communication system. The referral system will be
strengthened so that obstetric complications can be treated promptly and properly. This will
involve a multipronged approach. Firstly, referral forms, protocols, and guidelines will be
developed and disseminated to health facilities. Second, ambulances with basic resuscitation
equipment (ambu bag, IV fluids and giving sets, oxygen cylinder, drugs, gloves, and cotton wool
46
equipments) will be procured under Component 1 of the project. Boat ambulance will be
procured for the Kalangala district, which is made up of several islands. Additionally, bicycle,
motorcycle, or tricycle ambulances will be procured and placed in hard to reach communities to
increase utilization of maternal and neonatal services. Third, there will be a strong focus on IEC,
as a means to further increase the utilization of services. Specifically, community-based health
workers will register pregnant women in underserved and hard to reach communities, explain the
benefits of giving birth with the assistance of skilled health personnel, and encourage pregnant
women to deliver in health facilities.
142. Expanding and strengthening maternal and perinatal death reviews. Health Facility
Maternal and Perinatal Death Auditing Committees have been established in about 20 hospitals
to audit the reasons for deaths and to take steps to prevent similar deaths in these health facilities.
The coverage of these reviews and recommendations of the committees are not always duly
implemented. The project will support establishment of committees at all general hospitals.
143. Increasing the availability and demand for family planning services. This
subcomponent will expand the provision of family planning services at the existing health
facilities and in the communities. It will involve: (a) expanding and improving the quality of
facility-based family planning services; (2) expanding the provision of long-term and permanent
methods through NGOs; (c) providing community-based distribution of family planning
services; and (d) generating demand for services.
144. Expanding and improving the quality of facility-based family planning services.
Family planning protocols will be updated and disseminated to both public and private service
providers. Family planning nurses will be provided with hands-on training on, inter alia, the
insertion and removal of implants and IUDs and counseling so that clients can be provided with
the information needed to make informed choices. The ongoing integration of family planning,
ANC, postnatal care, and Preventing Mother-To-Child-Transmission of HIV (PMTCT) services
will be augmented to increase the number of family planning clients. All pregnant women
seeking ANC and PMTCT services will be offered individual family planning counseling and
follow-up postnatal care. Further, pregnant women who want to undergo sterilization will be
identified, and counseled so that the procedure can be performed immediately after delivery.
This subcomponent will also support the 2009-20 14 Uganda Reproductive Health Commodity
Security Strategic Plan to ensure the continuous availability of the full range of contraceptives,
Since the Government expects to increasingly provide more funding for contraceptives, this
project will initially fill any annual funding gaps, as the Government gradually absorbs the cost
of procuring contraceptives.
145. Expanding the provision of long-term and permanent methods through NGOs.
Currently, NGOs such as Marie Stopes International - Uganda (MSIU), Programme for
Accessible Health, Communication and Education (PACE), and Reproductive Health Uganda
(RHU) have an arrangement with the Government to provide long-term and permanent methods
(LTPM) at rural public facilities. The Government provides the contraceptives, while the NGOs
use their own equipment and staff to provide LTPM services at public facilities. The main
limitation in expanding LTPM is inadequate quantities of IUDs and implants. Cognizant of this,
the project will procure additional IUDs and implants. Further, to make LTPM more accessible
47
at the public facilities, the MOH will partner with these NGOs to provide hands-on training to
nurses and clinical officers (for IUD and implant insertion and removal) and to medical doctors
at the HC IV facilities and hospitals (to perform female sterilization). In addition to this, family
planning equipment will be procured for the public health facilities. This will include mini-
laparatomy kits (for female sterilization), vasectomy kits, implant insertion and removal kits, and
IUD insertion kits.
146. To complement the facility-based services, community-based distribution of family
planning services will be expanded to hard to reach and underserved communities. Each
selected health facility will identify and register community-based health workers who can
provide outreach services in the communities. These community-based health workers (who
could be a select group of the existing village health teams) will perform the following activities:
individual family planning counseling so that clients can make informed choices; home delivery
of condoms and pills; referral to the nearest family planning clinic (public or private) for LTPM;
and follow-up of clients using injectable contraceptives, implants, or IUDs who have failed to go
to the health facility for follow-up. Midwives at the health facilities will provide supportive
supervision to the community-based health workers who are mapped to their respective facilities.
The supervising midwife as well as the community-based health workers will be provided
incentives contingent on: maintaining accurate and complete records signed or fingerprinted
informed consent forms for LTPM, and the number of clients served.60
147. Generating demand for services. Appropriate and effective IEC and BCC materials
will be developed and disseminated to both generate demand for family planning services, and
dispel myths. The electronic and print media will be used to provide information on family
planning services, including the available range of methods, and information on key RH issues
such as the menstrual and ovulation cycle (only 16 percent of women, for example, know that the
mid-menstrual cycle is the fertile period). In addition to this, community leaders and Village
Health Teams (VHT) will also be encouraged to promote family planning delivery services and
newborn care. IEC materials on RH, for example, have already been incorporated in the VHT
handbook. This will be widely disseminated.
60
The Government is still considering the kind of incentives that will be given to village health teams
48
Annex 5: Project Costs
UGANDA: Uganda Health Systems Strengthening Project
Table A5-1: IDA Financing Table by Category (US$ million)
Total Including Contingencies
IDA Gov't Total Percent
Civil Works 57.32 12.59 69.9 1 48.5%
Goods 48.40 1.43 49.83 34.5%
TA 9.93 9.93 6.9%
Training 9.18 9.18 6.4%
Operating 5.17 0.29 5.46 3.8%
Grants
Project Total 130.00 14.31 144.31 100.0%
Table A5-2: IDA Financing Table by Component (US$ million)
Base Cost
IDA Gov't Total
1. Strengthen Human Resource Development and Management 4.87 0.04 4.9 1
2. Enhance Physical Functionality of Health Facilities 74.06 11 -52 85.59
, 3. Strengthen Leadership and Management Systems 10.23 0.63 10.86
4. Reproductive Health 30.00 30.00
Total Base Cost 119.16 12.20 131.36
Physical Contingencies 4.82 1.06 5.87
Price Contingencies 6.02 1.06 7.08
Total Project Cost 130.00 14.31 144.31
49
Table A5-3: Foreign Exchange (US%million)
Local Foreign Total
I. Strengthen Human Resource Development and Management 4.52 0.39 4.91
2. Enhance Physical Functionality of Health Facilities 69.24 16.34 85.59
3. Strengthen Leadership and Management Systems 9.20 1.66 10.86
4. Reproductive Health 10.16 19.84 30.00
Total Baseline Costs 93.12 38.24 131.36
Physical Contingencies 5.87 0.00 5.87
Price Contingencies 6.10 0.98 7.0'8
Total Project Costs 105.09 39.22 144.31
50
Table AS-4: UHSSP Project Costs by Subcomponent (US$ million)
Total Including Contingencies
IDA Gov't Total
1 Strengthen Human Resource Development and Management
.
1.1 Consolidate central level HRH functions 1.70 0.04 1.74
1.2 Strengthening human resource management functions 0.74 0.74
1.3 Improve Staff Retention in Remote and Hard-to-Reach Areas 1.47 1.47
1.4 Strengthen Pre-service and in-service training of health workers 0.96 0.96
Component Total 4.87 0.04 4.91
2. Enhance Physical Functionality of Health Facilities
2.1 Renovation of Selected Health Facilities 63.33 12.59 75.91
2.2 Provision of Medical Equipment 16.72 16.72
2.3 Improved Operations and Maintenance 0.19 0.19
2.4 Strengthen the referral system 4.66 1.05 5.71
2.5 Human Resource Related Issues
Component Tota 1 84.90 13.64 98.54
3. Strengthen Leadership and Management Systems
3.1 Performance Based Management Approaches 1.19 1.19
3.2 Hospital Policy Framework 0.35 0.35
3.3 Professional Management of Health Facilities 1.17 1.17
3.4 Logistics and Supply Chain Management 3.86 0.21 4.07
3.5 Strengthen Delivery of Health Services at the District Level 0.2 1 0.21
3.6 Project Management 3.46 0.43 3.88
Component Total 10.23 0.63 10.86
4. Reproductive Health
4.1 Expanding and improving quality of maternal and newborn care 9.65 9.65
4.2 Family Planning 20.35 20.35
Corn pone nt Tota 1 30.00 30.00
Total Costs 130.00 14.31 144.31
'Identifiable taxes and duties are US$ 14.3 million, and the total project cost, net of taxes, is US$130 million. Therefore, the
share of project cost, net of taxes, is 9.9 percent.
51
Annex 6: Implementation Arrangements
UGANDA: Uganda Health Systems Strengthening Project
148. The project will be implemented under the newly created framework for the
management of the development partner projects, the Long-Term Institutional
Arrangements (LTIA). The LTIA describes processes and measures to align and mainstream
programming and management of development partner projects to national processes and
systems, thus ensuring coordination and sustainability of programs. The LTIA is consistent with
the PEAP Partnership principles (2001) and Paris Declaration on harmonization and alignment of
development partner support. A manual has been developed and endorsed by the partners. It
describes principles on: (a) financing mechanisms; (b) planning and budgeting; (c) coordination
at central, sector, and district levels; (d) program implementation, procurement, and financial
management; and (e) program monitoring and evaluation.
149. This project will be among the first to use the LTIA framework. As the MOH
mainstreams its various projects, there will inevitably be initial implementation problems. But by
signing onto the LTIA, the World Bank, alongside other development partners will work
together to assist GOU establish a system that will ensure effective capacity to program
development assistance for health. It is acknowledged that specific interventions will be
necessary to strengthen capacity within the LTIA in the short medium and long term.
150. Guiding Principles. The following principles shall be the guiding principles for project
implementation consistent with the mainstreaming strategy adopted by Government:
(a) The use of the Government structures and systems for project implementation;
(b) The project components will be assigned and managed by the relevant departments
and/or divisions in the MOH;
(c) The project components will be supervised by component coordinators who shall be
heads of departments or divisions whose departmental/divisional mandates are consistent
with component activities;
(d) Where there are capacity gaps, the ministry will recruit TAs to assist the staff within the
ministry. Such TAs would mentor and train the staff heishe has been attached to. The TA
shall report to the relevant heads of department/division;
15 1. The MOH will have overall responsibility for implementation, accounting for
*
project funds and for coordinating project activities. The PS of the MOH will serve as the
"Accounting Officer" for the project, assuming overall responsibility for the execution of the
project and ensuring that project resources are used for their intended purposes and accounted
for. For proper coordination of execution of the project, the Permanent Secretary, MOH shall
appoint a Project Coordinator whose position shall not be below that of a head of department in
the MOH to provide overall coordination of project activities. The project coordinator will be
supported by Component Coordinators, who are heads of departments/divisions directly involved
in project implementation, and together with other relevant officials will constitute a Project
Secretariat. The departments/divisions include: Health Infrastructure, Human Resources for
Health, Reproductive Health, Curative and Clinical services, Quality Assurance, Procurement
52
and Finance. The component coordinators may appoint focal persons to manage specific project
subcomponent activities in their relevant departments/divisions.
152. Coordination of policy issues arising from the implementation of this project will be
through the respective existing Technical Working Groups and respective
departments/divisions for onward submission to Senior Management Committee of the
MOH. It will be the responsibility of the Project Coordinator to provide periodic reports to the
Senior Management and Top Management Committees as well as the Health Policy Advisory
Committee (HPAC), where partners and Government meet together. This arrangement will
ensure coordination and harmonization of policy proposals and decisions which affect the
implementation of the project specifically and the health sector generally. The project secretariat
will be responsible for coordinating day-to-day implementation of the project, timely project
reporting, fiduciary matters, and project monitoring and evaluation.
153. Technical advisors/specialists will be provided under the project. They will assist
with capacity building and other project implementation activities, inter alia, Financial
Management (Accountant), Procurement (Procurement Specialists); Monitoring and Evaluation
(M&E Specialist); Human Resources for Health (HRH Policy Advisor and HRH Management
System Strengthening Advisor); Health Infrastructure (Quantity Surveyor and Architect); and
Reproductive Health (RH Advisors). The Project Coordinator will also be supported by a project
officer. The consultants recruited under the project will be accountable and report to the
respective heads of departments or divisions to which they are assigned.
154. To ensure effectiveness of the project?s institutional arrangements and smooth flow
of communication between the Bank and Government, the following were agreed upon:
All official communication to the Bank on the project shall be under signature of the PS,
MOH;
All project decisions shall be made by the ministry through the PS, MOH, with advice
from the project coordinator and component coordinators;
Renewals of TAs contract shall be based on satisfactory performance assessment carried
by the ministry and agreed upon between the ministry and the Bank; and
Senior and top management of the ministry will be briefed by the project coordinator
from time to time regarding the progress of project implementation to ensure
transparency and ownership of project by ministry management.
Project terms of reference. The terms of reference for the key main positions in the
are included below. The terms of reference for the project secretariat, focal persons, and
the job descriptions for the various consultants are elaborated in detail in the project
implementation manual. Implementation arrangements regarding Financial Management,
Procurement, and Monitoring and Evaluation are described in the respective Annexes.
156. Permanent Secretary. In addition to the normal duties of the PS, under the project the
main functions of the PS will include:
(a) Main interlocutor between the Bank and Government on the project;
(b) Overall accounting officer, therefore answerable to Parliament and Bank on the project;
53
(c) Principal signatory to the project account;
(d) Responsible for all official communications to the Bank regarding the project;
(e) Providing policy guidance to the project within the context of the overall Health Sector
Strategic Plan.
157. Project Coordinator. The project coordinator will:
(a) Be responsible for the successful implementation of the project and achievement of its
objectives;
(b) Work closely with component coordinators to ensure timely implementation of
component activities;
(c) Brief PS, MOH on project implementation and draw hidher attention to policy issues
which might require attention at higher levels;
(d) Brief senior and top management on project implementation progress and emerging
issues;
(e) Responsible for collation and production of timely reports as required by the Bank for
submission to the Bank under signature of the Permanent Secretary, MOH;
(0Liaise with other projects/programs within the health sector to ensure synergy and
coordination;
(8) Review work plans from component coordinators and ensure that they are consistent with
the project document and objectives;
(h) Review all requisitions for payments from component coordinators to ensure that all the
necessary supporting documents are attached and then communicating to the PS, MOH to
that effect, confirming with a loose minute that the payment is for activities within the
project ;
(i) Counter-sign vouchers and second signatory to project account;
(j) Holds regular project management meetings with component coordinators and project
staff to review implementation progress, work plans, and budget;
(k) Liaise with the relevant departments of the ministry to ensure that the project is
adequately budgeted for in the MTEF and the ministry budget;
(1) Reports to the PS, MOH;
158. Component Coordinators. The component coordinators will be responsible for:
(a) Day to day implementation of the project component;
(b) Preparation of the component work plan, budget and progress report;
(c) Initiation of all component activities;
(d) Preparation of Terms of Reference and specifications of tasks to be contracted under the
component;
(e) Evaluations of technical proposal submitted from consultants/contractors for tasks to be
performed under hidher component;
(0Certification of works/services/goods provided under hidher components before
payments can be made;
(8) Briefing the project coordinator and senior management about progress of
implementation of the component activities;
(h) Keeping track of the component outputs and contribution to the KPI and PDO;
54
(i) Holding regular component coordination meetings with relevant component staff;
(j) Reports to the project coordinator.
55
Annex 7: Financial Management and Disbursement Arrangements
UGANDA: Uganda Health Systems Strengthening Project
Summary of Financial Management Assessment
159. The Bank undertook a financial management capacity assessment of the MOH in
accordance with the Bank's Operation Policy/Bank Procedures 10.02 with respect to financial
management, and the Financial Management Practices Manual issued by the Financial
Management Sector Board on November 3,2005.
160. The project's financial management transactions will be mainstreamed within the MOH
with the Permanent Secretary as the overall accounting officer. Daily operations will be handled
by the Accounting Department headed by an Assistant Commissioner. Due to the already
existing work load, additional accounting staff will be recruited under the project. The GOU
accounting policies and procedures documented in the Government's Treasury Accounting
Instructions 2003, issued under the Public Finance and Accountability Act 2003, will be used for
the project supplemented with additional guidance on Bank project requirements on external
auditing and financial reporting as documented in the Financing Agreement. Fiduciary oversight
will be provided through semi-annual internal audit reporting, Value-for-Money audits by the
Auditor General and annual financial audits of the project accounts. The accounts will be
handled using Navision accounting software pending configuration of the Integrated Financial
Management Information Systems (IFMIS) to handle preparation of project accounts. The
ministry has adequate internal audit arrangements and the internal auditors within the ministry
will include the project activities in their work plan. The project's financial statements will be
audited by the Auditor General in accordance with statutory requirements, and suitable Terms of
Reference will be developed.
16 1. The results of the assessment indicate that the Financial Management overall risk rating
for the project is Substantial after mitigating measures. Appropriate mitigating measures have
been identified and incorporated into the project design. In conclusion, the proposed financial
management arrangements put in place by the Program meet the Bank's minimum requirements
for project financial management as per OP/BP 10/02 and therefore are adequate to provide, with
reasonable assurance, accurate and timely information on the status of the project required by
IDA.
Country issues
162. The Public Expenditure and Financial Accountability (PEFA) Report of November 2008
issued in June 2009 and the Country Financial Accountability Assessments (CFAA) of 2004 and
2008 show that GOU has made substantial progress in improving its Public Financial
Management Systems but risks remain in terms of (a) quality and timeliness of in-year budget
reports since budget reports only include information on budget releases and not actual
expenditures; (b) stock and monitoring of expenditure payment arrears; (c) effectiveness of
internal audit; (d) oversight of aggregate fiscal risk from other public sector entities; (e)
effectiveness of measures for taxpayer registration and tax assessment; ( f ) legislative scrutiny of
external audit reports; (8) effectiveness of payroll controls; and (h) effectiveness in collection of
56
tax payments. The GOU has prepared a Financial Management Accountability Program
(FINMAP) to address the weaknesses in its Public Financial Management system. The FINMAP
is supported by a number of development partners (Public Financial Management Development
Partner Group) including the World Bank under the Local Government Management Service
Delivery Project (LGMSD).
Risk Assessment and Mitigation
163. The objectives of the project's financial management system are to (a) ensure that funds
are used only for their intended purposes in an efficient and economical way; (b) ensure that
funds are properly managed and flow smoothly, adequately, regularly, and predictably in order to
meet the objectives of the project; (c) enable the preparation of accurate and timely financial
reports; and (d) enable project management to monitor the efficient implementation of the
project; and to safeguard the project assets and resources. Furthermore, a strong financial
management system should include the following necessary features: (a) adequate number and
mix of skilled and experienced staff; (b) robust internal control system able to support orderly
and efficient payments and procurement processes, and ensure proper recording and
safeguarding of assets and resources; (c) an accounting system that can support the project's
requests for funding and meet its reporting obligations to fund suppliers, contractors and other
providers including the GOU, IDA, other development partners, and local communities; (d) a
system capable of providing financial data to measure project performance; and (e) an
independent, qualified auditor be appointed to review the Project's financial statements and
internal controls.
164. The table below identifies the key risks that the project management may face in
achieving these objectives and provides a basis for determining how management should address
these risks.
Table A7-1: Financial Management Risks and Mitigation Measures
Risk Risk Rating Risk Mitigation measures incorporated into Risk after
project design Mitigation
In herent Risk
A Government led PFM Reform Program is under
Country level: The 2o08 Moderate
implementation which addresses issues of
PEFA reported weaknesses
procurement and its related enforcement. Payroll
in Government PFM
and Pension reforms are being addressed through
systems, i.e., weak
the UPSPEP program under Ministry of Public
enforcement of procurement
Service.
and payroll rules and
An agreement has been reached to recruit staff
Entity level: Annual High Substantial
where gaps have been observed. Professional and
statutory audits have
experienced staff in finance, accounting and
highlighted various internal
procurement will be hired on contract for project
weaknesses of
implementation. The use of Direct payments to
accountability, delayed
suppliers and contractors will be emphasized to
payments to contractors
avoid payment delays.
resulting into uenalties. un
57
Risk Risk Rating Risk Mitigation measures incorporated into Risk after
project design Mitigation
flawed procurement rules
and procedures.
Project level: Multiple High In-depth semiannual internal audit reviews will be Substantial
construction sites involved carried out by the Inspectorate & Internal Audit
and transactions controlled department of MOFPED to provide independent
centrally at MOH. Inability internal verification of the transparency and
to use funds efficiently and soundness of key financial management tasks
economically for purposes under the project, including procurement
intended. procedures, processing of payments and
preparation of financial reports for Bank review.
The Auditor General will conduct two Value-For-
Money audits over the project duration to assess
effectiveness and efficiency in the utilization of
Credit proceeds. Fiduciary aspects of the project
will be embedded with monitoring and evaluation
so that there is a linkage between outputs that
contribute to indicators and resources. Further,
there shall be enhanced accounting and reporting
given the proposed contract staff hired by the
ministry. Independent external auditors shall be
engaged to conduct annual audits. A detailed and
comprehensive annual work plan and budget will
be developed and shall be strictly followed to help
monitor the rehabilitation and construction of
selected hospitals and Health Centers (HCs).
Overall inherent risk Substantial
Control risk
Budgeting: Some project Moderate Project budget plans to be prepared in sufficient Low
elements may be estimated detail which will be used as a management tool
below cost due to frequent and the PPF advance has been requested with
price escalations. sufficient consultancy costs to ensure initial
procurement process is done in advance before
effectiveness. This will mitigate on cost estimates.
The IFRs to be prepared will be used to monitor
variance analysis with budget.
Accounting and Substantial The Assistant Commissioner (Accounts) & Senior Moderate
Information System. Accountants in the ministry are qualified and
Inability for the Ministry to experienced in Bank funded projects. They will
manage the Project oversee and be responsible for the outputs of the
Accounts with sound contracted staff.
systems, which will slow
The ministry installed Navision Accounting
down the project activities.
system to process project accounting. The
ministry will require renewing the license and
uploading the latest version of the package for
utilization by the project.
Staffing at MOH may be Moderate MOH has agreed to hire a few technical staff to Low
58
Risk Risk Rating Risk Mitigation measures incorporated into Risk after
project design Mitigation
stretched to implement the complement their available personnel to
requisite control procedures efficiently implement the project. Finance,
as intended such as Accounting and Procurement are the critical areas
accounting and internal to be focused on.
controls
Fund release and usage: Substantial The method of Direct Payments will be actively Moderate
especially delays in used other than DA replenishments. Major
effecting payments to suppliers and contractors Communities will be
suppliers and contractors, paid directly through withdrawal application
funds for the project may instructions to the Disbursing office. The agreed
not be used in an efficient periodic internal audit reviews will ensure that
and economical way and payments are made for work done and where such
exclusively for purposes payments have been made for no work done,
intended. appropriate measures will be taken for refund.
Strictly adhere to the approved budget of the
project will be observed.
internal control: Risk of High The Ministry PDU together with the ongoing Substantial
influence peddling leading internal audit reviews will play a leading role in
to contractors inflating mitigating this risk. The Internal Audit department
prices for goods and civil will incorporate the project in their annual work
works. plans with regular internal control reviews. Other
Government law enforcement offices would be
informed in case need arises.
Reporting and Moderate The experienced Principal & Senior Accountants Low
Monitoring: financial at the ministry will primarily be responsible for
information may be financial reporting working together with
unreliable and submitted technical staff contracted. The project will initially
late. report through Statement of Expenditures (SOE)
until such a time when they will have built
sufficient capacity to use Report based IFRs.
External Audit Moderate The Auditor General is primarily responsible for Low
auditing all Government programs and projects.
He may subcontract CPA firms, with the final
report issued by the Auditor General with the TOR
satisfactory to IDA.
Overall control risk Moderate
Overall Project Risk Rating Substantial
H - High S - Substantial M - Modest L - Low
Strength and Weaknesses of the Management Unit
165. The assessment noted the following salient features as strengths for project financial
management: (a) accounting policies and procedures will be based on the Treasury Accounting
Instructions 2003, issued under the Public Finance & Accountability Act 2003; (b) qualified and
experienced accounting personnel within the ministry; (c) adequate arrangements for budgeting
59
and for external and internal auditing; (d) adequate funds flow arrangements; and (e) while the
IFMIS, which is the computerized accounting system for the ministry is not configured to be
used for projects, the project's accounts will be prepared using an appropriate accounting
package already in place.
166. The assessment identified salient weaknesses which would affect project financial
management. Although experienced staff exist, they are not adequate for the purposes of this
project financial management given they have to support other projects and continue with their
routine work. The Auditor General's audit reports for 30 June 2006, 2007, and 2008 for the
MOH identified accountability issues, which require the implementing entity to improve on its
internal control systems. In order to mitigate this risk, the funds for this project will be ring
fenced within the ministry and their use will be closely monitored by the Accounting Officer,
Internal Audit Department of the MOFPED, Auditor General's Office and the Bank to ensure
they are used for the purposes intended.
Institutional and Implementation Arrangements
167. There will be no Project Coordination Unit (PCU). The MOH shall coordinate project
implementation and manage: (a) procurement, including purchases of goods, works, and
consulting services; (b) project monitoring, reporting and evaluation; (c) contractual
relationships with IDA and other Cofinanciers; and (d) financial management and record
keeping, accounts and disbursements. The ministry will also constitute the operational link to the
IDA and GOU on matters related to the implementation of the project. The MOH will manage
the project as an autonomous project with a separate bank account and books of accounts.
Finances and other resources realized for the activities of the project shall not be used to cater for
other functions other than those budgeted for. The Permanent Secretary (PS) MOH will be the
"Accounting Officer" for the project, assuming overall responsibility for accounting for the
project funds.
Budgeting, Accounting and Staffing Arrangements
168. Government planning and budgeting procedures which are documented in the
Government's Treasury Accounting Instructions 2003 are adequate and will be followed. There
is a planning unit and a budget officer that is responsible for the budgeting process in the
ministry. All other departments are involved in the budgeting process.
169. Books of Accounts and List of Accounting Codes. The ministry will maintain similar
books of accounts to those for other IDA funded projects. A list of accounts codes (Chart of
Accounts) for the project should be drawn upon finalization of the accounting computerization
process. This should match with the classification of expenditures and sources and application of
funds indicated in the Financing Agreement.
170. Staffing Arrangements. The MOH is staffed with qualified and experienced accounting
personnel, but due to excess work load, the project's accounts will be prepared by a designated
contract staff who will report to the Senior or Principal Accountant who in turn will report to the
Assistant Commissioner and ultimately to the Permanent Secretary. The designated accountant
60
will be assisted by an accounts assistant. Otherwise the MOH has one Senior Accountant,
several Accountants and accounts assistants. In order to ensure that the project is effectively
implemented and funds put to their intended use recruitment of the project accountant will be a
condition of effectiveness for this project.
171. Information system. The ministry is connected to the Integrated Financial Management
System (IFMIS) but the Ministry will prepare the accounts for the project using its Navision
Accounting software. The team in Ministry is conversant with preparing the accounts using this
accounting software.
Internal Control and Internal Auditing
172. Internal Controls and Financial Management Manual. The existing Financial
Management Manual in the Ministry is the Government's Treasury Accounting Instructions
2003 issued under the Public Finance and Accountability Act 2003, These procedures, however,
fall short of project requirements on external auditing and financial reporting which will be
documented in the Financing Agreement. Thus a section in the Project Implementation Manual
(PIM) on Financial Management will describe the accounting system, i.e., major transaction
cycles of the project.
173. Internal Audit. The ministry has qualified and experienced internal auditors, Le., a
Senior Internal Auditor and an Internal Auditor. The internal audit unit issues out reports on a
quarterly basis based on their review of the internal control system of the ministry agreed to
incorporate the Uganda Health Systems Strengthening Project into their internal audit work plan.
The qualification and experience of the staff in the unit is adequate and their quality assurance is
monitored by the MOFPED under the Commissioner Internal Audit. In this regard, the internal
audit arrangements at the ministry are adequate.
Banking & Funds Flow Arrangements
174. The following bank accounts will be authorized by the MOFPED and maintained by the
Ministry for purposes of implementing the project:
(a) Designated Account (DA): Denominated in US dollars where disbursements from the
IDA will be deposited.
(b) Project Account: This will be denominated in local currency. Transfers from the
Designated Account (for payment of transactions in local currency) will be deposited
into account in accordance with project objectives.
175. These bank accounts shall be opened at Bank of Uganda in accordance with the
Financing Agreement. The signatories for the project accounts will be in accordance with the
Treasury Accounting Instructions/ Public Finance and Accountability Act 2003.
176. Disbursement Arrangements. The MOH will receive disbursements into the Designated
Account based on quarterly Interim Financial Reports (IFRs). Initial cash flow forecasts upon
which the advance disbursement will .be made from the IDA Credit should be prepared within
61
one month after the date of effectiveness. A duly authorized Withdrawal Application for the
additional cash replenishment required into the Designated Account will be provided along with
the IFRs. The withdrawal requests and IFRs should be submitted to the Bank within 45 days
after the end of the quarterly calendar periods. The cash flow projections will be supported by
work plans and procurement plans.
177. If ineligible expenditures are found to have been made from the Designated Account, the
Borrower will be obligated to refund the same. If the Designated Account remains inactive for
more than six months, the Borrower may be requested to refund to IDA amounts advanced to the
Designated Account. IDA will have the right, as reflected in the Financing Agreement, to
suspend disbursement of the Funds if reporting requirements are not complied with.
Figure A7-1. FUNDS FLOW CHART
f
\
Designated Account
(USD) in BOU
I
\
1
-
T
i
Project Account (UGX)
I~BOU
' 2
J
z
-
15-'
c
Financial Reporting Arrangements
178. As per World Bank guidelines, the project will issue quarterly interim financial reports
(IFRs) within 45 days after the end of each calendar quarter, which are designed to provide
quality and timely information to the project management, MOH, the Bank and various
stakeholders monitoring project performance and will be composed of the following:
(a) A statement of Sources and Uses of Funds for the reported quarter and cumulative period
(from project inception) reconciled to opening and closing bank balances; and
(b) A statement of uses of funds (expenditure) by project activity/component comparing
actual expenditure against the budget, with explanations for significant variances for both
the quarter and cumulative period.
(c) In addition to the above reports, the Ministry will submit to the Bank the following
information in order to support report-based disbursement, when systems are deemed
satisfactory:
(i) Designated Account (DA) Activity Statement;
(ii) DA Bank Statements;
62
(iii)Summary Statement of DA Expenditures for Contracts subject to Prior Review;
(iv) Summary Statement of DA Expenditures for Contracts not subject to Prior Review.
179. The annual financial statements should be prepared in accordance with International
Public Sector Accounting Standards (which inter alia includes the application of the cash basis
of recognition of transactions) for external audit. The IDA Financing Agreement will require the
submission of audited financial statements to the Bank within six months after the financial year
end.
External Auditing Arrangements
180. The Auditor General is primarily responsible for the auditing of all Government projects.
Usually, the audit may be subcontracted to a firm of private auditors, with the final report being
issued by the Auditor General and submitted to the Bank within six months after the end of each
GOU financial year, i.e., by 31 December. The private firms to be subcontracted should be
acceptable to the Bank. In case the audit is subcontracted to a firm of private auditors, IDA
funding may be used to pay the cost of the audit. The audits are done in accordance with
International Standards on Auditing. Appropriate terms of reference for the external auditor
should be developed by the Ministry and agreed with the Bank's Country Financial Management
Specialist.
Financial Management Action Plan
181. The action plan below indicates the actions to be taken for the project to strengthen its
financial management system and the dates that they are due to be completed by.
Table A7-2: Financial Management Action Plan
I Action I DateDue 1 Responsibility
1. I Production of formats of unaudited interim financial 1 Agreed at PPF I MOH and IDA
reports (IFRs) that will be used for the project and approval.
reaching agreement on them with IDA.
2 Recruitment of Project Accountant. Before Effectiveness MOH
3 Development of work plans and terms of reference Not more than 6 MOH
for internal audits and Value-for-Money audits6'. month after
effectiveness
4. Improve on MOH internal control systems to ensure To be done during MOH, Internal Audit
that the project's funds are used for purposes implementation. Dept., Auditor General's
intended. Office and IDA
6' A Department has been established in the Office of the Auditor General to conduct value-for-money audits. Generic TORS
already in existence will be adapted to the project.
63
Effectiveness Conditions and Financial Covenants
Effectiveness Conditions
182. The Recipient has recruited an Accountant.
183. Financial covenants are the standard ones as stated in the Financing Agreement Schedule
2, Section I1 (B) on Financial Management, Financial Reports and Audits and Section 4.09 of the
General Conditions.
Supervision Plan and Conclusion
184. Supervision missions will be conducted at least twice every year based on the risk
assessment of the project.
185. A description of the Ministry's financial management arrangements above assesses the
mitigated financial management risk as Substantial which satisfies the Bank's minimum
requirements under OP/BP10.02 with some improvements to be effected to the system to be
adequate to provide, with reasonable assurance, accurate and timely accounts/information on the
status of the Project as required by the Bank. The recommended improvements are detailed in the
risk table and the Financial Management Action Plan above.
64
Annex 8: Procurement Arrangements
UGANDA: Uganda Health Systems Strengthening Project
A. Background
186. Procurement activities for the proposed project will be implemented by the MOH,
Applicable Guidelines
187. Procurement for the proposed project would be carried out in accordance with the World
Bank's "Guidelines: Procurement under IBRD Loans and IDA Credits," dated May 2004, revised
October 2006, and "Guidelines: Selection and Employment of Consultants by World Bank
Borrowers," dated May 2004, revised October 2006, and the provisions stipulated in the Legal
Agreement. The various items under different expenditure categories are described in the
Procurement Plan below. The procurement entities as well as contractors, suppliers, and
consultants will observe the highest standard of ethics during procurement and execution of
contracts financed under this project. The project will carry out implementation in accordance
with the "Guidelines on preventing and combating Fraud and Corruption in projects financed by
IBRD Loans and IDA Grants" dated October 15, 2006 (the Anti-Corruption Guidelines).
B. Applicable Procedures
Use of National Procurement System
188. Procurement in Uganda is governed by the Public Procurement and Disposal of Public
Assets Act of 2003. The procedures in the PPDA act have been reviewed by the Bank and found
to be acceptable, subject to the following exceptions which will not be applicable under this
project:
(a) Negotiations with the best evaluated bidder. This practice is not appropriate, except for
consulting services, contracts, and for goods and works under exceptional circumstances,
and for contracts procured through direct contracting.
(b) The merit point system for bid evaluation. This shall not be applied for goods and works
contracts procured on basis of competition (ICB, NCB or restricted tender).
(c) Prequalifying bidders and then inviting only a few on a rotational basis. For shopping
procedures, the Procuring and Disposal Entity (PDE) will not be allowed to prequalify
suppliers on an annual basis and invite only a few on a rotational basis. Where
prequalification is conducted, all prequalified providers will be invited to submit bids.
Common supplies like stationery and consumables will be aggregated and procured
annually through framework contracts to enable implementing agencies to place orders
for urgently needed supplies at short notice, at a competitive price.
(d) Application of Domestic Preference under NCB. Domestic Preference shall only be
applied under ICB.
(e) Use of microprocurement. Microprocurement as defined in the PPDA Act will only apply
for contracts estimated to cost the equivalent of US$150 or less.
65
( f ) Selection of Consultants: The procedures for Selection of Consultants shall not apply as
they treat the selection of Consultants like the procurement of goods and works. Only the
Bank's guidelines shall apply for selection of all Consultants under the project,
189. Under the proposed project, procurement under ICB and selection of consultants using
QCBS shall also (in addition to the World Bank guidelines) comply with the national approval
system except where the two conflict when the World Bank guidelines will take precedence.
Specifically, the Contracts Committees shall perform their oversight functions at each of the key
procurement stages and contracts shall be subjected to the Solicitor General's clearance where
applicable. Shopping shall follow the RFQ procedures as defined in the PPDA Act and attendant
regulations with the exception of the rotation of bidders as indicated above. These procedures
have been reviewed by the Bank and found to be satisfactory. In addition, no negotiations shall
take place with respect to a quotation submitted by the supplier or contractor under shopping.
C. Solicitation Documents to be used
190. Goods and Works. The Bank's Standard Bidding Documents and Standard Form of
Evaluation will be used for procurement of all contracts under International Competitive Bidding
(ICB), and may also be used for procurement under National Competitive Bidding (NCB) with
appropriate modifications. Alternatively, for NCB the standard tender documents for
procurements of Supplies, Works and Non-Consultancy Services prepared and issued by the
Public Procurement and Disposal of Assets Authority (PPDA) may be used subject to
modifications to be agreed with the Bank for the SBDs for goods and works, such as the
following:
(a) Only the "Technical Compliance Selection methodology" (award to the lowest evaluated
responsive bidder) as defined in the Act shall be adopted. The rest of the methodologies
shall not be used, even for NCB, for the procurement of goods, works and nonconsulting
services.
(b) The following documentation or their equivalent shall not be treated as eligibility
requirements: (i) tax clearance certificates; (ii) VAT registration certificates; and (iii)
trading licenses. These may however be included as post qualification requirements, on
which clarificatiodadditional information can be sought during the evaluation.
(c) In accordance with para. 1.14 (e) of the Procurement Guidelines each bidding document
and contract financed out of the proceeds of the Financing shall provide that: (i) the
bidders, suppliers, contractors, and subcontractors shall permit the Association, at its
request, to inspect their accounts and records relating to the bid submission and
performance of the contract, and to have said accounts and records audited by auditors
appointed by the Association; and (ii) the deliberate and material violation by the bidder,
supplier, contractor, or subcontractor, of such provision may amount to an obstructive
practice as defined in paragraphs 1.14(a)(v) of the Procurement Guidelines.
19 1. Consulting Services. The Bank's Standard Request for Proposal document will be used
in the selection of consulting firms. The PPDA procedures for selection of Consultants including
bidding documents, evaluation forms, etc., shall not apply for this project.
66
D. Record Keeping
192. The PDU will be responsible for procurement record keeping and shall open a file for
each contract that they enter into. The file `should contain all documents relating to the
procurement process in accordance with the requirements and as described in the PPDA Act.
E. Scope of Procurement under the Project
193. Procurement activities to be financed by the Bank are:
(a) Procurement of Works. Works to be procured under this project would include: civil
works contracts for renovation of 2 Regional Referral Hospitals, 17 General Hospitals,
and 27 Health Centers Type IV.
(b) Procurement of Goods: Goods to be procured under this project would include: medical
equipment; ambulances and general purpose vehicles for hospitals; office equipment and
furniture; and setting up and managing a VOIP/e-Health Communication system between
the MoH Headquarters, Mulago, the 2 RRHs, the 17 GHs and 19 DHOs, etc.
(c) Procurement of nonconsulting services. Nonconsulting services will include, but not be
limited to (i) servicing of office equipment; (ii) repair and maintenance of project
vehicles; and (iii) services for Logistics and supplies contractor to pilot delivery of
medicines and health supplies from JMS and NMS to 9 Districts for 1 year. The
procurement of nonconsulting services shall follow the existing SBDs with appropriate
modifications.
(d) Selection of Consultants. The consulting services from firms and individuals required
for the project would comprise of contracts for: (i) design and preparation of bidding
documents for rehabilitation of the health facilities (3 Lots); (ii) construction supervision
of civil works (5 lots) for renovation of health facilities; (iv) technical assistant support to
the MOH; and (v) studies agreed upon during implementation.
(e) Operating Costs. The project will finance costs of the implementing agency that
directly relate to project implementation. The project's operating costs include
expenditures for routine repair and maintenance of equipment and vehicles used for
project implementation, fuel, communication costs, use of internet costs, stationery and
other office supplies, consumables, travel per diems, accommodation expenses related to
project implementation, workshop venues and materials, and costs of translation,
printing, photocopying and advertising. Salary top-ups, meeting allowances, sitting
allowances and honoraria to civil/public servants and contracted consultants shall not be
financed by the project.
( f ) Training plan. The project will formulate an annual training plan and budget which will
be submitted to the Bank for its prior review and approval. The annual training plan will,
inter alia, identify: (i) the training envisaged; (ii) the justification for the training, how it
will lead to effective performance and implementation of the project and or sectors; (iii)
67
the personnel to be trained; (iv) the selection methods of institutions or individuals
conducting such training; (v) the institutions which will conduct training, if already
selected; (vi) the duration of proposed training; and (vii) the cost estimated cost of the
training. Upon completion of training, the trainee shall be required to prepare and submit
a report on the training received. Additionally the Uganda Health Systems Strengthening
(UHSSP) Project Implementation Manual shall specify how candidates eligible for the
graduate training shall be selected. These procedures shall ensure equal opportunity to all
eligible participants.
F. Assessment of the agency's capacity to implement procurement62
194. The Procurement Function. The Project will be mainstreamed into MOH under the
direct oversight of the Permanent Secretary (the Accounting Officer). The procurement function
will be executed by the PDU. The PDU is headed by a Principal Procurement Officer who is
supported by 3 Procurement Officers (1 Senior Procurement Officer, and 2 Procurement
Officers); 1 Secretary; 1 Data Entry Clerk; and 1 Office attendant. Although the PDU
procurement staff possess the basic qualifications and are conversant with procurement
processing under the PPDA Act and regulations, none of them has experience in IDA financed
procurement management. The review of contract records found that although the procedures
followed in the preparation of documents, management of bidding process, bid evaluation, and
contract award were carried out in compliance to the PPDA Act, the procedures were not always
fully satisfactory. Key documents were found missing in the procurement files reviewed; the user
departments reported routine instances of misplacement of their requisitions and delays in
procurement processing; and space in the PDU was established to be insufficient for staff and
storage of procurement files.
195. The Contracts Committee. MOH has a Contracts Committee in place as per
procurement law. The Contract Committee meets at least weekly or as need arises. Due to poor
procurement documentation, the Contracts Committee often returns procurement documents to
PDU for revision leading to delays in the procurement cycle. To improve the quality of
procurement documents prepared by PDU, it is recommended that MOH recruit a Procurement
Specialisth, with TOR acceptable to IDA for at least the first two years to handle procurement of
contracts related to this project and provide hands-on coaching to PDU staff.
196. The PDU. Government has started to address the challenges in the PDU established
during the procurement assessment. A data entry clerk was engaged to enter information from
User Departments into the IFMIS and computers and a photocopier were purchased for the PDU.
The PDU will be allocated new offices once the extension building under construction is
completed in March 20 1 1. PDU will adopt framework contracts for procurement of common use
items, e.g., stationery, and delegate microprocurements (procurements under US$ 1,000) to user
departments to free PDU staff to handle the other contracts.
197. The Health Infrastructure Division (HID). The Health Infrastructure Department is
responsible for all health infrastructure related works, including medical equipment, in the sector
62The procurement assessment of the MOH to implement procurement for the project was carried out by Grace Munanura on
July 20, 2009.
68
financed by Government and other development partners. Under the project, it will coordinate
procurements on renovation of health facilities, medical equipment and vehicles, and supervise
consultants and contractors financed by the project. In addition to two Electrical Engineers
whose recruitment is underway, there are four Civil Engineers, two Medical Equipment
Engineers and one Sanitary Engineer in the division. The Division is currently engaged in
technical support to ongoing civil works carried in the Regional Referral hospitals; African
Development Bank financed rehabilitation of 26 HC 111's and 13 HC IVs, 5 Mental Units and
remodeling of Mbarara Hospital; JICA financed renovation of hospitals. The Health
Infrastructure Department will designate 2 Civil Engineers to the project and recruit an Architect
and Quantity Surveyor to supplement skills in the Division for the implementation of the project.
The MOH will also recruit 5 Clerks of Works with the responsibility of verifying onsite physical
quality of the works by contractors. The National Advisory Committee on Medical Equipment
(NACME) is a specialized committee in the MOH with representation from various ministries
charged advising Government medical equipment. The committee has prepared the Medical
Equipment Policy in three volumes: Volume 1 - Policy; Volume 2 - Guidelines, which contain a
list of the different medical equipment required at the different levels of Health facilities; and
Volume 3 - Specifications, which contain for the detailed technical specifications for the
different medical equipment for each level of health .facilities. In this regard, the MOH has
adequate capacity to prepare technical specifications for medical equipment.
198. National Medical Stores (NMS): National Medical Stores is a Government parastatal
agency with the mandate to procure and distribute essential medicines and supplies on behalf of
the MOH. NMS will procure essential supplies and commodities under the project mainly under
the component on maternal health, newborn care, and family planning. The PDU has one Head
of Department and 3 Procurement Officers and has handled similar procurements before. It is
currently processing a procurement of US$l 0 million for contraceptives and US$9 million for
Maama k i d 3 . Although the PDU staff lack IDA procurement experience, they are familiar with
the kind of procurements to be handled under the project and procurement management under
PPDA Act. The MOH will be responsible to prepare Technical Specifications under the project.
The records reviewed indicate that procurement processing in NMS is in compliance to the
PPDA Act. NMS will provide appropriate space for storage of procurement documentation. The
risk to the project procurement management by NMS is Moderate.
199. The overall risk to project procurement management by MOH to project is Substantial.
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The Maama kit contains basic materials to facilitate clean and safe delivery and reduce the risk of deadly infection to the
mother and her newborn baby i.e. sterile gloves, plastic sheets, cord ligature, razor blades, tetracycline, cotton, soap and sanitary
pads.
69
200. The proposed corrective measures which have been agreed to mitigate the overall risk are
indicated in the matrix below.
Table A8-1: Procurement Action Plan
Risk Action Completion Date Responsible
Entity
Inadequate capacity and Recruit a Procurement Specialist/s to By August 31,2010 MOH
procurement skills of provide hands-on coaching, mentoring
PDU staff to handle IDA of PDU staff and User Departments.
financed procurement PDU staff to attend ESAMI or GIMPA By twelve months MOH
management. courses in: after effectiveness
(i) procurement of works and goods
(ii) selection of consultants
Delegate to user departments micro- Immediately MOH
procurement function or use framework
contracts for common items
Inadequate procurement MOH to establish an acceptable MIS for Within six months of MOH
filing and record keeping procurement tracking as well as an effectiveness
system. acceptable procurement filing and record
keeping system.
Inadequate office space At least make available an office space By August 31,2010 MOH
for PDU staff and for the procurement specialist.
procurement files.
Inadequate skills mix in Recruit 1 Architect; 1 Quantity Surveyor Within 3 months of MOH
HID to provide technical and 5 Clerks of Works64. effectiveness for the
support to civil works Architect and Quantity
contracts. Surveyor; and within
12 months of
effectiveness for Clerk
of Works.
Inadequate procurement PDU to prepare a procurement plan for By project MOH
planning. the first 18 months in coordination with negotiations
the user departments.
Lack of understanding of (i) Prepare Procurement Manual to By effectiveness MOH
roles and responsibilities clarify roles and responsibilities of staff;
between user (ii) Train user departments in By six months of
departments and PDU. procurement and contract management. effectiveness MOH
G. Procurement Plan
201. The Borrower, at appraisal, developed a procurement plan for project implementation
which provides the basis for the procurement methods. This plan was agreed between the
Borrower and the Project Team on April 1, 2010 and endorsed during negotiations, and is
available at the MOH offices on Plot No. 6 Lourdel Road, Kampala. It will also be available in
the project's database and in the Bank's external website. For each contract to be financed by the
Credit, the different procurement methods, consultant selection methods, the need for
prequalification, estimated costs, prior review requirements, and time frame are agreed between
the Borrower and the Bank in the Procurement Plan. The Procurement Plan will be updated in
64
Recruitment of the above staff have been initiated through the prqject preparation advance.
70
agreement with the Project Team annually or as required to reflect the actual project
implementation needs and improvements in institutional capacity.
H. Frequency of Procurement Supervision
202. In addition to the prior review supervision to be carried out from Bank offices, the
capacity assessment of the Implementing Agencies has recommended at least one supervision
mission annually mission to visit the field to carry out post review of procurement actions.
203. Prior Review Threshold: The prior review thresholds are as follows:
I. Procurement of Goods and Works
Procurement Contracts Subject to
Method Prior Review
ICB All Contracts
< 5,000,000 NCB Selected Contracts as
I
indicated on Procurement
Plan
< 100,000 Shopping I None
2. Goods ~=500,000 ICB I All Contracts
<500,000 ;;:yted Contracts as
indicated on Procurement
<50.000 Sho in None
II. Selection of Consultants
<200,000 CQS, LCS, QBS, FBS Selected Contracts as
indicated on
Procurement Plan
All values I sss I AH contracts
(b) Individual 1 >=50,000 I IC I All contracts
1 A I Ivalues I sss I AH contracts
65Short list comprising entirely of national consultants: Short list of consultants for services, estimated to cost less than
US$200,000 equivalent per contract, may comprise entirely of national consultants in accordance with the provisions of
paragraph 2.7 of the Consultant Guidelines.
71
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Annex 9: Economic and Financial Analysis
UGANDA: Uganda Health Systems Strengthening Project
Introduction
204. Economic analysis plays a significant role in informing the choice of project
alternatives, design arrangements, and implementation strategies, and is often used to
make judgments on how a proposed or existing project involves the efficient use of
resources. In the health sector, economic analyses commonly rely on four techniques,
namely: cost-minimization analysis, cost-effectiveness analysis, cost-utility analysis, and
cost-benefit analysis. Because of measurement challenges arising from difficulties in valuing
incremental costs and the impacts of health interventions, rigorous economic analysis
commonly performed in other sectors are seldom conducted in the health sector. This analysis
assesses (a) economic rationale for investing in the health sector in Uganda; (b) economic
justification for the selection of the project components and activities; (c) financial
sustainability of the health sector; and (d) project sustainability. The analysis is mainly
informed by the recent assessment of fiscal space for health in Uganda.
Economic rationale for investing in a health sector in Uganda
205. Health status is a major determinant of individual wellbeing and a good marker
of country's level of development, particularly for developing countries. Health and
health care carry special characteristics that give them a claim on public resources. The
"public goods" nature and positive spillover effects of some elements of health care are
among the reasons why societies prefer public intervention in the provision of health care.
The uncertainty of illness in terms of occurrence, severity and cost of treatment together with
asymmetry of information regarding medical interventions are also among some of the
reasons used to justify investments of public resources into the health sector. Most countries
are concerned about existing inequalities in health status and provision of health care, and
justify the use of public resources to correct such inequalities on the principle of equity. The
private health sector in Uganda is underdeveloped, poorly regulated, and consists
predominantly of small clinics and drug shops offering basic curative care of sometimes
doubtable quality. The population is largely rural (85 percent) with a big proportion living in
abject poverty (3 1 percent) and unable to afford basic health care. Communicable diseases for
which cost-effective interventions exist are the major cause of disease burden and mothers
and children bear a disproportionate burden. In such a scenario, a network of public health
facilities that offer curative care as well as coordinate preventive health care services serve as
a safety net to the population, most especially to patients requiring hospitalization. It is
vitally important to ensure these health facilities are properly staffed and managed and
function adequately. While the private sector can deliver some of these services in the urban
areas, Government intervention is required in regulation and ensuring services which are not
provided by the private sector are made available in particular to the rural areas. Uganda is
witnessing a rapid rise in household out-of-pocket expenditures on health, and the level of
health spending is deemed catastrophic. Out-of-pocket health expenditures amounted to
almost 9 percent of total household consumption expenditure and represented about 37.9
percent of total health spending in 2006. Detailed analysis of the national household survey
data from 2006 indicates that, on average, almost 28 percent of sampled households faced
health expenditures that could be deemed "catastrophic," defined as health expenditures in
excess of 10 percent of total household consumption. In the absence of social health
76
insurance, as is the case in the context of Uganda, public provision will remain an important
aspect of health care service delivery.
Economic justification for the selection of the project components and activities
206. The project comprises three major components: (a) improving functionality of
existing physical health infrastructure; (b) improving health workforce development,
management, retention, and productivity; and (c) strengthening leadership, management, and
accountability for health service delivery.
207. Waste in public spending is a problem in the health sector and occurs in a
number of ways. These include leakages of funds before reaching the designated spending
entities, breach of Government financial and procurement regulations, weak execution of
Government regulations especially in respect to application of sanctions and from direct
abuse of public office. In fiscal 2005-06, approximately UGShs 36 billion, or 13 percent, of
health sector spending was lost due to waste (A9-1). The greatest source of waste was from
health worker absenteeism where approximately UGShs 26 billion was wasted because of a
daily average 37 percent absenteeism. The same analysis reported additional waste of UGShs
6 billion as a result of leakage of PHC non-wage and NGO grant and an additional UGShs 2
billion from questionable expenditures and ghost workers. Though not comprehensive, this
assessment of waste in the sector revealed significant waste in the management and
performance of the health workforce, drug procurement and logistics management, general
procurement in the sector and programming of development assistance for health. The project
will support Government to improve performance of the sector by addressing weaknesses in
some of these areas, in particular human resource management.
208. While the Government was originally interested in improving functionality of the
existing infrastructure, the project will focus on addressing critical health system
bottlenecks responsible for significant waste in the sector. The team will ensure that those
areas not covered by the project are addressed either by Government or through other
partners and programs. Efforts to strengthen drug supply chain management is expected to
led by USAID through SURE project while efforts on improving programming of
development assistance for health is being taken up through the MOFPED and will be
followed through the PRSC. As for health infrastructure, priority will be placed on
renovation of existing infrastructure with the aim of ensuring their functionality. In order to
mitigate the contingent liabilities arising from health infrastructure related works, expansion
of existing facilities and construction of new facilities will be discouraged.
209. The. benefits of investing in maternal and neonatal care in Uganda are obvious.
This is mainly because of the huge disproportionate burden of maternal and neonatal deaths
in Uganda and the fact that there are affordable and cost effective interventions to prevent
these avoidable deaths. Evidence from countries of similar economic development to
Uganda suggests that improved coverage with a package of interventions directed to maternal
and neonatal care is extremely cost-effective - US$82 - US$142 per DALY averted.66
Although difficult to value, there are also significant benefits to invest in maternal care
especially at the household level given the primary role that mothers play in the homes. In
addition, the high fertility, high unmet need for family planning and the large number of
h6 Disease Control Priorities in Developing Countries, 2"dEdition -Disease Control Priorities Project.
77
induced abortions with attendant complications do provide strong economic rationale to
invest in family planning.
Table A9-1: Calculations of waste in the health sector FY 2005-06
Problem Area Source LJCShsBn
PHC Non-Wage Grant leakages PETS 30
NGO PHC Grant leakages PETS 30
Questionable Expenditures Auditor General's Reports 24
Ghost Workers Payroll Clean-up Exercises IO
Health Worker Absenteeism Chaudury, et al 26 0
Drug Leakages NMS (Expiry) 13
Procurements
Total waste 36.1
Total health expenditures 285.0
Percent of health expenditure wasted 13 %
Source: Fiscal Source for Health in Uganda (2009)
Financial sustainability of the health sector
210. Uganda's total health expenditure per capita is about US$25, of which 28.5
percent of total health spending is by external sources, 37.9 percent from out-of-pocket
and the remainder (about 30 percent) from Government sources. Government spending
as a proportion of the overall budget is about 10 percent, 5 percent lower than the Abuja
Declaration's 15 percent target. In nominal terms, the health sector budget as a percentage of
the total Government budget grew from 7 percent in 1997-98 to 12 percent in fiscal 2002-03,
and has remained fairly constant at this level. Estimates from 2000-06 suggest that the
elasticity of Government health expenditure with respect to GDP when development partner
funds are included is about 1.44 percent, and 0.95 percent excluding external grants. Hence,
the extent of fiscal space for health derived from economic growth projections in Uganda is
likely to critically depend on the sustainability of global funding or the extent to which
domestic resources can be mobilized to substitute global funds if the latter become
unavailable.
21 1. The IMF projects economic growth in Uganda to continue to rise by 6 to 7
percent per year in real terms for at least the next 5 to 7 years, if not beyond.6'
Assuming that Government health spending will continue to respond in the same way to
growth as it has over 2000-06 these growth projections imply that Government per capita
health expenditure would double between 2007 and 2015 (from UGShs 19,453 to UGShs
41,214), rising from 3.13 percent to 4.08 percent of GDP (scenario 1). If a more prudent
approach is taken and the budget for health is kept constant as a share of GDP (Scenario II),
then per capita health expenditure will also rise considerably (from UGShs 19,453 to UGShs
3 1.582). On the premise of the two scenarios Uganda should be able to realize considerable
resources to the sector. The impact of the increase will however depend on the extent Uganda
can improve efficiency of health spending and address drivers of increased health spending.
"'IMF, Uganda Arrcle IVConsulratron (Washington, DC IMF, 2007)
78
Table A9-2: Fiscal Space for Health Projections Based on Economic Growth, 2007-15
Year 2007 2008 2009 2010 2011 2012 2013 2014 2015
Real GDP growth rate 6 20% 6 50% 6 50% 6 80% 7 10% 6 00% 6 50% 6 50% 6 50%
Nominal GDP (billions) 19,307 21,374 23,715 26,102 28,813 31,430 34,667 38,238 42,177
Population (millions) 31 1 322 334 345 36 374 389 403 41 8
Scenario I: Elasticity of health budget to GDP is 1.44
Government health 605 692 795 903 1,031 1,158 1,322 1,508 1,722
expenditure (billions)
Government health 3 13% 3 24% 3 35% 3 46% 3 58% 3 68% 3 81% 3 94% 408%
expenditure (% of GDP)
Government health 19,453 21,473 23,814 26,171 28,661 30,953 33,993 37,400 41,214
exoenditure per capita
Scenario 11: Health budget is constant share of GDP (3.13%)
Government health
expenditure (billions) 604 669 742 817 902 984 1085 1197 1320
Government health
expenditure (YO GDP)
of 3 13% 3 13% 3 13% 3 13% 3 13% 3 13% 3 13% 3 13% 3 13%
Government health
exoenditure per capita 19431 20777 2 2 2 2 4 23681 25051 26304 27894 29698 3 1 5 8 2
Note: G D P growth and nominal G D P projections data are from IMF (2007)). Population projections are from
HNPStats: Government health expenditure projections are derived from average elasticity o f Government health
spending with development partner funding. All figures in UGShs.
Project Sustainability
2 12. By addressing the health system bottlenecks and strengthening management
functions in the sector the project will be directly contributing towards the
sustainability of the project. The financial impact of the project on Government's health
spending will be felt mainly in terms of additional resources for maintenance of renovated
facilities and repairs and replacements of medical equipment. These costs will require
commitment by Government if the project benefits are to be sustained beyond the project's
life span. The project is part of the broader Government program under the SWAP and it is
included within the Government MTEF. Considering the projected increase in health
spending over the intermediate period, Uganda should be able to absorb the project costs into
its budget. This will however depend on continued development partner support, the
Government's commitment towards health and its emphasis on reducing waste in the health
sector.
79
Annex 10: Safeguard Policy Issues
UGANDA: Uganda Health Systems Strengthening Project
213. OP 4.01. The project triggers OP 4.01 on Environmental Assessment due to
renovation of existing hospitals and health centers. These include refurbishment or addition
of specialized wards, construction of incinerators and staff housing, and connections to water,
sewerage, and power facilities for the functionality of the health facilities. Key adverse
environmental impacts are those associated with construction phase activities (e.g., noise,
construction traffic, construction waste, visual impacts). Some potentially adverse impacts
are associated with operation of hospitals and health centers (e.g., medical waste generation
and disposal through incineration, waste water disposal, general waste disposal). Land
acquisition for construction of health and ancillary facilities has not been a common
occurrence. The project is not expected to have adverse cumulative or long-term impacts.
2 14. ESIA. To ensure compliance with environmental assessment requirements under the
Uganda National Environment Act (1 9 9 9 , National Environmental Impact Assessment
Regulations 1311998, other Ugandan environmental regulations, and the World Bank
safeguard policy OP 4.0 1 on Environmental Assessment, environmental due diligence for the
major civil works has been carried out through preparation of an Environmental and Social
Impact Assessment (ESIA), which includes an Environmental Management Plan. There are
no environmental or social issues which cannot be addressed through routine mitigation
measures and good construction practices and funded within the overall level of funding
allocated for the civil works activities. The Environment and Social Impact Assessment
(ESIA) undertaken in January 2010 that included visits to all sites has confirmed that there is
no need for additional land for project activities, and MOH and the relevant facilities have
acceptable proof of ownership of the available land and there are no disputes over this land.
The ESIA therefore determined that there are no involuntary resettlement issues associated
with this project and that OP 4.12 is not triggered. Individuals, who are staff of the health
facilities with non-health related activities like gardening on the facility land will be given
notice and a date for their departure or relocation will be set prior to the start of civil works.
2 15. Consultations. Local consultations were carried out through meetings and interviews
as part of the ESIA preparation at each of the project sites. The consultations included the full
spectrum of directly affected local stakeholders, were recorded by the ESIA team and
factored into preparation of the ESMP. One of the main concerns that emerged from the
consultations was access to health care during construction. The project will be implemented
in such a way that provision of health care services will continue at the target facilities during
the rehabilitation and construction works so outages of service will be minimized.
2 16. HCWMP. To manage environmental aspects of medical waste management, the
project will promote implementation of the HCWMP for 200912010 to 201 112012 that was
recently completed and disclosed. The project will also promote implementation of the
existing injection safety policy. The HC WMP outlines interventions for rationalizing,
improving and monitoring medical waste management to strengthen safety and reduce
environmental impacts. It includes capacity development and training measures. Following
the HCWMP, the project will fund construction and use of suitable medical waste
incinerators for the various levels of health facilities. Various incineration technologies were
considered. The final selection of waste incineration technology was determined with
environmental (air pollution) as well as operating (cost and sophistication) considerations in
mind.
80
2 17. Borrower Safeguards Capacity. The borrower has substantial experience in hospital
renovation and construction in compliance with Uganda's National Environmental
Management Authority guidelines, and some experience with World Bank safeguards.
Environmental compliance is the responsibility of the Environmental Health Division of the
MOH which is charged with executing the environmental health plans under the overall
policy guidance of the National Environmental Management Agency. Under the project, the
division will work together with NEMA to strengthen efforts in handling all environment
related issues, including those under civil works.
2 18. The MOH and the decentralized health service delivery points have some experience
with the formulation and implementation of the Health Care Waste Management Plan. In
addition the sector has a Uganda Safe Injection Policy. The challenge continues to be the
weak health care waste management due to insufficient and inadequate equipment for
handling of waste material, and the poor enforcement by the authorities.
219. Legal covenants and funding. Adherence to ESIA and HCWMP to IDA satisfaction
will be anchored in the covenants of the financing agreement. Funding for the prescribed
mitigation measures, including cost of mitigation measures associated with civil works and
medical waste management will be integrated in other project costs and financed by IDA.
81
Annex 11: Health Governance Strategy and Action Plan
UGANDA: Uganda Health Systems Strengthening Project
A. Introduction
220. This Health Governance Strategy and Action Plan (HGSAP) names the key
governance challenges and recommends reforms to meet those challenges. A number of the
initiatives recommended are already covered under Components 2 and 3 of the UHSSP. The
HGSAP draws on a governance diagnostic in the health sector to identify key project specific
and overall sector wide steps that could be undertaken to address governance challenges in
the sector. The governance diagnostic drew on the results of the assessment of human
resources management practices in the health sector using the World Bank Actionable
Governance Indicators, the Health Sector Public Expenditure Review (PER) and the draft
report on Governance and Political Economy Constraints for Development Effectiveness in
Uganda's Health Sector (August 20091. These reports emphasize governance challenges
relating to (a) ineffective policies regarding HR management leading to high vacancy rates
and absenteeism; (b) mismanagement of resources leading to poor policy implementation,
service delivery and grand corruption; (c) unclear definition of roles and manipulation of
existing structures to serve a few members of the population; and (d) very limited citizen
participation. The HGSAP provides actions to promote accountability for effective service
delivery both at the centre in the MOH and at district level right down to the lower level
health units.
B. Governance at the Country Level
221. At the Country level the GOU has pursued a combination of governance reforms.
Among the key initiatives are: (a) creation of a legislative framework for public finance
management; (b) service delivery arrangements under the sector wide approach (SWAP); (c)
political, administrative, and fiscal decentralization to local governments; (d) public sector
management reforms to regulate human resource recruitment, remuneration, and
performance; and (e) regulatory institutions put in place to ensure compliance with national
standards in several areas including drugs management. Overall progress has been mixed. At
the Country level, Uganda has maintained a Country Portfolio Index (CPI) score of below 3.0
(2.5 in 2009 and 2.8 in 2008) putting it among the weak performers. Results from the third
National Integrity Survey6* (NIS 111-2008) show that Government efforts have not yielded
significant impact, and that corruption is perceived to be increasing. Institutions in the health
sector, which hitherto were not reported to be corrupt, are now among the most highly
corrupt public institutions. The results of the NIS 111 established that 43 percent of
households regarded health workers as corrupt and that 54 percent of the respondents
indicated having known of a case of corruption in the health sector. With regard to
institutional effectiveness, the continued proliferation of districts has negatively impacted on
service delivery, impeding reforms in public finance management including procurement
because of limited capacity of the local governments, which are charged with the mandate of
delivering social services. Coupled with this is the weak capacity of key public institutions
charged with regulation. The elections scheduled for February 2011 are likely to lead to
68
The NIS I I I is the most comprehensive survey that done in Uganda to look at governance and anticorruption in service
delivery It was led by the Office of the Inspector General of Government's office
82
"political influence peddling" including creation of more new districts and further erosion of
the regulatory capacity of some of key public institutions.
C. The Health Governance Strategy and Action Plan
222. The HGSAP complements the MOH's efforts to address some of the key challenges
identified in the governance diagnostic and pursues a comprehensive approach to
strengthening governance and accountability in the UHSSP and the health sector as a whole.
The action plan presents a flexible design that will allow for (a) further development through
annual governance and anticorruption work plans that the GOU and the Bank will agree upon
based on the UHSSP's expected outcomes, and (b) the project to complement MOH and
work with the entire health sector and ensure progress in health financing, internal systems
reform and external accountability reforms. The HGSAP will focus on the following three
areas: (a) health sector stewardship; (b) strengthened internal efficiency through mitigating
risks related to resource management (financial and human); and (c) promotion of external
accountability. The HGSAP complements standard fiduciary accountability measures
discussed in detail under Annex 7 and 8 on financial management and procurement
management respectively. For the HGSAP to create maximum impact at national, district
and local levels, the project will identify appropriate heath governance structures to
mainstream governance into the health sector and, most importantly, as a key underlying and
component of new sector strategic plan under development that can be easily monitored.
D. Health Sector Stewardship
223. Leadership Capacity Development. To complement actions under Component 3 of
the UHSSP, HGSAP proposes structured exchanges with a focus on health sector health
leadership, regular regional face to face meetings, peer learning and formation of a
local/subregional network for exchange between health reform programs in different
landscapes. HGSAP proposes drawing upon expertise of the World Bank Institute to
implement this action.
224. Functional Communication Strategy. The MOH will develop and implement a
functional communication strategy in conformity to the Access to Information act and geared
towards enhancing both user access and internal information flow. Implementation of the
communication strategy will be led by the Permanent Secretary's Office in the MOH who
will be supported by professional communication officers and equipped with modern
communication channels or mechanisms.
E. Strengthened Internal Efficiency
Mitigating Financial and Procurement Risks
225. The HGSAP proposes to mitigate these risks by the following actions:
(a) Strengthened Budget and Procurement Management and Control. To enhance
transparency and accountability and complement actions on extension of IFMIS
detailed under Annex 7 and 8, the MOH under the HGSAP will publish procurement
information and activities on the MOH website and visible public bulletin boards to
inform suppliers and contractors of ongoing activities and update procurement
procedures and regulations;
83
(b) Further as part of project implementation and planned capacity building interventions
under Component 3, MOH will provide systematic training in public financial
management and procurement targeting health staffs working in these areas at the
MOH, districts, and subdistrict levels, as part of the overall training and capacity
bu i Id ing interventions;
(c) Effective and Timely Disciplinary and Sanction Mechanisms. The Ministry will as a
matter of procedure take disciplinary actions against noncompliance with budget and
procurement regulations in a timely and fair manner in order to raise the bar on
misuse of sector resources. This will be monitored as part of the implementation of
the HGSAP.
Mitigating Health Personnel Risk
226. The following measures will be implemented under Component 2 to mitigate health
personnel risks:
(a) Development and Piloting a sector specific incentive policy for Hard to Reach Areas;
(b) Establish a Job Bureau to Facilitate Recruitment and Rotation of Health Workers;
(c) Pilot Performance Contract and Performance Appraisal;
(d) Enforce Effective Disciplinary Actions.
F. Promote External Accountability
227. To promote external accountability, MOH and health service delivery institutions
will:
(a) Promote short route accountability service providers to citizens through
disclosure of information; development of a user complaints management system;
participatory approach in health policy making and service provisioning; and public
oversight in the context of the HSSP 111.
(b) Promote the use of Bulletin Boards to disclose information, scale up community
involvement and improve transparency. User Bulletin Boards will post information
relating to the district disease burden, health budget, drug information, community
outreach programs, health information, service standards under the Client Charter,
and recourse processes.
(c) Develop a User Complaint Management System at the district level in which inputs
and feedback from users will be fed into the decision making process of Health
Facility Management Committees and follow-up actions identified and taken. Specific
institutional arrangements at the district level shall be explored to manage complaints
and provide timely feedback to the public. Indicators of system efficiency will be
monitored and tracked as part of the HMIS.
(d) Support a training program to strengthen capacity of health CSOs that focuses on
governance and tools for policy advocacy and constructive engagement with policy
makers and health care providers to strengthen citizen participation in health policy
development and service delivery. With regards to participation of local communities
in service provisioning, the Village Health Team (VHT), a cornerstone of the HSSP
11, will be strengthened. VHT activities will encompass community health education,
assessment of user satisfaction through score cards, and channel the voice of local
communities into Community Health Management Committees. Financing for VHT
84
to carry out these activities will be considered through leveraging its support to VHTs
from other sources, including GAVI and CDD grant (IDA-LGMSDP).
(e) Conduct user/client satisfaction surveys on a regular basis in pilot districts. As part
of the Monitoring and Evaluation component under the UHSSP Results Framework,
an initial survey (User Score card) will be conducted to establish a baseline, after
which additional surveys will be initiated to track progress.
G. Implementation Arrangements
228. To ensure adequate implementation and monitoring of the proposed HGSAP, it
will be mainstreamed into HSSP 111. For the strategy to have maximum impact at the
national, district and local levels, an appropriate heath governance structure will be identified
to mainstream governance into key health sector activities as envisaged under the HSSP HI.
229. The Minister of Health with the support of the Permanent Secretary will lead the
implementation of the Health Sector Governance Strategy and Action Plan. He/she will
advocate the governance strategy among stakeholders inside and outside the health sector
through an effective communication strategy to be developed and implemented as
recommended by this strategy.
230. Day-to-day implementation of the health governance strategy shall be under the
responsibility of the team that is responsible for implementing the Uganda Health System
Strengthening Project.
85
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Annex 12: Project Preparation and Supervision
UGANDA: Uganda Health Systems Strengthening Project
Project Planning and Implementation
Stage Planned Actual
PCN review February 9,2009
Initial PID to PIC April 14, 2009
Initial ISDS to PIC August 4,2009
Appraisal March 15, 2010 March 17, 20 10
Negotiations March 29, 2010 April 15 - 16,2010
Board/RVP approval May 25,2010
Planned date of effectiveness August 2,2010
Planned date of mid-term review August 15,2012
Planned closing date July 31, 2015
Key institutions responsible for preparation of the project:
Ministry of Health
Ministry of Finance, Planning and Economic Development
Ministry of Public Service
Ministry of Education and Sports
Bank staff and consultants who worked on the project included:
Name Title Unit
Peter Okwero Senior Health Specialist AFTHE
Dominic Haazen Lead Health Policy Specialist AFTHE
Martin Fodor Senior Environmental Specialist AFTEN
Grace Munanura Nakuya Procurement Specialist AFTPC
Paul Kamuchwezi Financial Management Specialist AFTFM
Gayle Martin Senior Health Economist AFTHE
Martin Onyach-01aa Sr. Urban Development Specialist AFTUW
Barbara Magezi Public Sector Specialist AFTPR
Anne Marie Bodo ET Consultan t Pharmaci st AFTHE
Gladys Alupo Program Assistant AFMUG
Martin Fodor Sr. Environmental Specialist AFTEN
Mary Bitekerezo Sr. Social Development Specialist AFTCS
Katherine Anne Tulenko Public Health Specialist AFTHE
Innocent Mulindwa ET Consultant AFTED
Samuel Lantei Mills ET Consultant HDNHE
Rianna Lisa Mohammed Health Specialist AFTHE
Harry Wiebe Consultant Architect AFTED
Luis M. Schwarz Senior Finance Officer LOAFC
Evarist F. Baimu Counsel LEGAF
Philip Beauregard Senior Counsel LEGAF
Hege Hope Wade Operations Officer AFMUG
89
Bank funds expended to date on project preparation:
Bank resources: $148,966
Trust funds: 0
Total: $148,966
Estimated Approval and Supervision costs:
Remaining costs to approval: $50,000
Estimated annual supervision cost: $1 10,000
90
Annex 13: Documents in the Project File
UGANDA: Uganda Health Systems Strengthening Project
Health Sector Strategic Plan 2005/06 - 2009/10 Midterm Review Report, MOH,
October 2008;
National Health Policy (1999 - 2009) & Health Sector Strategic Plans (2000/01 -
2004/05 and 2005/06 - 2009/10);
Poverty Eradication Action Plan of 2000 and revised in 2004;
Fiscal Space for Health in Uganda May 20,2009 - Contribution to the 2008 Uganda
Public Expenditure Review;
The Republic of Uganda, Budget Speech, Financial Year 2009110 and National Budget
Framework Paper FY 2008/09 - 20 12/13;
Long Term Institutional Arrangements for Management and Coordination of Global
Health Grants in Uganda; Operational Manual, August 2008;
The World Bank Strategy for Health, Nutrition, and Population Results, April 2007;
and Improving Health, Nutrition, and Population Outcomes in Sub-Saharan Africa: The
Role of the World Bank, December 2004;
MOH, 201 0-201 5 Uganda Reproductive Health Commodity Security Strategic Plan;
Unpublished Report, World Bank, Contracting for Primary Health Care in Uganda,
February 2007;
Final Draft Report; Governance and Political Economy Constraints for Development
Effectiveness in Uganda's Health Sector; August 2009;
MOH and Capacity project, Uganda Health Workforce Study: Satisfaction and Intent to
Stay Among Current Health Workers, April 2009;
MOH and Capacity Project, Uganda Health Workforce Turnover Study, February 2009;
OPCS, 2009. Core Sector Indicators and Definitions - Health. OPCS, World Bank,
Washington, DC;
AFTHE, 2009. Results Chains for HNP;
Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and
Morbidity (2006 - 201 5);
Uganda Joint Assistance Strategv (UJAS 2005-2009).
91
Annex 14: Statement of Loans and Credits
UGANDA: Uganda Health Systems Strengthening Project
Difference between
expected and actual
Original Amount in US$ Millions disbursements
Project ID FY Purpose IBRD IDA SF GEF Cancel. . Undisb. Orig. Frm. Rev'd
PO92837 2010 UG Transport Sector Development Project 0 00 190 00 0 00 0 00 0.00 191 01 0 00 0 00
PI 12334 2009 UG Energy for Rural Transtormation 0 00 75 00 0 00 0 00 0.00 74.89 5 90 0 00
APL2
PI I I633 2009 UG SEC N-Uganda SAF (NUSAF2) 0 00 IO0 00 0 00 0 00 0.00 87.32 -15.30 0.00
(FY09)
PI 10803 2009 UG Post-Primary Educ & Trg APL-I 0 00 15000 0 00 0 00 0.00 152.19 0.00 0.00
(FY09)
PO90867 2008 UG Local Govt Mgt Svc Del Pjt (FYO8) 0 00 5 5 00 0 00 0 00 0.00 39.36 17.92 0.00
PO78382 2008 UG Kampala lnst & lnfrast Dev Prj 0 00 33 60 0 00 0 00 0.00 30.33 22.86 0.00
(FY08)
PI I0207 2008 UG Program for Control of Avian lnflu 0 00 I O 00 0 00 0 00 0.00 9.48 5 00 0 00
PO69208 2007 UG Power Sector Dev Project (FY07) 0 00 300 00 0 00 0 00 0.00 91.03 34 88 0 00
PO865 13 2006 UG Millennium Science lnit (FY06) 0 00 30 00 0 00 0 00 0.00 1728 0 44 0 00
PO50440 2006 UG Pub Serv Perform Enhance (FY06) 0 00 70 00 0 00 0 00 51.21 17.60 57 88 I60
PO74079 2005 UG Road Dev APL 3 (FY05) 0 00 IO7 60 0 00 0 00 0.00 10.27 2 73 3 63
PO83809 2005 UG Priv Sec Competitiveness 2 0 00 70 00 0 00 0 00 0.00 47.43 42 5 5 0 00
PO79925 2004 UG Natl Re Dev TAL (FY04) 0 00 30 00 0 00 0 00 0.00 8.46 I36 -0 09
PO65437 2003 UG PAMSU SIL (FY03) 0 00 27 00 0 00 0 00 0.00 0.03 -3 45 0 00
PO73089 200 I UG EMCBP SIL 2 (FYOI) 0 00 37 00 0 00 0 00 0.00 14.33 -3 21 7 29
PO70627 200 I Regional Trade Fac - Uganda 0 00 20 00 0 00 0 00 0.00 8.78 5 62 0 00
PO50439 2001 UG Priv & Utilitv Sec Reform (FYOI) 0 00 48 50 0 00 0 00 12.14 8.53 1722 I I 72
Total 000 1,353 70 000 000 6335 80832 19240 24 15
UGANDA
STATEMENT OF IFC's
Held and Disbursed Portfolio
In Millions of US Dollars
Com mitted Disbursed
IFC IFC
FY Approval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic
1996 AEF Agro Mgmt 0 26 0.00 0.00 0.00 0 26 0 00 0 00 0 00
I992 AEF Clovergem 0 84 0.00 0.00 0.00 0 84 0 00 0 00 0 00
1999 AEF Gomba 0 45 0.00 0.00 0.00 0 45 0 00 0 00 0 00
1998 AEF White Nile 0 IO 0 00 0.00 0.00 0 IO 0 00 0 00 0 00
2005 DFCU IO 00 0.00 0.00 0.00 I O 00 0 00 0 00 0 00
I998 Tilda Rice 0 48 0.00 0.00 0.00 0 48 0 00 0 00 0 00
2005 UMU 100 0 00 0.00 0.00 0 00 0 00 0 00 0 00
Total portfolio 13 13 0 00 0 00 000 I2 I3 0 00 0 00 0 00
92
Approvals Pending Commitment
FY Approval Company Loan Equity Quasi Partic
2002 Bui agal i 0 07 0 00 0 00 0 04
Total pending commitment 0 07 0 00 0 00 0 04
93
Annex 15: Country at a Glance
Uganda: Uganda Health Systems Strengthening Project
Uganda at a glance 2/9/09
Sub-
POVERTY and SOCIAL Saharan Low-
Develowmentdlamonb
Uganda Africa income
2008
P o puiatio n mid-year (millions) 317 88 973
Life expectancy
GNI per capita (Atlas method US$) 420 1,082 524
t33 885 513
T
GNI (Atlas method US$ biLons)
AVBrage a n n u a l g r o w t h , 2002-08
Population (%) 33 25 21
34 28 27 GN I Gross
1
Laborforce (%)
per primary
M o s t r e c e n t e s t i m a t e ( l a t e s t year a v a i l a b l e , 2 0 0 2 - 0 8 ) capita enrollment
Poverty ( 7f population belo wnationalpo vettyhnej
70 38
Urban po pulation (%of total population) 0 36 29
Life expectancy at birth (years) 53 52 59 .
A
Infant mortality (per 1000 /we births) 85 89 78
Child malnutntio n (%of children under 5) 16 27 28 Access to improved water source
Access to an improved water source (%ofpopulation) 64 58 67
-
Literacy(%ofpopulation age E+) 74 62 64
Gross pnmary enrollment (%of school-age population) ll7 98 98
Uganda Low-incomegroup
Male Iff 133 132
Female 116 93 95
KEY E C O N O M I C R A T I O S and LONG-TERM T R E N D S
1988 1998 2007
GDP (US$ billions) 65 66 11 9
Gross capital formation/GDP 138 164 22 1
Exports of goods and servicesiGDP 76 96 167
Gross domestic savings/GDP 06 57 82
Gross national savings/GDP 16 61 0 8
Curent account balanceiGDP -4 5 -116
Interest payments/GDP 07 05 01
Total debt/GDP 298 599 t35
Total debt serviceiexports 622 227 24
Present value of debt/GDP 78
Present value o f debtiexports 33 8 358 I
Indebtedness
1988-98 1998-08 2007 2008 2008-12
-
(average annualgmvdh)
GDP 69 71 66 95 57
Uganda Low-Incomegroup
GDP percapita 35 37 51 60 12
Exporls o f goods and services 00 113 122 73 21
STRUCTURE o f the E C O N O M Y
' 1988 1998 2007' 2008
(%of GDP)
Agncuiture 567 421 240 227
industry 132 SI 259 258
M anufactunng 58 91 77 76
Services 33 1 398 50 0 515
Household final consumption expenditure 913 814 789 824 03 04 05 OB 07 OB
General gov't final consumption expenditure 81 129 29 11 8 GCF -GOP
Imports o f goods andservices 5'8 204 306 334
(average annualgmvdh)
1988-98 1998-08 2007 p* 2008
I Growth of expo* and imports (Oh)
I
Agnculture 37 24 -03 91 30
25
industry 11 2 96 99 64 20
Manufacturing 00 67 43 81 15
Services 81 95 88 I30 10
5
Household final consumption expenditure 64 69 133 158 0
I I
General gov't final consumption expenditure 72 43 23 28 "? "l "6 "C "7
Gross capital formation 71 130 139 168 Expons . -
- 9 imports
Imports o f goods and services 78 94 167 28 1 O8
Note 2008 data are preiiminaryestimates
This table was produced from the Development Economics LDB database
'Thediamonds showfourkeyindicators in thecountry(in bo1d)comparedwith its income-group average Ifdataare missing thediamond will
be incomplete
94
P R I C E S and G O V E R N M E N T F I N A N C E
1988 1998 2007
Domestic prices
(%change) 20
Consumer prices 885 58 35 15
Implicit GDP deflator 190 0 88 73 63 '0
5
Government finance
0
(%of GDP rnciudes currenr grantsj
05 06 07 08
Current revenue 58 D6 P6 230
Current budget balance -0 6 10 11 14
GDP deflatoi 0
- - CPI
Overall surplusldeficit -5 6 -5 7 -5 1
I
TRADE
(US$ rniilionsj
Total exports (fob)
1988
298
1998
458
2007
1,521 1,787
Exportandimportlevels(US$mill.)
3500
I
Coffee 286 269 229 297 3000
Cotton 11 20 22 2500
M anufactures 2 000
I
Total imports (cif) 545 966 3 027 2912 1500
Food 1 000
Fuel and energy 69 84 403 403 500
Capital goods 0
Export pnce index (2000=MOj U8 a7 "a5 02 03 04 05 06 07 08
Import pnce index(2000=100j 87 Dl 141 81 .Exports Dimpons
Terms of trade (200O-WO) 258 P5 96 a2
83 ~
I
BALANCE of PAYMENTS
1988 1998 2007
Current account balance toGDP(%)
(US$ miilionsj
Exports o f goods and sewices 324 634 1998 2259 0
Imports o f goods and services 682 1,426 3 528 4361
Resource balance -358 -792 -1530 -2 D 2
Net income -57 -9 -224 -335
Net current transfers PO 37 9
Current account balance -295 -764 12
Financing items (net) 343 898 15
Changes in net reserves -48 - "a4 -682 -594
Memo. I
Reserves including gold (US$ millions) 57 750 2 080 2,673
Conversion rate [DEC iocai/US$j 60 0 1,149 7 17800 1.696.5
E X T E R N A L D E B T and R E S O U R C E FLOWS
1988 1998 2007' 2008
Compositionof20CBdebt(US$ mill.)
(US$ rniihonsj
Total debt outstanding and disbursed 1941 3,942 1.6D 2,249
IS RD 44 0 0 0
IDA 585 1947 840 1,004
Total debt service 202 253 65 74
I6 RD 6 0 0 0
IDA 6 n 5 ' 8 F 25
Compositionof net resource flows E 193
Official grants 187 534 l,VO 1,300
Official creditors 92 D9 424 223
Pnvate creditors -1 -2 -1 -1
Foreign direct investment (net inflows) 5 20 733 788
Portfolio equity(net inflows) 0 0 -23 -32
World Bank program
Commitments 235 184 425 521
Disbursements 74 I23 374 i72 A - IBRD E - Bilateral
Principal repayments 4 5 0 0 B - IDA D .Other rnultiiateral F - Private
C . IMF G. Short-term
Net flows 70 x)8 374 I72
Interest payments 8 P 5 7
Net transfers 62 95 368 85
Note This tablewas producedfrom theDeveiopment Economics LDB database PI9109
95
IBRD 33504R3
U GA N D A
DISTRICT CAPITALS DISTRICT BOUNDARIES
UGANDA NATIONAL CAPITAL INTERNATIONAL BOUNDARIES
RIVERS
MAIN ROADS
RAILROADS This map was produced by the Map Design Unit of The World Bank.
The boundaries, colors, denominations and any other information
shown on this map do not imply, on the part of The World Bank
Group, any judgment on the legal status of any territory, or any
endorsement or acceptance of such boundaries.
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AUGUST 2008