Kakaire Ayoub Kirunda
28 June 2008
column
Health managers consistently say increased funding would solve the problems afflicting our hospitals and the entire health system, but will money alone bring the improvements everybody agrees are needed?
It no doubt would help, but a number of experts say it is no magic bullet. The entire health system also needs better management, they argue. That is not to say that the money problem is insignifi - cant. While the Uganda government says it needs about $28 for every person per year to offer the basic health services (not counting HIV care), actual spending is only $ 8-9, including donor funding.
This figure is far less than half of the per capita expenditure recommended by the World Health Organisation, which is $38. But while health systems experts seem to concur that fi nancing is one of the major challenges facing low and middle income countries, they stress another need as well.
Writing in the Priorities in Health publication of the Disease Control Priorities Project, experts stated that the challenge of fi nancing is both to mobilise suffi cient funds for operating the health system and to apply those funds well.
And among those who agree with that assertion is Dr Freddie Ssengooba, a health economist and lecturer at the Makerere University School
of Public Health. Money is a big factor in the provision of effective healthcare, he argues, but poor leadership in managing the little resources also needs to be fixed.
"The government sends funds, which also include money for hospitals, to the different departments to implement programmes," Dr Ssengooba said. "But check on the dates for those releases, you will fi nd that the
money which is meant for the previous month is released a month late. The fact that that money is released not according to the plans of the hospitals is one of those big challenges.
You can never know when money will be released. This affects implementation of programmes." Dr Ssengooba says research conducted during the last political campaign season of 2005/06 concluded that conditions got worse for hospitals because money was diverted.
Health units sometimes went without money from the central government for three consecutive months. "There was no money fl owing to the hospitals, Dr Ssengooba said. "There were no drugs, everything was out of stock. What do you expect under such circumstances?
Medics just put off their white coats and go to their clinics, leaving patients to themselves." Mr James Kubeketerya, the chairman of the Social Services Committee of Parliament which oversees the health sector, has a similar view.
"If the Finance Ministry honoured the budgetary allocations to the Health Ministry, it would help a lot," he said. "The funding gap is always in billions of shillings. The Ministry of Finance needs to appreciate that the health sector is key to the good performance of other sectors. Other sectors require healthy people to keep them going."
Mr Kubeketerya further suggests that the government needs to drop its planned budget cut on the health sector in the near future since it is feared that donor support will go down. The legislator's views are consistent with the declaration of the fi rst global forum on human resources for health that was held in March at Speke Resort Munyonyo.
Among its recommendations,the forum asked governments to increase their own fi nancing of the health workforce, with international institutions relaxing the macroeconomic constraints on their doing so.
Dr Vinand Nantulya, a Ugandan working with the Geveva-based FIND (Foundation for Innovative New Diagnostics) as a senior policy and implementation offi cer, thinks some policies of the International Monetary Fund are not favourable to health delivery. He proposes drastic changes.
He says that the IMF's fi scal policy that focuses on currency stabilisation through strict control of public expenditures, including freezing staff recruitment into the public health sector as a means of containing infl ation, is quite fl awed. "The policy ignores the effect on health and social development," he said.
The small numbers of medics who are employed, he says,are overburdened by work, sometimes compromising quality. "Setting a freeze on staff recruitment at the expense of service delivery sacrifices the health outcomes and long term economic gains of a healthy population at the altar of short term inflation containing measures that set single digit infl ation as the yard stick for macroeconomic stability," he said. Dr Ssengooba, however, acknowledges that the shortage of health workers is a problem, but says it sometimes is exaggerated.
"I know workers are few but this is not the biggest problem," he said. "If you particularly look at doctors and specialists, you will go to this hospital and on the duty sheet you will fi nd a number of doctors but walk into that hospital anytime, you will be lucky to fi nd a doctor.
These doctors are on the payroll but they are not on the ground." The biggest problem, according to Dr Ssengooba, is how to manage resources. While doctors are paid "peanuts", he said, hospitals do not even get the value of the little they are paid.
"If one gets 25 per cent of their earnings from government, at least they should put in 25 per cent of that time in a government facility."
The recent forum on human resources for health also called on countries to create health workforce information systems to improve research and to develop capacity for data management in order to institutionalise evidencebased decision-making and enhance shared learning.
A concept paper by the USAID-funded Capacity Project, which is helping poor countries strengthen human resource information systems, shows that decision makers may not know, for example, how many doctors and nurses are being trained and in what specialties.
It further indicates that it may not be known how health sector workers are distributed across urban and rural areas, why health professionals are leaving the health workforce and other critical pieces of information necessary to assemble an effective human resources strategy for health.
"Understanding the answers to these and other key policy questions will help decision makers effectively plan to ensure a steady supply of trained health professionals, deploy human resources in the correct positions and locations to meet health care needs and retain health worker skills and experience in the country," the paper authors wrote.
A collaboration between Canada's International Development Research Centre and the Tanzanian Ministry of Health and Social Work demonstrated that better management can be just as important as more money in improving the capacity of healthcare systems.
The project provided local health sector-planning teams in two large Tanzanian districts (Rufi ji and Morogoro) with modest funding increases along with tools and strategies that allowed them to target their new resources on the biggest health problems and to improve the effi ciency of the health-care delivery system.
The result was a large decrease in mortality rates in both districts - particularly amongst children, putting them well on their way to reaching the UN Millennium Development Goal (MDG) of reducing child mortality by two-thirds by 2015.
The project partners concluded that "extensive experience in the two highly populated Tanzanian districts shows that investing in health systems - to increase the effi -ciency of health care delivery and to target the most pressing health problems - can lead to impressive results".
They argued that similar improvements could be replicated in other countries. Sector managers in Uganda might want to consider such findings the next time they argue that money alone will solve the problems in this country's healthcare system.
And while Tanzania is on the way to achieving one of the three MDGs that specifi -cally target health, it is not a rosy picture for Uganda if the mid term progress report released by the UNDP last year at the mid-point to 2015 is anything to go by.
Writing in the MDGs Uganda's Progress Report 2007, the UNDP Resident Representative, Mr Theophane Nikyema, said that although the country
had made some progress since the last reporting period, "there is still a long way to go if we are to achieve all the goals by 2015 especially the health related goals on child mortality and maternal health".
On MDG no. 4, which aims at reducing by two thirds, between 1990 and 2015, the number of children dying before age fi ve, the verdict is
that this target is unlikely to be met. The progress report says the way forward is to quickly boost female education beyond primary level, reduce teenage pregnancies, improve access to quality health services and achieve full vaccination coverage.
As for MDG no. 5 which calls for a three-quarter reduction between 1990 and 2005 the maternal mortality ratio, the report card reads the same:
unlikely to be met. The report calls for adequate funding and full implementation of the sexual and reproductive health and rights programme.
Not all is gloom, however. MDG no. 6, which calls for the combating of HIV/Aids, malaria and other diseases, has already caused some celebration especially as regards HIV/Aids. The target of halting the spread of HIV has been achieved. But some challenges are still in the way regarding malaria and other diseases.
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