AID Effectiveness and health: Theory and reality Perspectives from Civil society in Uganda

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AID Effectiveness and health Theory and
realityPerspectives from Civil society in
Uganda

• Dr Lorna B Muhirwe
• Uganda Protestant Medical Bureau
• Berlin 2009

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Overview of presentation

• Background of UPMB
• Budget financing and health sector SWap in Uganda
• Budget financing Challenges and opportunities
• Role of civil society
• Paris declaration and implications for civil
  society participation
• Conclusions

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UPMB Background information

• National umbrella organization
• Not a mini-ministry of health
• No direct jurisdiction
• A moral authority drawn from the corporate legal
  owners
• The respective religious denominations CoU and
  other churches
• One of the oldest civil society organizations in
  Uganda
• The voice at the centre (Kampala) of the over 260
  health facilities and health training
  institutions
• Especially those in the remotest areas of the
  Country

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UPMB - Structure
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The health sector in Uganda

• Key Actors
• Public health
• Private not for profit sector Facility based and
  non-facility based
• Private Health providers
• Traditional and complementary medicine
  practitioners

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About the PNFP sub sector

• The PNFP Health sub-sector is an old and
  important feature of the Uganda Health System
• Largely faith based and juridically (legally)
  private entities
• Operating out of social concern ?
• Enshrined in the constitution of each of these
  units are important principles
• They are meant to serve the people of Uganda
• Without discrimination of ethnicity, religion,
  gender, socio-economic status
• They are to align as far as possible with the
  Government policies in health
• They are meant to give priority to the poor

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PNFP subsector cont

• 85 located in rural environment
• Substantial capital/infrastructural investment in
  static health units
• Have some meaningful voluntary component e.g.
  provisions for subsidies of fees
• 33 of health sector workforce in Uganda
• Experience in providing healthcare under economic
  constraints

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Public-private partnership in health

• PPP-H dates since 1956 between the Ministry of
  Health and the facility based PNFP sector
• In 1997, government of Uganda reinstated
  financial and drug subsidies to private health
  providers
• Key feature of the National health policy and
  health sector strategic plans I II
• SWap (officially launched Aug 2000) greatly
  facilitated partnership at national level

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Budget financing and health sector Swap in Uganda

• Uganda health sector signed first Swap MOU in
  2000
• The five year health sector strategic plan I was
  developed in parallel with the lead-up to the
  Swap
• The Swap agreements rapidly resulted in increased
  budget financing as opposed to sector support
  from donors
• Ministry of finance was able to assume a stronger
  role in determining priorities.
• Budget (medium and long term) ceilings were set
  per sector within the framework of the PEAP

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Budget financing challenges and opportunities
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Opportunities created by budget financing

• Longer term commitments from donors enable
  countries to develop longer-term plans.
• Considerable potential to improve aid
  effectiveness
• Harmonisation
• Streamlining donor regulations
• One format for reporting / accountability
• Consolidated Audit
• Ownership - respect for Policies of recipient
  countries
• Alignment with national strategies, institutions
  and procedures
• Managing for Results monitor all interventions
  transparently (Document and share information,
  Joint Review Missions)
• Mutual Accountability both donor and southern
  governments

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Challenges with budget financing

• Budget financing strengthens the recipient
  governments role and responsibility, therefore
• Effectiveness depends on the quality of the
  national development strategies to be financed in
  the recipient countries.
• Difficulty in holding governments accountable
  not to donors, but to the citizenry
• Participation of civil society depends heavily on
• Level of maturity of democratic process in a
  given country
• Capacity and strength of civil society
• Significant challenges therefore exist in either
  poorly governed countries or where civil society
  is as poor (or weak) as the majority of the
  population

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The role of civil society

• A significant provider of basic services for the
  poor health, education, water and sanitation
• An important player in limiting pervasive powers
  of the state
• Specifically for aid effectiveness
• Important network of facilities implementing
  partners
• Often an effective channel for funding to the
  poor
• Important partners in determining national
  priorities and ensuring allocative efficiency of
  funding

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The Paris declaration(2005) and implications for
civil society participation
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At the national level

• Currently the Paris declaration is silent on the
  roles of civil society
• In Uganda dialogue around sector budgets at
  sector level is now ineffective in guiding
  allocative priorities of the health sector.
• WHY?
• Budget related dialogue occurs between MoFPED
  and multilaterals bilaterals rendering Swap
  structures of the health sector quite ineffective
• Civil society forced to seek most funding from
  government
• Limits creativity, advocacy role and
  accountability to constituents .especially
  important for watchdog CSOs

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At the institutional level

• Funding directly from civil society in developed
  countries to CSOs in developing countries has
  decreased markedly in the past four(4) years
• Governments of developed countries channeling
  more support directly to governments of
  developing countries leaving northern CSOs less
  able to access funding
• Large international NGOs pooling funds into
  common (but not government) basket
• E.g CSO basket fund for HIV/AIDS in Uganda

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Trends in government of Uganda support to PNFP
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At the institutional level

• Direct donor funding now largely constituted by
  disease specific projects
• Limits flexibility and responsiveness of CSOs
• Access to funding very competitive Limited
  access as many local and remote CSOs lack
  capacity in proposal writing and information
  management
• Decreased government and external support
• ? scale down services or turn to user fees
• ? decreased access to /utilization of services
• The poor are ultimately affected

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• Financing structure of the PNFP health sector
  July 2007

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Improving aid effectiveness in the health sector
(1)

• SWap mechanisms in Uganda have provided good
  lessons on how aid can effectively be managed and
  equitably distributed.
• If these mechanisms are supported and allowed to
  function!
• Recognition and involvement of civil society
  organisations
• In Sub saharan Africa, 30 70 of health
  infrastructure is held by faith based
  organisations.
• This recognition both by parent governments and
  donor governments

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Improving aid effectiveness in the health sector
(2)

• Refocus on health and community system
  strengthening in order to achieve primary health
  care for all
• Strengthening the health system will reduce waste
  and ensure
• Equitable distribution of HR, medicines
• Functional health infrastructure
• Functional HMIS to facilitate decision making
• Ensure better design of global funding
  initiatives
• Avoiding verticalisation, creation of parallel
  structures
• Addressing additionality to government resources
• Making these initiatives more responsive to needs
  of beneficiaries

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Recommendations (1)

• Review global aids effectiveness agendas and
  principles as they apply to the recognition of
  the roles of CSOs
• Northern CSOs should form strategic partnerships
  with southern CSOs beyond funding to include
  advocacy, sharing information and mutual learning
• Northern CSOs have a greater role to play in
  international level advocacy to influence
  decisions in the EU and global forums that
  Southern CSOs have limited access to

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Recommendations (2)

• Embrace more innovative and proactive funding
  solutions that foster sustainability on both
  sides
• Keep the door open for direct support that
  nurtures the growth of civil society in
  developing countries to avoid introducing
  imbalances in power.

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• THANK YOU FOR YOUR KIND ATTENTION!