PARLIAMENT OF UGANDA

REPORT OF THE SECTORAL COMMITTEE ON HEALTH ON THE SECTOR

MINISTERIAL POLICY STATEMENT AND BUDGET ESTIMATES FOR F"T 2OL9l20

APRIL,2Ol9

OFFICE OF THE CLERK TO PARLIAMENT PARLIAMENT BUILDING KAMPALA.UGANDA

Ito" 7 ,nW f.o rrtnooucrloN

In accordance with Articles 90 and 155 (4) of the Constitution of the Republic of Uganda, Section 13(5) of the Public Finance Management Act, 2015 and Rule 185 of the Rules of Procedure of the Parliament of Uganda, the Sectoral Committee on Health is mandated among other things to: 1) Examine and comment on policy matters affecting Ministries and Departments under their jurisdiction and; 2) Examine critically Government recurrent and capital budget estimates and make recommendations on them for general debate in the House. 3) Ensure Government compliance with approved plans and programmes.

Pursuant to the above mandate, the Minister for Health laid at Table the Ministerial Policy Statement (MPS) for Health Sector on 3'd April, 2019, and consequently, the Speaker referred the MPS to the Committee on Health for scrutiny. The Committee considered the Health Sector Ministerial Policy Statement together with statements from the auxiliary agencies and now reports.

2,O BACKGROUND

Ministerial Policy Statements set out the performance and plans of spending agencies, linking them with their policy objectives. Ministers present these statements to Parliament following the presentation of the Budget Framework Paper by the Minister of Finance, Planning and Economic Development. These statements are used by Parliament to assess the performance of sectors /spending agencies. This role of Parliament is provided for under Section 13(5) of the Public Finance Management Act, 2015.)

The MPS summarizes the past performance of the sector and the plans lor future expenditure and activities. They outline anticipated sectoral challenges and strategies to overcome them. They also present: planned outputs and the costing; final work plans; cash plans; and stafflng struct procurement f the sector among others.

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This report unpacks the Health Sector Ministerial Policy Statement for Fy 20181 t9.

4.O METHODOLOY

In scrutinizing the sector Ministerial Policy statements, the committee adopted the following methodologr.

(a) Held meetings with the following; Vote 114 Uganda Cancer Institute (UCI) Vote 115 Uganda Heart Institute Vote 116 National Medical Stores Vote 134 Health Service Commission Vote 151 Uganda Blood Transfusion Services Vote 161 Mulago National Referral Hospital Vote 162 Butabika National Reierral Hospital Vote 3O4 Uganda Virus Research Institute (UVRI) Vote 163 Arua RRH; Vote 165 Fort Portal RRH; Vote 165 Gulu RRH; Vote 166 Hoima RRH, Vote 167 Jinja RRH; Vote 168 Kabale RRH; Vote 169 Masaka RRH; Vote 170 Mbale RRH; Vote 171 Soroti RRH; Yote 172 Lira RRH; Vote 173 Mbarara RRH; Yote 774 Mubende RRH; 5q$*--'t" Vote 175 Moroto RRH; Vote 176 Naguru RRH;

3 ' Vote 177 Kiruddu NRH; Vote 178 Kawempe NRH; Vote 179 Entebbe RRH; Vote 180 Mulago Specialized and Neonatal Hospital; Vote 5O0 Local Governments. (bf National Drug Authority (on account of its centrality to the drug eflicacy in the country which is a health issue.

(cl Reviewed relevant literature including; i) National Development Plan; ii) Vision 2040; iii) Previous sector Parliamentary recommendations on the Ministerial policy Statements and budget framework papers; iv) Ministerial Policy statements for the Health sector for Fy 2olz l1g and 2ot8lt9;

v) Position Paper from the Civit Society Budget Advocacy Group (CSBAG); vi) Auditor General's Report on the Health Sector for Fy 2Ol7 I lg; vii)Health Sector Annual Performance Report Fy 2OtZ llg; viii) Budget Monitoring Unit of the Ministry of Finance planning and Economic Development (MoFPED);

5.O SBCTOR PERFORMANCE DURTNG Fy 20t7l ta

The Committee noted that; i) The Ministry of Health is a government body set up with the mandate of stewardship and leadership of the health sector. The Ministry of Health is responsible for policy review and development, supewision of health sector activities, formulation and dialogue with health development partners, strategic planning, setting standards and quality assurance, resource mobilization, advising other Ministries, departments and agencies on health-

related matters, and ensuring quality, health equity, and SS contribution towards the cost of health care.

4 vt. ii) In pursuit of the health system objectives, the Government of Uganda through the Ministry of Health ensures mechanisms that offer equity for all citizens in accessing health services for iife threatening health problems, particularly to avert pregnancy and birth-related mortality and childhood killer diseases, strengthen the capacity of heaith facilities to improve service provision, build and expand the national health infrastructure through a medium term health facility development plan, as well as establishing an appropriate and efficiently functioning referral system.

The committee was informed that during Fy 2o1g /20, the sector registered

a) Improvement in ART coverage from Z 3oh in 2016117 to g6% in Fy 2Ot7 l18, b) Improvement of HIV positive pregnant women not on HAART receiving ARVs for eMTCT from 90%o to 95%, c) commissioning of a newly constructed 4s0 bed Specialized women and Neonatal Hospital, d) Improved TB case detection from So%oin 2OL6l tT to 53%, e) Hepatitis B screening, vaccination and treatment, f) Reduction in the inpatient malaria deaths due to LLIN mass campaign, Indoor Residual Spraying of 1.3 million housing units,

g) A slight improvement in the stafhng levels from T2o/o to T4o/o, h) Installation of 13 medical oxygen plants at RRHs, i) Completed l9 medicines stores, ( j) Completed 1O0 units of staff houses at RRHs and k) Improved facility deliveries from SSyo to 6Ook compared to 2016/ I

l,* yt, 5 5.r cRoss currrNc ISsuEs 5.1. I compliance of the Ministerial policy statemeat to National Development Plan (NDP II) The overall purpose of compliance to NDp II is to institutionalize alignment of the annual budgets to the national planning frameworks. To the contrary, the Committee observed that;

The compliance certificate produced by National planning Authority (NpA) in line with Section 13(6) and l3(7) of the public Finance and Accountability Act 2o15, reveais that the health sector's Annual budget compliance level for FY 2018/19 dropped to sr.2o/o from 51.7 o/o in 2orr l1g out of the expected 1o0%. The decline is attributed to the low budget absorption by majority of the health sector institutions especially under projects on account of very low utilization of funds released. There are several aspects that are critical to the attainment of the NDp II targets and yet the sector assessment revealed non-compliance in them. These need greater attention and they include;

i) community empowerment through implementation of the community Hearth Education and Promotion Strategr; ii) Financial risk protection of households against impoverishment due to health expenditures as a result of absence ofthe National Health Insurance scheme (NHrS); iii) Malaria prevention;

iv) Integrated case management of malaria and other childhood illnesses; v) Review of the re-alignment of the essential health package including essential clinical care to the evolving health care needs of the population; vi) Advocacy, communication and social mobilization for increased funding and responslve awareness for Tuberculosis; vii) Dental services such as screening for and treatment of orai di SC particularly among primary school children; viii) Availability of mental, neurolo al an substance use servrces; ix) Training specialists in cardiologr, Oncologr, Nephrology, Diagnostics and Management; x) Accrediting Uganda Heart Institute, Uganda Cancer Institute; xi) The supra National Reference Laboratory and schools of public Health as regional training centres; xii)Promoting export of locally produced medical products among others.

Observation The Committee observed that; o Health sector financing and performance are hinged on the strategic directives set out in the Health Sector Development plan (HSDP) 2o1sl16 - 2019/20. . FY 2ol9 120 marks the last year of the HSDp which is a critical point of reflection o The declining trend in annual sector budget and policy compliance levels s absorption as well as slow policy implementation that has a bearing on the attainment of NDP II and HSDP strategic objectives.

Recommendation The Committee recommends that; a) The sector prioritized Jor Fy2ol9/2o should. place etrythasls on dlsease preaentlon fiteasttres at household and communltg leael, recntif,nent and. training oJ critlcal hea,lth staj!; b) Government should. prlortttze lmplementatlon oJ proJects under the sector, operationallzation oJ national health insurdnce, and a,ttraction of speciallst, consultants and senlor consultdnt leael posltlons in oarious Jaclllllies ccross the country; c) Prouision of mental and. neurological seny'.ces across health lacilitles should. be prioritizeQ

l/, lfi,u, ,--4__) 'd) The na:tlonal policg on Non- Communlcabte Ddseases (IlCDs) sltoutd. be expedited to further ulden the scope oJ preoentive rrleasufe for tl:'re increasing JVCD ccses; e) The low annual sector budget and policg compllance trend must be reaersed to aaold. challenges of lout fund.s absorption and. slow pollcg lrll.plementatlon.

5.1.2 compliance of the Ministerial policy statement to Gender and Equity section t3(15)(g) of the PFMA, 2ols provides that the Minister of Finance Planning and Economic Development shall, in consultation with the Equal opportunities commission issue a certiiicate of compliance to gender and equity, specifying measures taken to equalize opportunities for women, men, persons with disabilities and other marginalized groups. Specifical1y, section 9(6) of the PFMA, 201s provides that the Minister shall, in consultation with the Equal opportunities commission issue a certificate; (a) certifying that the Ministerial policy statement is gender and equity responsive and (b) specifying measures taken to equalize opportunities for women, men, persons with disabilities and other marginalized groups

Observation It was observed that;

The Minister of Finance Planning and Economic Development simply issued a generalized certificate for aII MDAs instead of a separate certificate for each Policy statement as required by the law. consequently, it was difficult for the committee to ascertain the basis upon which the certificate was issued in respect to the health sector. The certificate did not provide details as to which specific measures the MDAs have taken to equalize opportunities for men, women, persons with disabilities and other marginalized group for Fy 2019 20

For some entities, the scores contained in the report are not the same as those indicated in the individual entiW assessment. B

W- 'For example individual re-assessment report for Health service commission indicates that the entity scored 69.s% while the same commission,s General report on MDAs show 46.0%o before re-assessment.

Mulago Hospital complex did not meet the required standards for attainment of certilicate of Gender and Equity compliance as required by law as their rating was below 5o%. This has both financial implications to the effect that the entity,s budget cannot be approved with a rating below the required compliance level.

There is apparent lack of capacity in the MDAs to ensure compriance to gender and equity issues. This challenge has been recurring for a number of years with no deliberate strategies by Government to strongly address the issue. Recommendation rhe commlttee recort fi,Jends that Mlnlstry oJ Health together r,,ith the Equal opporhtnlties commrssion shourd ma.ke d,efiberate efforts to enhance the capacttg of the sector agencies to improoe on the sector posltion regardlng gender and eqult9 compllance.

5. 1.3 Compliance with parliamentary Recommendations Parliament made a number of recommendations that have financial imprications. consequently, these recommendations shourd be prioritised by the sector. The sector should update Parriament on actions taken in addressing the parliament recommendations on the Fy zol9/79 health sector budget. In particular, the extent to which these recommendations have been factored into next Fy 2019 l20 and in the medium term (summary of parliamentary recommendations 2018).

li" 9 .6.0 SECTOR BUDGET PERFORMANCE 6.1 Half Year Budget performance The table below shows the Health Sector Half year Budget performance Fy 2ore l20 Table l: Health Sector Half-year Budget performa,ce Fy 2og/rg (UGX, billions)

Category Approved Release Spent Unspent % o/o % Budget Release Unspent Release Spent Wage 593.20 296.843 280.30 16.55 5Oo/o 94o/o 5.6% Non-wage 473.42 26a.a40 244.7a 20.06 57o/o 93% 7 .5o/o Arrears 4.20 4.026 3.38 o.64 960/o a4Vo 15.9% Recurrent 1,o70.a2 569.709 532.47 37.24 5s% 93/o 6.5o/o GoU 173.4A 7t7.526 7 7.47 46.77 68o/o 6lo/n 39.2o/o Donor 7,069.96 477.415 444.26 (36.8s) 38o/o I09% -9.Oo/o Dev't 7,243.45 52A.947 579.67 9.27 43o/o 9Ao/o l.8o/o AiA 53.49 15.130 13.55 1.58 28o/n 90% lO.4o/o Total 2,367.76 1,113.780 1,065.69 48.09 47o/o 960/o 4.3o/o Source: Health Sector MpS Fy 2019/20 & MoFPED Half-year Budget Performance Fy 2018/ 19 The totai budget approved for Fy 201g/ 1g amounted to uGX 2,367.76bn, o,t of which UGX 1,070.82bn was for recurrent expenditure while UGX r,243.45bn was for development expenditure. It should be noted that the recurrent budget for the health sector accounted for 47o/o of the approved budget wh e the development component accounted for 53% - of this g6%o was external financing. The share ofthe approved budget by category is provided in Figure 1.

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C. Figure 1: Health Approved Budget by Category

AiA 2%

GoU Dev't Arrears 8o/o Oo/o

Source: Computations by pBO By the end of December 2018, a total of uGX 1,300.9bn had been released constituting 47 percent of the approved budget. This translates into a lower than expected release budget performance of 30k - assuming that the budget was to be released in four (4) equal parts (pro_rata).

Out of UGX 1,113.78bn released, a total of UGX 1,065.69bn had been spent by the close of December 20 18. This translates into an absorption rate of 96 percent. At this rate, a total 0f UGX 4g.0gbn (4.3 percent) remained unspent and or unabsorbed.

Observation

The Committee observed at; Non-absorption ' of rereased funds implies that pranned activities courd not be undertaken in a timely manner. This affects service delivery. There is risk of these funds getting diverted and or mis_used to non_ areas

\1. ltu .Le ,\L) with potential deviation from the approved planned output and outcome targets.

a The continued failure by MDAs to attract and retain critical staff for health. As a result, MDAs have had to return funds meant for wage. By the end of the first half of the FY 2or9lt9, a total of uGX 16.5sbn had not been absorbed' This translates into s.6o/o of the rereased wage funds for this period. specific votes with wage absorption challenges are summa rized in Table 2.

Recommendations The Committee recommends that

i) The sector's absorption capacitg need.s to be enhanced, through tlmelg plannlng and. executlon oJ proJects ii) Gouernment should credte a conduclue enolronment in public heatth facilities to oittrotct and retolin specialists Jor efficlent utage absorption.

6.2 Wage with Unspent Balances The table below shows the wage unspent balances for Fy 201g/ 19 by different institutions in the sector Table 2: Institutions with wage unspent balances Fy zolg / rg (UGX, billions % Budget 7o Release Vote Approved Release Spent Release Spent O t4 Ministry of Health 11.419 5.709 4.135 50% 72o/o 1 14 Uganda Cancer Institute 4.739 2.370 2.O40 5Oo/" 860/o I 15 Uganda Heart Institute 4.207 2.100 1.423 5Oo/o 680/" 134 Health Service Commission ) 20< 1. 163 0.618 500/" 53o/o 161 Mulago Hospital Complex 33.888 76.924 74.248 5Oo/o 84o/o 162 Butabika Hospital 5.423 2.569 50% 94o/o 122 Kampala Capital City Authority 16.647 4.32 3.277 5Oo/o 39%o 163 Arua Referral Hospital c lac. 4.449 2.O13 50% 83o/o

1

L; 164 Fort Portal Referral Hospital 5.415 2.708 2.277 5O%o 84% 165 Gulu Referral Hospital 5.O22 2.577 2.200 50% 88Yo

166 Hoima Referral Hospital 6.O94 3.O47 2.445 50% 8Oo/o 167 Jinja Refeffal Hospital 6.783 3.392 2.640 50% 78%

168 Kabale Referral Hospital 4.O73 2.O37 1.768 50% 87o/o

172 Lira Referral Hospital 5.r24 2.562 2.t99 5OV" 86o/n 174 Mubende Referral Hospital 5.226 2.673 7.472 50% 175 Moroto Referral Hospital 4.243 2.722 r.725 5Oo/o 81o/o 176 Naguru Referral Hospital 6.307 3.154 2.784 50% 88% 304 Uganda Virus Research Institute 1.541 o.771 o.658 5Oo/o 85% Source: Health Sector MPS Fy 2Ot9 l20 & MoFPED Half-year Budget performance Report

Obsenration The Committee observed that; ' There were unspent wage balances for many votes under the sector. This is attributed to absence of the requisite human resource for various positions with the staffing structure. o overall he recurrent expenditure rerease performed at slightly above the expected pro-rata levels at 53 percent; however the absorption was recorded at 93 percent, leaving UGX 37.24bn unspent (6.5 percent). ' The total development budget released performed below its expected pro- rata budget at 43 percent. This is attributed to the lower than expected release under the donor financing category at 3g percent. on the other hand, GoU development budget benefited from a front-loaded release up to 86 percent. Despite this over release, MDAs were slow in imprementing planned activities. The expenditure outturn was reco at 670/o leaving UGX 46. 1 1bn unspent (39.2 percent).

Recommendation The Committee recommends that; i. Gouentment should. ad.dress all erternal donor release condltlonalitles inctudlng Memorandum of Understandtng (Motls) y-

q ahead. of tlme to warrant tlmelg release oJ funds Jor oarious o,ctittlties. ii. Health service commission should. last track the recnfitment oJ all the stafJ of Ministry of Health Headquarters as approoed W the Mlnistry of htblic Sentice

7.O OVERALL SECTORAL OBJECTIVES/PRIORITIES AND LINK TO THE NATIONAL DEVELOPMENT PLAN II AND SUSTAINABLE DEVELOPMENT GOALS.

7.1 Sectoral Priorities for f,.y 2OLg t 20 The committee observed that in Fy 2olg l 19 the sector,s priorities included among others;

Mobilizing suflicient resources to fund hearth sector programmes; addressing human resource challenges in the sector; improvement of reproductive, maternal, neonatal, child and adolescent health services and curb mortality and morbidity; scaling up interventions to address HIV/TB, mararia burdens and nutritional challenges, environmental sanitation, hygiene, immunization and non_ communicable diseases; improving primary Health care; reduction of referrals abroad and training, recruiting and motivation of specialist, enhancing brood collection; control preparedness for disease outbreaks; improving key hearth infrastructure especialry at rower lever facilities; enhance hearth education for communities, families are individual; strengthening colraboration between the health sector, government ministries, departments and public and private institutions dealing with health and hearth related issues and; effective structured supervision.

However, for FY 2Ol9 120, the top priorities for the sector include; Prioritizing health promotion, prevention and early intervention with focus on scaling up interventions; infrastructurar deveropment; addressing human resource challenges; strengthening inter_sectoral challenges; improvement of reproductive, maternal, neonatal, child and adolescent health; address stock outages and supply side deficiencies; maximizing efficiency by garnering S 14 lil, il\(?"*"7 'savings with the existing domestic resources; reducing referrals abroad; improving health systems governance through capacity building; effective well- structured supervision to the Local Governments and strengthened regulatory authorities and; improving data quality and use for decision making and accountability.

The committee observed that although the change in priorities is more of a re- arrangement of the previous sector priorities save for improving data quality and use for decision making and maximizing efliciency, the rest have remained the same. This is not a very significant change to alter the direction of the sector but carries a more inclusive approach to the hearth service derivery system compared to past models of planning.

However, the Medium Term priority has not changed. In the medium term, the sector will continue to pursue interventions that reduce morbidity and mortality from the major causes of i11 health and premature death and reduce disparities therein.

7.2 Linkage with the Sustainable Development Goals, (Goal S.O) A11 the priorities are directly integrated and linked with objective No. 3 of the NDPII which is Enhancement of Human capitar Deveiopment, and the united Nations sustainable Development Goals (SDGs) - Goal No. 3 for Health. sDG No. 3 whose mandate is: - "fo ensure heatthg riues and promote weltbeing for afi at a ages". The inclusivity in planning goes a long way to addressing inequalities and inequity in the health service provision.

15 v- 8.O HEALTH SECTOR BUDGET OUTLOOK FOR Fy 20taltg

8.1 Health Sector Budget Proposals for fy 2Ol9l2O and the Medium Term

Table 3: Budget Proposals for FY 2019/20 (UGX, billions)

Category 2OrB/t9 2Ot9 /20 Change btn z0lal79 and, 2Ot9 /20 Share In Figures and Percentages

Wage 575.24 609.56 34.32 6.Oo/" 25% 24o/o

GoU 172.23 r57.12 (1s.11) -8.8% 7o/o 60/o

Donor t,067.32 r,r16.66 49.34 4.60/o 46yo 44o/o Dev't 1,239.55 1,273.78 34.23 2.8o/o SgVo 5lo/o

Total 2,337.51 2,512.24 174.73 7.5o/o l0Oo/o lOOo/o Source: Heal.th MPS & PBO Computations

The total health budget is projected to increase by UGX lr4.z3bn (7.5%) from ucx 2,337.51bn approved in Fy 2018/19 to UGX 2,sr2.24bninFy 2or9/20. This is an increase of UGX 175.01bn (4.6%). of this, ucx 1,238.46bn (49%) is for recurrent expenditure while UGX 1,223.78bn (51o/o) is for development.

Figure 2: Budget Share by Category by ExpenditureFy 2Ol9 l20

L6 ttu Non-waga 2s%

Dev Donor 45%

Wage

Source; Health MPS & PBO Computations

Observation The Committee observed that; . 55%o of the funding is GoU and 45% is Donor fund. r The wage bill is projected to increase by uGX 34.32b.- (6%) from UGX 575.24bn in FY 2018/19 to UGX 609.56bn. The observed increase is attributed to an addition UGX 22.4sbn earmarked to cater for wage for Health facilities currently being upgraded from HC II to HC III status.

a Non-wage budget category is projected to increase by UGX l06.1gbn (2O.3%l from UGX 522.73bn approved in Fy 2018/ 19 to UGX 628.91bn in FY 2or9 l20' This increase is attributed largery to the additional UGX 94bn under NMS, UGX 2.79bn under UCI and UGX 4.6lbn under UHI.

a GoU development budget allocation is projected to decline by UGX 15.1 lbn (8.8%) on account of projected decline in pHC Development budget by UGX 19.35bn.

External development budget is projected to increase by UGX 49.34b,, (4.6%) largely on account of additional uGX 56.3Ibn. Details are provided under Table 4 & Annex I.

(. ltu a External financing continues to dominate health sector budget expenditure despite Parliament's recommendation to Government to gradually earmark resources towards the sectors development priorities. For the FY 2Ol9 l2O, external funding towards development budget requirements is projected to amount to 88o/o compare to g6% in Fy 2OI8l19. Whereas the outlook looks positive, the continued dependence on external funding exposes Ugandans to health risks in the event ofnon- disbursement of donor funding.

Recommendation The Committee recommends that; i) Goaernment should expedtte the Heatth centres upgrade to aaert posslble non utilization oJ the utage allocatlon. ii) Gooernment should progressruerg increase financing to the hearth sector to auoid possible rrurnerabflttg tn case of puII out hg external Junders.

Table 4: Vote Specrfic Budget Allocation Fy 2O1g/20 Vote 2018 / 19 2019 /20 Changes Share 2078/ 2019 /2 19 0 014 Ministry of Health 1,131.09 t,197.32 66.22 5.9% 48.4Vo 47 .7Vo 1 14 Uganda Cancer Institute 93.O7 90.89 (2.18) 4.Oo/o 3.60/o 115 Uganda Heart Institute 19.57 24.33 4.76 24.3% O.ao/o l.Qo/o 1 16 National Medical Stores 300.09 396.17 96.08 32.OYo L2.8o/o 15.80/o 134 Health Service Commission 6.40 7.08 0.68 to.60/o o.30/o o.30/o 151 Ugalda BIood Tralsfusion Service 19.18 18.15 (1.0s) -5.4% O.8o/o O.7o/o 161 Mulago Hospital Complex 78.55 7 t.39 17 .17]. -9.7% 3.40/" 2.4% 162 Butabika Hospita-l 74.75 6.56 44.50/. O.60/o O.8o/o 122 Kampala Capital City Authority 18.q0 11.67 (7 .23l. -3A.2yo o.8% o.50/" 107 Ugarda AIDS Cornmission 6.86 6.86 o.o% o.30/" O.3o/o 163 Arua Referral Hospital 9.49 9.02 l{o.47) -4.9o/o o.4% o.4% 164 Fort Portal Referrat Hospital 9.83 9.47 o.04 o.40/n o.4vo o.40/o 165 Gulu Referral Hospital 9.25 9 _63 o.38 4.to/o o.40/o o.4% y- 18

L Vote 2018/19 2019 /20 Changes Share 2Ot8/ 2019 /2 19 0

166 Hoima Referral Hospitat 9.24 9.49 o.2s 2.7Vo O.4o/o o.4vo 167 Jinja Ref€rral Hospital tt.70 12.10 0.40 3.4Yo 0.50/o o.5% 168 Kabale Referral Hospital 8.10 4.49 0.39 4.90/" 0.3% o-syo 169 Masaka Referral Hospital 8.87 LO2 0.15 1.70/" 0.4o/o O.4o/o 170 Mbale Referral Hospital 13.42 14.29 o.a7 6.5o/o O.60/o O.6o/t 171 Soroti Referrat Hospital 8.64 4.78 0.14 r.7% o.40/o o.3% 172 Lira Referral Hospital 8.86 9.20 0.34 3.8% O.4o/o O.4o/o 173 Mbarara Referrat Hospital 10.65 11.91 1-.26 11.90/o 0.5olo O.5o/o 174 Mubende Referral Hospital 7 .92 8.06 0.14 1.8% 0.3olo 0.3% 175 Moroto Referal Hospital 6.80 Q.44 6.40/" o.30/o O.3o/o 176 Naguru Referral Hospital 8.66 8.98 0.31 3.6Vo O.4o/o o.4% 177 Kiruddu referral Hospital 4.73 o.oo/" o.oo/o Q.3o/o 178 Kawempe Referral Hospital a.7Q 8.70 o.oo/" O.Oo/o Q.30/o 179 Entebbe Regional Referral Hospital 0.45 0.45 O.Oo/o o.oo/o Q.Oo/o 180 Mulago Specialized W& Neonatat Hosp 5.00 5.00 o.o% O.Oo/o 304 Uganda Virus Research Institute 7.38 9.21 1.83 24.80/o 0.svo O.4o/o 501-850 Local Oovernments 535.99 5t7 .44 (18.ss) -3.5% ,c ao/^ 20.60/o Total 2,337.s 2,512.2 174.7 7.50/o 100.o too.v/o 1 4 3 o/o Source; Health MPS FY 2Ol9 /2O & PBO Computations

8.2 Budget Allocation to Newly Created Votes The Committee noted that;

In line with Parliament's recommendation, Kiruddu and Kawempe Hospitals have been granted a vote status as a national referral hospitals with effect from FY 2ol9 l2o. In addition, Entebbe Hospital has been given a vote status and upgraded to a regional referral status while Mulago Specialized women and neonatal hospital has been given a vote status and given a national referral hospital status. However, the budgetary allocation to these facilities is inadequate: t

( 19 It. (' .) a Kiruddu has been allocated UGX 8.73bn, of which UGX 4.Sbn is for wage while UGX 4.23bn is for non-wage. No allocation has been provided for development related activities. a Kawempe has been allocated UGX 8.7bn, out of which UGX 4.5bn is for wage while UGX 4.2bn is projected for non-wage activities. There is no allocation for development related activities. a Entebbe regional Referral hospital has received allocation of only UGX 0.45bn for non-wage activities. No allocation has been provided for wage and development expenditures. a Mulago specialized women and neonatal hospital has been provided with UGX Sbn for non-wage budget but there is no allocation for wage and development expenditure.

Recommendatlon

Consequently, the Committee recommends that;

l) Gouernment should allocate ad.ditlonal funds to d. /;rtne of UGX 77.4bn to Mulago Speclatized Women & Neonatal hospital for Wage at UGX 9.8bn ii) Gouernment q.llocates additionar UGX 4.sbn for medrcines to Kauempe NRH lll)Gouerament should. prouide additlonal funds to a atne oJ |IGX l4.sbn for wage requlrements tn 2o19/2o for Ka utempe Naflonar Referrar Hospital. la) Ministry of tinance ensures a s,,.ooth transltlon of uage ,,llocottlon Jrom Mulago Hospital Complex to Mulago Speclallzed. Women and, Neonatol Hospital lmmediate ty. u) Goaernment allocates [IGX. shn to Ktrt,,ddu National Re.ferral Hospltal for D{crlgsis se c

-(.Q-- ,9.O OBSERVATIONS AND RECOMMENDATIONS

9.1 VOTE O14: MINISTRY OF HEALTH

9.1.1 Inadequacy of Critical Human Resource for Health It was noted that the sector continues to suffer from inadequacy of health personnel at various levels of health service delivery with the national average at 7 3o/o by the end of June 2017 especially at Health centre II with a staffing level of 53% and at an average of 680/o.

The problem is precipitated by two factors namely; (i) Discrepancies in payments for scientists across government institutions that triggered an exodus of consultants and senior consultants in favour of education institutions leaving the health sector with serious staffing challenges and (ii) The wage ceiling imposed by the Ministry of Finance that cannot allow for recruitment of these very crucial human resource. Analysis of the recruitment plans for Fy 2ol9 l20 revealed that most of the positions aligned for filling relate to specialists but Iimited by wage. out of the 1092 required staffing norm for specialists for self-Accounting and the Regional Referral Hospitals, there are only 313 (30%) specialists. The staffing gap remains at 7 oo/o (7791 for self-Accounting and the Regional Referral Hospitals. Each RRH requires 4l specialists receiving a minimum pay of uGX 3m per month. with 17 RRHs, this would translated into UGX 35bn in Fy 2O1e I 20.

In a bid to address the above problem, public Service has adjusted the salary structure for consultants and senior consultants in the health sector to match that offered to scientist by education institutions. This is hoped to stem the exodus of scientists from the health sector and also serves as an attraction factor to specialists. However, this will be effected h Fy 2ol9 /2o with availability of resources- C

ZL 'Tabte 5: shows the staffing norms for specifi.c field"s in htbtic Heatth Instituttons Cadre Positions Total Total Filled %Filled Norms Lab Staff D OOe 2,740 2,756 lOlo/o

Nursing Staff 3,O32 18,843 17,258 87Vo

Midwifery 2,994 6,729 5,353 SOVo Theatre Staff 233 5t2 368

Health 3,150 3,778 2,185 5Bo/r Inspectors

Doctors 1,342 2,256 I,298 58Yo Pharmacy Staff 351 116 64 55%

Health 2,061 420 200 4Bo/o Educators

Anaesthetic 232 855 247 29o/" Officers MoH Human Resource for Health Audit Report, 2012

Stalling Levels for Specialists at RRHs Table 6: shotus staffing norms for specialists for Regional Referrals Cad.re Total Norms Total Fllled Staffi.ng Gap Senior Consultants 78s 60 12s Consultants 681 117 564 Medical Officers 226 136 90 Special Grade

100% 30% 70%

L Recommendation LrPl The Committee re-iterates i ar recommendations that;

22 .2 i '1) Gouernment allocates tlGX TObn in the sector hudget for trainlng of the Critlcat Cadre staff; iu Include UGX Sbn as a hard -to -reo,ch area allowance specificallg for specialists, consultants and other critical health core stafJ lor the hard-to-reach areas; irq Goaenment should. ad.dress all chaltenges related to ,r.otioation ol health personnel in a comprehensiue ma nner incruding provrsion of decent accommodatlon and. medical supplles; ilt) Illtnistry of Publtc sertice should. ttfi the cap on the recnlltmr,nt of health utorkers in the dlstrict; ,) Goaernment provides UGX Ssbn in Fy 2or9/2o lor 7T RRrrs, setf Accounting Efttlties qnd. 4l General Hospitals, so that theg go to the same leuel as their colleagues ln the education sector. ui) Goternment shourd. incrude the cad,re of super specrafists rn the Pubtic Sentice pag st ltcture

9,1,2 Intern Doctors and Senior House Oflicers It was observed that despite repeated calls to increase the allowances of Intern Doctors by the Parliament, Government is yet to prioritize this recommendation well knowing the important role that the Intern Doctors and senior House officers play in health care for the patients. Further, the car to have a comprehensive intern doctors' policy has not been met with the urgency it deserves.

The committee was informed that there are 7o4T Intern Doctors and Intern Nurses combined earning a gross salary of ucx g4o,0o0 each bringing their current annual allowance to UGX 1 1.gbn. The committee therefore the proposed salary enhancement for Intern Doctors is UGX 1.Sm

A total of 300 Senior House Officers ose current budget is 4.2bn where each is earning UGX 1m. The proposal is enh ce their salaries to UGX 3m which c^ requlres an extra UGX B.4bn. la 1-- "-(a' currently, the sector takes on nurses as well as doctors in training on internship, a strategr that limits the scope of doctor's training due to space and logistics.

Recommendation The Committee recommends that starting Fy 2Ol9l20;

i) Gouernment allocates UGX s.6bn to enhance tlrc rntern Doctors, allowances

iq UGX 8.4bn be prooided. for the enh,,ncement of the senior House Officers, allouances iii) The committee re-iterates its earlier recommr,ndation that the Minister Jor Health fast-tracks the approoat of the portcg for intern doctors' training and a Mlnistry o! Health T.rainlng policg.

9.1.3 Variations in project Implementation Time Frames The committee observed that the status of implementation of all the projects under the health sector to date and for Fy 2o1g /2o and medium term keeps varying. Many anticipated timeframes for completion of various externally funded projects are varied due to inability to meet certain requirements including counter-part funding and timeiy releases of funds meant for those projects. The situation is also attributed to very long and overry bureaucratic nature of some development partners such as worrd Bank who require votes of no objections for ( undertakings with sectors. The variations usually lead to continuous budge strains and project stagnations.

Recommendation c. The Committee therefore recommends that; i) Mintstry of Healthfast tracks att proJects urith the health sector shouing start and planned end. date, total proJect cost, cumulative

24 l,l, financlol and phgsical perfonnance to date as uell as planned. medlum term programmed. o,nnuo,l budgetary allocatton; ii) Minlstry of Health should alutags indicste o,ll the counterpdrt funding requiremcnts uthere applicable and an explanatlon in the lurrril:Iion of tlmeframe for project completion for proper follow up earlg enough.

9.1.4 Operationalization of the National Health Insurance Scheme

The committee observed that National planning Authority assessment report on compliance of sector to the annual budget and National Development plan of March, 2019, cited non-compliance by the health sector in the implementation of the National Health Insurance (NHI) scheme that should have led to a reduction in the linancial risk protection of households against impoverishment due to health expenditures. In the current Fy 2019/ lg, ucx 3bn was allocated to commence the process. To date, the progress on NHIS is slow. The Parliamentary recommendation to have the National Health Insurance scheme operationalized has not been treated with the importance it deserves and yet the scheme is an important precursor to the attainment of universal health coverage. A certificate of Financial Implications was issued over 3 years ago and thereafter, the progress has been very slow due to pending consultation by the Attorney General. It was however revealed to the committee that the draft Bill is before Cabinet.

As part of the core programmes within the National Resistance Movement (NRM) Manifesto, National Health Insurance (NHI) scheme and full staffing at all levels of health service delivery were envisage d by 2021. with one year to 2o2l and, t]ne failure to prioritize the Health Sector programs particularly National Health Insurance despite the attendant, there is no proof of serious commitment by Government to implement the scheme

25

<.L) 'Recommendation The Committee reiterates its earlier recommendation that; czovernm.ent tast-tracks the NHIS blll so that implementation starts Fy 2019/2O.

9.1,5 Preventive Health Care The Committee was informed that; seventy Five percent (7 5o/ol of the disease burden in Uganda is preventable and if Uganda is to achieve her target of Universal Health coverage, there is need to address public health focusing on prevention, health education and promotion. The committee appreciated the efforts to prioritize health promotion, prevention and early intervention with focus on scaling up interventions to address the high burden of HIV/TB, Malaria, nutritional challenges, environmental sanitation and hygiene, immunization, Hepatitis B and Non communicable Diseases (NCDs). Nevertheless, the policy direction and the budgetary allocations show a mismatch as they have not been explicitly reflected in the budget. The mis-match is indicated where the NCD department was allocated UGX 12om and Health Promotion allocated a sultry UGX 139m respectively for the entire year.

Additionally, the National Planning Authority has listed most of the above interventions as part of the areas where the sector is showing non-compliance. The planned introduction of community Health Extension workers stratesr (cHEws) to replace the Village Health reams (vHTs) did not take off although UGX 3bn was allocated for that cause in the current financial year. This had been envisaged as a more versatile team to scale up community health outreach progrErmmes at the grass roots.

Recommendation The Committee recommends that; i) Gooernment should address dlt NDp Ir compliance bottlenecks in the l*alth sector and. re-align policg, ptanning and bud.getary aflocatrons c.

ZO 'll) Government should dllocdte IIGX 7bn lor the Health promotlon Departtnent and Non Communlcable Disease to promote preuent te health care

9.1.6 Kidney Disease Burden and Care The committee noted with concern the rising kidney disease burden in the country. A study screening for Non- communicable Diseases revealed an unusually high prevalence of the chronic kidney disease at 21.4o/o in wakiso District alone. However, there are only 8 Nephrologists (Kidney specialists in the country, a ration that is unmanageable (1:5, 000,000 people)!

The committee noted that on 28l03l2oL9, the House deliberated on the disease burden, the unmet need for dialysis services for both adults and children, an acute shortage and unbearable cost of dialysis services. The House considered the need to offer more realistic support to the health system to deliver quality, safe, accessible, affordable and sustainable kidney care to the nation. The cost of setting up a 4 machlne dialysis centre in an existing structure costs s82.5m. consequently, the House adopted the motion and resolved that uGX 7.6bn be allocated in FY 2019/20 for targeted Kidney care services at Regional referral Hospital.

Recommendation The Committee recommends that Government should; l) Allocate UGX 7.6bn Jor targeted kldneg care services specificallg for diclysis ii) Ensure that dlalgsis senrices are decentrallzed to eoery Reglonal Referral Hospital to brlng serucces closer to the people and. decongest the onlg tuo referral centres in the country currentlg offering the sentice C- l/-" 9.1.7 Reproductive Maternal and Child Health Service Reproductive health encompasses a range of services including family planning, the prevention and treatment of HIV and AIDS, the diagnosis of sexually transmitted diseases/ infections, use of contraceptives, unmet needs for family planning and post-abortion care among others.

The committee observed that the Health sector Budget performance report for ?Y 2ol7 /18 revealed that the number of mothers dying due to delivery related complication had increased. The average number of maternal deaths in the regional referral hospitals (RRHs) alone was 20 with Hoima and Fort portal recording the highest at 53 an52 deaths respectively. Moroto (1), Gulu (2) and Kabale (21 had the lowest. There was a signilicant increase in the number of maternal deaths in Mbarara RRH from 24 in 2016llz to 4l deaths in 2oLZ llg whereas; Masaka RRH registered a decrease from 45 deaths rn2oL6llz to 2T in 2017118.

The committee noted that whereas the NDp II health impact indicator target is 30 for lnfant Mortality Rate (lMR) by 2o2ol2r, it currently stands at 43 per 100,000 live births (UDHS 2016). The shortfall from the NDp II target is 13. Further, the Maternal Mortality Ratio declined from 438 per 1oo,o00 (UDHS 2011) live births to 335 (UDHS 2016). This falls short of the NDp Health Impact Indicators of 21L by 2o2o I 2l . The differenc e of 124 maternal deaths is a significant ratio that is unattainable in the remaining two (2) years to the end of the NDP II unless efforts are doubled in implementation of the maternal mortality mitigating interventions.

For some RRHs such as Moroto, the performance on antenatal care and family planning hinge a lot on incentives such as distribution of food to attending pregnant mothers. When these services not incentivized, it leads to low turn up hence low performance. t

w" ( {. The committee further noted with concern the absence of an integrated health management information system (HMIS) that provides information on all reproductive maternal and child related health indicators in real time.

Recommendation The Committee therefore recommends that; 7) Goaernm.ent should. urgentlg come up utlth a poticu and. guldelines on maternal" child., ad.olescent and sexual reproductlue healtfu 2) Deliberate etforts should be made to functionallze HCrvs to offer comprehensiae obstetric and. neonatal care serulces, 3) The commlttee relterdtes po,rllament recommend,afion that maternal health audits (report on mate"fto,l and child mortalitg lndicators) should alutags be submltted to parliament bg the Mintstry of Heatth on a quarterlg basis. 4) Parllament allocates IIGX lobn rlng-fenced Jor mediclnes and suppties catering for hgpettensioe diseases in pregnancies since it is the leadlng cause of maternal/neo-natal morAatitg. 5) Gouernment should. fuuifl rts commrtment of usD sM eoery financrar gear for reproductioe health care.

9.1.8 Upgrade of Health Centres The committee noted that whereas 331 sub counties do not have HC IIIs, there 132 sub counties in the country that do not have any health facility. Further, of the 29o constituencies, 29 do not have HC IVs yet these ones are supposed to offer comprehensive obstetrics. Government has secured UGX 200bn to partly 331 HC IIs to HC III.

Recommendations The Committee recommends that Government; l) should secure LIGX 74sbn to constrltct heqlth centre rrrs in the ls2 sub counties that completelg have no health lacilitg ( l/" 2 ii) Should secrtre UGX lo2bn to construct HCIVs in constituencies that do not hante HCIVs.

9.1.9 Salary Enhancement for Dlstrict Health Officers (DHOsl The committee observed that one ofthe causes ofpoor supervision and therefore poor health service delivery was among others poor remuneration of health workers and the unfavourable working condition. Government, in Fy 2018/ 19, through staff salary enhancement for scientist moved in to provide financial motivation to all health worker across government health facilities. However, the District Health officers (DHos) were not considered causing general demoralization and discontent amongst them. The allocated IJGX 4.2m per DHo which brings the total sa1ary enhancement to UGX 2.2g6bn for Fy 201g should take effect in 2OI9 l20. This expected to revive effective supervision of the district health service services.

Recommendation Committee recommends that; Gooernment should. arrocate ucx 2.2a6bn as sarary enhancement for District Health Q;ffilcers, elfectiue Fy 2O1g/2O The Ministry oJ Health Head,quarters should, strengthen its supentisory and. ooerslght tanctlon

9.1,10 Over Dependence on External Financing The Committe e observed that; There is consistent and hear,y reriance on external financing for program interventions. overall, external Iinancing of the health sector budget for Fy I 2or4l19 accounted for 47vo while Government of uganda share is projected at 53%. This over-dependence exposes lives of Ugandan to high health risk in the event that donors withdrew their support.

It should be noted that development partners have put Uganda on notice over their intention to stop funding HIV by 2030 and also provision of traditional vaccines for immunization. 30 k- rl whereas a number of donor-financed projects require counter-part funding, most of the time it is not available or comes very late. This usually results into delayed disbursements of donor funds leading to delays in project implementation and budget absorption challenges similar to what is being experienced in FY 2018/ 19 and previously.

Recommendation The Committee re-iterates tts preaious recornmendo,tion tho:t; a) Goaernmeftt must graduallg increase its budgetary allocation towards the Health sector as a meo,ns of mrtigating potential risk of d.onor dependencg otheruise Parliament shouldn't d.pptoae tl:.r- Health sector bud.get where the share of Goverfimerrt oJ Uganda d,euelopment Jinancing in the total sector budget is not growing. bl Goaernment should reneu, lts commit rtent toward,s cou,.te'-p,,rt Junding to match d,onor Jinanclng requlrements as a means of mitigatlng budgetary absorption challenges ctrrentlg faced. bg the sector crs uell ds the potential burden oJ penaltles, litigotlons and their llkely conseqttences Transfer to policg areds.

9.1.11 Supenrision of Health Facilities and Health Serrrice Delivery The committee observed that inadequate supervision of health services at all levels was noted as one ofthe causes ofpoor performance ofthe sector outcomes. superuision especially of the Regional Referral Hospitals and the lower health units is now extremely difficult. The Committee discovered that this challenge is caused by; i) Lack of prioritization of supervision by government was helping to curtail the sector's ability to carry out supervision visits; and ii) Absence of clear linkage betwe the Ministry of Health and the respective local governments where health ervl elivery takes place. 0

ft" 7 As a result, there is weak technical collaboration to ensure supervision of health sector projects and programmes. This has created a supervision vacuum leading to poor service delivery

Recommendation The Committee recommends that; l) Gorernment should. provide UGX lobn for supenislon of health Jacllltles in the country startlng Fy 2Ol9/2O; iil Gouernment should. put in place a pollcg to strengthen the monltoring and. eaaluatlon unlt, For example, an inter-ministerial committee to cluster the inter-linkages betueen Mlnlstry of Locat Gooernment and. Ministry otHealth.

9.1.L2 operationalization ofthe super specialized Hospitals and the status ofthe Law on Organ Transplant In order to operationalize the super specialized Mulago, there is need for a law on organ transport and a 1aw on surrogacy, sperm, and egg donation.

Recommendation The Committee recommends that; Ministry should. Jast tra'ck the bill on organ transplant and. other releaant la.uts to allout the hospitats to functlon.

9.1.13 Inadequate Clinical and Diagnostic Imaging Equipment The committee noted that clinical imaging is an essential component of health care which supports and improves the effectiveness of clinical decision-making. Their availability and use stems wrong diagnosis and treatment, unnecessary health expenditures, and poor health outcomes. Further, the regional referral hospitals need high quality diagnostic imaging services in order to provide expert care and bridge the continuum of c by stemming the flow of uncomplicated cases general from hospitals to Na nal erral Hospitals. A

It f 2 "n'fi l/" {) s -l-: The diagnostic imaging equipment recommended by Ministry of Health for regional level hospitals in Uganda includes; x-ray generating apparatus; duo- diagnostic; fluoroscopy; three-phase radiography system; mobile / portable x- ray, ultrasound machines, CT Scan machines and MRI machines among others. The

The Ministerial Policy statement for the health sector for Fy 2ol9 120 does not provide for the purchase of these assorted diagnostic equipment save for Butabika. The Ministry indicated that undertakings by the Netherlands and the Ugandan governments on a 507o-50%o sharing agreement to provide assorted diagnostic equipment to the RRHs and the NRHs necessitated their exclusion from the budget. However, it should be noted that the delay to expedite such undertakings render health facilities incapable of carrying out required diagnosis a service that is inevitable in treatment of medical cases. Additionally, it is a reflection of the over reliance on external fundino

Recommendation The contnittee therefore reiterates its earlier recornmend.atlons that; l) Gorernment should allocate resources for procurement of diagnostic machines instead on solelg relging on a d.onatlon/grant from external sources. A sum of UGX Tobn for the purchase of cr scan machines and. UGX TOObn Jor the MRI mrachines should. be prouided lor this expenditure ii) A sum of 3.4bn should be prouid.ed. for supervision of regional uorkshop malntenance and supenision bg the RREs.

(_ u, .1O. VOTE SPECIFIC OBSERVATIONS AND RECOMMENDATIONS

10.1voTE114: UGANDA CANCER INSTTTUTE (UCrl The committee observed that uganda cancer Institute (UCI) there are on-going cancer outreach programs beyond Kampala. The planned set up of Regional cancer centres seek to extend cancer preventive and treatment related services to the population at lower levels and to decongest the cancer institute. The idea of mobile cancer vans used in the outreach programs for sensitization was viewed as an initiative that would deepen, farther and promote quick access to cancer screening and promotion of access to information related to cancer treatment and care.

The institute is challenged with inadequate specialized diagnostic capacity like lack of PEST scan, lack of surgical ward for post-operative patients, limited radiation oncologr, inadequate staffing levels due to restricted staff structure particularly the radiologz unit.

It was however noted that the institute lacks critical information and documents such as an approved strategic pran, Nationar cancer contror pran, no pag poticg for the cancer treatment and services in spite of widespread public outcry that the services are expensive. Relatedly, there is no clear information on the procurement of cancer drugs, no data on cancer mortality, no clear policy on training, unending bunker projects and no clear expenditure on student training under the ADB loan. This is a manifestation of rack of accountab itv and r transparency in the institution. L Recommendations The Committee recommends that; i) Ministry of lleatth should. enforce po tation, transparencg and. accountq.btlitg of the instltute; ii) Government provides fand.s lor the estabfisho.ent of Regronar cancer Centres; 34

a_. Itl) Institute cofites up utith the National Cancer Control plan; to) The Institute should. com'e up utith a robust strategg and. ptan to curb the rampant extortlon.

1O.2 VOTE 115: UGANDA HEART INSTITUTE The committee was concerned that despite of the central role the institute plays in cardiac care and treatment in the country and the move towards super specialization of cardiac service both in the region and world over, the Uganda Heart Institute (uHI) is still grappling with inadequate space to fully utilize its capacity. The Intensive care unit that would facilitate critical post operation care for heart patients and enable a churning out of a commendable number of operations is incomplete.

The institute is further challenged by limited funding for specialized sundries and human resource development for the institute to enable more cardiac interventions and train staff in areas of cardiac surgery, anesthesia, critical care, perfusion and cardiologz.; Secondly, the institute suffers from inadequate super specialized cadre of staff due to lack of proper remuneration and recognition. However, part ofthe probrem stems from the public service pay which does not capture the super specialists.

The committee however noted that the institute did not have any deliberate plans to extend the cardiac services to the regions of the country. This is essence will continue to cause severe congestions at the UHI. The reluctance to extend the cardiac services especially the message on prevention and health promotion ( to the lower units will most likely lead to overwhelmin number of cases even those that do not require referral.

Recommendations The Committee recommends that; i) Gouernment secures UGX 262bn to help lleqra Alte constrltct a. stc,nd.- alone Centre of Excellence of an International sta.ndard. 35 l,fr, t<- 'll) Goaerntnent should provlde additional funding oJ 2.2bn Jor the completion oJ Intensiue Care unit fiCU) Ward, lC Mulago Comptex; iii)A total of Tobn should be allocated, to trHr purposelg Jor procurement of sundries, perfonnance of specrarized ca,rdr,.c rnteruentrons and. human r e soll;rc e deue lo p me nt ;

1O.3 VOTE 116: NATIONAL MEDICAL STORF,Si (NMSI 1O.3.1 Stock-Outs of Medicines and Medical Supplies Drugs The committee noted with great concern the widespread public outcry over perennial stock-outs of medicine in the public heaith facilities despite the increment in the National Medical Stores budgetary allocation for medicines. It was observed that aithough an additional allocation of UGX 41bn was effected in FY2018/ 18, it did not significantly improve medical supplies whose stock-outs are still high. The entity was constrained due to budgetary shortfalls.

Upgrading of HCIIs, construction of more HCIIIs and the upgrading of some facilities to both Regional Referral Hospita-ls and national Referral Hospitals will increase the need for medicines and supplies expected. The upward projection, the upgraded facilities and the new facilities means a significant budget increase for medicines and suppries. The entity needs funds an oxygen suppiementary plant and the laboratory in order to maintain supplies to General Hospitals and other lower health facilities. The committee however acknowledged the current funding gap of uGX Sbn for medicines for emergencies and epidemics, UGX 5bn to ensure availability of enough vaccines for routine immunization , IJGX 22bn for Mama Kits for safe delivery to mother, UGX 1Sbn for Essential Medical and Health Supplies (EMHS) to RRHs, GHs, HCIV, HCIII and HCIIs and UGX 2bn for TB vaccines to accredited facilities. u

Recommendation li; 36 il fhe Corlnm:ittee therefore recommends that Goaernmcnt o,lloca;tes additional UGX SObn to JVIES to improoe on the antattabilttg oJ drugs and other medical supplles in the heo'lth lacillties across the country; fq Governm.ent should. prouid.e UGX ggbn for procurlng Laboratory commodltles.

1O.4 VOTE 134: HEALTH SERVICE COMMTSSION (HSC) The committee was informed that the Health service commission,s mandate is to appoint, coniirm, promote and review the terms and conditions of service, training and qualifications of health workers. It is also mandated to foster professional and work ethics, and exercise disciplinary control over health workers under its jurisdiction;

During FY 2018119, the HSC recruited and appointed Nine Hundred sixteen (916) Health workers out of the planned g50. This represents a lo7o/o performance of the entity against the set target. Further, the HSC recommended ten (10) Medical specialists and one (1) Hospital Director to H.E the president for appointment;

The commission carried out support supervision in seventy seven (77) Districts and Eleven (11) Regional Referral Hospitals. This represents 91.7o/o performance of the targeted districts and 78.6 7o of the RHHs;

The HSC also provided technical guidance to eighteen (1g) districts,and District Service Commissions (DSCs).

The committee observed that the commission secretariat is under staffed, there is little funding for operations, lack of enough space, and a problem of old equipment and motor vehicles that need replacement. It was noted that the recruitment for health units under KCCA is not reflected in eHS policy statement and yet it handles recruitment for them. 37 ttu Recommendation The Committee recommends that; l) The Health Senice Commission should pack*ge infortnatlon on recntit nent and funding ln a uag that ensures requlred attention ls giuen to health sendce dellvery issues related. to stn cture, operatlons and human resource. ii) Goaernment should protfide o,dditional landing to the commlssion to a tune of UGX 2bn requlred, to tacilitate the recrultment of commisslon Secretarlo:t in its uork.

1O.5 VOTE: 151 UGANDA BLOOD TRANSFUSION SERVICES (UBTSI The uganda Blood rransfusion Service (UBTS) is a semi-autonomous, centrally coordinated organization in the Ministry of Health sufficiently decentralized whose strategic objective is to make available safe and adequate quantities of blood to all hospitals for the management of patients in need in all healthcare facilities. It has been noted that for three (3) successive years, the country has experienced a crisis due to lack of blood especially around December and January. This trend usually triggers a country-wide concern and eventua,lly leads to supplementary funding.

UBTS indicated that in the previous Fy 2o1g/ 19 it achieved among others; mobilization of 230,000 blood donors, collection and testing of l29,o4o units of blood, and issuance of 120,093 units of blood to health facilities. However, these figures vary from those provided in the Budget Framework paper (BFp) for Fy 2ol9/20 where 2o9,633 units of blood was collected and processed and197, Bg5 units issued.

The entity further indicated gaps in planning as the committee struggled to get basic information and formula on; (a) determining the national blood requirement, (b) the cost of processing a unit of biood and (c) the determinant for the quantity of kits supplied to UBTS by NMS. The absence of clear ft; 38 -- a '-L (_

c. explanation to such basic information renders the Committee unable to recommend allocation of resources to the entity unless clear explalation is given to that effect.

The committee indeed observed that whereas the agency requested for additional funding 0f 9bn to increase blood collection, and whereas funds to a tune of uGX lbn was allocated to Red cross to help in the mobilization of blood donors, the units of blood collected did not change significantly to reflect the increment.

Recommendation i) Tle comtnittee reiterates lts earlier recommend.ation ln the sectoral Budget Frameuork Paper that IIBTS be audited to establish ualue for moneg ln its expendlture; ii) The entitg should provide a cleqr strategg for increasing auailabllitg oJ safe blood to the population abooe the a oerage l2o,ooo units collected. annuallg; iii)I/Brs should. proulde a comprehensioe formula used to arrive at the natlonal blood requirement/need,, and. the cost of processing cr unit of blood.. it) UGX 2,2bn should. he prould.ed to enhance tle capacltg o! Uganda Red Cross in Blood. mobilizdtlon.

10.6 VOTE 161: MULAGO HOSPITAL COMPLEX The committee noted that Mulago Hospital complex was still undergoing renovations, remodeling and equipping. It also observed that the facility is not complete and needs an additionai UGX 35bn in order to reach operati level.

Recommendation The Committee recommends that; UGX 35bn should be prouid.ed to complete the facllltg

la 39 -( c'\,r cr 1O.7 VOTE 152: BUTABIKA NATIONAL REI.ERRAL HOSPITAL The committee noted that Butabika National Referral Hospital provides psychiatry services to over 1000 patients with over g50 residing in the institute inpatient wards meant for only 550. The institute also provides outpatient services to those from within the surrounding communities with minor cases that don't require hospitalization.

The institute is however challenged with inadequate human resource due to inadequate budget and the difficulty in attracting the requisite cadres. secondly, the patient attendance is higher than the bed capacity.

The committee was informed that the bed occupancy at Butabika National Referral Hospital has remained at 150% over the last two years. patient attendance has also remained high in spite of the mental health units at all RRHs. Itwas further noted that the institute experiences high maintenance costs owing to the nature of illness of the patients. The patients often mete destruction on infrastructure and consumables at a high rate.

Recommendations The Committee reiterates its earlier recommendations that; l) Gouernment should operatlonallze all the tnental health units t Reg io nal Referral Ho spltals ii) Pubttc servlce shoutd reuiew the stntcture oJ Butabika National ReJerral Hospital to meet the d.emands of the cunent times.

1O.8 VOTE 179: ENTEBBE REGIONAL REFERRAL HOSPITA The committee was informed that the upgrading of Entebbe General Hospital to RRH status was strategic in offering services to Very Important persons (vlps) and the surrounding communities. The poricy statement however showed no wage allocation for the institutions despite the wage requirement of uGX 7.2bn. It was further indicated that hospital had for capital development projects b lfrt 40 -(- L-^*) executed FY 2ol9 l2o which include setting up an isolation unit and oxygen plant but there is no allocation for capital development.

Observation The committee observed that there is no financial provision given to run this hospital despite attaining a new status as a vote and as a referral

Recommendation The Committee Recommends that UGX 12bn for urage and. non-uage be provided. to ruft thls hospltal

1O.9 VOTE 18O: MULAGO SPECIALIZED trrOMEN AND NEONATAL HOSPITAL The committee noted that the hospital was launched in october 2018 and received a vote status at the beginning of April 2019. However, some of its budget lines such as capital development and wage category are still being held by Mulago. The hospital has recorded 4728 outpatients, carried 254 deliveries and received 414 inpatients from October 201g to date.

The charges at the Mulago specialized women and Neonatal Hospital vary according to level. There are three (3) levels of care and these include Sliver, VIP and wIP. It was noted that the charges were higher than the charges levied by the private service providers. For example deliveries are charged as follows:

Table 6 showing charges for detiuery at Mulago specialized- women and neonatal Hospital

SERVICE CHARGE Delivery by Level Silver VIP \/IP Normal SVD O.Bm 7.2m 1.5m

C-Section 2.Om 2.5m J Source: MSWNH, Apil, 2019 47

"\-L,, Recommendation The Committee recommends that; i) The rrutndgement of the hospltat should. leaae out a floor ds paft of sentice provlslon for rlgandans uho ca,nnot afford. ds the country utalts for heo-lth insurance. i) Mtnistry of ?lnance should transJer the uage of the Mulago specialized. Women and Neonatol Hospital lrom the Vote L6l-Mulago Hospltal Comptex;

1O.1O VOTE 3O4: UGANDA VIRUS RESEARCH INSTITUTE (UVRI) The Committee noted that; Uganda Virus Research Institute, (UVRI) is a government medical research institute whose mandate is to conduct scientific investigations on viral and other diseases to contribute to knowledge, policy and practice and engage in capacity development for improved public health.

During FY 2018/ 19, the institute contributed to the policy on combination prevention therapy including ABC, Test and rreat through Epidemiological and behavioural cohort studies, provided data on the extent of HIV epidemic in the fishing communities in Masaka and completed two projects on influenza. The institute's Arbovirologr Laboratory was selected to become Eastern Africa yellow Regional Reference Laboratory for Fever. The Institute also made two (2) major publications in peer reviewed journals among others.

The committee observed that the institute is faced with:- understaffing, inadequate and dilapidated infrastructure, lack of transport especially for field activities such as collection and movement of samples, inadequate funding for disease surveillance, encroachment on Zika forest by the surrounding communities and waste disposal.

ftr 42

C The committee noted that one of the institute's serious concerns is the lack of efforts to create awareness about HIV/AIDS amongst its staff and little efforts towards mainstreaming gender and equity.

Recommendation The Committee reiterates its recommendations that; a) The Ministries of I'ocal Gouernment, Health and the National Eorestry Authoritg utork together to establlsh tegal boundaries of the zika forest and. d.eclare it a protected. area gazetted. for research. b) ucx 2,2bn be allocated to the lnstif,.tte to facilttate the renooatlon works on lts old. and dilapidated. buildtng. c) ucx o.o2obn he allocated to the instltute to facllitate actitrities focused. on gender and equitg mainstreaming. d) Gooernment should allocqte UGX o.2sobn for the constntction of the inclnerator for the tnstltute to mlnlmize the exposure of the enuironment to negatiue efJects. e) Gooernment should. arrocate UGX o.sbn Jor the procurement of a field oehicle with its malntenance and operation costs. fl Resources shou Id be allocated. to the institute lor the constructton of tuto (2 bedroomed. hozses, a research science building, labordtory maintenance and. recttitment of staff in critlcal posltlons.

11.O VOTE 163-176: REGIoNAL REFERRAL HosPITALs

The committee noted that there are 14 Regional Referral Hospitals located in different regions of Uganda namely: Arua, Fort portal, Gulu, Hoima, Jinja, Kabale, Masaka, Mbale, Soroti, Lira, Mbarara, Mubende, Moroto, and Entebbe.

The committee was concerned over refugee inflr:x and the attendant resource constraints on the RRHs that lie with refugee catchment areas such as Arua, Hoima and Fort Portal. The committee further observed that capitar Development Projects have been ongoing without feasible dates of completion. The RRHs have overcommitted Government to capital development p that Ita 43 q go beyond the medium term expenditure framework thus making it very dilficult to complete them on time. The protracted projects have also been a subject of court litigation and several changes in contractors and contractor managers thereby raising the cost of projects.

Obeervation whereas a total of UGX 20bn was being allocated for infrastructural development for all regional referral hospitals, the irrational budgetary allocations makes it thinly distributed and therefore ineffective

Recommendation The Committee recommends that; i) ucx Tobn be prouided to Reglonal ReJerral Hospltals to fast tro,ck the current capital deoelopment proJects becquse theg have gone on for a long time; ii) Mintstry of Health should. Jact track and. supenise afl caprtar deuelopment projects to complefion

11.1 Emergency Medical /National Ambulance Service System The committee noted that there is absence of a functional emergency medical system which includes care at the scene of emergency, care during transportation and care at the facility. severely affected areas include island districts especially for purposes of emergency transport.

Recommendation The Committee recommends that; i) Goaernment should allocate UGX 6gbn Jor the establlshment o! the National Emergencg Medico.t and. Ambulance Senice Sgstem annuallg for the next S gears. ii) The Islo,nd districts be priorltized. and, giaen boat ambulances rn Dy 201e/2o

+4 k; ,-<'-\-L, 11.2 Governance ofthe Referral Hospitals The committee noted with great concern the absence of boards for RRHs and yet their role is very critical in providing oversight and direction to the hospitals.

Although political preferences and lack of agreement on representation is cited as a major challenge to the existing of boards, there is not much effort from the mother Ministry to push for the reconstitution of these vital organs.

The committee further noted that the absence of these boards deprives Regional Referral Hospitals ofthe vital guidance in technical areas such as hnance, capital development among others.

Recommendations The Committee recommends that; I rhe Ministry should ot)ersee the setting up o! RRl{ boards quickrg to bridge the apparent goverrtdnce gap at these lnstltutlons;

1 1.3 Inadequate Counter-part Funding It was observed that general lack of counterpart funding for extemally funded projects under the sector is constraining timely execution and completion for externaily funded projects. The committee noted that the delay to complete Busolwe and Kawolo Hospitars by 2ors I 19 was as a result of inadequate counterpart funding. The committee also noted that many externally funded projects did not take off due to poor prioritization of co-funding by Government. For example, Government failed to avail UGX 6bn required as counterpart funding for the above projects leading to delays in project completion under the JAICA initiative. consequently, a breach of terms of contract was cited leading to withdrawal of the initial grant.

The Committee recommends that; +5 l/z' u

t l) Ministry of Health sho',.ld protid,e a compendiutn of alt planned, donor funded proJects for FY 2OI9/2O that require counterpdrtfundlng and. present them to Parllament for approlal of fund.s. ii) Parllament approves UGX 6bn as counter part Funding for the Kauolo qnd. Busolute Hospltal projects

11.4 Constituency Health Assembly Fund The Committee observed that; Government is undertaking significant health development projects in different districts. However, central supervision and involvement is limited. It would be important for Parriament to actively participate in oversight.

Recommendations: The committee recommends the rernstatement of the ucx 6bn Constltuencg Health Assemblg Fund

11.5 Nodding Disease Syndrome

The in preceding financial year, MoFpED provided supprementary budget of UGX 1.4bn to the districts in Acholi Sub Region affected by the Nodding Disease Syndrome. This was a one-off alrocation. However, it is important for the Government to continue with the rehabilitative services for the affected communities.

Recommendation The Committee recommends that; UGX 1.4bn should be prourd,ed. annuaflg for the next 4 gears in order to establish proper rehabilitofioe seny'rce s.

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(-' 12.O UNFUNDED PRIORITTES F"r 2Ot9l2O Various critical activities and or projects remain unfunded to the tune of UGX i,:r,Fy 24o.o4bt despite additional allocation to the sector budget 2079 120 (Table 8). overtime, MDAs have tended to ignore key priorities during the budget process and instead earmark resources to activities that could wait and or may not signilicantly affect achievements of planned outputs and outcome targets. Extra budgetary requirements over the available budget projections is an indication of poor planning and or prioritization on the part of the Ministry.

Table 7: Summary of unfunded Actiuities

ITEM AMOUNT UGX n w for M S ecialized Women & Neonatal Hos ital 17.4 Non-W for M S ecialized Women & Neonatal Hos ta-1 9.8 Medicines to Kawem NRH 4.5 w t for Kawem e NRH 14.5 Allocation to Kiruddu NRH for Dial SETVICCS 5.0 Allocation for of the Critical Cadre sta_ff 10.0 Allocation as hard -to -reach area allowance specifically for 5.0 specialis ts, consultants and other critical health care staff for the hard-to-reach areas Allocation to 17 RRHs, Self-Accounting Entities and 4l General 35.0 Hospitals, so that they go to the same leve1 as their colleagues in the education sector A ocati n to enhanC e the In tern DoctorS allowanceS 5.6 Allocation for the enhancement of the Senior House Officers, 8_4 allowances Allocation to the departments of Health Promotion and Non 7.0bn Communicable Disease to reventive hea-lth care A1 ocatlon to RRH S for targeted kidney care SErvlc e S Specifically 7.6 fof d al S 1S Rin fenced alloC ation for m dic1neS and Supplie S C atertn for 10.0 hypertenS e d 1seaSe S 1n pregnanc e S s1nc e t 1s th e lead1no cauS of matern a1 n o natal mortali Government annual commitment for roductive health care 18.0 Allocation for construction of Hea-1th Centre IIIs in the 132 sub 145.0 counties that com 1e have no health facili Allocation for constructi on of Health Centre IVs in Constituencies that to2.o do not have HCIVs. Allocation as salary enhancement for District Health 2.28 Os effective FY 20 19 20 Qfficers' l/" 47

't ,4 t-,/ , q- Allocation to Ministry of Health for supervision of health facrlities in 10.0 the coun s FY 2019 20 Allocation for the urchase of CT scan machines 70.o 100.o Allocation for se of MRI machines D ostic E en Allocation for supervision of regronal workshop and maintenance of 3.4 t the RRHs Allocation to help Heart Institute construct a stand- alone Centre 262 of Excellence of International standard Allocation for the completion of Intensive Care Unit (lCU) ward - no 1CM Com lex A11 ocation to NM S to lmprove on the availability of dru gs and other 50.0 mediCal su s 1n th h alth facilitieS across the coun Allocation for Laborat commodities 39.0 All ocation to facilitate the recruitment of Hea]th Commission 2.O Secretariat in its work Allocation to enhance the capaci ty of Uganda Red Cross in Blood 2.2 mobilization. Aliocate to com lete the Mul Hos ital Com lex facili 35.0 Allocation for w and non- e for runni Entebbe RRH 72.O Allocation to the Uganda Virus Research Institute to; - Facilitate the renovation works; - Construct of the incinerator; - Procure of a field vehicle with its maintenance and operation 0.250 costs o.30 Allocation to Regional Referral Hospitals to fast track the current 70.o c tal devel ent ects A11 oc ation to enabIe the establishment of the Nationa-l Emergency 68.O Medical and Am buIal Service tem annuall for th next arS Allocation as Counter Part Funding for the Kawolo and Busolwe 6.0 Hos tal ro ects Reinstatement of the Constituen Health Assembl Fund 6.0 Annual allocation to Nodding Disease Slmdrome rehabilitation 7.4 for the next 4 years in order to establish proper rehabilitative SCTVlCES Total 1,143.sO Source: Health MPS FY 20i.9 / 20

RECOMMENDED BUDGET ALLOCATIONS TOWARDS THE HEALTH SECTOR pY 2Ot9l2O

The Commrttee has recommended the following a-llocations in the next Fy O for the Health Sector as indicated (Table 7). t* 48

1q$,'*'S Table 9 sholuing recommended allocations touards the health sector yF 2O j9/ 20

Vote Recurrent Development Total Vote 014 Health 91,926,652,000 1, 105,388,360,000 1,197,315,012,000 Vote 107 UAC 6,731,122,OOO 127,809,000 6,858,93 1,000

Vote 1 14 UCI 1,9,674,224,OO0 7l ,2t7 ,477 ,OOO 90,891,70 1,000 Vote 115 UFII t9 ,679 ,4 tO ,OOO 4,650,000,oo0 24 ,329 ,4tO,OOO Vote 1 16 NMS 396,t72,275,OOO 396,t72,215,OOO

Vote 122 KCCA 10,730,000,000 940,OO0,000 1 1,670,O00,000

Vote 134 HSC 6,807 ,27 0,OOO 263,400,000 7,O70,670,OOO Vote 151 UBTS 16,198,641,000 2,870,000,000 19,068,641,OO0 Vote 16l Mulago Hosp. Comp. 58,553,663,000 6,020,000,000 64,573,663,000 Vote 162 Butabika Hospital 13,007,192,000 8,308, 141,O00 21,3 15,333,000 Vote 163 Arua RRH 7,959,569,000 1,O60,000,000 9,019,569,000 Vote 164 Fort Portal RRH 8,814, 178,000 1,060,000,000 9,874,178,O00 Vote 165 Gulu RRH 8, r40,106,000 1,488,000,OO0 9,628,106,O00 Vote 166 Hoima RRt{ 8,429,836,O00 1,060,000,oo0 9,489,836,000 Vote 167 Jinja RRH 10,612,090,o00 1,488,000,000 12,100,090,000

Vote 168 Kabale RRH 7,OO3,726,000 1,488,000,000 I,491 .726,OOO Vote 169 Masaka RRH 7,241,335,000 2,058,000,000 9,299,335,000 Vote 170 Mbale RRH 1r,229,995,000 3,058,000,000 14,287 ,995,OOO Vote 17l Soroti RRH 7,090,710,000 1,488,000,000 8,s78,710,000 Yote 172 Lira RRH 7,995,875,O00 1,488,000,000 9,483,875,000 Vote 173 Mbarara RRH 9,936,26s,000 r,987,800,O00 11,924,065,OO0

Vote 174 Mubende RRH 6,999 ,7 t9 ,OOO 1,060,o00,000 8,059,719,000 Vote 175 Moroto RRH 5,750,343,000 1,488,000,000 7,238,343,000 Vote 176 Naguru NRH 7,920,642,OOO 1,055,562,O00 8,976,204,000 VotelTT Kiruddu NRH 8,730,000,000 0 8,730,000,000 Vote 178 Kawempe NRH 8,657,000,000 o 8,657,000,000 Vote 179 Entebbe RRH 2,577,6t8,OOO o 2,577,6t8,OOO Vote 180 Mulago SWN Hosp 1 1,778,000,000 o 11,778,000,000 Vote 304 UVRI 6,805,128,O00 2,450,000,000 9,255,128,OOO Vote 50 1-85O LGs 46s,8 10,000,000 54,900,O00,o00 s20,710,000,o00 Total Sector Budg€t t,254,962,524,OOO |,274,462,549 ,OOO 2,537 ,425,073,OOO

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a 11.O CONCLUSION Health is critical to the development and productivity of labor as a factor of production and therefore should be a priority of Government not only in policy statements but also in actual allocation and utilization of resources. The need to closely monitor the health outcomes is critical lest we fa-1l victim to superfluous reporting in policy documents but with no bearing to the realities in the communities. MoH should always consider planning before embarking on any new programs. Government should progressively increase funding to the health sector beyond the current allocations and prioritize expenditure on health as investment rather than expenditure. This will help to avert over dependence on external donor financing to the sector and possible challenges due to donor pull out. Rt. Hon. Speaker and Hon. Members,

I beg to report.

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oo @ >o f. t- MEMBERSHIP OF THE COMMITTEE ON HEALTH

NO NAME CONSTITUENCY PARTY SIGNATURE 1 Hon, Buken Michael- rson Coun NRM 2 Ifon. maS nza- Y Chair DWR o o NRM o Hon. Ssebikaali Yoweri Joel Ntwetwe Coun NRM 4 Hon Stella DWR Moroto MRM 5 Hon. Kamusiime Innocent Pen Butembe Coun NRM 6 Hon. A Rose Atim DWR Maracha NRM 7 Hon k Judith DWR Kole NRM 8 Hon. Kemirembe Pauline DWR L tonde NRM 9 Hon. Muheirwe Daniel Buh Coun NRM l0 Hon. Mu M DWR Butale a NRM 11 Hon. Ssemba Edward Ndawula Katikamu South NRM 72 Hon. N bale lvia DWR Gomba NRM 13 Hon. A bazibwe Jastine DWR I ro NRM 74 Hon. Bebona Ba Jo hine DWR Bundibu NRM l5 Hon. L moki Sam Workers Re NRM 16 Hon. Rwal