SYMPOSIUM ON PARTNERSHIPS, POLICY, AND SYSTEMS DEVELOPMENTS FOR UNIVERSAL HEALTH COVERAGE

PROCEEDINGS REPORT 17TH- 29TH AUGUST 2019 GOLF-COURSE HOTEL KAMPALA, UGANDA

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2019 UHC Symposium Proceedings Report

SYMPOSIUM ORGANISERS

THE REPUBLIC OF UGANDA MINISTRY OF HEALTH

SYMPOSIUM PARTNERS

i Contents List of Acronyms ������������������������������������������������������������������������������������������������������������������������������������������������� iv Symposium Keynote Speakers ������������������������������������������������������������������������������������������������������������������������� vi Symposium Statement �������������������������������������������������������������������������������������������������������������������������������������� vii Setting the Stage ������������������������������������������������������������������������������������������������������������������������������������������������ x 1.0 Introduction �������������������������������������������������������������������������������������������������������������������������������������������������� x Key note presentation ���������������������������������������������������������������������������������������������������������������������������������������� 1 Official Symposium Opening Ceremony ����������������������������������������������������������������������������������������������������������4 PANEL DISCUSSION 1: How can the UHC and health improvement agenda be mainstreamed across sectors of government and society? �����������������������������������������������������������������������������������������������������������������������������11 SESSION 1A: YOUTH PANEL: “Nothing for Us, Without Us”: Putting the Youth at the center and as focus of development efforts ������������������������������������������������������������������������������������������������������������������������������������������ 17 SESSION 1B: Trade liberalization and its implications on realization of Universal Healthcoverage in Uganda �������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 19 KEYNOTE ADDRESS 2: PUBLIC-PRIVATE PARTNERSHIPS FOR UNIVERSAL HEALTH COVERAGE ��������������� 22 Expanding the scope for public-private partnerships for health improvement across sectors ������������������� 22 Panel Discussion ����������������������������������������������������������������������������������������������������������������������������������������������� 25 Best practices to achieve Universal Health Coverage in Uganda ����������������������������������������������������������������� 25 DAY 2: KEYNOTE ADDRESS: How are partnerships for health systems strengthening advancing UHC goals? Reflecting on 40 years of Primary Health Care. ����������������������������������������������������������������������������������������������27 Professor Bart Criel – Institute of Tropical Medicine (ITM), Antwerp. ������������������������������������������������������������27 PANEL DISCUSSION ����������������������������������������������������������������������������������������������������������������������������������������� 29 Dr. Juliet Nabyonga (WHO-AFRO) – Partnerships for UHC and learning from other countries. ��������������� 29 Prof. Charles Hongoro – Learning from the South African experience on private sector participation in health service delivery. ������������������������������������������������������������������������������������������������������������������������������������� 30 Ms. Robinah Kaitiritimba (UNHCO) – Role of Civil Society in the UHC discourse ���������������������������������������� 31 SESSION 1D: Financing Universal Health Coverage Efforts ��������������������������������������������������������������������������� 33 SESSION 2A: Social Determinants of Health ������������������������������������������������������������������������������������������������� 35 SESSION 2B: Health Systems Governance ����������������������������������������������������������������������������������������������������� 37 SESSION 2C: Learning from Collaborative Efforts ����������������������������������������������������������������������������������������� 39 SESSION 2D: UHC and Policy developments ������������������������������������������������������������������������������������������������� 43 SESSION 3A: National and Subnational Level Partnerships for Strengthening District Management and Workforce Performance for the Advancement of UHC in Uganda ��������������������������������������������������������������� 46 SESSION 3B: Decentralization Developments For Health Improvements ����������������������������������������������������� 47 SESSION 3D: Health Care Access ������������������������������������������������������������������������������������������������������������������� 50 PLENARY SESSION 5: Special Presentation And Panel Discussion ���������������������������������������������������������������� 51 PLENARY 6: How can multisectoral efforts be nurtured to advance Universal Health Coverage (UHC) and what mechanisms are available to ensure coordination and coherence in action for UHC across sectors of government? ����������������������������������������������������������������������������������������������������������������������������������������������������� 53 PANEL DISCUSSION on Leveraging Health Benefits From Non-Health Sectors ������������������������������������������� 55 SYMPOSIUM CLOSING REMARKS ��������������������������������������������������������������������������������������������������������������������57 AWARDS ����������������������������������������������������������������������������������������������������������������������������������������������������������� 60 SYMPOSIUM PARTICIPANTS ������������������������������������������������������������������������������������������������������������������������������ 61 SYMPOSIUM ORGANISING COMMITTEES ����������������������������������������������������������������������������������������������������� 68

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Brief about SPEED The Supporting Policy Engagements for Evidence-based Decisions (SPEED) for Universal Health Coverage in Uganda is a 5 year partnership supported by European Union that started in 2015. The partnership comprises Makerere University School of Public Health (Lead Agency), Uganda National Health Users Consumers’ Organization (UNHCO), Economic Policy Research Centre (EPRC), National Planning Authority (NPA), Institute of Tropical Medicine (ITM) Antwerp Belgium and Human Science Research Council (HSRC), South Africa..

THE VISION The SPEED project has a two-part vision: 1. Makerere University School of Public Health (MakSPH) with an outstanding track record and sustainable capacity for policy analysis, advice and influence for universal health coverage (UHC) and the resilience of health systems in Uganda. 2. Having state and non-state agencies that understand what UHC entails, and what roles they individually and collaboratively have to play in its realization. SPEED Objectives Overall objective: To strengthen capacity for policy analysis, advice and influence at MakSPH and partner institutions and contribute to accelerating progress towards universal health coverage and health systems resilience in Uganda.

Specific objectives are: 1. To engage and influence policy makers with contextually adapted evidence for health policy and systems changes to advance UHC. 2. To support policymakers to monitor the implementation of vital programs for the realization of policy goals for UHC. 3. To enhance the expertise, knowledge and resources for policy analysis and advice and influence at MakSPH and partner institutions. The SPEED partnership seeks to engage policy makers with contextually adapted evidence for health policy and systems changes to advance UHC and to support policymakers to monitor the implementation of vital programs for the realization of policy goals for UHC. The contributions of this partnership thus include engaging decision makers in forums that enhance shared learning, shared vision of UHC goals, and collaborative decision making. In order to contribute towards these goals, SPEED planned to host three symposia in years one, three and five. The first was held in 2015. This has been thend 2 Symposium.

iii 2019 UHC Symposium Proceedings Report List of Acronyms BCC Behavior Change Communication BTC Belgian Technical Cooperation EU European Union HPPM Department of Health Policy Planning and Management HSG Health Systems Global HMIS Health Management Information System HSSP Health sector strategic plan LMIC Low and Middle Income Countries MakCHS Makerere University College of Health Sciences MakSPH Makerere University School of Public Health MDG Millennium Development Goal MoFPED Ministry of Finance Planning and Economic Development PBF Performance Based Financing RBF Results Based Financing SDG Sustainable Development Goals SPEED Supporting Policy Engagement for Evidence-based Decisions UHC Universal Health Coverage WHO World Health Organization

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Symposium Objectives Symposium Themes 1. Share experiences, reflections and evidence 1. Social Determinants of Health and Multisectoral to guide global, regional, national and Collaboration for UHC subnational choices and strategies for 2. Policy and Systems Developments for UHC reducing the burden of preventable ill-health Partnerships and need for health care services. 3. Tracking UHC and evidence-informed decision 2. Build consensus among stakeholders on the making priority and plausible policies and systems developments required for effective health promotion in LMICs. Expected Outputs 3. Discuss domestic, insurance and other The symposium was expected to generate discussions, financing modalities required to expand and experiences and lessons that would sustain coverage of vital interventions for wellbeing. • Inform the development of subnational, national, regional and global partnerships for achieving 4. Propose ways through which actors at UHC and health improvements in LMICs. various levels can better support partnerships development for ensuring good health and • Inform advocacy efforts and initiatives on policy wellbeing for all. and systems developments for UHC partnerships. • Inform future stakeholder engagement strategies for the SPEED Project. • Help to compile papers and proceedings that would be disseminated widely.

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Symposium Keynote Speakers

Prof Yoswa Mbulalina Dambisya (MB ChB; PhD) is the Director General of ECSA-HC since August 2014. Prior to joining ECSA-HC, Prof Dambisya worked for the University of Limpopo in South Africa. As Director General, he is charged with providing overall leadership and guidance to the technical and corporate programmes towards the realization of the ECSA-HC mandate. Prof Dambisya is a medical graduate with the MBChB degree from Makerere University, Kampala, and a PhD (Pharmacology) from the Chinese University of Hong Kong. He has undertaken several short-courses in various fields, including leadership and management, monitoring and evaluation, Prof Yoswa Mbulalina medical education, global health diplomacy, and strategic planning Dambisya (MB ChB; PhD)

Prof. Khama Rogo is Lead Health Sector Specialist with the World Bank and Head of the World Bank Group’s Health in Africa Initiative. He is a Professor in Obstetrics and Gynecology and a prominent advocate and global authority on reproductive health issues. He is a visiting professor at several universities and author of over 100 papers and book chapters. He served on the Gender Advisory Panel of WHO, the Advisory Committee of the David and Lucile Packard Foundation, and the board of the Center

KEYNOTE SPEAKERS KEYNOTE for African Family Studies. He is currently on the board of INTRAHEALTH, among other responsibilities.

Prof. Khama Rogo

Prof. Bart Criel, works at the Institute of Tropical Medicine (ITM) since in 1990. He is currently Professor and Head of the Equity & Health Unit (formerly Health Financing Unit) in the Department of Public Health. His main areas of work are the study of health care delivery systems and systems of social protection in health in Low and Middle Income Countries. In the ITM’s Masters course (Masters in Public Health or MPH), he is in charge of the modules Local Health Systems Analysis, and Social Health Protection. He is currently co-director of the MPH, and in that function responsible for the management and teaching policies of this international public health course. He is involved in a number of health systems research projects in various sub-Saharan African countries and in charge of the institutional collaborations ITM has developed with sister academic institutions in the Democratic Republic of Congo (School of Professor Bart Criel Public Health in Lubumbashi) and India (the Institute of Public Health in Bangalore).

Prof. Pamela Kasabiiti Mbabazi is a Ugandan university professor, academic, and academic administrator, who currently serves as the Chairperson of the National Planning Authority of Uganda. Prior to this position, she served as the deputy vice- chancellor of Mbarara University of Science and Technology (MUST). Since 1998, Mbabazi has served as the Dean of the Faculty of Development Studies at Mbarara University of Science and Technology. She is credited for setting up the faculty and developing curricula for the degree courses in development studies and business administration. In 2010, she was appointed as Deputy Vice Chancellor at MUST. In April 2019, she was sworn-in as the new Chairperson of the National Planning Prof. Pamela Kasabiiti Authority of Uganda. Mbabazi

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Symposium Statement

THE KAMPALA SYMPOSIUM STATEMENT ON PARTNERSHIPS, POLICY, AND SYSTEMS DEVELOPMENTS FOR UNIVERSAL HEALTH COVERAGE THE GOLF COURSE HOTEL, KAMPALA, AUGUST 27-29, 2019

INTRODUCTION In 2015, the global community adopted 17 (SPEED) for UHC in Uganda project, in collaboration Sustainable Development Goals (SDGs) with 169 with the Ministry of Health, Uganda, hosted an indicators. SDG3 entails ensuring good health International Symposium on Partnerships, Policy, and wellbeing for all at all ages. Universal Health and Systems Developments for Universal Health Coverage (UHC) is framed under SDG3 along Coverage. The symposium theme was “Partnerships other targets for health. Goal 3 also addresses all for Health Improvements across Governments, and major priorities in health and introduces a broader Societies at Local, National and Global Levels”. agenda for promoting good health, reducing The overall aim of the symposium was to critically health risks and investing in the determinants of examine the developments in partnerships for good health and well-being. achieving UHC, and share experiences, lessons and reflections across countries and stakeholders, Successfully pursuing this broad agenda requires so as to build consensus on priority and plausible partnerships for policy actions in a complex and policies, partnerships, and systems developments increasingly multisectoral arena, with legitimate required to effectively advance the agenda for role-bearers ranging from sectors such as; Health, UHC, good health and wellbeing in the region. Finance, Education, Local Government, Gender and Labor, Housing, Social Development and Symposium participants included members of the among development partners, private sector and research community, policy makers, Development civil society organizations including the media. Partners, Practitioners, civil society, NGOs and These partnerships need to embrace “whole-of- students. Over 250 participants came from 10 government” and “whole-of-society” approaches, countries – Ghana, Nigeria, Democratic Republic where efforts to promote good health and well- of Congo, Kenya, UK, Belgium, Malawi, South being are mainstreamed in policies and programs Africa, India, and Uganda. Up to 64 abstract of all actors. Therefore, the need to pool efforts presentations and 7 plenary sessions were covered, and leverage collaborations and partnerships to broadly addressing areas of the thematic areas for advance good health and well-being is an urgent improving partnerships in policy design, systems call. development, financing arrangements, and private sector engagements. Participants shared evidence From the 27-29 August 2019, Makerere University for workable and sustainable approaches to School of Public Health – Supporting Policy working collaboratively and the critical need for Engagement for Evidence-Based Decision Making better mechanisms of coordination.

OBSERVATIONS We the delegates made the following observations hospital care and services. Efforts in pursuit in line with the subthemes of the Symposium. of Universal Health Coverage must focus on the social determinants of health through a) Social Determinants of Health and Multisectoral Collaboration for UHC multisectoral action to achieve good health and wellbeing. For example, water 1. There is still lack of clarity about the UHC and sanitation, nutrition, environmental concept. Misconceptions about UHC are protection, roads and road safety, individual prevalent amongst many stakeholders. and household incomes, education, among Without a common understanding of the others. Actors beyond the traditional health concept itself, convening and working care sector, including communities, are vital together may be complex and compromised. to this agenda. 2. Health should be looked at in a broader 3. The pursuit of effectiveness of partnerships perspective beyond narrow focus on should be built on the Paris and Accra

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accords, among others. The key tenets of these 3. The current funding structure is still more accords – country ownership, harmonization, inclined to hospital care and services. The alignments to national systems and priorities, resources to the preventive and promotive shared results, mutual accountability and health agenda remains sub-optimal, yet this trust, and capacity development – were has the potential to reduce the bulk of disease emphasized. burden and can reduce health system costs in 4. Despite reference to multi-sectoral the long term. programming and the guidance of the 4. As actors and stakeholders increase, the agencies for national coordination, such need for a regulatory mechanism becomes as, the National Planning Authority (NPA) in apparent. Appropriate approaches to Uganda, many sectors still work independently enhance capacity for regulation of state in a ‘siloed’ manner. Although agencies and non-state actors, can help to focus mandated to coordinate government stakeholder efforts towards clear goals for programmes exist (such as Office of the Prime the broader public good. Incentives are also Minister (OPM)), there are apparent gaps in important in this regard. intersectoral coordination that need to be 5. Local governments that carry the mandate plugged, to ensure an effective “whole-of- for service delivery in most countries, need to government” approach to address Universal be resourced. The current allocations to local Health Coverage. governments may not be adequate to allow 5. Partnerships come with increased costs of them effectively undertake their mandate. coordination, engagement and monitoring performance. There is need for a balance c) Tracking UHC and Evidence-informed to organize partnerships to reduce the Decision Making transaction and coordination costs. Skills in 6. Tracking progress towards UHC is critical. leadership to steer and negotiate partnerships However, this requires clearly identified, for the interests of the public are important feasible, and agreeable objectives, indicators, to build. As actors for health programming and means of tracking them. It was noted that increase, the administration costs need to be in Uganda, the National Planning Authority checked to focus resources more on service is currently developing tools that will be delivery. integrated in all sector plans. b) Policy and Systems Development for UHC 7. Research and evidence are vital inputs in Partnerships UHC policy and programming. Research institutions such as Universities have a big 1. Awareness of the interrelationships between role to play in investigating and identifying Primary Health Care and Universal health workable innovations and solutions that can coverage is vital to ensure a people-centered accelerate progress towards achieving UHC. and integrated health systems that put However, evidence becomes relevant if the communities as not only the focus but also questions are generated by the policy makers. with core responsibilities to undertake to Continuous strengthening of relationships improve their own health. between research institutions and policy 2. The rapid population growth and the institutions is vital. emerging demographic structure can both 8. Partnerships for the contextualization of be a blessing and a challenge, depending evidence, knowledge translation, and on how countries effectively programme information dissemination, are important in to address the population growth and ensuring systematic identification, synthesis demographic dividend. Effective participation of evidence, and provision of information to of the youth in the UHC agenda is paramount. various actors, particularly policy and decision Health concerns of the youth – mental and makers. Evidence-based decisions have great reproductive health and anxiety, etc., need possibilities of success. to be addressed. Effective ways to organize the youth in school and out of school, and identifying opportunities for them, is a vital step to harnessing the youth potential.

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RECOMMENDATIONS From the three-day deliberations, we the symposium delegates propose that: 1. Countries need to conduct an honest assessment or evaluation of why previous efforts of‘Health-For- All’ and other initiatives, did not achieve their goals, and what lessons we can learn from them. 2. Countries must identify and mobilize key actors and stakeholders to bring resources to the Universal Health Coverage (UHC) agenda. To make partnerships work effectively, there is need for shared goals, roles, responsibilities, complementarity, trust, and mutual accountability.

ACTOR SPECIFIC CALL FOR ACTION Government: 4. Monitor and Identify service coverage gaps and 1. Mainstream health and wellbeing improvements provide effective advocacy and identify remedial in all policies and agenda of Government using programs for vulnerable communities. the Health in All Policies (HiAP) approach –to Development partners optimize the contributions of other sectors to 1. Health Development Partners (HDPs) achieve health and wellbeing outcomes. should recommit to working together with 2. Strengthen and adequately facilitate the government. HDPs must come together to coordination framework that currently exists, address possible programme duplicities that building on the convening mandate and likely arise from parallel programming and legitimacy of the Office of the Prime Minister, financing arrangements. HPDs should effectively to ensure “all-government” works together in operationalize the ‘Working as one’ initiative. a coherent manner. A thematic approach to 2. Invest in strengthening the capacity for coordination can help to rally actors along multisectoral action and coordination (such themes of their interest and expertise. as capacity for planning in different sectors) 3. Emphasize and support stakeholder and identify a support framework to effectively engagements in all UHC discussions, policy and facilitate these processes. decision making processes and implementation 3. Leverage the special place the HDPs occupy to ensure ownership, responsibility, and mutual to task government and other actors to ensure accountability that a multi-sectoral approach is used as a 4. While different actors and stakeholders come mechanism through which programmes should together to synergize and bring resources be implemented to leverage resources across together, government should continue to allocate the board. more resources for implementation of UHC interventions. The National Health Insurance Academia and research institutions 1. Undertake operational and implementation Scheme which is in the offing should be expedited. research that is geared to supporting Civil society and Media government and other stakeholders, as well 1. Work closely with government, communities, and as identifying institutional frameworks and other stakeholders to engage in advocacy for models that can facilitate working together. partnerships, budget allocations, accountability 2. Create spaces for engagement and debate from actors, and the need to focus on preventive and sharing of evidence and experiences on and promotive health. policy and implementation issues relevant to 2. Create platforms to generate common Universal Health coverage. understanding and conceptualization of Universal Health Coverage, as a starting point for coherent policy and programming. 3. Create platforms for improving information and awareness on improving healthy behaviors, self-help community programs, service delivery and quality challenges, and bringing community voices to the discussion.

ix Setting the Stage 1.0 Introduction he International Symposium on Health Financing for Universal Health Coverage (UHC) was held on T27-29 August 2019, under the theme: “Partnerships for Health Improvements across Governments, and Societies at Local, National and Global Levels”. The symposium was organized by Makerere University School of Public Health – Supporting Policy Engagement for Evidence-Based Decision Making (SPEED) for UHC in Uganda program in collaboration with the Ministry of Health, Uganda. The symposium critically examined the developments in partnerships for achieving UHC in Uganda and other low and middle-income countries so as to inform strategies that are geared towards achieving UHC. The symposium provided a platform for sharing experiences, lessons and reflections across countries and stakeholders, so as to build consensus on priority and plausible policies, partnerships, and systems developments required to effectively advance the agenda for UHC, good health and wellbeing in the region.

Prof. Freddie Ssengooba – the SPEED Director, welcoming symposium participants

Symposium participants included members of the research community, policy makers, Development Partners, Practitioners, civil society, NGOs, students, the media, academia and researchers, politicians, and leaders at different levels, from institutions of government, private sector players, etc. Over 250 participants came from 10 countries – Ghana, Nigeria, Democratic Republic of Congo, Kenya, UK, Belgium, Malawi, South Africa, India, and Uganda. Up to 64 abstract presentations and 7 plenary sessions were covered, broadly addressing thematic areas for improving partnerships in policy design, systems development, financing arrangements, and private sector engagements. Participants shared evidence on workable and sustainable approaches to working collaboratively and the critical need for better mechanisms of coordination. Several plenary and parallel sessions were convened with various presentations made around three main themes; 1. Social Determinants of Health and Multisectoral Collaboration for UHC 2. Policy and Systems Developments for UHC Partnerships 3. Tracking UHC and evidence-informed decision making 2019 UHC Symposium Proceedings Report KEY NOTE PRESENTATION Regional Partnerships to Advance Universal Health Coverage and Wellbeing: What Is Working or Not; and How Do We Move Forward?

Prof. Dambisya, presenting the kenynote Speech

The symposium stage was set by Prof Yoswa fundamental right that everyone must attain a high Mbulalina Dambisya, the Director General of standard of health. This was a commitment that was East Central & Southern Africa-Health Community dopted more than 70 years ago that governments (ECSA-HC), based in Nairobi, Kenya, who delivered had responsibility for the health of their people. In a keynote address. The Keynote address tackled the the PHC declaration of 1978, emphasis was placed existing regional and country-level partnerships and on: (1) the need to ensure government addresses collaborations aimed at advancing the health for all all health and development needs of their people; objective, and how these frameworks are working, (2) the role of other sectors and not just the health the challenges, and the lessons and experiences that sector; and (3) the need to ensure political, social, can be learned, as countries and the region generally and economic acceptability of the approaches strives to achieve Universal Health Coverage (UHC). adopted. The role and responsibility of government for the health of their populations was clarified and The historical perspective of the UHC concept PHC was seen as the target for all by the year 2000, The keynote underscored the fact that Universal unfortunately many countries in Africa, however, Health Coverage (UHC) is not a new concept. UHC missed the target. It was noted that the Helsinki is historically founded in the Greek Philosophy of a declaration of 2013, re-emphasized the idea of HiAP, healthy mind in a heath body. Furthermore, the WHO and the need to prioritize health and equity as a core constitution in 1946, makes a reference to the central responsibility of government to its people. To achieve role of health in everything. Health was defined by this, however, required an urgent need for policy WHO as state of complete physical, mental and social coherence for health and wellbeing, multi-sectoral well-being and not merely the absence of disease collaboration, broader stakeholder engagement, or infirmity or disease. Health is recognized as a mobilized political will, courage, and strengthening

1 2019 UHC Symposium Proceedings Report strategic oversight. towards bridging the Human Resources for Health gap to enable the region increase the pool Universal Health Coverage and the SDG agenda. of HRH through the ECSA College of surgeons. Prof. Dambisya noted that the Millennium yy Efforts to address deficiencies in lab services and Development Goals (MDGs) agenda has just infrastructure, skills, standards through the east ended in 2015 with many LMICs not achieving much Africa laboratory skills standards. progress. In the new development agenda – the Sustainable Development Goals (SDGs) (2015- yy Efforts to build capacity in policy dialogue through 2030), Goal 3 (SDG3) is focused on health and strengthening global health diplomacy, ACHEST, wellbeing of all people. From the SDG perspective, EQUINET, ECSA-HC, to increase capacity to health is central to sustainable development. Health engage in global health diplomacy. benefits are not only a consequence of development Issues to note about the regional initiatives but also a contribution towards that development. approach: Health is an important end itself but also an integral part of all dimensions of human beings. Universal The keynote speaker noted that there was a number Health Coverage (UHC) has been identified as the of issues within the regional initiatives and platforms main vehicle to achieving SDG3. With the evolution that needed to be noted, including: of agendas, the key question that everyone should yy The verticalisation of effort in-spite of including answer was whether this was a cause for optimism or health systems strengthening components. reason for skepticism for Universal Health Coverage. yy Most programmes that regional platforms undertake are generally implemented through a The need to bring players together ‘project mode’ approach to programming, rather Prof. Dambisya noted that a number of regional than through integration. Although this allows for and national level networks and platforms already adequate resource mobilization, it could exclude existed, through which a lot of knowledge and other critical areas of need. experience sharing had been taking place, and yy Most regional initiatives and forums have indeed some commitments have been made through generally been sustained on external funding these spaces. Among these platforms, were: (1) or financing. While this generates relatively the Regional WHO committee in Brazzaville, which sufficient resources, it may not be sustainable. has been very instrumental in policy harmonization across countries, and (2) the African Union (AU) yy Regional initiatives have built a pool of champions which has taken on a critical role in ensuring within countries for purposes of driving certain health improvement across the partner countries. agendas and policy reforms. However, there are Additionally, it was noted that various regional cases where there has been in-fighting within networks and partnerships have been working on the champions in countries over who should advancing the population health agenda, and these be doing what. Sometimes the agendas have have been very critical on pushing forward the disappeared when the champions move on to discussions. These include: something else (for example retire or leave the yy Learning and knowledge generation and sharing, sector). networks, for example, AfHEA, EQUINET, etc. yy Domestication of regional and global yy Policy dialogue mechanisms and processes, for commitments proceeds at different paces example WHO AFRO, QAU/AU, RECS/ RHO that especially should there be changes in the lead have increasingly taken on a health agenda 263. actors or champions. This is coupled with limited country ownership of regional and global yy Multilateral partnerships. Mostly dedicated to commitments. regional implementation of global goals, for example the SADC E8 initiative for elimination of yy Limited country-level mechanisms for multi- malaria, etc. sectoral engagements or involvement. yy Harmonization of health in Africa. The Moving forward: Harmonization of Health Africa (HHA) is a Prof. Dambisya noted a number of actions that collaborative initiative originally supported participants needed to reflect on as countries strive by AFDB and other development partners to to accelerate progress towards achieving Universal support governments in Africa on strengthening Health Coverage (UHC): their health systems. A key outcome of this HHA initiative, was the TUNIS declaration. 1. Stakeholders should be open to learning from yy ECSA – which is a regional collaborative efforts each other and rethink the long-held views, as

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new evidence emerges possible. Political actors, for example, should be 2. While, UHC may be a case of ‘old wine in new facilitated and resourced to make decisions that bottle’, the need to cover all people equitably aim at improving people’s health. remains vital. There is need to focus on the 6. A multisectoral approach is the best approach nuisances of the new discourse, to allow for new to achieve Health for All. All sectors and actors perspectives. must be brought on board. However, ownership 3. Families and communities must be brought at the highest decision making level is crucial. on board to commit to personal responsibility 7. Inclusive platforms and partnerships need to towards their own health, without necessarily be created with key stakeholders including diminishing the role of government in health Government, non-state actors, and the service delivery. communities themselves. 4. There is need to reflect on the relationship Other considerations and reflections: between UHC and PHC, otherwise it may be ‘a As countries pursue Universal Health Coverage, new wolf in a sheep skin. The global community additional areas to reflect on and explore, include: needs to be careful to try and replace UHC 1) exploring and taking advantage of the new for PHC, because this would be making one- possibilities that information and health technologies step forward and two-steps backwards, and are presenting to ensure we prepare populations that would not be progress at all. PHC is for the fourth industrial revolution; 2) ensuring comprehensive and could be the vehicle for accountability and progress monitoring; 3) preparing achieving health for all. a leadership that raises the profile of health but also 5. Universal Health Coverage not only requires with ability to negotiate with others organizations and strong commitments, but also deliberate actors to achieve shared goals; and 4) appreciating processes to empower different actors to that health issues are complex issues which do not act on these commitments as effectively as lend themselves to simple solutions.

Key Points yy Universal Health Coverage is not a new concept, except that it has been evolving overtime yy Achieving UHC requires multi-sectoral and multi-stakeholder action that can be optimized through strengthening networks and forums across stakes and geographies. yy There exists a number of regional networks, forums, and initiatives that should be leveraged for knowledge and experience sharing and learning across countries yy While these regional platforms exist, there is need to build country-level ownership and participation to harness their benefits.

Ms. Elizabeth Ongom & Mr. Thomas Tiedemann (Head of Co-operation, European Union) sharing during the A section of symposium participants, listening to symposium presentations

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Official Symposium Opening Ceremony Prof. Fredrick Makumbi, Ag. Dean, Makerere University School of Public Health (MakSPH)

he Dean of the School of Public Health (MakSPH), represented by the Deputy Dean, Prof. Fredrick Makumbi. TOn behalf of MakSPH, the Ag. Dean, welcomed and appreciated the participants who had chosen to attend the symposium.

Prof. Fredrick Edward Makumbi, Ag. Dean, MakSPH

He particularly thanked the European Union (EU) for supporting MakSPH through the SPEED Project for the five years that the project has been implemented. The Ag. Dean noted that the mandate of the University is to conduct teaching, research and community service, and through pursuing these mandates, the University generates research evidence and engages stakeholders on matters of national and global debate. The Dean appreciated the work SPEED has been involved in, especially the stakeholder engagements and involvement in decision making spaces with the Ministry of Health and other stakeholders. The Dean noted that it was through engagements that the right policies and feasible program implementation structures, can emerge, which ultimately benefit the population. The Dean appreciated the contribution and support that Government has continuously provided to Makerere University, but challenged government to sustain the support to ensure that the University optimizes its capacity to contribute to national development. The Dean appreciated the strong relationship between MakSPH and the MOH that had enabled even the SPEED project to succeed, and pledged, on behalf MakSPH, continued support and engagement with the MOH, and more especially with the fast-moving debates on the National Health Insurance.

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Prof. Charles Ibingira, Principal, Dean, Makerere University College of Health Sciences (MakCHS) Prof. Charles Ibingira, the Principal MakCHS, welcomed participants and symposium speakers, more especially the international participants. The Principal noted that such symposia, have created an opportunity for MakCHS engage in dialogue and disseminate her research and hence contribute to the development of health policy in Uganda and the region.

Prof. Ibingira, Principal, MakCHS

The Principal appreciated the contribution of the SPEED project to enhancing the visibility of Makerere University and ensuring that the University maintains a presence in the policy discourse in the country. Beyond the SPEED work, the Principal noted that MakCHS has also had partnerships with government in the area of training, research, and service. He appreciated the support of the European Union (EU) for the continued support for research and capacity building in Makerere University, and more particularly the support that EU provided for the Makerere Application to host the World Health Summit, coming up in November, 2019. The Principal, requested the MOH to continue to support MakCHS to strengthen the health system, because partnerships are needed for accelerating UHC and the SDGs. MakCHS strongly supports partnerships to synergize skills, experiences, and resources. He concluded by extending an invitation to everyone for the upcoming World Health Summit, where the theme on UHC was expected to be extensively discussed

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Prof. Barnabas Nawangwe, Vice Chancellor, Makerere University n his remarks, the Vice Chancellor started by acknowledging the contribution and support that government Iof Uganda has been providing to Makerere University, to ensure that the University becomes more relevant and contributes to national development. The VC reported that government had earmarked UGX 30 Billion in the 2019/2020 fiscal budget to support research and innovation at the University. He argued the government to sustain this support to ensure that context specific research that addresses priority areas national importance can be addressed. The Vice Chancellor also noted that, in addition to research, Makerere University was working on engaging government MDAs and other stakeholders through translating and packaging research in versions that are usable and understandable to the different stakeholders. The VC appreciated the contribution of MakCHS as a flagship college at Makerere University, which is leading in research output, and currently ranked the second best medical school in Africa. It is through research that country-specific development challenges can be addressed.

Prof. Barnabas Nawangwe, the Vice Chancellor, Makerere

The VC appreciated the strong relationship between Makerere and the Ministry of Health, albeit a few issues around medical training that require continuous dialogue between the two institutions. The VC concluded by appreciating the funding support from the EU towards capacity development at Makerere University. He reported that a number of Masters and PhD students have benefited from the EU support, and this was clear manifestation that the EU was a reliable partners in research and higher education. He argued the symposium participants to use the symposium as a platform to share experiences and learning that should feed into decisions and also feed into research iteratively.

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Dr. Sarah Byakika, Commissioner Planning, Ministry of Health Dr. Byakiika added her voice to previous speakers in appreciating all participants. She appreciated the work the SPEED Project for the work they have been involved in since inception.

Dr. Sarah Byakika, Ministry of Health

She reported that MOH had greatest beneficiated from the SPEED work, as it seeks to pursue the Universal Health Coverage goal. Notable contributions from SPEED included; steering the UHC agenda discussions in Uganda and pushing government to make appropriate program and policy reforms that are necessary for the UHC goal. She also reported that SPEED Project was leading the development of the UHC Roadmap for Uganda. The Commissioner reported that MOH was committed to pursuing UHC, and welcomed all support from stakeholders to ensure that this goal becomes a reality within the timeline. Dr. Byakika reported that the MOH was currently working on the National Health Insurance, which is a critical reform for UHC. The Ministry of Health was also committed to working with other sectors in a multi-sectoral approach, and challenged the Office of the Prime Minister, that has inherent constitutional mandate to coordinate government players, to streamline that mandate and responsibility. Dr. Byakika concluded by reiterating the commitment of the Ministry of Health to take forward the discussions and proposals that would come through the symposium and the subsequent deliberations.

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Mr. Thomas Tiedemann, Head of Co-operation, European Union

Mr. Thomas Tiedemann, Representing the European Union at the symposium

The EU representative appreciated symposium of health. The EU had been working on the participants and more specially the delegates who determinants of health – in agriculture, Public Finance had travelled from other countries to be part of the Management, nutrition, etc. The EU believes that the symposium. He noted that the EU had been a long- health sector should be adequately funded to deliver time partner of the Government of Uganda for over on its mandate and address global health security 30 years. He revealed that the EU had spent more threats. There is need to re-focus on demography and than EUR 90 Million so far in the health sector in population issues to address the issue of high fertility Uganda. rates, and teenage pregnancies. Reflecting on the demographic structure of Uganda, Mr. Tiedemann Mr. Tiedemann noted that health is has not been observed that up to 76% of Ugandans are below 30 the main focus of the EU, rather the area of good years. This population structure was both a challenge governance. However, the EU had still been and an opportunity depending on how the issue supporting specific programs in health. The European is handled. The population structure, for example, Commission (EC) had contributed to the Global Fund presented a challenge of high dependence ratios, where it had contributed up to UGX 7 Trillion since which was a big worry in terms of where resources 2002, in addition to supporting other of the Ministry to finance the proposed national health insurance of Health. There were additional programs supported would be generated from. by the EC in Uganda, including Nutrition for conflict and post-conflict communities in Northern Uganda, The EU representative reported that the 8th African clinical trials partnerships, Erasmus Scholarship population conference was coming up in November, Program, and now the support to UHC in Uganda 2019, where the issue of population would be at the through the SPEED support. The European Union core of the discussions. (EU) was proud for the work that SPEED has been doing. The EU representative noted that what SPEED Mr. Tiedemann noted that Universal Health Coverage had been doing was a reflection of the capacity is a potentially political issue that could be framed for that was manifested during the proposal selection the upcoming election session in Uganda. However, process, where the SPEED team competed globally communities and people need to be empowered to undertake this work. to raise these kind of issues. He noted that, as the National Development Plan 3 (NDP3) is currently Mr. Tiedemann noted that Universal Health Coverage being worked, it offers an opportunity to include and (UHC) had been at the center of the current global mainstream UHC in this ongoing process as well as development agenda. It has been recommended into the whole of Government. that UHC should be framed along the determinants

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Hon. Dr. Moriku Joyce Kaduchu, Minister of State for Health, Uganda (& Representing the Prime Minister of Uganda).

Hon. Dr. Moriku Joyce Kaduchu, Minister of State for Health, Uganda

The Minister welcomed all symposium participants countries to abolish user-fees as far back as 2001, and thanked the organizers of the symposium for to enable the poor to access health services without bringing different stakeholders together to discuss a lot of financial constraints. The Minister stressed matters of Universal Health Coverage in low and that the MOH recognized the need for intersectoral middle income countries. She further thanked the collaboration. She noted that without addressing the European Union for the support extended to the key determinants of heath, not much may be achieved SPEED Project and Makerere University School of in the context of Universal Health Coverage. Public Health, and appreciated the work that SPEED has been doing together with the MOH to propel the The Minister reported that the MOH had established UHC agenda. different structures for example, the Health Advisory Committee, and Technical Working Groups (TWGs), The Minister noted that Uganda is deeply engaged but additional effort in the area of convening in ensuring that the sustainable development goals stakeholders, is needed. The Hon. Minister especially SDG3 is achieved. All health sector policy commended all efforts of key partners and agencies documents now explicitly specify expanding good to support the ministry of health and generally quality services to all people as a priority area. The government, as we strive to improve the health of current Health Sector Development Plan (HSDP) has our people. its overriding objective as accelerating movement towards Universal Health Coverage, and ensuring The Minister, however, recognized a number of that Ugandans live a healthy and productive life. challenges that needed to be addressed; including the emerging burden of disease for NCDs (double The Minister observed that over the years, Uganda burden of CDs and NCDs), inadequate funding for had registered a significant reduction in key health health, the demographic challenge, malaria, and indicators such as Maternal Mortality Rate (MMR), new emerging diseases. These challenges require Infant Mortality Rare (IMR), life expectancy, and all collective responsibility and working together. She other measures of health outcomes at population noted that Government of Uganda was already level. She noted that Uganda is one of the first working on a number of initiatives in line with

9 2019 UHC Symposium Proceedings Report pursuing Universal Health Coverage, including: 1. A Roadmap for UHC in Uganda was being developed, to guide long-term planning and programming for UHC effort 2. The National Health Policy (NHP3) is currently being reviewed and revised alongside developing the ten year Health Workforce strategy. Furthermore, the National Development Policy (NDP3) is currently under development. Both of the two initiatives offer clear opportunity to mainstream UHC in government policy 3. The presented had launched a Mass Action against Malaria (MAAM) program, and a recommitment to funding malaria prevention was made by the president. 4. The Government had just approved the draft National Health Insurance Policy whitepaper and the discussions were now moving to parliament. This is vital for health financing within the context of UHC. 5. There are other existing efforts to improve and strengthen the health system, including, expanding health infrastructure, accreditation of providers, etc., to reduce distance for the people to reach facilities 6. Government had also launched the physical exercise program, that aims at encouraging Ugandans to keep physically fit and everybody should participate to benefit from this initiative. The Minister stressed government’s commitment to ensuring access to services by everyone. She noted that government had already made preparatory work for UHC, although more needs to be done in the area of workforce development, health systems strengthening, retention and motivation of Health Workers for better production and productivity.

The Minister appreciated the work that Makerere University was already doing in training and capacity building for health workers in Uganda and the region (the medical school). She reported that Government indeed has decided to prioritize research and had earmarked UGX 30b in financial year 2019/2020 for research and innovation at makerere University. She noted that Government believes that investing in people through education and training, was an important cornerstone to growth and development. Lastly, the Minister stressed that the future for health in Uganda lies in Public Private Partnerships for Health (PPPH). The health sector would continue to look out for partnerships and innovative ways of sustaining the PPPH framework.

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PANEL DISCUSSION 1 How can the UHC and health improvement agenda be mainstreamed across sectors of government and society? DAY ONE DAY

Some of the Panelists (L-R): Dr. Hamis Mugendawala (NPA), Dr David Okello (ACHEST), Dr. Sam Okuonzi (ACHEST)& Dr. Sarah Byakika (MOH)

reamble: The World Bank reforms initiated in the in order to achieve UHC. P1990s, brought in a lot of changes in the way governments, particularly in LMICs, operated. One example of the reforms that were implemented was the Sector-wide Approach (SWAP). The SWAP was an attempt to move health and related discussions out of the ministry of health to ensure that it was everybody’s business and not merely a matter of the Ministry of Health or the Health Sector. More recently the discussion on Health in All Policies (HiAP) also came on board, where there was an attempt to ensure that health issues are integrated and mainstreamed in all government sectors and policies. This panel aimed at sharing different perspectives on how health can be mainstreamed across sectors of Dr. Hamis Mugendawala – National Planning Authority government and society. From the panel discussion, (NPA) the following issues were noted: here are a number of experiences in Uganda that Tclearly point to the need to protect the population Dr. Hamis Mugendawala – National against financial risks that come with access to and Planning Authority (NPA) utilization of health care. For example, increasing rom the planning perspective, Universal Health cases of patients being held at hospitals after FCoverage (UHC) is currently being treated as a discharge, patients being denied certain emergency planning issue. Sustainable Development Goals services unless they guarantee payment beforehand, (SDGs) and Universal Health Coverage targets have etc. These are examples, where all stakeholders must been integrated in the current national planning rethink the framework of financing health in Uganda. framework. For example, one of the targets already embedded in the framework is to increase access to He also noted that UHC as a goal should be health care, with 70% of Ugandans having access to explained to every stakeholder to understand what health care without being financially constrained. In their roles and expectations are in advancing this addition, the NPA has also set a target of ensuring agenda. It was noted that the current narrative being financial protection for at least 50% of the population, perpetuated by mainly the media was that UHC

11 2019 UHC Symposium Proceedings Report means national health insurance, which tended to be Dr. Sam Okuonzi – Africa Center for Health misleading, because NHIS is a very small component Research (ARCHEST) of the UHC discourse. Appreciating the concept itself niversal Health Coverage (UHC) is not necessarily was a starting point for mainstreaming UHC in all a new word. It has been around for a long discussions. Once the concept is ably understood U time only that it has metamorphosed into different by all stakeholders, the next step then would be to concepts. Previously, there has been ‘Health for All’, adopt a programmatic approach to implementing ‘Health in All Policies’ and now ‘Universal Health UHC. Uganda needed to focus on the overarching Coverage’. Irrespective of the concept used at a priorities that are beyond one single sector. particular point in time, the content and intention is The National Planning Authority was currently all nothing new but the same thing. He noted that spearheading the development of the National what was new, however, was the level and extent of Development Plan III (NDP3), and UHC is already misunderstanding of the concept itself. Many people included as a sub-program in this new plan. The are yet to understand what UHC is all about. The specific areas that need to be looked at include: starting point for Uganda as a country is to develop a common understanding about UHC, otherwise it will 1. Expanding investment in interventions that be difficult to integrate and implement it in different reduce risks to heath. This is health prevention sectors. This common understanding must include and promotion, because this is critical in bringing on board the population. reducing the costs of curative care 2. Functionalizing health facilities that currently exist. Data shows that about 75% of the population live within 4km of a health facility. The challenge though is that most of the health facilities are not functional as expected. There is need to increase capacities of these facilities, including expanding the human resource, and increased financial allocations, etc. 3. Embracing models that allow players outside government to provide health and be compensated. This is the private-public partnerships for health improvement 4. Harmonizing existing policy tensions to accommodate the UHC agenda. Dr. Okuonzi Sam 5. Adopt a programmatic approach to planning for health. There is need for a mechanism where Dr. Okuonzi applauded the approach suggested by every institutional budget must be approved NPA – having an awareness programme at different after demonstrating interventions for UHC. levels, and for different leaders can help to address 6. Mobilizing different sectors to contribute to the this knowledge gap, so that it is easy for the different UHC agenda, for example, education, water and sectors and role bearers to know their contribution. sanitation, environment, agriculture, etc. Sectors In countries where the concept has been appreciated should be encouraged to dedicate particular and a common understanding developed, a lot of budgets towards interventions that contribute to progress has already been registered in the UHC the UHC agenda. journey, and the policy trends are different. In Ghana, 7. Developing a clear indicator measurement for example, coverage for UHC is currently at 58%, framework, so as to measure and track progress. compared to 4% for Nigeria. The difference observed In this regard, the NPA has already developed a between the two countries emerge from the levels tool – a Budget compliance to NDP tool – whose of understanding of UHC. Uganda is still grappling major objective is to evaluate whether sector with the concept itself. The first thing therefore is to plans are compliant to the development plans. develop consensus on the concept itself. Sectors budgets will not be approved if they are not aligned and compliant to the NDP. The second most important point to note is that UHC does not imply expanding access to hospital services. According to Prof. Omaswa, a renowned public Health Practitioner and former Director General

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Health Services, MOH, health is actually made 6. Water and sanitation. This contributes almost at home and not in health facilities, and it is only 70% of all communicable diseases in our repaired in hospitals. The starting point for improving communities and if this is addressed, it can go a health, therefore, is the home. Government therefore long way in addressing health challenges needs to start from the basic things that need to be 7. Public participation – communities that do not done at home – prevention and promotion services. participate and express their experiences and Until these elements are brought on board and opinions, their health status and progress tend accelerated, health improvement will not be attained. to be low. Community voices have an impact Health promotion, prevention, and social on leaders who to make choices and decisions determinants of health fall in different sectors, that are responsive to population needs, and although someone must take responsibility for each this is more so if these voices come through of them. A few examples demonstrate this: democratic processes. 1. Health is related to income. This is not about How then should resources for UHC be wealth, but rather income, which is having cash raised? with you. When individuals have income, they yy Universal Health Coverage (UHC) should be can access services, can easily find transport made a political issue. If the politicians who to reach facilities, can make life choices, etc. make the decisions cannot take the decisions Programs to increase income have to be brought that promote health, then constituents should on board and this brings into focus the Ministry push them out of leadership. Leaders must of Finance be pushed to make political choices. Political 2. Food and nutrition. This is not only about the commitment must be extracted. Communities presence or availability of food, but also how it is should make it risky for any leader not to make consumed and in what proportions. Sometimes health improvement core to their agenda. the food may be available but people don’t yy The public must be made aware of their role consume it in the right balance. There is a strong and how they can participate in improving their link between food and nutrition and longevity. own health. People should be encouraged to Certain specific foods have higher effect on life contribute towards expanding the (resource) expectancy. Food and nutrition is a matter of revenue base for government to provide the the agriculture sector, and the health sector only services. Individuals should be encouraged to comes in to educate people about how the food enroll for the National Health Insurance Scheme impacts on health as a way of contributing to financing their own 3. Level of education. Primary and secondary health education have a great impact on health yy Mechanisms to improve household incomes status. For example Universal Primary Education should be identified and implemented so as to (UPE) alone (p7) and especially for the girl empower people economically, for example, child, reduces mortality rate of children born through trade, agriculture, etc. This will make it by them. At that level, basic information about easier to raise the necessary resources to invest vaccination, nutrition, immunization, hygiene, in UHC programming. etc. can be provided and this is important in helping girls to bring up their children. This is a Dr. Sarah Byakiika – Commissioner mandate of the Ministry of education. Planning, Ministry of Health, Uganda 4. Gender and women empowerment. A lot of Dr. Byakika noted that the Ministry of Health health issues surround disempowerment of appreciates that indeed the UHC concept needs to women by culture, practices, and attitudes. be understood by all stakeholders. She further noted This falls across different sectors, if it is being that there was a traditional and widely held view mainstreamed. that health is an issue of the ministry of health, yet 5. Hygiene and sanitation – at home and personal the definition of health clearly shows that health is hygiene, etc. At home, keeping clean where you not the business of the health sector alone. It is true sleep, utensils used in homestead, etc., are very that the MOH has a constitutional mandate but other important for health. This falls under community sectors have a role to play to ensure Ugandans are development, local government, health, and so healthy. we must take note of these when we allocate roles to different sectors

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that allows for regular engagements with other sectors and local government players to harmonize the mandates and ensure that we are moving in the same direction.

What is the Ministry of Health currently doing? In the context of Universal Health Coverage (UHC), the Ministry of Health has spearheaded the completion of the UHC Roadmap for Uganda (2020- 2030). All key stakeholders have been involved in this process through identified representatives who Dr. Sarah Byakika, Ministry of Health constitute a multi-sectoral committee that developed the roadmap. The constitution of the sector wide Overtime, the MOH has developed policies to meet committee was to ensure that that no stakeholder was this mandate and ensure the Uganda Minimum Health left behind during the process. The UHC Roadmap Care Package (UMHCP) is accessible to everybody. identifies areas of focus, specific interventions and But even within the UMHCP, there are elements programs that should be prioritized for UHC, and such as health promotion, prevention, curative and how these interventions and programs should be palliative services, which are cross-cutting issues. sequenced to optimize their effectiveness. The health sector has also been operating on five Secondly, the ministry has worked with stakeholders year strategic plans to operationalize the policies. to clearly define and contextualize the UHC concept. In all these strategic plans, an emphasis has been To the conventionally known definition of UHC, the put on delivering health interventions using a multi- MOH has added “………without financial difficulties, sectoral approach. However, all Health Sector within a multisectoral approach”. The MOH believes Reviews show that multi-sectoral collaboration is that this reflects a commitment to implement UHC in one of the weakest areas that has not been well a collaborative approach. done and there are gaps that need to be addressed. Where there has been attempts at multi-sectoral Lastly, facilitating working together within the approach, the efforts have been lukewarm, for broader government, requires a strong convening example in water and sanitation, education through and coordination framework. Already the OPM health training institutions, among others. There are has convening mandate for government, but the no concrete programs that show that multisectorility NPA should work closely with OPM to ensure this is being encouraged and fully operationalized. In mandate is carried through. In addition, monitoring addition, there are no mechanisms for holding each and measuring progress should be embedded player accountable for actions that they are expected within the coordination framework. There should to undertake. be deliberate effort to provide information to other sectors to enable them understand and appreciate While the Ministry of Health is expected to play a lead their role in promoting the health of Ugandans. The role in health issues, it does not have the mandate general public too, should be made to understand to hold other players accountable. Outbreaks like these different mandates so that they can demand typhoid, cholera, etc., are often blamed on Ministry accountability from appropriate institutions using of Health, yet, these are a result of typical failures their rather powerful community voices and power in other sectors, for example the failure of the water that they wield over leaders, rather than the persistent sector to facilitate access to clean water. The policy blame that is wrongly directed to the Ministry of framework as it currently stands, is that, health service Health. delivery is a mandate of the local governments, and the Ministry of Health ministry is just to provide policy Dr. Edson Muhwezi – United Nations Family guidance and enforcement of standards. Even under Planning Agency (UNFPA) this framework, issues of health service delivery Uganda has one of the fastest growing populations failures are still blamed on MOH and there are no in the world, growing at 3%. This can be viewed as mechanisms to hold local governments accountable. good but also as a challenge in equal measure. It Absent health workers at health facilities are blamed can be good if it is tapped, but if it is ignored, it can on MOH yet they are recruited and supervised by be a recipe for disaster. It is projected that, by 2050, local governments. There needs to be a mechanism Uganda will have a population of about 100 million

14 2019 UHC Symposium Proceedings Report people. Government should begin to think better Dr. Edson noted that Development partners (DPs), ways of population management and control. There particularly the UNFPA, were committed to supporting is need to expand investments in family planning, government of Uganda to achieve some of the UHC education, health, and employment, so as to harness aspirations. He however challenged Government to the demographic dividend. The country should work walk the talk and implement policies that already towards a population structure with less dependence. exist and well written, but not much implementation There are already experiences that Uganda can is happening. Structures and platforms that bring learn from Japan on how the population challenge different players together to address population issue was addressed. In Japan after the 1950s, following should be put in place, facilitated and functionalized. a population explosion, they focused on reducing Institutional mandates need to be re-defined and fertility rates, and this was a foundation for Japan’s reinvigorated. faster economic growth and development. Government must come up with a clear way forward. Roles, responsibilities, and accountabilities for each sector must be defined. Investment in systems should be improved and different institutions should be held together for one common objective. There is need for a committed and strong leadership at all levels that ensures that everybody is involved in these discussions. There are already proven cost-effective interventions that give value for money and these should be implemented. It is going to be critical to not only work hard but also work smart. Health and population issues should be mainstreamed in all Mr. Edson Muhwezi – United Nations Family Planning government. Agency (UNFPA)

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Key/emerging issues: 1. The first step in pursuing Universal Health Coverage is to understand the concept first. All stakeholders need a conceptual understanding of the agenda to be able to tease out their roles and responsibilities. 2. Political will is very important in the UHC discussion. Unfortunately the politicians are not on the UHC table yet. For example, few political leaders are in the room, yet they should be listening to these important deliberations. 3. Collaborating partners should be facilitated and financed. It is not enough to call upon partners to come together without resourcing them. For example, districts do not have enough resources and yet there are being pushed to do a lot of service delivery. The example in education is that private universities are doing a lot of work in training medical students but government is not supporting them, in any case they are over taxing them instead of subsidizing them. 4. Uganda like other countries, committed to the Abuja declaration on health financing, to allocate 15% of the budget to health. As a country we need to review progress in respect of this and similar commitments, and what lessons we can learn from how far we have come. 5. The number one family planner should be the ministry of education especially in respect of girl child education. There is a lot of evidence that education of the girl child education prolongs the need for marriage and child bearing and this a sustainable way to address high fertility rates. 6. Universal Health Coverage should be situated in the broader political economy discussion. Politicians have a lot of choices to make with less resources and we need to repackage UHC to ensure it makes political and economic sense so that politicians can commit to it as one of their choices 7. Mechanisms for holding stakeholders accountable need to be identified and enforced. Each sector has mandates, and so there is need to find a way of operationalize health in all policies. This will open up mandates and ensure health is mainstreamed in all policies. 8. Universal Health Coverage (UHC) is a goal under SDG3. The SDG3 targets health and wellbeing. UHC is more than ‘care”, and includes health promotion issues and actions that aim at keeping people healthy. 9. Family planning should not be a health sector issue but rather across the board including education and gender, etc. 10. Without addressing rapid population growth through lowering fertility rates, Uganda may not achieve vision 2040. Once this message is packaged, the politicians will easily understand and be attracted to it. 11. To achieve Universal Health Coverage, different stakeholders have a role: the private sector, government, implementing partners, the communities, the church, and the individuals themselves. 12. There is need to clarify mandates but also creating mechanisms to hold different players accountable for their mandates and roles. However, the stakeholders need to be resourced and or facilitated. 13. A strong coordination and convening mechanism should be identified, facilitated, and strengthened

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SESSION 1A: YOUTH PANEL “Nothing for Us, Without Us”: Putting the Youth at the center and as focus of development efforts his youth panel was organized by the National more broadly the health improvement discourse. The TPlanning Authority, the Ministry of Gender, Labor session discussed two broad topics: and Social Development, and the Office of the 1. Effective Youth Participation in Public Policy in Uganda Youth Leader to the United Nations. The Uganda: Challenges, Opportunities and way session aimed to discuss effective youth participation forward to advance the UHC agenda, and in public policy, the mental health needs of the young SESSION 1A people in Uganda, and review the extent to which the 2. Mental Health Needs for young people in Youth are currently involved in the UHC agenda and Uganda.

A section of the panellists at the Youths Session on UHC

he session panelists and participants included the including unemployment. The Youth livelihood fund, Tyouth from institutions of higher learning, those in and other special interest group funds have been different youth leadership positions, those common earmarked for youth as a special group that needs youth on the streets of Kampala, other symposium affirmative action. However, budget allocations to participants, etc. It was noted that the Youth Panel health do not clearly specify what areas are being was very timely since the UN General assembly addressed. Issues of adolescent and reproductive was happening in September 2019, where UHC was health are outstanding issues for the youth, but it is going to be discussed as one of the key topics at the complex to trace allocations through general sectoral assembly. budgets, to ascertain how much goes into this area. The session noted that youth involvement is quite The youth need to be fully involved in decision diverse. There are different organizations and various making. Government cannot purport to plan for the committees that focus on the youths in Uganda. youth without the youth being involved. The issues of However, it was important that youth are categorized teenage pregnancies, abortions, high school dropout into different segments, because this helps to clearly rates, drug abuse, crime and violence, are currently identify and understand their different health needs. inflicting the youth in Uganda and elsewhere. For example, youth from urban areas have unique Government has been designing programs to challenges and needs compared to their counterparts address these challenges, yet the youth who suffer in the rural areas who also have context specific these challenges are not involved in program design challenges and needs. This distinction is critical for and implementation. Once the youth feel their voices programmes and policies that attempt to address and concerns are not taken care off, they cannot the youth issues. own the policies and programmes, and this causes failure. For effective programming, the youth need to In terms of budgeting and resource allocation, it be involved in identifying problems, proposing and was noted that Uganda was doing relatively well on implementing solutions together with government. identifying resources to address youth challenges

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What are the benefits of youth involvement this effect, empowerment programs, advocacy, in the UHC discourse? skilling, and innovation, etc., should be the major for government to harness the demographic There are quite a number of benefits centered dividend. on generational benefits that come with youth involvement. What needs to be done to enhance youth yy Governance, accountability and service participation in decision making? delivery. The young people are an information yy The starting point is for stakeholders to technology generation. Statistics show that there acknowledge what the youths are putting on the is 13% of internet penetration rate in Uganda, table. and of this, 9% is accounted for by the youths. With this kind of Social media participation, yy Different youth-friendly platforms should be the youths can voice out their concerns on created to allow the youth to be involved. governance, accountability, service delivery, etc., Uganda is a youthful country and therefore the using the social media channels. Unfortunately, voice of the youths should not be allowed to miss lately government has imposed a tax on social on any matters and more so matters that affect media use, which is making it costly for the youth the youth. with no clear sources of income to use and take yy Build capacity of the young people to gain advantage of the internet. The youth argued confidence, self-esteem and belief in themselves government to review this policy and instead as an important component of decision making. create an enabling environment for as many The young people can be mentored to be policy young people to use technology. makers, enthusiastic people, and agents of yy Human capital development. Current change, after all, they still have the energy and projections shows that by 2030, there will be enthusiasm to drive agendas. an 18 million health workers deficit in Uganda. yy There is need to amplify issues of reproductive Government could therefore begin to invest in and adolescent health, health education, human capital by taking advantage of the young behavioral change communication, positive people, train them into health workers so as to living, and provision of youth friendly services. prepare the system to address the anticipated yy The youths should be empowered on advocacy gaps. This would help the country to achieve the skills such as writing, public speaking and others. UHC ambitious goal. To this extent, the Higher The education system should be reviewed and Education Loan Scheme programme was a reformed to produce innovators and job creators, welcome move but more was needed to reduce rather than theoretical knowledge that would costs of education so that young people can only bring out job seekers. access the education and skills needed to enable them serve the community and participate in the yy Provision of information to the young people. A economy in the coming period. well informed youth can immensely contribute to development and growth agenda of yy Innovation and inventions. The youth are Government. Social media can therefore be used innovative and inventive. As a country, Uganda as a platform to share information and identify can harness this untapped potential. The young and communicate opportunities for the young people must be given opportunities, resources, people. there is emerging evidence and support to innovate to address problems HOWEVER, that social media was one of the leading causes inflicting our own survival. Young people should of mental health issues among the youths. So, be able to start-up small scale businesses and as social media platforms proliferate, safeguards take them to scale. Statistics show that Uganda need to be created to address its likely destructive has one of the highest start-up businesses, but effect. The social media can also waste allot more than 90% of these do not survive for three of productive time and so there is need for a years. If well supported, the youth are well placed balancing act to ensure that again this does not to reverse this trend, so that unemployment can turn out to be a challenge. be addressed. yy Mainstreaming the youth agenda in the whole of yy Demographic advantage. Uganda has one of government – that is, all policies of government the youngest populations in the world. This is an must articulate the youth agenda opportunity that needs to be taken advantage of, instead of becoming a challenge. This, however, requires proactive policy reforms to harness the energies and enthusiasm of the young people. To

18 SESSION 1B Trade liberalization and its implications on realization of Universal Healthcoverage in Uganda his special session was organized session by Southern and Eastern Trade Information and Negotiations TInstitute (SEATINI)-Uganda, Uganda Medical Association (UMA), and the Center for Health, Human Rights and Development (CEHURD), Institute for Social and Economic Rights (ISER), and Coalition for Health Promotion and Social Development (HEPS). The session aimed to discuss the implication of health sector liberation and the pursuit of UHC in Uganda. This is particularly given the fact that liberalization of the health sector is turning access to health into big business rather than a fundamental human right, and what this SESSION 1B portents for access to health for vulnerable and marginalized communities.

Participants at the Organised session on trade liberalisation and Health

The session was also a platform for Health and Human Rights activists to engage with policymakers and discuss a way forward for ensuring that marketization and commercialization of health does not constrain the efforts of Uganda to achieve the UHC targets. The session panelists were drawn from the different institutions of civil society, the private sector, human rights activists, and policy makers.

Ms. Jane Nalunga (SEATINI, Uganda) availability, affordability, and quality of health goods and services, and equity in access to the same. Ms. Jane, noted that liberalization had opened up Advanced technology in the medical industry has markets without much growth in regulatory capacity. been one of the main drivers of high costs of care, yet Under this context, provision of and access to health it is only accessible to individuals that have resources, as a right was under threat. Economic liberalization leaving out the poor and vulnerable. Government had removed a lot of restrictions on health services must thus ensure that the negative effects of trade and products and this has negative implications on liberalization policy are minimized. population health. Under such a regime, anyone can procure medicines and technologies without much The General Agreement in Trade and Service (GATS) restriction and sometimes with questionable quality is a global agreement that provides a regulatory and standards. framework for trade in services but this should be domesticated and contextualized for Uganda to While liberalization is generally good, it can influence

19 2019 UHC Symposium Proceedings Report ensure quality and standards in the market. The deaths. You require more than this. Government must issue of intellectual property rights must be discussed appreciate that health is a public good and therefore because this has implications on access to essential totally liberalizing it is bound to create problems. medicines, products and technologies. When certain Finally, the market will always have failures and this products are patented, it can be complex to negotiate means government should create a framework and as countries for subsidies because the cost of R&D is build capacity to regulate the market so that it does high and owners of patents always argue that they not work for the interest of the few but everybody must recover their costs. can benefit.

Trade liberalization especially agreements around Ms. Allana Kembabaazi (ISER) trade in goods can open up markets leading to unhealthy commodities and foods that flood the Ms. Allana, observed that, in Uganda, the private market e.g. Tobacco and alcohol, processed food, sector has been growing and expanding rapidly, and and these have an effect on the consumption and so has its role in health service delivery. The question health patterns of a country’s population. The that should be posed is: how do private sector players global food system and the opening up of food affect the right to health?She noted that access to markets to international food trade may lead to the health services for vulnerable people such as those diffusion of harmful foods that leads to the rise in with Disabilities (PWDs) and the poorest populations non-communicable diseases and the dual burden can be affected negatively, if the access to care costs disease. Therefore, there is need for a coherent, through the private sector are not regulated. and integrated approach to policy formulation and There is evidence that private sector service costs implementation in the trade and health space in are high and sometimes prohibitive and vulnerable the era of trade liberalization. The public-private sections of community struggle to access and utilize partnerships can help address some of the salient them. Private sector providers can influence the issues that could emerge from a liberalized regime, quality, availability and patient centeredness of care. but a strong policy and institutional framework is If poor people are not able to pay, discrimination may apparent. be observed. Government or the state is a steward Finally, it is worth noting that regional and global and has inherent and traditional mandate to protect agreements and country commitments have people and enforce their rights and more especially implications on domestic policy regimes. For the vulnerable. Protection means that there must example, commitments on free movement of labor be regulation, there must be available essential across countries may have negative consequences medicines too. on availability and quantity of human resources for A number of bilateral agreements that government health (HRH). Such agreements could either enhance has signed and committed to must, be scrutinized. brain-drain or attract expertise in the country Government must avoid committing to agreements depending on how it is handled. Commitments can that constrain her ability to regulate players such as also affect working conditions of people and the investors. Finally, Universal Health Coverage requires minimum wage policies, which are directly linked to building a resilient public health system that can employment or the lack of it. withstand any crises. There is need to rethink the funding model for public health in Uganda to ensure Dr. Ekwaro Obuku (Uganda Medical that allocations are good enough to guarantee Association) access to health in the context of health as a Dr. Obuku highlighted that the market is too rough for fundamental right. Low income countries (LICs) to survive in trade. For example, there are new health insurance companies Mr. Moses Mulumba (Center for Health, in Uganda but to survive, they work with foreign Human Rights & Development, CEHURD) collaborating companies especially from America. Mr. Mulumba’s submission focused on how to ensure Health Markets in LICs should be structured around that health remains a public good and a human right. local challenges, products and solutions developed He noted that liberalization is a complex issue which within that context. He noted that the ministry of has wider implications for Universal Health Coverage health has been doing a lot and indeed progress in (UHC). Initially, the health systems had been built improving health indicators had been achieved, for to deliver primary health care, but later, the global example MMR, IMR, etc., but a lot still needs to be economics changed, and this came with a change in done. While most hospitals have better and latest perception about the role of government in provision technology for example MRI and CT scans, this may of social services including health. There was an however, may not reduce maternal and neonatal

20 2019 UHC Symposium Proceedings Report ideological shift to the view that government should are producing drugs under patent and so this not be in business and only the private sector should is not allowing for open competition that would be allowed to do business. The disempowered naturally bring costs down the costs of medicines government was only left to play peripheral roles, and supplies. and ultimately ceded space for the private sector. 5. Health financing: The government has just proposed a national health insurance, but who With an expanded private sector and a liberalized exactly is targeted for this policy and who is market, health has been commodified. This, however, going to be paying for this insurance? There is has generated a number of challenges, which can be no doubt that even under the national social analyzed along the system building blocks: insurance, a bulk of financing is going to be 1. Health service delivery: There are now controlled by the private sector. “specialized people”, who provide “specialized 6. Governance: Reflecting on the WHO operations, services”, but these can only be accessed at data shows that the Bill and Melinda Gates prohibitive costs. Foundations, supports the WHO budget more 2. Health workforce: The level of brain-drain is high than the funding support provided by Germany in Uganda. The country invests a lot in training and Japan combined. It may not be possible for and capacity building programmes for health such an organization to be independent of any workers, but the benefits are not being realized influences when it does not necessarily have because a very unattractive environment. funding of its own, but rather on the mercy of 3. Health information systems: The question big funders. that we must ask is who exactly owns our Therefore it is important to reflect on the local information? Who hosts, accesses, and uses our (contextual) realities before countries adopt global information is a security issue that government policy reforms. Liberalization was a global reform and all stakeholders must be interested in. But that was ‘sold’ to countries like Uganda, yet the also there is huge information being collected local realities were not ripe for its operation. Even through HMIS, DHIS2 and other platforms, which essential services that were ordinarily a mandate should be processed to feed into the policy and of government ended up being liberalized at the programming aspects of government. detriment of the people that government is expected 4. Medicines and supplies: All Pharmaceuticals to serve.

Key/emerging issues: 1. Workforce: The level of brain-drain is high in Uganda. The country invests a lot in training and capacity building programmes for health workers, but the benefits are not being realized because a very unattractive environment. 2. Health information systems: The question that we must ask is who exactly owns our information? Who hosts, accesses, and uses our information is a security issue that government and all stakeholders must be interested in. But also there is huge information being collected through HMIS, DHIS2 and other platforms, which should be processed to feed into the policy and programming aspects of government. 3. Medicines and supplies: All Pharmaceuticals are producing drugs under patent and so this is not allowing for open competition that would naturally bring costs down the costs of medicines and

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KEYNOTE ADDRESS 2 PUBLIC-PRIVATE PARTNERSHIPS FOR UNIVERSAL HEALTH COVERAGE Expanding the scope for public-private partnerships for health improvement across sectors KEYNOTE ADDRESS 2 KEYNOTE

Prof. Khama Rogo, delivering the keynote Speech

he Keynote address for the theme: “Public-Private and foreign investors, as has been common in many TPartnerships for Universal Health Coverage, was countries. delivered by Professor Khama Rogo, Lead Health Sector Specialist with the World Bank and Head of Whereas there has been general complaints about the World Bank Group’s Health in Africa Initiative, the private sector and its shortcomings, it is here World Bank Group, Kenya. In his keynote address, to stay. In fact it is expanding faster than the public Prof. Khama Rogo began by noting that the future sector. Governments and policy makers need to of health care in Africa and more generally in LMICs acknowledge that there are things that the public lie in both public and private sectors. If the Public- sector can do efficiently, and those that it is limited Private Partnerships for Health (PPPH) arrangements in capacity. Equally, the private sector can do certain can be crystalized well, most health care delivery things well and has failures on others. The ultimate challenges would be addressed. The private sector framework is for both the public and the private plays a critical role, including in the area of training sector to come together and harness synergies. and capacity building for – many private institutions Policy frameworks at country level need to articulate are now responsible for a critical mass of doctors and what each sector can do and what can be done other HR cadres that sustain country health systems. together in a complementary approach rather than being unnecessarily competitive. It is important, however, to conceptually understand the meaning of “private sector”. Simply put, the Whereas there has been general complaints about private sector refers to “anyone or any institution the private sector and its shortcomings, it is here that is not public”. The PPPH arrangement should not to stay. In fact it is expanding faster than the public be seen as merely something between Government sector. Governments and policy makers need to acknowledge that there are things that the public

22 2019 UHC Symposium Proceedings Report sector can do efficiently, and those that it is limited others players can make a contribution to the health in capacity. Equally, the private sector can do certain sector. In 2010, the World Bank conducted a study to things well and has failures on others. The ultimate establish why Africa was not going to meet the MDGs framework is for both the public and the private by 2015. In this study, it was noted that countries sector to come together and harness synergies. needed to harness the contribution of non state Policy frameworks at country level need to articulate actors, because they come with additional resources, what each sector can do and what can be done which could complement government effort amidst together in a complementary approach rather than resource constraints. The World Bank then created being unnecessarily competitive. a program to work with African countries to create an enabling environment for non state actors to be he World Bank proposes an approach that equal and appreciated as participants in the health Tshould be adopted to improve health service space. delivery, and this approach focuses on: 1) Improving the policy environment; 2) Modifying existing The keynote speaker, however, stressed that, whereas regulatory and legislative frameworks to align with public-private partnerships are the recommended changing contexts;3) Enhancing revenue generation framework within which the health sector should and capacity to finance health systems; and 4) play, it is critical to recognize that this arrangement Leveraging and building local and international comes with challenges, including: partnership. Related, the Accra Accord described key components of a partnership, namely; Ownership, yy Weak and unorganized Regulatory capacity. alignment, harmonisation, common results, and Most regulators (MOH) do not have the capacity mutual accountability. A current reflection on many to regulate the sector players, and in some countries’ health systems shows that most of these cases, there is self-interest that ‘masquerade’ as components are non-existent, and so feasible public interest. This needs to be identified and partnerships do not exist. There is limited country- guarded against. country learning and experience sharing, and this yy Limited manpower planning. There are always creates a situation where countries continue to re- challenges in understanding how many of health invent new strategies and yet the basics are the workers exist in the system, what are the gaps, same. and how the existing ones can be optimally deployed. For most countries, health has been defined to be a mandate of the Ministry of Health alone, and yy The high cost of capital. Individual investors in yet MOH may not done everything reflected in the health care find it challenging to access adequate definition of health. There is need to define roles capital due to high interest rates, and this makes and mandates across sectors and stakeholders. For it hard to expand businesses, to the detriment of example, Ministry of Health should focus establishing the poor regulation, laws, policy, and strategy. Then the things yy Inequities in access to care through the private that the private sector can do better, should be left sector. The existing business models are to the private sector and instead be supported to structured such that its complex to provide care deliver them better and equitably. However, there to everybody through the private sector, but only is also need to recognise that the bulk of things fall those who can afford. The poor are often left out in the middle – they can never be done by either of these models. sectors on their own alone. These are better done through partnerships. The focus would then not be Areas where partnerships are necessary about whether the government wins or whether the yy Education; in terms of ownership, alignment private sector wins, rather whether the population of production to deployment, harmonizing wins, whichever approach is adopted. curriculum with market demands, and accountability for results. The Private sector has recently seen a fastest growth in the health sector. In terms of training institutions, yy Medical tourism. This is currently the one of the historically, public institutions like Makerere, Nairobi, largest foreign exchange earnings for many and Dares Salaam took the lead in producing health countries such as India. Makerere Medical workers. However, in the past 20 years, private School is one of top 10 suppliers of doctors training institutions have been producing the largest in the USA. East Africa sends $1bn to India for numbers of medical workers (health workers). The treatment. Why would it be okay to send patients government should create an environment in which to private institutions in India and pay cash, but

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it’s not okay to establish these institutions in our A lot of medical equipment is procured but lies countries so that we can keep the skills here and redundant in health facilities. In some cases, save a lot of resources? There is need to rethink there is no capacity to operate the equipment. this business model. Possible models such as ‘leasing’ of equipment yy Governance – that is creating an enabling rather than complete buying can address such environment for entrepreneurship and sunk costs. innovation to take place. Regulation comes in yy Functionalizing health facilities through under governance. With an unregulated sector, outsourcing. Experiences on this model are players take advantage of the clients to make available in Nigeria and Kenya quick money. This also has an impact on quality yy Manpower planning – to ensure that trained of services. health workers have the right skills and are yy Trade, finance, agriculture, water, food security, appropriately deployed to address incessant malnutrition and water and environment, among shortages. But for those that cannot be absorbed, others, are key areas where countries have then an environment can be created to enable to synergize between the private and public the private sector to absorb them, either as self- sectors. A model that encourages corporate employed or working within existing facilities. social responsibility for business entities, could yy Bringing on board innovative health financing attract resources into health. Private sector models. The private sector can expand investors in health could also negotiate with the opportunities for accessing finance or reducing finance sector to subsidize the cost of capital, as the cost of access to finance. Government long as they demonstrate a spillover effect for could negotiate with the private sector to create the poor and vulnerable population. special lending mechanisms for entrepreneurs Additional areas where non-state actors working within the heath sector, and more so, could play critical roles those in disadvantaged geographies. This could help individual to start-up small health clinics, yy Streamlining supply chains for medicines, pharmacies, distribution chains, training centers, including negotiating and ordering directly from etc. producers with a view of avoiding middle men who often increase the cost of procurement, or The keynote speaker concluded by noting that, Public avoiding statutory monopolies in supply chain Private Partnership is not just another option, it is a for the public system (by NMS). MUST for the attainment of UHC. It is an effective resource management approach. It is essential yy The private sector has overtime developed for financial and manpower management. PPP technology which can be used to procure and catalyses innovation and enhances best practices in deliver medicines on time, and this reduces the partnership, ownership and harmonization. cost of the supply-chain. yy Addressing redundancies in medical equipment.

Key/emerging issues: 1. The private sector has expanded in health across many countries and is playing critical roles in health service delivery, human capital and skills development, and facilitating access to critical finance. 2. Government must work with the private sector or non-state actors through the Public Private Partnerships for health (PPPH) framework to leverage the opportunities that private sector possess, including innovation, streamlining business, and employment 3. Countries, however, must recognise that PPPH framework has its own challenges, including weak regulation, inequities in access, high cost of services, among others. These challenges need to be addressed 4. A wide range of areas exist where private sector and non-state actors have leverage and can play critical roles, including trade, medical tourism, education and training, governance, etc. 5. To achieve Universal Health Coverage (UHC), working through the PPPH arrangement is no longer an option, but a must.

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Ms Elizabeth Ongom ( EU) and Prof Bart Criel (ITM)

Panel Discussion 1. Best practices to achieve Universal Health Coverage in Uganda Dr. Kirunga Tashobya – Post Doctoral Fellow, SPEED, Makerere University School of Public Health In line with the key note address, Dr. Kirunga noted that following key issues that must be addressed to achieve UHC in Uganda: 1. There is need to rethink the model of financing health in Uganda and look at implementing new and innovative heath financing mechanisms that have been tested and succeeded elsewhere. She detested the practice of relying more on government to fund health, which was slowly loosing traction across many countries. 2. The second point made was the need to subsidize non-state actors as complementary partners. In the past, in Uganda, Government used to provide substantial subsidies to the private and non-state sector to ensure adequate provision of essential services to the population. Supporting the non-state sector helps to expand services especially in areas where the public sector Dr. Kirunga Tashobya – Post Doctoral Fellow, SPEED, either has limited reach or limited capacity. The Makerere University School of Public Health pharmaceuticals industry in Uganda is slowly emerging, although it still produces less than

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20% of the country’s medicine needs. Due to Ms. Salima Namusobya – Executive the high interest rates and cost of capital, goods Director, Initiative for Social and Economic from Uganda to other countries do not have a Rights (ISER) competitive advantage. Therefore capacities should be enhanced, and government could Ms. Salima noted that the continued privatization subsidize investments so that the subsidies can and marketization of health tends to compromise the cascade to the consumers in terms of low costs cardinal principle that UHC emphasizes access to of services. good quality and effective health care for all. There has been a perception that expansion of private 3. The third area is on ensuring standards and sector in health portents good for health because of quality of medicines. Existing data shows that perceived good quality. There has also been a feeling currently Drug verification has increased from that government can be left to do governance and 2% to 47% in Uganda, but other East African stewardship roles and leave the rest to the market to Community (EAC) States still have big issues, provide. This cannot be a good approach. Already and this challenge is escalated with the trade there are geographical places where the private agreements signed between countries. sector is absent and those also where government Dr. Kirunga concluded by underscoring the fact sector is absent, especially in hard-to-reach areas. that private sector is indeed here to stay, and The private sector is also sometimes driven by so government should find ways of working in a the profit motive rather than the public good. In complementary approach with the private sector. circumstances where the state is not adequately prepared and resourced to provide services, while at 2. Increased private sector the same time the private sector cannot guarantee involvement in health and full access by all, then private-public partnerships Universal Health Coverage should be nurtured and supported. However, for PPPH to function appropriately, a regulatory framework should be established and strengthened. The private and public sectors should look at each other as partners, and complementary and no so much as competitors, because they all serve the same population. In all this, however, the community must be involved. Communities have a strong role to play and are an essential component under the human rights based approach. Uganda must create mechanisms of how to leverage the resources and opportunities that exist within the private sector while protecting the users against any possible exploitations. Ms. Salima Namusobya – Executive Director, Initiative for Social and Economic Rights (ISER)

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DAY 2: KEYNOTE ADDRESS How are partnerships for health systems strengthening advancing UHC goals? Reflecting on 40 years of Primary Health Care. Professor Bart Criel – Institute of done. Many countries have not fully succeeded in implementing PHC, yet it’s the central nervous system Tropical Medicine (ITM), Antwerp. of countries’ health systems. They is no Universal This Keynote address was delivered by Professor Health Coverage (UHC) without Primary Health Care Bart Criel, of the Institute of Tropical Medicine (ITM), (PHC). Antwerp, Belgium. In his keynote address, Prof. Bart Criel began by reflecting on Primary Health Care PHC, UHC and the concept of Health (PHC) as a multi-sectoral approach towards the The speaker underscored the fact that it is not possible development of people-centered and integrated to talk about PHC and UHC without understanding the health systems. Primary Health care emerged from the concept of health. The definition of health has evolved Alma Ata declaration of 1978, which brought a new overtime, with implications on the understanding perspective in health care delivery. This was a time of and implementation of UHC. Health is a state of crystalizing lessons that had been accumulated over complete physical, mental and social well-being and the years, about dysfunctional health systems, huge not merely the absence of disease or infirmity. The inequalities in health care access, patronization of definition is clearly beyond medicine and includes the health workers, etc. social determinants of health. Health is a means to an end, it is a status that allows people to live social and economic lives that are productive. Health is DAY 2: KEYNOTE ADDRESS KEYNOTE 2: DAY therefore the ability to adapt and self-manage. The pillars of positive health include: Daily functioning; Social and societal participation; Meaningfulness; Mental wellbeing; Social functions; and Quality of life.

Models of implementing PHC The keynote speaker highlighted different models of implementing PHC. These models are NOT about EITHER/OR but rather AND/AND.

Prof. Bart Criel delivering a keynote speech • Strengthening the community health system – there is need to institutionalize and consider Understanding the PHC Concept the CHW sub-system within the overall system. CHWs need to be fully supported, facilitated, The concept of Primary Health Care (PHC) is about professionalized, remunerated and integrated access, equity, need, and collaboration. The 1978 into formal health systems. landmark agreement, summarized in 10 articles on three pages was a call for scientifically sound health • District health systems should be strengthened care delivered using best approaches. It was a call to and integrated especially where they have address social, political, and economic determinants mandates to provide and supervise service of health. Overtime, however, the world has changed, delivery. Hospitals and health facilities too should vulnerabilities have expanded, and recorded have their capacities strengthened particularly by epidemiologic and demographic dynamics. There increasing their staffing levels. are now increased inequalities, heightened political • Mixed health systems – these are centrally exclusion, unregulated markets, etc. On a positive planned government health systems that operate note however, there has been expanded possibilities side by side with private market players to provide for patient choices, and relatively stronger country similar or complementary products and services health systems. However, a lot remains to be • Strengthening health system governance and

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stewardship – The Fellowship in Health Systems Analyzing the Universal Health Coverage Management (FHSM) programme between (UHC) Dimensions MakSPH, ITM and MOH, is a critical example of The UHC concept has been summarized into three capacity building for health systems management major dimensions represented on the UHC cube. This and strengthening service delivery. cube, however, has notable limitations: • Use of family doctors. This model has particularly • It is only about health services been used in West Africa, Northern Africa, and other parts of the world. Family doctors operate • it does not integrate multi-sectoralism as the first line service providers. The existing • It does not incorporate social determinants evidence so far show that this is a promising of health (SDH), yet this is a powerful and model but more evidence may be needed to comprehensive approach. The cube does not demonstrate how such a model can be effectively also explicitly address the issues of quality of integrated in the system care. Without quality, UHC would be an abstract and Rethinking the PHC Model meaningless construct. There is also still a lack of Since the year 2000, different partnerships, clarity and understanding of the concept and its resources, actors, and services, have emerged operations. The 2014 framework proposed by the to promote PHC, albeit with limited coordination. WHO incorporates a people centered and integrated Trisha Greenhalgh proposes a number of features health system that includes community networks and for a “new primary health care model”: These are;1) systems as well. a multi-professional team; 2) Proactive as well as The keynote speaker concluded with the following reactive care, and 3) Population as well as individual points to note: care. The focus must shift away from structure to the core values. The genotype of PHC is about values, • SDGs are much more comprehensive than the accessible health care, and citizen participation. MDGs which were disease oriented, and now The Phenotype is about socio-cultural context, and the SDGS incorporated UHC in the multi-sectoral available resources. There is a lot of experience in vision of PHC the global south that the northern partners can learn • Expansion of UHC is essential but it has to focus from, otherwise called reverse innovation. on quality services • Multi sectoral collaboration is a good approach to implementing the UHC agenda, but it is difficult to put in practice • Social workers are boundary scanners in enhancing health systems. Both formal health systems and community systems must be strengthened and facilitated to carry on their mandate.

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Panelists at a session on partnerships for Health systems Strengthening. R-L; Ms Robinah Kaitiritimba (UNHCO), Prof Charles Hongoro (HSRC), Dr Henry Mwebesa (Director General of Health Services, MOH), Prof Bart Criel (ITM), Dr Juliet Nabyonga ( WHO Afro Regional Office) DISCUSSION PANEL Dr. Juliet Nabyonga (WHO-AFRO) – Partnerships for UHC and learning from other countries. The presenter defined partnerships as collaborative relationships between entities to work towards an agreed goal. She noted that partnerships are complex because they involve different actors with virtually different mandates and capacities, and interests. Partnerships and collaborations require building mutual trust – which is a complex issue. Successful collaborations required mutually agreed division of labor, which calls for dialogue so that each partner understands and agrees to the identified and allocated roles and expectations. From the global, regional and national perspectives, complexities and challenges to collaborations and partnerships are virtually the same. At country level, institutions do compacts, code of conduct, Memoranda of Understanding (MOU), etc. These Dr Nabyonga (WHO Afro) making her remarks frameworks help players to agree on objectives, roles, responsibilities, and commitments. There Dr. Nabyonga noted that, in many countries, there are incentives and benefits to working together, are multiplicity of partnerships that are not necessarily including: the added value in working together itself, complementing each other. There are cases where harnessing resources and synergies, etc. However, documents are duplicated, or even contradictory. the challenges must be taken note of, including: The other challenge is the issue of managing the need for adequate resources, attribution of conflict of interest. A systematic process needs to be contribution across partners, and the over-emphasis developed to manage those conflicts. There may also on short-term results. be recognizable imbalance across the actors in terms of capacity to engage in policy discussions. Within this context, government has a big role to play. She recommending the need to develop a mechanism for monitoring agreements between partners, and demanding accountability from actors, etc.

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It was noted that the WHO-AFRO had identified UHC as a flagship program and WHO is currently working with all countries to develop UHC roadmaps with more emphasis on the role of partnerships. The WHO has also focused on strengthening leadership and capacity for policy dialogues, and strengthening capacities of in-country UHC teams.

Prof. Charles Hongoro – Learning from the South African experience on private sector participation in health service delivery. however other allied professionals who could be leveraged to provide PHC. The GP Networks are contracted to provide PHC. In terms of training, the nurse cadre are generally trained by the private sector, and there are already proposals for the private sector to start training doctors. The private sector in South Africa is a large employer. Even when enrolled in the government service, doctors are allowed the opportunity to assist in private clinics (contracting in). In terms of health insurance, private insurance and medical schemes exist. These have started developing low cost packages that include cancer screening, etc., which are critical opportunities that can be harnessed. There is also now the vitality component – health promotion which has been included and these efforts are linked to insurance cards. But by and large they focus on hospital care, and there are already discussions on reforms that Prof Charles Hongoro (HSRC) can be adopted to ensure that the PHC components are included in insurance. His submission focused on experiences from the private sector in South Africa. He noted that the In the area of pharmaceuticals, there is already a South African health system is typically mixed, with program for distribution of medicines for chronic both the private sector and public sector operating conditions at the patients’ convenient places. The side-by-side. Up to 8.5% of the SA budget is spent on client only requires to register, their prescription health, with a GINI coefficient of 7.1, implying a fairly script, and indicate their pickup points. equitable system. However, enhancing private sector participation in South Africa has a very big and thriving private health service delivery, as well as wider application sector in health. Some organizations and institutions of such technology (mHealth and eHealth) requires have established their own health facilities, for an appropriate regulatory and incentive framework. example the mines have over the years developed The South African Government had already drawn their own facilities, although these private facilities out a social compact for government and private are still integrated with the public system, where for sector to agree on how the private sector can help example the mine facilities refer their clients to high government to deliver and this framework provides level public facilities. room for complementarity rather than unnecessary competition. South Africa has an extended network of GPs who work as primary health care workers. There are

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Ms. Robinah Kaitiritimba (UNHCO) – Role of Civil Society in the UHC discourse

Ms Robinah Kaitiritimba (ED, UNHCO)

From the civil society standpoint, Ms. Robinah the voice of the community to the policy making acknowledged the role of civil society in improving institutions such as parliament. These community health of the people in Uganda. CSO have brought voices are highly needed in the UHC discourse. their voices to bear on the way policy is designed There are other challenges that CSO are facing and implemented, and ensuring accountability at that needed to be noted, including: the question of all levels of service delivery. The Uganda National legitimacy. In some cases, some CSO themselves are Health Consumers Organization (UNHCO), for struggling with accountability issues coupled with example, developed a scorecard for accountability unclear mandates. As CSOs seek for accountability and citizen participation. UNHCO also developed from other stakeholders, they should also be seen a Rights Charter which specifies the rights and to be clean in their dealings because this promotes responsibilities of everyone including government, confidence, and enhances their legitimacy. Secondly, citizens, health workers, and other players. Civil there is sometimes lack of clarity of roles between society has also been engaging government different CSOs, and sometimes between CSOs and and parliament on issues of service delivery, government or implementing partners. This often accountability, resource allocation etc. Ms. Robinah affects the work relations, results into unnecessary reported that UNHCO together with other CSOs duplicity, and wastage of resources. are currently engaging parliament on the national health insurance bill, and the right to health bill. The Ms. Robinah recommended the following key issues work of civil society, however, needs to be supported that should be considered as Uganda pursues the so that more engagements can be done. Universal Health Coverage agenda: • There is need to harness community resources, However, she noted that CSO participation and by clearly defining the role of the community in spaces in Uganda are shrinking and this is a major Universal Health Coverage. concern. There seems to be a lack of appreciation • Investments should be expanded in the area of from the government of the critical role that CSOs preventive and promotive health rather than a are playing. It is the CSOs that have capacity to bring focus on curative and hospital based care and

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services • Promote education and more especially the girl child because this has a strong impact on population health. • Promotion of social justice. A lot of injustices are meted to different individuals and communities, yet there are no effective rules to protect the poor and guarantee their rights. The promotion and strengthening of the justice system is critical for improving health, if one reflects on the wholistic definition of health according to the World Health Organization. • The roles and mandates of CSOs need to be clearly defined and government should support and build capacities of CSOs because they are partners in development

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SESSION 1D Financing Universal Health Coverage Efforts The cost of obstetric and neonatal care: long-run. Therefore scaling up adequately funded Case study of the Jason Sendwe hospital non-medical interventions is cost-effective and can maternity in Lubumbashi, DRC – Masau help achieve health benefits to the population and Nkola, University of Lubumbashi, DRC hence accelerate UHC. The presentation highlighted results from a cross- Indoor Residual Spraying for malaria sectional study of user cost for obtaining obstetric prevention in Uganda: Options for cost and neonatal care during childbirth. The study was minimization – Tony Odokonyero, EPRC. SESSION 1D conducted at the maternity ward of Jason Sendwe hospital in Lubumbashi on the. From this study, key This presentation was about an analysis of the findings were that: (1) the cost of normal deliveries cost of country-wide roll out of IRS under different was five times more than cost of complicated implementation models, cost implications of phasing vaginal delivery; 2) costs incurred for complicated IRS, and identifying cost minimization strategies. This vaginal delivery were nearly two times cheaper than analysis was based on data from Uganda National caesarian deliveries; 3) user cost of obstetric and Household Survey (2016/17), market price data, as neonatal care incurred during childbirth are more well as data from IRS pilot districts in northern and than catastrophic for households, and 4) that user eastern Uganda. fees are a barrier to access and utilization of quality From this analysis, it was reported that: 1) up to US$ care. The study recommended that a review of health 63.5 million was required to finance country-wide care financing policy and system to ensure increase implementation of IRS using an integrated district- access to quality care for all. led (IDL) approach; 2) the overall cost per structure and average cost per person protected are US$ 8 Cost savings attributable to ‘Operation Fika and US$ 2 respectively; 3) the largest cost driver for Salama’; Case Study of Health Facilities an IRS programme is the insecticide, which accounts handling Road Traffic Accident injuries for about 66% - 81% of the total cost depending on along Kampala-Masaka Road – Pascal the implementation approach adopted; 4) the IDL Kaganda, MakSPH approach was associated with the least cost—about A road traffic intervention Ffika– Salama(Arrive six times cheaper than project-led approach; and 5) Safely)(OFS) – was implemented along the Kampala- compared to LLINs and case management, IRS is the Masaka highway, at the height of road accidents optimal option. on this road. The intervention aimed at reducing The study concluded and recommended that; ) traffic accidents by mounting on-spot checks, traffic a investments in malaria prevention using IRS is a less roadblocks, and instant prosecution of offenders. costly more sustainable; government should utilize This study thus, was an assessment of the medical b) existing District Local Government and community- and non-medical cost savings to the health care based structures, as well as spray logistics in IRS pilot system, of implementing the OFS intervention. The districts, to minimize cost; using existing spray assessment was to demonstrate whether investments c) logistics on a rotational basis; using locally available in other non-health sectors have any impact on resources as Spray Operators; incorporating IRS the population health and the health system in Behavioral Change Communication (BCC) into general. The following key observations emerged immunization BCC; subsidies or fiscal incentives from the assessment: (1) the Intensive phase of the d) to domestically manufacture insecticides; sourcing intervention resulted into injury and fatality reduction insecticides at competitive rates; and using a of 83%, and a 66% reduction in injuries in the re- e) private-sector model of service delivery combined loaded phase; 2) In the phase where there was with a public health approach are some of the cost some relaxation of the intervention, minor injuries minimization policy options to be adopted. increased; and 3) the estimated average cost savings was UGX 5,424,489/= per RTA injury averted. The study concluded that leveraging programming in other non-health sectors is an effective approach to reducing costs incurred by the health system in the

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Improving health facility deliveries in It was further noted that the community mobilization resource limited settings through local model helps to empower the informal sector, and transportation voucher scheme: results the approach is beneficial to members and service from a Donor partnership with Agago providers, and creates strong relationships within district local government, Uganda – communities but also between communities and providers. Community cooperatives, thus, have the Emmanuel Otto, Agago DLG capacity to reach out to informal sector, making it The presentation noted that the provision and use an ideal model for a country that’s is struggling to of local transport voucher saves lives by enhancing move toward universal health care, without relying access to emergency obstetric and neonatal care. on significant government investment. Vouchers alleviate the financial burden to poor communities and can be used for accessibility to Willingness to Pay for health insurance health care for many disease conditions other than among commercial motorcyclists in Nakawa deliveries and emergency referrals. And the transport division, Kampala Capital City Authority, voucher pilot scheme in Agago district has shown Uganda – Judith Kiconco, St. Augustine’s that indeed access to and utilization of emergency International University. obstetric services increased for the most in need. This was a presentation of results from a study Health Cooperatives: A Community conducted in Nakawa among commercial partnerships initiative to ensure affordable motorcyclists, to establish their level of willingness to health care coverage for all Ugandans pay for health insurance. The key findings were that – Ahaabwe Manisurah, Health Partners the willingness to pay for health insurance is fairly high among commercial motorcyclists in Nakawa Uganda. Division at 70%. The study thus recommended This presentation focused on mobilizing communities that government should consider rolling out and/ for health, through the community health insurance or expanding the motorcycle loan scheme in which framework. Health partners has been organizing riders can personally own a motorcycle as a loan community groups that are then structured to save and clear the payments in installments. This creates for health. The experiences for these arrangements more riders who are self-employed and hence more show that: 1) locally generated, owned, and managed willing to contribute to health financing through solutions are easily taken up by communities; and 2) paying for insurance. mobilizing communities to take charge and control to their own health is a sustainable approach to health financing.

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SESSION 2A SOCIAL DETERMINANTS OF HEALTH Achieving Universal Health Coverage predictors of adolescent pregnancy. There were (UHC) through harnessing the also regional variations in adolescent pregnancies demographic dividend for Uganda – Ms. with the North and Western regions having higher Judith Mutabazi, NPA numbers compared to other regions. This presentation recognized the high fertility rate The analysis concluded that having education currently at 5.4%, a high population growth rate (secondary) and wealth (richer quintile) contributed

of 3%, with rapidly declining mortality leading to to a decline in adolescent pregnancy, although this SESSION 2A unfavorable age structure with high dependency decline can easily be undermined by early sexual burden. In addition, it was noted that Uganda has debut. one of the youngest populations in world, 15 years and below constitute about 49.3% with low propensity Making health everybody’s business: to save and invest both at household and national Addressing key health determinants as a levels. The unfavorable age structure manifested by responsive approach for the implementation many dependents plus poor skills constrain those of UHC – Sharon Mokua, Kenya few in the working age. The Kenyan government had set out to give everyone This population structure can however be leveraged an opportunity to be health, no matter who they are. to the advantage of the country, and hence the The UHC agenda has been included in the priority concept of demographic dividend. Some of the agendas for government. Although the intentions by approaches that should be adopted to leverage the government are just, more actions are needed to the demographic dividend include: 1) promotion of address the broader determinants of health such as fertility decline through family planning and sexual education and living conditions among others which and reproductive health programming; 2) skilling affect people’s health and their access to services. the population to ensure it is actively involved in If UHC is to be achieved, there is need to reach into production; and 3) creation of opportunities for every community, including the poorest and hardest youth involvement, among others. to access in a strategic and innovative way through the channels of PHC. Ms. Judith concluded by noting that: a) multi-sectoral approach where all sectors and stakeholders get This study used an exploratory qualitative study design involved, is critical for harnessing demographic to collect information on population-driven needs for dividend; b) increase and rationalize the budget an effective Universal Health Coverage program in for health and other social sectors; c) increased the selected pilot counties, Isiolo, Kisumu, Machakos understanding of the complexity of UHC, that it and Nyeri targeting the, community members, is not just about a minimum package but making CHVs and other key informants in the health sector. progress on several fronts such as managing drivers Furthermore, facilitators, barriers, current and future of development outcomes, changing demographic feasible strategies and priority setting mechanisms profiles, etc. were comprehensively explored through focus group discussions with various population groups, and Determinants of Adolescent Pregnancy in Members of County Assembly as well as in-depth Uganda, UDHS 2000-01- 2016 – Catherine interviews with health service providers, partners, Mbabazi policy makers and County health Management teams. This analysis used the UDHS Data to investigate the determinants of adolescent pregnancies in From participant feedback, it was established that: Uganda. The analysis focused on the adolescents access to and role of mass media, and emerging between the 15-19-years. Adolescent pregnancies technologies, geographical access to health facilities, have consequences on the total fertility rates for road infrastructure, household poverty resulting the country, and also on the maternal and infant in lack of money for transportation to facilities, mortality rates. Results from the analysis showed ingrained cultural norms and illiteracy including that time of first sexual debut, education level, and language barrier, health behaviors among others. wealth or socioeconomic status were significant The study further established a critical relationship

35 2019 UHC Symposium Proceedings Report between these determinants and the role and Improved Water Access as social and importance of actions across all sectors through a environmental determinants of health multisectoral approach which recognizes that health among primary pupils –Kenshunga is affected by, and affects, housing, education, and Kiruhura District - George Oryongatum public water supplies and others. Water related diseases such as diarrhea, cholera The presenter concluded that using the principle and dysentery are among the most common cause that health is everybody’s business, would enable of death among children globally. In Uganda only Kenya and other countries to achieve health for all. about 30% of the primary school have reliable water Additionally, no single sector of society alone can source facilities, and the situation is not any different be able to effect the changes necessary to improve in Kiruhura District, Uganda. A three year project population health. All sectors must work together. that involved sinking of boreholes in schools was implemented in addition to establishing school health When the cost of obstetric complications clubs, sanitation competitions, construction of hand becomes unaffordable: Qualitative study washing facilities, etc. Results from the intervention of the social consequences on households show that there was a significant reduction in the and health facilities in Lubumbashi, DR number of diarrhoeal and typhoid cases in the Congo – Angela Musau schools from 2013 (baseline) to 2018 (completion). The result also underscored the importance of Because user fees for obstetric and neonatal care are collaboration and partnerships to improve water too expensive with no mechanisms to cover health safety and health outcomes. care costs for the poor and poorest, the study aimed to explore the social consequences of the high financial Trends Analysis of the Prevalence of Soil- cost for obstetric complications, on households and Transmitted Helminth Infections in Lira health facilities in the city of Lubumbashi, DRC. The study established that when the cost of obstetric District from July 2015 to July 2017 – Brenda complications becomes unaffordable, patients Nakazibwe remain in a cycle of impoverishment. Most patients This stud was intended to analyze the prevalence end up paying through improvising, receiving help of helminths infections in Lira district by place, time from relatives, sale of property, and borrowing, and person in order to guide specific and tailored loss of all income, rent food etc. or non-payment interventions. The study used data from the District which results in detention at the facility. Detention Health Information database (DHIS-2) from July in turn results into increased hospital stay hence 2015- 2017. The results showed an increase in the extended maternal absence, decrease in family prevalence of helminths infections, and was a second income, family conflict as well as poor health care. major cause of morbidity and mortality in Lira District. The study recommends that to achieve UHC in such The study further revealed that STH was higher circumstances, government should implement a among males and females of 5-59 years across the long-term policy of subsidizing care, or promoting study period, while rural sub counties posted more risk sharing mechanisms such as health insurance STH infections than the urban counterparts, and the prevalence or STH increased throughout the study period. The study recommends that targeted programs and interventions should be strengthened and tailor made targeting women and people in rural communities, with emphasis being placed on sensitization and public health programmes like mass deworming in order to curb this trend.

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SESSION 2B HEALTH SYSTEMS GOVERNANCE This session was chaired by Dr. Sarah Nahalamba of the NPA. The session discussion was focused on “Why governance is not given adequate attention in Africa.”

Dr. Grace Kiwanuka Ssali – Africa and society Alongside a popular version, robust Collaborative for Health Financing Solutions communication strategy must be available that (ACS) maps out audiences, while considering their unique communication needs, contains short, simple, key Dr. Grace Kiwanuka noted that Uganda has been messages and appropriately used tools and relevant SESSION 2B significant strides in the pursuit of UHC. Indeed, the channels for reaching them within conducive contexts. concept of UHC had been customized and clearly The Ministry of Health in collaboration with the ACS defined within the context of Uganda, to mean initiative were currently working on simplifying the “all persons in Uganda having equitable access to UHC roadmap and repackaging it, mainly to ensure comprehensive quality health and related services that all stakeholders have the same understanding without financial constraints, delivered through and speak the same ‘language’. a multisectoral approach”. Uganda had already clarified and mapped the pathway to the pursuit of Dr. Hellen Ekpo – Strengthening Capacities the UHC agenda, by developing a UHC Roadmap for of Ward Development Committees to Uganda. The roadmap is a package of intervention, strategies and resource requirements, sequenced promote health in Osun State, Nigeria. along the UHC path that would, if adequately Osun state in Nigeria is one of the states with poor implemented, enable Uganda to achieve UHC by health indicators, including high infant mortality 2030. However, beyond the UHC Roadmap, there is rate, high under-five mortality, and poor health need for stakeholders to gain a wider understanding infrastructure. Residents have opted for care from of what UHC is, beyond the definition. There must private providers with consequent high costs and also be high level support and leadership in the form medical bills leading to impoverishments and of political will/ buy-in/ support catastrophic expenditures. It is also important to note that UHC needs to To improve the situation, Government in be made relevant to all, have multi-sectoral collaboration with USAID implemented a Basic convergence, collaboration, cohesion and synergy Health Care Provision Fund (BHCPF) in 2018, to in planning and policy and have empowered and revitalise and strengthen PHC service delivery in the informed populations. A conducive implementation state, to achieve the goal of UHC. The main aim of environment is also critical facilitated by partnership the new programme is to strengthen capacity of the and collaboration between the state and non-state Ward Development Committee (WDC) members actors. and staff of the PHCs to understand their roles and responsibilities in mobilizing local resources for While the UHC Roadmap exists, there are still a improved quality of service delivery: number of challenges that need to be addressed, including: The program involved: sensitization meetings with ¾¾ The roadmap is a technical document across all the PHC staff; aassessment of Health facilities the content, language & jargon. It may not be an for the available infrastructure; ddevelopment of easy document to navigate and understand by quality improvement plans with the staff; training all stakeholders, although It is comprehensive in on implementation of the BHCPF; and to improve multi-sectoral inclusion the relationship between the PHC staff and WDC members towards mobilizing local resources for ¾¾ The UHC Roadmap may need to be simplified improved health care services at the PHC. into popular versions of information for easy comprehension and communication and From implementing the program, a number of lessons readership, especially by the technocrats and were learnt including: (1) Strengthening capacities decision makers. of the staff of the facility and ward development A popular version of the report is necessary to ensure committees and sensitizing them on their roles and coordination and coherence across government responsibilities, fosters better relationship between

37 2019 UHC Symposium Proceedings Report the community and facilities and ultimately improves better resourced, but often times wasteful, it serves the quality of health services at the community level; 40% of the population, but is also marred by Illegal and (2) communities need to be part of programmes user fees and conflicts of interest. This compares aimed at benefitting them. Once they appreciate with a weaker and poorly resourced private sector, the benefits, they can mobilize community level yet serving more than 60% of the population. The resources to ensure the programme succeeds. public sector is good at resource mobilisation while the private sector is good at good monitoring and Dr. Ekwaro Obuku – Agenda setting and supervision. policy change, using a case of the 2018 UMA industrial action. Given that each of the sectors have both strengths and challenges, it is important that they synergise Dr Ekwaro Obuku, as a president of the Uganda through a public-private mix arrangement to harness Medical Association (UMA) was at the centre of resources and strategy to improve health service industrial action by medical workers who were delivery and achieve Universal Health Coverage. demanding for better working conditions in addition to improved remuneration. He noted that Dr. Solome Okware – Leveraging the Ebola for any industrial action to be sustainable, proper Viral Disease Emergency Preparedness for identification and definition of the problem must be Universal Health Coverage” conducted, solutions identified and then appreciating the political context. In August 2018, the Democratic Republic of Congo notified an Ebola Viral Disease (EVD) outbreak. The major identified problem was Shortage of In response, Uganda strengthened emergency Medicines & Supplies which was termed as “poor preparedness efforts in anticipation of spill over of working Conditions”. Multiple strategies including the outbreak. Emergency preparedness improves industrial action must be evaluated, including the health system’s ability to anticipate, respond to weighing their cost-benefit, until you arrive at the and recover from public health emergencies. A study best option that speaks to the context. was conducted to assess the potential effects of emergency preparedness for EVD on health system Once an alternative is adopted, all members of strengthening and its potential impact on Universal the association had to be convinced to stick to Health Coverage (UHC) in Uganda. the agenda, including providing legal support to individual members in case action would be taken Findings show that capacity building efforts were against them as individuals. Members require directed to coordination, case management, assurances of safety and job security. surveillance, risk communication, vaccines and logistics. This in return contributed to service delivery, The 2018 UMA industrial action indeed had obvious health workforce development, financing, leadership negative consequences, including: Interrupting health and governance, health information systems. It was services; and suffering (increased illness and deaths) also noted that EVD vaccine deployment improves on the part of the common people. Nonetheless, this cold chain capacity for routine immunisation and presented an important window of opportunity for surveillance, improves overall infectious diseases policy makers to discuss comprehensive reforms for targets through early detection. bettering health service delivery in Uganda. An important lesson learnt from the Ebola outbreak, Dr Were John Wadenya – Private Health is that, emergency preparedness strengthens the Sector is key to Universal Health Coverage health system and potentially influences UHC, in Uganda” through: 1) provision of promotive, preventive and curative services; 2) supporting adaptability Dr John Were brought to light the glaring disparities within the health system and building resilience; in the distribution of the scarce resources between 3) providing an avenue to empower communities the public and the private sector and Highlighted to be part of their own health outcomes; and 4) some efforts being made in championing investment expanding the pool from which resource can be in the private health Sector. The presenter noted pulled to address health system emergencies. that governments committed to allocating at least Finally, the experiences brought a new appreciation 15%of their GDP on health according to the Abuja of the interconnectedness between emergency commitments. preparedness and Universal Health Coverage. However, Uganda is still way below this target. He acknowledged the fact that the public sector is

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SESSION 2C LEARNING FROM COLLABORATIVE EFFORTS Enhancing coordination of multisectoral involved in the business of generating evidence, a few actions for health in LMICs: what are we partnerships are being developed to link research learning from social science theories? – Dr. and policy. In addition, there are a number of tools Aloysius Ssennyonjo (MakSPH) in health economics that can be used for resource allocation and prioritization, but a few of these tools Dr. Ssennyonjo elaborated that in dealing with and evidence is being used in decision making and multisectoral approach, there are important budget processes. Establishing a framework to link processes for identifying and agreeing on the academia, researchers, and the policy makers, SESSION 2C coordination mechanisms. They has been, however, can help tap into different capacities, resources, and limited effort in trying to understand these processes. synergies, for better decision making. It was necessary to explore the drivers and evolution mechanisms to advance multi-sectoral effort. Two The University of York Center for Health Economics strands of theories are worth noting: the Economic (CHE) had already pioneered work in Malawi, and based theories, and the politically related theories. established a Health Economics Unit (HEU) at the The central propositions of these theories are that; University of Malawi, with support from the TLO costs are central to managing relationships, and that programme. The aim of the HEU was to support contracts and incentives are necessary to manage capability building in different disciplines to enable relationships and actions. It is important, however, to and facilitate the use of research within policy note that these propositions do not take cognizance making processes. The TLO work in Malawi is a of the influence of context on actors and their typical experience of how to build and institutionalize actions. Furthermore, there are cases where actions structures through which researchers and policy are required from actors yet the resources to act are makers can support each other and provide evidence not necessarily in their control. And then we must that is responsive to immediate policy needs by recognize the political economy of things, where combining policy analysis and evidence use. These actions or courses of action may be influenced by structures can be able to support Policy influence, ideas, values, institutions, and norms that actors find monitoring and supervision, and mentorship, which themselves in. are critical elements for research uptake. These processes at national level must, however, take Coordination is thus a function of processes that interest in global discussions, because the decisions needs to be negotiated. Some questions that need at country level are sometimes influenced by what to be considered while identifying and structuring a happens at international level. coordination framework, include: a) is coordination necessary, b) is it a concern of stability or certainty, The CHE was already in discussions with MOH and and c) is it an effort to achieve legitimacy? MakSPH in Uganda to replicate these experiences from Malawi to Uganda. Finally, there is need to appreciate the fact that coordination is a multi-dimensional effort. We Priority setting for health systems research must draw from literature and theory to ensure in Uganda – Dr. Obuku Ekwaro (Center for that coordination frameworks are identified and Systematic reviews, MakCHS) implemented within the context of evidence and what is known, in order to achieve the intention. Using scientifically proven and rigorous approaches to priority setting are critical in enhancing buy-in A novel partnership for evidence generation and uptake of research evidence. The Center for and informing policy formulation on Systematic Reviews at the College of Health Sciences, resource allocation in health. Experience Makerere University purposively selected decision from the Thanzi La Onze programme in makers, different interest groups, and researchers who came together to discuss priority areas for health Malawi – Paul Revill (York, CHE) systems research in Uganda. In addition, a literature This presentation aimed at sharing experiences from search and review was conducted using a Cochrane the TLO programme in Malawi on how to use evidence approach, and the WHO health systems building to influence policy and decision making processes. It blocks framework. The major aim was to understand was noted that while research institutions are heavily what the decision makers wanted to do and what

39 2019 UHC Symposium Proceedings Report type of evidence would help them achieve what they perfect equality want to do. A PDQ framework was applied where 5. Benefit incidence analysis – this determines who 10 dimensions or important areas were identified to benefits from government expenditure or from facilitate this research priority setting process. a particular intervention. It combines service utilization with costs across health service types. From the discussions and analysis, it was noted that most of the required evidence is already out Health equity is a key goal in global health and there, but what is majorly needed is the synthesis existing techniques can be used to estimate the extent and communication of this evidence to the decision of inequity and identify alternative interventions to maker. From this process, the major priority health address the identified inequities. Government budget system issues identified included: governance and expenditure can actually be used to promote equity, accountability, benefit package for the national but this would depend on the resource allocation health insurance, the tax regime, and how payment formula that has been adopted. mechanisms for the proposed insurance. Building residence in epidemic management Conclusively, engaging stakeholders can be helpful through health policy and systems research in identifying priority areas of research whose – Doreen Tuhebwe (MakSPH) evidence would be critical in decision making. In The presentation relied on an analysis of the addition, working together with decision makers and emergency management cycle, and what lessons other stakeholders to identify those priority research can be learnt from there. Two methods – Delphi questions can facilitate research uptake. method and social network analysis – were used to Incorporating concerns for equity into draw experiences from the 2017 Marburg outbreak in Kween district, North Eastern Uganda. The aim healthcare resource allocation decisions – of the analysis was to map the various actors that Mr. Edward Kataike (ECSA) are involved in an epidemic management cycle and This presentation was based on work that ECSA and how they relate to each other during the epidemic the University of York under the TLO programme management time, and whether or not their actions have been doing in Malawi, from which a working complement each other. paper has been developed. The working paper was motivated by the importance of equity in health It was noted that the control of outbreaks requires policy and how equity affects health outcomes. A an effective mitigation system often characterized number of techniques have already been developed by multiple actors. Experiences in outbreak to measure health equity and these techniques can investigations shows that some actions require and be applied in resource allocation. These techniques indeed draw more resources compared to others. were applied to resource allocation decisions There are also contradictions in Standard Operating in Malawi to understand the extent of inequities Procedures (SOPs) around case management and in health. Equity analysis is important in trying these can lead to confusion and suboptimal results. to understand the questions of: a) Does health By the nature of epidemic management and control, expenditures benefit the rich or the worse off? b) multiple players are always involved. Facilitating How can government promote health equity using working together, thus, require and understanding health expenditure? c) Which interventions provide of each other’s roles and mandates. the best value for money in promoting health equity? Results from the analysis showed that during To determine the current level of inequity in health, a epidemic outbreaks additional actions beyond those number of techniques can be used: envisaged in SOPs, come up, and these draw in even more actors. Furthermore, more actions are 1. Linear index of inequality – which disaggregates expected but relatively fewer players are available to households into socioeconomic quintiles. Equity take up the roles. There are many players expected analysis then compares across different five to be part of the team but actually less are observed quintiles. on ground. There are some actors that are initially 2. Slope index of inequality – quantifies the expected to play periphery roles, but actually end differences between the groups. up playing core roles. It was also noted from the 3. Relative index – provides results of the differences analysis that some players or actors are present on between groups in percentage terms the site but what they are actually doing is not clear 4. Lorenz and concentration curves – these show and known to the rest, and it is hard to understand the distance away from the diagonal line of what they were actually doing. Major actors like the

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Office of the Prime Minister (OPM) are expected involvement in community health insurance for but sometimes not observed on site. It was also households to reduce out of pocket. The model also noted that many actors needed capacity building to targets increased women participation in decision undertake their roles. making about health. Save for Health, Uganda, adopted a KPMG model that emphasizes genuine In summary, across all phases of epidemic control commitment to collaboration, transparency, patience and management, critical actors need to be mapped, and persistence. SHU is also doing the coordination roles streamlined and allocated systematically, and of the partnership with local governments in district a coordination system specified to allow for better of SHU work are on board. coherence in action. So far, experiences show that enrolment into CBHIS Collaboration between universities and has tremendously increased and this has been local governments in programming and due to the partnerships established at different evidence: the case of Indoor Residual levels. Service providers have also benefited from Spraying – Nduhura E. (Mbarara partnerships in terms of cost recovery, run-away University) cases have reduced, and so everybody has benefited from the partnership. Microfinance institutions have Indoor residual spraying has been recommended benefited from the leadership structures because as one way of eradicating malaria in areas of high they help in the recovery of the loans. The major burden. IRS is done at regular intervals particularly lessons from this work are: due diligence is critical in areas that are high risk. In 2018, the One Health in all decisions; identified partners should be those Central and Eastern Africa (OHCEA) dispatched that add value to the partnership, learning from a team to Tororo to understand issues around IRS each other, and holding each other accountable for especially given that previously the district had actions helps to facilitate partnerships. resisted the programme of spraying their houses and communities. The team was multidisciplinary in Contributing local resources voluntarily to nature, and included the local police, district team, end HIV/AIDS in Uganda. The case of the and social scientists, among others. private sector One-Dollar Initiative – Mr. The team conducted a rapid assessment after the George Tamale (Private Sector Foundation spraying, to understand the issues, even when Uganda). IRS indeed is an effective approach to mosquito Most of the funding for HIV/AIDS programmes in reduction. Uganda comes from external sources, and limited The team found that initial resistance was caused by contribution from Government of Uganda. HIV/AIDS the perceived side-effects of chemical, the mysteries affects everybody directly and indirectly. It is therefore that spraying increases bedbugs, or that spraying in the best interest of all to address the epidemic. does not achieve its objective at all, and then the Everyone can make a difference in the fight against evasive smell of the chemicals. From this rapid HIV/AIDS if each one contributed small resources. assessment, it was learnt that communities need Cognizant of this reality, the Private sector to be intensively sensitized with adequate, timely, foundation started a one-dollar initiative in 2017. and rightful information. There is need to engage Under this initiative, individuals can make a voluntary communities before interventions are implemented, contribution of one dollar per year. Contributions and address the political issues that get colored into can also be in-kind directed towards sustaining programs. HIV families. Corporate organizations, rotary clubs, religious organizations, etc. are all targeted in this Leveraging community partnerships for initiative. Once these resources are pooled together, efficiency and sustainability of programs: they are given out based on well written proposals of experiences from community health interventions that address issues of HIV/AIDS. These programs in five districts of Uganda – resources benefit both government and private Mukaire Fredrick (Save for Health, Uganda) service providers, civil society, and government for Save for Health, Uganda, is a local NGO aimed at critical needs. improving health through community health financing One important lesson learnt from this initiative is approaches, livelihood improvement, women that Small contributions can effectively generate empowerment, and advocacy for quality service substantial resources that are critical to address the delivery. Save for Health is involved in encouraging financing gap for HIV/AIDS programming. There is

41 2019 UHC Symposium Proceedings Report an untapped potential for individuals to contribute responsibilities in relation to the right to health care. to health financing, but individuals lack information This literature was supplemented by key informant on how they can contribute and make a difference. interviews with relevant stakeholders and officials. Finally, the private sector can actually contribute immense resources for health but they need to be A number of issues were noted from this study: 1) convinced and assured of accountability and rightful Citizen Rights and entitlements in the context of health use of the resources. were highlighted in virtually most policy documents; 2) there were explicit statements that mentioned Exploring how the existing legal and policy health care access for border communities; 3) framework on healthcare access for border documents, however, did not clarify benefits for non- residents in East Africa affect UHC and citizens of particular country; and 4) there was no clarity on whether the stated rights can be exercised global health security agendas – Ms. Susan beyond the borders. In addition, from key informant Babirye (MakSPH) responses, it was noted that there were no laws that The people of the East Africa are in one way or the allowed cross-border access to care. Institutional other related. In some circumstances, the colonial arrangements and travel requirements existed, borders split communities across different countries, but different countries had different health care yet they are historically the same. Because of these financing arrangements. The insurance system in historical connections, people often cross borders Rwanda, for example, would not allow an individual to access health services in a neighboring country. from the neighboring country to access health care For example people from Eastern DRC cross to in Rwanda, unless that had obtained the Rwanda Kasese and other border districts to seek care. This insurance card. is because probably the facilities across the border are the nearest and better placed to provide the Documents, however, spelt out collaborative and services. cooperation arrangements between countries on matters of disease surveillance and epidemic One of the challenges, however, for this cross border control. Such a framework could be leveraged to access to care is the legal and regulatory regimes deliver health services, for border communities. that obtain in the different countries, sovereignties, In addition, countries need to take advantage of and sometimes different currencies and payment regional integration efforts to agree on framework for mechanisms. The study explored the existing legal provision of health services for border communities and institutional frameworks and how these affect within the context of free movement of individuals, access to health care for cross border communities. goods and services, for example under the East The study involved review of documents, including African Community treaties or other bilateral and international treaties, laws and regulations, and multilateral cooperation arrangements. etc. rights, entitlements, state obligations, and

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SESSION 2D UHC and Policy developments This session discussed Universal Health Coverage in light of the policy developments that have happened across countries. Presenters in the session shared policy experiences, ranging from analysis of policy processes, best practices for policy formulation and reform, and success stories from the MDG movement and how this can inform the current pursuit for UHC. Areas for policy focus within the context of health systems limitations and constraints were also discussed agenda – to reduce 1/3 premature mortality from Adopting Regulatory Best Practices for SESSION 2D Universal Health Coverage in Uganda – non-communicable diseases through prevention Abubakar Muhammad Moki and treatment and promote mental health and well- being by 2030. In the early 2000s, Uganda adopted international best practice in development of policy, laws and From their exploratory work, the researchers found regulation, which emphasized the need to focus on that most countries in SSA do not have national citizen’s needs. In 2004, the president endorsed by salt policies. The few existing policies are not signing a Foreword of “Thinking about Regulation? backed by context specific needs assessments. A Guide to Good Regulation” published in 2004. The There is limited stakeholder engagement in policy President also issued a directive in May 2005 to all processes and discussions. Further, the approaches MDAs for implementation of regulatory best practice to implementation of public policies isn’t based on across the whole of Government. what works. To address these challenges, it was necessary to invest in context-driven empirical Unfortunately there is limited awareness on regulatory research coupled with relevant multi-stakeholder best practices among stakeholders despite being partnerships during the process of policy formulation. introduced in early 2000. Adopting Regulatory Best With limited time and resources; there is an apparent Practice for Universal Health Coverage in Uganda need to re-evaluate the available options and make would lead to enhanced problem identification, and recommendations for policy re-design if the region introduction of alternative innovative solutions for so as to achieve the targets set for morbidity and inclusiveness. mortality linked to non-communicable diseases by 2030. Evaluation of Public Policy for Population Wide Health Reforms in Sub-Saharan An evaluation of the success stories of Africa; A Critical Review of Salt Reduction low-income countries that met Millennium Policies in South Africa & Nigeria – Amable Development Goal 5 target and lessons A.N Muhumuza learnt – Robert Basaza The presenter focused on policies to reduce salt intake The Millennium Development Goals (MDGs) ended as a mechanism to address the challenge of NCDs in 2015. Only few Low income countries managed in South Africa and Nigeria. Salt intake is a known to reach the MGD5 target, including Rwanda, and risk factor for high blood pressure (hypertension) Eritrea. Uganda achieved a few targets majorly in which in turn increases the chances of developing education and literacy. Analysis of those countries cardiovascular disease and other NCDs. In SSA, that met the target, show an increased health sector NCDs are now the leading cause of morbidity and funding (budget allocation) during that period. premature mortality. There are additional reforms witnessed in those The World Health Organization recommends a countries, such as: 1) increased government control maximum dietary salt intake of less than 6g per day. and planning for all investments into the health With the existing health systems already grappling sector to ensure alignment of resources to plans and with the burden of communicable diseases; limited guidelines, 2) training and deployment of community resources and the impact of urbanization; there is health workforce to supplement formal health need to facilitate the use of population wide health workers but majorly focus on preventive health; 3) interventions to reduce the rising incidence of NCDs. implementation of community and national health This is in line with achieving target 3.4 of the SDG insurance, and 4) establishment of a framework for routine monitoring of outcomes and using the

43 2019 UHC Symposium Proceedings Report evidence to provide feedback loops into programme The position of social determinants of still-births implementation. received equal consideration where national priorities had initially focused more on health In all, bringing all sectors on to the UHC discussion, systems’ access challenges to services. There was strengthening health information systems, and now more emphasis placed on preventive aspects leveraging human resources for health, are critical of the problem through addressing the pre-existing areas that need to be emphasised for a country to risk factors. achieve UHC and more generally the SDGs. The lesson that was learnt from translating global Frequent and incoherent shifts in maternal campaigns into national policy options, is that, it death problem definition and interventions important to balance between individual partners’ in Uganda: Missed MDG 5 and lessons for values and health systems’ capacities to deliver in SDG 3.1 – Moses Mukuru order to avoid policy incompatibility especially within the context of a complex heath system. The factors that influence maternal mortality ratio (MMR) have been changing over the years, and so Policy processes and economic analysis for are the definitions. In the 2000 and 2005, maternal health benefits package design – Paul A mortality was mainly due to Obstetric emergencies, Revill coupled with health system and individual level factors facilitated by the “three-delays”. From 2006 Economic analysis is a critical scientific approach to to 2010; it was stated that “anything” could cause setting priorities, more especially for health systems maternal death. From 2011 to 2015, the definitions that are resource constrained, yet need to achieve included: Criminal negligence by frontline health high results. Understanding costs of interventions is workers, Criminal negligence and violation of important because they affect the choice of which the right to life by government; maternal death interventions can be delivered, at what scale and to due to inequality, poor accountability and lack of whom, from the resources available. Priority setting is prioritization of causes and interventions; Lack of both a technical and political process. However, use action to address known causes of maternal death. of sound methods is necessary to meet the ultimate objective of improving population health. It is true that policies may innocently recreate, perpetuate or even worsen a problem they are intending to address. The lack of a coherently articulated problem linked to the causes of high maternal death may lead to uncoordinated policy response and hence missed opportunities. Therefore to achieve SDG 3.1, there is need for: • Consensus and clear articulation of the maternal death problem across all stakeholders. • Establishment of stable, feasible, and targeted interventions to address maternal mortality. Value frameworks and policy processes; Dr Paul Revill (University of York) How Global partnership values shaped Health system constraints (supply and demand sides) the translation of stillbirth campaigns into mean that interventions cannot currently be delivered national policy priorities for Uganda – Eric at 100% coverage; therefore decision making is key Ssegujja at this point. The TLO programme working together with University of Malawi and the Malawi MOH, Value informed policies play a significant part in designed health benefit package which was a result determining the health systems ability to respond to of a rigorous priority setting process that involved public health challenges. Attention to still births as a a range of stakeholders. And from this experience, neglected public health concern gained momentum it is clear that a participatory process can generate in 2010 and thereafter value framing by different policy or programmatic outcomes that are agreeable partners set into force to direct the campaigns to all stakeholders, which eases the implementation with subsequent gains reflected in how countries process. translated these global still-birth campaigns into policy. Therefore, public policy in an era of limited resources and unlimited need, can provide solutions with

44 2019 UHC Symposium Proceedings Report maximised cost-benefit and cost effectiveness, setting in the allocation of health resources. From the reduced almost to minimal out of pocket payments analysis, it was noted that decision making for health to health spending because of a focus on primary in Malawi is influenced and shaped by politics. This prevention which is known to cover entire population ppolitics occurs at the macro, meso, micro levels. groups. Public policy discourse offers a platform to At micro level there is the politics of policies being discuss interventions that can reduce the bottlenecks made; which is generally subjective to interests of the commonly incurred during service delivery, hence public; politics also happens at implementation level allowing for effective use of health resources which influences a lot the design and implementation modalities of programmes. Therefore, priority setting The Politics of Health in Malawi – Alan Mosa, and resource allocation decisions do not only involve Department of Politics/ Interdisciplinary technical but also political choices. Global Development Integration of private health practitioners Malawi is committed to pursuing Universal Health into the district health The effect of Coverage. Indeed, Malawi has recently developed government contracting with faith-based the National Health Policy (NHP) and the Health health care providers in Malawi – Wiktoria Sector Strategic Plan (HSSP) which aim to achieve Universal Health Coverage (UHC) and health- Tafesse, Centre for Health Economics, related goals of the Sustainable Development Goals University of York, UK (SDGs). However, decision makers are faced with Faith based organizations are becoming integrated the challenge that population health needs exceed into national health systems to reach a more available resources. equitable access to health. Governments now create service delivery agreements with PNFPs to provide As in many low-income settings, Malawi has adopted resources in return for expanded service delivery, an Essential Health Package (EHP) which lists cost- and these service level agreements in one way or effective health interventions delivered for free to the other, affect the supply and demand of health all people at the point of use of the national health care. The Malawian government contracted with system. Although the flourishing research about faith based providers to eliminate co-payment and health resources recognizes that priority setting reform reimbursement (fee for service). This resulted in health is political as much as it is technical, the into increased skilled birth deliveries at faith based complex social and political drivers in the Malawian hospitals and reduction in home births and assisted context remain understudied. deliveries by friends/family, increased demand for Field interviews were conducted in Malawi in 2018 prenatal care at faith based health centres and and 2019 with state and non-state actors whose reduced maternal mortality. Indeed, establishing work within the implementation of health policy or an integrated system that brings on board the non- delivery of healthcare. The aim was to understand state sector can increase access to and utilization of the political context of decision making and priority services and help to achieve better health outcomes.

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ORGANISED SESSION 3A SESSION 3A: NATIONAL AND SUBNATIONAL LEVEL PARTNERSHIPS FOR STRENGTHENING DISTRICT MANAGEMENT AND WORKFORCE PERFORMANCE FOR THE ADVANCEMENT OF UHC IN UGANDA PERFORM2SCALE is a partnership implemented by Dr. Martin Sendyona (Ministry of Health) MakSPH, Swiss TP, MOH, districts, and other partners. The Ministry of health partnered with MakSPH to SESSION 3A It is a multi-country programme implemented in implement the PERFORM project. The MOH already Uganda, Malawi and Ghana. It is funded by the has a quality improvement framework and a fully- European Union. In Uganda, PERFORM2SCALE has fledged quality assurance department that aims been implemented in selected districts to improve at ensuring that Government programs can be capacity at local government level to improve delivered effectively and of high quality. It was noted governance, decision-making, and service delivery. that working with the PEFORM project revealed that The initial phase of PERFORM focused on Jinja, involving actors in decision making improves their Luwero, kabale while in the scale up phase, we have self-confidence and motivation and is highly linked to added Nakaseke, Luwero, Ntoroko and Bunyangabu. better performance. Empowering and strengthening This session aimed therefore at sharing experiences teams to identify their challenges using data from the project implementation and lessons learned generated by themselves can improve outcomes. which could be taken up by government, local From the MOH perspective, PEFORM build district government and other implementing stakeholders. level capacity in the area of problem identification, analysis, proposition of solutions that are context Dr. Xavier Nsabagasani specific, locally driven and feasible. The Ministry hoped to build on this capacity to improve service He shared experiences on district capacity building, delivery within districts who have the mandate to using the case of the PEFFORM2SCALE programme. deliver health services. Through PEFORM2SCALE, MakSPH has been working with local governments to develop capacity PEFORM2SCALE experiences from Luwero of the human resource for improved performance and service delivery. PERFORM2SCALE uses the District – Dr. Innocent Nkonwa, DHO Luwero Action Research approach that ensures stakeholder Using the P2SCALE framework, the district team participation in problem and solution identification, conducted a root-cause analysis of the inadequate and applying the PLAN-ACT-OBSERVE-REFLECT and sub-optimal health service delivery in the district. framework. Luwero district had been grappling with low cure rates for TB in the district. The Root-cause analysis PLAN (1) ACT (2) revealed absenteeism, due to lack of monitoring and Problem identification Implement strategies supervision and related tools. One of the solutions Have a situation according to work plans. that was suggested was the adoption of a Results- analysis Based Financing (RBF) approach for payment of Development of health workers only for those days when they are strategies and work present at work. Once this solution was shared plans. with all health workers, they had to ensure they are available to ensure that continuity of care was Reflective diaries (4) OBSERVE (3) achieved. From our experience, PERFORM Led to Support visits to DMT How implementation of an improvement and optimization of Health Worker Inter district meetings strategies is taking place performance by identifying the challenges and Monitoring for effects of devising solutions together – solutions that take strategies using indicators advantage of the available resources. One important lesson learnt from this process is that continuous visits have to be made to the district to Mr. Godfrey Adru (HR department, PSC) ensure they continue with the PDCA cycle. Mr. Adru noted that Human Resources for health

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(HRH) is very critical in ensuring achievement of Universal Health Coverage. He acknowledged that government had been working on improving human resources for health, especially recruitment that now stands at more than 70% in the public sector. However, gaps still exist in the areas of capacity, skills mix, leadership and management capacities, and motivation and performance. He proposed that a strong focus should be geared towards building: 1) a result oriented management; 2) adopting Results-Based Financing, and 3) operationalization and strengthening of the Rewards and sanctions mechanisms. He applauded the work of PERFORM2SCALE in the local government and pledged the public service’s commitment to continue to build on those efforts.

SESSION 3 B: DECENTRALIZATION DEVELOPMENTS FOR HEALTH IMPROVEMENTS

Dr. Christine Tashobya – Health System and output indicators; and a composite index for Performance Assessment at the sub ranking. It was initially met with a lot of enthusiasm national level: a case study of the Uganda but many concerns were later raised. district league table The main question is: what would be an appropriate There has been global interest in health systems district health system performance assessment performance assessment (HSPA) over the last 3 framework in a LIC like Uganda? There has been decades. However, there has been challenges in notable challenges with the current DLT framework. HSPA frameworks in low income countries (LICs). • Because the DLT has limited participation mostly In Uganda, there are limited appropriate tools to at the national level and technical officials. conduct assessments to support decision making Therefore this participation has to be widened to at the central & district levels. Additionally, where included more stakeholders there exists a multiplicity of performance assessment • The need to use data and models to highlight frameworks especially along the major disease causality and other links conditions with duplication, overlap, gaps still exist, coupled with the poor use of information for decision- The presenter recommended a reflection on key making especially at sub national levels. thematic areas in order to re-motivate health systems performance assessments and make them relevant The Uganda district league table (DLT) has been in for UHC. use since 2003, and uses a number of input, process Health system • Develop an explicit HSPA framework conceptual model relating to health system conceptual conceptual framework recognizing Social Determinants of Health model • HSPA conceptual framework related to the district level given mandates for health system versus healthcare system Relate to • Acknowledge complexity and dynamism of Uganda health system and take advantage policy and of devolution organizational • Emphasize data collection, analysis & use of information for decision-making at the context district & lower levels • Emphasize learning, adaptation, innovation Elaboration of • Dual objectives (support decision making, accountability), with emphasis on former framework • Conceptual model explicitly indicated; dimensions – along determinants of health & Donabedian results chain model • Indicators – strategic, technical quality, feasible, pragmatic, • Strategic phasing in of indicators - new indicators for management processes & filling other gaps Institutional • Set up HSPA unit at national level set-up for • Diversify sources of data for district HSPA – HMIS + Surveys, Sentinel Sites HSPA • Hold regular Data Quality Assessments • Improve HSPA networks • Build HSPA Capacity at all levels; have teams to support HSPA at district level • Create and Support Champions

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Mechanisms • Follow explicit data analysis & presentation plan – level, focus, periodicity; emphasize to elicit district; qualitative and quantitative data; change • Use LT ranking + cluster analysis; social network analysis; trend analysis; manager information; • Dissemination –national, regional; district, community • Mechanisms: make clear and relate to decision making cycle: • Benchmarking, QIIs, Public reporting Adaptability of • Should be dynamic & flexible– some aspects should be the same but some flexibility the framework across the country • Regular changes should take place, in line with strategic plan development • •Phased approach to implementation- pilot major changes to learn more e.g. social network analysis

Ms. Vento Auma – Decentralization and Susan Wandera – Experiences from the the Uganda Health system - What can we RHITES model for integrated support to local learn from past experiences to facilitate the government health services management. achievement of UHC? The RHITES model has been an example of a Uganda operates a decentralized system where success story of how to improve use of data to service delivery is the mandate of the district local guide implementation of targeted interventions, government. Uganda has an elaborate local integrated service delivery at the district level. From government institutional framework from DHT, this experience, it was noted that successful reforms HUMCs, to VHTs. The challenge, however, is the require more ownership and commitment to results effective functionality, decision and fiscal spaces for by District leadership, and improvement in service these structures. Additionally, there are inadequate delivery indicators. The challenges however, include; capacity in community structures to ensure effective Urgency for response beyond project mandate, participation and quality health services, and Weak Leadership and Governance, Sustainability of ineffective facilitation for the local government achievements, Limited financing for health. From the systems hamper engagement RHITES perspective, the lessons learned include: In terms of service delivery, a recent developed • Integrated mentorships improve performance of PPPH policy has recognized and enabled the facility health workers complementarity between the private and public • Community champions are useful in mobilizing sectors. Currently, the proportion of the population communities for critical health services. living within the 5km radius of a health facility • Facility and district data reviews improve data increased from 41% (1991), 57% (1999) and 72% quality. (2004). The challenge, however, is the low level • Using data to target real needs improves health of motivation of the human resources owing to impact low remuneration, and the lack of political and • Leveraging partner support helps expand managerial accountability for health services. coverage and access to services How then can decentralization be harnessed • Lay workers are very critical in making linkages, referral of clients and follow up of lost to follow to achieve UHC up. There is need for a comprehensive review of the • Use of technology for communication improves decentralization reform policy; expanding fiscal utilization of services and decision spaces, strengthening intermediate management and administrative structure; Dr. Juliet Nabyonga – Lessons from the WHO expanded space for community engagement; AFRO region and beyond on optimising building capacity for stakeholder engagement; and decentralized health services delivery for the implementation of a multi-sectoral approach to a UHC decentralized health system response The District health system in Uganda remain weak, under-resourced and under-managed. Historically, district health systems have grown out of hospital- based curative care. The administration of health service delivery remains ‘top-down’; horizontally-

48 2019 UHC Symposium Proceedings Report networked DHS based on coordination for community but little implementede.g., Lesotho, Tanzania, access and navigation still largely lacking. The main Botswana: little operational information, esp. notable reasons for poor service delivery at district- Communication channels level include: unavailability of drugs and equipment • District management and leadership; limited (39.1%), poor attitude of health providers (27.7%), effectiveness due to national level controle.g., delays in the provision of care and long waiting time The Gambia: limited managerial capacities for (13.1%); Low levels of involvement of communities in budgeting, planning and staffing decision-making (organization of service delivery) in East/Southern (48.8%), West (44.0%), Central sub Opportunities region (41.8%), among others. The SDGs are inherently broad and necessitate a holistic approach – facilitating a PHC approach. There are notable challenges with Bridging organizational and management capacity decentralization, including gaps between national and district levels presents • Insufficient decentralization; narrow decision opportunities to improve district health systems. space, destructive PHC (people are in charge There must be deliberate strategic focus aimed of SD but have no financial capability e.g., at capacity building for district leadership and deconcentration in Zambia: resulted in moderate management; identifying and building a leadership power transfers; devolution in Kenya resulted in focused on creative actions to promote innovation empowered local government, but not necessarily and learning; reduction of program verticalization. health teams Other strategic areas include: encouraging greater • Financing and resource allocation; reliance on policy ownership, resource control; capacitating national level allocation, limits district-generated Ministries of Health to lead on inter-sectoral action; funds e.g., Ghana increasing wage bill and and promoting integrated and comprehensive decreasing programme funds leaves less for district planning; and changing organizational service provision incentives to support increasingly dependent district • Community participation and engagement; health systems community voice not heard, policy guidance exist

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SESSION 3D HEALTH CARE ACCESS Factors associated with health-seeking technological platforms to provide information on behavior amongst Malawians (2010-2016) services and general health education. Patients – Mr. Winston Ng’ambi (Malawi). also reported that they do not know the services in facilities and they just walk in, which causes recurrent This work was motivated by the fact that not much referrals that delays access to care and sometimes literature is available on health seeking behavior deaths. Long queues at facilities were also cited as amongst Malawians. This study, conducted as part challenge yet they could find other facilities and get of the Thanzi La Onze (TLO) programme, used data speedy health attention.

SESSION 3D from the Malawi household survey, on questions that were focused on care-seeking behavior during illness From these findings, it was apparent that technology situations. Additional information on demographic could be a critical tool that could generate real of respondents was also collected. time information to the public on availability of services and how they can navigate the challenges The analysis found that most households reported anticipated. It was important that providers should illnesses at health facilities, the common illnesses provide information on what services they provide being reported were malaria, respiratory illness, so that people do not waste their time when actually etc., and up to 58% of respondents sought care at they can’t find the services there. Information facilities. Health seeking behavior varied by age, technology and innovation has capacities to address residence, type of illness. People living in urban all these challenges. areas were likely to seek care compared to their rural counterparts. Care seeking practice decreased Assessment of the barriers for uptake of with age. Individuals with fever, and hypertension refractive services among secondary school were likely to seek care. Therefore, Universal Health students in central Uganda – Kagumba Coverage (UHC) programs need to consider the different factors that can influence care seeking Nicholas behavior to boost access and utilization of health Uncorrected refractive errors have been noted to be services. a major cause of visual impairment and blindness and can constrain individual’s education, personal Monitoring access to functional health development, and career opportunities. Interventions facilities: Challenges in Uganda – Tijah that address this issue differ from country to country Igbazenda (Cavendish University) depending on contextual factors. This study was conducted in two secondary schools in Kampala to It was noted that information is a very important determine the prevalence of uncorrected refractive element in Universal Health Coverage. People can errors and associated factors. only live healthy if they have information about managing their health, services and where they This study found that up to 10.8% of study participants are offered. There has been complaints that public with uncorrected errors had sought treatment from sector facilities do not have enough capacity and a practitioner but were dissatisfied with the service so sometimes one could go there and waste time. they received. They didn’t know what practitioners This study wanted to explore whether information they went to. The barriers to access were both service technology can be harnessed to address these related and individual related. Fear of surgery and challenges. Information technology can provide not knowing where to get the service were the major a platform that links the provider, client, and the barriers identified. At second level analysis, the major facility together, so as to improve utilization of health barriers included: costs, perception that they didn’t services. An identifier application, can easily provide have a serious problem, and the caretakers thought it information on services offered at a particular, which was not necessary to correct the problem. Individual facility is congested or relatively free at a particular related barriers were more common compared to time to aid decisions of where to seek care and service related barriers. There is therefore need to reduce costs of time. provide adequate information for people to know where to access the right services, and the existence From this study, participants reported that they look of non-evasive techniques of managing the errors. for information on health through the internet and technology. This is a good opportunity to use these

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PLENARY SESSION 5 SPECIAL PRESENTATION AND PANEL DISCUSSION Role of research and monitoring systems in advancing collaborative UHC efforts The Role of Policy Analysis in Shaping the UHC Discourse Professor Charles Hongoro, Deputy designing solutions for the current and prospective Executive Director, Research use and future challenges. But this requires: Impact Assessment (RIA), Human Sciences 1. Clarity of aspirations. These aspirations must Research Council (HSRC), South Africa. be shared and agreeable. The challenge here is that different people have different world views This presentation focused on the need for evidence and perspectives. It is critical that consensus is and the means to facilitate evidence informed policy built through negotiations between and within and practice for the advancement of Universal groups to ensure buy-in. Health Coverage. Prof. Hongoro acknowledging the fact that without research evidence, policies and 2. Implementation. There are so many policies decisions may not be effective because they are that have perhaps passed through rigorous not founded on solid evidence. Avoiding the use of processes, but may stay on the shelf if they evidence in decision making is like taking a short cut were written for different contexts, or if which later creates challenges. Every country has implementation resources are not available. PLENARY SESSION 5 unique challenges and contexts and so it is would It is therefore important that designed policies not be advisable to copy and paste best practice must be fit-for purpose and can feasibly from other settings. Different policy options need be implemented within existing institutional to be weighed and analyzed against each other to arrangements and with reasonable transaction identify and implement the most feasible ones. This costs. requires capacity building for policy analysis. 3. Resources: It may take more than 20 years for a serious policy to work and generate A number of approaches exist to conduct policy meaningful impact. It may get worse when analysis: policy is introduced, before it eventually gets 1. The scientific approach – systematic search for better. It is therefore important to manage truth, and build theories about policy actions. expectations. Resources are needed and This approach focuses on rigor more especially in the initial stages of policy 2. The professional approach – involving the implementation, because many policies fail if synthesis of evidence to understand implication they started on a wrong footing. of alternative policy options 3. The political approach – focuses on advocacy Dr. Abubakar Muhammed – Commissioner, and support for preferred policies, and the Policy Development and Capacity Building. use of legal and economic political arguments Office of the President (Uganda) that consistent with preferred and politically Dr. Abubakar made stressed a case for capacity feasible options building for policy analysis for government. He Whichever approach that is adopted, there is need argued that Policy analysts were a key cadre in as to reflect on a number of outstanding questions, far as policy development and implementation is namely: whether UHC can be achieved within concerned. Currently, every government department the public funding portfolio only, whether UHC is and ministry almost has policy analysts. These achievable through public provision only, what however, may need to be boosted, and their capacity incentive and regulatory mechanisms need to be in continuously developed to keep pace with current place for effective partnerships, and to what extent realities. At the core of any policy, however, the the MDAs and implementing partners align with citizen must be a priority. Policies need to articulate programs for UHC. with clarity, simplicity, and practicality, what the public issues are and how it will address them. Simple tools Prof. Freddie Ssengooba – SPEED Director have been developed and can be adopted for use, In policy making process, there are a lot of challenges for example the problem tree for problem analysis, and sometimes not well thought through solutions. among others. Scientists and researchers, must be preoccupied by

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Mr. Edward Kataike – ECSA Secretariat From the ECSA perspective, ECSA has put in place an institutional framework for high level discussions and sharing experiences across the policy makers from the member countries. ECSA for example has a council of Ministers of Health from member countries, and meets every to focus on specifically agreed policy reforms and agenda relevant to the member countries. This council of Ministers is advised by a committee made up of technical members. The council brings together experiences of countries in as far as implementation of country specific policies, is concerned. One important lesson that ECSA has learnt overtime, is that countries need to invest in context-driven empirical research evidence to inform the decision making process. In addition, a broader spectrum of stakeholders need to be brought on board in planning and policy processes to make these policies embraced. There are often notable challenges when policies are affected by politics that tends to elevate subjective interests over rational decisions. This politics eventually cascades into policy implementation and this tends to fail policies and programmes, and this must be addressed at all levels.

52 2019 UHC Symposium Proceedings Report DAY 3 PLENARY 6 How can multisectoral efforts be nurtured to advance Universal Health Coverage (UHC) and what mechanisms are available to ensure coordination and coherence in

action for UHC across sectors of government? PLENARY 6 Prof. Pamela Mbabazi Kasabiti: The practice in Uganda has always been for different Chairperson, Uganda National Planning government ministries, departments and agencies Authority (NPA) (MDAs) to focus on their individual mandate without exploring the synergies and complementarities that Dr. Pamela started her keynote presentation by first come with a multi-sectoral response. This is to a recognizing the significance of a healthy human large extent perpetuated by inadequate integration capital as one of the fundamentals and cornerstone of policies, the ‘silo’ institutional setting, the silo any country like Uganda to harness the opportunities planning, budgeting, and implementation. This ‘silo’ available for economic growth and development as mentality needs to be broken, so as to promote well as fast-tracking social economic transformation. working together. Accordingly, Universal Health Coverage (UHC) is a critical pathway to developing and achieving a One of the reasons for poor health outcomes healthy and productive human capital in Uganda. can be attributed to the way health is narrowly Achieving UHC, however, requires action across conceptualized and how government policies, different sectors and players. This means deliberate health systems and institutions have been designed efforts must be invested in a well nurtured and and operationalized in a silo mode. The challenges implemented multi-sectoral mechanism to ensure caused by such designs makes MDAs (Ministries, stronger coordination, harmonization, and coherent Departments, and Agencies) to reconsider the action for UHC. traditional methods of work against the multi- sectoral approach. The multi-sectoral approach can In many LMICs especially in Africa, poor population help improve service delivery and achieve better health outcomes remain one of the constraints health outcomes by adopting three key approaches: to social economic transformation. Investment and resultant outcomes in health, education, • Adopting and implementing a Health in All skills development, social protection and good Policies (HiAP) approach to delivering health population management are the key building blocks services. This approach requires systematic for a sustainable for economic transformation. The integration and mainstreaming of health in all objective of Uganda’s Vision 2040, is to transform other sector policies and programs. Uganda into a Middle Income country. Uganda may • Program based planning, budgeting and not however achieve this target if attention is not implementation. This addresses the challenge paid to improving the health of the population. of working in silos and facilitates systematic working together to achieve common results in a sustainable manner. It enhances synergies and linkages across sectors, increases efficiency in resource allocation and use, improves service delivery and brings together all implementing partners to plan, budget, implement, monitor and report in a well-coordinated and harmonized manner • Strategic alliances and partnerships with government, implementing partners (IPs), the private sector, other non-state actors, and civil society organizations. The role of implementing Prof Pamella Mbabazi ( NPA) giving a key note address partners, private sector, and CSOs in health care

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delivery and financing cannot be underestimated UHC as key to achieving NDP3. To this effect, there and is key in ensuring UHC. In Uganda, IPs are has been deliberate effort to mainstream the health contributing a sizeable amount of health care component in all policies. Prof. Pamela hoped financing. IPs also have accumulated experience that the key recommendations from this particular in the area of partnerships and alliances which symposium would be critical input to feed into the need to be tapped. The private sector too plays a on-going discussions and formulation of the NDP3. big role through direct investments in healthcare, public private partnerships, direct health service The keynote speaker concluded by reflecting ion delivery, and provision of training and capacity on the SDGS and noting that majority of health building. In areas of specialized health services determinants are beyond the mandate and control such as cancer and heart diseases, the private of the health sector. The biggest players for example sector can be attracted to invest in centers of in health promotion and disease prevention are not excellence for such care, and research and the health sector practitioners but other non-health training in partnership with government and sector stakeholders. This implies that resources for development partners. In addition the private health financing should not only be placed in the sector can be incentivized to expand coverage health sector but also in the non-health sectors such of services in areas where government has as water and environment, works and transport, limited capacities. agriculture, education and community development. This was enough ground for a coordinated multi- Dr. Pamela noted that Government of Uganda was sectoral strategic partnership with other sectors. currently developing the third National Development Plan (NDP3) and these efforts were being Finally, communities need to own and participate spearheaded by the National Planning Authority in contributing to their own health, but this requires (NPA). Within the NDP3, government had purposed to deliberate campaigns to raise awareness about work proactively to create a conducive environment the need for health promotion effort. The role of that attracts investors in particular strategic sectors individuals households need to be emphasized for of government and health is one of these areas that purposes of ownership. has been highlighted. The NDP3 also recognizes

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PANEL DISCUSSION ON LEVERAGING HEALTH BENEFITS FROM NON-HEALTH SECTORS CLOSING PLENARY CLOSING

R-L Dr Norah Madaya (former Head Statistical Cooridnation, UBOS), Maureen Bakunzi (Asst Commissioner OPM), Prof Pamella Mbabazi (NPA), Prof Freddie Ssengooba (Director, SPEED)

Maureen Bakunzi – Office of the Prime Mr. Ejolu Innocent – United Nations Minister Development Programme (UNDP) Ms. Maureen, recognized the importance of Achieving Universal Health Coverage (UHC) is not multisectoral collaboration because not a single a mandate and role of the health sector only, but sector can handle service delivery on its own. She rather multifaceted and multi-sectoral, given the noted that Government in 2003 passed a framework nature and indicators that are embedded in this that specifies the institutional mechanism through goal. If this is multi-sectoral and cross cutting, then which various actors need to be coordinated. Indeed a framework for coordination of effort is important. the office of the Prime Minister has the mandate The demand for coordination should however loudly to play a coordination role for all government come from the health sector as a lead sector on programs. However, there are capacity issues at pursuing UHC. It is through proper coordination the level of this office that need to be recognized that issues of prioritization, resource allocation, and addressed. Playing a coordination role does shared roles and responsibilities can be discussed not also imply that Government should solve all to avoid verticalization and duplicities. In Uganda, the issues. The OPM is pushing for stakeholder the potential for a multi-sectoral approach is clearly involvement, and a review and clarification of existent and needs to be tapped through the roles of each stakeholder so that each sector and government mandate enshrined in the OPM. actor is accountable for particular results to avoid duplication of responsibilities. There is however Norah – Uganda Bureau of Statistics need to create awareness across all actors and Across the discussions, it has appreciated by sectors that it is in synergizing that resources can be everybody that multi-sectoral approach is the way pulled together and make substantial contribution to to go, because it helps to create synergies and service delivery. She challenged research institutions share resources for a common goal. Multi-sectoral to identify and advise government on what feasible approach should not however be embraced for its coordination frameworks need to be adopted for own sake, there must be clarity on the quality and better operations. Evidence must come to bear on nature of partners and partnerships that are required government decisions to ensure effectiveness and on the table, otherwise the partnership risks being efficiency of policies. another forum for sharing and wining without much to show for. There is need to create strategic and

55 2019 UHC Symposium Proceedings Report smart partnerships, build capacity for smart leaders, and a complete mindset change. Government must deliberately nurture the multi-sectoral approach, but putting the people first. There is need to explore ways of harnessing the technological revolution to build, strengthen and sustain multisectorality. Finally, while the health sector invite other sectors and actors to come and work with them in health and on health issues, actors within the health sector should also be prepared to go and work with other sectors on other agendas. It has to be multi-directional.

Ms Bakunzi, making her presentation of coordination in government

Dr. Musoba – Uganda AIDS commission Dr. Musoba shared experiences of the Uganda AIDS Commission as an institution that is at the center of the HIV/AIDS fight in Uganda, and more particularly charged with coordinating the HIV response in Uganda. In his submission, Dr. Musoba stressed the importance of identifying and understanding the key actors on a particular policy issue. The next level is then to clarify the roles and responsibilities of each of the actors, vis-à-vis their legally understood mandates. Then, it is critical to map the resources required to execute the tasks. In addition, there must be a recognition that even within programmes, there are sub-components that also bring on board a lot of stakes. Managing these stakes can be a challenge. This however can be surmounted by ensuring that the stakeholders that are brought together have a Mr Ejolu (UNDP) sharing his experience of government shared vision and goals around a particular issue. coordination

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Symposium Closing Remarks

Dr. Aloysius Ssennyonjo – Vice-Chair, key players who did not have the opportunity to Symposium organizing committee attend can feed into the discussions for onward action. He concluded by appreciating the University Dr. Aloysius Ssennyonjo on behalf of the organizing for providing an enabling environment for research, committee appreciated all the participants, funders teaching and engagements and noted that it is this and the members of the committee towards which had enabled the five-year SPEED program to the success of the event. He specially noted the register great success. presence of Teams from KEMRI Kenya, Malawi, and the University of York, UK who had participated Dr. Juliet Nabyonga – Representing WHO- as big delegations. He promised to conclude the proceedings report and share with all participants AFRO and relevant stakeholders to ensure that policy On behalf of WHO-AFRO, Dr. Juliet Nabyonga, and decision makers reflect on the discussions and noted that the WHO was glad to be associated with emerging recommendations. the symposium and commended SPEED project for steering discussions on Universal Health Coverage, Prof. Freddie Ssengooba – Director SPEED not only in Uganda, but also in the region, and being Project. part of global discussion. She emphasized the need PLENARY CLOSING for UHC to be contextualized and customized to The Director Speed project, thanked all delegates country-specific conditions, in addition to ensuring for their contributions towards the success of the that all stakeholders and actors have a common symposium. He specially thanked the MakSPH for understanding of the UHC concept. She noted that providing an enabling environment for the SPEED all issues discussed at the symposium including project to be implemented. He in a special way partnerships, multisectoral action, monitoring appreciated the EU for the funding support since progress, etc. are apparently challenging for many the project started, and the MOH for the strong countries, and this presents an opportunity to collaboration and working relationship, given that learn with and from each other as countries while MOH are the main clients of the SPEED products. addressing these challenges. She observed that He thanked all SPEED partners for contributing the academia have generated a lot of evidence but immensely towards the success of the symposium. this evidence is yet to fully be appreciated and used Prof. Freddie acknowledged the immense amount in the decisions of policy makers. She reiterated of knowledge that has been shared through various WHO’s commitment to working with countries in presentations at the symposium, and only hoped that surmounting the challenges that were highlighted the engagements and shared learning can continue in the discussions. To this end, WHO would follow even after the symposium. He encouraged all up with the recommendations made from the participants to share learnings from the symposium symposium and not only share them across the across all their networks and challenged everyone to stakeholders but also facilitate discussions around work on the commitments that have come through those proposals. the various deliberations. Dr. Edward Kataike – ECSA Health Prof. Fredrick Makumbi – Dean MakSPH Community: Prof. Makumbi, the deputy dean, who represented Dr. Edward Kataike, on behalf of ECSA, thanked the Dean, thanked MOH and all other partners for the SPEED project for convening a very successful supporting MakSPH in a number of engagements. symposium, where informative and high quality The Dean noted that MakSPH appreciates the value discussions have been shared. He appreciated the of partnerships, and it is through this that the school lessons and experiences that came through the is able to continue growing year by year to contribute symposium discussions and pledged the commitment research and contribute through research, teaching of ECSA to continue to be part of these discussions and community service. The Dean noted the need to going forward. The ECSA group would be joining the strengthen partnerships in order to realize the health upcoming high level discussions on improving health goals. Prof. Makumbi pledged the school’s continued of the people in LMICs in Japan in September 2019 search for and strengthening partnerships, engaging and hoped to share some of the issues that emerged partners and generating evidence. He challenged from the symposium. He challenged the organizers all participants to share the lessons learnt so that

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and partners to not make this a last symposium but continue to create similar forums and spaces that bring stakeholders together in the spirit of shared responsibility and action. Dr. Sarah Byakika – Ministry of Health Representative: Dr. Byakika, the Commissioner planning, added her voice to the previous speakers to appreciate all participants for attending a three day symposium. Specifically, she thanked MakSPH through SPEED project for steering the UHC agenda in Uganda and for pushing government to rethink the approach that is going to move the country faster to achieve UHC. She noted that MOH was happy to be part of the discussion and was committed to pick the lessons and recommendations emerging from the discussions to make policy decisions. She appreciated the healthy engagement that MOH has had with SPEED for the last five years, and believed that a lot of impact has been created in the way things are done at the MOH because of this continuous engagement. She concluded by re-emphasizing that the Government of Uganda s committed to achieving UHC and will continue to engage with all partners and stakeholders to ensure this commitment is achieved.

Dr Byakika ( MOH) appreciating the SPEED and participants

Prof. William Bazeyo – Deputy Vice Chancellor, Makerere University The Deputy Vice Chancellor thanked everyone for putting aside the three days to participate in the symposium. He more specially thanked delegates who had travelled from other countries to be part of the symposium, including colleagues from ITM, Antwerp who have been long-time friends and partners of Makerere University particularly the School of Public Health. He further thanked National Planning Authority for participating in the symposium and encouraged them to embed the issues discussed into the new plan that currently is being developed. Prof. Bazeyo also congratulated Prof. Ssengooba, the SPEED director, and team for coming up with a symposium statement and challenged everyone to own the statement and take forwards the lessons learnt. Prof William Bazeyo (Ag. Deputy Vice Chancellor, Finance & Administration, Makerere University)

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On behalf of Makerere University, Prof. Bazeyo appreciated Government for the commitment it made to fund research and innovation from Government Budget. He announced that Government had allocated up to UGX 30 Billion in 2019/2020 financial year and already researchers are putting together ideas to respond to Uganda’s challenges. With this allocation, the University was poised to be relevant to government and hoped this funding would continue even in the subsequent years. He therefore challenged the policy makers in MOH and the rest of Government to partner with Makerere, and bring forth the questions and outstanding issues that need research evidence, and Makerere would address them through this new funding platform.

A group photo of the participants from the Thanzi la Onze group (University of York) and dignitaries at the closing ceremony

Finally, the DVC appreciated the European Union for the funding for not only SPEED but also for other programmes of Makerere and Government. To him, these are the kinds of smart partnerships that should be encouraged and taken forward because they provide an opportunity to work together, but also learn together. He wished every participant journey mercies back to their respective destinations and officially closed the symposium.

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Awards AWARDS

Ms. Wikitoria ( University of York) being recognised as the Prof Bazeyo handing a certificating to Prof. Ssengooba 2nd best presenter

Mr Katumba Kenneth (MRC- Uganda) recognized as the Handing over the Certificate for Ms. Lilian Magezi for being best presenter her outstanding journalistic work on UHC

Group Photo at the Closing Ceremony

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Symposium Participants

No Name Organization Email 1 Ahimbisibwe Expeditus MOH [email protected] 2 Aineomugisha Elizabeth MakSPH [email protected] 3 Alex Ssempuuma Creation Media 4 Allana Kembabazi ISSER [email protected] 5 Aloysius Ssennyonjo SPEED Manager [email protected] 6 Alule James RBF-FP [email protected] 7 AMA POKUAA FENNY University Of Ghana, ISSER [email protected] 8 Andrew Weil Semulimi Student [email protected] 9 Angela Kisakye MakSPH [email protected] 10 Angella Nanyanzi MakSPH [email protected] 11 Anita Kaluba Ministry of Health Zambia [email protected] 12 Apio Brenda MOH /Economist [email protected] 13 Arthur Rutaro AFHEA [email protected] 14 Aziz Maija Majex Investments Ltd [email protected] 15 B.Nawangwe VC Muk 16 Babirye Susan MakSPH [email protected] Uganda Health 17 Baguma TR [email protected] Communication Alliance 18 Bahireira Sylvia RBF/FIP KAMWENGE [email protected] 19 Balizzakiwa Thomas MakCHS [email protected]

20 Bart Criel Institute Tropical Med Antwerp [email protected] PARTICIPANTS SYMPOSIUM 21 Batte Martin Zinabala Makerere University [email protected] 22 Bernard .W. Byagageire PATH-ABH [email protected] 23 Birungi Joy AUB-University [email protected] 24 Bosco Turyamureba MakSPH [email protected] 25 Bramali Mark Bonny BTC [email protected] 26 Brendan Kwesiga MOH [email protected], [email protected] 27 Bumba Ahmed DHO-Kibuku [email protected] 28 Byaruhanga Chris Kabarole-RBF FP [email protected] 29 C G Orach MakSPH [email protected] Campos da Silveira 30 Institute of Tropical Medicine [email protected] Valéria 31 Carol Makerere University [email protected] 32 Catherine Mbabazi SPEED Fellow [email protected] Queen Mary University 33 Catherine Fung [email protected] London 34 Charles Ssemugabo MakSPH [email protected] 35 Chickna Toure R4D [email protected] 36 Chris Atim AFHEA [email protected] 37 Christine K Tashobya MakSPH [email protected] 38 Christine Namayanja Abt Associates [email protected] 39 Christopher Tusiime The Observer [email protected] 40 Criel Bart Institute of Tropical Medicine [email protected] 41 Cynthia Charchi [email protected] 42 Darinka Perisic WHO-Zambia [email protected]

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No Name Organization Email 1 Ahimbisibwe Expeditus MOH [email protected] 2 Aineomugisha Elizabeth MakSPH [email protected] 3 Alex Ssempuuma Creation Media 4 Allana Kembabazi ISSER [email protected] 5 Aloysius Ssennyonjo SPEED Manager [email protected] 6 Alule James RBF-FP [email protected] 7 AMA POKUAA FENNY University Of Ghana, ISSER [email protected] 8 Andrew Weil Semulimi Student [email protected] 9 Angela Kisakye MakSPH [email protected] 10 Angella Nanyanzi MakSPH [email protected] 11 Anita Kaluba Ministry of Health Zambia [email protected] 12 Apio Brenda MOH /Economist [email protected] 13 Arthur Rutaro AFHEA [email protected] 14 Aziz Maija Majex Investments Ltd [email protected] 15 B.Nawangwe VC Muk 16 Babirye Susan MakSPH [email protected] Uganda Health 17 Baguma TR [email protected] Communication Alliance 18 Bahireira Sylvia RBF/FIP KAMWENGE [email protected] 19 Balizzakiwa Thomas MakCHS [email protected] 20 Bart Criel Institute Tropical Med Antwerp [email protected] 21 Batte Martin Zinabala Makerere University [email protected] 22 Bernard .W. Byagageire PATH-ABH [email protected] 23 Birungi Joy AUB-University [email protected] 24 Bosco Turyamureba MakSPH [email protected] 25 Bramali Mark Bonny BTC [email protected] 26 Brendan Kwesiga MOH [email protected], [email protected] 27 Bumba Ahmed DHO-Kibuku [email protected] 28 Byaruhanga Chris Kabarole-RBF FP [email protected] 29 C G Orach MakSPH [email protected] Campos da Silveira 30 Institute of Tropical Medicine [email protected] Valéria 31 Carol Makerere University [email protected] 32 Catherine Mbabazi SPEED Fellow [email protected] Queen Mary University 33 Catherine Fung [email protected] London 34 Charles Ssemugabo MakSPH [email protected] 35 Chickna Toure R4D [email protected] 36 Chris Atim AFHEA [email protected] 37 Christine K Tashobya MakSPH [email protected] 38 Christine Namayanja Abt Associates [email protected] 39 Christopher Tusiime The Observer [email protected] 40 Criel Bart Institute of Tropical Medicine [email protected] 41 Cynthia Charchi [email protected] 42 Darinka Perisic WHO-Zambia [email protected] 43 Daniel Lukooya MakSPH [email protected] 44 Danielle Bloom Results for Development [email protected]

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45 David Ogubi IHSU [email protected] 46 Denis Kibira ED-HEPS-UGANDA [email protected] Primature, Cabinet du Premier 47 Dieudonné Kwete [email protected] Ministre Insititue of Development 48 Dimitri Renmans [email protected] Policy 49 Doreen Tuhebwe MPH Field Co-ordinator [email protected] 50 Dorothy Balaba PACE/PSI [email protected] Society of Private Medical and 51 Isaac C. N. Morrison [email protected] Dental Practitioners 52 Drileba Paul DHO Arua [email protected] 53 Edna Joyce Nagaddya Makerere University [email protected] 54 Ekwaro A Obuku UMA [email protected] [email protected], elisa.rutalingwa@ 55 Elisa Rutalingwa BTC btccb.org 56 Elizabeth Ekirapa MakSPH [email protected] 57 Elizabeth Ongom EU [email protected] 58 Emmanuel Mugisha PATH [email protected] 59 Emmanuel Ochola St.Mary’s Hospital Lacor [email protected] Management Sciences for 60 Emmanuel Tieh Delamy [email protected] Health - MSH 61 Enid Kemari SPH [email protected] 62 Enyaku R WB [email protected] 63 Eric Ssegujja MakSPH [email protected], [email protected] 64 Espilidon Tumukunde USAID [email protected] 65 Esther Buregyeya MakSPH [email protected] 66 Etrima Sunday Parliament [email protected] 67 Eve Jagurewics Independent consultant [email protected] MAKERERE SCHOOL OF 68 EVELYNE NYACHWO [email protected] PUBLIC HEALTH 69 Everd Maniple [email protected] 70 Eyomu Silver MakSPH [email protected] [email protected], filippocurtale@sanugit. 71 Filippo Curtale UNDP PULSE LAB com Firimooni Rweere [email protected], [email protected]. 72 Bishop Stuart University Banugire ac.ug 73 Frances Ilika USAID, HFG HFA [email protected] 74 Francis Omaswa ACHEST [email protected] 75 Freddie Ssengooba Director Speed Project [email protected] 76 Galbert Fedjo BTC/Uganda [email protected] 77 Garoma Kena USAID [email protected] 78 Gemma Ahebwa EPRC [email protected] 79 George kiwanuka MakSPH [email protected] Private Sector, Federation of 80 George Tamale [email protected] Uganda 81 Georges KONE HFG/USAID, Abt Associetes [email protected] 82 Gerald Karegyeya PWC-Uganda Voucher Plus [email protected] 83 Gideon Olaya BTC [email protected] 84 Gladys Khamili MakSPH [email protected]

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ED, Uganda Health Care 85 Grace S Kiwanuka [email protected] Federation 86 Graham .D. Tugume Watoto [email protected] 87 Ibingira Charles MakCHS/ Principal [email protected] 88 Ibrahim Kasirye EPRC [email protected] 89 Irye Dumateri FCC BTC [email protected] 90 Itaaga Lydia A MakSPH [email protected] 91 Jacinta Sabiiti MOH [email protected] 92 Jane Ruth Aceng MOH/Minister [email protected] 93 Jeff Kabinda CCSC-DRC [email protected] 94 John Agaba New vision [email protected] 95 John K.W. Waswa NIRA john.waswa.nira.og 96 John Kasibante Gulu University [email protected] 97 John Ssekamatte NPA [email protected] 98 Jonathan Nkalubo MakCHS [email protected] 99 Joseph Akuze MakSPH [email protected] 100 Joseph Wamala BTC [email protected] 101 Jude Bigirwenkya PATH [email protected] 102 Judith Alyek MP [email protected] 103 Judith Mutabazi NPA [email protected] 104 Juliet Nabirye MakSPH [email protected] 105 Julliet Nabyonga WHO [email protected], [email protected] 106 Justine Mirembe UPMB [email protected], [email protected] 107 Justine Namakula Research Fellow/ MakSPH [email protected], [email protected] 108 Kabir Sheikh PHFI [email protected] 109 Kabunga Fahad Media [email protected] 110 Kaganda Paschal MakSPH [email protected] 111 Kaitirimba Robinah ED UNHCO [email protected] 112 Kakaire Ayub Kirunda MakSPH [email protected], [email protected] 113 Kamateeka Jovah MP Mitooma [email protected] 114 Kamya Ivan DHO Kiruhura [email protected] 115 Kasirye Gerald UBC TV [email protected] 116 Kasirye Juliet New Vision Photographer [email protected] 117 Kasyaba Ronald UCMB [email protected] 118 Kathy Kantengwa The Globa Fund [email protected] 119 Kebirungi Sally Sandra MakSPH [email protected] 120 Kirigwajjo Moses UNHCO [email protected] 121 Lillian N Magezi Newvision [email protected] 122 Lydia Kabwijamu MakSPH [email protected] 123 Lydia Namulondo BTC [email protected] 124 Lyne Kay NAFOPHANU [email protected] 125 Lynn Atuyambe MakSPH [email protected] 126 Martha Akulume MakSPH [email protected] 127 Marvin Kansiime MakSPH [email protected] 128 Mayora Chrispus MakSPH [email protected] 129 Milly Nattimba MakSPH [email protected] Mbarara University of Science 130 Mirembe Joel [email protected] and Technology

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131 Monica Okuga MakSPH [email protected] 132 Monika David L.G.A [email protected] 133 Moses Mukuru MakSPH [email protected] 134 Moses Tetui Researcher-MakSPH [email protected] 135 Muganda Ayubu MakSPH [email protected] 136 Muhindo Zuura BDLG-BBF [email protected] 137 Mukisa Allan Makerere [email protected] Center For Health, Human 138 Mulumba [email protected] Rights and Development 139 Mutebi Aloysius Research Fellow/ MakSPH [email protected] 140 Mutoni Suzan MakSPH [email protected] 141 Mutumba Samuel Creation Media [email protected] 142 Mwaka Agoba BTC MOH [email protected] 143 N M Tumwesigye MakSPH [email protected] 144 Nabaggala Aisha MakSPH [email protected] 145 Nahalamba Sarah National Planning Authority [email protected] 146 Najjuko Suzan MOH /Senior Economist [email protected] 147 Nakaayi Agnes Health Partners Uganda [email protected] 148 Nakasiko Esther MakSPH [email protected], [email protected] 149 NAKAZIBWE BRENDA MakSPH [email protected] 150 Nakiwala Stella Regina Health Partners Uganda [email protected] 151 Namanya B Didacus MOH [email protected] 152 Nampijja Prossy Makerere University [email protected] 153 Namubiru Leticia MakSPH [email protected] 154 Namuhani Noel MakSPH [email protected] 155 Namulondo Proscovia Save For Health Uganda [email protected] JSI-Research and Training 156 Nancy Adero [email protected] Institution Inc. 157 Nansamba rukia UMMB [email protected] 158 Nanyondo Veronica MP Bukomansimbi [email protected] 159 Nasasira John MP (Parliament) [email protected] 160 Nasasira John Parliament [email protected] Makerere University School of 161 Ndagire Margaret [email protected] Public Health Civil Society, Private - Private 162 NIIWO SAMUEL [email protected] Sector Forum 163 Ninsiima Evas MakSPH [email protected] 164 Niyongabo Filimin MakSPH [email protected] 165 Njuguna David Ministry of Health [email protected] 166 Nkalubo Jonathan MakCHS [email protected] 167 Nsamba Patrick O MPKasambya County [email protected] 168 Nsereko Vicent MakCHS [email protected] 169 Ntuuyo Arajabu Student 170 Obed Katureebe Uganda Media Center [email protected] 171 Obol James Henry Gulu University [email protected] 172 Olaro Charles MOH [email protected] 173 Olive Kobusingye MakSPH [email protected] 174 Oloya Denis Koboko DLG [email protected] 175 Omar Mohamed Ministry of Health, Kenya [email protected]

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Omoding Patrick Ministry of Tourism, Wildlife 176 [email protected] Jonathan and Antiquities 177 Opolot Mouris EPRC [email protected] 178 Owomugisha Paula MUST [email protected] 179 Patrick Birungi Director NPA [email protected] 180 Patrick Kadama ACHEST [email protected] 181 Patrick Mwanza SELF [email protected] 182 Peter Asiimwe BTC [email protected] 183 Peter Okwero SHS-World Bank [email protected] 184 Peter Waiswa MakSPH [email protected] 185 Phyllis Awor MakSPH [email protected] 186 Prajwol Nepal Possible [email protected] Global Health Unit, Institute of 187 Pratik Khanal [email protected] Medicine, Nepal 188 Racheal Bakubi Partner Institute [email protected] 189 Rebecca Nayiga SPEED [email protected] 190 Remco Das ITM [email protected] 191 Richard Kabagambe AC/B4F (MOH) [email protected] 192 Richard Ssewakiryanga UNNGOF [email protected] 193 Robert Basaza IHSU [email protected] 194 Ronald Kamara UCMB [email protected] 195 Rutebemberwa Elizeus MakSPH [email protected] 196 Rwabwogo Sylvia MP [email protected] Commuity Health Alliance 197 Sam Asiimwe Mugalura [email protected] Uganda (CHAU) 198 Sam Orach Executive Secretary UCMB [email protected] 199 Sebastian O Baine MakSPH [email protected] Namutumba district local 200 Serunjogi Brian [email protected] government 201 Seruwagi Gloria MakSPH [email protected] 202 Simon Kasasa MakSPH [email protected] Makerere University, School of 203 Simon Kibira [email protected] Public Health 204 Ssemuyaba John Bosco Student KIU [email protected] 205 Stella Kakeeto MakSPH [email protected] 206 Stephen Asiimwe ICOBI [email protected] 207 Stephen Mwanje Rotary International [email protected] 208 Steve Kasiima Uganda Police [email protected] 209 Sudat Kaye UBC TV [email protected] 210 Susan Tusiime TMR International Hospital [email protected] 211 Suzanne Kiwanuka MakSPH [email protected] 212 Swaleh Sebina MOH Economist [email protected] 213 Sylvester Mubiru MOH [email protected] 214 Sylvia Bahireira RBF-FP [email protected] Federation of Uganda 215 Tamale George [email protected] Employers 216 Taremwa Kelly MUST [email protected] 217 Tebandeke Grace UNACOH [email protected] 218 Tefula Trevor Kwagala Makerere University [email protected]

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219 Thomas Walusimbi MOH [email protected] 220 Timothy Musila MOH [email protected] 221 Tom Aliti MOH [email protected] 222 Tonny Odokonyero EPRC [email protected] 223 Toure Chickna R4D [email protected] 224 Trevor Ariho UNIHEALTH (U) LTD [email protected] 225 Tweheyo Raymond MakSPH [email protected] 226 William Bazeyo MakSPH [email protected], [email protected] 227 Rhona Mijumbi MakCHS [email protected]

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SYMPOSIUM ORGANISING COMMITTEES Steering Committee Publicity and Communication 1. Prof. Freddie Ssengooba (Chair) 1. Ms. Lilian Magezi (Chair) 2. Dr. Aloysius Ssennyonjo (Vice-Chair) 2. Mr. Mayora Chrispus (Vice chair) 3. Prof. Elizeus Rutebemberwa 3. Milly Nattimba 4. Dr. Elizabeth Ekirapa 4. Mr. Richard Ssempala 5. Mr. Tony Odokonyero 5. Mr. Marvin Kansime 6. Dr. Timothy Musila (MOH) 6. Ms. Lydia Namulondo (BTC) 7. Mr. Marvin Kansime 8. Ms. Milly Nattimba Logistics & Resource Mobilization 1. Prof. Freddie Ssengooba (Chair) Scientific Committee 2. Ms. Enid Kemari (Vice Chair) 1. Dr. Aloysius Ssenyonjo (chair) 3. Dr. Aloysius Ssennyonjo 2. Elizabeth Ekirapa 4. Ms. Stella Kakeeto 3. Dr. Christine Kirunga 5. Ms. Lydia Itaaga 4. Mr. Mayora Chrispus 5. Mr. Marvin Kansime 6. Prof. Ellie Rutebemberwa 7. Mr. Tony Odokonyero 8. Ms. Judith Mutabazi 9. Dr. Hamis Mugendawala 10. Prof. Freddie Ssengooba

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For details about SPEED Makerere University School of Public Health, College of Health Sciences Level 3, School of Public Health Building, Mulago Hospital Complex Office: Room 323, MakSPH Building Website: www.speed.musph.ac.ug

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