Analysis Resilience and high performance amidst conflict, epidemics and extreme poverty The Lacor Hospital, Northern Uganda Volker Hauck John Saxby Pretoria, South Africa A case study prepared for the project ‘Capacity, Change and Performance’ Discussion Paper No 57A September 2004 European Centre for Development Policy Management Centre européen de gestion des politiques de développement Study of Capacity, Change and Performance Notes on the methodology The lack of capacity in low-income countries is one of the main • External context:How has the external context- the constraints to achieving the Millennium Development Goals. historical, cultural, political and institutional environment, Even practitioners confess to having only a limited and the constraints and opportunities they understanding of how capacity actually develops. In 2002, the create - influenced the capacity and performance of the chair of Govnet, the Network on Governance and Capacity organisation or system? Development of the OECD, asked the European Centre for • Stakeholders:Whathas been the influence of stakeholders Development Policy Management (ECDPM) in Maastricht, the such as beneficiaries, suppliers and supporters, and their Netherlands to undertake a study of how organisations and different interests, expectations, modes of behaviour, systems, mainly in developing countries, have succeeded in resources, interrelationships and intensity of involvement? building their capacity and improving performance.The • External interventions:How have outsiders influenced the resulting study focuses on the endogenous process of capacity process of change? development - the process of change from the perspective of • Internal features and key resources:Whatare the patterns those undergoing the change.The study examines the factors of internal features such as formal and informal roles, that encourage it, how it differs from one context to another, structures, resources, culture, strategies and values, and and why efforts to develop capacity have been more successful what influence have they had at both the organisational in some contexts than in others. and multi-organisational levels? The study consists of about 20 field cases carried out according The outputs of the study will include about 20 case study to a methodological framework with seven components, as reports, an annotated review of the literature, a set of follows: assessment tools, and various thematic papers to stimulate • Capabilities:How do the capabilities of a group, new thinking and practices about capacity development.The organisation or network feed into organisational capacity? synthesis report summarising the results of the case studies will • Endogenous change and adaptation:How do processes of be published in 2005. change take place within an organisation or system? • Performance:Whathas the organisation or system The results of the study, interim reports and an elaborated accomplished or is it now able to deliver? The focus here is methodology can be consulted at www.capacity.org or on assessing the effectiveness of the process of capacity www.ecdpm.org. For further information, please contact development rather than on impact, which will be Ms Heather Baser ([email protected]). apparent only in the long term. The simplified analytical framework External context Stakeholders Core variables Capabilities Endogenous Change and Performance adaptation External intervention Internal features and resources Resilience and high performance amidst conflict, epidemics and extreme poverty The Lacor Hospital, Northern Uganda Volker Hauck A case study prepared for the project 'Capacity, Change and Performance' September 2004 ii Contents Acronyms iv Acknowledgements iv Preface v Summary vi 1Introduction 1 2Background 2 3 External context and integration into the national health system 3 4Internal organisational features 5 5The influence of outside stakeholders 8 6Endogenous change and adaptation 11 7Emerging capabilities 13 8Performance 16 9Final comments 18 Epilogue 21 Annex I: Fact sheet Lacor Hospital 23 Annex II: Individuals interviewed 26 Annex III: The Board of Lacor Hospital 27 References 28 This study was undertaken by ECDPM in the context of the OECD/DAC study on Capacity, Change and Performance. Following the completion of the study, the Piero and Lucille Corti Foundation financed the publication of the paper and funded the participation of the author at the strategic workshop at Lacor Hospital in 2004. The European Centre for Fondazione Piero e Lucille Corti Development Policy Management Via N. Torriani, 6 Onze Lieve Vrouweplein 21 I-20122 Milano, Italy NL-6211 HE Maastricht, The Netherlands Tel +39-02-67076722 Tel +31 (0)43 350 29 00 [email protected] Fax +31 (0)43 350 29 20 www.lacorhospital.org [email protected] www.ecdpm.org iii Discussion Paper No. 57A Capacity Study Analysis Acronyms AISPO Associazione Italiana per la solidarietà tra i Popoli DAC Development Assistance Committee (OECD) DHA district health authorities ECDPM European Centre for Development Policy Management IMF International Monetary Fund LRA Lord's Resistance Army NGO non-governmental organisation PNFP private not-for-profit OECD Organisation for Economic Cooperation and Development SWAp sector-wide approach TA technical assistance UCMB Uganda Catholic Medical Bureau UEC Uganda Episcopal Conference UMMB Ugandan Muslim Medical Bureau UPMB Ugandan Protestant Medical Bureau Acknowledgements The author wishes to thank all of those who spared their valuable time to be interviewed, who provided in- depth views, who shared documents and to those who made the effort to travel to Kampala for interviews with the author in June 2003. The names of staff, board members and other resource persons who provided inputs to this study are listed in Annex II. Thanks also to all stakeholders of the hospital who provided valu- able comments on the draft report and who helped to verify the content of the text. A word of appreciation goes also to the staff of the logistics office of the Lacor Hospital in Kampala, who provided efficient support in organising the interviews and the author's visit to Lacor in May 2004. A final word of thanks goes to the ECDPM core team for the wider study on Capacity, Change and Performance, to Heather Baser, ECDPM Programme Coordinator, and to ECDPM Associates Peter Morgan and Tony Land. They accompanied this research and provided stimulating comments and reflections prior to and during the writing of this report. Valerie Jones has been a most patient and capable editor. While this study contains many inputs from Lacor Hospital stakeholders and the study team, the sole responsibility for the interpretation of data and their analysis rests with the author. iv Capacity Study Analysis Discussion Paper No. 57A Preface The idea to undertake this study of St Mary's ment, staff of the Uganda Martyrs' University Hospital, known locally as Lacor Hospital, was born (known locally as Nkozi University) and ECDPM have during an informal encounter in Milan between the developed a plan to encourage such reflection. It author and Dr Dominique Corti. She is the daughter will be implemented during the course of of Dr Piero Corti and Dr Lucille Teasdale, who arrived 2004/2005. in Uganda in 1961 with the vision to build and to run a medical centre of excellence to serve the poor Third, the results of this case could be communica- in the north of the country. The encounter in Milan ted to an international audience concerned with provided for a first exchange on the Lacor Hospital, the design of policies and strategies aimed at which seemed to be an extraordinary example of conflict prevention and the stabilisation of fragile resilience and high performance amidst conflict, environments. The Lacor case is important for two epidemics and extreme poverty. It was followed up reasons. First, it is the example of a private organi- by a more structured exchange of information and sation that stands at the front line in the effort to documents, from which it soon became clear that a combat poverty, misery and despair, and which study of the Lacor Hospital could serve three pur- supplements insufficient government services. poses. Being located in the centre of a civil war in a region that has been severely destabilised by the Lord's First, it could provide inputs for a wider programme Resistance Army rebels and not far from war-torn of the European Centre for Development Policy southern Sudan, it is an outpost of hope for the Management (ECDPM), entitled Capacity, Change Ugandan people and provides some stability to the and Performance, which seeks both to provide prac- region. The case also highlights the consequences of tical guidance on capacity and capacity develop- the Ugandan health reform and the change in ment and, more specifically, to foster a better donor policy on the funding of organisations like understanding of the interrelationships between Lacor. While the hospital management and the capacity, organisational change and performance. board expressed full agreement with the govern- Undertaking a case study of Lacor Hospital was ment's health policy, which aims to extend and har- seen as a unique opportunity to understand what it monise heath services throughout the country, they takes to perform effectively in a fragile environment feel the negative impact of changing donor policies characterised by conflict, epidemics and extreme with regard to budget support. They are also aware poverty. of the fragility of a new