The Cohabitation of the Profit and Voluntary Private Sector Providers in the Delivery of Health Care in Eastern Africa:

Insight from Uganda Frederick Mwesigye Center for Basic Research

Kampala, Uganda

Government support for social services, mainly health care, has dramatically declined since the early 1970s. This deterioration of the health system in Uganda is only partly due to the complex legacy of bad post-colonial rule which helped to push the country into political, economic and social turmoil.

1960 1990: The rise and fall of the health sector in Uganda

From a historical perspective, several scholars have argued that by 1962 Uganda, with 27 hospitals and a staff of 1,288 serving a population of 7 million people, offered the best health service network in sub Saharan Africa (Nabuguzi, 1995; Owor, 1987). With the addition of 22 hospitals during the subsequent early years of independence, Ugandas health service system was steadily growing and quite promising. During that time, the government saw itself as the motor of development and the provider of services. Its strategy included centralizing political and economic activities, secularizing education and health institutions and restricting non governmental activities in general. However, events transpired resulting in turmoil in service provisions and the public sectors. In the period of 1971-1986, during the regime of Idi Amin and the subsequent instability that followed his ouster, economic decline and anarchy were prevalent. This in turn led to the collapse of government services. Some examples of these worsening conditions are: a) hospitals were affected by both the expulsion and immigration of trained personal. From 1972 to 1996, the number of doctors dropped from 1171 to 964; with a population ratio more than doubling from 1:9090 up to 1:20228; b) though the number of nurses increased slightly from 3877 to 4059, the population ratio again rose from 1:2745 to 1:4804. Similarly, for mid-wives and medical assistants the population ratio rose from 1:3917 to 1:7431 and 1:24457 to 1:29367 respectively; c) for rural health centres and dispensaries [which never had resident doctors or pharmacists] the most severe problem was the lack of medical supplies. In 1988, a WHO Report estimated that these government health units dropped by half between 1976 and 1988; and attributed this drop to a gross shortage of drugs. Private and informal enterprises emerged to meet Ugandas unsatisfied health services, primarily involving health personal employed in government services. Self medication also increased dramatically. The traditional medicines, which predates the advent of Western medicine and had been restricted to only localized

use through colonial government legislation, saw a renewed use during this period. By the early 1980s, the health service sector had deteriorated beyond what even the most pessimistic predictions have made. Additionally insecurity and civil strife worsened, the economy rapidly declined, and other state run services collapsed giving rise or resulting in complicated informal solutions. In 1987 the newly installed NRM Government appointed a thirteen man commission to review, examine and inquire into the health system and its policies with a view to recommending reforms in the health system. This Commission considered views from 260 individual respondents, several interest groups, over 150 written memoranda as well as more than 50 written papers. Amongst its subsequent recommendations this Commission recommended the following: i) ii) implementation of primary health care policies through inter-sectoral and inter-Ministerial collaboration; and, improvement in maternal and child health care services by insuring that all health care units in the country provide such services, including family planning while training and supporting traditional birth attendance; and, decentralization of authority and transfer of financial control to the districts; and, close cooperation between the Ministry of health and the traditional practitioners; and, encouraging alternative sources of financing, mainly through costsharing; and, community participation through health committees.

iii) iv) v) vi)

1993- Present: Looking for Solutions

Following the Commissions Report, the Government seemed committed to implementing the recommendations, but it achieved little success. For example, in 1989 the Government introduced a strategy to increase financing for health mainly by charging the users [cost-sharing]. This particular strategy was defeated in Parliament and the Government shelved it. In 1993 another Government White Paper on health stressed primary health care [PHC] as the main goal. However the allocation of budget funds does not reflect this as a priority. Most of the Government money was allocated to curative services, leaving only multilateral and bilateral donors funding for PHC. Between 1992 and 1996, donors funds for PHC averaged 82% of the their total requirements, while the Government allocated and average of 22% of their budget to this goal.

During this time period, decentralization was initiated in 13 Districts on an experimental basis. Under the decentralization policy, these Districts were mandated to formulate, approve and execute their own development plans. These plans were to be comprehensive, while incorporating local governments needs, and all to fit within the parameters of the National Development Plan. These plans were all submitted to the national planning authority. Where implementation and supervision were made at the District level, a further mandate was also granted to raise finances though District revenue sources are very limited. This had to be with the concurrence of the local governments. And was achieved through fees and taxation, receiving donations, or taking loans that did not exceed 25% of locally raised revenues. These Districts would then approve and execute their own budget. Starting in 1997-98, Districts were also allowed to run District hospitals. They could also determine the structure of the District civil service through opening or closing service points, recruiting and transferring personal and adjusting salaries. These steps were also to be within conformity of the National Policy Guidelines. As a result, by this time Districts were actively involved in: curative services; health centers; dispensaries and aid posts; and, maternal and child health care in addition to PHC.

The New Cohabitation of Private and Public Actors in the Health Sector in Uganda

Uganda has experienced other extensive social and economic reforms primarily inspired by neo-liberal thought. In the health service sector, the major reform of decentralization had been complicated by the issues of integration of the nonstate actors. A great variety of such practitioners, both profit and non-profit making, have emerged to fill the gap left by the ever shrinking state delivery system. These have combined to create a kind of jungle of service providers outside of the public service provision area. It is still not clear what role they play and which gaps they fill. Recent studies have shown that in fact the majority of rural Ugandans benefit from very little established health units and personal. Likewise, those in urban areas still face very significant service shortages, however they have access to more drug shops (Mwesigye, 2002). Non-State and not for profit health service providers can be national or international organizations. It has to be noticed that in most cases those providers do not own or operate the facilities they work from. They support and/or undertake development activities in partnership with either the local or central government

health facilities; or other private not for profit providers, or communities. A wide range of services are either offered or supported ranging from social awareness and advocacy to more specific disease control programs, emergency and relief, training, funding support, etc. The providers are: a) International Fixed- term and Resident Not for Profit Providers: Fixed-term providers are mainly international NGOs and agencies with theoretically time limited programs. Some think they should not become permanent providers, though it is increasingly difficult to phase out through handing over to resident resources. Earlier studies have found that the very complex process of phasing out and integrating these programs into the existing publicly run ones is usually due to the vertical and autonomous nature of such programs. There are also significant technical and financial constraints to taking over such programs by the central or local governments (de Torrente & Mwesigye, 2000). The other international providers with long term health programs offered over an indefinite period of time are largely funded by multilateral or bilateral donors or foundations, and also by self generated funds. Good examples are: AVSI, CARE, CUAMM, OXFAM, SAVE THE CHILDREN FUND, etc b) National Not for Profit Providers These national NGOs and development agencies implement programs at the national level and/or in various parts of the country. This also includes national umbrella organizations, and national faith-based organizations. Examples include: TASO, AIC, FPAU, UCBHCA, UNASO, Uganda Protestant Medical Bureau, Roman Catholic Church, etc. Faith-based organizations are in this category, but unlike other national actors, have been pioneers in the health sector and continue to have well established infrastructures. Non State actors can also be local actors. These NGOs and community based groups work only at the local level not exceeding one District and carry on programs similar but smaller than international and national NGOs and agencies. Of course, this description has to be completed by taking in account the for profit sector. Made of both professional and non professional individuals, this sector provides services with a profit motive. They usually work from small scale clinics and drug shops, and provide almost exclusively curative services. As well, traditional healing remains an important aspect of health services in Uganda. Though very hard to define, given the great variety of services offered, these healers work from a spiritual and traditional basis.

All the actors previously mentioned are taking more of the centre stage compared to their previous filling of the gap role and their integration into the health system is both unclear and intricate. While the proliferation of these actors was largely precipitated by the near total collapse of the state led health service delivery apparatus and the very slow process of revamping, the neo-liberal approach also plays a role in the phenomena of more actors in the health sector. One of the principal tenets of the neo-liberal approach is that the state must drop its monopoly of service delivery and adopt a Sector Wide Approach (SWAP) where all the actors form partnerships. Such partnerships should also spell out the roles and obligations of each actor. The National Health Policy makes explicit reference to the public/non public partnership. It assumes that, under this division of roles and responsibilities, partnerships mechanisms are a given and that non state actors have specific binding obligations. This is a faulty logic as: a) most non state actors are voluntary. They only choose to do what they wish to do and establish themselves in areas they select, putting at risk geographical and equitable distribution of services; b) until recently, most non state actors have been the partners of choice for both multilateral and bilateral donor agencies. These agencies were also concerned with their own priorities. Recently though there has been movement in supporting the emerging national priority areas and goals; c) non state actors are shifting from direct service delivery to capacity building, technical assistance and advocacy. All of which are less clearly defined for accountability purposes.

Challenges

The progressive move to SWAPs and central budget support mechanisms means that fewer donor resources are now directly available to the non state actors especially the national local and community level. Does this mean that a significant number of actors may be forced to move out of the health sector in a near future? Governments capacity to itself deliver health services is hampered by: low revenue base; ineffective priority setting process; lack of living wages for government employees; and, extremely low rural income. Can support for improved public sector services be increased while the government strengthens the financing of its economic base? The general assumption is that non state actors, excluding faith-based organizations, filled the gap. Recent studies (de Torrente & Mwesigye, 2000) show that NGOs in fact, increase their activities in areas where they can find

money. Accordingly, can it be said that gaps become the deserted areas of services? It is also been asserted that non state actors have a comparative advantage with lower operating costs than the state. The Ugandan Government owns and controls more than 65% of the health service system infrastructures, other facilities being owned by faith-based organizations who benefit from an historical advantage. As a matter of fact, a recent UNICEF study indicates that the non state facilities have higher operating costs than state run facilities. Would acknowledging the actual cost-advantage of publicly run health facilities provide an argument for a shift in defining the best way to support the development of health services in Uganda and in other Eastern African countries?

REFERENCES

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Mwesigye F., Health-Care financing : the Role of User Charges and Health Insurance, 1997, Kampala, unpublished Research Report. Mwesigye F., Effects of User-Charges on Quality of Curative Services: A Perspective of Ugandas Rural Health Units, 1995, Kampala, Unpublished Research Report. Okuonzi S. & Lubanga F.X.K., Decentralization and Health Systems Change in Uganda: A Report on the Study to Establish Links Between Decentralization and Changes in the Health System, 1995, Kampala, Unpublished Research Report. WORLD BANK, Financing Health Services in Developing Countries: An Agenda for Reform, Washington D.C., 1992.