The Uganda Experience
Context and Health Workforce Challenge
The HRH Action Framework (HAF) application process in Uganda, which began in September 2007, took approximately one year to complete. The process followed a four phase protocol called ‘HAF in Countries’ (See Annex 1). The Ugandan Minister of Health provided his support in the summer of 2007, allowing for the in-country preparation in September 2007. The Ugandan HRH Strategic Plan 2005-2020 (HSP) had just been published.
The Ugandan Health Workforce (HW) shows serious shortcomings. Its size is less than 50% of the minimum recommended by the World Health Organization (WHO); 70% of the doctors and 40% of the nurses serve only 12% of the population, and productivity is low. In spite of its comprehensive nature and the involvement of many stakeholders in the production of the HSP, this plan did not propose interventions to resolve these major workforce problems. The main reason was that the HSP was forced into the Long Term Expenditure Framework (LTEF) which capped growth of the Health Budget until 2020. The budget was expected to increase at only about the same rate as the projected growth of the Ugandan population.
HAF Application: Methodology and Process
During the actual HAF application the following key strategic outcomes were considered to be of primary importance:
- Convince the Ministry of Health(MOH), and others, that the capped HSP would not bring much change and that political debate had to be pursued by presenting alternative scenarios (See Annex 2).
- Take care that all activities are country-led initiatives. Consequently, a MOH led Leadership Team (See Annex 3) was formed consisting of a Policy Team (in view of the political nature of the LTEF) and a Technical Leadership Team; existing structures were used for these two functions.
- Make sure that the HAF application outcomes become, like the HSP, part of the national planning & budget cycles, and thus are positioned as a HSP Supplement 2009.
For the HAF based analytical work, the MOH created, following the HAF Action Fields, six multi-sector analysis subgroups. These groups met for 3 days, using a HAF guide (See Annex 4), to complete their analyses.
Two opportunities proved to be important stepping-stones towards impact on the Ugandan health workforce. The first was the Global Health Workforce Alliance Partners Forum held in March 2008 in Kampala. It strongly motivated the MOH and other policy makers to maximize health workforce strengthening efforts. The second was the Master Plan for Accelerating Performance in the Health Sector (See Annex 5), a document, which appeared around the same time, written by request of the President.
The fact that the HRH crisis was presented in the Master Plan at the centre of all health sector problems (See Annex 5) resulted directly from the key messages emerging from the ongoing HAF application. This HRH crisis signaled in the Master Plan provoked a response from the Presidential level acknowledging the problem and providing some seed funding. In the fall of 2008, Uganda and the World Bank came to agreement on a loan of $100 million per year for five years to improve the health system. Health workforce strengthening will be at the center thereof. Applying the HAF at the country level aims precisely at such an impact.
Annex 1: HRH Action Framework in Countries