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Civil Society presents policy paper on Primary Health Care to Parliament

A CSO policy paper on the Primary Health Care budget was presented to the parliamentary committee on health on 15th April 2014. Below is a video (click link below) with highlights of the meeting; the paper is also presented below.




Inadequate Primary Health Care – a product of planning crisis

A CSO policy paper presented to the parliamentary committee on health about the Primary Health Care budget



A call to action from policy to practice on PHC

The questions we seek to address

  1. How does policy envisage achieving a healthy population in Uganda?
  2. Is primary health care an answer to majority of Uganda’s health challenges?
  3. What was rationale of introducing PHC?
  4. Have we done what it takes to actualise it?
  5. How did we find ourselves where we are?
  6. Where do we go from here – from policy to practice?

1.0 Background

Voices for Health Rights (VHR) and partner CSOs envision A Uganda where the health Care system guarantees full enjoyment of the Right to health by all people.’ This feeds into the 2008 Ouagadougou Declaration on Primary Health Care which reaffirmed the principles of the Declaration of Alma-Ata of September 1978, particularly in regard to health as a fundamental human right and the responsibility that governments have for the health of their people. This speaks with Uganda’s Decentralisation policy of the Health sector system from the National referrals, Regional Hospitals, Health Centre IVs, IIIs, IIs, and Village health teams.

CSOs working in the health sector have had a long standing relationship with parliament and government institutions at large. Responding to the main criticism that existed by then – being critics of government without offering alternatives, towards the end of 2010 CSO deliberately shifted and (i) coordinated themselves, (ii) aligned to government priorities and (iii) have since worked constructively to support government institutions to work towards improving social services.


Significant gains have been achieved since then; (i) there is an MoU with parliament; (ii) parliament has deliberately incorporated suggestions of CSOs in its advocacy strategy, (iii) The decision to recruit more health workers and enhance their salaries; (iv) resounding resolutions on maternal and child health and; (v) your commitment to health to the extent of a standoff we saw in 2013.


We acknowledge the role of parliament in the prioritisation of social services in Uganda. We have seen commitment grow overtime both in terms of priority and oversight. We know that the budget is the opportunity to address the key needs in the country even when we acknowledge the scarcity of resources. This in itself is more compelling to have priorities set right at planning and providing sound oversight during implementation. Honourable members we now draw your attention to the heath challenges in this country. We have set ourselves 5 questions to guide our dialogue on the solutions.

Question 1: How does government policy envisage achieving a healthy population in Uganda?

  1. 1.       VISION 2040

Aspiration (d): Ugandans desire to have access to affordable quality health and education services.

“The slow progress is mainly attributed to the current health service delivery system which is facility-based. During the Vision period, there will be a paradigm shift from facility-based to a household based health delivery system…. This shift will be anchored on preventive over curative health service delivery approaches”.

  1. 2.       National development plan

Objective 2: Ensure universal access to quality UNMHCP with emphasis on vulnerable groups.

It observes; “High mortality is not due to lack of appropriate policies in Uganda but rather due to inadequate policy implementation …over 75% of the disease burden in Uganda can be prevented through health promotion and prevention… preventive interventions though cost-effective have been given adequate attention”.

  1. 3.       The second National Health Policy

The National Health Policy emphasizes that PHC remains the major strategy for the delivery of health services in Uganda because more than 75% of the overall burden of disease is preventable (NHP 1999).  Greater attention and support shall be given to health promotion, education, environmental health, enforcement and preventive interventions as defined in the UNMHCP.

  1. 4.       NRM Manifesto 2011 – 2015

In its manifesto, the ruling government says: “As a pro-people Movement, the NRM advocates for health for all the people of Uganda. The NRM policy is to prevent preventable diseases through immunization, observing good hygiene and nutrition and to provide curative medicine to those who fall sick. The NRM recognizes that a healthy population is both an input as well as a consequence of economic and social development”.

In its way forward, the ruling party suggests; “In the next five years, the NRM government will put in place measures to ensure that health services are better managed by both the central and local governments and that there is stronger coordination between the various government ministries and departments to maximize synergies and complementarities in order to consolidate these achievements and accelerate progress…”

  1. 5.       The president’s commitment – state of the nation address 2013/14

He observed; “Universal Immunization with vaccines against six preventable diseases was launched in 1987. If the Ugandans, individually and/or collectively, could add hygiene, nutrition and personal discipline (e.g. avoiding umalaya, alcohol, smoking and obesity), the total disease burden eliminated would amount to 80%. We would only remain with 20% of diseases and traumas to deal with”.


From the above, Uganda’s policy is unanimously focused on achieving a healthy population through primary health care. There are no contradictions across all policies on this. It therefore makes technical and political sense to say that the current health challenges are not routed in policy but practice.

Question 2: Is primary health care an answer to majority of Uganda’s health challenges?

From figure 1 below, there is slow progress on the health status indicators whose causes are preventable. For example; “good prenatal care can prevent up to a quarter of maternal deaths by increasing a woman’s awareness of potential complications and danger signs during pregnancy” A promise renewed… many mother do not receive any post natal care yet 60% of the maternal mortality occurs between 23 -48 csoshours after delivery” and the causes are preventable.

Question 3: What was rationale of introducing PHC?

According to Kirunga andOgwang(2003) “The health system in Uganda has undergone a number of changes since independence in 1962 and the PHC concept was a timely innovation”… Uganda adopted it after the Alma Ata conference as the focus of its health system development…with the focus of changing from provision of hospital-based care to more community oriented health services.

The health sector vision and mission are also in tandem; “A healthy and productive population that contributes to socio-economic growth and nationaldevelopment”. And “To provide the highest possible level of health services to all people in Uganda through deliveryof promotive, preventive, curative, palliative and rehabilitative health services at all levels”. MoH 2010.


PHC is the primary approach envisaged to deliver the minimum health care package in Uganda. This emphasises reorientation of the healthcare system from heavily curative to preventive care. Unfortunately, the planning and implementation has not reflected this shift, it remains said and not done.

Question 4: Have we done what it takes to actualise it?

The biggest achievement has been the enactment of relevant policies and implementation frameworks as discussed under question 1. As MoH rightly observes, the problem has been and remains with implementations. According to the NDP, “The per capita cost of providing the current UNMHCP was estimated at USD 41.2 in 2008/09. It has since remained chronically underfunded at USD 10.4 in 2009 to USD 11 (~UGX 27500/person/year) in 2013. Even the target is of USD 28 is far below the WHO costing. National Health Accounts Survey 2013.

While PHC funding has been increasing (see table 1 below), this has not significantly affected per capita expenditure partly because population has grown and this allocation is not sensitive.

Table 1: Primary Health Care Grants FY 2000/2001-2012/13 in billions of Ug. Shillings


PHC Wages

PHC (Non-Wage


General Hospitals

PHC (Dev’t Grant)





























































































Source: Approved Budget Estimates of Revenue and Expenditure – MoFPED


From the National Health Accounts for 08/09 and 09/10, expenditure on curative functions remains high with expenditure of Ushs 3,600 billion on curative functions compared to Ushs 1,413 billion on preventive functions. This is contrary to the all the policies and plans for achieving a healthy population as defined by Uganda and of course make it impossible to implement PHC.

Question 5: How did we find ourselves where we are?

The policies that needed to be made were made but they were not followed with the required budget allocation for effective implementation and it has since remained chronic underfunded to delivery any meaningful PHC seen through the crowded health facilities from the lowest to the national referral hospital.


At the moment, the health system has prepared itself to receive clients as patients and this can only change if the funding priorities change. The best way of reducing mortality is by preventing chances of falling sick than planning to treat.

Question 6: Where do we go from here – from policy to practice?

It is clear Hon. Chairperson that our health challenges are a result of the planning crisis which we see manifesting in poor mortality indicators. You got the policy right, and we congratulate you on that but the budget has not been directed to the implementation for the policy you supported. Your own resolutions on maternal health can mainly be implemented through primary healthcare. We would like to suggest to you as follows in line with government policy on primary health care;

  1. Increase per capita investment on primary health care to meet the MoH projection of USD 28 from the current USD 11 (from UGX 27,500 to the estimated 70,000)
  2. This financial year; work towards meeting the MoH estimate required to effectively implement PHC from the actual 15.84 billion to the project 56.7575 billion. As you can see the gap is very wide and requires deliberate effort to bridge it.
  3. Strengthen accountability and community participation in the course of implementation so that there is value for money.

Hon. Chairperson and Members of the committee, these are our humble submissions that we think can turn around our health sector.

Parliamentary resolutions on maternal health (also refer to the Remy resolutions)

Resolution 1

“That Parliament urges government to carry out maternal deaths’ audits annually, to establish the causes and publish its findings”.

Resolution 3

That government undertakes to reform the midwifery training curriculum by enhancing the duration of training in maternal and child health modules.

Resolution 4

That Government re-centralises the recruitment of medical personnel and addresses the critical shortage of medical professionals particularly, through recruitment of more 2,000 well trained, motivated and equitably deployed midwives, in order to reverse the current rate of deaths resulting from preventable maternal related causes.

Resolution 5   

That Government empowers the community and enhance their capacity to get involved in the fight against maternal and infant mortality by requiring that all local council 1s in the country do maintain a register of pregnant women in the village, indicating the outcome of the pregnancy, and make returns to the sub-county quarterly which in turn should compile half-yearly reports to be transmitted to the District.

Resolution 6.  

That Government compiles and tables to Parliament annual reports on the status of maternal health in the country with a full National maternal mortality audit report and that Parliament. Shall dedicate a particular day to debate this report and propose the way forward.

Resolution 7.  

That government provides free HIV testing services and free ARVs for every HIV positive woman in the reproductive age, as a strategy to secure an AIDS free generation and also does scale up the accessibility to family planning services throughout the country.

Resolution 8.  

Government convenes a national convention for the dominant voices to reconcile their stand on family planning with a view of harmonizing family planning messages

The civil society coalition members present their case on Primary Health Care during the meeting with the Parliament Health Committee

The civil society coalition members present their case on Primary Health Care during the meeting with the Parliament Health Committee


Press Conference: Journalists interview members of the civil society coalition

Press Conference: Journalists interview members of the civil society coalition






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