Uganda - First Health Project

Document of The World Bank FOR OFFICIAL USE ONLY eC4Z 9q6l-ua- Report No. 7203-UG STAFF APPRAISAL REPORT THE REPUBLIC OF UGANDA FIRST HEALTH PROJECT June 24, 1988 Population and Human Resources Division Eastern Africa Department This do_ment bas a resticted disrbo and may be used by *entu only In the perfonmance of ther omcial dus Its contents may not othenwise be dOSd woot Wodd Bank uoizao  UGANDA: FIRST HEALTH PROJECT CURRENCY EQUIVALENTS Currency Unit = Uganda Shillings (USh) 60.001 USh 1.00 = US$0.0117 SDR 1.00 = US$1.38 US$ 1.00 = SDR0.72 METRIC EQUIVALENTS Metric System GOVERNMENT FISCAL YEAR July 1 = June 30 This report is based on the findings of a combined preparation and appraisal mission in January and February 1988. comprising of Mr. John Evans, Dr. Vulimiri Jagdish. Dr. David Sebina, Mr. Frederick Walker. Mrs. Ishrat Husain and Ms. Beatrice Bashore. Drs. Samuel Adeniyi-Jones. Peter Fesan (WHO) and Joe Kasonde (WHO) and Messrs. Edward Echeverria. Joannes Jilch. Norbert Kerschbaum. P. C. Mohan and Pieter Van Dijk took part in the mission as consultants. 1 After currency reform and exchange rate adjustments of May 15. 1987. 2 At April 30. 1988  FOR OFFICIL I ONLY Basic Data (All figures apply to 1985 unle s otherwise indicated) Total Land Area 236.000 sq.ka Population 15,159.00Q (1986) Population Density 64 per km Rural Population as a Proportion of Total Population 93Z Crude Birth Rate 50/1000 population Crude Death Rate 17/1000 population Rate of Population Growth 2.8% Infant Mortality Rate 120/200 per 1000 live births GNP per capita (US$) 230 (1988) Halth: Population per Physician 21,300 Population per Nurse 1,900 Population per Hospital Bed 7,600 Government Expenditure oan Ministry of Health as percentage of GDP 2.12 This document has a rsddistributionand may be ued by repients only in the pfonance of their oMca dutel Its contents may not otherwi be dbscld wihout Wodd Bank authorlztL|  UGANDA: FIRST HEALTH PROJECT ABBREVIATIONS AND ACRONYMS ACP AIDS Control Program AIDS Acquired Immuno Deficiency Syndrome AMREF African Medical Research Foundation BCG Bacille de Calmette et Guerin (TB Test) CBD Community-Based Distribution CMS Central Medical Stores CSSD Central Sterile Supplies Department DANIDA Danish International Development Agency DMO District Medical Officer DMS Director of Medical Services DPT Diphtheria. Pertussis and Tetanus EDF European Development Fund EPI Expanded Program on Immunization GDP Gross Domestic Product GPA Global Program on AIDS GOU Government of Uganda HIV Human Immunodeficiency Virus ICB International Competitive Bidding IEC Information, Education and Communication KAP Knowledge. Attitudes and Practices LCB Local Competitive Bidding MCH Maternal and Child Health J4HUD Ministry of Housing and Urban Development MIB Ministry of Information and Broadcasting MLG Ministry of Local Government MOP Ministry of Finance MOH Ministry of Health NGO Non-Government Organization NORAD Norwegian Aid Agency N1RM National Resistance Movement ODA Overseas Development Administration ORS Oral Rehydration Salts PHC Prim.ary Health Care PIU Project Implementation Unit PPF Project Preparation Facility PS Permanent Secretary SIDA Swedish International Development Agency SOB Statement of Expenditures STD Sexually Transmitted Diseases UNDP United Nations Development Prograw UNICEF United Nations Children's Fund UNIDO United Nations Industrial Development Organization USAID United States Agency for International Development WHO World Health Organization  UGANDA: FIRST HEALTH PROJECT Definitions Contraceptive Prevalence Rate: The percentage of married women of reproductive age who are using (or whose husbands are using) a modern method of contraception at any given point in time. Crude Birth Rate: The number of births per 1.000 population in a given year. Crude Death Rate: The number of deaths per 1.000 population in a given year. Infant Mortality Rate: The number of deaths of infants under one yea. of age in a given year per 1,000 live births in that year. Life Ezpectancy at Birth: The average number of years an infant will live if the current age - specific mortality trends prevailing at the tine of birth were to c=ztinuc. 1 - 5 Year Mortality Rate: The number of deaths of infents between the ages of one and five years per 1.000 population in a given year.  UGANDA: FIRST HEALTH PROJECT STAFF APPRAISAL REPORT TABLE OF CONTENTS PaOe No. CREDIT AND PROJECT SUMSIR. ................................. i I. HEALTH SECTOR STATUS AND ISSUES In troducth0n Stat..................................... 1 A. Health Statug ..T.................................. I1 D. Conclusion: A Plan of Action .... 14 E. Needs for External Financing...................... 15 II. THE PROJECT As bea 15 B. Design and Objectives...... 16 C. Detailed ProjectDescription...................... 18 III. PROJECT COSTS AND FINANCING A* ot 26 Be Finac t 4 31 IV. PROJECT IMPLEMENTATION. PROCUREMENT, DISBURSEMENT AND AUDITS A. Status of Project Prepai . .. on 33 B. Organization sad Managem enten...... eseeseoseosooe 34 C. Monitoring. Reporting sad Evaluation. ............ 35 D. Procurement 36 E* Diesbursements............*......*. ......ee .. 39 F . Accounts and Audit ..................... 39 V. PROJECT BENEFITS, JUSTIFICATION AND RISKS A. Benefits and Justification...........e..on....... 40 Be R CE. 42 VI. ASSURANCES AND RECONNATONMHENDATI....*.O N... 42  TABLES IN TEXT 1. Project Cost by Expenditure Category.............. 28 2. Project Costs by Financing Source................ 30 3. Proposed Project Financing ..................... 32 4. Procurement Table.............................. 37 ANNEXES 1. Statistical Annex............................... 46 2. Project Objectives and Activities by Responsible Institution......4 ................... 51 3. Documents Available in Project File............... 54 4. Project Costs and Schedules....................... 56 5. External Donor Activities........................ 61 6. Community Initiatives .. .. ................. 64 7. List of Hospitals to be Rehabilitated ............. 65 8. Guidelines for ICB and LCB........................ 66 CHART 1. Current Organization of the Ministry of Health.... 71 MAP IBRD 20861 - Uganda - Hospital Rehabilitation and Construction  UGANDA: FIRST HEALTH PROJECT Credit and Proiect Summary Borrower: The Republic of Uganda Amount: SDR 38.0 million (US$52.5 million equivalent) Terms: Standard IDA Terms with 40-year maturity Project The proposed project has three main objectives: Objectives (a) to rehabilitate a selected number located and Description: hospitals and health centers; (b) to promote health status by strengthening preventive health programs; and (c) to ensure the long-term sustainability and viability of the health care delivery systems. Regarding the rehabilitation program, the project would carry out essential rehabilitation activities at nine hospitals and thirty rural health centers including the national referral hospital so that key services. water and electrical supplies and sewage systems. are reestablished. It would also provide essential equipment and upgrade staff quarters. The project would also finance the construction of a hospital in Rakai district, a district which is reported to have a substantial number of Acquired Immune Deficiency Syndrome (AIDS) cases. Regarding health education the project would finance a multi-disciplinary health education program using a wide variety of media, support to the Health Education Division of the Hinistry of Health (MOH), and studies to evaluate the effectiveness of the health education program. The project would also provide for the development of programs in counselling and patient manageurent for AIDS-infected people and their families. Regarding long-term sustainability, the project would develop skills and capabilities in planning, monitoring and evaluation for the MOR. strengthen management capability in the health sector (both in MOH and in hospitals) and study alternative schemes for financing the health sector. The project would also provide support to local Non-Government Organisations (NGOs), which have generally re- established themselves well.  -il- Risks: The project faces three main risks. The first relates to the implementation capacity of the MO which is understaffed and organizationally and managerially weak. The project therefore provides systematic support to the KOH and structures the implementation program so as to avoid over eztending the staff of the HE. The second risk relates to the financial sustainability of the project. The entablisbhent of hospital and health centers management boards. the emergene of local self- help programs to saintain and expand facilities, and of the Resistance Committees as strong cmunity forces suggest that complementary financing methods to be tested under the project are likely to be found to alleviate this risk. The third relates to low levels of staff motivation, which pezmeate the health services. Low pay. poor working conditions, and lack of drugs and supplies are the basic causes. The project. through improved management system. better working conditions and the involvement of local communities in supporting and financing health care delivery systens should alleviate this problem.  I. UKALTE SEMCOR STATtS AND I851=5 Introduction 1.01 Modern health services were introduced to Uganda around 1897 when missionaries began working amongst the African population. From the early 1960s until the early 1970s the Government of Uganda (GOU) developed its health service into one of Africa's most effective and efficient. The political turmoil and civil strife of the past two decades has resulted in a near total collapse of the health sector. Health facilities have been destroyed and equipment and supplies looted. Staff were oftel! unpaid for long periods and the supply of drugs became very irregular. As a result the health status of Ugandans. particularly women and children, has deteriorated dramatically. Non-Government Organizations (NGOs) and private practitioners. though subject to the same difficult environment, were nevertheless able to maintain a reasonable provision of services in the areas where they are located. With the establishment of the National Resistance Movement (NRM) Government in 1986. peace has returned to much of the country. The Government is now faced with the formidable task of providing its people with health services at a time when there is a resmzrgence of diseases of public health importance and in spite of a severe economic crisis. A. Health Status 1.02 Data on mortality and morbidity are extremely poor and limited. The epidemiological reporting system broke down during the 1970. and has yet to be reestablished. It is therefore difficult to undertake an epidemiological analysis of the health status of Ugandans. Assessment of mortality and morbidity is based upon limited information from Government. NGOs. reports of other agencies and observations of health workers. 1.03 The limited evidence available points to a deterioration of health status over the past 20 years. The 1969 census estimated a crude death rate of 19 per 1.000 population and an infant mortality rate of 120 per 1.000 live births, reflecting a steady decline in mortality rates over the previous decades. The loss of the 1980 census data and the breakdown of the health-reporting system makes it difficult to estimate trends. While a further decline in mortality rates in the early 1970s is plausible, most health observers believe that these levelled off by the late 1970s and then began to increase with the deterioration in health services. Some reports suggest that the infant mortality rate is now between 12U-200/1.000 live births and that the maternal mortality rate is more than 5 per 1.000 pregnancies. Until 1969 the level of mortality approximated that of other East African  -2- countries. At present the level of mortality in Uganda is significantly higher than in Kenya. Tanzania and Zimbabwe. 1.04 TI- leading causes of mortality for all ages. according to a 1981 World Health Organisation (WHO) survey were: measles (24%). respiratory tract infections (17%). gastroenteritis (11%). anemia (6%) and malaria (5%) (Annex I. Table 1). The three leading causes alone account for 52% of mortality - easily preventable by simple low-cost preventive measures. Recent data shows that 1-5 year child mortality has risen as high as 24 and 40 per 1.000 in Karamoja and Lira districts. respectively. 1.05 The leading causes of mortality amongst children are measles. gastroenteritis, malaria and respiratory tract infections. Health workers observe that the prevalence of malaria and of tuberculosis appear to have risen significantly. Malaria prevalence rates are unknown but hospitals in Kampala report that falciparum malaria. the most severe type. is common. 1.06 In recent years the Acquired Imuno Deficiency Syndrome (AIDS), caused by the Human Immuno Deficiency Virus (HIV), has become a disease of public health significance. Known as "SLIM" disease in Uganda. AIDS was first diagnosed in Rakai district in 1984. Since then HIV infection has become pandemic in Uganda. A national sero-prevalence survey is being undertaken by WHO and the results are expected to be available later this year. 1.07 From smaller surveys and hospital records, the following preliminary information has been gathered about HIV infection in Uganda. It must however be stressed that these figures are said to be based on the Elisa test only (the Elisa test being used in Uganda is the Welcosyme test. It is said to be 87% sensitive and 95% specific). Confirmation by Western Blot is not routinely available in Uganda. Between 15% to 25% of recipients of blood transfusion are estimated to get HIV infection due to inadequate screening. At Mulago. the national referral hospital in Kampala, an estimated 2.500 persons are infected annually from contaminated blood. Blood transfusion services in Kampala are currently operating at one- fourth of their potential demand. About 25Z of pregnant women attending Kampala hospitals have tested positive for HIV. It has been reported that nearly 60% of the population of Rakai dist=ict has HIV infection. Figures of HIV infection in the armed forces are difficult to obtain but estimates of between 20Z - 40X infectivity have been made. HIV infections are spreading throughout the country. In some hospitals up to 30Z of the beds are occupied by patients with HIV infection. Other Sexually Transmitted Diseases (STD). particularly gonorrhea. appear to be on the increase.  -3- B. Sector Status Healtb Facilities 1.08 Uganda's health facilities consist of hospitals. health centers, dispensaries-cum-maternities. maternities. dispensaries. sub-dispensaries and first aid posts. There are two National Referral Hospitals. six regional hospitals. 71 rural and district hospitals. 107 health centers. 89 dispensaries-cum-maternities. 40 maternities. 82 dispensaries. 366 sub-dispensaries and 163 first aid posts. About 30% of the larger facilities. particularly in rural areas, are operated by missions. Both MOH and Mission facilities were damaged and looted during the years of turmoil with the MOH facilities bearing the brunt of the damage. Because of staff motivation (better salaries and benefits) and support from external sources. Mission facilities have managed to rehabilitate themselves and provide services of reasonable quality again. On the other hand. MOH facilities have had no support for rehabilitation, pay low salaries to staff. are poorly managed and have not been able to become effective again. 1.09 In virtually all MOH facilities the following are the major constraints: (i) low staff morale due to poor working conditions, low levels of remuneration and inadequate housing; (ii) boiler rooms, kitchens, laundries and central sterilization departments non-operational due to lack of equipment, spare parts and fuel and often without water and electricity; (iii) lack of laboratory equipment, reagents and supplies resulting in a total lack of diagnostic testing; (iv) lack of sterilization techniques leading to cross infection in wards through needles, syringes, and surgical equipment; (v) lack of cross matching ability of equipment and poor refrigeration. resulting in mismatched or infected blood transfusions; and, (vi) badly damaged beds and mattresses and a lack of drugs and supplies. 1.10 Equally important is the virtual lack of management of health facilities. Support systems are lacking or have broken down. Consequently pilferage is high and the running of f&cilities is inefficient. Due to poor remuneration and lack of housing, staff  -4- motivation is poor. As a result staff do not do their job and it is difficult, if not impossible. to maintain discipline and efficiency. During negotiations. Government agreed that during the rehabilitation of each facility under the project. a manpower analysis and management study would be carried out by the Government so as to ensure that management improvement and manpower standards would be introduced and go hand in hand with physical rehabilitation. Establishment of staffing standards. elimination of redundant positions and workers and redeployment of staff would be finalized by the time of completion of the civil works at each facility (para. 6.02(i)). Health Ifrtgams 1.11 Ezpanded Program on Immunization (EPI). Like all other health programs in Uganda. such as malaria control and eradication. the EPI has broken down since the late 1970s. BCG immunizations, for example. which covered 702 of the target population in 1971 had fallen to less than 52 by 1984. DPT and polio coverage in 1984 was less than 32 of the target population. Lack of transport. complete breakdown of the cold chain and ineffective vaccines (loss of potency due to imperfect refrigeration) have been the leading causes of poor coverage. The United Nations Children's Fund (UNICEF) has been providing substantial resources to revitalize the immunization program. In 1988 an estimated US$2.6 million will be provided for this purpose. Total UNICEF inputs from 1985-1990 are expected to be US$10.5 million. In 22 districts where the program is being fully implemented. BCG coverage has now reached 702 and for other antigens 402. Coverage in the other 11 districts has not yet begun due to poor security conditions (in eight districts) and physical inaccessibility (in three districts). 1.12 Maternal and Child Health (MCH). Between 1960 and 1970 Uganda pioneered many low-cost interventions such as growth monitoring and nutrition rehabilitation. These activities were gradually abandoned as the political and security situation became worse. At present maternal health services are totally inadequate and maternal mortality is rising. Few health facilities provide family planning. Management of MCH programs at the district level and supervision of MCH activities by health workers is non-existent. Under-fives' health clinics are being reintroduced in health facilities but the infant mortality and 1-5 mortality rates are still high. 1.13 Health Education. Few health education activities are undertaken by the MOH. A Health Education Division exists in the NOR but has been given meager resources to develop health education programs. Radio may reach up to 152 of the population. television coverage is less than 1% and the largest newspaper circulation is 15,000. Mass media coverage could be significantly increased  -5- through relatively small but highly targeted investments. In addition, the existence in districts of a large number of organizations such as Resistance Councils. religious groups. women's groups and cooperatives provide great opportunities for developing information programs. UNICEF is launching a program to train district health educators. The contribution of these educators will be critical in developing health education activities at the district level. 1.14 In light of the current weakness of the Health Education Division there has been a tendency in some programs to plan separate education activities for specific diseases and a real danger ezists that vertical programs may be established causing unnecessary duplication and waste. While such an approach could have short-term benefits. it will have major detrimental effects on the Health Education Division in the medium and long term. MOH have r Efirmed that the Health Education Division has overall responsibility for health education activities. 1.15 Special Program for AIDS. Recognizing the need to control the growing AIDS epidemic, the Government of Uganda. in 1986. established a National Committee for the Prevention of AIDS. An AIDS Control Program (ACP) was established in February 1987 with WHO assistance. A donors' meeting was held in May 1987 and pledges for US$12.0 million over a five-year period were obtained. Tm addition, UNICEF made a commitment to raise US$8.0 million over five years to expand their own program of assistance in the field of health education. For the first year approximately US$6.0 million were pledged but only about US$3.8 million had been received by December 1987. 1.16 The ACP is headed by an Assistant Director of Medical Services who is directly accountable to the Assistant Director of Medical Services (Communicable Diseases and Public Health). Administrative matters are handled by an Administrator, while technical matters are the responsibility of a Chief Technical Officer. The Chief Technical Officer. a position that is still vacant. is responsible for program design. management. information, education and communication (IEC), surveillance and laboratory and blood transfusion services. In view of the shortage of qualified Ugandan officials, WHO has made available a number of expatriate professionals to assist the Assistant Director in running the program. 1.17 The ACP has started some IEC activities and a number of posters, stickers and badges have been made and distributed. A comprehensive IEC program has not been initiated. Coordination with the MOH's Health Education Division has been minimal and there is a real danger that the IEC efforts of the ACP could become a vertical activity. Consistent with the principle that henceforth all health education programs and activities would come under the Health  -6- Education Division (para. 1.14), it has now been decided that the Health Education Division will develop and implement AIDS health education activities. 1.18 Laboratory. sero epidemiological and surveillance activities of the ACP are under various stages of implementation. A national sero survey has been initiated and a surveillance system has now been introduced into 50% of all hospitals. Screening facilities at blood banks have been introduced into 15 hospitals only out of a possible 79. Plastic gloves are not available in medical facilities and the rural areas, and neither are condoms available in rural areas. Confirmation of the Elisa test by Western Blot is very limited. Though there has been considerable progress in the development of the ACP. substantial gaps remain which need to be addressed urgently. These include a comprehensive health education system. delivery of "safe" blood at all hospitals, supply of gloves to maternity units, prevention of infection in health facilities through contaminated needles, and clinical management of patients in hospitals, including counselling of patients and their families. Drug Supply 1.19 The total drug requirements for the country as a whole are estimated at US$13.0 million per year by the Central Medical Stores (CMS). Of this requirement only 10-20X of drugs, worth between US$1.3 - US$2.6 million have been made available during the last three years from government resources. The Danish Red Cross provides additional drugs to the value of US$6.0 million. The CMS is responsible for the supply of drugs, which it sells to local authorities (for health centers and dispensaries) and to missions. The funds received go to the Treasury and are put in a special fund. In the case of the hospitals, CMS directly supplies drugs for in- patients. Since 1985 the Danish International Development Agency (DANIDA) has entered into an agreement with the Danish Red Cross to supply drugs for out-patient services at all levels and this program, at present, serves 700 health facilities. Two hundred kits of boxes of essential drugs are supplied against a list contained in a manual prepared by the Red Cross. 1.20 Under the agreement with DANIDA signed in 1985, GOU was to take over the drug supply over a six-year period, but given the current shortage of funds in the health sector. DANIDA has eased the terms of the agreement for the second phase. Under this second phase, which will run for another three years. the GOU is expected to contribute 20% in the first year rising to 25% and 30% respectively in the following two years. Clearly a large funding gap will still exist even in 1990 unless GOU takes measures to improve the supply of drugs, develop local manufacturing and recover its costs. Under-utilization of some government health facilities  -7- is attributed to the shortage or sporadic availability of drugs. Under the agreement. staff of the health facilities are trained by the Danish Red Cross. wLo also monitor and evaluate the use of drugs. Manpower 1.21 In 1986 there were 9.205 established posts in the MOH. MOH surveys of staff in position at that time indicated that there were about 8,500. The 1985/86 estimates provided for 13.122 staff in the MOH. Annex 1. Table 2 gives the MOH establishment by cadre and Annex 1. Table 3 presents a comparison between staff figures in estimates and MOH establishment figures. Part of the problem appears to be the recruitment of many staff on temporary terms over the past two decades. In 1985 there were 2.215 staff on temporary terms. The majority of these staff have been on temporary terms for over 5 years and some have been so for over 20 years. Since staff on temporary terms are not pensionable this situation has had a negative effect on morale. The situation is now being corrected. No new staff are being recruited on temporary terms and incumbent temporary staff are being regularized if they have appropriate qualifications. 1.22 Establishment of positions has traditionally been the role of the Ministry of Public Service and Cabinet Affairs in conjunction with the Ministry of Finance. Figures are set annually at the time of publication of the Annual Recurrent Estimates and represent the limit of staffing permitted for each health facility and provide authorization to recruit up to that limit. The Ministry of Finance is concerned with overall financial control by budget head, rather than with exactly what types of staff are working where. It is the responsibility of the MOH to allocate its establishment to individual programs. UnfortunaL.ly. control of manpower has been weak and there are serious geographical differences as well as recruitment of certain cadres beyond authorized levels (Annex 1. Table 3). A review of existing manpower and optimal staffing patterns is urgently required and a staff development and deployment plan needs to be developed. Government has therefore agreed to submit to IDA by December 31. 1989 a review of existing manpower and an optimal health sector staffing plan, together with an implementation plan (6.02(iv)). 1.23 Training of doctors is undertaken by Makerere University and is the responsibility of the Ministry of Education. Training of nurses, midwives and other health auxiliaries is the responsibility of the MOH. Missions also train a number of health auxiliaries. The MOH also offers a number of post-basic courses. The relevance of these courses to the country's health needs requires further study and would depend upon completion of the recommended staff  -8- development and deployment plan (para. 1.22). The medical curriculum is presently being reviewed with UNICEF assistance to focus on Child Survival issues. 1.24 Uganda was once a center of excellence for the training of health personnel in Africa. As a result, many of the more senior staff still in service are very well trained. However. with the depressing state of training institutions (physical facilities are run down. there are virtually no teaching materials or visual aids. and the hostels are in poor condition) it is likely that the quality of recent graduates would have declined considerably. Mission training facilities are better equipped and could train some staff needed by the MOH. 1.25 Figures on attrition of staff are not available. These figures would anyway be of limited value because of the extreme conditions of the past several years. However, staff motivation is low because of poor working conditions, conditions of employment and the lack of career structures. In addition to the problems of temporary staff, permanent staff often function in acting capacities and this has prevented promotion. Because of these factors performance standards are low. Organization and Management of the Sector 1.26 A number of organizations are responsible for the provision of health services. The MOH is responsible for provision of health services from the district hospital and above while the Ministry of Local Government (MLG) is responsible for the provision of peripheral health services. The latter include school health services. maternal and child health services, rural ambulance services. health education and the control of communicable diseases. In addition missions. private practitioners and traditional practitioners all operate independently to provide health services. The present organizational structure of the MOH (Chart 1) is a legacy of the past, when MOH was mainly concerned with the management of curative institutions. Under the present organization the Permanent Secretary has overall responsibility for administration of the MOB. Reporting to the Permanent Secretary are the technical and administrative branches of the Ministry. The technical branch is headed by the Director of Medical Services (DMS). The DMS has two Deputy Directors and nine Assistant Directors. Two undersecretaries. one for finance and establishment and the other for planning and administration are responsible for administration of the MOH (Chart 1). 1.27 In practice there has been considerable confusion between the roles of the Permanent Secretary and the DMS. There is a lack of understanding in the MOH about the functions of each department  -9- and matters requiring the attention of the DMS have often been sent to the Permanent Secretary who in turn has redirected them. As a result there often are delays. Furthermore, the DMS is often contacted directly by Assistant Directors and others because of the lack of a deputy. An inordinate amount of the DMS' time is spent on matters which ought to be dealt with at a lower level. These matters are further compounded by weak administration throughout the MOR and by the lack of adequately qualified staff. 1.28 At the regional level (i.e.. a group of districts) a team composed of a Regional Medical Officer. a Senior Medical Officer. a Senior Health Inspector, a Principal Health Inspector, a Health Educator and a Senior Dispenser, as an Inspector of Drugs, has been posted since 1979. The regional teams. whose function are coordination of district. urban and hospital services have never been effective due to lack of support or funds. and imprecise allocation of responsibilities or authority. 1.29 At the district level there is a dual responsibility for health services between the MOH and MLG which has led to considerable confusion. In particular. referral from facilities run by MLG to facilities run by MOH and vice-versa is non-existent. The district teams, which consist in principle of the District Medical Officer (DMO). Medical Superintendent (MS) and the medical officer of health are not operational in all districts. The few districts with teams are hampered by lack of support and funds. Furthermore it is not clear to whom the teams are accountable and through which channels they should report. In addition the complex arrangements between the PS and the DMS at Headquarters are mirrored at district levels between the DMO and MS. During negotiations, it was agreed that by December 31, 1989, the MOR would submit a proposal for the development of a referral system and implementation plan both to be satisfactory to IDA (para. 6.02(v)). 1.30 To overcome these institutional problems the Government requested a Health Policy Review Commission, appointed in 1986 (see para. 1.37). to review the organization and management of the health care delivery system. The Commission's main recommendations in that area are: (i) the MOH should be restructured so that three Deputy Directors of Medical Services would assist the DMS: (ii) the functions of planning and manpower development should be transferred from the Office of the Minister to the Director of Medical Services; (iii) the functions of the MOH and its statutory powers should be consolidated into seven areas;  -10- (iv) four fully staffed regional teams should be established with adequate support and funds and the role of the regional teams should be defined so as to allow them to monitor and supervise district and hospital activities; (v) district health teams should be established; (vi) decentralization of the health system should be accompanied by adequate allocation of manpower. finance. supplies and transport; and (vii) a National Health Advisory Council to advise the Minister of Health on policies and to promote intersectoral coordination should be established with membership of key government ministries. NGOs and the public. 1.31 The organization and management recommendations of the Health Policy Review Commission provide a useful framework to undertake more detailed management reviews. and to subsequently introduce appropriate changes. During negotiations. it was agreed that MOH would produce by December 31. 1988 a timetable for implementation of mutually agreeable recommendations deriving from the Health Policy Review Commission Report regarding the organization and management of the health system (para. 6.02(vi)). Health Financing 1.32 Total health expenditures (public and private) in 1986/87 are estimated to have been US$73 million or about 2.1% of GDP. This is US$55 million less than the estimated expenditure on health in 1982. Public sector expenditures on health in 1986/87 amounted to 3.8% of total government expenditures. In fiscal year 1982 these expenditures amounted to 4.1%. Development expenditures fluctuate more than recurrent expenditures. reflecting the grim economic situation of the country. Approved estimates do not ensure availability of funds and in 1986/87. despite inflation of over 100%. actual expenditure amounted to only 77% of approved estimates. The percentage of the recurrent budget spent on salaries is extremely high. namely 98.4% of funds allocated to regional and district health services and 54% of funds allocated to hospitals. This undermines the provision of meaningful care. Annex I. Table 4 presents estimates of Total Public Expenditure on Health Care 1986/87. 1.33 Annex I. Table 5 presents Trends in MOH Health Expenditures from 1972 to 1988. Particularly striking is the continued underfunding of government recurrent expenditures. The resulting lack of funds for supplies. including drugs. and for maintenance has substantially reduced efficiency; as a result  -11- utilization of government health facilities has declined. Estimated expenditures for hospitals have decreased from 33.9Z in the 1985/86 MOH budget to 27.5% in 1986/87 and to 21.42 in the 1987/88 budget. 1.34 Regarding the provision of peripheral health services (health centers and below) which are the responsibility of rural and urban authorities under the Ministry of Local Government (MLG). local authorities are expected to raise funds locally from a graduated tax. market dues. fees and licenses. They also receive block grants from MLG. At one time local authorities were able to meet all the financial costs of the health services they were responsible for. Currently. however. most local authorities are unable to meet their recurrent expenditures. and the MOH has been providing subsidies to local authorities for health services. There have been no MLG funds to build new health facilities. but some primary health facilities have been built or rehabilitated by Donors. 1.35 While Uganda has had a tradition of free health services in the public sector. Mission and private facilities have charged for services. It is estimated that 80% of their recurrent budget revenue comes from patient fees. Not surprisingly. and as in many other countries. government facilities are in poor shape. have few drugs or supplies. and are underutilized. whereas Mission and private facilities provide better quality services. have drugs and supplies and are heavily utilized. Since it is no longer feasible for the Government. both central Government and MLG. to finance public health services by itself. it needs to consider ways to supplement public funding including options such as health insurance. cost recovery including revolving drug funds and other methods of direct community financing for health. It should also recognize that improvement in quality is an essential prerequisite for the introduction of cost recovery. In addition ways to improve efficiency need to be examined concurrently. including various methods of oversight. budgeting as well as improving staff morale through subsidization of health workers. transport and the provision of meals (paras. 2.25 and 2.27). During the mid-term review of project implementation (para. 4.07) there will be a review of health sector financing and recurrent cost financing to ensure that Government is providing sufficient funds to sustain the health service (para. 6.02(iii)). C. Promising Trends Health Plans and Policies 1.36 Following independence in 1962 the Government adopted pragmatic health policies which supported the development of rural and urban health services. Preventive health programs were  -12- emphasized. As a result by the early 1970s Uganda had one of the most outstanding health services in Africa. However with the civil strife and turmoil of the 1970s health services rapidly deteriorated. Physical destruction of facilities. lack of supplies and salaries and a rapidly deteriorating economy led to an exodus of trained personnel. Recognizing the rapid decline in health services the Government appointed a Commission of Inquiry into the Medical Services of Uganda. This Commission submitted its report in 1977. Though its recommendations were accepted, further political instability resulted in their non-implementation through neglect. In the ensuing years other plans were drawn up such as the Recovery Program for 1982-84 and the National Plan of Action on Primary Health Care. However, none of these programs could be fully implemented. 1.37 With the establishment of the NRM Government in 1986 a Health Policy Review Commission was established. Its report was submitted to the Government towards the end of 1987. The Commission's major policy recommendations include: 'i) decentralization of services to be the cornerstone of the Government's health policy; (ii) local and urban authorities to be responsible again for peripheral health care while the Ministry of Health (MOH) be responsible for health services at the district level and above and for the development and implementation of the country's health policy; (iii) the Mulago hospital to be made autonomous; (iv) all hospitals to have Hospital Advisory Committees; (v) regional medical officers with a more clearly defined role, to be field based and not attached to hospitals in order to strengthen regional management of health services; (vi) district medical officers to be appointed and have authority, financial control and accountability for the health services provided in the districts; (vii) consideration to be given to the introduction of user charges at all hospitals and to the introduction of a health insurance scheme for government servants; (viii) the budgeting process of the MOH to be strengthened and technical staff to be trained (i.e. department heads) in budgeting; and  -13- (ix) the Government to support staff development by establishing a Center for Continuing Education in the MOH. 1.38 The recommendations of the Health Policy Review Commission are generally sound and are currently being reviewed by Government. 1.39 While the Health Policy Review Commission report provides an excellent framework for the development of a national health policy, the MOH also needs to have a comprehensive strategy for the development of the health sector. To that intent, and through the IDA financed Technical Assistance Credit (Credit 1434-UG) the MOH engaged the African Medical Research and Education Foundation (AMREF). a Kenya based international NGO. to undertake a series of studies which would provide necessary background information in subsequent project preparation. A complete set of these documents are in the project file and are listed in Annex 3. The next crucial step for the MOH is to utilize these studies and to prepare a national health plan which would identify priority areas in the health sector. A national health plan would also form the basis of future IDA assistance. During negotiations. it was agreed that the MOH would recruit a consultant. whose experience and qualifications are satisfactory to IDA. to assist the MOH to undertake the preparation of the National Health Plan. The plan would be completed no later than December 31, 1988 (para. 6.02(vii)). Community Initiatives 1.40 There are also promising trends at the community level where facilities are being rehabilitated with materials financed by the local people and with the labor provided by skilled workers. These workers have handled both the rehabilitation of existing facilities and the construction of small simple new buildings including kitchens and toilet facilities. At Mulago Hospital, despite an almost complete lack of facilities. equipment and tools. maintenance work is going on in a rudimentary fashion on simple breakdowns and repairs. All these activities are supported by and funded by the local communities. Other Positive Factors 1.41 As mentioned above. NGO and missionary hospitals, which have continued to function, provide a potential basis to draw upon to rebuild administrative systems and staff training for the public sector. In addition it was clear that staff in government hospitals continued to provide services part-time, particularly when drugs were available. Furthermore at the level of particular hospital facilities, a number of initiatives could be observed to improve services, including the organization of Governing Boards both to oversee the operations of the hospital and to generate some  -14- financial support. Finally the Government had already provided for an autonomous managerial and financial structure for Mulago hospital as recommended by the Health Policy Review Commission (para. 1.37). This would hopefully set a precedent for similar measures at district level. Annex 6 gives examples of some community initiatives. D. Conclusion: A Plan of Action 1.42 Rising death rates. breakdown of the health system, a resurgence of diseases such as measles and malaria. and the rapidly growing AIDS epidemic all point to the health crisis that is rapidly developing in Uganda. Nevertheless there are also elements of hope upon which Government could build a revitalization strategy for the sector (paras. 1.36-1.41). Such a strategy would require actions to deal with both immediate problems and longer term challenges. To address the immediate needs of the health sector. urgent action is required to provide drugs, equipment, and reconstruct damaged health facilities. At the same time it must be recognized that such efforts would have little permanent impact unless the complex interrelated and fundamental longer term issues facing the health sector are addressed simultaneously. Such longer term issues include planning and progrsaming, financing. manpower development. and management strengthening. 1.43 Planning and Programming. The Government of Uganda has made an excellent start in the development of a national health policy on the basis of the recommendations of the Health Policy Review Commission it had appointed. Nevertheless. it still lacks a comprehensive strategy for the development of the sector (para. 1.39). The development of a national health plan to set out priorities within a framework of affordability and replicability is therefore urgently required and would be expected by December 31. 1988. Included in the plan should be an indication of which health programs (para. 1.11 to 1.18) to reactivate, and in which order of priority, together with the outline of an implementation program. 1.44 Financing. As discussed in paras 1.32 - 1.35 there are serious shortfalls in the resources available to the public sector. The development of alternate ways of financing the health sector, definition of the roles of NGOs and the private sector, and identification of ways to improve the efficiency and effectiveness of the public sector systems are critical. At the same time it will be necessary to examine ways and means by which the remuneration (and/or benefits) of public health sector employees can be increased without adding to the burden of the recurrent budget. 1.45 Manpower Development. The development of appropriate manpower for the changing needs of the health sector is another  -15- critical issue. At present there is substantial maldistribution of manpower, excessive reliance on temporary staff. lack of career development opportunities and more recently declining quality of staff (para 1.21 to 1.25). As part of the health plan Government has agreed to develop programs to transfer excess staff to the extent practicable from certain categories to categories with less staff and providing the necessary training for redeployed staff (paras. 1.10 & 6.02(iv)). 1.46 Management Strengthening. Management at all levels of the health system is weak. The Health Policy Review Commission has identified a number of problem areas at the headquarters, regional and district levels of the health system. Additionally management of health facilities needs substantial improvement. Specific management studies and development of plans to implement the recommendations are urgently required. E. Needs for External Financing 1.47 The cost of undertaking the above rehabilitation strategy of Uganda's health syctem is clearly beyond the Government's available financial resources and considerable external financing by the intesnational donor community will be needed. 1.48 At the present time a number of agencies are already providing assistance to Uganda. These include African Development Bank. DANIDA, the European Development Fund, the Federal Republic of Germany. Uganda-Italian Health Cooperation, the Overseas Development Administration (ODA), the United Nations Development Program (UNDP). UNICEF, the United States Agency for International Development (USAID), and the World Health Organization (WHO). A short description of their activities is given in Annex 5. It is expected that all these agencies will continue their support. In addition. several other agencies have indicated their interest in becoming associated with IDA in cofinancing this first project to meet urgent rehabilitation requirements and to support the longer term overhaul of the system. Preparation by the Government of a health plan and strategy would provide a basis for further support to the health systems by the donor community and for the coordination of such support. IDA would support such initiatives both financially and through assistance in donor coordination if so requested. II. THE PROJECT A. General 2.01 The proposed project, the first of a series of health  -16- projects. has three main objectives: (a) to carry out urgent physical rehabilitation of selected health care facilities and build a hospital in Rakai district; (b) to promote health status through strengthening :rreventive health programs; and (c) to improve the internal efficiency as well as the long-term effectiveness of health care delivery. These three objectives will be achieved under the proposed project through both short-term and long-term measures and sub-components and through mobilizing the resources of both the Government and NGOs. B. Design and Obiectives 2.02 More specifically the project would consi3t of the following: Part A: Rehabilitation a d Construction of Health Facilities. US$36.9 million' Objective: to complete the urgent rehabilitation of a selected number of health care facilities so as to make them operational again and to build a hospital in Rakai District. presently unserved but affected by the highest HIV prevalence in the country. Activities: (a) Rehabilitate key areas of Mulago Hospital including the water supply and sewage system, the elevators. the laundry, kitchens and Central Sterile Supplies Department (CSSD). Build an electrical and maintenance workshop and rehabilitate essential nurses' and doctors' flats, hostels and quarters. Repair essential roads and provide security fencing. (b) Re-equip the Blood Transfusion Center with blood typing and screening equipment and cold storage facilities. (c) Rehabilitate eight district hospitals with emphasis on water supply. sewage systems. equipment and furniture. (d) Rehabilitate some thirty rural health facilities. (e) Build a hospital of about 100 beds in Rakai district. 1Cost excluding contingencies.  -17- Part B: Health Education and Community Activities. US$10.3 million Objective: to promote health status by creating awareness health education programs and providing health education to all levels of the population. Activities: (a) Health Education (i) Expand the use of mass media using radio. television and newspaper. (ii) Train journalists and health educators in mass media techniques. (iii) Hold workshops and arrange training for health educators and village level workers. (iv) Produce health education materials for the National Adult Literacy Association of Uganda (an NGO). 'v) Provide program support to the Health Education Division of the MOR. (vi) Construct lean-to-shelters at 30 rural health centers. (vii) Carry out studies of Knowledge. Attitudes and Practices (KAP) in response to health education. (viii) Provide health education support to the Army. (ix) Carry out an interim evaluation of the IEC program. (b) Community Activities (i) Develop a community-based distribution program for drugs and supplies required for major preventative programs starting with the distribution of condoms and oral rehydration salts (ORS). (ii) Develop a program for counselling and patient management for those with AIDS and complementary assistance to their families.  -18- (iii) Development and implementation of a health and hygiene education program to support a water supply and sanitation project being considered by IDA. Part C: Strengthening Health Care Delivery. US$3.5 million Obiective: to ensure the long-term sustainability and financial viability of the health care system and its components, MOH. MLG and NGOs. Activities: (a) Strengthen the Health Planning Unit of MOH and carry out studies. (b) Strengthen the management capability in MOH. hospitals and rural health facilities through management training and development programs. workshops and study tours. (c) Identify and review alternative ways of ensuring adequate financing of the health sector both through improved planning and budgeting and through coot sharing with beneficiaries and/or communities. (d) Provide support for a number of NGO programs and initiatives. (e) Provide assistance for project management and to prepare a second project. 2.03 The project will be implemented over a four-year period. C. Detailed Project Description 2.04 Part A. To achieve the first objective the proposed project will contain components concentrating on rehabilitating health care facilities. The main activities are: (a) Rehabilitation and Construction of Health Facilities 2.05 Mulago Hospital. a conglomeration of buildings on a 28- acre site in Kampala has received little or no mainrenance over the last 15 years. As a result a major rehabilitation program is necessary to reestablish its facilities and to ensure that it can  -19- carry out its role as the national referral hospital. The full scope of works is clearly beyond the current proposed project but essential priority civil works have been discussed and agreed with the MOH. The project would: (a) continue the reestablishment of water supply to the hospital and install/refurbish the sewage system; (b) rehabilitate the elevators; (c, renovate and reequip the laundry; (d) renovate and reequip the kitchens; (e) renovate and reequip the Central Sterile Supplies Department; (f) build and equip a new electrical and mechanical workshop and provide technical assistance to train hospital maintenance workers; (g) build security fencing around key areas to reduce pilferage; (h) provide equipment and furniture; (i) supply drugs and consumable supplies for four years;(j) rehabilitate nurses' and doctors' flats, hostels and quarters so that they have water, electricity, sewage systems and laundry facilities; (k) repair essential roads and pavings. and (1) cover the cost of professional fees for architects and quantity surveyors. 2.06 Although the buildings of the Blood Transfusion Center. Kampala. are being rehabilitated under a grant from the European Development Fund (EDF). new equipment to screen. type and store blood under refrigerated conditions would be provided under the project. In addition. to reestablish the supply of blood. ne-w donor facilities would be fitted out and vehicles provided both to transport collection teams and for blood delivery and collection. 2.07 Eight district hospitals2 would be rehabilitated with the emphasis again on essential services including water supply and sewage systems. On the basis of "dilapidation" reports prepared in 1982 and which would be updated, each hospital would be refurbished and reequipped. The eight district hospitals were selected on the basis of the following criteria; (a) catcbment area; (b) population per bed; (c) lack of local NGO facilities; (d) no other donor activity; and (e) access and security. In addition some 30 rural health centers located in the areas surrounding the eight selected district hospitals would be physically rehabilitated and provided with furniture, equipment and essential vehicles. 2.08 Rakai district, in the southwest is one of four districts of Uganda which does not have a hospital. The district, which was created in 1979. now has a population of about 400.000 and the majority live some 63km from the nearest government hospital in Masaka. Under the project a new 104 bed hospital would be built at a site which will ensure that some 75% of the population of the district will be no more than 30km from the hospital. The new hospital will be based on an existing design with minor modifications and would include the provision of staff housing for key hospital workers and medical staff. The project will support 2 Annex 7 lists the hospitals to be rehabilitated.  -20- the furnishing and initial provision of supplies and equipment to the new hospital. Selection of a site acceptable to IDA would be a condition of disbursement of the credit funds related to the new Rakai District hospital (para. 6.03(i)). 2.09 Maintenance of hospital equipment and buildings is essential if the project investments are to be sustained. Under the project two buildings and maintenance workshops will be established to provide service to both Mulago Hospital and the district hospitals. During negotiations, Government agreed to supply IDA with an acceptable staffing resources plan for each facility to be financed under the project no later than June 30. 1989 and a similar staffing resources plan for the workshops no later than December 31, 1989 (6.02(i)). 2.10 Part B. The second objective will be achieved through a number of sub-components: (a) Information. Education and Communication (IEC) Program 2.11 The project would support (a) the expanded use of mass media to support better health for the population of the country; (b) the training of journalists and a selected number of Health Education Officers in newspaper. radio and television techniques; (c) workshops for Health Education and Assistant Health Education Officers together with village level workers in three selected district; (d) production of health education materials for use by the National Adult Literacy Association of Uganda (an NGO); (e) provision of program support equipment to the Health Education Division of the MOH; (f) construction of 30 covered lean-to- shelters at the 30 rural health centers being rehabilitated; (g) research on Knowledge. Attitude and Practices (KAP) of people on their response -o health messages and health education; (h) health education for the army; and (i) evaluation of the IEC sub-project during the third year to enable adjustments to be made if necessary to increase and improve responsiveness. 2.12 Taking these sub-components in turn: mass media. A weekly health page would be included in New Vision, the English language paper of the Government of Uganda. Circulation stands at 15.000 currently for each of the tri-weekly issues with an estimated readership of 250.000. The project would provide 400 tons per annum of newsprint which would help the paper to double the circulation on a daily basis and increase readership to approximately one million. The newsprint would be sold at cost to the newspaper. Government has agreed that the proceeds would be used to establish a health development fund (see paras. 2.28 and 6.02(viii)). Financial support would also be given to Munno. the most influential Luguanda newspaper to publish a weekly health page. The paper published daily, is reported to have a readership of a quarter of a million.  -21- An eight-page comic book would be developed. printed and distributed through the school system reaching some two million schoolchildren. It would also be distributed in limited numbers to the Ugandan Army. Picture postcards with selected health themes would be printed by the Posts and Telecommunications Corporation. In addition health messages would be carried on the sides of long-distance buses, urban and rural van-taxis and on the reverse side of lottery tickets and on the inside covers of school exercise books. There are an estimated three million radios in Uganda and 300,000 television sets. The project will seek to increase the frequency, upgrade the quality and place health messages on the radio at prime time. This will be done by enabling the Ministry of Information and Broadcasting (NIB) to improve its studios and transmitters by providing equipment and spare parts. The support to the Ministry of Information and Broadcasting will comprise; (a) developing transmitter capability so health messages can reach the whole country; (b) providing trainnm materials; (c) supporting regional studios and four mobile cinema vans; and (d) supporting the Development Broadcasting Program of the MIB. Locally, two short films would be produced each year to be shown in rural areas; training: the project would support training for one newspaper journalist on a one year course, two television/radio journalists every year and one health educator annually on health issues and their presentation in the media. This training would be carried out in an appropriate developing country; worhos: a series of workshops is planned for 33 Health Educators one for each district) and for the 66 Assistant Health Educators. During the project pilot workshops will be held for village-level workers in three districts; health education materials: the National Adult Literacy Association. a Ugandan NGO. with 20 literacy centers will be provided with health training materials using posters and flipcharts on themes developed each year by the Health Education Division; support to the Health Education Division: whilst support in manpower is developing well and the new staffing and organization structure have been agreed. the division will need basic functional equipment at district, regional and the central levels. Such support will include tape recorders, cassette players and battery operated slide projectors for community level meetings. The project would assist the reintroduction of district focus programs with health education as a major component supported by locally oriented non-formal education programs. documentary health dramas and cartoons aimed at reaching all sectors of the population; lean-to-shelters: 30 simple lean-to- shelters will be included in the rehabilitation of the rural health care centers to be used to pass on health messages to mothers and out-patients; research: a Knowledge. Attitudes and Practices (KAP) study will be initiated before the introduction of the enhanced health education program and followed up with two further studies during the project; the Army: the Army will develop its own independent health education program with support from the MOH aimed primarily at the prevention and control of AIDS and STDs; evaluation: the evaluation will be tied to a second KAP study.  -22- 2.13 The coordinating role of the Health Education Division of the MOH in the development of IEC activities is crucial. During negotiations. Government agreed that by December 31. 1988 it would appoint a health education coordination committee or similar mechanism chaired by the Director of Medical Services and including representatives from other MOH divisions. the Ministry of Education, Ministry of Information and Broadcasting and the New Vision and Munno newspapers (para. 6.02(ix)). (b) Community-Based Distribution Program 2.14 A major constraint in the delivery of health services is the lack of knowledge about illnesses and drug supplies to deal with them in rural areas. The project would therefore support the development of community-based distribution (CBD) programs which would make available information and drug supplies to rural communities. In the first phase the CBD program would supply condoms and oral rehydration salts to communities. Subsequently, malarial tablets would be introduced in the CBD program. 2.15 The project would support the renovation of the central medical stores in Entebbe and construct and equip four new regional medical stores. With this a distribution system both for pharmaceuticals and the CBD program would be established. Regional stores would supply district hospitals from where health centers would be supplied. CBD volunteers, usually members of the Resistance Committee. would collect supplies from the health centers for their respective communities. Two months of short-term technical assistance would be provided annually. A training program comprised of national and district level workshops would be held annually. The project would also supply two vehicles for the CMS. 100 bicycles would be provided for CBD volunteers. (c) Counselling and Patient Manazement for those with AIDS 2.16 A vital factor in the control and prevention of AIDS is the effective counselling of people who test positive for the AIDS virus. Evidence already exists that patient reaction to a positive test can vary but changes in behavioral patterns tend to be extreme ranging from suicide and acute depression to revenge and an inclination to infect others. Given the relatively long period of symptom development. AIDS positive patients require continuous counselling to reinforce behavioral patterns which could reduce the spread of infection. The project will support workshops at the national, regional and district hospitals to health service providers on counselling not just for patients but also their families. These workshops will aim to cover all 33 districts and will lay the foundation of a national counselling system.  -23- 2.17 In addition management of terminally ill patients suffering AIDS-related complications will require health service providers to be able to identify those symptoms which can be treated within the patient's home and community and those which require hospitalization. Contrary to expectations, the extended family system in Uganda has not been able to absorb the issues and problems of dealing with AIDS patients and local communities have as yet not developed supportive attitudes to dealing with terminally ill patients with AIDS. The project will support the development of training materials and local technical assistance (possibly including local NGOs) to organize workshops for health care providers to deal with these issues. (d) Health and Hygiene Education 2.18 The project would also support development and implementation of a health and hygiene education program to support a water supply and sanitation project being considered by IDA. This would build upon the training of health inspectors financed under the water supply and sanitation rehabilitation project (CR 1510-UG) which is nearing completion. As the details of the program are still to be worked out, their finalization would be a condition of disbursement of the funds related to this sub-component (para. 6.03(ii)). 2.19 Part C. To achieve the third objective the proposed project will focus on the longer term institutional aspects of the system as follows: (a) Planning. Monitoring and Evaluation 2.20 The Health Planning Unit of MOR will be strengthened in development planning. monitoring and evaluation skills and capabilities. The project would provide four months of short-term overseas technical assistance in health planning techniques, plus overseas training for a number of members of the Health Planning Unit on the basis of onc person for three months each year of the four-year project cycle. In country, a national workshop for health administration would be held followed by seven regional and ten district workshops. 2.21 Under the project four studies would be carried out at the rate of one a year. namely (a) following the collection of manpower data completed by AMREF, a manpower analysis is now needed to identify the correct staffing of MOR facilities at all levels and to identify training and retraining needs. Other studies would cover (b) the Development of Health Information and Management Systems (c) the Efficiency and Effectiveness of the Health System. and (d) the Establishment of Community-Based Distribution Systems for drugs. condoms and supplies. Annual work plans will be produced based on a component by component review of progress in the preceding year.  -24- Finally. a comprehensive mid-term review of progress will take place no later than December 31. 1990. Government has agreed that the results of the studies outlined above would be made available to IDA within six months of their completion for review and comments (pars. 6.02(xi)). (b) Strengthening Management Capability 2.22 Critical to the long-term success of the project is the need to strengthen management capability in the health sector and to improve the effectiveness and efficiency of the health care delivery system. The project emphasis will be on essentially in-country training with workshops leading to action-oriented training programs with implementation of changes in managerial practices as the key objective. Through technical assistance the project will aim to provide on-going management training and development during the four-year life cycle of the project. A long-term experienced management development specialist supported through the project will be assigned to the MOH and will be responsible. according to a strict timetable. for developing analysis of the required skill mixes. identifying of training needs and preparing a management development plan for all levels of managers in the health sector. The management development plan will be supported by short term consultancies. Given the cost-effectiveness of in-country training and its direct relation to local needs, only limited, focussed and structured overseas short-term study tours will be financed for three senior officials each year for two weeks, to visit other developing countries where health problems and solutions are relevant to the abilities of Ugandan staff and to the available facilities. supplies and drugs. 2.23 Comprehensive management development will be enhanced by a series of workshops at national. regional and district level on health facility management and will cover, through some 18 workshops. 600 managers in the health sector. Training and management development programs will be essentially practical with trainers drawn from existing experienced managers and workshops will focus on providing managers with action-oriented plans and programs for implementation when they return to their health facility. The results of these action plans and their implementation would be reviewed periodically to reinforce changes in managerial practices. 2.24 Overseas training, qupported by the project. will provide for one person each year to attend a three-month course in management development. In addition one person will be sent to overseas training for a year in hospital administration for Mulago Hospital.  -25- 2.25 Government has agreed that Hospital and Health Center Management Committees will be established for each facility by December 31. 1989 with a composition and function acceptable to IDA (para. 6.02(ii)'. The Committees might, for example, be chaired by the Resistance Committee Chairman with representation of MOH. MLG, facility administration and prominent community leaders as members. These Committees would be responsible for the periodic oversight of the facility as well as assisting in generating additional funding particularly with respect to facilities rehabilitated under this project where cost recovery should be introduced once the rehabilitation is complete (para. 6.02(ii)) thus complementing the professional and administrative supervision from MOH. Government has agreed during the mid-term review (para. 4.07) there will be a detailed examination of the introduction and effectiveness of the financial plans, resource generation and cost recovery at the rehabilitated facilities to ensure that such plans and activities are properly established and appropriately implemented (para. 6.02(ii)). (c) Alternate schemes for financing the health sector 2.26 Currently the health sector, managed by MOH. provides. except on an exceptional basis. free medical treatment at the district hospitals and Mulago Hospital. Financial responsibility for the primary health centers is vested in MLG. Under the project short-term technical assistance would be provided to examine the continued viability of the split for the health care system between the two ministries and to help design a cost recovery system at all levels. cost it. and help implement it as facilities are rehabilitated and reestablished. Research would also be carried out on the feasibility of introducing health insurance either on a community or district basis and of introducing revolving drug funds. 2.27 Other forms of community participation in the support of local health services would also be studied with the aim of developing participation in health financing. Informal committees have been established in some areas but to be successful all these financing schemes will have to be designed to ensure that the monies received remain within the health sector and are not remitted to Treasury. Arrangements will also have to be made to ensure that the revolving drug fund receives sufficient foreign exchange to be able to replace drugs and supplies on a regular basis. Program support will be provided for the start up of these health financing schemes. During negotiations. it was agreed that the Government would by June 30, 1989. be prepared to allow funds generated through community and health related financing activities including cost recovery to be rechanneled to the respective facilities (para. 6.02(x)). 2.28 Under the project the 30 rehabilitated health centers vould be provided with medical supplies with a value of US$1,000  -26- each to establish and launch revolving drug funds and a similar sum to develop community participation schemes to finance health service delivery. Similar arrangements would be made for a limited number of NGOs. For the district hospitals supplies valued at US$5.000 would be provided for both the drug fund (U.$2.500) and financing activities to generate funds for the hospital (US$2.500). For Nulago Hospital the project would provide supplies valued at US$10.000 to establish a revolving drug fund. These supplies would be procured by the MOH in bulk and issued to the health centers against credit vouchers. Government has agreed to submit to IDA for approval. proposals for income generating activities. based on community participation (using the revolving funds) as well as including accounting mechanisms (para. 6.02(xii)). 2.29 The funds in local currency deriving from the New Vision for the newsprint provided to introdu.e a health page (para. 2.12) would be used to establish a health development fund to support mother and child health care programs through national NGOs. (d) Support for NGOs 2.30 The NGOs provide essential complementary support to the government health services. Under the project a national workshop would be held to establish and define the roles and relationships of the NGOs and the Government. To that intent a consultant would be provided for three months to develop and plan the workshop and to carry out follow-up work. The project would also support the establishment of a coordinating body for NGO activities in the health sector and provide funds for new initiatives of the NGOs, with particular emphasis on the development of women's groups. Government agreed that each NGO proposal. inclIding its accounting mechanisms, would be submitted to IDA for review and comment prior to implementation (para. 6.02(xiii)). (e) Project Management 2.31 About four staff years of specialist services would be provided for a project coordinator, and another 12 staff months to assist in preparation of a follow-up project. III. PROJBC? ODSTS AND iINANCING A. Costs 3.01 Although the project has been designed to be implemented over a four-year period, it has been costed over a seven-year  -27- period. to have a disbursement profile corresponding to the standard profile for Uganda (Annex 4). Total costs of the proposed project are estimated at USh3.916 million (US$65.5 million equivalent). Base costs are calculated at US$50.7 million equivalent (100%) and contingencies at US$14.8 million equivalent (291). Foreign eachange costs account for US$45.1 million or 692 of total project costs. Taxes and duties have been excluded in calculating the project costs. However these are negligible since all items imported specifically for the project would be exempt from custom duties and sales taxes. Project costs by expenditure category are summarized in Table I below. and details are provided in Annex 4. Civil works account for 38% of base costs; furniture. equipment. vehicles. supplies and materials for 31X; monitoring for 42; technical assistance for 7M training for 32; and incremental recurrent costs (building. equipment and vehicle operation and maintenance) for 17X.  -28- Table I: PROJECT COSTS. CAGTEGORY _ ~~~~.2 '?. ..i .0.0. Ziotils s * Z Fiedu late I fShnm ha LOCal PFeO1*t I?.'!