We interviewed civil administrators, managers, health facilities, and project staff. The sample consisted of 32 respondents from the three districts who represented different profiles. Overall, 23 males and 9 females were interviewed in each participant group with most having qualified with a degree or more. The respondent’s demographics and location are shown in Table 2.
Table 2
Districts and participant profiles
District
|
N=32
|
Civil Administrator
|
Health Manager
|
Service provider
|
UN/INGO Project staff
|
District
Arua
|
11
|
3
|
2
|
2
|
2
|
Adjumani
|
12
|
3
|
2
|
2
|
2
|
Moyo
|
9
|
3
|
2
|
2
|
0
|
Sex
|
|
|
|
|
|
Male
|
23
|
9
|
3
|
3
|
3
|
Female
|
9
|
2
|
3
|
3
|
2
|
Age in years
|
|
|
|
|
|
|
|
|
|
|
|
26 – 35
|
3
|
0
|
1
|
1
|
2
|
35 – 44
|
18
|
5
|
4
|
4
|
2
|
>45
|
11
|
4
|
1
|
1
|
0
|
Education
|
|
|
|
|
|
Diploma
|
4
|
0
|
0
|
4
|
0
|
Degree
|
16
|
3
|
8
|
2
|
3
|
Post graduate
|
12
|
6
|
5
|
0
|
1
|
Health services organization
Based on the analysis, the most frequently discussed aspects of the organization of health services in this thematic area included; the model of health service delivery, planning, and management, and coordination.
Planning and management of health service delivery
Before the repatriation exercise, the District Health Team (DHT) and NGOs collaborated on planning and management of health services for refugees and host communities in all three districts. Following the repatriation exercise, the DHT assumed overall responsibility for health service delivery for refugees and host community (Table 3). These included planning and management, and allocation of resources for health services at all administrative levels. The DHT delivered health services based on national health policies. Health services were delivered by the DHT in collaboration with the UNHCR and other partners.
“As the DHT, we took over all health services in line with MoH governance structure at all levels including, sub-county, health facility and the community levels. These included primary health facilities previously managed by aid agencies. We ensured that all service delivery including management and administration, disease management protocols and guidelines, service delivery, health workers and infrastructure were according to Ministry strategies”.(District Health Officer)
While the DHT assumed responsibility for healthcare services, the UNHCR and other agencies continued to support health service delivery to refugees. This arrangement was apparent in Adjumani district where a considerable number of refugees remained following the repatriation exercise. In all three districts, the DHT utilized administrative and service providers in facilities at various levels to facilitate health service delivery for both refugees and host communities.
“The DHO continued to receive donations and capacity building from NGOs and other partners following the repatriation of refugees in the district. We also continued to make plans and discussion with the UNHCR regarding health services particularly for refugees.(District Health Officer)
Model of health service delivery
Health services for refugees and host populations are provided based on an integrated approach following the repatriation exercise in all three districts. Health facilities, equipment, ambulances, and other forms of support previously owned and managed by implementing partners were handed over to the DHT in all three districts. All forms of support by aid agencies were provided through the DHT.
“When the refugees were repatriated, and NGOs left all technical departments like DHO were in charge of service delivery. All assistance for service delivery and structures managed and operated by NGOs were absorbed by the DHO. NGOs only reinforced the districts with some financial support, drugs and supplies in a few areas and health facilities where refugees are present”.(District planner)
“As a district, we supported and facilitated the integration of health services for both refugees and host communities. Well, the integration started when the refugees were still here, but it became more rooted following the repatriation exercise.”(District Health Officer)
Coordination of health service delivery
Health services for both refugees and host communities in the three districts are coordinated by the DHO after the repatriation exercise. Respondents indicated that transferring coordination of health services to the DHO enhanced the process of integration, bringing together resources and technical expertise to ensure that the needs of all communities were met.
“It has not been easy but the DHO has been organizing health in the complexity of meeting the health needs of refugees and host communities because of many stakeholders… With the repatriation exercise, the district took over organization of health services ... The DHO ensured more structured system and personnel that made it easier to provide services. The health department is therefore in better position to respond to the health problems in the communities.”(District Health Officer)
Planning, coordination, and management, of health services in Arua was mainly the roles of the District Health Office, while in Adjumani, implementing partners played a role during the pre-repatriation period in all the three districts (Table 3). In Arua, health services were integrated while in Moyo and Adjumani, a mix of both parallel and integrated models were used. Health Service delivery in all three districts were delivered based on a decentralized framework with a minimum basic package of health services. Health services were provided in Primary Health Care Facilities in settlements before the repatriation of refugees. Government funding through the Primary Health Care grant was the main source of funding for health services with additional support from humanitarian agencies.
Table 3
Health system building block
|
Before repatriation
|
After repatriation
|
Arua
|
Adjumani
|
Moyo
|
Arua
|
Adjumani
|
Moyo
|
Health service delivery
|
• Focus of health service delivery
|
Emergency, curative, and preventive health services for refugees.
|
Emergency, curative, and preventive health services for refugees.
|
Emergency, curative, and preventive health services for refugees.
|
Comprehensive health care services to address the health needs of both refugees and hosts communities.
|
Comprehensive health care services to address the health needs of both refugees and hosts communities.
|
Comprehensive health care services to address the health needs of both refugees and hosts communities
|
|
Emergency medical assistance with shift to PHC
|
Emergency medical assistance with shift to PHC
|
Emergency medical assistance with shift to PHC
|
Focus of PHC in all health facilities
|
Focus of PHC in all health facilities
|
Focus of PHC in all health facilities
|
• Framework for service delivery
|
Decentralized health service delivery
|
Decentralized health service delivery
|
Decentralized health service delivery
|
Decentralized health service delivery
|
Decentralized health service delivery
|
Decentralized health service delivery
|
|
Based on Uganda Minimum Health Care Package.
|
Based on Uganda Minimum Health Care Package.
|
Based on Uganda Minimum Health Care Package.
|
Health services integrated with other related sectors.
|
Health services integrated with other related sectors.
|
Health services integrated with other related sectors.
|
|
Basic health services provided in first line health facilities HC II, III and IVs.
|
Basic health services provided in first line health facilities HC II, III and IVs.
|
Basic health services provided in first line health facilities HC II, III and IVs.
|
Health services provided in permanent health facilities.
|
Health services provided in permanent health facilities.
|
Health services provided in permanent health facilities.
|
Health service availability
|
Basic health services provided in first line health facilities HC II, III and IVs.
|
Basic health services provided in first line health facilities HC II, III and IVs.
|
Basic health services provided in first line health facilities HC II, III and IVs.
|
Health facilities serve a defined catchment of both refugee and host population.
|
Health facilities serve a defined catchment of both refugee and host population.
|
Health facilities serve a defined catchment of both refugee and host population.
|
|
Health services provided in permanent structures.
|
Health services provided in intermediate – semi permanent health facilities linked to referral system.
|
Health services provided in intermediate – semi permanent health facilities linked to referral system.
|
Tiered network of primary, secondary, and tertiary levels of health facilities
|
Tiered network of primary, secondary, and tertiary levels of health facilities
|
Tiered network of primary, secondary, and tertiary levels of health facilities
|
|
Strict referral system for emergency and specialized care for refugees
|
Strict referral system for emergency and specialized care for refugees
|
Strict referral system for emergency and specialized care for refugees
|
Health facilities providing an integrated continuum of health care.
|
Health facilities providing an integrated continuum of health care.
|
Health facilities providing an integrated continuum of health care.
|
|
Secondary and tertiary health care provided by HC IVs and hospitals.
|
Secondary and tertiary health care provided by HC IVs and hospitals.
|
Secondary and tertiary health care provided by HC IVs and hospitals.
|
Secondary and tertiary health care provided by HC IVs and hospitals.
|
Secondary and tertiary health care provided by HC IVs and hospitals.
|
Secondary and tertiary health care provided by HC IVs and hospitals.
|
Access to health services
|
Health facilities responsible for up to 50,000 or more inhabitants.
|
Health facilities responsible for up to 50,000 or more inhabitants.
|
Health facilities responsible for up to 50,000 or more inhabitants.
|
Health facilities responsible for up to 10,000 or more inhabitants.
|
Health facilities responsible for up to 10,000 or more inhabitants.
|
Health facilities responsible for up to 10,000 or more inhabitants.
|
|
Health services provided free of charge to both refugee and host populations.
|
Health services provided free of charge to both refugee and host populations.
|
Health services provided free of charge to both refugee and host populations.
|
Health services provided free of charge to both refugee and host populations.
|
Health services provided free of charge to both refugee and host populations.
|
Health services provided free of charge to both refugee and host populations.
|
|
Health service delivery supported by a strong referral system.
|
Health service delivery supported by a strong referral system.
|
Health service delivery supported by a strong referral system.
|
Referral systems weakened in former refugee health facilities
|
Referral systems weakened in former refugee health facilities
|
Referral systems weakened in former refugee health facilities
|
|
Heath facilities located in and around refugee settlements < 5 km distance
|
Heath facilities located in and around refugee settlements < 5 km distance
|
Heath facilities located in and around refugee settlements < 5 km distance
|
Health facilities accessible to most populations within ≤ 5km distance.
|
Health facilities accessible to most populations within ≤ 5km distance.
|
Health facilities accessible to most populations within ≤ 5km distance.
|
Model of health service delivery
|
Integrated health services for refugees and hoists
|
Parallel and integrated health services
|
Parallel and integrated health services
|
Integrated health services for refugees and hosts
|
Integrated health services for refugees and hosts
|
Integrated health services for refugees and hosts
|
Management and administration
|
DHO with District Health Team (DHT) members
|
DHO and UNHCR implementing partners - NGOs
|
DHO and UNHCR implementing partners - NGOs
|
DHO for both refugees and host communities
|
DHO for both refugees and host communities
|
DHO for both refugees and host communities
|
Planning
|
DHO for both host and refugees’ communities
|
DHO for host and UNHCR/NGOs for refugee communities
|
DHO for host and UNHCR/NGOs for refugee communities
|
DHO for both refugees and host communities
|
DHO in consultation with UNHCR
|
DHO for both refugees and host communities
|
Coordination
|
DHO and UNHCR/NGOs implementing partners
|
DHO for host and UNHCR/NGOs for refugee communities
|
DHO for host and UNHCR/NGOs for refugee communities
|
District Health Office
|
District Health Office
|
District Health Office
|
Table 4
Health system building block
|
Before repatriation
|
After repatriation
|
Arua
|
Adjumani
|
Moyo
|
Arua
|
Adjumani
|
Moyo
|
Health financing
|
Source of health financing
|
Government funding through PHC grant
UNHCR/WHO/UNICEF and other donors
|
Government funding through PHC grant
UNHCR/WHO/UNICEF and other donors
|
Government funding through PHC grant
UNHCR/WHO/UNICEF and other donors
|
Government financing through PHC grant
|
Government financing through PHC grant
|
Government financing through PHC grant
|
|
Private out of pocket in private health facilities
|
Private out of pocket in private health facilities
|
Private out of pocket in private health facilities
|
Out of pocket payment in private health facilities
|
Out of pocket payment in private health facilities
|
Out of pocket payment in private health facilities
|
|
Funding for service delivery provided by UNHCR and NGOs.
|
Funding for service delivery provided by UNHCR and NGOs.
|
Funding for service delivery provided by UNHCR and NGOs.
|
No additional support by UNHCR
|
Partial financial support by the UNHCR
|
No additional support by UNHCR
|
|
Limited government funding for refugee health services
|
Limited government funding for refugee health services
|
Limited government funding for refugee health services
|
Increased government funding to former refugee health facilities
|
Increased government funding to former refugee health facilities
|
Increased government funding to former refugee health facilities
|
Table 5
Human resources for health
Health system building block
|
Before repatriation
|
After repatriation
|
Arua
|
Adjumani
|
Moyo
|
Arua
|
Adjumani
|
Moyo
|
Human resources for health
|
Health worker availability
|
Health services provided largely by health workers in public facilities.
|
Health services provided by public and expatriate/contract health workers.
|
Health services provided by public and expatriate/contract health workers.
|
Health workers available in the health facilities
|
Inadequate and unevenly distributed human resources across former refugee health facilities
|
Inadequate and unevenly distributed human resources across former refugee health facilities
|
Skills mix
|
Appropriate skill mix among health workers
|
Inadequate skills mix among health workers due to transfers and laying off staff.
|
Inadequate skills mix among health workers due to transfers and laying off staff.
|
Appropriate skill mix among health care workers
|
Inadequate skills mix among health care workers.
|
Inadequate skills mix among health care workers.
|
Support for human resources for health
|
Health workers recruited and paid by Government and NGOs.
|
Health workers in refugee health facilities recruited and paid by NGOs.
|
Health workers in refugee health facilities recruited and paid by NGOs.
|
Limited support by UNHCR
|
Partial health workers support by UNHCR
|
Limited health worker support by UNHCR
|
|
Training of health workers by government and NGOs.
|
Training of health workers by government and NGOs.
|
Training of health workers by government and NGOs.
|
Training of health workers by government
|
Training of health workers by government
|
Training of health workers by government
|
Health management
|
Recruitment and payment by the DLG
|
Recruitment and payment by DLG and NGOs
|
Recruitment and payment by DLG and NGOs
|
Absorption of NGO staff into local health service.
|
Absorption of NGO staff into local health service.
|
Absorption of NGO staff into local health service.
|
|
|
|
|
Redeployment of health workers in health facilities
|
Redeployment of health workers in health facilities
|
Redeployment of health workers in health facilities
|
|
|
|
|
|
Laying off non-qualified health staff
|
Laying off non-qualified health staff
|
Table 6
Medicines, supplies and equipment
Health system building block
|
Before repatriation
|
After repatriation
|
Arua
|
Adjumani
|
Moyo
|
Arua
|
Adjumani
|
Moyo
|
Medicines, supplies & equipment
|
• Source of medicines and supplies
|
Government through National Medical Stores,
UNHCR and other aid agencies - WHO & UNICEF.
|
Government through National Medical Stores,
UNHCR and other aid agencies - WHO & UNICEF.
|
Government through National Medical Stores,
UNHCR and other aid agencies - WHO & UNICEF.
|
Mainly government through National Medical Stores
|
Mainly government through National Medical Stores
|
Mainly government through National Medical Stores
|
|
|
|
|
Limited or no additional support from humanitarian agencies
|
Additional support from the UNHCR
|
Limited or no additional support from humanitarian agencies
|
Availability of medicines and supplies
|
Medicines and supplies available with stock outs in most health facilities
|
Medicines and supplies available with stock outs in most health facilities
|
Medicines and supplies available with stock outs in most health facilities
|
Frequent stock out of essential medicines and supplies in former refugee health facilities
|
Frequent stock out of essential medicines and supplies in former refugee health facilities.
|
Frequent stock out of essential medicines and supplies in former refugee health facilities
|
|
|
|
|
|
Rationing and sharing of drugs in health facilities
|
Rationing and sharing of drugs in health facilities
|
Health services delivery
The analysis revealed several features related to health service delivery including focus of health service delivery, framework for service delivery, and the availability and accessibility of health services.
Focus of health service delivery
In all three districts, the DHT provided comprehensive health services in all facilities (Table 3). Health services delivery focused on maintaining and provision of health (curative services) to both refugees and host populations. This contrasts with the pre-repatriation phase where health service delivery was dominated by the provision of curative services by NGOs that focused on emergency care services. The DHO and UNHCR/NGOs provided health services for both refugees and host communities with the available resources.
“The DHO provided health services to meet the health needs of both refugees and host communities, which is the goal of the decentralized health services. But also, while we did this, we ensured that the health needs of both communities addressed with the resources which were available.”(District Health Officer)
Framework for health service delivery
Health service delivery is based on the decentralized framework in all three districts. Participants observed that while for several years’ decentralization has been the overarching principle, the refugee emergency made its operationalization challenging. However, following the repatriation exercise, health services were organized by the DHT.
“As a district, we have been following decentralized structure for service delivery. So, health services have also been delivered following these guidelines even when the refugees were still here. But for the time we hosted refugees, the implementation of services using the framework was difficult, for example, the implementing partners would not disclose and share their budgets with the local authorities.”(District Planner)
In all three districts, health services for refugees and host populations is based on national guidelines and standards. This contrasts with the pre-repatriation period where health service delivery by NGOs was focused on emergency health care. The NGOs used humanitarian standards and guidelines to support health service delivery. This was applied across all levels of care for both refugees and host communities.
“Health service delivery was based on the Uganda National Minimum Healthcare package at all levels of care post repatriation …. The focus was on providing priority health services using available resources to improve the well-being of the population, by promoting health, and responding to community health problems. The services were for both populations at referral hospitals, district hospitals, sub-district and lower-level facilities”(District Health Officer)
Availability of health services
Health services are provided for defined population in specific locations following the repatriation exercise in all the three districts. In several former refugee settlements, prior to repatriation, health services were available through a tiered network of lower-level health facilities with specialist care available in hospitals in the region. Health services are provided through a continuum of integrated facilities in all three districts. This is in contrast to the pre-repatriation phase which was characterized by the provision of health services in temporary facilities that exclusively served refugee communities.
Coverage of essential health services varied considerably from one health facility to another following the repatriation exercise in the three districts. Health services in most facilities in Arua district were available as most remained operational with health workers, drugs and supplies. While in Adjumani and Moyo districts, availability of health services in several facilities varied. In these facilities’, coverage was affected by operational status of facilities, availability of resources including health workers, drugs and medical supplies.
“As the district health office, we observed differences in volume of services following repatriation and restructuring of health facilities. Lack of medicines and other supplies and health workers affected service delivery in facilities. Several facilities opened for only a few hours because staff were either laid off or posted to other facilities. We observed that few people were using the services.”(Refugee health focal person)
Health service were delivered through a network of linked permanent facilities in all three districts. However, several facilities were in poor structural conditions in all three districts. The DHT inherited facilities from aid agencies that were operated in temporary structures. Many were not in line with the guidelines of the Ministry of Health. As such, a few facilities did not receive accreditation from the Ministry of Health. These facilities did not receive any public funding, and other forms of support.
“While services were available in all areas, it was also a challenge because of poor infrastructure. Up to the time of repatriation even after more than 10 years, some health facilities continued to be operated in semi-permanent structures and in a poor physical state and not recognized by the Ministry of Health. In fact, several facilities till now don’t receive government funding and support because they were not approved by the ministry.”(Refugee Health Focal Person)
The district health services reorganized and restructured health facilities to ensure they remained operational and minimized disruptions in all the three districts. Facilities were renovated and new ones were built in certain locations. In other instances, facilities that did not meet minimum requirements for a designated level were downgraded or even closed. In Adjumani district, two facilities were relocated to new locations. These included redistribution of health workers, rationing, and sharing drugs and other supplies to support and ensure the facilities remained operational.
Medicines, supplies and equipment
Government supplies through the National Medical Store was the main source of drugs and supplies for most health facilities. Health facilities accredited by the Ministry of Health were supplied drugs and other supplies. Adjumani district continued to receive some support for medicines and other supplies through the UNHCR. This facilitated service delivery to refugees who remained in the district. However, there were shortages of drugs and supplies in health facilities. Shortages were more pronounced in Arua and Moyo districts where aid agencies withdrew completely affecting service delivery.
Human resources
From the informant’s discussion, three aspects emerged about human resources; availability of health workers, skills mix in health facilities, support by aid agencies, and health worker reforms.
Availability of health workers
Health worker availability varied in several health facilities and in each of the three districts following repatriation exercise. Health workers were generally available in all facilities in Arua compared to Adjumani and Moyo districts. Respondents indicated that during the establishment of the refugee facilities in Arua district, the administration made efforts to ensure that staffing of all facilities was conducted according to MoH guidelines and with the involvement of the local government.
“The repatriation affected the distribution and availability of health workers in refugee facilities differently. The district administrative and DHO engaged the UNHCR and its partners to ensure health facility staffing was guided by the Ministry of Health and Ministry of Public Service standards. Health workers were recruited and paid through the district services commission. In this way, repatriation did not affect health service through the would-be departure of contracted staff”(District Health Officer)
In Moyo and Adjumani districts, health service delivery was affected by inadequate numbers and skills mix following the repatriation exercise. Respondents indicated that health workers recruited and paid by the aid agencies were laid off following the repatriation exercise. Staffing levels were below the minimum standards required to ensure effective service delivery in several health facilities. Health workers who did not have the necessary qualifications in accordance with the guidelines of the Ministry of Health and Ministry Public Service were laid off.
“The health facilities were affected by the reduction of number of health workers. Several facilities lacked staff to function according to established guidelines. Health workers employed by NGOs were out of contract could not continue working. However, we also laid off some because of lack of academic qualification according to the public service and ministry guidelines. There were also recruitment and transfer of health workers to beef up understaffed facilities”.(District Health Officer)
Health worker reforms
To address the gaps, the administrators, and technical departments in Adjumani and Moyo, reorganized the recruitment and redeployment of staff to meet the service delivery goals. In Adjumani district, a few qualified health workers previously employed by aid agencies were absorbed by the district health office. The UNHCR facilitated the recruitment and supported salaries of health workers in selected health facilities serving refugees who had remained.
“As the DHO, we had to ensure that the facilities are delivering services. We advertised, conducted interviews, and recruited health workers. Few qualified NGO staff were absorbed by the DHO. The UNHCR recruited and continued to pay four health workers, two midwives and two nurses in facilities where refugees had remained. Others were deployed to understaffed facilities.”(District Health Officer)
Financing
Government funding, and partial support by the UNHCR were the main sources of health financing in all three districts. The Primary Health Care Conditional Grant (PHC-CG) disbursed by the central government to District Local Governments for the implementation of Uganda National Minimum Health Care Package (UNMHCP) in public and Private not for Profit (PNFP) health facilities was the main source of funding. Most (pubic and PNFP) health facilities in all the three districts were funded through PHC grants. Government provides per capita based funding for the provision of the UNMHCP in all facilities estimated at US$41.2 in 2008/2009 rising to US$47.9 in FY2011/2012. These funds were used to cater for health service delivery for both refugees and host populations in all the three districts. Most refugee established health facilities that had been accredited receive the PHC grant to support health service delivery following the repatriation of refugees.
Cost-sharing was used to ensure service delivery in all three districts. The PHC grant and UNHCR funding were the main sources of health financing in Adjumani district. The UNHCR continued supporting the DHO to provide health services to host and refugee communities who had remained in the district. Funding for the few facilities established for refugees was challenging as they were never absorbed by the government, meaning these could not access PHC funding. The DHO and administrative authorities had to manage resources to support the facilities not supported by the PHC grant.
“The main source of funding for health services in the refugee hosting districts was the PHC grant and limited specific support by the UNHCR for service provision for refugees. For example, salaries for midwives and nurses in refugee established facilities and fuel and service for the ambulance were provided by UNHCR”(District Health Officer)