KABALE UNIVERSITY.

SCHOOL OF MEDICINE.
PUBLIC HEALTH DEPARTMENT.
GROUP 3 ROTATION COURSE WORK.
DATE: 14TH MARCH, 2023.
NAMES:
NAMANYA AUDREY 2019/A/KMS/1161/F
AKUGIZIBWE CATHERINE 2019/A/KMS/1166/F
NSIIMA NDYAKYIRA 2019/A/KMS/0111/F
TWESIGYE ARNOLD 2019/A/KMS/1156/F
KASSIM ABDULRRAKIIBU 2019/A/KMS/1179/F
MUSASIZI STUART 2019/A/KMS/0124/F
PANDE ESTHER 2019/A/KMS/1119/F
NABAZIWA SYLIVIA 2019/A/KMS/0132/F
NAMATOVU BERNA 2019/A/KMS/0117/F
LUNYOLO FAITH DAPHINE 2019/A/KMS/0120/F
Coursework.
1.
(a) What factors led to the introduction of PHC in 1978.
(b) What is the relevance of PHC in 2023.
2. Read Uganda’s national health policy for 2021-2030 and answer the following.
(a) What is the universal health coverage (UHC)?
(b) Why should Uganda be concerned about UHC?
(c) What does the policy propose to do in order to achieve UHC by 2030?
3. Read the Uganda MOH Annual Health Sector Performance Report of 2021/22 and answer the
following:
(a) What is a “social gradient” as far as health is concerned?
(b) Using information from the national health policy, the AHSPR and any other source that you should
cite, prove that there exists a social gradient in health in Uganda.
(c) Study the district league table in the AHSPR. Which district is worst off and why do you think its at
that level.
(d) You have been appointed the DHO of that district. What would be your plan to improve the
performance of that district in the DLT within 3 years? Describe the problems to tackle and actions in
order of priority.

1. (a) What factors led to the introduction of PHC in 1978?

The Alma-Ata Declaration of 1978 emerged as a major milestone of the twentieth century in
the field of public health, and it identified primary health care as the key to the attainment of
the goal of Health for All. The following are excerpts from the Declaration:

The Conference strongly reaffirms that health, which is a state of complete physical, mental,
and social well-being, and not merely the absence of disease or infirmity, is a fundamental
human right and that the attainment of the highest possible level of health is a most important
world-wide social goal whose realization requires the action of many other social and economic
sectors in addition to the health sector.
The existing gross inequality in the health status of the people, particularly between developed
and developing countries as well as within countries, is politically, socially, and economically
unacceptable and is, therefore, of common concern to all countries.
The people have a right and duty to participate individually and collectively in the planning and
implementation of their health care.
Primary health care is essential health care based on practical, scientifically sound, and socially
acceptable methods and technology made universally accessible to individuals and families in
the community through their full participation and at a cost that the community and country
can afford to maintain at every stage of their development in the spirit of self-reliance and self-
determination. It forms an integral part both of the country's health system, of which it is the
central function and main focus, and of the overall social and economic development of the
community. It is the first level of contact of individuals, the family, and community with the
national health system bringing health care as close as possible to where people live and work,
and constitutes the first elements of a continuing health care process.
An acceptable level of health for all the people of the world by the year 2000 can be attained
through a fuller and better use of the world's resources, a considerable part of which is now
spent on armaments and military conflicts. A genuine policy of independence, peace, détente,
and disarmament could and should release additional resources that could well be devoted to
peaceful aims and in particular to the acceleration of social and economic development of
which primary health care, as an essential part, should be allotted its proper share.

b) What is the relevance of PHC in 2023?

Primary Health Care (PHC) is the most inclusive, equitable, cost-effective and efficient approach to
enhance people’s physical and mental health, as well as social well-being. Evidence of wide-ranging
impact of investment in PHC has continued to grow around the world, particularly in times of crisis such
as the COVID-19 pandemic and the post COVID-19 era.
Across the world, investments in PHC improve equity and access, health care performance,
accountability of health systems, and health outcomes. While some of these factors are directly related
to the health system and access to health services, a broad range of factors beyond health services play
a critical role in shaping health and well-being. These include social protection, food systems, education,
and environmental factors, among others.

PHC is also critical to make health systems more resilient to situations of crisis, more proactive in
detecting early signs of epidemics and more prepared to act early in response to surges in demand for
services. There is recognition that PHC provides the foundation for the strengthening of the essential
public health functions to confront public health crises like disease outbreaks.
PHC addresses the broader determinants of health and focuses on the comprehensive and interrelated
aspects of physical, mental and social health and wellbeing. It provides whole-person care for health
needs throughout the lifespan, not just for a set of specific diseases.
Primary health care ensures people receive quality comprehensive care ranging from health promotion
and disease prevention to treatment, rehabilitation and palliative care as close as feasible to people’s
everyday environment.
Primary health care addresses the health needs of all patients at the community level, integrating care,
prevention, promotion and education. A higher primary care orientation is likely to produce better
health for a population at a lower cost.
The total health-care expenditure is generally higher in countries where health-care systems are left to
the fluctuation of market forces. Free market systems appear to have higher inpatient costs per capita
and a higher per capita expenditure on medication. Primary health care improves the performance of
health systems by lowering overall health care expenditure while improving population health and
access.
The restriction of specialists to hospitals and their payment by salary are generally associated with a
better systems performance for the population as a whole. The regulation of the location of physicians
and their equitable distribution across the population are generally associated with better health system
performance.

2. Read Uganda's National Health Policy for 2021-2030 and answer the following:
(a) What is Universal Health Coverage (UHC)?
Universal health coverage is defined as a system that ensures access to quality essential health services
and financial risk protection for all people, without discrimination of the socio-economic status of the
people, geographic location and including both preventive and curative services that would protect
themselves from financial ruin caused by medical expenses.
This includes preventive, promotive, curative, palliative, and rehabilitative services, as well as essential
medicines and vaccines. Universal health Coverage is recognized by the World Health Organization
(WHO) as a key component of sustainable development and a means of achieving health and well-being
for all.
The policy aims to achieve Universal Health Coverage by focusing on key areas such as health financing,
service delivery, health workforce, health information systems, and access to essential medicines and
technologies. The ultimate goal of Universal Health Coverage is to improve the health and well-being of
the population by reducing health inequalities and ensuring that all individuals have access to quality
health services when and where they need them, without incurring financial hardship therefore
improving the population health, safety and management.

(b) Why should Uganda be concerned about UHC?

Although the UHC is aimed to achieve three specific goals, first, to analyse the status of the
critical health infrastructure needed to attain sustained progress towards UHC; second, to
review Uganda’s progress towards UHC and lastly to provide policy recommendations on how
Uganda can accelerate its progress towards UHC, Uganda has to be concerned about:-
The fundamental challenges to the critical health infrastructure needed to deliver UHC in
Uganda which include;-
 Spatial inequality in the health facility population coverage with the eastern and
northern regions experiencing the least coverage.
 Low private sector health facility establishments (investments) in the northern and
eastern regions.
 Distance to health facilities which posed a barrier to health care access to some
segments of the population (for instance, women of reproductive age).
 Limited functionality and availability of necessary infrastructure at the health facility
level.
 Low health workforce density was widespread, indicating that the existing health
workforce is deficient and unable to expand population-based healthcare services.
 It is worth noting that the specific critical cadre gaps (for doctors, nurses and midwives)
are not substantial, however, the overall health workforce density remains very low
compared to the WHO standard for expanding population-based healthcare.
 There is need to review the current staffing norms especially for critical cadres, to
recruit more critical health workers to satisfy the revised staffing norms and to
implement staff retention initiatives.

(c) What does the policy propose to do in order to achieve UHC by 2030?

A 6 steps agenda set milestones to take action for achieving Universal Health Care by 2030
through the following six steps.
1. LEAD. Ensure Political Leadership beyond Health implementing policies through a
health-in-all-policies approach that comprehensively address social, economic,
environmental and other determinants of health. Prioritizing health promotion and
disease prevention through public health policies, good governance of health systems,
education, health communication and health literacy, as well as healthy cities. Provide
strategic leadership at the highest political level and promote greater policy coherence
and coordinated actions through all levels of government. Set measurable national
targets and strengthen national monitoring and evaluation platforms to support regular
tracking of the progress and to evaluate the impact of policies and programs.

2. PROTECT Leave No One Behind – Pursue equity in access to quality health services with
financial protection. Establish resilient, responsive and inclusive health systems that are
accessible to all, irrespective of socioeconomic or legal status, health condition or any
other factors. Pursue efficient health financing policies that respond to unmet needs and
eliminate financial barriers to access. Establish health systems that promote equity,
reduce stigma and remove barriers based on multiple types of discrimination. Ensure to
reach the furthest behind of populations, including vulnerable people, and empower
them by addressing their physical and mental health needs.
 .
3. LEGISLATE Regulate and Legislate – Create a strong, enabling regulatory and legal
environment responsive to people’s needs. Strengthen legislative and regulatory
frameworks that promote responsiveness and inclusiveness of all stakeholders.
Implement national quality control mechanisms or minimum national quality health
service standards. Build effective, accountable, transparent and inclusive institutions at
all levels to end corruption and ensure good governance. Improve the availability,
affordability and efficiency of health products by increasing transparency of prices
across the value chain.

4. ADVOCATE Uphold Quality of Care – Build quality health systems that people and
communities’ trust. Implement effective, quality-assured, people-centered interventions
with measures built in for quality assurance and optimization. Strengthen the capacity
for health interventions through assessment, data collection and analysis to achieve
evidence-based decisions at all levels. Invest in health technology innovation, including
the promotion of digital health tools and AI to provide new opportunities to respond to
the unique needs of each person. Scale-up efforts to promote the recruitment, training
and retention of health workers, especially in rural, hard-to-reach and underserved
areas.

5. INVEST More, Invest Better – Sustain public financing and harmonize health
investments. Set nationally appropriate spending targets for investments in health
consistent with sustainable national development strategies that ensure the efficient
and equitable allocation of resources. Prioritize debt restructuring to address the debt
sustainability challenges faced by many countries. Ensure sufficient domestic public
spending on health and pool health financing to maximize efficiency and ensure that
everyone can access the health services they need without financial hardship. Foster
strong alignment among global health stakeholders and development partners to
support financing mechanisms.

6. COLLABORATE Move Together – Establish multi-stakeholder mechanisms for engaging

the whole of society for a healthier world. Enable and introduce processes for the
structured and meaningful engagement of diverse stakeholders, including government,
civil society, the private sector, youth and academia. Empower individuals, families,
communities, local providers and civil society organizations by strengthening and
enhancing community capacity to get involved in decision-making and accountability
processes. Improve health literacy, legal and systems literacy and capacity for health
decision-making through a multi-sectoral approach at the local level. Revitalize and
promote strong global partnerships with relevant stakeholders to collaboratively
support the efforts of Member States.
3. Read the Uganda MOH Annual Health Sector Performance Report of 2021/22 and answer the
following:
(a) What is a “social gradient” as far as health is concerned?

SOCIAL GRADIENT
DEFINITION
Life expectancy is shorter and most diseases are more common further down the social ladder
in each society. (Richard Wilkinson and Michael Marmot)
Health policy must tackle the social and economic determinants of health. Poorer people live
shorter lives and are more ill than the rich.
Poor social and economic circumstances affect health throughout life. People further down the
social ladder usually run at least twice the risk of serious illness and premature death as those
near the top. Nor effects confined to the poor; the social gradient in health runs right across
society, so that even among the middle-class office workers, lower ranking staff suffer much
more disease and earlier death that higher ranking staff. (Richard Wilkinson and Michael
Marmot)
Social and economic conditions result in a social gradient in diet quality that contributes to
health inequalities. The main dietary difference between social classes is the source of
nutrients. In many countries, the poor tend to substitute cheaper processed foods for fresh
food. High fat intakes often occur in social groups. People on low incomes, such as young
families, elderly people and the unemployed, are least able to eat well.
REFERENCE: Social determinants of Health “SOLID FACTS” Edited by Richard Wilkinson and
Michael Marmot in 2003 for World Health Organization.

(b) Using information from the National health policy, the AHSPR and any other source that you
should cite, prove that there exists a social gradient in health in Uganda.
 The poor are often disadvantaged, whatever the dimension assessed- that they suffer more ill
health, utilize less, and pay more of their income on healthcare than the better off.

 Geographical access to health care has been limited to about 40% of the population, i.e.
population living within five kilometers of a health service unit mainly because health facilities
are mostly located in towns along main roads. Rural communities are particularly affected,
mainly because health facilities are mostly located in tows along main roads.

 The different health needs and priorities of women and men have not been identified and
addressed by the health system. Health problems related to gender-based violence and female
genital mutilation are increasingly notable.
 The increasing burden of disease resulting from poor environmental health, particularly by
placing greater emphasis on rural areas where the population has low access to safe water and
poor latrine coverage.

 Inappropriate attention regarding health care for the elderly.

 Gender related barriers to health where there is lack of equal weight given to knowledge, values
and experiences of women and men as well as equal participation in research, policy and
decision making, thus a need for gender sensitive and responsive national health system.

 Sexuality and sexually related behavior and gender relations including child sexual abuse,
violence against women, genital mutilation and other harmful practices.

 Violence against women which includes domestic violence, female genital mutilation.

 Micronutrient deficiency among the poor, young children, pregnant and lactating mothers and
obesity among the rich.

 Health education and promotion among the richer population who are able to access quality
education where common ailments are addressed, environmental sanitation and personal
hygiene and promotion of appropriate nutrition practices.

 Natural and man-made disasters for example landslides and floods which mainly affect people
of lower social economic status that reside around mountainous and swampy areas.

 Mother’s characteristics in comparison with the health outcomes of the child for example age at
childbirth e.g. children born by young mothers are more likely to suffer from ill health than
those of adult mothers, furthermore, given that stunting can be cross generational i.e. mothers
who were stunted during childhood are more likely to produce stunted children. Education
attainment can also affect a woman’s ability to process health information which has direct
bearing on the child’s health. (Obtained from Research series No.9 on the causes of health
inequalities in Uganda by Sewanyana Sarah and Kasirye Ibrahim in October, 2012)

 Household characteristics such as wealth status where incomes are important for nutrient
availability and treatment of illnesses unlike the poor who cannot afford.

(c) Study the District League Table in the AHSPR. Which district is worst off and why do you think it is
at that level?
Hoima district is the district that is worst off as shown by the District League Table.
I think that the poor health performance of Hoima district is attributed to many factors which include
the following;
  Inadequate Access:
Inadequate access to basic healthcare services such as shortage of medical professionals, a lack of
quality assurance, insufficient health spending, and, most significantly, insufficient research funding.
 Low Budget:
The low budget allocated to public health care by the policy makers has led to the limited health
resources hence the worst annual health performance.
 Inconsistent drug distribution.
The problem of inconsistent drug distribution by the policy makers affects the provision of health
services to the people who seek the health services.
 Lack of Preventive Care:
Some common morbidities are as a result of lack of preventive measures which are so important in the
control of diseases.
 Lack of Medical Research:
Lack of medical research and community assessment in order to establish appropriate measures to fight
and treat common diseases contribute to the poor health performance.
 Lack of social cohesion.
Population groups who live in cohesive and mutually supportive societies generally have better health.
In Hoima, many individuals and families may be facing the problem of lack of social support which affect
the quality of their health.
 Housing
Overcrowding and poor-quality housing may be a major social and public health problem for many
families in Hoima. Overcrowding encourages the spread of diseasesfor example, tuberculosis and skin
infections.
 Limited income.
The residents of Hoima district may probably be facing economic challenges where by they are not able
to afford private health services when required.
 Poor Policy making:
Policy making is undoubtedly crucial in providing effective and efficient healthcare services. In Hoima,
the supply of health requirements may be poor because of the poor policy making.
 Shortage in Professionals:
In Hoima, there may be a shortage of doctors, nurses, and other healthcare professionals who mainly
move to other places with improved facilities and adequate salaries paid to them.
 Paucity of Resources:
Doctors work in extreme conditions ranging from overcrowded out-patient departments, inadequate
staff, medicines and infrastructure.
  Lack of quality education and employment
Many individuals may be affected by lack of proper knowledge concerning their health while others
have poor working environments that put them at risk of acquiring occupational diseases.
In summary, health is affected by the interaction between personal and environmental factors.
Environmental influences include physical, socio-economic, cultural and political factors, as well as the
availability of health services.

(d) You have been appointed as the DHO of that district, what would be your plan to improve
the performance of that district in the DLT within 3 years? Describe the problems to tackle
and actions in order of priority. 
  
The district that is worst off in the health performance is Hoima District with a score of 37.5%.
My plan as the newly appointed District Health Officer of Hoima District would be as follows.
The strategy below consists of a problem and how in conjunction with the district leadership
board and the community would manage it within 3 years.  

 Poor sanitation.
Water and sanitation are essential for life and health, they are part of human rights,
fundamental to every child and adult. But in Uganda especially districts such as Hoima, poor
sanitation and hygiene as well as unequal access to safe drinking water make thousands of
children very sick and at risk of death. Therefore, solving this problem as the DHO would be my
first action and this would be accomplished through the following strategies;

 Providing technical and backup support to the communities in regard to environmental

health services and Managing sensitization programs about Primary Health Care in the
communities.
 Participating in planning, coordinating & budgeting, managing, monitoring and
evaluating environmental health service delivery programs in the district.
 Updating Health Management System in the District.
 Managing the implementation of Environmental Health Policies and programs;
 Producing reports on environmental health programs.
 Carrying out staff performance appraisal and other Human Resources Management
functions.
 Compiling and submitting monitoring and evaluation reports on environmental health
programs.
 Developing and implementing Environmental health Research plans.
 Producing plans and budgets for environmental health services delivery.
  Immunization
Hoima district has a poor immunization program performance and therefore this has greatly
contributed to its poor health performance
 Maternal health care
According to the 2014 national housing and population census report, the infant mortality rate
of Hoima District was estimated at 53 deaths per 1000 live births in 2014. The maternal deaths
are associated with lack of operational theatres in health centre IVs and shortage of
ambulances to transport mothers to Hoima regional referral hospital in case of an emergence.  
This can be solved by advocating for an increment in wage structure of Hoima Regional referral
hospital and the health centre in the FY2023-24 so as to improve the staff enrollment and also
setting up of functional theatres in different health centres.  
 Disease outbreaks 
Hoima district is one of the common districts affected by disease outbreaks with the latest
example being on 23rd February, 2018, where the Uganda Ministry of Health (MOH) declared a
cholera outbreak affecting more than 60 persons in Kyangwali Refugee Settlement near the
border of Democratic Republic of Congo (DRC), Hoima District. 
Such outbreaks are mostly associated with drinking of contaminated stream water and often
prolonged, affecting a large number of sub-counties and divisions in the district therefore
greatly affecting the health performance of the district. 
My plan about this problem would be focused on improving sanitation by
recommending boiling of drinking water, increasing the district latrine coverage and provision
of safe water to the people. 

 Utilization of Health Care Services.

Decreased utilization of Health Care Services such as OPD attendance and deliveries, this
indicates that people are actually not utilizing the already available services. This can be solved
by increased sensitization about how to access government services through health talks on
radios and scheduling physical community health talks with different health personnel.

 Trained health workers

No conduction of training of Health workers on Continuous Profession Development among
others, this is essential in keeping the health professionals with updated skills about their roles,
it also emphasises team work amongst health workers.
  Hygiene standards.
Poor public hygiene standards in Hoima Municipality is a major challenge for the town. Irregular
garbage collection and mismanagement of waste disposal systems has been one of the biggest
problems of the outgoing Hoima municipal council. Waste management is an activity that
involves multiple stakeholders such as government, waste companies and the community
playing effective roles. A holistic approach would need to be adopted in intervening because
the problems are interlinked. In order to address the challenge multidimensional and multilevel
interventions are required. As the DHO together with the other local government authorities, i
would need to enforce sanitation and solid waste management by-laws on solid waste
management for the waste companies to follow the standard procedure in solid waste
management and need At the community level, there is a need for the local government
authorities to enforce sanitation and waste management regulations in households for the
sanitary disposal of waste at the community level.

 Poor education system

Education officials in Hoima district are concerned about the poor reading skills in the district.
The July National Assessment of Progress in Education-NAPE  by UNEB found out that only 5%
of the pupils in Hoima could read in P3 with the assessment covering both private and
government schools. A team of UNEB and district Education officials sampled reading skills by
giving assessment exercises. Together with the hoima district inspector of schools, i would
advocate for more financial government support to the health sector since health co-exists with
literacy and therefore improvement in education would in return greatly improve the health of
people in hoima distrcit.