CHAs Biennial ConferenceKampala – Speke Resort, Munyonyo

Governance and management capacity building of UCMB health facilities

Dr. Sam Orochi OrachAg. Executive Secretary - UCMB

Purpose of presentation

To highlight importance of good governance and management for sustainability of health care

Share UCMB’s experience in strengthening governance and management in the network

Outline of presentation

Brief background of UCMB network Core function of UCMB Why the focus on governance and

management What UCMB has done to strengthen

governance and management

270 Facilities registered with UCMB by level

HC IV, (5) 2%

HC III, (151) 56%

Hospitals, 29, 11%

HC II, (85) 31%

Regional distribution of UCMB Health Facilities (269 Registered)

Western79(29.26%)Western79(29.26%)

Central92(34.07%)Central92(34.07%)

Northern 58 (21.48%)Northern

58 (21.48%)

Eastern41(15.19%)Eastern41(15.19%)

Core functions of UCMB

UCMB not owner Facilities owned by dioceses or religious

congregations Final responsibility lies with the owners Hence the focus on strengthening local

governance and Based on principle of subsidiarity

UCMB acts as coordinator, advocate and provides technical assistant / advice

Core function of UCMB Systems strengthening

Improving managerial, administrative, fiscal, legal capacities of RCC Health Services

Advocacy, representation and Liaison on behalf of network

Facilitating the work of the Health Commission and AGM

Report to the Catholic Bishops’ Conference

Why systems strengthening as core function?

Central to any success Often least funded or paid attention to Identified as major cause of weakness of

health sector in Uganda But UCMB saw this many years ago

Hence concentration on systems strengthening Avoid concentrating on what is already

done by many others

The Context

Ageing institutions With a good reputation still Becoming more and more costly Becoming less efficient Often with uncertain organizational set-up

Increasing opportunities for partnership Increasing demand for accountability But also increasing stress on systems

Especially the GHI (mainly for HIV/AIDS) All these demand strengthening of

systems and capacities (governance and management)

What has UCMB done?

Improving management capacity and processes Initially received greater attention

While improving governance Initially received less attention Now receives greater attention in our

strategic and operational plan. Key to embedment of systems built at

diocesan and facility levels

What has UCMB done?1. Developed governance and management

tools Governing charters / constitutions HR manuals / Employment manuals Finance management manuals Various guidelines Formats – e.g. Annual analytical report format

To encourage analytical thinking Reports assessed and scored

Etc. Encouragement of utilisation of these tools

Developed tools to assess implementation

What has UCMB done? Advisory services on governance and

development to individual hospitals and dioceses

Technical Assistance in long-term (strategic) planning

Feedback on annual performances with focus on TRENDS Focused on 4 composite indicators / indices

“Access”, “Equity”, “Productivity” and “Quality” Analyses help identify need for management

and governance strengthening and informs further planning and

What has UCMB done? Data must be presented to and discussed

by boards of governors to take delicate and pragmatic decisions

E.g. What is the give and take between Rising unit cost of service (driven by cost of HR)

Amidst reducing budget support from govt Temptation to raise fee / unit output (↓ equity) This begins to affect utilisation (↓ access) Eventually counter affects income from user fees So far quality is maintained at cost of access

Examples will be seen in the presentation on using ICT to strengthen management and health systems

What has UCMB done?

2. Institution of an annual accreditation system (About 10 yrs ago – 1st in Uganda)

Not for punitive purpose But as a learning process

Has: Statutory criteria – approved by the Health

Commission of UEC Undertakings or commitments agreed on

annually with hospital managers or diocesan - incremental

What has UCMB done?3. Strengthened HMIS and ICT Hospitals and diocesan health offices able to produce

and analyse data Improve planning – short term and strategic Building capacity of governors to use analysed

information for strategic decisions Ability to use data / information at source

Many targeted trainings Sharing of data and information at workshops

All UCMB hospitals and Diocesan Health Offices, HC IVs and Training schools connected to internet / e-mail

Improved reporting

What has UCMB done?

4. Provide financial management advisory services

Encouraged shift to “cost- / Accrual-based” “cost-centre” accounting

Developed accounting software (modular) to enable electronic accounting

Based on cost-based, cost-centre accounting

Provided training and back-up support for the use of the software

What has UCMB done?

5. Human Resource management Advisory services

6. UCMB Scholarship scheme- encourage management courses

UCMB Scholarship Fund - Awards per type of training

22

81

139

102

29 28 29

83

404832

26 2531

16162013

0

20

40

60

80

100

120

140

160

2000 2001 2002 2003 2004 2005 2006 2007 2008

Clinical / technicalManagerial

What has UCMB done?

7. Training of managers Institutional training

Target to have at least 3 people in hospital management position having recognized training in health management

Masters, Diplomas, Certificate High priority choice for UCMB scholarship to

the network Is becoming part of accreditation criteria

Twice-yearly technical workshops Supervision

What has UCMB Achieved? 25/27 accredited (2

more are new) have boards inducted

15/19 Diocesan health boards inducted

25/27 hospitals have at least 2 of people in management position having had formal HSM training

UCMB Hospitals and No. of managers having formal HSM training

23

15

7

0

2

4

6

8

10

12

14

16

1 manager 2 managers 3 managers 4 managers

What has UCMB Achieved? Governors and managers beginning to make

informed decisions E.g. What is the give and take between

Rising unit cost of service (driven by cost of HR) Amidst reducing budget support from govt

Temptation to raise fee / unit output (↓ equity)

Beginning to affect utilisation (↓ access) Eventually counter affects income from user

fees So far quality is maintained at cost of access

What has UCMB achieved? Management greatly improved

Both diocesan health coordination and hospital Various tools / guidelines are being used

but to varying levels Still a lot depends on sustained over-sight

by UCMB Not healthy for sustainability

Hence emphasis to shift oversight capacity and responsibility to owners and governors Closer to the point of service

Emphasising good corporate governance

Why the emphasis on good corporate governance? In the nineties the world started registering very

important scandals and critical accidents in corporate life E.g. BCCI, Barings Bank, .....Enron.... Due to gross managerial malpractices that

boards should have been able to detect and correct

The questions arose How comes that this could happen? How comes that those who were supposed to be

in the know (the boards) did not know? How comes managers had so much leeway in

doing what they were doing?

In Uganda, A number of organisations continue to

collapse or under perform due to poor corporate governance

We have had bank closures We continue to have high cases of

corruption/fraud by managers that go undetected by boards or condoned by the boards

Why are public hospitals not performing well?

Why emphasis on governance?

Hence a new interest for the specific function of oversight A lot was known about what managers should do

and not do But little if anything was clear about the function

of oversight and control This global situation was also true for UCMB

network Emphasis was put on strengthening

management and little on governance The current UCMB strategic plan puts

emphasis on building and enhancing good governance by targeting the stewards (boards)

Governance and management

“………. If management is about running business, governance is about seeing that it is run properly.”

Prof Bob Tricker, 1984

Importance of Good corporate governance

Central to good health system

Increased efficiency Strengthened transparency and accountability Reduced risks of conflict Teamwork enhanced Improved communication Key to sustainability Credibility and increased capacity to attract

attention and support

What is UCMB doing now? Emphasis on good corporate

governance The three levels / tiers in our case

Ownership Governance Management

Each with its own clear roles Complement each other Management strengthening not

abandoned

What is UCMB doing now?

Ensure governance structures in place and trained Regional training workshops on

corporate governance Jointly for managers and governors

Induction of boards continues Hospital boards - Diocesan health boards As undertakings considered for

accreditation

What is UCMB doing now?

Developed set of “must-ask” and “must-be-answered” questions

Require evidence of reporting to the Board

Require confirmation that external audit has been carried out (part of accreditation criteria)

Challenges The major challenge is to embed / root

what has been created with help of UCMB into the systems at the lower levels

Also greatly affected by HR attrition Unwillingness of many partners to support

these aspects of systems strengthening External developments that limit funding of

health services Frustrates people who see “no benefits” of the

changes they have made UCMB itself needs sustained support in

order to sustain implementation of its mandate

Conclusion We have gone a long way

But also still remain a long way to go Strengthening of local governance and

management is key to sustainability It is important to support / strengthen

national coordination bodies (CHAs) to sustain that support to the local governance and management efforts

THANK YOU FOR LISTENINGTHANK YOU FOR LISTENING