End-of-Project Evaluation of the Capacity Project | i 
END-OF-PROJECT 
EVALUATION OF THE 
CAPACITY PROJECT 
FINAL EVALUATION REPORT 
March 2010 
This document was produced for review by the United States Agency for International Development 
(USAID/Uganda). It was prepared by The Mitchell Group, Inc. for the Uganda Monitoring and Evaluation 
Management Services, herein referred to as UMEMS, Contract Number 617-C-00-08-00012-00 
End-of-Project Evaluation of the Capacity Project | ii 
End-of-Project Evaluation of the Capacity Project 
Prepared for 
United States Agency for International Development 
USAID/Uganda 
Team Members: 
Paul Freeman, Dr PH, MBBS. MHP (ED) MPH (TH) 
Grace Kwiyucwiny MBA, PGD. Dip Man, BA (SS) 
Nathan Nshakira, M.D, MPH 
Denis Muhangi BA (SWSA), MA, PhD 
James Tapera, BSc, ACCA, ACPA. 
The Mitchell Group, Inc.
1816 11th Street N.W. 
Washington, D.C. 20001 
DUNS#: 17528-5121 
TIN#52-1467119 
Telephone: (202) 745-1919 
Facsimile: (202) 234-1697 
Internet: the-mitchellgroup.com 
Kampala 
March 2010 
End-of-Project Evaluation of the Capacity Project | iii 
Executive Summary 
Introduction: The USAID-supported Capacity Project in Uganda was a 5-year project to 
improve human capacity to implement quality health programs. It was implemented by a 
consortium led by IntraHealth International Inc., as part of a multi-country initiative that reached 
48 countries between October 2004 and September 2008. The project had three main objectives: 
to enhance capacity for human resources for health (HRH) policy and planning at the central and 
district levels; to strengthen systems for effective performance-based health workforce 
development; and to identify and promote health workforce management practices for improved 
performance and retention. 
This end-of-project evaluation was commissioned by USAID/Uganda in February 2010 to 
determine whether the project achieved the expected specific results; and to examine the factors 
that facilitated and/or hindered its achievement of planned results. The evaluation was also to 
assess the extent to which the assistance provided by the project contributed to overall 
performance in delivery of health services in Uganda. It aimed at identifying the remaining 
gaps/weaknesses in HRH systems in the country to inform implementation of a new Capacity 
Program to be supported by USAID/Uganda for five years. 
The evaluation adopted a qualitative methodology, which included review of more than 80 
documents, and interviews with over 80 respondents in Kampala and six out of 12 districts 
reached by focused project activities in northern and western Uganda. Data analysis and 
conclusions were based on triangulation of qualitative data from respondents and quantitative 
information extracted from reviewed documents. This report presents the key evaluation findings 
along the three project objectives and a synthesis of general findings focused on the remaining 
HRH gaps. It makes recommendations for continuation of specific elements of the project, and 
new interventions to address some of the issues not covered in the completed project. 
Key findings: The general evaluation finding is that the project was successful in initiating 
critical interventions to improve HRH in Uganda. The most outstanding finding was an increase 
in health staff power positions filled (by an average of 25 percentage points). There was some 
evidence of improved service delivery in the six districts studied, in improved rankings on the 
annual District League table, and in increased coverage of HIV services. Findings specific to the 
three project objectives are summarized below. 
Objective 1: Enhanced capacity for HRH policy and planning 
• An integrated human resource information system (iHRIS) was introduced, including iHRIS 
Qualify for the four health professionals’ councils, and iHRIS Manage at the Ministry of 
Health (MOH) and in nine districts. A knowledge management portal was developed at the 
MOH, and electronic reference hard-drives (e-granaries) were installed at the Makerere 
University medical library and the health staff power development centre in Mbale. 
• Data from the established HRIS and other studies supported by the project informed the 
refining of the health workforce projections in the HRH Strategic Plan 2005-2020, and 
accelerated recruitment of health staff in the supported districts. 
• The project linked multiple actors at central level (in the health, public service, local 
government and finance sectors) to enhance strategic planning for health workforce growth; 
End-of-Project Evaluation of the Capacity Project | iv 
and supported district health and personnel offices, together with district service 
commissions to manage recruitment of health workers. 
• All districts were supported to develop annual HRH action plans as an integral element in 
district development strategies and budgets. 
• Opportunities for building strategic alliances and collaboration for HRH were provided at the 
international level (inherent in the multi-country design for the project) and within the 
country, including HRH forums for PEPFAR implementers in Uganda, and inter-district 
collaboration in northern Uganda (in partnership with NUMAT). 
Objective 2: Strengthened systems for health workforce development 
• Performance improvement was supported through training, district-based assessments, and 
development of tools to guide performance improvement planning and monitoring. The 
MOH was supported to develop a performance management strategy. 
• Three health professionals’ councils were supported to improve registration, licensure and 
promoting adherence to professional standards for the respective professionals (through the 
iHRIS). The Pharmacy Council is still in the early stages of establishment and not ready for 
such support. 
• Provided institutional development support to the health professionals unions—the Uganda 
National Association of Nurses and Midwives (UNANM)—to enhance mobilization, mutual 
support, and welfare and protection advocacy for members. 
Objective 3: Improved health workforce performance and retention 
• The MOH was supported to map HRH management processes, and to facilitate application of 
the results oriented management (ROM)—a pre-existing commitment of government for all 
levels of operation—in district health services. 
• Support to districts to assess and conduct rapid recruitment to meet the existing critical health 
workforce shortages resulted in large increases in staffing levels. 
• Health workforce satisfaction and retention was enhanced through studies on retention and 
turnover, improving payroll management, and development of a staff motivation and 
retention strategy. 
• Community participation in health service improvement was increased through facilitating 
field training for medical students at Mbarara University, which focused on training and 
support to village health team (VHT) operations. 
• The MOH was supported to develop workplace safety policy and guidelines, and to roll-out 
their application in selected districts. 
Gaps, Challenges, and Constraints 
• Roll-out and application of data from the HRIS was still in the early stages, constrained by 
weak information technology (IT) application and maintenance capacity at the MOH and in 
the districts. 
• Inclusion and focus on specific HRH issues in private not for profit (PNFP) and private for 
profit (PFP) sectors was limited. 
• District roll-out of performance improvement was not fully achieved. The tools were difficult 
to understand and use, and many districts lacked funds to support this as part of routine work. 
• Support to the Health Manpower Development Center (HMDC) in Mbale to harmonize pre￾and in-service training was constrained by delayed institutional restructuring. 
End-of-Project Evaluation of the Capacity Project | v 
• Adoption of ROM as a performance improvement approach was constrained by inadequate 
follow-up and support to lower level health facilities, and lack of management skills among 
In-Charges of health centers (HCs). 
Other General Findings 
• The project design, based on the human capacity development cycle (Plan, Develop, and 
Support) was appropriate, and the consultative approach to implementation very well 
appreciated. 
• There is still a major gap in availability of key mid-level management staff, especially 
doctors at health sub-district level (HCIV); turnover at this level is high, largely because 
staffs are over-burdened with non-medical duties, have limited equipment and supplies, and 
are disillusioned. 
• Services at the health centers visited are still severely constrained by prolonged medicine 
stock-outs, unmotivated and overworked staff, limited local accommodation, limited 
transport, no planned in-service training and career development, and poor pay. 
• The approach to project monitoring focused on activities and their outputs (with occasional 
review and evaluation studies). Measurement of quality of project outputs and life-change 
results and outcomes was limited. 
• Achievement of project results was enhanced by the appropriate design and implementation 
strategy adopted, adequate funding, good project leadership, competent technical advisors, 
and committed counterpart leaders (in central and district governments). 
Recommendations: The evaluation recommends continuation of key project interventions to 
complete planned cycles of intervention development and trial implementation, and to 
institutionalize successful innovations into government and private sector health systems. 
Examples of specific areas for further support include HRIS roll-out and application in the MOH 
and at the district level; institutional and operational support to health professionals’ councils and 
associations; performance improvement in district health services; and in implementation of the 
MOH staff motivation and retention strategy. 
Sustained deployment of appropriate technical assistance to districts (senior nurses experienced 
in district health services management) is recommended to provide mentoring and hands-on 
support to health facility officer’s in-charge. This approach will ensure diffusion of district level 
capacity building to lower level health centers; development of learning organizations/team at 
the health centre level, building peer learning and support, and strengthening linkage and support 
between health centers and the communities they serve. 
End-of-Project Evaluation of the Capacity Project | vi 
Table of Contents 
EXECUTIVE SUMMARY ........................................................................................................ III
ABBREVIATIONS AND ACRONYMS ................................................................................... IX
1.0 INTRODUCTION................................................................................................................ 1
1.1 Global focus of the Capacity Project ................................................................................. 1 
1.2 Overall Technical Approach .............................................................................................. 1 
2.0 THE CAPACITY PROJECT IN UGANDA ..................................................................... 2
2.1 The Capacity Project Approach ......................................................................................... 2 
2.2 The HRH Situation in Uganda ........................................................................................... 4 
2.3 Rationale for the Capacity Project ..................................................................................... 6 
2.4 Key Questions for the Evaluation ...................................................................................... 7 
2.5 Methodology ...................................................................................................................... 8 
3.0 EVALUATION FINDINGS .............................................................................................. 10
3.1 Introduction ...................................................................................................................... 10 
3.2 Enhancing Capacity for Human Resources for Health Policy and Planning ................... 12 
3.2.1 Strengthening the human resource information system (HRIS) ................................................................ 12
3.2.2 HRH policy review, analysis, and reform ................................................................................................. 16
3.2.3 Health workforce strategic planning ......................................................................................................... 18
3.2.4 Strategic alliances for HRH ...................................................................................................................... 20
3.3 Strengthening Systems for Performance-Based Health Workforce Development .......... 20 
3.3.1 Harmonizing pre-service and in-service training of the health workforce with integrated HIV/AIDS 
and reproductive health needs and priorities ..................................................................................................... 20
3.3.2 Activities to develop and promote approaches for effective performance improvement at the central 
 and district levels .............................................................................................................................................. 20
3.3.3 Professional registration, licensure, and continuing professional development ....................................... 21
3.4 Identification and Promotion of Health Workforce Management Practices for Improved 
Performance and Retention ....................................................................................................... 22 
3.4.1 Strengthening systems for health workforce performance management ............................................... 22
3.4.2 Developing strategies and systems for improved recruitment and deployment ..................................... 24
3.4.3 Developing tools and initiatives for improved job satisfaction and retention ....................................... 27
3.4.4 Enhancing systems for community participation in health services .......................................................... 30
3.4.5 Strengthening systems for workplace safety, protection, and care of the health workforce .................. 31
3.5 Project Design and Implementation Approaches ................................................................ 31 
3.6 Other Findings .................................................................................................................... 32 
3.7 Other Major Donors ............................................................................................................ 34 
3.8 The For-Profit Health Sector in Uganda in the Area of HRD ............................................ 36 
4.0 CONCLUSIONS AND LESSONS LEARNT .................................................................. 36
4.1 Overall ................................................................................................................................ 36 
End-of-Project Evaluation of the Capacity Project | vii 
4.2 Appropriateness of the Capacity Project Approach ............................................................ 36 
4.3 Achievement of Intended Results ....................................................................................... 37 
4.4 Enhancing Capacity for Policy and Planning ..................................................................... 37 
4.5 Strengthened Health Workforce Systems and Improved Performance .............................. 37 
4.6 Key Project Successes and Failures .................................................................................... 37 
4.7 Unintended Results ............................................................................................................. 38 
4.8 Factors Hindering/Enabling Success .................................................................................. 38 
4.9 Remaining Gaps .................................................................................................................. 38 
4.10 Lessons Learned ............................................................................................................... 39 
5.0 RECOMMENDATIONS ...................................................................................................... 40
5.1 Introduction ......................................................................................................................... 40 
5.2 Enhancing Capacity for Human Resources for Health Policy and Planning ...................... 40 
5.3 Strengthening Systems for Effective Performance-Based Health 
Workforce Development ........................................................................................................... 42 
5.4 Identification and Promotion of Health Workforce Management Practices for 
Improved Performance and Retention ...................................................................................... 45 
5.5 Other Recommendations .................................................................................................. 47
APPENDICES ............................................................................................................................. 49
Appendix 1: Map of Uganda Showing Districts Visited .......................................................... 49 
Appendix 2: Capacity Project District Intervention Matrix, 2009 ............................................ 50 
Appendix 3: Evaluation Itinerary ............................................................................................. 51 
Appendix 4: Documents Reviewed .......................................................................................... 52 
Appendix 5: List of Key Persons Interviewed at the National and District Levels ................. 56 
Appendix 6: Guidelines for In-Depth Interviews ..................................................................... 59 
Appendix 7: Standardized Instrument to document Components of a 
Capacity-Building Organization ............................................................................................... 71 
Appendix 8: Strategic Objectives for Uganda Human Resources for 
Heath Strategic Plan 2005 -2020 .............................................................................................. 74 
Appendix 9: Capacity Evaluation—USAID/Uganda Questionnaire May 12, 2008 ................ 75 
Appendix 10: Achievements against Planned Activities per Objectives .................................. 78 
Appendix 11: Sample Output Data from HRIS Qualify Databases .......................................... 84 
Appendix 12: Performance Improvement Assessment Report ................................................. 86 
Appendix 13(A): List of Consultants Available For Work on HRH ...................................... 107 
End-of-Project Evaluation of the Capacity Project | viii 
Appendix 13 (B): Potential Private Consultants Available at the 
School of Public Health, University of Makerere ................................................................... 108 
LIST OF TABLES 
Table 1: Illustrative list of Actions within each element of the HCD Cycle .................................. 2
Table 2: Focus of Capacity Project Implementation in Uganda ..................................................... 3
Table 3: Number of Health Staff Employed and Percent of Positions Filled ............................... 10
Table 4: District League Table showing ranking of Districts according to level of Health Service 
Performance in the Sample Capacity Project Districts ................................................................. 11
Table 5: District League Table showing Service Provision Performance for HIV/AIDS in the 
Sample Capacity Project Districts ................................................................................................ 11
Table 6:Summary of Health Workers Establishment Status as at January 2010 .......................... 15
Table 7: Projected growth in HRH between 2008 and 2020 – BU and HP Scenarios ................. 18
LIST OF FIGURES 
Figure 1: Flow Chart of the HRIS Strengthening Process ............................................................ 12
Figure 2: Health Workforce Information Domain Map ................................................................ 15
End-of-Project Evaluation of the Capacity Project | ix 
Abbreviations and Acronyms 
AHPC Allied Health Professionals Council 
AIDS Acquired Immune-Deficiency Syndrome 
AMREF African Medical and Research Foundation 
ANC Antenatal Care 
ART Anti-Retroviral Therapy 
COP Chief of Party 
CORP Community-Owned Resource Person 
CP Capacity Project 
CPD Continuing Professional Development 
CRS Christian Rural Service 
DANIDA Danish International Development Agency 
DFID Department for International Development 
DHMT District Health Management Team 
DHO District Health Officer 
DPO District Personnel Officer 
DSC District Service Commission 
EU European Union 
FBOs Faith-Based Organizations 
FP Family Planning 
HAF Health workforce Action Framework 
HC Health Centre 
HCD Human Capacity Development 
HIV Human Immune-deficiency Virus 
HMDC Health Manpower Development Center 
HR Human Resource 
HRDD Human Resource Development Division 
HRDTCG Human Resource Donor and Technical Consultative Group 
HRH Human Resources for Health 
HRHD Human Resource for Health Development 
iHRIS Human Resource Information System Software 
HRIS Human Resources Information System 
HRWG Human Resource Working Group 
HSS Health Systems and Strengthening 
HU Health Unit 
HW Health Worker 
HWAB Health Workforce Advisory Board 
IFMS Integrated Financial Management System 
IPPS Integrated Personal and Payroll System 
IST In-Service Training 
KMRC Knowledge Management Resource centre 
LAN Local Area Network 
MGT Management 
MOES Ministry of Education and Sports 
End-of-Project Evaluation of the Capacity Project | x 
MOFPED Ministry of Finance, Planning, and Economic Development 
MOGLSD Ministry of Gender, Labor, and Social Development 
MOH Ministry of Health 
MOPS Ministry of Public Service 
MoU Memorandum of Understanding 
MUST Mbarara University of Science and Technology 
NGOs Non-Governmental Organizations 
OIC Officer in Charge 
PEPFAR Presidential Emergency Program for AIDS Relief 
PFP Private for Profit 
PHC Primary Health Care 
PI Performance Improvement 
PM Performance Management 
PMPs Performance Management Plans 
PMTCT Prevention of Mother to Child Transmission of HIV 
PNFP Private Not for Profit 
RC Resource Centre 
RFA Request for Applications 
RHD Reproductive Health Division 
ROM Results-Oriented Management 
TASO The AIDS Support Organization 
TRT Technical Resource Team 
UMDPC Uganda Medical and Dental Practitioners Council 
UNANM Uganda National Association of Nurses and Midwives 
UNMC Uganda Nurses and Midwives Council 
UPMB Ugandan Protestant Medical Board 
USAID U.S. Agency for International Development 
VHT Village Health Team 
WHO World Health Organization 
End-of-Project Evaluation of the Capacity Project | 1 
1.0 INTRODUCTION 
1.1 Global focus of the Capacity Project 
The goal of the 5-year Capacity Project was to improve human capacity to implement quality 
health programs and focused on three intermediate results: 
• Improved workforce planning and leadership to ensure that the right type and number of 
health workers are deployed where they are needed; 
• Better education and training programs so that health workers have the skills and 
knowledge to meet the needs of the communities they serve; and 
• Strengthened systems to support quality workforce performance and encourage workers 
to remain on the job. 
The project design placed emphasis on human capacity development with a program focus, 
within the five strategic objective areas of the USAID Bureau for Global Health.1
 The project 
also aimed to address the strategic objective of the USAID Office of Population and 
Reproductive Health to advance and support voluntary family planning and reproductive health. 
In addition, the Capacity Project aimed at responding to the human capacity implications of HIV 
and AIDS as a key element in accomplishment of the PEPFAR goals, and a major stress factor in 
the fragile health systems.2
 
Project funding was derived from two main sources: core funding from USAID/Washington, and 
field support funding from the USAID missions in the respective countries of focus. In general, 
core funding was dedicated to project elements with multi-country relevance; while field support 
funding focused more on specific country priorities in Human Resources for Health (HRH), and 
the demands of each USAID mission. A total of US$103,409,066 was invested by USAID in the 
five years of Capacity Project implementation: 74.2 percent as field support funding, and 25.8 
percent as core funding. 
1.2 Overall Technical Approach 
The technical approach adopted in the Capacity Project was based on the Human Capacity 
Development (HCD) Cycle; with three fundamental elements of HCD: planning, development 
and supporting human capacity.3
 
Table 1 below presents the key actions in each element of the HCD cycle. 
 
1
 WHO (2006) Working Together for Health: World Health Report 2006 
2
 Ibid 
3
 Ibid 
End-of-Project Evaluation of the Capacity Project | 2 
Table 1: Illustrative List of Actions within Each Element of the Human Capacity 
Development (HCD) Cycle 
Plan Develop Support
• Understand the HCD 
environment 
• Set objectives and 
strategies 
• Conduct policy audits 
• Develop supportive 
policies 
• Use information in 
decision-making 
• Advocate for HCD policies 
and systems 
• Allocate resources 
• Plan for workforce needs 
• Deploy workforce 
rationally 
• Set quality standards 
• Establish clear, rational 
compensation and reward 
systems 
• Link health system 
demand with educational 
system supply 
• Recruit future health 
workers into pre-service 
programs 
• Ensure correct educational 
and training content 
• Develop quality faculty 
• Establish appropriate 
practicum and training 
sites 
• Ensure use of best 
education and training 
methodology and 
innovative approaches 
• Strengthen linkages 
between Ministries and 
between the public and 
private sector, as needed 
• Harmonize pre-service, in￾service, and continuing 
education 
• Foster good performance 
• Ensure adequate and 
supportive supervision 
• Achieve high job satisfaction 
and motivation 
• Provide the needed work 
environment and 
infrastructure 
• Increase teamwork and 
problem solving skills 
• Maintain strong accreditation, 
licensing and certification 
systems 
• Ensure functioning human 
resources management and 
quality assurance systems 
• Increase dialogue between 
health sector leadership and 
educational system 
practitioners 
 
2.0 THE CAPACITY PROJECT IN UGANDA 
Implementation of the Capacity Project in Uganda started in June 2005, initially as a field 
operation through an in-country consulting firm, PS Consulting. A country project office was 
established in 2006, and operated until the end of the project in September 2009. In addition to 
the project consortium partners, implementation in Uganda included the following in-country 
partners: 
• Government Ministries – Health, Public Service, Education, and Finance 
• Other Capacity Building Projects – EU/Developing Human Resources for Health 
• Health Training Institutions – Aga Khan University 
• Faith-Based Health Networks – Uganda Protestant Medical Bureau (UPMB) 
• Consulting Groups – Human Resources Development Partner Group, Health Resources and 
Services Administration, PS Consulting 
2.1 The Capacity Project Approach 
According to the Capacity Project Chief of Party in Uganda, the approach adopted in the Uganda 
implementation emphasized four main aspects including 1) the imperative of human resources in 
delivery of all health services; 2) direct partnership with and support to the MOH as the primary 
End-of-Project Evaluation of the Capacity Project | 3 
mover and owner of the HRH agenda; 3) a program orientation in all HRH support to enable 
stakeholders appreciate the problem and achievement of the program results; and 4) a 
decentralized focus on specific units within the MOH and the district health services, in line with 
government decentralization policy. 
Capacity Project strategy was to identify the HRH issues, formulate plans, develop the systems, 
and support the Health Sector at Ministry of Health and District levels. It also had a strong link 
with other USAID funded projects; they met periodically to discuss about the challenges of HRH 
and the need to address these challenges in respective areas of implementation. The Northern 
Uganda Malaria, HIV/AIDS and TB Program (NUMAT) undertook a specific intervention on 
HRH and supported recruitment of 242 health workers in Gulu, Kitgum, and Pader Districts and 
supported the attachment of 157 medical students from Makerere and Gulu Universities to 
peripheral sites in the country. 
Project implementation in Uganda addressed all three intermediate result areas, with focus and 
illustrative outputs as presented in Table 2 below.4
Table 2: Focus of Capacity Project Implementation in Uganda 
Objective 1: To enhance capacity for HRH policy and planning at the central and district levels to ensure 
adequate health workforce for integrated HIV/AIDS and reproductive health services 
• Strengthening the human resource information system (HRIS) at the central level 
• Enhancing the MOH capacity for HRH policy review, analysis, and reform 
• Enhancing the MOH capacity for long-term strategic health workforce planning, roll-out, and reviews 
• Strengthening district capacity to translate HRH policy and strategic plan into action plans to address HRH 
priorities at the district level 
• Strengthening networking and strategic alliances for HRH 
Objective 2: To strengthen systems for effective performance-based health workforce development 
• Harmonizing pre-service and in-service training of the health workforce with integrated HIV/AIDS and 
reproductive health needs and priorities 
• Developing and promoting approaches for effective performance improvement (mentoring, performance 
improvement, support supervision, action learning, etc). 
• Developing strategies to motivate continuing professional development including standards for accreditation, 
certification, licensure 
• Strengthening the role of the health workforce professionals’ councils and associations in in-service training 
and continuing professional development 
Objective 3: To identify and promote health workforce management practices for improved performance 
and retention 
• Strengthening systems for health workforce performance management 
• Developing strategies and systems for improved recruitment and deployment 
• Developing tools and initiatives for improved job satisfaction and retention 
• Enhancing systems for community participation in health services 
• Strengthening systems for workplace safety, protection and care of the health workforce 
 
4
 Capacity Project (2008) The Capacity Project in Uganda, Capacity Project Knowledge Sharing, Country Brief No. 
4 Nov 2008 
End-of-Project Evaluation of the Capacity Project | 4 
The Capacity Project was implemented in 13 districts but with more in-depth support provided 
for Kabarole, Oyam, and Amolatar districts (see Map, Appendix 1). Specific activities included 
training in Human Resources Information System (HRIS), HRH action planning, performance 
improvement, performance management, support to the recruitment process, payroll 
management, workplace safety, and village health team (VHT) development. While other 
activities were implemented in only 13 districts, the workplace safety was disseminated in all the 
districts in the country. The details of what activities were implemented where, is presented in 
Appendix 2. 
2.2 The HRH Situation in Uganda 
A total of 85 documents were reviewed as in the attached literature. This section highlights the 
HRH situation that prevailed before the Capacity Project intervention. 
The Capacity Project and Ministry of Health conducted a number of studies from 2006 to 2008 
to understand the HRH situation in Uganda and define possible strategies and specific indicators 
to address the inherent human resources (HR) issues. Also, the study would provide the Ministry 
of Health data on health workforce turnover trends that could assist in planning and deployment 
of the health workforce in Uganda,5
 enhance effective management of health workforce, and 
minimize waste of the scarce human resource. Management Sciences for Health (MSH) and the 
African Medical and Research Foundation (AMREF), with support from the Office of 
HIV/AIDS of the U.S. Agency for International Development (USAID), also undertook an 
exploratory study of managers with significant responsibility for human resource management in 
health institutions in the four East African countries: Uganda, Ethiopia, Tanzania, and Kenya.6
The study was designed to document the role and experience of health professionals with 
significant responsibility for HRM; identify the challenges that these health professionals face, 
identify additional skills and knowledge needed by these health professionals to address human 
resources management (HRM) challenges, and solicit recommendations for changes in pre￾service and in-service HRM training. 
These studies revealed significant problems with working conditions in all health facilities.7
Overall, there is less satisfaction especially with salaries. Doctors are significantly unhappy and 
ready to leave (57 percent of the doctors interviewed) as compared to nurses (20 percent of the 
nurses interviewed). The working conditions of health staff are often difficult, characterized by 
poor infrastructure, lack of staff accommodation, inadequate equipment and supplies, work 
overload, and inadequate remuneration. The poor working condition is aggravated by weak HRH 
management. The managers of human resources are not adequately prepared for the 
responsibility and lack basic requirements to perform their functions. 
 
5
 Uganda Health Workforce Turnover study, December 2008 
6 Competency Gaps in Human Resource Management in the Health Sector: An Exploratory Study of Ethiopia, Kenya, Tanzania, 
and Uganda, Prepared by the African Medical and Research Foundation (AMREF) and Management Sciences for Health (MSH) 
July 2009
7 Capacity Project Knowledge sharing: The Capacity Project in Uganda, November 2008 
End-of-Project Evaluation of the Capacity Project | 5 
Performance management, regulatory, and disciplinary mechanisms are ineffective. These poor 
working conditions do not attract staff nor motivate them to stay. As a result the staff turnover is 
high, particularly in remote rural districts generally regarded as difficult to reach and difficult to 
stay in. The morale of health workers is low, which in part results into poor attitude towards 
clients, absenteeism, and low productivity. The public image of health staff has been eroded, the 
quality of care provided is perceived as poor, and the utilization of health services is not optimal. 
The studies asserted that despite rising attention to the acute shortage of health care workers, 
little attention has been paid to the role of those who have human resource management 
responsibilities and whose job it is to transform health workers into a productive, motivated, and 
supported workforce capable of improving health and saving lives. The ministries were 
responsible for essential HR functions—recruitment, deployment, HR planning, personnel 
policy, performance management, training, HR data systems, strategy development, and HR 
leadership and management. Lower level managers, mainly at the district levels, lacked the 
knowledge and skills to carry out many of their HR functions and address the many challenges in 
their work, including understaffing, lack of employee satisfaction, lack of skilled clinical staff, 
poor working conditions, and inadequate mechanisms for dealing with staff grievances. 
During the implementation of the Capacity Project in Uganda, a HRH assessment was carried 
out in nine districts and a dissemination workshop was done in Acholi and Lango sub-regions.8
The workshop report highlights some of the key HRH issues as; 
• An expensive recruitment process, especially the cost of advertisements in the local 
media, which the districts cannot afford regularly 
• Poor living conditions, especially of staff living up-country and in internally displaced 
camps in the north 
• The long process by health workers to access payroll due to delays in confirmation of 
their Tax Identification Numbers 
• Inadequate definition and guidelines for qualifications making recruitment of 
comprehensive nurses difficult 
• Lack of performance appraisal upon which confirmation in service and promotions would 
be made 
• Poor performance management arising from lack of a written job description, 
performance appraisal reports, and skills in managing the appraisal process 
• Poor HRH information management resulting in inaccurate and outdated staff records 
like the payroll 
• High staffing gaps in many health facilities, especially the lower levels, due to difficulties 
in attraction and retention of staff 
• Incomplete composition and poor facilitation and funding of the District Service 
Commission activities 
• Failure to induct newly recruited staff due to lack of orientation plans and insufficient 
funding 
• Lack of personnel officers in both numbers and skills in the districts 
• Lack of promotion of staff due to inadequate awareness on promotion process and plans 
 
8 Dissemination Workshop Report on HRH Assessment Report and follow-up visit in nine Districts in Northern Uganda (Acholi 
and Lango Sub Regions) 2008
End-of-Project Evaluation of the Capacity Project | 6 
As specified in the Capacity Project’s Performance Plan (PMP), the technical capacity 
interventions in each of the result areas and the four cross cutting areas were expected to result in 
the following: 
• Quality assessment of needs for changes in the workforce planning process implemented 
• Workforce data systems developed or strengthened 
• Country specific workforce aligned to better meet the priority health objectives 
• Pre-service education for specific cadre strengthened 
• In-service education systems strengthened 
• Health professional councils increased 
• HRH management capacity demonstrated 
• Health sector human resource management systems strengthened 
• Worker retention systems strengthened 
• Global partnering on HRH developed 
• HR planners and managers of Human Capacity Development (HCD) initiatives 
developed under the Capacity Project demonstrated 
• Increased awareness of the value of workforce gender equity in planning and policy 
development promoted 
Increased capacity of faith-based organizations (FBOs) to respond to HRH issues 
developed 
2.3 Rationale for the Capacity Project 
Human resource management and capacity are increasingly acknowledged as components of 
health systems that directly impact the success or failure of USAID and Ministry of Health 
investments in the health sector. Uganda, like many developing countries, is experiencing a 
human resources crisis in health. The health workforce is lacking both the numbers and the skill 
mix required to respond effectively to Uganda’s health needs. Meanwhile, the HIV/AIDS 
epidemic placed an additional demand on these already stretched human resources because of 
both the special skills required for HIV/AIDS prevention and treatment, and health workers 
themselves being affected by the disease. Besides, the institutional capacity for human resources 
for health (HRH) policy and planning within Uganda historically has been weak. Capacity to 
develop, regularly monitor and review HRH policy and plans either at national or district level is 
limited. Although significant steps have been taken in the development of a human resources 
(HR) policy and strategic plan, HRH development, deployment, and utilization are still not 
rigorously directed in a sustainable manner. This results in a mismatch between service 
requirements and training, both in numbers and skills, and inequities in the distribution of the 
available human resources.
There was an urgent need therefore, to professionalize the HRH role and develop a cadre of well￾trained HR managers, especially in large public sector and private sector health institutions. This 
would include expanding both the number of HR managers and the organizational view of their 
role, as well as updating their skills. These changes would also enable HR managers to be more 
effective in leading and implementing positive solutions that in turn would improve the 
performance and retention of staff. 
End-of-Project Evaluation of the Capacity Project | 7 
2.4 Key Questions for the Evaluation 
The purpose of this evaluation is to provide USAID/Uganda with an independent assessment of 
field support-funded work under the Bureau for Global Health’s Capacity Project.9
 Key findings 
and recommendations should provide an overview of program results to date and inform 
strategies and approaches for USAID/Uganda’s new Capacity Project Associate Award, awarded 
in September 2009, and future human resources for health initiatives. 
The primary purpose of this review was to critically examine the overall project to: 
• Determine whether the Capacity Project achieved the expected specific results identified for 
each objective and examine what factors facilitated and/or hindered its achievement of 
planned results 
• Determine to what extent the human resource development assistance provided by Capacity 
Project contributed to the MOH and district overall performance in delivery of health and 
HIV/AIDS programs 
• Identify remaining gaps/weaknesses in HRH systems 
• Determine if the Capacity Project approach for capacity building was cost-effective 
• Identify lessons learned and best practices, particularly health workforce management 
practices for improved performance and retention, that will inform USAID/Uganda’s 
Capacity Project Associate Award and other USAID, Government of Uganda, and 
development partners’ future capacity building programs 
Key questions that the evaluation addressed include the following: 
• How appropriate was the Capacity Project’s approach for HRH policy development and 
health systems strengthening? 
• How has the Capacity Project enhanced capacity for HRH policy and planning at the central 
and district levels to ensure an adequate health workforce for the provision of integrated 
HIV/AIDS and reproductive health services? 
• To what extent has Capacity Project achieved its intended results for both the central and 
district levels? 
• What factors facilitated and/or hindered its achievement of planned results? 
• What are the remaining gaps/weaknesses in Uganda’s human resource systems? 
• To what extent has the Capacity Project’s assistance contributed to strengthened health work 
force systems and improved performance in the provision of quality service delivery? 
 
9
 Scope of Work for End-of-Project of the Capacity project (CP) – Dec 7, 2009 
End-of-Project Evaluation of the Capacity Project | 8 
• How cost-effective were the Capacity Project interventions? 
• What are the key successes of the Capacity Project? What are the key failures? 
• What are the key lessons learned and best practices from the work of the Capacity Project in 
Uganda? 
• Has the Capacity Project had any positive or negative unintended results? To what factors 
can such unintended results be attributed? 
2.5 Methodology 
To answer the above questions, the evaluation not only assessed project performance but also 
looked for other areas of deficit in capacity building that go beyond the project that could be 
addressed in future interventions. Consequently the evaluation focused on two themes in 
deriving the methodology, analysis, and recommendations, namely contribution of the Capacity 
Project and gaps and needs for future consideration. The evaluation itinerary is presented in 
Appendix 3. 
Data collection was conducted using a combination of the following activities and techniques: 
• Review of relevant program documents. So far, 85 documents relevant to this project were 
reviewed (Appendix 4). At this stage, key documents describing program work plans, 
quarterly and annual reports, and end-of-project review reports, monitoring system, and 
performance management plans (PMPs) have been reviewed to identify documentation of 
project achievements so far and inform the further collection of data through interviews and 
capacity tool assessment. Remaining reports listed will be reviewed in an ongoing manner as 
the evaluation progresses. 
• Site Visits at which data was collected included the major institutions and organizations 
involved in the project at the national level and district level in six of the 13 partner districts 
involved in the project. These districts were chosen because they are representative of the 
areas of the country involved in the project and the number of project interventions per 
district. The districts included Kabarole and Kamwenge (both in the South-West with one 
receiving extensive support and the other receiving significant support); Oyam and Amolatar 
(both in the north and receiving extensive support); and Apac and Lira, also both in the North 
but receiving only a significant level of support. 
In each of the districts, one of two categories of primary health facilities were visited; Health 
Center level IV (catchment population of 100,000) or Health Center level III (catchment 
population of 20,000) was visited to understand the actual relationship between the Capacity 
Project support provided and the health services provided. 
End-of-Project Evaluation of the Capacity Project | 9 
A Regional Health Planning Workshop for northern Uganda in Gulu was attended to 
understand the context of planning process, the prevailing HRH issues, and to take the 
opportunity to interview some persons otherwise not reachable. 
The School of Clinical Officers was also visited to gauge the supply and demand of health 
professional for the health facilities. 
• Key informant interviews were held with the key stakeholders including the Chief of Party 
of the Capacity Project and the Monitoring and Evaluation expert. Other interviews were 
done with the NUMAT Deputy Chief of Party and Capacity Building Manager in Gulu. 
Details are in the list of persons interviewed. 
• In-Depth Interviews were held with all those listed in Appendix 5 representing the Ministry 
of Health, Ministry of Public Service, Ministry of Finance, Planning and Economic 
Development, Ugandan Protestant Medical Board (UPMB), Uganda Catholic Medical 
Bureau (UCMB), and other key persons. Within each of the six districts, those interviewed 
include the District Health Officer, the District Personnel Officer, the District HMIS focal 
person, Assistant District Health Officer for Maternal and Child Health, HSD in-charges 
Hospital in-charges, Assistant District Health Officer for Environmental Health, District 
HIV/AIDS focal persons and Chairpersons/Secretaries of District Service Commissions. 
A total number of 77 officials at national and district levels were interviewed over a period of 
16 days. The full list of those interviewed is attached in Appendix 5. 
General and specific guideline questions were developed and used in the interviews at the 
national and district levels according to responsibilities of respective persons interviewed. 
These general guidelines are included in Appendix 6. 
• A standardized capacity assessment tool was developed and used to ascertain capacity 
status in the supported institutions and identify remaining gaps/weaknesses (MOH and 
districts). This tool was used to collect data in Kabarole, Kamwenge, Oyam, Amolatar, Apac, 
and Lira Districts. While this tool contained standardized questions to allow summation of 
data, allowance was made to include further qualitative data to provide elaboration of the 
answers to each question. This tool is included in Appendix 7. 
• Data Analysis, Conclusions, and Recommendations
Focusing on the scope of the evaluation, analysis of data was based on triangulation of 
qualitative and quantitative data from the above sources, content analysis, tabulation of 
frequencies from the standardized instrument and interpretation of qualitative analysis. 
Conclusions from the analysis and recommendation of the key findings from document 
review and relevant articles concerning capacity building and AIDS programs in Uganda and 
input from USAID have all been considered in this report. In addition, issues raised from 
other interviews from key stakeholders at the national and other district were also included 
for discussion and confirmation as relevant. This report is written up following the format 
presented in The Mitchell Group proposal document. 
End-of-Project Evaluation of the Capacity Project | 10 
3.0 EVALUATION FINDINGS 
3.1 Introduction 
The Project’s strategies and activities were found to be consistent with those of the Uganda 
Human Resources For Heath Strategic Plan 2005-2020, (Appendix 8), those of the Global Health 
Workforce Alliance10 and the wishes of the USAID Mission expressed during the evaluation of 
the multi-country Capacity Project in 2008 (see Appendix 9). A summary table presenting 
achievements against planned objectives is presented in Appendix 10. At the end of this 
appendix a table summarizes the Chief of Party’s (COP) explanations for why activities were not 
completed as scheduled. Where further elaboration is needed, this is presented under the relevant 
Objective in Findings. 
As illustrated in the table below, for the six districts studied, the most outstanding achievement 
of the project was the increase in the number of health staff positions that were filled. 
Table 3: Number of Health Staff Employed and Percent of Positions Filled 
District Actual 
Number 
at 2004
Percent 
Staff 
Level 
2004
Actual 
Number at 
2009
Percent 
Staff Level 
2009
Remarks
Amolatar 102 68 128 85 Recent recruitment 
data not included 
Apac 231 45 350 67.5 
Kabarole 224 38 376 62.5 
Kamwenge 174 48 290 80 
Lira 392 76 443 86 
Oyam 135 50 204 76 
The above table illustrates that the average number of health positions filled in these districts 
increased by 25 percent to average over 76 percent as a result of project support. 
Most findings about projects dealing with the issues covered in this Capacity Project are 
qualitative in nature. Any link with changes in HIV and reproductive health outcomes is not seen 
directly. Similarly, increases in services provided in relationship to these areas may not be 
evident in the short term. Also the Capacity Project is not the only project whose activities may 
increase the delivery of HIV/AIDS and reproductive service. For example, in Lira there were 
five other donor agencies supporting the provision of HIV/AIDS-related services. Findings from 
the District League table are presented below as an indicator of the improvements in health 
services that might be seen from a general increase in staff numbers. 
 
10 See http://www.who.int/workforcealliance
End-of-Project Evaluation of the Capacity Project | 11 
Table 4: District League Table showing ranking of Districts according to level of Health 
Service Performance in the Sample Capacity Project Districts 
2007/8 2008/9
District Total Score National 
Ranking
Total Score National 
Ranking
Kabarole 68 12 62.6 41
Lira 68 13 76.9 6
Amolatar 58 41 69.6 26
Oyam 55 57 60 48
Apac 53 65 52 69
Kamwenge 51 72 62.7 39
National Average 62 65.9 
Key: Bold = Above national average Italics = Improvement from previous year 
The above table shows that all the districts studied except Kabarole had increased their District 
League table National Ranking—a ranking based on the scores of a composite of many 
indicators covering the full range of primary health care service—during the time of project 
support when average number of health positions filled in these districts increased by 25 percent 
to average over 76 percent. Within the composite District League table score is an indictor of the 
rate of provision of HIV/AIDS services. These results are presented below for the same period. 
Table 5: District League Table showing Service Provision Performance for HIV/AIDS in 
the Sample Capacity Project Districts 
2007/8 2008/9
District HIV/AIDS 
Service 
Provision
Score National 
Ranking
HIV/AIDS 
Service 
Provision
Score National 
Ranking
Kabarole 72% 7 12 100% 10 41
Lira 84% 8 13 98% 10 6
Amolatar 65% 7 41 100% 10 26
Oyam 83% 8 57 70% 7* 48
Apac 91% 9 65 98% 10 69
Kamwenge 74% 7 72 100% 10 39
Key: 
Score 10: Best performance and improvement from previous year 
Bold Black = Performance above national average 
Italics = Below national average 
Blue = Improved but below national average 
Red = Regression from previous national position 
Red with Star = Regression from previous HIV/AIDS service performance 
The above table shows that HIV/AIDS service provision had increased in all districts studied, 
even when the national ranking of some decreased. These improvements may be attributed in 
part to the project—remembering other projects active in the area—but the evidence is not 
strong. In Amolatar, Oyam, and Kabarole, the project also supported the promotion of attendance 
for antenatal care and PMTCT at local health centers. 
End-of-Project Evaluation of the Capacity Project | 12 
3.2 Enhancing Capacity for Human Resources for Health Policy and 
Planning 
This section presents findings with respect to the first project objective: to enhance capacity for 
HRH policy and planning at the central and district levels to ensure adequate health workforce 
for integrated HIV/AIDS and reproductive health services. Project activities to achieve this 
objective focused on two main HRH problems: shortage of health workforce and inadequate 
HRH data. The project support under this objective addressed four main areas: 
• Strengthening human resource information system (HRIS); 
• Enhancing capacity for HRH policy review, analysis, and reform; 
• Enhancing capacity for long-term strategic health workforce planning, roll-out, and reviews; 
and 
• Strengthening networking and strategic alliances for HRH. 
3.2.1 Strengthening the human resource information system (HRIS) 
The project introduced HRIS to the MOH and districts as a platform for managing information 
on the trained, registered, and licensed HRH in the different disciplines (HRIS Qualify), and the 
health workforce deployed in the public sector at different levels (HRIS Manage). The third 
component in this software package, for projecting the future HRH requirements (HRIS Plan), 
was still under development by the end of project implementation. HRIS Qualify was provided 
to the four health professionals’ councils in the MOH: Nursing and Midwifery, Medical and 
Dental Practitioners, Allied Health Professionals, and Pharmacy. The need to provide HRIS 
Qualify to the MOH Human Resource Development Division (to track training of all health 
professionals in the country) was recognized during project implementation, and included in the 
activities for the follow-on Capacity Program. 
HRIS Manage was provided to the MOH Human Resource Management (HRM) division and 9 
districts. The system development process started in 2006 with the Nursing and Midwifery 
Council, and evolved progressively through the other professional councils, the MOH Resource 
Centre, and finally to the districts. Most roll-out in the districts was done in 2009, and ran until 
the end of the project implementation period in September 2009. 
The project design outlined the HRIS roll-out process in four main steps, as shown in Figure 1 
below. 
Figure 1: Flow Chart of the HRIS Strengthening Process 
Source: Capacity Project Knowledge Sharing Legacy Series No. 6 – September 2009 
End-of-Project Evaluation of the Capacity Project | 13 
A highly consultative and participatory approach was used in rolling out the HRIS in Uganda, 
which resulted in the formation of a Health Workforce Advisory Board (HWAB) as a structured 
and sustained HRH reference group. This experience was hailed as an exemplary “good practice” 
in a multi-country evaluation of the HRIS development component of Capacity Project, 
conducted in Rwanda, Swaziland, and Uganda in July 2009. The excerpt from the evaluation 
report presented in the text box below illustrates some of the factors that contributed to this 
success. 
 Source: HRIS evaluation report, July 2009 
The other phases in the HRIS establishment process that were most felt and appreciated by 
evaluation respondents include: 
• The participatory approach used in assessment of the data available, the critical 
information needs at each point, and the IT capacity in place (hardware, software, 
connectivity, staff skills, etc.). 
• Provision of IT hardware and software, and enhancing local area network connectivity in 
some settings. 
• Training of existing staff in data entry, and in actual use and management of the 
information system. 
• Providing on-going support in use and management of the system, including refining of 
the data entry and analysis capabilities, and basic hardware and software maintenance. 
In general, the HRIS system was established up to basic utilization level at all 14 points covered 
by the project. Appendix 11 shows sample outputs from the HRIS Qualify databases on 
registered health professionals at the time of evaluation. A key observation at evaluation was on 
lack of standardization of entries with regard to professional categorization, the primary basis for 
all HRIS Qualify databases. This limits the accuracy of HRH estimates based on the database. 
The stakeholder engagement process in Uganda was very successful, as the Health 
Workforce Advisory Board (HWAB) met more or less monthly during its initial 
phase, remained stable and made significant development contributions, without 
being seen as duplicating efforts made by an existing HR Working Group. The 
following factors contributed to the success of the SLG in Uganda: 
• Members were highly motivated and committed to participate in meetings; even 
though no reimbursements were provided. 
• Some members had pre-existing working relationships focused on HRH, 
including joint analysis of HRH data and recognition of gaps that needed to be 
addressed. 
• Dedicated and diplomatic leadership by the group chair and close support and 
participation by senior in-country Capacity Project leaders (Chief of Party and 
Senior Workforce Planning and Policy Advisor). 
• The HWAB “Guiding Principles” that largely focused on the HWAB members’ 
relationships and organizations and stressed respect, equality, mutual support 
and efficiency. 
End-of-Project Evaluation of the Capacity Project | 14 
Evaluation findings from documents reviewed and interviews with system users at the different 
levels indicate factors that constrained the pace and effectiveness of the HRIS roll-out process. 
Examples include: 
• Inadequate numbers and limited skills of the data entrants available for training. 
• Busy schedules of data entrants and systems users trained (reduced concentration during 
training, and application of skills gained to actual system development and use). 
• Absences of IT personnel at all levels—a critical cadre of staff in operation and 
maintenance of such an integrated information system. 
• Inadequate resources to support demands for hands-on follow-up support in the districts, 
which turned out to be more than initially planned for as a result of limited basic IT skills 
of most people trained. 
Respondents interviewed for the evaluation at the national and district levels appreciated the 
value and benefits from computerized management of HRH data through the project-supported 
HRIS development. Examples quoted include improved efficiency in processing data, greater 
accuracy in data records, identification and weeding out of personnel with forged academic 
papers, and improved data accessibility for in-house and external use. 
The system was found operational and in use at all sites visited at central level and in one out of 
four districts visited. One other district had a functional system that was not in active use because 
the biostatistician in the DHO’s office had shifted the equipment to the District Personnel Office. 
“After the training, I entered all the data about health staff into the system, and 
generated some reports, which we sent to MOH. The system is very powerful, with many 
functions; it is too big for our office. I thought it would fit well under the personnel office, 
since they are in the same building with the Registry and more directly linked to each 
other in function. The system should be used for other sectors and not just health, in 
which case the personnel department is best suited to manage it. I discussed these views 
with the HRIS technical support person, and I then moved the computer with the software 
to personnel office.” 
(Key Informant Interview, Biostatistician) 
Since nobody from the personnel office had been trained in using the software, the system was 
not in use at the time of this evaluation. 
In the other two districts, the system visited was not functional. One had experienced computer 
breakdown problems and returned the computer central processing unit to Capacity Project for 
repair. The system in other district had stopped functioning in December 2009, when payroll 
management software from the Ministry of Finance was installed on the same computer. 
Although the fault was reported to Capacity Project, no support had been received to reactivate 
the system by the time of evaluation visit. Instead, an alternative system (in Microsoft Access) 
had been developed by the district Chief Administrative Officer, and was in use to manage data 
on the entire workforce of the district (including health workers). A summary on health workers 
extracted from this system is presented in Table 6 below. 
End-of-Project Evaluation of the Capacity Project | 15 
Table 6: Summary of Health Workers Establishment Status as at January 2010 
Category Approved 
Positions
Positions 
Filled
Positions 
Vacant
Staff 
Excess*
District Health Office 6 3 3 0 
Medical Officers 4 2 2 0 
Nursing 253 200 58 5 
Clinical Officers 36 28 8 0 
Laboratory 34 11 23 0 
Environmental Health 44 16 28 0 
Dental 2 1 1 0 
Anesthesia/Theatre 8 2 6 0 
Asst. Health Educator 2 0 2 0 
Cold Chain 3 2 1 0 
Pharmacy/Dispenser 2 1 2 0 
Health Information 17 12 5 0 
Admin staff 168 84 87 3 
Total 579 362 226 8 
Source: Access Database of all district personnel; Kabarole district 
Users interviewed at the national level were satisfied with the level training and follow-up 
support received to ensure optimum utilization of the system. However, respondents in all 
districts visited indicated that the level of training received (category and number of people 
trained, duration of training, provision of reference materials, etc.) and the follow-up support 
from the project were not adequate. 
Figure 2: Health Workforce Information Domain Map 
Data on HRH based in the private sector health facilities (both PNFP and PFP), and in the health 
programs of non-governmental and 
community-based organizations (NGOs 
and CBOs) is not yet included in the 
current HRIS at district or central level. 
Data on HRH training in the country is 
also not yet included in the current 
HRIS. The health workforce 
information domain map utilized in the 
Project (as shown in Figure 2) 
recognizes all these among the critical 
data necessary to create a complete 
picture of the health workforce. 
Source: Capacity Project; Legacy Series No. 6 – Sept 2009 
An integrated knowledge management portal was established at the MOH Resource Centre, at 
the Capacity Project global office in United States, based on the model established at the Global 
HRH Resource Centre in Chapel Hill, NC. The web-based portal is linked through the MHO 
local area network to three of the four HRIS Qualify databases at the professional councils, and 
End-of-Project Evaluation of the Capacity Project | 16 
to the HRIS Manage database at MOH. The database of the Nursing and Midwifery Council, 
which is housed in premises separate from the MOH, is connected to the portal through the 
internet. None of the nine HRIS Manage databases at district level has an internet connection to 
the portal; data from the districts is reentered/imported into the portal system at the MOH 
Resource Centre. 
As part of the support to establish the knowledge management portal, two e-granaries (hard-drive 
digital libraries containing over 10 million resources on a variety of educational topics 
downloaded from the web) were procured and installed. One, installed at the Makerere 
University College of Health Sciences, was set up as an integral element in the on-line 
information at the main medical library. Staff interviewed in the evaluation indicated that a 
number of academic and research users at the library had utilized the resource and commended 
its extensive content. Its set up did not provide for monitoring of use, or for generating feedback 
on how to improve the resource. However, its adapter connection to the electricity mains had 
blown out, so it was not in use at the time of the evaluation. One of the challenges about the 
operation and maintenance of the device is that it was installed in a program-specific office 
(Uganda Chartered Healthnet) but was neither formally integrated as a program-owned resource, 
nor clearly allocated as a resource for the medical library that needed to be managed at its 
“remote” location. The other e-granary, installed at the Health Manpower Development Centre 
(HMDC) in Mbale, was acknowledged as a useful addition to the resource materials pool at the 
centre. However, it had not been used much by the time of evaluation because of limited 
activities in the entire centre as it undergoes restructuring. 
Data generated from the HRIS system established was used in revising the HRH projections for 
Uganda, and in periodic HRH updates published with support from the Capacity Project, as 
discussed further in sections 3.2.2 and 3.2.3 below. As a result of valuable HRH data generated 
from the district HRIS and applied in planning for necessary recruitment, the WHO Country 
Office supported roll-out of the system to 10 more districts, as part contribution to the Capacity 
Program. 
3.2.2 HRH policy review, analysis, and reform 
The project was implemented in an evolving national policy context, especially with respect to 
poverty eradication and long-term development focused on the millennium development goals 
(MDGs); review of the second Health Sector Strategic Plan (HSSP II) and formulation of HSSP 
III; and revision of the national health policy. There was concern about the slow progress in 
maternal and child health indicators towards the MDGs and country targets for poverty 
eradication. HRH is a specific focus in the current national health policy, with focus on: 
• Addressing the major constraint of inadequate numbers and inappropriate distribution of 
trained health personnel; 
• Developing guidelines for optimal development of health personnel; and 
• Ensuring increased productivity in accordance with the results oriented management (ROM) 
approach. 
End-of-Project Evaluation of the Capacity Project | 17 
The specific commitments of the health policy on HRH are shown in the box below. 
 Source: HRH Strategic Plan 2005-2020 
The core HRH problem in the 2005-2020 HRH strategy for Uganda is the health workforce as a 
critical constraint to delivering the Uganda National Minimum Health Care Package equitably to 
all. The underlying causes described in the strategy include: 
• Inadequate numbers and poor skills mix for service delivery; 
• Deficient knowledge and information base to guide HRH management; 
• Mismatch between health service requirements and HRH training output; 
• Weak HRH management (inequitable distribution, poor retention, and low productivity); 
and 
• Weak capacities for maintaining professional standards. 
These contextual realities influenced the project approach and focus in supporting HRH policy 
review, analysis, and reform. The project worked closely with the MOH and districts to produce, 
disseminate, and apply critical analysis of HRH issues (employment, deployment, and gaps; 
skills audit; retention and intention to stay in service; etc.) that informed key health policy 
processes that were concurrent with the project period. Key among these policy processes were 
refining and initial implementation of the HRH Strategic Plan 2005-2020; review of HSSP II and 
development of HSSP III; and revision of the National Health Policy. 
The project deployed a consultant to support the MOH in producing an HRH biannual report in 
April 2009 based on data generated from the HRIS. The report provided a basis for health sector 
budgeting to include projected HRH recruitments; its timing for April aimed to have input in the 
budget for the next financial year, which starts on July 1. The MOH intention is to produce the 
second report in September in order to inform district planning and budgeting, which takes place 
in October-November. The September 2009 report was still in draft form at the time of the 
evaluation. Its development was supported by the same consultant. Review of the April and 
September reports at the evaluation found substantial overlap in the HRH data presented in both 
reports. Investment in production of one report each year may be adequate to inform both district 
and national level budgeting. 
Health Policy Commitments on HRH 
• Strengthen human resources management at all levels. 
• Promote equal opportunities for both men and women in the health professions. 
• Develop and promote incentive schemes for equitable deployment and retention of health 
workers, especially to the rural areas. 
• Establish national guidelines for staffing standards (based on expected workload) for all 
categories of health workers and institute effective mechanisms for implementing them. 
• Establish and maintain mechanisms for assuring relevant continuing education for and 
supportive supervision of all health personnel. 
• Decentralize in-service training including its funding to district level. 
• Develop and update training standards in collaboration with the Ministry of Education. 
• Promote the training and support of Community Resource Persons. 
End-of-Project Evaluation of the Capacity Project | 18 
One of the key elements in the published supplement to the HRH strategy is a refined projection 
of the anticipated growth in HRH deployed in public, PNFP, and PFP services, based two 
scenarios: continuing at the current pace of “natural” growth (business as usual); or the 
accelerated growth as proposed in the “Health for People” option in the HRH strategy. Table 7 
below presents the projected trend between 2008 and 2020 in both scenarios. 
Table 7: Projected growth in HRH between 2008 and 2020 – BU and HP Scenarios 
Year Public Sector PNFP PFP Total
BU HP BU HP BU HP BU HP
2008 25.9 25.9 10.1 10.1 10.7 10.7 46.7 46.7 
2009 27.3 30.4 10.6 11.8 11.1 10.8 49.0 53.0 
2010 28.8 35.7 11.1 13.8 11.4 12.2 51.3 61.7 
2011 30.5 41.9 11.7 16.2 11.8 13.7 54.0 71.8 
2012 32.3 49.2 12.3 18.9 12.2 15.5 56.8 83.6 
2013 34.4 57.7 13.1 22.1 12.5 17.5 60.0 97.3 
2014 36.8 67.7 13.9 25.8 12.9 19.7 63.6 113.2 
2015 39.5 79.4 14.8 30.2 13.3 22.2 67.6 131.8 
2016 42.7 93.2 15.9 35.3 13.6 25.1 72.2 153.6 
2017 46.2 109.4 17.0 41.3 14.0 28.3 77.2 179.0 
2018 50.4 128.4 18.4 48.3 14.4 31.9 83.2 208.6 
2019 55.3 150.6 19.8 56.4 14.9 36.0 90.0 243.0 
2020 61.1 176.7 22.8 66.0 15.3 39.3 99.2 282.0 
Ratios 
2008 57% 57% 22% 22% 21% 21% 100% 100% 
2020 63% 63% 23% 23% 14% 14% 100% 100% 
BU: Business as usual option HP Health for People option 
In the above projections, the PNFP and PFP sectors will continue to play a major role as settings 
for HRH deployment and health service delivery. The HRIS so far developed through Capacity 
Project support does not include complete capture of HRH deployed in PNFP health facilities, 
health programs operated by NGOs and CBOs, and the PFP health care points (including 
established private hospitals and nursing homes, and the less structured clinics and doctor’s 
offices). Since many of the NGO and CBO health programs often operate at the community level 
and in settings other than recognized health facilities, systems to capture a complete picture of 
HRH deployment should include such levels of care and service delivery. 
Staff at health professional councils, the MOH, and districts (health, personnel, and planning 
departments) were trained to take on relevant policy analysis and implementation action (e.g., on 
ethical standards and code of conduct for the different health professionals, harmonizing and 
standardizing in-service training as an integral element in continuing professional development, 
etc.). 
3.2.3 Health workforce strategic planning 
The project supported central actors (MOH/HSC, MOPS/PSC, MOFEP, and MOLG) to integrate 
HRH recruitment and deployment into the national annual development planning and budgeting 
End-of-Project Evaluation of the Capacity Project | 19 
process. The Capacity Project played a key role as an “independent broker” to link the different 
government ministries, departments, and agencies with a role to play in HRH improvement. 
Provision was made for step-wise recruitment of health personnel at different levels, integrated 
with necessary adjustments in the wage budget provisions, and ensuring provision of other 
requirements for necessary service growth (health facilities, equipment, drugs and other supplies, 
etc.). 
The project initiated partnership with the Uganda National Association of Nurses and Midwives 
(UNANM), as an example of a health workers union, to foster health workforce mobilization and 
mutual support. It supported research to review and recommend strategies to improve the 
relevance of the association in meeting the felt needs of members. The project also supported 
training of association leaders at the national level and in four out of six regional centers in 
communication skills to enhance effective engagement with media and the general public as a 
mechanism for positive image building for the nursing profession. Association leaders 
interviewed in the evaluation indicated that the communication skills gained were also useful in 
advocacy engagements with government and other employers to improve the conditions of 
service and workplace safety for nurses and midwives. In addition, the skills were put to use in 
improving internal communication between the association and members. 
“The communication consultant did a very good job in training the executive members, 
and supporting us to train leaders and members in four regions. We have worked with 
many radio stations and the government television station to discuss issues faced by 
nurses and midwives at work, and to explain why our services may occasional fall below 
the expected standard. I have collected at least 1,500 e-mail addresses of members (out 
of a total membership of 8,000) and I am now in regular communication with them.” 
(Key Informant Interview, UNANM General Secretary) 
Interviews in the districts visited at evaluation found the Uganda Medical Workers Union as the 
most active grouping that brings together health workers across the different cadres to address 
common welfare issues. Most of the health workers who are members in the union have a 
standing commitment for a 2 percent deduction from their monthly salary towards the operations 
of the union. However, concern was expressed that although the central office was supposed to 
disburse 20 percent of the total contribution to district union branches to support their operations, 
this had not been received for a long time. 
All districts in the country were supported to develop HRH action plans. More than half of the 
districts received follow-up support on integrating the HRH action plans into the district health 
plans and budgets to ensure sustained implementation. Based on the national level provisions, 
supported districts were able to recruit, orient, and deploy the necessary health workforce (e.g., 
54 people in Apac district, and 27 in Lira district). Districts were supported to orient recruited 
staff on the different aspects of district operations and services. 
Challenges experienced in adapting the HRH improvement plans to existing government plans at 
national and district levels include delays in negotiating the necessary adjustments in wage bill 
ceilings to accommodate new staff; failure to attract some cadres of health workers (especially 
medical officers); and difficulties in accommodating some health cadres in the current workforce 
End-of-Project Evaluation of the Capacity Project | 20 
structure (e.g., comprehensive nurses, Nursing Officers in midwifery). Although the private 
sector (both PNFP and PFP) is a recognized player in development and deployment of the health 
workforce in the country, its inclusion and involvement in HRH strategic planning was limited. 
3.2.4 Strategic alliances for HRH 
The project supported national and district-level actors to build and nurture networking and 
collaboration relationships at different levels. It sponsored MOH and PNFP personnel to 
participate in international workshops, conferences, and learning attachment visits. The project 
also organized national and sub-national consultations on HRH (e.g., PEPFAR implementers 
meetings on HRH, HRH planning for northern Uganda districts, etc.). The project worked 
closely with the WHO at global and country levels to promote application of the HRH action 
framework, and in application of HRIS at national and district levels. 
However, efforts at collaboration and joint working were constrained at some points by 
differences in strategic orientation and working approaches. Many of the MOH actors and the 
development partners operating within the Paris framework for harmonization of aid preferred a 
more integrated and sector-wide approach. This contrasted in many ways with the USAID￾supported and project-focused approach in the Capacity Project (e.g., in locus of resource control 
responsibility, differences in payment rates for different activities, etc.). 
3.3 Strengthening Systems for Performance-Based Health Workforce 
Development 
The second objective of the Capacity Project focused on strengthening systems for performance￾based health workforce development. Three main activities were implemented by the project 
under this objective, namely 1) harmonize pre-service and in-service training of the health 
workforce with integrated HIV/AIDS and reproductive health needs and priorities; 2) develop 
and promote approaches for effective performance improvement at the central and district levels; 
and 3) develop strategies for continuing professional development, including issues of 
accreditation, certification, licensure, in-service training, and strengthening the role of health 
workforce professional councils. 
3.3.1 Harmonizing pre-service and in-service training of the health workforce with integrated 
HIV/AIDS and reproductive health needs and priorities 
To implement this activity, the project had planned to work with the Health Manpower 
Development Center in Mbale. An e-granary digital library was set up with materials on clinical, 
public health, and management aspects of health. However, with the restructuring of educational 
entities under the Ministry of Education and Sport, the center lost its budgetary support and so 
there was no longer anyone with whom the project could continue development. 
3.3.2 Activities to develop and promote approaches for effective performance improvement at 
the central and district levels 
A central-level technical resource team was trained in a performance improvement approach 
based on staff performance in each facility against standards and with their aid and the aid of 
local sensitized district health team (DHT) members and officers in charge (OICs) of local HCs, 
performance improvement assessments were performed at all levels in nine districts. These 
End-of-Project Evaluation of the Capacity Project | 21 
assessments were then meant to be used to develop health unit intervention plans as a basis for 
supportive supervision and regular follow-up. An example of these assessments is included in 
Appendix 12. 
However, project reports stated that only a few districts developed these health unit intervention 
plans. The development of these intervention plans had been left to the districts. It was also 
expected that this process would be supported by other actors (e.g. NUMAT). The Capacity 
Project supported this development to lower levels in only three core districts. According to 
interviews with DHT staff members, in Kabarole district apparently there was already a 
reasonably well functioning system of performance improvement and supportive supervision in 
place, as staff had received previous training, including additional training in quality 
improvement at the hospital and Health Center IV level, and staff continued to use this. 
A common finding from district health officers (DHOs) and HCs in which these assessments had 
taken place in four of the districts visited was that although they could be understood and 
followed at the district level, they were too difficult for local lower level HC staff to understand. 
These assessments were also seen as too long and time consuming in several HCs. In several of 
the districts, follow-up supervision did not take place apparently due to lack of funds. HCs in all 
four districts visited did not follow up on these assessments other than in relationship to initial 
visits from the higher levels. 
National level nursing trainers were oriented to the Learning for Performance Approach and 
trainers were trained in this method.11 Similarly, district trainers in Kabarole were supported to 
carry out mentoring training on infection control in 21 health facilities. While this training was 
apparently initially effective, further follow-up evaluation is needed to assess the degree of 
success of these approaches in the early stages of the new project. Apparently this has not been 
done at this stage because these activities were initiated late in the project. 
With the Ugandan Protestant Medical Board (UPMB), a regular HMIS to report disease statistics 
and a parallel HMIS to record performance improvement in use of the regular HMIS were 
developed and tested at 72 health facilities in the UPMB system. The HMIS assessing 
performance improvement used observations based on performance standards for assessment to 
be used in supportive supervision. The tool used in this assessment of performance improvement 
measured good practices that local teams should follow in registering, compiling, analyzing, 
reporting, and using local HMIS information in their new HMIS for proper decision making in 
the management of health units. Follow-up impact assessment of this tool found marked 
improvement almost uniformly against all standards. For example the standard use of data in 
decision-making increased from 28 percent at baseline to 72 percent one year later. These 
improvements in performance were noted uniformly across all levels of health facilities 
involved—hospitals, HCIVs, HCIIIs, and HCIIs. 
3.3.3 Professional registration, licensure, and continuing professional development
Computerized databases for professional registration were established and are functioning 
successfully at all professional councils. Most recently standards for continuing professional 
 
11 Gaye. PA, Nelson D. Effective scale-up: avoiding the same old traps. Human Resources for Health 2009,7:2. 
End-of-Project Evaluation of the Capacity Project | 22 
development (CPD) were developed successfully with the professional councils and published in 
the book Standards for Accreditation of Continuing Professional Development for Health 
Workers. Development in this area has now proceeded to the stage that the current approach is to 
accredit institutions that have satisfactory courses and equipment as CPD centers. Professionals 
will then attend courses at these centers until they complete their CPD requirements for renewal 
of registration. This process was not completed at the end of the project due to delays in 
dissemination of the guidelines. 
The project carried out several activities to strengthen the Uganda Nurses and Midwives 
Association (UNANM). An assessment to determine nurses’ and midwives’ satisfaction with 
services from UNANM was performed, and a communication strategy for UNANM produced 
and implemented, including workshops, production of a UNANM handbook and brochures, and 
the development of a UNANM website. Evaluations of the communication workshop found that 
people who participated in the communication workshops were using better communication 
approaches, were positive about improved communication with patients, and UNANM leaders 
said they were better able to communicate with policy makers and with the media.12 Nurses 
interviewed in these evaluations attributed increases in UNANM enrollments to the newly 
acquired skills in communication and leadership facilitated by the Capacity Project. 
Codes of ethical professional conduct have been developed and published in booklet form. These 
codes have been well received, widely distributed, and used in orientation proceedings. The only 
complaint has been that most districts wanted additional copies of these booklets. 
3.4 Identification and Promotion of Health Workforce Management 
Practices for Improved Performance and Retention 
The project activities under Objective 3 of the project broadly focused on five groups of 
activities: 1) strengthening systems for health workforce performance management, 2) 
developing strategies and systems for improved recruitment and deployment, 3) developing tools 
and initiatives for improved job satisfaction and retention, 4) enhancing systems for community 
participation in health services, and 5) strengthening systems for workplace safety, protection, 
and care of the health workforce. The presentation of findings in this section follows these five 
groups of activities. 
3.4.1 Strengthening systems for health workforce performance management 
Interventions for improved workforce performance management were based on a study 
supported by the project entitled “Mapping HRH Management Processes,” Following this, the 
project supported introduction of output-based performance management practices based on the 
Result Oriented Management (ROM) approach. To further build local capacity in leadership and 
management, MOH staffs from HRM and HMDC were sponsored to attend an HR leadership 
and management development program in Nairobi. The team thereafter drafted and shared a 
concept paper on developing leadership in Uganda. 
 
12 Yinger.N, McQuide P, Neema S, Olenja J, Zuyderduin, Mayer D. Strengthening Health Professional Associations in Kenya and Uganda: A 
Project Assessment Draft report 9/28/09. Capacity Project
End-of-Project Evaluation of the Capacity Project | 23 
The ROM approach supported by the project had already been adopted by the Government of 
Uganda through the Ministry of Public Service, although its implementation had not been 
effectively realized. The project support towards the implementation of this approach entailed: 
• Developing a strategy and tools for ROM and 
• Testing the approach in three districts, including training of managers and staff in the 
processes of staff appraisal using ROM principles. 
District level staff interviewed during this evaluation appreciates the value of performance-based 
appraisals supported by the project. It was argued that the process enables staff to be conscious 
of their job descriptions, and to focus their energies on fulfilling them. The process also enables 
staff to set performance goals, identify indicators of performance, set targets, and make 
commitments to achieve them. 
A number of challenges with this process were identified however. 
In most of the districts visited, the appraisal process was still not embraced by staff as an 
important practice. In Kabarole district for instance, it was reported that some staff do not 
remember to complete appraisal forms in time as scheduled and wait to be reminded and pushed 
to do so. 
Very few people (staff and managers) take appraisals as an important responsibility. 
Most times they have to be forced to do it—by circumstances such as need for 
confirmation, promotion or recommendation for training 
(Personnel Officer, Kabarole) 
Problems of supplies of appraisal forms were also reported, with the result that often, staff have 
to buy photocopies of the forms themselves. In addition, little progress was being made to 
achieve the targets due to a multiplicity of challenges including lack of drugs, equipment, 
funding, and support supervision. 
The other problem is that while appraisals may document some achievements and commitments 
to improve, this is often not related to the reality on the ground. There is little follow-up to verify 
and support such improvements. In a number of districts including Apac and Kabarole, staff in 
charge of the personnel office decried lack of resources to monitor the performance of staff in 
health centers. They argued that the approach used by the DHT to provide support supervision 
cannot bring out the real truth about the presence and performance of staff because they follow 
scheduled visits, and health centre staff make sure that they are present and working when the 
supervision team is expected. The personnel offices wish to conduct impromptu, unannounced 
visits and interaction with the consumers of services to understand the true situation on the 
ground. 
Another challenge identified was lack of leadership and management skills among health 
workers entrusted to manage others at the different levels of the health system. This is coupled 
with little time available for officers in charge to attend to staff issues. Failure to address staff 
concerns was thought to be leading to low morale that may ultimately result in poor 
performance, absenteeism, and staff turnover. 
End-of-Project Evaluation of the Capacity Project | 24 
In addition, uncoordinated trainings were found to be frequently taking several health workers 
away from their work stations, thus affecting the delivery of services. 
3.4.2 Developing strategies and systems for improved recruitment and deployment 
In order to improve recruitment and deployment of health workers for district health services 
provision, the project supported districts to advertise identified vacancies for health workers. 
This was however preceded by supporting processes to identify vacant posts, done in two ways: 
1) through the iHRIS systems of the districts that show established posts, those filled and those 
that are vacant; and 2) through nation-wide staff audits that show the existing staff and the 
shortages in all health centers. 
Advertising vacant positions in districts was done through central advertising by the MOH, 
instead of the adverts by individual districts, which has often been costly for districts as it 
involves paying newspapers to run several full pages of adverts containing vacancy details, job 
descriptions, and application procedures. Centralized newspaper adverts were supplemented 
through adverts on notice boards and radio announcements directing the public to where the 
adverts can be found. 
A review of one of the adverts placed by the MOH advertising for health workers in The Monitor 
of June 27, 2007 shows that the advert focused on Northern Uganda, including an “inducement” 
of 30 percent of 6 months basic pay – given as a one-off allowance (pledged to be paid by UN 
agencies). The objective as stated in the advert was to increase staffing levels from 33 percent to 
55 percent (HSSP target). The number of positions advertised in the project districts included: 
• 27 in Lira 
• 46 in Apac 
• 9 in Docile 
• 11 in Oyam 
• 8 in Amolatar 
• 38 in Amuru 
The project also paid sitting allowances for members of the DSC during the process of 
interviews and the technical persons that were co-opted to participate in interview panels. 
The project also supported the introduction of software for short-listing applicants. The system 
for e-short-listing was expected to save time, reduce costs, and promote objectivity by enhancing 
adherence to merit in the short-listing process. This software was installed in Lira, Amolatar, 
Kabarole, Dokolo, and Amuru districts (the latter two not in the study sample). District staff 
were trained to use the software. In some districts, the short-listing software was successfully 
used, resulting in time-savings and easing work. A good example of such districts is Amolatar; 
where staff interviewed indicated that the short-listing process was handled by only 3 people and 
completed in 4 days – usually it takes the entire District Service Commission 2 weeks of sitting. 
In others, the system did not work. In Lira for instance, the system was never used, the problem 
being attributed to the caliber of staff that had been trained to use the system. Within the Lira 
DSC, which is responsible for short-listing, a clerical officer had been trained, together with a 
records assistant from health. Key informants at the district thought that more competent people 
such as the statistician are the ones who should have been trained to use the system. 
End-of-Project Evaluation of the Capacity Project | 25 
In districts where the system was put to use, such as Amolatar, the users were pleased with the 
help afforded by the system. As the acting secretary to the DSC in Amolatar observes: 
…We were trained on how to shortlist electronically, which was very good. It made 
things easy for us. It would be good to use the same system to shortlist candidates 
applying to other sectors. 
(Acting Secretary, DSC, Amolatar) 
Before the project, there was simply no money to recruit staff. For example, in Lira, the DSC’s 
budget for FY 2009/2010 was only enough for the DSC to sit for only 21 days. 
The project helped the district to advertise vacant posts, which was done centrally. This 
saved the district a lot of money. If the district was to advertise on its own, probably it 
would not afford it. The district receives only Ug Shs 29 million (US$13,875) for a whole 
year, which may not even be released at once. 
(Secretary, DSC – Amolatar) 
Staff in Kamwenge reported that before support from the Capacity Project, the district had not 
done any recruitment for three years because of the cost. It was reported that the advertisement 
alone costs Ug Shs 13 million (US$6,220), while one sitting by the DSC costs over Ug Shs 2 
million (US$957). In several districts, it was reported that the staffing for health had improved as 
a result of the project support. 
As previously observed, staffing levels had increased for the districts supported by the project to 
undertake recruitment of health workers. It must however be cautioned that not all the observed 
increases can be attributed to the Capacity Project, as other interventions were also going on, e.g. 
the 30 percent salary incentive paid in the north supported by UNICEF/DFID in 2007. 
Nevertheless, the fact that districts were enabled to recruit additional staff means that the project 
made a significant contribution. 
Districts were further supported to orient newly recruited staff. A total of 371 newly recruited 
staff for Lira, Amolatar, Kabarole and Kamwenge were inducted. In Lira, the DHO reported that 
for the first time in a long time, the district was able to induct newly recruited staff. 
Before this, any new staff would be posted to work stations without any orientation. This could 
mean that they would not understand their job description, their immediate work environments, 
and other aspects important for their integration into the workforce of the specific health system 
of the district. However, it was observed that the orientation carried out covered general issues 
and left out the technical aspects related to individual job requirements. In Kamwenge, 
orientation of health staff was conducted and the topics covered included terms and conditions of 
service, record keeping, payroll management, and HR issues. The orientation did not include 
technical issues that relate to the facilities and services because this should be done at the 
department level. District informants in several districts reported that it was preferable to include 
an attachment of each new staff to an officer already in post for at least one or two months before 
one can go and take his or her post. Although this can be viewed as purely a management issue 
that district and health facility managers should have been able to handle on their own, many 
such managers reported that they needed support to also be able to do technical orientation. 
End-of-Project Evaluation of the Capacity Project | 26 
Apac district reported that support for recruitment of staff had translated to better service 
provision in the following ways: 
• The critical vacant posts were filled and this has improved the availability of staff at the 
facilities and increased coverage, improved OPD attendance and immunization coverage. 
• The quality of the services provided improved because of the presence of qualified staff. 
Despite project support, some districts reported persistent problems in attracting staff and filling 
vacant posts. In Apac, the district had advertised four posts of medical officers but had not 
received any applicant. Informants from the district attributed this to lack of incentives to attract 
staff to these “hard-to-reach” districts. They compared themselves to districts such as Moroto (in 
northeastern Uganda) and Nebbi (West Nile region), which pay special allowances to attract 
staff. In all districts, particular cadres of staff were reported to be difficult to attract. These 
include medical officers, cold chain technicians, and laboratory technicians. 
Some of the problems/challenges affecting recruitment were found to include 
• There is a ceiling set at central level that determines the total salary bill. Recruitments have 
to fit all health staff within that ceiling and this therefore determines the total number that 
districts can recruit and the specific cadres that can be included. In Apac district for instance, 
it was reported that they cannot recruit the second Assistant DHO (for Environmental Health) 
because of the ceiling. District informants further reported that even the agreed wage bill 
often gets cut by the Ministry of Finance, meaning that they do not have adequate funds to 
pay all their staff. In Apac, it was reported that the money for wages had been cut by Ug Shs 
400 million (US$191,387). In Kabarole, two assistant DHOs recruited in July 2009 had never 
been appointed due to inadequate funds for wages. 
This evaluation however found that part of the problem with wage bill management is partly 
attributable to lack of information to districts about the actual ceilings on the wage bill. The 
Ministry of Finance releases 65 percent of the funds approved for the wage bill, the rest 
being accessible upon request by the districts. Many districts are not aware of this and they 
only operate within the 65 percent allocation. 
• In Oyam district where a PNFP agency set up seven health centers expecting that the district 
would provide staff to work there, the district could not provide such staff due to the limits 
on the number of staff that can be hired. 
• The short-listing system was set up to be used only for health staff. It would have been good 
if the system could also shortlist for other sectors. 
• In some of the districts such as Amolatar, the training for using the short-listing software 
came after job applications had been received. This meant that the applications had to be 
entered into the system and this delayed things a bit. Had the training taken place earlier, 
every application would have been entered as soon as it came in and this would have moved 
things much faster. 
End-of-Project Evaluation of the Capacity Project | 27 
• For most districts, not all the required staff were recruited. Some positions did not attract any 
qualified applicants. Part of this problem arose because of the centralized advertising. When 
vacancies are centrally advertised, a jobseeker can see that the same vacancy exists in several 
districts. S/he can therefore choose to apply to work in a better located or a well-resourced 
district, and will not apply to hard-to-reach districts. Similarly, because of central advertising, 
some staff that are already in post in certain districts opt to apply to go to better off districts. 
Apac reported that they lost a number of nurses and clinical officers who opted to go and 
work elsewhere. While this might have a positive side in terms of enabling health workers to 
exercise some choice about where they should work, enabling them to realize their career 
growth, and probably getting them better motivated, it definitely has serious implications for 
the attraction and retention of staff to remote, hard-to-reach districts. 
• The project was only willing to pay allowances for DSC members at lower rates than what 
they normally earn as per government guidelines. DSC members normally earn a total of 
290,000 Ug Shs (US$138) per day (i.e.140, 000 or US$67 for night allowance and 150,000 
or US$71 for each day’s sitting). The project only paid them a lump-sum of Ug Shs 900,000 
(US$430) for the whole process from short-listing to conducting interviews. DSC members 
first had to be encouraged before they were wiling to work on those terms. 
• For some districts such as Amolatar, the information about vacant posts needed for purposes 
of central advertising was obtained by the project directly from the DHO. Under normal 
circumstances, they should have gotten them from the DSC. The DHO should have 
forwarded them to CAO, who would then have forwarded them to DSC, and the DSC would 
advise the project. Because of the procedure used, some positions that do not exist in the 
staffing structure for Amolatar were advertised and recruited for. It was discovered later that 
some of the positions that had been recruited for did not exist. The DSC had to renegotiate 
with the candidates to accept lower positions or to cancel their appointments. 
3.4.3 Developing tools and initiatives for improved job satisfaction and retention 
The project undertook studies whose findings provide essential information about the status and 
challenges of HRH in Uganda. One was the retention study carried out in July 2006 entitled 
“Uganda Health Workforce Retention Study: Satisfaction and Intent to Stay among Current 
Health Workers.” This study focused on health workers job satisfaction, motivation, and intent to 
stay or leave the service. The findings of this study showed that levels of satisfaction with their 
jobs, salaries, and work environments were generally low, and about 24 percent of the health 
workers planned to leave their jobs soon. The second study focused on documenting the rate of 
turnover among health workers and was conducted in 2008. Entitled “Uganda Health Workforce 
Turnover Study,” this study showed that average annual attrition rates were 1.2 percent and 13.0 
percent in public and PNFP sectors respectively. Absconding was one of the major causes of 
staff turnover. 
Based on the findings generated by the above studies, the project supported the development of a 
“Motivation and Retention Strategy for Human Resources for Health” for Uganda’s health sector 
(dated October 2008) to be implemented over five years. The goal of the strategy is to strengthen 
the capacity of the health system to improve the attraction, retention, equitable distribution, and 
End-of-Project Evaluation of the Capacity Project | 28 
performance of health workers. The strategy elaborates the actions needed in order to 
institutionalize and maintain sustainable schemes for salaries and benefits to attract and retain 
health workers; strengthen leadership and management capacities to mange health workers; 
strengthen mechanisms for planned career progression; and provide and maintain flexible, 
conducive, and safe working environments for all heath workers. 
The Motivation and Retention Strategy was presented at the Annual Health Sector Performance 
Review Meeting in 2009, at which the MOH and other stakeholders adopted the strategy, and 
agreed that it should be costed and implemented. Some development partners, including the 
World Bank have already agreed to support some elements of the strategy. 
In addition, the project supported districts in payroll management. Regional trainings in payroll 
management were conducted for all districts and regional hospitals in the country, followed by 
on-site, hands-on support in 13 districts. These trainings targeted payroll managers in the 
districts and regional hospitals. In addition, copies of the payroll management manual were 
distributed to districts. The evaluation found evidence of possession of these copies in the 
districts. Interviews with the Ministry of Public Service (MOPS) indicate that the national 
average access to the payroll for health workers increased from 50 percent to 90 percent 
following these trainings. Interviews with districts also show that following this training, access 
to the payroll increased. In Oyam, no health staff were not on the payroll by the time of this 
study. In Amolatar, only one staff member was known not to be on the payroll by the time of this 
study. In other districts, however, such as Kamwenge, problems in accessing the payroll had 
persisted. 
With project facilitation, personnel from the UPMB and UCMB attended a conference in Nairobi 
in 2006 where they learned about a program designed to strengthen leadership and management 
skills—the Virtual Leadership Development Program (VLDP) developed by MSH. The UPMB 
and UCMB personnel formed a team and chose, as their leadership challenge, to reduce the 
attrition rate at their health facilities from 18 percent when they started the VLDP to 10 percent 
within a year. The team developed a joint position paper to present to the government, seeking 
input from hospital managers and using concepts from the VLDP’s approach to facing 
challenges. This paper communicated the current situation the organizations face as well as their 
contribution to the health system of the country. The two bureaus also had joint planning 
workshops with health facilities to address their human resource challenges. The UPMB/UCMB 
team completed and implemented its strategy to reduce attrition among its health centers. The 
final evaluation completed by all the VLDP participants at the conclusion of the program 
documented that 78 percent of the participants have brought about changes in their organizations 
as a direct result of the VLDP, with 98 percent of participants stating that they would 
recommend the VLDP to others (downloaded from http://capacityproject.org, February 26 2010). 
The current HRH technical advisor for UCMB informed the evaluation team that the strategy did 
indeed reduce attrition to 10 percent but with subsequent changes, attrition in UCMB facilities is 
now 20 percent in hospitals and 18 percent in lower level facilities although they are still 
applying this strategy. 
End-of-Project Evaluation of the Capacity Project | 29 
Some of the districts have, on their own, taken measures to attract and retain key staff such as 
medical doctors. In Kamwenge, it was reported that the district council had approved a top-up 
allowance of Ug Shs 700,000 as an attraction package for medical doctors. 
Discussions with MOPS officials indicated that a software system “Integrated Pay Roll and 
Personnel System” (IPPS) for payroll management, supported by World Bank funding, has been 
introduced by the Ministry of Public Service and will be piloted in Lira and Jinja districts starting 
in July 2010. It will cover information such as payroll status, staff details, qualifications, 
probation, confirmation, vacancies, short-listing, trainings, enrollment for training, and 
deployment of staff. A back-up system has also been provided for at-source (districts), the 
MOPS, Jinja and Nairobi. The system has training modules designed for the staff, and the 
Integrated Financial Management System (IFMS) infrastructure has already been installed in all 
the local governments with support from the World Bank. 
Some of the existing challenges to staff retention were reported to include the following: 
• The turnover of health workers is high in the districts mainly because the promotional 
outlets are limited. When people attain higher qualifications and they cannot be 
accommodated in the existing district staffing structure, they look for opportunities for 
better career growth elsewhere. Because of the limitations imposed by the current staff 
establishment, health workers who get an additional qualification and are eligible for 
promotion may not be promoted immediately because there is no vacancy to which they 
wish to be promoted. Consequently, such staff members decide to leave their current 
district of service to go and work elsewhere where they can be appointed to a higher post. 
This appears to be a key challenge to staff retention. 
• Poor retention was also thought to be arising from delayed confirmation and promotion 
of staff. Promotion and confirmation are not effectively done by the DSC and this has left 
many staff waiting and static in one position or probation level for as many as 12 years. 
• Inadequate motivation is another cause for poor retention. Poor motivation was attributed 
to lack of housing accommodation at work stations, low salaries, poor allowances, and 
lack of training opportunities for staff. In addition, some districts reported that they no 
longer provide uniforms and shoes to nursing staff, yet they expect them to appear in 
uniform every day. Such a situation was reported in Apac. 
• Poor retention is also arising from few organized opportunities for further training. 
Health workers who struggle on their own to find study opportunities, including those 
who sponsor themselves for further study, have no commitment to their districts of 
service and often do not return after the training. The system of bonding staff members 
that are offered study leave was reported not to be effectively enforced to retain staff. 
• Some districts reported the persistence of problems in getting some staff members onto 
the payroll. In Apac district, it was reported that six of the staff recruited in 2007 had not 
accessed the payroll up to February 2010. In Kabarole, the evaluation team found that 
one of the medical officers managing a health sub-district and two of his colleagues, 
End-of-Project Evaluation of the Capacity Project | 30 
along with six other staff members, all recruited in September 2009, had not accessed the 
payroll by the time of this study. While the district had committed itself to supporting the 
doctors with Ug Shs 300,000 per month, they had received this money only once. 
Kamwenge also reported persisting problems with the payroll, although the situation had 
improved (e.g. the DHE recruited in September 2009 was not on the payroll by the time 
of this study). 
Problems in payroll management are still related to inaccurate filling in of forms and code sheets, 
as well as lack of communication from MOPS as to any errors or problems in the forms that need 
to be corrected by the districts. 
3.4.4 Enhancing systems for community participation in health services 
The project worked with Mbarara University of Science and Technology (MUST) to implement 
a village health team (VHT) strategy in the districts of Kabarole and Kasese and to attach 
students in communities for practical training. Project documents indicate that the project 
supported the placement of Mbarara University students in health centers in Kabarole and 
Kasese districts where they worked closely with VHTs. The focus was on getting the students to 
work at the community level to support VHT functioning and address community needs in the 
areas of PMTCT, HCT, and family planning. The students participated in VHT training and 
development in Kabarole and Kasese districts, and a total of 63 new VHTs were supported in 
providing PMTCT, HCT and family planning services. The project distributed VHT 
development guidelines from the MOH to the university and the districts. Students also worked 
with health centre staff to provide outreach services. 
Interviews with some stakeholders indicated that the process had helped to expose medical 
students to work in remote rural settings, making them more disposed towards working in similar 
settings in the future. The support that the students offered to VHTs was reported to have 
enabled VHTs to respond to community needs, and stepped up community mobilization and 
resulted into increased turn up for PMTCT, HCT, and immunization services. 
Although project documents indicate that the students worked with the district VHT facilitators 
and trainers as well as VHTs themselves, interviews with district staff revealed that the actual 
processes of student placement, day-to-day work, and supervision were managed by the 
university with little involvement of the district managers. The districts were only informed that 
the placements were taking place. In addition, a major weakness in the development of the VHTs 
acknowledged both in project documents and from the interviews carried out for this evaluation, 
was the lack of system for regular supervision and ongoing support to the VHT once they had 
been trained. 
It should be noted, however, that in most districts, VHTs had been trained in the past before the 
advent of the Capacity Project. VHTs had worked well under the Home-Based Management of 
Fever (HBMF) Strategy, distributing HOMAPAK (the prepackaged anti-malarial consisting of 
Chloroquine and Fansidar [Sulfadoxine Pyrimethamine]). However, they slackened because of 
poor motivation, including poor facilitation and lack of medicine supplies after the change in the 
treatment regimen from Fansidar SP to Coartem. Other programs have utilized them in recent 
years (since 2008), including for distribution of family planning products, ITNs, and 
End-of-Project Evaluation of the Capacity Project | 31 
mobilization for in-door residual spraying of mosquitoes. In Northern Uganda, VHTs have been 
variously trained by different agencies such as THETA, UNICEF, and NUMAT. In many places, 
VHTs’ management of information did not take off well, with the use of the Village Health 
Register not being closely followed up, and the value of the register not well appreciated. The 
general challenge with VHT work is lack of follow-up and support. 
In some districts, such as Apac, it was reported that they wished to hold annual health assemblies 
at HSD and district levels, where all health workers would have the opportunity to participate. 
These had however not been held because of lack of resources. 
3.4.5 Strengthening systems for workplace safety, protection, and care of the health 
workforce 
The project supported the MOH to develop a Workplace Safety Policy and Guidelines. The 
policy and guidelines were printed, distributed, and disseminated at national and district levels. It 
also facilitated the formation of workplace health and safety committees at district level. Such 
committees were found to have been formed in the districts of Oyam and Kabarole. 
By the time of this study, the committees in Oyam and Kabarole had not met and had not 
undertaken any other activities. In Oyam, the district committee was awaiting the formation of 
lower level committees at health facilities, while in Kabarole, it was reported that the committee 
was awaiting formal appointment by the district authorities. 
At the health unit level, it was found that implementation of workplace safety procedures was 
hampered by a number of constraints including lack of basic supplies such as soap, detergents, 
and gloves. Such constraints were reported in Apac hospital. Another problem reported was 
under-staffing, which means that overworked and hasty health workers may fail to observe all 
necessary safety precautions and procedures. 
In all districts, it was found that districts/health centers no longer provided staff uniforms for 
health workers, and the heath workers are supposed to buy their own uniforms. Many work 
without protective gear like gumboots and gloves, which puts them at risk of infectious diseases 
like HIV/AIDS. 
District informants in the north reported that besides the interventions of the Capacity Project, 
their main actions to improve workplace safety in recent years had focused on making medical 
injections safer; a process that has been supported by USAID through JSI. The process included 
training staff and improving waste management for all health staff in the district, even those in 
NGO and private facilities. Most recently, NUMAT has supported training staff involved in HIV 
care and PMTCT on AIDS service delivery. Districts also reported that they had received 
training on hepatitis prevention, but they did not have the vaccines to immunize staff at risk. 
They reported that they had auto-disposable syringes in all facilities, to prevent disease spread 
through injection reuse. 
3.5 Project Design and Implementation Approaches 
End-of-Project Evaluation of the Capacity Project | 32 
The approach of the project to design and implementation was widely praised. Initial 
consultation with stakeholders, most commonly at the MOH, began from the point of view of 
asking what are your problems and needs and therefore what the project can offer to meet these 
needs. These needs were then met through the activities in the project design. Only in a few 
districts did DHT staff feel that implementation strategies were being imposed on them. The fact 
that all project consultants were based in Kampala is important to note from the point of view of 
ability to engage in ongoing activities such as mentoring often needed by weaker partners. For 
many system-focused interventions this is not important, as arguably DHT members should be 
providing this mentoring, but observations demonstrated that this was certainly not the case for 
health center-level staff. In the short term such mentoring is necessary for weaker stakeholders 
until they achieve basic competency that can then be maintained locally. 
The approach of the project to monitoring and evaluation used indicators that monitored only 
completion of activities rather than including measures of quality of outcomes. However, quite 
often independent evaluation of the quality and impact of key project activities did take place 
and could be found in reports published online at http://www.capacityproject.org. 
3.6 Other Findings 
In order to meet the scope of this evaluation—to identify other areas of capacity building not 
currently addressed—the evaluators probed for factors that affected human resource 
development and capacity in addition to those not covered by the project. While problems in 
recruiting medical officers for HCIV level were found everywhere, some district hospitals were 
also short of doctors and clinical officers were filling in for them. The few doctors found in place 
at HCIV level were obviously overburdened with non-medical duties, disillusioned with not 
being able to practice their craft because few patients needed their advanced knowledge, and 
supplies and equipment including electricity were inadequate to perform operative procedures. 
The doctors interviewed felt that they were being deskilled by their current work and were 
planning to move on for further training in clinical specialties within a year. They were the 
personification of the young rural medical officer the Medical Council Registrar interviewed 
described when he said, “A major reason doctors leave, overriding no pay, no housing, and poor 
general conditions, is that they cannot practice their skill….with a lack of equipment, they do not 
get much useful experience in developing their clinical skills and are not doing the work they 
were trained to do.” 
Similarly wherever the evaluators went at the health center level, the same problems were clearly
evident as many reviews have documented: lack of drug supplies for months, staff absent or 
physically appearing obviously overworked, no local accommodation or adequate transport for 
staff, no planned in-service training, poor pay with few prospects of increase or promotion, no 
staff development, cheerless empty-feeling buildings at the HCIII level or buildings crowded 
with patients and few staff at the HCIV level late in the day. However, in several places staff 
were well motivated and some were keen on furthering their careers themselves. At one HCIV 
center, four staff were away for up to five years furthering their careers in achieving Masters 
degrees or becoming doctors. Of note is that while this center officially had four staff positions 
vacant, two of them medical officers, functionally eight staff members were absent. Many of the 
End-of-Project Evaluation of the Capacity Project | 33 
OICs interviewed in HCs said that they needed further training in management specifically in the 
areas of leadership, staff management, planning, and logistics. 
An interview with the principal of the Gulu School of Clinical Officers and his deputy was in 
stark contrast. He stated that the school produced 90 graduates per year and that competition for 
places in their training program was fierce. However, there were never enough places available 
to employ all his graduates in Uganda. Some have left the country for Sudan and Kenya. In 2005, 
a draft curriculum was developed that would enable a clinical officer to become a doctor after 
three years further training instead of the current five years. This was supported by AMREF and 
the MOH. However, nothing has been heard of this draft since then. A clinical officer costs many 
times less than a doctor to be trained, is internationally less marketable and therefore more likely 
to remain in Uganda if employed, and could be encouraged to stay working in rural health 
centers for a number of qualifying years before s/he is allowed to undertake a shorter course to 
become a doctor, if the course mentioned above was mobilized. Unprompted, the principal and 
his deputy also identified addressing all the general factors listed in the previous paragraph, as 
well as provision of access to soft loans, as needed to improve clinical officer performance. 
A recent study of AIDS treatment in Uganda found that 64 percent of the people who prescribe 
antiretroviral treatment were not doctors.
13 Findings like these suggest that there is need to 
redefine the role of doctors limiting them to only those clinical services for which their expertise 
is needed so that the few present, with a transport arrangement, could cover several HCIV 
facilities, if standards of clinical care are to be maintained. This, along with equipping selected 
rather than all HCIVs with adequate equipment to do common operations may be one way to 
rationalize the use of doctors. The HCIVs that are chosen for adequate equipment could be 
chosen on the basis of mapping all health facilities in each district and seeing that these equipped 
facilities are well-spaced through the district. Making sure there is an adequate emergency 
transport system from centers not so well-equipped would be an essential part of the system. 
The evaluators also assessed the need for human resource and management support through the 
use of the standardized tool presented in Appendix 7. The detailed findings of the use of this tool 
are also presented in that Appendix. In summary health manpower planning was good in all six 
districts, and the DHT has a reasonable knowledge of current staffing gaps. Review and day-to￾day planning meetings generally take place on an approximately weekly basis and DHT 
members participate in planning and problem solving. HCII staff had no role in district planning. 
No analysis of workforce data takes place, and while records do include gender of staff, no 
considerations with regards to gender take place. All districts had established procedures for 
recruitment and orientation of new staff but these were inadequate in those districts that had not 
been supported directly by the project. None gave any technical orientation. All said they had job 
descriptions but no one could produce theirs and examination of summary documents, where 
possible, showed that job descriptions did not exist for all positions. Regular performance 
appraisal takes place for all staff but only one district had clear performance standards that 
included ethical standards and standards concerning data confidentiality, although these could 
not be produced. 
 
13 Lutalo IM, Schneider G, Weaver MR et al. Training needs assessment for clinicians at antiretroviral therapy 
clinics: evidence from a national survey in Uganda. Human Resources for Health 2009,7:76. 
End-of-Project Evaluation of the Capacity Project | 34 
Generally there is no fully operational system that records staff level of training and in-service 
and continuing education received. There is no formal curriculum for in-service training. 
Individual staff normally identify continuing education opportunities themselves and then seek 
OIC and DHO approval to train. The village health teams are supervised by the health centers 
directly but also by the senior or an assistant health educator from the district level in some 
districts. There are checklists and reporting systems used. Monthly supervision is supposed to be 
the norm but this may not be followed due to lack of resources. Generally there are minimal or 
no training facilities for health at the DHO. Each training is planned for including all its 
consumables, which are purchased at the time of training. Training materials, when supplied, are 
those supported by whatever project is operational in the area. 
The data the evaluators obtained was incomplete but is consistent with a general increase in 
recruitment to over 85 percent of positions available and prompt payment of pay as a result of 
Project activities. Payroll access in districts increased on average from 50 percent to above 85 
percent. 
3.7 Other Major Donors 
As requested by USAID/Uganda the evaluators interviewed other major donors who planned to 
have activities in the next year in the area of HRD in health. 
World Bank 
The World Bank (WB) has extended to the Government of Uganda a US$130 million health 
sector loan, which has four components of health infrastructure development, leadership & 
management systems, human resources development and management, and project 
implementation and management. The details of the new project that the WB is funding can be 
seen in overview from the concept paper for the World Bank project document.14 The Capacity 
Project facilitated the development of this document for the MOH. 
Within the human resources development and management component, the loan will focus on 
technical assistance and training. With regards to HRD, the World Bank project will generally 
focus on 44 districts, while the Capacity Project and the WHO will cover the remaining districts 
between them. Within this component, the major areas are consolidating central level HRH 
functions; strengthening personnel management functions; improving staff retention in remote 
and hard-to-reach areas; and improving pre-service and in-service education. 
The leadership and management systems component covers performance-based management 
approaches; hospital regulatory framework; professionalizing management of health facilities; 
logistics and supply chain management and strengthening delivery of health services at the 
district level. Within hospitals, an emphasis will be placed on strengthening teams of dedicated 
experts dealing with clinical management of newborns and mothers. Most support will be 
through the central level but some support will be given to some districts directly with specific 
needs. 
 
14 Uganda Health Systems Strengthening Project Concept Paper Prepared for World Bank Funding Republic of Uganda Ministry 
of Health, August 2009 
End-of-Project Evaluation of the Capacity Project | 35 
The World Health Organization (WHO) 
The WHO works to provide technical support to countries in its key areas of intervention, such 
as policy guidance, development of guidelines, and health research. The WHO’s focus, therefore, 
is on improving HR planning capacities using evidence from HR information systems. 
The second concern is improving health workforce productivity. A strategy for incentives for 
health workers in hard-to reach areas was drafted years back but there is still need for dialogue 
and agreement between the MOH, MOPS, and MFPED and PNFPs. This issue has been on the 
table for debate for about 10 years, and is not just about salaries, but broadly about equity issues. 
A pilot intervention was implemented in 2007/2008 with funding from DFID channeled through 
UNICEF, but initiated by the UN system under its humanitarian response initiative. Health 
workers in the Northern Districts were paid a top-up equivalent to 30 percent of their monthly 
salaries for six months. This initiative had a positive impact—in terms of attracting staff but only 
for low cadre staff. It didn’t work for doctors. Adverts for vacancies were put out, and it was 
mentioned that the top-up would apply to existing as well as new staff, and those in PNFPs. 
There was an overwhelming response—but again not from doctors. Such an incentive system is 
at the top of the WHO and other partners’ agenda, but it cannot be operational zed until there is 
agreement. PNFPs, for instance, are concerned that if it is implemented only in government 
facilities, their staff will run away to work in government. 
Danish International Development Agency (DANIDA) 
DANIDA is working closely with the Belgian Technical Cooperation, UNFPA, and the Italian 
Cooperation in the sector-wide framework. Their focus on system support is on improving skills 
at the lower level, in the local governments where service delivery takes place. They support two 
main areas: relevant training and technical support supervision. They have an elaborate 
framework for technical support supervision based on area teams composed of central level and 
regional staff (from regional referral hospitals) providing regular back-stopping support to 
districts. Their approach to training support is to provide scholarships for staff to upgrade, with a 
current focus on nurses and mid-wives. 
The informant, Peter Ogwang of DANIDA, saw management capacity of health managers, as a 
direct and deliberate investment. In the past all people posted in management positions had to 
spend 2 weeks at the Uganda Management Institute to get grounding in the specifics of 
management in public service. 
Belgian Technical Cooperation 
The Belgian Technical Cooperation (BTC) supports the Government of Uganda in the health 
sector through two mechanisms. Each year they give €5 million through sector support to the 
GoU as they participate in the 10 technical working groups supporting health one of which 
focuses on human resource development. They also have a €6.5 million project running over four 
years that supports capacity building working centrally and in two regional referral hospitals, a 
few general hospitals, districts, and health sub-districts in areas nearby. They informed 
evaluators that it is worthwhile for USAID and the Capacity Project to familiarize themselves 
with the three-year priorities of the Joint Budgetary Support Framework managed through the 
Office of the Prime Minister that works with the MOH. Budget support donors donate through 
this framework using a common frame with four sets—water and sanitation and health are two of 
End-of-Project Evaluation of the Capacity Project | 36 
these sets. Priorities are set year by year over three years. Indicators at least on deliveries, 
immunization, drug supplies, and human resources monitor progress. The Swedish International 
Development Agency is also giving project support to the tune of €1.2 million in similar areas of 
activities to the BTC. From a technical document available through the UMEMS office, the 
evaluators were able to get an overview of their project.15 The project plans to create two formal 
training centers for training of HSD management teams located at HCIV level, and work with the 
MOH to develop a coordination system for donor capacity building efforts. Close collaboration 
will take place with the Institute of Tropical Health Antwerp, and the School of Public Health at 
Makerere University. Synergies and coordination will be sought with USAID, the World Bank, 
and Japan International Cooperation Agency (JICA). 
3.8 The For-Profit Health Sector in Uganda in the Area of HRD 
The evaluators discussed the for profit health sector with the COP of the Capacity Project, MOH 
personnel, and staff at the School of Public Health at Makerere University. Generally no formal 
system exists. Individuals are usually approached because of personal connections. Newspaper 
advertisements are generally not fruitful. The COP of the Capacity Project provided us with a list 
of Ugandan private consultants in the area (Appendix 13(a)). The MOH often approaches staff 
members at the University of Makerere for consultancy work. Potential consultants from the 
School of Public Health at Makerere University are usually contacted by MOH staff or NGOs 
directly on a one-to-one basis. A list of the teaching staff at the School of Public Health, their 
area of specialization, and qualifications is in Appendix 13(b). The Martyrs’ University also has 
a reputation for teaching health management topics and has an agreement with the MOH to do 
so. 
4.0 CONCLUSIONS AND LESSONS LEARNT 
4.1 Overall 
The project has been successful in stimulating and supporting initial implementation of specific 
interventions at the central level and in a few districts to improve HRH. It has contributed to 
increased acknowledgement and operational focus on HRH issues as priorities in health service 
improvement, as evident in generation and application of HRH data in health service planning, 
and in recruitment of additional health personnel to rapidly fill critical gaps in district health 
services. Although the project approach adopted was useful in linking multiple government 
sectors with a stake in HRH improvement, it also resulted in innovations and successes that are 
not fully integrated into the routine operations of districts and central government. Sustained 
implementation of such interventions and their scale up to all districts in the country will require 
further support and necessary adaptation in the approaches used to empower and support 
government staff as the main drivers of interventions. 
4.2 Appropriateness of the Capacity Project Approach 
 
15 Technical & Financial File. Institutional Capacity Building in Planning, Leadership and Management in the 
Ugandan Health Sector Project. Uganda DGDC Code NN 3008322 BTC Code UGA 017011. 
End-of-Project Evaluation of the Capacity Project | 37 
The HCD cycle (plan, develop, and support) was appropriate as a framework to define and 
respond to specific issues in planning, developing, and supporting HRH improvement. Project 
interventions strengthened data-based decision making on HRH deployment, in enhancing 
mechanisms to support continued professional development of health personnel, and in 
reinforcing support systems to increase health worker motivation, productivity, and efficiency. 
However, other challenges in the broader health system context (e.g., inadequate equipment, 
drugs and other supplies) were key mitigating factors that prevented optimal benefit from the 
HRH improvement interventions. The projects approach to implementation of first asking 
stakeholders what assistance they wanted and moving from there to show how the project 
implementation met their expressed need was widely appreciated, especially by the MOH 
counterparts. 
4.3 Achievement of Intended Results 
The project was successful in realizing most of the stated outputs in the project plan. Where the 
project did not achieve planned results was reasonable and usually beyond their control (See 
Table A10 in Appendix 10). However, the project design and monitoring indicators did not 
include explicit outcome and impact results, although these were often available in separate 
follow-up evaluation reports and publications. 
4.4 Enhancing Capacity for Policy and Planning 
The project strengthened capacity for policy and planning by strengthening systems to generate 
dependable data, supporting analysis and publication of key information to inform HRH 
decisions, and facilitating revision, dissemination, and application of key policies and guidelines 
relevant to HRH improvement. 
4.5 Strengthened Health Workforce Systems and Improved Performance 
The Project strengthened health workforce systems with regards to much easier determination of 
health workforce needs, advertising for new staff, short-listing of applicants, and their 
orientation. However, further follow-up facilitation is needed to make wide use of the iHRIS 
more sustainable through more careful selection of who is going to be in charge of the system, 
the number of operators to train at each site, and sustainable hardware and software support. The 
performance improvement assessment system linked to follow on planning and implementation 
of supervision had limited success because many DHTs did not do the follow-on planning and 
implementation that they were meant to do. The procedures used were also too complicated for 
health personnel in health centers at the lower levels. Modification and further development of 
these systems needs to be undertaken to encourage their wider use. 
4.6 Key Project Successes and Failures 
The notable successes of the project include the roll-out of HRIS at the central level and in nine 
districts, support to districts to recruit health personnel, and support to the MOH to produce a 
number of key documents to inform HRH support and improvement decisions. The project 
played a critical role in development and functioning of the HWAB as a functional reference 
End-of-Project Evaluation of the Capacity Project | 38 
group on HRH, and in coordinated planning for necessary adjustments in the HRH payroll and 
its management. However the project successes at the level of national and district strategic 
decision-making were not matched at operational level, especially when interventions were 
meant to be carried down from the DHT level to lower-level health centers. Challenges such as 
inadequate operational funding, and medicine stock-outs were a key constraint at this level. 
4.7 Unintended Results 
Payroll management was not initially planned for and a big impact was not anticipated but it 
proved to be very popular and a major motivator for staff retention. The general accessibility to 
the payroll increased from about 40 percent to 85 percent for health personnel in the districts, 
and from 90 percent to 95 percent at the national level. The payroll intervention had spillover 
effects that were beneficial to all public service employees. Similarly, the iHRIS in Lira was 
found to be beneficial to all public service district staff, not just those in the health sector. This 
was a deliberate intervention whose impact was far more than expected because helping health 
staff also benefited all employees who were paid through the public service system. 
4.8 Factors Hindering/Enabling Success 
Effective implementation of project interventions was a result of an appropriate design and 
implementation strategy, existing momentum and basic commitment to HRH improvement 
globally and in Uganda, adequate funding to support all project activities, and the appropriate 
people deployed in project leadership as technical assistance to government and as counterpart 
leaders in the government offices that worked with the project. 
Weak government IT infrastructure and support systems, inadequate funding for routine health 
systems operations and inadequate equipment and supplies in health facilities were important 
constraints to project implementation and sustained benefit from its interventions. Staff mobility 
and absenteeism, known to often be over 48 percent, were common impediments. Staff may 
continue in a similar role but move to a different district rather than resign. 
4.9 Remaining Gaps 
The HRH interventions introduced or strengthened by the project have worked well through a 
project approach. There remains a critical need to sustain this experience as an integral element 
in routine government functioning at the central level and in the districts reached. The project 
successes most evident in the three districts of focus need to be taken to scale in the other seven 
districts where partial interventions were supported, and indeed across the country. Task shifting, 
especially in relation to the roles of the medical officer versus that of clinical officers and nurses, 
is an important area to be addressed. Indeed the important role that VHT members and 
community members can have in promoting attendance for antenatal care, follow up of PMTCT, 
promotion of HIV prevention and reproductive health at low cost needs to addressed, though not 
necessarily through this project. To quote the WHO “From 70 to 90 percent of all sickness care 
takes place in the home. Household members, especially mothers, make the primary diagnoses of 
illnesses, assess the severity and likely outcomes, select among available providers and treatment 
End-of-Project Evaluation of the Capacity Project | 39 
options, and procure and administer treatments.”16 Interventions, including those for HIV have 
been demonstrated to be relatively inexpensive in Africa.17
4.10 Lessons Learned 
The constraints of working in the Ugandan health system—high staff mobility, high absenteeism 
rates, and low morale in some workers—mean that capacity building is problematic. 
Sustainability and scalability of activities to strengthen systems should therefore be taken into 
account at the planning stage. For example, in establishing iHRIS systems at the district or 
indeed the central level, not just the proffered users should be trained but also several other 
personnel who have a high chance of rotating into the role of current designated users. How the 
system is likely to be used in the real world needs to be examined at time of planning and setup 
on the basis of what happens already needs to be considered. Two backup systems or, as 
practical and affordable, distant or on-line backup solutions need to be considered. If there is 
only one backup system, then surely it will fail. Perhaps the CPO should have an emergency 
backup disc in his/her safe. 
Systems that rely on local planning and trickle down of learning at the district level to lower 
levels in the health system often did not work. What is already happening in a particular location 
before training is a good indicator of what is likely to happen after training. Lack or resources is 
a common, perhaps legitimate excuse, but even supplying resources for supervision does not 
mean that they will be used appropriately. Capabilities of local actors need to be considered. In 
some locations, mentoring of particular individuals may be needed. Motivations that would 
encourage DHT members to do follow-up planning and supervision need to researched and 
tested. 
Addressing HRH issues necessitates addressing other non-HR aspects if health workers are to 
translate their competences into improved services. The required resources, supplies, and a 
conducive working environment need to be considered also. In this respect, the efforts by the 
current Capacity Program to work closely with other USAID implementing projects that may 
provide these other necessary inputs is commendable. 
The involvement of local actors from an early stage in planning, implementation, and evaluation 
creates ownership and commitment towards sustainability. For example, this was the case in the 
establishment of the iHRIS system as expressed by Dr. Edward: 
“Everybody felt they were able to contribute and were part of the process of developing a 
human resources database for Uganda that would be functional. That approach ensures 
that the program that’s being designed fully meets the local requirements and promotes 
use of information from the human resources team for policy decisions and allocations. 
The three key words here are ownership, sustainability and capacity-building.”
(Dr. Edward Mukooyo, Assistant Commissioner, Resource Center, Uganda MOH)18
 
16 WHO, World Health Report 2002. Reducing Risks, Promoting Healthy Life. WHO Geneva 2001 
17 Community Directed Interventions for Major Health Problems in Africa. A multi-country study final report. Special Program 
for Research & Training in Tropical Diseases UNICEF/UNDP/WHO/World Bank ISBN 9789241596602 2008. 
End-of-Project Evaluation of the Capacity Project | 40 
Mapping and analysis of complex processes can produce key unexpected results. This was the 
case when the project analyzed reasons for staff satisfaction and raised morale of many health 
staff greatly by increasing the rate of timely access to payroll from 45 percent to 85 percent. 
5.0 RECOMMENDATIONS 
5.1 Introduction 
The recommendations below are based on the findings described in the previous section, the 
project related documents viewed, and the reading of the current relevant literature and 
experience in similar circumstances. It is important to remember that the Capacity Project has 
been implemented in Uganda for just over three years under the many constraints have listed in 
section 3.6. Many of the activities only began in 2009 and so there has been limited time for 
promising activities to reach their full potential. Therefore many of the recommendations are 
basically concerned with continuing activities that are showing promise while others are new. 
The latter will be elaborated upon in more detail. It can be assumed that the recommendation is 
for the project to follow the same processes as previously stated unless there are comments 
otherwise. Recommendations are grouped according to the relevant Objective. Other 
recommendations in relation to broader issues raised in Section 3.6 are grouped here. 
5.2 Enhancing Capacity for Human Resources for Health Policy and Planning 
The Capacity Program should provide further support to the health professional councils 
and MOH Resource Centre/HRD/HRM to consolidate HRIS operation. 
This is a follow-on from previous project activities and would deal with such issues as keeping 
data input up-to-date, conduct regular analysis and produce reports as needed, and apply data in 
operational and strategic decisions and actions. Using the previously successful approach, 
support to the professional councils should include development of comprehensive strategic 
plans and resource mobilization strategies to enable them to fulfill their mandate as defined in 
law. The MOH Human Resource Development Division should be supported to develop and 
utilize an HRIS Qualify that captures data on all HRH trained in the country, including nationals 
who may go abroad for health-related training. 
District health offices, with necessary support from MOH and the Capacity Program, 
should lead the process to refine the district HRIS roll-out strategy. This should include 
building the district HRIS as a shared resource, useable in the district health office, district 
personnel department, and the district planning unit. 
Effort should be made to learn from and integrate local innovations in database development 
(e.g., the Access-based system in Kabarole district), to inform HRIS adaptations that would 
enhance sustained utilization in the districts. Training for district users of the HRIS should be 
structured to meet the needs of basic or starter IT users, and should include appropriate reading 
 18 Capacity Project Knowledge Sharing: A National Impact: Local Ownership of Health Workforce Initiatives in Uganda, 
November 2008 
End-of-Project Evaluation of the Capacity Project | 41 
materials as handouts. Follow-up support to districts after training in HRIS use should include a 
minimum of monthly remote contact (e.g., phone discussion or e-mail exchange) and quarterly 
visits that provide for adequate time to review and address issues on system utilization, and 
generation of analysis reports and using them to discuss specific HRH issues in the district. 
Districts should be supported by the Capacity Project and the appropriate organs in central 
government (e.g., Ministry of ICT, Uganda Communication Commission, MOH-Resource 
Centre) to develop basic IT troubleshooting and maintenance capacity. 
The Capacity Program, the MOH, and district local governments should include clear 
mechanisms and adequate provision for operation and maintenance of new technologies 
introduced for data and information management to enhance their sustained utilization. 
Consideration should be made to integrate operation and maintenance of the new technologies 
into existing mechanisms for equipment management. Necessary adaptations in existing systems 
(e.g., training of personnel supplementing toolkits and expanding connections to expert support 
through referrals) should be provided for, and monitored as necessary to ensure performance and 
sustainability. 
The Capacity Program should provide further support to the Health Workforce Advisory 
Board (HWAB) to consolidate its role as an HRH reference group that cuts across the 
different government sectors, and includes representation from the other stakeholders. 
Other stakeholders suggested to be involved include training and research institutions, faith￾based agencies operating PNFP health facilities, and NGOs involved in health care, etc. This 
broader involvement would raise the influence and profile of the HWAB and enable it to 
promote good quality HRH. Support should be provided to refine the terms of reference for the 
HWAB and its mandate to coordinate and guide HRH issues 
The Capacity Program should expand engagement with and support to associations for 
health professionals, including the medical workers union, as a mechanism for 
strengthening workforce organization, mobilization, and motivation. 
The project should reinforce institutional strengthening and strategic planning support to 
UNANM. Dialogue should be established with associations for Allied Health Professionals, 
Medical and Dental Practitioners, and Pharmacy professionals to explore ways in which their 
role in mobilizing and motivating health professionals can be strengthened. Specific partnership 
should be developed with associations of private practitioners (e.g., the Private Midwives 
Association, and Private Medical Practitioners Association), as an entry point for capturing HRH 
and service data from this important domain of the health workforce. 
The Capacity Program should build on the experience of partnership with UPMB to 
enhance support and inclusion of the broader range of PNFP health service providers as 
key players in training and deployment of HRH. 
The project should provide further support to UPMB for HMIS improvement, solidifying and 
extending their previous success in this area, and apply relevant lessons to strengthening HMIS 
End-of-Project Evaluation of the Capacity Project | 42 
practice in the other PNFP medical bureaus, UCMB and UMMB. The bureaus should also be 
supported to develop HRIS to capture their training and deployment of health workers. Their 
contribution to continuing medical education and to management of district health services (e.g., 
as HSD lead health facilities) should be specifically strengthened. 
5.3 Strengthening Systems for Effective Performance-Based Health 
Workforce Development 
The Capacity Program should support the reorganized Health Manpower Development 
Center (HMDC) to harmonize pre-service and in-service training of the health workforce 
with integrated HIV/AIDS and reproductive health needs. 
HMDC is now in the process of being moved to part of HRDD. With this movement it should 
have a budget again. Before restructuring, this center was effective in communicating distance￾education for health professionals with up to 1,500 enrolled students per year. With adequate 
support it can become so again. 
The process of disseminating the standards for continuing education and the accreditation 
of institutes for delivering CPD not finished in this project should be supported in the new 
project. 
This process was proceeding successfully in the previous project. All the relationships and 
facilitation from the previous project are still in place. 
In order to develop effective performance improvement procedures, the processes used in 
this project should be reexamined and developed with local MOH input at all the levels in 
the health system that they are to meant to be used to make them more user-friendly. 
This process of local consultation and revision could be followed in a few trial districts so that 
new procedures can be developed. Experience of successful application of performance 
improvement procedures, as represented in the current instrument, by members of the Capacity 
Project overseas suggest that it is worthwhile giving them a further trial in the new project after 
local adaptation with appropriate stakeholder input. 
As part of this redevelopment of performance improvement procedures feedback loops 
should be established: 
(a) on supervisory assessments performed at the HC levels so that supervisors at higher 
levels can see that assessments are actually taking place at lower levels. 
(b) from higher to lower levels so that lower levels know what is being done with the data 
sent to higher levels. 
Such feedback loops improve these procedures as in (a) they let supervisors at higher levels 
know that programs area being followed. In the case of (b), feedback helps motivate those at 
lower levels to collect the desired data since they come to appreciate how it is being used and 
End-of-Project Evaluation of the Capacity Project | 43 
analyzed. These loops can be established by establishing regular report flows for this purpose 
that are also discussed by supervisors when they visit. 
Once innovations in effective performance improvement (and other aspects of health 
program management) are established, their sustainability and ongoing development 
should be established by linking them with appropriate established institutions. 
Established institutions with expertise in health systems management include Martyrs 
University, which already has an agreement with the MOH for the training of health staff in 
management, and the School of Public Health at Makerere University. With such linkages, 
successful innovations can be maintained, further developed, and evaluated, despite the constant 
change of both MOH staff and supporting health projects. These linkages could be established by 
involving the selected institutions in the ongoing development of these tools from the early 
stages of the new project. 
Two experienced nurses should be recruited as consultants and based at the district level in 
two different regions to act as local workshop leaders, facilitators, and mentors of OICs in 
local HCs. 
Their key functions would be: 
1) To follow up local project workshops at the district level, concentrating on those OICs 
identified as needing mentoring, to see that information and skills learned at this level are passed 
down to the HC levels. As indicated, with appropriate support, they can help with adaptation of 
materials used in workshops that are understandable at HCIII and HCII. 
2) As a trial to support HCs IV (where there is no doctor present), III and II to aid development 
at these levels of one local learning center in HCs at each level in one location. The HC chosen 
for these centers will be determined by the presence of a positive OIC and a local community 
open to working closely with their local HC. 
At and through these centers: 
a. Performance appraisal assessment linked with supportive supervision will be established 
in association with that happening at higher levels in the district. 
b. The building of local positive learning organizations and teams will be established to 
facilitate the motivation and delivery of good quality primary health care services, 
especially for reproductive health and HIV. 
c. Once these HC learning centers are functioning well, other OICs and staff from 
surrounding HCs can attend for peer mentoring, discussion, and skill-building so that 
they can return to their own facilities and apply what they have learned there. 
d. The development of local consultative networks can be facilitated between local OICs so 
that they can give one another mutual support and help in solving common problems. 
End-of-Project Evaluation of the Capacity Project | 44 
e. If as recommended below, training in management is undertaken for health center OICs, 
these consultants could follow-up practice of learning at workshops, through local 
mentoring or indeed lead such workshops themselves. 
The process to establish these centers would include: 
a. Careful selection of the nurse facilitators. These nurses would already have qualifications 
and experience in management, be relatively experienced and dedicated, selected with 
some input from nurses in the area in which they will work and already orientated to 
living in rural areas.19
b. Careful selection of positive OICs and associated communities where these centers are to 
be established so that the chance of initial success can be maximized and positive 
learning processes established. 
c. Training of the consultant nurses in the group processes necessary to facilitate the 
building of learning organizations. To build local positive learning organizations, a basic 
approach to team building, development of common goals, group problem solving and 
appreciative enquiry techniques would be built through a facilitated group process. These 
techniques are now used in USAID-funded child survival programs. An appropriately 
skilled external consultant would need to be recruited to facilitate this process through 
recurrent visits over a one-year period. In addition, community support and appreciation 
of their local health workers would be built through locally appropriate processes such as 
political support. (The project Chief of Party is experienced in what may work best in 
Uganda to build community support). 
d. Establish these centers through the application of the facilitation processes learnt above 
gradually through a plan agreed by consultation between the local HC members and their 
community over an initial six months trial period. 
e. Once a few centers are successfully functioning, the consultant nurses could move on to 
other health centers where the nurses invite them. Through this on-site learning and peer 
learning and support this approaches would gradually go to scale. 
It is proposed that these local learning centers be NOT resourced at any more than the basic level 
required for the delivery of good basic health care. At most, accommodation for a few visiting 
staff at a time should be added to these centers. 
The establishment of such centers is proposed because, appropriately facilitated, they have 
potential to address many facets of poor motivation, absenteeism, and poor esteem contributing 
to poor delivery of health services in rural Uganda. Although it is common knowledge that 
attitudes of health professionals at lower levels in rural health services in Uganda towards their 
work and of community members towards them is generally negative, this does not mean that 
 
19 Apparently such nurses would be relatively easy to find—indeed an interviewee from the WHO already can think of some suitable candidates 
from her involvement in health system management courses at the Martyrs University.
End-of-Project Evaluation of the Capacity Project | 45 
such a change is not possible. Change often begins with “early adopters” who are later joined by 
others as these see change is possible. Such an approach, properly facilitated, concentrates on 
individual and group strengths and appreciation of one another rather than problems, builds 
group cohesion, and mobilizes group-think towards solving manageable problems.20 
A study should be carried out of those who are regularly practicing supportive supervision 
in demanding areas in rural Uganda to ascertain their characteristics. 
A current area of management development is the use of Positive Deviance analysis in 
identifying those managers who are practicing well despite demanding circumstances that defeat 
many others. Such a study may identify some characteristic that are worth including in training 
programs. Indeed identifying these positive deviant practitioners as models and leaders for 
training would be useful. 
a) Follow-up evaluation of the application of the training of trainer’s courses in the 
Learning for Performance Approach method should be performed early in the new project. 
b) Follow-up evaluation of the application of the training of trainer’s courses for District 
trainers in Kabarole on mentoring training on infection control should be performed early 
in the new project. 
These activities were performed in 2009 and so apparently there has not been time for follow-up 
evaluation of the application of the skills learned in these trainings. Such a evaluative report 
would, of course, include examination of the course reports documenting the skills acquired by 
students trained by these trainers. 
5.4 Identification and Promotion of Health Workforce Management Practices 
for Improved Performance and Retention 
Management capacity building training should be provided for the health facility IV, III, 
and II levels with an emphasis on planning and budgeting, supervision of staff, and 
relationship with the communities. 
 
The basis for this recommendation is that it was commonly observed by the evaluators that OIC 
Health Centers often lacked basic management skills. This recommendation can be implemented 
by a) on-the-job management training courses for the OICs of health facilities designed in 
modular form to enable them work and practice at the same time, and b) posting management 
mentors at some selected health center IVs who will support the planning and management 
functions for a defined period of time. The management mentor will also support the HCIII and 
II. The two nurse consultants mentioned above could also support these processes. Since the 
Martyrs University already undertakes this type of training on behalf of the MOH, the possibility 
of them undertaking this role for the project should be explored. Staff members at the School of 
Public Health at Makerere University have also lead short training courses in management at the 
district level for NGOs. 
 
20 Hammond, S.A. (1998). The Thin Book of Appreciative Inquiry. Plano, TX: Thin Book Publishing Company.
End-of-Project Evaluation of the Capacity Project | 46 
The orientation of new staff should be comprehensive and include both the general and the 
technical aspects to ensure a solid foundation for service provision. 
The orientation should be done through attachment of staff to an officer of a particular title and 
job description (internship) for at least one or two months. It should be the responsibility of the 
DHO/DHT that this orientation is carried out. An on-the-job training curriculum should be 
developed that covers critical health issues and challenges, roles and standard procedures, the 
health worker’s role as part of a mutually supporting health team, relationships with the 
community, and workplace safety. As above, for sustainability, it may be desirable that this 
activity be facilitated by an established institution. 
A system for staff development should be reestablished and those with responsibilities in 
this area should receive formal training in planning and supporting staff development. 
An inclusive and ongoing consultation process including key stakeholders, likely students, and 
those with responsibilities in this area, should take place so that a practical and sustainable 
system is developed and adopted. This system should encourage staff to pursue their own 
professional development while at the same time encouraging them to develop or strengthen the 
skills needed to deal with local health needs. 
The Capacity Program should continue supporting DSCs to undertake recruiting, 
confirming, promoting, and disciplining district staff. 
Running the business of DSCs was found to be very expensive for districts. Some districts 
reported a big backlog of staff that are overdue for confirmation and promotion, which indirectly 
affects their motivation and retention. Continuing support to DSCs, with which many good 
relationships have been established, is desirable until improvements in the above areas become 
institutionalized and so more likely to be maintained. 
The Capacity Program should continue to support payroll management reform and help 
develop a feedback mechanism from MOPS to districts. 
During the previous phase of the project, district personnel were trained in filling in payroll 
forms. However, some districts still face challenges in getting their staff onto the payroll. They 
attribute this to unexplained problems at the MOPS. More hands-on training by MOPS staff 
should be facilitated until the level of error by all parties involved is reduced to an acceptable 
level. 
The Capacity Program should facilitate the implementation of the health sector staff 
motivation and retention strategy. 
The motivation and retention strategy has elements on staff remuneration and benefits, 
opportunities for career progression, institutional accommodation for health workers, support 
supervision, safety at workplaces, continuing professional development and in-service training, 
and other job and work environment elements. All these elements require financial and technical 
End-of-Project Evaluation of the Capacity Project | 47 
support if they are to be realized. A key aspect of this strategy is to work out special incentives to 
attract and retain health workers in the hard-to-reach districts. Working with other health sector 
partners, the project can facilitate the implementation of this strategy as practical. Given the 
project’s other commitments, this support may not be financial. 
The Capacity Program should follow-up on the earlier successful retention initiatives 
carried out by the UCMB and UPMB. 
Initiatives undertaken by these bodies with Capacity Project facilitation were successful in 
increasing staff retention in 2007. Although these initiatives are still in place, staff retention is 
down to its old level. Further support is needed to help them correct this situation. 
The short-listing software should be made usable for short-listing staff in other sectors. 
Since this software is used by the DSC, which manages all recruitments for the whole district, 
training DSC staff to use this software for all district recruitment will lead to the software 
becoming part of their normal procedures and so increase its sustainability, especially given the 
high rate of staff turnover of DSC staff themselves. 
5.5 Other Recommendations
Primary health care services budgets should be justified on the basis of lives saved by 
services delivered. 
There is no doubt that, even with improved efficiency and effectiveness, the current national 
health budget needs to be increased to improve health workforce and resources levels. Several 
interviewees have volunteered that a method is needed to justify increased funding in terms of 
results. The Bellagio (Lives Saved) calculator is an established method to quantify the health 
benefits in terms of lives saved of common primary health care interventions. Using a reasonably 
rigorous measurement of, usually, under-5 mortality (DHS Survey), an established measure of 
the efficacy of a particular intervention, and a change in coverage of the intervention, the benefit 
of the change in coverage in terms of lives saved can be measured. These calculations can, in 
turn, be used to justify the increased budget necessary to provide the resources, including 
manpower, to bring about this increase in coverage. This is a recently established valid practice. 
Further information about the Bellagio calculator can be obtained from 
http://www.jhsph.edu/dept/ih/IIP/list/index.html
To implement this approach, a short-term consultant experienced in the use of the Bellagio 
calculator and budgeting needs to be recruited to train appropriate MOH staff members in the 
development of increased budgets for HIV/AIDS, reproductive health and primary health care 
services justified on the basis of measurable health benefits. 
The Capacity Program should continue its activity in promoting dialogue about task 
shifting. 
The role of doctors, nurses, and clinical officers in the rural Ugandan health system is clearly a 
End-of-Project Evaluation of the Capacity Project | 48 
long-standing area of contention in which many agendas abound. The role of none of these 
groups can be considered in isolation from the others. Rightfully, doctors are concerned with 
standards of practice in relationship to complex areas such as the management of ARV therapy, 
but what is the evidence of what those few doctors present are actually doing? To forward this 
dialogue, it is proposed that a national level workshop be supported that helps key stakeholders 
build a common practical vision of what Ugandans want their rural health care system to be 
based on—the best evidence available. 
This workshop needs to be informed by actual current practice of doctors, nurses, and clinical 
officers in rural Uganda. Their representatives must testify and the current state of the literature, 
reasonable estimates of the costs of different scenarios, and reasonable representations of the 
current manpower system, present in many documents that the project has helped develop, must 
be examined. Informed by this background information, key stakeholders could be guided 
towards this common practical vision. A working committee towards such a national event 
would need to be formed to gather all the necessary evidence and present it in an accessible form 
for all stakeholders. For actual facilitation of the workshop, relevant costs need to be estimated 
beforehand and an expert in the field be available at the time of workshop to estimate any 
scenarios envisioned. 
Further, if wanted, the common vision could be widened to include the general roles of other 
health workers and that of the community. Again, an evidence-based background should be used 
to inform this vision. While this may be too big a step in one workshop, it may be an important 
step to include at a later date. Alternatively, with careful facilitation and political support, a 
momentum could be created that would lead to real change. 
End-of-Project Evaluation of the Capacity Project | 49 
APPENDICES 
Appendix 1: Map of Uganda Showing Districts Visited 
Districts colored red are those visited by the evaluation team. Districts colored purple are the 
other districts in the Capacity Project. 
End-of-Project Evaluation of the Capacity Project | 50 
Appendix 2: Capacity Project District Intervention Matrix, 2009
This matrix shows the activities implemented by the Capacity Project and the districts covered. 
However, the Workplace Safety training was done in all the 80 districts in Uganda. 
CAPACITY PROJECT DISTRICT INTERVENTION MATRIX 2009
DISTRICT HRIS
ACTION 
PLAN PI PM
RECRUIT
MENT
PAYROLL 
MGT
WORK 
PLACE 
SAFETY
VHT 
DEVELOP
MENT
Gulu * * * * 
Amuru * * * * * 
Kitgum * * * * 
Pader * * * * 
Lira * * * * * * 
Apac * * * * 
Dokolo * * * * * 
Amolatar * * * * * * * 
Oyam * * * * * * * 
Kabarole * * * * * * * * 
Hoima * * 
Kamwenge * * * 
Bulisa * * 
KEY 
HRIS Human Resources Information System 
 PI Performance Improvement 
PM Performance Management 
VHT Village Health Team 
 MGT Management 
End-of-Project Evaluation of the Capacity Project | 51 
Appendix 3: Evaluation Itinerary
Period of Evaluation 
The end-of-project evaluation for Capacity Project was done from 1 February to 10 March 2010. 
 
Details of Activity (including field travel work plan) 
Days and Dates Team Activity
Wednesday 9 Feb Whole team Travel to North 
Thursday to Saturday 10-13 
Feb 
Whole team Interviews in Lira 
Monday to Tuesday 
15-16 Feb 
Group 1 
Group 2 
Interviews in Amolatar District 
Interviews in Apac District 
Tuesday 
15 Feb 
Group 1 Interviews with NUMAT and Gulu School of 
Clinical Officer 
Wednesday 
16 Feb 
Group 1 Return to Kampala 
Wednesday to Thursday 
16-17 Feb 
Group 2 Interviews in Oyam District 
Thursday to Friday 
18-19 Feb 
Group 1 Interviews in Kampala 
Friday 19 Feb Return to Kampala 
Monday to Friday 
22-26 Feb 
Group 1 Interviews in Kampala 
Monday to Thursday 
22-25 Feb 
Group 2 Interviews in Kabarole and Kamwenge 
Friday Group 2 Return to Kampala 
Monday to Friday 
1-6 March 
Whole Team Interviews in Kampala 
Report writing/analysis of draft report 
Debrief to USAID Mission 
Monday to Wednesday 
 8-10 March 
Report writing Debrief to USAID Mission 
Submit Final Draft Report to USAID UMEMS 
End of Evaluation 
 
 
 
End-of-Project Evaluation of the Capacity Project | 52 
Appendix 4: Documents Reviewed
Capacity Project Documents
1. Request for applications (RFA) Number M/OP/GH/POP-04-961 Human Capacity 
Development Project, April-May 2004 
2. Original Proposal for Human Capacity Development Project (HCDP) Number GPO-A￾00-04-00026-00, September 2004 
3. USAID/Uganda UMEMS Technical Proposal for the Evaluation of the Capacity Project: 
Volume 1, January 2010 
4. Scope of Work for End-of-Project Evaluation of the Capacity Project (CP), Dec 7, 2009 
5. UMEMS Evaluation, Special Studies and New Activity Design Protocol, June 2009 
6. Capacity Project Monitoring and Plan, September 2005 
7. Evaluation of the Capacity Project: Assessing Progress on HRH Issues, August 2008 
8. Annexes: Evaluation of the Capacity Project: Assessing Progress on HRH Issues, August 
2008 
9. Human Resource for Health Bi-Annual Report, April 2009 
10. Human Resource for Health Bi-Annual Report, September 2009 
11. Ministry of Health Sector Strategic Plan II, 2005/06 – 2009/2010, Volume 1 
12. Capacity Project Quarterly Report, July – September 2009 
13. Capacity Project Quarterly Report, April – June 2009 
14. Capacity Project Quarterly Report, January – March 2009 
15. Capacity Project Quarterly Report, April – June 2008 
16. Capacity Project Quarterly Report, January – March 2008 
17. Capacity Project Quarterly Report, October – December 2007 
18. Capacity Project Quarterly Report, June 2007 
19. Capacity Project Annual Report, October 2006 – September 2007 
20. Revised Final Draft Capacity Project Work Plan, 2007 – 2008 
21. Final Draft Capacity Project Work Plan, 2008 – 2009 
22. Capacity Project Annual Report, October 2007 – September 2009 
23. Payroll Management Manual for the Traditional Public Service 
24. Strengthening Health Workforce Systems in Uganda; Review Report December 2009 
25. Uganda Human Resource for Health Strategic Plan 2005 – 2020: Responding to Health 
Sector Strategic Plan and Operationalising the HRH Policy, June 2007 
26. Uganda Health Workforce Retention Study: Satisfaction and Intent to Stay Among 
Current Health Workers, Ministry of Health, 2006 
27. Uganda Health Workforce: Satisfaction and Intent to Stay Among Current Health 
Workers, April 2009 
28. Competency Gaps in Human Resource Management in the Health Sector: An 
Exploratory Study of Ethiopia, Kenya, Tanzania, and Uganda. Prepared by the African 
Medical and Research Foundation (AMREF) and Management Sciences for Health 
(MSH), July 2009 
29. Uganda Health Workforce Turnover Study, December 2008 
30. Standards for Accreditation of Continuing Professional Development for Health Workers 
End-of-Project Evaluation of the Capacity Project | 53 
31. Strengthening the Uganda National Association of Nurses and Midwives (UNANM) 
Communication Capacity, February – June 2007 
32. Policy for Mainstreaming Occupational Health and Safety the Health Services Sector, 
February 2008 
33. Mapping the Human Resources Management Processes in Uganda, March 2008 
34. Health Workforce Action Framework: Integrative Analysis Reports, June 2008 
35. The Payroll Management Manual for the Traditional Public Service, December 2008 
36. Guidelines for Occupational Safety and Health: Including HIV in the Health Sector 
Services, February 2008 
37. Motivation and Retention Strategy for Human Resources for Health, October 2008 
38. Professional Code of Conduct and Ethics for Pharmacists in Uganda, September 2009 
39. Professional Code of Conduct and Ethics for Nurses and Midwives, September 2009 
40. Code of Conduct and Ethics for Allied Health Professionals, September 2009 
41. Human Resources for Health Audit Report, May 2009 
42. Leadership and Management Development, February 2009 
43. Ministry of Health. Quality of Care Improvements Tools for MCH/HIV Services, 
October 2006 
44. The Human Resources for Health Strategic Plan 2005 – 2020, A Health Workforce Crisis 
in Uganda: Time for Real Action – Supplement, 2009 
45. Annual Health Sector Reform Report, Financial Year 2009/2010 
46. An Overview of the Human Resource for Health Audit Report for 2008, Ministry of 
Public Service 
47. Performance Improvement for Health Management Systems of the Uganda Protestants 
Medical Bureau, July 2009 
48. Implementation of Performance Support Approaches in Central America and Uganda 
49. Assessment of Capacity for Provision of PMTCT and Family Planning Services in 
Kabarole District Report, March 2008 
50. Assessment Report on Action Points on Capacity to Implement PMTCT and Family 
Planning in Kabarole District, June 2008 
51. Dissemination Workshop Report on HRH Assessment Report and follow-up visit in nine 
Districts in Northern Uganda (Acholi and Lango Sub Regions), 2008 
52. Capacity Project Team-Building Retreat Report. Jinja Resort Hotel, 11-12 September 
2008 
53. Study of Nurses’ and Midwives’ Perception of the Roles and Functions of the Uganda 
National Association of Nurses and Midwives, 2008 
54. Report on the Performance Improvement Assessment, Kabarole District, April 2009 
55. Assessment Report and Action Points on Capacity to Implement PMTCT and Family 
Planning in Kabarole District, June 2008 
56. Assessment of Capacity for Provision of PMTCT and Family Planning Services in 
Kabarole District, March 2008 
57. Kioga Health Sub Draft Work Plan 2009 and 2010 (Revised) 
58. Amolatar Health District Development Plan 2009/10 to 2010/2011 (Revised) 
59. Performance Improvement Assessment Report for Dokolo District Carried Out in January 
2009. Report of Performance Improvement Assessment in Gulu District 
60. Project No. IAEHAR/2006/02 Support to Human Resource for Health (HRH) 
Component: 30 Percent Top-Up Final Report to DFID, 2007 
End-of-Project Evaluation of the Capacity Project | 54 
61. Oyam District Health Sector Integrated Annual Work Plan, Financial Year, 2009/10 
62. HMIS Report 2008/2009, Oyam District 
63. Erute North Health Sub-District: Ogur Health Center IV Annual Work Plan for Financial 
Year 2009/2010. 
64. Kamwenge District Health Annual Development Plan, 2009/2010 
65. Capacity Project Knowledge Sharing: The Impact of Human Resources Information 
Systems (HRIS) Strengthening. Daniel H. de Vries, Dykki Settle and Pamela A. 
McQuide, IntraHealth International, September 2009
66. Capacity Project Knowledge Sharing: Task Shifting—Field Officers in Uganda, April 
2007 
67. Supporting Health Worker Performance with Effective Supervision. Bruno M. 
Benavides, Jhpiego, September 2009
68. Strengthening Professional Associations for Health Workers. Nancy Yinger and Pamela 
A. McQuide, IntraHealth International, September 2009 
69. Health Workforce: “Innovative Approaches and Promising Practices” Study: 
Incorporating Lay Human Resources to Increase Accessibility to Antiretroviral Therapy: 
A Home- Based Approach in Uganda, July 2006 
70. The President’s Emergency Plan for AIDS Relief: Next Generation Indicators Reference 
Guide, August 2009 
71. Evaluation of the Capacity Project’s Human Resources Information Systems (HRIS) 
Strengthening Process in Swaziland, Uganda, and Rwanda, July 2009 
72. Global Health Workforce Alliance: Working Group on Tools and Guidelines
73. Capacity Project Knowledge Sharing: From Nightmare to Awakening—Performance 
Improvement for Health Management in Uganda 
74. Planning, Developing, and Supporting the Health Workforce: Results and Lessons 
Learned from the Capacity Project, 2004-2009 
75. Capacity Project Knowledge Sharing: The Capacity Project in Uganda, November 2008 
76. Capacity Project Knowledge Sharing: Building HR Information Systems—Leading the 
Way Together in Uganda, February 2007 
77. Capacity Project Knowledge Sharing: A National Impact—Local Ownership of Health 
Workforce Initiatives in Uganda, November 2008 
78. Performance Improvement Toolkit. IntraHealth/PRIME II Project (implemented in 
partnership with in collaboration with partners Abt Associates, EngenderHealth, Program 
for Appropriate Technology in Health and Training Resources Group, and supporting 
institutions, the American College of Nurse-Midwives and Save the Children. 
http://www.intrahealth.org/sst/intro.html (Accessed 22 February, 2010) 
79. Capacity Project Knowledge Sharing: Sharing Knowledge—From Nightmare to 
Awakening Performance Improvement in Health Management in Uganda, April 2009 
80. Capacity Project Knowledge Sharing: Supporting Health Workers Performance with 
Effective Supervision, September 2009 
81. Capacity Project Knowledge Sharing: Knowledge Management and Human Resources 
for Health Using Quality Information to Make Better Decisions, September 2009. 
82. Uganda Health Systems Strengthening Project Concept Paper Prepared for World Bank 
Funding, August 2009 
83. The Uganda In-Service Training Strategy – 2000 
End-of-Project Evaluation of the Capacity Project | 55 
84. A Review of the In-Service Training Strategy of the Ministry of Health Uganda, 
September 2007
85. Health Sector Strategic Plan III 2010/11-2014/15 
End-of-Project Evaluation of the Capacity Project | 56 
Appendix 5: List of Key Persons Interviewed at the 
National and District Levels
Serial 
No.
Name Title Contact
Ministry of Health and other institutions in Kampala 
1 Dr. Ndiku John Medical and Dental Practitioners Council 
2 Dr. Juliet Bataringaya 
Wavamunno 
National Professional Officer, Health 
Systems Development – WHO Uganda 
3 Ruth Nabaggala UPMB Monitoring & Evaluation Officer 0414271776/0772415
886 
4 Isaac Kagimu UCMB HRH Technical Advisor 
5 Dr. George Bagambisa, Asst. Commissioner, HRD – MOH 
6 Okello Patrick OIC Payroll Management in the Ministry 
of Public Service 
7 Kamya Mugalu Assistant Commissioner HRM, Ministry 
of Public Service 
8 Charles Isabirye Senior Health Training Officer, HRD 
Division 
9 Dr. Michael Igune Director HMDC Mbale 0772565494 
10 George Pariyo School of Public Health, Makerere 
University 
11 Dr. Joshua Kiwanuka Uganda Medical Practioners Board 0772418281
12 Dr. Luc Geysels Belgian Technical Corporation 0414230543 
13 Rose Kato Belgian Technical Corporation 
Uganda Nurses and Midwives Council (UNMC)
14 Janet Obuni President 0712845181 
15 Patrick Baleganya General Secretary 
14 Juliet Ezaga Senior Nursing Officer, OIC Training 0772452604 
15 Eunice Tushemereirwe Data Manager/Records Officer 0772513194 
16 Rebbeca Kwemogera Senior Records Assistant 0772928547 
17 Joyce Muwanga Senior Nursing Officer, OIC 
Administration 
0772369888 
World Bank
18 Dr. Peter Okwero World Bank 
Danish Embassy
19 Peter Ogwang Danish Embassy 
Swedish International Development Agency (SIDA)
20 Ulrika Hertel SIDA OIC Health System 0772707103 
Amolatar District
21 Dr. Quinto Okello District Health Officer (DHO ) 
22 Harriet Miriam Atim Senior Nursing Officer (SNO) 
End-of-Project Evaluation of the Capacity Project | 57 
23 Ambrose Ocen Acting Secretary to the District Service 
Commission/Town Clerk at Amolatar 
Town Council 
24 Sharon Atimango Enrolled Nurse 
25 Henry Oddi Health Assistant, Aputi Health Centre III 
26 Ogwal Alex Principal Health Inspector/HIV/AIDS 
focal person 
0772676408 
0392887985 
Apac District
27 Dr. Emer Mathew District Health Officer 
28 Sabiti Mbabazi Atenyi District Health Inspector, Environment 
29 Opio A. 
Peter.Chrisostom. 
Principal Dispenser, Apac Hospital; also 
Chairperson Apac District Medical 
Workers’ Union 
30 Sr. Anne Grace Auma In-Charge Pediatric Ward (and Member, 
Infection Control Committee), Apac 
Hospital 
31 Sr. Consolata Akulu Assistant DHO 
32 Francis Odap Principal Personnel Officer 
33 Dr Semugenyi OIC Aduku HCIV 
Kabarole District
34 Dr. Richard Mugahi OIC Rukuunyu HCIV 
35 Tonny Mugisa OIC Ruteete HCIII 
36 Fulgensio Ntegyereize Acting DHO/Assistant District Health 
Officer, Environment 
0775401191 
37 Rita Ahaisibwe Records Officer 0782902562 
38 Kamuhanda Gideon Senior Personnel Officer 
39 Mpuuga Hosea District Health Educator 0772654376 
mpuugahosea@yahoo.co.uk
40 Maanimake Elizabeth Senior Nursing Officer 0772665338 
bethmake@yahoo.com
41 Baguma Joseph Acting DHDI 0772563907 
bagwojoseph@gmail.com
42 Tumwebaze Mathias DHT Member 0772916618 
mathias@yahoo.com
Kamwenge District
43 Magezi Kisembo Acting OIC Ntara HCIV 
44 Katembo Mwesigwa Acting OIC Rukunyu HCIV 
45 Kabatoro Pussy Nursing Assistant Bigodi HCIII 
46 Habassa Elia Nursing Assistant Bigodi HCIII 
47 Katirimo Gad HMIS 
48 Ssozi Chris G. Secretary, District Service Commission 
49 Mpaka A. John Principal Health Inspector 
50 Boaz Katuramu Principal Personnel Officer 0772662466 
Lira District
51 Bernard Ogwang Principal Personnel Officer/Secretary 
District Service Commission 
End-of-Project Evaluation of the Capacity Project | 58 
52 Lillian Eyal District Principal Personnel Officer 0772663258 
53 Henry Omoo HMIS Statistician 
54 Okao Ben District HIV Focal Person/TB and 
Leprosy Supervisor 
55 Ojok Milton Personnel Officer 
56 Dr. Tom Odongo OIC Ogul HCIV 
57 Thomas Bell Akaki Senior Health Educator 
58 (Name not given) Enrolled Midwife from Olilim HCIII 
59 John Nelson Opio Assistant DHO, Environmental Health 
60 Paul Omoko Town Clerk, Lira Municipality 
61 Dr. Peter Kusolo District Health Officer (DHO) 
62 Leo Okol Medical Records Assistant 
63 Fred Ogwang Medical Workers Union, Lira District 
Branch 
0772398613 
64 Sr. Christine Atyam Senior Nursing Officer/Acting Deputy 
RH 
Oyam District
65 Acan Margaret 
Ogomarach 
Senior Nursing Officer, DHO’s Office 
66 Francis Leone Ocheng DHI (also focal person for performance 
improvement) 
67 Orech John Bosco Senior Health Educator 0772831744 
68 Michael Mulindwa Principal Personnel Officer 
69 Sarah Awor Biostatistician 0702227668/0774470
761 
70 Richard Atepo Assistant Health Educator 0772951367 
Other Districts
71 Dr. Samuel Ojok District Health Officer, Dokolo District 
72 Kiboko Olobo James Principal Head, Gulu School of Clinical 
Officers 
0782440375 
kikek2james@yahoo.com
73 Martin Onek Ocaya Deputy Principal, Gulu School of 
Clinical Officers 
0772594290 
martin.onek@gmail.com
74 James Otim Deputy Chief of Party, NUMAT 
75 William Oloya Program Officer, NUMAT 
Capacity Program (Former Capacity Project)
76 Dr. Vincent Okectho COP Capacity Program 
77 Fred Kakaire Chief Executive Officer, Uganda Chartered 
Healthnet – Makerere University College of 
Health Sciences 
78 Ernest Mwebaze Former Employee – Healthnet Uganda 
End-of-Project Evaluation of the Capacity Project | 59 
Appendix 6: Guidelines for In-Depth Interviews
6A: General Key Informant Interview Guide for National-Level 
Issues for discussion 
1. The strategic focus of the Capacity Project (CP); how it fits with the priorities for 
Uganda 
Please describe/explain to me your understanding of the Capacity Project and its intentions 
Use prompts where necessary: its goal and objectives; the key elements in its design; the results 
it intends to achieve at different levels; any differences in its intentions at global, country, and 
sub-national levels.
How do the intentions of CP fit with/contribute to the priorities for Uganda? 
Prompts: in health service development and support, in HRH development, in USAID support 
objectives. 
2. The specific value that CP adds to health and development in Uganda 
What do you consider to be the main ‘value addition’ from CP to health and development in 
Uganda? 
Prompts: value from the project design and outputs; value with respect to HRH development in 
Uganda; value with regard to health service delivery (Especially in AIDS, RH) value with 
respect to an integrated approach to health service planning and development.
3. Gaps, weaknesses in CP design, implementation 
What gaps or weaknesses (if any) do you see in the design and implementation of CP in Uganda? 
Prompts: aspects of HRH that CP did not recognize/address; priority health problems and 
interventions that the project did not recognize/support; important stakeholders in HRH that CP 
did not recognize/include as necessary. 
4. Specific CP activities implemented in each organization
What activities did the CP undertake in relationship to your HRD responsibilities? 
Was the activity well or not well implemented? Explain? 
What hindered or facilitated the activity? 
Was the CP approach used appropriate? Suggestions to improve it? 
When was last CP support given in relation to this activity? 
Is this activity being maintained now? Why/why not? 
Where any activities that you know about planned but not implemented? Why? 
5. Key lessons, good practice experiences from CP 
Please give examples of key lessons or good practice experiences (if any) you know about from 
CP implementation in Uganda. 
Prompts: aspects of the project that performed particularly well; what other countries have 
come to learn from in CP implementation. 
End-of-Project Evaluation of the Capacity Project | 60 
6. Suggestions for future HRH support/work 
Please make suggestions on what you consider to be important things for the new Capacity 
Project in Uganda to focus on and address. 
Prompts: what design modifications to do from CP I; changes in the implementation approaches 
and processes; changes in focus at national level, changes in focus at district level; changes in 
sector inclusion and involvement. 
End-of-Project Evaluation of the Capacity Project | 61 
6A1: Key Informant Interview Guide for National-Level—Respondent 
Category 1: Strategic Leaders (MOH, CP-COP, and USAID) 
Introduction: Introduce yourself to the respondent, and mention the focus of this evaluation is: 
• Our understanding of Capacity Project in Uganda – part of the global whole (active in 48 
countries); a three-fold focus (plan, develop, support HRH) 
• This evaluation – commissioned by USAID/Uganda, to focus on CP results and lessons from 
the Uganda work, to inform priorities and methods in a new Capacity Program started in 
October 2009 
• Evaluation approach – both strategic and operational, cover national and district-level work, 
use qualitative methods (Documents Review, Key Informant Interviews) 
Issues for discussion 
1. The strategic focus of CP; how it fits with the priorities for Uganda 
Please describe/explain to me your understanding of the Capacity Project and its intentions 
Use prompts where necessary: its goal and objectives; the key elements in its design, the results 
it intends to achieve at different levels; any differences in its intentions at global, country, and 
sub-national levels
How do the intentions of CP fit with/contribute to the priorities for Uganda? 
Prompts: in health service development and support, in HRH development, in USAID support 
objectives, etc. 
2. The specific value that CP adds to health and development in Uganda 
What do you consider to be the main ‘value addition’ from CP to health and development in 
Uganda? 
Prompts: value from the project design and outputs; value with respect to HRH development in 
Uganda; value with regard to health service delivery (in AIDS, RH, etc.) value with respect to an 
integrated approach to health service planning and development, etc.
What are some of the specific examples of CP interventions and their specific outputs that you 
are personally familiar with? 
Prompts: activities that you personally participated in/witnessed; activities that have achieved 
results most relevant to your work, activities that you consider to have made most difference, etc. 
Give details on amounts of output, what show that it was effective, efficient; is it a sustainable 
result; etc.
 
3. Gaps, weaknesses in CP design, implementation 
What gaps or weaknesses (if any) do you see in the design and implementation of CP in Uganda? 
Prompts: aspects of HRH that CP did not recognize/address; priority health problems and 
interventions that the project did not recognize/support; important stakeholders in HRH that CP 
did not recognize/include as necessary, etc. 
4. Key lessons, good practice experiences from CP 
Please give examples of key lessons or good practice experiences (if any) you know about from 
CP implementation in Uganda. 
Prompts: aspects of the project that performed particularly well; what other countries have 
come to learn from in CP implementation, etc. 
End-of-Project Evaluation of the Capacity Project | 62 
5. Suggestions for future HRH support/work 
Please make suggestions on what you consider to be important things for the new Capacity 
Program in Uganda to focus on and address. 
Prompts: what design modifications to do from CP I; changes in the implementation approaches 
and processes; action research priorities in HRH; changes in focus at the national level; 
changes in focus at district level; changes in sector inclusion and involvement, etc. 
End-of-Project Evaluation of the Capacity Project | 63 
6A2: Issues for Discussion with Other National-Level Strategic Leaders 
These issues will be discussed with leaders in other agencies and institutions with interest in 
health systems strengthening (HSS) and human resources for health development (HRHD). 
Examples of agencies and institutions to target include development partners (World Bank, EU, 
DFID, DANIDA, Irish Aid, WHO etc.); Academic/Research Institutions (Makerere University￾College of Health Sciences/School of Public Health, Mbarara University of Science and 
Technology, Gulu University Medical School, Uganda Christian University-Department of 
Health Sciences, Uganda Martyrs University – Faculty of Health Sciences, etc.) and Project 
Management Offices for specific HSS and HRHD Projects. 
1. The priorities in HRH and HSS in Uganda 
Please describe/explain to me your understanding of the priority issues for HRHD and HSS for 
Uganda 
Use prompts where necessary: what the main challenges are, what is currently addressed in 
health sector strategies, what is addressed by the agency/institution you work for 
2. The specific HRH and HSS interventions of the agency/institution you work for 
What HRH and/or HSS interventions has your agency supported or implemented over the recent 
past? 
Prompts: projects supported research studies undertaken, training courses sponsored/supported, 
etc. Ask for documents that may provide details on such interventions 
What HRH/HSS interventions are included in the current and near future plans of you 
agency/institution? 
Prompts: Ask for documents that may provide details on such interventions 
3. Gaps, weaknesses and challenges in HRH and HSS in Uganda 
What gaps, weaknesses or challenges (if any) do you see in the design and implementation of 
HRHD and/or HSS interventions in Uganda? 
Prompts: aspects of HRHD/HSS that are not adequately recognized/addressed; factors that 
make HRHD/HSS interventions ineffective, inefficient, unsustainable, etc. 
4. Key lessons, good practice experiences from HRHD/HSS Interventions 
Please give examples of key lessons or good practice experiences (if any) you know about in 
HRHD and HSS interventions that could be of value for Uganda. 
Prompts: examples from Uganda and other developing countries; examples from developed 
countries; aspects from such experiences that need to be modified for application in Uganda, etc. 
5. Suggestions for future HRHD and HSS support/work in Uganda 
Please make suggestions on what you consider to be important considerations for HRHD and 
HSS interventions in Uganda. 
Prompts: what priority interventions to focus on for national, district, and community levels; 
what priority action research topics to focus on in HRHD and HSS; the key sectors that need to 
be involved and their respective roles (government, FBOs, NGOs, private sector, etc.); the 
potential sources of funding for such interventions, etc. 
End-of-Project Evaluation of the Capacity Project | 64 
6A3: Key Informant Interview Guide for National-Level - Respondent 
Category 2: Operational Leaders (MOH, CP-Country Office, NUMAT, 
MOPS, MOGLSD, MOFPEP, MOES, UPMB, UCMB, UNANM, etc.) 
Introduction: Introduce yourself to the respondent, and mention the focus of this evaluation is: 
• Our understanding of Capacity Project in Uganda – part of the global whole (active in 48 
countries); a three-fold focus (plan, develop, support HRH) 
• This evaluation – commissioned by USAID Uganda, to focus on CP results and lessons from 
the Uganda work, to inform priorities and methods in a new Capacity Program started in 
October 2009 
• Evaluation approach – both strategic and operational, cover national and district-level work, 
use qualitative methods (Documents Review, Key Informant Interviews) 
Issues for discussion 
1. Project design/intentions 
Please describe/explain to me your understanding of the Capacity Project and its design 
intentions. 
Use prompts where necessary: its goal and objectives; the key elements in its design and how 
they fit together (the model), the results it intends to achieve at different levels; any differences in 
its intentions at global, country, and sub-national levels 
2. The CP implementation process (as you know it; as you experienced it; as 
specific/relevant to your work) 
Please describe/explain to me the different activities that CP supported in your 
organization/agency/ institution/department/office. 
Prompts: Ask the respondent to provide all relevant details (including copies of plans, reports, 
etc., that can help us appreciate all the contribution made by CP. Ask for sample products from 
information systems developed by CP. 
What was your main role in implementation of the project? Who else in your department/section 
participated in implementation, monitoring, review, supervision, etc.? 
Would you say that the activity was well or not well implemented? Explain? 
Prompts: What hindered or facilitated the activity; were the approaches used in CP appropriate; 
was the activity implemented to completion (if not, why); etc. 
3. Trickle-down and scale-up 
Our understanding is that CP support in Uganda’s decentralized context also included the 
intention to “trickle down” HRH planning, development, and support to the district and lower 
levels. What is your experience and opinion about the progress in this aspect of CP work? 
Prompts: How have the district and lower levels participated in and/or benefited from the CP 
supported activities and outputs; which districts and other lower levels have 
participated/benefited most and why; what plans were made/implemented for taking such 
participation/benefit to other settings; what scale-up/trickle-down opportunities are present in 
the country but were not fully used in CP? 
 
End-of-Project Evaluation of the Capacity Project | 65 
4. Gaps, weaknesses in CP design, implementation 
What gaps or weaknesses (if any; as relevant to your work) do you see in the design and 
implementation of CP in Uganda? 
Prompts: aspects of HRH that CP did not recognize/address; priority health problems and 
interventions that the project did not recognize/support; important stakeholders in HRH that CP 
did not recognize/include as necessary, etc. 
5. Key lessons, good practice experiences from CP 
Please give examples of key lessons or good practice experiences (if any) you know about from 
CP support/implementation in your work, and in other settings in Uganda. 
Prompts: aspects of the project that performed particularly well; what has been documented and 
disseminated as a good practice example; what other countries have come to learn from in CP 
implementation in Uganda, etc. 
Are there any results from the CP (positive or negative) that were not anticipated or planned for? 
6. Suggestions for future HRH support/work 
Please make suggestions on what you consider to be important things for the new Capacity 
Program in Uganda to focus on and address. 
Prompts: what design modifications to do from CP I; changes in the implementation approaches 
and processes; changes in focus at national level, changes in focus at district level; changes in 
sector inclusion and involvement, etc. 
Approaches for adaptation of the discussions for different categories of respondents 
All or most of the above issues will be relevant for respondents in the MOH. Respondents in 
other government or non-government settings may have had more targeted involvement in CP. In 
such cases, the approach will be to understand and focus on the relevant areas of experience, 
rather than go through the whole set of questions and prompts. The issues of focus for each 
category, as presented in Table 1 below, will be useful reference in deciding the approach to 
focused discussions. 
End-of-Project Evaluation of the Capacity Project | 66 
Table 1: Categories and key elements of interest for national level KI 
Category Approximate number of KI Key issues to discuss 
Project Lead Team 
In-country 
Global Office 
2-4 Country Team 
2-3 Global Team 
All elements in project 
Strategic issues (as for MOH leaders) 
Operational details (as for MOH Op. Team) 
Cost-effectiveness 
USAID Uganda 
Country Office 
Supported Projects (NUMAT, 
UHMG, JCRC/TREAT, etc.) 
2-4 People 
2 People in each project 
All elements in project – Strategic level 
Operational details (as for MOH Op. Team) 
Other development Partners 
European Union; DFID; DANIDA; 
Irish Aid; WHO; World Bank 
1 or 2 people each General elements on HRH and HSS in Uganda 
A: MOH Leaders: 
1. Director General; Commissioner 
Planning; 
2. Assistant Commissioners: 
(Human Resource Dev., HMIS￾Resource Centre’ Human Resource 
Dev.) 
B: Health Services Commission 
Chairman; Secretary; Commissioners 
C: Health Workforce Advisory Board 
D: Health Resources Working Group 
5 People (1 person each office) Strategic level; all 3 Intermediate Results 
The strategic focus of CP; how it fits with national 
priorities 
Value addition from CP – in design, in outputs (Generic 
to HRH, specific to programs of focus – AIDS/RH, in 
integrated health service delivery) 
Gaps, weaknesses in CP design, implementation 
Un-met HRH needs, priorities 
Suggestions for future HRH support/work 
MOH Operational Teams 
1. Resource Centre; HRD; HRM; 
ACP 
2. Professional Councils (4) 
3. HMDC 
12 people (1 person each 
Council; 2 people each unit) 
Operational details 
Project design/intentions 
Implementation – milestones, achievements, good 
practices, why 
Gaps, weaknesses in implementation; and reasons why 
Trickle down intentions and experiences (to districts; to 
program/ service delivery level) 
Scale up opportunities, possibilities, plans 
Lessons learnt from implementation process 
Other government ministries 
MOPS; MOFEP; MOES; MOGLSD 
5 people (2 MOPS; 1 each for all 
others) 
Linkage issues 
Capacity Project and its connections to the ministry 
(results achieved, good practices, lessons learned; gaps, 
issues not addressed 
Other HRH issues of relevance to the ministry 
Suggestions for future HRH development 
Other stakeholders 
1. FBO Medical Bureaux 
UPMB; UCMB 
2. Health Prof. Associations 
UNANM; UMA 
3. Private Practice Associations 
UPMA; Uganda Private Doctors 
Assoc. 
4. Universities 
MU-CHS (Principal); MUST (VC); 
Gulu Univ (VC); UCU (Head; Health 
Sciences); UMU (Head; Health 
Sciences) 
5 people (2 each for UPMB and 
UNANM; 1 UCMB) 
 
Participation, impact issues 
Capacity project and the opportunities it represented for 
you 
Experiences of connection and benefit from CP 
Un-met expectations from CP, areas of HRH need in 
your work 
Suggestions for future HRH improvement – in your 
work; nationally 
End-of-Project Evaluation of the Capacity Project | 67 
6B1: General Question Guide for Key Informants at the District Level (DHO 
& other DHT Members) 
 
1. What activities were implemented in this district under the Capacity Project? 
2. What are the major changes in how you do things here as a result of the project? 
3. Tell us more about each of the activities that were implemented: What did each entail (tackle 
them one by one)? Typical activities include: 
a. The HRIS computerized system at the district level 
b. Supporting the health department to identify its HR needs and gaps 
c. Supporting the health department to formulate annual HR action plans 
d. Supporting the district to integrate health HR action plans into district plans 
e. Training and support in performance improvement 
f. Improving supportive supervision of health workers in the district 
g. Supporting the district to recruit health staff 
h. Support in orienting recruited staff 
i. Training in payroll management 
j. Supporting VHT training, supervision, and facilitation 
k. Dissemination of workplace safety guidelines 
l. Training of health workers in workplace safety and health 
m. Support to form occupational and safety committees 
Probes 
1. Did this activity take place in this district? 
2. Was the activity well or not well implemented? Explain? 
3. What hindered or facilitated the activity? 
4. Was the CP approach used appropriate? Suggestions to improve it? 
5. When was last CP support given in relation to this activity? 
6. Is this activity being maintained now? Why/why not? 
7. Where any activities that you know about planned but not implemented? Why? 
4. In total about how many members of staff in your district benefited from the 
trainings/technical assistance provided by the project? 
5. To what extent would you say the project support contributed to better delivery of HIV/AIDS 
and family planning/reproductive health services in the district? Any concrete examples of 
this contribution? 
6. Overall, would you say the project was a success? What are your reasons for this assessment? 
7. What are the remaining problems/gaps in human capacity that the project did not address? 
8. If the project were to continue, what changes would you like to see in the 
design/implementation? 
9. Which of the activities implemented here do you think can be/should be rolled out to other 
districts? 
The remaining questions are general questions not directly related to the CP project. 
10. Tell us about the processes you use to develop local action and work plans? 
11. What role do staff members have in developing these plans? 
12. What processes do you have to solve work-related problems in your organization? 
13. What do you do to encourage participation of staff and community representatives in local 
planning and decision making? 
End-of-Project Evaluation of the Capacity Project | 68 
6B2: Question Guide for Key Informants at the District Level (Personnel 
Officer and the Chair/Secretary of District Service Commission) 
 
1. What activities implemented in this district under the Capacity Project were you involved in? 
2. How were you involved? 
3. What are the major changes in how you do things here as a result of the project? 
4. Tell us more about each of the activities that you were involved in: What did each entail 
(tackle them one by one)? Typical activities include: 
a. The HRIS computerized system at district level 
b. Supporting the health department to identify its HR needs and gaps 
c. Supporting the health department to formulate annual HR action plans 
d. Supporting the district to integrate health HR action plans into district plans 
e. Supporting the district to recruit health staff 
f. Support in orienting recruited staff 
g. Training in payroll management 
Probes 
1. Did this activity take place in this district? 
2. Was the activity well or not well implemented? Explain? 
3. What hindered or facilitated the activity? 
4. Was the CP approach used appropriate? Suggestions to improve it? 
5. When was last CP support given in relation to this activity? 
6. Is this activity being maintained now? Why/why not? 
7. Where any activities that you know about planned but not implemented? Why? 
5. What is your overall assessment of the activities that the project supported in which you were 
involved? 
Probe: Would you say the project helped you to improve your work? Did the project 
activities help to improve the HR management practices?) 
What are your reasons for this assessment? 
6. What are the remaining problems/gaps in human capacity that the project did not address? 
7. If the project were to continue, what changes would you like to see in the 
design/implementation? 
8. Which of the activities implemented here do you think can be/should be rolled out to other 
districts? 
9. What other actors (donors, projects, NGOs, etc) have been involved in supporting district 
HRD activities? 
10. What have these actors done? What activities have they supported? 
11. Comment on what they did; what was good? What did not go well? 
12. Did they support any similar activities as the Capacity Project? Which ones? 
End-of-Project Evaluation of the Capacity Project | 69 
6B3: Question Guide for Key Informants at the District Level (Hospitals) 
 
1. What activities implemented under the Capacity Project was your organization (hospital) 
involved in? 
2. How were you involved? 
3. What are the major changes in how you do things here as a result of the project? 
4. Tell us more about each of the activities that were implemented: What did each entail (tackle 
them one by one)? Typical activities include: 
a. The HRIS computerized system at district level 
b. Supporting the health department to identify its HR needs and gaps 
c. Supporting the health department to formulate annual HR action plans 
d. Supporting the district to integrate health HR action plans into district plans 
e. Training and support in performance improvement 
f. Improving supportive supervision of health workers in the district 
g. Supporting the district to recruit health staff 
h. Support in orienting recruited staff 
i. Training in payroll management 
j. Supporting VHT training, supervision, and facilitation 
k. Dissemination of workplace safety guidelines 
l. Training of health workers in workplace safety and health 
m. Support to form occupational and safety committees 
Probes 
1. Did this activity take place in this district? 
2. Was the activity well or not well implemented? Explain? 
3. What hindered or facilitated the activity? 
4. Was the CP approach used appropriate? Suggestions to improve it? 
5. When was last CP support given in relation to this activity? 
6. Is this activity being maintained now? Why/why not? 
7. Where any activities that you know about planned but not implemented? Why? 
5. In total about how many members of staff in your organization benefited from the 
trainings/technical assistance provided by the project? 
6. To what extent would you say the project support contributed to better delivery of HIV/AIDS 
and family planning/reproductive health services by this organization? Any concrete 
examples of this contribution? 
7. Overall, would you say the project was a success? What are your reasons for this assessment? 
8. What are the remaining problems/gaps in human capacity that the project did not address? 
9. If the project were to continue, what changes would you like to see in the 
design/implementation? 
10. Which of the activities implemented here do you think can be/should be rolled out to other 
similar organizations? 
The remaining questions are general questions not directly related to the CP project. 
11. What processes do you have to solve work-related problems in your organization? 
12. What do you do to encourage participation of staff and community representatives in local 
planning and decision making? 
13. What other actors (donors, projects, NGOs, etc) have been involved in HRD activities in 
your organization? 
End-of-Project Evaluation of the Capacity Project | 70 
14. What have these actors done? What activities have they supported? 
15. Comment on what they did; what was good? What did not go well? 
16. Did they support any similar activities as the Capacity Project? Which ones? 
End-of-Project Evaluation of the Capacity Project | 71 
6B4: General Question Guide for Key Informants at the District Level (HMIS 
Focal Person) 
 
1. What activities were implemented in this district under the Capacity Project? 
2. What are the major changes in how you do things here as a result of the project? 
3. Tell us more about each of the activities that were implemented: What did each entail 
(tackle them one by one)? Typical activities include: 
a. The HRIS computerized system at district level 
b. Supporting the health department to identify its HR needs and gaps 
c. Supporting the health department to formulate annual HR action plans 
d. Supporting the district to integrate health HR action plans into district plans 
e. Training and support in performance improvement 
f. Improving supportive supervision of health workers in the district 
g. Supporting the district to recruit health staff 
h. Support in orienting recruited staff 
i. Training in payroll management 
j. Supporting VHT training, supervision, and facilitation 
k. Dissemination of workplace safety guidelines 
l. Training of health workers in workplace safety and health 
m. Support to form occupational and safety committees 
Probes 
1. Did this activity take place in this district? 
2. Was the activity well or not well implemented? Explain? 
3. What hindered or facilitated the activity? 
4. Was the CP approach used appropriate? Suggestions to improve it? 
5. When was last CP support given in relation to this activity? 
6. Is this activity being maintained now? Why/why not? 
7. Where any activities that you know about planned but not implemented? Why? 
4. In total about how many members of staff in your district benefited from the 
trainings/technical assistance provided by the project? 
5. To what extent would you say the project support contributed to better delivery of HIV/AIDS 
and Family Planning/Reproductive Health services in the district? Any concrete examples of 
this contribution? 
6. Overall, would you say the project was a success? What are your reasons for this assessment? 
7. What are the remaining problems/gaps in human capacity that the project did not address? 
8. If the project were to continue, what changes would you like to see in the 
design/implementation? 
9. Which of the activities implemented here do you think can be/should be rolled out to other 
districts? 
End of Project Evaluation of the Capacity Project | 71 
Appendix 7: Standardized Instrument to document Components of a Capacity-Building Organization 
This tool is a sample that was used to ascertain the management capacity of the District Health Team/Organization and showing 
evidence of practice as per the third column. Key information drawn from the filled forms in all the six districts visited is summarized 
herein. 
The column “Evidence” will be filled in if the evaluation team members see documents that give objective supportive evidence. 
Serial 
Number 
Standardized Instrument to Document Components of a Capacity Building Organization Yes No Evidence
Management Systems
1 Does the organization have a mission statement or equivalent statement of common goals? 
Comment on what this is if present 
2 Strategic planning takes place for HRD at national/district level 
3 HRD needs of districts incorporated into national-level strategic planning 
4 Technical aspects of strategic planning for HRD at national level incorporated into district-level 
plans 
5 Human resource planning incorporated into local action plans 
6 Annual action planning including monitoring and evaluation of HRD needs takes place 
7 Monitoring plan-based review meetings take place regularly (at least three monthly) 
8 Weekly work plan and review meetings take place 
9 Staff members other than managers have an active role in planning their work 
Comment on in which meetings staff have a decision-making role 
10 Does group problem solving take place involving management and staff? 
Comment 
Workforce Planning and Policy
11 Does the organization have up-to-date/accurate data on its workforce? 
12 Does the organization keep gender disaggregated data on staffing? 
13 Does the organization know the actual gaps in staffing (or have data on staffing gaps?) 
14 Is the HRIS supplied by the CP project in current use? 
Give examples or recent use 
End of Project Evaluation of the Capacity Project | 72 
Serial 
Number 
Standardized Instrument to Document Components of a Capacity Building Organization Yes No Evidence
Systems for Recruitment and Performance-Based Health Workforce Development
15 Does the organization have an established procedure for recruitment of staff? 
16 Does the organization have an established system for orientating new staff? 
17 Does the organization have clear job descriptions for all health staff? 
18 Do staff interviewed know or have a copy of their job descriptions? 
19 Does staff know standards for performance, data confidentiality, and ethics? 
20 Does staff receive at least monthly feedback on their work, including reports? 
21 Is there a system for regular performance review using objective performance standards? 
22 Is there a system for recognition, promotion, or reward based on this performance review? 
Comment 
23 Is there a system that records staff level of training, in-service, and continuing education 
received? 
24 Is there a system of appeal to address grievances of staff that staff members know about? 
25 Is there a system of staff discipline and firing that staff state is fair? 
Comment 
26 Is there a training curriculum and plan for in-service training? 
27 Do district staff perform regular supervision of VHTs using a systematic approach (checklists or 
similar) 
28 How often does this supervision occur? (state frequency) frequency
Health Workforce Management Practices for Improved Performance and Retention
29 Is there a system that allows staff to have input into decisions that affect their working 
environment? 
30 Describe. 
31 Is there a workplace committee for maintaining workplace safety standards? 
32 Is there a system for regular maintenance of facility equipment used for training? 
33 Is there a system for timely ordering of consumables used for training? 
Payroll and Posts Filled
34 Percent of staff accessing payment: before (B) vs. after (A) capacity project B A 
35 Percent of posts filled in the organization (district) before versus after the capacity project B A 
End of Project Evaluation of the Capacity Project | 71 
Appendix 7B: Summarized Information from the Standardized Instrument on 
Components of a Capacity-Building Organization 
Planning is taking place at the district and even sub-district levels. The strategic district health 
planning takes place annually using the guidelines for district action plans developed by CP. The 
HRH needs are accordingly identified and integrated into the national level through the guide on 
planning indicators and wage bill ceilings. Health facilities generate their own plans that is 
harmonized at the HCIV, integrated into the District Health Plans, and then into District 
Development Plan. However, the challenges identified are seldom responded to. These include 
housing, transport, and power, especially for HCIV and III. 
The DHT undertakes quarterly integrated monitoring and evaluation using the PHC funds. 
Monitoring plan and review meetings and weekly meetings are not regular. This is inadequate 
for mentoring and backstopping (monthly is preferred). 
 
Recruitment is planned by DHT, using the existing staff and gaps by category identified. This is 
submitted to the local council, who then recommends the plan to the MOH for approval. 
Recruitment was accordingly done in all the districts. Orientation training for the new staff was 
also done in all the districts for a period of one to two days and covered general issues. However, 
the orientation is inadequate since it left out the crucial technical work-related part regarding 
health issues and challenges, scope and state of facilities, the health team as a resource, and 
relationship with the community. It was preferable to include an attachment to an officer of a 
particular title and job description (internship) for at least one or two months before one can go 
and take his/her post. 
Staff Levels in the Districts 
District Actual 
Number 
at 2004
Percent 
Staff 
Level 
2004
Actual 
Number at 
2009
Percent 
Staff Level 
2009
Remarks
Amolatar 102 68 128 85 Recent recruitment 
data not included 
Apac 231 45 350 67.5 
Kabarole 224 38 376 62.5 
Kamwenge 174 48 290 80 
Lira 392 76 443 86 
Oyam 135 50 204 76 
The capacity to manage and for one to have management skills at the health facilities is more 
critical. The management committees are weak. The clinical officer in charge of the health 
facility therefore has to: 
• Ensure the facility is running; 
• Plan for the health facility and manage their budgets (for drugs, human resources, and 
finances); 
End of Project Evaluation of the Capacity Project | 72 
• Lobby for staff and ensure that the staff members are available at the facility; 
• Hold routine monthly meetings with the staff; 
• Supervise the staff through all the departments; 
• Appraise the performance of staff and recommend them for promotion, award, etc; 
• Receive and solve all HR complaints including salaries, payroll issues, accommodation, 
transport, meals, uniforms and gadgets, and drugs; 
• Select and forward staff members for training; and 
• Coordinate with the community on management of the facility. 
Workplace Safety Policy and Guidelines 
Medical waste management and safety equipments are expensive to manage because of a lack of 
funds and logistics at the districts. The policy has brought additional duties, which some of the 
staff do not want to take on. Yet there are more cost implications that go with the duties. It is 
good to compensate the workers. However, the districts need to be helped by the Ministry of 
Health because they cannot afford the compensations.21 A health workforce management 
committee is in place in Apac Hospital called the “Infectious Control Committee.” They look 
into health risks and infections between health workers, health workers and patients, and patients 
and patients. Most of the health facilities are managed by clinical officers. 
As far as training is concerned, there is no formal curriculum for in-service training. The staff 
normally identifies training opportunities and then seeks approval to train. 
• A health service training card was introduced by the MOH four years ago. The training 
provider signs on a staff card at every training attended 
• In Lira a training attendance book is kept (innovation) 
• The Capacity Building training program sponsors District Local Government (DLG) staff 
for training 
• No formal management training or on job training 
The main performance management/improvement tools are the performance appraisal forms 
(for personnel) and the performance improvement assessment form (for services). The two tools 
should be managed hand-in-hand to improve the quality of both the personnel and services 
provided. The appraisal forms must be objectively filled in and information used for 
strengthening performance rather than use it as a routine. Meanwhile the assessment tools are too 
long and time consuming, and it is important to harmonize them with existing assessment tools 
to make them user friendly. 
The Village Health Teams supported by other programs, including CRS, NUMAT, and 
UNICEF, exist and they are supposed to be supervised by the health facilities. There are 
checklists and an elaborate reporting system in Kamwenge. The VHTs need more supervision. 
The HRIS supplied by the CP are not functional due to challenges ranging from viruses, lack of 
back up, centralized data (computer and software only in the personnel officer’s office), and poor 
linkage between the health and district personnel. Data is not analyzed or used for decision￾making. In Apac, the HRIS has crashed and are still waiting for a backup. Kabarole has resorted 
 
21 Capacity Project: Strengthening Health Workforce Systems in Uganda, review report, December 2009 
End of Project Evaluation of the Capacity Project | 73 
to using own systems and in Kamwenge the system was not introduced. There was also the 
challenge of installing an internet connection in the Ministry of Health to different districts due 
to unreliable electricity, especially in the rural areas. By the end of December 2009, the 
following had not been done: 
• Off site back up for the MOH HRIS 
• Linking the district HRIS database to the resource centre 
• Establishment of the HRIS in six out of the 12 planned districts 
• Evaluation of the HWAB 
• The planned development of district HRH plans in 10 districts 
While the records of staff members show Gender Disaggregated data (the female and male 
categories), it does not highlight challenges and deliberate interventions for support to the 
women or men. 
End of Project Evaluation of the Capacity Project | 74 
Appendix 8: Strategic Objectives for Uganda Human Resources for Heath 
Strategic Plan 2005 -2020 
SOB 1: Attain the right HRH numbers and skills mix to populate the health sector taking into 
account recurrent budget constraints. 
SOB 2: Create, maintain, and use a strong knowledge and information base for evidence based 
and effective HRH functions.
SOB 3: Build capacity for HRH training and development to ensure constant supply of adequate, 
relevant, well-mixed, and competent health workforce. 
SOB 4: Manage HRH efficiently and effectively, with the aim of attracting and maintaining a 
sufficient, equitably distributed, well-motivated, empowered, and productive health workforce. 
SOB 5: Maintain standards and promote the transformation of present practices into an ethical, 
professional organizational culture. 
SOB 6: Build sustainable partnerships and strengthen coordination among HRH stakeholders, 
including the community. 
SOB 7: Manage scarce financial resources in support of HRH in a cost-effective and efficient 
manner. 
SOB 8: Develop capacities for HRH policy stewardship and evidence-based planning, 
monitoring, analysis, and review in line with a changing environment. 
End of Project Evaluation of the Capacity Project | 75 
Appendix 9: Capacity Evaluation—USAID/Uganda Questionnaire 
May 12, 2008
1. What did you want the Capacity Project to accomplish in your country? Provide technical 
assistance (TA) for addressing HRH gaps for delivery of HIV/AIDS services. 
2. Were your expectations fulfilled? If not, why not? To a great extent, our expectations 
were met. However, CP spent a lot of time developing the HRIS for nurses and 
midwives and only focused on the other aspects of HRH in the third year.
3. What do you consider the most effective activities or aspects of the assistance you have 
received from the Capacity Project? TA for HMIS, retention study, establishment of a 
coordination mechanism for all stakeholders in HRH. 
4. What do you consider the least effective activities or aspects of the assistance you have 
received from the Capacity Project? How might you structure these activities or use Capacity 
differently if you were able to do them over? Moving from TA to actual implementation of 
activities that would address the gaps in HRH like recruitment, deployment, 
retention, availability, appraisal, motivation. 
5. How would you describe the Capacity Project’s performance in terms of providing timely 
assistance that demonstrated general responsiveness and technical proficiency, appropriate to 
the country setting? CP was very responsive to the Mission and Ministry of Health 
requests and needs. The technical competence improved with time and was able to 
hire additional staff that would address the HRH needs beyond HRIS and the 
nursing profession. 
6. How has the Capacity Project managed its personnel and resources in your country? 
Excellent.
7. How did the work of the Capacity Project complement the efforts of bilateral projects in your 
country? The CP is a counterpart to the head of the Human Resource and Personnel 
Departments of the Ministry of Health. The CP worked through the Ministry of Health 
multi-sectoral Human Resource Working Group and was Secretariat to the Health 
Workforce Advisory Board (HWAB), which has both Government of Uganda and 
Development Partner representation. 
8. If the Capacity Project implemented core-funded activities in your country, did they 
complement or detract from your field-supported activities? Please provide a brief 
explanation. The Mission activities focused only on HIV/AIDS. In general, core and 
field support activities complemented each other, although at first it was difficult to 
for CP to address the HRH gaps in HIV/AIDS. By design, core funds focused on TA, 
yet the Mission wanted a balance of TA and service delivery. CP found it difficult to 
respond to this requirement because they are used to providing TA alone.
End of Project Evaluation of the Capacity Project | 76 
9. What do you see as the added value of using a centrally-managed project instead of a 
bilateral project to address human resource issues in your country? It is easier and quick to 
access the mechanism if use centrally-managed projects, especially if they are 
responsive to the Mission SOW. 
10. Any other comments or feedback? 
FUTURE DIRECTIONS 
11. If there were to be another centrally-managed mechanism with a focus on human resources 
for health (HRH), would you be interested in using it? If not, why not? Yes
12. If you would, which of the following areas would be of interest/use to you (place an X in 
front of those items)? 
X Human resource information systems (HRIS) 
X Human resources management 
 Human resources policy 
X Workforce planning, including data-driven decision-making 
X Leadership for human resources 
 Pre-service education systems 
 In-service/continuing education systems 
 Innovative curriculum design and delivery (team-based learning, community-based 
learning, integrated pre- and in-service programs) 
 Information and communication technologies for pre- and in-service education (distance 
learning, telemedicine, e-learning, web-based learning, etc.) 
X Strengthening/development of professional associations 
X Task shifting/task alignment/task allocation 
X Incentive/retention programs 
X Performance-based financing 
X Productivity interventions 
 Supportive supervision/quality assurance 
 Other—please specify (list as many areas as you need) 
13.If there were to be a centrally-managed mechanism for HRH, it could be structured as either a 
Leader with Associate Award Cooperative Agreement (LWA) or an Indefinite Quantity 
Contract (IQC). To help us decide which mechanism to choose, please indicate your order of 
preference for how you would use your field support funds to access the central project. Use 
1 to indicate your top preference, 2 your second choice, 3 your third choice and 4 your least 
favorable option. 
4 Field support to the Leader Award (LWA) 
1 Develop your own Associate Award (LWA) 
3 Field support to a central Task Order (IQC) 
2 Develop your own Task Order (IQC) 
End of Project Evaluation of the Capacity Project | 77 
14. Please share with us why you made these choices. 
The preference is to develop a Mission LWA or IQC because this is the only way the 
Mission can have more control on the implementation of the program and balance TA 
with service delivery. 
End of Project Evaluation of the Capacity Project | 78 
Appendix 10: Achievements against Planned Activities per Objectives 
The table below shows the status of activities planned for each objective and Result Area. By the end of the project in September 
2009, a number of activities were implemented. Those that were not were no implemented for a number of reasons including: 
• Concentration in a few districts and activities to ensure efficient and effective functionality of the systems; 
• Inadequate budget; 
• Technical delay; and 
• Internal delays in some local governments. 
Objective 1: To enhance capacity for HRH policy and planning at the central and district levels to ensure adequate health workforce for integrated 
HIV/AIDS and reproductive Health services 
Planned Activities Achievements by September 2009 Comments/ Shortfalls
1.1 Strengthen HRIS at the 
central and district levels 
• HRIS established in the four health professional councils and the HRM Division of 
the MOH 
• Able to generate reports automatically from the database 
• Regular updating of data possible 
• Hardware and software installed at these institutions 
• Key users of the data trained 
• Data from the professional councils’ databases linked to the HRM databases at the 
MOH via the Knowledge Management Portal 
Planned off-site back-up not yet 
established by June 2009 
• Rolled out HRIS establishment in nine out of 12 planned districts, including 
Kabarole, Amolatar, Gulu, Mukono, Wakiso, Oyam, Lira, Kitgum, and Pader 
• Average of three users trained in each district 
Roll-out of HRIS happened in 9 out 
of 12 planned districts 
• Data from HRIS databases analyzed and used to produce HRH bi-annual reports 
• Knowledge Management Portal established as an online resource at MOH. By Sept 
2009, over 700 materials uploaded onto the portal 
• One fulltime MOH/Library staff trained to manage the Knowledge Management 
Centre 
• HRIS officially launched by the Minister of Health 
• Portal being used by average of 15-19 users per day, with a total of over 1,430 visits 
in 2nd quarter of 2009 alone 
Planned link of district HRIS to 
MOH HRIS did not happen 
End of Project Evaluation of the Capacity Project | 79 
Planned Activities Achievements by September 2009 Comments/ Shortfalls
1.2 Enhance MOH and District 
capacity for HRH policy and 
planning, reviews, and 
development
• The HRIS used as a more reliable source of information for planning. This data used 
to revise the workforce projections; and to identify priorities for the HSSP III 
iHRIS Plan software being developed 
at IntraHealth Headquarters as the 
HRH Planning Model and tool not 
ready for adaptation and adoption 
• Staff from HRDD, Nursing Council, MOH, and HMDC supported to attend 
workshops and training courses 
• Worked with MOH to produce HRH Strategic Plan Supplement, HSSP II MTR 
report, and to undertake turnover study 
District HRH work plans and budget 
not developed due to budget 
constraints 
• Worked with MOH to review policy issues relating to the HRH component of the 
National Health Policy under formulation. 
• Support provided to the HWAB and HRWG Planned evaluation of HWAB not 
done because there were no clear 
Terms of Reference (TOR) 
• Capacity Project staff and Commissioner of Planning (MOH) attended HAF Review 
meeting in Amsterdam; project reports widely shared; worked with NUMAT to 
organize a District Leaders meeting in Northern Uganda; and organized the Second 
PEPFAR implementers’ meeting on HRH 
1.3 Enhancing MOH capacity for 
long-term strategic health 
workforce planning, roll-out, 
and reviews 
• TA and facilitation provided to HRWG; introduced Health Action Framework 
(HAF) as a thinking tool for the Health workforce; HWAB formed and its mandate 
expanded beyond HRIS to include other HR issues; HWAB facilitated to meet 
Planned evaluation of HWAB not 
conducted 
• HRH District Action Workshop held during 2007/08 to translate policy and 
strategies into district operational plans 
• Two workshops on HRH organized in 2007 targeting district staff all over the 
country; attended by representatives from 78 out of 80 districts; focused on 
developing HRH plans; districts encouraged to implement HRH plans 
1.4 Strengthen district capacity 
to translate HRH policy and 
strategic plan into action plans to 
address HRH priorities at the 
district level 
• Regional HRH action planning workshops conducted covering 78 districts 
• Districts supported to identify priority actions and formulate action plans 
Planned development of annual HRH 
plans for 10 districts not done 
1.5 Strengthen networks and 
Strategic Alliances for HRH 
• Participated in networking meetings 
• Project briefs produced an disseminated to stakeholders 
• Good collaboration achieved with NUMAT in northern Uganda 
End of Project Evaluation of the Capacity Project | 80 
Objective 2: To Strengthen Systems for Effective Performance-based Health Workforce Development 
Planned Activities Achievements by September 2009 Comments/ Shortfalls
2.1 Harmonizing pre-service and in-service 
training of the health workforce with 
integrated HIV/AIDS and reproductive health 
needs and priorities; strengthen systems for in￾service training and continuing professional 
development 
• HMDC supported to install e-granary—a resource for learning 
materials for trainers and health worker trainees 
2.2 Developing and promoting approaches for 
effective performance improvement 
(mentoring, performance improvement, 
support supervision, action learning, etc). 
• A central level technical resource team trained in performance 
improvement 
• DHT members in nine districts sensitized in performance 
improvement 
• Performance assessment tools developed, assessments conducted in 
nine districts, and results disseminated 
• Supported Kabarole district to implement PI process. Activities 
included training the DHMT, undertaking performance assessment, 
developing a district intervention plan and health unit intervention 
plans, and providing infection control equipment to the district 
Only few health units developed an 
intervention plan 
• National-level trainers oriented to Learning for Performance 
Approach; 
• Learning for Performance training of facilitators and trainers 
conducted 
• District trainers in Kabarole supported to carry out mentoring 
training on infection control in 21 health facilities 
• Worked with MOH to monitor, evaluate, and document PI 
experiences and lesson and plan roll-out to other districts 
• Supported UPMB to mainstream PI approaches in support 
supervision activities 
2.3 Developing strategies to motivate 
continuing professional development including 
standards for accreditation, certification, and 
licensure 
• Supported the MOH and the professional councils to develop 
IST/CPD standards and guidelines 
• Standards and guidelines for accreditation of IST/CPD launched 
• Updated professional ethics and codes of conduct for health workers 
launched 
Professional councils and associations 
not oriented in the use of IST/CPD 
accreditation guidelines due to the 
launch taking place very close to end of 
project 
2.4 Strengthening the role of the health 
workforce professional councils and 
associations in in-service training and 
continuing professional development 
• Assessment carried out to determine nurses and midwives 
satisfaction with services from their association UNANM 
• A communication strategy for UNANM produced and implemented, 
including workshops and production of UNANM handbook and 
brochures 
• UNANM website developed 
Some of the planned activities not 
implemented due to lack of funds 
End of Project Evaluation of the Capacity Project | 81 
Planned Activities Achievements by September 2009 Comments/ Shortfalls
• Worked with professional councils, associations and MOH and other 
stakeholders to review the ethical codes of conduct. 
• Reviewed ethical codes of conduct launched 
• Copies of codes of conduct printed and distributed 
• Supported placement of MUST students to work in community 
contexts working with VHTs to provide PMTCT,HCT and Family 
Planning Services 
End of Project Evaluation of the Capacity Project | 82 
Objective 3: To Identify and Promote Health Workforce Management Practices for Improved Performance and Retention 
Planned Activities Achievements by September 2009 Comments/ Shortfalls
3.1 Strengthening systems for 
health workforce 
performance management 
• Conducted mapping of HR processes; copies of report distributed 
• In collaboration with MOH, HMDC, AMREF, and Makerere University, 
organized and attended consultative meetings on health sector HR leadership 
and management development 
• Developed strategy and tools for performance management 
• Tested the concept of performance management using Results Oriented 
Management (ROM) in three districts, Oyam, Amolatar, and Kabarole; 
supported development of an implementation strategy for performance 
management in collaboration with MOH and MOPS 
3.2 Developing strategies and 
systems for improved recruitment 
and deployment 
• Introduced a computer-aided short-listing program, which was used in Lira, 
Dokolo, Amolatar, Kabarole, Amuru districts, thus reducing the cost and time 
previously associated with manual short-listing 
• Supported districts to do centralized/joint advertising, thus reducing cost of 
advertising by more than half 
• Procedures of advertising of vacant posts modified to include radio and notice 
boards, not just newspapers 
• Supported DSCs to identify vacant posts, advertise, and recruit 
• Supported districts to induct newly recruited staff 
Amuru district not supported to induct 
staff 
• Nationwide staff audits conducted to inform district recruitment plans Recruitment plans not formulated 
3.3 Developing tools and 
initiatives for improved job 
satisfaction and retention 
• Retention and turnover studies done; reports printed and disseminated 
• Comprehensive motivation and retention strategy finalized, printed, and 
disseminated 
• Payroll management training done for all districts 
3.4 Enhancing systems for 
community participation in health 
services 
• Collaborated with MUST to implement the VHT strategy in Kabarole and 
Kasese districts using MOH guidelines 
• Supported community attachment of MUST students 
3.5 Strengthening systems for 
workplace safety, protection, and 
care of the health workforce 
• Supported the MOH to develop the Workplace Safety Guidelines and policy; 
copies printed and disseminated; policy and guidelines disseminated; trained 
health workers in workplace safety and health in Kabarole district; formed 
Occupational and Safety Committees in Amolatar, Oyam, and Kabarole 
districts 
End of Project Evaluation of the Capacity Project | 83 
Table A10 Capacity Project Activities not Completed as Scheduled 
Uncompleted Activities 
(as per project documents)
Comment from COP
1.1 Planned off-site back-up not yet 
established by June 2009 
Process was delayed due to unresolved 
debate about where to locate the back-up; 
External consultant supporting the process 
available in Uganda on and off for short 
periods of time 
Roll-out of HRIS happened in nine 
out of 12 planned districts 
Realized 12 districts were too ambitious; 
reduced target to nine 
Planned link of district HRIS to MOH 
HRIS did not happen 
Thought linking only nine districts would 
not have desired impact; decided to do the 
link when at 20 districts; have 19 so far 
1.2 iHRIS Plan software being developed 
at IntraHealth Headquarters as the 
HRH Planning Model and tool not 
ready for adaptation and adoption 
Yes, software not received in time for 
adaptation 
District HRH work plans and budget 
not developed due to budget 
constraints 
District HRH work plans done—only that 
there was no follow-up to ensure that they 
were integrated into district plans and 
budgets 
1.3 Planned evaluation of HWAB not done 
because there were no clear Terms of 
Reference (TOR) 
No TOR establishing the roles of the 
HWAB; these are now to be developed as 
the HWAB transitions into a program 
steering committee 
2.2 Only few health units developed an 
intervention plan for PI
Process of developing health unit 
intervention plans left to districts, expected 
to be supported by other actors e.g. 
NUMAT. Project supported these to lower 
levels only in the three core districts 
2.3 Professional councils and associations 
not oriented in the use of IST/CPD 
accreditation guidelines due to the launch 
taking place very close to end of project 
Yes, launch of the guidelines happened 
very late; no time to do orientations 
2.4 Some of the planned activities not 
implemented due to lack of funds 
CP had very little funding from field 
support to work with UNANM 
3.2 Amuru district not supported to orient 
staff 
Amuru had internal problems including 
interdiction of the district Chief 
Administrative Officer (CAO); activity re￾allocated to Kamwenge district 
Recruitment plans not formulated Had planned to develop a national 
recruitment plan based on the staff audit 
report. Funding was to come from MOH 
partnership fund but was never realized 
End of Project Evaluation of the Capacity Project | 84 
Appendix 11: Sample Output Data from HRIS Qualify Databases
(Four health professional councils) 
Cadre Registered
Male Female Total
Nursing and Midwifery Council 
Registered Clinical Nursing Degree 31 121 152
Registered Health Tutor Midwifery Diploma 0 59 59
Registered Health Tutor Nurse Diploma 10 62 72
Registered Nurse Diploma 542 3803 4345
Registered Public Health Nurse Diploma 0 119 119
Registered Comprehensive Nurse Diploma 239 315 554
Registered Mental Health Nurse Diploma 227 262 489
Registered Pediatric Nurse Diploma 16 96 112
Registered Midwife Diploma 7 2884 2891
Enrolled Nurses Certificate 1235 5022 6257
Enrolled Comprehensive Nurse Certificate 530 1500 2030
Enrolled Mental Health Nurse Certificate 225 113 338
Enrolled Midwife Certificate 5 4293 4298
Total 3067 18649 21716
Allied Health Professionals Council 
Biomedical Sciences (Degree and above) 0 1 1
Anesthesia (pre-degree) 86 62 150
Theatre Techniques (Certificate) 41 35 77
Clinical Medicine and Community Health 1692 523 2228
Public Health Dental Assistants 121 58 179
Prosthetist and Orthodontist (Degree +) 1 0 1
Environmental Health Science (Degree +) 18 8 26
Environmental Health Science (Pre-degree) 790 278 1073
Medical Laboratory Technology (Degree +) 10 8 18
Medical Laboratory Technology (Pre-degree) 796 274 1071
Medical Radiology (Degree +) 14 3 17
Medical Radiology (Pre-degree) 65 10 75
Occupational therapy (Degree +) 0 1 1
Occupational therapy (Pre-degree) 33 17 50
Orthopedic medicine/technology (Pre-degree) 222 52 274
Dispensing/Pharmacy (Pre-degree) 144 62 207
Physiotherapy (Degree +) 3 9 12
Physiotherapy (Pre-degree) 37 21 59
Medical Entomology (Diploma) 79 15 92
Mental Health (Diploma) 35 11 46
Ophthalmic medicine (Diploma) 25 19 44
Cataract surgery (Diploma) 0 0 0
Ear Nose and Throat (ENT) (Diploma) 1 1 2
Public Health (Certificate) 0 1 1
Total 4213 1469 5704
End of Project Evaluation of the Capacity Project | 85 
Cadre Registered
Male Female Total
Medical and Dental Professionals 
Medicine and Surgery (first degree) 2042 824 2866
Dental Surgery/Public Health (first degree) 160 51 211
Post-graduate diploma 48 29 77
Post-graduate degree (clinical) 75 15 90
Post graduate degree (Management/PH) 24 12 36
Member, Royal College 4 6 10
Fellow, Royal College 17 1 18
Doctorate/PhD 18 4 22
Total 2,388 942 3,330
Pharmacy Council 
Pharmacy – Degree 187 84 276
Pharmacy – Masters 23 11 34
 Total 210 95 310
End of Project Evaluation of the Capacity Project | 86 
Appendix 12: Performance Improvement Assessment Report
The following example of an assessment performance report from Gulu District in 
northern Uganda shows the practice adopted the importance of the assessment tool in 
identification of the HRH issues and bringing them up for planning and decision making. 
Report of Performance Improvement Assessment in Gulu District 
Overview 
1.1 INTRODUCTION 
1.1.1 Geographical profile 
Gulu district is situated in Northern Uganda, located between longitudes 31° E-32° E, 
latitude 02° N - 04° N. It is bordered by Amuru district in the West, Pader district in 
the East, Kitgum district in the North-East, Lira and Apac districts in the South- East. 
The district total area is 344,908 square kilometers of which 96.9 sq km (0.8 percent) 
is covered by open water and swamps. It is 1.44 percent of the national land area. 
The district headquarters: Gulu Municipality is at a road distance of 332 kilometers 
from Kampala, the capital city. There is modern communication network. 
Administratively the district is divided into two counties and one municipality, 11 
sub-counties, four municipal divisions, 69 parishes (of which 16 are municipal 
wards), and 233 villages. The counties make up the three health sub-districts (HSD) 
of Aswa, Gulu Municipality, and Omoro. 
The socio-economic condition of the people is very poor. Due to persistent insecurity, 
over 60 percent of the people continue to live in the internally displaced people’s 
camps and settlements. Due to the insecurity, the vast fertile land for cultivation 
remains unutilized except those very close to the camps. 
It is obvious from the above that very little socio-economic activities are possible as 
the people are predominantly cultivators. Livestock farming is likewise very limited 
since most of the livestock were looted. 
The people have been reduced to relying heavily on food relief from WFP, and non￾food items from relief agencies. 
End of Project Evaluation of the Capacity Project | 87 
1.1.2 Demographic Features 
Table 2: Demographic profile, infrastructure, and manpower distribution 
HSD S/counties Population Infants Pregnant 
Mothers
Health Unit Ownership Current 
Staffing
Staffing 
Norm
Gap Status
ASWA Awach 12,631 543 632 Awach HCIV G 18 50 32 F
Paibona HCII G G 0 9 9 C 
Bungatira 25,934 1,115 1,297 Pabwo HCIII G 0 19 19 C 
Punena HCII G G 0 9 9 C 
Rwotobilo HCII 
G
G 0 9 9 C 
Coope E G 6 9 3 F 
Paicho 28,155 1,211 1,408 Kal Ali HCII G 5 9 4 F 
Te Ato HCII G 0 9 9 C 
Omel HCII G 0 9 9 C
Cwero HCIII G 5 19 14 F
Unyama HCII G 7 9 2 F
PakweloHCII G 0 9 9 C
Palaro 7,480 322 374 Labworomor 
HCIII G
3 19 16 F
Oroko HCII G 0 9 9 C
Patiko 9,450 406 472 Patiko HCIII G 6 19 13 F
Pugwinyi HCII G 0 9 9 C
Lugore E 2 9 7 F
Total 83,650 3,597 4,183
GMC Bardege 41,489 1,784 2,075 Independent H P
Bardege HCII G
Lacor H NGO
St Philip HCII 
Ngo
End of Project Evaluation of the Capacity Project | 88 
HSD S/counties Population Infants Pregnant 
Mothers
Health Unit Ownership Current 
Staffing
Staffing 
Norm
Gap Status
St. Luke HCII 
Ngo
Laroo 24,011 1,035 1,201 Gulu H G
Pece HCII G
St Mauritz HCII 
Ngo
Layibi 28,779 1,237 1,439 Techo HCII G
Pece 40,896 1,759 2,045 Aywee HCII G
Total 135,174 5,812 6,759
Bobi Bobi HCIII G 9 19 10 F
Palenga E G 3 9 6 F
Lelaobaro G 0 9 9 C
Minakulu NGO
Koro 20,536 883 1,027 Lapainat HCIII G 3 19 16 F
Abili E G 3 9 6 F
Lakwatomer 
HCII
G 0 9 9 C
St. Luke NGO 0
Lakwana 15,147 651 757 Opit HCIII NGO 6 19 13 F
Lanenober HCIII G 0 19 19 C
Parak HCII G 0 9 9 C
Awoo HCII G 7 9 2 F
Lalogi 20,723 891 1,036 Lalogi HCIV G 17 50 33 F
Idobo HCII G 0 9 9 C
Odek 27,443 1,180 1,372 Odek HCIII G 4 19 15 F
Acet HCII G 5 9 4 F
Awere NGO 7 9 2 F
Dino G 3 9 6 F
St. Peters NGO 0 9 9 C
End of Project Evaluation of the Capacity Project | 89 
HSD S/counties Population Infants Pregnant 
Mothers
Health Unit Ownership Current 
Staffing
Staffing 
Norm
Gap Status
Ongako 16,248 699 813 Ongako HCIII G 4 19 15 F
119,014 5,118 5,951
151,013 7,098 7,551
Source DDHS 
Status 
C = Closed due to insecurity and the staff deployed elsewhere 
F= Functional 
G = Government 
E = Emergency unit built in underserved camps 
End of Project Evaluation of the Capacity Project | 90 
Infrastructure 
Both HCIV referral (Lalogi and Awach) are partially operational, although both theatres 
being incomplete and without equipment. Lalogi has no maternity ward; instead the 
theatre, which was badly built, is being used temporarily. Laboratory and staff 
accommodation is inadequate. 
All eight government HCIII are lacking either maternity or a general ward. Two of these 
have been abandoned due to unfavorable security. Generally the OPDs are very small, 
and staff accommodation inadequate. The HCIIIs are in dire need of rehabilitation. Most 
of them have to be upgraded in terms of adding wards, maternity units, and staff 
accommodation. 
There are 29 HCII, of which 15 are closed due to insecurity. Staff accommodation is 
inadequate in all the HCIIs with five without any staff housing at all. 
Most of the health units are in various states of disrepair, and the abandoned structures 
have been further damaged by disuse and termite damage. 
Human Resources 
During the year, about 75 percent of PHC staff allocated for the district was recruited, 
upgrading the staffing norm to about 60 percent according to the old structure. However, 
this picture is drastically reduced when the new structure is oprationalized. 
Attracting and retaining certain cadres of staff, especially doctors, laboratory staff, and 
midwives, has been difficult due to poorer service conditions in the district (insecurity, 
lack of incentives, etc). 
The health worker to patient ratio is unfavorable, as shown below. Staffing in Lower 
Level NGO Units is very miserable except in the HCIII. 
Table 3: Showing the ratio of health worker to population 
Category Gulu Uganda
Doctor to population ratio 1:15,983 1:18,600
Nurse and midwife to population ratio 1:2,677 1: 2,870
End of Project Evaluation of the Capacity Project | 91 
General Observations During the Assessment of PMTCT and 
Reproductive Health Services 
1. A number of health facilities that are located near camps that were/are used for 
the internally displaced persons are realizing low antenatal attendances. Many 
people have responded to the government’s decision to send people back to their 
villages since there is security in the region now. This has consequently affected 
the delivery rate at the health facilities. Some of the affected units visited are: 
Labworomor HCIII, Patiko HC III and Odek HC III 
2. In some of the health facilities, antenatal services are not held on daily basis as 
recommended by the MOH. 
3. Some units had been used as training centers previous to the training of the DHT, 
which was done twice with Gulu. This opportunity of being assessed twice before 
made the health workers more knowledgeable and they performed very well e.g. 
Lalogi HCIV, Bobi HCIII. 
4. The majority of units had no televisions at all. A few units had received them 
from NUMAT, and Pathfinder. The reasons for their not being functional were 
lack of power or fuel for running generators, or not being connected. 
5. The recommended Policy Guidelines and Job Aides were not available in many 
units as they have not been supplied by the district. 
End of Project Evaluation of the Capacity Project | 92 
Local Management Clinical 
Competencies
Provider-Client 
Interaction
Information to 
Clients
Infection Prevention
Opit HCIII
Opit Health Unit is an NGO facility 
under Lacor Hospital. It has good 
infrastructure. The compound was 
littered with polythene bags as a result 
of food distribution to HIV/AIDS 
clients, otherwise a clean environment 
Staffing 
1 Clinical officer in charge 
1 Registered nurse 
1 Enrolled nurse 
1 Enrolled midwife 
1 Laboratory assistant 
2 Assistant health educators 
5 Nursing assistants 
1 Data clerk 
2 Support staff 
No guidelines on opportunistic 
infections, STI management and 
infection prevention in ANC and 
prescription room 
No schedules for health education 
(HE) talks nor plan for HE sessions 
However: 
Unit has both incinerator and medical 
waste pit in good use 
Has running water 
The patient/client load is high and 
HIV/AIDS clinic is well attended. 
This facility performed fairly well in 
the assessment 
The health worker 
assessed was an 
enrolled midwife. She 
performed well, 
especially in the areas 
of history-taking, 
physical and obstetric 
examination of the 
mother, and asking and 
recording of the 
necessary information 
on the mother’s 
integrated card 
The midwife however 
did not measure all the 
vital signs because 
there were no 
thermometers. There 
was only one blood 
pressure machine and 
one weighing scale in 
use at the outpatient’s 
department 
HB, VDRL/RPR, and 
urine tests for all 
mothers were not 
requested for at their 
first ANC visit 
Introduced herself and 
asked mothers to 
introduce themselves 
Spoke in low tone using 
the language 
understood by mothers 
However: 
She did not ask about 
past or current 
symptoms of STIs 
Did not educate on the 
use and provide 
mothers with ITNs as 
they were out of stock 
Did not counsel 
mothers regardless of 
their HIV status 
Did not give mothers 
information on routine 
HIV counseling and 
testing, lab tests on HB, 
syphilis, blood 
grouping, and urine 
testing 
Did not inquire nor 
administer tetanus 
toxoid (TT). She said 
TT is not given due to 
workload 
The unit had no 
decontamination 
containers and utility 
gloves. 
No posters were 
displayed on infection 
prevention in treatment 
room as they don’t have 
them 
Did not dry hands with 
a single use towel as 
towels are not available 
End of Project Evaluation of the Capacity Project | 93 
Local Management Clinical 
Competencies
Provider-Client 
Interaction
Information to 
Clients
Infection Prevention
Odek HCIII
Name of Staff 
Omon Paul - SCO in charge
Okello Labedo - CO 
Akullo Agnes Omara - EM Laker 
Milly Grace - EN 
Okite James - HA 
Ogal Ensio - NA 
Acan Evelyn - NA 
Adongo Teddy - N A 
Abalo Pamela - NA (maternity 
leave) 
Aciro Norah - NA (Staff for Binya 
HCII awaiting completion of their 
HC 
Akidi Alice - NA (as above) 
Odongo Yoel - HA (as above) 
Midwife was absent so the NAs 
were running the ANC and carrying 
out HIV testing. 
Unit has no lab assistant. Only tests 
done by the NA and trained village 
health workers are HIV 
This unit is located near a camp and 
has no accommodation for staff. One 
old house nearby houses six staff, 
three nursing assistants reside in two 
rooms adjacent to labor ward and 
one male nursing assistant resides in 
the YCC clinic. 
ANC services are offered on 
Tuesdays and Friday of every week. 
The person assessed 
was a nursing assistant 
who has limited 
knowledge in 
midwifery 
Health worker The Nursing Assistants 
running the clinic were 
limited in the 
knowledge to share 
with the mothers. There 
were many copies of 
the Birth Preparedness 
Plan on the table but 
they did not know what 
they were for 
No hand-washing 
facilities therefore the 
nurse did not wash her 
hands. 
Equipment is not 
sterilized as there is no 
paraffin. Use Jik when 
available 
Lab has no sink neither 
container for water 
Placentas are disposed 
off in a nearby pit 
latrine which is also 
still in use. Has no 
cover and exudes a 
terrible stench 
End of Project Evaluation of the Capacity Project | 94 
Local Management Clinical 
Competencies
Provider-Client 
Interaction
Information to 
Clients
Infection Prevention
HIV testing therefore is done only 
on those days so mothers who come 
on any other day do not get tested 
50 ampoules of morphine injection 
and 25 vials of injection ketamine 
were found in the maternity store 
just on the slab. The NAs did not 
know their use or importance. CO 
reported that the drugs were a 
donation by a certain organization. 
Drugs were withdrawn and taken to 
DHO store for supply to the 
deserving health facility 
There is no placenta pit 
Bobi HCIII
Unit has two COs, one EM, one EN, 
one lab assistant, one lab technician, 
five NAs, three support staff. All the 
qualified staff members were not in 
the unit. The NA was therefore 
running the unit 
Had no policy guidelines as they 
have not been provided by the 
district 
Test kits for HB had been out of 
stock for many months 
The person assessed 
was a nursing assistant 
who has limited 
knowledge in 
midwifery 
Did not introduce 
herself to the mother 
and never encouraged 
questions 
Important information 
was not given to the 
mother such as when to 
come back when ill, 
summary of findings 
etc 
Hand-washing facility 
not provided in the 
room. 
No pit for medical 
waste instead they use 
the old pit latrine, 
which is also full 
Laboromor HCIII
Newly renovated by ICRC 
The WHO also supports the unit 
with various supplies 
UNICEF also provides some 
supplies such as Mama Kit 
The midwife is 
knowledgeable on 
required procedures. 
She checked for edema 
while patient is lying 
down. Said this is how 
Did not introduce her to 
the mothers and did not 
call them by name. 
Says that the mothers 
already knew her 
 The health worker used 
the same towel for 
cleaning hands more 
than once. It 
permanently hangs by 
the washstand. 
End of Project Evaluation of the Capacity Project | 95 
Local Management Clinical 
Competencies
Provider-Client 
Interaction
Information to 
Clients
Infection Prevention
Unit has only two qualified staff, 
one CO, one MW, one HA, and 
three NAs 
they were trained 
Lalogi HCIV
Supported by Medicines San 
Frontiers 
Have six midwives. Two are from 
government, while four are 
employed by MSF 
All drugs are available 
Midwife was 
knowledgeable 
although some 
procedures were being 
done to impress the 
assessors as they were 
not routine 
 There were no 
decontamination 
containers 
The incinerators and 
waste bins were in 
place and in use 
Lapainat HCIII
Government facility with a total 
number of 16 health workers and 
one support staff. Despite this big 
number of staff, only one NA and 
watchman were on duty 
Has good infrastructure including 
staff houses. Was constructed by 
World Vision 
No incinerator nor medical waste pit 
No recommended guidelines at all 
places. Say these had not been 
supplied 
No schedules for H/E talks. Did not 
know their importance 
RPR, HB, and Urine test kits were 
not available 
The person assessed 
was a nursing assistant 
who has limited 
knowledge in 
midwifery 
History taking, 
physical, and obstetric 
examination were not 
thoroughly performed. 
Other important 
procedures, like asking 
the mother to empty her 
bladder, were also 
omitted 
Provider tried to use the 
language spoken by the 
mother despite herself 
not knowing the 
language well 
However, she forgot to 
ask the mother whether 
she has any other 
general health problems 
Mothers were not 
counseled at all 
Summary of findings 
not given to mothers 
HE was given to 
mothers and their 
companions on 
personal hygiene. 
However, mothers were 
not told to come back in 
case of fever, cough, or 
per vagina bleeding 
Importance of taking 
iron, folic acid and 
multivitamin tablets not 
mentioned 
Did not educate on the 
use and provide 
mothers with ITNs as 
they were out of stock 
The unit had both 
sterile and non-sterile 
gloves and safety boxes 
for sharps. However, 
the NA did not wash 
hands before, between 
and after examining 
mothers (no soap) 
No running water, 
instead rain and bore 
hole water is used 
All rubbish is disposed 
off in a shallow pit. 
The three-bucket 
decontamination system 
is not in use due to lack 
of buckets and Jik 
Cwero HCIII
The unit is understaffed. Qualified 
staff has left due to non-salary 
payment 
There were no mothers 
attending antenatal 
services so this area 
There were no mothers 
attending antenatal 
services so this area 
There were no mothers 
attending antenatal 
services so this area 
Hand-washing facilities 
not available 
No decontamination 
End of Project Evaluation of the Capacity Project | 96 
Local Management Clinical 
Competencies
Provider-Client 
Interaction
Information to 
Clients
Infection Prevention
Unit currently is ran by one CO and 
two NAs 
No drugs for opportunistic infections 
No TV 
ANC run on Tuesday and Friday. 
No revised PMTCT guidelines. 
No test kits for HIV, VDRL, and 
reagents for urine 
No integrated AN Cards 
was not assessed was not assessed was not assessed containers available 
No incinerator 
available. All rubbish is 
disposed in a shallow 
pit, which is only burnt 
when it gets full 
Ongako HCIII
Government health facility with one 
CO, one EN, one EM, one lab 
assistant, and two volunteers 
Has OPD and maternity and 
patients/client attendance. 
HB test kits had been out of stock 
for many months. 
No guidelines, job aides in the unit 
The MW was on leave 
so the CO who is the 
OIC was assessed 
Did not ask the mother 
to empty her bladder 
Did not take vital signs 
as there were no 
weighing scales, BP 
machine 
Did not introduce 
herself nor did she ask 
the mothers to 
introduce themselves. 
Counseling was not 
done at all 
Did not give the mother 
a birth plan form and 
encourage her to share 
the plan with her 
husband 
Unit has no running 
water. Use borehole 
water 
After hand-washing, 
she dried hands with 
her handkerchief. This 
is because there were 
no hand towels 
There were no posters 
displayed on infection 
prevention 
Aywee HCIII
Staff at the unit included one CO, 
one EM, one lab technician, and four 
NA support staff. 
Mothers’ ANC attendance is very 
low 
No revised PMTCT manual or STI 
management manual 
Audio/visual equipment present but 
not functional due to lack of power 
EM was assessed and 
attended to clients well. 
She took all 
measurements of vital 
signs but did not carry 
out a complete physical 
inspection of the 
mother. Did not palpate 
the neck for enlarged 
Did not ask mothers to 
introduce themselves 
Did not ask mothers to 
introduce themselves 
nor did she introduce 
herself to them 
She did not ask the past 
or current history of 
STI symptoms from 
Did not provide 
counseling on STI, or 
safer sex practices 
Did not provide 
information on safer 
breastfeeding option 
Did not counsel the 
mothers at all 
Did not tell the mothers 
Hand-washing facility 
not provided inside the 
room 
No safety boxes for 
sharps but use an 
improvised Jerry can 
End of Project Evaluation of the Capacity Project | 97 
Local Management Clinical 
Competencies
Provider-Client 
Interaction
Information to 
Clients
Infection Prevention
No posters on infection prevention 
Safe water for swallowing drugs was 
not available 
glands mothers 
Mothers were not asked 
to empty their bladders 
before examination 
to come back in case 
they felt unwell 
Awach HCIV
Government unit supported by 
NUMAT, UNICEF, Baylor College 
of Medicine. 
Staff present were one CO, one EM, 
one RM, two NAs. 
Audio/visual equipment present but 
not working due to lack of power. 
No revised PMTCT model 
No STI management guidelines 
No HB or RPR for mothers for ANC 
Inadequate topics for HE 
ANC Clinic run by 
registered midwife 
Did not explain to the 
mother to the mother 
what her care will 
consist of 
Privacy was not offered 
to mothers as the door 
was kept open during 
examination and other 
persons were not 
restricted from entering 
the room 
Did not inform mothers 
about safer feeding 
options and signs and 
symptoms of labor 
onset 
Did not provide 
counseling on STIs 
Did not tell the mothers 
to come back in case 
they felt unwell 
No auto disposable 
syringes 
No incinerator. All 
rubbish in the Unit is 
disposed of in an old pit 
latrine 
No decontamination 
containers 
The placenta pit is not 
properly constructed 
Gulu Hospital
Gulu is a government regional 
referral hospital with an MCH 
department that provides 
reproductive health and PMTCT 
services 
Has TV but department not 
connected to power 
No revised PMTCT policy 
guidelines 
No STI management guidelines 
No HB or RPR for mothers for ANC 
The RN/RM was 
trained in the provision 
of PMTCT services. 
She performed very 
well in most of the 
areas 
However, she did not 
ask about the past 
history or current 
symptoms of STIs 
Did not measure the 
vital signs except the 
BP and weight because 
there were no 
thermometers and 
Did not ask mothers to 
introduce themselves. 
Did not ask about the 
past history or current 
symptoms of STIs and 
any symptoms related 
to HIV 
Did not counsel clients 
at all 
Did not explain the 
importance of taking 
iron, folic acid, and 
multivitamin tablets 
Did not explain 
importance of a birth 
plan and mention the 
items in the birth plan 
to the mother 
Did not tell mothers to 
come back to health 
facility as soon as they 
experience fever, 
diarrhea, productive 
cough, rash, and PV 
Washed hands with 
water and soap but used 
her handkerchief to dry 
her hands because there 
were no hand towels 
End of Project Evaluation of the Capacity Project | 98 
Local Management Clinical 
Competencies
Provider-Client 
Interaction
Information to 
Clients
Infection Prevention
height measure. 
Did not ask the mother 
to empty her bladder 
bleeding 
Patiko HCIII
No PMTCT Policy Guidelines 
displayed/in use 
HB and urine testing not done in unit 
due to lack of reagents and no 
laboratory assistant 
The midwife was 
assessed. She was not 
consistent in carrying 
out physical 
examination 
 Did not ask the clients 
if they had any 
questions 
Did not talk about the 
birth plan and its 
importance 
Mothers were not 
informed when to come 
back in case they are 
not feeling well 
No running water at the 
unit. The borehole was 
converted into 
motorized system but is 
not in use due to lack of 
fuel for running it 
Midwife did not wash 
hands before, between, 
and after examination 
of mothers 
Rubbish pit is full 
No posters on infection 
control/prevention 
End of Project Evaluation of the Capacity Project | 99 
RECOMMENDATIONS 
1. The District Health Team should ensure that all recruited staff members are at their 
stations of work by carrying out regular support supervision. 
2. The district should employ qualified staff and ensure that all those employed are 
working. 
3. The district should ensure that the salaries of the newly recruited staff are paid as 
soon as they resume duty. 
4. The nursing assistants should be given more training skills in midwifery. 
5. Decent accommodation for staff should be provided. 
6. The district should employ qualified health personnel and ensure that there is 
adequate qualified staff offering services. 
7. Support supervision to the health units should be done frequently. This will also help 
to curb absenteeism at the health facilities. 
8. Supplies such as test kits should be provided. 
9. The health districts and sub-districts should ensure availability of drugs and other 
essential supplies in all the health facilities. 
10. New PMTCT policy guidelines should be sent to the district by the MOH. 
11. The medical superintendent should allocate the weighing scale with weight measure, 
which is in the OPD Minor Theatre, to the MCH Department where it is most 
required. 
12. The medical superintendent should buy a three meter piece of cloth for MCH to be 
cut into the size of face towels and used for hand-drying as single use towels. 
13. The medical superintendent should collect posters on infection prevention and policy 
guidelines on PMTCT from the MOH and distribute to all departments in the hospital 
where they are required. 
14. Revitalization of the Health Unit Management Committees should be completed. 
15. The district assistant drug inspector should carry out support supervision to the 
health facilities regularly to verify drugs in use and coordinate with partners in the 
supply of required drugs. 
16. The district should equip all the laboratories so that all tests can be done in the health 
units. Dressing rooms should also be equipped accordingly. 
17. The district should ensure that all the health facilities have adequate hand-washing 
facilities. 
18. Incinerators and placenta pits should be provided in all health facilities. 
19. There is need to educate the health workers on the importance of the health education 
plans and schedules as they did not know what these were. Provision of required 
stationery is equally important as they have no papers and files for developing the 
schedules and plans. 
End of Project Evaluation of the Capacity Project | 100 
ACTION PLAN 
Short Term 
No Activity Responsible Party
1. Organization of regular refresher courses for nursing 
assistants 
DHO’s office 
2. Revised PMTCT policy guidelines should be availed 
and implemented in all the health units 
DHO’s office/HSD 
MOH 
3. Provision of drugs to the health units DHO’s office 
4. Immediate access to the payroll by newly recruited staff DHOS office, District Personnel 
Office 
5. Support supervision to monitor staff performance DHO 
6. Health units to have health education books/files DHO/NUMAT/CP 
7. Revitalization of health unit committees DHO 
8. Provision of hand-washing facilities and soap DHO/NUMAT/CP 
Long Term 
No Activity Responsible Party
1. Provision of accommodation to all health staff GLG, MOH 
2. Employment of qualified health personnel GLG, MOH 
3. Equipment of all laboratories with test kits, reagents, and 
equipment 
DHO’s office 
4. Provision of incinerators, placenta pits, waste bins, 
decontamination containers in all the health units 
DHO’s office, 
5. Development of the motivation policy for the health staff 
e.g. promotions and confirmations in service and 
transport 
DHO, GLG, Donors 
6. Release of requested drugs and supplies to the health 
units to avoid stock outs, misuse, and expiry of drugs 
MOH, DHO 
End of Project Evaluation of the Capacity Project | 101 
31
34
36
53
53
59
64
66
66
69
69
81
52
0 10 20 30 40 50 60 70 80 90 100
Percent
Lapainat HCIII
Labworomor HCIII
Pabwo HCIII
Gulu Hospital
Awach HCIV
Bobi HCIII
Opit HCIII
Cwero HCIII
Aywee HCIII
Ongako HCIII
Odek HCIII
Lalogi HCIV
Gulu District
Health Facility
LOCAL MANAGEMENT
The results show that Lalogi HCIV performed best in local management while Lapainat and Labworomor’s performance was low. 
Lalogi is supported fully by Medicines San Frontiers (MSF). MSF has recruited additional trained staff and provides medicines and 
supplies. It has improved on the existing buildings, some of which are housing the staff, and is constructing more buildings including 
an operating theatre. Lapainat and Labworomor have minimal support in all areas, and there is pervasive staff absenteeism, especially 
of qualified personnel who would be steering the health facility. 
End of Project Evaluation of the Capacity Project | 102 
45
89
71
67 67
57 57 56
50 47
33 33
29
0
10
20
30
40
50
60
70
80
90
100
Percent Gulu District
Ongako HCIII
Lalogi HCIV
Opit HCIII
Lapainat HCIII
Cwero HCIII
Pabwo HCIII
Bobi HCIII
Gulu Hospital
Labworomor HCIII
Aywee HCIII
Odek HCIII
Awach HCIV
Health Facility
Infection Prevention
End of Project Evaluation of the Capacity Project | 103 
0
0
21
36
41
57
60
61
63
65
67
72
79
48
0 10 20 30 40 50 60 70 80 90 100
Percent
Pabwo HCIII
Cwero HCIII
Lapainat HCIII
Odek HCIII
Patiko HCIII
Gulu Hospital
Aywee HCIII
Lalogi HCIV
Bobi HCIII
Awach HCIV
Labworomor HCIII
Ongako HCIII
Opit HCIII
Gulu District
Health Facility
Clinical Technical Competence
End of Project Evaluation of the Capacity Project | 104 
0
36
50
56
58
62
65
69
72
75
79
82
58
0 10 20 30 40 50 60 70 80 90 100
Percent
Pabwo HCIII
Labworomor HCIII
Cwero HCIII
Lalogi HCIV
Odek HCIII
Lapainat HCIII
Ongako HCIII
Bobi HCIII
Awach HCIV
Opit HCIII
Gulu Hospital
Aywee HCIII
Gulu District
Health Facility
Client-Provider Interaction
End of Project Evaluation of the Capacity Project | 105 
44
67 64 63 63 63
57
52 51
33 30
21
13
0
10
20
30
40
50
60
70
80
90
100
Percent Gulu District
Bobi HCIII
Cwero HCIII
Labworomor HCIII
Aywee HCIII
Gulu Hospital
Pabwo HCIII
Lalogi HCIV
Awach HCIV
Opit HCIII
Odek HCIII
Ongako HCIII
Lapainat HCIII
Health Facility
Provision of Information to Clients
End of Project Evaluation of the Capacity Project | 106 
PMTCT Performance Assessment Team for Gulu District 
1. Mr. Lokach Okot G Ag DHO 
2. Dr. Lawino Anna M/O Lalogi HCIV : Tel No 0772448801 
3. Ms. Anena Grace Ag DHV 
4. Mr. Yoweri Idiba Biostastician, DHO Office: Tel No 0775 3416 
5. Mr. William Onyai Clinical Officer, Awach HCIV: Tel No. 0772939754 
6. Mr. Opwonya Boniface Ag District Health Inspector 
7. Mr. Ogwang Oscar District Cold Chain Technician 
8. Mr. William Nyeko Senior Clinical Officer In charge HSD 
9. Ms. Maginoh Olwit Ruth Senior Training Officer, MOH 
10. Ms. Matte F Rita Program Officer, Capacity Project 
End of Project Evaluation of the Capacity Project | 107 
Appendix 13(A): List of Consultants Available For Work on HRH 
# NAME AREA OF EXPERTISE CONTACT
1 Prof. Sam Luboga Health Worker Training 
2 Prof. Anne Katahoire Social Research, HIV/AIDS 
3 Mr. William W. Ogulei Human Resource Management 
4 Dr. Andrew Mwanika Health Worker Training Tel: 0712-812294 
5 Dr. Joseph H. 
Kyabaggu 
Health Systems 
Management/Development 
6 Dr. Sam A. Okuonzi Health Policy and Planning 
7 Dr. Elidad Mabumba Public Health Interventions Tel: 0772670319 
8 Mr. W. Rwandembo 
Mugisha 
Curriculum Development/Review Tel: 0772-442833 
9 Mr. Benjamin Udong Health Professional Councils’ 
Management 
10 Dr. Sebastian Baine Health Care Financing sbaine@musph.ac.ug
11 Mr. Festus Kibuuka Capacity Building 
12 Dr. Mbona 
Tumwesigye 
Health Statistics and Data Analysis 
13 Dr. Elizeus 
Rutebemberwa 
Policy and Planning ellie@musph.ac.ug
14 Ms. Adrienne Karianah Marketing Research adrienne@transparencyresear
ch.co.uk 
 Source: Capacity Project
End of Project Evaluation of the Capacity Project 108
Appendix 13 (B): Potential Private Consultants Available at the 
School of Public Health, University of Makerere 
This appendix is in an appended PDF document by the same name. It lists the staff, 
qualifications, and areas of expertise of academic staff at the School of Public Health University 
of Makerere, Kampala.
Names Position Specialization Qualification E-mail 
Dr. J. Konde￾Lule 
Associate 
Professor 
Epidemiology and 
Research Methods 
MBChB, DPH, 
MSc 
jkonde@musph.ac.ug
Dr. F. 
Wabwire￾Mangen 
Associate 
Professor 
Epidemiology & 
Biostatistics 
MBChB, MPH, 
PhD 
fwabwire@musph.ac.ug
Dr. David 
Ndungutse 
Senior Lecturer Epidemiology and 
Research Methods 
MBChB, DPH, 
MSc 
dndungutse@musph.ac.ug
Dr. David 
Guwatudde 
Senior Lecturer Biostatistics PhD dguwatudde@musph.ac.ug
Dr. Nazarius 
Mbona 
Tumwesigye 
Lecturer Biostatistics B. Stat., MA 
(Demo), MSc, 
PhD 
tmbona@musph.ac.ug
Dr. Fredrick 
Edward 
Makumbi 
Lecturer fmakumbi@musph.ac.ug
Dr. Dan 
Bagenda 
Lecturer Biostatistics B. Stat., MSc, 
PhD 
dbagenda@musph.ac.ug
Dr. Edith 
Nakku Joloba 
Lecturer Epidemiology MSc Epi, PhD 
Mr. Simon 
Kasasa 
Ass. Lecturer Biostatistics B. Stat., MSc skasasa@musph.ac.ug
Mr. David 
Mukaga Odaka 
Ass. Lecturer Epidemiology B. Pharm, MPH dmukanga@afenet.net 
Dr. Joan 
Nankya 
Ass. Lecturer Epidemiology MBChB, MSc. 
Epi 
Mr. Francis 
Muwonge 
Teaching 
Assistant 
Demography B. Stat., M. Stat fmuwonge@musph.ac.ug
Dr. Jude 
Olinga 
Teaching 
Assistant 
Health Informatics MBChB 
Dr. Nakacubo 
Gitta Sheba 
Research 
Fellow 
Epidemiology B. Dental Surgery, 
MPH 
sgitta@musph.ac.ug
Dr. Roy 
William 
Mayega 
Research 
Fellow 
Epidemiology MBChB, MPH rmayega@musph.ac.ug
Mrs. 
Tabusibwa 
Kirunda B. 
Eva 
Ass. Lecturer Epidemiology BSc. FST, MPH bkirunda@musph.ac.ug
Dr. Juliet 
Sekandi 
Academic 
Coordinator 
MHSR 
Epidemiology MBChB, MPH jsekandi@musph.ac.ug
Dr. Noah 
Kiwanuka 
Lecturer Epidemiology MBChB, MPH, 
PhD 
Noah.kiwanuka@case.edu
Dr. George W. Senior Lecturer International MBChB, MSc, gpariyo@musph.ac.ug
End of Project Evaluation of the Capacity Project 109
Pariyo Health/Health Systems 
Management 
PhD 
Dr. S.O. Baine Lecturer Health Care Financing MBChB, 
DTM&H, MPH, 
PhD 
sbaine@musph.ac.ug
Dr. Olico-Okui Lecturer Health Management & 
PHC 
MBChB, DPH, 
MSc 
ookui@musph.ac.ug
Dr. Suzanne 
Kiwanuka 
Lecturer Health Policy & 
Planning 
BDS, PhD skiwanuka@musph.ac.ug
Dr. Freddie 
Ssengooba 
Ass. Lecturer Health Care Financing MBChB, MPH sengooba@musph.ac.ug
Dr. Elizabeth 
Ekirapa 
Kiracho 
Ass. Lecturer Health Economics MBChB, MPH, 
MPH(Econ.) 
ekky@musph.ac.ug
Dr. Peter 
Waiswa 
Ass. Lecturer Primary Health Care MBChB, MPH 
Mr. Chrispus 
Mayora 
Teaching Asst. Health Economics BA(Economics) 
Dr. Elizeus 
Rutebemberwa 
Research 
Fellow 
Health Planning & 
Management 
BA, BTh., 
MBChB, MPH 
ellie@musph.ac.ug
Dr. Virgil 
Onama 
Research 
Fellow 
Health Systems 
Management 
MBChB, MSc. vonama@musph.ac.ug
Mr. Edward 
Galowango 
Site Operations 
Coordinator, 
Iganga￾Mayuge DSS 
Demography BA, MA 
(Demography) 
egaliwango@musph.ac.ug
Dr. Moses 
Arinaitwe 
Research 
Fellow 
Population & 
Reproductive Health 
MBChB, MSc. 
(Pop & RH) 
marinaitwe@musph.ac.ug
Mr. Aloysius 
Mutebi 
Research 
Fellow 
Public Health/Statistics B. Stat. MPH amutebi@musph.ac.ug
Dr. Christine 
Nalwadda 
Research 
Fellow 
Field Coordinator BDS, MPH enalwadda@musph.ac.ug
Dr. Nicholas 
Ayebazibwe 
Research 
Fellow 
 MBChB, MPH naybazibwe@afenet.net
Ms. Enid 
Kemari 
Administrative 
Asst. 
Public Administration 
& Management 
BA(Arts), 
MA(PAM) 
ekemari@musph.ac.ug
Mrs. Adikini 
Anne J. Oketch 
Administrative 
Asst./Secretary 
Administration BA(SS) PGD(HR) jadikini@musph.ac.ug
Dr. David 
Serwadda 
Associate 
Professor 
Epid. & Comm. D’se 
Control 
MBChB, MMed, 
MPH 
dserwadda@musph.ac.ug
Dr. William 
Bazeyo 
Senior Lecturer Occupational Health MBChB, MMed wbazeyo@musph.ac.ug
Mr. M. 
Oryema￾Lalobo 
Senior Lecturer Entomology/Parasitolo
gy 
BSc. MPH mlalobo@musph.ac.ug
Dr. Fred 
Nuwaha 
Senior Lecturer Communicable 
Disease Control 
MBChB, MPH, 
PhD 
fnuwaha@musph.ac.ug
Dr. Margaret 
Muganwa 
Lecturer Env. Health & Food 
Hygiene 
MBChB, MPH, 
DFH, MS 
mmuganwa@musph.ac.ug
Dr. John 
Ssempebwa 
Lecturer Environmental 
Toxicology 
BSc., MSc. PhD jssempebwa@musph.ac.ug
Dr. Juliet 
Babirye 
Ass. Lecturer Disease Control MBChB, MPH jnbabirye@MUph.ac.ug
Dr. John Bosco 
Damulira 
Ass. Lecturer Public Health MBChB, MPH 
End of Project Evaluation of the Capacity Project 110
Dr. Esther 
Buregyeya 
Ass. Lecturer Occupational Health MBChB, M. Phil 
Health Science 
eburegyeya@MUph.ac.ug
Mr. Abdallah 
Ali Halage 
Teaching Asst. Environmental Health BEHS 
Mr. Stephen 
Tusingwire 
Teaching Asst. Environmental Health BEHS 
Ms. Ruth 
Mubeezi 
Teaching Asst. Environmental Health BEHS, MSc. 
(Env. Sc.) 
rfmubeezi@yahoo.com 
Mr. Richard 
Mugambe 
Teaching Asst. Environmental Health BEHS, MSc. 
(Env. Sc.) 
Rose 
Namuyanyi 
Personal 
Secretary