Challenges faced during the development of new high demand public

hospitals with limited budgets, land and time constraints in the City of
Kampala, Uganda
D. Abola2, P. Kaliba2, R. Sengonzi2, S. S. B. Wanda2 and C.I. Meirovich1
1
Meirovich Consulting, Healthcare Facilities Planner, Madrid, Spain
2
Improvement of Health Services Delivery at Mulago Hospital and in the City of Kampala Project (MKCCAP), Ministry of
Health, Kampala, Uganda
e-mail: claudio@meirovichconsulting.com; Address: Rodas 5 2-2, Madrid 28005, Spain; Ph. (+34) 91 530 3076
e-mail: ruthsengonzi@yahoo.co.uk; Address: P. O. Box 8096, Kampala – Uganda

The 11th Biennial SAFHE/CEASA Conference and Exhibition, 11-13th August 2015, Sandton,
Johannesburg, RSA

Abstract
The population of a city is usually represented by the resident population and planning of the
required city infrastructure in several cases only takes into account this population. Kampala
City’s population is erroneously represented as the night/resident population (approx.
1.7Million) without consideration of the transient day population (approx. 4Million) who also
seek health services, among other things, from the city. Ideally, it is the day population that
proposed facilities should consider in planning and decision-making.

The “Improvement of Health Services Delivery at Mulago Hospital and in the City of Kampala
Project” (MKCCAP) funded by the African Bank of Development and the Nigerian Trust Fund
was designed to improve access to quality and affordable health care services for the population
of the City of Kampala by among other activities, constructing and equipping two new regional
hospitals in Kawempe and Kiruddu in the City. Each hospital has a capacity of about 170 beds
with a gross floor area of 13,000m2, on less than 2 acres and with a budget of approximately 11
Million US Dollars.

In an ideal situation and following international standards for sustainability, with regard to
environmental friendliness, a general hospital design would require a) a ratio of between 100 –
120 m2/bed that the City of Kampala did not have available; b) a budget for medical equipment
between 40% - 50% of the construction cost, that the project was not able to fund; and, c) any
construction activities would include temporary infrastructure to continue providing services
while the new infrastructure is built, that was not provided for in the project’s design.

As a result the project team has had to overcome a number of challenges to achieve the required
objectives while at the same time meeting minimum “local” / custom standards. A single design
was used to optimize the use of resources and existing plots were identified to take advantage of
the available land instead of having to acquire new land. The design was concluded with a 76.22
m2/bed ratio; and, the medical equipment requirements were split between essential and non-
essential to limit the initial purchase to the minimum necessary (essential) to open the hospital
while leaving the rest to a second phase.

The projects are estimated to be concluded after 30 months of design, construction and
equipment and are currently at 65% of progress. They are expected to become a reference for
future similar projects in the city and in the country.

Key words: ADF, donor-funded projects; Kampala City; quality and affordable healthcare;
Uganda
1 
 
1.0 Introduction
1.1 Background
Uganda is located in East Africa, sharing its borders with Kenya to the East, South Sudan to the
North, Democratic Republic of Congo to the West, and Rwanda and Tanzania to the South. It
covers an area of 241,038 square kilometres, of which land is 197,097 square kilometres. The
minimum altitude above sea level is 620 meters and the maximum level is 5,110 meters. The
vegetation is composed of savannah grassland, woodland and tropical high forests.

As per the recent national census that was carried out in 2014 by the Uganda Bureau of
Statistics (UBOS) the population of Uganda stands at 34.1Million people increasing the average
population density from 133, to 156 persons per square kilometre. The percentage of males
stands at 48.5% of the population, while 51.5% are female; with 88% of the population resident
in rural areas. The population growth rate is estimated at 3.2% per annum translating into annual
increments of approximately 1 million people.

The projected population demographics for Kampala for the period under review have been
calculated basing on the annual population growth of the capital city which is estimated to be
3.6% (Population Report 2012 by Uganda Bureau of Statistics (UBOS)) hence estimating a total
of 1,788,682 persons. However it should be noted that the city attracts approximately 4 million
people during the day. The figure below shows a map of Uganda and Kampala (inset).

 
Figure 1: Project Map Area, Source: African Development Bank, 2009

2 
 
1.2 Project Rationale
The Government of Uganda represented by Ministry of Health secured a loan from the African
Development Fund (ADF) and the Nigerian Trust Fund (NTF) to improve health services delivery
at Mulago National Referral Hospital and the City of Kampala. The proceeds of this loan are being
applied to the implementation of a project designed to increase access to quality and affordable
health care services for the population of the Kampala Metropolitan area under the “Improvement
of Health Service Delivery in Mulago Hospital and in the City of Kampala Project (MKCCAP).

The MKCCA Project is centred on three broad strategic outcomes:

 Capacity development and system strengthening
 Revitalized referral and counter referral system and
 Expanded and improved health facilities and services

This project was designed to redirect the high demand for basic healthcare that currently congests
services delivery at Mulago Hospital-the tertiary care facility for medical services by supporting
the establishment of two new secondary health care facilities and a referral system. It was also
designed to improve access to quality and affordable health care services for the population of
the City of Kampala by among other activities, constructing and equipping two new regional
hospitals in Kawempe and Kiruddu in the City. Each hospital has a capacity of 170 beds with a
gross floor area of 13,000m2, on less than 2 acres and with a budget of approximately 11
Million US Dollars. The construction of the two hospitals is under the expanded and improved
health facilities and services.

2.0 Healthcare Service Delivery in Uganda and the City of Kampala

2.1 Access to health services
An estimated 24.5% of the population lives below the poverty line, 34.2% from rural areas and
13.7% from urban areas. While physical access (residing within 5 km radius of a health facility)
has improved, reaching over 72% of the population, utilization and effective coverage of key
interventions present a mixed picture1. Interventions targeted to HIV/AIDS and Malaria
Control Programs registered marked progress since 2004/05. Coverage of: (a) children under-
five who receive effective treatment for fever within 24 hours increased from 60% to 71%; (b)
pregnant women who receive Intermittent Presumptive Treatment (IPT) for malaria during
pregnancy increased from 34% to 47%; and (c) households with at least one insecticide treated
bed nets (ITN) increased from 15% to 42% between 2004/5 and 2010/11.

Uganda has registered improvements in Health Nutrition and Population (HNP) outcomes, but
the outcomes remain by and large poor compared to other countries in the region. Maternal
Mortality Rate (MMR) is estimated at 438 deaths per 100,000 live births, Infant Mortality Rate
(IMR) at 54 deaths per 1000 live births and stunting in children under five at 13.8%, but
projected to be 12.5% by 2015.

The status of key Health Nutrition and Population (HNP) outcomes is outlined in Table 1.

                                                       
1
Health Sector Strategic Plan 2005/06 – 2009/10 Midterm Review Report, Ministry of Health, October 2008
3 
 
Table 1: Health Outcome Indicators 1989 – 2011
1989 1995 2000 2006 2011
Infant Mortality 119 97 88 76 54
Under five mortality 180 147 152 137 90
Infant Immunization Rate 31% 47% 38% 46.5% 68%
Maternal Mortality 523 506 505 435 438
Deliveries supervised by skilled health providers 38% 38% 38% 41% 42%
Total Fertility Rate 7.3 6.9 6.9 6.7 6.05
Contraceptive Prevalence Rate 5% 15% 18% 23.7% 33%
Stunted children (chronic malnutrition) 43% 38.8% 38% 32% 33%
Source: Uganda Demographic Health Surveys 1989, 1995, 2000, 2006 and 2011

The health sector in Uganda is geared towards reducing morbidity and mortality from the major
causes of illness by delivering the Uganda National Minimum Health Care Package (UNMHCP)
– the foundation of health reforms enacted with the adoption of the Poverty Eradication Action
Plan in the 1990s. The Government of Uganda’s (GoU) current commitments with regard to the
UNMHCP are captured in the National Health Policy II (NHP II) for the period 2010-2020 and
the Health Sector Strategic and Investment Plan (HSSIP) which covers the period 2010/11 -
2014/15.

The 2011-2015 Country Strategy Paper (CSP) pillars focus on: (a) supporting infrastructure
development (Pillar I); and (b) improving capacity skills development for poverty reduction
(Pillar II). During its inception, the MKKCA project was expected to benefit the entire national
population estimated at 31.8 million (at the time circa 2009) since Mulago Hospital is the main
National Referral and Teaching Hospital. Immediate project beneficiaries are estimated at 3
million people (9.4% of the national population), and the city residents estimated at over
1.7Million. However it should be noted that the city attracts approximately 4 million people
during the day. The majority beneficiaries are the vulnerable groups (women and children)
under 15 years. The project’s emphasis targets efficiency in services planning and management
to ensure the effective delivery of the UNMHCP.

2.2 National Health Infrastructure – Situation Analysis

Provision of health services in Uganda is decentralized through a tiered structure with districts
and health sub-districts (HSDs). Unlike many other countries, in Uganda there is no
‘intermediate administrative level (province, region). The health services are structured into
National Referral (NRHs) and Regional Referral Hospitals (RRHs), general hospitals, health
centre IVs, HC III, Health Centre II and HC-Is. The HC-I has no physical structure but a team
of people (the Village Health Team (VHT)) which works as a link between health facilities and
the community.

Table 2 summarises the various levels of Health facilities in Uganda. The total service outlets
comprise 4,497 facilities, of which 2,809 are Government owned, 899 belong to Private-not-for-
Profit (PNFP) and 789 belong to the private sector.

The facilities include:

 155 Hospitals (65 Government, 63 PNFP and 27 Private)
 206 Health Centre IV (182Government, 17 PNFP and 7 Private)
 1327 Health Centre III (977 Government, 325 PNFP and 25 Private)
 2809 Health Centre II (1734 Government, 494 PNFP and 581 Private)
4 
 
 Table 2: Health Care Provisions in Uganda
Health Unit Infrastructure Beds Location Population
Health Centre I None 0 Village 1,000
Health Centre II OPD 3 Parish 5,000

Health Centre III OPD, Maternity, General 8 to 24 Sub-County 20,000

Ward
Health Centre IV OPD, General ward, 25 to 59 County 100,000
Theatre, Maternity
General Hospital OPD, various Wards, Lab, 60 to District 100,000 to
(GH) X-ray, Kitchen/Laundry. 249 1,000,000
Regional Referral All the above plus 250 to Region (3 to 1,000,000 to
Hospital (RRH) Specialists in various fields 500 5 districts) 2,000,000
National Referral Advanced Tertiary Care 450 to National Over 30,000,000
Hospital (NRH) 1,500

The Government owned Hospitals are Fifty Seven (57) in number as indicated in Table 3 below.

Table 3: Government Hospitals in Uganda

Category Hospital Name
National Referral and Teaching Mulago (including the Heart Institute), Butabika, Gulu and
Hospitals (4No.) Mbarara

Regional Referral Hospitals (12 Arua, Hoima, Jinja, Kabale, Fortportal, Masaka, Mbale, Lira,
No.) Soroti, Naguru, Mubende and Moroto.
General Hospitals (41No.) Abim, Adjumani, Anaka, Apac, Atutur, Bududa, Bugiri,
Bukwo, Bundibugyo, Busolwe, Buwenge, Bwera, Entebbe,
Gombe, Iganga, Itojo, Kaabong, Kalisizo, Kagadi, Kambuga,
Kamuli, Kapchorwa, Kisoro, Kawolo, Kayunga, Kiboga,
Kiryandongo, Kitagata, Kitgum, Kyenjojo, Lyantonde, Masafu,
Masindi, Mityana, Moyo, Nakaseke, Nebbi, Pallisa, Rakai,
Tororo, Yumbe

2.3 The Kampala Metropolitan area health situation analysis

Kampala is the capital city of Uganda. Kampala covers a geographical area of about 241,038
square kilometres. As shown in Figure 1 (Section 1.1), administratively, it has 5 divisions
namely: Nakawa, Kawempe, Central, Rubaga, and Makindye, and with 100 parishes and 803
zone/villages. In 2014, the resident population of Kampala was approximately 1.7Million and
the transient day population was 4Million (HMIS Office, KCCA 2014).

Table 4 below shows demographic information for the city, the projects (vulnerable) target
groups (children and women) cover a large percentage demographic at 56% for children below
18years and 23% for women of reproductive age.

5 
 
Table 4: Demographic Information
Demographic Variables  Proportion (%) Population
Total Population  100 1,788,682
Children below 18 years  56 1,001,662
Adolescents and youth (young people:  34.70 620,673
10‐14 years) 
Orphans (for children below 18 years)  10.90 194,966
Infants below 1 year  4.30 76,913
Children below 5 years  19.50 348,793
Women  of  reproductive  age  (15‐49  23 411,397
years 
Expected number of pregnancies   5 89,434
Source: HMIS Office, KCCA 2014 

3.0 Project Challenges

3.1 Competing needs for effective delivery of essential healthcare services
Kampala health systems are challenged by the competing needs for effective delivery of
essential health care services including reproductive and neonatal health care. As a result
Mulago Hospital’s tertiary care and referral support is neither being fully resourced nor utilised
in line with its national mandate. Furthermore, Uganda needs to respond and better manage new
challenges posed by the epidemiological transition challenges posed by the rising prevalence of
chronic diseases such as cardiovascular diseases, diabetes and cancer. More effective, but also
more expensive, service delivery standards and health technologies are required to assure
attainment of better health outcomes.

The MOH currently has oversight on only Mulago Hospital and Butabika Hospital (a mental
health facility) as there are no other government managed referral hospitals in this area. As a
result, Mulago Hospital is the main tertiary health care facility for medical referrals from both
government and privately managed facilities.

Moreover, according to the KCCA Annual Health Report for the year ending 30 June 2014,
there are 1,370 health facilities in Kampala providing curative health services to an estimated
catchment population of 4 million people in the capital city per year. A significant percentage
(90%) of the health facilities in Kampala are Private For Profit (PFP) facilities and are at Health
Centre (HC) II level. Among the government health facilities, Kampala Capital City Authority
(KCCA) operates six (6) health facilities located in the five divisions of Kampala City serving
an estimated catchment population of 400,000 people per year. Four (4) of the health facilities
are Health Centres III, one (1) Health Centres IV.

Table 5: The breakdown of the facilities by ownership and level

Facility Level Ownership Total (%)
Govt. NGO Private
Hospital 6 9 10 25 (1.82)
HCIV 5 3 7 15(1.09%)
HCIII 7 39 21 67(4.89%)
HCII 8 20 1235 1263(92.19%)
TOTAL (%) 26 (1.90%) 71 (5.18%) 1273 (92.92%) 1370 (100%)
Source: HMIS Office, KCCA 2013/2014 
6 
 
As shown in Table 5 above, public facilities only account for 1.90% in terms of number of
health facilities in Kampala. This implies due to lack of other public providers, Mulago Hospital
is usually diverted from its core mandate of providing national referral services to cater for the
lower level services.

3.2 Lack of adequate infrastructure and logistics for provision of equitable health services
especially for the urban poor
In Uganda, about 15% of all pregnancies develop life threatening complications and require
emergency obstetric care (EmOC) and only 11.7% of women deliver in fully functional
comprehensive EmOC facilities and as it was pointed out in the Health Sector Strategic Plan
(HSSP III), the slow progress in addressing maternal health problems in Uganda is due to lack
of HR, medicines and supplies and appropriate buildings and equipment including transport and
communication equipment, among others. The objective of the Health Infrastructure
Development and Management Plan (HIDM) in the HSSP II (2008) was to ensure a network of
functional, efficient and sustainable health infrastructure for effective health services delivery
closer to the population. The Government of Uganda is committed to provide equitable health
services especially for the urban poor who cannot afford to pay for services in the
predominantly for-profit healthcare industry in the City. The medium term plan for the
Government of Uganda is to establish 5 general hospitals, one in each of the City divisions. The
construction of the 5 new city hospitals is a response to the HIDM mandate.

3.3 Budgetary Constraints

Currently, under this MKCCAP Project, as mentioned earlier, 2 General Hospitals are being
constructed at Kawempe and Kiruddu to decongest Mulago National Referral Hospital to enable
it focus on delivery of super specialized health services. In order to enable the delivery of super-
specialised services at Mulago, the project is also charged with a comprehensive renovation of
the Hospital, which was commissioned in the early 1960s, including a total overhauling of
electro-mechanical services, construction of a new theatre block, improved A&E and
diagnostics infrastructure. At project appraisal, construction and equipping the three hospitals
was estimated to cost USD 75Million. The 2 new hospitals are expected to provide services at
the Regional Referral Hospital level (refer to Table 2 for expected services) and are to be
accommodated within a 10-strorey building. Therefore, the project is currently faced with
budgetary constraints of having to establish the 2 new hospitals and fully renovating the national
referral hospital, as well as fully equipping all three, within the budgeted 75Million UD Dollars.

3.4 Outdated project estimates

The project appraisal was carried out in 2009 but actual project implementation did not take
place until October 2012. Therefore, the estimates that were prepared at inception of the project
were rendered outdated because of the long passage of time between 2009 and the time of
tendering the works and consultancy services in 2013. This has implied that the project
implementation team has to constantly keep adjusting the original scope of work envisaged at
the project feasibility stage while at the same time having to strike a balance with the expected
project outcomes.

3.5 Late recruitment of the Biomedical Engineer

During the appraisal stage of this project, it was planned that only a few key technical staff
would be initially recruited to supervise day-to-day project activities such as overseeing design
reviews and coordinating supervision consultancy activities for the three hospitals’ construction.
7 
 
These were referred to as long-term technical assistants. The long-term technical staff recruited
at the time included the project health architect, the project engineer, the project quantity
surveyor, the procurement officer, the financial specialist and his assistant. The other short-term
technical assistants including the biomedical engineer would come on board later on during the
project’s implementation. As such, the biomedical engineer came on board much later on, after
the 2 hospitals’ designs had already been reviewed and construction of the structural frame and
walling in advanced stages. The biomedical engineer’s tasks involved reviewing the designs and
development of room-by-room equipment lists, among other tasks. The biomedical engineer
found several design flaws that could affect the optimal functionality of the hospitals and
medical equipment, and hence advised on remedial design changes which involved demolition
of walls and electro-mechanical works re-alignment. The changes further stretched an already
constrained budget and caused delays due to rework.

In addition, after preparing room-by-room equipment lists and estimates, the biomedical
engineer discovered that the allocated budget of under 2Million US Dollars per hospital was not
sufficient for loading the hospitals with the required medical equipment and equipment, for the
designed level of service. Therefore, if the biomedical engineer had been on board from the on-
set, such information would have been available much earlier on in the project.

4.0 The Solutions

4.1 Compromising with space standards
Generally, land acquisition within urban areas especially in the city comes at a premium. The
loan amount borrowed for this project was not sufficient to acquire land in the city as well as to
construct the 2 hospitals that used to be at health centre level, on bigger acreage befitting
hospital status. As such, the Ministry of Health had to improvise and directly use the health
centres’ land to put up the 2 new hospitals. In order to meet the high demand for lower level
services, this project has had to cram various clinical services (i.e. A&E; pathology; OPD with
services including dental, Eye/ENT, orthopaedics, antenatal, paediatrics; imaging diagnostics &
laboratories; 5 operating theatres and inpatient services) into a small acreage (less than 2 acres).
Each of the hospitals will have 173 beds and a total built area of around 13,000m2 housed in a
ten (10) storey building.

From review and measurement of the design drawings carried out to determine the total net
area2 assigned to the different clinical, clinical support, non-clinical support and administrative
services, the total area is estimated to be around 7,800 m2.

These figures are used to compare the project with previous ones in similar settings. The first
ratio that is determined is the gross to net ratio. In this case this ratio is 1.69 which is considered
as average in hospital projects.

The second ratio that is calculated is the cost per square meter. In this case this ratio probably
includes only the “grey” construction with some installations (like electricity, HVAC, fire
detection, water sewage, water treatment) but it may probably not include specialized
                                                       
2
The estimated net area doesn’t include corridors, escalators, elevators, balconies or any common areas.
8 
 
installations like medical gases or clean HVAC for theatres, laboratories and CSSD. In this case
the ratio, of about 860USD/m2 and 786USD/m2, is low for both hospitals as compared to other
similar projects.

The third ratio estimates the total space per bed. In this case it goes up to76sqm/bed which used
to be considered adequate in the 1980s but that is considered to be low to achieve and comply
with a number of international standards. Ratios above 100 would be more appropriate. In these
two cases just reducing the number of beds per room/bay would bring the hospital to about 150
beds and to a higher spatial and quality standard. However, due to space constraints while at the
same time having to deliver the project objective of decongesting the national referral hospital
as well as achieving the appraisal target, having less than 170 beds was non-negotiable.

The following tables summarize the information collected and processed from the drawings and
the project quarterly reports.
Table 6: Kawempe General Referral Hospital construction project key data
Kawempe General Referral Hospital
Buildings
Main Building 10 Levels
Service and Admin Block 3 Levels

Total built area (m2) 13,185.56

Total estimated net area (m2) 7,785.58
Total Contract Sum (USD) 11,341,651,23

Table 7: Kawempe hospital key design indicators

Ratio 1 Estimated m2/bed ratio 76.22
Ratio 2  Estimated USD/m2 ratio (just construction) 860.16
Ratio 3  Estimated gross/net ratio 1.69

Table 8: Kiruddu General Referral Hospital construction project key data

Kiruddu General Referral Hospital
Buildings
Main Building 10 Levels
Service and Admin Block 3 Levels

Total built area (m2) 13,185.56

2
Total estimated net area (m ) 7,785.58
Total Contract Sum (USD) 10,369,012.18

9 
 
Table 9: Kiruddu
u hospital key design in
ndicators
Ratio 1 Estimated
E m2/bed ratio 76.22
Ratio 2  Estimated
E USSD/m2 ratio (just construuction) 7786.39
Ratio 3  Estimated
E gro
oss/net ratio 1.69

In adddition, the rev

view of the project
p site and
a design sshows a lackk of space to develop thee design
horizoontally which h is clearly seen
s by the number
n of pparking spaces that havee been includded and
uilding goes up the 10th floor in a foootprint that is not biggerr than 1500ssqm.
the facct that the bu

The nu umber of ellevators in th

his 10-storeyy building iis just 2 genneral elevatoors and one service
elevato
or which do oes not seemm enough fo or a 170-bedd fully workking hospitall. The solutiion has
been to
t include a ramp wrap--around designed arounnd the bank of elevatorss to ensure a quick
evacuaation way bu ut under norrmal operatiion a patientt in a wheelcchair wouldd have to maake 460
metress to get from
m the entrance to the 100th floor. Orrdinarily, in other countrries and witth more
space and less buddgetary constraints, two more elevatoors would bee consideredd as a minim mum.

Figure 2: Kawempe
K Site
e Layout

Emerg gency servicces need to be

b on the gro ound floor aas well as maany other suupport servicces like
the lauundry, kitch
hen, workshops, generattors, water treatment plants, the w warehouses aand the
morgu ue. A solutio
on was found d to assure easy
e access to the OPD in the seconnd floor. Hoowever,
locatin
ng the imagiing diagnostiics equipmen was done heere, could become a
nt in the thirrd floor, as w
challennge by itselff not only beecause of th
he load the sstructure willl have to beear but also tthe fact
that floors and ceiilings will have
h to be leeaded. The sstructural designs were eenhanced to ensure
the loaadbearing caapacity of thhe floors waas improvedd to carry thee heavy diaggnostic equiipment.
10 
 
Careful planning is crucial to enable the success of the equipment installation on this level.
Figure 2 above, shows a site layout of one of the two hospitals. Note the level of congestion on
site and the footage of the buildings in comparison to the available acreage.

4.2 Stakeholder Involvement

At the onset of the project’s implementation, architectural and structural designs had already
been prepared by another consultant during the feasibility stage. However, due to passage of
time, key stakeholders had changed and with the advent of new information, the designs had to
be reviewed and modified by another consultant (who is also responsible for day-to-day
supervision of ongoing works). With the budgetary and space constraints, it was deemed
important to involve stakeholders in the design review. That way, no matter what compromise
had to be reached, stakeholders would be part of the problem-solving and their buy-in was
considered critical to the success of the constrained project. As such, stakeholders have been
involved in the project’s implementation ever since the design review stage, evaluation stage for
both supervision consultants and building contractors, as well as the construction stage during
which stakeholders are playing an active role in decision making and attending the monthly site
meeting.

4.3 Re-programming of project funds

In order to overcome budgetary deficits brought about by: revised designs, price fluctuations
arising from passage of time between appraisal stage and actual implementation (2009 v. 2013),
as well as fluctuating dollar rates, the project has had to re-programme funds that were
previously allocated to activities that are no longer considered a priority in order to cater for
critical activities. For example, the two hospitals were originally allocated less than USD
2Million for medical equipment and furniture. However, upon deep analysis and with the
expansion of services to be provided at the new hospitals, the original allocation could no longer
provide for the required level of service. The revised estimated cost for medical equipment
doubled to about 4Million US Dollars necessitating that the shortfall be sought from other
planned but non-priority project activities.

5.0 Conclusion and Recommendations

The construction of the 2 new hospitals is in advanced stages, at about 65% progress and with a
scheduled completion date of 31st December 2015. The tenders for equipping the hospitals have
also been advertised by now. It is hoped that the hospitals will be ready for occupation and
functional by end January 2016 and that the people of Kampala City and Uganda as a whole
will be able to reap the health services benefits that the project was envisaged to deliver. The
hospitals are expected to become a reference for future similar projects in the city and in the
country.

It is recommended that for the next 2 hospitals to be built in the other 2 city divisions, and any
other future donor-funded health infrastructure projects, the following actions be taken to
overcome the challenges experienced in this project.

11 
 
 i) Phasing of works
The desire for the Government of Uganda to decongest Mulago National Referral Hospital by
setting up the 2 city hospitals is commended. However, in future, it is recommended that where
funds are inadequate, projects be phased by using the available funds to first provide priority
infrastructure and services according to international health spatial standards. The phased
hospitals’ designs should have built-in flexibility to allow for future expansion of services
vertically and horizontally when more funds are made available. That way, over-stretched
budgets, space constraints and congestion will be avoided and health facilities built to
recommended international space standards. Otherwise, the same problems currently being
experienced at Mulago National Referral Hospital may be transferred to the new city hospitals.

ii) Assembling the full technical teams early

In order to avoid the problems that occurred because of the late arrival of the biomedical
engineer on the team, projects should consider recruiting the biomedical engineer alongside the
other key technical staff. That way, the biomedical engineer’s input is available from the onset
of the project and demolitions and reworks can be avoided. The biomedical engineer’s services
could also be phased in order to have them available whenever needed while at the same time
avoiding redundant periods when they are not fully engaged in the project’s implementation
stage.
iii) Provision of contingency to cover unknown eventualities
Against the backdrop of an ever decreasing financial base upon which governments have to
deliver public services and with increasing project costs, even with borrowed funds, it is
appreciated that budgeted funds are never a bottomless pit. However, projects especially those
being implemented long after feasibility and appraisal stage should have contingency funds built
in to cater for unknown financial eventualities such as price and foreign exchange fluctuations.
This way, the project’s implementation is provided with a safety net to back up any cost
shortages in order to deliver the projects to original plan.

iv) Early stakeholder involvement

During the course of project implementation, stakeholder involvement has been key for the
current evolution of the project and that it is considered as a remarkable condition not seen in
many other countries and public projects. It is recommended that stakeholders are involved
earlier than later in the project in order to get their views on board as soon as possible. Their
early involvement may enable more effective management of stakeholder expectations while at
the same time increasing satisfaction with the end result.

12 
 
References and Bibliography

C. Meirovich, "New District Hospital Design, Construction and Equipment Budget Review," Ulaanbaatar, 
Mongolia, May, 2012. 

C. Meirovich, "New Songinokhairkhan district hospital site review," Ulaanbaatar, Mongolia, May, 2012.

Health Sector Strategic Plan 2005/06 – 2009/10 Midterm Review Report, Ministry of Health,  October 
2008 
 
Kampala Capital City Authority, Directorate of Public Health and Environment, Annual Health Report for 
the year ended 30 June 2014, Kampala 
 
Ministry of Health of Uganda, National Medical Equipment Policy, 4th ed., Kampala, 2009, p. 40. 

Ministry of Health of Uganda, “National Hospital Policy,” Kampala, 2006. 

Ministry of Health of Uganda, “Health Sector Strategic Plan III 2010/11‐2014/15,” Kampala, 2010. 

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