Introduction

The health care industry is an important contributor to the economy, especially to that of the area surrounding health institutions. This effect is even more marked in the case of rural facilities. At national level, it comes in the form of ensuring a healthy productive population and saving costs that would have otherwise been spent on treatment, thus liberating them for use on other developmental purposes. However, being a labour-intensive industry, it also contributes by providing employment for a significant section of the working-age population. At local level, in addition to the general benefits mentioned above, it comes in the form of attracting significant government and external investment to the area, and providing a market for local goods and services. It also helps to ‘keep health dollars at home’by ensuring that locals are treated within their area and thus retaining their health expenditure within their own economy. Yet, the economic impact of the health care industry is still under-estimated the world over, Uganda inclusive. Until recently, most studies of economic impact concentrated on the contribution of activities other than health care (Scorsone 2001; Scorsone 2002) and as such, there are few articles available to be reviewed about healthcare.

Although healthcare contributes to economic growth, some studies have not found it to be among the leading causes of rural economic growth. In a study of rural USA, presence of healthcare services was not perceived by the respondents to be even one of the top 25 causes of rural economic growth (Aldrich and Kusmin 1997). This study in Lacor was therefore done to try to identify and highlight the economic contribution of St. Mary’s Lacor Hospital to the war-torn Gulu region of northern Uganda, which contribution though quietly perceived, has never been quantified and, as such, appears to have been ignored.

By the economic impact of an organisation on an area, we refer to the influence of that organization on the local economy in terms of the level of economic activity generated as a result of the presence of that organisation.

The institution absorbs inputs from outside the local economy and uses some from the local economy to produce its products. Its products are consumed by the local community and beyond. The institution may also make expenditures and investments outside the local economy as shown in this second model.

Economic impact studies try to measure the direct, indirect and induced effects of an institution on the economy. The institution’s direct expenditure, such as when a hospital pays its local staff, is a direct input into the local economy. Purchase of goods and contracted services from the local area such as office and medical supplies, kitchen, cleaning and laundry supplies, masonry etc. is an indirect input. When the employees of the health care institution and those of its suppliers of goods and services get and spend their money in the local economy, this is an induced impact on that economy due to the presence of that institution. Thus, initial expenditures in the health sector cause a ripple of expenditures in the economy, the so-called ‘ripple effect’. The health sector and hospitals in particular are regarded by many a policy maker as economic ‘black boxes’, merely absorbing resources with, in most cases, no light on how they spend them or as ‘bottomless black holes’consuming resources on end. Rarely are they seen as “economic boosters”or ‘productive’entities. In reality, however, the health sector leads to the creation and thriving of support business and payment of taxes around it (Philippakos et al. 2002). That is not to mention the economic impact that is gained by the local economy when the people are treated and gain energy to produce or the gains due to the cost of illness and death saved by receiving health education on health promotion and prevention of illness or actually being treated or rehabilitated in the hospital. Apart from health care provision at various levels, Lacor hospital makes similar economic contributions to the area of Gulu District.

Although the primary mission of a health care institution is to provide quality health care services to the users and contribute to the improvement of their health status, it has become clear that the actual contribution of health care facilities goes far beyond and they also contribute in many ways to the economy of an area. The direct contribution of a health institution in terms of its monetary expenditure is easier to measure than the indirect contribution. Hospitals do not just provide jobs but support the economy by paying taxes, licensing fees and providing uncompensated benefits. Even where hospitals are nonprofit, like Lacor, and may be entitled to some tax exemptions, they still pay a lot of money in taxes. In the Washington state of USA in the year 2000, 36 urban hospitals paid over US $360 million in taxes (Health Care Personnel Shortage, 2003). In fact, in the 2001/2002 Financial Year, Lacor Hospital paid over Uganda Shillings 308 million in taxes and statutory costs other than VAT (Driwale et al. 2003).

Hospitals make a place attractive to live in for many people and in countries with pension and Medicaid schemes, hospitals offering quality services attract retirees to live nearby. These retirees receive money from outside the local area on a regular basis either as pension or as medical care expenses. If they are insured, the money is received directly in the hospitals. Depending on its reputation, ‘medical tourists’–people from outside the normal catchment area of the hospital also come to benefit from the services of the hospital. Thus in a way, the hospital ‘exports’its services and gets paid, bringing in money from outside the local economy and is an important ‘engine’of economic growth.

In Georgia State, (USA) the Economic Forecasting Center of Georgia State University reported that hospitals in the state had contributed US $26 billion to the state’s economy in 1997 and that in the city of Athens alone, three hospitals had had an economic impact of US $656 million, creating 8,146 new jobs on top of their 3,000 payroll (Jones and Salzer 1999). Economic impact studies in rural Georgia (Dever et al. 2000) and the Johns Hopkins University Hospital (JHU) in Baltimore, Maryland, 2002, have shown that most rural health care providers offer employment to the local population, purchase goods and services from the surrounding community and their employee incomes are mostly spent locally. In addition, the presence of a health institution in a locality can induce other economic investments such as banks, markets and shopping malls. These economic investments result from the perception of the people of the benefits that can accrue from the presence of a given health institution. Apart from being major employers, usually the second after schools, rural hospitals pay relatively higher salaries than other employers in the area and purchase a lot of goods and services from the local market. The Georgia Hospital Association (GHA) found that the total economic impact of rural hospitals in Georgia in 1998 amounted to US $5.5 billion, of which indigent care, charity care and other non-reimbursed care was valued at US $172 million and US $29 million was paid in taxes (Philanthropic Collaborative 2002). The South Georgia Medical Centre alone contributed US $438 million to the state economy in 2001. According to the GHA, the direct hospital expenditure was about US $146 million but when combined with an output multiplier, it increased by US $327 million of which US $110 million was earned through the household earnings multiplier (Watson 2003).

Even where researchers have not used multipliers, health care has still proved to be a leading industry. Mary Stefl and Richard Butler are reported to have shown that despite heavy tourism and military industries in the San Antonio (Texas, USA) area, even without using multipliers, health care was by far the leading source of income, raising US $7.5 billion in direct expenditure against tourism’s US $4.05 billion in 1999. The same authors emphasise that although there had been slower growth in the health care industry of the area, “even slow growth in a big industry has some impact”(Silva 2000).

Hospitals also serve to retain in the local economy funds that would have been spent on health care elsewhere. A hospital in an area helps retain these ‘health care funds’and thus prevents their ‘leakage’outside the local economy. Nowhere has this effect probably been as well documented as in North Dakota (USA), where the economic impact of Community Hospitals, which mainly treat residents, was very significant even without adding the impact of funds received in Military, Veterans, Administration, State and Native American facilities that may also treat foreigners and visitors to the state. North Dakota community hospitals and associated clinics and nursing homes accounted for about US $807 million of in-state expenditures and net returns, employed 14,000 full-time-equivalent positions and still paid US $47 million in state-collected tax revenue in 1997 (Moran 1999). This much would have probably been spent outside the state, the jobs would not have been created locally and the taxes paid locally, had there not been those community hospitals.

In a graphical story, the true economic impact of the hospital sector, even the non-profit ones like Lacor, is further highlighted in The Cincinnati Enquirer of July 29^th 2003 (Kentucky, USA). “Many know that Greater Cincinnati’s economy benefits from the tourists who come here to watch pro sorts or to visit the zoo. But who knew that medical tourists –out-of-town residents coming here for hospital care –generated more than US $363 million last year for the local economy? The figure dwarfs the estimated US $75 million out-of-town fans are expected to spend this season at the new Great American Park Ball. It blows away the US $19.5 million in new money brought to town by the visitors to the Cincinnati Zoo…..”“Even though every hospital in the metro region is a non-profit organization, they still generate US $216 million a year in local and state income taxes, mostly from employee earnings”. The story further highlights the similarity of the negligence of this type of hospitals by their respective local governments and the politicians in developed as in developing countries –“Maybe it’s because hospitals have been a part of their communities for such a long time that they seem like nothing special ……”(Bonfield 2003). In particular, the statement about taxes is also true for Lacor, as evidenced in Driwale et al. (2003) where 12% of the employment costs were paid in taxes other than VAT, from which the hospital is not exempt, (mainly as statutory costs like National Social Security Fund contribution and Pay-As-You-Earn income tax). In most cases, the total revenue of a health institution is the only known value of the potential economic impact on the area. However, a lot of other monetary exchange which is also dependent on the presence of the hospital takes place outside the influence of the hospital. For example, if a hospital has revenue of 5 million dollars, then this figure is, for sure, a potential direct economic impact on the community but if visitors to patients, to staff and to the hospital also spend money outside the hospital but in the same economy, that is never captured in the books of accounts of the hospital (Scorsone 2002).

As a way of improving efficiency and effectiveness, many services in health units like food supply, printing and stationery, cleaning and laundry, construction works and maintenance are usually contracted out to private providers (Dever et al. 2000). In most cases, the tenders for the supply of these services are picked by individuals and organizations from the area surrounding the health institution. A health institution may also have a significant impact on the economy of its surrounding area through the expenditure behaviour of its employees. Most of the revenue of the institution may filter down to the local economy if the employees spend a large part of their incomes locally. This is most marked if the majority of employees are locals. These expenditures in turn support a large number of other jobs like shops, domestic hands, mechanics, carpentry, restaurants and bars. These jobs then generate additional income and another round of spending as these recipients spend money on similar goods and services, thus generating a ‘ripple effect’on the economy. In a study of the economic impact of Knox County Hospital (Kentucky, USA), it was found that the hospital had an impact of nearly US $16 million of which US $12 million represented the hospital’s direct purchases from the community and US $4 million was due to business spending by local hospital suppliers and employees’purchases in the local economy. Therefore, if the expenditures leave the local community, via taxes and non-local spending, they can be seen as real loss of potential jobs and incomes to the local residents (Scorsone 2002; Phillippakos et al. 2002). In Cincinnati, (Kentucky, USA), it was reported that 32 local hospitals had a combined economic impact of US $7.55 billion of which US $3.18 billion was spent in households and 93,518 jobs were supported by the hospitals. Having read the results of that study, the President of the Chamber of Commerce remarked: “this study confirms that the hospital industry is a tremendous driver of the Cincinnati USA economy through the attraction and retention of a highly skilled, well-paid workforce, combined with capital expenditures and the utilization of cutting-edge technology”(Cincinnati Business Courier 2003). In Atoka County, Oklahoma (USA), it was also found that apart from health care provision to the community, the health care sector also provided 11% of the non-farm employment in the county (Doeksen and Schott 2003). Another study covering 9 other Oklahoma counties found that approximately 9% of the total employment for each of the studied counties was directly working in the health sector and, by applying multipliers ranging from 1.45 to 1.87, the health sector accounted for up to 14% of the total employment in the state (Doeksen et al. 1998)

There are various methods of measuring economic impact. In all cases however, it is appreciated that health expenditure has a ‘ripple effect’, cascading to have influence on other sections of the economy. As such each, expenditure has a multiplier effect and by determining the multipliers of each category of expenditure, one can determine the ultimate economic impact of an activity. For example, in Illinois (USA), Monge and Ellis (1997) measured the economic impact of the health care industry in Southernmost Illinois after determining that direct income impacts like staff salaries, wages, local purchases of goods and services, expenses made locally by out-of-the-area visitors of non-resident hospital patients had an income multiplier of 2.0157 and an employment multiplier of 1.2236. In effect this meant that for every dollar expended directly to local recipients by the health care industry, an additional $1.02 would be generated in the local economy and that an additional 1.2 new jobs would be created. Adding this effect to the initial revenue resulted in a very significant impact resulting from the industry.

Multipliers are specific to regions and sectors and are not applicable across the board to other regions or sectors without caution. In addition, the ripple effect from multiplier takes time to develop fully such that within the first year, only 50% may have been realised and it comes to 0 by the 6^th year. According to Scorsone (2002), multiplier effects are a simplified way of representing economic effects in a local economy. The multiplier can be interpreted as the impact of a one-unit change in sales, employment or income that results in a given impact on the local economy. It represents the recycling of money and income in the economy and this recycling process may create new job opportunities and higher wages for individuals. A multiplier is a ratio that helps to calculate the total economic effect for a variety of economic activities.

For an enterprise to have a big economic impact, the ‘leakage’of its resources from the local economy to the outside in form of non-local purchases of goods and services must be minimised. For a rural hospital in developing country like Lacor, this is only possible to a certain extent for, of necessity, some expenditure must be made be outside the local area like that for vehicles, some medical equipment, personnel services, some reagents, and some medical sundry. A few drugs must also be purchased outside the local economy. Some specialized services, e.g. audit and legal services must also be purchased outside. Equally, some income of the hospital employees must also be spent outside the local economy. All these represent leakages on the economic impact.

Purpose of the study

This study was done to try and shed some light on the true economic impact (direct, indirect and induced effects) of Lacor Hospital on the surrounding community, in the hope that the findings thereof may help the hospital management, the local and central government authorities and the surrounding community, appreciate the hospital as an economic resource and make hospital, local and central government policies geared to making the hospital (and others in similar conditions) even more economically relevant to the surrounding community. Having appreciated this role, the local community may move to make the utmost benefit out of it by reducing the leakage of hospital resources outside the area.

Objectives

The study had as objectives, for the Financial Year 2001/2002, to determine

1. The direct impact of Lacor Hospital in form of its revenue
2. The proportion of total hospital revenue that was retained in the area
3. The contribution of Lacor hospital to formal employment in Gulu district
4. The value and types of goods and services supplied to Lacor hospital by local suppliers
5. The expenditure patterns of the employees of Lacor hospital and its suppliers
6. The economic activities in the surrounding communities attributable to Lacor hospital and
7. The perception of the local community about the contribution of Lacor hospital to their livelihood.

Methodology

We conducted a descriptive cross-sectional study, gathering both quantitative and qualitative data from within Lacor Hospital and the 15 km radius surrounding it. We studied the hospital’s financial records for the year 2001/2002, observed the business activities in the surrounding community, held key-informant discussions with the management and staff of Lacor hospital, suppliers of the hospital and their employees, Gulu District local government administrators and held focus group discussions with owners of small-scale businesses in the area surrounding the hospital. Assuming that 95% of the hospital employees spend more than 50% of their earnings locally, we used the Cochran formula to calculate a minimum sample size of 76 health workers and identified the distribution across the different cadres by Probability Proportional to Size (PPS) and identified the respondents by systematic sampling. We used the same formula to determine the 36 small scale businesses to be studied and purposively selected them. In all cases, we added some extra study units to reduce the effect of non-response. Some key Gulu district administration officials like the District Director Health Services (DDHS), the Chief Administrative Officer (CAO), the District Personnel Officer and the Revenue Officer, were purposively selected because of their roles in the district and the information they could provide. Three focus group discussions were held, consisting of 7-10 participants purposively selected from the community (opinion leaders, business proprietors, employees of the hospital).

The revenue of the hospital was spent as shown in the table below.

Table 2 Expenditure areas for Lacor Hospital F/Y 2001/2.

Note: Employee costs including wages of construction workers was 1,851,038,000/=

Of the Uganda Shillings 1,851,038,000 spent as employee costs, 1,376,510,150 (74%) was spent on salaries, wages and allowances and at least 1,170,033,627 (85%) of this was later retained in the local area. Of the 705,732,000 spent on supplies, goods and services, 429,741,950 (61%) was retained in the area. In this category of expenditure, the respective proportions retained in the area are illustrated in the figure below.

Hospital foodstuffs and building materials formed the bulk of the local purchases, followed by vehicle spares and stationery services. Materials for major renovation and construction of buildings were purchased from outside Gulu district, mainly from Kampala-based factories. Hospital equipment was also purchased from outside the district. All in all, 52% of the total hospital income was spent in the area while 48% was spent outside the district.

(Figure 1, 2, 3)

Contribution of Lacor hospital to formal employment in Gulu District

We defined ‘formal employment’as that which is recognised by the government authorities, is subject to public scrutiny and even taxation should the package of benefits fall within the taxable range. The results are shown in the table below. Considering the health sector alone, there were a total of 996 health workers in the district. Lacor Hospital therefore employed 50% (509/996) of the total district health workforce as illustrated below:

Table 3 Formal employment in Gulu District, FY 2001/2

Note: In addition to the 509 permanent health workers cited above, Lacor hospital employed 145 construction casual workers.

Graduated tax contributions by the different employment sectors in the FY 2001/2.

Other benefits for hospital staff

Employee costs amounted to Uganda Shillings 1,851,038,000 (41% of the total hospital revenue) where salaries and wages alone took up to 1,376,510,150 (74% of the total employee costs) and the rest was spent on staff training, travel allowances outside Gulu district, taxes and NSSF contribution. The hospital had an interest free loan scheme for its employees, whose main purpose was to help the staff pay school fees and construct personal houses. Ninety eight percent (98%) of the staff who borrowed, indicated that they intended to use the funds to pay school fees for their children and dependants, presumably within the area. Members could borrow up to 10,000,000/= at any one time and the duration of repayment depended on the individual’s ability to pay back. Total membership to the scheme as of 30^th June 2002 was at 257 members, of whom 236 (92%) had accessed loans amounting to Uganda Shillings 89,821,100 in 2002 alone.

Perception of the community towards Lacor Hospital

The community appreciated the fact that the hospital offered employment for health professionals and peasants from the community around and that the nurses’training school absorbed mostly locals, who later became employees of the hospital. The hospital’s construction, carpentry and masonry departments were training grounds for many of the school dropouts in the community and it was a general feeling that this informal training kept the youth occupied and out of risky behaviors like joining rebel activity and robbery. All the focus groups highlighted the important role of the hospital in offering security to the people, whereby, in order to escape insecurity in their home areas at night, an average of 3,500 people, mostly women and children, trooped to sleep in the hospital compound every night, returning home in the morning. These people made some of their purchases from the center and boosted the local business. The shops and market adjacent to the hospital also benefited from the security personnel at the hospital. Other reported economic contributions of Lacor Hospital included material support to orphans, school fees for needy children and orphans and holiday employment for some school children. Guardians and parents of these children often exchanged their labour for either monetary benefits and/or material support. The immediate communities also accessed clean water from bore holes sunk by the hospital and often, the community provided labour for the construction of these boreholes.

On the contrary, some district officials indicated that the hospital had become too expensive and out of reach for the rural people. One key informant even thought that the hospital had become as expensive as any other profit-making business. Recognising the economic importance of the hospital, they suggested that the hospital could diversify its programmes to include other economic activities like grain milling, vocational training and public construction of buildings so as to create more employment for the area. However, the hospital managers thought that the community did not appreciate these economic contributions. They acknowledged that this may be partially a result of the hospital not informing the community about all its activities and their economic implications. In one of the group discussions, participants suggested that the hospital should find a forum to discuss with the community its plans and objectives. However, general consensus from the group discussions revealed that the community did appreciate the health and economic role of the hospital. Sentiments expressed in the discussions included “If the hospital is not there, how shall we survive?”“Lacor is the umbilical cord, removing it is putting all people of Gulu in problems”. “If Lacor Hospital is not there, it is equivalent to a family well drying up”

Applying the income multiplier

In order to determine the total economic impact on the area produced by the investments into Lacor, we first determined the income multiplier. We agreed that since the hospital had no intention to save any of the funds it received in a year, 100% of the funds were to be spent (x = 1.00). Since 99% of income of the hospital employees and 93% of the income of the employees of the suppliers to the hospital was spent within Gulu, we made an average of these two and came up with 96% as the average percentage spent by staff within the area (y = 0.96). The hospital itself spent 52% of its revenue within the area (z = 0.52). Using the formula cited from Coppedge earlier, we determined that the income multiplier for the health sector in Gulu area, for a PNFP hospital was 1.9968. This meant that for every dollar spent in the area for health, 1.9968 dollars would be obtained, a net effect of 0.9968 dollars. Thus for Lacor Hospital which had a direct impact of Uganda Shillings 4,506,885,000 a total impact of Uganda Shillings 8,999,347,968 would be realised within no more than 6 years, a net effect of Uganda Shillings 4,492,462,968 as indirect impact, most of which would be realised in the first year.

Discussion

The study shows that Lacor, like other health institutions has an importance way beyond its ‘natural constituency’of health care. It has a significant direct economic impact on the surrounding area. By way of external funds attracted to the area, local health care funds retained and employment created, the hospital is indeed an engine of economic growth for the Gulu area. The hospital attracted Uganda Shillings 3,920,989,950 as ‘new money’coming into Gulu from outside the area. Together with the local money, a total impact of Uganda Shillings 8,999,347,968 could be realised in the area surrounding the hospital within a six year period. This means that continued presence of the hospital will continue to bring about development in the area since more money will continue to flow into the hospital.

Lacor hospital made a significant contribution to the total district graduated tax collection but Gulu district local government did not make any direct monetary contribution to the running of the hospital activities. Local taxes are spent on creating public goods and services like roads and schools and this helps to strengthen the area economically. Lacor Hospital is designated as a parish and, according to the Local Government Act, 25% of all locally collected taxes should be refunded by the district to the collecting parish. We noted that this was not being done in the case of Lacor. Were it to be done, Lacor would be receiving from the district an annual refund of Uganda Shillings 3.6 million for local social development. Probably by now, the bitumenising of the road between the hospital and Gulu Municipality or another project of similar magnitude and importance would have been implemented.

There is strong evidence that Lacor Hospital has played and continues to play a key role in the establishment of small-scale businesses in the surrounding community. Considering that their customers were patients, patient attendants, visitors and staff of the hospital, it can be assumed that the hospital indirectly contributed to the development of the businesses. Studies have shown that the presence of a health care institution in an area may result in the attraction and retention of businesses. In the study of the economic impact of Johns Hopkins university hospital in Maryland, it was found that a number of businesses sprang up because of the presence of the university hospital. These businesses contributed up to six billion dollars in economic activities in that area. In all areas where opinions were sought about the economic contribution of Lacor Hospital, there was a strong consensus that the hospital did contribute to the economy of the area although this feeling was not captured by the hospital management. The study established that the community did appreciate the economic and health roles of the hospital more than the top managers realized.

The feeling by the population that the user fees charged were too high and that the hospital was behaving like a profit making enterprise couldn’t be ignored and could be due to the extreme poverty obtaining in the area, whereby even fees that would be very low in other parts of the country are deemed to be too high here. What remains to be seen is whether the total economic impact from the hospital is transformed into a visible improvement of the livelihood of the population but this cannot be anymore a role for the hospital.

Conclusion

In the financial year 2001/2002, St Mary’s Hospital Lacor attracted Uganda Shillings 3.9 billion ‘new money’into the Gulu area and out of its revenue of Uganda shillings 4.5 billion, injected at least 2.3 billion (52%) in the local economy. A total impact of Uganda Shillings 8.9 billion is anticipated as a result of this investment. The hospital, with a staff of over 600 people, was the major single employer in the district and, with over 95% of its staff hailing from Gulu District, and many others training in various skills, is a major developer and consumer of the local human capital. This is a significant contribution to the economy of an area that has been destabilized by insecurity for a long time, bringing most economic and social activity to a standstill.

References

1. The Johns Hopkins University (2003) A study of John Hopkins University Hospital Economic Impact in Maryland on http://www.jhu.edu/news_info/reports/impact/ accessed on October 9^th 2003
2. Aldrich L, Kusmin L, (September 1997), Rural economic development: What makes rural communities grow? US Department of Agriculture, Agriculture Information Bulletin No. 737
3. Arua Regional Referral Hospital. 2002. Annual Report 2001.
4. Bonfield T (2003) Hospitals Cash Cows for City, The Cincinnati Enquirer, June 5^th 2003 on http://enquirer.com/editions/2003/06/05/loc_hospitals0 5.html accessed on July 29th 2003
5. Buffalo Business First, Report says hospital cuts will wound economy, April 7^th 2003 on http://www.bizjournals.com/buffalo/stories/2003/04/07 /daily9.html?t=prinatble accessed on July 29^th 2003
6. Cincinnati Business Courier, June 2^nd 2003, ‘Local Hospitals have $7B economic impact’on http://cincinnati.bizjournals.com/cincinnati/stories/2003 /06/02/daily/37.html accessed on July 14th 2003
7. Coppedge RO, (May 2003) Income multipliers in economic impact analysis, Guide Z-108, Cooperative Extension Service, College of Agriculture and Home Economics, on http://www.cahe.nmsu.edu accessed on October 9^th 2003
8. Cordes S, Van der Sluis E, Lamphear C and Hoffman J (1999) Rural hospitals and the local economy, The Journal of Rural Health, Spring 1999, Vol. 15 No. 2 pp. 189-201
9. Determining your airport’s economic impact, on http://www.californiaaviation.org/pdf_files/airport_eco nomic_impact.pdf accessed on October 9th 2003
10. Dever A. G .E (2000) What are the facts about health care in Rural Georgia?
11. Direct Economic Impact of NASA Langley on Virginia and the nation. http://oea.larc.nasa.gov/org/impact96/VA_Nation_Imp act.html
12. Doeksen G A. (1997) Measuring the economic importance of the health sector on a local economy: A brief literature review and procedures to measure local impacts. Starkville, MS, Southern Rural Development Center, 1997
13. Doeksen G A. (2003) Economic importance of the health-care sector in a rural economy, Rural and Remote Health 3 (online), 2003.
14. Doeksen G A., Johnson T, Biard-Holmes D and Schott V (1998) A healthy health sector is crucial for community economic development, The Journal for Rural Health, Winter 1998, Vol. 14, No.1 pp. 66-72
15. Driwale A, Lokong J A, Corrado B, Bikaitwoha M, Giusti D and Odaga J (2003). Recurrent costs and sources of finance of Lacor Hospital from 1997/98 to 2001/02 Uganda Health Bulletin, Vol. 9
16. Economic Base Concept: Income and Employment Multipliers on http://faculty.washington.edu/krumme/systems/multipli er.html accessed on October 9th 2003
17. Economic Impact of the University of Saskatchewan 1996/97. http://www.IA.usask.ca/ accessed on February 6^th 2003
18. Health Care Personnel Shortage (H-Pro), 2003, Economic Impact: Community benefits on http://www.healthcarepersonnel.org/impact.htm accessed on July 14th 2003
19. Jones W and Salzer J, (1999) Report: Hospitals give state economy $26 billion, in OnlineAthens, June 22^nd 1999 accessed on July 29th 2003, on http://www.onlineathens.com/stories/062299/new_062 2990016.shtml
20. Maryland Hospital Association, Economic impact of Maryland Hospitals on http://www.mdhospitals.org/Facts/economic.impact.htm accessed on July 29th 2003
21. McLure, J, Schools (2002) Hospitals hiring as manufacturers cut staff, Missouri Digital News, State Capital Bureau, December 13^th 2002 accessed on http://www.mdn.org/2002/stories/economy.html on October 9th 2003
22. Ministry of Health (The Republic of Uganda) 1999. Annual Report.
23. Ministry of Public Service (The Republic of Uganda), 2002, Circular Standing Instruction No. 2 of 2002: Salary structure for 2002/2003 Financial Year, Schedules A-2 and B, Kampala, July 2002
24. Monge E A and Ellis R J., (1997), Measuring the economic impact of the health care industry in Southernmost Illinois, Center Research Briefs, Vol. 3 No. 1 1997, Center for Rural Health and Social Service Development, Office of Economic Regional Development, Southern Illinois University Carbondale.
25. Moran, G, (1999) Hospitals important contributor to state’s economy, News for North Dakotans, January 28^th 1999 accessed on July 29th 2003 on http://www.ext.nodak.edu/extnews/newsrelease/1999/0 12899/02hospit.htm
26. Philanthropic Collaborative (2002) Improving Rural Health: An Issues Paper on http://www.philanthropiccollaborative.org/pconetscape/ RHbriefjan02.pdf accessed on October 9th 2003
27. Philippakos E, Hodges A W and Mulkey D (2002) Economic impacts of healthcare in the Rural Health Networks of Florida on http://economicimpact.ifas.ufl.edu/publications/RHNPaper6.pdf accessed on October 9th 2003
28. Probst, J C, Samuels M E, Hussey J R, Berry D E and Ricketts T C (1999). Economic impact of hospital closure on small rural counties, 1984 to 1988: Demonstration of a comparative analysis approach, The Journal of Rural Health, Fall 1999 Vol. 15 No. 4 pp. 375-388
29. Scorsone E A (August 2002). The Economic impact of the local Health Care System on the Lee County Economy on http://www.ca.uky.edu/KRHW/ accessed on October 9^th 2003
30. Scorsone E A, Garcia S and Adams B (December 2001) Economic impact of Knox County Hospital on http://www.ca.uky.edu/krhw/ accessed on June 29^th 2003
31. Scorsone E A (May 2002) Economic impact of Rural Health Care and Hospitals on their Local Economies on http://www.ca.uky.edu/krhw/pubs/02ec_impact_rural.html accessed on June 29th 2003
32. Scorsone E A (October 2002) The Economic impact of the local Health Care System on the Letcher County economy on http://www.ca.uky.edu/krhw/ accessed on October 9^th 2003
33. Shields M, (2003) The Hospital Sector’s Contribution to the Pennsylvania State Economy, College of Agricultural Sciences, Cooperative Extension, 2003
34. Silva L T, (2000) Health care industry leads the pack, study shows, San Antonio Business Journal, September 4^th 2000 accessed on http://sanantonio.bizjournals.com/stories/2000/09/04/story7.html on July 29th 2003
35. Song B, Woods M D, Doeksen G A and Schreiner D, (1990) Multiplier analysis for agriculture and other industries, Oklahoma State University, Extension Facts, F-821 on http://pearl.agcom.okstate.edu/agecon/resource/f821.pdf accessed on October 9^th 2003.
36. The Tanner Health System (2002), Tanner Health System contributes $283.3 million to Area Economy, accessed on July 30^th 2003, on http://www.tanner.org/tmc.nsf/0/d23e7ed0e2838cd285 256dc30067d4df?OpenDocument
37. Watson S (2003) South Georgia Medical Center contributes $438 million to the area’s economy, SGMC News, February 19^th 2003, on http://www.sgmc.org/news/econimpact2003.htm?Displ ayPrintHeader=true accessed on July 29^th 2003
38. Weisbrod G and Weisbrod B (1997). Measuring Economic Impacts of Projects and Programs, Economic Development Research Group, 10 High Street, Suite 620, Boston, MA 02110,
39. Uganda Bureau of Statistics (UBOS), (2002) Population and Housing Census 2002
40. Ministry of Finance and Economic Planning (MoFEP), 1993 Background to the budget 1993/1994
41. Walden M L (2003) Measuring how much economic change will mean to your community, on http://www.ces.ncsu.edu/resources/economics/change/ accessed on October 14^th 2003

Copyright 2003 - Department of Health Sciences of Uganda Martyrs University