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Use of National Health Accounts – the Case of Uganda HEALTH DIVISION DOCUMENT HEALTH DIVISION DOCUMENT HEALTHDIVISION DOCUMENT HEALTH DIVISION MARCH 2006 • HEALTH DIVISION Health Division Document 2006:1 Issue Paper on NHA Use of National Health Accounts – the Case of Uganda HEALTH DIVISION HEALTH DOCUMENT DIVISION HEALTH DOCUMENT HEALTH DIVISION DOCUMENT HEALTH DIVISION DOCUMENT HEALTH DIVISION DOCUMENT HEALTH DIVISION DOCUMENT DIVISION HEALTH DOCUMENT DIVISION HEALTH HEALTH DIVISION HEALTH DOCUMENT DIVISION HEALTH DOCUMENT Content Executive summary ...................................................................... 3 Abbreviations ...............................................................................5 1. Introduction ............................................................................. 7 1.1. Background ..................................................................................7 1.2. Objective, method and structure of the report ............................8 1.3. Limitations ...................................................................................8 2. Overview of the Ugandan Health Sector ..................................... 9 2.1. Recent reforms in the Ugandan health sector ........................... 10 2.2. Provision of health care services ................................................12 2.3. Funding of health care services ................................................. 13 3. Uganda NHA .......................................................................... 15 3.1. First round of NHA .................................................................. 15 3.2. Second round of NHA .............................................................. 16 4. The use of Health Expenditure Data and NHA in Uganda ............ 18 4.1. Opinions regarding health expenditure data ............................ 18 4.2. The use of NHA in Uganda ......................................................18 4.3. Future of NHA in Uganda – a third round? .............................20 5. Concluding Remarks ............................................................. 22 References ................................................................................ 24 List of Health Division Documents ................................................26 1 The views and interpretations expressed in this document are the author’s, and do not necessarily refl ect those of the Swedish International Development Cooperation Agency, Sida. Published by Sida 2006 Department for Democracy and Social Development Authors: Anna H Glenngård and Frida Hjalte, IHE, The Swedish Institute for Health Economics Printed by Edita Communication AB, 2006 Art. no.: SIDA26891en ISBN 91-586-8260-0 ISSN 1403-5545 This publication can be downloaded/ordered from www.sida.se/publications 2 Executive summary National Health Accounts (NHA) is a tool specif cally designed for policy makers and managers of the health sector. It is designed to help them in their efforts to improve health systems performance and make evidence based policymaking by providing useful information of the current use of f nancial resources. This report describes the use of health expenditure data for health policy purposes in Uganda. It is based on interviews with people involved in the Ugandan health sector, on policy documents and other published literature. The interviews were conducted in Kampala during September 2005. The health sector in Uganda has undergone tremendous changes over the past 20 years and multilateral and bilateral donor organisations have gradually moved from project to budget support over the period. The f ndings of the latest Annual Health Sector Performance Report support that the performance of the Ugandan health sector is improving. In 2005, however, the Global Fund to Fight AIDS, TB and Malaria was temporarily suspended due to suspected misappropriated use of funds. The f rst round of NHA in Uganda covered the f nancial year 1997/1998 and was published in year 2000. It was f nanced by Sida, USAID and WHO and produced by the Ministry of Health (MoH) and the Economic Policy Research Centre (EPRC) at Makerere University. The results from the second round were published in 2004 with data covering the f nancial years 1998/1999–2000/2001. The second round was f nanced by Danida and WHO and produced by a team of members from the MoH, WHO, EPRC, Religious Bureaus and Uganda Bureau of Statistics. Although two rounds of NHA have been produced and results from NHA are being used by the MoH as well as by multilateral and bilateral donor organisations the NHA process is not institutionalised in Uganda. There is in-country capacity to produce the accounts but there is no single person or unit that has the responsibility, commitment as well as capacity to lead the process. Both the MoH and development partners foresee a need for a third round. A third round of NHA is believed to facilitate the implementation of the second Health Sector Strategic Plan (HSSP) in Uganda and the evaluation of the f rst HSSP and the health Sector Wide Approach (SWAp). NHA results are believed to provide good information about the impact changes in the health sector have had on health care f nancing. 3 A number of obstacles for the production of a third round, including diff culties in prioritising among different tasks at the ministry level and overall low level of funding in the health sector, have been identif ed in this study. Based on the results from this study it seems appropriate to conduct a third round of NHA covering the years 2001/02–2004/05. When conducting a third round efforts should be made to collect data from the informal sector. A third round could also preferably cover regional spending and sub accounts for one area, e.g. reproductive health. 4 Abbreviations AIDS Acquired Immunodef ciency Syndrome Danida Danish International Development Agency DFID Department for International Development (UK) DHS Demographic and Health Survey ECSA East, Central and Southern Africa EPRC Economic Policy Research Centre EU European Union GFATM Global Fund to f ght Aids, Tuberculosis and Malaria HIV Human Immunodef ciency Virus HMIS Health Management Information System HSD Health Sub-Districts HSSP Health Sector Strategic Plan IDA International Development Agency MDG Millennium Development Goals MoFPED Ministry of Finance, Planning and Economic Development MoH Ministry of Health MoU Memorandum of Understanding MTEF Medium Term Expenditure Framework NGO Non-governmental Organisation NHA National Health Accounts NHP National Health Policy PEAP Poverty Eradication Action Plan PER Public Expenditure Review PNFP Private Not-for Prof t Sida Swedish International Development Cooperation Agency SWAp Sector Wide Approach TB Tuberculosis UN United Nations UNDP United Nations Development Programme UNICEF United Nations Children Fund UNMHCP Uganda National Minimum Health Care Package USAID United States Agency for International Development Ushs Uganda Shillings WB World Bank WHO World Health Organization 5 6 1. Introduction 1.1. Background Many countries in the developing world face poor health conditions and increased burden of disease. In the East, Central and Southern Africa (ECSA) many countries are reforming their health care systems to provide eff cient health care services that better meet the needs of the population. Policy makers need tools to wisely manage the health care resources. National Health Accounts (NHA1) is an internationally recognised tool providing information about a country’s total expendi- ture on health. NHA is a tool specif cally designed for policy makers and managers of the health sector to help them in their efforts to improve health systems performance and make evidence based policymaking by providing useful information of the current use of f nancial resources. It is important to note that NHA provide only a f nancial dimension of the health system and that it has to be combined with other non-f nancial form of data such as health care output and health care outcome in order to get a comprehensive picture of the health sector performance. Today, about 80 countries around the world have developed and implemented NHA and approximately half of those have institutional- ised NHA, i.e. conducts NHA on a regular and sustained basis [1]. It is not enough to make the accounts once; they have to be up-dated regu- larly in order to provide decision makers with accurate information to base policy decisions upon. Previous experiences show that political will to produce and use NHA can be found in several countries that have suc- ceeded in institutionalising NHA. One of the most important factors in the institutionalisation process is the government’s actual use of the NHA results. The government’s perception of the NHA results can be of major importance. There is a risk that the data is being suppressed and kept in draft form rather than being recognised off cially if the results not are in line with the expectations of decision makers. Further, if methods and sources of data used when conducting NHA can be questioned the results also risk not being recognised [2, 3]. Uganda and nine other countries in the ECSA region2 completed their f rst round of NHAs in the late 1990s/ early 2000s. The production of the f rst round of NHA involved the formation of the ECSA NHA 1 Expenditures are organised in a set of tables that in a comprehensive manner gives a picture of the fl ow of funds within the health sector, i.e. the sources of funds, how the funds are channeled, and how the funds are fi nally being utilised. 2 The other nine countries were Ethiopia, Kenya, Malawi, Mozambique, Rwanda, South Africa, Tanzania, Zambia
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