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Utilization of Public Health Financing in Uganda's Primary Health Care

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Utilization of Public Health Financing in Uganda's Primary Health Care Utilization of Public Health Financing in Uganda’s Primary Health Care Program Mailing Address PO Box 7404 Kampala, Uganda Street Address Ntinda Complex 2nd Floor, Block B, Plot 33 Ntinda Road PO Box 7062 Kampala, Uganda www.path.org © 2021 PATH. All rights reserved. Kisaame EK. Utilization of Public Health Financing in Uganda’s Primary Health Care Program. Kampala, Uganda: PATH; 2021. March 2021 ii Contents Objectives of the study ......................................................................................................................... 7 Data collection ....................................................................................................................................... 9 Key informant interviews ..................................................................................................................... 9 Data management and analysis .......................................................................................................... 9 Limitations of the study ...................................................................................................................... 10 PHC expenditure at local government and health care facility levels ........................................... 12 Performance in non-wage and development grants ....................................................................... 13 Adherence to PHC grant utilization guidelines ................................................................................ 15 Procurement using PHC funds .......................................................................................................... 16 Functionality of health unit management committees .................................................................... 18 Functionality of the village health teams .......................................................................................... 20 Utilization of other PHC resources (results-based financing) ........................................................ 21 Annex 1. Detailed breakdown of primary health care grants to the local governments in the study 29 ABBREVIATIONS .................................................................................................................................. 3 EXECUTIVE SUMMARY ........................................................................................................................ 4 INTRODUCTION ..................................................................................................................................... 6 Objectives of the study ............................................................................................................................ 7 APPROACH AND METHODOLOGY ..................................................................................................... 8 Data collection ......................................................................................................................................... 9 Key informant interviews ......................................................................................................................... 9 Data management and analysis ............................................................................................................. 9 Limitations of the study ......................................................................................................................... 10 1 OVERVIEW OF HEALTH SECTOR EXPENDITURE .......................................................................... 11 PHC expenditure at local government and health care facility levels ................................................... 12 Performance in non-wage and development grants ............................................................................. 13 USE OF PHC FUNDS AT LOCAL GOVERNMENT AND FACILITY LEVELS ................................... 15 Adherence to PHC grant utilization guidelines...................................................................................... 15 Procurement using PHC funds.............................................................................................................. 16 Functionality of health unit management committees ........................................................................... 18 Functionality of the village health teams ............................................................................................... 20 Utilization of other PHC resources (results-based financing) ............................................................... 21 EFFECTS OF COVID-19 ON HEALTH SECTOR AND PHC EXPENDITURE .................................... 25 CONCLUSIONS AND RECOMMENDATIONS .................................................................................... 27 ANNEXES ............................................................................................................................................. 29 Annex 1. Detailed breakdown of primary health care grants among the local governments in the study ..................................................................................................................................................... 29 REFERENCES ..................................................................................................................................... 31 2 Abbreviations COVID-19 coronavirus disease 2019 DHT district health teams EMHS essential medicines and health supplies FY financial/fiscal year HUMC health unit management committee KII key informant interview MoFPED Ministry of Finance, Planning and Economic Development MoH Ministry of Health PHC primary health care RBF results-based financing UGX Uganda shilling VHT village health team WHO World Health Organization 3 Executive summary Primary health care (PHC) provision around the world has been constrained by many challenges— perhaps none greater than limited financing. Recognizing the gaps in health coverage, in 2019, the World Health Organization recommended that countries increase spending on PHC by allocating at least 1% more of their gross domestic product to PHC; this would enable the world to meet the health coverage targets set out in the Sustainable Development Goals. However, the gap between basic community health needs and PHC provision has persisted. In some cases, the gap has increased despite increases in PHC resources—especially in low- and middle-income countries. The limited financing that characterizes PHC provision in low- and middle-income countries like Uganda suggests a need to effectively and efficiently utilize the limited resource available for PHC coverage. Furthermore, effective utilization of resources (financial and otherwise) is at the heart of many health systems strengthening initiatives in Uganda and the world over. However, there is limited literature on the use of PHC funds in Uganda and the rest of the world. Most of the available PHC financing literature focuses on the gaps in financing and the strategies to increase funding. Against such a background, PATH commissioned a study to assess the trends in expenditure/use of PHC finances in Uganda. The overall aim of the study was to examine the use of Uganda’s public PHC funding at both national and subnational levels over a period of five years from fiscal year (FY) 2015/2016 to FY 2019/2020. The study specifically reviewed trends in the expenditure/use of PHC finances at different levels of the health sector and how these have been affected by COVID-19. It examined the limitations in utilization of PHC funds at the central and local government levels. It also examined the functionality of oversight structures such as health unit management committees (HUMCs). The study examined expenditure patterns of PHC non-wage and development funds over the National Development Plan II period. The focus was placed non-wage and development expenditure because these are the PHC grants that are directly used to fund service delivery outputs. In addition, PHC wage grants are paid directly into the respective bank accounts of the health workers on payroll. The study employed an adaptation of the World Bank’s public expenditure review methodology, focusing on the second of six questions under the public expenditure review: “How much was spent and what it was spent on?” This involved analysis of the approved budgets and outturns for the health sector. This was complemented with key informant interviews (KIIs) with actors in the Ministry of Health (MoH); Ministry of Finance, Planning and Economic Development; district health offices; and health facilities. KIIs at the subnational level were conducted in the districts of Arua, Kasese, Kisoro, Mukono, and Tororo. These were purposively chosen on the basis of geographical representation, high disease burdens, and their beneficiary status under any of the results-based financing (RBF) projects being implemented in the country. RBF refers to the use of explicit performance-based subsidies to encourage delivery of services by paying providers (government or development partners) based on clearly defined quality outcomes. RBF in Uganda is delivered through Government of Uganda and development partner–funded projects, which complement PHC financing. The study concludes that while spending at the central government level suffered from budget cuts, as demonstrated by shortfalls in the funds released to them, local governments and health facilities received most, if not all, of the funds in their approved budgets during the reference period. It was also noted that
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