Health Care Inputs Have Doubled in Uganda: What Has Been the Role of Health Financing Reforms?

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1 Health Care Inputs Have Doubled in Uganda: What Has Been the Role of Health Financing Reforms? Presentation at CERDI Health Financing Conference 1 December 25 Rob Yates, Christine Kirunga-Tashobya, Valeria Oliveira-Cruz, Barbara McPake, Hanif Nazerali Summary of the Health Budget Reforms Radical changes in health financing in Uganda have enabled GoU to implement a systems approach to health sector development. Budget financing is more efficient and equitable than donor project funding and user fees. The budget financed systems approach is delivering substantial increases in health outputs which should improve health outcomes.

2 The HSSP Financing Reforms Modest increase in overall envelope 18% in real terms in 5 years GoU health budget doubled: Donors switching to budget support and more GoU domestically generated funds Abolition of user fees NGOs trying to follow GoU lead Financing reforms facilitate concurrent health systems reforms 45 Recent Financing of the Ugandan Health Sector (23/4 prices) 5 Billion shillings = approx 1 $ per capita 4 35 B illio n s o f S h illin g s /98 98/99 99/ /1 1/2 2/3 3/4 4/5 Total Resources MTEF Envelope Other Sources GoU Budget Donor Projects

3 The Ugandan Health Budget: Improved Efficiency and Equity Improved allocative efficiency. District PHC funding up from 33% to 54% of GoU budget Massive increase in basic inputs per capita drug funding up 88%, proportion of posts filled with trained health workers up from 33% to 68%, 8 health units built or rehabilitated Ring-fencing of funds for essential inputs eg drugs Improved equity neediest district receives 44% more PHC funding per capita than Kampala Key elements of the systems reforms Massive investment in decentralised integrated services Strengthened management capacity Improved planning linked to the budget process Rapid disbursement of budget funds Improved drug supply systems Improved salaries and payroll management Quarterly monitoring of district performance

4 Health sector performance is improving No outcome data since 2 Outpatient attendances up 163 % since 1999/2 Immunisation rates up 117 % Deliveries in health units stagnant at 25% New Outpatient Attendances in Government of Uganda and Private Not for Profit Health Units M illions / / / 2/1 21/2 22/3 23/4 24/5

5 GoU budget expenditure and total outpatient attendances O ut-patient attendances (m illions) /5 23/4 22/3 21/2 1998/ / 2/1 1997/ GoU Budget Expenditure (Billions of Shillings 23/4 Prices) Projects are less efficient: breakdown of 66 Bn shillings expenditure by DPs: USAID, SIDA, GTZ, DFID, DANIDA Human Resources 3% Other Inputs 68%!! " #$! Drugs and Supplies 1% Other Recurrent 6% Capital non infrastructure 9% Infrastructure 4%

6 1% 9% 8% DPT3 immunisation rates for children under one year 84% 83% 89% 7% 63% 6% 5% 4% 41% 48% 3% 2% 1% % 1999/2 2/21 21/22 22/23 23/24 24/25 Proportion of Babies Delivered in Government and Private Not For Profit Health Units 3% 25% 2% 25% 23% 19% 2% 24% 25% 15% 1% 5% % 1999/2 2/21 21/22 22/23 23/24 24/25

7 4 New Monthly Outpatient Attendances in Kisoro District User fees abolished 16% increase Jan 98 Jan 99 Jan Jan 1 Jan 2 Jan 3 Jan 4 Outpatient attendances 12 month moving average 6 5 New Monthly Outpatient Attendances in 2 Neighbouring Hospitals GoU User fees abolished PNFP reduces fees 1 Jan 99 Jul 99 Jan Jul Jan 1 Jul 1 Jan 2 Jul 2 Jan 3 Jul 3 Jan 4 Mutolere PNFP Kisoro Government 12 month moving average 12 month moving average

8 25 New Monthly Outpatient Attendances at Bugangari HCIII Bamako Initiative User fees abolished Jan 97 Jan 98 Jan 99 Jan Jan 1 Jan 2 Jan 3 Jan 4 Outpatient attendances 12 month moving average Utilisation rate (visits per year) by socio-economic category J F M A M J J A S O N D J F M A M J J A S O N D Poores t Les s poor Better of f Ric hes t

9 $ &! '() * The mission also noted the findings of a recent World Bank study confirming that the government policy to abolish user fees for health services triggered a massive increase in the consumption of basic health services. Of great significance for poverty alleviation strategies, poor people have benefited disproportionately, with the lowest income quintile capturing 5% of the benefits from this policy change. This finding augurs well for maternal and infant mortality interventions and the government is congratulated on this impressive pro-poor initiative." World Bank PRSC Appraisal Mission 13-3 March 24 Final Aide Memoire) % $,-. $ *, *.$ *, #! *#! /,,.! $ $ 1!, 2 3%4! %54.6! * $! $ $ * %+

10 6 $.7* (!, 2! 8#, *.!,* $# (! $, *. 9*!!: $,.!: *,*.9,! $!, 39!, $,* - %5 Concluding Remarks The sector can absorb substantially more resources especially for drugs and supplies Increasing the health budget for imported commodities will not damage the macroeconomy Recent experience shows that a bigger health budget will result in higher outputs If Uganda is to make improvements towards achieving the health MDGs the health budget must increase rapidly ;