UGANDA HEALTH ACCOUNTS

Transcription

1 THE REPUBLIC OF UGANDA MINISTRY OF HEALTH UGANDA HEALTH ACCOUNTS NATIONAL HEALTH EXPENDITURE Financial Year 2010/11 and 2011/12 A publication of the Ministry of Health, Uganda

2 TABLE OF CONTENTS LIST OF TABLES...i LIST OF FIGURES...iii FOREWORD...iv STATEMENT FROM THE MINISTER OF HEALTH...v KEY MESSAGES FROM THE NHA REPORT vi ACKNOWLEDGEMENT... vii ABBREVIATIONS...viii EXECUTIVE SUMMARY...x 1.0 Background Introduction Structure of the Health Sector and the Flow of Funds Methodology Current Health Expenditure (CHE) Trends in Current Health Expenditure (CHE) Current Health Expenditure in Relation to GDP Current Health Expenditure per Capita Financing of Current Health Expenditures Revenue of Financing Schemes Financing Schemes Current Health Expenditure by Providers Health care Providers Hospital Expenditure Non-Hospital Expenditure Current Health Expenditure by Function Inpatient and Outpatient Care Services Medical Goods Preventive Care Government Current Health Expenditure Government Expenditure on Health Government Current Health Expenditure by Sources Government Current Health Expenditure by Providers Current Health Expenditure by disease and conditions Government Current Health Expenditure by Functions Private Current Health Expenditure Private Current Health Expenditure by Sources Private Current Expenditure by Financing Schemes Private Current Health Expenditure by Functions Development Partners (Rest of the World) Development Partners (Rest of the World) funding by Providers Development Partners (Rest of the World) funding by Functions Capital Expenditure... 43

3 9.1. Types of Assets in production of health services Capital Expenditure by Sectors Government Capital Expenditure Factors of Health Care Provision Factors of Provision for GCHE Government Inpatient Disease Based Costs Expenditure by Disease Government Inpatient Disease Based Costs Expenditure by Disease Conclusions and recommendations Bibliography and References Annexes Annex One: National Health Accounts-Summary of Key Indicators FY2010/ / Annex Two: Disease-based Cost for FY2010/11 to 2011/ Annex Three: Summary Table NHA 2010/ Annex Four: Summary Table NHA 2011/ Annex Five: Summary Table NHA 2010/ Annex Five: Summary Table NHA 2011/

4 LIST OF TABLES Table 0-1 National Health Accounts-summary of key indicators FY2010/ /12... xi Table 0-2 Disease-based Cost for FY2010/11 to FY2011/12... xv Table 3-1 CHE, GDP, Annual Growth Rates and Share of Health on GDP, 2010/11 to 2011/ Table 3-2 Current Health Expenditure by Financing Schemes, 2010/11 to 2011/ Table 4-1 Hospitals, Health units, private clinics and other providers of health goods...8 Table 4-2 Current Health Expenditure at Hospitals by financing source, 2010/11 and 2011/ Table 5-1 Current Health Expenditure by Function, 2010/11 to 2011/ Table 5-2 Share of current health expenditure functions by financing source;...14 Table 5-3 Medical goods expenditure by sub classes Table 5-4 Preventive care by categories of service (Millions UGX), 2011/ Table 6-1 Government Health Expenditures (UGX), 2008/09 to 2011/ Table 6-2 Sources of Government Current Health Expenditures (UGX), 2010/11 to 2011/ Table 6-3 Government Current Health Expenditures by Providers (UGX), 2010/11 & 2011/ Table 6-4 Current Health Expenditure by disease and conditions Table 6-5 Share of Individual Development Partners Funding Table 6.6 Reproductive Health Expenditure Table 6-6 Government Current Health Expenditures by Functions, 2010/11 and 2011/ Table 6-7 GHCE by Preventive care categories, FY 2010/11 and 2011/ Table 7-1 Private Current Health Expenditure by Sources, 2010/11 to 2011/ Table 7-2 Private Current Health Expenditure by Schemes, FY2010/11 to FY2011/ Table 7-3 Overall expenditure by all providers Table 7-4: Private Current Health Expenditure by Functions, 2010/11 to 2011/ Table 8-1 Financing contributions by Development Partners, FY2010/11 to FY2011/ Table 8-2 Financing contributions of Development Partners as a share of CHE, 2010/11 and 2011/ Table 8-3Allocation of Development Partners funding by Providers, FY2010/11 to FY2011/ Table 8-4 Allocation of Development Partners funding by Functions, FY2010/11 to FY2011/ Table 8-5 Preventive Care Funding by Development Partners, FY2010/11 to FY2011/ Table 8-6 Disease based costs by financing source for FY 2010/11 and 2011/ Table 8-7 Disease based costs summary FY 2010/11 and 2011/ Table 8-8 OOP per capita expenditure on health Table 8-9 Total and per capita out of pocket expenditure by quintiles amounts in Billions of shs...38 Table 8-10 Total and per capita health out of pocket expenditure by sub-regions-ugx...38 Table 8-11 Total and per capita out of pocket expenditure by regions Table 8-12 Total household expenditure by service provider (billion shs.)...39 Table 8-13 Total household expenditure by service provider (billion shs.) Financial year 2010/ Table 8-14 Total out of pocket expenditure by service paid for-billions...40 Table 8-15Total household expenditure by health condition-billions Table 8-16 Total household Health expenditure by age-billions and per capita expenditure by age...42 Table 8-17 Total household Health expenditure by conditions-billions Table 9-1 Capital Expenditure by Type of asset, FY2010/11 to FY2011/12- nominal...43 i

5 Table 9-2 Capital Expenditure by Sectors, FY2010/11 to FY2011/ Table 9-3 Capital Expenditure by Public Sector (Government), FY2010/11 to FY2011/ Table 9-4 Capital Expenditure by Private Sector, FY2010/11 to FY2011/ Table 9-5 Capital Expenditure by Development Partners, FY2010/11 to FY2011/ Table 10-1 Percentage breakdown of GCHE by Factors of Provision Table 11-1 Disease-based Cost for FY2010/11 to FY2011/ Table 11-2 Disease-based Cost for FY2010/11 to FY2011/ ii

6 LIST OF FIGURES Figure 3-1 Contribution of current Health Expenditure by financing source Figure 4-1 Share of Current Health Expenditures by Providers (%), 2010/11 to 2011/ Figure 4-2 Share of Current Health Expenditures by Providers (%), 2011/ Figure 4-3 Share of Current Health Expenditure at Hospital by financing source 2010/11 and 2011/ Figure 5-1 Current Health Expenditure by function (%), 2010/11 to 2011/ Figure 5-2 Share of Preventive care by Source (%), 2010/11 to 2011/ Figure 5-3 Share of Preventive care by categories of service (%), 2010/11 to 2011/ Figure 6-1 GHE as a % of TGE from 2003 to 2011/ Figure 6-2 Share of Government Current Health Expenditure by Provider, 2011/ Figure 6-3 Government Current Health Expenditure by Functions, 2011/ Figure 7-1 Domestic revenues account and voluntary prepayments of PCHE in 2011/ Figure 7-2 Private Current Health Expenditure by Providers, 2010/11 to 2011/ Figure 7-3 Share of Private Current Health Expenditure by Functions, FY2010/11 to FY2011/ Figure 8-1 Share of funding by Development Partners (%), 2011/ Figure 8-2 Allocation of Development Partners funding by Functions, FY2010/11 to FY2011/ Figure 8-3 Total household expenditure by service provider (billion shs.)...39 Figure 8-4 Total out of pocket expenditure by service paid for FY 2010/11-Billions...40 Figure 9-1 Capital Expenditure by Type of asset, FY2010/11 to FY2011/12 (nominal millions UGX) Figure 10-1 Human Resources expenditure by Providers Figure 10-2 The percentage of funds spend on human resource for health Figure 10-3 Healthcare Services expenditure by health Providers Figure 10-4 Pharmaceutical expenditure by health Providers FY 2010/ Figure 10-5 Pharmaceutical expenditure by health Providers FY 2011/ Figure 10-6 Other Healthcare goods expenditure by Providers FY2010/11 to FY2011/ Figure 10-7 Factors of Provision costs by Health Providers Figure 10-8 Cost drivers in the health system iii

7 FOREWORD Evidence and information in the health sector are a prominent component of providing decision makers with options to make key decisions on health. These decisions are important because they shape how the health sector promotes wellness and treats illness, which in turn influences the overall health and well-being of the Uganda-n population. This report describes the health care system from an expenditure perspective. Such information provides policy or decision makers opportunities for improving access, equity, efficiency, and financial risk protection as part of the national effort to bring services closer to our citizens and accelerate Uganda s progress towards Universal Health Coverage. The NHA tool has become such an integral output of the Ministry of Health that our commitment is reflected in the establishment of a technical team headed by the National Health Accounts coordinator and the creation of a vote function in the Output budgeting tool specifically for National Health Accounts. I must congratulate the NHA technical team for making UGANDA one of the first countries in Africa to present the 2010/ /12 NHA report using the new System of Health Accounts (SHA) The SHA 2011 provides a more detailed report of tracking expenditures on health. Whilst there are limitations in terms of costing outpatient admissions associated to diseases, the limitations themselves provide the Ministry with opportunities and direction to explore areas of improvement in information systems, reporting mechanisms and data collection which are vital instruments for providing evidence. I also take this opportunity to thank the Ministry of Health, Ministry of Finance, Planning and Economic Development, the Bureau of Statistics, WHO,USAID and UNFPA who have made significant contribution to the successful compilation of this report. Dr. Jane Ruth Aceng Director General of Health services iv

8 STATEMENT FROM THE MINISTER OF HEALTH Key health sector policy issues facing most African Countries are related to health financing and bring to mind questions such as; how much resources are flowing into the health sector; Are these resources adequate to meet the national strategic goals?; How additional resources be mobilized;? How investments given available resources?;, what is the appropriate mix of financing mechanism to finance the for a universal minimum health care package? Who is managing most of the health finances, what are the services being provided and who are the beneficiaries? National Health Accounts (NHA) is a useful tool for understanding and informing responses to these health sector policy concerns and this report was developed in fulfilment of the Government s commitment to regularly compile the NHA. Resource tracking through institutionalization of NHA is a Global agenda in Health financing monitoring. Prior to NHA studies, there were a number of attempts by partners and key stakeholders to estimate health expenditure through studies, surveys and public expenditure reviews, however these were generated without a standard approach. NHA constitutes a systematic, comprehensive, and consistent monitoring of and tracking of resource flows and amounts into a country s health system. It is a tool specifically designed to inform the health policy process, including policy design and implementation and policy dialogue. The Ministry of Health (MoH) recognizes the importance of availability of quality data on Health Financing in order to inform development of good financing policies. Uganda s commitment to Institutionalize NHA dates back to 1997/1998 on the notion that regular preparation of NHA helps policy formulation and evidence based decision making in the health sector. For example, the MoH has used the NHA framework to produce estimation for Health expenditure for the financial years 1999/00, 2000/01, 2005/06, 2008/09 and 2009/10 which enabled the development of the health care financing strategy for Uganda. NHA has also impacted policy on several fronts including serving as a basis for advocating for increased government spending in health informing resource allocation decisions and civil society advocacy efforts, fostering need for greater coordination, monitoring progress towards spending goals and highlighting weaknesses in the health systems. Government has worked in consultation with other development partners to put appropriate systems in place to prepare NHA on regular basis. I would like to put on record our sincere appreciation and gratitude to WHO,UNFPA,USAID and other Health Development Partners for the continued support extended to the Health Sector in preparation of this NHA report and in our efforts to institutionalize NHA in Uganda. It is my sincere hope that the health sector stakeholders would use the NHA findings to refocus their resources to cost effective interventions that will accelerate our pace to achieving the MDGs. All stakeholders should join hands in ensuring that the objectives of compiling the NHA for FY 2010/11 and 2011/12 are fully realized. Hon. Dr. Elioda Tumwesigye Minister of Health v

9 KEY MESSAGES FROM THE NHA REPORT The Country needs to address high levels of out of pocket expenditure in order to protect households from catastrophic spending by broadening pre-payment mechanisms such as Social Health Insurance. This is in line with World Health Assembly resolution of 2005 on universal coverage and sustainable health financing and as well as revisiting the Paris Declaration that calls for greater Investments in the Health Sector and Social Health Insurance and Financing 2. Increase government investment in health towards meeting the Abuja Declaration target and reduce the dependence on external resources to finance health care. This is especially more critical now given the macro-economic challenges facing most industrialized countries. 3. Strengthen government s stewardship role in coordinating donors and ensuring alignment to country strategies in line with the Paris Declaration principles for more effective aid. In this regard, the development of strategic partnerships which allow for predictability of funds over a longer period will ensure sustainability of funding. 4. Explore alternative ways of mobilizing domestic resources to improve financial sustainability including the improvement of efficiency in resource use. 5. Refer to the abrigded version of thr NHA report for a summary of the key messages. vi

10 ACKNOWLEDGEMENT The development of this fifth publication of Uganda National Health Accounts is based on the internationally recognized and revised 2011 version 3.30 of System of Health Accounts (SHA 2011). This was made possible through the collaboration and support of the World Health Organisation. We express our sincere gratitude and recognise the support from the Uganda Bureau of Statistics for providing statistical data on households and national macro-economic statistics which were used to compile this report. They made significant contribution towards the compilation of this publication. We also wish to thank the entire National Health Accounts (NHA) team members for their patience and support throughout the production and development of this publication. Special thanks to Mr. Ezrah Rwakinanga Trevor - Lead Consultant and Hapsa Toure Technical Advisor (TA) from Ivory Coast for a wonderful effort in guiding the NHA technical editing in support of the full time NHA Coordinator Mr. Tom Aliti. Next, it is important to note that this publication would have not been possible without the participation and support of many individuals and organisations in both the public and private sector that have cooperated in providing data; the aid liaison section and the OBT Secretariat of Ministry of Finance,planning and Economic Development for provision of raw government data, for distribution of public health programme funds into various NHA functional activities, insurance companies, private hospitals, private health clinics, private providers including doctors and pharmacists, health partners & development partners, non- governmental organisations, banks and other statutory bodies for provision of data through survey questionnaires. Data analysis was done using Health Accounts Analysis Tool (HAAT). Interpretation of the results and the drafting of the report were done by the entire NHA team including Dr Grace Kabaniha of WHO- Uganda. The NHA Technical Team would also like to thank Dr. Wilberforce Owembabazi (USAID) and Dr. Solome Bakeera for their insightful comments during the reviewing process which allowed improvements and enhancements to bring this report in compliance with SHA 2011 standards. Also thanks to Ms. Susan Najjuuko for her editorial comments. Finally, the efforts, contributions and the enormous support from the various divisions, programs and sections of Ministry of Health are greatly acknowledged. Dr. Asuman Lukwago Permanent Secretary, Ministry of Health vii

11 ABBREVIATIONS AHC Ambulatory Health Care NHA National Health Accounts AIDS Acquired Immune Deficiency Syndrome NHIS National Health Insurance Scheme ASMC Ancillary Services to Medical Care OECD Organization of Economic Corporation Development ATP Alternative or Traditional Practitioners OOP Out-of-Pocket Expenditure CSOs Civil Society Organizations PATHS Partnership For Transforming Health Systems 2 CWIQS Core Welfare Indicator Questionnaire Survey PHC Primary Health Care DFID Department for International Development RH Reproductive Health ENSK Expenditure Not Specified Kind SHA System of Health Accounts MOH Ministry of Health MOH Ministry of Health GDP Gross Domestic Product TB Tuberculosis GGE General Government Expenditure THE Total Health Expenditure GGHE General Government Health Expenditure UNAIDS United Nation Aids GHS General Household Survey UNFPA United Nation Fund for Population Activities HAAT Health Accounts Analysis Tool USAID United States Agency for International Development HIV Human Immunodeficiency Virus WHO World Health Organisation HMBs Health Management Boards CHE Current health expenditure HMN Health Metrics N+etwork GoU Government of Uganda HMOs Health Maintenance Organizations MoLG Ministry of Local Government ICHA International Classification for Health Accounts PHP Private Health Providers IMNCH Integrated, Maternal, Newborn and Child Health PNFP Private Not for Profit IEC Information, Education and Counselling IGA Income Generating Activities LG Local Government UCMB Uganda Catholic Medical Bureau LGA Local Government Act UPMB Uganda Protestant Medical Bureau LGHE Local Government Health Expenditure UMMB Uganda Muslim Medical Bureau MDAs Ministries, Departments and Agencies GHI Global Health Initiatives MDGs Millennium Development Goals UGX Uganda shillings UAC Uganda Aids Commission OOP Out of pocket contributions NASA National Aids Spending Assessment WHS Work Health and Safety Information UBOS Uganda Bureau of Statistics US$: United states dollars UDHS Uganda Demographic and Health Survey PER Public Expenditure review NGO Non-Governmental Organisation AHSPR Annual Health Sector Performance Report FB Facility Based UBOS Uganda Bureau of Statistics NFB Non Facility Based MMMMMMM IFMS Integrated Financial Management system CHE Current Health Expenditure GF Global Fund viii

12 FA FP Financing Agents Factors of Health Care provision GHE Government Health Expenditure ( CHE plus capital spending) FS Revenues of health financing schemes HK Capital Expenditure DBC Disease based costing ICD International Coding of Diseases DHO District Health Officer IP Inpatient HDP Health Development Partners JICA Japan International Cooperation Agency HPAC Health Policy Advisory Committee NCD Non Communicable diseases GCF Gross Capital Formation OP Out Patient GDP Gross Domestic product PCHE Private Current Health Expenditure GFCF Gross Fixed Capital Formation DHIS2 District Health Information System GGCHE General Government CHE TGE Total Government Expenditure HA Health Accounts THE Total Health Expenditure HC Health Care Functions UNAIDS Joint United Nations Programme On HIV/AIDS HF Financing Schemes UNICEF United Nations Children s Fund HH Households NPISH Not for Profit Institutions Servicing Households HP Health Care Providers OTC Over the Counter Drugs LTC Long Term Care PHI Private Health Insurance MOFPED Ministry of Finance PPP Purchasing power parity NEC Not Elsewhere Classified PVHI Private Voluntary Health Insurance NPISH Not for Profit Institutions Servicing Households SHA Systems of Health Accounts Traditional, Complementary and Alternative OTC Over the Counter Drugs TCAM Medicine United Kingdom Fund for International PHI Private Health Insurance DFID Development PPP Purchasing power parity PVHI SHA Private Voluntary Health Insurance Systems of Health Accounts ix

13 EXECUTIVE SUMMARY The total Current Health Expenditure (CHE) in Uganda in 2010/11 of Shs. 4,585 billion with a per capita spending of Shs. 130,448 ($54) increased in nominal terms by 3.6% and in real terms by Shs. 166 billion to 4,751 billion in 2011/12 with a per capita spending of 130,723 ($53). The CHE for both years in a row is much lower than the $84 per capita recommended for quality care. Over the same period, GDP grew in nominal terms by 15% and in real terms by Shs. 7,258 billion. Current health spending as a ratio of GDP was at 10% for 2010/11 and 8.9% for 2011/12. Government spending as a ratio of GDP is at 1.4% which is far below the recommended 5% of GDP. Globally, it has been noted that Universal Health coverage is difficult to achieve if public health financing is less that 5% of GDP. Higher government spending generally provides adequate public infrastructure and health service delivery at subsidised cost. The allocation between public, private and development partners for current health expenditure from 2010/11 to 2011/12 is as follows: The contribution of public funds increased from 13.8% to 15.3%; private funds increased from 36.5% to 38.4%; Development partner funds decreased from 49.7% to 46.5%. The 1.9% increase in private sector contribution to current health expenditure in 2011/12 was attributed to mainly increase in household OOP expenditure from Shs. 1,241 billion in 2008/09 to 1,775 billion in 2011/12 in absolute terms. However, the actual percentage of household out of pocket expenditure to the current health expenditure reduced from 43% in 200/10 to 37% in 2011/12 owing to the increase in funding from Global health initiatives in the period under review. Increase in investments into health over the past two years are collectively attributed to expenditure by Health Development partners, households and Government as indicated in table 3-1. Monitoring these trends over the next years will inform policy questions like equal access to health care and the ability of a citizen to guarantee and contribute towards their own health. Health care providers that accounted for most of the health expenditure in 2010/11 and 2011/12 were hospitals and lower level health centres averaging 49% during the two years closely followed by providers of health systems administration and ancillary services. Most of the expenditures were financed by health development partners and private sector as indicated in Table 3-1. In terms of how the health budget was used Health Functions, the largest share of health spending went to curative services forming an average of 53% of the current health expenditure during the two years. 24% of the curative care budget was spent on inpatient and 47% on outpatient care. The second largest expenditure was on prevention (16%) followed by medical goods (5%). The expenditure on curative appears to be so large because households spend almost 95% of their OOP health expenditure on Curative care and government considers curative services an emergency on the already sick person and tends to provide for it more than providing for those who are yet to fall sick or prevent anticipated sickness from occurring. The share of PCHE by Functions clearly indicates that Health goods, though it dropped approximately 0.6% in 2011/12, still holds the third highest share. Ancillary Services decreased its shares from 0.2% in 2010/11 by 0.1% in 2011/12. The expenditure on preventive care reduced from same (0.5%) to 0.1% in 2011/12 as a share of PCHE. This implies private providers and households spend less on preventive care than curative probably because it is not considered as an emergency on their side Health care expenditure in Uganda remains largely funded by health development partners channelled through government offices and the private sector. Hospitals and health centres have been the major recipient of the financing. Health administration remains a significant item of government spending on health over the period under review. x

14 Table 0-1 National Health Accounts-summary of key indicators FY2010/ /12 INDICATORS UNITS FY2010/2011 FY2011/2012 Population Millions Gross Domestic Product (GDP)- current prices UGX Millions 45,944, ,202,000 Total Government Expenditure (TGE) UGX Millions 8,972,500 9,273,400 Current Health Expenditure (CHE) UGX Millions 4,585,470 4,751,261 CHE plus Capital Spending UGX Millions 4,710,813 4,898,580 CHE Per Capita - UGX 139, ,207 Exchange rate UGX (NCU per US$) UGX 2,557 2,609 General CHE per Capita- USD CHE as % of nominal GDP nominal 10% 2 9% Household Expenditure on Health UGX Millions 1,533,500 1,775,600 Household Expenditure on Health as a % of CHE Household expenditure as % of private CHE Household OOP expenditure on health per capita UGX Household OOP expenditure on health per capita US$ Percentage 33% 37% % 91% 96% UGX 46,610 52,070 US$ Bilateral donors contribution to CHE UGX Millions 1,821,190 1,633,981 Bilateral Donors contribution to CHE % 39.7% 34.4% Share of HDPs funding Multilateral donors contribution to CHE Multilateral Donors contribution to CHE Rest of the World Contribution to CHE Private Donors/Rest of the World Contribution to CHE UGX Millions 334, ,331 % 7.3% 9.2% UGX Millions 120, ,973 % 2.6% 2.7% xi

15 INDICATORS UNITS FY2010/2011 FY2011/2012 Government Current Health Expenditure (GCHE) 3 UGX Millions 633, ,903 General Government Health Expenditure (GGHE) including k formation UGX Millions 724, ,702 Private Health Expenditure(PCHE) UGX Millions 1,673,905 1,824,334 Development Partners funding UGX Millions 2,278,361 2,202,025 GCHE as a % of CHE % 13.8% 15.3% Private Health Expenditure as a % of CHE Development Partner funds as a % of CHE % 36.5% 38.4% % 49.7% 46.3% CHE as a % of GDP % 10.0% 8.9% Revenues of Schemes GCHE as a % of TGE % 7% 8% GCHE as a % of GDP % 1.38% 1.36% GCHE per capita UGX 19,787 21,321 GCHE per Capita US$ GGHE per capita US$ GGHE UGX Millions 724, ,702 GGHE as % of TGE UGX 8% 9% Private Current Health Expenditure as a % of GDP Development Partners funding as a % of GDP % 3.6% 3.4% % 3.4% 4.1% xii

16 INDICATORS UNITS FY2010/2011 FY2011/2012 Financing Schemes Government Financing Schemes as a % of CHE Voluntary Health Insurance Schemes as a % of CHE Out of Pocket (OOP) expenditure as a % of CHE % 74.2% 71.6% % 2.8% 1.4% % 33% 37% Curative spending as a % of CHE % 77% 70% Inpatient Care as a % of CHE- % 32% 27% Health Functions Outpatient Care as a % of CHE % 46% 44% Preventive Care as a % of CHE % 10% 16% RH expenditure as a % of CHE % 12.4% 12% Hospital spending as a % of CHE % 39% 59% Health Providers Other providers as a % of CHE % 17.4% 8% Providers of health system administration and financing ( LGs) % of CHE % 38.6% 28% Medical goods as a % of CHE % 5% 5% Factors Capital formation Expenditure on Government Human Resources as a % of CHE Expenditure on Government Human Resources as a % of GCHE % 31.2% 30% % 48% 42% Expenditure on capital formation UGX Millions 125, ,319 Capital Formation Capital expenditure as a % of CHE plus capital spending (GHE) Government Capital expenditure as a % of GHE Expenditure on infectious and parasitic diseases Infectious and Parasitic diseases expenditure as % of CHE % 3% 3% % 1.6% 1.6% UGX Millions 3,017,560 3,149,317 % 65.8% 66.2% xiii

17 INDICATORS UNITS FY2010/2011 FY2011/2012 Expenditure on Reproductive Health UGX Millions 569, ,404 Reproductive Health expenditure as % of CHE % 12.4% 12% Expenditure on Nutrition deficiencies UGX Millions 115, ,053 Nutrition deficiencies expenditure as % of CHE % 2.5% 2.7% Expenditure on NCDs UGX Millions 176, ,726 Non Communicable Diseases Expenditure as % of CHE % 3.9% 4.7% Expenditure on injuries UGX Millions 104, ,839 Injuries expenditure as % of CHE % 2.3% 2.4% Non Disease specific expenditure UGX Millions 138, ,475 Non Disease specific expenditure as % of CHE % 3.0% 3.2% Expenditure on conditions (n.e.c) UGX Millions 462, ,447 Other conditions (n.e.c) as % of CHE % 10.1% 8.8% xiv

18 Table 0-2 Disease-based Cost for FY2010/11 to FY2011/12 DISEASE SHA- CODE DISEASE NAME / SHA-CATEGORY FY2010/11 FY2011/12 (UGX Millions) Share (%) (UGX Millions) Share (%) 3,017,560 3,149,317 Infectious and parasitic diseases DIS.1.1 HIV/AIDS 1,656, % 1,783, % DIS.1.2 Tuberculosis 46, % 86, % DIS.1.3 Malaria 971, % 945, % DIS.1.4 Respiratory infections 160, % 181, % DIS.1.5 Diarrheal diseases 49, % 60, % DIS.1.6 Neglected tropical diseases 1, % % DIS.1.7 Vaccine preventable diseases 43, % 49, % DIS.1.nec Other infectious and parasitic diseases (n.e.c.) 89, % 42, % Reproductive health 569, ,404 DIS.2.1 Maternal conditions 268, % 306, % DIS.2.2 Perinatal conditions 160, % 184, % DIS.2.3 Contraceptive management (family planning) 64, % 38, % DIS.2.nec Other reproductive health conditions (n.e.c.) 76, % 36, % Nutritional deficiencies 115, % 128, % Non-Communicable diseases 176, ,726 DIS.4.1 Neoplasms 28, % 37, % DIS.4.2 Endocrine disorders 2, % 2, % DIS.4.3 Cardiovascular diseases 13, % 14, % DIS.4.4 Mental disorders 25, % 28, % DIS.4.9 Other noncommunicable diseases (n.e.c.) 106, % 140, % Injuries 104, % 114, % Non-disease specific 138, % 152, % Other diseases / conditions (n.e.c.) 462, % 416, % Total 4,585, % 4,751, % xv

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20 Uganda Health Accounts - National Health Expenditure - CHAPTER ONE 1.0 BACKGROUND 1.1. Introduction The publication of the Fifth round of the National Health Accounts (2010/ /12) report records health expenditure in Uganda using the System of Health Accounts (SHA) 2011 Edition. The changes to the SHA 2011 are a reflection on how the dynamics and environment surrounding health has transformed considerably on the global level since the release of the previous version of the SHA framework in The increased complexities of the health sector that are strongly influenced by culture, socio-economic and political factors further constrained by limited resources, challenges the Ministry of Health to provide greater in-depth information and analysis of health care expenditure over time to respond accordingly and plan for future health reforms. The SHA 2011 framework was also intended to provide greater consistency and comparability in the measurement and reporting of health expenditures between developed and developing countries. The report makes an effort to track financial resources into the health system, and provide evidence to guide development of health financing strategy, effective and efficient resource allocation and respond to health financing policy questions. Specifically this report addresses the following healthcare financing policy issues: 1. Resource mobilisation: 2. Resource management: 3. Efficiency and effectiveness 4. Equity concerns The report introduces a number of changes and improvements compared with previous NHA reports. The major changes and additions are as follows: The re-demarcation of revenue sources and schemes Costing of inputs through the factors of production more aligned to the current budget estimate reporting system used by Ministry of Finance. Costing of disease based on the International Classification of Diseases (ICD -10). Treatment of capital investment separate from the total current health expenditure Structure of the Health Sector and the Flow of Funds Structure of health sector The Ministry of Health implements both clinical and public health programs and activities through a decentralized health system that caters for integrated health care at primary, secondary and tertiary care level. This is not the same with the administration and management of medicines and supply, which are centralized. There are 2 national referral hospitals, 15 regional referral hospitals, 3 specialised institutions, 137 Local Governments, 67 PNFP hospitals, 46 General Hospitals and 4235 lower level health units both public and private.(source. HMIS 2013). 1

21 Uganda Health Accounts - National Health Expenditure - CHAPTER ONE Flow of funds A major change in tracking the flow of funds towards health in SHA 2011 is the identification of the actual source of how revenue was raised and collected by responsible agencies (Revenue Source) in addition to the institution that manages and distributes funds (Financing Schemes). SHA 2011 apart from demonstrating that majority of the public health sector funding in Uganda is financed by partners, also explores in detail how revenue is generated and collected. Furthermore, SHA 2011 also describes the distribution of household or business/ corporate taxes, Development Partner grants and transfers and government taxation through various modes of delivery schemes which could also be through central government schemes, insurance schemes or directly through household out of pocket expenses. The funds are also tracked to providers of health care and their functions as per below Methodology The SHA 2011 provides a standard for classifying health expenditures according to the three axes of consumption, provision and financing. It gives guidance and methodological support in compiling health accounts. SHA 2011 provides the basis for collecting, cataloguing and estimating all the monetary flows related to health care expenditure. More specifically, the purpose of the SHA 2011 is threefold viz. i) to provide a framework of the main aggregates relevant to international comparisons of health expenditures and health systems analysis; ii) to provide a tool, expandable by individual countries, which can produce useful data in the monitoring and analysis of the health system; iii) define internationally harmonized boundaries of health care for tracking expenditure on consumption. Sampling design The sampling frame was developed by UBOS for the study. All health providers, NGOs and partners in the country were listed with information about their address and information to identify if their primary purpose is health service delivery). Disproportionate stratified sampling was used instead of proportionate sampling because private health insurance accounts for a small proportion of health financing in the country. Proportionate sampling would have resulted in a relatively small number of Local Governments in the sample, impacting estimates for the Local Governments component and their precision. A systematic sample was constructed separately and purposefully for development partners, line ministries and private firms. The response rates were well over 78% in all categories of respondents, with Development partners, line ministries, health insurance firms, Local Governments and regional referral Hospitals registering 100% response rates. Household OOP expenditure on health Health expenditure by households - out-of-pocket spending is one of the private expenditures on health. The other components include; expenditure by firms, non-governmental organizations and medical insurance schemes. In National Health Accounts, out-of-pocket spending by households comprises direct spending by households and through deductions as co-financing premiums for health insurance. The direct spending is not separated from the co-financing premiums for health insurance due to lack of data from the health insurance organisations. The approach to estimate household out of pocket spending on health is to derive estimates directly from a 2

22 Uganda Health Accounts - National Health Expenditure - CHAPTER ONE nationally representative survey the Uganda National Household Survey for the year The estimates refer to a period 30 days preceding the survey. We computed the total household out-of-pocket expenditure and divided by the sample size the number of individuals in the survey to obtain the average amount. To obtain annual estimates for the financial year 2012/13, the monthly estimates were multiplied by 12 months - the number of months in a calendar year. To obtain the 2010/11 and 2011/12 estimates from the base estimates of 2012/13, we used the Health consumer price index as a deflator Government Data Sources The estimates of government expenditure presented in the 2010/ /12 NHA report are based on statistics obtained from the Ministry of Finance, the institutions and integrated Financial Management System (IFMS) Unit and is a reflection of the actual expenditure captured in its final closing of accounts report for both the years through the IFMS. The provided National and macro-economic data such as population and official Gross Domestic Product figures for 2010/11 and 2011/12 were obtained from the Uganda Bureau of Statistics (UBOS). Data from other agencies that provide health related services such as Ministry for Education, Ministry of Local Government, Ministry of Internal Affairs and Ministry of Defence is included in this report. Since the Ministry of Health financial data in the IFMS system is input based accounting whereas NHA reporting focuses on expenditure leading to the delivery of outputs, the NHA Technical team used the IFMS chart of accounts and mapped the IFMS directly to the new SHA 2011 classification. In ensuring continuity of comparison of results from all the past reports to the new classification, a major activity earmarked for 2014 is the mapping of the provision of expenditure trends for the past 2 NHAs for the years (2008/09 and 2009/10) Other Data Sources Data sources from the private sector for 2010/11 and 2011/12 were obtained through surveys. As per the recommendation of the last report and given the new requirements of the SHA 2011 classification and the NHA tools in the NHAPT, all survey questionnaires were vetted by the Technical team to reflect the needs of SHA 2011 reporting. The detailed questionnaire may have led to reluctance by Development Partners, Insurance, and Employers to either report correctly or report at all even after various verbal and written assurances that individual information would be treated with the highest confidentiality and that aggregate (rather than individual) information was the interest for this report. Nevertheless, there is always room for improvement especially with data collection and validation and thus, a number of lessons were noted for improving future NHA reports. 3

23 2.0. Current Health Expenditure (CHE) Uganda Health Accounts - National Health Expenditure - CHAPTER TWO Current health expenditure (CHE) measures the economic resources spent by a country on healthcare services and goods, including administration and insurance. Current expenditure includes, for example, nurses salaries, the costs of a nation-wide vaccination programme and payments for hospital cleaning services, among many others. According to System of Health Accounts (SHA) 2011 the aggregate CHE combines in a single figure the monetary value of the final consumption of all health care goods and services. CHE equals final consumption expenditure on health care goods and services by residents of a given country during a given period. CHE excludes capital expenditure on health care Trends in Current Health Expenditure (CHE) The Current Health Expenditure (CHE) in Uganda was Shs 4,751 billion in 2011/12, with per capita spending of Shs. 130,723($53) 1 and Shs. 4,585 billion in 2010/11 with per capita spending of Shs. 130,448 ($54). From 2010/11 to 2011/12, current health expenditure increased both in nominal terms by 3.6% and in real terms by Shs. 166 billion. Over the same period, GDP grew in nominal terms by 15% and in real terms by 7,258 billion.current health spending as a ratio of GDP was at 10% for 2010/11 and this 8.9% for 2011/12. The allocation between public, private and development partners for current health expenditure is as follows: In 2011/12, public funds contributed 15.3%, private funds 38.4% and development partner funds 46.5%. Development partner funds decreased from 49.7% in 2010/11 to 46.5% in 2011/ Current Health Expenditure in Relation to GDP The gross domestic product (GDP) is one of the primary indicators used to gauge the health of a country s economy. It represents the total dollar value of all goods and services produced over a specific time period. The ratio of UGANDA- s CHE to its GDP (health to GDP ratio) provides an indication on the proportion of the health sector contributing to the overall economic activity. Between 2010/11 and 2011/12, health spending as a ratio of GDP averaged 9.5% (Table 3-1). Table 3-1 CHE, GDP, Annual Growth Rates and Share of Health on GDP, 2010/11 to 2011/12 Financial Year Public Current Health Expenditure (UGX Millions) Private Dev t Partners Share of Current Health Expenditure (%) Total Public Private Dev t Partners Current Health Expenditure as a Share of GDP (%) Total Public Private Dev t Partners Total 2010/ ,204 1,673,905 2,278,361 4,585, % 36.5% 49.7% 100.0% 1.38% 3.64% 4.96% 10.0% 2011/ ,903 1,824,334 2,202,025 4,751, % 38.4% 46.3% 100.0% 1.36% 3.43% 4.14% 8.9% Dev t stands for Development 1 Currency exchange rate is based on WHS 4

24 Uganda Health Accounts - National Health Expenditure - CHAPTER TWO Figure 3-1 Contribution of current Health Expenditure by financing source 100% 90% 80% 70% Parcentage 60% 50% 40% 30% 20% 10% Development Partners Private Public FY2010/2011 Year FY2011/ Current Health Expenditure per Capita As the population grows, and demands for improved care also rise, health expenditure in most countries and most of the time increases correspondingly. It is useful to examine health expenditure on a per capita basis in order to remove the influence of changes in the overall size of the population. GDP per capita is often considered an indicator of a country s standard of living. The estimated CHE per capita has increased from UGX.130,448 in 2010/11 to UGX.130,723 in 2011/12 (Figure 3-1). In US dollar terms the per capita health expenditure decreased from US$ 54 in 2010/11 to US$ 53 in 2011/12. This translates to a 2% decrease in current per capita expenditure. The per capita health expenditure is below the minimum recommended WHO per capita expenditure on health for low developing countries of US$ 84 per capita for health. 5

25 3.0. Financing of Current Health Expenditures Uganda Health Accounts - National Health Expenditure - CHAPTER THREE The revenues of health financing schemes (FS) describes; i) The contribution mechanisms the particular financing schemes use to raise their revenues, and ii) The institutional units of the economy from which the revenues are directly generated Revenue of Financing Schemes The major source of revenue in 2010/11 and 2011/12 for the health sector comes from the Health Development partners (Table 3-1) and averages 49% of current health expenditure. Government health financing has increased from 13.8% in 2010/11 to 15.3% in 2011/12 and remained 1.37% as a share of GDP for both years. The other main sources of funding are the private sector and development partners. The share of private financing has fluctuated between 2010/11 and 2011/12; the trend for the private sector shows an increase from 36.5% in 2010/11 to 38.4% in 2011/12 of the Current Health Expenditure (CHE). The share of funding by development partners as a percentage of CHE has decreased from 49.5% in 2010/11 to 46.3% in 2011/12. In the private sector, most of the funding comes from Households, which accounted for 90% of the PCHE over the period 2010/11 to 2011/12. The Private Current Health Expenditure (PCHE) changed as a share of GDP from 3.64% in 2010/11 to 3.43% in 2011/12 though this did not have any significant impact on financing health services Over the period 2010/11 to 2011/12 PCHE increased by 1.9% (refer Table 3-1). The total PCHE as a percentage of CHE was 36.5% (UGX1,673 billion) in 2010/11 and 38.4% (UGX1,824 billion) in 2011/12 and in both years account for 3.5% of the GDP on average. The share of development partners expenditure as compared to the CHE had decreased from 49.7% in 2010/11 to 46.3% in 2011/12. The share of expenditure by development partners also decreased from 4.96% in 2010/11 to 4.14% in 2011/12 as a share of GDP, this may have resulted into budget cuts. Over the period 2010/11 to 2011/12 development partner s contribution towards health expenditure has decreased by UGX 66 billion in real terms due to the global financing challenges Financing Schemes SHA 2011 explains health care financing schemes as the main types of financing arrangements through which people obtain health services or can get access to health care. A financing scheme defines who is obliged to participate in the scheme, what the basis for entitlement to health care is and what benefits the scheme offers as well as the rules on raising and pooling the contributions. Health care financing schemes include direct payments by households for services and goods and thirdparty financing arrangements. Third party financing schemes are distinct bodies of rules that govern the mode of participation in the scheme, the basis for entitlement to health services and the rules on raising and then pooling the revenues of the given scheme. Table 3-2 shows that Government financing schemes were the major schemes accounting for 48.5% in 2010/11 and 45.5% in 2011/12 of the CHE. The health system is mostly financed through the national budget. This increased from 22% and 25% compared with the previous NHAs showing that government is increasingly gaining more space in determining priority areas in which funds should be allocated to. 6

26 Uganda Health Accounts - National Health Expenditure - CHAPTER THREE Table 3-2 Current Health Expenditure by Financing Schemes, 2010/11 to 2011/12 Financing Scheme FY2010/2011 (UGX Millions) Share (%) FY2011/2012 (UGX Millions) Share (%) Government schemes 2,225, % 2,161, % Voluntary health care payment schemes - Employer-based insurance 139, % 48, % - NPISH financing schemes (including development agencies) - Enterprises (except health care providers) financing schemes 548, % 492, % 21, % % Household out-of-pocket payment 1,533, % 1,775, % Rest of the world financing schemes (nonresident) 117, % 272, % Total 4,585, % 4,751, % Households are the dominant financing schemes in the private sector which accounts for 33.4 % of CHE in 2010/11 and 37.4% of CHE in 2011/12. Household Out-of-pocket (OOP) are direct payments made by users of health at the time of service being provided. The OOP reflected in this table is presumed to be predominantly cash. Other private funds are mainly through private insurance firms (1%) and private firms (10%). Partners (also known as Rest of the World in the SHA 2011 financing schemes classification) as a percentage of CHE account for 2.6% in 2010/11 and 5.7% in 2011/12.This excludes partners who give support under general budget support. The Government provides funding for the healthcare system in Uganda through general tax- financing and general budget support. Overall there was an increase in government funding from 2010/11 to 2011/12 (Table 3-1). The increases were mostly due to development partners funds which came through the Government consolidated funds and were reflected in Government current health expenditure (GCHE) as cash grants and general budget support. The total GCHE as a percentage of CHE was 13.8% (UGX 633billion ) in 2010/11 and 15.3%% (UGX.724 billion ) in 2011/12 and in both years on average account for 1.37% of current GDP. The total development partner contribution as a percentage of CHE was 49.7% (UGX.2,278 billion) in 2010/11 and 46.3% (UGX2,202 billion) in 2011/12 and on average in both years accounted for 4.5% of the current GDP. 7

27 Uganda Health Accounts - National Health Expenditure - CHAPTER FOUR 4.0. Current Health Expenditure by Providers Health Care Providers encompass all organizations and actors that deliver health care goods and services as their primary activity, as well as those for which health care provision is only one among a number of activities (SHA 2011). 4.1 Health care Providers Hospitals, Health units, private clinics and other providers of health goods and providers of ambulatory health care remain the top providers in terms of accounting for health expenditure. This is apparent given the fact that the largest recipients of revenue and utilization of resources are mainly the health units and hospitals. A substantial increase is noted in expenditure by providers towards procuring and delivering preventive care. There is an additional UGX 321 billion increase from UGX 457 billion (2010/11) to 778 billion (2011/12). This may be attributed to the increased support from partners for preventive services in areas such as social mobilisation sanitation and community empowerment. Table 4-1 Hospitals, Health units, private clinics and other providers of health goods FY 2010/2011 FY 2011/2012 (UGX Millions) Share (%) (UGX Millions) Share (%) Hospitals 1,788, % 2,789, % Residential long-term care facilities 10, % 20, % Providers of ambulatory health care 578, % 966, % Providers of ancillary services 15, % 22, % Retailers and other providers of medical goods 216, % 228, % Providers of preventive care 212, % 153, % Providers of health care system administration and financing 1,191, % 363, % Rest of economy 52, % 58, % Rest of the world % 39, % Other health care providers (n.e.c.) 519, % 109, % Total 4,585, % 4,751, % 8

28 Uganda Health Accounts - National Health Expenditure - CHAPTER FOUR Figure 4-1 Share of Current Health Expenditures by Providers (%), 2010/11 to 2011/ % 60.0% 85.7% 50.0% Percentage 40.0% 30.0% 20.0% 38.0% 20.4% 26.0% 10.0% 0.0% Hospitals 12.6% 11.3% 4.6% 7.6% 4.7% 1.2% 4.8% 0.8% 0.2% 3.2% 0.3% 1.1% 2.3% 0.4% 0.5% 0.01% Providers of Ambulatory health care Retailers and other providers of medical goods Providers of health care systems administartion and Financing Rest of the world Healthcare Provider In 2011/12, hospitals expended an additional 1,001 billion in their current expenditure relative to 2010/11. Hospital spending increased as a percentage share to CHE from 39% in 2010/11 to 58% in 2011/12 (refer Table 4-1). Expenses incurred by the Clinics and other providers of health care recorded a decrease of expenditure by 410 billion from Shs 519billiob in 2010/11 to Shs109 billion in 2011/12. Ambulatory Health Care expenditure increased from 578 billion 2010/11 to 967 billion in 2011/12 (refer Table4-1). Most health service delivery takes place at lower level but still half of the health expenses takes place at hospital level hence the inequity in resource allocation with potential for widening disparities. Figure 4-2 Share of Current Health Expenditures by Providers (%), 2011/12 Hospitals 85.7% Residential longterm care facilities 0.4% Providers of ambulatory health care 10.4% Other health Providers (n.e.c) 2.3% Rest of the world 0.8% Providers of ancillary services Retailers and other providers of medical goods 4.8% Rest of economy 1.2% Providers of health care system adninistration and Financing 7.6% Providers of preventive care 3.2% 9

29 Uganda Health Accounts - National Health Expenditure - CHAPTER FOUR 4.2 Hospital Expenditure Hospital expenditure in Uganda is mainly funded by private sources. Figure 4-3 highlights an increase in expenditure at hospitals by almost a Shs.1,001 billion from 2010/11 to 2011/12 an increase as a percentage of current health expenditure from 39% (2010/11) to 59% (2011/12). This may be attributed to the increase in support to hospitals by health development partners and increase in utilisation of hospitals by households. The private sector though reflects increased activity, as demonstrated through an increase in expenditure level by Shs. 113 billion from 2010/11 to 2011/12. The percentage share contribution to health expenditures in hospitals by the private sector in absolute terms increased. Table 4-2 Current Health Expenditure at Hospitals by financing source, 2010/11 and 2011/12 YEAR (UGX Millions) Public Private Development Partners Share (%) (UGX Millions) Share (%) (UGX Millions) Share (%) TOTAL (UGX Millions) FY2010/ , % 1,134, % 439, % 1,788,098 FY2011/ , % 1,247, % 1,272, % 2,789,125 Figure 4-3 Share of Current Health Expenditure at Hospital by financing source 2010/11 and 2011/12 10

30 Uganda Health Accounts - National Health Expenditure - CHAPTER FOUR 4.3 Non-Hospital Expenditure Non-hospital expenditure refers to the expenditure of other health providers as categorized in the SHA 2011 health provider classification. Expenditure decreases were recorded by providers of preventive care from Shs.212 billion (2010/11) to Shs.153 billion (2011/12), providers of ambulatory care registered an increase in expenditure from Shs.578 billion (2010/11) to Shs. 966 billion (2011/12) and retailers and other providers of medical goods from Shs. 216 billion (2010/11) to Shs.228 billion (2011/12). Retailers and other providers of medical goods are involved in providing pharmaceuticals and other durable health goods to outpatients. CHE for these providers increased by Shs.12 billion over the two years of reporting. Providers of preventive care consist of various public health programs coordinated by the private and public health sector. Providers of Ambulatory Health Care (not necessarily preventive) recorded an increase from Shs. 578 billion in 2010/11 to Shs 966 billion in 2011/12. This accounted for an increase of slightly over Shs.388billion from 2010/11 to 2011/12. Providers of health care system administration and financing also recorded a decrease from Shs. 1,191 billion in 2010/11 to Shs. 363 billion in 2011/12. This large decrease may mainly be attributed to more resources allocated for health service delivery than administration of health systems. 11

31 5.0. Current Health Expenditure by Function Uganda Health Accounts - National Health Expenditure - CHAPTER FIVE Health expenditure by function simply means the services and goods for which the health money has been spent. The international SHA methodology categorizes certain areas of use and functions, and codes them using the ICHA-HC classification (see also table 5-1). The analysis by function is important for any health system as it delivers information relevant for the policy level. For example the balance between inpatient and outpatient care expenditure, or how much was spent on preventive care, curative care and on Health administration. In this way, health expenditure by function provides a platform for policy makers to move from input based to output based health service delivery. The Ugandan National Health Accounts (UNHA) systematically classifies the purposes or functional uses of health expenditures. Table 5-1 shows the distribution of CHE by function in 2010/11 and 2011/12. There was slight decline in the proportion of expenditure for outpatient care, health goods dispensed to outpatients expenditure increased, prevention and public health services and governance, health systems & financing administration expenditure increased marginally. However CHE on ancillary services more than doubled probably due to increased demand for medical investigations. None the less in nominal terms, there was a remarkable increase in CHE on preventive care from Shs. 457 Billion to Shs. 778 Billion. This may be attributed to shift in policy to emphasise more preventive care though it was still far below the amount spent on curative. More emphasis is also put on the sick which is an emergency and the services provided for the sick are majorly curative. There has been a shift in the policy to emphasize preventive care. However, in spite of the nominal increase for preventive from Shs. 457 billion to Shs. 778 billion between 2010/11 and 2011/12 the proportion of expenditure for preventive health care fell slightly from 45.8% to 44% and it is also still far below what was spent on curative care (see figure 5-1). There was also a slight decline in the proportion of expenditure for outpatient care, health goods dispensed to outpatients expenditure increased, and public health services and governance, health systems and financing administration expenditure drastically declined. However CHE on ancillary services more than doubled probably due to increased demand for medical investigations. Table 5-1 Current Health Expenditure by Function, 2010/11 to 2011/12 Health Expenditure FY2010/2011 Share (%) (UGX Millions) FY2011/2012 Share (%) (UGX Millions) Inpatient curative care 1,467, % 1,278, % Day curative care 7, % 37, % Outpatient curative care 2,098, % 2,092, % Rehabilitative care and Long-term care (health) 24, % 53, % Ancillary services (non-specified by function) 1 12, % 127, % Medical goods (non-specified by function) 270, % 303, % Preventive care 457, % 778, % Governance & health system & financing administration 247, % 80, % TOTAL 4,585, % 4,751, % 12

32 1 Ancillary services to health care include laboratory and imaging services Uganda Health Accounts - National Health Expenditure - CHAPTER FIVE Figure 5-1 shows CHE by functions for the years 2010/11 to 2011/12. The Figure shows that expenditure on outpatient curative care is more than inpatient curative care. The increase in outpatient care expenditure compared to outpatient care expenditure is largely due to the increase in private health expenditure in 2010/11 and 2011/12 from households. Outpatient care expenditure remained almost the same in 2010/11 to 2011/12 while the inpatient expenditure decreased slightly by 5% as a share of CHE. Figure 5-1 Current Health Expenditure by function (%), 2010/11 to 2011/12 There was increase in expenditure for health goods ( %) and a slight increase of 0.5% in expenditure on rehabilitation and long term care, while governance, health systems & financing administration expenditure reduced by 3.7% to 1.7 % of CHE in 2011/12. In 2011/12 there was an increase in expenditure as a share of CHE for ancillary services from 0.3% to 2.7% of the CHE. Overall, Uganda spent 10% and 16% of CHE on preventive care in 2010/11 and 2011/12 respectively. The expenditure on preventive care increased from UGX 457 billion in 2010/11 to UGX.778 billion in 2011/12, equating to a 7% increase. Uganda spent more on governance, health systems & financing administration when compared to expenditure on rehabilitation in both years Inpatient and Outpatient Care Services The largest part of health spending by function is for curative care (inpatient and outpatient care services) as shown in Table 5-1. Inpatient care is mainly financed by the private sector (includes funds from development partners, households, private firms and health insurance), which accounted for 90% in 2010/11 compared and 91 % in 2011/12 (Table 5-2). Outpatient care was also mainly financed by the private sector with private shares of 85% in 2010/11 compared to 96 % in 2011/12. Note that Households spend almost 95% of their OOP health expenditure on outpatients care that probably explains the high percentage. 13

33 Uganda Health Accounts - National Health Expenditure - CHAPTER FIVE Table 5-2 Share of current health expenditure functions by financing source; FY2010/2011 FY2011/2012 Public Private Public Private Inpatient curative care 9.1% 90.9% 7.0% 93.0% Day curative care 0.0% 100.0% 0.0% 100.0% Outpatient curative care 14.1% 85.9% 4.0% 96.0% Rehabilitative care and Long-term care (health) 4.5% 95.5% 9.3% 90.7% Ancillary services (non-specified by function) 51.2% 48.8% 32.4% 67.6% Medical goods (non-specified by function) 16.7% 83.3% 26.1% 73.9% Preventive care 21.0% 79.0% 51.4% 48.6% Governance, and health system and financing administration 22.8% 77.2% 32.3% 67.7% Note: Private Expenditure also includes Development Partners 5.2. Medical Goods The third major component of health spending by function is medical goods. This category includes only pharmaceutical and therapeutic appliances and comprises sales of medicines and other health goods from private pharmacies and other clinics. This is because under the SHA guidelines, expenditure on pharmaceuticals during an inpatient episode of care is categorized as inpatient expenditure. Drug consumption under government facilities are coded to inpatient and outpatient care and not included under this category. Thus it is important to note that the expenditure on medicines included in this category accounts mainly for clinic sales by private pharmacies and drug shops. Uganda spent UGX 303 billion or 6.5% of CHE in 2011/12 on health goods to outpatients (Table 5-1). This has increased in percentage terms since 2010/11 (6%) despite the decrease in dollar value. The increase in Uganda is either an increase in drug prices or increased quantity of purchased drugs. Nevertheless this is an important indicator to monitor since in the private sector this is largely financed by households out of pocket expenses. Table 5-3 Medical goods expenditure by sub classes Pharmaceuticals and other medical non-durable goods FY2010/2011 (UGX Millions) Share (%) FY2011/2012 (UGX Millions) Share (%) - Prescribed medicines 59, % 65, % - Over-the-counter medicines 5 0.0% 2 0.0% - Other medical non-durable goods 32, % 41, % Therapeutic appliances and other medical goods 178, % 196, % TOTAL 270, % 303, % Table 5-3 shows expenditure on medical goods by subclasses in 2010/11 and 2011/12. It reflects that 14

34 Uganda Health Accounts - National Health Expenditure - CHAPTER FIVE 22% of the expenditure on health goods was spent on prescribed medicines while very little was spent on over the counter medicines. The expenditure on health goods accounts for 6% and 6.4% of CHE in 2010/11 and 2011/12 respectively Preventive Care SHA 2011 explains Preventive care is any measure that aims to avoid the occurrence or the severity of injuries and diseases and their complications. Prevention is based on a health promotion strategy that involves a process to enable people to improve their health through the control over some of its immediate determinants. This includes a wide range of expected outcomes, which are covered through a diversity of interventions, organized as primary, secondary and tertiary prevention levels. The expenditure mostly includes primary and secondary prevention programmes. Preventive care expenditures accounted for UGX778 billion or 17 % of CHE in 2011/12. This signifies a substantial increase in comparison with the previous year (UGX457 billion or 10% in 2010/11) (Table 5-1). This increase in the share was due to an increase in funding by Government and development partners for public health programs. Figure 5-2 shows that approximately, 21% of the financing of these programs was through Government funding, 79% from development partners and the private sector in 2010/11. For 2011/12, 51% of the financing of these programs was through Government funding, 49% from development partners and the private sector. Table 5-1 shows that the expenditure on preventive care increased by UGX321 billion in 2011/12 and accounted for 17% of CHE. Figure 5-2 Share of Preventive care by Source (%), 2010/11 to 2011/12 15

35 Uganda Health Accounts - National Health Expenditure - CHAPTER FIVE Figure 5-3 Share of Preventive care by categories of service (%), 2010/11 to 2011/12 Figure 5-3 shows that information, education and counselling programmes accounted for on average 38% of total preventive care expenditure in 2010/11 and 2011/12. The second largest portion of preventive care was spent on risk, surveillance and disease control programmes on average about 32%. There was a decrease in expenditure for early disease detection programmes, immunisation and monitoring for the year 2011/12 compared to 2010/11. Table 5-4 Preventive care by categories of service (Millions UGX), 2011/12 Information, education and counselling programmes Public FY2011/2012 Development Private Partners TOTAL 54, , ,261 Immunisation programmes ,460 37,703 Early disease detection programmes - - 4,947 4,947 Healthy condition monitoring programmes Epidemiological surveillance and risk and disease control programmes Preparing for disaster and emergency response programmes Total Expenditure on Prevention and Public Health programs 291, , ,033 53,424 2,343 86, , ,890 2, , ,153 16

36 Uganda Health Accounts - National Health Expenditure - CHAPTER SIX 6.0. Government Current Health Expenditure This chapter looks at Government Current Health Expenditure (GCHE) and provides details to show where and how this money is being spent Government Expenditure on Health Analysis of Government spending as in Table 6-1 shows that over the four (4) year period, Government Health Expenditure (GHE) has increased in nominal value (current). In real terms this means that Government s expenditure on health in 2011/12 (UGX 724) was less than what Government has spent from 2008/09 to 2010/11. Table 6-1 Government Health Expenditures (UGX), 2008/09 to 2011/12 Billions of UGX Financial Year 2008/ / / /12 Nominal value (current)-ugx Total Government expenditure(tge)-ugx 4,949 6,318 8,972 9,273 TGCHE per capita $ % of TGE 9% 7% 7% 8% GHE when reflected as a percentage of Total Government Expenditure (TGE) averaged to 8% and has remained relatively constant over the period from 2008/09 to 2011/12 (refer table 6-1). The trend indicates that the GHE per capita has been reducing in the 2 years of study mainly due to high population increase annually. The World Health Organization (WHO) in its research suggests that universal health coverage and equal access to health care maybe attained if Governments spend at least 10% to 15% of TGE on health (World Health Report 2010). The WHO Commission of Macro Economics on Health suggests that TGCHE per capita should be at least $34 for Sub-Sahara African countries to steadily move towards UHC and HSSIP suggested a minimum of $17 per capita to attain high health status in Uganda. Figure 6-1 GHE as a % of TGE from 2003 to 2011/12 The increase and decrease is largely driven by fluctuations in Government revenues (thus affecting the Government fiscal position) over those years, but less aligned with the health status of the population and the increasing (financial) needs for people with chronic diseases. The drop in 2009/10 was due to substantial increase in TGE. As a percentage of GDP, GHE has averaged 1.5% over the period 2008/09 to 2011/12. The 17

37 Uganda Health Accounts - National Health Expenditure - CHAPTER SIX percentage has remained relatively constant without any significant increase over the last 4 years (refer Figure 6-3) Government Current Health Expenditure by Sources Government had spent UGX 633 Billion in 2010/11 and UGX.724 billion in 2011/12, an increase of UGX.91billion in the GCHE in 2011/12 over 2010/11 (refer Table 6-2). This reflects a nominal increase from 2010/11 to 2011/12. Table 6-2 Sources of Government Current Health Expenditures (UGX), 2010/11 to 2011/12 FY2010/2011 FY2011/2012 (UGX Millions) Share (%) (UGX Millions) Share (%) Transfers from government domestic revenue (allocated to health purposes) 633,204 46% 724,903 33% Transfers from foreign origin 716,544 54% 1,441,120 67% TOTAL 1,349,748 2,166, % The GCHE also includes expenditures against development partners as cash grants which channelled through the Government system (budget support) and reflected in the annual budget. Over the two year period the GCHE averaged of 40% funding directly from Government domestic revenues and 60 % funding distributed by Government from foreign origin through project funding/ off budget support as shown in Table Government Current Health Expenditure by Providers Government health providers exist at different levels within the healthcare system and they are determined by the types of the health services they provide. As outlined in Table.6-3 we distinguish between hospitals, Long-term care facilities, Providers of Ambulatory health care, Providers of ancillary services, Providers of preventive care, Providers of health care system administration and financing, Rest of economy (which constitute other industries within the country as secondary providers of healthcare) and rest of the world (which constitute mostly expenditure by health development partners). 18

38 Uganda Health Accounts - National Health Expenditure - CHAPTER SIX Table 6-3 Government Current Health Expenditures by Providers (UGX), 2010/11 & 2011/12 FY2010/2011 (UGX Millions) Share (%) (UGX Millions) FY2011/2012 Share (%) Hospitals 214, % 268, % Providers of ambulatory health care 70, % 105, % Retailers and other providers of medical goods 24, % 19, % Providers of health care system administration and financing 200, % 315, % Rest of the world 123, % 16, % TOTAL 633, % 724, % Figure 6-2 shows the distribution of Government current health expenditures among the health providers that constitute the major recipients of Government health funds in 2011/12. Figure 6-2 Share of Government Current Health Expenditure by Provider, 2011/12 19

39 Uganda Health Accounts - National Health Expenditure - CHAPTER SIX Hospitals which include regional referral hospitals, Health units, NGO hospitals, and General hospitals, mental and specialized hospitals/institutions account for the largest share of Government spending. This was also the case as reported in the Uganda Health Account reports for 2008/09 and 2009/10 and thus, for the last 3 years health care facilities remain the major recipient of government health spending. Hospital expenditure equates to 37% of GCHE in 2011/12 (refer Figure 6-2). Of this value 23% is spent on Regional referral hospitals, 66% in primary health care hospitals and 11% in speciality hospitals/institutions. From 2010/11, there was an increase in funding to primary health care facilities perhaps as a result of additional human resource recruitment. In 2011/12 there was an increase in ambulatory care expenditures arising from reforms to strengthen primary health care by increasing the effectiveness of the services provided at health centres through investigations. Providers of ambulatory care refer to expenditures at health centres. In 2011/12 this accounts for 14% of GCHE and equates to UGX105 billion, an increase of expenditure by 4% from 2010/11 (refer Table 6-3). The ambulatory care expenditure consisted of both health centres managed by government and PNFP facilities. This expenditure includes spending on ancillary services. Ancillary services refer to expenditures for laboratory services, imaging services and patient transportation. The bulk of ancillary expenditure pertain to the cost of consumables and reagents for both imaging and laboratory services. Providers of preventive care expenditures were included under health systems administration. There was a massive increase in these expenses in 2011/12. The main reason is due to increase in expenditures in the on-going preventive programs such communicable and Non-Communicable Diseases (NCDs) and also inclusion of new programs such as Global Fund/TB Program and GAVI reflected within the Government system from 2011/12. Other Health care system administration and financing expenditure includes activities in overall administration of the health care sector, including administration of health financing such as formulation, supervision, coordination, administration and monitoring of overall health policies and budgets which accounts for UGX 315 billion or 43% of GCHE in 2011/12 (refer Table 6-3). Rest of the economy refers to industries or organizations that offer health care as a secondary activity. Rest of the economy accounts for UGX 123 billion or 20% of GCHE in 2010/11 (refer Table 6-3). The staff costing spent on salary and wages is distributed across all providers and is incorporated into expenditures of health providers. 20

40 Uganda Health Accounts - National Health Expenditure - CHAPTER SIX 6.4. Current Health Expenditure by disease and conditions Table 6-4 Current Health Expenditure by disease and conditions Disease SHA-code Disease Name /SHA-Category (UGX Millions) FY2010/11 Share (%) (UGX Millions) FY2011/12 Infectious and parasitic diseases 3,017,560 3,149,317 Share (%) DIS.1.1 HIV/AIDS 1,656, % 1,783, % DIS.1.2 Tuberculosis 46, % 86, % DIS.1.3 Malaria 971, % 945, % DIS.1.4 Respiratory infections 160, % 181, % DIS.1.5 Diarrhoeal diseases 49, % 60, % DIS.1.6 Neglected tropical diseases 1, % % DIS.1.7 Vaccine preventable diseases 43, % 49, % DIS.1.nec Other infectious and parasitic diseases (n.e.c.) 89, % 42, % Reproductive health 569, ,404 DIS.2.1 Maternal conditions 268, % 306, % DIS.2.2 Perinatal conditions 160, % 184, % DIS.2.3 Contraceptive management (family planning) 64, % 38, % DIS.2.nec Other reproductive health conditions (n.e.c.) 76, % 36, % Nutritional deficiencies 115, % 128, % Non-Communicable diseases 176, ,726 DIS.4.1 Neoplasms 28, % 37, % DIS.4.2 Endocrine disorders 2, % 2, % DIS.4.3 Cardiovascular diseases 13, % 14, % DIS.4.4 Mental disorders 25, % 28, % DIS.4.9 Other non-communicable diseases (n.e.c.) 106, % 140, % Injuries 104, % 114, % Non-disease specific 138, % 152, % Other diseases / conditions (n.e.c.) 462, % 416, % TOTAL 4,585, % 4,751, % Analysis of the current health expenditure by disease and conditions indicate that HIV/AIDS takes the largest portion of expenditure at 36% reflecting 1,656 billion of the CHE in 2010/11 and 37.5% (1,783 billion) in 2011/12, followed by expenditure on Malaria 21% (971 billion) in 2010/11 and 20% (945 billion) in 2011/12, Reproductive health conditions account for 12.4%(569 billion) of the CHE in 2010/11. Non communicable disease expenditure accounts for 3.8% (176 billion) of the CHE in 2010/11 and 4.8% (223 billion) in 2011/12, and the lowest expenditure is on injuries and nutrition at an average of 2.4% (114 billion) during the period under review. This calls for the need to increase funding for nutrition and NCDs. 21

41 Uganda Health Accounts - National Health Expenditure - CHAPTER SIX Other disease conditions not elsewhere classified (n.e.c) accounted for 10% (462 billion) of the expenditure in 2010/11 and 8.8% (416 billion) in 2011/12 (table 6-5) Government contributes 15% of the finances to the disease based costs and the development partners and the private sector contribute 85% of the funding. The major contributor to the CHE from the development partners is USAID 61% (1,392 billion), followed by Belgium (10%) 226 billion and Global fund (7%) 148 billion in 2010/11. These figures remained constant in 2011/12. Other partners contribution, the bilateral and multilateral contributions has been highlighted in the table 6-5 below. Table 6-5 Share of Individual Development Partners Funding FY2010/2011 FY2011/2012 Share (UGX Millions) (%) (UGX Millions) Share (%) Bilateral donors 1,821,190 1,633,981. Belgium 226, % 17, %. Canada 1, % 0.0%. Denmark 48, % 42, %. Germany 7, % 0.0%. Ireland 40, % 40, %. Italy 1, % %. Japan % 0.0%. Netherlands % 0.0%. Norway 2, % %. Sweden 5, % 4, %. United Kingdom 92, % 55, %. United States (USAID) 1,392, % 1,469, %. Other bilateral donors (n.e.c.) 2, % 3, % Multilateral donors 334, ,331. AfDB 6, % 1, %. EU Institutions 6, % 6, %. GAVI % 187, %. Global Fund 148, % 4, %. UNAIDS % 1, %. UNDP % 12, %. UNFPA 15, % 56, %. UNICEF 34, % 19, %. WHO 7, % 15, %. Other multilateral donors (n.e.c.) 113, % 134, % Private donors 120, ,973. Gates Foundation (BMGF) 4, % 4, %. Other private donors (n.e.c.) 20, % 26, %. Other Rest of the world (n.e.c.) 95, % 94, % TOTAL 2,276, % 2,198, % 22

42 Uganda Health Accounts - National Health Expenditure - CHAPTER SIX Table 6.6 Reproductive Health Expenditure 2010/ /12 Reproductive health % of 569,164 % of CHE 566,404 CHE DIS.2.1 Maternal conditions 268, % 306, % DIS.2.2 Perinatal conditions 160, % 184, % DIS.2.3 Contraceptive management (family planning) 64, % 38, % DIS.2.nec Other reproductive health conditions (n.e.c.) 76, % 36, % Reproductive Health expenditure accounted for 12.4% (UGX 569 Billion) of the CHE in 2010/11 and 12% (566 Billion) of the CHE in 2011/12. Much of the expenditure under reproductive health was for maternal conditions followed by perinatal conditions. Government finances about 14% of the reproductive health expenditure and the rest of the finances comes from the private sector (rest of the world) 76% Government Current Health Expenditure by Functions This section focuses on Government current health expenditures (GCHE) by function and is reflected in Table 6.6. Table 6-6 Government Current Health Expenditures by Functions, 2010/11 and 2011/12 FY2010/2011 (UGX Share (%) Millions) FY2011/2012 (UGX Share (%) Millions) Inpatient curative care 133, % 139, % Outpatient curative care 294, % 310, % Rehabilitative care and Long-term care (health) Ancillary services (non-specified by function) 1, % 2, % 6, % 41, % Medical goods (non-specified by function) 45, % 68, % Preventive care 96, % 136, % Governance, and health system and financing administration 56, % 26, % TOTAL 633, % 724, % Note: GCHE on health goods are incorporated into the above categories mainly in curative care (inpatient and outpatient care) Curative services incur the largest expense, 67% in 2010/11 and 62% in 2011/12 (Table 6.6 of GCHE). Curative services comprise of both inpatient and outpatient services. The increase in preventive care expenditure in 2011/12 is attributed to the increase in support to government under Global fund and 23

43 GAVI for malaria control and immunisation respectively. Uganda Health Accounts - National Health Expenditure - CHAPTER SIX In 2010/11 inpatient was 21% of GCHE whilst outpatient was 46% and in 2011/12 inpatient was 19% of GCHE whilst outpatient was 43%. Costs for services have increased over the two year period. In-patient services are mostly provided at hospitals and inpatient expenditure has increased in shillings value in 2011/12 although the percentage declined against the GCHE. The outpatient services which are provided at hospitals and ambulatory health centres and clinics and have also increased in Shs. value but in terms of percentage remained constant at about 44% on average of GCHE. The increase in outpatient expenditure in percentage terms may relate to the increase in the support to primary health care services. The increase in costs do not necessarily indicate improved efficiency nor does it measure the quality of health care delivered; this will require more in-depth studies and analysis which can assist in developing some monitoring and evaluation system to monitor these two critical services in terms of both costs and quality. Figure 6-3 Government Current Health Expenditure by Functions, 2011/12 Governance, and health system and financing administration accounted for 3.6% of the functional expenditure which accounts for in 2011/12 of GCHE. These are expenditures which involve administration of management of funds, formulation and administration of Government policies and monitoring and evaluation of such resources. Preventive care has the third largest share of health expenditure which accounts for 15.2% (UGX 96 billion) in 2010/11 and 19% (UGX136 billion) in 2011/12 of GCHE. Preventive care programmes are further broken down into six (6) categories of services and the expenditures have been distributed accordingly by respective years as shown in Table 6.7 Health expenditures in both years have been 24

44 mostly on Information, education and counselling (IEC) programmes. Table 6-7 GHCE by Preventive care categories, FY 2010/11 and 2011/12 Uganda Health Accounts - National Health Expenditure - CHAPTER SIX FY2010/2011 FY2011/2012 (UGX Millions) Share (%) (UGX Millions) Share (%) Information, education and counselling programmes 17, % 18, % Immunisation programmes % % Early disease detection programmes 0 0.0% 0 0.0% Healthy condition monitoring programmes 0 0.0% 0 0.0% Epidemiological surveillance and risk and disease control programmes Preparing for disaster and emergency response programmes 70, % 99, % 8, % 18, % TOTAL 96, % 136, % Ancillary services which is related to diagnosis and monitoring services accounted for 1% (UGX6.3 billion) in 2010/11 and 5.7% (UGX.41 billion) in 2011/12 of GCHE. The expenditure has increased drastically over the period 2010/11 to 2011/12 probably because of the emphasis on investigations and expansion of the laboratory network in 2011/12. Rehabilitative care has the lowest expenditure and accounted for only 0.3% (UGX1 billion) in 2010/11 and 0.3% (UGX 2 billion) in 2011/12 of Government Current Health CARE Expenditure (GCHE). Rehabilitative services are treatments provided to improve or restore impaired body functions and structures (e.g. disease, disorder, orthopaedics and injury) to improve the quality of life. The GCHE on health goods for both 2010/11 and 2011/12 are incorporated mostly into curative care (in-patient and outpatient care). Government spending on pharmaceuticals not specified by function (nsf) either to inpatient or outpatient is shown in figure 6-8 and that accounts for 9.4% of the GCHE in 2011/12 25

45 7.0. Private Current Health Expenditure Private Current Health Expenditure (PCHE) in this chapter represents all money spent on health either by households, private firms or organizations and excludes development partners and the government sector. This chapter explains where the money for private healthcare is coming from, who handles these funds, the services providers and the type of services provided Private Current Health Expenditure by Sources Uganda Health Accounts - National Health Expenditure - CHAPTER SEVEN The Private sector contributes significantly to the health sector and an analysis of health expenditure over the period 2010/11 to 2011/12 shows that there is an overall increase by UGX 151 billion in 2011/12. In 2010/11, PCHE was UGX 1,673 billion and by 2011/12, it had increased to UGX 1,824 billion (refer Table 7-1) The source of revenue for the private sector is mainly from other domestic revenues (households) and voluntary prepayments (individuals, employers and other). Domestic revenues account for 94% and voluntary prepayments 3% of PCHE in 2011/12 (refer Table 7-1.). Table 7-1 Private Current Health Expenditure by Sources, 2010/11 to 2011/12 FY2010/2011 FY 2011/2012 (UGX Millions) Share (%) (UGX Millions) Share (%) Compulsory prepayment from employers % % Voluntary pre-payment from employers 131, % 48, % Revenues from households 1,533, % 1,775, % Other revenues from corporations 9, % % TOTAL 1,673, % 1,824, % Figure 7-1 Domestic revenues account and voluntary prepayments of PCHE in 2011/12 26

46 Uganda Health Accounts - National Health Expenditure - CHAPTER SEVEN Household Out-of-Pocket (OOP) revenues increased in UGX value by UGX 242 billion from UGX 1,533 billion in 2010/11 to UGX 1,775 billion in 2011/12 (refer Table 7-1). However, it decreased as a share of the CHE from 43% in 2009/10 to 37% in 2011/12 due to overall increase in CHE. OOP is the largest revenue source for PHE. Table 7-2 Private Current Health Expenditure by Schemes, FY2010/11 to FY2011/12 FY2010/2011 (UGX Millions) Share (%) FY2011/2012 (UGX Millions) Share (%) Compulsory private insurance schemes % % Employer-based insurance (other than enterprises schemes) Other voluntary health insurance schemes (n.e.c.) Enterprises (except health care providers) financing schemes 131, % 48, % % % 9, % % Revenues from households 1,533, % 1,775, % TOTAL 1,673, % 1,824, % 7.2. Private Current Expenditure by Financing Schemes Figure 7-2 shows the PCHE by schemes. Schemes relates to financing arrangements through which people pay for their health service. In Uganda the two most common options are voluntary insurance, or pay at the point of service from their primary income/savings (.i.e. out of pocket). Households OOP is a direct payment made for services either from primary income or savings. The financing schemes for the private sector are mainly from OOP and voluntary health insurance. Voluntary health insurance schemes include employer based insurance, employee based voluntary insurance and other insurance coverage such as those from group or community based schemes. Expenditures in these schemes have decreased in Shs. value expect out of pocket expenditure on health which has increased by 242 billion from 2010/11 to 2011/12. Figure 7-2 highlights that household out-of-pocket expenditure accounts for an average of 94%, followed by private health insurance (5.2%). 27

47 Uganda Health Accounts - National Health Expenditure - CHAPTER SEVEN Figure 7-2 Private Current Health Expenditure by Providers, 2010/11 to 2011/ % 60.0% 56.4% 57.4% 50.0% Percentage 40.0% 30.0% 20.0% 18.5% 17.9% 10.2% 10.5% 10.0% 10.2% 10.6% 10.2% 10.5% 0.0% Government Owned Hospitals 0.0% 0.0% Other General Hospitals 1.2% 0.4% Providers of Ambulatory health care 0.1% 0.0% Retailers and other providers of medical goods. 2.9% 3.1% 0.1% 0.0% 0.4% 0.1% 0.0% 0.0% Providers health care system administration and financing Rest of the world FY 2010/2011 FY 2011/2012 Table 7-3 shows the overall expenditure by all providers had increased by about 10 % in 2011/12 over 2010/11. Some notable expenditure that contributed towards this increase was clinics and other providers of health goods and Private Health Practices. Table 7-3 Overall expenditure by all providers FY2010/2011 FY2011/2012 (UGX Millions) Share (%) (UGX Millions) Share (%) Government Owned Hospitals 171, % 193, % Private Owned Hospitals and clinics 943, % 1,046, % Other General hospitals % 0 0.0% Specialised hospitals (other than mental health hospitals) 19, % 7, % Providers of ambulatory health care 309, % 326, % Providers of ancillary services 1, % % Retailers and other providers of medical goods 170, % 191, % Providers of preventive care 1, % 0 0.0% Providers of health care system administration and financing 6, % 2, % Rest of economy 48, % 56, % Rest of the world % 0 0.0% TOTAL 1,673, % 1,824, % 28

48 7.3. Private Current Health Expenditure by Functions Uganda Health Accounts - National Health Expenditure - CHAPTER SEVEN The PCHE by function shows that there were increases for all categories in Shs. value, but varied share wise. Health goods having the highest expenditure for both years also showed an increase from 2010/11 by UGX 151 billion. Table 7-4: Private Current Health Expenditure by Functions, 2010/11 to 2011/12 FY2010/2011 FY2011/2012 Health Expenditure Share Share (%) (UGX Millions) (UGX Millions) (%) Inpatient curative care 651, % 717, % Outpatient curative care 846, % 906, % Rehabilitative care and Long-term care (health) % 10, % Ancillary services (non-specified by function)nsf 3, % % Medical goods (non-specified by function)nsf 163, % 187, % Preventive care 7, % 2, % TOTAL 1,673, % 1,824, % In 2011/12, the largest PCHE spending is on outpatients curative care averaging 50% (906 Billion) during the two years. In patient Curative care had the second largest functional expenses 39% out of the PCHE; Expenditure on Medical goods (non-specified by function) was the third largest expenditure function by the private sector. In 2010/11 inpatient was 38% of curative care whilst outpatient was 50.6% and in 2011/12 inpatient was 30% of curative care whilst outpatient was 50%. As evidently shown curative care continues to show a noticeable increase. In the private sector there are not many facilities for inpatient or rehabilitative care hence, health expenditure in these areas are very small. Alternatively the private sector could be selectively damping expensive inpatient and rehabilitative services to the public facilities or the beneficiaries find it more affordable to access such services away from the private sector. Outpatients and purchase of health drugs and consumables are common services provided by the private sector hence, the high expenditures in these areas. In the private sector, a large part of health services is directly funded by households through out-of-pocket expenditure. With increase in fees for service by clinics due to an unregulated market, households and individuals who can afford to are purchasing health care services either through their employer or insurance purchases to avoid direct payments at the point of service. 29

49 Uganda Health Accounts - National Health Expenditure - CHAPTER SEVEN Figure 7-3Share of Private Current Health Expenditure by Functions, FY2010/11 to FY2011/12 The share of PCHE by Functions clearly indicates that Health goods, though it dropped approximately 0.6% in 2011/12, still holds the third highest share. Ancillary Services decreased its shares from 0.2% in 2010/11 by 0.1% in 2011/12. The expenditure on preventive care reduced from same (0.5%) to 0.1% in 2011/12 as a share of PCHE. This implies private providers and households spend less on preventive care than curative probably because it is not considered as an emergency on their side. 30

50 Uganda Health Accounts - National Health Expenditure - CHAPTER EIGHT 8.0. Development Partners (Rest of the World) Development partners in this section also refer to Rest of the World as classified in SHA It is noted the information presented here under only reflects development partners who responded to the NHA questionnaire distributed. The Health sector continues to benefit from Health development partners and receives this support through direct, in kind financial contributions, technical expertise, supplies and equipment. The Health sectors traditional bilateral partners are USAID, BTC, DFID, SIDA, JICA, DANIDA and multilateral agencies include WHO, UNFPA, UNICEF, GAVI, ADB, World Bank and the Global Fund. Table 8-1 reflects development partner investment to the Health sector which has seen a steady increase from 2008/09 with a reduction in allocations from UGX 2,276 billion in 2010/11 to UGX 2,202 billion in 2011/12. Table 8-1 Financing contributions by Development Partners, FY2010/11 to FY2011/12 FY2010/2011 FY2011/2012 Share (%) (UGX Millions) (UGX Millions) Share (%) Bilateral donors 1,821, % 1,637, % Multilateral donors 430, % 533, % Private donors 24, % 31, % TOTAL 2,276, % 2,202, % Figure 8-1 Share of funding by Development Partners (%), 2011/12 Figure 8-1 depicts share of the budget by development partner. USAID is the Health sectors largest development partner whereby in 2010/11 the sector received UGX 942 billion from USAID and in FY 2011/12 it received UGX 931 billion and representing 43% of the total development partner support. The decrease in financing from FY 2010/11 to 2011/12 is attributed to the commencement of the support from Global Health initiatives to which the US governments contributes too. The 2009/10 NHA Report estimates USAID contribution to the Health sector in 2010 represented 49% of the total health development partner budget excluding Global initiatives to which the US government contributes too. USAID level of support reduced proportionally in 2011/12(43%), however there was an increase in nominal allocation. 31

51 Uganda Health Accounts - National Health Expenditure - CHAPTER EIGHT Table 8-2 Financing contributions of Development Partners as a share of CHE, 2010/11 and 2011/12 Year CHE (UGX Millions) Funding by External Partners (UGX Millions) Ratio of External funding to CHE (%) FY2010/2011 4,585,470 2,278, % FY2011/2012 4,751,261 2,202, % In 2010/11 the development partner budget was UGX 2,278 billion and represented 49.7% of CHE. The Health development partner budget decreased from UGX. 2,278 billion in 2010/11 to UGX. 2,202 billion in 2011/12 and represented 46% of CHE. This decrease is attributed to some partners not honouring their planned investments in the period under report Development Partners (Rest of the World) funding by Providers In 2010/11 the provider receiving the largest share of the development partner funding was health systems administration (43%) followed by hospitals (19%). This trend remained the same in 2011/12. Within the health care systems administration, the HIV/AIDS program was allocated the largest stake, followed by malaria control programs. The funding allocated to HIV/AIDS is attributed to the commencement of the IFMSobal Fund project within the Ministry of Health. Table 8-3Allocation of Development Partners funding by Providers, FY2010/11 to FY2011/12 FY2010/2011 (UGX Millions) Share (%) FY2011/2012 (UGX Millions) Share (%) Hospitals 439, % 424, % Residential long-term care facilities 10, % 11, % Providers of ambulatory health care 198, % 191, % Providers of ancillary services 15, % 15, % Retailers and other providers of medical goods 21, % 19, % Providers of preventive care 210, % 202, % Providers of health care system administration and financing 983, % 951, % Rest of economy 3, % 4, % Rest of the world 394, % 380, % TOTAL 2,278, % 2,202, % The provider receiving the second largest development partner funding is hospitals. This provider covers training institutions in hospitals and reflects developments and investment support to the Ministry of Health in training health professionals to respond to Uganda s population health needs, accommodate expansion of services, construction of new health facilities, and attrition of staff through migration and internal mobility Development Partners (Rest of the World) funding by Functions In 2011/12 and 2010/11, Health development partner funds were allocated by functions mainly to curative care services (66%), 21% was assigned to prevention and 5% for health system, financing and 32

52 Uganda Health Accounts - National Health Expenditure - CHAPTER EIGHT administration. This allocation reflects historical universal practices whereby curative services, civil and capital works are funded by Health development partners. Table 8-4 Allocation of Development Partners funding by Functions, FY2010/11 to FY2011/12 FY2010/2011 FY2011/2012 Share (%) (UGX (UGX Millions) Millions) Share (%) Inpatient curative care 682, % 470, % Day curative care 7, % 37, % Outpatient curative care 956, % 1,103, % Rehabilitative care and Long-term care (health) 22, % 38, % Ancillary services (non-specified by function) 2, % 85, % Medical goods (non-specified by function) 62, % 36, % Preventive care 353, % 375, % Governance, and health system and financing administration 191, % 54, % TOTAL 2,278, % 2,202, % Figure 8-2 Allocation of Development Partners funding by Functions, FY2010/11 to FY2011/12 33

53 Uganda Health Accounts - National Health Expenditure - CHAPTER EIGHT A breakdown of the 2011/12 allocation indicates the function receiving the largest provision of development partner funding was disease control programs; IEC followed by immunization. Governance, and health system financing and administration accounts for 5% of the development partner budget and attempts to breakdown these costs proved.to make this information more meaningful in the future will require the development of standard transaction definitions to enable standardized coding and subsequent analysis and reporting of health functions in future NHA reports. Table 8-5 Preventive Care Funding by Development Partners, FY2010/11 to FY2011/12 FY2010/2011 Share (%) (UGX Millions) FY2011/2012 Share (%) (UGX Millions) Information, education and counselling programmes 103, % 122, % Immunisation programmes 52, % 37, % Early disease detection programmes 5, % 4, % Healthy condition monitoring programmes 1, % % Epidemiological surveillance and risk and disease control programmes Preparing for disaster and emergency response programmes 80, % 124, % 110, % 86, % TOTAL 353, % 375, % Analysis of table 8.7 indicates disease based expenditures, data shows that HIV/AIDs programmes expenditure represents 38%( 1,783 billion) in 2011/12 of the current Health Expenditure this is followed by Malaria control program 20% ( 945 billion ) and reproductive health in the third 306 billion representing 12% (564 billion). Table 8.6 indicates the financing sources for all disease expenditures; the data indicates health development partners contribute substantially to prevention of HIV/AIDs 69% UGX 1,527 billion, followed by malaria control program 12.6% UGX 277 billion. Government expenditure on HIV/AIDS was 124 billion and the private sector UGX 131 billion in 2011/12. 34

54 Uganda Health Accounts - National Health Expenditure - CHAPTER EIGHT Table 8-6 Disease based costs by financing source for FY 2010/11 and 2011/12 FY2010/11 FY2011/12 DISEASE SHA- CODE DISEASE NAME / SHA-CATEGORY GOVERNMENT (UGX Millions) Share (%) PRIVATE (UGX Millions) Share (%) DEVELOPMENT PARTNERS (UGX Millions) Share (%) GOVERNMENT PRIVATE DEVELOPMENT PARTNERS (UGX Millions) Share (%) (UGX Millions) Share (%) (UGX Millions) Share (%) Infectious and parasitic diseases 316, ,299 1,859, , ,981 1,936,729 DIS.1.1 HIV/AIDS 214, % 113, % 1,327, % 124, % 131, % 1,527, % DIS.1.2 Tuberculosis 20, % % 25, % 38, % % 47, % DIS.1.3 Malaria 47, % 492, % 430, % 99, % 569, % 277, % DIS.1.4 Respiratory infections 5, % 140, % 13, % 6, % 162, % 13, % DIS.1.5 Diarrheal diseases 2, % 36, % 11, % 2, % 41, % 16, % DIS.1.6 DIS.1.7 DIS.1.nec NeIFMSected tropical diseases Vaccine preventable diseases Other infectious and parasitic diseases (n.e.c.) Reproductive health % % % % % % 1, % % 40, % 3, % % 46, % 24, % 55, % 9, % 20, % 12, % 8, % 82, , , , ,097 58,832 DIS.2.1 Maternal conditions 40, % 217, % 9, % 60, % 230, % 15, % DIS.2.2 Perinatal conditions 16, % 139, % 3, % 21, % 161, % 1, % DIS.2.3 DIS.2.nec Contraceptive management (family planning) Other reproductive health conditions (n.e.c.) Nutritional deficiencies 4, % 1, % 59, % 16, % % 21, % 20, % 1, % 53, % 15, % % 20, % 1, % 99, % 14, % 1, % 115, % 10, % Non-Communicable diseases 146,430 22,516 7, ,289 25,746 18,691 DIS.4.1 Neoplasms 25, % 1, % 2, % 33, % 1, % 1, % DIS.4.2 DIS.4.3 Endocrine disorders Cardiovascular diseases 1, % % % 2, % % % 11, % 1, % % 13, % % % DIS.4.4 Mental disorders 9, % 15, % % 10, % 18, % % DIS.4.9 Other noncommunicable diseases (n.e.c.) 98, % 4, % 4, % 119, % 5, % 15, % Injuries 10, % 93, % % 19, % 88, % 6, % Non-disease specific Other diseases / conditions (n.e.c.) 56, % 6, % 75, % 60, % 3, % 88, % 18, % 250, % 194, % 55, % 279, % 81, % TOTAL 633, % 1,673, % 2,278, % 724, % 1,824, % 2,202, % 35

55 Table 8-7 Disease based costs summary FY 2010/11 and 2011/12 Disease SHA-Code Disease Name / SHA-Category FY 2010/11 FY 2011/12 (UGX Millions) Share (%) (UGX Millions) Share (%) Infectious and parasitic diseases 3,017,560 3,149,317 DIS.1.1 HIV/AIDS 1,656, % 1,783, % DIS.1.2 Tuberculosis 46, % 86, % DIS.1.3 Malaria 971, % 945, % DIS.1.4 Respiratory infections 160, % 181, % DIS.1.5 Diarrheal diseases 49, % 60, % DIS.1.6 Neglected tropical diseases 1, % % DIS.1.7 Vaccine preventable diseases 43, % 49, % DIS.1.nec Other infectious and parasitic diseases (n.e.c.) 89, % 42, % Reproductive health 569, ,404 DIS.2.1 Maternal conditions 268, % 306, % DIS.2.2 Perinatal conditions 160, % 184, % DIS.2.3 Contraceptive management (family planning) 64, % 38, % DIS.2.nec Other reproductive health conditions (n.e.c.) Uganda Health Accounts - National Health Expenditure - CHAPTER EIGHT 76, % 36, % Nutritional deficiencies 115, % 128, % Non-Communicable diseases 176, ,726 DIS.4.1 Neoplasms 28, % 37, % DIS.4.2 Endocrine disorders 2, % 2, % DIS.4.3 Cardiovascular diseases 13, % 14, % DIS.4.4 Mental disorders 25, % 28, % DIS.4.9 Other noncommunicable diseases (n.e.c.) 106, % 140, % Injuries 104, % 114, % Non-disease specific 138, % 152, % Other diseases / conditions (n.e.c.) 462, % 416, % TOTAL 4,585, % 4,751, % 36

56 .Total House hold expenditure on health Uganda Health Accounts - National Health Expenditure - CHAPTER EIGHT The annual total national household expenditure on health is estimated at Ushs. 2,056 billion in financial year 2012/13. The composite consumer price index (CPI) is used to scale the 2012/13 estimate to 2010/11 and 2011/12. Uganda Bureau of Statistics indicates the CPI for 2010/11 and 2011/12 as and with base period 2005/06=100. Therefore making the base 2012/13, the CPI for 2010/11 becomes (142.17/190.60=0.7459). Then the annual total national household expenditure on health in financial year 2010/11 is estimated at Ushs. 2,056 x = 1,533.5 billion. The annual total household expenditure on health in financial year 2011/12 is estimated at Ushs. 2,056 x /190.60=1,775.6 Billion. Refer to table 8.8. Per capita expenditure on health Per capita expenditure on health is the total expenditure divided by the total population is estimated as shown below. Table 8-8 OOP per capita expenditure on health Year Population Estimate Out of Pocket Expenditure (Billion) Per Capita OOP Expenditure (UgSh) Per Capita OOP Expenditure (US$) Health- CPI Exchange rate A B C D=C/B E=D/G F G 2008/09 29,592,600 1, , /10 30,661,300 1, , /11 31,755,550 1, , /12 32,939,800 1, , /13 34,131,400 2, , Equity analysis Total and per capita household out-of-pocket expenditure by quintiles Looking at average expenditure by quintiles and in absolute amounts, Figure 8-8 shows that the richest quintile spent more than other quintile as the expected pattern. Table 8.8 further shows that all income groups registered increases in expenditure between the observed periods. This is probably due to relatively the poor quality of health services in some public facilities compared to private facilities. This may help government to understand this increase in OOP in relation to introduction and retention of households in the National Social Health insurance scheme. The drivers of the increase of household expenditure include; inflation, population growth, accessibility of private health services, sickness treated as an emergency in households, private wings establishments in government public facilities. Government may need to improve further quality of services in public facilities not just increase resource availability if the country is to reduce Household OOP to 20% of the CHE which is the maximum % acceptable according to WHO. 37

57 Uganda Health Accounts - National Health Expenditure - CHAPTER EIGHT Table 8-9 Total and per capita out of pocket expenditure by quintiles amounts in Billions of shs. 2010/ /12 -UGX Billions UGX -Per capita UGX-Per capita Poorest , ,236 Second , ,542 Third , ,755 Fourth , ,887 Richest 1, ,605,785 1, ,913,985 TOTAL 1, ,775.6 Table 8-10 Total and per capita health out of pocket expenditure by sub-regions-ugx 2010/ /12 UGX billions UGX billions Kampala Central Central East central Eastern Mid-Northern North-East West Nile Mid-Western South-Western TOTAL 1, Table 8-11 Total and per capita out of pocket expenditure by regions 2010/ / /13 Central Eastern Northern Western TOTAL 1, , ,056 Provider analysis Household out-of-pocket expenditure on health in private for profit facilities constitutes more than half of the total expenditures. Even with free services at public facilities, the share of Household expenditure spent in public health facilities is about 24.5% percent, which is significant. Public includes the following categories of health units: a) health unit government, b) hospital government, and c) Community health worker. Evidence indicates that the inadequate resources to deliver health services in public facilities to some extent indirectly impacts on the amount of household expenditure on health. Private for Profit includes the following categories of health units: a) Drug shop/pharmacy, b) HOMAPAK drug distributor, c) Drug shop/pharmacy, and d) Private clinic. Private not for profit includes the following categories of health units: a) health unit NGO, and b) hospital NGO. Traditional healer does not have sub-categories. Others include the following categories: a) Drugs at Home, b) Neighbour/ Friend, c) others not classified elsewhere. 38

58 Table 8-12 Total household expenditure by service provider (billion shs.) Uganda Health Accounts - National Health Expenditure - CHAPTER EIGHT Provider 2010/ / /13 percentage Government Hospital % Government Health Centres % Outreach Service % Fieldworker/VHT % Other Public Sector (specify) % Private Hospital/Clinic , % Pharmacy % Private Doctor % Outreach Service % Community Health Worker % Other private medical sector (specify) % Shop % Traditional practitioner % Market % Others (specify) % TOTAL 1, , , % Source: UBOS-Household survey 2012/13 Table 8-13 Total household expenditure by service provider (billion shs.) Financial year 2010/11 Base Percentage (%) FY- 2010/11 FY-2011/12 FY-2012/13 Public Private Traditional Others TOTAL Figure 8-3 Total household expenditure by service provider (billion shs.) Financial year 2010/11-Billions Service analysis 1, Public Private Traditional Others 39

59 Table 8-14 Total out of pocket expenditure by service paid for-billions Uganda Health Accounts - National Health Expenditure - CHAPTER EIGHT Services 2010/ / /13 Percent for the 3 years Consultation fees Medicines , Hospital/clinic charges Traditional doctors fees/medicines Other expenses/transport TOTAL 1, , , Figure 8-4 Total out of pocket expenditure by service paid for FY 2010/11-Billions 1, , , Consultation fees Medicines Hospital/clinic charges Traditional doctors fees/medicines Transport to and from Other expenses In the functional analysis of household OOP expenditure on health, no differentiation was made between the insurance co-financing premium component of the OOP and direct payments. The value analysis of the services purchased by households was not technically done due to lack of data. Policy analysts should note that some of the direct payments by households may be used to purchase unwarranted selfmedication that may have little or even indeed harmful effects to health. Health Condition analysis Household out-of-pocket health expenditure on malaria constitutes 31 percent of the total. Child birth related is only 9 percent, however this may be an under estimation. 40

60 Table 8-15Total household expenditure by health condition-billions Uganda Health Accounts - National Health Expenditure - CHAPTER EIGHT Diseases FY 2010/11 FY 2011/12 FY 2012/ Percent for the Billion (s) Billion (s) Billion (s) three years Diarrhoea (acute) Diarrhoea (chronic, 1 month or more) Weight loss (major) Fever (acute) Fever (recurring) Malaria Skin rash Weakness Severe headache Fainting Chills (feeling hot and cold) Vomiting Cough Coughing blood Pain on passing urine Genital sores Mental disorder Abdominal pain Sore throat Difficulty breathing Burn Fracture Wound Child birth related Other(specify Total , Age analysis Household out-of-pocket health expenditure varies with age. For example, while the 65+ year olds constitute 3.0 percent, their spending accounts for 9 percent. On the other hand, while the 5-14 year olds constitute 33 percent, their expenditure is only 16 percent. Perhaps this is because the bulk of illnesses in the younger age group is communicable and relatively less expensive to treat whereas the older age category has NCDs which are comparatively more expensive to treat. Total household expenditure by age-billions and per capita 41

61 Uganda Health Accounts - National Health Expenditure - CHAPTER EIGHT Table 8-16 Total household Health expenditure by age-billions and per capita expenditure by age 2010/ / /13 Age groups Average Percent for the 2 years , TOTAL 1, , Table 8-17 Total household Health expenditure by conditions-billions 2010/ /12 Age groups Percentage Percent for the 2 years Child Health Child Health Reproductive Health Sub total 1, , Others TOTAL 1,

62 Uganda Health Accounts - National Health Expenditure - CHAPTER NINE 9.0 Capital Expenditure SHA 2011 describes Capital Expenditure (HK) as a very integral component in health expenditure and it s an important factor due to its contribution in production of health services. For example construction of new health facilities or expansion/upgrading of existing ones, training, investment into new health equipment or upgrading or enhancements in computer or information systems or DHIS2 and IFMS. The HK information helps in analyzing the health systems production capability whether it s appropriate, deficient or excessive. This chapter provides how much HK was spent on the production of services and which Government, private and development partners have contributed towards the formation of this HK and what types of services have been provided. The information presented on private and development partners have been consolidated from the survey responses Types of Assets in production of health services Capital Expenditure (HK) are classified under two (2) major category of 1) Gross capital formation which comprises of three sub- categories namely infrastructure, machinery and equipment and ICT related equipment and other machinery & equipment not specified elsewhere; 2) Non-produced nonfinancial assets which comprises of land and others. Figure 9-1 provides the amount spent on various types of assets for the period 2010/11 to 2011/12. Table 9-1 Capital Expenditure by Type of asset, FY2010/11 to FY2011/12- nominal FY2010/2011 FY2011/2012 (UGX Millions) Share (%) (UGX Millions) Share (%) Infrastructure 61, % 39, % - Residential and non-residential buildings 58,702 37,868 - Other structures 2,905 1,651 Machinery and equipment 15, % 46, % - Medical equipment 13,018 2,937 - Transport equipment ,716 - ICT equipment Machinery and equipment n.e.c. 1,802 17,564 Intellectual property products % % - Computer software and databases Intellectual property products n.e.c Changes in inventories % 9 0.0% Research and development in health 39, % 52, % Education and training of health personnel 8, % 9, % TOTAL 125, % 147, % 43

63 Uganda Health Accounts - National Health Expenditure - CHAPTER NINE Figure 9-1 Capital Expenditure by Type of asset, FY2010/11 to FY2011/12 (nominal millions UGX) total capital expenditure which contributed towards the production of health services in 2010/11 was UGX125 billion compared to UGX147 billion in 2011/12. The major expenditure was from infrastructure which relates to civil works, health equipment, transport, ICT and others equates to UGX. 61 billion (49%) in 2010/11 and UGX.39 billion (27%) in 2011/12 of the HK. The second largest HK category was research and development in health accounts for 39 billion (31%) in 2010/11 and UGX. 52 billion (35%) in 2011/12 of the HK. Non-produced non-financial assets which relates to land purchase and development was the lowest and accounted for UGX.141 million (0.1%) in 2010/11 of the HK (refer Table 9-1) Capital Expenditure by Sectors Figure 9-2 shows the contribution of HK by each sector for the years 2010/11 to 2011/12. Table 9-2 Capital Expenditure by Sectors, FY2010/11 to FY2011/12 FY2010/2011 Share (%) (UGX Millions) FY2011/2012 Share (%) (UGX Millions) Government 91, % 78, % Private % % Health Development Partners 33, % 68, % TOTAL 125, % 147, % Government of Uganda (GOU) was the largest contributor in HK followed by Health Development Partners (HDPs) and lastly the private sector. Both Government and private sector expenditure includes the construction or upgrading of infrastructures, purchase of equipment, vessels, vehicles such as ambulances and ICT equipment & software in their respective sectors. The HK by development partners is mostly investments made in the form of new infrastructure, maintenance of existing health facilities and equipment purchase. 44

64 9.3. Government Capital Expenditure Uganda Health Accounts - National Health Expenditure - CHAPTER NINE Government capital expenditure mostly includes the construction or maintenance/ upgrading of infrastructures and purchase of equipment. The overall Government capital expenditure (HK) increased by 12% between FY2010/2011 and FY2011/12 (Table 9-3). Table 9-3 Capital Expenditure by Public Sector (Government), FY2010/11 to FY2011/12 FY2010/2011 FY2011/2012 Share (%) Share (%) (UGX Millions) (UGX Millions) Infrastructure 32, % 32, % - Residential and non-residential buildings ,053 - Other structures Machinery and equipment 41, % 41, % - Medical equipment Transport equipment 80 23,127 - ICT equipment Machinery and equipment n.e.c. 17,292 17,496 Intellectual property products 0 0.0% % Changes in inventories % 0 0.0% Research and development in health 0 0.0% 4, % Education and training of health personnel 0 0.0% % TOTAL 91, % 78, % N.B: Much of the capital expenditure in the health sector was spent on medical equipment and machinery in both FY2010/2011 and FY2011/2012. Table 9-4 Capital Expenditure by Private Sector, FY2010/11 to FY2011/12 FY2010/2011 (UGX Millions) Share (%) FY2011/2012 (UGX Millions) Share (%) Infrastructure % 0 0.0% - Residential and non-residential buildings Other structures 58 0 Machinery and equipment % % - Medical equipment Transport equipment ICT equipment Intellectual property products % % - Computer software and databases Changes in inventories % 0 0.0% Research and development in health 0 0.0% 0 0.0% Education and training of health personnel % % TOTAL % % 45

65 Uganda Health Accounts - National Health Expenditure - CHAPTER NINE Table 9-5 Capital Expenditure by Development Partners, FY2010/11 to FY2011/12 (UGX Millions) FY2010/2011 Share (%) (UGX Millions) FY2011/2012 Share (%) Infrastructure 16, % 6, % Machinery and equipment 5, % 12, % Changes in inventories 3 0.1% 9 0.0% Research and development in health 10, % 47, % Education and training of health personnel 0.0% 1, % TOTAL 33, % 68, % N.B. Capital allocation priorities for public sector compared to development partners are inverted. This may require harmonisation in prioritization. 46

66 Uganda Health Accounts - National Health Expenditure - CHAPTER TEN Factors of Health Care Provision This classification of health expenditure here specifically focuses on the inputs needed to produce the health care goods and services (Factors of Provision). The discussion and results presented here pertain only to Government funded health care goods and services since it was not possible to collect (nor estimate) the resource inputs of the Private and Development Partners sectors. The classification of Government current health expenditure by factors of provision was relatively straight forward since the global (financial management information system (IFMS) is an input based expenditure recording system. Tracking these inputs can help identify cost drivers in the health system (e.g. wages and salaries of health professionals, medicines, etc.) Factors of Provision for GCHE Of important note is that the high expenditure on wages and salaries average about 30% of the factors of provision during the period under review may imply that much of the health expenditures are spent on employ costs and very little is used for actual service delivery. This may explain the rather poor quality of services in most government health facilities. Table 10-1 Percentage breakdown of GCHE by Factors of Provision (UGX Millions) FY2010/2011 Share (%) (UGX Millions) FY2011/2012 Share (%) Wages and salaries 1,386, % 1,351, % Social contributions 7, % 2, % All other costs related to employees 79, % 50, % Self-employed professional remuneration 49, % 57, % Health care services 660, % 713, % Pharmaceuticals 1,254, % 1,030, % Other health care goods 84, % 36, % Non-health care services 99, % 100, % Non-health care goods 114, % 98, % Other materials and services used (n.e.c.) 64, % 42, % Consumption of fixed capital 10, % 2, % Other items of spending on inputs 380, % 811, % Other factors of health care provision 392, % 452, % TOTAL 4,585, % 4,751, % 47

67 Figure 10-1 Human Resources expenditure by Providers Uganda Health Accounts - National Health Expenditure - CHAPTER NINE The percentage of funds spent on human resource for health is so high compared to funds spent on actual service delivery. Human resource inputs are very expensive and constitute an important share of service delivery. E.g. in order to treat pneumonia there needs to be a doctor to make the diagnosis, the lab to provide the results, the dispenser/nurse to administer the treatment. Combined the HR remuneration will be high for a single episode Figure 10-2 The percentage of funds spend on human resource for health N.B. A lot of funds are spent on human resources for health in Hospitals yet more people sick health care from the lower level health units. There is there fore need to harmonisse the staffing norms to achieve efficiency in service delivery. 48

68 Figure 10-3 Healthcare Services expenditure by health Providers Uganda Health Accounts - National Health Expenditure - CHAPTER NINE N.B. Hospitals still take a large proportion of the funding for health service delivery despite the fact that the primary pillars of health care service delivery are the lower level health units. Figure 10-4 Pharmaceutical expenditure by health Providers FY 2010/11 N.B. Much of the funding towards pharmaceuticals is still managed and controlled by hospitals in the country and yet the primary health care facilities serve the largest catchment area of the population. 49

69 Figure 10-5 Pharmaceutical expenditure by health Providers FY 2011/12 Uganda Health Accounts - National Health Expenditure - CHAPTER TEN Figure 10-6 Other Healthcare goods expenditure by Providers FY2010/11 to FY2011/12 50

70 Figure 10-7 Factors of Provision costs by Health Providers Uganda Health Accounts - National Health Expenditure - CHAPTER TEN Tracking these inputs can help identify cost drivers in the health system (e.g. wages and salaries of health professionals, medicines, etc.) Figure 10-8 Cost drivers in the health system 51

71 11.0. Government Inpatient Disease Based Costs Uganda Health Accounts - National Health Expenditure - CHAPTER ELEVEN Measuring spending on disease is key to understanding the value of health care available to the users of this health care (Rosen and Cutler). The analysis of mortality and morbidity are a means a country can use to measure the disease profile of its people and consequently make decisions (on patient treatment, financing allocations, planning, health systems support, disease control and so forth) Expenditure by Disease Table 11-1 Disease-based Cost for FY2010/11 to FY2011/12 DISEASE SHA-CODE DISEASE NAME / SHA-CATEGORY FY2010/11 (UGX Millions) Share (%) (UGX Millions) FY2011/12 Share (%) Infectious and parasitic diseases 3,017,560 3,149,317 DIS.1.1 HIV/AIDS 1,656, % 1,783, % DIS.1.2 Tuberculosis 46, % 86, % DIS.1.3 Malaria 971, % 945, % DIS.1.4 Respiratory infections 160, % 181, % DIS.1.5 Diarrheal diseases 49, % 60, % DIS.1.6 Neglected tropical diseases 1, % % DIS.1.7 Vaccine preventable diseases 43, % 49, % DIS.1.nec Other infectious and parasitic diseases (n.e.c.) 89, % 42, % Reproductive health 569, ,404 DIS.2.1 Maternal conditions 268, % 306, % DIS.2.2 Perinatal conditions 160, % 184, % DIS.2.3 Contraceptive management (family planning) 64, % 38, % DIS.2.nec Other reproductive health conditions (n.e.c.) 76, % 36, % Nutritional deficiencies 115, % 128, % Non-Communicable diseases 176, ,726 DIS.4.1 Neoplasms 28, % 37, % DIS.4.2 Endocrine disorders 2, % 2, % DIS.4.3 Cardiovascular diseases 13, % 14, % DIS.4.4 Mental disorders 25, % 28, % DIS.4.9 Other noncommunicable diseases (n.e.c.) 106, % 140, % Injuries 104, % 114, % Non-disease specific 138, % 152, % Other diseases / conditions (n.e.c.) 462, % 416, % TOTAL 4,585, % 4,751, % 52

72 11.2 Government Inpatient Disease Based Costs Measuring spending on disease is key to understanding the value of health care available to the users of this health care (Rosen and Cutler, year????). The analysis of mortality and morbidity are a means a country can use to measure the disease profile of its people and consequently make decisions (on patient treatment, financing allocations, planning, health systems support, disease control and so forth). Table summarises the expenditure patterns by disease/condition. The highest expenditure overall was on HIV/AIDS, followed by malaria and then maternal health conditions. The expenditure does not necessarily follow the burden of illness or level of required inputs. For example, the high inputs for HIV/AIDS is probably a reflection of the development partner investment future analysis should include a break down with the gaps for required needs viz a vis actual expenditure Expenditure by Disease Table 11-2 Disease-based Cost for FY2010/11 to FY2011/12 Disease SHA- Code DISEASE NAME / SHA-CATEGORY Uganda Health Accounts - National Health Expenditure - CHAPTER ELEVEN (UGX Millions) FY2010/11 Share (%) (UGX Millions) FY2011/12 Infectious and parasitic diseases 3,017,560 3,149,317 Share (%) DIS.1.1 HIV/AIDS 1,656, % 1,783, % DIS.1.2 Tuberculosis 46, % 86, % DIS.1.3 Malaria 971, % 945, % DIS.1.4 Respiratory infections 160, % 181, % DIS.1.5 Diarrheal diseases 49, % 60, % DIS.1.6 NeIFMSected tropical diseases 1, % % DIS.1.7 Vaccine preventable diseases 43, % 49, % DIS.1.nec Other infectious and parasitic diseases (n.e.c.) 89, % 42, % Reproductive health 569, ,404 DIS.2.1 Maternal conditions 268, % 306, % DIS.2.2 Perinatal conditions 160, % 184, % DIS.2.3 Contraceptive management (family planning) 64, % 38, % DIS.2.nec Other reproductive health conditions (n.e.c.) 76, % 36, % Nutritional deficiencies 115, % 128, % Non-Communicable diseases 176, ,726 DIS.4.1 Neoplasms 28, % 37, % DIS.4.2 Endocrine disorders 2, % 2, % DIS.4.3 Cardiovascular diseases 13, % 14, % DIS.4.4 Mental disorders 25, % 28, % DIS.4.9 Other noncommunicable diseases (n.e.c.) 106, % 140, % Injuries 104, % 114, % Non-disease specific 138, % 152, % Other diseases / conditions (n.e.c.) 462, % 416, % TOTAL 4,585, % 4,751, % 53

73 Uganda Health Accounts - National Health Expenditure - CONCLUSION Conclusions and recommendations Overall Health Spending Households contribute over 37% of CHE funds, which widens inequities in general health, access and utilization of health care services. This also increases the incidence of catastrophic expenditures thus increasing incidence of poverty (Maximum recommended OOP level as a % of CHE is 30%) Per capita government health on health was around 9US$, which is far below the estimated US$44 target of the innovative task force on health financing and estimated requirement in the HSSIP of US$17. Overall spending per capita is below the recommended level (US$53) compared to WHO recommended minimum level of US$60 to provide a basic health care service Abuja Declaration on TGHE as % of TGE was a minimum of 15%, results showed Uganda at an average of 9% for the two years of the study. The non-public sector is a major player managing over 50% of health expenditures. Biased expenditure on curative services accounting for 73% of CHE for the two years of the study. Recommendations Increase public spending to meet both the Innovative task force on health financing estimated requirement of US$44 per capita and the Abuja Declaration target (15% of total government expenditure on health) Develop financing mechanisms to manage HH funds used as OOP payments in a more equitable way through pre-payment mechanisms(e.g. National health insurance, community insurance schemes) Address the decline in the share of the provision of prevention and public health programs by increasing focus on preventive health care. Implementation of the PPPH policy that has just been finalised should be expedited and effective monitoring mechanisms, to monitor activities of non-public providers should be put in place. In addition, harmonised and all-encompassing planning frameworks must be implemented. Health service resource allocation and Prioritization should be based on evidence of impact and results. 54

74 Uganda Health Accounts - National Health Expenditure - BIBLIOGRAPHY Bibliography and References 1. A short guide to producing national health accounts, World Health Organization, Regional Office for the Eastern Mediterranean Cairo, National Health Accounts Where Are We Today? SIDA Issue Paper by Catharina Hjortsberg, National Health Accounts of Uganda, 1999/ National Health Accounts: Policy Brief on Concepts and Approaches; Regional Health Forum WHO South-East Asia Region Volume 7 Number 2, Dr U Than Sein; Dr Abdullah Waheed 5. SHA Guidelines Practical guidance for implementing, A System of Health Accounts 2011: the Office for National Statistics (UK) 6. Uganda Demographic Health survey ( UDHS 2013). 7. Synthesis of findings from NHA studies in Twenty Six Countries, July 2004 Susna De et al. 8. National technical paper to Guide data entry for National Health Accounts, Burkina Faso, Annual reports and strategic plans of disease based programes Annual reports of the Health development partners and NGOs National Health Accounts reports Qatar,Zanzibar, Zambia, Fiji islands,seychelles Island Commonwealth Health partnerships 2012 report 13. IFMS Reports (Uganda) Ministry of Finance, Planning and Economic Development Annual reports Bank of Uganda,Annual performance reports Final Accounts for all Government Institutions sampled for FY 2010/11and 2011/ Development cooperation report , Ministry of Finance, Planning and Economic Development 18. Summary of project support managed outside government systems, Ministry of Finance, Planning and Economic Development Commission for Macroeconomics and Health, WHO, Uganda Demographic and Health Survey. Uganda Bureau of Statistics WHO (World Health Organization) (2003), Guide to producing national health accounts. With special applications for low-income and middle-income countries. WHO, Geneva. (available at publications/2003/ pdf). 22. WHO Guide for estimating Out Of Pocket Spending. 23. Health care financing profiles of East, Central and Southern African Health Community countries ECSA. 24. Abolition of user fees: the Uganda paradox. Nabyonga Orem et al, Uganda Bureau of Statistics- Statistical Abstracts UDHS report World Health Organization statistics Annual Health Sector Reports 2010/ / Costing study of selected health facilities in Uganda 55

75 Uganda Health Accounts - National Health Expenditure - BIBLIOGRAPHY 29. HMIS facility reports Budget estimates 2010/ /13,Ministry of Finance 31. National Health Accounts report, Uganda 2009/ Health Sector strategic Investment plan , Ministry of Health. 33. OECD,2000. A system of Health Accounts. Paris 2011 Edition. Organisation for Economic Cooperation and Development. 34. The World Health Report 2010; Health systems financing: the path to Universal Health Coverage, WHO WHO, Guide to producing National Health Accounts; with special application for low income and middle income countries. Geneva, Switzerland: WHO 36. Uganda Health systems Assessment report 2011, Makerere University School of Public Health 37. Fiscal Space for Health in Uganda Peter Okwero. (Footnotes) 1 See relevant chapters for breakdown of the global figures in this column 2 For detailed explanation of this percentage and others in the table, see relevant chapters 3 Note that part of the Government Current and Capital Health Expenditure is financed by external partners through general budget support 56

76 Uganda Health Accounts - National Health Expenditure - ANNEXES Annexes Annex One: National Health Accounts-Summary of Key Indicators FY2010/ /12 INDICATORS UNITS FY2010/11 FY2011/12 General Population Millions Share of HDPs funding Revenues of Schemes Financing Schemes Gross Domestic Product (GDP)-current prices UGX Millions 45,944,000 53,202,000 Total Government Expenditure (TGE) UGX Millions 8,972,500 9,273,400 Current Health Expenditure (CHE) UGX Millions 4,585,470 4,751,261 CHE plus Capital Spending UGX Millions 4,710,813 4,898,580 CHE Per Capita - UGX 139, ,207 Exchange rate UGX (NCU per US$) UGX 2,557 2,609 CHE per Capita- USD CHE as % of nominal GDP nominal 10% 9% Household Expenditure on Health UGX Millions 1,533,500 1,775,600 Household Expenditure on Health as a % of CHE Percentage 33% 37% Household OOP expenditure on health per capita UGX UGX 46,610 52,070 Household OOP expenditure on health per capita US$ Bilateral donors contribution to CHE UGX Millions 1,821,190 1,633,981 Bilateral Donors contribution to CHE % 7.3% 9.2% Multilateral donors contribution to CHE UGX Millions 334, ,331 Multilateral Donors contribution to CHE % 39.7% 34.4% Rest of the World Contribution to CHE UGX Millions 120, ,973 Private Donors/Rest of the World Contribution to CHE % 2.6% 2.7% Government Current Health Expenditure UGX Millions 633, ,903 General Government Health Expenditure (GGHE) UGX Millions 724, ,702 including k formation Private Health Expenditure UGX Millions 1,673,905 1,824,334 Development Partners funding UGX Millions 2,278,361 2,202,025 GCHE as a % of CHE % 13.8% 15.3% Private Health Expenditure as a % of CHE % 36.5% 38.4% Development Partner funds as a % of CHE % 49.7% 46.3% CHE as a % of GDP % 10.0% 8.9% GCHE as a % of TGE % 7% 8% GCHE as a % of GDP % 1.38% 1.36% GCHE per capita UGX 19,787 21,321 GCHE per Capita US$ GGHE per capita US$ GGHE UGX Millions 724, ,702 GGHE as % of TGE UGX 8% 9% Private Current Health Expenditure as a % of GDP % 3.6% 3.4% Development Partners funding as a % of GDP % 3.4% 4.1% Government Financing Schemes as a % of CHE % 74.2% 71.6% Voluntary Health Insurance Schemes as a % of CHE % 2.8% 1.4% Out of Pocket (OOP) expenditure as a % of CHE % 33% 37% 57

77 Uganda Health Accounts - National Health Expenditure - ANNEXES INDICATORS UNITS FY2010/11 FY2011/12 Health Curative spending as a % of CHE % 77% 70% Functions Inpatient Care as a % of CHE- % 32% 27% Outpatient Care as a % of CHE % 46% 44% Preventive Care as a % of CHE % 10% 16% RH expenditure as a % of CHE % 12.4% 12% Health Providers Hospital spending as a % of CHE % 39% 59% Other providers as a % of CHE % 17.4% 8% Providers of health system administration and financing( % 38.6% 28% LGs) % of CHE Medical goods as a % of CHE % 5% 5% Factors Capital formation Capital Formation Expenditure on Government Human Resources as a % of % 31.2% 30% CHE Expenditure on Government Human Resources as a % of GCHE % 48% 42% Expenditure on capital formation UGX Millions 125, ,319 Capital expenditure as a % of CHE plus capital % 3% 3% spending(ghe) Government Capital expenditure as a % of GHE % 1.6% 1.6% Expenditure on infectious and parasitic diseases UGX Millions 3,017,560 3,149,317 Conditions/ Disease based expenditure Infectious and Parasitic diseases expenditure as % of CHE % 65.8% 66.2% Expenditure on Reproductive Health UGX Millions 569, ,404 Reproductive Health expenditure as % of CHE % 12.4% 12% Expenditure on Nutrition deficiencies UGX Millions 115, ,053 Nutrition deficiencies expenditure as % of CHE % 2.5% 2.7% Expenditure on NCDs UGX Millions 176, ,726 Non Communicable Diseases Expenditure as % of CHE % 3.9% 4.7% Expenditure on injuries UGX Millions 104, ,839 Injuries expenditure as % of CHE % 2.3% 2.4% Non Disease specific expenditure UGX Millions 138, ,475 Non Disease specific expenditure as % of CHE % 3.0% 3.2% Expenditure on conditions (n.e.c) UGX Millions 462, ,447 Other conditions (n.e.c) as % of CHE % 10.1% 8.8% N.B. Detailed explanation on each of the percentages and the desegregated data is contained in the various chapters of this document. Note that part of the Government Current and Capital Health Expenditure is financed by external partners through general budget support. Other providers include; providers of ancillary services, preventive services, long term care services, rest of the economy and others not specified by kind. Matrices on the appendix have the details aggregation. 58

78 Annex Two: Disease-based Cost for FY2010/11 to FY2011/12 Uganda Health Accounts - National Health Expenditure - ANNEXES FY2010/11 FY2011/12 DISEASE SHA-CODE DISEASE NAME / SHA-CATEGORY (UGX Millions) Share (%) (UGX Millions) Share (%) Infectious and parasitic diseases 3,017,560 3,149,317 DIS.1.1 HIV/AIDS 1,656, % 1,783, % DIS.1.2 Tuberculosis 46, % 86, % DIS.1.3 Malaria 971, % 945, % DIS.1.4 Respiratory infections 160, % 181, % DIS.1.5 Diarrheal diseases 49, % 60, % DIS.1.6 Neglected tropical diseases 1, % % DIS.1.7 Vaccine preventable diseases 43, % 49, % DIS.1.nec Other infectious and parasitic diseases (n.e.c.) 89, % 42, % Reproductive health 569, ,404 DIS.2.1 Maternal conditions 268, % 306, % DIS.2.2 Perinatal conditions 160, % 184, % DIS.2.3 DIS.2.nec Contraceptive management (family planning) Other reproductive health conditions (n.e.c.) 64, % 38, % 76, % 36, % Nutritional deficiencies 115, % 128, % Non-Communicable diseases 176, ,726 DIS.4.1 Neoplasms 28, % 37, % DIS.4.2 Endocrine disorders 2, % 2, % DIS.4.3 Cardiovascular diseases 13, % 14, % DIS.4.4 Mental disorders 25, % 28, % DIS.4.9 Other noncommunicable diseases (n.e.c.) 106, % 140, % Injuries 104, % 114, % Non-disease specific 138, % 152, % Other diseases / conditions (n.e.c.) 462, % 416, % TOTAL 4,585, % 4,751, % 59

79 Annex Three. Summary tables NHA 2010/11. Uganda Health Accounts - National Health Expenditure - ANNEXES Reported currency: Ugandan shilling (UGS) Currency: Ugandan shilling (UGS) Classification of diseases / conditions DIS.1 DIS.2 DIS.1.1 DIS.1.2 DIS.1.3 DIS.1.4 DIS.1.5 DIS.1.6 DIS.1.7 DIS.1.nec DIS.2.1 DIS Institutional units providing revenues to financing schemes Ugandan shilling (UGS), Million Infectious and parasitic diseases HIV/ AIDS Malaria Respiratory infections Tuberculosis Diarrheal diseases Neglected tropical diseases Vaccine preventable diseases Other infectious and parasitic diseases (n.e.c.) Reproductive health Maternal conditions FS.RI.1.1 Government 316, ,786 20,233 47,608 5,690 2, ,856 24,334 82,928 40,403 16, FS.RI.1.2 Corporations 65,348 1, ,276 1, ,658 30,352 26,243 1,2 FS.RI.1.3 Households 775, , , ,549 35, , , FS.RI.1.4 NPISH ,425 FS.RI.1.5 Rest of the world 1,859,139 1,327,529 25, ,888 13,800 11, ,365 9, ,757 9,754 3,8 Used data sources: FS.RI Bilateral donors 1,463,408 1,183,765 20, ,946 8,855 7, ,280 4,077 94,613 4,805 2,6 FS.RI Belgium 52,622 14, ,405 7,338 FS.RI Canada 1,603 1,603 FS.RI Denmark 48,015 48,015 FS.RI Germany 3,534 3,534 3,534 FS.RI Ireland 40,385 40,385 FS.RI Italy FS.RI Japan FS.RI Netherlands FS.RI Norway 1,888 1, FS.RI Sweden 3,522 3,522 1,723 FS.RI United Kingdom 53,518 40,172 5,133 4,312 3, ,092 4 FS.RI United States (USAID) 1,255,358 1,033,992 20, ,911 4,543 3, ,925 4,801 2,6 FS.RI nec Other bilateral donors (n.e.c.) 2,901 2,901 FS.RI Multilateral donors 289,300 43,747 5, ,034 4,915 3, ,330 27,887 4,499 1,0 FS.RI AfDB 4, ,552 1,304 1, ,490 FS.RI EU Institutions 6,173 1,037 5, FS.RI GAVI 2 2 FS.RI Global Fund 146, , , , FS.RI UNAIDS FS.RI UNDP FS.RI UNFPA 14,494 FS.RI UNICEF 21,527 1, ,749 3,200 2, , FS.RI WHO 1, ,125 1, FS.RI nec Other multilateral donors (n.e.c.) 107,607 39, , ,086 2, FS.RI Private donors 22,684 22,684 FS.RI Gates Foundation (BMGF) 3,517 3,517 FS.RI nec Other private donors (n.e.c.) 19,167 19,167 FS.RI.1.5.nec Other Rest of the 83,746 world (n.e.c.) 77, , , Per con tion Donors NGOs Employers Insurances Government sources Households DANIDA; SIDA; DFID; NORWAY; USAID; ITALIAN GOVERNMENT; IRISH AID; JAPAN EMBASSY; BELGIUM; AUSTRIA; AfDB; UNFPA; GAVI; UNAIDS; UNICEF; GLOBAL FUND; WHO; EUROP CARITAS UGANDA; INTRA HEALTH; UHMG; CUAMM; PACE; CSF; NACWOLA; FOO; HEPS; IDI; TASO; AVSI FOUNDATION; MSH; THETA; WATER REED PROJECT; MARI STOPES; MALAR BAYLOR; HOSPICE; IRCU; ICOBI; PLAN UGANDA; IRC; LION AID NORWAY; John Snow Inc; ABT Associates; Partnership for Supply Chain Mgt; University Research Council; Cardino Emergen QUALITY CHEMICALS; AIRTEL UGANDA; UMEME; UGANDA BAATI; TORORO CEMENT; BAT UG; NHCC; UNBS; NWSC; MONITOR; ROOFINGS; INDEPENDENT; CENTURY BOTTLING; BA JUBILEE; UAP; AAR; Local Government Uganda; Uganda; Uganda CAPITAL; MOHProg; Other Line Ministries and Agencies; 60

80 Uganda Health Accounts - National Health Expenditure - ANNEXES DIS.3 DIS.4 DIS.5 DIS.6 DIS.nec All DIS DIS.2.1 DIS.2.2 DIS.2.3 DIS.2.nec DIS.4.1 DIS.4.2 DIS.4.3 DIS.4.4 DIS.4.9 Maternal conditions Perinatal conditions Contraceptive management (family planning) Other reproductive health conditions (n.e.c.) Nutritional deficiencies Noncommunicable diseases Neoplasms Endocrine disorders Cardiovascular diseases Mental disorders Other noncommunicable diseases (n.e.c.) Injuries Non-disease specific Other diseases / conditions (n.e.c.) 40,403 16,923 4,726 20,876 1, ,430 25,386 1,856 11,758 9,362 98,068 10,841 56,407 18, ,204 26,243 1,280 1,163 1, ,181 1, , ,112 21,255 6,774 9, , , ,015 99,678 15,335 15,335 72, ,760 1,533,500 1, ,330 9,754 3,874 59,014 52,115 14,374 7,613 2, , , ,812 2,276,031 4,805 2,605 54,267 32,936 13, , ,807 1,821,190 6, , , ,253 1,603 48,015 1,767 1,767 7,067 40,385 1, , ,630 1,723 5, ,060 25, ,702 92,256 4,801 2,605 43,001 5,518 12, ,098 14,414 1,392,729 2,901 4,499 1,061 3,228 19,100 1,277 5, , ,568 7, ,402 1, , , , , ,034 11,460 1,086 15, ,714 1,246 1, , ,218 4,329 34,335 1, , , ,812 2, , ,633 1,200 1, ,792 1,200 1,200 4, , , ,014 4,542 95,647 ND; WHO; EUROPEAN UNION; IDA; I STOPES; MALARIA CONSORTIUM; John Hopkins Univ; Community Connector; AIC; AMREF; Elizabeth Glazer Paed Aids; Peace Corps Ug; MILDMAY INTL; WORLD VISION; FHI; SAVE THE CHILDREN; il; Cardino Emergency; RECO Inds; Social and Scientific Systems; RY BOTTLING; BARODA BANK; SCOUL; RWENZORI; UGANDA CLAYS; KINYARA; MULAGO MED SCH; PPDA; URA; CDC; 61

81 Uganda Health Accounts - National Health Expenditure - ANNEXES Annex Four. Summary Tables NHA 2011/12. Reported currency: Ugandan shilling (UGS) Currency: Ugandan shilling (UGS) Classification of diseases / conditions Institutional units providing revenues to financing schemes Ugandan shilling (UGS), Million DIS.1 DIS.1.1 DIS.1.2 DIS.1.3 DIS.1.4 DIS.1.5 DIS.1.6 DIS.1.7 DIS.1.nec DIS.2.1 DIS.2 Infectious and parasitic diseases HIV/AIDS Malaria Tuberculosis Respiratory infections Diarrheal diseases Neglected tropical diseases Vaccine preventable diseases Other infectious and parasitic diseases (n.e.c.) Reproductive health Materna condition FS.RI.1.1 Government 294, ,261 38,685 99,034 6,394 2, ,329 20, ,475 60,192 FS.RI.1.2 Corporations 19,528 1, , ,924 11,343 8,331 FS.RI.1.3 Households 898, , , ,580 40, , ,950 FS.RI.1.4 NPISH , FS.RI.1.5 Rest of the world 1,936,236 1,527,111 47, ,344 13,033 16, ,018 8,337 57,773 15,357 FS.RI Bilateral donors 1,467,926 1,239,341 36, ,884 3,288 3,717 37,599 1,986 22,209 9,818 FS.RI Belgium FS.RI Denmark 42,100 42,100 FS.RI Ireland 40,903 40,903 FS.RI Italy FS.RI Norway FS.RI Sweden 4,179 4, FS.RI United Kingdom 34,352 34, FS.RI FS.RI nec United States (USAID) Other bilateral donors (n.e.c.) 1,345,499 1,117,835 36, ,652 3,223 3,696 37,128 1,896 21,014 9, FS.RI Multilateral donors 363, ,518 7, ,327 9,744 13,241 8,419 6,090 17,145 4,222 FS.RI EU Institutions 1,327 1,327 FS.RI GAVI 3, , FS.RI Global Fund 184, ,667 6,122 42, FS.RI IDA + IBRD (World Bank) 4,157 4,157 FS.RI UNAIDS 1,537 1, FS.RI UNFPA 1,294 FS.RI UNICEF 29,956 3, ,572 4,743 5,352 3,194 3,312 1,845 1,172 FS.RI WFP 11,871 1, ,924 3,353 1,949 1,579 FS.RI WHO 5, ,118 1, ,296 1,298 FS.RI nec Other multilateral donors (n.e.c.) 120,765 40,099 76,549 2,310 1,807 11,190 1,457 FS.RI.1.5.nec Other Rest of the world (n.e.c.) 91,927 86,279 4,208 1, All FS.RI 3,149,317 1,783,003 86, , ,682 60, ,703 42, , ,429 Used data sources: Donors NGOs Employers Insurances Government sources Households SEC DANIDA; SIDA; DFID; NORWAY; USAID; ITALIAN GOVERNMENT; IRISH AID; JAPAN EMBASSY; BELGIUM; AUSTRIA; AfDB; UNFPA; GAVI; UNAIDS; UNICEF; GLOBAL FUND; WHO; EUROP CARITAS UGANDA; INTRA HEALTH; UHMG; CUAMM; PACE; CSF; NACWOLA; FOO; HEPS; IDI; TASO; AVSI FOUNDATION; MSH; THETA; WATER REED PROJECT; MARI STOPES; MALAR BAYLOR; HOSPICE; IRCU; ICOBI; PLAN UGANDA; IRC; LION AID NORWAY; John Snow Inc; ABT Associates; Partnership for Supply Chain Mgt; University Research Council; Cardino Emergen QUALITY CHEMICALS; AIRTEL UGANDA; UMEME; UGANDA BAATI; TORORO CEMENT; BAT UG; NHCC; UNBS; NWSC; MONITOR; ROOFINGS; INDEPENDENT; CENTURY BOTTLING; BA JUBILEE; UAP; AAR; Local Government Uganda; Uganda; Uganda CAPITAL; MOHProg; Other Line Ministries and Agencies; 62

82 Uganda Health Accounts - National Health Expenditure - ANNEXES DIS.2 DIS.3 DIS.4 DIS.5 DIS.6 DIS.nec All DIS DIS.2.1 DIS.2.2 DIS.2.3 DIS.2.nec DIS.4.1 DIS.4.2 DIS.4.3 DIS.4.4 DIS.4.9 Reproductive health Maternal conditions Perinatal conditions Contraceptive management (family planning) Other reproductive health conditions (n.e.c.) Nutritional deficiencies Noncommunicable diseases Endocrine disorders Neoplasms Cardiovascular diseases Mental disorders Other noncommunicable diseases (n.e.c.) Injuries Nondisease specific Other diseases / conditions (n.e.c.) 114,475 60,192 21,876 16,575 15,832 1, ,289 33,920 2,026 13,858 10, ,053 19,257 60,744 55, ,903 11,343 8,331 1, ,990 1, ,626 5,403 3, , , , , ,414 17,756 17,756 83, ,769 1,775,600 1, , , ,740 57,773 15,357 1,222 21,244 19,950 10,841 16,866 1, ,328 6,572 88,398 81,599 2,198,285 22,209 9, ,171 5,997 2,583 3, ,165 1,451 75,793 60,393 1,633,981 17,232 17,232 42,100 40, , ,815 55,360 21,014 9,171 5,982 5,860 2,569 1,956 1,956 1,311 58,138 39,440 1,469, , , ,425 17,145 4,222 1,000 6,528 5,396 8,258 13,239 1, ,163 4,728 10,907 20, ,331 1, , , ,191 4,157 1,537 1,294 1,294 11,132 12,426 1,845 1, ,421 5, ,730 2,362 6,980 3,434 56,462 1,092 1,774 1,774 1,189 1,540 2,027 19,493 2,296 1, , , ,136 11,190 1,457 4,951 4,781 1,272 1, , , , , , ,630 38,640 36, , ,726 37,183 2,400 14,987 28, , , , ,447 4,751,261 FUND; WHO; EUROPEAN UNION; IDA; ARI STOPES; MALARIA CONSORTIUM; John Hopkins Univ; Community Connector; AIC; AMREF; Elizabeth Glazer Paed Aids; Peace Corps Ug; MILDMAY INTL; WORLD VISION; FHI; SAVE THE CHILDREN; ncil; Cardino Emergency; RECO Inds; Social and Scientific Systems; TURY BOTTLING; BARODA BANK; SCOUL; RWENZORI; UGANDA CLAYS; KINYARA; MULAGO MED SCH; PPDA; URA; CDC; 63

83 Uganda Health Accounts - National Health Expenditure - ANNEXES Annex Five. Summary Tables NHA 2010/11. Reported currency: Ugandan shilling (UGS) Currency: Ugandan shilling (UGS) Revenues of health care financing schemes FS.1 FS.2 FS.4 FS.5 FS.1.1 FS.1.2 FS.1.4 FS.4.2 FS.5.2 Financing schemes Ugandan shilling (UGS), Million Transfers from government domestic revenue (allocated to health purposes) Internal transfers and grants Transfers by government on behalf of specific groups Other transfers from government domestic revenue Transfers distributed by government from foreign origin Compulsory prepayment (other than FS.3) Compulsory prepayment from employers Voluntary prepayment Voluntary prepayment from HF.1 Government schemes and compulsory contributory health care financing schemes 621, ,106 3,792 1,603, HF.1.1 Government schemes 621, ,106 3,792 1,603,203 HF Central government schemes 609, ,210 3,792 1,234,255 HF State/regional/local government schemes 4,896 4,896 12,106 HF.1.1.nec Other government schemes (n.e.c.) 8,000 8, ,842 HF.1.2 Compulsory contributory health insurance schemes HF Compulsory private insurance schemes HF.2 Voluntary health care payment schemes 3,792 3, , ,0 HF.2.1 Voluntary health insurance 139, ,0 schemes HF Primary/substitutory health insurance schemes 139, ,0 HF Employer-based insurance (other than enterprises schemes) 139, ,0 HF Complementary/supplementary insurance schemes HF nec Other voluntary health insurance schemes (n.e.c.) HF.2.2 NPISH financing schemes (including development agencies) HF NPISH financing schemes (excluding HF.2.2.2) HF Resident foreign development agencies schemes HF.2.2.nec Other NPISH financing schemes (n.e.c.) HF.2.3 Enterprise financing schemes 3,792 3, HF Enterprises (except health care providers) financing schemes HF.3 Household out-of-pocket payment HF.3.nec Other household out-of-pocket payment (n.e.c.) HF.4 Rest of the world financing schemes (non-resident) HF.4.2 Voluntary schemes (non-resident) HF Other schemes (non-resident) 3,792 3, HF HF Philanthropy/international NGOs schemes Foreign development agencies schemes HF Schemes of enclaves (e.g. international organisations or embassies) HF.4.nec Other rest of the world financing schemes (n.e.c.) All HF 625, ,106 7, ,603, , ,0 64

84 Uganda Health Accounts - National Health Expenditure - ANNEXES FS.6 FS.7 All FS FS.5.2 FS.6.1 FS.6.2 FS.6.3 FS.7.1 FS.7.2 FS.7.3 FS FS FS FS FS Voluntary prepayment from employers Other domestic revenues n.e.c. Other revenues from households n.e.c. Other revenues from corporations n.e.c. Other revenues from NPISH n.e.c. Direct foreign transfers Direct foreign financial transfers Direct bilateral financial transfers Direct multilateral financial transfers Other direct foreign financial transfers Direct foreign aid in kind Direct foreign aid in goods Other direct foreign aid in goods Other direct foreign transfers (n.e.c.) 2,225,201 2,225,100 1,843,257 17, , ,071 11,523 9,193 2, , , ,694 15, , , , , , , , , , ,330 2, , , ,970 15, , , ,132 2,330 2, , , ,618 15, , , , ,352 8,352 8,352 8,352 9,193 9,193 8,723 8,723 8,723 21,708 9,193 9,193 8,723 8,723 8,723 21,708 1,533,500 1,533,500 1,533,500 1,533,500 1,533,500 1,533, , ,647 62,835 5,049 40,763 1,034 1,034 1,034 8, , , ,604 62,835 5,006 40,763 1,034 1,034 1,034 7, , , ,604 62,835 5,006 40,763 1,034 1,034 1,034 7, , , ,012 62,835 5,006 40, , , ,071 1,545,023 1,533,500 9,193 2, , , ,528 20, ,704 1,226 1,226 1, ,188 4,585,470 65

85 Uganda Health Accounts - National Health Expenditure - ANNEXES Annex Five. Summary Tables NHA 2011/12. Reported currency: Ugandan shilling (UGS) Currency: Ugandan shilling (UGS) Revenues of health care financing schemes FS.1 FS.2 FS.4 FS.5 FS.1.1 FS.1.2 FS.4.2 Financing schemes Ugandan shilling (UGS), Million Transfers from government domestic revenue (allocated to health purposes) Internal transfers and grants Transfers by government on behalf of specific groups Transfers distributed by government from foreign origin Compulsory prepayment (other than FS.3) Compulsory prepayment from employers HF.1 Government schemes and compulsory contributory health care financing schemes 716, , ,441, HF.1.1 Government schemes 716, , ,441,120 HF Central government schemes 716, , ,389,165 HF State/regional/local government schemes 18,804 HF.1.1.nec Other government schemes (n.e.c.) 33,151 HF.1.2 Compulsory contributory health insurance schemes HF Compulsory private insurance schemes HF.2 Voluntary health care payment schemes HF.2.1 Voluntary health insurance schemes 48 HF.2.2 HF HF Primary/substitutory health insurance schemes Employer-based insurance (other than enterprises schemes) HF Complementary/supplementary insurance schemes HF nec Other voluntary health insurance schemes (n.e.c.) NPISH financing schemes (including development agencies) HF NPISH financing schemes (excluding HF.2.2.2) HF Resident foreign development agencies schemes HF.2.2.nec Other NPISH financing schemes (n.e.c.) HF.2.3 Enterprise financing schemes HF Enterprises (except health care providers) financing schemes HF.3 Household out-of-pocket payment HF.4 HF.3.nec Other household out-of-pocket payment (n.e.c.) Rest of the world financing schemes (non-resident) HF.4.2 Voluntary schemes (non-resident) HF Other schemes (non-resident) HF Philanthropy/international NGOs schemes HF Foreign development agencies schemes HF.4.nec Other rest of the world financing schemes (n.e.c.) HF.nec Other financing schemes (n.e.c.) All HF 716, , ,441,

86 Uganda Health Accounts - National Health Expenditure - ANNEXES FS.5 FS.6 FS.7 FS.nec All FS.2 FS.5.2 FS.6.1 FS.6.2 FS.7.1 FS.7.3 FS FS FS from employers Voluntary prepayment Voluntary prepayment from employers Other domestic revenues n.e.c. Other revenues from households n.e.c. Other revenues from corporations n.e.c. Direct foreign transfers Direct foreign financial transfers Direct bilateral financial transfers Direct multilateral financial transfers Other direct foreign financial transfers Other direct foreign transfers (n.e.c.) Other revenues (n.e.c.) 04 3,740 2,161,411 3,740 2,161,307 2,105,611 18,804 3,740 36, ,079 48, , , ,133 45, ,507 44, ,320 48,079 48,079 48,079 48,041 48,041 48,041 48,041 48,041 48, , , ,133 45, ,507 44, , , , ,501 44, ,507 44, , ,632 46,632 46,632 46, ,775,600 1,775,600 1,775,600 1,775,600 1,775,600 1,775, , , ,207 10,160 29, , , ,507 66,860 10,160 29, , , ,507 66,860 10,160 29, , , ,469 66,420 9,562 29, ,469 1,038 1, , , , , ,347 26,076 26,076 26,076 26, ,079 48,079 1,776,150 1,775, , , ,417 55, ,994 44,367 3,740 4,751,261 67

87 Uganda Health Accounts - National Health Expenditure - CHAPTER ONE Annex Four. Summary Tables NHA 2011/12. 68