Financing Mental Health Care in Uganda

1. Financing Mental Health Care in Uganda Presented by Costella Mbabazi Research Officer 24th September 2010

2. Structure • Background • Methodology • Main Sources • Decision making • Use of allocated funds • Impact on mental health care • Limitations • Emerging gaps • Recommendations • Conclusion

3. Background • It is estimated that a 1% allocation out of the Primary Health Care envelope is made to mental health, but this has been found to be less: • Out of a PHC budget of 351,684,208/= for FY 2008/2009, one Health Sub-district had a consolidated allocation of 138,000/= for mental health and reproductive health. (circa 0.04%)

4. PHC Budget allocation to MH UGX 2008/2009 (Case study)

5. Justification • Limited or unequally distributed mental health resources hinder increasing access to mental health treatment. Studies indicate that in the poorest countries, the smallest percentage of overall health budgets goes to mental health care (Saxena et al., 2007). Lack of transparency about the sources and allocations of funds for mental health contributes to these barriers (Knapp et al., 2006).Findings will: • influence mental health policy& mental health care financing decisions, inform more in-depth studies on financing or costing future community based psychiatric interventions, &set a framework for tracking finances for mental health services in districts.

6. Methodology Descriptive study, purposive samples • Case Study • Document review • Key informant interviews • Trend analysis Study areas • Ministry of Health • Ministry of Finance, Planning & Economic Development • National Regional Referral Hospitals, District Health Office, District Finance Departments &lower health centers in Hoima, Buliisa & Amuria

7. Data analysis • Qualitative data: document review matrix, coding according to predetermined themes, cross tabulation. triangulated • Quantitative data: Analyzed & presented using tables & graphs to illuminate trends

8. Main sources • The Government through the Ministry of Finance, Planning and Economic Development (most sustainable). • Allocates to the Ministry of Health, districts and National Referral Hospitals against an annual budget. Allocation trends illustrated on next slide

9. Health sector financing 2004/2005-2008/2009

10. Main sources cont’d • Direct donor funding, now diminished because of the economic crisis • Out of pocket expenses, yet within East Africa Uganda has the highest level of income poverty with an annual income per capita of $300 as compared to $350 and $580 for Tanzania and Kenya respectively. • Health insurance, however contracts don’t usually include coverage for severe psychiatric and neurological disorders. • Good will organizations

11. Decision making for funds allocation • Some reliance on contextual political, socio-economic and environmental factors, e.g. because of reliance on donors • Centrally a 9 step process presented in the next slide.

12. 1. National Strategic Planning Process 1.1 Health Sector Strategic Plan II (5 year plan) 2. Ministry of Health defines priorities for the Financial Year in a planning workshop to include key interventions for mental Health 3. Integrated into the annual Ministry policy statement 4. Ministry develops annual work plan 5. Used by districts and lower health centers to develop individual plans 6. Government reviews plans and communicates indicative figures for thefinancial year. 7. Ministry Budget Working Group makes allocations to districts &programmes. Discussed byrelevant management teams 8. Departmental plans &budgets are issued to district councils&In Charges for approval 9. Health centers make final allocations based on unique priorities

13. Use of allocated funds • Largely for diagnostic and treatment purposes. • Purchase of psychotropic and anti convulsant medicines. • Recruitment and payment of personnel • Medical supplies • Administration costs • Outreach clinics • Community sensitization • Health education

14. Use of allocated funds • Development of Information, Education and Communication materials • Home visits • Policy development • Legislation development • Advocacy • Holistic mainstreaming and integration

15. Impact on mental health care • Minimal allocations for mental health care yet not always disbursed. • Poor drug supply, especially for psychotropic drugs • Cheaper and alternative modes of treatment sought by patients, eg traditional healers • Health budgets rarely cater for logistical support needed for support supervision. • Continued stigma

16. Impact on mental health care • Ill skilled healthcare personnel resulting into poor and unprofessional service. wrong prescriptions and dispensing with dire results, e.g. Chlorpromazine a.k.a. CPZ (psychotropic) instead of Carbamazepine a.k.a. CBZ (anti convulsant) • Negative impact on women as primary caregivers, e.g. walking long distances at the opportunity cost of gainful activity

17. Emerging gaps • No information on cost effectiveness of currently funded services YET: • the number of mental health cases treated at Butabika Hospital rose from 4,274 in 2005/2006 to 5,604 in 2006/2007 (Dr. James Walugembe RIP). • one third of the Ugandan population has been said to have some form of mental disorder. (Ssebunya et al 2009)

18. Limitations • Samples were largely purposive and case study limited to BasicNeeds project areas • Lack of written documents in some study areas, eg financial accountability reports at district finance offices, so had to rely on memory recall

19. Recommendations • Districts • Advocate for fund allocation towards recruitment of specialized personnel. • Support supervision to ensure effective update of HMIS necessary as evidence of financing need. • Ensure that planned for funds are adequate to support content of the Health Sector Strategic Plan.

20. Recommendations cont’d • Ministry of Health • Increase funding allocations to mental health. • Lobby government for ring fenced funds for drugs and complimentary services for community mental health. • Awareness creation among key decision makers and policy makers. • 4. Current service analysis for effective resource utilization.

21. Recommendations cont’d Government • Increase annual budget allocation to the health sector. • Allocate ringfenced funding for mental health as a priority health issue.

22. Conclusion • Government alone, is not to blame. Other stakeholders like users need to own the advocacy process to influence the decision making process and policy makers.