Donor financing and expenditure for PHC in Uganda

1. Donor financing and expenditure for PHC in Uganda Dr. Betty Kyaddondo Population Secretariat Uganda

2. Introduction • The disease burden in Uganda requires principles of cost effectiveness. • The health sector objectives are outlined in the 10-year National Health and the HSSPs. in line with the PEAP. • PEAP aims to address the health needs of the population with emphasis on PHC. • The sector has undergone several reforms translating into the realization of its goal and objectives. • Inadequate funding remains the biggest challenge.

3. Health Sector Challenges • Inadequate funding. • Restrictive macro economic policies setting un realistic and inflexible spending ceilings. • Political influence. • Poor planning amidst the weak health system.

4. Financing and Expenditure • The goal of the HSSP is to raise sufficient resources to fund the plan. • Funding from national revenue and donors. • The Health Financing strategy estimated US$ 28 per capita to deliver the HSSP II Uganda Minimum Health Care Package, but this has ranged between US $6-8. • Total Public funding has been increasing. • Dependent on donor assistance.

5. The goal of government is to decrease reliance on external Aid in the long term. Source: Ministry of Health Annual Sector Performance Reports

6. Despite the increments, inadequate funding remains the primary constraint inhibiting the development of the health sector. Source: Ministry of Health Annual Sector Performance Reports

7. Donor projects and global initiatives

8. Donor support mechanisms • Budget support and Non-budget support. • Budget support is preferred. • GOU has integrated donor aid into the MTEF as part of the PEAP implementation, a process undermined by restrictive government policies which have led to: • More “ear marked funding” limiting reallocation of funds to priority sector interventions. • Delays in implementation of activities, due to bureaucracies in disbursing Ear marked funds from the National Treasury. • Project support

9. Challenges of donor Aid • Uncertainty of magnitude. • Poor disbursements, may worsen with the global crisis. • Budget support doesn’t always translate into government priority spending.

10. Public system linkages • Flow of funds through government existing systems and structures. • Allocations to district health services has improved, PHC benefiting the biggest allocation increases (19% to 42%). • Discordance between budgeting and planning cycles of GOU and donors. • Project support (Private/NGO sector) with outputs from the public sector poses inefficiency in the donor allocations.

11. Monitoring donor aid • Often not in relation to the integrated support systems. • Vertical programmes through project support difficult to monitor. • Limited stakeholder involvement/analysis. • Reporting is more activity based and less on results.

12. Challenges in tracking AID • No common reporting format (s). • Fragmentation of financial flow and the reporting pathways poses challenge in monitoring fiduciary discipline, transparency and accountability. • MOH’s failure to compile Annual Expenditure from donor project accounts. • Detailed work plans/budgets, yet insufficient expenditure reports. • Joint evaluations (government and donors) exist but donor project reports don’t take into account the HSSP, thus don’t adequately reflect the efficiency and impact of AID.

13. Key concerns • Donor dependency is strong. • Priorities are set right, health systems and processes are weak. • Some Aid channeled through system wide approaches leading to marginal returns. • Project support leads to difficulties in accounting structures and mechanisms. • Some programs are driven by donor interests.

14. Way Forward • Project funding should displace GoU budget money. • Monitoring is critical step for GOU. • Exploration of other financing mechanisms. • Capacity building for systems strengthening. • Harness existing resources to improve management, allocation and utilization of resources. • Health insurance? • Coordination of planning and budgeting processes. • Alignment of project funding to sector priorities.

15. Summary • Pro poor policies. • Increasing donor funding but still inadequate to address the needs. • Declining government expenditure on health. • Expenditure on vertical programmes or through projects. • Inadequate expenditure/improvements on PHC due to Inadequate community mobilization and participation in health promotion and disease prevention • Without a functioning health system and emphasis on PHC, Uganda will not achieve her poverty reduction strategy and MDGs.