1. Aid effectiveness in Uganda by Enyaku Rogers ACHS ( B & F) Presentation at Fifth IHP+ Country Health Teams Meeting 2-5 December 2014, Sokha Angkor Resort, Siem Reap, Cambodia 1

2. Key features of health financing General Government Health expenditure per capita is US $ 9 excluding external financing Health development partners contribute about 45%: NHA report for FY 2011/12 On average domestic resources constitute about 53% of the CHE. GCHE as % of GDP is 1.38%, HSSIP recommends minimum of 4%, GGHE as % of TGE is at an average of 9% for the last three years Free access Health services in public facilities 2

3. Structure of Aid in the Health Sector In Uganda, on-budget aid is defined as aid that is included in the Medium Term Expenditure Framework (MTEF). General and sector budget-Targeted-support are always classified as on-budget. General Budget support is aid that is not attached to particular projects, but it is usually accompanied by conditions for policies and/or governance Earmarked/Targeted aid resources, or project aid, may be on-budget or off -budget. 3

4. Categories of General Budget Support MFPED registers four categories of General Budget Support (GBS): grants, loans, debt relief and grants for the Poverty Action Fund (PAF 4

5. Off Budget Support Off budget aid includes donor resources channeled to the government but also resources transferred to the private for profit or not for profit sector. – support to the war zone in North Uganda. USAID – Programme Funding-PEPFAR and PMI (the President’s Malaria 5

6. Trends in Targeted Funding to the Health Sector In 1999, the Government of Uganda and a large group of donors agreed on a Sector Wide Approach (SWAp) in support of HSSP 1.  User charges for government health care facilities were abolished in 2001. the years 2005/06 to 2009/10. HSSP 1 brought an increased  focus on primary health care (PHC) through a reallocation of  resources towards districts, and via the districts to lower level health units. 6

7. Trends in Targeted Funding Cont’d there has been substantial increase in project funding for health from around 2003-4 onward,  largely as a result of the global health funds and other vertical funds for health. large part of this funding is off budget Declined 2007 due to suspension of GAVI & Challenges with GFATM 7

8. Government allocation to health sector 2004/5-2013/14. 8

9. Health Sector Financing 2004/5-2014/15 9

10. Positive Effects of Targeted Aid in the Health sector Increased funding to the Sector Focus on primary health care (PHC) through a reallocation of resources towards districts More harmonized approach to Planning & Monitoring in HSSP 1 thru; SWAP -Partnership Instruments: HPAC, JAF. IHP+ 10

11. Positive Effects of Targeted Aid in the Health sector Thru the use of the Joint Budget Support Frame work the following was put to practice: Use by DPs of Data by provided by GOU as highlighted by the Paris declaration of 2005 Emphasis on removal of barriers on Public Finance management Use of the Sector Results matrix Inclusion of Donor Performance in the Assessment More Disease specific Interventions; – HIV, Malaria, Tb..? 11

12. Increase of Health Facilities 2004-2011 that reduced length to nearest facility Level20042011 Hospital5565 HC IV151166 HC III718868 HC II10551662 Total19792761 12

13. Negative Effects of Targeted Aid in the Health sector Unpredictability of the aid Less than appropriate input mix In accordance with a study commissioned by ACCORDAIDI in 2011: – In 2006/07, 74% of all donor funding to the health sector was channeled to the private sector in health a bulk of which procured non-HSSP inputs 13

14. Expenditure on Donor Project Aid by Input 2004/5-2006/7 Input 2004/5 (%) 2005/6 (%) 2006/7 (%) Average (%) Human Resource 4575 Training0142413 Drugs20581029 Other Recurrent 722010 Capital non Infrastructure 4714 Infra structure 9456 Non HSSP Inputs 5893133 14

15. Effects of the Health Sector Financing On average an estimated 37% of the disease based expenditure is spent on HIV/AIDS,20% Malaria and only 14% on reproductive Health. Only 16 % of the CHE was spent on prevention according to the NHA latest report About 66% of the CHE is spent on infectious and parasitic diseases and only 4.3% on average is spent on non communicable diseases 15

16. Total Funding by commodity area 2010 - 2013 16

17. Percentage of total funding by commodity area in 2012/13 17

18. Other Challenges to Maximizing Benefits from Targeted Aid to Health Institutional Capacity Aligning Donor practices Reducing GOU stewardship Accountability Overload of Senior Management Movement of senior staff to Donor organizations Epidemics (Ebola, Murberg) 18

19. Other Challenges to Maximizing Benefits from Targeted Aid to Health Donors by passing LTIA arrangements e.g HSBWG and funding departments and Local Governments Direct targeting of Depts and LGs reduces adherence to one M & E system More emphasis on outputs than outcomes More emphasis on curative vis avis prevention Weak inter sectoral collaboration 19

20. Government Efforts to Minimize Challenges Revise the Health Financing Strategy including: – Harnessing complementary financing schemes More emphasis on Prevention thru revision of VHT strategy Requirement by Donors to seek permission from MoH before going to LGs Strengthening Accountability Measures Improve resource tracking of off & on budget funds to ensure alignment and harmonization 20

21. THANK YOU 21