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

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.

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.

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.

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

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

Donor projects and global initiatives 1. UNICEF7. Germany13. Netherlands 2. USAID/PEPFAR 8. Japanese Government 14. WHO 3. DFID9. World Bank15. GAVI 4. DCI10. UNFPA16. Global Fund 5. African Development Bank 11. DANIDA17. Consolidated Appeal Process (CAP) 6. Italian Cooperation 12. Sweden

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: a)More “ear marked funding” limiting reallocation of funds to priority sector interventions. b)Delays in implementation of activities, due to bureaucracies in disbursing Ear marked funds from the National Treasury. c)Project support

Challenges of donor Aid 1.Uncertainty of magnitude. 2.Poor disbursements, may worsen with the global crisis. 3.Budget support doesn’t always translate into government priority spending.

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.

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.

Challenges in tracking AID a)No common reporting format (s). b)Fragmentation of financial flow and the reporting pathways poses challenge in monitoring fiduciary discipline, transparency and accountability. c)MOH’s failure to compile Annual Expenditure from donor project accounts. d)Detailed work plans/budgets, yet insufficient expenditure reports. e)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.

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.

Way Forward 1.Project funding should displace GoU budget money. 2.Monitoring is critical step for GOU. 3.Exploration of other financing mechanisms. 4.Capacity building for systems strengthening. 5.Harness existing resources to improve management, allocation and utilization of resources. 6.Health insurance? 7.Coordination of planning and budgeting processes. 8.Alignment of project funding to sector priorities.

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.