Charlotte M Zikusooka, Mark Tumwine, Patrick Tutembe HealthNet Consult
Executive summary
Global health initiatives (GHIs) are an emerging and global trend in health that focus on partnerships. The introduction of GHIs in Uganda has had significant impacts on the overall health care financing, but there has been no assessment of their impact on equity in overall health sector financing in Uganda. This report, commissioned by the Regional Network for Equity in Health in East and Southern Africa (EQUINET) from Healthnet Consult with mentoring from University of Cape Town Health Economics Unit and Training and Research Support Centre, explores and presents the current patterns of AIDS, TB and Malaria (ATM) financing within the health sector, and investigates the extent to which GHI financing for ATM has influenced heath care financing reforms.
We obtained information for this paper through key informant interviews and extensive literature review from international and local sources. The key informants included the various funding sources and the key agents in managing and using ATM resources.
With an average 0.13% contribution by private health insurance schemes and no compulsory national health insurance scheme, financing for Uganda's health sector is largely not prepaid. However, there has been an improvement in ensuring access to services through the removal of user fees and increasing government funding of health services. There is limited cross-subsidy and high fragmentation between health financing mechanisms. Specifically, there is fragmentation between government and donor project funding, and also within donor project funds, which negatively impacts on creation of larger pools. Donor funding channelled through projects and global health initiatives targeting specific diseases may undermine equity between geographic areas. The lack of effective coordination of donor project funds is a potential source of inefficiencies and inequity.
Sources of funding for ATM in Uganda include government, donors, GHIs and households. It is difficult to estimate the proportion of government ATM funding because of the integrated nature of health service delivery in Uganda. The President's Emergency Plan for AIDS Relief (PEPFAR) and President's Malaria Initiative Programmes (both from the United States Government) seek to meet legislatively-mandated targets on prevention, treatment and care for HIV and AIDS and malaria. PEPFAR and US President's Malaria Initiative resources are primarily channelled outside government systems and are not aligned to government planning processes. The Global Fund for AIDS TB and Malaria (GFATM) seeks to strengthen country-ownership of programme activities. Initially channelled through projects, the GFATM funds in Uganda have been impeded by bottlenecks associated with poor management of resources, also affecting the flow of funds from the principal recipient (who receives the funds) to the sub-recipients (or implementers of the health services). The disbursement of funds has been unpredictable and has severely affected service delivery. The World Bank's Multi-country HIV/AIDS Programme (MAP) (which has been discontinued) was primarily focused on strengthening the national AIDS response. The largest share of MAP funding was directed to community-level activities, while funds under MAP were routed through government systems. The World Bank's stringent accounting procedures and requirements slowed the flow of funds, as did the government bureaucratic procedures.
One of the key reforms in health financing has been the development of long-term institutional arrangements (LTIAs) for the management of the GFATM resources, following the temporary suspension of funds disbursed to Uganda in 2007. LTIAs are a new mechanism designed to harmonise development aid within the health sector. They are a management mechanism for channelling donor resources agreed on by the government, the Uganda AIDS Commission and other stakeholders, which cover financing, planning, budgeting, co-ordinating, implementation, procurement, monitoring and evaluation, as well as participation by civil society organisations. Actual implementation of the LTIAs has not yet fully taken off. Another important change occurred when the Ministry of Finance, Planning and Economic Development (MoFPED) started allowing GHIs to help set the medium-term expenditure framework (MTEF) ceilings for the health sector, thereby allowing additional funds into the sector. We failed to establish the basis for this flexibility on sector ceilings.
GHI funding for ATM has had positive impacts on overall health sector financing and related reforms, including: significant increases in resources for the health sector; the ability to afford expensive, but life-saving technologies and interventions; and flexibility in MTEF ceilings for the health sector. It has also had negative impacts, including: undermining of sector-wide approach (SWAp) processes by creating parallel implementation channels and relying on the project mode for transmitting resources; unreliable funding and delays in disbursements to the country (especially for the GFATM); displacement of funding from other sources (bilateral and government); and retention of significant amounts of GHI funds at higher levels, with little funding reaching lower-level facilities. It is difficult to assess the overall effect given both positive and negative impacts.
We identified some key equity-related issues. Routing GHI resources in project mode does not allow for effective co-ordination and harmonisation, and not all GHI resources are aligned to sector priorities. This is likely to promote gender and geographic inequities, considering that project funds and some GHI funds are usually spent on selected geographic areas, the selection of which might not be always based on equity considerations, such as need. Although each GHI creates a relatively large risk pool, there is limited integration between the different GHIs. The lack of integration is likely to lead to inefficiencies, such as through an overlap in funding from different donors for certain areas or interventions. In the case of PEPFAR, the predetermined allocation of resources without Uganda's input or without considering specific country needs may enhance unequal allocations between the different types of interventions, as well as geographical inequities.
We recommend that the Ministry of Health redouble its efforts to improve co-ordination and harmonisation of all development aid, including support from GHIs. The LTIA is a starting point for this process, but more buy-in is required in order for it to be accepted by all stakeholders. Government will need to design mechanisms that will help integrate GHIs resources to allow for greater cross-subsidy and to reduce overlaps and inefficiencies. We suggest that the Ministry of Health (MoH) negotiate with development partners to channel GHI resources through one common structure within the MoH. When setting up this structure, the MoH would need to address the transparency and accountability concerns of the partners and other stakeholders.
We further propose that the MoH monitor equity in the health sector, including health financing equity, equity in access to care, geographical equity and gender equity. Initially, special equity studies could be conducted but regular equity indicators should be developed and reported on in the annual health sector performance reports. Technical programmes in the MoH should undertake in-depth spending assessments for HIV, AIDS, TB and malaria, including an assessment of private spending on these diseases. We also identified some research gaps, which need to be addressed. There is virtually no data on household expenditure for HIV, AIDS, TB and malaria, and, similarly, a lack of empirical evidence on who is accessing ART services and who needs or accesses the publicly funded health package. In addition, there are no specific requirements on the side of GFATM and no explicit guidelines on the side of government on how to allocate resources geographically, which creates the potential for inequitable allocations.