Presentation given by Sophie Witter & Christabel Abewe at the 2023 IHEA conference. It was entitled 'Financial protection in Uganda: Reflections from an HFPM assessment'

1. Financial Protection in
Uganda:
Reflections from an HFPM assessment
Presenters: Sophie WITTER & Christabel ABEWE
Saturday 8th July 2023
15th IHEA World Congress on Health Economics

2. Background (1)
 Three main revenue sources for financing of
the health sector: domestic public (15%),
private (43% --mainly household out-of-
pocket expenditure) and external sources
(42%)
 The high OOPE arises from a combination of
informal payments in the public sector and
formal payments in the private sector
And not much change over past decade
 There is very low health insurance coverage:
less than 5% coverage rate (mostly CBHI)
 Uganda has doubled its service coverage
index from 22% to 50% between 2000 and
2020, however, it has failed to make similar
progress for financial protection with high
catastrophic expenditure and
impoverishment rates
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14% 16% 14% 15% 17% 18% 15% 16% 16% 17% 15%
44% 39%
36%
39%
46% 46%
42% 43% 41% 40% 43%
42%
46%
50%
46%
37% 36%
43% 41% 43% 44% 42%
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Revenue Sources for Health In Uganda
External as % total health spending (Ext%CHE)
Private as % total health spending (private...%CHE)
Domestic public as % total health spending (GGHE-D%CHE)

3. Background (2)
 Uganda has very high catastrophic health spending
affecting 13.6% of the population at the 10%
threshold and 3.6% at the 25% threshold in 2020
 Further, there has not been significant progress in
catastrophic expenditure over the past two decades
in Uganda
 When compared with other countries in the region
with similar UHC coverage, Uganda has the highest
percentage of people facing financial hardship as a
result of out-of-pocket payments
 The percentage of the population that is
impoverished because of health expenditure is
estimated to be 3.1%, which is very high as
compared to other countries in the region
e.g., Kenya at 1.3%, Tanzania at 1.2%, Rwanda at 0.7% ,
Ethiopia at 0.5% and Zambia at 0.3%
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49.6%
44.0% 42.5% 40.9%
31.6%
27.1% 25.0%
2.7%
2.5% 2.5% 4.0%
3.2%
3.0% 3.1%
1996 1999 2002 2005 2009 2012 2016
Further impoverished Impoverished
9.4%
20.3%
16.8%
15.3%
0%
5%
10%
15%
20%
25%
2000 2005 2010 2015
Catastrophic Health Expenditure at 10% Threshold
Kenya Rwanda Tanzania Zambia Ethiopia Uganda

4. Distribution of OOP Payments across quintiles, Uganda, 2009/10
(Kwesige et al .2020)
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5. APPROACH
• Populated using a multipronged
approach mainly using literature and
document review, qualitative interviews
with key informants, and consultative
meetings and workshops with key
stakeholders and the Ministry of Health
technical team.
• An external review was conducted by
two external experts.
• Uganda completed the Health Financing
Progress Matrix by Feb 2023
• Findings presented in a summary report.
• Contributed to mid-term review of
Health Financing Strategy
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Step 1: Complete the HFPM
• Conducted a deep dive on financial
protection in Uganda.
• Relied on the HFPM primarily as well as
other relevant secondary sources of
data/analyses on financial protection in
Uganda.
• We then identified the drivers for poor
financial protection resulting into
catastrophic and impoverishing health
expenditures.
• We mapped the identified drivers of the
catastrophic and impoverishment to
relevant HFPM questions.
Step 2: Deep dive on FP drivers
• After mapping the drivers of financial risk
to the HFPM financial protection
questions, we obtained the country’s
HFPM assigned score, and assessment,
for those mapped financial protection
questions.
• Using the HFPM guide, and the mid-term
review of the HFS, we highlight policy
shifts which will support progress to the
next level/score.
Step 3: Policy shift recommendations

6. Drivers of poor financial
protection in Uganda’s
health system
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7. Simplified schema for drivers of financial protection in health care,
Uganda
7

8. Key drivers of poor financial protection in Uganda’s health system
1. Low quality and availability of health services in the public sector
 Low quality of health services in the public sector affects utilization patterns: this has caused low utilization of health services in the
public sector and increased uptake of health services in the PNFP and PFP sectors, even by poor, where payment is mostly out-of-
pocket at market rate
 According to the UBOS house survey of 2019/20, 45 percent seek care from private hospitals and clinics compared with 34% at government health facilities when
sick
 Views on quality of care reflect this gradient in quality across sectors, as perceived by users (UBOS survey)
 A major feature of the quality gap, also driving OOPE, is stock-out of essential medicines and supplies in the public health facilities;
medicines are the largest item in OOPE, also the main concern users highlight and their main recommendation for improvement
 A contributing factor is lack of incentives and strategic purchasing arrangements to ensure quality improvement in the public sector
2. Insufficiently funded Essential Health Care Package
 Low public resource allocation to the health sector (7.4% of the annual national budget) results in underfunded essential health care
package (funding below estimated cost of provision, especially given cost increases in recent years, with stagnant support)
 This contributes to insufficient inputs to health services (especially medicines and supplies), reflected in shortages, unofficial payments,
and people turning to private pharmacies and facilities
 In the UBOS household survey of 2019/20, half of the persons that sought care (55%) had made a payment to get services. 51 percent had paid official health
facility fees, while three percent paid unofficial fees that were demanded
 Further exacerbated by the aid architecture, where approximately 70% of the external aid is routed off-budget. These funds do not
directly support the provision of the essential health care package (rather these funds go to vertical disease programmes)
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9. Mapping drivers of poor
financial protection to
relevant HFPM questions
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10. Driver of poor
Financial
Protection
Mapped HFPM Question
on Financial Protection
Key Findings from Uganda HFPM
1. Low quality and
availability of
health services in
the public sector
4.3 Do purchasing
arrangements promote
quality of care?
2/4 (Progressing):
• Purchasing arrangements for public resources have not been linked to quality of care
in the past. A RBF nation-wide scheme has been approved for the next FY.
• There are no contracts on performance agreement between the purchaser and the
provider.
• Data are not used to analyze practice patterns nor to provide feedback to providers
4.5 Is the information on
providers’ activities
captured by purchasers
adequate to guide
purchasing decisions?
2/4 (Progressing):
• Detailed and comprehensive data and information on patient encounter is not
captured
• There is very low utility of available data from the DHIS II to generate system-wide
situational analyses on a continuous basis to guide purchasing decisions.
4.6 To what extent do
providers have financial
autonomy and are held
accountable?
1/4 (Emerging):
• In the public sector, health facilities have very limited financial autonomy e.g. the PHC
allocations are very conditional and the percentage that is unconditional has spending
guidelines.
• Performance accountability to assesses progress towards UJHC is very weak with
stronger emphasis put on financial accountability that focuses on alignment to PFM
rules.
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11. Driver of poor
Financial
Protection
Mapped HFPM question on
financial risk protection
Assigned HFPM score for Uganda
2. Insufficiently
funded Essential
Health Care
Package
5.1 Is there a set of explicitly
defined benefits for the entire
population?
2/4 (Progressing):
• While an essential health care package has been developed for Uganda, it is
underfunded thus undermining the intended universal benefits of the package.
• This results into some implicit rationing of the resources for service provision.
• Government has established general standards for delivering the essential health care
package, the enforcement of service delivery standards through contracts is very
weak coupled with sub-optimal functionality of the health facilities.
5.5 Are defined benefits
aligned with available
revenues, available health
services, and purchasing
mechanisms?
2/4 (Progressing):
• The defined essential health care package is very comprehensive and broad to
account for the high disease burden and a rapidly growing population.
• The cost of delivering the essential health care package is estimated to be $48 and the
per capita public health expenditure is estimated as $20.0.
• As such, there is a mismatch between the essential health care package and the
available public revenues.
7.2 Do pooling arrangements
promote coordination and
integration across health
programmes and with the
broader health system?
2/4 (Progressing):
• While public resources are pooled in one large pool, there is significant fragmentation
in the off-budget external resources to support vertical programming.
• High fragmentation in the voluntary insurance schemes (CHBI and private schemes)
• The high fragmentation doesn’t promote coordination and integration across the
health programmes.
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12. HFPM POLICY SHIFT
RECOMMENDATIONS
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13. Driver of poor
Financial Protection
Mapped HFPM question on
financial risk protection
Recommended Policy Shift to move to Established Score
1. Low quality and
availability of Health
Services
4.3 Do purchasing
arrangements promote quality
of care?
Current HFPM Score: 2/4
(Progressing)
• Strengthen strategic purchasing arrangements through mainstreaming of the
results-based financing into the PHC financing.
• Build capacity of the RBF unit at MOH to implement strategic purchasing
• Build capacity of managers to improve accountability for quality of services.
4.5 Is the information on
providers’ activities captured
by purchasers adequate to
guide purchasing decisions?
Current HFPM Score: 2/4
(Progressing)
• Capacity building to improve the quality of information/data and to increase
the uptake and utility of information/data for decision making.
4.6 To what extent do providers
have financial autonomy and
are held accountable?
Current HFPM Score: 1/4
(Emerging)
• Fully transition to Program Based Budgeting that has the potential to improve
financial autonomy.
• Strengthen performance management measures to positively impact the
quality of services offered in the public sector.
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14. Driver of
Financial Risk
Mapped HFPM question on
financial risk protection
Recommended Policy Shift to move to Established Score
2. Insufficiently
funded
Essential
Health Care
Package
5.1 Is there a set of explicitly
defined benefits for the entire
population?
Current HFPM Score: 2/4
(Progressing)
• Articulate and revise the essential health care package regularly using evidence
based priority setting tools like Health Technology assessments.
• Monitor and evaluate the delivery of the essential health care package routinely
5.5 Are defined benefits aligned
with available revenues, available
health services, and purchasing
mechanisms?
Current HFPM Score: 2/4
(Progressing)
• Increase the allocation of public resources to primary health care for the delivery of
the essential health care package
• Explore contracting arrangements for private providers to provide services in urban
areas and in hard-to-reach areas
• Ensure adequate availability of essential drugs, medicines and supplies at public
health facilities
7.2 Do pooling arrangements
promote coordination and
integration across health
programmes and with the broader
health system?
Current HFPM Score: 2/4
(Progressing)
• Strengthen joint planning (between government and development partners) for
implementation and funding.
• Encourage Health Development Partners to provide ear marked on budget support
for health or consider other strategic pooling options.
• Explore other strategic pooling options for the external aid – virtual pools.
• Establish NHIS which integrates resources from all other insurance schemes
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15. Thank you
For more information, please contact:
Name: Christabel ABEWE
Title: Health Financing Officer, WHO-Uganda
Email: abewec@who.int