Kampala: The health sector still has funding gaps even though it's not making the most of the money it has. In our continuing series, Budget Review series, Evelyn Lirri analyses the health budget.

In February, Mr Daniel Tukakundana, joined the agony queue at the Mulago Cancer Institute, the only cancer ward in a country of 32 million. Once a rare disease, cancers of various kinds are as common today as the adage that patients in Uganda go to hospital to die.

Mr Tukakundana is one of the 10,000 Ugandans who report suffering from cancer every year. But they are little-noticed by health care managers in the country. Funding - most of it from foreign donors - largely goes to three diseases: HIV/Aids, tuberculosis and malaria. These account for more than 70 per cent of the country's health care budget.

But ailments like respiratory tract infections, malnutrition, maternal mortality and non communicable diseases like cancer are contributing to a large share of the country's disease burden. Between 2006/7 and 2010/11, the government set out to achieve three ambitious goals: reduce the high incidence of malaria through promotion and purchase of 18 million nets to cover 80 per cent of the population by 2010, introduce a health insurance scheme and construct more health facilities.

The numbers tell a story we don't like to face: every day, spending decisions by a host of different players - the national government, local governments, international donors, and millions of Ugandans who pay for their health care with their own money - determine what health services are available and hence who lives and who dies. Yet the different actors often fail to plan or coordinate their spending decisions or to ensure that the money is spent to achieve the greatest impact.

As a result, some sectors are flush with cash while others are starved, and evidence is mounting that Ugandans are not getting the greatest value for their money. This inefficiency is undermining gains that could be achieved through substantial increases in spending for the health sector.

Money allocated to the health sector has steadily gone up from Shs139.23 billion in 2006/7 to Shs734 billion in 2009/2010. Officials in the Ministry of Health say this total is simply not enough to fund the basic minimum health care package and at the same time hire health workers to deliver these services.

Dr Francis Runumi, the chief planner at the ministry, says at least Shs1.5 trillion is required annually to deliver the ideal health services that Ugandans would want to have - roughly twice the amount currently available. Few disagree with Dr Runumi's point. Public per capita spending on health has been fluctuating. It increased from $8 to $11 from 2001/2 to 2006/7, but reduced to $ 8.4 in 2007/8 and then increased again to $10.4 in the 2008/9 financial year. However, it remains significantly lower than the target of $28 per capita that would be required to provide the Uganda National Minimum Health Care Package - the services Ugandans believe should be available to all.

Average outcome

But various studies and reports tell a more complicated story. When all sources of funding are counted, they show that Uganda is spending about $25 per capita on health - much closer to the targeted amount. Yet the basic package of health services remains a distant goal.

The Ministry of Finance complains that central administration rather than the actual delivery of health services is claiming a growing share of the country's health resources.

Mr Fred Mutyama, a commissioner for budget in the finance ministry said an assessment of the 2009/10 budget performance shows that at least 7.2 per cent - about Shs1.64 billion of all non wage discretionary expenditure under the ministry of health - is allocated to fuel and lubricants, a reflection of a large fleet management cost.

"This is 160 per cent the aggregate allocation to fuel under the other 22 centre votes including 15 referral hospitals," Mr Mutyama says. Workshops and seminars also account for 7.3 per cent or Shs1.704 billion -- of the health ministry budget. Overall, the Shs22 billion for recurrent expenditure for the ministry is twice the total amount of Shs11.5billion allocated to 15 referral hospitals.

A 2010 World Bank study suggests that Uganda could be getting more for the money it is spending. It shows that several countries have achieved better outcomes than Uganda despite spending the same amount or less on health.

Madagascar, for instance, spends far less on health than Uganda -- $13 per capita compared to $25 - yet its child mortality rate is about half-that of Uganda. Child and infant mortality in Bangladesh, another country with relatively low total health expenditures per capita, stands at 69 and 52 per 1,000 births respectively, compared to rates of 134 and 78 in Uganda.

The target to reduce malaria has not been met. At least 300 people still die of malaria every day - the same number that was dying five years ago. The Ministry of Health just purchased the first phase of 17 million mosquito nets in April and the impact has not been registered yet.

The Global Fund to fight HIV/Aids, Malaria and Tuberculosis is funding the mosquito nets programme to a tune of $125 million. Health officials are hopeful that by December 2010, 80 per cent of all homes will own at least one mosquito net - a significant increase from 42 per cent of the population currently owning at least one mosquito net. While the reasons for such disparities are complex and not fully understood, Dr Peter Okwero, one of the authors of the report, says they do suggest that Uganda could do better with the resources it has. "In reality the money is small, but we have failed to be strategic in the way we use these resources," he suggests. "Policies need to be put in place to utilise the available money effectively."

One reason why Uganda has trouble strategically allocating its resources is because a big part of its budget - about half - is financed by donors who often have different priorities than those of the government. In fact, the government has had a hard time tracking donor money or determining how much is provided compared to what is promised.

Volatile aid

The World Bank's Public Expenditure Review, completed in 2008 and presented to the Ministry of Finance Budget division, noted the dangers for the health sector in relying heavily on donor aid which the report described as "volatile and unpredictable."

Another report by the Action Group for Health Human Rights and HIV/Aids, which has been tracking donor support to the health sector, also notes that heavy reliance on external aid in the long run "may create a funding gap where donors fail to honour their commitments."

The challenge is compounded by the fact that most donor support is off-budget, with the donors choosing where they want to invest their money. The government doesn't set the priorities for these projects and it can't track how much money the donors eventually give from what they have promised.

But Ms Ulrika Hertel, the chairperson of the health development partners in Uganda, said only 35 per cent of donor money is off-budget and not targeted towards the Ministry's Health priorities. Ms Hertel said most of the off-budget spending is chanelled through the local government and non-governmental organisations for projects in specific health interventions like HIV/Aids. She said although the health sector needs additional money to operate, it should be more realistic in spending the money available to it - sometimes even making hard choices on what the money should be spent on.

A study that was undertaken in 2008 on behalf of the Ministry of Health illustrates the kind of "hard choices" that would have to be made if the government wanted to get the most benefit out of limited resources. It says government would for example consider the provision of the health care package at all levels, but delivered through fewer facilities. This would be supported by these few facilities having all the required inputs to operate efficiently like health workers, drugs and equipment.

Another consideration would be putting the limited resources to conditions responsible for the highest disease burden and where huge gains can be realised like nutrition, hygiene, and health education.

The Ministry of Health says while 75 per cent of diseases could be prevented through health promotion, only about 10 per cent of the available funds are allocated for them.

The new National Development Plan hopes to make disease prevention a top priority. "Preventive interventions like immunisation, promotion of sanitation and promotion of nutrition - though cost effective - have not been given adequate attention," the plan reads in part. For instance, keeping an HIV/Aids patient is more costly than preventing a mother from dying during pregnancy, yet much of the donor funding is directed towards HIV/Aids programmes compared to reproductive health services, despite the fact that on average 14 women will die in Uganda everyday as a result of pregnancy related complications.

Dr Runumi said the ministry is discussing with the donors to see whether the ministry and donors can jointly monitor how the funds are allocated and utilised. But supervising donor funds isn't the government's only challenge. The government also has no control over the large and growing private sector, even though that's where most Ugandans get their health care today.

The World Bank estimates at least 46 per cent of Ugandans seek health care from private clinics and 13 per cent from a drug shop or pharmacy. That means the private sector dwarfs government health care. Just 22 per cent seek care from government health units, despite the abolition of user fees in government health facilities in 2001.

Dr Okwero said most people go to the private health sector because of proximity, but adds that the sector needs to be regulated since it's a key player in the health delivery chain. "The challenge is when people go to these services; you can't validate the kind of care that they receive," he said.

Dr Runumi said Ugandans are already paying out of pocket which estimates roughly what government and donors are paying for medical care - about Shs800 billion per year.

High absenteeism

While experts like Dr Okwero decry the lack of regulation of private providers, others say the government needs to concentrate first on getting its own house in order. Much work is needed. Widespread absenteeism is costing up to Shs26 billion annually, according to the World Bank report. The bank estimates 37 per cent of health workers are absent daily.

Dr Runumi acknowledges that absenteeism is a huge challenge but says the issue needs to be tackled cautiously. "You need to understand why people are absent from work. Some have not accessed the payroll much as they have been recruited. Some (are absent) because of the poor leadership and management at the various levels. Others have no medicines and other health supplies to work with. So do you expect them to just keep standing like watchmen in these facilities doing nothing?" he asked.

"There are a number of factors we are looking at and they should all be addressed in their own way."

President Museveni has said health workers will get a pay increase in the 2010/11 budget. Significant inefficiencies in procurement, storage and distribution of drugs have also contributed to waste in the sector. Finance Minister Syda Bbumba in her half year budget performance report for 2009/10, said despite stock outs, the National Medical Stores was the top under spender within the sector - with majority of the unspent money accumulated from delays in the provision of health supplies.

But the NMS general manager, Mr Moses Kamabare, said the performance report did not capture all the spending money since NMS usually doesn't pay its suppliers as soon as they deliver the medicines.

The World Bank estimates that leakage of essential medicines results in waste of Shs3billion annually. Finally, the government has compounded its problems through poor planning. Over the past decade, government has focused more on expanding infrastructure by building health facilities that it cannot properly man and equip. The result has been that only half of the total health work force in the country has been filled.

National officials acknowledge the massive construction of health facilities has dotted the landscape with white elephants, but they blame districts for putting up health facilities without consulting them.

"They build without understanding the recurrent cost implication of their investment, then they throw their whole burden to us the centre to provide the money and health workers for them," says Dr Runumi.

He says the government is drawing a new policy shift that would put construction of health infrastructure under the control of the central administration to reduce on unnecessary costs that come with new structures.

The proposed health insurance scheme that would increase the total amount of money for healthcare hasn't take off because it was widely criticised by the public who believed the health ministry would not run such a huge scheme given its previous record of corruption.

So what is the right amount to be spent on health? It's hard to say. But one thing is clear: While Uganda needs to continue exploring ways of getting more funds to finance the health sector, it may be difficult to achieve that goal unless it shows that it can make better use of the resources it already has.

Keywords: budget monitoring, health, service delivery, Uganda