Health Financing Progress Matrix assessment Uganda 2023 Summary of findings and recommendations THE REPUBLIC OF UGANDA
Health Financing Progress Matrix assessment Uganda 2023 Summary of findings and recommendations THE REPUBLIC OF UGANDA Health Financing Progress Matrix assessment, Uganda 2023: summary of findings and recommendations ISBN 978-92-4-007861-1 (electronic version) ISBN 978-92-4-007862-8 (print version) © World Health Organization 2023 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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In no event shall WHO be liable for damages arising from its use. iii Foreword ................................................................................................................................................................................................................................v Acknowledgements ............................................................................................................................................................................................................ vi About the Health Financing Progress Matrix .....................................................................................................................................................vii About this report................................................................................................................................................................................................................... ix Abbreviations ............................................................................................................................................................................................................................x Methodology and Timeline ........................................................................................................................................................................................... xi Uganda UHC Performance .............................................................................................................................................................................................. 1 Summary of findings and recommendations by desirable attributes of health financing ................................................... 5 Stage 1 assessment .............................................................................................................................................................................................................13 Stage 1. Health coverage schemes in Uganda: health financing arrangement ..........................................................................14 Health expenditure by Stage 1 coverage schemes .......................................................................................................................................20 Stage 2 assessment .............................................................................................................................................................................................................21 Summary of ratings by assessment area.............................................................................................................................................................. 22 Assessment rating by individual question .......................................................................................................................................................... 23 Assessment rating by UHC goals ..............................................................................................................................................................................24 Assessment rating by intermediate objective .................................................................................................................................................. 25 Resources ..................................................................................................................................................................................................................................26 Annexes ..................................................................................................................................................................................................................................... 30 Annex 1. Selected contextual indicators...............................................................................................................................................................31 Annex 2. Desirable attributes of health financing ..........................................................................................................................................35 Annex 3. HFPM assessment questions ...................................................................................................................................................................37 Annex 4. Questions mapped to objectives and goals .................................................................................................................................39 Contents iv Fig. 1: Four phases of HFPM implementation ....................................................................................................................................................vii Fig. 2: Service coverage index trend in Uganda 2000-2019 ........................................................................................................................ 1 Fig. 3: Antenatal care and DPT3 coverage by wealth quintile in 2016 ................................................................................................. 2 Fig. 4: Trend in catastrophic health spending in Uganda 1996-2016 .................................................................................................... 3 Fig. 5: Impoverishing out of pocket health spending in Uganda 1996-2016 ................................................................................... 4 Fig. 6: Expenditure flows by scheme (Sankey diagram) ..............................................................................................................................20 Fig. 7: Average rating by assessment area (spider diagram) .................................................................................................................... 22 Fig. 8: Average rating by goals and objectives (spider diagram) .......................................................................................................... 22 Fig. 9: Assessment rating by individual question ........................................................................................................................................... 23 Fig. 10: Assessment rating by intermediate objective and final coverage goals ........................................................................24 Fig. 11: Health expenditure indicators for Uganda .........................................................................................................................................31 Fig. 12: Revenue sources for health in Uganda .................................................................................................................................................32 Fig. 13: Recurrent expenditures by revenue source 2020 ..........................................................................................................................32 Fig. 14: Cigarette affordability in Uganda .............................................................................................................................................................33 Fig. 15: Excise tax share in Uganda ............................................................................................................................................................................33 Fig. 16: Total tax share in Uganda.............................................................................................................................................................................. 34 Figures vForeword The Health Financing Progress Matrix is a tool developed by the World Health Organization Department of Health Systems Governance & Financing. It assesses a country’s health financing system against a set of evidence-based benchmarks that were identified as being key to make progress towards Universal Health Care (UHC). The matrix signals the direction in which the various aspects of health financing system need to develop. In 2016, the Ministry of Health launched the Health Financing Strategy 2015/16 -2024/25 with the aim of responding to the dynamic aspirations of the broader national health strategies and plans. Whilst Uganda’s macro-economic and fiscal context has remained roughly the same, the health financing landscape has significantly changed since the development of the Health Financing Strategy (HFS). For example, the government budget allocation to the health sector increased, however, there has been a marginal reduction in development assistance for the health sector. The government also undertook major public financial management reforms; including the shift from Input-Output budgeting to Programme Based Budgeting, the introduction of Results Based Financing (RBF) mechanisms, and a Resources Allocation Formula (RAF) to allocate Non-Wage Recurrent (NWR) budget to Districts Local Governments aiming to improve equity and efficiency of resources allocation. It was therefore critical to assess the progress and impact of all these reforms on the health financing landscape in Uganda and the Health Financing Progress Matrix provides a set of evidence-based benchmarks framed upon nineteen desirable attributes upon which progress can be assessed. The process of updating Uganda’s Health Financing Progress Matrix was led by the Ministry of Health and technically guided by Health Financing experts from Makerere University School of Public Health and from the WHO Country Office in Uganda. The report was developed using a consultative approach, and the recommendations were reviewed by several experts from both within and outside of the country. The Ministry of Health is thankful to its staff, development partners, and other health stakeholders, especially in the health financing space, that contributed to various efforts in developing this report. The Government of Uganda is fully committed to utilizing the recommendations made by this assessment and we look forward to working across the health sector with our partners and stakeholders to ensure every Ugandan will not be exposed to financial risk as they seek health care services. We hope that this publication will be of great use to policy-makers throughout the health sector in Uganda. For God and My Country Dr Diane Kanzira Atwine PERMANENT SECRETARY MINISTER OF HEALTH vi Acknowledgements WHO and the Ugandan Ministry of Health would like to thank Dr Sarah Byakika (Commissioner for Planning, Financing and Policy, Ministry of Health) for her valuable technical guidance throughout this assessment. Special thanks go to Mr Aliyi Walimbwa (Senior Planner, Ministry of Health), who acted as the focal point for the assessment. The input, feedback, and oversight provided by the Technical Steering Committee established by the Ministry of Health to oversee the assessment is also greatly appreciated and acknowledged. The contributions and guidance provided by Dr Elizabeth Ekirapa (Makerere University School of Public Health, Kampala, Uganda), the Principal Investigator for the assessment, and her team are highly appreciated and valued. WHO and the Ugandan Ministry of Health would like to extend their gratitude to the following for their contributions and guidance: Mrs Christabel Abewe (WHO Country office in Uganda, Kampala), Dr Sunny Okoroafor (WHO Country office in Uganda, Kampala), Dr Ogochukwu Chukujekwu (WHO Regional Office for Africa), Mrs. Diane Karenzi Muhongerwa (WHO Regional Office for Africa), and Dr Matthew Jowett (WHO headquarters). Further input was provided by Dr Grace Achungura (WHO Country office in India, New Delhi), and Mrs Sophie Witter, who performed the external peer review. Special thanks also go to Mr Juan Gregorio Solano who compiled and analysed data from official sources to generate all charts and diagrams used in the report. vii About the Health Financing Progress Matrix The Health Financing Progress Matrix (HFPM) is WHO’s standardized qualitative assessment of a country’s health financing system. The assessment builds on an extensive body of conceptual and empirical work and summarizes “what matters in health financing for Universal Health Coverage (UHC)” into nineteen desirable attributes, which form the basis of this assessment. The report identifies areas of strength and weakness in Uganda’s current health financing system, in relation to the desirable attributes, and based on this recommends where relevant shifts in health financing policy directions, specific to the context of Uganda, which can help to accelerate progress to UHC. The qualitative nature of the analysis, but with supporting quantitative metrics, allows close-to-real time information on how the health financing system is performing to be provided to policy-makers. In addition, the structured nature of the HFPM lends itself to the systematic monitoring of progress in the development and implementation of health financing policies. Country assessments are implemented in four phases as outlined in Fig. 1; given that no primary research is required, assessments can be implemented within a relatively short time-period. Fig. 1. Four phases of HFPM implementation PHASE 1 PREPARATION PHASE 2 CONDUCTING THE ASSESSMENT PHASE 3 EXTERNAL REVIEW PHASE 4 REPORT FINALIZATION & PUBLICATION viii Phase 2 of the HFPM consists of two stages of analysis: • Stage 1: a mapping of the health financing landscape consisting of a description of the health coverage schemes which make up the country’s health system. The key design elements of each scheme are then mapped, including the target population, the basis for entitlement, revenue sources and the provider payment mechanisms used. This provides a picture of the structure of the health system and the extent of fragmentation. • Stage 2: thirty-three questions which assess health financing policy in detail, each carefully selected to provide a picture of how the health system is performing in relation to one or more desirable attribute of health financing, as well as the intermediate objectives and final goals of UHC. Countries are using HFPM findings and recommendations to feed into policy processes including the development of new health financing strategies, the review of existing strategies, and for routine monitoring of policy development and implementation over time. HFPM assessments also support technical alignment across stakeholders, both domestic and international. Further details about the HFPM are available online: https://www.who.int/teams/health-systems-governance-and- financing/health-financing/diagnostics/health-financing-progress-matrix. ix About this report This report provides a concise summary of the Health Financing Progress Matrix assessment in Uganda, identifying strengths and weaknesses in the health financing system, and priority areas of health financing which need to be addressed to drive progress towards UHC. Findings are presented in several different summary tables, based on the seven assessment areas, and the nineteen desirable attributes of health financing. By focusing both on the current situation, as well as priority directions for future reforms, this report provides an agenda for priority analytical work and related technical support. The latest information on Uganda’s performance in terms of Universal Health Coverage (UHC) and key health expenditure indicators, are also presented. Detailed responses to individual questions are available on the WHO HFPM database of country assessments or upon request. This assessment is a living document and is circulated for further feedback and comments; it also forms the basis of annual updates for monitoring purposes. xAbbreviations AHSPR Annual Health Sector Performance Report AIDS Acquired Immune Deficiency Virus AMR Antimicrobial Resistance CAO Chief Administrative Officer CBHI Community Based Health Insurance CDC Center for Disease Control DAH Development Assistance for Health DHO District Health Officer DHT District Health Team GDP Gross Domestic Product FY Financial Year HFPM Health Financing Progress Matrix HFS Health financing Strategy HIV Human Immunodeficiency Virus HSDP Health Sector Development Plan IFMS Integrated Financial Management System JMS Joint Medical Stores LG Local Government MOU Memorandum of Understanding MOFPED Ministry of Finance Planning and Economic Development MTEF Medium Term Expenditure Framework MTP Motor Third Party MTPI Motor Third Party Insurance MTPL Motor Third Party Liability NHA National Health Accounts NDP National Development Plan NHIS National Health Insurance NMS National Medical Stores NWR Non-Wage Recurrent OOP Out of Pocket Payments PBB Programme Based Budgeting PBF Performance Based Financing PHC Primary Health Care RAF Resource Allocation Formula RBF Results Based Financing SDG Sustainable Development Goals SHI Social Health Insurance UBOS Uganda Bureau of Statistics UNEHCP Uganda National Essential Health Care Package UHC Universal Health coverage UNHS Uganda National Household Survey USG United States Government WHO World Health Organization xi Methodology and Timeline The assessment was originally led by Dr Elizabeth Ekirapa Kiracho. A review of key national, programme and policy documents were undertaken. The documents included the health financing strategy, the UHC road map, the National Development Plan III, the National Health Policy III, the Health Sector Development Plan II (Draft), the human capital development implementation plan, the Uganda national Primary health care guidelines, the public private partnership policy, the National Health Accounts (NHA) as well as implementation plans of the key health financing reforms such as the Program based budgeting (PBB) reform, the performance-based financing reform, Public Finance Management Act and Guidelines, etc. Key informant interviews and stakeholder consultation workshops were conducted but the detailed findings are reported elsewhere. The other investigators included: • Dr Chrispus Mayora a co-investigator who supported the review and synthesis of findings. • Dr Aloysius Ssennyonjo a co-investigator who also supported the review and synthesis of findings • Mr Noel Namuhani, study coordinator and supported the review of documents and compiling the report. • Ms. Barbra Elsa Kiconco, a research officer who supported the review and extraction of data.
122 28 36 43 46 48 49 28 31 35 37 41 42 42 0 25 50 75 100 2000 2005 2010 2015 2017 2019 2021 Uganda LI (avg) Uganda UHC Performance SDG indicator 3.8.1 relates to the coverage of essential services and is defined as the average coverage of essential services based on tracer interventions that include reproductive, maternal, newborn and child health, infectious diseases, noncommunicable diseases and service capacity and access (World Health Organization, 2021). The service coverage index is a score between 0 and 100, which in Uganda has doubled since 2000. Fig. 2. Service coverage index trend in Uganda, 2000–2019 Source: Global Health Observatory 2022 (https://www.who.int/data/gho/data/themes/topics/service-coverage) 2Antenatal care +4 visits National average (2017): 60.2% Value by quintile – 2016 Q1 (poorest) Q2 Q3 Q4 Q5 (richest) 53.1% 58.4% 60.9% 62.9% 66.9% DTP3 coverage 1 year National average (2017): 79.3% Value by quintile – 2016 Q1 (poorest) Q2 Q3 Q4 Q5 (richest) 78.6% 79.2% 79.0% 81.6% 78.4% For some service components of the index, it is possible to obtain disaggregated information, as shown in Fig. 3, to get a picture of inequalities in access, which have decreased over time. Fig. 3. Antenatal care and DPT3 coverage by wealth quintile in 2016 Source: Antenatal: https://apps.who.int/gho/data/view.main.94030; DPT3: https://apps.who.int/gho/data/view.main.94200 SDG indicator 3.8.2 relates to financial protection, measured in terms of catastrophic spending, and defined as the “Proportion of the population with large household expenditure on health as a share of total household expenditure or income”. Large is defined using two thresholds first greater than 10% of the household budget and secondly greater than 25% of the household budget. 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 1995 2000 2006 2011 2016 Q1 Q2 Q3 Q4 Q5 30% 40% 50% 60% 70% 80% 90% 1995 2000 2006 2011 2016 Q1 Q2 Q3 Q4 Q5 20% 25% 30% 35% 40% 45% 50% 5% 60% 65% 70% 1 95 2 0 2 06 20 1 2016 Q1 Q2 Q3 Q4 Q5 30% 40% 50% 60% 70% 80% 90% 1 95 2 0 2 06 20 1 2016 Q1 Q2 Q3 Q4 Q5 3Fig. 4: Trend in catastrophic health spending in Uganda 1996-2019 Source: Note that data up to 2016 come from the Global database on financial protection assembled by WHO and the World Bank, 2021 update. SDG 3.8.2 Catastrophic health spending (and related indicators) [online database]. Global Health Observatory. Geneva: World Health Organization; 2021. (https://www.who.int/data/gho/data/themes/topics/financial-protection) The data for 2019 comes from the Uganda Statistical Office report: https://dc.sourceafrica.net/documents/121051-Uganda-National-Survey- Report-2019-2020.html Whilst not an official SDG indicator, an additional measure of financial protection looks at health spending which leads to impoverishment. Some people (the poor and the near poor in particular) are not able to spend more than 10% of their household budget on health. Indicators of impoverishing health spending are defined as the proportion of the population pushed and further pushed into extreme poverty (living with less than 2011 PPP$1.90 a day per person) by out-of-pocket health spending. 14.6 9.4 9.6 20.3 16.8 15.7 15.3 13.6 2.4 0.8 0.7 2.2 1.4 3.6 3.8 3.6 0 5 10 15 20 25 1996 1999 2002 2005 2009 2012 2016 2019 % o f t he p op ul ati on with OOPs > 10% of household total consumption with OOPs > 25% of household total consumption 4Fig. 5: Impoverishing out of pocket health spending in Uganda 1996-2016 Note: PPP – Purchasing Power Parity. People are considered impoverished when the total per capita consumption of their household (including OOP health spending) is above a poverty line, but per capita consumption net of out-of-pocket health spending lies below it. People are further impoverished when their total household per capita consumption already lies below a poverty line and includes any out- of-pocket health spending. Source: Data from the Global database on financial protection assembled by WHO and the World Bank, 2021 update. SDG 3.8.2 Catastrophic health spending (and related indicators) [online database]. Global Health Observatory. Geneva: World Health Organization; 2021. https://www.who.int/data/gho/data/themes/topics/financial-protection 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 % o f t he p op ul ati on Further impoverished Impoverished 5Summary of findings and recommendations Assessment area Summary findings Status Policy process & governance There is a Health Financing strategy 2015/16 – 2024/25 that is in place to guide the generation, pooling and use of funding within the health sector as it strives to achieve Universal Health Coverage. The strategy has a clear goal and objectives that are system wide and aimed at enhancing the achievement of UHC. Accountability structures for funds that flow through the public sector are well established. The government, through responsible bodies, has put in place accountability mechanisms to measure the performance of key government sectors including the health sector. However, accountability and monitoring structures mostly focus on financial accountability and much less on non-financial accountability. The Government through the Ministry of health has instituted many tools and studies that regularly generate health financing information. However the financial information is not directly linked with performance data, which limits its usefulness in promoting effective delivery of services. Established Revenue raising The country already has an existing 10-year Health Financing Strategy launched in 2016. The process of developing the strategy was all-inclusive with extensive stakeholder participation. The strategy is also based on international and national evidence on which proposed strategic areas contained therein are anchored. The Health financing strategy highlights key strategies for innovative revenue raising including introducing sin tax, advocating for increased government funding for health, maximizing efficiency gains, increasing external resources and their predictability. However, the implementation of these strategies is yet to be fully realized, despite the attempts. Uganda relies heavily on external support and out of pocket payments. External support has reliability and sustainability challenges, and OOP is very regressive in nature. The government budget allocations have remained low for a long time. Even then, Government budget funds are derived from taxation, loans, grants, and on-budget external funding. Most tax revenue is generated through indirect taxes and is only slightly progressive. The country still relies heavily on OOP which is highly regressive. Established Summary of findings and recommendations by assessment area Using the guidelines to the Health Financing Progress Matrix, the below seven paragraphs summarize the key recommendations that are important for Uganda to make further progress towards UHC. All recommendations are backed by evidence on what other countries needed to do to progress towards universal health care. For all the below sections, the recommendations are coming from the extensive evidence review that WHO conducted and documented in the guidebook of the Health Financing Progress Matrix. The recommendations are adapted to the Uganda context. WHO has summarized what works and has worked in other countries with regards to health financing reform in the various areas to make progress towards UHC. The way the below recommendations should be read therefore are “based on evidence from other countries, if we implement this, we will make progress towards UHC”. 6Summary of findings and recommendations Assessment area Summary findings Status Pooling revenues The main sources of pooling revenue currently existing in Uganda are the government budget, the voluntary private commercial insurance schemes, and the community-based health insurance schemes. The main limitation of the government budget is its limited amount. Over the past decade the government has allocated only between 5% and 9% of the national budget to health. Uganda doesn’t have a national social insurance scheme, yet most countries are moving towards this. The government budget is used to purchase the package of services articulated under the UNMHCP and these are provided free for all people in Uganda. The funds from external funders that go through standalone vertical projects purchase specific benefits from the package for specific targeted sections of the population depending on their levels of vulnerability. The voluntary pooling schemes generally purchase whatever packages of benefits are agreeable between the insurer and the service provider. The contribution of voluntary pooling mechanisms is very insignificant in the health financing landscape in Uganda given that less than 5% of the population has some form of insurance. There is a large degree of fragmentation of funding pools, and this permeates to the fragmentation in service delivery and hence undermines efficiency. Progressing Purchasing health services Uganda is making some progress in strategic purchasing. It uses some simple measures of need such as population size and disease burden (infant mortality) as well as indirect measures of service access to allocate resources to providers. Government has largely been using input-based approaches, until recently when the URMCHIP performance-based system was launched which is now in more than 130 out of 146 districts of Uganda as a mechanism for institutionalizing performance-based pay through the primary health care grants that are provided to health facilities. Most of the project-based funding from IPs and donors, include some output-based funding components and in some cases a mixture of input-based and output-based systems. We also note that for government systems, there is very limited use of the data from provider activities to determine resource allocation. For project or performance-based systems, provider activity significantly influences purchasing and resource allocation decisions. Government purchasing systems, monitor service quality through facility assessments and reporting systems, however this information is largely not considered during provider payment. However in performance and project-based systems there are inbuilt processes to incentivize quality of services provided. Progressing Benefits & condititons of access The Uganda National Minimum Health Care Package (UNMHCP) contains a list of cost-effective interventions that the government of Uganda committed to providing to its population through various health centres and hospitals in Uganda. The Package reflects the health priorities of the population. There are also explicit mechanisms of accessing the benefit package, through the public facilities for free and through the private sector or private wings of public facilities at a subsidized fee. The challenge, however, is that the benefit package or commitment is not aligned to the existing public resource envelope, as such, the government cannot guarantee its provision. That means, that while the commitment is to provide the package, this may not be possible, and therefore, the benefit package represents an aspiration to provide services that meet the essential needs of the people. While all population groups are eligible to receive the services, implicit rationing occurs because of resource constraints. The benefits of the package have been clearly spelt out through various channels for instance through the guidelines to the district local governments, the client charters, and explicitly indicated on public platforms at health facilities showing a range of services offered at that health facility level. However, entitlements and conditions of access are not clear to the entire population especially those who are not literate. This is further complicated by the rampant informal payments, stock-outs of essential medicines and supplies, and an ineffective gate-keeping system. User fees were abolished in all government health centres and hospitals in 2001 to facilitate easy access to services especially by the low socioeconomic status. Indeed, this increased access and utilization in public facilities by both the poor and the rich, although the ensuing informal payments undermined access by the poor. Thus, despite free access to services the poor are still not fully protected financially because of those unsanctioned informal payments. Progressing 7Summary of findings and recommendations Assessment area Summary findings Status Public financial management The Public financial management system is well elaborated and guided by the PFM Act. The IFMS is a major mechanism for managing various phases of the budget cycle. The MoFPED as the overall steward of resources provides guidance and oversight across sectors on the budgeting and financial management processes. The Ministry of Finance releases the MTEF every budgeting period to guide sectors the budgetary celling for each sector. There are also guidelines for expenditure and how to treat over-spending and underspending of funds. There are also elaborate accountability mechanisms including rules around public accountability and access to expenditure and financial information. The Government of Uganda embarked on implementing Program Based Budgeting (PBB) in FY 2017/18 with a view of strengthening the link between government strategic objectives, budget allocations and service delivery outcomes/results. A 2020 WHO assessment on the transition to PBB in Uganda’s health sector noted that the transition has not been without challenges, some of the which are intrinsic to the complex health financing landscape of Uganda, while others pertain to the roll out and operationalization of the reform. Established Public health functions & programme There are different health programmes which are well-integrated into the Health sector strategic plan 2020/21-2024/25 and the National development plan III. These strategic documents take into consideration the population needs with major principles of equity, client focus and responsiveness. The programmes are funded through on budget and off budget support. The inability of some HDPs to communicate aid commitments in the government’s Medium-Term Expenditure Framework (MTEF) causes uncertainty in the operational funds and disrupts implementation of programmes. Some partners still have individual project funds, which are not integrated into consolidated programme plans. This arrangement is inefficient as it results in fragmented micro-programming. Resources for IHR are generally donor funded especially by WHO and CDC/USG. An emergency public financing mechanism exists that allows for structured reception and rapid distribution of funds in response to public health emergencies. However, there is no flexibility in budget at subnational level with poor accountability. Furthermore, there is still room to improve coordination and integration among programmes by streamlining budgets and resource mobilization. Funding arrangements, requirements for accountability and reports tend to promote silos in programmes. Progressing 8Policy process and governance Desirable attribute GV1 Health financing policies are guided by UHC goals, take a system-wide perspective and prioritize and sequence strategies for both individual- and population-based services Key areas of strength and weakness in Uganda The goal of the strategy is aligned to the UHC goals. It also has a specific set of objectives that are aligned to the key health financing functions that address key health system bottlenecks that influence successful health financing. The HFS has a series of strategies and interventions that are sequenced in implementation. The strategy also outlines key performance indicators for the implementation of the health financing strategy. However, implementation of the HFS has been suboptimal. Recommended priority actions 1. Finance tracking processes should be linked to and used to inform budgeting and resource allocation. 2. Recommendations from reviews and evaluation of the HFS should be implemented to enhance progress in achieving the HFS objectives. Desirable attribute GV2 There is transparent, financial and non-financial accountability in relation to public spending on health Key areas of strength and weakness in Uganda There are clear mechanisms and structures for promoting accountability particularly for public funds. These mechanisms are specified in the law particularly the Public Finance Management Act (PFMA). However, public accountability systems focus more on financial accountability and less on performance and value for money accountability. Additionally, the public finance accountability systems tend to discover major deviations and accountability gaps when they have already happened and cannot be reversed. Social accountability mechanisms have been tried but have not been successfully implemented, partly because they are not institutionalized and embedded in law. There is also a disconnect between accountability mechanisms of government and those of other implementing partners imply that it’s not easy to understand the extent of utilization and effectiveness of funds on service delivery. Recommended priority actions 1. Balance financial and performance accountability by linking financial data with performance data more routinely and build the capacity of the oversight structures to utilize the additional information. 2. Review current mechanisms of social accountability and scale up those that are most feasible as a means of further strengthening existing accountability processes. 3. There is need to synchronize financing and accountability processes for government and implementing partners to ensure all resources invested in service delivery can be tracked, monitored, and evaluated to enhance the effectiveness of services delivered. Desirable attribute GV3 International evidence and system-wide data and evaluations are actively used to inform implementation and policy adjustments Key areas of strength and weakness in Uganda International evidence and some regular studies and surveys are conducted in Uganda such as the National Health Accounts (NHA), National AIDS Spending Assessment (NASA), expenditure tracking surveys etc. and used minimally to guide policy decisions. Financial evaluation review studies are not conducted regularly. Financial and performance data are not integrated routinely, and this limits their use. Recommended priority actions 1. The government should improve the use of key studies (such as the National Health Accounts, cross programmatic efficiency studies, expenditure tracking survey reports) to improve health policy and implementation of key government objectives within the health sector by — Appropriately disseminating key findings to targeted audiences and specifying actions that need to be taken by different actors. — Developing an elaborate monitoring and evaluation plan for key health financing actions specified in the HFS and other key financial documents. 2. Identify mechanisms for integrating financial and performance data at all levels, including creating observatories at district level to monitor performance of particular health financing indicators Summary of findings and recommendations by desirable attributes of health financing 9Revenue raising Desirable attribute RR1 Health expenditure is based predominantly on public/compulsory funding sources Key areas of strength and weakness in Uganda External funding and private sector financing especially from out-of-pocket still contribute the largest share of THE. Public Expenditure as a proportion of THE is about 17% which is very low. The health sector allocation as a proportion of total budget allocations for FY2022/2023 is 6% and has for a long time oscillated between 5% to 9%, which is significantly below the 15% Abuja target. The OOP is still very high which undermines the capacity of households to access health care and contributes to catastrophic expenditures and impoverishment. The limited public expenditure on health means that there is high reliance on external funding and OOP which have challenges of unreliability, un-sustainability, and inequity – particularly for OOP. Recommended priority actions 1. Continue engaging MOF to see how to increase domestic funding for health by providing compelling evidence and stepping up advocacy efforts to increase National budget allocations for health. 2. The Uganda revenue authority should expand the tax base by strengthening tax administration to increase the funds collected from motor third party insurance, sin taxes, trust funds in addition to introducing new taxes such as the airline tax. 3. A motor third party liability grant should be set up to allow the allocation of 5-10% of third-party insurance funds to health facilities to facilitate treatment of uninsured accident victims. 4. Mandate all MDAS to budget 2% of their budgets for health prevention and promotion activities as one of the cross-cutting issues. 5. The country should enhance efforts to expand the national income through harnessing natural resources such as petroleum to expand the fiscal space for health spending. 6. Step up advocacy efforts to support NHI as a means of mobilizing funds from households. Desirable attribute RR2 The level of public (and external) funding is predictable over a period of years Key areas of strength and weakness in Uganda The MTEF system allows for a relative level of predictability of funds (through the national budget) over the short and medium term. However, Off-Budget external funding is very unpredictable because it depends on the priorities of the funding agency for that particular year. In fact there are reported circumstances where donors make commitments, but the actual disbursements are less than the commitments. This often distorts planning and budgeting. Recommended priority actions There is a need to increase predictability of donor funding, especially by agitating for more on-budget funding. The ultimate is to wane the country away from over-dependency on donor support, which will imply more allocation of public funding to health. Desirable attribute RR3 The flow of public (and external) funds is stable and budget execution is high Key areas of strength and weakness in Uganda Public funds are released on time by the ministry of finance. Once public funds have been approved through the national budget, releases to done on a quarterly basis, directly from the Ministry of Finance to service delivery institutions using the IFMS system. However, for external (off-budget) funds, their flow depends on the structure of the programmes they support and whether the resources go through fund-holders or direct to implementers, hence their flow is less stable. They are also subject to the ever-changing donor dynamics. Budget execution is high for the public funds (over 90%) except for capital development which is constrained by lengthy procurement processes. Budget execution for donor funds is less (75%). Recommended priority actions 1. Review and amend the PPDA requirements that lead to protracted procurement processes. 2. Develop cooperative agreements with HDPs to improve predictability of external funding. Desirable attribute RR4 Fiscal measures are in place that create incentives for healthier behaviour by individuals and firms Key areas of strength and weakness in Uganda Government has been heavily taxing products that undermine healthy life and are associated with NCDs, such as Alcohol and Tobacco. The main objective for government has been to raise enough revenue given that these products are by nature ‘price’ insensitive, which creates an opportunity to tax them more and to reduce consumption of unhealthy products. However, there seems to be no direct link between taxes, prices, and demand (apart from the theoretical understanding). So it’s not conclusive whether these taxes are indeed incentives for certain healthy behaviour. There has, therefore, not been deliberate studies to understand the impact of taxation on consumption behaviour of certain foods. The World Bank recently in its advocacy for sin-taxation demonstrated the impact of certain tax rates on consumption but also on revenue from those goods. It’s so far the only study and we may not be conclusive based on this one study. Recommended priority actions 1. There is need for a robust study to establish a clear threshold tax rate that could be levied to achieve both revenue raising targets and behavioural change targets. 2. Taxes should be aligned to the risk associated with consumption of the goods. Taxes on alcohol should therefore be aligned to the alcoholic content of the drinks. 3. The taxes levied on alcohol and tobacco should be increased to match the recommended WHO levels of 70%. Current alcohol retail taxes stand at 55%. 4. Ear mark a percentage of the funds generated from sin taxes for the expansion of health prevention activities for noncommunicable diseases and specialized services for noncommunicable diseases. 5. Expand and extend incentives and subsidies such as service vouchers to promote uptake of health promotion actions. 10 Pooling revenues Desirable attribute PR1 Pooling structure and mechanisms across the health system enhance the potential to redistribute available prepaid funds Key areas of strength and weakness in Uganda There is lack of a unified scheme for pooling resources from donors. The government pooling system through the budget attempts to distribute resources equitably through the use of a simple allocation formula that captures elements of need – such as population size, geographical location, and burden of disease (infant mortality). The formula, however, is unable to consider other population needs and service provider-related considerations such as provider performance and workload. The formula is revised from time to time in an attempt to capture current service delivery, access, and utilization dynamics however these efforts have been constrained by the poor availability of reliable population and service data. The current HFS highlights the need for pooling resources and proposes strategies such as national health insurance and establishing a joint pool of resources, (basket funding) although this is yet to be implemented. There is also an attempt by the Ministry of Health to implement a ‘zoning’ approach where IPs are zoned to different regions and districts to avoid issues of duplication but also achieve balanced coverage. This is, however, yet to be fully actualized for all service areas (apart from the area of HIV/AIDS). Recommended priority actions 1. Hasten the approval and implementation of the NHIS to bring fragmented pools together into one major feasible pool for all Ugandans. 2. Encourage harmonization and federation of the existing CBHI schemes to allow for cross subsidization of funds. 3. Advocate for improved accountability so as to enhance the pooling of development assistance funding into the national budget to achieve better alignment and address verticalization and possible duplicities in service delivery. 4. Extend the practice of zoning donors to all the other donor supported activities. Desirable attribute PR2 Health system and financing functions are integrated or coordinated across schemes and programmes Key areas of strength and weakness in Uganda The different schemes remain uncoordinated. Each scheme has its own revenue-raising mechanisms, pooling mechanisms, and purchasing arrangements. We observe different benefit packages being purchased although they may eventually be aligned to the national benefit package framework. Each scheme provides a package depending on the resource portfolios available to them. There is no coordinated pooling and alignment across the schemes remains suboptimal or even non- existent. This misalignment contributes to inefficiencies in service delivery. Recommended priority actions 1. Address bottlenecks that have hampered the establishment of a joint health fund which pools all resources for health into one basket. 2. Establish structures that can facilitate joint budgeting, coordination and implementation of on-budget and off-budget funded activities at the national, district and facility level to ensure coordinated implementation of activities and to reduce duplicate funding of activities. 3. Support CBHI growth in the country by setting up regulatory and implementation frameworks to support awareness raising, co-financing and building of managerial capacity. 4. Strengthen the link between funding and service delivery objectives by using the PBB approach to budgeting. Purchasing health services Desirable attribute PS1 Resource allocation to providers reflects population health needs, provider performance or a combination Key areas of strength and weakness in Uganda The resource allocation formulae was recently modified to include some simple measures of population health needs such as population size, ease of accessing services and disease burden, but not provider performance. The need to include provider performance has recently gained traction and now the URMCHIP programme is a key first attempt to institutionalize this in the public system. The project-based or programme-based system of service delivery, however, reflect both population-health needs and provider performance, because projects mainly focus on specific services designed for specific target populations in need. Recommended priority actions 1. Continue the process of Institutionalizing pay for performance for primary health care so as to link the payment of providers to the health needs of the population and to the quality of services provided. 2. Expand the use of utilization data at facility level by establishing a reliable real time reporting system that can be used more easily to influence resource allocation and broader planning. Desirable attribute PS2 Purchasing arrangements are tailored in support of service delivery objectives Key areas of strength and weakness in Uganda Purchasing arrangements under the RBF and project-based, support service delivery objectives since they focus on improving delivery and utilization of particular services by linking performance to payment. However, purchasing through the government budget is only slightly linked to performance, efficiency, and cost containment for input-based payments. Within the government purchasing, the elements of performance and quality of service are not yet adequately embedded in the purchasing mechanisms, however the government is in the process of introducing an element of performance-based payment for part of the primary health care grants. Recommended priority actions 1. Expand the electronic data collection of key service outputs and increase its linkage with financial and human resource data to enhance performance-based payment. 2. Institute accreditation of public and private facilities to allow the selection of facilities that provide quality services. 3. Strengthen district led regular monitoring of quality of services and feedback to enhance provider performance by strengthening the role of DHO, regional referrals through capacity building such that they are in position to manage partnerships and service outputs from these partnerships. 4. Expand the use of employment contracts for higher level managers within the health sector that contain desired service delivery expectations as a means of strengthening accountability of service providers. 5. Harmonize provider payment mechanisms across different purchasing arrangements. 11 Purchasing health services Desirable attribute PS3 Purchasing arrangements incorporate mechanisms to ensure budgetary control Key areas of strength and weakness in Uganda Budgetary control within the government system is maintained through the use of public financial management rules, and now the Integrated Financial Management System (IFMS). If funds are not utilized after the required time, they are automatically remitted back to the consolidated fund. Beyond this, however, there are no-inbuilt mechanisms to identify under use or overuse of services. Projects tend to spend money in accordance with the financial guidelines provided by their funders and so their purchasing arrangements are usually in line with their budgets. Recommended priority actions 1. Regularly track and assess service utilization patterns to identify underlying drivers of underuse or overuse of prioritized tracer services. 2. Institute mechanisms for monitoring efficiency. Benefits and entitlements Desirable attribute BR1 Entitlements and obligations are clearly understood by the population Key areas of strength and weakness in Uganda The government has made an attempt to inform the population about their entitlements and obligations. The patient charter has been key, with civil society led by the National Health Consumer’s Organization advocating for the same and ensuring that people know about their rights and entitlements. There are also guidelines that provide for the provision of information on facility noticeboards about what services are provided and how people can access them. However, there is undeniably a big section of the population that may not have enough information about these issues and no wonder, those users still continue to pay informal payments to access services, yet services are free of charge in government facilities. A section of the population is also unable to access this information because of a combination of factors including low literacy levels and inability to travel to the health facility where the information could be obtained. Advocacy and communication about entitlements is therefore still limited. Recommended priority actions 1. Increase mass sensitization of the eligible population about the benefits that they are entitled to. 2. Increase health system investments required to make the different levels of service delivery fully functional to allow for a smooth implementation of the referral system. Desirable attribute BR2 A set of priority health service benefits within a unified framework is implemented for the entire population Key areas of strength and weakness in Uganda A set of priority health services has been defined in the benefit package represented by the Uganda National Minimum Health Care Package. The challenge is that the existing resources are too constrained to guarantee full delivery of the package to the population, hence the package is offered by both public and private facilities. It is offered freely in the public facilities and for payment through OOP in the private facilities, hence those served primarily by only private facilities may be unable to access some services if they cannot afford to pay for them. Thus, while the package is explicitly outlined, not everyone can access the package because the delivery of all elements of the package are not guaranteed due to resource challenges. It is therefore not uncommon for individuals to walk into health facilities and not get certain services, yet they are expected at that level of care. Delivery of the package is further constrained by the high and ever-increasing population. Recommended priority actions 1. Regular revision of the UNMHCP so as to align it with current health realities. 2. Identify innovative financing mechanisms so as to increase the funding available for health. 3. Enhance the use of strategic purchasing for services coupled with increased heath systems investment so as to promote the functionality of facilities. 4. Put in place mechanisms that can enable joint planning and coordination of off budget and on budget resources so as to avail more resources for meeting the cost of the unified package. Desirable attribute BR3 Prior to adoption, service benefit changes are subject to cost–effectiveness and budgetary impact assessments Key areas of strength and weakness in Uganda The UNMHCP design explicitly addresses the most prevalent disease conditions/ disease burden in the country. Inclusion of interventions is also guided by the cost effectiveness of interventions. However access to relevant data limits the use of these criteria. Furthermore, the package is not aligned with the existing government resources. As indicated earlier, by the time of this report, the UNMHCP was currently being reviewed by the Ministry of Health. Recommended priority actions 1. The current ongoing review of the UNMHCP should use quality and rigorous data that can help in identifying cost and cost-effective interventions for inclusion in the benefit package. 12 Benefits and entitlements Desirable attribute BR4 Defined benefits are aligned with available revenues, health services, and mechanisms to allocate funds to providers Key areas of strength and weakness in Uganda Financing the implementation and delivery of the Uganda Minimum Health care package is still a major challenge because of the high population, high disease burden and restricted resource envelop. Hence, the existing benefit package is not aligned to the existing resources to deliver the same. The resources are very limited, and this has undermined comprehensive delivery of the package. Recommended priority actions 1. Modify resource allocation formulae to reflect population needs more holistically and health worker performance. 2. Enhance the use of strategic purchasing for services coupled with increased heath systems investment so as to promote the functionality of facilities by — Encouraging development partners to channel funding for PHC through UgIFT, this will increase the funding available for services that government has prioritized, and this will encourage sustainability. 3. Continue institutionalization of RBF through UgIFT. 4. Reduce taxes and license fees for private sector working in remote areas, as an incentive for the private sector to work in the rural areas. Desirable attribute BR5 Benefit design includes explicit limits on user charges and protects access for vulnerable groups Key areas of strength and weakness in Uganda Access to the package of benefits in the UNMHCP is free of charge in public facilities, because user charges were abolished in 2001 in public health facilities, except in privately wings of public health facilities and in the private sector. This demonstrably increased access to care by the vulnerable poor. Relatedly, some specialized facilities by policy have recently started charging formal fees, including the Women’s specialized hospital, etc. While their prices are ‘subsidized’ and exemption mechanisms in place for those who can’t completely afford, these systems expose vulnerable groups to financial risks to access essential care. However, informal charges have increasingly been identified as a key impediment to access to services. This is coupled with other challenges of providing care in the public system including stock-outs, inadequate health workers etc. These conditions often push part of the population to utilize the private sector hence exposing the vulnerable groups to financial risk or to seek alternative methods of treatment including traditional and spiritual healers. Recommended priority actions 1. Set up a social protection system for the vulnerable to ensure that they can access services. 2. Ensure that resource allocation formulae/ systems include additional funds for targeting vulnerable groups e.g. through the use of service vouchers and establishment of health equity funds. 3. Enact laws in the public sector to regulate prices in the private sector Public financial management Desirable attribute PF1 Health budget formulation and structure support flexible spending and are aligned with sector priorities Key areas of strength and weakness in Uganda The budget process allows for priorities to be captured from the different levels and aggregated into the sector budget. The input- based system where resources are allocated along line items allows less flexibility to address emerging needs. The PHC subventions to local governments, for example, have conditionality attached that guide on how to spend funds and any deviations are tantamount to misappropriation. In cases where re-allocation of resources is required from one budget line to another, one requires authorization from higher level authorities. This is the same process in case there is a need for supplementary funding. Efforts are ongoing to ensure better alignment between budgets and sector priorities. However, the strong PFM rules and limited resource envelopes undermine flexible use of budget funds. Program based budgeting promises to support coordination across sectors to address crosscutting priorities. Recommended priority actions 1. Consolidate efforts to allow for more flexible spending by aligning budgets to programme priorities and programme outputs by strengthening the capacity to implement and monitor implementation of the programme-based budgeting. 2. Review and revise the votes under the programme-based budgeting approach to allow for more coordinated implementation of multisectoral actions and reduced duplication. 3. Document lessons from implementation of PBB and ensure timely enactment of corrective actions. Desirable attribute PF2 Providers can directly receive revenues, flexibly manage them, and report on spending and outputs Key areas of strength and weakness in Uganda The existing PFM rules do not allow spending from source. Spending from source means that an institution can spend directly the resources they have generated. The law requires that whatever revenues are generated are first deposited in the consolidated funds and then an institution seeks funds for whatever expenditure they want to make. There are however a few exceptions to this moratorium on expenditure from source. For the health sector, the only revenues generated are through private wings of health facilities and high-end specialized facilities authorized to charge user fees. But they must seek authorization from the sector accounting officer before any expenditures can be done, otherwise all revenue must be deposited in the consolidated fund of government. The specialized facilities are only allowed to spend the money that was budgeted for them even if they generate more than that amount. If they require more funds they have to request for a supplementary budget. Recommended priority actions 1. Review the PFM and other financial management rules and guidelines to allow for flexibility in resource generation and use with reasonable controls to avoid abuse of the flexibility. 2. Modify the PFM rules to allow for accountability of both on budget and off budget funds received at national and subnational levels. 3. Modify the PFM rules to allow for local use of locally generated funds under specific circumstances e.g. disasters, user fee revenue in specialized units such as heart institute. 4. Modify the PFM rules to cater for expedient use of resources during emergencies (this could include the waiving of specific functions or /alternative procedures for approval) 5. Continue to explore opportunities for expanding provider autonomy without undermining accountability needs. 13 Stage 1 assessment The health coverage schemes included in the Stage 1 assessment were selected according to the criteria outlined in the HFPM Country Assessment Guide. The aim is not to conduct an inventory, but rather to describe the main health schemes and programmes which make up the health system, and around which health financing and other policies are made, and through which money flows to health facilities. 14 Key design feature Government health budget Vertical Disease Programmes/project based Results Based Financing Community based and Private Health Insurance A) Focus of the scheme The government-funded scheme aims at providing preventive and curative services at the primary, secondary and tertiary level as stipulated in the country’s National Minimum Health Care Package. Projects are disease or programme focused, only providing access to specific targeted services. In Uganda, the focus has mainly been HIV/AIDS, TB, Immunization, and more recently RMNCAH. Some health system strengthening is undertaken mainly for purposes of supporting the programme. RBF programmes generally focus on both preventive and curative services. But have largely been focused on MCH services such as institutional delivery, ANC 4, PNC, immunization, etc. The current URMCHIP RBF programme focuses on RMNCAH services. The CBHIs targets selected providers mainly within communities where the CBHIs are established. The PHI are mainly voluntary and enrol individuals from the corporate and formal employment because for most employment, health insurance is part of the fringe benefits of employment. B) Target population All people residing in Uganda can access care at public health facilities in Uganda The target population is determined by the programme focus, and this is determined at programme design, for example focus on access to maternal care for women in hard-to-reach areas, immunization for zero-doze and underserved communities, Provision of ART for PLWHIV, or access to HIV care for Key populations, such as sex workers, MSMs, etc The target population is determined by the project objectives, right at design level. The objective determines what services to provide and what population. For example, if its increasing institutional deliveries, then the target are pregnant mothers, if the target is immunization completion, then the target are children, or some populations in hard-to reach areas, etc. CBHIs are community-based and those who enrol are usually community level people, with small premiums and a very narrow package of services covered. The private HI mainly targets individuals in formal employment and particularly the corporate employment (usually covered by their employers as part of employment benefits). C) Population covered The actual population covered depends on those in need of the service, the availability of the service, and the resources available to provide or rollout the particular service or intervention. This is because everyone in Uganda is eligible to access the services in the public system. Population covered varies with programmes – each programme is designed to focus on particular population, usually based on particular vulnerabilities or needs. The population covered is therefore embedded in the programme design – but mainly children, pregnant mothers, PLWHA, Family Planning, etc. This depends on the objective of the programme. The current URMCHIP Programme now covers more than 135 districts, and mainly focused on Reproductive Maternal, Neonatal, and Adolescent Health Services. The exact number so far covered was not ascertainable at the moment without proper project records. A small group of community- level individuals and households covered with small premiums. Very narrow scope of services, for CBHIs. The PHI includes mainly individuals in formal employment and particularly the corporate employment (usually covered by their employers as part of employment benefits). D) Basis for entitlement/ coverage Automatic: The Uganda National Minimum Health Care Package (UNMHCP) reflects a commitment by government to provide a minimum package for essential services to all people living in Uganda for free at all public facilities across the country. This is part of the commitments in the constitution and other national policies. Conditional. Those covered have to be eligible to receive the service based on the disease targeted or programme objective. The entitlement is based on the target population meeting a certain criterion for qualification. The characteristics may include disease, geography, or other individual/ population characteristic. Conditional. Those covered have to be eligible to receive the service based on particular criteria specified by the programme objective or programme design. If its enhancing institutional deliveries, the programme/ project will generally specify its geographical coverage and particular characteristics of beneficiaries and its on this basis that individuals qualify. Payment of premiums either into a CBHI or a private health insurance scheme, entitle members to claim benefits associated with those premiums as well as benefits that accrue to membership. Stage 1. Health coverage schemes in Uganda: health financing arrangement 15 Key design feature Government health budget Vertical Disease Programmes/project based Results Based Financing Community based and Private Health Insurance E) Benefit entitlements The Uganda National Minimum Health Care Package (UNMHCP) stipulates a package of entitlements for a broad range of primary health care (PHC) and hospital care interventions provided free for all. The UNMHCP is structured along five key thematic service areas/ clusters – 1) Disease Prevention and Promotion; 2) Prevention and Control of Communicable Diseases; 3) Prevention and Control of noncommunicable diseases; and 4) Maternal and Child Health Services. This UNMHCP is currently under revision to ensure its specific while comprehensive and takes into considerations the resource situation of the country. The revised package is also anticipated to include both a positive and negative list. Benefit entitlements are specified in the design of the specific programme. For example HIV related programmes tend to provide a range of preventive services (condoms, HIV testing and counselling, safe male circumcision, PMTCT services, PrEP, PEP, ART services, and more recently diagnosis and management of specific NCDs in HIV/AIDS. Benefit entitlements are spelt out by the programme, and generally depend on the objective of the programme. Most RBF programmes in Uganda, and specifically the Uganda Reproductive Maternal and Child Improvement Programme (URMCHIP programme) provides ANC, delivery, PNC, IPT for malaria, OPD services, short term and long-term contraceptives, immunization, etc. Benefits and entitlements based on premiums paid and contracts entered into for both the CBHIs and PHI. Most CBHIs provide basic packages that are generally OPD Centered. This is because their premium portfolios are very small to include secondary care interventions. For PHIs, the benefit packages can include primary and secondary care interventions offered through a network of preferred provider organization (PPOs), depending on the insurance contracts entered. F) Co-payments (user fees) All services accessed at public facilities are free for all. However, government allowed for the operationalization of private wings within public facilities to serve users who have capacity to pay. At these private wings, some fees are required to access services, although most times the fees payable is subsidized such that clients may not pay full fees because most inputs used in providing the services (such are health workers and other capital inputs) are part of the government facility establishment. Generally no co-payments, given that projects focus on providing services for targeted populations that are usually in particular vulnerable situations. Generally no co-payments for the performance-based projects. However some pilot voucher projects have had a system where vouchers are sold to eligible people at subsidized rates and redeemable at the service utilization points. For example, if a pregnancy delivery is UGX 100,000, the project sells the access voucher at UGX 20,000 to ensure even the low income can access the service. The difference is subsidized by the RBF project (example of the Uganda Reproductive Health Voucher II Project). The benefit package is restricted to the premiums and contracts signed between the insured and the service provider. Any additional services beyond the prescribed package are paid for by individual fees. Some insurance contracts provide for co-payments. So this really varies from one contract to another. 16 Key design feature Government health budget Vertical Disease Programmes/project based Results Based Financing Community based and Private Health Insurance G) Other conditions of access The government has developed the Service Standards and Service Delivery Standards for the Health Sector. These stipulate service packages expected to be provided at each level of care within the health care delivery system starting from a health centre II upwards to a national referral hospital. Individuals/users are not expected to access services at a higher-level facility which ordinarily are within the package of a lower-level facility (referral or gate-keeping system), unless they present a referral document from the lower-level facility. Unfortunately this is just a specification in the policy, but never concretely followed because of a lack of a robust gate-keeping system, limited capacities to provide designated packages at lower facilities, and the fact that access to care is free in Uganda, meaning no one can ordinarily be stopped from accessing care anywhere at any level in Uganda. Projects or programmes operate in specific geographical areas or work with specific health facilities, and so targeted individuals must be served by those specified health facilities within specified geographies. Sometimes, there are clear documents given to qualifying individuals which they present whenever they come to access the services. The RBF programmes specify what services to access, where to access them from, and a clearly articulated referral system. Unless this is followed, it sometimes may be difficult for service providers to claim their reimbursement. To facilitate this, some documents/ cards are given to qualifying individuals which they are required to present whenever they access services. Cardholders only access (predetermined)services through predetermined and contracted providers. H) Revenue sources The major sources of funds for the government system is the government budget allocation – which is a pool of funds collected through tax revenue, loans, grants, and on-budget support from development partners. There are also additional off- budget support from funder/ IPs to health providers especially in the area of health systems strengthening. For private wings in public facilities, revenue is generated through out-of-pocket payments and services provided to insurance subscribers. Projects are largely supported by donors or implementing partners that often include through international agencies, multilateral agencies, bilateral funding, etc. Since 2003 when RBF pilot projects started in Uganda, these have largely been funded by donors. However, URMCHIP the largest RBF programme aimed at institutionalizing RBF in the health sector, is supported by donors with a government co-financing element. Households/individual payments of premium contributions. For PHIs, these are contributory schemes where employers pay some amount and employees may also be required to contribute some amount to their insurance card. It is these premiums that are paid to service providers as their revenue source. 17 Key design feature Government health budget Vertical Disease Programmes/project based Results Based Financing Community based and Private Health Insurance I) Pooling Revenue collected through taxes by the Uganda Revenue Authority – a statutory body mandated to collect tax revenue in Uganda. These funds are pooled together into the national budget which is under the mandate of the Ministry of Finance Planning and Economic Development (MoFPED). Related, funds from external sources (donor funds and loans) are partially pulled through the national budget through on-budget support (21% of donor funds within the health sector). Also loans from both external and domestic sources are also pooled through the national budget. While there exists the notion of Trust Funds such as the HIV/AIDS Trust Fund and the Immunization Fund, these have been passed by legislation but remain non- operational due to some legal impediments that need to be clarified. Several fragmented pools. The different vertical disease programmes each have their own small pool of funds. Sometimes, the donor passes funds through fund- holders who then support programme implementation. Each RBF project has its own funds. However, in some instances several donors come together to support a particular RBF programme. For example, the URMCHIP is largely funded by pooled funds from the World Bank (through GFF), SIDA and government co-financing. Each CBHI and PHI scheme have individual pools that manage their own membership and funds. 18 Key design feature Government health budget Vertical Disease Programmes/project based Results Based Financing Community based and Private Health Insurance J) Governance of health financing Sectors (including health) generate sectoral plans and budgets right from the local government through a bottom-up planning and budgeting process. The sectoral priorities and funding needs are aggregated at ministry level to develop a sector budget which is submitted to the MoFPED within the framework of the MTEF. MoFPED aggregates sectoral budgets into one national budget which is submitted to Parliament for approval for every financial year (July -June). Once the sectoral allocations have been approved, MoFPED will send subvention inform of PHC Funding to local governments (districts and health facilities directly) with regulations or guidelines on expenditure. Other funds are sent to the Ministry of Health headquarters for governance and other operational activities; and other funds sent to self- accounting institutions and service providers (such as blood bank, National Medical Stores, etc) for service delivery. The monitoring and supervision for the use of the finances is done by the Ministry of Health headquarters in collaboration with the DHOs office. The service delivery mandate falls with the district local governments within the framework of the decentralization policy. Accountability for resource use is followed by the office of Auditor General every after a specific period. Most funds sent to districts and facilities are conditional, hence sub national leaders have very limited fiscal and decision space. Development partners who fund the projects play a lead role since they decide how funds are to be disbursed and spent. While the Ministry of Health is aware of which Programme is implemented where, by which implementing partner, the ministry has limited influence on implementation decisions. Development partners who fund the projects play a lead role since they decide how funds are to be disbursed However, they work with the Ministry of health. The country has a National framework guiding implementation of RBF within the country. The current URMCHIP programme has been designed based on the National RBF framework and because it is an effort to institutionalize RBF, the Ministry of Health is in-charge of implementation. An RBF Unit has been created in the Ministry of Health within the Directorate of Planning and Financing, and the RBF unit is largely in-charge of URMCHIP Implementation. Pools are managed locally given that the pools are really small, and the management arrangements vary from CBHI to CBHI. Similarly, under the PHI, Insurance Companies or firms have distinct governance arrangements. They are managed as corporate firms with no link to Ministry of Health and only deal with health service providers (who are mainly private and PNFP providers). 19 Key design feature Government health budget Vertical Disease Programmes/project based Results Based Financing Community based and Private Health Insurance K) Provider payment Line-item budget. Providers are predominantly paid using an input-based method where providers present budgets with key line items representing inputs necessary to delivery services within that particular financial year. Government then approves and provides resources to cover those budgets. The budgets usually contain conditional allocations and non-conditional allocations. These could cover capital inputs/ expenditures and variable expenditures such as wages, salaries, medicines and supplies, and other administrative or overhead expenditures. Line-item budget, Performance based, and sometimes a mixture. Donors tend to use largely line-item budgets. But in some cases some degree of performance-based financing is also practiced for example in immunization. Bonuses are provided if specific targets are met. Performance based financing for services is the main form of financing. Usually performance payment rates and performance indicators are agreed upon in contracts signed between the payer and the provider prior to implementation Payment mechanisms are specified in service contracts between the insurance scheme and the provider. But usually, providers are paid after providing services. Normally providers invoice the insurance scheme periodically after providing services. It could be capitation, case-based, or some other agreed method. This varies from scheme to scheme. L) Service delivery & contracting Services are provided largely through public facility with very limited autonomy (some degree of autonomy can be seen at higher level facilities such as regional referrals and national referrals). Primary, secondary, and tertiary services are delivered mainly through public facilities that are arranged by a referral system from VHTs (Lowest level) to the regional and national referral and specialized hospitals (upper level). Public facilities have limited autonomy including in decision spaces where they may not be allowed to shift funds across line- items depending on local need unless they have sought some kind of authorization from higher authorities. Government contracts private providers to provide particular services such as immunization services, HIV/AIDS services, and a broad range of other services especially through PNFPs that are situated where there is limited presence of the public sector. These contracts are in form of MoUs with corresponding subsidies payments to the contracted parties. Government also contracts out health education and promotion to non-state entities such as Health Communication Partners (HCP) former UHMG, etc and these entities are paid based on contract negotiations. Public (No autonomy) Private (Non-Profit) Private (Profit) Projects or programmes are free to contract any providers whether public or private to offer their services, depending on the design and objective of their programme. Public (No autonomy) Private (Non-Profit) Private RBF projects or programmes are free to contract any providers whether public or private to offer their services, depending on the design and objective of their programme. The URMCHIP project, for example is working with both public and selected PNFP facilities. Providers are contracted to provide services. For some insurance companies, a network of providers is contracted to provide services and the card-holders can only utilize services in those predetermined providers (PPOs). Others allow access to services anywhere (including private wings of public facilities). Referrals to public facilities (private wings) may also be accommodated. All these depend on the stipulations of the insurance contract. 20 H ea lt h e xp en di tu re b y St ag e 1 co ve ra ge s ch em es Fi g. 6 : E xp en di tu re fl ow s by s ch em e (S an ke y di ag ra m ) So ur ce : H ea lth A cc ou nt s 20 19 . M in is tr y of H ea lth , U ga nd a 21 Stage 2 assessment 22 Source: Based on HFPM data collection template v2.0, Uganda 2022 Source: Based on HFPM data collection template v2.0, Uganda 2022 Fig. 7: Average rating by assessment area (spider diagram) Fig. 8: Average rating by goals and objectives (spider diagram) Summary of ratings by assessment area 0 1 2 3 4 Health financing policy, process & governance Revenue raising Pooling revenues Purchasing and provider payment Benefits and conditions of access Public financial management Public health functions and programmes 4. Advanced 1. Emerging 2. Progressing 3. Established 0 1 2 3 4 Equity in finance Financial protection Health security Quality Service use relative to need Efficiency Equity in resource distribution Transparency & accountability 4. Advanced 1. Emerging 2. Progressing 3. Established 23 Assessment rating by individual question 1. Health financing policy, process & governance 3. Pooling revenues 5. Benefit and conditions of access 7. Public health functions and programmes 2. Revenue raising 4. Purchasing and provider payment 6. Public financial management Advanced Established Progressing Emerging Q1.1 Q1.2 Q1.3 Advanced Established Progressing Emerging Q3.1 Q3.2 Q3.3 Q3.4 Q3.5 Advanced Established Progressing Emerging Q5.1 Q5.2 Q5.3 Q5.4 Q5.5 Advanced Established Progressing Emerging Q7.1 Q7.2 Q7.3 Q7.4 Advanced Established Progressing Emerging Q2.1 Q2.2 Q2.3 Q2.4 Q2.5 Advanced Established Progressing Emerging Q4.1 Q4.2 Q4.3 Q4.4 Q4.5 Q4.6 Advanced Established Progressing Emerging Q6.1 Q6.2 Q6.3 Q6.4 Q6.5 Fig. 9: Assessment rating by individual question See Annex 3 for question details 24 Assessment rating by UHC goals Equity in finance Health security Service use relative to need Financial protection Quality Advanced Established Progressing Emerging Q2.1 Q2.3 Q2.4 Q3.3 Q3.5 Q5.1 Advanced Established Progressing Emerging Q3.2 Q4.6 Q6.2 Q7.3 Q7.4 Advanced Established Progressing Emerging Q2.2 Q2.3 Q3.1 Q3.2 Q3.3 Q3.4 Q3.5 Q5.1 Q5.3Q4.1 Q5.4 Q6.2Q5.5 Advanced Established Progressing Emerging Q2.1 Q2.3 Q2.4 Q3.1 Q3.2 Q3.3 Q3.4 Q3.5 Q5.1 Q5.3 Q5.5Q5.4 Advanced Established Progressing Emerging Q4.3 Q4.5 Q4.6 Fig. 10: Assessment rating by intermediate objective and final coverage goals 25 Assessment rating by intermediate objective Efficiency Transparency & accountability Equity in resource distribution Advanced Established Progressing Emerging Q1.1 Q1.2 Q1.3 Q2.1 Q2.2 Q4.6 Q5.2 Q5.3 Q5.5 Q6.1 Q6.5Q6.3 Advanced Established Progressing Emerging Q3.1 Q3.2 Q3.3 Q3.4 Q3.5 Q4.1 Q4.2 Q4.5 Q6.2 Advanced Established Progressing Emerging Q3.2 Q3.3 Q3.4 Q3.5 Q4.2 Q4.4 Q4.5 Q4.6 Q6.1 Q7.1Q6.4 Fig. 10 (continued): Assessment rating by intermediate objective and final coverage goals See Annex 3 for question details 26 Resources 1) Jowett M, Kutzin J, Kwon S, Hsu J, Sallaku J, Solano JG. 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DONOR POWER AND PRIORITIZATION IN DEVELOPMENT ASSISTANCE FOR HEALTH POLICIES : THE CASE OF UGANDA. https://www.ajpojournals.org/journals/ index.php/JDE/article/view/640 72) Margini, Federica, Anooj Pattnaik, Tapley Jordanwood, Angellah Nakyanzi, and Sarah Byakika. 2020. “Case Study: The Initial COVID-19 Response in Uganda.” Washington, DC: ThinkWell and Ministry of Health Uganda. https://thinkwell.global/wp-content/ uploads/2020/09/Uganda-COVID-19-Case-Study-_18- Sept-20201.pdf 73) World Health Organization (2017): Joint external evaluation of IHR core capacities of the Republic of Uganda: executive summary, June 26-30, 2017. World Health Organization. https://apps.who.int/iris/ handle/10665/258730 License: CC BY-NC-SA 3.0 IGO 74) Wanduru, P., Tetui, M., Waiswa, P., 2020 COVID -19 responses in Uganda: notes and reflections. blog. BmJ Global Health 30 Annexes 31 Annex 1: Selected contextual indicators Fig. 11: Health expenditure indicators for Uganda General goverment expenditure (GGHE-D % GGE) Out of pocket spending (OOPS % CHE) Total health spending (CHE per capita current USD) GGHE P.C. (current USD) Public spending on health as GDP (GGHE-D % GDP) Source: WHO Global Health Observatory, 2020 (https://apps.who.int/nha/database/Home/Index/en) 7.0% 7.1% 6.9% 7.1% 7.3% 7.0% 5.1% 5.2% 3.9% 4.2% 3.1% 3.1% 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 42.8% 37.4% 33.0% 37.5% 42.5% 40.1%39.5%40.6%38.1% 35.6% 38.3%37.4% 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 0.8% 1.1% 0.9% 0.9% 1.0% 1.0% 0.8% 0.8% 0.6% 0.7% 0.6% 0.7% 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 44.4 52.0 55.3 55.1 53.0 51.0 40.2 39.1 31.5 33.0 33.4 33.9 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 16.9 22.8 22.1 20.8 22.2 22.0 17.5 17.3 14.3 15.9 14.3 16.1 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 32 Fig. 12: Revenue sources for health in Uganda Fig. 13: Recurrent expenditures by revenue source 2020 Source: The Global Health Observatory, 2020 (https://apps.who.int/nha/database/Home/Index/en) Source: The Global Health Observatory, 2020 (https://apps.who.int/nha/database/Home/Index/en) 14% 16% 14% 15% 17% 18% 15% 16% 16% 17% 15% 17% 44% 39% 36% 39% 46% 46% 42% 43% 41% 40% 43% 42% 41% 45% 50% 46% 37% 36% 43% 41% 43% 44% 42% 41% 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 External as % total health spending (Ext%CHE) Private as % total health spending (private...%CHE) Domestic public as % total health spending (GGHE-D%CHE) 17% 37% 1%4% 27% 14% 17% 42% 41% 1.Public General budget 2.Private OOPS Other Voluntary prepayment 3.External/donors Direct foreign transfers Transfers from foreign govs. 33 Fig. 14: Cigarette affordability in Uganda Reducing affordability is an important measure of the success of tobacco tax policy. In the longer term, a positive, higher measure means cigarettes are becoming less affordable. Short term changes in affordability are also presented. Source: WHO report on the global tobacco epidemic 2019 (https://www.who.int/teams/health-promotion/tobacco-control/ who-report-on-the-global-tobacco-epidemic-2019) Source: WHO report on the global tobacco epidemic 2019 (https://www.who.int/teams/health-promotion/tobacco-control/ who-report-on-the-global-tobacco-epidemic-2019) Fig. 15: Excise tax share in Uganda WHO recommends an excise tax share of 70%. Total tax share includes import duties and levies. 9% 11% 10% 11% 11% 12% 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% 2010 2012 2014 2016 2018 2020 Uganda AFRO (avg) LI (avg) 44% 29% 20% 28% 33% 31% 28% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 2008 2010 2012 2014 2016 2018 2020 Uganda AFRO (avg) LI (avg) 34 Source: WHO report on the global tobacco epidemic 2019 (https://www.who.int/teams/health-promotion/tobacco-control/ who-report-on-the-global-tobacco-epidemic-2019) Fig. 16: Total tax share in Uganda This indicator represents the best comparable measure of the magnitude of total tobacco taxes relative to the price of a pack of the most widely sold brand of cigarettes in the country. Total taxes include excise taxes, VAT/sales taxes and, where relevant, import duties and/or any other indirect tax applied in a country. 59% 45% 35% 36% 42% 40% 35% 0% 10% 20% 30% 40% 50% 60% 70% 2008 2010 2012 2014 2016 2018 2020 Uganda AFRO (avg) LI (avg) 35 Annex 2: Desirable attribute of health financing Policies which help to drive progress to UHC are summarized n terms of nineteen desirable attributes of health financing policy. For further information see: https://www.who.int /publications/i/item/9789240017405 Table 1: Desirable attributes of health financing systems H ea lt h fi n an ci n g p o lic y, p ro ce ss an d g o ve rn an ce GV1 Health financing policies are guided by UHC goals, take a system-wide perspective and prioritize and sequence strategies for both individual and population-based services GV2 There is transparent, financial and non-financial accountability, in relation to public spending on health GV3 International evidence and system-wide data and evaluations are actively used to inform implementation and policy adjustments R ev en u e ra is in g RR1 Health expenditure is based predominantly on public/compulsory funding sources RR2 The level of public (and external) funding is predictable over a period of years RR3 The flow of public (and external) funds is stable and budget execution is high RR4 Fiscal measures are in place that create incentives for healthier behaviour by individuals and firms P o o lin g re ve n u es PR1 Pooling structure and mechanisms across the health system enhance the potential to redistribute available prepaid funds PR2 Health system and financing functions are integrated or coordinated across schemes and programmes P u rc h as in g an d p ro v id er p ay m en t PS1 Resource allocation to providers reflects population health needs, provider performance or a combination PS2 Purchasing arrangements are tailored in support of service delivery objectives PS3 Purchasing arrangements incorporate mechanisms to ensure budgetary control B en efi ts a n d c o n d it io n s o f ac ce ss BR1 Entitlements and obligations are clearly understood by the population BR2 A set of priority health service benefits within a unified framework is implemented for the entire population BR3 Prior to adoption, service benefit changes are subject to cost–effectiveness and budgetary impact assessments BR4 Defined benefits are aligned with available revenues, health services and mechanisms to allocate funds to providers BR5 Benefit design includes explicit limits on user charges and protects access for vulnerable groups P u b lic fi n an ci al m an ag em en t PF1 Health budget formulation and structure support flexible spending and are aligned with sector priorities PF2 Providers can directly receive revenues, flexibly manage them and report on spending and output 36 Table 1: Desirable attributes of health financing systems P u b lic h ea lt h f u n ct io n s an d p ro g ra m m es 3 GV1 Health financing policies are guided by UHC goals, take a system-wide perspective and prioritize and sequence strategies PR1 Pooling structure and mechanisms across the health system enhance the potential to redistribute available prepaid funds PR2 Health system and financing functions are integrated or coordinated across schemes and programmes PS2 Purchasing arrangements are tailored in support of service delivery objectives PF1 Health budget formulation and structure supports flexible spending and is aligned with sector priorities 37 Annex 3. HFPM assessment questions Assessment Question number code Question text 1) Health financing policy, process and governance Q1.1 Is there an up-to-date health financing policy statement guided by goals and based on evidence? Q1.2 Are health financing agencies held accountable through appropriate governance arrangements and processes? Q1.3 Is health financing information systemically used to monitor, evaluate and improve policy development and implementation? 2) Revenue raising Q2.1 Does your country’s strategy for domestic resource mobilization reflect international experience and evidence? Q2.2 How predictable is public funding for health in your country over a number of years? Q2.3 How stable is the flow of public funds to health providers? Q2.4 To what extent are the different revenue sources raised in a progressive way? Q2.5 To what extent does government use taxes and subsidies as instruments to affect health behaviours? 3) Pooling revenues Q3.1 Does your country’s strategy for pooling revenues reflect international experience and evidence? Q3.2 To what extent is the capacity of the health system to re-distribute prepaid funds limited? Q3.3 What measures are in place to address problems arising from multiple fragmented pools? Q3.4 Are multiple revenue sources and funding streams organized in a complementary manner, in support of a common set of benefits? Q3.5 What is the role and scale of voluntary health insurance in financing health care? 4) Purchasing and provider payment Q4.1 To what extent is the payment of providers driven by information on the health needs of the population they serve? Q4.2 Are provider payments harmonized within and across purchasers to ensure coherent incentives for providers? Q4.3 Do purchasing arrangements promote quality of care? Q4.4 Do provider payment methods and complementary administrative mechanisms address potential over- or under-provision of services? Q4.5 Is the information on providers’ activities captured by purchasers adequate to guide purchasing decisions? Q4.6 To what extent do providers have financial autonomy and are held accountable? 38 Assessment area Question number code Question text 5) Benefits and conditions of access Q5.1 Is there a set of explicitly defined benefits for the entire population? Q5.2 Are decisions on those services to be publicly funded made transparently using explicit processes and criteria? Q5.3 To what extent are population entitlements and conditions of access defined explicitly and in easy-to-understand terms? Q5.4 Are user charges designed to ensure financial obligations are clear and have functioning protection mechanisms for patients? Q5.5 Are defined benefits aligned with available revenues, available health services, and purchasing mechanisms? 6) Public financial management Q6.1 Is there an up-to-date assessment of key public financial management bottlenecks in health? Q6.2 Do health budget formulation and implementation support alignment with sector priorities and flexible resource use? Q6.3 Are processes in place for health authorities to engage in overall budget planning and multi-year budgeting? Q6.4 Are there measures to address problems arising from both under- and over-budget spending in health? Q6.5 Is health expenditure reporting comprehensive, timely, and publicly available? 7) Public health functions and programmes Q7.1 Are specific health programmes aligned with, or integrated into, overall health financing strategies and policies? Q7.2 Do pooling arrangements promote coordination and integration across health programmes and with the broader health system? Q7.3 Do financing arrangements support the implementation of IHR capacities to enable emergency preparedness? Q7.4 Are public financial management systems in place to enable a timely response to public health emergencies? 39 Annex 4: Questions mapped to objectives and goals Each question represents an area of health financing policy, selected given its influence on UHC intermediate objectives and goals, as explicitly defined below. Objective / goal Question number code Question text Equity in resource distribution Q3.1 Does your country’s strategy for pooling revenues reflect international experience and evidence? Q3.2 To what extent is the capacity of the health system to re-distribute prepaid funds limited? Q3.3 What measures are in place to address problems arising from multiple fragmented pools? Q3.4 Are multiple revenue sources and funding streams organized in a complementary manner, in support of a common set of benefits? Q3.5 What is the role and scale of voluntary health insurance in financing health care? Q4.1 To what extent is the payment of providers driven by information on the health needs of the population they serve? Q4.2 Are provider payments harmonized within and across purchasers to ensure coherent incentives for providers? Q4.5 Is the information on providers’ activities captured by purchasers adequate to guide purchasing decisions? Q6.2 Do health budget formulation and implementation support alignment with sector priorities and flexible resource use? Efficiency Q3.2 To what extent is the capacity of the health system to re-distribute prepaid funds limited? Q3.3 What measures are in place to address problems arising from multiple fragmented pools? Q3.4 Are multiple revenue sources and funding streams organized in a complementary manner, in support of a common set of benefits? Q3.5 What is the role and scale of voluntary health insurance in financing health care? Q4.2 Are provider payments harmonized within and across purchasers to ensure coherent incentives for providers? Q4.4 Do provider payment methods and complementary administrative mechanisms address potential over- or under-provision of services? Q4.5 Is the information on providers’ activities captured by purchasers adequate to guide purchasing decisions? Q4.6 To what extent do providers have financial autonomy and are held accountable? Q6.1 Is there an up-to-date assessment of key public financial management bottlenecks in health? Q6.4 Are there measures to address problems arising from both under- and over- budget spending in health? Q7.1 Are specific health programmes aligned with, or integrated into, overall health financing strategies and policies? Q7.2 Do pooling arrangements promote coordination and integration across health programmes and with the broader health system? 40 Objective / goal Question number code Question text Transparency and accountability Q1.1 Is there an up-to-date health financing policy statement guided by goals and based on evidence? Q1.2 Are health financing agencies held accountable through appropriate governance arrangements and processes? Q1.3 Is health financing information systemically used to monitor, evaluate and improve policy development and implementation? Q2.1 Does your country’s strategy for domestic resource mobilization reflect international experience and evidence? Q2.2 How predictable is public funding for health in your country over a number of years? Q4.6 To what extent do providers have financial autonomy and are held accountable? Q5.2 Are decisions on those services to be publicly funded made transparently using explicit processes and criteria? Q5.3 To what extent are population entitlements and conditions of access defined explicitly and in easy-to-understand terms? Q5.5 Are defined benefits aligned with available revenues, available health services, and purchasing mechanisms? Q6.1 Is there an up-to-date assessment of key public financial management bottlenecks in health? Q6.3 Are processes in place for health authorities to engage in overall budget planning and multi-year budgeting? Q6.5 Is health expenditure reporting comprehensive, timely, and publicly available? Service use relative to need Q2.2 How predictable is public funding for health in your country over a number of years? Q2.3 How stable is the flow of public funds to health providers? Q3.1 Does your country’s strategy for pooling revenues reflect international experience and evidence? Q3.2 To what extent is the capacity of the health system to re-distribute prepaid funds limited? Q3.3 What measures are in place to address problems arising from multiple fragmented pools? Q3.4 Are multiple revenue sources and funding streams organized in a complementary manner, in support of a common set of benefits? Q3.5 What is the role and scale of voluntary health insurance in financing health care? Q4.1 To what extent is the payment of providers driven by information on the health needs of the population they serve? Q5.1 Is there a set of explicitly defined benefits for the entire population? Q5.3 To what extent are population entitlements and conditions of access defined explicitly and in easy-to-understand terms? Q5.4 Are user charges designed to ensure financial obligations are clear and have functioning protection mechanisms for patients? Q5.5 Are defined benefits aligned with available revenues, available health services, and purchasing mechanisms? Q6.2 Do health budget formulation and implementation support alignment with sector priorities and flexible resource use? 41 Objective / goal Question number code Question text Financial protection Q2.1 Does your country’s strategy for domestic resource mobilization reflect international experience and evidence? Q2.3 How stable is the flow of public funds to health providers? Q2.4 To what extent are the different revenue sources raised in a progressive way? Q3.1 Does your country’s strategy for pooling revenues reflect international experience and evidence? Q3.2 To what extent is the capacity of the health system to re-distribute prepaid funds limited? Q3.3 What measures are in place to address problems arising from multiple fragmented pools? Q3.4 Are multiple revenue sources and funding streams organized in a complementary manner, in support of a common set of benefits? Q3.5 What is the role and scale of voluntary health insurance in financing health care? Q5.1 Is there a set of explicitly defined benefits for the entire population? Q5.3 To what extent are population entitlements and conditions of access defined explicitly and in easy-to-understand terms? Q5.4 Are user charges designed to ensure financial obligations are clear and have functioning protection mechanisms for patients? Q5.5 Are defined benefits aligned with available revenues, available health services, and purchasing mechanisms? Equity in finance Q2.1 Does your country’s strategy for domestic resource mobilization reflect international experience and evidence? Q2.3 How stable is the flow of public funds to health providers? Q2.4 To what extent are the different revenue sources raised in a progressive way? Q3.3 What measures are in place to address problems arising from multiple fragmented pools? Q3.5 What is the role and scale of voluntary health insurance in financing health care? Q5.1 Is there a set of explicitly defined benefits for the entire population? Q5.4 Are user charges designed to ensure financial obligations are clear and have functioning protection mechanisms for patients? Quality Q4.3 Do purchasing arrangements promote quality of care? Q4.5 Is the information on providers’ activities captured by purchasers adequate to guide purchasing decisions? Q4.6 To what extent do providers have financial autonomy and are held accountable? Health security Q3.2 To what extent is the capacity of the health system to re-distribute prepaid funds limited? Q4.6 To what extent do providers have financial autonomy and are held accountable? Q6.2 Do health budget formulation and implementation support alignment with sector priorities and flexible resource use? Q7.3 Do financing arrangements support the implementation of IHR capacities to enable emergency preparedness? Q7.4 Are public financial management systems in place to enable a timely response to public health emergencies? 42
For additional information, please contact: Department of Health Financing and Economics World Health Organization 20 avenue Appia 1211 Geneva 27 Switzerland Email: healthfinancing@who.int Website: http://www.who.int/health_financing