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Raising finances for Universal Health Care coverage: Experiences from one of the world’s poorest countries



Future Health Systems

By Elizabeth Ekirapa-Kiracho, FHS Uganda Country Coordinator

I come from a country called Uganda in East Africa. It is among the 50 poorest countries in the world. The upcoming Universal Health Coverage (UHC) day has made me ponder over the issue of UHC and what my country needs to do to achieve it. My country is very good at developing policies but not at implementing them. Perhaps that is why things have not changed much. As I think about UHC, I wonder whether a country as poor as ours can actually achieve it. How can we raise sufficient funds to ensure that everyone has access to high quality services without incurring financial hardship? The 2010 World Health Report recommends that countries take three main steps to ensure they have sufficient financing for UHC. The first step is to raise adequate financial resources. The second is to reduce reliance on direct payments to finance services. The third is improving efficiency and equity. My country has three main sources of financing - out of pocket payment (40%), donor aid (34%) and government financing from tax revenue (16%).

The health financing review that was done for Uganda in 2010 highlighted certain key points. It noted that although government financing for health had increased, it had not even reached 10%. This is way below the 15% that the country promised when it signed the Abuja declaration where countries promised to spend 15% of their budget on health. The financial review recommended that we need to negotiate for more public funding for health, but we also need to have the absorptive capacity for this funding. The fact that government financing for health is not increasing shows that we are not prioritizing health enough as a country. Other individuals have said that our Ministry of Finance feels that the health sector is not showing value for money. Whether they are justified in saying this is a story for another day, the point is we need more domestic resources for health because that is more sustainable. But we must increase our tax base so that we have more money for health. There is a need for us to identify other areas where we can raise taxes that can be earmarked for the provision of health services. The report also stated that we need to exploit sources that have so far been underutilized, such as philanthropists.

Ugandan households contribute 50% of the total health expenditure in the country. However, this is spent through direct purchasing and not through prepayment. The contributions from households could be used more effectively if they were contributed through prepayment schemes. This would also offer financial protection for the poor. This could be done through health insurance. The country is currently planning to implement a National health insurance scheme. However this has been discussed for the past two decades and we have not made any significant progress. I guess there are several reasons for this. One of them is the poor quality of services in the country. Workers are not willing to join the insurance system when they have no assurance that they will receive good quality services. So we must put in place mechanisms to strengthen the health system and ensure that it has a basic level of functionality. This however requires some seed funding, which perhaps implementing partners and government could provide. Secondly we need to ensure that our payment methods for providers give incentives for improved quality and efficiency.

Another reason why people are hesitant about the scheme is the fear of corruption. We have had several corruption scandals in our country and so people fear that their funds might be misused. We must put in place more strict measures to ensure that this does not happen. The last and probably most important reason is the policy dilemma that we have in our country. The government abolished user fees in 2001 except in private wings of hospitals. It is therefore difficult to hold a massive campaign that encourages households to join prepayment schemes since these services are supposed to be “free”. Until we sort out these problems we may not be able to “walk the talk”. However, like they say, miracles still happen, so perhaps by the next UHC day things will have changed. Another blog about this time next year is something to look out for.