Utilization of Public Health Financing in

Utilization of Public

Health Financing in

Uganda’s Primary

Health Care Program

ii

Mailing Address

PO Box 7404

Kampala, Uganda

Street Address

Ntinda Complex

2nd Floor, Block B, Plot 33

Ntinda Road

PO Box 7062

Kampala, Uganda

www.path.org

© 2021 PATH. All rights reserved.

Kisaame EK. Utilization of Public Health Financing in Uganda’s Primary Health Care Program.

Kampala, Uganda: PATH; 2021.

March 2021

http://www.path.org/

1

Contents

Objectives of the study ......................................................................................................................... 7

Data collection ....................................................................................................................................... 9

Key informant interviews ..................................................................................................................... 9

Data management and analysis .......................................................................................................... 9

Limitations of the study ...................................................................................................................... 10

PHC expenditure at local government and health care facility levels ........................................... 12

Performance in non-wage and development grants ....................................................................... 13

Adherence to PHC grant utilization guidelines ................................................................................ 15

Procurement using PHC funds .......................................................................................................... 16

Functionality of health unit management committees .................................................................... 18

Functionality of the village health teams .......................................................................................... 20

Utilization of other PHC resources (results-based financing) ........................................................ 21

Annex 1. Detailed breakdown of primary health care grants to the local governments in the

study 29

ABBREVIATIONS .................................................................................................................................. 3

EXECUTIVE SUMMARY ........................................................................................................................ 4

INTRODUCTION ..................................................................................................................................... 6

Objectives of the study ............................................................................................................................ 7

APPROACH AND METHODOLOGY ..................................................................................................... 8

Data collection ......................................................................................................................................... 9

Key informant interviews ......................................................................................................................... 9

Data management and analysis ............................................................................................................. 9

Limitations of the study ......................................................................................................................... 10

2

OVERVIEW OF HEALTH SECTOR EXPENDITURE .......................................................................... 11

PHC expenditure at local government and health care facility levels ................................................... 12

Performance in non-wage and development grants ............................................................................. 13

USE OF PHC FUNDS AT LOCAL GOVERNMENT AND FACILITY LEVELS ................................... 15

Adherence to PHC grant utilization guidelines...................................................................................... 15

Procurement using PHC funds.............................................................................................................. 16

Functionality of health unit management committees ........................................................................... 18

Functionality of the village health teams ............................................................................................... 20

Utilization of other PHC resources (results-based financing) ............................................................... 21

EFFECTS OF COVID-19 ON HEALTH SECTOR AND PHC EXPENDITURE .................................... 25

CONCLUSIONS AND RECOMMENDATIONS .................................................................................... 27

ANNEXES ............................................................................................................................................. 29

Annex 1. Detailed breakdown of primary health care grants among the local governments in the study

..................................................................................................................................................... 29

REFERENCES ..................................................................................................................................... 31

3

Abbreviations

COVID-19 coronavirus disease 2019

DHT district health teams

EMHS essential medicines and health supplies

FY financial/fiscal year

HUMC health unit management committee

KII key informant interview

MoFPED Ministry of Finance, Planning and Economic Development

MoH Ministry of Health

PHC primary health care

RBF results-based financing

UGX Uganda shilling

VHT village health team

WHO World Health Organization

4

Executive summary

Primary health care (PHC) provision around the world has been constrained by many challenges—

perhaps none greater than limited financing. Recognizing the gaps in health coverage, in 2019, the

World Health Organization recommended that countries increase spending on PHC by allocating at

least 1% more of their gross domestic product to PHC; this would enable the world to meet the health

coverage targets set out in the Sustainable Development Goals. However, the gap between basic

community health needs and PHC provision has persisted. In some cases, the gap has increased

despite increases in PHC resources—especially in low- and middle-income countries.

The limited financing that characterizes PHC provision in low- and middle-income countries like

Uganda suggests a need to effectively and efficiently utilize the limited resource available for PHC

coverage. Furthermore, effective utilization of resources (financial and otherwise) is at the heart of

many health systems strengthening initiatives in Uganda and the world over. However, there is limited

literature on the use of PHC funds in Uganda and the rest of the world. Most of the available PHC

financing literature focuses on the gaps in financing and the strategies to increase funding.

Against such a background, PATH commissioned a study to assess the trends in expenditure/use of

PHC finances in Uganda. The overall aim of the study was to examine the use of Uganda’s public

PHC funding at both national and subnational levels over a period of five years from fiscal year (FY)

2015/2016 to FY 2019/2020. The study specifically reviewed trends in the expenditure/use of PHC

finances at different levels of the health sector and how these have been affected by COVID-19. It

examined the limitations in utilization of PHC funds at the central and local government levels. It also

examined the functionality of oversight structures such as health unit management committees

(HUMCs).

The study examined expenditure patterns of PHC non-wage and development funds over the National

Development Plan II period. The focus was placed non-wage and development expenditure because

these are the PHC grants that are directly used to fund service delivery outputs. In addition, PHC

wage grants are paid directly into the respective bank accounts of the health workers on payroll.

The study employed an adaptation of the World Bank’s public expenditure review methodology,

focusing on the second of six questions under the public expenditure review: “How much was spent

and what it was spent on?” This involved analysis of the approved budgets and outturns for the health

sector. This was complemented with key informant interviews (KIIs) with actors in the Ministry of

Health (MoH); Ministry of Finance, Planning and Economic Development; district health offices; and

health facilities. KIIs at the subnational level were conducted in the districts of Arua, Kasese, Kisoro,

Mukono, and Tororo. These were purposively chosen on the basis of geographical representation,

high disease burdens, and their beneficiary status under any of the results-based financing (RBF)

projects being implemented in the country. RBF refers to the use of explicit performance-based

subsidies to encourage delivery of services by paying providers (government or development

partners) based on clearly defined quality outcomes. RBF in Uganda is delivered through Government

of Uganda and development partner–funded projects, which complement PHC financing.

The study concludes that while spending at the central government level suffered from budget cuts,

as demonstrated by shortfalls in the funds released to them, local governments and health facilities

received most, if not all, of the funds in their approved budgets during the reference period.

It was also noted that while the MoH had issued Sector Guidelines for Budgeting and Utilizing PHC

grants to health facilities, the majority of actors at that level remained unaware of the guidelines or

had not yet started to use them. Thus, PHC budgeting and expenditure remained inconsistent at

facility level despite the existence of the Sector Grant and Budget Guidelines to Local Governments

5

and the Primary Health Care Non-Wage Recurrent Grant and Budget Guidelines to Health Centre II,

III , IV, and General Hospitals.

It was noted that the PHC budgets and expenditure in FY 2019/2020 were not affected by the

economic disruptions that arose from the containment of COVID-19. In addition, local governments

received an additional Ugandan shilling (UGX) 165 million and regional referral hospitals received an

additional UGX 270 million to combat the spread of COVID-19. The pandemic, however, affected

access to PHC services, as many people could not travel to the health facilities during the lockdown.

The study noted several challenges in the spending of PHC resources. The key challenges included

the parallel planning, reporting, and accounting processes for RBF projects at the health facility level,

which likely constrained the effective and timely implementation of the mainstream PHC activities.

Additionally, the disbursement of RBF funds continued to be characterized by delays, which affected

the implementation of planned projects. On the other hand, it was also noted that while PHC funds

were disbursed by the tenth day of the quarter, receipt of the funds on facility accounts continued to

be characterized by slight delays. This likely arose from delays in warranting processes for the grant

transfers.

Finally, while the HUMCs played a significant role of representing communities in PHC resource

allocation and utilization decisions, limited training and limited awareness of their roles constrained

their effectiveness in exercising oversight over PHC expenditure. Along with the HUMCs, the village

health teams (VHTs) also played a significant role as the first points of call in Uganda’s health system.

However, the voluntary nature of this role limited their effectiveness, as the VHTs prioritized earning a

living.

Based on these conclusions, the study makes the following recommendations:

• The MoH should consider increasing awareness around the Sector Grant and Budget Guidelines

to Local Governments and Primary Health Care Non-Wage Recurrent Grant and Budget

Guidelines to Health Centre II, III , IV, and General Hospitals. The guidelines were found to be

comprehensive and could solve several procedural challenges experienced in spending PHC

resources.

• The MoH should consider publishing updated HUMC operational guidelines and conducting

regular training of the HUMC members in order to improve their oversight function at the health

facility level.

• The MoH, in collaboration with its RBF development partners, should consider streamlining RBF

planning, reporting, and accountability processes into the administrative processes for the

mainstream PHC funds to lessen the administrative burden placed on the health workers.

• Local government administrations should consider improving their effectiveness in warranting the

transfer of funds in order to minimize delays in receipt of PHC grants in health facility accounts. It

was found that while release of funds was timely (by the tenth day of the quarter), slight delays

continued to characterize the receipt of these funds in health facility accounts, with challenges

being noted in the warranting process.

• The MoH and its RBF partners should consider digitalizing the management of all RBF projects in

the country to minimize the delays in reimbursement. While RBF was reported to have improved

service delivery at health facilities, it was also reported that the process of claiming

reimbursements was characterized with bureaucratic delays.

• The MoH should consider designating a proportion of the PHC non-wage funding as allowances

for VHTs to facilitate their work. This is envisaged to go a long way in redeeming some of the time

that VHT members lose to earning a living—time that can be put to undertaking their health

promotion role.

6

Introduction

Primary health care (PHC) has come to be known as the bedrock of health systems around the world

and as the foundation on which universal health coverage is built.1 It has been noted that countries

with strong PHC programs report better health outcomes.2 The World Health Organization (WHO)

defines PHC as:

a whole-of-society approach to health that aims to ensure the highest possible

level of health and well-being and their equitable distribution by focusing on

people’s needs and preferences (as individuals, families, and communities) as

early as possible along the continuum from health promotion and disease

prevention to treatment, rehabilitation and palliative care, and as close as

feasible to people’s everyday environment.

PHC provision around the world has been constrained by many challenges—perhaps none greater

than limited financing. Recognizing the gaps in health coverage, in 2019, WHO recommended3 that

countries increase spending on PHC by allocating at least 1% more of their gross domestic product to

PHC; this would enable the world to meet the health coverage targets set out in the Sustainable

Development Goals. However, the gap between basic community health needs and PHC provision

has persisted. In some cases, the gap has increased despite increases in PHC resources—especially

in the developing world.

Developing countries like Uganda already commit a large proportion of their health sector budgets to

PHC with the aim of improving health coverage. A study4 conducted by PATH in 2019 noted

increases in PHC funding over the five-year period that led up to the study year. In fiscal year (FY)

2018/2019, for example, PHC accounted for about 70% of the health sector funding when considered

collectively with the supply of emergency medicines and health supplies (EMHS). Nonetheless, the

health policy literature notes persistent financing gaps within PHC even considering the funding

increment.5

The persistent, and in some cases widening, gap between community PHC needs and the available

funding in low- and middle-income countries like Uganda suggests a need to effectively and efficiently

utilize the limited resources available to improve the coverage and quality of PHC. Furthermore,

effective utilization of resources (financial and otherwise) is at the heart of many health systems

strengthening initiatives in Uganda and the world over.6 However, there is limited literature on the use

of PHC funds in Uganda and the rest of the world. Most of the available PHC financing literature

focuses on the gaps in and strategies to increase financing.

Against such a background, PATH commissioned a study to assess the expenditure/utilization of PHC financing in Uganda. The study focused on different levels of health service delivery in five selected districts that represent the major regions of Uganda. Findings from this study are envisaged to contribute to the growing body of available literature on PHC financing and expenditure in Uganda. The study is also envisaged to provide policy evidence to strengthen advocacy efforts on PHC financing and expenditure— especially as the country moves into another phase of implementing the new National Development Plan II, the Health Sector Development Plan, and the universal health coverage agenda.

Additionally, the study is expected to contribute evidence on how COVID-19 has affected overall

health sector financing and the provision of PHC in Uganda. The study was conducted when Uganda,

along with the rest of the world, was battling to contain COVID-19 and to recover from the devastation

caused by the pandemic. Pandemics such as COVID-19 are often accompanied by economic shocks

that place unpredictable pressures on already limited resource envelopes in developing countries

such as Uganda. The health sector in Uganda was and continues to be at the forefront of efforts to

contain the spread of the pandemic in the country. Country efforts to combat the pandemic were

financed via supplementary budgets mainly from grants and additional borrowing from the country’s

development partners.

7

Objectives of the study

The overall aim of the study was to examine the use of Uganda’s public PHC funding at both national

and subnational levels. The study objectives were to:

1. Review the expenditure/utilization trends of PHC finances at different levels of the health sector

and how these have been affected by COVID-19.

2. Examine the limitations in the utilization of PHC funds at central and local government levels.

3. Examine the functionality of oversight structures, such as health unit management committees

(HUMCs) and expanded district health teams.

8

Approach and methodology

PATH focused its analysis of trends in the use of PHC public funding on recurrent non-wage functions

and development (capital) expenditure at both the national (central) and subnational (local

government) levels. The scope of the study was limited to funding from the Government of Uganda

and development partners over the five-year period from FY 2015/2016 to FY 2019/2020.

PATH used the following criteria to select study districts at the local government level: The study team

purposively sampled the study districts to ensure regional representation. In order to maintain

consistency in its PHC analyses, PATH took efforts to maintain three of the districts—Mukono, Arua,

Kisoro—that were part of the PHC financing study that PATH conducted in 2019. PATH also

purposively selected study districts with a high burden of disease. PATH added the criterion of

implementation of results-based financing (RBF) projects to ensure that all PHC financing (including

co-funding arrangements between the Government of Uganda and its development partners) were

represented in the study. Following these criteria, the districts of Arua, Kasese, Kisoro, Mukono, and

Tororo were selected for data collection (see Table 1 for details).

Table 1. Purposive sampling criteria used to select study districts.

Subregion District Rationale/characteristics considered Eastern Tororo ⎯ High disease burden.

⎯ Results-based financing beneficiary district (currently part of Uganda Reproductive, Maternal and Child Health Improvement Project).

⎯ Border district to Kenya.

Central Mukono ⎯ Combination of urban and rural characteristics.

⎯ Taken as a proxy for Uganda’s capital given its proximity to the capital.

⎯ Results-based financing beneficiary district (Uganda Reproductive, Maternal and Child Health Improvement Project).

South-Western Kisoro ⎯ Hard-to-reach areas due to a mountainous terrain.

⎯ Border district to Rwanda.

⎯ Results-based financing beneficiary district (Uganda Reproductive, Maternal and Child Health Improvement Project).

West Nile Arua ⎯ Refugee hosting dynamics.

⎯ Results-based financing beneficiary district (Establishing a Financial Mechanism for Strategic Purchasing of Health Services in Uganda).

Western Kasese ⎯ Border district with the Democratic Republic of the Congo.

⎯ Hard-to-reach areas due to a mountainous terrain

⎯ Results-based financing beneficiary district (currently Uganda Reproductive, Maternal and Child Health Improvement Project).

9

Data collection

PATH used two approaches to collect data: key informant interviews (KIIs) and review of available

documents.a These approaches generated financial, statistical, and graphical data as well as other

information for analysis.

Key informant interviews

PATH conducted KIIs with key actors at both the central and local government levels. At the central

government level, the study team held KIIs with key actors in the Ministry of Finance, Planning and

Economic Development (MoFPED), the Ministry of Health (MoH), and civil society organizations that

were undertaking PHC activities. At the local government level, the study team held KIIs with key

actors in the district health departments as well as coordinators of the village health teams (VHTs) to

obtain views from the district administration.

The study team also conducted interviews at health facilities—at three levels of care (health center II,

health center III, and health center IV) that make up the health subdistrict. The health subdistrict was

considered because Uganda runs a referral-based system of care, in which the bulk of PHC services

are delivered in the health subdistrict. Four health facilities were purposively selected to represent the

three levels of care as well as the private, not-for-profit facilities, which also receive PHC funding from

the government. Additionally, facilities were purposively selected to reflect both urban and rural

settings in the district. In Arua, one of the facilities was selected because it was in a refugee camp.

The study team undertook KIIs with health unit in-charges and the chairperson of the HUMC, or

another member of the HUMC in the chairperson’s absence. In addition, the study team conducted

exit interviews of patients at health facilities to obtain the views of the users of PHC services. A

breakdown of the interviews undertaken is presented in Table 2.

Table 2. Key informant interviews undertaken in the districts.

District HUMCs In-charges Patients VHT coordinators

DHOs Row totals

Arua 4 4 11 1 1 21

Kasese 5 4 10 1 1 21

Kisoro 4 4 11 1 1 21

Mukono 4 4 10 1 1 20

Tororo 3 4 8 1 1 17

Column totals 20 20 50 5 5 100

Note: DHO, district health officer; HUMC, health unit management committee; VHT, village health team.

Data management and analysis

The study team analyzed both qualitative and quantitative data. The management and analysis of the

quantitative data were done using Microsoft Excel. Qualitative data obtained from the KIIs were

transcribed (verbatim) in Microsoft Word documents to form the interview transcripts. The interview

transcripts were entered into ATLAS.ti to form a hermeneutic unit (qualitative database) that was used

for analysis. In ATLAS.ti, the qualitative data were analyzed along content themes that were

developed from the reviewed literature.

a The documents reviewed for the study are provided in the reference list of this study report.

10

Limitations of the study

The study was undertaken in the middle of the COVID-19 pandemic. As a result, the study team faced

a lot of constraints in collecting data, especially the absence of key informants. Many of the targeted

respondents were among the first responders and also part of the various task forces convened to

combat the pandemic. To mitigate this challenge, the study team replaced these respondents with

other actors in the same entities so as not to derail the study. In addition, the study team faced

challenges in accessing budget outturn (expenditure) data and other information at local government

and facility levels due to the limited availability of approved expenditure reports. The team therefore

sought to obtain data from MoFPED; however, these data were also limited because the local

governments were only added to the program budgeting system in FY 2018/2019. Therefore, while

the reference period for the study was the five-year period from FY 2015/2016 to FY 2019/2020, the

analysis was affected by missing data in some instances.

11

Overview of health sector expenditure

Over the reference period of the study, the health sector budget increased from Ugandan shilling

(UGX) 1.271 trillion in FY 2015/2016 to UGX 2.589 trillion in FY 2019/2020. However, over the same

period, it was noted that the sector persistently received and subsequently spent less than what had

been appropriated by the Parliament of Uganda. See Figure 1 for details; note that “released” funds

represent the actual public funds received by the government spending entities.

Figure 1. Health sector budget performance patterns and trends (in billion UGX).*

Source: Computations from the Annual Health Sector Performance Reports over the years.

Note: FY, fiscal year; National Referral Hospital; UGX, Ugandan shilling.

* Outturn data for FY 2015/2016 were missing in that fiscal year’s Annual Health Sector Performance Report.

It was noted that there was no discrepancy between what the local governments received and spent

compared to what was appropriated. Among the government entities that made up the health sector,

the MoH was the most affected by the challenge of receiving less funds than what was appropriated.

This trend was mostly attributed to revenue shortfalls for the Government of Uganda budget lines and

delayed disbursement of funds from development partners for the externally financed budget lines.

For instance, in FY 2016/2017, the health sector received about 66% of the funds appropriated to it,

with the MoH receiving only 36% of the funds it had been appropriated. The FY 2016/2017 Annual

Health Sector Performance Report attributed these shortfalls to low disbursements from the MoH’s

key development partners, namely Gavi, the Vaccine Alliance and the Global Fund to Fight AIDS,

Tuberculosis and Malaria.

It is notable that the challenge of budget cuts (i.e., releases of funds less than budgeted amounts) in

the Government of Uganda budget lines is not unique to the health sector. These cuts mostly arise

from shortfalls in domestic revenue collection, which compel the Government of Uganda to cut back

-

500

1,000

1,500

2,000

2,500

3,000

Appro

ved

Re

leased

Spen

t

Appro

ved

Re

leased

Spen

t

Appro

ved

Re

leased

Spen

t

Appro

ved

Re

leased

Spen

t

Appro

ved

Re

leased

Spen

t

FY 2015/16 FY 2016/17 FY 2017/18 FY 2018/19 FY 2019/20

Other NRH (Naguru, Kawempe & Kiruddu) Kampala Capital City AuthorityLocal Governments Regional Referral HospitalsUganda Virus Research Institute (UVRI) Butabika HospitalMulago Hospital Complex Uganda Blood Transfusion Service (UBTS)Health Service Commission National Medical StoresUganda Heart Institute Uganda Cancer Institute

12

on its planned spending if additional revenue is not raised through borrowing. However, it was noted

that this expenditure trend persisted across the reference period of the study when the health sector

benefited from revised budgets that were higher than their approved budgets, mostly due to

supplementary funding to deal with health emergencies. Despite this, the health sector still ended up

receiving less funds than what was budgeted. Most of the funds the sector received were spent—on

average, between 98% and 100% absorption/consumption.

PHC expenditure at local government and health care facility levels

Further scrutiny of the sector budgets over the reference period revealed that the disruptions arising

from budget cuts mostly affected central government entities of the health sector. Local governments,

which only receive PHC funds, either registered supplementary budget releases or received more

than 97% of their budgeted funds. In FY 2016/2017, several local government votes received

supplementary funding (extra funds), which resulted in 101% and 97% of these transferred/released

funds being spent. In FY 2018/2019 and FY 2019/2020, local governments received 99.6% and

97.0% of their budgets respectively (see Figure 2 for details).

Figure 2. Performance in releases/transfer of PHC grants to local governments.

Source: Computations from Ministry of Finance, Planning and Economic Development data.

Note: FY, fiscal year; PHC, primary health care; UGX, Ugandan shilling.

In the KIIs, respondents from local government administrations and health facilities attributed the high

level of expenditure performance at the local government level mostly to the insufficiency of the PHC

funds. As a result, these funds are often quickly spent and used up before health needs are met. At

times, local government PHC funds require supplementary allocations in the case of emergencies.

Comments from the respondents included the following:

Now how can you have unspent PHC money? We are

already getting little money. Now how can you fail to

spend it? The money is little, so by the time it comes you

already have a number of debts here and there. Then

how can you fail to spend the money?

-

100,000

200,000

300,000

400,000

500,000

600,000

ApprovedBudget

TotalReleases

ApprovedBudget

TotalReleases

ApprovedBudget

TotalReleases

FY 2016/17 FY 2018/19 FY 2019/20

UG

X i

n M

illio

ns

13

– District health officer

[There are] no balances apart from the money we leave

to maintain the account, because if they give us 5 million

shillings and a few cents, we use most of the money for

activities and the rest to secure the account and for bank

charges.

– Health facility in-charge

At health facility level, the high level of expenditure performance was reported to be similar across the

public and the private, not-for-profit health facilities. It was also similar across all levels of care

assessed (health center II, health center III, and health center IV).

Performance in non-wage and development grants

The study sought to assess performance in the PHC non-wage and development grants across the

reference period. Local governments receive a recurrent non-wage grant to fund the day-to-day

running of their health departments and the health facilities. In addition, they receive a PHC

development grant for the maintenance of health infrastructure and, in subcounties without a health

center III, for the upgrading of health center II facilities into health center III facilities. In selected local

governments, the PHC transitional development grant funds hospital rehabilitation and other specified

capital investments.

Over the study period, the study sites demonstrated high levels of budget performance in PHC non-

wage and development grants, with most the budgeted funds released to the local governments (see

Figure 3).

Figure 3. Performance in PHC grants to local governments.*


-

20,000

40,000

60,000

80,000

100,000

120,000

140,000

Budget Releases Budget Releases Budget Releases Budget Releases

FY 2016/17 FY 2017/18 FY 2018/19 FY 2019/20

UG

X i

n M

illio

ns

Transitional Development Non-Wage Development

14

Note: FY, fiscal year; PHC, primary health care; UGX, Ugandan shilling.

* FY 2016/2017 and 2017/2018 reflect no development funding because local governments did not receive PHC

development grants.

It was noted that the PHC transitional development grant accounted for most, if not all, discrepancies

between the amounts budgeted and the amounts received by local governments. In FY 2018/2019

and FY 2019/2020, local governments received 45% and 70% of the budgeted transitional

development grants respectively. These performance levels could be attributed to revenue shortfalls

and procurement delays.

Among the study districts, only Tororo district and Arua district budgeted for PHC transitional

development grants in FY 2019/2020. However, while the other study districts received all of their

budgeted amounts across all of their budgeted funds, Arua did not receive any of its budgeted PHC

transitional development grant (see Table 3 for details).

Table 3. PHC grants transfer performance in fiscal year 2019/2020 (in UGX).

PHC Non-Wage PHC Development Transitional Development Grant

Local Government Approved Budget

Total Releases

Approved Budget

Total Releases

Approved Budget

Total Releases

Arua District 701,701,135 702,180,975 162,348,223 162,348,223 213,165,330 -

Arua Municipality 46,151,129 46,151,151 6,012,897 6,012,897 - -

Kasese District 971,256,400 969,537,590 1,134,543,803 1,134,543,803

- -

Kasese Municipality 44,709,783 47,360,050 12,025,794 12,025,794 - -

Kisoro District 583,862,464 579,482,278 602,311,301 602,311,301 - -

Kisoro Municipality 54,530,859 54,530,885 500,092,049 500,092,049 - -

Mukono District 340,500,257 339,261,725 78,167,663 78,167,663 - -

Mukono Municipality

35,306,647 35,306,663 12,025,794 12,025,794 - -

Tororo District 806,277,232 807,202,850 614,337,095 614,337,095 250,000,000 250,000,000

Tororo Municipality 59,652,476 59,652,504 18,038,691 18,038,691 - -

Grand Total 3,643,948,382 3,640,666,671

3,139,903,311 3,139,903,311

463,165,330 250,000,000


Note: PHC, primary health care; UGX, Ugandan shilling.

The PHC expenditure was noted to be similar across the years (See Annex 1) as well as across

districts and municipalities (municipalities receive their funding independent of the districts where they

are located). Over the course of FY 2019/2020, utilization of development grants was reported to

have improved relative to previous years. This was mostly attributed to a reform instituted by the

MoFPED to transfer all development grants to local governments by the end of the third quarter. This

ensured that local governments had a whole quarter in which to spend the funds, which minimized the

unspent balances that arose from procurement delays in previous years when some development

funding was transferred in the final quarter of the fiscal year.

While the timeliness of the disbursement of funds has greatly improved and is now predictable,

timeliness in the receipt of grants remains a challenge. In 2014, the MoFPED instituted a reform to

disburse funds by the tenth day of every quarter. However, the literature on public expenditure

indicates that government spending entities are still receiving funds late due to delays in warranting

and in submission of relevant supporting documents.7

15

Use of PHC funds at local government and facility levels

The study sought to assess the processes through which PHC funds are used at both local

government and health facility levels. In particular, the study team undertook consultations with

various actors at these levels with regard to procurement, use of MoH guidelines, and the oversight

roles of actors such as the HUMCs. This section delves into the findings from these consultations.

Adherence to PHC grant utilization guidelines

Budgeting and expenditure at the local government and health facility levels are guided by the MoH’s

Sector Grant and Budget Guidelines to Local Governments. Over the reference period for this study,

the MoH had not produced health facility–level guidelines since 2003, which provide comprehensive

guidance on the utilization of and accountability in PHC non-wage and development grants

transferred to health center II, health center III, and health center IV facilities, as well as general

hospitals. As a result, there was a lot of inconsistency in how PHC funds were used at the facility

level. The MoH resumed the publication of guidelines for health facilities’ utilization of PHC funds with

the FY 2020/2021 guidelines. This was a result of policy recommendations made by PATH in its 2019

study and other studies5 that recommended the same.

The study assessed awareness of and adherence to the guidelines among district health officers,

health facility in-charges, and VHT coordinators. The study team worked under the assumption that

the guidelines had been used during the budgeting for FY 2020/2021. The study team also assumed

the guidelines were being used for expenditures since data collection took place in August—midway

through the first quarter of FY 2020/2021.

The study findings showed that district health offices/departments were fully using the health

guidelines. In contrast, the majority of the health facility in-charges, members of the HUMCs, and VHT

coordinators who were consulted either were not aware of the guidelines or were aware but had not

received a copy of the guidelines. Furthermore, even in instances where in-charges reported being

aware of the guidelines, their facility budgets were inconsistent with the provisions of the guidelines.

For instance, while the guidelines allocate 30% of the PHC recurrent non-wage grant toward outreach

activities, most facilities reported allocating between 40% and 50% to outreach programs; they

claimed that this was based on the allocations on the guidelines. Furthermore, inconsistencies were

noted between the allocation patterns of the public and the private, not-for-profit facilities. Comments

from respondents included the following:

The 50% goes for medicine; that is, NMS [National

Medical Stores]. The remaining 50% is divided into two:

30% for top up of salaries for staff while 20% for

maintaining the facility. They know that our collection may

not be enough to undertake all our activities.

– Respondent from private, not-for-profit organization

The PHC grant has its own way of expenditure; the

money comes with directions on how it should be spent—

16

for example, 40% for outreaches, 30% for management,

and 30% for transport and support services. So this

money is spent in line with the above stipulation as per

the MoH guidelines.

– Health center III in-charge

The persistent inconsistency across facilities implies that the MoH’s guidelines were not disseminated

to the health facilities. There is therefore a need to widely circulate the guidelines to ensure service

provision is consistent across the country. This dissemination ought to also extend to the HUMCs,

which oversee expenditures at the health facility level. Consultations with the HUMCs revealed that

they were not aware of the new guidelines.

Procurement using PHC funds

Procurement is a significant part of expenditure of public funds, such as the PHC recurrent non-wage

and development grants. Over the years, procurement delays have been cited as a major challenge

to the effective utilization of PHC and other public funds in Uganda. It is worth pointing out that the

Primary Health Care Non-Wage Recurrent Grant and Budget Guidelines to Health Centre II, III, IV,

and General Hospitals provide a comprehensive guide to procurement processes at both local

government and health facility levels.

The guidelines state that health departments are expected to be familiar with the procurement

procedures laid out in the guidelines, since the departments have had the guidelines for several

years. The health facilities, on the other hand, are envisaged to have implementation gaps since they

have not had guidelines to refer to for several years.

At the departmental level of local governments, the district is expected to have an approved

procurement plan that is incorporated in the local government procurement plan. Procurement is

expected to be undertaken in adherence to the Public Procurement and Disposal of Public Assets

Authority regulations. In addition, it is expected that the signing of contracts for construction under the

PHC development grants is witnessed by the HUMC or hospital board of the affected facility.

Consistent with the grant utilization guidelines, all KII respondents at local governments and health

facilities reported that they had functional procurement committees in place. These work with the

procurement departments and the user departments (the departments that undertake the purchase to

contracting) to advertise, scrutinize bids, and award contracts in conformity with Public Procurement

and Disposal of Assets Authority regulations. A respondent reported:

We have the procurement committee, and on that

committee, we have the Chief Administrative Officer who

sends the budget to the procurement committee with

items for procurement. The procurement department then

organizes the bid documents and advertises. After

advertising, the procurement committee seats and

awards the contract. Now the head of department is the

vote controller, and also plays a role of supervision, and

17

writes the technical report that is used to pay the

contractors.


Procurement committees were also reported to be in existence at the local government level with

varying degrees of functionality. Facilities that benefited from RBF reported that the existence of

procurement committees was a prerequisite for the receipt and use of RBF funds. These facility

procurement committees were reported to handle procurements that do not exceed UGX 1 million.

Thus, procurement using PHC development funding is undertaken at the local government

administrative level and procurement using the PHC recurrent non-wage grant is undertaken at the

health facility level. As a respondent explained:

Now let me tell you, every facility that is implementing

RBF has what we call a procurement committee. And at

facility level, they are able to discuss and procure

commodities which don’t go above 1 million. So

commodities which go above 1 million, we use the district

procurement officer with a plan. We have a procurement

officer at this level through, which all these go through.


KIIs with the HUMCs and health facility in-charges also confirmed the existence of functional

procurement committees. However, while the majority of the HUMCs reported having functional

procurement committees or subcommittees, in some of the facilities, the HUMCs reported having

limited involvement in the procurement and disposal of assets. Health facilities reported that they did

not have the mandate to dispose of Government of Uganda assets. Disposal of assets, such as

expired or soon-to-expire medicine, is done in collaboration with the district health department and

National Medical Stores. A respondent reported:

For disposal of assets, first of all, the health facility

doesn’t have a mandate of disposing—it is the district

[that has this mandate]. Therefore, when the district

officials…come to register those assets to be disposed of,

obviously they interact with the health in-charge and the

HUMC members who tell them which items are no longer

in use and can’t be used again at the facility.

– Health unit management committee member

18

Districts also reported having comprehensive procurement plans that were developed in consultation

with actors at all levels. Procurement at the health facility level is undertaken in line with annual work

plan budgets, with the HUMCs inspecting and approving the purchases. Items such EMHS are

procured on a quarterly basis. As a respondent noted:

We have a procurement plan that we worked on together

with the Joint Medical Store that supports the district in

the supply of drugs, and that procurement plan [was]

done in collaboration with the facility in-charges for health

centers II, III, IV, and hospitals. The health centers, they

come seat together and say for us we shall meet a, b, c

per quarter as per the work plans and they are sent to the

ministry. They plan for the year, but they keep on

requesting per quarter, because what they require varies

and this depends on their consumption rate.


The current study’s findings revealed that challenges continue to plague procurement of EMHS and

their effective delivery. PATH’s 2019 study on PHC financing in Uganda revealed major funding gaps

in both credit line and non-credit line commodities of the EMHS.b The study estimated that in FY

2018/2019, credit and non-credit line commodities had funding gaps of about 42% and 22%

respectively.

The funding gaps for EMHS heighten the need for effective and efficient use of the limited resources

available. However, while the health facilities’ requisition systems for EMHS have been reported to

function effectively, discrepancies between what was requisitioned and what was delivered have also

been reported.5 Discrepancies have been reported both in the quantities delivered and in the

composition of the delivery. In some instances, health facilities have been reported to receive

consignments meant for other health facilities. In addition, the available literature points to a lack of

feedback and responsiveness from the National Medical Stores when such discrepancies are

reported. Such system challenges ought to be rectified for health facilities to effectively and efficiently

use their credit lines for EMHS.

Functionality of health unit management committees

The HUMCs undertake an important role of exercising oversight on the utilization of PHC resources at

health facilities.

Composition of HUMCS: It was observed that the Sector Grant and Budget Guidelines to Local

Governments outlined the functions of the HUMC in the use of PHC resources. However, the

guidelines did not comprehensively delineate the composition of the HUMCs. The HUMC guidelines

that were published in 2003 are outdated and have not been accessed by many of the current health

b Credit-line commodities are essential medicines and health supplies that are entirely funded by the Government of Uganda and have budget

ceilings/expenditure limits, which are solely controlled by the health facilities. On the other hand, non-credit line commodities are co-funded by the

Government of Uganda and its development partners. The quantification and budget control functions are under the MoH.

19

facility staff and HUMC members. It was observed that the composition of HUMCs varied greatly,

including the gender compositions of these committees.

The 2003 HUMC guidelines called for a minimum of four members, including a chairperson, the

facility in-charge (secretary of the HUMC), a teacher in the zone where the facility is located, and a

representative from each parish that the health facility serves. Thus, the number of members of

HUMCs varies depending on the number of parishes served by the given health facility. Across the

facilities visited, the composition of the HUMCs ranged from three members (contravening the

minimum number required) to nine members. The HUMC guidelines were silent on the gender

distributions of the membership, and it was noted that all the HUMCs included in the KIIs were male

dominated.

Meeting frequency: Meetings are essential to the effective functionality of the HUMCs. They

enhance accountability by ensuring that decisions are not made by the chairpersons and in-charges

alone. HUMCs are required to meet at least quarterly, as per the HUMC guidelines of 2003. Indeed,

the majority of the HUMC members interviewed for this study reported that they met quarterly.

However, there were a few cases in which the HUMCs reported that their meetings were infrequent;

these HUMCs depended on the in-charge convening them and the availability of PHC resources to

fund the allowances of the members. As one respondent commented:

We are supposed to meet quarterly but because of the

PHC, we meet when funds are available, because you

cannot tell people to meet and then tell them to go

without transport, as you know our people.

– Health unit management committee member in

Kisoro

Understanding of their roles: Knowledge plays an important part in the effective delivery of any role.

When HUMC members asked about whether they were oriented to their roles, the study team

received mixed reports: some HUMC members reported having been oriented and other HUMC

members even within the same districts reported not being oriented. Orientations were conducted by

various actors, including the chief administrative officer of the district, the district health officers, and

staff of nongovernmental organizations. As a respondent said regarding training of HUMC members:

It’s supposed to be so, but you find that the subcounty

has limited resources for training those people…but there

are some other partners like World Vision or Plan

International that train. Like just of recent it was Plan

International who took us for training on management of a

facility.

– Health unit management committee member in

Tororo

20

It is important to orient HUMC members to their roles in order for them to be effective in exercising

oversight over PHC expenditure at the facility level. There were reports of the HUMCs being highly

influenced by the facility in-charge in undertaking their duties, which blurs the lines of accountability

and constrains the oversight. The knowledge acquired through orientations will empower the HUMC

members to provide oversight.

Functionality of the village health teams

In Uganda’s referral-based health system, the VHTs play an important role of being the first

responders. They play a significant role in promoting health, sensitizing communities, and creating

awareness on disease prevention. The VHTs therefore significantly contribute to the decongesting of

Uganda’s health center II facilities by providing basic diagnostics and first aid, as evidenced by the

following comment:

[The] government established them [VHTs] as health

center I. First of all, they help us in mobilizing in the

communities. At the same time, they help in community

sensitization, especially on healthy practices at

household level as far as PHC is concerned, like having

sanitary facilities at household level, proper use of treated

mosquito nets, and then access of health services at the

right time and from the right place. And they help us

reach out to the communities. Occasionally, they are our

entry points to the community: like under PHC, we have

health camps. We engage them to mobilize, like I said.

And also, they demonstrate…those practices that need to

be demonstrated to the communities before they can

adopt them.

– Village health team coordinator

In the country’s effort to combat the spread of the COVID-19 pandemic, VHTs have played an

important role in creating awareness about the virus and the standard procedures put in place to

minimize the spread of the virus. For example, a respondent note:

Their role as VHTS is very critical; for example, the first

alerts we got of people passing through porous borders

was through them. Everybody identified with

abnormalities is reported immediately and we were

picking them. So their systems are the ones which have

helped us safeguard our district from intruders and

21

maybe infection from across borders. So the role in

COVID-19 vigilance has been critical and has helped us.

– Village health team coordinator in a border district

Challenges faced: While the VHTs operate voluntarily and are only paid a modest allowance, their

coordination function is meant to be facilitated through the funding for PHC. However, the VHT

coordinators interviewed in this study reported that their funding was meager and unpredictable based

on activities. While some of the districts have established proportions to be allocated to these

coordination functions under the RBF projects, these have not been adhered to, mostly due to the

inadequacy of PHC funding. A KII respondent noted:

For sure, in terms of percentages, I can’t lie to you.

Because even as the board controller in my department,

I’m supposed to be allocated 15%, but I don’t see even 2

or 1%. My other colleague who is supposed to be given

8% gets 2%, but you are only allocated an activity and

under that activity you realize the only person you can

mobilize is the VHT. There is no clear budget or

proportion given to them… they are only given

allowances based on the activities they’re engaged in and

that also depends on the implementing partners.

– Village health team coordinator

Utilization of other PHC resources (results-based financing)

The provision of PHC in Uganda, along with other developing countries, is constrained by well-

documented financing challenges.8 Over the last 17 years, RBF projects have been implemented in

the health sector to complement the limited PHC resources available.9 The main feature of RBF is the

payment for results attained, as per the health facility’s performance improvement plan.

RBF has significantly improved the financing for PHC in Uganda. For instance, in FY 2018/2019, the

Kasese district received a total payout of UGX 2.965 billion for its facilities that implemented RBF; this

was funded by Enabel, a Belgian development agency. In FY 2017/2018, the facilities that

implemented RBF in the district received a total payout of UGX 3.131 billion from Enabel. These

resources were significantly higher than the sum of the PHC non-wage and development grants that

the district received in that year.10 Several other districts in the Rwenzori and West Nile Region have

benefited from this kind of funding, as illustrated in Figure 4.

22

Figure 4. Fiscal year 2018/2019 results-based financing payouts by Enabel.

Source: Rwenzori Center for Research and Advocacy, 2019.

Note: UGX, Ugandan shilling.

Similar payouts have been received around the country: RBF currently covers over three quarters of

the districts in Uganda.

Use of RBF: There are strict guidelines for the use of RBF funds that are separate from the Sector

Grant and Budget Guidelines to Local Governments. Beneficiary facilities must develop a

performance improvement plan that includes all RBF activities that it will undertake. Thus, while the

funding is complementary, it comes with parallel utilization, reporting, and accounting procedures,

which place additional administrative requirements on the health facility staff. As a respondent

reported:

Every quarter, we fill monthly invoices according to our

performance per month. Then, after calculating our

performance output, we convert it into monetary value.

So, at the end of the quarter, we come up with a quarterly

invoice, which we send to the Ministry of Health through

the district RBF focal person. Then, from the district RBF

focal person, she organizes a DHT (district health team)

to come and to audit what we did in that quarter. So, they

look at the self-assessment we did as a facility, whether it

rhymes with what the DHT has seen. So, when the DHT

is done, they make a report to the Ministry of Health RBF

unit. Then the MoH decides and sends external auditors

to come and counter-check what the DHT did. Now, after

approving the invoices, the money is sent according to

how we performed.

48 49202

363481 513 518 599 671 727 792

9051,116

2,965

0

500

1,000

1,500

2,000

2,500

3,000

3,500P

ay-o

uts

in

Millio

n U

GX

23


Considering that the RBF activities are highly incentivized, and the funding is significantly higher than

the PHC non-wage grant allocations, there are indications that the RBF administrative requirements

are prioritized ahead of the PHC administrative requirements. As one respondent noted:

… Off that money, we calculate the 40% and we share as

staff then the 60%. We look at our performance

improvement plan of that quarter to see what we need to

buy; then the procurement committee sits and they plan

how to procure.


Benefits of RBF: Health facilities that implemented RBF projects reported that several benefits arose

from the implementation of the RBF projects. For example, with regard to health outcomes, RBF

incentivizes results, which leads to improved health outcomes, especially in reproductive, child,

maternal, and adolescent health. RBF complements allowance payments to health workers, which are

usually limited under the mainstream PHC grants. A respondent noted:

Our maternal services have greatly improved with RBF.

We managed to construct a ward for the pregnant

mothers, and our newborn care has therefore improved.

Another thing is that staff motivation has increased, so

now they work harder so as to benefit from the funds.

– Health center II in-charge

Challenges in implementation: Due to the additional administrative requirements placed on the

health facility workers, several KII respondents reported delays in the disbursement of the RBF funds:

The major challenge is the inability of the center to meet

and beat the timelines that are set according to our

guidelines; for example, now we are in the first quarter of

a new financial year but we are just receiving third-

quarter RBF facilitation for the last financial year. That

has been a great source of demoralization and has

affected the perception of the program among the staff.

24

– Health center II in-charge

The Annual Health Sector Performance Report for FY 2018/2019 acknowledged that delays in

disbursement of funds was one of the major challenges in the implementation of RBF projects.

However, even when funds have been disbursed on health facility accounts, withdrawals exceeding

UGX 1 million require consent from the district health department, which adds bureaucratic delays to

the use of the RBF funds. These challenges need to be addressed to improve the effectiveness in

implementing RBF projects. They also require streamlining the administration of funds to ensure that

RBF administrative requirements are not implemented at the expense of mainstream PHC

administrative components.

25

Effects of COVID-19 on health sector and PHC

expenditure

COVID-19 has devastated global economies since the turn of the year 2020. At the time of the

drafting this report,c WHO reported a total of 58,900,547 confirmed cases of COVID-19, including

1,393,305 deaths. Uganda, at that time, had registered 18,165 confirmed cases, including 181

deaths.

COVID-19 has been both a health and an economic shock—placing additional stress on already

stretched resource envelopes of the country and the health sector. The containment measures put in

place by Government of Uganda required the country to go into lockdown for about three months.

During that time, several PHC service delivery activities, such as those conducted through community

outreaches, ground to a halt. Moreover, the lockdown also meant that potential clients of the health

facilities could not travel to the health facilities due to the travel restrictions. Comments from patients

included the following:

Some blood testing kits and other supplies have been

lacking, and therefore getting services has been delayed.

The other thing is that the staff [who were] supposed to

give us help struggled to come to work, so we waited for

so long for services.

– Patient at exit interview

Okay, there is fear that I might go to the health facility and

I contract this disease COVID-19. So, most of us actually

fear to go to health facilities because of that fear that we

may actually catch the disease.

– Patient at exit interview

Health facilities in Uganda continued to provide PHC services despite the challenges. In some

instances, respondents in the exit interviews reported that services continued to be provided, with the

MoH standard procedures to contain COVID-19 as the only difference. For example, patients without

masks were not allowed to access the health facilities.

Effect on the health sector budget: It is worth noting that, based on the releases data for FY

2019/2020, the PHC grants to local governments were not affected by COVID-19. However, with such

an unprecedented economic shock, most of the Government of Uganda’s responses to the pandemic

were funded via supplementary budgets, which were mostly from external financing (both grants and

loans).

c Statistics accessed from the Coronavirus Disease (COVID-19) Dashboard, with the latest update logged at 6:08 p.m. CET, November 24, 2020.

26

Data obtained from MoFPED indicate that the overall budget for the multisectoral COVID-19 response

is projected to be UGX 2.221 trillion. By June 30, 2020, a total of UGX 766.7 billion had been received

and committed toward COVID-19 prevention and response interventions; of this amount, UGX 386.6

billion had already been disbursed by the Government of Uganda to various sectors with

commitments for on-budget support from development partners and contributions from individuals and

the private sector. This left a gap of UGX 1.454 trillion, which would have to be sourced through

additional borrowing.

By the end of FY 2019/2020, the MoH had received and spent a total of UGX 264 billion as budget

support from both the Government of Uganda and development partners. At the facility level,

MoFPED data indicate that the MoH had disbursed UGX 270 million to 16 regional referral hospitals

and UGX 165 million in direct releases to local governments in response to COVID-19.

Expenditure commitments reflect that the funding was broken down as follows: about 35% on supply

chain management; 15% on health infrastructure; 12% on leadership, coordination, and stewardship;

10% on community engagement and social protection; and 7% on surveillance and laboratory costs,

as well as logistics and operations. The remainder was to be spent on human resources, case

management, and risk communication, among others.

27

Conclusions and recommendations

The study examined expenditure patterns in PHC non-wage and development funding over the

National Development Plan II period. This report concludes by highlighting some the key findings from

the analysis. It was noted that while spending at the central government level suffered from budget

cuts, demonstrated by shortfalls in the funds released to them, local governments and health facilities

received most, if not all, of the funds in their approved budgets during the reference period.

It was also noted that while the MoH had issued Sector Grant and Budget Guidelines to Local

Governments and the Primary Health Care Non-Wage Recurrent Grant and Budget Guidelines to

Health Centre II, III , IV, and General Hospitals to health facilities, the majority of actors at that level

remained unaware of the guidelines or had not yet started to use them. Thus, PHC budgeting and

expenditure remained inconsistent at the facility level despite the existence of the guidelines.

It was noted that the PHC budgets and expenditure were not affected by the economic disruptions

that arose from the containment of COVID-19. Indeed, local governments received an additional UGX

165 million and regional referral hospitals received an additional UGX 270 million to combat the

spread of COVID-19. The pandemic however affected access to PHC services, as many people could

not travel to the health facilities during the lockdown.

The study also noted several challenges in the spending of PHC resources. The key challenges

included the parallel planning, reporting, and accounting processes for RBF projects at the health

facility level, which likely constrained the effective and timely implementation of the mainstream PHC

activities. Additionally, the disbursement of RBF funds continued to be characterized by delays, which

affected the implementation of the planned projects. On the other hand, it was noted that while PHC

funds were disbursed by the tenth day of the quarter, receipt of funds in a few facility accounts

continued to be slightly delayed. This likely arose from delays in warranting processes for the grant

transfers.

Furthermore, while the HUMCs played a significant role of representing communities in PHC resource

allocation and utilization decisions, limited training in and limited awareness of their roles constrained

their effectiveness in exercising oversight over PHC expenditure. Along with the HUMCs, VHTs also

played a significant role as the first points of call in Uganda’s health system. However, the voluntary

nature of this role limited their effectiveness, as the VHT members prioritized earning a living.

Based on these conclusions, the study makes the following recommendations:

• The MoH should consider increasing awareness around the Sector Grant and Budget Guidelines

to Local Governments and the Primary Health Care Non-Wage Recurrent Grant and Budget

Guidelines to Health Centre II, III, IV, and General Hospitals. The guidelines were found to be

comprehensive and could solve several procedural challenges experienced in spending PHC

resources.

• The MoH should consider publishing updated HUMC operational guidelines and conducting

regular training of the HUMC members to improve their oversight function at the health facility

level.

• The MoH, in collaboration with its RBF development partners, should consider streamlining RBF

planning, reporting, and accountability processes into the administrative processes for the

mainstream PHC funds to lessen the administrative burden placed on the health workers.

• Local government administrations should consider improving their effectiveness in warranting the

transfer of funds to minimize delays in the receipt of PHC grants in health facility accounts. It was

28

found that while release of funds was timely (by the tenth day of the quarter), slight delays

continued to characterize the receipt of these funds in health facility account, with challenges being

noted in the warranting process.

• The MoH and its RBF partners should consider digitalizing the management of all RBF projects in

the country to minimize the delays in reimbursement. While RBF was reported to have improved

service delivery at health facilities, it was also reported that the process of claiming

reimbursements was characterized with bureaucratic delays.

• The MoH should consider designating a proportion of the PHC non-wage funding as allowances

for VHT members to facilitate their work. This is envisaged to go a long way in redeeming some of

the time that VHT members lose to earning a living—time that can be put to undertaking their

health promotion role.

29

Annexes

Annex 1. Detailed breakdown of primary health care grants to the

local governments in the study

Fiscal Year 2016/2017

Local Government APPROVED RELEASES

Development Non-Wage Transitional Development

Development Non-Wage Transitional Development

Arua District - 1,010,890,466

50,537,422 - 993,488,206

116,117,079

Arua Municipal Council

- 67,565,405 - - 66,402,281 -

Kasese District

Kasese Municipal Council

- 83,475,939 - - 82,038,919 -

Kisoro District - 643,243,871

- - 632,170,568

-

Kisoro Municipal Council

- 54,530,859 - - 53,592,122 -

Mukono District - 439,939,795

- - 432,366,327

-

Mukono Municipal Council

- 111,050,897

- - 109,139,180

-

Tororo District - 916,360,769

418,760,017

- 900,585,817

300,000,000

Tororo Municipal Council

- 54,450,802 - - 53,513,443 -

Grand Total - 3,381,508,802

469,297,439

- 3,323,296,863

416,117,079


Arua District 386,788,312

4,080,048,704

1,166,564,289

292,997,506

3,206,904,130

233,333,333


93,758,917 234,113,983

77,182,764 179,508,76

0

Kasese District 2,845,063,132

4,879,189,199

2,869,964,

063 4,131,105,5

50


576,267,160

689,715,645

559,712,45

7 318,821,99

6

Kisoro District 794,534,498

2,934,575,577

880,631,64

5 2,310,614,7

43


500,092,049

180,164,740

773,959,66

5 167,734,68

5

Mukono District 418,901,193

2,127,475,841

1,550,000,000

284,533,418

1,696,857,581

1,216,666,667


709,515,887

731,606,971

524,139,64

4 396,428,00

2

Tororo District 1,395,167,325

4,011,867,994

1,150,000,000

1,489,704,616

3,214,373,884

883,333,333


51,444,422 238,061,371

40,868,271 194,056,70

4

Grand Total 7,771,532,896

20,106,820,025

3,866,564,289

7,793,694,050

15,816,406,034

2,333,333,333

FY 2018/19

Arua District 162,348,223

701,701,135

213,165,330

162,348,223

702,180,975

-


6,012,897 46,151,129

6,012,897 46,151,151

30

Kasese District 1,134,543,803

971,256,400

1,134,543,

803 969,537,59

0


12,025,794 44,709,783

12,025,794 47,360,050

Kisoro District 602,311,301

583,862,464

602,311,30

1 579,482,27

8


500,092,049

54,530,859

500,092,049

54,530,885

Mukono District 78,167,663 340,500,257

78,167,663 339,261,72

5


12,025,794 35,306,647

12,025,794 35,306,663

Tororo District 614,337,095

806,277,232

250,000,000

614,337,095

807,202,850

250,000,000


18,038,691 59,652,476

18,038,691 59,652,504


3,643,948,382

463,165,330

3,139,903,311

3,640,666,671

250,000,000


Arua District 83,753,881 1,291,178,730

108,036,291

83,753,880 1,291,120,138

-


62,881,792 69,006,352

62,881,791 69,003,220 -

Kasese District 723,289,147

1,720,912,775

723,289,14

6 1,720,834,6

83 -


539,377,138

102,239,923

539,377,13

7 102,235,28

3 -

Kisoro District 36,501,126 720,082,166

36,501,126 720,049,49

0 -


54,530,859

54,528,385 -

Mukono District 125,381,320

655,869,147

750,000,000

125,381,319

653,913,728

750,000,000


419,425,728

211,528,744

419,425,72

8 213,444,80

2 -

Tororo District 565,809,493

1,114,112,109

565,809,49

2 1,114,061,5

51 -


8,541,503 60,084,901

8,541,504 60,082,175 -


5,999,545,706

858,036,291

2,564,961,123

5,999,273,455

750,000,000


31

References

1 Bitton A, Ratcliffe HL, Veillard JH, et al. Primary health care as a foundation for strengthening

health systems in low- and middle-income countries. Journal of General Internal Medicine.

2017;32(5): 566–571. https://doi.org/10.1007/s11606-016-3898-5.

2 Bresick G, Christians F, Makwero M, Besigye I, Malope S, Dullie L. Primary health care

performance: a scoping review of the current state of measurement in Africa. BMJ Global Health.

2019;4(Suppl 8):e001496. https://doi.org/10.1136/bmjgh-2019-001496.

3 World Health Organization (WHO). Primary Health Care on the Road to Universal Health

Coverage: 2019 Monitoring Report. Geneva: WHO; 2019. https://www.who.int/docs/default-

source/documents/2019-uhc-report.pdf.

4 PATH. Primary Health Care Financing in Uganda. Seattle, PATH; 2019. [Unpublished report.]

5 Kisaame EK, Mukundane M, Ggoobi R, Ayesigwa R. Assessing Public Expenditure Governance of

the Primary Health Care Programme in Uganda. Kampala, Uganda: Advocates Coalition for

Development and Environment (ACODE); 2019. ACODE Policy Research Paper Series, No. 88,

2019. https://www.acode-u.org/Files/Publications/PRS88.pdf.

6 Egger D, Ollier E, Tumusiime P, Bataringaya JW. Strengthening Management in Low-Income

Countries: Lessons from Uganda. A Case Study on Management of Health Services Delivery.

Geneva: World Health Organization; 2007. WHO/HSS/healthsystems/2007.4 Working Paper No.

11. https://www.who.int/workforcealliance/knowledge/resources/management_strengthening/en/.

7 Kisaame EK, Ayesigwa R. Monitoring of Local Government Budgets and Road Transport Services

in Quarter II FY 2019/20. Kampala, Uganda: Advocates Coalition for Development and

Environment (ACODE); 2020. ACODE Policy Briefing Paper Series, No. 52, 2020.

https://www.acode-u.org/uploadedFiles/PBP52.pdf.

8 World Health Organization (WHO). Building the Economic Case for Primary Health Care: A

Scoping Review. Geneva: WHO; 2018. WHO/HIS/SDS/2018.48. https://www.who.int/docs/default-

source/primary-health-care-conference/phc---economic-case.pdf?sfvrsn=8d0105b8_2

9 The Republic of Uganda, Ministry of Health (MoH). Results Based Financing Framework.

Kampala, Uganda: MoH; 2016.

10 Rwenzori Center for Research and Advocacy (RCRA). Financing for Women Children and

Adolescent Health in Kasese District, Uganda: CSO Scorecard. Kasese, Uganda: RCRA; 2019.

https://www.rcra-uganda.org/wp-content/uploads/2020/04/GFF_Results-Based-Financing-

RMNCH-implementation-in-Kasese-Uganda_scorecard-report-2019.pdf.

https://doi.org/10.1007/s11606-016-3898-5

https://doi.org/10.1136/bmjgh-2019-001496

https://www.who.int/docs/default-source/documents/2019-uhc-report.pdf

https://www.who.int/docs/default-source/documents/2019-uhc-report.pdf

https://www.acode-u.org/Files/Publications/PRS88.pdf

https://www.who.int/workforcealliance/knowledge/resources/management_strengthening/en/

https://www.acode-u.org/uploadedFiles/PBP52.pdf

https://www.who.int/docs/default-source/primary-health-care-conference/phc---economic-case.pdf?sfvrsn=8d0105b8_2

https://www.who.int/docs/default-source/primary-health-care-conference/phc---economic-case.pdf?sfvrsn=8d0105b8_2

https://www.rcra-uganda.org/wp-content/uploads/2020/04/GFF_Results-Based-Financing-RMNCH-implementation-in-Kasese-Uganda_scorecard-report-2019.pdf

https://www.rcra-uganda.org/wp-content/uploads/2020/04/GFF_Results-Based-Financing-RMNCH-implementation-in-Kasese-Uganda_scorecard-report-2019.pdf

Utilization of Public Health Financing in

Documents

Transcript of Utilization of Public Health Financing in