UWOPA GENDER AUDIT OF THE HEALTH SECTOR BUDGET FOR FY 2012/13 AND BUDGET PROPOSALS FY2013/14

UWOPA GENDER AUDIT OF THE HEALTH SECTOR BUDGET FOR FY 2012/13 AND BUDGET PROPOSALS FY2013/14

Introduction
1. Over the years, government of Uganda has committed to improvement in the health sector service delivery, through a number of interventions and policies. The health Sector has been identified as one of the key priorities in the National Development Plan (NDP) and it contributes to all NDP objectives but is particularly focused on objective 4 'Increasing access to quality social services" This is through provision and utilization of promotive, preventive, curative and rehabilitative services, and involves Strengthening Health Systems and ensuring universal access to the Uganda National Minimum health care package (UNMHCP)

2. The minimum health care package in Uganda consists of the most cost-effective priority healthcare interventions and services addressing the high disease burden that are acceptable and affordable within the total resource envelope of the sector.
The package consists of the following clusters .
(a) Health promotion, environmental health, disease prevention and community health initiatives, including epidemic and disaster preparedness and response
(b) Maternal and Child Health
(c) Prevention, management and control of communicable diseases
(d) Prevention, management and control of non-communicable diseases

3. To achieve the above objectives, the health sector provision should be seen to reflect this proposition if government is to achieve universal access to health services especially to the most vulnerable groups who mostly reside in the rural areas.

4. The national budget, has not addressed this in form of budget allocation to the health sector in the medium term. According to the Draft Budget Estimates for FY 2013/14, the health sector budget constitutes 9 % of the total budget and this falls short of the Abuja declaration where government committed to spend at least 15% of their budget on the health sector.
This inevitably will not make it possible for Uganda to achieve the minimum health care package.
5. In the national Budget Framework Paper, government acknowledged persistent policy and implementation challenges to be addressed and these include; gaps in access to health care between urban and rural areas, high and stagnant infant and maternal mortality rates and continued prevalence of communicable and non communicable diseases
This GENDER Audit of the health sector examines the key salient issues in health sector budget performance for FY 2012/13 budget and the Budget estimates for FY 2013/14 with a view of establishing whether the budget resources address some of the critical gender concerns in the health sector.

Health Sector Overview
6. The total budget for the health sector is projected to increase by one percentage point (1%) i.e. from eight Percent (8%) in FY 2012/13 to nine percent (9%) in FY 2013/14. However, this share is projected to decline in the medium term resulting from a decline in external financing during the same period. Figure 1 below shows how the sector budget excluding external financing is projected to increase in the medium term though its share of the national budget is projected to remain stagnant at around seven percent (7%) as can be observed in table 1 (Annex).
Figure 1: Past and Projected Health Sector Budget in the Medium Term between
(FY 2012/13 – 2015/16)

Source: MTEF

BUDGET ALLOCATION FOR FY2013/14 AND ITS IMPLICATIONS ON THE DELIVERY OF HEALTH SERVICES
7. Though as already indicated above, the health sector budget has received a percentage increment, given the magnitude of the disease burden in the country including health infrastructure and human resource needs.
In FY 2013/14, the health sector budget is to fund the following activities; District Primary Health Care (39%), National Medical Stores (31%) and Ministry of Health (7%) It is worth noting that the sector allocation is projected to remain below the Abuja Declaration in the medium term contrary to Parliament`s recommendation.

Vote 014: MINISTRY OF HEALTH
8. The Ministry`s total budget had a release performance of 145% due to the funding from external sources that performed at 170%. However, with regard to the Government of Uganda allocation, the ministry received 65% of the approved budget as can be observed in table 4 of the annex 1. Wage releases were 70% of the approved budget while non wage performed least at 60%.
On the other hand, the Ministry`s budget is projected to initially increase then decrease in the medium term as a result of a decrease in external financing as can be observed in figure 2 below.
Figure 2: Allocation to Ministry of Health in the Medium Term in Billions UGX

Source: Health Sector Ministerial Policy Statement Financial Year 2013/2014
9. The budget is projected to increase by 73% from UGX 274.6 billion in FY 2011/12 to UGX 474.2 billion in FY 2013/14. This is mostly due to external financing that is projected to increase by 93%. However, it is worth noting that Government of Uganda Allocation to the Ministry is projected to decline by 6% resulting from the non wage reduction of 18%.
SPECIFIC GENDER CONCERNS IN THE HEALTH SECTOR BUDGET
10. NUTRITION and CHILD HEALTH. Nutrition cluster seems not to be given the attention that it deserves in the budget allocation for FY2013/14. A recent Government/World Food Program report found that one third of the children in Uganda suffer from stunting, a condition with life time consequences for children’s physical and cognitive development, leading to poorer school performance and lower earnings, hence violating their right of access to good education. Child health covers disease prevention and treatment for newborns and under-5’s and the promotion of early childhood development. Funds allocated for child health in FY 2012/13 were Ug.Shs 102 million and an estimated Ug.Shs FOR 2013/14. However in FY 2012/13, only Ug Shs 48 million was released by the government. As mothers, we cannot associate with a budget that does address the plight of children
MARTERNAL AND CHILD HEALTH
11. According to the Uganda Demographic and Health Survey (2011), Adult mortality is slightly higher among men than among women (6.5deaths and 5.3 deaths per 1,000 populations, respectively). Twenty percent of women and 25 percent of men are likely to die between ages 15 and 50. These probabilities have decreased for both women and men since 2000-01, with most of the decreases occurring between 2006 and 2011. Maternal deaths account for 18 percent of all deaths to women age 15-49.
12. Despite the above figures and although the priority areas are in line with National Policy, the resource allocation does not seem to reflect all the key priority areas identified by the sector. For example Uganda Blood Transfusion Service remains with funding gaps for human resource and equipment. These are all critical in reducing mortality rates. Sector priorities need to be reflected by resource allocation as well.
HUMAN RESOURCES
13. While Human resource attraction; motivation and retention is a key priority of the ministry, only wages for medical officers at HCIIIs and IVs were enhanced, those of other health workers were not increased. In the proposed budget, there is no provision for their enhancement which provides a disincentive to other health workers given their limited supply. This not only could lead to reduction in their labour supply resulting from brain drain but also increase absenteeism as the health workers look for alternate sources of income given the rising cost of living. As a result, this could reduce the pace at which MDG goals on Maternal and Infant mortality rates are achieved. In addition there seems to remain a ban on recruitment. How the ministry intends to motivate the health workers does not come out clearly
14. The national Development plan (2010/11-2014/15) highlights the shortage of health workers as major challenge in improving the health of the Ugandan population. The Health worker to population ratio in Uganda is 1:1298 compared to the World Health Organization (WHO) guidelines of 1:439 . The Ugandan health sector has experienced challenges related to recruitment and retention of qualified staff; this is mainly due to low remuneration as well as insufficient career opportunities. In 2010 there was a very low doctor to patient ratio of 1: 24,725 and a nurse to patient ration of 1:11,000. Both at an international and regional level, remuneration of health workers in Uganda is much lower than most countries. A doctor in Kenya for example earns approximately four times more than their counterpart in Uganda
Magnitude of Health work shortage/ Number of health workers in selected government health facilities
15. An audit carried out in 2011 by the Ministry of Health established the following:
Health Facility No. of Units % Filled
Mulago Hosipital 1 87%
Butabika Hosipital 1 93%
Regional Referral Hospital 13 72%
General Hospitals 39 63%
District Health Offices 112 57%
Health Centre 1V 164 60%
Health Centre III 803 60%
Health Centre II 1321 45%
Urban Authorities 155 50%
National Level 2,609 58%
Source: Human Resources for Health Audit report 2011, Ministry of Health
16. The table indicated that 42% of all health workers positions were vacant in 2011. Staff shortages were more acute form lower level health facilities such as health centre IIs, where about 55% of positions were vacant. Although last FY 2012/13, government addressed this challenge by providing funds for the recruitment of health workers especially at lower units, reports indicate that the wage/salary enhancement has worsened the situation and created a bigger problem in the health sector human resources. Some health facilities are now operating with very limited personnel and there are frequent changes as staff seeks better wages. This has greatly undermined service delivery especially to the majority poor who rely on government facilities. I argue members of UWOPA to take keen interest in health facilities in their constituencies in view of establishing the critical shortages. One an aggregate figure is obtained, government can them be compelled to increase the allocation for purposes of recruitment of health workers. More midwives, nurses and other categories of health workers are needed not only in lower health units but also in district and referral hospitals.

LOCAL GOVERNMENT FUNCTIONALITY
17. With regard to human resources required to functionalizing hospitals and lower health facilities, Parliament had recommended among others: Government coming up with a concrete deliberate plan to increase the number of critical cadre of health workers; CAOs to inform medical workers in health centre IIIs and IVs of their retention allowance; Enhance the salary of all health workers and if not possible provide UGX 50bn for retention of critical cadres such as lab assistants, midwives, anesthetists in HC IIIS and HCIVs.

DEATH AUDITS
18. Mortality is one of the key concerns in the health sector and given the fact that each death provides clues, audit reviews play an important role in the reduction of mortality rates. From Pg.5, of the MPS for the health sector, the ministry will continue to conduct Maternal and perinatal death audits. An update on the status of findings of the audits and their link to policy reviews could be useful in revealing policy gaps.
IMMUNIZATION
19. Immunization of children against the eight vaccine-preventable diseases (tuberculosis, diphtheria, Whooping cough (pertussis), tetanus, hepatitis B, Haemophilus influenza, polio, and measles) is crucial to reducing infant and child mortality. According to the Uganda Demographic and Health Survey (2011)Vaccination coverage decreases as birth order increases; first births are more likely to be fully immunized (58 percent) than births of order six and higher (43 percent). Children living in urban areas are more likely than those living in rural area to be fully vaccinated (61 percent and 50 percent, respectively). Among the regions, the proportion of children that received all of their basic vaccinations varies. Children residing in Kampala are the most likely to have received all of their vaccinations (63 percent), while children living in the East Central region (39 percent) are the least likely to be fully immunized when compared with children living in other regions. In addition, Vaccination coverage increases as the educational attainment of a child’s mother also increases.

20. Under immunization services provided (pg.63), the allocation remains the same at 1 billion UGX over years, despite the increasing coverage, growing population and new vaccines introduced. This funding situation is under a context that Uganda has the second lowest immunization coverage for children (only better than Somalia) and the highest number of unimmunized children in the region.

21. On a positive note, Government has secured USD 37.9 million from Global Alliance for Vaccines and Immunization (GAVI) for pneumococcal vaccine (against pneumonia) for two years as indicated on pg.5. However, there is need for government to plan to allocate funds after the two years given the fact that at the moment, both this vaccine and that for Rota virus are on the market at very high prices

FAMILY PLANNING

22. Parliament observed that there was a presidential pledge made during the London summit on Family planning to increase the Family Planning budget by UGX 5bn annually that was not reflected in the budget. Given the increasing population and its effect on not only the health sector, but the entire economy, government should be seen increasing the allocation for family planning.
COMMUNICABLE DISEASES: HIV/AIDS
23. With regard to HIV it is observed that despite the enormous efforts by government, the spread has not reduced, instead, more people are getting caught up. Parliament had recommended that Government establishes an HIV Trust Fund to secure universal treatment of all Ugandans irrespective of their CD4 counts. There is no mention of this fund.

NON-COMMUNICABLE DISEASES (NCD)

SICKLE CELL ANAEMIA

24. Inadequate attention seems to have been paid to sickle cell awareness, screening and dissemination of information on sickle cell anaemia. The sickle cell Mulago unit does not operate 24 hours. As mothers, we cannot sacrifice our children and leave them without being attended too. The allocation to this unit is inadequate to make it run effectively.
MONITORING
25. Under support supervision provided to Local Governments and referral hospitals(Pg.9), the allocation is reduced from 0.427 billion UGX in FY 2012/13 to 0.392 billion UGX, while the planned number of support supervision visits per district is increased from three in FY 2012/13 to four. This puts into question if and how a reduced budget can support 33% more field support supervision visits.

INFRASTRUCTURE/MAINTENANCE OF EQUIPMENT AND MACHINES
26. Pg. Xii shows that the Ministry plans to procure ambulances for 19 hospitals and mobile workshop vehicles yet one challenge major challenge that has been identified is that the sector allocates a fixed budget to maintenance of equipment and machinery without regard to inflation costs. This is evidenced by for example some ambulances not operating due to lack of tyres. Matching capital development funds with updated maintenance costs could increase efficiency of the budgets. Many mothers have died because ambulances do not have fuel of tires. This is not acceptable. Adequate maintenance provision should be made to ensure that ambulances are functioning.

LEGAL AND REGULATORY ENVIROMENT
TRADITIONAL HEALERS
27. Parliament got a submission from regional referral hospitals about the increasing cases of uterus ruptures as a result of the ‘medicines’ administered to the pregnant mothers by the healers. Parliament then recommended that a register of genuine traditional healers should be established with the support of the traditional healers association to weed out quack healers.
Parliament further recommended that the traditional healers bill be expedited to regulate the traditional medicine, and that the Medical Council be facilitated to supervise and discipline unethical medical practitioners. As legislators, we cannot wait to see many mothers dying at the hands of medicine men who carry out their activities with impunity due to lack of regulation.

VILLAGE HEALTH TEAMS (VHTs)
28. VHT POLICY: It was observed that the response to health challenges starts with communities and hence Government had established Village Health Teams (VHTs). As a result, GAVI funds had been secured to strengthen VHTs. Parliament had earlier recommended that part of the funds be reallocated to cater for motivation of the VHTs. Second, VHTs be made accountable to their communities through various responsibilities, and Government through the Ministry of Health enacts a VHT policy. Experience from other countries in the region like Rwanda, shows that the VHTs has significantly contributed to the decline in maternal death. This thefore calls for improved financing of this activity if tangible results
ABSORPTION
29. In addition almost each activity under the National Disease Control programme spent less than 50% of the approved budget. While UGX 1bn had been approved for immunization, UGX 264 million was spent though it is not clear what activities these were as can be observed on pg. 61. Furthermore, with regard to Photo-biological Control of Malaria, the expenditures do not reflect the six districts where the pilot was to be completed and yet in FY 2013/14 there seems to be no continuation plan.

BEDS & MATRESSES

30. Parliament had observed that during the monitoring and evaluation field visits, most health facilities were found to have old and dilapidated beds and mattresses. Parliament was informed that previously, National Medical Stores had planned to procure beds and mattresses using its budgeted funds of UGX 16.8 Billion, and embarked on the procurement of the same. However, the funds were not released by Ministry of Finance, and the procurement process was terminated. Parliament then recommended that UGX 16.8 Billion be urgently availed to NMS to procure and supply beds and mattresses to all health facilities in the country.

VOTE 134: HEALTH SERVICE COMMISSION
31. By end of May 2013, 95% of the funds approved to the commission had been released with the remaining 5% attributed to wages as can be observed in table 8 of annex 1. This suggests that by the end of the financial year the release performance could be 100%. The budget for the commission is projected to decrease by UGX 17 million due to a 1.5% reduction in the non wage bill. However the wage bill is projected to increase by 4% below the medium term inflation target of 5%. Otherwise, the budget for the commission is projected to increase in the medium term as can be observed in figure 6 below.

VOTE 151: UGANDA BLOOD TRANSFUSION SERVICE (UBTS)
32. Though the priority areas are in line with National Policy, the resource allocation does not seem to reflect all the key priority areas identified by the sector. For example: while human resource (attraction motivation and retention)is a key priority area, it is not clear how this will be achieved since Health Service Commission has a declining budget for recruitment due to a continued freeze on recruitment. In addition, enhancing blood collection is another key priority yet Uganda Blood Transfusion Service remains with funding gaps for human resource and equipment. These are all critical in reducing mortality rates. Sector priorities need to be reflected by resource allocation as well. A response to pervious Parliament`s recommendations is very important
By end of May 2013, 59% of the funds approved to UBTS had been released and this performance is attributed to the development and wage poor performances of 39% and 45% as can be observed in table 9 of annex 1. This suggests that there could be vacancies in UBTS to explain the poor release performance of the wage bill.

Figure 7: Allocation to Uganda Blood Transfusion Service in the Medium Term in Billions UGX

Source: Health Sector Ministerial Policy Statement Financial Year 2013/2014
VOTES 163- 176: REGIONAL REFERRAL HOSPITALS
33. By end of May 2013, 46% of the funds approved to regional referral hospitals had been released and this performance is attributed to the poor performance of development (36%) and wage bill (46%) as can be observed in table 12 of annex 1. The budget for the RRHs excluding non-tax revenue, taxes and arrears is projected to increase by 22% due to a 30% increase in the wage bill and 28% increase in the development budget. During the medium term, the budget to referral hospitals is projected to increase with the least increment in the development budget as can be observed in figure10 below.

Figure 10: Allocation to Regional Hospitals in the Medium Term in Billions UGX

Source: Health Sector Ministerial Policy Statement Financial Year 2013/2014
MACHINARY
34. According to the association of obstetricians & Gynaecologists of Uganda, there were only 3 dialysis Machines in Uganda all in Mulago. However, these machines have now been increased to 16 but all are in Mulago Hospital Complex. This implies that all patients in the country who need to use this machine have to travel to Kampala. Stocking the regional referral hospitals each at least with one machine for the start could help reduce on the number maternal deaths that could result from delay in transporting patients to Kampala.

MATERNAL AND CHILD HEALTH
35. Under Output 085606 prevention and rehabilitation services provided where immunization, antenatal care and family planning services are provided by regional referral hospitals, 10 out of the 13 regional referral hospitals (except Fort Portal, Masaka and Mubende) have seen very significant reduction, 50% or more in most cases, while the planned targets either remain the same or go up. The total allocation to the 13 regional referral hospitals under this output is reduced from about 3 billion UGX in FY 2012/13 to about 1.5 billion UGX, or a 48% reduction. This puts into question how the quantity and quality of theses essential services to infants and mothers can be ensured with this meagre allocation.

REVIEW OF REFERRAL SYSTEM

36. It is observed that Uganda had got an elaborate 7 – tier referral system and there were concerns that the current referral system may be less cost-effective and ultimately, un-sustainable. Moreover, the purpose for which referral system may have been established may not have been achieved since even the national referral hospitals such as Mulago remain over-congested and continue to operate as general ordinary hospitals. Even at Mulago, crazy things still happen including theft of children and mothers dying due to inadequate attention given to them.

VOTES 163- 176: LOCAL GOVERNMENTS
37. By end of May 2013, 76% of the funds approved to local Governments had been released and this performance is attributed to the poor performance of development budget which performed at 65% as can be observed in table 13 of annex 1. The budget for the RRHs excluding non-tax revenue, taxes and arrears is projected to increase by 22% due to a 35% increment in the wage bill and 14% decrease in the development budget. It can be clearly observed from figure 11 below that in FY 2013/14, 91% of funds allocated to the local governments are for Primary Health Care.

Figure 11: Share of FY 2013/14 Budget for Local Government

Source: Health Sector Ministerial Policy Statement Financial Year 2013/2014

INADEQUATE FUNDING
38. It is observed that, under the Local Government Act, districts and municipal councils are responsible for medical and health services except regional referral hospitals. However, only UGX 41.185 Billion had been allocated as non wage recurrent budget to run health service delivery in 137 local governments, and UGX 41.2 Billion was required to boost non-wage recurrent budget. Parliament learnt that the above mentioned proposed allocations were not based on realistic primary healthcare plans but on top-down allocations.

RECOMMENDATIONS AND WAY FORWARD
39. Health Financing: Currently, about 40% of health development budget resources are provided by donors. This is an over-reliance on external sources, and it subjects the health sector to external conditionality and unpredictability of aid flows—as the 2012/13 health budget cut demonstrates. It is recommended that the government of Uganda increases internal sources of health financing especially the development budget. It has been reported that investment in capital development of over Ushs. 50 bn annually has not been followed by commensurate increments in recurrent budgets. A clear way of improving health financing in the long run would be allocating some of the expected oil revenues towards the health sector. In the short time, government should prioritise service delivery at the primary level and limit the budgets going to non-wage expenditures at the central ministry level

40. Improve remuneration of health workers; salaries for health workers need to be raised to match those of neighbouring countries like Rwanda or Kenya to avoid health workers seeking for better pay abroad. It is a huge cost on the side of government to train health workers who later abandon the country for green pastures

41. Government should also explore provision of other incentives such as staff accommodation or adequate travel allowances if accommodation is not provided especially in the hard to reach areas. This will attract health workers to those areas and perhaps reduce on the maternal death on account of absence of health workers.

42. Recruit more staff to the health sector. Although government has made an attempt to increase the number of health workers, there is need for more especially at the lower health centres IIs and IIIs. There is need for more recruitment to be able to meet the WHO recommended guideline of having a health worker to population ratio of 1:439.

43. There is need for increase in government funding to the health sector with more focus on; Immunization to ensure universal coverage, child health and the blood bank to save thousands who die from cases that could be managed.
Government, development partners and civil society organizations need to urgently address the challenges of health service delivery. There should be budget tracking to ensure that all the funds approved and disbursed are spent on the delivery of health outcomes especially in rural areas where the majority cannot afford private health services in a timely manner.

44. The Ministry of Health should establish an effective monitoring and evaluation system: There is need for the Ministry of Health to strengthen the health monitoring and evaluation framework by developing easy monitoring indicators especially of physical performance. There has been an over reliance on financial audits which do not give a realistic picture of what is happening on the ground.
45. An effective M&E system would require monitoring structures with appropriate staff, a good information network system with provision for early warning, and appropriate reporting formats/registers and procedures that enable maintenance of reliable statistics. The monitoring should also involve tracking the use of resources to support management and decision making by the stakeholders.

46. Policy evaluation: There is need for policy evaluation to ensure that all the policies implemented deliver the expected health outcomes. For example, the policy shifts towards single procurement and disbursement of government medicine by the National Medical Stores. Reports have showed that some medicine gets expired before delivery to health units because of lack of transport, yet in actual sense many lower health units in local governments lack essential drugs.

47. Capacity building for district local governments: The Ministry of Health should assist districts to develop standardized methods of disaggregating health funds according to the various priorities. This will not only make it easy to track funding sources and expenditures but also promote accountability for funds from government, development partners and other sources by having clear indications of allocations against expenditure. This will also improve the absorptive capacity of the sector.
48. Universal access and equity in resource distribution should be ensured especially to cater for hard to reach areas e.g. the Island districts which include, Namiyango, Kalangala, Buvuma and parts of Wakiso and Mukono and others.
49. The ministry of health should also always into consideration the recommendations of Parliament especially in areas that affect women including maternal health. A compendium of Parliamentary resolutions reveals that some of them are never put into consideration by the Ministry.
50. The ministry of health should work hand in hand with UWOPA in finding a lasting solution to service delivery especially in areas of concern to members not limited to maternal and reproductive health. This may involve sharing information on the ministry activities in different constituencies and districts.

References
BMAU briefing Paper (10/12) and (6/13) Budget Monitoring and Accountability Unit (BMAU), Ministry of Finance, Planning and Economic Development.

Ministry of Finance, Planning and Economic Development: Approved Estimates of Revenue and Expenditure (Recurrent and Development); Various Years

Ministry of Finance, Planning and Economic Development: Background to the Budget for FY2013/ 14 and Approved Estimates of Revenue and Expenditure for FY 2008/9 to FY 2012/13.
Uganda Bureau of Statistics: Statistical Abstract; 2012

National Budget Framework Paper 2013/14.

National Development Plan FY 2010/11-FY 2014/15; Ministry of Finance, Planning and Economic Development; National Planning Authority.

Heath Sector Strategic Plan 2010

Ministry of Health; Ministerial Policy Statement FY 2013/14

Ministry of Health; Human Resources for Health Audit Report 2011

Ministry of Health Motivation and Retention Strategy 2009