By Chrispus Mayora
By 2020, every Ugandan should be able to access quality health services without incurring unnecessary costs. That dream, underpins the Universal Health Coverage agenda.
Indeed, on 16 -18 August 2017, the SPEED programme at Makerere University School of Public Health in collaboration with the Ministry of Health, hosted a symposium where researchers, policy makers and various stakeholders in health, discussed what additional funding and financing strategies are necessary to accelerate progress towards achieving UHC.
Achieving UHC is a tall order especially for resource-constrained countries such as Uganda. It is quite clear that to deliver this ambitious UHC goal, countries will require sufficient investment in health systems. For long, experts, health policy makers and advocates have been rallying for more health sector funding and for government to meet its commitment of 15 per cent budget allocation made under the Abuja Declaration.
The advocacy for more funding has been premised on the view that marginal improvement in the population’s health is due to marginal investments (funding) in the health sector. With UHC, it is obvious that we will require additional resources.
However, to stop at calling for additional resources into the health sector is to tell half the story. We must also ask what the current funding can deliver. Is the healthcare system providing value for money for us to argue for additional funding? Are there areas within the service delivery system where we can make savings due to efficiency improvements? I believe so.
I recently visited my home district to undertake a mini-survey of in-patient health facilities. This was because I belong to an association that wanted to contribute to health facilities back home, but were not sure of the pressing challenges we could contribute to. At one facility I visited (a Health Centre III), I found an overwhelming number of in-patients admitted. This number was beyond the bed capacity of the facility. Some patients did not have mattresses so they used mats and other forms of beddings.
During my interaction with management at this facility, I learnt that up to about 20 mattresses were in the store. These mattresses had been provided by the sub-county administration but unfortunately, the specifications – size and type – could not serve the purpose. The facility could not use them and understandably so. It was procurement gone wrong and the resources would never serve its intended purpose.
The media has published reports of drugs and supplies that expire in stores – either because procurement did not recognise that expiry dates were soon, or there was poor projection on drugs required based on consumption needs.
Similar reports have emerged where either government or donor agencies have distributed equipment to facilities, but two or three years later, boxes have not been opened, or skills or funds to operate them are lacking. There are cases where a small item is missing or needs repair and the machine gets abandoned altogether. We have seen government construct health facilities including health centres up to parish level, yet no staff are recruited. Sometimes patients bypass these facilities and travel long distances to access services elsewhere.
The media has also reported about cases where some health workers recruited by government are either unavailable at workstations, work irregularly or juggle jobs in government health facilities and private clinics. Added to this is the problem of ‘presenteesm’, a phenomenon where staff who show up at work cannot perform their duties due to shortage of resources. You will find them at work but idle or doing tasks unrelated to what they are paid for. These examples reflect how much resources the health sector loses in unproductive investments.
My call is that in addition to advocating for more funding for health, we should also focus on ensuring that existing resources are efficiently and optimally used. Mechanisms that include strengthening monitoring and supervision of activities in health facilities, streamlining procurement systems, and mainstreaming value for money audits, are crucial.
There is also need to reflect on and review the remuneration system. Instead of paying salaries to health workers, government can consider a payment system that allows for more accountability, such as employment on contract basis, or offering pay for performance (performance-based financing).
With a constrained health budget, we can’t avoid demanding value for money from the little we get for health spending.
Mr Mayora is a Health Economist – SPEED Project – Makerere University School of Public Health