For Better Success, First Make Sure This “Basket” Of Social Health Insurance For UHC In Uganda Can “Hold Water”?




By Suzanne Kiwanuka


Social health insurance appears to be a frontrunner among strategies to increase resources available for use in the health sector. By definition a social health insurance scheme is one where the policy-holder is obliged or encouraged to insure by the intervention of a third party (https://stats.oecd./ ).

I personally hold the belief that the sector has so many resources, one can almost say, adequate resources to deliver sufficient resources. The principal problem of the sector is that available resources are contained in leakage prone structures and these leakages manifest in various shapes, shades and sizes across all health systems blocks. This efflux of resources from the sector is so rampant that citizens have coined catch phrases to facilitate swift communication. Manifesting as “ghost workers”, “procuring air” “drugs developing legs” “managed absenteeism” “desk accountability” “cooking data” and “political medicine” these phrases depict people’s perspectives on corruption in Uganda (


Corruption in the health sector is a concern in all countries (Vian 2002). It reduces the resources effectively available for health, lowers the quality, equity and effectiveness of health care services, decreases the volume and increases the cost of provided services. It ultimately has a corrosive impact on the population’s level of health, the ultimate goal of universal health coverage. Indeed, despite the abolition of user fees more than 10 years ago, available data shows that recurrent health spending is over US$12 per head but out-of-pocket expenditure still accounts for about 70% of total expenditure – and three quarters of this is spent on drugs (Caines 2003).

For instance in Uganda and Tanzania, local or district councils have diverted large parts of the funds disbursed by central government to other uses as well as for private gains, with leakages affecting up to 41% of the allocated resources. In Ghana, only 20% of non-wage public health expenditures actually reached the service delivery points, with a large proportion of the leakage occurring between line ministries and district levels. In Cambodia, 5-10% of health budgets are said to disappear before they even leave the ministry of health (Transparency International 2006:23).


Given the porosity of our system, a system where most “pooled” funds appear to be undoubtedly kept in leaky baskets, it is unlikely that increasing the volume of resources flowing into the pool will create appreciable changes in service delivery or health outcomes. Social health insurance seems to be a reasonable solution to resource mobilization and pooling but given the robustness of the accountability and regulatory structures in Uganda (I actually allude to the obvious lack thereof), this solution “does not hold water”.



A few strategies to plug the holes


Measuring and documenting abuse and corruption is essential to diagnosing, locating and addressing problems in the provision of basic health services. A series of empirical tools have been developed in the past few years to measure corruption, leakages and efficacy of public spending, identify and target areas vulnerable to corruption (Weerasuriya 2004). This document, available online offers a detailed account of high-risk areas for corruption and how they can potentially be addressed.

In the health sector areas identified to be prone to high resource leakages which should be targeted include


  1. Provision of services by medical personnel: the asymmetry of information between providers and clients means that a high degree of discretion given to providers in choosing services for patients put patients in a vulnerable position. In most countries health professionals are thought to be above suspicion yet they often have conflicts of interest that affect their judgment sometimes diverting clients from public sector and or charging informal payments (Savedoff, 2004: Nilufur, 2003)
  2. Human resources management: as a result of inadequate performance incentives and poor performance management resulting in low productivity because of insulation from competition or external accountability (Savedoff, 2004)
  3. Drug selection and use- where brand name drugs are selected in favor of generic, counterfeit and sub standard drugs, drug pilferage and irrational prescribing and unethical drug promotion.
  4. Procurement of drugs and medical equipment: Irregular procurement processes, poor transparency and poor maintenance of equipment.
  5. Distribution and storage of drugs- high costs of distribution and losses due to expiries, obsolescence
  6. Regulatory systems: Inadequate or lack of regulation, bureaucratic processes which exacerbate inefficiencies.
  7. Budgeting and pricing: prices setting and regulation, inappropriate priority setting and budget allocation

A two-pronged strategy which focuses on increasing both the benefits of being honest and the costs of being corrupt has been recommended Rose-Ackerman (1998). These are outlined below in six complementary approaches

  1. Paying civil servants well.
Creating transparency and openness in government spending.
  3. Cutting red tape
  4. Replacing regressive and distorting subsidies with targeted cash transfers
  5. Establishing international conventions
  6. Deploying smart technology


A handbook titled “Tools for Assessing Corruption & Integrity in Institutions” that looks specifically at several sectors, including health (IRIS 2005). Other empirical tools include Focus Group Surveys, Price Information Comparisons, Public Expenditure Tracking Surveys (PETS), Quantitative Service Delivery Surveys and Firm Level Surveys. These tools could be employed to facilitate stakeholders in Uganda to identify, analyse, and develop effective strategies towards “zero tolerance” to corruption but I insist, unless funds stop behaving like fluids in baskets or baskets can be made impervious, social health insurance in Uganda can predictably go the way of water collected in straw baskets.

Do you think these social health insurance funds will be safe? Please share your experiences and thoughts on how the safety of funds going towards social health insurance can be guaranteed.

Dr. Suzanne Kiwanuka is Senior Lecturer in the Department of Health Policy, Planning and Management at Makerere University School of Public Health. She is Co-Investigator on the SPEED initiative.



Vian, T. (2002) “Corruption and the Health Sector” U.S. Agency for International Development (USAID) and Management Systems International (MSI)

Caines K BJ, Lush L, Murindwa G, Hatib N’ jie. Impact of Public-Private Partnerships Addressing Access to Pharmaceuticals in Low Income Countries: Uganda Pilot Study. Geneva: The Initiative on Public-Private Partnerships for Health, Global Forum for Health Research; 2003. pp. 10–11.


TI (2006) Transparency International’s Global Corruption Report 2006


Weerasuriya, S.(2004) Text written for Transparency International by, July 2004


Savedoff, D.W. (2003) “The Characteristics of Corruption in Different Health Systems”, World Health Organization, draft, p.6 LINK:

Nilufur, A. (2003) “Voices of Stakeholders in the Health Sector Reform in Bangladesh”, in Health Policy Research in South Asia: Building Capacity for Reform, The World Bank, p. 377 http://www- PK=523679&entityID=000090341_20031208111101

IRIS Center (2005) “Tools for Assessing Corruption & Integrity in Institutions”, 2005, U.S. Agency for International Development (USAID)