Health financial risk protection – Is this achievable in Uganda?


By Phyllis Awor MD, PhD – Makerere University School of Public Health

The overachieving aim of Universal Health Coverage (UHC) is to ensure that everyone in Uganda has access to affordable and quality health products and services when they need it, regardless of their background. Financial risk protection is a key component of Universal Health Coverage (UHC), and is defined as access to all needed quality health services without financial hardship.

Living in Uganda and accessing health care here, it is easy to forget that health care is actually a human right – as engrained within the African Charter on Human and Peoples’ Rights, signed by Uganda in 1986. Article 16 of this charter clearly says that “States parties shall take the necessary measures to protect the health of their people and to ensure that they receive medical attention when they are sick.” Is this responsibility being taken seriously by the government of Uganda?

Who really pays for health care in Uganda and how is it paid for?

Uganda has a policy of free health care for all. But in reality, the government expenditure on health is too little to ensure free health care for everyone in Uganda. The table below shows the total health expenditure for an individual (per capita) in Uganda and where it comes from. In addition, I compare this total health expenditure with that in Kenya, Rwanda and Ghana.

Table 1: Health care financing in Uganda, Kenya, Rwanda and Ghana









Total per capita expenditure on health in US $

(WHO recommends $ 84 for SSA)

59 67 95 100

Public health care financing





22% 51%

Out of pocket/household expenditure for health

37% 30% 18% 36%
  Development partners 47% 26% 38% 13%
Health Insurance   1% 13% 100% 34%

The very low government health expenditure per individual in Uganda (16% of the total health expenditure) compared to other countries in the table, needs to be addressed and urgently increased, if the government is to be taken seriously as providing health care for Ugandans. The high out-of-pocket financing of health care – direct payment for services at the time of need – of 37% in Uganda cannot ensure financial risk protection as households or people may not seek care when they need it, due to lack of money. Further, high out-of-pocket payment favors the rich and often leaves out the poor. The high reliance on development partners to finance health care (47% of total health expenditure) is unstainable as donor interests and priorities change frequently. However, this high development partner contribution is an opportunity which should be harnessed and aligned with national health priorities to ensure maximum and lasting benefits.

Health insurance

Financial risk protection can be ensured by greatly increasing the government financing for health. While I strongly advocate for this, I am cognizant of the fact that due to a low GDP per capita of only US$ 700 in Uganda, government contribution alone is not sufficient. Mechanisms for pre-payment for health and for risk pooling including health insurance can be very useful for financial protection. Health insurance is a type of insurance coverage that pays for medical and surgical expenses that are incurred by the insured person or group. However, the concept of taking out any type of insurance, even a vehicle insurance, is still poorly understood and subscribed to in Uganda. For example, less than 1% of people in Uganda are actually covered by any health insurance.

For many years, the Ministry of Health has been drafting a health insurance policy, but this process has been understandably riddled with challenges of how to ensure that every Ugandan will routinely make their health insurance payments, even when they do not get sick. The challenge of collecting a “health tax” from all Ugandans, over 80% of whom are not formally employed, would be daunting even for the Uganda Revenue Authority – the tax collection body.

Challenges notwithstanding, even construction of the tallest building begins with a good design and laying of the first brick. A well-pondered and designed national health insurance policy will be a good starting point. And a phased inclusion approach as proposed – starting with formally employed people and slowing including the informal sector is logical.

Way forward

Achieving financial risk protection by 2030 will not be easy in Uganda. However, as we learned from the MDG era, a clear strategy and concerted efforts can greatly contribute to positive results. Local political commitment to achieve UHC is paramount; government expenditure on health must be greatly increased; we should harness the contribution from development partners for more long term gains; and there is need to re-direct the high household and individual out-of-pocket health expenditure into a pre-payment and insurance-based mechanism in order to ensure financial risk protection.



Meanwhile: how would you measure health care financial protection in Uganda?

Please join this very interesting international debate on the SDG indicator (number 3.8.2) for financial risk protection! If you are an epidemiologist, public health official, policy maker, health worker, health advocate, health economist, etc. tell us how we should measure financial protection. Give reasons for your choice considering for example validity of the measure, feasibility of data collection, and comparison across countries. The two proposed indicators for measuring financial risk protection are below:

A: Number of people with large household expenditure on health as a share of total expenditure/income (greater than 25%) per 1000 population

B: Number of people covered by health insurance or a public health system per 1000 population

I look forward to your comments on any section of the blog.