Who pays for and who benefits from health care services in Uganda?

Abstract

Background: Equity in health care entails payment for health services according to the capacity to pay and the receipt of benefits according to need. In Uganda, as in many African countries, although equity is extolled in government policy documents, not much is known about who pays for, and who benefits from, health services. This paper assesses both equity in the financing and distribution of health care benefits in Uganda.

Methods: Data are drawn from the most recent nationally representative Uganda National Household Survey 2009/10. Equity in health financing is assessed considering the main domestic health financing sources (i.e., taxes and direct out-of-pocket payments). This is achieved using bar charts and standard concentration and Kakwani indices. Benefit incidence analysis is used to assess the distribution of health services for both public and non-public providers across socio-economic groups and the need for care. Need is assessed using limitations in functional ability while socioeconomic groups are created using per adult equivalent consumption expenditure.

Results: Overall, health financing in Uganda is marginally progressive; the rich pay more as a proportion of their income than the poor. The various taxes are more progressive than out-of-pocket payments (e.g., the Kakwani index of personal income tax is 0.195 compared with 0.064 for out-of-pocket payments). However, taxes are a much smaller proportion of total health sector financing compared with out-of-pocket payments. The distribution of total health sector services benefitsis pro-rich. The richest quintile receives 19.2% of total benefits compared to the 17.9% received by the poorest quintile. The rich also receive a much higher share of benefits relative to their need. Benefits from public health units are pro-poor while hospital based care, in both public and non-public sectors are pro-rich.

Conclusion: There is a renewed interest in ensuring equity in the financing and use of health services. Based on the results in this paper, it would seem that in order to safeguard such equity, there is a need for policy that focuses on addressing the health needs of the poor while continuing to ensure that the burden of financing health services does not rest disproportionately on the poor.

Figure 1

Distribution of the burden of out-of-pocket payments across quintiles of socio-economic status.

Figure 2

Distribution of the burden indirect taxes across quintiles of socio-economic status.

Figure 3

Distribution of the burden direct taxes across quintiles of socio-economic status.

Figure 4

Distribution of health benefits for each quintile of socio- economic status from different health care providers.

Figure 5

Distribution of total benefits versus need.