Turbulences in Uganda’s Global Aid Construct

At a time when to care about Uganda’s health system a model shift is required to be drawn for the coverage and effectiveness of aid to yield more productive results, this paper scrutinizes the changes, the form, and the applicability of external financing for health to Uganda and evaluates the level of influence of new alternatives available for health sector development

By Michael Ssemakula

Health Rights Advocate

Human Rights Research Documentation Center (HURIC), and PHM-Network, Uganda

Turbulences in Uganda’s Global Aid Construct

Is the Contemporary Aid Effective Enough to Transform Uganda’s Health System to Achieve UHC?


Over the last sixty-two years, Africa land mass has received an enormous share of foreign aid of over one-trillion US-Dollars (USD). This has intently been given to fight absolute poverty, hunger, and disease, humanitarian causes such as addressing internal conflicts, child labor and human trafficking to lessen the contemporary cross-Atlantic slave trade, and debt reliefs through the multi-lateral debt relief initiatives to expand the fiscal spaces of the resource poor countries especially in the sub-Saharan Africa, the world’s poorest region. Uganda in a particular has been in position to improve its health through Development Assistance for Health (DAH) for activities within health sector such as population programmes and Health Development Aid (HDA) from external resources in form of financial or in-kind aid that is directed to fund health-allied activities such as water and sanitation programmes (F, 2016). But, the disease burden continues to thrive in Uganda despite of all the multi-million dollar donations from external assistance for health.

The paper scrutinizes the changes, the form, and the applicability of external financing for health to Uganda and evaluates the level of influence of new alternatives available for health sector development. Aid has been contracted significantly for health sector projects’ support and enhancing national budget expenditures towards health to expand our fiscal space and attain the Sustainable Development Goals’ agenda…. which are supposed to guide countries to improve their health and development at large, to leave no one behind. But grants and loans given to accelerate health accessibility and poverty reduction programs have shown low propensity in health sector improvement. Case in line, Mulago Specialized Women and Neonatal Health Hospital in Uganda was renovated partly through the support of the donor’s aid to improve reproductive and maternal health services, but it has continued to set exorbitant fees for patients to access health thus expanding the inequality gap in accessing health in impoverished communities, and worsening the public decry, according to a report by (Atwine, 2018).  Over eras-of-time, health has been renowned to be a significant component for Gross Domestic Product (GDP) growth and economic development as a populace in good health can raise the productivity and efficiency of the State’s labor force while plummeting poverty. Therefore it is imperative to view access to good adequate health as a fundamental basic human right enshrined in the international covenant on social economic and cultural rights, a fulfillment and global commitment for both developed and countries in low-levels of economic transition.

Uganda needs approximately USD 15 billion to achieve affordable, acceptable and accessible health for all Ugandans through well planned holistic pre-payment mechanisms such as the National Health Insurance Scheme and Uganda National Minimum Health Care Package in our health system that can cover all citizens in their diverse income stratas. This comes at the time when donor environment over time has reformed the mechanisms through which they fund programmes. In Uganda, Structural Adjustment Programmes and State Wide Approaches were widely applied in many sectors like health and education (which were centralized systems of funding that circled macroeconomic policies in their operations such as retrenchment policies, liberalization and privatization drives to make state governments more efficient), to now project based form of funding which has been incorporated in projects like Global Financing Facility of the World Bank group and European Union Emergency Trust Fund for Africa (EUTF). All these models have been designed by the donor communities and the recipient state governments to improve health systems and infrastructure developments in the resource limited settings like Uganda, but the inequality gap in health accessibility does not correlate with the amount of aid pumped into the countries’ health sectors and other health-related activities to achieve Universal Health Coverage (UHC). The state is nevertheless the chief actor in the strengthening of the development assistance for health processes to maximize the health outcomes. Therefore the link between donors and state’s health sector should be purely interpreted as a cordial relationship formed to increase free-of-cost health service provision, through establishment of a strong health infrastructural system and well streamlined strategy for the proper utilization of development aid assistance.

Uganda has applied a queue of health development strategies and policies such as the Health Sector Development Plans and so many others to improve health with more than 45% dependence on aid from donors, foundations, philanthropists, and non-government organizations (Health, 2014/15 & 2015/16). The state of poor health system in Uganda and other countries in the East African bloc amidst the increasing donor funding is attributed to a multiplicity of factors. Research shows the contemporary aid given in most of times is largely shrouded with donor interests. Further, it is being taken as a conduit for expansion of influence and conglomerates of the multinational private companies especially the pharmaceutical corporations; this is because many of these leverage on the partnerships they have with the global financing trust funds through contract provision of certain services such as, infrastructure development, medicines and technologies. They eventually price their services or health products so highly thereby enlarging the health accessibility disparity in the vulnerable communities, which is contrary to the principles of public health. Unendurable conditionalities are part of the mix in the aid construct which in most cases are hard to meet to yield the desired results. For instance, the Global Financing Facility (GFF´s) Results-Based Financing (RBF) model in its monitoring framework which focuses on specific indicators to determine fund disbursement at health facility and district level has been encircled with many inadequacies in Uganda.  The approach is meant to increase the motivation of healthcare workers and the financial autonomy of healthcare facilities, in order to improve performance of health systems and ultimately improve the health outcomes. However, emerging evidence of this financing approach reveals an irregular performance record. In adding, the broad implementation of RBF across a feeble or unprepared health care system raises many concerns. Experience shows that health facilities with existing poor performance levels will simply not succeed in creating a sufficient inflow of funds through RBF mechanism. Struggling health centres failing to reach RBF targets risk penalization through aid-cuts for failure to meet the set targets as part of the conditionalities in this funding modality, thereby demoralizing health workers and creating greater inequity as these health centres and the populations they serve are left behind, (Paul E, 2018).

Apparently, NGOs and the third-sector which are essentially the second engine of the health sector functioning in Uganda have a remarkable role to play as their sovereignty and self-sufficiency raises above the state’s; this is reflected through the variance in support towards the health sector by the government and the donor community. Uganda has experienced so many periods of incapacity to meet the required global financing commitments to health to provide its primary health care services to the society, which has prompted the donors (internally and externally) and lenders of all sorts to intervene through credits, grants, aid and others. Aid given to economies in transition such as those in the great-lakes region of Africa, is majorly destined to assist these states to undertake and complete their health and development projects. These aids usually come from the ex-colonial monopole and partnership financing initiatives to fortify bilateral-ties and advance donor interests. In sub-Saharan Africa, foreign aid now comes in numerous forms but the most common one is through partnership trust funds like Global fund, Global Alliance for Vaccines and Immunizations (GAVI); International Monetary Fund (IMF) through World Bank Group, European Union Emergency Trust Fund for Africa, and Global Financing Facility of the World Bank Group. These support projects that involve investment in health (such as advancing Primary Health Care, health infrastructure development and health system upgrade: case in line Uganda upgraded health centres in 2018 in different levels to revive its referral system), technical assistance of the various projects, budget support, debt reliefs through multilateral debt relief initiatives; not to mention investing in people to harness better social welfare provision and improve our Human Development Index, bio-diversity protection and climate change, support to non-state institutions involved in the human development and humanitarian causes, food security, migration problems, and so on. However, due to the dynamics in the contemporary aid, a lot of inadequacies surround aid given. There is always a lacuna in its effectiveness, delays and postponements in execution of projects due to aid’s volatility and unpredictability.

Currently, most of the aid financing modalities intends to leverage on lending. For instance, the Global Financing Facility project on Reproductive Maternal Newborn Child and Adolescent Health and Nutrition (RMNCAH+N), being implemented in Uganda and other sub-Saharan Africa states, links its grant money to World Bank lending. At the onset, an average of USD $1 of a GFF grant was matched with USD $4 of a World Bank loan. Three-years ahead, this fraction has almost doubled, ascending to USD $1: USD $7. With several GFF eligible and qualified countries already worryingly and severely indebted, additional increases in nation’s indebtedness are troubling. In the long-term, such heavy dependence on credit risks forming untenable loan repayment burdens. If the countries prioritize the servicing of these debts, this may force governments into resolutions to cut their spending in other areas, such as indispensable essential social services. Ultimately, this undermines or weakens health systems.

Conclusion and Recommendation

To care about our health system, a model shift is required to be drawn for the coverage and effectiveness of aid in Uganda to yield more productive results. Therefore close monitoring of aid especially in form of credit both short- and long-term effects is crucial. In countries such as Uganda where the risks of debt increases are deemed high, aid structures need to be revised and implement measures to protect the delivery of essential health services for the long-term. Establishment of strong robust evaluation mechanisms, and adaptation of design and implementation modalities is required. This can be backed by continuing a thorough and transparent review of health and equity outcome data under performance-centric schemes on aid effectiveness.



Atwine, A. (2018). Public anger as Govt sets exorbitant charges for new Mulago women hospital. Kampala: daily post Uganda.

F, N. (2016). Failure of Foreign Aid in Developing Countries: A Quest for Alternatives. Accra: Business and Economics Journal.

Health, M. o. (2014/15 & 2015/16). National Health Expenditure. Kampala: Ministry of Health.

Paul E, A. L. (2018). Performance-based financing in low-income and middle-income countries: isn’t it time for a rethink? BMJ global health, pg e000664.