The Influence of Public Financial Management (PFM) on Public Health System Efficiency in Uganda: A Scoping Review

Abstract

Uganda's public health system operates under a persistent and consequential paradox. Over the past two decades, the country has made notable gains across several key health indicators, yet the efficiency with which public health resources are converted into outcomes remains systematically constrained by weaknesses in public financial management (PFM). Health sector budget absorption rates hover between 72 and 88 percent, with significant fourth-quarter expenditure concentration that distorts planning and service delivery. Drug and medical supply stockouts affect an estimated 28 to 44% of public health facilities. National Medical Stores procurement cost premia of 15 to 30% above commercial market prices represent a chronic, unaddressed allocative inefficiency. Office of the Auditor General reports consistently identify irregularities in health sector financial management, yet resulting policy recommendations achieve implementation rates of only 40 to 60%. Despite the scale of these inefficiencies, the mechanisms linking PFM quality to health system efficiency in Uganda remain insufficiently synthesised relative to the challenge they present. This scoping review maps and synthesises available evidence on PFM and health system efficiency linkages in Uganda. A systematic search across five databases and grey literature identified 26 eligible sources from 198 records. Findings reveal that PFM influences health system efficiency through five interrelated mechanisms: budget formulation quality and alignment with actual needs; budget execution consistency, timeliness and predictability; procurement and supply chain management, with implications for input cost and availability; accountability, audit and oversight, with deterrence effects on waste and fraud; and intergovernmental fiscal transfer design, with incentive effects on district health performance. Cross-cutting themes, decentralisation fragmentation, donor alignment challenges, and human resource financial management, run through all five mechanisms. The review proposes the PFM-Health Efficiency Integration Agenda for Uganda and concludes with evidence-based recommendations for the Ministry of Finance, Planning and Economic Development, the Ministry of Health, and development partners.

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