purchasing health care services for universal health...

205

10

Purchasing Health Care Services for Universal Health Coverage: Policy and Programme Implications for Uganda

Elizabeth Ekirapa-Kiracho, Chrispus Mayora, Aloysius Ssennyonjo, Sebastian Olikira Baine, Freddie Ssengooba

Key Messages

• Thepurchasingarrangementsinacountrycandirectlyinfluencethedemandforandutilisationofqualityinterventionsbythepopulation.Thereisneedforcarefulselectionanddeliveryofinterventionsthattargethigh-priorityneedsthroughmethodsthatnotonlyallowtheequitable distribution of key resources, but also promote efficientdelivery and transparency at an affordable cost to key populationgroups.

• Ugandaiscurrentlyunabletoprovideuniversalaccesstoitsminimumhealth care package largely because of inadequate resources. TheMinistry of Health should develop a road map for the phasedimplementationoftheminimumhealthcarepackage,givenitslargesizeandthelimitedresourcesavailabletothehealthsector.

• Toincreaseaccesstohealthservicesforthemajorityofthepopulation,the central government should allocatemore funds to lower-levelhealthfacilitieswherethemajorityofthepopulationseekcareandtopreventiveservicesbecauseofthehighburdenofpreventablediseasesandconditions.

Citation: F. Ssengooba, SN Kiwanuka, E. Rutebemberwa, E. Ekirapa-Kiracho (2017), Universal Health Coverage in Uganda: Looking Back and Forward to Speed up the Progress. Makerere University, Kampala Uganda.

206 Universal Health Coverage in Uganda- Part III

• The central government should consider using a combination ofinput-basedandresults-basedpaymentmethods.Thecurrentinput-basedpaymentsystemisuseful forcostcontainmentbutdoesnotgive optimal incentives for improving quality and efficiency. Theresults-basedpaymentmethods,ifwelldesigned,provideincentivesfortheproviderstoimprovethequantity,efficiencyandqualityofinterventionsespeciallyforeasilyverifiableresults.

• The structures formonitoring grants and subsidies to public andprivateprovidersneedtobestrengthenedtoensurethattheservicesprovidedareofgoodvalueforthemoney.

Introduction

This chapter introduces strategic purchasing and explores its place in theuniversal health coverage (UHC) agenda, reviews the key health servicespurchasing arrangements in Uganda, and analyse their performance inrelationtothethreekeyactionsforpurchasingandtheirimplicationsfortheUHCobjectives,namely:

1) increasing the provision of essential quality services; 2) expandingcoverageofthepopulation;3)increasedfinancialprotectionandinvestinginstrongandresilientsystems(1).Inaddition,thechapterseekstoanswerthreemainquestionsthatarelinkedtothemainactionsinstrategicpurchasing:(a)How canUganda prioritise the selection of interventions, taking intoaccountpopulationneeds,nationalhealth revenues andcost-effectiveness?(b) How can Uganda organise service providers so as to maximise theirdifferentcapabilitiesinreachingthepopulationinneedofservices?(c)HowcanUganda regulate the different institutions that are involved in serviceprovisionsoastoensurethattheyfacilitatetheprovisionofquality,efficientpro-poorservices? Thechapterconcludeswithasummaryofprogrammaticand policy implications for enhancing strategic purchasing for UHC inUganda.

Strategic Purchasing

Oneofthekeyfunctionsofahealthsystemistodelivertoitspopulationtheservicesthattheyneed(2).Ugandahasmadesignificantstridesinanumberofpopulationhealthindicatorsoverthelast10years,includingincreasedlifeexpectancy,reducedmortalityandmorbidityfromvarioushealthconditions,

207Chapter 10: Purchasing Health Care Services

andareductioninfertilityrates.However,somesectionsofthecountrystillsuffer high morbidity and mortality from both communicable and non-communicable illnesses (3-6).This highlights the need formore strategicpurchasingofservicesarrangements,whichcanallowforexpandeddeliveryofcost-effective,high-impactinterventions,usingtheappropriatemixofserviceproviderswhoareincentivisedtodeliverqualityservicestothepopulationinaccordancewiththeirlevelofneed.Whereaspassivepurchasingarrangementstend to simply involve the retrospective and prospective payment of billsforresourcesusedandservicesprovided,strategicpurchasinginvolvesmoredeliberateattemptstonotonlyprovideservicesthatmeetsocietalobjectives,but also influence provider behaviour in amanner that ensures improvedefficiency,qualityandequitabledistributionoftheservicestothepopulationcovered(7,8).

Strategic purchasing and UHC

The purchasing arrangements utilised by a country impacts on the mainUHCobjectivesdirectlyandindirectly(seeFigure10.1).Itwilldeterminewhatandhowinterventionsareprovidedtothepopulation.Thiswilldirectlyinfluencetheproportionofthepopulationthatisabletoreceiveparticularinterventions and the quality of services that they receive.The system ofpurchasingcanalsoimpactontheUHCobjectivesindirectly(9).Purchasingarrangementscanleadtotheequitableorinequitabledistributionofservicesandthis,inturn,willinfluencetheutilisationofservicesbythoseinneedand,subsequently,theirfinancialprotection.Forexample,whenthepopulationisunabletoaccesspublicly fundedservices, theyenduppayinghighout-of-pocketcosts tomeettheirhealthcareneeds(10).Inaddition,differentpurchasingsystemsprovidedifferentincentivesforincreasingaccountability,efficiency and quality. Arrangements that have a positive effect on theseattributes contribute to a wider proportion of the population receivingqualityservicesatanaffordablecost(2).


Figure 10.1: Purchasing and UHC

Interventionsprovided

Services

Provider payment methods

Equitable resource distribution

Transparency and accountability

Increased coverage of the population

Quality

Universal

protection

Source: Kutzin et al., 2013, (9)

Purchasing of Services in Uganda

PurchasingofhealthcareservicesinUgandaisdonebyavarietyofstakeholdersthat include the government, households, employers, donors and healthinsuranceschemes(mainlyprivatecommercialaswellascommunity-based).Duringthecolonialdaysandimmediatelyafterindependence,healthservicesinUgandaweremainlyprovidedthroughpublichospitalsanddispensaries.Thepopulationofthecountrywasstillsmallandmostbasicserviceswereavailabletothepopulationfreeofcharge.Thecountrywentthroughaperiodofinsurgencybetween1972and1986.Thisresultedinabreakdownofthepublichealthsystem.Duringthisperiod,thecountrythenreliedmainlyonnon-governmentalorganisations(NGOs)whoprovidedlimitedcoverageofservicestopopulationsthattheycouldreach.Indeedtheearliestdemographicandhealthsurveysconductedreportedpoorhealthoutcomes.Forexample,maternalmortalitystoodat524per100,000andunder-fivemortalityat117per1,000livebirths(3).


In 1986 the National Resistance Movement (NRM) took over thegovernmentandbegantorebuildthehealthsystem,andaseriesofreformschampionedbytheWorldBankandtheIMFwereembraced.In1999thecountrydevelopedaminimumhealthcarepackage(UMHCP)–apackageofservicesthatthegovernmentwasexpectedtoguaranteeanddelivertothepopulation.TheMHCPiscurrentlyofferedthroughanetworkofpublicandprivatefacilitiesunderadecentralisedhealthsystem.Effectivedeliveryofthispackageishoweverhamperedbyseveralinadequaciesresultingininequitableaccesstoandutilisationofservicestosomeareasandsometargetgroups(10).

Asaresultofthechallengesintheprovisionofpublicservices,asignificantproportionofhouseholdsinUgandapurchasetheirservicesonanindividualbasisthroughout-of-pocket(OOP)paymentsfromprivate-for-profit(PFP)and private-not-for-profit (PNFP) providers. The recent National HealthAccounts (NHA) for Uganda shows that 41 per cent of the total healthexpenditureforthecountryarisesfromdirectpaymentsforhealthservicesbyhouseholds(11).Literaturealsoshowsthatasignificantnumberofpatientsseek services from the private sector (12-14). These services are paid forthroughOOPpaymentmechanisms.OOPmechanismsarelargelyregressive,tendtohindertheutilisationofservicesbythoseinneedyethavenocash,andresult in catastrophicpaymentswhenhouseholds incurhugemedicalbills(15).Furthermore,thequalityofservicesprovidedbyprivatefacilitiesmaynot alwaysbe assured (16,17).A significantproportionof thedirectpaymentsbyhouseholdsgo to alternativehealthproviderswith treatmentoptionsthatarelessregulatedforoptimalbenefitstothepopulation.

Donors also provide support to theGovernment ofUganda throughon-andoff-budget supportmechanisms.Thissupport isusedtopurchaseservicesthroughthepublicdeliverysystemandthroughNGOsandPNFPs.Lastly, services are also purchased in Uganda through community-basedandprivatecommercialinsuranceschemes.ThehealthinsurancemarketinUgandahaslargelyremainedsmallrelativetothepublicandprivatesectors,contributingconsistently less than2percentofhealthfinancing,and lessthan2percentofUgandanspurchaseservicesthroughinsurance.However,Ugandaisdevelopinganationalhealthinsurance(NHI)scheme,andasofendof2017,theNHISBillisbeforetheParliamentofUgandaforapprovalandeventualimplementation.


Aspects of Strategic Purchasing

Strategic purchasing comprises three main aspects: 1) prioritising ofinterventions;2) choosingproviders; and3)determininghow services arepurchased.

Prioritisation of interventions or services purchased

Oneofthekeyinitialstepsinthepurchasingprocessinvolvesselectingthepackageofinterventionsthataretobeprovided.ForcountrieslikeUganda,withmajorfinancialchallenges,theprioritiesthatfittheaffordabilitycriteriaarefewerthantheneedsofthepopulation.OneofthepremisesofUHCistoensurethatpriorityservicepackagesareidentifiedandexpandedovertimetoreflectthehealthneedsofthepopulation.Fourthings,therefore,becomeparticularlyimportantintheprocessofprioritisinginterventions.

v) The needs of the population One of the commonly used approaches to identifying the needs of thepopulation is mapping the disease burden of that respective population.Once the disease burden has been identified, appropriate interventionscan be provided. Uganda, like other low- and middle-income countries,is undergoing an epidemiological transition, with recent data showing ahigh burden of communicable and non-communicable diseases (NCDs).AccordingtoUganda’sHealthSectorDevelopmentPlan(HSDP),over75percentoftheillnessesthatleadtoprematuredeathinthecountry,suchasmalaria,HIV/AIDsetc.,arepreventable.Maternal,childhoodandperinatalconditions contribute a sizeable proportion of the burden of disease inUganda.Anyproposed interventions inUgandamust, therefore, focusonthesehigh-burdenareas(5).Ahighfertilityrateandthepersistentdesirebycommunitiestohavelargefamilysizesareprominentdriversofpopulationgrowthand,byextension,theserviceburdenandcoststothehealthsystem.Fromthisperspective,interventionstocontrolunwantedpregnancywouldbehigh-priorityforthecountrybutacceptabilitybythecommunitiesneedstobeaddressed.

The Sustainable Development Goals (SDGs) give prominence tothe factors that influence health outside the health sector, implying thatinterventionsbeyondthehealthsectorarerequiredtotacklesuchproblemsand address the high burden of preventable illnesses. In line with the


primaryhealthcare(PHC)approach,Uganda’spolicies,suchastheNationalDevelopmentPlan(NDP)andtheHealthSectorDevelopmentPlan(HSDP),highlighttherolethatdifferentsectorsplayinimprovinghealth(18).Indeed,somestepshavebeenmadetoimplementinterventions,suchasimprovingaccesstocleanwater,improvedroadnetworks,latrinesanduniversalprimaryeducation(UPE).However,theseinterventionsareoftenimplementedinaverticalmanner,whichunderminesthehealthbenefitsthatcouldbeachievedfrom them. For example, while Uganda has several community-basedworkers,theyareresponsibleforprovidingservicesonlywithinthesectorswheretheyareemployed(sanitation,agriculture,health)ratherthanacrossallthesectors.Thebudgetingfortheseworkersandinterventionsisalsooftendoneinaverticalmannerratherthanusingamorecollaborativeapproach.

vi) Current coverage of priority interventions The current coverage of priority interventions also needs to be carefullymapped out so that underserved populations and geographies are moretargeted. Table 10.1 shows access to a selected group of interventionsidentifiedinUganda’sHSDPaspriorityinterventions.Dataontheregionaldistributionofthese interventions is,however, lacking,yet it iscritical forallowingthedistrictstotargetinterventionstowardsthosewhoareinneed.

Table 10.1: Performance against the health service outcome targets

Indicator 2014/15 2015/16 2016/17 HSDP target

ARTcoverage 56% 64.4% 73% 65%

HIV+pregnantwomennotonHAARTreceivingARVsforeMTCTduringpregnancy,labour,deliveryandpostpartum

72%(2013/14)

68.3% 90% 87%

TBcasedetectionrate(allforms) 80%(2014/15)

50.7% 50% 75%

IPT2dosescoverageforpregnantwomen

53.4%(2014/15)

55% 54.4% 71%

Under-fivevitaminAseconddosecoverage

26.6%(2013/14)

28% 25.3% 60%

DPT3HibHeb3coverage 102.4%(2014/15)

103% 99.2% 95%


Indicator 2014/15 2015/16 2016/17 HSDP target

Measlescoverageunder1year 90%(2014/15)

96% 86.7% 92%

Contraceptiveprevalencerate 30% 30% 39% 39%

ANC4coverage 37% 38% 37% 40%

Healthfacilitydeliveries 53% 55% 58.1% 56%

HCIVsofferingCEmOCservices 33% 36% 44.6%(83/186)

55%

HCIVsconductingC/S 51% 62% 70.4%(131/186)

55%

HCIVsconductingbloodtransfu-sion

38.5%(75/198)

40.4% 47.3%(88/186)

55%

Source: GOU, Annual health sector performance report 2016-2017(19)

vii) Package of interventions to be implemented TheWorld Health Organisation (WHO) recommends that each countryshouldhaveanessentialhealthcarepackage,whichisnotonlycost-effectiveandaffordabletothecountry,butalsoaddressesthehighestburdenofdiseaseinthecountry(2).Thepackageofinterventionstodelivertheessentialhealthcarepackagemustbeidentified,withdueconsiderationtolocalcontextualissues.Ugandahas aminimumhealth carepackage (UNMHCP)of cost-effectiveinterventionsthattargetthehighestcausesofmortalityandmorbidityinthecountry.TheUMHCPcomprisesservicesthathavebeenclassifiedintofourclusters: (1)healthpromotion,environmentalhealthandcommunityhealthinitiatives;(2)maternalandchildhealth;(3)communicablediseasecontrol;and(4)preventionandcontrolofNCDs,disabilitiesandinjuries,andmentalhealthproblems(20).Thecountry,however,doesnothaveadequateresources to provide this entire package to the population. In 2016/17,Ugandaallocatedonly8.9percentof thenationalbudget tohealth (19).Consequently,thepackageofservicesprovidedtothepopulationislimitedbothinscopeandcoverage(21).Evenwithinthehealthsector,moreresourcesareallocatedtowardscurativeactivitiesorthecurativeagenda,ratherthanpreventiveactivities,yet70percentofthediseasesinUgandaarepreventable(11).Thishasresulted inastrongeremphasisontheprovisionofcurativeservicesratherthanpreventiveservices(22).Consequently,servicessuchas


immunisationandfamilyplanningthatnotonlykeytopreventingmaternalandchildmortality,butalsohavewiderandlong-termeconomicdividend,arestillunderutilised.Only40percentofchildreninurbanareasand35percentofchildreninruralareasreceivedallageappropriatevaccinationswhiletheunmetneedforfamilyplanningamongmarriedwomeninUgandastandsat28percent(23).Furthermore,interventionsthatareprovidedinthecountryareheavilyreliantonandinfluencedbyfundingfromdevelopmentpartners.Donorfundsarequiteoftenearmarkedandspentonafewdiseasespecificprogrammes(especiallyHIV,malariaandtuberculosis),leavingthelargerdiseaseagendawithoutenoughfundingandresources.Theearmarkingofdonorfunds,therefore,underminesthegovernment’seffortsatfocusingonkeynationalpriorities.

Lastly, the increasingcostsofnew interventions isanother factor thatisfurtherconstrainingthebudgetforfundingtheseinterventionpackages.Thishasarisenwithadvancementsintechnologythathasbroughttotheforenewmedicinesandvaccines,aswellasalternativemedicalproceduresandinterventions.Thesehavebeenaddedtotheroutineservicedeliverysystems,sometimes without adequate assessment of the cost-effectiveness of thesenewtechnologies,medicines,vaccinesandprocedures–resultinginwhatisreferredtoas“medicalinflation”.

viii) Capacity of the country to deliver priority interventions Even when new and priority interventions are identified and proposed,for their successful implementation, the country needs to have adequatecapacity, including earmarking sufficient resources for service delivery.However,Uganda,likemanylow-andmiddle-incomecountries(LMICs),doesnothave adequate capacity tooffer the required services.ThehealthsysteminUgandaismarredbyseveralinadequaciesthatincludeinadequatehumanresourcesforhealth, lowhealthworkermotivation,absenteeismofhealthworkers,drugstock-outs,poorhealthworkerattitudesandskillsaswellas inadequate infrastructure(19,24,25).While theWHOestimatedthat governmentsneed to spendat least10-15per centof theirGDPonhealth to achieve UHC, Uganda spent only 7 per cent of its GDP onhealth in 2014 (8). Poor allocative efficiency in the distribution of thesefundsworsens the situation.TheNHAfor2012 showed thatat leasthalfof the currenthealth expenditure is at hospital level and yet themajorityofthepopulationutiliseservicesatlower-levelfacilities(11).Morefundingneedstobeallocatedto lower-level facilities that servethemajorityof the


population.The infrastructure for servicedelivery is also inadequate (26).Inadequacies inservicedeliveryalsoarise fromwastage.Oneof themajorsourcesofwastagearisesfrommedicinesandtechnology.Lackofdiagnosticequipmentoftenresultsinpresumptivetreatmentofpatients,withtreatmentbeing administered to patients who do not need treatment. Purchase ofequipmentthatcannotbemaintainedlocallyandpoormaintenancepracticesalsoresultinfrequentbreakdownsandlossofresources(27).Anothersourceofwastagearises frompoorharmonisationand implementationofverticaldonorprogrammes,whichleadstoduplicationofservices,weakeningofthehealthsystemandhighadministrativecosts.Reducingtheabove-mentionedinadequacieswill require increased funding forhealthaswell as improvedpublicsectormanagementoffundswiththestrengtheningofaccountabilityandpublicfinancemanagementsystemssoastoenhancevalueformoneyandreducecorruption(10,28).

Choosing Service Providers

Once an appropriatemix of interventions is selected, an appropriatemixofprovidersisthenrequiredtodelivertheseinterventionstotheintendedbeneficiaries inamannerthat isresponsivetotheir individualneeds.It is,therefore,importanttomapthetypeofprovidersavailable,theservicestheyprovide and their competitive advantage, and then purchase the requiredservicesaswellasensureefficientandqualitydelivery. Healthservicesareoftenorganisedinthreemainways:1)hierarchicalbureaucracies;2) long-termcontractualarrangementswithvaryingdegreesofmarketcontrol;and3)directmarket-basedinteractionsbetweenpatientsandproviders.

Public provision

PublicservicesinUgandaareprovidedthroughahierarchicalbureaucraticarrangement under a decentralised system of governance. Primary careservices areprovidedby anetworkof facilities that includehealth centres(HC) I, II and III, while more specialised services are provided by HCIVs,generalhospitals,regionalreferralhospitalsandtertiaryhospitals.Thelowerlevelsoffacilitiesare,however,unabletoprovidethefullpackageofservices,withthefullUNMHCPbeingavailableonlyathigher-levelfacilities(HCIVandabove)(21).Thisresultsinreducedaccessibilitytoservices.Tominimise thiseffect,Ugandaneeds to improve its referral system.Ugandarecentlydevelopedanationalambulanceservice,althoughitisyettobefully


functional. An effective referral systemwould reduce the need to providespecialised services at lower-level facilities while ensuring that patientswhorequirespecialisedcareareabletogetthecaretheyrequireinatimelymanner.Thiscallsforinvestmentinprovidingadequateambulanceservicesandacommunicationsysteminadditiontoimprovingthemanagementoftheexistingreferralnetworks.AsreflectedinFig12.8,referralfacilitiessuchasHCIVslackthecapacityforbloodtransfusionandmanydonothavethevitalcapacitytoprovideservicessuchasC-sections.

Contractual provision

Long-term contractual arrangements with private-for-profit providers andNGOsarealsoused toprovide services.Ugandahasa significantnumberofprivate-not-for-profit(PNFP)providerswhoplayakeyroleinprovidingservices to ruralpopulations.Thegovernmentprovidesa subsidy tomanyof these facilities to expand provision, especially for the rural poor (29).Recentevidenceshowsthatmanyofthesefaith-basedfacilitiesarestrugglingtomeettheirrunningcosts,whichcannolongerbemaintainedbydonorcontributionsandusercharges(30).Whereascommunitiesthatareservedprimarily by PNFP providers experience some financial difficulties whenaccessingservices,wheretheyarethemainproviders,theircollapsemayleadtolossofservicecoverageforthesecommunities.Thegovernment,therefore,needstomapoutareasthatareservedpredominantlybyprivateproviderssothatitcanprovideappropriatesubsidiesandincentivestomaintainandexpandcoveragethroughcontractualarrangements.

Funds from development partners are also used to purchase servicesthroughNGOsusingshort-termorrelationalcontracts.Suchrelationshipsallow theprovisionof services/ interventions that areoften lacking in thepublicsystem,suchasantiretroviraltherapy(ART),preventionservicesforNCDsorservicesforspecialpopulations,suchassexworkers.They,therefore,meetacriticalneedandallowincreasedcoveragetovulnerablepopulationgroups.Suchsynergiesbetweengovernmentanddonorprogrammesshouldbepromotedbyclearlyidentifyingareaswhereeachplayer’scapacitycanbeleveraged.Forexample,inadditiontotheabove,donorscancontributetomeetingthecapitaldevelopmentcostsofmajorhealthsystemprojectswhilethegovernmentmeetstherecurrentcosts.


Market-based provision

Direct market-based interactions between patients and providers arecommonlyused topurchase services fromtheprivate sector.Themajorityof minor illnesses are covered through modern and traditional market-based approaches with direct out-of-pocket payments.The growth of theprivatesector,especiallyinurbanandperi-urbansettings,hasgenerallybeenattributedtothelimitationsexperiencedinpublicprovision,anditisthusan indication of the expanding market-based model. Close collaborationbetween the government and the providers in themarket-basedmodel isvitaltoensureservicesofgoodqualityandvalueformoney.Thegovernmentcansubsidiseconsumersthroughtheprovisionofservicevouchersandothersimilar tools to expand coverage of market-based provisions and ensureaffordabilitytothepopulation(31).

Community-level health production

Asnotedintheprevioussection,theprovisionofpreventiveserviceshasnotbeenoptimal.Althoughthegovernmenthasacommunityhealthstrategy–withthestructureofVillageHealthTeams(VHTs)–theimplementationofthestrategyhasbeenconstrainedbyseveralfactors.TheseincludeinadequatefundingforoperationalcostsandremunerationoftheVHTs,lackoftraining,andsupervision.Inaddition,thelinkagebetweentheVHTsandtheformalhealthsystemhasbeenweak.Thishasaffectedthesuccessfulpromotionofhealthactionsanddiseaseprevention–especiallywherethefinancingshouldbe aimed at supporting communities to undertake activities that improvetheirownhealth. Thegovernmentisintheprocessofpilotinganewcadre,the community health extension workers (CHEWs), who are supposedto further strengthen thepromotion andpreventive services (18).Carefulplanningandimplementationofthisstrategyiscriticalforstrengtheningandfinancingofcommunitylevelactionsthatimprovehealth.

Determining How Services Are Purchased

Governmentshaveakeyrole toplay intermsofensuringthat there isanappropriate regulatory framework and guidance for key stakeholders toguaranteethatpublichealthprioritiesareconsideredinresourceallocationandpurchasingchoices.Purchasers,ontheotherhand,needtoensurethatpopulationneedsareidentifiedandprovidersareheldaccountabletomeet


theseneeds(32).Countries,therefore,needtohaveanappropriatemixoforganisational structures, institutional arrangements and incentives if theyare to provide the rightmix of services that willmeet the needs of theirpopulations(2).Thestructuresandincentivesrequiredwouldvarydependingonhowservicedeliveryisorganised(2).Indecidingpurchasingmechanisms,thefollowingkeyareasarecritical:

i) Ensuring quality services. Mechanisms that ensure that providers offerqualityservicesarerequired.Asizableproportionofhouseholdspurchasetheir services through directmarket-based interactions and pay for theirservices through out-of-pocket expenditure (11). In this case the clientsare the ones who choose the services that they would like to purchase.According to theprincipal agency theory, the clients (principal)maynotbeinapositiontodeterminewhattheyrequireandthey,therefore,dependontheagents(healthproviders) tochooseforthemthemostappropriateservices.Tominimiseexploitationbyhealthcareproviders,countriesneedtohavestrongregulatorysystemsthatwillmonitorboththetypeandqualityof servicesprovidedtotheclients.Thiscanbedonethroughprofessionalcouncilsaswellasthroughbodiesthataremandatedtomonitortheservicesdelivered. Licensing of the providers’ organisations/institutions needsto be controlled by professional councils that have the required capacityand autonomy. Uganda currently does not have an accreditation body.This function is therefore largely done by district health teams, who areresponsibleforsupervisionofbothpublicandprivatefacilities.Thesedistricthealthteamsare,however,oftenunabletoprovideadequatemonitoringofservices.They are also constrainedbypolitical interference.TheCatholicMedicalBureau,however,offerssignificantoversightandcapacity-buildingtotheinstitutionsthatareunderit.Lastly,functionalaccountabilitysystemscan also ensure that providers are held accountable to provide qualityservices.Withinthehealthfacilities,healthmanagementboardsandhealthmanagementcommitteesareexpectedtoplaythisrole.However,manyofthecommitteesarenotfunctional,whereaswheretheyarefunctional,thisrole is not performed aswell as expected. Similarly, reward and sanctionsystemsthataresupposedtohelpenhanceappropriatebehaviourbyhealthworkersarealsolargelyinactiveinmanyfacilities.Citizenandcommunityscorecardsarealsobeingusedasamechanismtopromoteaccountability.However,thisisstillonasmallscale.


ii) Promoting efficient provision of services.Paymentmethodsforprovidersalsoinfluencethequality,efficiencyandcostatwhichservicesareprovided.Different typesofpaymentmethodsareused topay theproviders.Theseinclude fee for service, capitation, diagnostic-related groups and lineitem budgets. In Uganda, line item budgets are often used. While lineitem budgets are useful for containing costs, they often do not providean incentive for improving quality or efficiency. On the other hand,methods such as capitation and diagnostic-related groups are applaudedfor theirability topromoteefficiencyandcontrolcosts.Fee for service isofteneasytouse,especiallyundercontractingarrangements,butitsmaindisadvantageisitstendencytopromoteover-provisionofservices,insomecaseswithreducedattentiontothequalityoftheservicesprovided.Italsorequiresmore sophisticated administrative systems for successful delivery.InUganda,servicespurchasedbytheGovernmentofUgandaareprovidedthrough a network of public andnon-profit private facilities.Thepublicfacilitiesreceiveannualbudgetallocationsformeetingtheirinputs.Fundsaredisbursedquarterly to thehealth facilitiesandmonthly in thecaseofwages to theproviders (paid through salaries).Nopublichealth facilitiescharge official user fees except in privatewings of referral hospitals (20).Servicespurchasedoutofpocketarepaidthroughafee-for-servicesystem.When development partners contract different providers, then contractsthatspecifythetypeofservicetobeprovidedandthemethodofpaymentareagreedupon.Thepaymentsystemusedbythegovernmentprovidesjobsecurityforitsworkers,whichisimportantforpromotingjobsatisfaction(33). However, it does not give an incentive to improve efficiency andquality.TheInstituteofHealthmetricsshowedthatfacilitiesinUgandahadlowerefficiency(31percent)comparedtofacilitiesinKenya(41percent)andZambia(42percent)(34).Improvingtheefficiencywithwhichservicesareprovidedcanreduceabsenteeism,wastageandcorruptionand,therefore,allowsservicestobeprovidedtomorepeopleinneed.Accountabilityandpublicfinancemanagementsystemsalsoneedtobestrengthenedtoenhancevalueformoneyandreducecorruption(10,28).

Althoughtheevidencebaseforperformance-basedpayment(PBF)inLMICsisstillinconclusive(35-37),recentevidenceshowsthatperformance-basedpaymentmethodshavethepotentialtoimproveaccountability,strengthenstewardship, and improve allocative efficiency and productivity of healthworkers(38-40).PBFapproachesare,however,facedwithseveralchallengesthatincludedelayedreimbursementtoproviders,gamingbyhealthproviders


and neglect of services that are not funded. The current service deliverysysteminUgandausesinformalpricingandasystembasedonsubsidies.Thetruecostofmanyinterventionsis,therefore,notknown.Aspublicprivate-partnershipexpandsinUganda,weneedtopurchasemoreservices,butwealsoneedtoknowthecostoftheseservices.Itis,therefore,necessaryforthecountrytobuildcapacityintheareaofcostingandeconomicevaluation.

Over the last two decades, results-based financing (RBF) mechanismshave emerged as ameans to improve the performance of health systems. Bydefinition,RBFrefersto“acashpaymentornon-monetarytransfermadetoanationalorsub-nationalgovernment,manager,provider,payerorconsumerofhealthservicesafterpredefinedresultshavebeenattainedandverified.Paymentis conditional on measurable actions being undertaken. RBF is an umbrellaterm for anumberof approaches that involve linking retrospectivepaymentstotheachievementofquantitativeorqualitativeindicators.RBFhasbeenusedsynonymously with pay for performance (P4P), performance-based paymentand performance-based incentives (PBI). In principle, RBF arrangementsare characterised by the following: 1) use of either financial or non-financialincentivesorboththataredirectedtowardseitherserviceproviders,beneficiariesorboth;2)deliveryofresultsrewardedafterverificationusuallydonebyathirdparty;and3)contractualarrangementsthatembodythetargetsandincentives.Therearedifferentformsofpayforperformance:performance-basedfinancing(PBF);performance-basedcontracting(PBC);cashondelivery(COD);output-basedaid(OBA);conditionalcashtransfers;vouchers;andperformance-relatedpayments(PRPs).InPBF,theprincipalisthepurchaser–thepartysettingtargetsandbuyingresultsfromtheprovidersinspecificgeographicalcatchmentareas.Theagentistheprovider–responsiblefordevelopinginnovativestrategiesandimplementingactivitiesthatwillimprovethevolumeandqualityofservicesandachievetheagreed-uponhealthtargetsorgoalsefficiently.Theremayalsobeanintermediarycontrollerbetweenthesetwopartieswhoestablishesandoverseesadherencetorulesandregulations.

Lastly, efficient and effective use of these purchasing approachesrequiresthatacountryisabletoachievethefollowing:specificationofthedeal (servicepackageandquality);adequate funds topay for thepackage;adequatecapacityofagentstoservicethedeal(HRH,technology,coverage);pricesforcompensationoftheproviders(providerutility);effectivedemandbybeneficiaries;informationandauditingofserviceutilisation;andtimelypaymentsofagents.


Programme and Policy Implications for Enhancing Strategic Purchasing of Health Services in Uganda

Ugandaneedstomoveawayfromusingmainlypassivepurchasingmethodstomorestrategicpurchasingmethodswithevidence-basedselectionoftheservices,volumeandprovidermix.Tothiseffect,thefollowingareasneedtobelookedat:

Prioritising interventions

1. Ugandadoesnothaveadequatefundscurrentlytoprovideuniversalaccesstoitsminimumhealthcarepackage.TheMinistryofHealthshoulddevelop a roadmap for thephased implementationof theminimumhealthcarepackage,givenitssizeandtheresourcesavail-abletothehealthsector.Initially,moreattentionshouldbegiventoconditionsthatcontributethehighestburdenofdisease(prematu-rity,pneumonia,diarrhoea,malariaandperinatalconditions).

2. Provisionofuniversal access to the agreed servicepackagewill re-quireincreasedallocationofresourcestothehealthsector.Increasedallocationof funds to thesector,however, shouldbeaccompaniedbyimprovedpublicsectormanagementoffundswiththestrength-eningofaccountabilityandpublicfinancemanagementsystemssoastoenhancevalueformoneyandreducecorruption.Donorfundsshouldalsobeused to fundkeypriority services identifiedby thecountryratherthanbeingearmarkedforafewprioritydiseases.

3. Toexpandthepopulationthatiscovered,specialtargetingofvulner-ablegroupsthatarecurrentlyunderservedisnecessary.Thismayin-cludetheuseofdemandandsupplysideprogrammes(e.g.targetedvouchersandperformance-basedpayments)thatallowthetargetingofsuchvulnerablegroups.

Choosing providers

1. AccordingtotheNHA,morefundsareallocatedtohospitalscom-paredtolower-levelhealthcentres.Thecentralgovernmentshouldallocatemore funds to lower-level facilitieswhere themajorityofthepopulationseekcare. Thiswill allowfunctionalisationofexist-ing lower-levelhealthcentres.Thecentralgovernment shouldalso


progressivelyallocatemorefundingforpreventiveservices.Approxi-mately75percentofthediseaseburdenresponsibleforprematuremortality in Uganda is preventable. In addition, the burden ofNCDsissteadilyincreasing.However,allocationoffundingfavourscurativecare.

2. Thelocalgovernmentsshouldpaymoreattentiontotheorganisa-tionofthedeliveryofpreventiveservicesthroughtheVHTsandtheplannedcommunityextensionhealthworkers.Furthermore,multi-sectoralplanningandtheimplementationofinterventionsthatpro-motebenefitsbeyondhealthshouldalsobeenhanced.

3. Thecentralandlocalgovernmentsshouldworkwithdevelopmentpartnerstostrengthenthereferralsystemsoastoincreasethepro-portionofthepopulationthatisabletoaccessservicesthatarenotavailableatlower-levelhealthfacilities.

Determining how services are purchased

1. The central government should consider using a combination ofinput-based and results-basedpaymentmethods. Though the cur-rent payment system for providers is useful for cost containment,it doesnot give an incentive for improvingquality and efficiency.Theresults-basedpaymentmethodswillprovide incentives fortheproviderstoimprovethequantity,efficiencyandqualityofservicesthattheyprovide.Inaddition,theycanalsobeusedtostrengthentheprovisionofpriorityservicessuchaspreventiveservices.Further,theywillstrengthenprovideraccountabilityfortheservicesthattheyprovide.However,attentionmustbepaidtoputtinginplacethein-stitutionalarrangementsrequiredformeasuringandverifyingthere-sultsaswellasensuringtimelypaymentofproviders.Healthsystemstrengtheningandcapacity-buildingshouldalsobeundertakenpriortotheinitiationofaresults-basedpaymentapproachtoensurethatfacilitiesthatarecontractedareabletoprovidetherequiredservices.

2. Thecentralandlocalgovernmentsshouldstrengthenthecoordina-tionofdonorfundsandprogrammesatnationalanddistrictlevelssoastopromotemoreeffectiveservicedelivery. DevelopmentpartnersprovideasignificantamountofservicesthroughNGOs.Morehar-monisationandcoordinationwillaidinreducingthefragmentation


offinancingpools,wastageandduplicationbymaximisingthesyn-ergiesthatexistbetweenthepublicandtheprivatesectors,leadingtomoreefficientdeliveryofqualityservices toawiderpopulationthatisinneed.

3. Thestructuresforsupportsupervisionandmonitoringofprovidersatthenationalandlocallevelsneedtobestrengthenedtoensurethattheservicesprovidedareoftherequiredquality.AlthoughUgandahas a purchaser-provider split inwhich the central government isthepurchaserofservicesandthelocalgovernmentistheprovider,thereisaweakmonitoringsysteminplacetoensurethattheservicesprovidedmeettherequiredstandards.Thisneedstobestrengthenedthroughcapacity-buildingandtheuseofapproachesthatpromoteaccountabilityandofevidencefordecision-making.Institutionalisa-tionofexistingscorecards,suchasthereproductivematernalneona-talandchildhealthscorecard,isoneoftheapproachesthatshouldbepromoted.

References

1. WorldHealthOrganisation2010,Health systems financing: the path to universal coverage, The World health report 2010.

2. WorldHealthOrganisation2000,The world health report 2000: health systems: improving performance,WorldHealthOrganisation.

3. UgandaBureauofStatistics(UBOS)1988,Uganda Demographic and Health Survey, Kampala,Uganda.

4. UgandaBureauofStatistics(UBOS)andORCMacro2014,Uganda Malaria Indicator Survey 2014-15: Key indicators, UBOS and ICFInternational,Kampala,UgandaandRockville,Maryland,USA.

5. Mayega, R, Ekirapa-Kiracho, E & Kirunda, B 2018, ‘Non-communicable diseases in low-income countries: implications forunivershal health coverage’, in Achieving UHC in Uganda, p. 45,FountainPublishers,Kampala.

6. Awor, P et al. 2018, ‘Improving child survival in Uganda.Trends,opportunities and implications for achieving universal health carecoverage in Uganda’, in Achieving UHC in Uganda, FountainPublishers,Kampala.

7. Honda,A2014,What is strategic purchasing for health?


8. WorldHealthOrganisation2017,Health financing for universal health coverage. Moving from passive to strategic purchasing.

9. Kutzin, J2013, ‘Healthfinancing foruniversal coverageandhealthsystemperformance:conceptsandimplicationsforpolicy’,Bulletin of the World Health Organisation,vol.91,no.8,pp.602-611.

10. WorldHealthOrganisation2016,Public financing for health in Africa: from Abuja to the SDGs.

11. GovernmentofUganda2012,National Health Accounts (FY 2010/11 & 2011/12). National Health Expenditure Financial Year 2010/11 and 2011/12.

12. Rutebemberwa,Eetal.2009,‘Utilisationofpublicorprivatehealthcareprovidersby febrile childrenafteruser fee removal inUganda’,Malaria Journal,vol.8,no.1,p.45.

13. Awor,Petal.2012,‘Privatesectordrugshopsinintegratedcommunitycasemanagementofmalaria,pneumonia,anddiarrheainchildreninUganda’,The American Journal of Tropical Medicine and Hygiene,vol.87(5Suppl),pp.92-96.

14. Konde-Lule,Jetal.2006,The potential of the private sector to improve health outcomes in Uganda, MakerereUniversity InstituteofPublicHealthGoogleScholar,Kampala.

15. Baine, OS et al. 2018, ‘Resource mobilization in the context ofuniversalhealthcarecoverage’,in Achieving UHC in Uganda, FountainPublishers,Kampala.

16. Nshuti,Letal.2001,‘Publicandprivateproviders’qualityofcarefortuberculosispatientsinKampala,Uganda’,The International Journal of Tuberculosis and Lung Disease,vol.5,no.11,pp.1006-1012.

17. Waiswa,Petal.2015,‘DifferencesinessentialnewborncareatbirthbetweenprivateandpublichealthfacilitiesineasternUganda’,GlobalHealthAction,vol.8,no.1,p.24251.

18. GovernmentofUganda2015,Health Sector Development Plan 2015-2020, Kampala, Uganda.

19. Government of Uganda 2017, Annual Health Sector Performance Report 2016-17.

20. GovernmentofUganda2010,Health Sector Strategic and Investment Plan II 2010-2015, MinistryofHealth,Kampala.


21. Ssengooba,F2004,‘Uganda’sminimumhealthcarepackage:rationingwithintheminimum?’ Health Policy and Development,vol.2,no.1,pp.14-23.

22. Nattimba,M,Ssemugabo,C&Aloysius,S2018,’Healthpromotion’,in Achieving UHC in Uganda,FountainPublishers,Kampala.

23. UgandaBureauofStatistics(UBOS)&ICFInternationalInc.2016,Uganda Demographic and Health Survey 2016, Kampala,UBOSandICFInternationalInc.,UgandaandCalverton,Maryland.

24. Okello,Detal.1998,‘ThechallengetorestoringbasichealthcareinUganda’,Social Science & Medicine,vol.46,no.1,pp.13-21.

25. Mbonye,Aetal.2007,‘DecliningmaternalmortalityratioinUganda:priorityinterventionstoachievetheMillenniumDevelopmentGoal’,International Journal of Gynecology & Obstetrics, vol. 98, no. 3, pp.285-290.

26. Rutebemberwa,E&Hongoro,C2018,‘HowisphysicalinfrastructureinUgandasupportingUniversalhealthcoverage’,inAchieving UHC in Uganda,FountainPublishers,Kampala.

27. Kisakye,A,Mwaka,E&Wanda,S2018‘HarnessinghealthtechnologiesandequipmentforUniversalhealthcoverageinUganda’,inAchieving UHC in Uganda,FountainPublishers,Kampala.

28. Ssengooba,F,McPake,B&Palmer,N2012,‘Whyperformance-basedcontractingfailedinUganda-an“open-box”evaluationofacomplexhealthsystemintervention’,SocialScience&Medicine,vol.75,no. 2,pp.377-383.

29. Tashobya,CKetal.2006,Health systems reforms in Uganda: processes and outputs, Health Systems Development Programme, LondonSchoolofHygiene&TropicalMedicine,London.

30. Ssenyonjo,Aetal.2018,‘Governmentresourcecontributionstotheprivate-not-for-profit sector in Uganda: evolution, adaptations andimplications for universal health coverage’, International Journal for Equity in Health(inpress).

31. Alfonso,YNetal.2013,’Cost-effectivenessanalysisofavoucherschemecombinedwithobstetricalqualityimprovements:quasiexperimentalresultsfromUganda’,Health Policy and Planning,vol.30,no.1,pp.88-99.


32. Resyst. 2016, Strategic purchasing for universal health coverage: a critical assessment. The South African integrated public system. Research Brief, http://resyst.lshtm.ac.uk/sites/resyst.lshtm.ac.uk/files/SA%20purchasing%20brief%20integrated%20public%20system.pdf.

33. Franco, L.M., S. Bennett, and R. Kanfer, Health sector reform and public sector health worker motivation: a conceptual framework.Socialscience&medicine,2002.54(8):p.1255-1266.

34. Institute forHealthMetrics and Evaluation (IHME) 2014, Health service provision in Uganda: assessing facility capacity, costs of care, and patient perspectives, Seattle,Washington, USA.

35. Eldridge,C&Palmer,N2009, ‘Performance-basedpayment: somereflections on the discourse, evidence and unanswered questions’,Health Policy and Planning,vol.24,no.3,pp.160-166.

36. Ssengooba,FP2010,Performance-based contracting: a case study of non-profit hospitals in Uganda,PhDthesis,LondonSchoolofHygieneandTropicalMedicine,UniversityofLondon.

37. Ireland,M, Paul, E&Dujardin, B 2011, ‘Can performance-basedfinancingbeusedtoreformhealthsystemsindevelopingcountries?’Bulletin of the World Health Organisation,vol.89,no.9,pp.695-698.

38. Sy,A,Sekabaraga,C&Soucat,A2010,More and better performing health workers: reforms and the health labor market in Rwanda (African Region Human Development Series),TheWorldBank,Washington.

39. Basinga,Petal.2011,‘EffectonmaternalandchildhealthservicesinRwandaofpaymenttoprimaryhealth-careprovidersforperformance:animpactevaluation’,The Lancet,vol.377,no.9775,pp.1421-1428.

40. Meessen, B, Soucat, A. & C. Sekabaraga, C. 2011, ‘Performance-basedfinancing:justadonorfadoracatalysttowardscomprehensivehealth-carereform?’ Bulletin of the World Health Organisation,vol.89,no.2,pp.153-156.

purchasing health care services for universal health...

Documents