A number of Results-Based Financing (RBF) initiatives have been (or are being) implemented in Uganda over the last decade, yet so far the RBF movement has not taken off in the country. It’s not really clear why this is the case. The need to bridge this information and evidence gap motivated a team of researchers from Makerere University School of Public Health (MakSPH) and the Ugandan Ministry of Health (MoH) to apply successfully for a grant to understand the extent and determinants of RBF scale-up in Uganda. This case study is part of a multi-country research initiative supported by the Institute of Tropical Medicine (ITM), Antwerp and the WHO Alliance for Health Policy and System Research (AHPSR). This will provide lessons for future RBF scaling up and sustaining the momentum at national and international level. In this blog post, I will zoom in on some ongoing processes.
RBF: “Your flight has been delayed…”
While scaling up of effective health interventions or strategies is considered essential to benefit more people, there is limited documented evidence on how to foster such scaling up process, particularly on Results-Based Financing (RBF). Many countries are at different levels of integrating RBF in the health system.
Where is Uganda currently in this integration process? Well, RBF in Uganda feels a bit like a plane ready for take-off, but then the plane is postponed for a number of reasons unknown to most passengers. Our job is to find out why and then try to make sure the plane gets in the air, at last. And that it is ensured of a safe journey, then, of course!
Our own (research) focus in Uganda will be to explore the evolutionary journey of four RBF schemes that have been implemented in Uganda over the last 10 years, trying to understand also why there was little integration of RBF into the national health system till now.
The schemes being studied include two supply side pilots namely a World Bank project and the NuHealth project still being implemented since 2011 and ending in 2015. The other two schemes are demand side projects, the Safe Delivery project implemented from 2009 to 2011 and a Safe Motherhood voucher system implemented between 2006 and 2011. This is a qualitative research project, using three data collection methods namely document/literature review, key informant interviews and participant observation.
National consultation workshop on RBF
Recently (16-17 February 2015), a national workshop on RBF took place at Serena Hotel, Entebbe. The meeting was co-organised by the Ministry of Health (MoH) and the Belgian Technical Cooperation (BTC). At the meeting, it became clear that the RBF future looks perhaps brighter than ever in Uganda. The RBF plane might - at last - be ready for take-off, capitalizing, among others, on the Universal Health Coverage drive.
BTC and the Ministry of Health (MoH) are currently launching a new RBF pilot project in two regions in the country. This National Consultation Workshop on RBF was organized in preparation for this project, with support from Makerere University School of Public Health (MakSPH), the Institute of Tropical Medicine, Antwerp (ITM) and WHO Country Office. It was noted by the BTC Project architects that the different schemes (over the last decade) have been implemented as standalone projects with little cross linkage/learning taking place between them. Thus the main purpose of the workshop was to share experiences from implementers, academics and donors such that the new pilot draws lessons from the previous RBF initiatives.
This national consultation workshop provided a unique platform for us to assess the current dynamics of RBF in Uganda. It was an opportunity to explore the MoH’s and BTC’s commitment, readiness and willingness to learn from previous initiatives. It was also an opportunity to understand the proposed RBF design and how it can be leveraged for scale-up nationally.
Will RBF take off this time?
One of the key workshop presentations was made by the Director of Planning at MoH, Dr Isaac Ezati. Dr Ezati provided an overview of the overarching objectives of the Health sector Strategic and Investment Plan (2015/16-2019/20) currently under development. He explained that the overall sectoral objective over this period was achieving Universal Health Coverage (UHC) in line with the Post-2015 development goals. He emphasised that RBF in Uganda is being discussed now in light of the UHC agenda. In fact, he indicated that MoH saw one of the roles of RBF as engendering strategic purchasing for UHC. So it appears that UHC ensures some vital ‘kerosene’ to the RBF movement.
The workshop was another opportunity for various RBF schemes implemented in Uganda thus far to showcase their experiences and achievements. This demonstrated BTC/MoH’s willingness to learn from local experiences. The schemes demonstrated diversity in design and institutional arrangements and provided a wide scope of lessons for BTC to learn from. But as one participant lamented, there was generally little discussion on the costs of RBF pilots, yet high costs have been cited as a barrier for buy-in. To address this challenge, BTC considers hiring a consultant to undertake a costing study for services under the Uganda national Minimum Health care package (UNMHCP).The UNMHCP will be the minimum benefit package under the BTC pilot.
Another presentation from WHO noted that several other health financing reforms such as developing a health financing strategy, finalising fund allocation formula and a National health insurance Scheme (now at Bill level) are taking place simultaneously. This presentation implied that for a pilot to be successful, its design must take into account wider health system issues to enable scale up in entire country. Several health system bottlenecks have to be addressed to allow national scale up of RBF (not unlike for a plane which also needs an entire “eco-system” to function well, both on the ground and in the air, in order to be able to take off, fly and land safely ).
Accordingly, participants discussed a number of constraints such as understaffing leading to heavy workload, poor supervision and poor logistics management. Given these health system bottlenecks, it was emphasised that the BTC model should not be after punishing poor performers to prevent system paralysis. In the meantime, the MoH must articulate a strategy to upgrade facilities with bottlenecks to reach a specific level of functionality to deliver the basic health care package. Otherwise, effectiveness and scalability of RBF in the future would be jeopardized.
Other design parameters discussed related to the utilisation of rewards. It was underscored that allowing autonomy strengthens responsiveness of the health provision and gives room for entrepreneurship. However, this workshop brought to the fore the challenges of extending RBF to public health facilities (which must take place if national scale up is to be achieved). It was noted that almost all previous RBF schemes left out the public health facilities leading to a dearth of experiences on how RBF works in the Public sector. To allay these concerns, the MoH & BTC indicated that the RBF plane will take off from the Private-Not-For Profit (PNFP) airport but will extend to the public sector airport in the second project year. It remains to be seen how this will be realised!
Formation of Working groups…
Participants agreed that it is time to move beyond RBF pilots to national scale up in the country. To facilitate scaling up, the Ministry and BTC pledged to allow for flexibility in the design and implementation. This brought forth other challenges to the scheme as it has to balance demonstrating effectiveness (as accountability to donors) and trying to fit into the country’s learning agenda. Learning during implementation would obviously boost the chances of taking corrective and preventive actions on a timely basis. Indeed, to support the learning function, a Learning Committee supported by MakSPH and ITM was proposed to avoid perverse results as noted in the first Ugandan pilot. BTC assured the participants that there is a budget for these activities.
The workshop did not agree on the design for the BTC pilot. For pragmatic reasons, it was agreed that such technical issues could not be resolved in a plenary. Accordingly, a Technical Working Group under MoH and BTC was proposed to follow up on this issue. However, strangely enough its exact membership composition and timelines were not clearly communicated (air traffic controllers’ communication can still be improved…). This issue has implications considering that the MoH/BTC reported that they were planning to go ahead with the launch of the pilot in a month or so. The fear that this lack of clarity of structure may be detrimental to the buy-in of stakeholders is not far-fetched, especially as engagements with sub-national stakeholders are going into high gear.
RBF: ready for boarding?
As became clear during the workshop, the BTC pilot will start soon. What remains to be seen, though, is the extent to which it will catalyse the momentum towards integrating RBF into the entire national health system. The commitment and enthusiasm from the MOH and BTC representatives was palpable. However, it has to be noted that the proposed RBF design is still a work in progress. Hopefully at the end of all these efforts, Uganda will for the first time have a RBF scheme reflecting its national health agenda, with attributes rendering it scalable throughout the country.
And once that is the case, I'm sure the RBF plane is set for a wonderful journey in Uganda!