Support the quality improvement by the Result Based Financing in Uganda Contribution of the RBF in the implementation of the Ugandan Quality improvement Strategic Plan

More than 70% of the population lives <5Km from a health facility, Context More than 70% of the population lives <5Km from a health facility, but Clinics and HC II represents around 70% of the Health facilities Mismatch between health infrastructure development and other resources: personnel, equipment, medicines and supplies Inadequate or poor medical equipment in existing facilities: only 40% of the available equipment is in good condition Inequitable distribution of providers especially those providing specialist care Guidelines for Designation, Establishment and Upgrading of Health Units (MoH, 2011) CT-FBP

Context Improving health coverage without improve the overall quality will not led to UHC goals Need to upgrade Health Centre 2 CT-FBP

Context Ugandans do not received the services they need missed opportunities leading to waste and inefficiency delayed care leading to dissatisfaction and ineffective services Ugandans received many services they do not need Ugandans are harmed by some services they receive Medical errors generate additional cost and waste, leading to inefficiency and dissatisfaction

Context: HSSP III There is a lack of supervision skills, at all levels of the system… technical supervision is weak and this has affected quality of service delivery. Productivity is low due to high rates of absenteeism and rampant dualism (estimates the cost of absenteeism at 26 billion UGX annually) The poor attitude of health workers to clients affects utilisation of services. Health workers often do not feel accountable to client communities Delays in procurement, poor quantification by and late orders from facilities and poor records keeping … contribute to shortage and wastage of medicines

Context: Weakness in Health Information System Weakness in HIS Limited access to information/data on quality of care Incomplete and untimely data when existing Data focused on key health sector indicators than progress made in the implementation of work plans Limited capacity for data synthesis, analyses and problem solving

May the result Based Financing solve these problems? Usually, RBF focus on infrastructure, availability of equipment and drugs, facility management (77% of indicators) with 41% related to infrastructure and equipment There is far limited evidence on what works for improving quality outcomes in RBF environment There are many side effects of the RBF Neglected services that are not rewarded Cream skimming: offer of costless services Supplier induced demand services that are remunerated Shorter time for the patients or delegation to unqualified staff due to increase workload Irrational Reference of costly patients to avoid costs Falsification of evidence or manipulation of data to receive more funds 43 quality checklists from 3 regions 39 latest versions and 4 older versions Funded by governments, World Bank, USAID, CDC and KFW CT-FBP

Proposed interventions in the “Quality Improvement Strategic plan” (MoH, 2010) Fedjo

How can the PNFP project contribute to quality improvement? Target (District level) Interventions Coverage plan Accreditation Output Based Payment Third party payment Result Geographic access with Efficiency Quality of care Financial access and financial protection Outcome UHC & MDG Inputs: Infrastruct ures, Equipmen t, HR Proces s: CQI, Strategic managem ent Output : Public health priorities Equity HSS Coverage plan: access to UNMHCP with efficiency in resources allocation IN “Guidelines for Designation, Establishment and Upgrading of Health” Units (MoH, 2011) Accreditation (HSS): Quality Improvement Strategic plan (MoH, 2010) Output subsides: NHP II & Health Financing strategy Financial access and financial protection (No catastrophic expenses) Equity and UHC: constitution of Uganda CT-FBP

Performance assessment Inputs Process Outputs Pre qualification Basic structural standards: minimum inputs to protect health and safety of the public Quality assessment Optimal but achievable standards to foster the culture of QI and stimulate performance improvement Production Health outputs / patient outcomes: achieve quantitative and qualitative goals by setting maximum achievable standards CT-FBP

Overview of RBF procedures Prequalification Accreditation Output payment Selection of health Facilities based on basic requirement of Infrastructures, equipment and human resources corresponding to the level of care that they are supposed to deliver Prequalified facilities are assessed according to the quality standards (cross cutting) and for the implementation of the quality improvement plan Quarterly assessment of output according to composite (quantitative and qualitative) indicators that determines the financial support from the RBF scheme If not qualified, Health facility is planned for corrective investments in order to re-submit the candidature, and supported to enable them to fulfil the criteria Initial investment for drugs and sundries for an optimal kick-off, Quarterly quality credit payment from RBF scheme in which personnel incentive are paid Fund received are re-invested in the service delivery and quality improvement initiatives as in the business plan

RBF incentives calculation formula Fedjo

Hypothesis 1: The prequalification and the accreditation process will be adopted by the stakeholders Opportunities Observation Catholic and Protestant medical bureaus have been conducted accreditation of Health facilities under their umbrella organization The MoH will develop a more comprehensive accreditation system as part of the national QM plan and strategy (HSQIFSP) The Prequalification tool may had been used to assess facility out of the project area by UOMB, without the Result based Financing The results of the assessment has contributed to prepare comprehensive supervision by the PNFP coordinating bodies

Hypothesis 2: Different stakeholders at local level will invest in the improvement of the quality of care Opportunities Observations Follow up of the Guidelines for Designation, Establishment and Upgrading of Health Units (MoH, 2011) by the elaboration and implementation of District coverage plan With the decentralization, the local authorities are interest in avoiding wasteful investments The Health Centre have increase their investment (using the user fees) in capital cost to prepare the prequalification assessment Fund raising was done in the church by a rural Health Centre in Kamwenge District to invest in infrastructure Fedjo

Hypothesis 3: “Quality can be measured externally Hypothesis 3: “Quality can be measured externally. Internally it can be measured and improved” (R.H. Palmer) Observations Opportunities The internal verification is emphasize in the Uganda RBF model The identification of the discrepancy between the number of case in the HIMS and the number of case verify is an entry point for the quality improvement The computerization of the Health facilities will increase the availability and the quality of data Self assessment as compulsory criteria for prequalification has led to urge improvement without any investment for the project

Zero based budget as benchmark in the planning process Hypothesis 4: The generalization of the flat fees will be an incentive for the quality improvement Opportunities Observations Training in cost study and the use of the cost study result to improve the Health facility business plan Zero based budget as benchmark in the planning process No competition for contracts among facilities and other stakeholders, or the high expenses on staff incentives: the health Facility are not encourage to reduce the investment on quality improvement initiatives The RBF fund are estimated to close the financing gaps in the health facility, but avoid the institutionalization of inefficiencies The health Facility will realise that the poor quality is most expensive (direct and indirect costs) than good quality CT-FBP

Hypothesis 5: The generalization of the flat fees will increase the perceived quality Opportunities Only one payment, hence less queue at the cashier will led to decrease of waiting time in the health facility User fees will be predictable and may strengthen the public’s confidence in health services The National Health accounts indicated that 49% of total health expenditure in Uganda is paid out of pocket Scott and Farrar 2002 CT-FBP

Hypothesis 6: The prequalification and the accreditation process is sustainable Institutional level The intervention is design (and the indicators are defined) to support the implementation of the Health Sector Quality Improvement Strategic Plan (2010) Health Facility Quality of Care Assessment Program Organizational level The quarterly quality assessment, Improve the strategic management in Health facility Create the best environment for the quality improvement Stimulate the Quality improvement initiatives Individual level The monitoring and evaluation and the clinical audits are entry points to identified the causes and consequences,(include the medical errors) of the poor quality of care