From RBF to public Insurance? Go toward universal coverage

Context: Particular challenge in Uganda Uganda Health System WHO District concept Community/Households Households Households Households Households Households Households

Context: PNFP contribution from 2,585 in 2004 to 3,396 in 2010 Number of health facilities (public and PNFP) The PNFP health providers Constitutes 23% of health facilities: 606 in 2004 and 774 in 2010 Contribute to about 50% of outputs Receive a subsidy from the Government (20% of the total expenditure of the health facilities) Perceived user fees (# public facilities) Fedjo

Context: Policy objectives Constitution of the Republic of Uganda: equal rights and opportunities, access to health services, clean and safe water and education for all people in Uganda Policy objectives of the NHP II (2 among others) Facilitate access of the private sector to development capital, essential medicines and supplies for healthcare developments vital to service expansion to the population Formalize commitments with the PNFP sub-sector through memoranda of understanding and service level agreements with the view of ensuring that the level of subsidies is linked to agreed outputs with the objective of improving access for vulnerable populations Fedjo

Issues in the Performance Based Financing debate “The level of subsidies is linked to agreed outputs”!??? Little evidence (both in health care and in non-health settings) to support the effectiveness of paying for performance A management myth? predicated on assumptions rather than on solid evidence?

Critical alignment or opportunist decision? Cordaid project “Classic PBF” DFID project Research project Controlled trial: Performance Based Financing Vs input based financing BTC project Improve the value for money to convince people who endorse policies Pooling fund Prepare third part payment Feed the central level: refine health financing strategy

Performance evaluation: underlying framework Structure Process Output Resources and how they are organized How resources are used What is achieved in terms of health output and satisfaction Fedjo

External evaluation activities Accreditation Infrastructures and equipment Human Resources Public health objectives: coverage plan, financial access Certification Strategic management Quality assurance: guidelines, ME Working environment Production Health outputs Quality of services Health facilities organization Fedjo

Costing Fedjo Refine expected outputs according to UNMHCP Estimate unit flat cost Consider the cost in the lowest facility Fedjo

Other strategic choices in RBF pilot model Emphasis on facility financing Progressive purchaser/provider split Regulation Quality improvement initiatives Serious regulation of ffinancial incentives for staff Avoid overlaps and conflict of interest Manage adverse effect of the RBF Many measures beside and complementary to RBF

Use of subsides Conditional grant and organizational evaluation (10%) User fees and production evaluation (80%) Fixed costs accommodations maintenance and depreciation costs investments administration security Financial incentives bonuses trainings Recurrent costs salaries drugs consumables

Role of the RBF in the Health System Strengthening RBF is a mean Not an objective Not a magic bullet A fund allocation mechanism Health system strengthening Health Financing strategy Fund mobilization Result Based Financing !? Underlying ideological and political values

Result Based financing with a long-term vision RBF pilot initiatives RBF and third part payment by a Basket fund Universal Public Health Insurance scheme Health is a public good No privatisation MoH on driver seat No NGOs for controlling Lack of technical skills Not cost-effective Fedjo

Phasing towards the Public Health Insurance Scheme RBF fund at limited scale Support providers Increase access Basket Fund Multiple donors GoU participation National trust Fund Real purchaser-provider split Nationally owned Budget Support Belgian Cooperation RBF pilot model Gradually extend Nation wide RBF system Nationally owned contracting system and Insurance PNFP project

Contribution of Belgian Cooperation in the Health Sector Coordination between donors (BS-led) Pooling funds : Creating Basket Fund Developing a common long-term vision Piloting the model for HSS: (PNFP – ICB -led) Defining structures and functions Mastering the process (the ‘how’)

RBF institutional relationships in PNFP Project Controlling team

Proposed RBF institutional relationships at later stage Controlling team

Model of financing mechanism for affordable quality care National Trust Fund Government direct or indirect taxes Donor basket fund Salary deduction from civil servants and formally employed people Informal sector contribution Audits, Quality control Payments Health facilities Delivering care Provide necessary information's Elaborate invoices for payment National Trust Fund Managing financial means Purchasing health care Ensure patients rights Reporting Invoices Small patient contribution

Purchaser provider split at later stage Negotiate national funding Budgetary projections and feasibility analysis Contracting health services Pay performance Quality control and feedback to MoH / LG / PNFP Protect patient’s rights Protect financial accessibility ‘Protect’ non-wage recurrent budget National Trust Fund: Management of the resources Discuss the scope of UHC Define packages of care and standards Manage major investments and maintenance Ensure quality assurance, quality of care Manage costing and financial strategy Manage training Manage remuneration policy MoH: Stewardship and regulation

The end Fedjo

Context Area Projected population life expectancy (2011) 241,000 km² Area 35,356,9001 Projected population 57 and 54 for females and males respectively 45 years in 2003 life expectancy (2011) 6.2 birth/woman Total Fertility Rate 24% Contraceptive prevalence rate 72% Households within 5 Km from a health facility Fedjo

Objectives of PNFP Project Contribute to strengthen service delivery capacity at district level to effectively implement PHC activities and deliver the UNMHCP to the target population General Objective PNFP output and patients’ accessibility to quality health care have increased through a strengthened MoH-PNFP partnership with regards to the financial, human resources and functional aspects of the Ugandan health system Specific Objective

Main activities at the preparation phase 1 Joint accreditation procedures (Health center master plan?) 2 RBF manual of procedures 3 Computerization of hospital management Information system 4 Cost study and zero base budgeting exercises 5 Coverage pan and business plans 6 Quality improvement procedures 7 Training material in RBF and Short course in RBF 8 Study tours Fedjo