1. 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

2. 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)
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3. Context
Improving health coverage without improve the overall quality will not led to UHC goals
Need to upgrade Health Centre 2
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4. 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

5. 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

6. 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

7. 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
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8. Proposed interventions in the “Quality Improvement Strategic plan” (MoH, 2010)
Fedjo

9. 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
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10. 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
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11. 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

12. RBF incentives calculation formula
Fedjo

13. 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

14. 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

15. 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

16. 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
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17. 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
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18. 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