1. From RBF to public Insurance?
Go toward universal coverage

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

3. 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

4. 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

5. 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?

6. 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

7. 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

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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’)

16. RBF institutional relationships in PNFP Project
Controlling team

17. Proposed RBF institutional relationships at later stage
Controlling team

18. 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

19. 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

20. The end
Fedjo

21. 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

22. 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

23. Main activities at the preparation phase1
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