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Policy implementation remains an under researched area in most low and middle income countries and it is not surprising that several policies are implemented without a systematic follow up of why and how they are working or failing. This study is part of a larger project called Supporting Policy Engagement for Evidence-based Decisions (SPEED) for Universal Health Coverage in Uganda. It seeks to support policymakers monitor the implementation of vital programmes for the realisation of policy goals for Universal Health Coverage. A Policy Implementation Barometer (PIB) is proposed as a mechanism to provide feedback to the decision makers about the implementation of a selected set of policy programmes at various implementation levels (macro, meso and micro level). The main objective is to establish the extent of implementation of malaria, family planning and emergency obstetric care policies in Uganda and use these results to support stakeholder engagements for corrective action. This is the first PIB survey of the three planned surveys and its specific objectives include: assessment of the perceived appropriateness of implementation programmes to the identified policy problems; determination of enablers and constraints to implementation of the policies; comparison of on-line and face-to-face administration of the PIB questionnaire among target respondents; and documentation of stakeholder responses to PIB findings with regard to corrective actions for implementation. The PIB will be a descriptive and analytical study employing mixed methods in which both quantitative and qualitative data will be systematically collected and analysed. The first wave will focus on 10 districts and primary data will be collected through interviews. The study seeks to interview 570 respondents of which 120 will be selected at national level with 40 based on each of the three policy domains, 200 from 10 randomly selected districts, and 250 from 50 facilities. Half of the respondents at each level will be randomly assigned to either face-to-face or on-line interviews. An integrated questionnaire for these interviews will collect both quantitative data through Likert scale-type questions, and qualitative data through open-ended questions. And finally focused dialogues will be conducted with selected stakeholders for feedback on the PIB findings. Secondary data will be collected using data extraction tools for performance statistics. It is anticipated that the PIB findings and more importantly, the focused dialogues with relevant stakeholders, that will be convened to discuss the findings and establish corrective actions, will enhance uptake of results and effective health policy implementation towards universal health coverage in Uganda.

We highlighted the importance of undertaking value assessments for health system inputs if allocative efficiency is to be achieve with health system resources, with a focus on low- and middle-income countries. However, methodological challenges complicated the application of current economic evaluation techniques to health system input investments.

ABSTRACTSeveral purchasing arrangements coexist in Uganda, creating opportunities for synergy but also leading to conflicting incentives and inefficiencies in resource allocation and purchasing functions. This paper analyzes the key health care purchasing functions in Uganda and the implications of the various purchasing arrangements for universal health coverage (UHC). The data for this paper were collected through a document review and stakeholder dialogue. The analysis was guided by the Strategic Health Purchasing Progress Tracking Framework created by the Strategic Purchasing Africa Resource Center (SPARC) and its technical partners. Uganda has a minimum health care package that targets the main causes of morbidity and mortality as well as specific vulnerable groups. However, provision of the package is patchy, largely due to inadequate domestic financing and duplication of services funded by development partners. There is selective contracting with private-sector providers. Facilities receive direct funding from both the government budget and development partners. Unlike government-budget funding, payment from output-based donor-funded projects and performance-based financing (PBF) projects is linked to service quality and has specified conditions for use. Specification of UHC targets is still nascent and evolving in Uganda. Expansion of service coverage in Uganda can be achieved through enhanced resource pooling and harmonization of government and donor priorities. Greater provider autonomy, better work planning, direct facility funding, and provision of flexible funds to service providers are essential elements in the delivery of high-quality services that meet local needs and Uganda’s UHC aspirations.

ABSTRACTThe most effective way to finance universal health coverage (UHC) is through compulsory prepaid funds that flow through the government budget. Public funds—including on-budget donor resources—allow for pooling and allocation of resources to providers in a way that aligns with population health needs. This is particularly important for low-income settings with fiscal constraints. While much attention is paid to innovative sources of additional financing for UHC and to implementing strategic purchasing approaches, the government budget will continue to be the main source of health financing in most countries—and the most stable mechanism for channeling additional funds. The government budget should therefore be front and center on the strategic purchasing agenda. This commentary uses lessons from Tanzania and Uganda to demonstrate that more can be done to use the government budget as a vehicle for making health purchasing more strategic, across all phases of the budget cycle, and for making greater progress toward UHC. Actions need to be accompanied by measures to address bottlenecks in the public financial management system.

ABSTRACTThe Strategic Purchasing Africa Resource Center (SPARC) developed a framework for tracking strategic purchasing that uses a functional and practical approach to describe, assess, and strengthen purchasing to facilitate policy dialogue within countries. This framework was applied in nine African countries to assess their progress on strategic purchasing. This paper summarizes overarching lessons from the experiences of the nine countries. In each country, researchers populated a Microsoft Excel–based matrix using data collected through document reviews and key informant interviews conducted between September 2019 and March 2021. The matrix documented governance arrangements; core purchasing functions (benefits specification, contracting arrangements, provider payment, and performance monitoring); external factors affecting purchasing; and results attributable to the implementation of these purchasing functions. SPARC and its partners synthesized information from the country assessments to draw lessons applicable to strategic purchasing in Africa. All nine countries have fragmented health financing systems, each with distinct purchasing arrangements. Countries have made some progress in specifying a benefit package that addresses the health needs of the most vulnerable groups and entering into selective contracts with mostly private providers that specify expectations and priorities. Progress on provider payment and performance monitoring has been limited. Overall, progress on strategic purchasing has been limited in most of the countries and has not led to large-scale health system improvements because of the persistence of out-of-pocket payments as the main source of health financing and the high degree of fragmentation, which limits purchasing power to allocate resources and incentivize providers to improve productivity and quality of care.

ABSTRACTBackground: Results-based financing has been promoted as an innovative mechanism to improve the performance of health systems in achieving universal health coverage. Several results-based financing models were implemented in Uganda between 2003 and 2015 but with limited national scale-up.Objective: This paper examines the evolution of results-based financing models and the reasons for the slow national adoption and implementation in Uganda.Methods: This was a qualitative study based on document review and key informant interviews. The models were compared to show modifications overtime. The reasons for the slow national scale-up were analyzed using variables from the Diffusion of Innovations Theory.Results: This study covered seven schemes implemented in the Ugandan health sector between 2003 and 2015. The models evolved in several aspects: 1) donor reliance with fundholding and purchasing delegated to non-state organizations; 2) establishment of ad-hoc structures for learning; 3) recent involvement of the government agencies in verification processes; 4) Involvement of public providers, and 5) expansion of services purchased from the national minimum health-care package. The main reasons for slow national adoption were the perceived complexity and incompatibility with public sector systems. The early phases comprised barriers to public sector reforms. However, recent adjustments to the schemes have enabled greater involvement of public providers and government stewardship. Stakeholders also reported progressive learning across projects and time.Conclusion: Overall, the study findings show scheme actors’ deliberate efforts to adapt their models to the Ugandan health system and public sector context. Results-based financing is a complex intervention that takes time for the capacity to be built among vital actors. Progressive re-designing of models enhances fitness to the health systems context. From this study, we advise that Uganda and similar countries should undertake deliberate efforts to customize such models to the capacity and institutional architecture of their health systems.

ABSTRACTBackgroundResults-based financing initiatives have been implemented in many countries as stand-alone projects but with little integration into national health systems. Results-based financing became more prominent in Uganda’s health policy agenda in 2014–2015 in the context of the policy imperative to finance universal health coverage.ObjectiveTo explore plausible explanations for the increased policy interest in the scale-up of results-based financing in Uganda.MethodsIn this qualitative study, information was collected through key informant interviews, consultative meetings (2014 and 2015) and document reviews about agenda-setting processes. The conceptual framework for the analysis was derived from the work of Sabatier, Kingdon and Stone.ResultsFour alternative policy arguments can explain the scale-up of results-based financing in Uganda. They are: 1) external funding opportunities tied to results-based financing create incentives for adopting policies and plans; 2) increased expertise by Ministry of Health officials in the implementation of results-based financing schemes helps frame capacity accumulation arguments; 3) the national ownership argument is supported by increased desire for alignment and fit between results-based financing structures and legitimate institutions that manage the health system; and 4) the health systems argument is backed by evidence of the levers and constraints needed for sustainable performance. Shortages in medicines and workforce are key examples. Overall, the external funding argument was the most compelling.ConclusionThe different explanations illustrate the strengths and the vulnerability of the results-based financing policy agenda in Uganda. In the short term, donor aid has been the main factor shifting the policy agenda in favour of results-based financing. The high cost of results-based financing is likely to slow implementation. If results-based financing is to find a good fit within the Ugandan health system, and other similar settings, then policy and action are needed to improve system readiness.

ABSTRACTBackgroundThere is international consensus on the need for countries to work towards achieving universal health coverage (UHC) whereby the population is given access to all appropriate promotive, preventive, curative and rehabilitative services at affordable cost. The World Health Organisation (2013) urges all countries to undertake research to customise UHC within national development agendas.ObjectiveTo describe the process used to prioritise UHC within the health systems research and development agenda in Uganda.MethodsTwo national consultative workshops were convened in May and August 2015 to develop a UHC research agenda in Uganda. The participants included multisector representatives from local, national, and international organisations. A participatory approach with structured deliberations and multi-voting techniques was used. Stakeholders’ views were analysed thematically according to health systems building blocks, and multi-voting was used to assign priorities across themes and sub-themes. The priorities were further validated and disseminated at national health sector meetings.ResultsOf the 80 invited stakeholders, 57 (71.3%) attended. The expressed priorities were: 1) health workforce; 2) governance; 3) financing; 4) service delivery, and 5) community health. The participants also recommended crosscutting research themes to address the social determinants of health, multisectoral collaboration, and health system resilience to protect against external shocks and disease epidemics.ConclusionDiscussions that capture the diverse perspectives of stakeholders provide a way of exploring UHC within health policy and systems development. In Uganda, attention should be paid to the principal challenges of mobilising financial and technical capabilities for research and strengthening the link between evidence generation and policy actions to achieve UHC.

ABSTRACTBackground: The perception within literature and populace is that the private for-profit sector is for the rich only, and this characteristic results in behaviours that hinder advancement of Universal health coverage (UHC) goals. The context of Northern Uganda presents an opportunity for understanding how the private sector continues to thrive in settings with high poverty levels and history of conflict.Objective: The study aimed at understanding access mechanisms employed by the formal private for-profit providers (FPFPs) to enable pro-poor access to health services in post conflict Northern Uganda.Methods: Data collection was conducted in Gulu municipality in 2015 using Organisational survey of 45 registered formal private for-profit providers (FPFPs),10 life histories, and 13 key informant interviews. Descriptive statistics were generated for the quantitative findings whereas qualitative findings were analysed thematically.Results: FPFPs pragmatically employed various access mechanisms and these included fee exemptions and provision of free services, fee reductions, use of loan books, breaking down doses and partial payments. Most mechanisms were preceded by managers’ subjective identification of the poor, while operationalisation heavily depended on the managers’ availability and trust between the provider and the customer. For a few FPFPs, partnerships with Non-governmental organisations (NGOs) and government enabled provision of free, albeit mainly preventive services, including immunisation, consultations, screening for blood pressure and family planning. Challenges such as quality issues, information asymmetry and standardisation of charges arose during implementation of the mechanisms.Conclusion: The identification of the poor by the FPFPs was subjective and unsystematic. FPFPs implemented various innovations to ensure pro-poor access to health services. However, they face a continuous dilemma of balancing the profit maximization and altruism objectives. Implementation of some pro-poor mechanisms raises concerns included those related to quality and standardisation of pricing.

ABSTRACTBackground: In the context of declining international assistance for ART scale-up in Sub-Saharan Africa, the institutionalization of ART programs through integrating them in the organizational routines of health facilities is gaining importance as a program sustainability strategy.Objective: The aims of this study were; (i) to compare the level of institutionalization of ART programs in health facilities in Uganda and (ii) to explore reasons for variations in the degree of program institutionalization.Methods: In Phase One, we utilized Level of Institutionalization Scales developed by Goodman (1993) to measure the degree of institutionalization of ART interventions in 195 health facilities across Uganda. The 45-item questionnaire measured institutionalization based on four sub-systems (production, maintenance, supportive, managerial) theorized to make up an organization assessed against two levels of institutionalization; routines (lowest) niche saturation (highest). In Phase Two, four health facilities were purposively selected (2 with the highest and 2 with the lowest institutionalization scores) for a multiple case-study involving semi-structured interviews with ART clinic managers(n = 32), on-site observations and document review.Results: The two highest scoring health facilities had a longer HIV intervention implementation history of between 8 and 11 years. The highest scoring cases associated intervention institutionalization with sustained workforce trainings in ART management, the retention of ART-trained personnel and generating in-house ART manuals. The turnover of ART-proficient staff was identified as a barrier to intervention institutionalization in the lowest-ranked cases. Significant differences in organizational contexts were identified. The two highest-ranked health facilities were well-established, higher-tier hospitals while the lowest scoring health facilities were lower-level health facilities.Conclusions: The level of institutionalization of ART interventions appeared to be differentiated by level of care in the Ugandan health system. Interventions aimed at strengthening program institutionalization in lower-level health centers at the level of human resources for health could enhance ART scale-up sustainability.