Results-based financing for quality health care
Project Title: NU-Health Location: Uganda Client: DFID Date: October 2011 - September 2015
NU-Health is a results-based financing project working with private-not-for-profit health centres in Northern Uganda. The project has demonstrated that results-based financing improves the quality of health care.
Northern Uganda is in transition from a fragile, post-conflict setting, still recovering from 20 years of humanitarian crisis following a protracted conflict between the insurgent Lord’s Resistance Army (LRA), and Ugandan government forces. With the cessation of conflict in late 2006, the population began moving back to their land and rebuilding their lives. It has taken longer, however, to re-establish social services including ensuring access to nutrition and health services across the region. Health systems remain weak and challenges remain around access, staff retention, quality of care, and the availability of essential medicines and health supplies (EMHS).
While traditional donor inputs into health systems support have relied on a financial input based model, it is unclear whether this approach leads to the most effective results for both quality of care or system strengthening. There has been little work to date to look at alternative funding mechanisms, particularly the impact of supply side results based financing.
As part of the UK aid funded Post-Conflict Development Programme in Northern Uganda, NU Health aimed to generate evidence on how local and national mechanisms for governance and accountability can be most effectively strengthened, and access to health and other social services improved. The programme provided both direct health systems support in two regions, and a robust evaluation of the two financing models used - ‘Results based financing’ (RBF) and ‘Input based financing’ (IBF). The study included a regular facility level on-site verification methodology, quality of care audits, value for money analysis, client perception surveys and broader qualitative reviews.
By linking payments to achievement of defined performance targets, RBF aims to align the incentives of providers, purchasers and consumers of health services, to improve both health system effectiveness and efficiency. While conventional “input-based financing” focuses on getting key inputs in place, it does not address the issue of the “production process,” and how inputs come together to create desirable outputs and outcomes. By contrast RBF provides incentives to health service providers to focus on health outputs and outcomes with the potential for increasing accountability.
NU Health consisted of an RBF intervention group of 21 eligible private-not-for-profit (PNFP) health facilities in the Acholi subregion of Northern Uganda, and a comparison IBF group of 10 PNFP in the neighbouring sub-region of Lango. In addition, there was a strong institutional strengthening component focusing on the District Health Teams in both sub-regions. Capacity development activities included secondment of staff, joint quality assurance monitoring and support supervision, and training on health data management and analysis.
The project demonstrated that the quality of care provided by the RBF health facilities improved more quickly and remained at a higher level than the comparison IBF group. The results of the project are influencing national policy and thinking on the role of result-based financing in the health sector.
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