A necessity, not a choice: the case for purchasing COVID-19 services from the private sector in Uganda

26 May 2020

This piece originally appeared on Health Systems Governance Collaborative.

As country governments execute their COVID-19 response, the World Health Organization and other stakeholders have stressed the importance of engaging the private sector. One critical part of that is purchasing health services from private providers, the case for which is strongest in places where private health facilities account for a significant share of service provision.

Uganda serves as an example of such a country. According to the 2018 master facility list, nearly 55% of all health facilities in Uganda are private (either for-profit or not-for-profit). The distribution is particularly skewed in urban settings. In the capital city of Kampala, the public sector accounts for only 2% of health facilities in the city, while private for-profit facilities account for 94% (see figure). While the Government of Uganda has a long history of engaging with faith-based not-for-profit private facilities (PNFP), they have limited mechanisms to use public funds to purchase services from private for-profit facilities.

The absence of such capacity to work with private for-profit providers in urban Uganda is a challenge in the best of times. Now with the arrival of COVID-19 in Uganda, it becomes all the more imperative to engage the private sector.

Uganda’s response to the pandemic so far

The first case of COVID-19 in Uganda was identified in late March and has the potential to rapidly overwhelm urban health systems as they are currently assembled. The Government of Uganda moved swiftly to lock down the country, (re)allocate public funds for the response, and set up a coordination approach across multiple sectors. The National Taskforce set up by the Ministry of Health to coordinate the response includes private sector representation through the Uganda Healthcare Federation (UHF), an umbrella association for private providers. The Taskforce has issued guidance to public and private providers on how they should manage COVID-19 and other essential services, which UHF and ThinkWell have used to train private providers. The Government has also conducted service capacity assessments for all faith-based providers and select large for-profit private facilities on their readiness to handle cases.

What else can be done?

Uganda can do much more to leverage the private sector to expand testing, identify and isolate cases, coordinate referrals, and help keep access open for routine services not related to COVID-19, especially in urban areas that have large, densely-packed populations. There is international guidance on how this can be achieved – the WHO has released an action plan for ministries of health to engage the private sector in response to COVID-19. Other outlets have recommended phased approaches with the private sector, starting with the acute response in the next 3 months, and longer-term phases that involve peer-to-peer support and improving private sector governance.

One promising avenue is that health authorities in Uganda are discussing whether to adopt a “hub and spoke” model. This is a way to organize the system where there is a main hub (e.g. regional referral hospitals and select large private hospitals in Uganda) that can handle moderate and severe COVID cases. This hub is complemented by an array of spokes, or satellite facilities like lower tier public and private facilities, that can handle testing, case management, and if necessary, refer to the hubs. These primary health care (PHC) facilities can also ensure continued access to routine services. These models have been found to be highly scalable and efficient, as well as having the potential to enhance quality, coverage, and improve operational consistency.

To realize the potential of this model in Ugandan towns and municipalities, we recommend the following steps:

Clarify the capacity of private facilities to decide how they fit into a hub-and-spoke model
Channel essential supplies, like personal protective equipment (PPE) and oxygen, to equipped providers along with technical assistance in exchange for joining and reporting into the national health information system
Communicate training packages to clarify guidelines and protocols around COVID-19 testing, tracking, and referrals
Provide logistical and clinical backup mechanisms to support referral of cases
Set up contract arrangements with private providers to receive payments for COVID-related activities

Call to action

As we have seen around the world, this disease can spread quickly and overwhelm health systems. To protect against this risk, the Ugandan Government should take the steps needed to include the private sector in urban areas to expand the capacity and scale of their response. Preliminary steps have been taken by the Government and discussions around a hub-and-spoke model are promising, but practical steps are needed to take this attractive model and make it work in places like Kampala. The threat of COVID-19 spreading in these highly vulnerable urban areas presents a unique opportunity for the Government to put effective mechanisms in place to purchase health services from the private sector, which it can leverage for achieving universal health coverage going forward.

Written by Anooj Pattnaik, Tapley Jordanwood, Angellah Nakyanzi, Federica Margini, and Nirmala Ravishankar