SP4PHC in Uganda

The Government of Uganda (GOU) is implementing reforms to improve how it purchases primary health care, as envisaged in the 2016 Health Financing Strategy.  Key among these, following many years of implementing externally funded results-based financing (RBF) projects, is mainstreaming the RBF approach into its public financial management (PFM) systems. The ThinkWell SP4PHC team in Uganda supported the GOU to develop and refine its mainstreaming strategy by providing extensive guidance on the key considerations for implementation. The team commissioned relevant research, with our local learning partner, the Makerere University School of Public Health (MakSPH), that focused on mechanisms for contracting and purchasing PHC services at the national and subnational levels, and facilitated the policymaking process throughout governmental review and approval. Our current focus is on supporting the GOU to implement, refine, and evaluate its RBF mainstreaming policy.

ThinkWell’s accomplishments in Uganda

  • Assessed Uganda’s reproductive health voucher schemes and documented how the lessons learned can be applied to Uganda’s health financing system.
  • Provided embedded support to the RBF Unit in the MOH for the roll-out of the GFF-funded RBF mechanism, achieving nationwide coverage in April 2020.
  • Conducted a review of Uganda’s purchasing landscape and undertook operations research to explore issues like how funds flowed to facilities and how these funds were used.
  • Published a study on the use of RBF income by local governments and health facilities, which was was approved through formal MOH processes.
  • Supported the GOU to develop a strategy for integrating RBF into government PFM systems under the World Bank-funded Uganda Inter-Fiscal Transfer (UgIFT) program and facilitated the process for its approval by the Ministry of Finance.
  • Supported the Kampala Capital City Authority (KCCA) to analyze causes for congestion at high-volume public health centers, assessed the readiness of the private sector for contracting, and profiled the women accessing care in Kampala’s public facilities. This evidence informed the co-design of a prototype model for government purchasing PHC services from private providers.

Current workstreams and activities

Workstream one: Support the MOH to institutionalize RBF into government purchasing

  • Retrospectively analyze the World Bank RBF project to further inform the design and implementation of GOU mainstreaming.
  • Document how RBF was mainstreamed into GOU PFM mechanisms, detailing the key considerations and tradeoffs.
  • Conduct a difference-in-difference analysis on the affect of RBF on service utilization and quality.
  • Support GOU processes for RBF mainstreaming, including revision of PHC grant guidelines on how local governments and facilities will spend RBF funds.

Workstream two: Facilitate learning focusing on contracting for PHC services

  • Partner with the Makerere School of Public Health to facilitate learning exchanges focusing on strategic purchasing, RBF, and private sector contracting.
  • At the request of the MOH, support prototyping the NHIS implementation framework.
  • Build engagement around a prototype for KCCA to purchase PHC services from private providers.

More information about the project can be found in this one-pager and in this slide deck.

Featured learning products

Results-based financing and local health system performance: Lessons from Uganda

The Ugandan government commissioned ThinkWell to undertake a study to document how the recent nationwide results-based financing (RBF) program worked. Specifically, ThinkWell looked at the effect on 1) revenue, 2) how the funds were used, and 3) service delivery and facility performance. This was a mixed-methods study that started in January 2019 and used a combination of quantitative and qualitative data, focusing on LGs and health facilities during the first phase of RBF implementation. This brief, published in February 2024, summarizes the study and provides 10 key takeaways about the RBF project’s implementation in Uganda and how the government can integrate its lessons.

The Impact of COVID-19 on Health Financing in Low- and Middle-Income Countries: The case of Uganda

This study, published in September 2022, examines Uganda’s COVID-19 response and how alterations to the health financing system helped make the system more resilient. Understanding the interaction between the pandemic and Uganda’s health financing system contributes to global evidence on how to strengthen health systems to better respond and be resilient to the effects of the pandemic.

Results-Based Financing for Primary Health Care: How local governments and frontline facilities plan, use, and account for RBF funds

Starting in financial year 2018/19, the Ministry of Health (MOH) began implementing results-based financing (RBF) under the Uganda Reproductive, Maternal, and Child Health Improvement Project (URMCHIP). Building on more than 15 years of experience with related health financing approaches, the MOH introduced performance-linked payments to eligible public and private not-for-profit (PNFP) health facilities and hospitals, providing them with additional revenue based on their service outputs and quality. The aim was to increase utilization of selected primary health care (PHC) services, and providers were given discretion to use their additional revenue to enhance performance, including by distributing bonuses to health workers, procuring supplementary medicines and supplies, upgrading their facilities, and more. The MOH undertook this operational research study in early 2023 to inform development and implementation of its RBF mainstreaming strategy.

An Overview of Health Financing Flows in Uganda

This report, published in April 2021, documents the nature and magnitude of financial flows to Uganda’s health sector and the purchase of primary health care services. Against international benchmark estimates that $86 per person is required to deliver essential health services in low- and middle-income countries, this study documents that the current level of government funding to primary health care services is below levels needed if Uganda is to achieve its universal health coverage goals.

Other learning products

SP4PHC aims to improve how governments purchase primary health care services, with a focus on family planning and maternal, newborn, and child health. SP4PHC is supported by a grant from the Bill & Melinda Gates Foundation.