Many people in developing countries, especially those living in rural areas, face UGANDA

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1 UGANDA STRIDES LEGACY SERIES STRENGTHENING HEALTH SERVICES WITH PRIVATE SECTOR SUPPORT IN UGANDA Photo by RUI PIRES STRIDES for Family Health increased access to and improved the quality of integrated reproductive health, family planning, child survival, and nutrition services in Uganda. Management Sciences for Health (MSH) implemented the project with core partners Communication for Development Foundation Uganda (CDFU), Jhpiego, and Meridian Group International. Funded by the US Agency for International Development (USAID), STRIDES worked in 15 districts of Uganda: Kamwenge, Kalangala, Nakasongola, Kyenjojo, Mityana, Kasese, Bugiri, Mayuge, Kamuli, Kayunga, Mpigi, Kaliro, Kumi, Luwero, and Sembabule. Many people in developing countries, especially those living in rural areas, face challenges accessing health care. Serious resource constraints and insufficient political support severely hamper health service delivery. Barriers to access include distance to service points, availability of medicines, lack of skilled staff, poor morale among health workers, and the cost of care. In recent years, Uganda s Ministry of Health (MOH) has renewed its commitment to improving access to high-quality reproductive health (RH), family planning (FP), and maternal and child health services. 1 The average Ugandan woman gives birth to 6.2 children a fertility rate that is among the five highest in sub-saharan Africa. 2 Reducing the country s fertility rate would contribute to a corresponding decrease in maternal and child mortality. The ministry has recognized that private providers, such as those employed in the commercial sector or by nongovernmental or faith-based organizations, play an important role in providing health services, particularly for mothers and children. 3 For instance, just as many people obtain contraceptives from private medical facilities as they do from public facilities. 4 However, most private providers work in isolation 1. A Strategy to Improve RH in Uganda MOH, July 2004; Roadmap for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Uganda ; National Child Survival Strategy: Briefing Paper for Policy Makers and Planners 2009/ /15. MOH, July Uganda Bureau of Statistics (UBOS) and ICF International Inc Uganda Demographic and Health Survey Kampala, Uganda: UBOS and Calverton, Maryland: ICF International Inc., (UDHS 2011), p Private providers refers to professional health workers such as doctors, midwives, nurses, medical clinical officers, medical officers, laboratory technicians, and drug sellers who are not employed by the Ugandan public health system. 4. UDHS, 2011.

2 without proper oversight and the district health management information system (HMIS) often does not capture their service data. To reach communities underserved by the public health sector, STRIDES for Family Health engaged private health care providers through a performance-based contracting (PBC) program. This intervention was one of STRIDES key strategies in providing access to quality health care for rural populations in Uganda. The project built the PBC program based on MSH s technical leadership in performance-based contracting and financing in 21 countries on three continents. PBC offers incentives designed to encourage providers to improve the quality, demand for, and use of services. 5 With STRIDES technical and financial support, partners were able to assist the public sector in expanding services for maternal and child health, RH, FP, nutrition, and malaria to underserved communities in 15 districts between October 2009 and December Selecting Partners In 2009, STRIDES performed an assessment to determine the most pressing health needs that the private sector could address within the project scope. The project noted that partners could provide effective interventions, including family planning and administration of readily available medicines. Map: STRIDES PBC subcontractors In consultations with the MOH and USAID, STRIDES developed a request for proposals from private sector providers that addressed community-based service delivery, delivery of long-acting and permanent family planning methods, and procurement of basic FP/RH and child survival (CS) equipment for both the public and private sectors. Over the course of three rounds of competition (see map), STRIDES received 294 proposals, which were reviewed and scored by an evaluation committee including USAID and MOH representatives. STRIDES awarded 73 PBCs with a total value of approximately $10 million. KASESE KYENJOJO KAMWENGE Lake Albert STRIDES Round 1 STRIDES Round 2 STRIDES Round 3 SEMBABULE MITYANA MPIGI NAKASONGOLA KALANGALA KAMULI KALIRO LUWERO KAYUNGA Lake Victoria MAYUGE BUGIRI KUMI Recipients included 48 for-profit and not-for-profit organizations, large and small, both national and international. The geographic area of intervention varied by partner. One partner provided services throughout the 15 districts, some partners worked in multiple districts, and most of the small ones focused their activities in one district. With 75 percent of these partners providing services directly at the district level, STRIDES was able to help dramatically expand access to maternal and child health and family planning services. The budgets of all proposals receiving adequate scores on the technical content were reviewed to verify that the cost corresponded to the scope of work. The project ensured that the final budget was reasonable, consistent with market rates, and had best value for the US Government. Cost-sharing was recommended, but not mandatory. STRIDES asked finalists to explain their technical approach and experience in delivering similar projects, and then conducted an in-depth pre-award survey at each bidder s office to determine operations capacity, human resources management expertise, and implementation ability. As part of the contracts, STRIDES and the private providers agreed on a monitoring plan that included indicators, baseline values, targets where they were applicable, data sources, and frequency of data collection. 5. For a deep understanding of PBF and PBI see: USAID. Performance-based Incentives Primer for Missions AIDSTAR-Two Project. The PBF Handbook: Designing and Implementing Effective Performance-Based Financing Programs. Version 1.0. Cambridge: Management Sciences for Health, n STRIDES LEGACY: PRIVATE SECTOR SUPPORT IN UGANDA

3 Figure 1. The PBC process 1 SITUATION ANALYSIS 2 SOLICITATION DESIGN 3 PRE-BIDDING WORKSHOPS 5 CLARIFICATION & DISCUSSION SELECTION COMMITTEE REVIEW RECOMMEND 6 CONDUCT PRE-AWARD SURVEY 4 PROPOSAL EVALUATION Initial Screening Cost Analysis Selection Committee DECLINE 8 AWARD 7 PERFORMANCE MONITORING PLAN NEGOTIATION NOTIFY SHORTLISTED APPLICANTS INDUCTION WORKSHOP 9 IMPLEMENTING THE PLAN M&E & Technical Support 10 CLOSE-OUT Implementing the Program STRIDES followed a rigorous process to verify PBC partners results. The project required partners to submit quarterly reports detailing achievements, lessons learned, challenges, and performance against their set targets. The project verified and scored deliverables based on a weighted indicator payment plan, which formed the basis for payments. Partners that met or exceeded their targets were given a bonus which was 10 percent of the total STRIDES contribution budget. STRIDES also required all private service delivery organizations to report to the HMIS and to collaborate closely with the district health offices. Many of STRIDES PBC partners were small, community-level facilities, which were unfamiliar with the management and programmatic standards required by major international donors such as USAID and lacked the data management skills and organizational capacity to adequately document their services. With support from STRIDES, the partners established a results-oriented culture, systems to monitor their activities, and innovative strategies to improve coverage. STRIDES also provided clinical training and support for the facilities quality of care, service protocols, and data systems. Figure 1 summarizes the PBC process. Infant receives Vitamin A supplementation Targeted Interventions to Improve Access to Key Health Services STRIDES PBC partners provided a broad range of services, including reproductive health information for families and young people, antenatal care (ANC), screening for cervical cancer, diagnosis and treatment for sexually transmitted infections, and family planning counseling and contraception. Children received vaccines, Vitamin A supplements, deworming, and treatment of common illnesses such as malaria, pneumonia, and diarrhea. Children also attended growth monitoring sessions and received nutritional support. Photo by TADEO ATUHURA STRIDES LEGACY: PRIVATE SECTOR SUPPORT IN UGANDA n 3

4 Table 1. STRIDES PBC awards and areas of focus ROUND KEY SERVICES # PARTNERS TOTAL CLIENTS SERVED ONE Community-based service delivery Delivery of long-acting and permanent methods (LAPMs) for FP Private sector distribution channels for FP/RH and CS products 12 international and local organizations 717,170 Integrated outreach on FP/RH Public-private partnerships for health Basic FP/RH and CS equipment for both public and private sectors Malaria prevention and treatment Community dialogue targeting males for FP/RH TWO Community-based FP/RH and CS service delivery approaches that involve the private sector Increasing availability of LAPMs in the private sector Supporting expansion of services through public-private partnerships 14 international and local organizations 586,360 Using private sector delivery channels to increase availability of FP/RH/CS products Collaboration with companies to increase access to FP/RH/CS among their employees Introduce midwives-managed ultrasound diagnosis at ANC to screen for obstetric risk Equipment maintenance and repair Nutrition programs at community level Malaria prevention and treatment Integrated outreach on FP/RH Community dialogue targeting males for FP/RH THREE Home care for pregnant women as well as postnatal care Infrastructure and basic medical equipment Training in FP/RH/CS to improve service delivery 26 small health facility service providers 350,556 Integrated outreach Cervical cancer screening Maternal and child nutrition Young people-friendly services and adolescent sexual and reproductive health Postnatal care and male involvement in FP/RH Malaria prevention and treatment Integrated outreach on FP/RH Community dialogue targeting males for FP/RH Table 2. Number of clients reached by PBC partners by health service ROUND Reproductive & Maternal Health Family Planning Child Health Nutrition TOTAL ONE 217, ,135 62,640 7, ,170 TWO 148, , ,834 85, ,360 THREE 59, , ,134 8, ,556 TOTAL 424, , , ,388 1,654,086 4 n STRIDES LEGACY: PRIVATE SECTOR SUPPORT IN UGANDA

5 The STRIDES PBC partners provided integrated services to women and children at the community level through a one-stop shop approach, such as outreach through mobile teams. STRIDES PBC program also helped partners expand the range of services they provided and improve the functionality of their facilities by procuring or repairing medical equipment. Some of the interventions yielded positive secondary benefits. For example, the addition of ultrasound services in hospitals and health centers strengthened male participation, since partners were motivated to see their babies in utero. The PBC program reached 1,654,086 men, women, young people, and children in 15 districts in more than three years (see Table 2). Almost 40 percent of these clients received family planning services and about 35 percent were children who received essential health services. Some of the interventions yielded positive secondary benefits. For example, the addition of ultrasound services in hospitals and health centers strengthened male participation, since partners were motivated to see their babies in utero. Reaching Women and Children STRIDES achieved impressive results through its work strengthening the public sector and greatly augmented its impact through the PBC program. Table 3 shows the impact of the private partner accomplishments on some of STRIDES results. By far, the biggest contribution that private partners made toward the overall project results was the expansion of contraceptive options. Sixty percent of the implants and IUDs that were offered by STRIDES-supported providers were supplied by private partners. Insertion of IUDs and implants led to a significant increase in couple years of protection, particularly through Marie Stopes Uganda (MSU) and the Family Life Education Program (FLEP). FHI360 also contributed substantially to the expansion in the provision of injectable contraceptives. Table 3. Achievements and PBC contribution on selected indicators INDICATOR Number of new FP users Implants and IUDs inserted Children under 5 years of age who received 2nd dose of Vitamin A Pregnant women who received 4 ANC consultations Pregnant women who received 2+ doses of IPT Live births delivered at a health facility Clients served at baseline (PY1) Clients served in PY5 Percent increase from PY1 to PY5 Total clients served (PY2- PY5) Percent PBC Contribution 136, ,554 50% 655,494 12% 6,402 40, % 91,069 60% 197, ,334 89% 1,074,049 16% 83,775 98,414 17% 318,357 16% 97, ,681 38% 435,740 13% 73, ,039 46% 360,575 11% Photo by RUI PIRES STRIDES LEGACY: PRIVATE SECTOR SUPPORT IN UGANDA n 5

6 Photo by RUI PIRES Figure 2 shows an increase in uptake of implants from year three of the project when the partners started implementing activities. Women received contraceptive implants mainly through outreach conducted by MSU at static public health facilities in the 15 STRIDES-collaborating districts. Reduced activities at the end of contracts were largely responsible for a signifi cant drop in the number of users of implants and IUDs in the fi fth year of the project. Reaching the Hard-to-Reach Figure 2. Number of implants and IUD insertions 12,000 PBC APPROACH APPLIED 10,000 8,000 Total STRIDES supported the partners to provide outreach services in areas with poor access to health services. For example, the Ernest Cook Ultrasound Research and Education Institute (ECUREI) provided ANC services on the remote Bunjako Islands of Mpigi district. Another partner, Suubi Medical Centre in Mayuge district, conducted outreach activities in fi shing villages where children had never been immunized and were dying from dual malaria and measles infection. In Kalangala district, the Walter Clinic and St. Philomena Clinic increased family planning services, immunization, and ANC services in communities located on the Ssese Islands in Lake Victoria. To provide youth-friendly services to communities in the mountainous regions of Kasese district, STRIDES engaged Pathfi nder International to provide technical assistance to a peer-to-peer program in which young mothers mapped households with pregnant women, and when possible, conducted regular counseling and follow-up with them and their partners. 6,000 4,000 2,000 0 Implants IUDs PY2 PY3 PY4 PY5 Supporting Local and Innovative Solutions The PBC program encouraged partners to develop innovative solutions to address priority health needs. These included training for midwives to diagnose obstetric risks through ultrasound; male-targeted reproductive health messages and activities; malaria prevention and treatment for pregnant women; health services for youth; community mobilization to improve health and nutrition; and provision of demand-side incentives (vouchers) to help women deliver at hospitals, pay for transportation, and receive special services such as lab tests and surgery. STRIDES partner Midas Touch Medical Services, a private clinic in Kyenjojo district, received a PBC to mobilize mothers to access free ANC and comprehensive 6 n STRIDES LEGACY: PRIVATE SECTOR SUPPORT IN UGANDA

7 A PBC with STRIDES partner Midas Touch Medical Services motivated pregnant women to complete the standard four ANC visits to receive other services. Mothers who completed the fourth visit received a voucher that entitled them to access free services, such as ultrasound scanning, cesarean section, lab tests, and postnatal care. emergency obstetric and newborn care services through a voucher scheme. Pregnant women were encouraged to complete the standard four ANC visits to be eligible to receive the other free health services. Mothers who completed the fourth visit received a voucher that entitled them to access free services, such as ultrasound scanning, cesarean section, lab tests, postnatal care, and postabortion care. This signifi cantly increased the number of women who accessed these services at clinics and outreach sites. Figure 3 shows the number of pregnant women who attended four ANC visits increased almost seven-fold in two years and those who received intermittent preventive treatment (IPTp) for malaria increased to 12 times the baseline number. Most impressively, the number of women who came to the health facility to deliver their babies rose from 191 to 3,274, a 16-fold increase. ECUREI also implemented an innovative model to improve maternal and neonatal health in Mpigi district. With support from STRIDES and the University of Washington and General Electric, ECUREI donated portable solar-powered ultrasound machines to 15 health centers in Mpigi and trained midwives to use ultrasound to diagnose risk factors for emergency obstetrics and refer clients accordingly. The health centers provided free ultrasound scanning to pregnant women attending ANC which motivated them to complete four ANC visits and deliver at the health facilities. ECUREI also offered an innovative training model by providing substitute midwives to keep services running at government facilities while staff attended trainings. Other partners adopted reduced prices to ensure access to services. Sustainability of these services remains a challenge, given that clients are unable to pay nonsubsidized prices and public health facilities still lack suffi cient resources to provide adequate care. Figure 3. Voucher program effect on high-impact health interventions 5,000 4,000 3,000 2,000 1,000 PBC APPROACH APPLIED IPTp2 4th ANC Live Births Delivered 0 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 PY2 PY3 PY4 baseline Ultrasound Makes a Life-Saving Discovery Annette Mbwirahe (not pictured here) didn t know what was wrong the pain in her lower abdomen wasn t getting any better. Finally, unable to endure it, she decided to get help. Mbwirahe, 25, left Buyiwa village and went to Buwama Health Center III in the district of Mpigi. There, midwife Zura Kyotazaala examined her with an ultrasound scan. The scan showed that Mbwirahe had a heterotopic, or multi-site, pregnancy: a rare and complicated twin pregnancy with one twin in the womb and the other in the fallopian tube (ectopic). She required immediate surgery. Without treatment, heterotopic and ectopic pregnancies can be fatal for the mother. Kyotazaala referred Mbwirahe to Mulago Hospital in Kampala, 60 kilometers away. A scan there confi rmed Kyotazaala s diagnosis, and Mbwirahe underwent life-saving emergency surgery. Photo by RUI PIRES STRIDES LEGACY: PRIVATE SECTOR SUPPORT IN UGANDA n 7

8 Photo by TADEO ATUHURA PBC made it possible to train health workers to deliver family planning and ultrasound scanning services in rural areas. Conclusion STRIDES experience suggests that performance-based financing using incentives can increase access to and use of a broad range of services. Supported by the PBC program, private providers and public facilities were able to provide high-quality services to geographically hard-to-reach and underserved areas. In addition to fostering a strong results-oriented culture in the organizations and among private providers, the model facilitated stronger linkages between public and private facilities. Coordination with district health officials was an important element. For example, most partners obtained some of their medical supplies, such as vaccines and FP commodities, through the district supply chain. With STRIDES s support, districts have increasingly led community outreach activities, fostering collaboration among private providers, nongovernmental organizations, and public facilities. District health teams increasingly need to plan, manage, and monitor the support provided by private partners. This can result in a total local health system where the public and private sectors can expand quality services to all. While performance-based schemes are not a panacea for all problems within health systems, they are a promising and innovative strategy for using the private sector to rapidly scale up priority services, implement innovative models of public-private partnerships, and target hard-to-reach, underserved populations. STRIDES results show that performance-based incentives can be used successfully across a wide range of services and program interventions. n ACKNOWLEDGEMENTS STRIDES for Family Health gratefully acknowledges the US Agency for International Development for the generous support that made the performance-based contracting program possible. STRIDES also acknowledges the Government of Uganda and the Ministry of Health as vital partners, as well as district health and government officials. This document in the legacy series was developed by Richard Ssewajje of STRIDES and Fabio Castaño of Management Sciences for Health, with contributions from the following individuals: Celia Tusiime Kakande, Tadeo Atuhura, Henry Kakande, Thomas Emeetai, and Miriam Mutabazi of STRIDES for Family Health and Management Sciences for Health. This product is made possible by the support of the US Agency for International Development (USAID) under Cooperative Agreement No. 617-A The contents are the responsibility of STRIDES for Family Health and do not necessarily reflect the views of USAID or the US Government. 8 n STRIDES LEGACY: PRIVATE SECTOR SUPPORT IN UGANDA