52 years old Alfred Ocolla, has a kidney and heart problem. He would travel 80kms away from his home to Arua Regional Referral Hospital for routine check-ups. Sometimes, Ocolla would be referred to Lacor hospital in Gulu for oxygen.

According to Dr Jammy Omara, the Medical Superintendent of Nyapea hospital, the ultrasound department which was closest to Ocolla was non-functional for 3 years due to lack of equipment. Hence, patients including Omara who sought for ultrasound services were referred to Arua.
Today, several public health facilities are faced with similar challenges including poor infrastructure, human resource gaps and regular drug shortages.
Besides, the high cost of health services especially at the private not-for-profit health facilities scared away many patients from seeking professional treatment thus resorting to self-prescription, sharing of medicine and sometimes use of herbs.

To help change this situation, Enabel supplied the facility with a cardiography and x-ray machine. Today, because of the new machines Ocolla receives his routine check-ups at Holy Family Hospital, Nyapea located in his home area.

Since 2016, Enabel has been implementing the National Results-Based Financing policy which provides for the extension of direct financial support to health facilities to enable them purchase equipment and other necessary items.

The funds are however provided on condition that health facilities attain pre-determined targets. The organisation piloted this health service delivery model in 80 health facilities including Holy Family Hospital Nyapea.

Dr Sarah Byakika, the Commissioner Planning, Financing and Policy at Uganda's Health Ministry, also the National Results-Based Financing Coordinator, says the approach was adopted by government to improve productivity and ensure access to quality health services for all.

“No doubt the delivery of quality health care services especially to women and children in the two regions has improved,” Byakika said.

According to the In-charge Warr Health Centre IV in Zombo district, Dr Imelda Kawambe, majority of the clients who seek services at the facility are women with labour complications and children.

Flexibility in utilisation of funds
Enabel's Project Technical Officer Richard Musabe says the flexibility in utilisation of funds provided enabled beneficiary facilities to invest in critical areas including infrastructure and incentivizing of front line health workers.

“For our case, we recruited additional 2 clinical officers and midwives but also enhanced staff salaries,” says Dr. Jammy Omara, the Medical Superintendent of Nyapea.

For Maureen Kusemererwa, enrolled midwife Bundibugyo, the cash incentives given to staff were an extra motivation.
 “This motivated me to handle mothers kindly especially during pregnancy, delivery and after,” she said.

34-year old Harriet Kelike acknowledges the improvement in the quality of care at Moyo general hospital, another facility benefiting from the Results-based financing scheme. 

The mother of 2 says the last time she delivered her child at the facility, the baby was underweight. Kelike says the nurses closely monitored and counseled her until the baby weight increased to 2.5kgs, “that is when I was discharged,” the smiling Kelike says.

Increased deliveries at lower health facilities

Another deliberate effort of the project was to reduce maternal and child deaths by ensuring the quality of deliveries at HC III levels were done under the care of a skilled health worker.

RBF support improved the quality of deliveries in the supported health facilities. According to the District Health Information System (DHIS), deliveries at the health centres increased to 64 percent compared to 49 percent at the start of the project.

Reduced congestion in general Hospitals

Investing in HC IIIs and IVs, Musabe says eased access to services since patients nolonger have to travel long distances in search of medication.  

This he says reduced the number of patients admitted at General Hospitals and HC IVs because lower-level health facilities are able to handle most cases without referral to the higher level health facilities.

Better organised referrals

Where referral is recommended, Dr. Byakika says prolonged delays have been eliminated because of the now efficient ambulance system.

At Nyapea hospital for instance, the number of women coming for antenatal services increased partly due to referral from lower level facilities. The facility now carries out about 7 deliveries daily.

Reduced user fees in private not-for-profit health facilities

According to Robert Nyakana, Accountant Virika hospital in Rwenzori region, the reduced user fees led to an increase in the number of people seeking medical attention.

“We used to get about 10 people per day but today we get more than 25 patients a day,” Nyakana said.
Regina Kabasiita, a patient says the hospital is now affordable to low-income earners.
Improved health supplies

RBF focal person in Moyo, James Alule says previously medicine would be prescribed before testing, against standard procedure, leading to inappropriate drug use.

The facility was however revamped and various testing equipment provided. Consequently, the number of patients increased from 80 to 450. The facility has also registered 10% revenue increase.

Drug stock out was also tackled. Sr, Juliet Asiimwe, Administrator, Rwibale HC IV says, this was the norm at the facility, but then when the project started, the facility was given buffer funds to stock essential drugs.
“Today, we get many clients coming here because they are sure they will get the medicine available,” says Asiimwe.
Improved data and financial management

Richard Musabe says funds were also invested in financial training and book keeping equipment to ensure up-to-date record keeping, proper data management and accountability.

Dr Byakika confirms that the project was a stimulus for health facilities to understand and analyse their data and timeliness in reporting which has become a routine of keeping up-to-date data.

While the Results based financing approach has been a game-changer in health service delivery, a lot still needs to be done to address poor infrastructure, human resource gaps, inadequate medical equipment, frequent drug shortages and low motivation of health workers if Uganda is to achieve universal health coverage by 2030.