BTC’s Private-Not-For-Profit project assists faith based health facilities in delivering the best possible healthcare services for their patients. To bring Uganda one step closer to universal healthcare coverage, a new system of performance-based financing is introduced. A system that rewards the outputs instead of funding the inputs of the health facilities. Good performing hospitals and health centers will receive financial support to be used with more autonomy.

One of the regions where BTC is helping to set up performance-based financing (PBF) is the West Nile region. It lies in the north-west of Uganda bordering the Democratic Republic of Congo and South-Sudan. Many people fleeing conflicts or difficult economic situations in these countries are looking for medical treatment in a region that is yet to fully recover from the violent conflict between Joseph Kony’s Lord’s Resistance Army (LRA) and the Ugandan government.

 In 2006 a truce between both parties was signed. Since then improvement in poverty reduction has been made but according to the Ugandan Poverty Status Report of 2014 the Northern part of Uganda remains the poorest of the country.

Here health service providers are trying to deliver quality healthcare to an often very poor population. Our Private-Not-For-Profit project (PNFP) assists through Ugandan ministry of health the private-not-for-profit health facilities with capacity building in quality improvement initiatives, leadership and management.

Flipping the old logic
Traditionally funding for health has been directed towards inputs like salaries, construction, training and equipment. People thought that improved healthcare would follow but this hasn’t always been the case. The new system of performance-based financing flips the old logic around and focuses on improved performance.

Health facilities receive quarterly incentive for initiatives that are taken to implement the quality standards defined by the Ministry of Health. They are also rewarded for quantitative performance targets like “number of child malnutrition correctly treated’, ‘number of fully immunized children’ or ‘number of deliveries well managed’. The quantity and quality of delivered health services will be verified on a quarterly basis.

Reducing the patient's bill
  In the performance contracts signed between the health facilities and the Local Government, the subsidies granted for achieving these quantitative performance targets are linked to reducing the patient’s bill. Currently user fees contribute to 50 to 60% of the total income of the health facilities, this is too high. According to World Health Organization recommendations, not more than 20% of the cost of the health services should be covered by user fees.

13 of the facilities (4 hospitals and 9 health centers) in the West Nile region have been selected to start with performance-based financing. By turning away from centering attention on inputs, RBF aims to improve both health system effectiveness and efficiency. Health providers at a district level are free to use the grants to implement their own work plan.

Local decision making power
Managers, doctors and nurses can set their own priorities according to the needs on the ground and will receive the spending autonomy to back their choices up. They will gain more decision making power, and become responsible for their own performance. This shift from a centralized budget to more local decision making power is an important reform that BTC, together with the Ugandan government, is helping become a reality.

This is just the beginning of a challenging but exciting process. Two other east-African countries, Rwanda and Burundi already introduced a system of performance-based financing with promising results to show for. To give two examples: according to the Africa health forum of 2013 post-natal care visits in Burundi have gone up and the overall quality of care in health facilities using PBF has increased in Rwanda. With the Ugandan government, the ministry of health and the local PNFP partners on board, BTC believes that performance-based financing could be a real game changer for the health sector in Uganda.