NU Health Uganda

1. Results-based Financing v Input-based Financing:Association Between Funding Modality & Clinical CareAn Interim Assessment         NU Health Uganda Drs. Solome Kiribakka Bakeera, Willy Agings, Eunice Esule, Stephen Kadde, Ezra Anyala, Eva Okullo & Paula Quigley 3rd Global Symposium on Health Systems Research Cape Town 2014

2. RBF v IBF Clinical Care & OutcomesOverview • Background Health Sector in Uganda & Northern Uganda • Introduction to Northern Uganda Health (NU Health) • Clinical Audit Study – objectives, methodology and results • Conclusions • Next Steps

3. Background: Health Sector in Uganda • Per capita GDP 2014 $626 • Gov. health spending 8% of GDP in 2012; household health spending 6-8% avg monthly budget • Policy aim that public health facilities serve as a safety net for poor and vulnerable groups • Weak health system: inadequate financing + maldistribution of staff + poor organisational capacity= low functional coverage • Nascent private sector including insurance is poorly regulated, expensive and with coverage limited to urban centres

4. Political Map of UgandaSource: mapsofworld.com SOUTH

5. Background: Northern Uganda • Fragility from years of brutal conflict: Lord’s Resistance Army • Relative income poverty: monthly income North avg. UGX 141,400 ($53.91) v National avg. UGX 303,700 ( $116.41) • Relatively poor access to health services from non-state providers:

6. Introduction to NU Health—1 • Part of the DFID/UKaid-supported Post-Conflict Development Programme (Oct 2011 – Mar 2015) • To strengthen mechanisms for governance and accountability to improve coverage with quality health care among the vulnerable in the Acholi sub-region • To generate evidence on the costs and benefits of RBF compared with traditional input-based financing (IBF) for improving coverage and quality of care

7. NU Health—2 Coverage Following an assessment of “readiness,” 21 of Acholi sub- region’s 180 PNFP facilities were enrolled in the RBF arm and 10 of Lango’s facilities in the IBF comparison arm

8. NU Health—3: Key Indicators Maternal care • Antenatal care with defined quality parameters • starting before 16 weeks with 4+ visits • provision of tetanus vaccination and malaria prevention • appropriate measures for the prevention of mother-to-child transmission (PMTCT) of HIV • Delivery in a health facility • using a Partograph • emergency obstetric care & referral provided as needed • early breastfeeding • appropriate postnatal care Child care • fully vaccinated, appropriate diagnosis and treatment of major causes of mortality

9. Clinical Audit Study—Objectives General Objective: To identify associations between financing modality and selected evidence-based care clinical interventions and health outcomes Specific Objectives • Compare the use of partographs between the RBF and IBF health facilities and assess any associated differences with perinatal outcomes • Compare the use of partographs between the RBF and IBF health facilities and assess any associated differences with emergency Caesarean Section rates • Compare differences in treatment adherence between RBF and IBF facilities for malaria, pneumonia and diarrhoea in children.

10. Clinical Audit Study—Methodology • A clinical audit consisting of five protocols conducted on a quarterly basis in each RBF and IBF facility as part of a larger Quarterly Quality Assurance (QQA) process • The process of conducting the QQA in itself mentors staff to identify areas of weak performance and support adherence with standard treatment protocols in both the RBF and IBF facilities • Supporting providers to focus on how to improve as well as incentivising good performance in the RBF facilities provides a stimulus to improving quality of care.

11. Study Design—Objectives

12. Clinical Audit Study—Results

13. Percentage of perinatal deaths in RBF and IBF HFs that received any monitoring (partial or complete) with a partograph(no significant difference)

14. Percentage Caesarean Sections that received any monitoring (partial or complete) with a partograph(no significant difference)

15. Delivery Care and C-Sections RBF No significant association between the occurrence of an emergency CS and complete monitoring during labour for mothers for the baseline and the first year of implementation IBF No association between the occurrence of an emergency CS and complete monitoring during labour for the baseline and the first year of implementation

16. Percentage of pneumonia cases treated correctly in RBF vs IBF arms Adjusted OR 5.12 CI 3.34-7.87

17. Percentage of diarrhoea cases treated correctly in RBF vs IBF arms Adjusted OR 5.66 CI 3.70-8.66

18. Percentage of malaria cases treated correctly in RBF vs IBF arms (not significant) Adjusted OR .95 CI 0.59-1.32

19. Conclusions • Implementation of RBF is associated with early improvements in adherence to some clinical guidelines • Incentivisation of specific practices & attention to data verification • Are associated with improved adherence in relatively simple care • Are not associated with improved adherence in more complex care • Although not a consideration in this study per se attention to building the capacity of the district health teams is a priority to scale up if these data suggest the RBF can contribute to better adherence to protocol and clinical outcomes than IBF

20. Next Steps • 2nd year Clinical Audit data will be collected in late 2014, analysed in early 2015 • An external evaluation of the programme will be completed in late 2015 • These data & evidence will inform plans for scale up

21. THANK YOU! For more information about NU Health, please contact DrSolomeBakeera, Programme Director, on solome@nugandahealth.org www.healthpartners-int.co.uk