CONCEPT FOR RBF CURRICULUM SUBMITTED TO Belgium Technical Co-operation/Ministry of Health, Uganda
  1. BACKGROUND

1.1.INTRODUCTION

In May 2014 the Kingdom of Belgium and the Government of Uganda signed a Specific Agreement for the Project “Institutional support for the Private-Non-For Profit health sub-sector (PNFP) to promote universal health coverage in Uganda". The objective of the project is to contribute to strengthen service delivery capacity at district level to effectively implement Primary Health Care activities and deliver the Uganda National Minimum Health Care Package (UNMHCP) to the target population. The project centres on the following principles:

  • Coherence and alignment with the national Ugandan policies.
  • Strengthening of the partnership between Ministry of Health (MoH) and PNFP health sub-sector in order to:provide public-oriented quality service, strengthen functional integration of the health system and increased financial accessibility for the poor.
  • Strategic options: combined geographical concentration (for functional integration) and countrywide coverage (for partnership modalities) and, developing sustainable financial modalities for PNFP (Result-Based Financing - RBF).

The 4-year project will be based at the MoH at the central level and in the Rwenzori and West Nile region.

The project aims at training a critical mass of people within the health sector on RBF objectives up that they master the concepts and objectives of RBF and can contribute to the health financing strategy and health system strengthening strategy. It will orient the implementers on practical issues such as implementation strategies, determinants of performance and reward mechanisms, and promote harmonization of expectations among the main stakeholders vis-à-vis RBF. In light of the above, the Belgian Development Agency (BTC) in conjunction with the MoH recruited Makerere University School of Public Health (MakSPH) to support the MoH in the elaboration of a curriculum for RBF in Uganda’s health sector

TRAINING OBJECTIVES.

Evidence shows that where RBF has been successfully implemented, it was preceded in all countries by successful engagement and orientation of all key stakeholders. This points to a need to provide a sound scientific background and technical orientation to all stakeholders who might be involved in RBF project in order to promote harmonization within different stakeholders/actors. This curriculum has been developed to achieve the following specific training objectives:

  1. To present theoretical concepts relating to implementing RBF as strategy towards health systems strengthening.
  2. To present the local experiences and discuss benefits (efficiency, efficacy, cost-effectiveness), sustainability, risk management and mitigation (inflated costs, unnecessary demand, neglected services, etc.) of implementing RBF in the Ugandan context.
  3. To present the model proposed by the new PNFP project and discuss the expectations, roles and responsibilities of various actors with reference to the purchaser, contracting and verification mechanisms.
  4. To orient the implementers on practical issues such as implementation considerations and determinants of performance, information and reward systems.

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  1. METHODOLOGY FOR CURRICULUM DEVELOPMENT
  2. Conceptual Framework.

Conceptualization of the content topics of the curriculum (see figure 1) has been guided by among others the concepts of agency theory and expectancy theory on the demand side. On the supply side, the concepts of demand for services and utility gained by the users of services have been used. Across these, the trainees (District officials and health facility managers) will be introduced to the relational and market variables necessary to develop a business plan that will guide them as they implement RBF programs a the district level.

2.1.1.Supply Side Content:

On the supply side, the theory of agency supports the identification of the key relational aspects between the service providers (PNFP/agents) and the principal (fund holder). Key among these relational variables is the contract. Contracts, MoUs or similar tools provide the agreement for the exchange relationships – usually specifying the performance expectations i.e. the range of services, the beneficiary groups, the service targets and the standards (quality/protocols). In terms of determining the motivational value of the contracts to the providers, the curriculum will cover topics that expectancy theory brings into focus in contract relationships. These include 1) awareness of contract expectations; 2) the capability to provide the contracted services (efficacy to supply); 3) performance feedback 4) the link between satisfactory performance and the rewards, 5) size of the rewards relative to the efforts of the agents and 6) systems for determination of performance (indicators, information and audit system) and 6) rules and design of the RBF schemes. This framework (Ssengooba el al 2014)[1] guides and frames the required actions with the health facilities and between the agents, the district and the national level actors.

Figure 1: RBF and the applicable concepts on the demand and supply side

2.1.2.Demand Side Content:

On the demand side, the curriculum addresses topics related to the market concept, accountability to the clients and approaches to optimizing client satisfaction. These include topics related to demand-creation; provider alternatives (self-care, public, private and VHTs) customer-care and addressing the health care needs of the clients (utility). A business plan that incorporates effective competition and collaboration will be discussed. Internal clients of the health facilities (health workers) are also a key constituency for RBF. Like patients, internal clients are affected by supply, demand and utility variables. If satisfaction from their work environment is inadequate, they may underperform or transfer their labour to other providers. From this perspective, the curriculum will address topics such as workforce motivation, teamwork, conflict resolution, performance appraisals and feedback, supervision and continuous professional development and the role of financial and non-financial incentives.

2.2.Health System Strengthening

The figure above is nested in the broader health systems. The curriculum addresses topics related to health system strengthening and levers of performance improvements from the external environment. Topics here include governance-relationships and their roles at facility, district and sector levels. In this respect, it addresses topics such as accreditation, regulations and policies that support performance improvements. Other topics concern the financing of health care, management of medicines; information systems and key stakeholder institutions in the health system.

2.3.Target Groups for the Curriculum:

The curriculum blends the training needs of the operational level managers that will be serving as service providers together with the training needs of the up-stream agencies serving as purchasers (fund holder), performance auditor and health system support agencies like DHOs and MOH. Where feasible, these will be trained together to enable the dialogue necessary for the RBF contractual relationships to start and to allow for shared learning by understanding the concerns of different parties. Other target groups will be explored in partnership with RBF project (MOH and BTC) as the RBF model to be implemented becomes clear.

In brief, the beneficiaries of this training fall under the following categories:

  • District health providers (hospital and health centre managers)
  • District health officials responsible for the performance auditing and support supervision
  • National level organizations that will serve different roles for RBF such as fund holders, oversight and accreditation.

2.4.Training Needs Assessment:

Training needs assessment has been carried out using two main approaches. First, the proceedings of the national consultative meetings on RBF were used to draw implications for trainings needs. The consultation meetings about RBF were held in March 2014 and February 2015. Secondly, the draft curriculum will be presented to stakeholders for validation and enrichment. In addition, reports and publications from RBF pilots have be reviewed with a view to map out the necessary competences for RBF and the competence gaps identified in the previous pilots in Uganda and beyond (Ssengooba Ssennyonjo et al)[2].

2.5.Delivery methods:

The preparation of the curriculum has been guided by the nature of the target audiences. The target audiences for this curriculum are adult learners with vast experiences in their technical and professional fields. From this perspective, the curriculum draws upon adult learning methodologies. The main methods in the curriculum include:

  • Interactive lectures – guided discussions structures by an expert;
  • Group exercises – collaborative discussions focused on a group task.
  • Case studies – realistic situations and scenarios demanding innovative solutions;
  • Expert panels – expressions of difference perspectives, viewpoints of stakeholders;
  • Experience sharing – gain tactical and context expertize from practitioners those that have served different roles in RBF.
  • Self-study – to provide opportunity for curiosity and self-directed learning.

2.6.Training Duration

This is a 5-day course. Draft course content outline is provided in subsequent section. Due to the limited period of course implementation, the course will provide “orientation” of trainee to RBF implementation but will not be able to build “expertize”. During implementation, a learning program is expected to identify specific training gaps/needs and provide on-going trainings for quality improvement.

2.7.Implementation.

The curriculum has been designed to take 5 days and assumes a residential set up where the providers are trained together with the district-level officials in the target regions. Training workshop will be held at a time to be determined by BTC. The provision of the training services are to be outsourced separately in a different bid by BTC.

  1. DRAFT OF COURSE OUTLINE
    Draft course content is as follow: will be divided into two sections.

SECTION A: HEALTH SYSTEMS, ORGANISATION AND DETERMINANTS OF THEIR PERFORMANCE.

This section will cover conceptual issues related to health systems, building blocks, organisation and determinants of health system performance.

  1. Health systems and their objectives-This chapter will introduce to the participants the different models and their ideological underpinning of the way health systems are organised (socialized, market-based and Hippocratic). The WHO health systems framework will be key in elaborating this. Participants will be requested to reflect on organisation of Uganda’s health system.
  2. Service delivery and performance determinants-The chapter will cover factors that determine the way health services are delivered. The role different actors in the delivery of services will be discussed. Monitoring and evaluation of Performance (key indicators and outcomes) of service delivery arrangements will be learnt. The determinants of system performance will be explored. Participants will be requested to share the factors that facilitate or undermine effective and efficient service delivery at their facilities and share experiences on strategies, and how they performed and reasons for the above.
  3. Health financing, costs and resource allocation-This chapter will cover the conceptual issues related to health financing (revenue collection, pooling and purchasing/provision of services). The implications of the way health financing functions are organised on health system performance and achievement of equity, efficiency and health improvement goals will be explored. It will also provide overview of the significance of global reforms in health financing such as Global health partnerships/initiatives and UHC movement on health financing in developing countries particularly Uganda. The current and proposed health financing arrangements in Uganda will be discussed including proposed National health insurance, PHC grants to Private Not for profit (PNFPs) facilities. Participants will be invited to share their experiences with these financing arrangements.

SECTION B: RBF & RELATED CONCEPTS AND IMPLEMENTATION CONSIDERATIONS.

  1. Introduction to RBF - the economic and market theories; this chapter covers key economic and market theories that underpin health policies towards health systems strengthening.

Key aspects to be covered are Principles of health economics (including the notions of scarcity, supply and demand, marginal analysis, distinctions between need and demand, opportunity cost, margins, efficiency and equity). Other likely areas include principal-agent models and incentives modifying provider behaviour, Market structure vs pricing regulation, competition, Consumer choice, Market failure and justification for government intervention, Public private partnerships in health care-Contracting.

  1. Performance management and the role of RBF: This chapter will introduce concepts of results oriented management (ROM) and performance management (PM). It will cover the benefits of PM and the performance management cycle, and how RBF promotes performance management in delivery of services.

5.5 The balanced score card in RBF management; the rationale for score card (Tying payments to performance on quality), components of quality scorecard per implementation level/agency and auditing process will be covered.

  1. Information systems in RBF results management; this course unit will cover data collection, management, analysis and utilisation considerations. The role of existing HMIS and other information systems will be discussed. Data and information flow under proposed RBF schemes will be elaborated. The data/information requirements per accounting and financial management tools will be considered. It will also address data quality expectations and implications of data fabrication and poor data quality.
  1. Experiences from the field- Experiences of RBF implementation fund holders and auditors; and Experience of RBF - implementation provider roles.This course unit will provide an opportunity to course participants to hear from experiences of representatives from agencies and health facilities where RBF has been implemented in Uganda. This will be an interactive session with people with hand-on experience. Speakers are likely to come from following agencies (Nu-health/HPI/Montrose, MarieStopesUganda, Cordaid, health facility managers from implementation areas). It will elaborate the role of the actual health workers and how benefits will be distributed with the providers.
  1. RBF interactions and potential unintended effects.-This course unit will examine the spillover effects and downside of RBF as a financing mechanism. The issues about fraud (diagnosis shifting, neglect of non-remunerated services and ignoring long term goals due to counterproductive incentive frameworks etc.),Failure to determine individual contribution to teamwork, limitation of contracts-information asymmetry.
  1. Implementing RBF as a learning process-This will relate to generation of evidence on what work to inform RBF policy and scale up. The role of the different actors in providing and collaborating evidence will be emphasised.
  1. Proposed RBF model-Having discussed the key aspects related RBF, the institutional and implementation arrangements of the proposed RBF will be shared. The operational manual will be discussed and the participants invited to share their opinions, fears and expectations of the intervention. The roles of different actors will be clarified.

References

  1. Meessen B, Soucat A, Sekabaraga C: Performance-based financing: just a donor fad or a catalyst towards comprehensive health-care reform?Bull World Health Organ 2011, 89:153-156.
  2. Morgan, Lindsay and Rena Eichler. December 2011. Performance-Based Incentives in Sub-Saharan Africa: Experiences, Challenges, Lessons. Bethesda, MD: Health Systems 20/20, Abt Associates.
  3. Ssengooba, F., McPake, B., & Palmer, N. (2012). Why performance-based contracting failed in Uganda–An “open-box” evaluation of a complex health system intervention. Social science & medicine, 75(2), 377-383.
  4. Ekirapa-Kiracho et al 2011: Increasing access to institutional deliveries using demand and supply side incentives: early results from a quasi-experimental study. BMC International Health and Human Rights 2011 11(Suppl 1):S11.

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[1] Ssengooba Et al- Implementing RBF programs within the institutional framework of the health system (in press)

[2] Ssengooba , Ssennyonjo et al Learning from Multiple Results-Based Financing Schemes: An analysis of the policy process for Scale-up in Uganda (2003-2015) – a study protocol, Makerere University School of Public Health