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STRIDES LEGACY SERIES

STRENGTHENING HEALTH SERVICES WITH PRIVATE SECTOR SUPPORT IN UGANDA Photo by RUI PIRES Photo by RUI

STRIDES for Family Health any people in developing countries, especially those living in rural areas, face challenges accessing health care. Serious resource constraints and insuf cient increased access to and improved the M political support severely hamper health service delivery. Barriers to access quality of integrated reproductive include distance to service points, availability of medicines, lack of skilled staff, poor health, family planning, child survival, morale among health workers, and the cost of care. and nutrition services in Uganda. In recent years, Uganda’s Ministry of Health (MOH) has renewed its commitment to Management Sciences for Health (MSH) 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 implemented the project with core children—a fertility rate that is among the ve highest in sub-Saharan Africa.2 Reducing partners Communication for Development the country’s fertility rate would contribute to a corresponding decrease in maternal Foundation Uganda (CDFU), Jhpiego, and child mortality. and Meridian Group International. The ministry has recognized that private providers, such as those employed in the commercial sector or by nongovernmental or faith-based organizations, play an Funded by the US Agency for important role in providing health services, particularly for mothers and children.3 For International Development (USAID), 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 STRIDES worked in 15 : Kamwenge, Kalangala, 1. A Strategy to Improve RH in Uganda 2005-2010. MOH, July 2004; Roadmap for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Uganda 2007-2015; National Child Survival Strategy: Brie ng Nakasongola, Kyenjojo, Mityana, Kasese, Paper for Policy Makers and Planners 2009/10-2014/15. MOH, July 2009. 2. Uganda Bureau of Statistics (UBOS) and ICF International Inc. 2012. Uganda Demographic and Health Survey 2011. Bugiri, , Kamuli, Kayunga, , Uganda: UBOS and Calverton, Maryland: ICF International Inc., (UDHS 2011), p 57. 3. “Private providers” refers to professional health workers such as doctors, midwives, nurses, medical clinical of cers, , Kaliro, Kumi, Luwero, and medical of cers, laboratory technicians, and drug sellers who are not employed by the Ugandan public health system. Sembabule. 4. UDHS, 2011. 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 nancing 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 nancial 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 2013. 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. 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, Map: STRIDES PBC subcontractors 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. Recipients included 48 for-pro t and not-for-pro t 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

Lake was able to help dramatically expand access to maternal and child Albert health and family planning services. KUMI NAKASONGOLA

KAMULI The budgets of all proposals receiving adequate scores on the technical KALIRO LUWERO content were reviewed to verify that the cost corresponded to the scope KAYUNGA KYENJOJO of work. The project ensured that the nal budget was reasonable, consistent BUGIRI MITYANA with market rates, and had best value for the US Government. Cost-sharing KAMWENGE MAYUGE KASESE MPIGI was recommended, but not mandatory. SEMBABULE STRIDES asked nalists to explain their technical approach and experience in KALANGALA delivering similar projects, and then conducted an in-depth pre-award survey at each bidder’s of ce 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 STRIDES plan that included indicators, baseline values, targets where they were applicable, data Round 1 sources, and frequency of data collection.

STRIDES 5. For a deep understanding of PBF and PBI see: USAID. Performance-based Incentives Primer for Missions. Round 2 2010. http://pdf.usaid.gov/pdf_docs/PNADX747.pdf.The AIDSTAR-Two Project. The PBF Handbook: Designing and Implementing Effective Performance-Based Financing Programs. Version 1.0. Cambridge: STRIDES Management Sciences for Health, 2011. Round 3

2 n STRIDES LEGACY: PRIVATE SECTOR SUPPORT IN UGANDA Figure 1. The PBC process

1 2 3 SITUATION SOLICITATION PRE-BIDDING ANALYSIS DESIGN WORKSHOPS

4 PROPOSAL 5 EVALUATION CLARIFICATION RECOMMEND Initial Screening & DISCUSSION Cost Analysis Selection Committee 6 DECLINE SELECTION CONDUCT COMMITTEE REVIEW PRE-AWARD SURVEY

7 8 PERFORMANCE NOTIFY SHORTLISTED AWARD MONITORING PLAN APPLICANTS NEGOTIATION

INDUCTION 9 10 IMPLEMENTING THE PLAN CLOSE-OUT WORKSHOP M&E & Technical Support

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 veri ed 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 of ces. Many of STRIDES’ PBC partners were small, community-level facilities, which were unfamiliar with the management and programmatic standards required by major Infant receives Vitamin A supplementation 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. Targeted Interventions to Improve Access to Key Health Services ht by TADEOATUHURA Photo 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.

STRIDES LEGACY: PRIVATE SECTOR SUPPORT IN UGANDA n 3 Table 1. STRIDES PBC awards and areas of focus TOTAL # CLIENTS ROUND KEY SERVICES PARTNERS SERVED ONE ▲ Community-based service delivery 12 717,170 ▲ international Delivery of long-acting and permanent methods (LAPMs) for FP and local ▲ Private sector distribution channels for FP/RH and CS products organizations ▲ 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 14 586,360 private sector international and local ▲ Increasing availability of LAPMs in the private sector organizations ▲ Supporting expansion of services through public-private partnerships ▲ 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 26 350,556 ▲ small health Infrastructure and basic medical equipment facility service ▲ Training in FP/RH/CS to improve service delivery providers ▲ 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 Reproductive ROUND & Maternal Health Family Planning Child Health Nutrition TOTAL ONE 217,099 430,135 62,640 7,296 717,170

TWO 148,643 104,468 247,834 85,415 586,360

THREE 59,102 126,643 156,134 8,677 350,556 TOTAL 424,844 661,246 466,608 101,388 1,654,086

4 n STRIDES LEGACY: PRIVATE SECTOR SUPPORT IN UGANDA The STRIDES PBC partners provided integrated services to women and children at the Some of the interventions community level through a “one-stop shop” approach, such as outreach through mobile yielded positive secondary 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 bene ts. For example, the medical equipment. addition of ultrasound services Some of the interventions yielded positive secondary bene ts. For example, the in hospitals and health centers addition of ultrasound services in hospitals and health centers strengthened male strengthened male participation, participation, since partners were motivated to see their babies in utero. since partners were motivated The PBC program reached 1,654,086 men, women, young people, and children in 15 to see their babies in utero. 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. 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 signi cant 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 Photo by RUI PIRES Clients Percent served at Clients increase Total clients baseline served in from PY1 to served Percent PBC INDICATOR (PY1) PY5 PY5 (PY2- PY5) Contribution Number of new FP users 136,272 204,554 50% 655,494 12% Implants and IUDs inserted 6,402 40,247 529% 91,069 60% Children under 5 years of age who received 2nd dose of 197,259 372,334 89% 1,074,049 16% Vitamin A Pregnant women who received 4 83,775 98,414 17% 318,357 16% ANC consultations Pregnant women who received 2+ 97,738 134,681 38% 435,740 13% doses of IPT Live births delivered at a health facility 73,136 107,039 46% 360,575 11%

STRIDES LEGACY: PRIVATE SECTOR SUPPORT IN UGANDA n 5 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 signi cant drop in the number of users of implants and IUDs in the fth year of the project. Reaching the Hard-to-Reach STRIDES supported the partners to provide outreach services in areas with poor access Figure 2. Number of implants and IUD to health services. For example, the Ernest Cook Ultrasound Research and Education insertions Institute (ECUREI) provided ANC services on the remote Bunjako Islands of . Another partner, Suubi Medical Centre in , conducted outreach activities in shing villages where children had never been immunized and were dying from dual 12,000 PBC APPROACH APPLIED malaria and measles infection. In , 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 10,000 communities in the mountainous regions of , STRIDES engaged Path nder International to provide technical assistance to a peer-to-peer program in which young Total 8,000 mothers mapped households with pregnant women, and when possible, conducted regular counseling and follow-up with them and their partners.

6,000 Supporting Local and Innovative Solutions Implants The PBC program encouraged partners to develop innovative solutions to address 4,000 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 2,000 mobilization to improve health and nutrition; and provision of demand-side incentives (vouchers) to help women deliver at hospitals, pay for transportation, and receive IUDs special services such as lab tests and surgery. 0 STRIDES’ partner Midas Touch Medical Services, a private clinic in , PY2 PY3 PY4 PY5 received a PBC to mobilize mothers to access free ANC and comprehensive

6 n STRIDES LEGACY: PRIVATE SECTOR SUPPORT IN UGANDA 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 Figure 3. Voucher program effect on women were encouraged to complete the standard four ANC visits to be eligible to high-impact health interventions 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, PBC APPROACH APPLIED cesarean section, lab tests, postnatal care, and postabortion care. 5,000 This signi 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 4,000 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. 3,000 ECUREI also implemented an innovative model to improve maternal and neonatal IPTp2 health in Mpigi district. With support from STRIDES and the University of Washington and General Electric, ECUREI donated portable solar-powered ultrasound machines 2,000 4th ANC 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 1,000 Live Births them to complete four ANC visits and deliver at the health facilities. ECUREI also Delivered offered an innovative training model by providing substitute midwives to keep services running at government facilities while staff attended trainings. 0 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Other partners adopted reduced prices to ensure access to services. Sustainability of PY2 PY3 PY4 these services remains a challenge, given that clients are unable to pay nonsubsidized baseline prices and public health facilities still lack suf cient resources to provide adequate care.

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 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 con rmed Kyotazaala’s diagnosis, and Mbwirahe underwent life-saving emergency surgery. Photo by RUI PIRES Photo by

STRIDES LEGACY: PRIVATE SECTOR SUPPORT IN UGANDA n 7 ht by TADEOATUHURA Photo

PBC made it possible to train health workers to deliver family planning and ultrasound scanning services in rural areas.

Conclusion ACKNOWLEDGEMENTS STRIDES’ experience suggests that performance-based nancing using incentives STRIDES for Family Health gratefully can increase access to and use of a broad range of services. Supported by the PBC acknowledges the US Agency for program, private providers and public facilities were able to provide high-quality services International Development for the to geographically hard-to-reach and underserved areas. generous support that made the performance-based contracting program In addition to fostering a strong results-oriented culture in the organizations and among possible. STRIDES also acknowledges the private providers, the model facilitated stronger linkages between public and private Government of Uganda and the Ministry facilities. Coordination with district health of cials was an important element. For of Health as vital partners, as well as example, most partners obtained some of their medical supplies, such as vaccines and district health and government of cials. FP commodities, through the district supply chain. With STRIDES’s support, districts have increasingly led community outreach activities, fostering collaboration among This document in the legacy series private providers, nongovernmental organizations, and public facilities. District health was developed by Richard Ssewajje teams increasingly need to plan, manage, and monitor the support provided by private of STRIDES and Fabio Castaño of partners. This can result in a “total local health system” where the public and private Management Sciences for Health, sectors can expand quality services to all. with contributions from the following individuals: Celia Tusiime Kakande, While performance-based schemes are not a panacea for all problems within health Tadeo Atuhura, Henry Kakande, systems, they are a promising and innovative strategy for using the private sector Thomas Emeetai, and Miriam Mutabazi to rapidly scale up priority services, implement innovative models of public-private of STRIDES for Family Health and partnerships, and target hard-to-reach, underserved populations. STRIDES’ results show Management Sciences for Health. that performance-based incentives can be used successfully across a wide range of This product is made possible by the support of n services and program interventions. the US Agency for International Development (USAID) under Cooperative Agreement No. 617-A-00-09-00005-00. The contents are the responsibility of STRIDES for Family Health and do not necessarily reect the views of USAID or the US Government.

8 n STRIDES LEGACY: PRIVATE SECTOR SUPPORT IN UGANDA