HealthPartners
Collaborations Project Semi-Annual Report July-December 2012
OAA-A-11-00010
Photo by Ilia Horsburgh
Authors: Jennifer Stockert, Director Maale Julius Kayongo, Operations Manager David Muhumuza, Monitoring and Evaluation Manager Paul Walters, Coordinator Herbert Asiimwe, Transitional Manager
Date: December 21, 2012
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Abbreviations and Acronyms
AGM Annual General Meeting BOD Board of Directors CDO Cooperative Development Organizations CDP Cooperative Development Program CHI Community Health Insurance CI Communication of Innovation CLARITY Cooperative Law and Regulation Initiative Co-op Cooperative COP Chief of Party CRI Criterion Referenced Instruction DHT District Health Team FY Financial Year HIV/AIDS Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome HMIS Health Management Information System HPC HealthPartners Cooperative HSSP Health Sector Strategic Plan ID Identification IEC/BCC Information, Education and Communication/Behavior Change Communication IR Intermediate Result KPC Knowledge, Practices and Coverage Survey LOP Life of Project MCP Malaria Communities Program METRICS Measurements for Tracking Indicators of Cooperative Success M&E Monitoring and Evaluation MOH Ministry of Health MOU Memorandum of Understanding OCDC Overseas Cooperative Development Council OVCAT Operational Viability and Capacity Assessment Tool PAR Prioritized Allocation of Resources PMP Performance Management Plan PQA Provider Quality Assessment SF Sustainability Framework UCBHFA Uganda Community Based Health Financing Association UCCC Uganda Crane Creameries Cooperative UGX Uganda Shillings UHC Uganda Health Cooperative USAID United States Agency of International Development VHT Village Health Team VSLA Village Savings and Loan Association WAD West Ankole Diocese WRA Women of Reproductive Age
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Table of Contents
I. Project Summary...... 4
II. Progress Report...... 6
III. What Works and What Will be Changed ...... 12
IV. Key Issues...... 21
V. Plans for the Next Six Months ...... 26
VI. Success Stories ...... 31
Annex A: Site Visit Report from Joel Kisubi, Uganda Mission ...... 32
Annex B: Site Trip Report—Paul Walters, September 7-21, 2012 ...... 34
Annex C: Prioritized Allocation of Resources ...... 36
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I. Project Summary
HealthPartners Cooperative is a community based health insurance model that provides resources for capacity building and network development that empower local stakeholders including women and the poor to access care, recognize and demand quality and improve health outcomes.
HealthPartners Collaborations Project development hypothesis is that by empowering and building the capacity of rural stakeholders, especially women of reproductive age and the poor, enabling them to maintain community owned prepaid health co-ops with linkages to strengthened health systems, local stakeholders can sustain increased access to quality preventive care and treatment with increased accountability and improved health outcomes for the community.
Development Challenge Development goals of the Government of Uganda include accelerating economic growth to reduce poverty ensuring that all people have equitable access to the basic package of health care and improving the health status of the people of Uganda. Thirty-one percent of Ugandans were living below the poverty line in 2005 and Uganda remains one of the poorest countries ranking 145 on the global Human Development Index. A direct relationship has been demonstrated between poverty and health. Poverty reduces access to health care and catastrophic illness can lead to poverty. Incidence of malaria, dysentery and diarrhea are more prevalent among the poor than the rich1. Nearly two-thirds of the households in the Central and Western regions of Uganda descended into poverty over the past 25 years as a result of ill health and health related costs2. The Ministry of Health in Uganda has been working to put in place a National Health Insurance Scheme for many years; a national health plan has been drafted but the implementation of this plan and its impact on the rural poor may still be years away. The lack of a comprehensive social security system makes the poor more vulnerable in terms of affordability and choice of health provider. This situation is compounded for women in Uganda since the rural birth rate is 7.13 children per woman, women are traditionally primary care takers, culturally women lack power and control to make decisions, and women have less access to capital.
The Collaborations project design includes strategic approaches that draw on the significant motivation that co-ops have to deal with endemic disease threats, increased purchasing power of the group, taking advantage of their potential roles in education and service delivery, and the availability of the resources needed to realize that potential.
1 Government of Uganda Health Sector Strategic Plan III 2010/11-2014/15 2 Krishna, Anirudh. “The Stages of Progress: Methodology, Assets, and Longitudinal Trends: Results from a Five-year Study in 236 Communities of Five Countries.” Brookings/Ford Workshop Paper. 2006. 3 Uganda Demographic and Health Survey 2006 4 | Page
The Collaborations project has a been crafted to avoid contributing to dependency by 1) including stakeholders in program design and planning to ensure their priority needs are being addressed and to build ownership; 2) basing all activities and interventions on sustainable systems including using Ministry of Health (MOH) Health Management Information System (HMIS) tools and timelines; 3) promoting partnerships based on documented responsibilities with measures of accountability; 4) developing a graduation plan with stakeholders as a measure of success; 5) including the Uganda Health Cooperative (UHC) as a “graduate” from direct development assistance, now in a position to mentor new co-ops through the process of orientation, implementation, support supervision and eventually leading to their graduation from external support.
HealthPartners believes that these design, planning and management principles will significantly accelerate progress toward self-reliance while, at the same time, minimizing the possibilities of creating dependency.
Expected Outcomes and Impact The Collaborations project addresses quality, accountability and accessibility of health care through the development of six new community owned health co-ops that will serve at least 30,000 women of reproductive age (WRA) and at least 85,000 members overall in Southwestern Uganda. Forty-two co-op member groups will elect private providers based on measures of quality and will establish memorandums of understanding (MOUs) with them for quality service and accountability.
Each co-op will be empowered to develop private and public partnerships creating annual action plans for improved health. At least five partnerships per co-op will be developed with local organizations including district health teams (DHT) whose village health team (VHT) volunteers will be offered discounted rates for co-op membership since their services have been shown to directly increase community health through disease prevention and treatment seeking behaviors which in turn directly increases cost savings for health co-ops. Eighteen Private health care providers will employ data entrants to track monthly co-op performance and fill MOH HMIS forms contributing to their own and the MOH ability to make results-based decisions. All six co-ops will elect their own board of directors to maintain a sustainable financial co-op cost balance with annual provider surpluses and a reserve fund.
Co-ops will be linked nationally to the Uganda Community Based Health Financing Association (UCBHFA) and to other in-country Cooperative Development Program (CDP) partners for work on The Cooperative Legal and Regulatory Initiative (CLARITY) and to address the issue of measuring co-op performance through Measurements for Tracking Indicators of Cooperative Success (METRICS). HealthPartners will join CDP workshops and working groups to contribute to CLARITY, METRICS and IMPACT initiatives (comparing the co-op model impact to business and other development models.) By the end of the project, evidence will show how the project model, strategies and lessons learned have been adopted by the MOH and partners. 5 | Page
II. Progress Report
Objective/ End of Project Goals 2012 Target Achievements to date, Dec. 2012 Activity O1: Annual stakeholder workshop reports for 6 co-ops detail public/ private partnership action plans for improved health Three (3) district level meetings were 1.1. Sensitize conducted reaching a total of 253 leaders. district leaders 4 stakeholder Participants included 85 (63 male and 22 1.1: 6 stakeholder on the HPC workshop reports females) district leaders from Ntungamo workshop reports model, share detailing public / district, 85 leaders (66 males, and 19 females) detailing baseline private for Mbarara dairy cooperative union, and 83 public/private results, and partnership action leaders (68 males, and 15 females) for partnership action for develop a for improved Ntungamo dairy cooperative union. The improved health program health conducted. above leaders participated in discussions response about how HealthPartners co-op model works. A pool of 21 Mbarara district HPC trainers (7 males and 14 female) was created and currently serves Ankole health coop, and Mbarara archdiocese co-op. There are currently 12 new providers out of which 11 have signed MOUs for health coop partnership with HealthPartners Uganda, and 1.2: Training 1.1.2: 18 coop 4 coop providers 5 providers have started providing health care District providers who signed signed MOUs with to group members as indicated below; Trainers on MOUs with member 43 member Ankole Health cooperative: 7 new groups HPC model groups groups served by Ruharo Mission hospital, St. Johns Biharwe health centre signed MOUs. Mbarara Archdiocese: 5 groups served by St. Josephs Rubindi and Kakoma Health centre signed MOUs. West Ankole Diocese: 31 schools served by Katungu Mission Hospital signed MOUs On-site training was conducted in 12 health facilities covering 323 (181 female and 142 male) health workers. MOUs have been signed with Kathe Medical Center, Mbarara Moslem HC, Ibanda Mission HC, West ankole 1.3. On-site 1.1.2: 18 coop Diocese, Kakoma HC, St John’s Biharwe, St 4 coop providers training of providers who signed Joseph’s Rubindi, Tumu Hospital, St. Mary's signed MOUs with service MOUs with member Kibuza, and St. Lucia Kagamba, and Mbarara member groups provider staffs groups Community hospital. Out of the 12 providers oriented on HPC model, 11 have signed MOUs for health coop partnership with HealthPartners Uganda. Ruharo Mission Hospital has signed MOUs with member groups but is still reviewing the terms of an 6 | Page
Objective/ End of Project Goals 2012 Target Achievements to date, Dec. 2012 Activity MOU for cooperative development support from HealthPartners Uganda. 405 (229 female and 176 male) VHT from 21 parishes were trained on HPC model during the period under review. A total of four (4) VHT groups have been enrolled. Overall, a 1.4. Training 1.2.2 : 42 groups 43 groups total of 43 groups have been enrolled and are VHT on HPC register with health registered with accessing health care under the new health model co-ops health co-ops coops. Out of the existing 34 groups under UHC, 8 groups were enrolled during the review period while 1 group (Musimenta high school) dropped out. Provider support supervision is scheduled to 1.1 4 stakeholder begin in February 2013 after coop boards 1.5. Conduct 6 stakeholder workshop reports have been established and their capacity built integrated workshop reports detailing public / on provider support supervision. During the provider detailing private review period, a provider quality assessment support public/private partnership action (PQA) tool was developed and pretested with supervisions partnership action for for improved Buredo Health Center in Buhweju district. improved health health Results indicated 77.8% member satisfaction with the quality of health care. No interactive drama shows were conducted 1.6. Conduct using CDP direct funding. However, the interactive 8 Interactive Malaria Communities Program (MCP) drama shows 1.2 drama shows commissioned 6 Interactive drama shows that in strategic 52 Interactive drama conducted with included malaria prevention and treatment locations to shows conducted support from CDP and health co-op messages in the following promote with support from to encourage locations to: Rweibare Church of Uganda in health CDP to encourage community Sheema district, Rukararwe Catholic Church in financing using community members members join Mitooma district, Nyakashaka and Katinda HealthPartners join Health Coops Health Coops Trading Centres in Buhweju district, as well as cooperative Bubare sub county headquarters and Kashaka model Trading Centre in Mbarara district. 1.7. Air radio 23 radio talk shows and 198 radio spots with spots and talk 1.3 and 1.4 combined messages on malaria prevention 8 Radio talk shows to 52 approved Radio and treatment and co-op health financing shows, and 96 promote talk shows, and 624 were aired during the review period. radio spots aired health radio jingles/spots to promote financing using aired to promote community health HealthPartners community health financing. cooperative financing. model 1.8. Print and 1.5 5,200 materials 5,000 posters and 2,000 brochures were distribute 16,030 IEC materials distributed to distributed to VHT to promote cooperative IEC/BCC distributed to support support increased health financing. 2000 t-shirts were materials to VHT to help people co-op membership distributed to key partners and stakeholders.
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Objective/ End of Project Goals 2012 Target Achievements to date, Dec. 2012 Activity the community join health to promote cooperatives community Health Financing. There are currently 12 new providers out of which 11 have signed MOUs for health coop partnership with HealthPartners Uganda, and 5 providers have started providing health care to group members as indicated below; 1.9. Orient 1.1.1 4 coop providers Ankole Health cooperative: 7 new groups Institutional 42 coop member signed MOUs with served by Ruharo Mission hospital, St. Johns heads on the groups affiliated to 43 member Biharwe health centre signed MOUs. HPC model HealthPartners co-ops groups Mbarara Archdiocese: 5 groups served by St. Josephs Rubindi and Kakoma Health centre signed MOUs. West Ankole Diocese: 31 schools served by Katungu Mission Hospital signed MOUs 1.10. Provision Startup kits have not yet been procured using of CHI startup CDP funding. However, using MCP resources, kits to 10 laminating machines were procured. For 1.1.2 providers to 4 coop providers CDP, Community Health Insurance (CHI) kits 18 co-op providers support signed MOUs with are planned for procurement in March 2013 sign MOUs with providers to 43 member after the 12 providers have enrolled member member groups start and groups groups. The 8 UHC providers will also be launch new provided with startup kits scheduled for member January 2013 since they already have enrolled groups members. 1.11. Conduct 1.1.3 Worked with partners for data collection to provider 90% of providers have document baseline indicators, coordinated quality improved ratings on the development of PQA tool using Criterion assessments their member quality Referenced Instruction (CRI) to support (PQA) and assessment scores stakeholders to develop a relationship with share results 1.1.4: 90% of staff in health care providers based on measures of health facilities quality. Pretested provider quality 1.12. Conduct working on the day of assessment methodology in December with quarterly the serve BUREDO health care provider and member meetings with 1.1.5: 100% of coop stakeholders. service health facilities with providers to first line medication Provider surplus for the 4 co-ops are stated share support 1.1.6: 100% of health below: supervision facilities with Uganda Health Co-op: Uganda Shillings (UGX.) results, guidelines for care of 218,283 Cooperative children and adults Ankole Health Co-op: UGX.1,353,275 performance 2.1: Provider surplus West Ankole Diocese: UGX.96,616,450 summary, and averages at least Mbarara Archdiocese: UGX.0 mapping tool 500,000 8 | Page
Objective/ End of Project Goals 2012 Target Achievements to date, Dec. 2012 Activity 2.2 Total annual coop 46.2% of the health care providers reported a reserve balance of at surplus in 2012. least 3,000,000 2.3: 80% of Health care providers with 78.5% of co-op members paid premiums on annual surplus time. 2.4: 30% of coop members pay premiums on time 100% of the health facilities maintain up-to- 2.1.2: 100% of health date records of sick clients. facilities maintain up to date records on sick clients A total of 1,646 Sub county level leaders from 1.13: 1. 85,000 people 28 sub counties were sensitized (547 were Sensitization of covered by USG 5,500 people female and 1,099 males.) As a result, 26,813 sub county supported health enrolled in health members were enrolled with 14,252 females, level leaders financing coops. and 12,561 males. Out of these; 5,189 are on HPC model arrangements UHC while 21,624 are for the new health coops. There are currently 12 new providers out of which 11 have signed MOUs for health coop partnership with HealthPartners Uganda, and 5 providers have started providing health care to group members as indicated below; 4 MOUs signed 1.14: Provider 42 MOUs signed Ankole Health cooperative: 7 new groups annually between enrollment of annually between co- served by Ruharo Mission hospital, St. Johns co-ops and local new member ops and local health Biharwe health centre signed MOUs. health group stakeholders Mbarara Archdiocese: 5 groups served by St. stakeholders Josephs Rubindi and Kakoma Health centre signed MOUs. West Ankole Diocese (WAD): 31 schools served by Katungu Mission Hospital signed MOUs 1.15: Quarterly There are currently 12 new providers out of meetings which 11 have signed MOUs for health coop between partnership with HealthPartners Uganda, and providers and 5 providers have started providing health care group 4 MOUs signed to group members as indicated below; 42 MOUs signed members to annually between Ankole Health cooperative: 7 new groups annually between co- deliver health co-ops and local served by Ruharo Mission hospital, St. Johns ops and local health education, health Biharwe health centre signed MOUs. stakeholders review scheme stakeholders Mbarara Archdiocese: 5 groups served by St. performance Josephs Rubindi and Kakoma Health centre and close signed MOUs. health coop West Ankole Diocese: 31 schools served by gaps identified Katungu Mission Hospital signed MOUs 9 | Page
Objective/ End of Project Goals 2012 Target Achievements to date, Dec. 2012 Activity O2: Six health co-op boards maintain their co-op cost balance with annual provider surpluses and reserve fund 2.1. Ensure co- Provider surplus for the 4 co-ops are stated op below: stakeholders at Uganda Health Co-op: UGX. 218,283 the Trial stage 2.1 Ankole Health Co-op: UGX. 1,353,275 are successful Provider surplus West Ankole Diocese: UGX. 96,641,450 0 UGX. by facilitating averages 500,000 or Mbarara Archdiocese Health Co-op: UGX. 0 support more per co-op supervision from co-op stakeholders 2.2. Conduct UHC and WAD coops have reserve fund bank 2.2: Total co-op monthly accounts. Data management training for all reserve fund balance meetings with Reserve funds not new providers was conducted. Monthly Data is 3,000,000 or more data entrants anticipated until Entrants meetings were conducted with Coop 2.11: 18 providers to strengthen 2014 provider representatives. 13 out of 20 turn in coop tracking their capacity providers who have signed MOUs for both tools on time in data new health coops and UHC turned in their management monthly Coop data performance reports. 2.3. Conduct 28 members from West Ankole Diocese and Sustainability 29 from Ankole Diocese were trained in 2.3 Planning 0% of health care sustainability planning during the period 80% of health care Workshops for providers with under review. providers with annual health annual surplus surplus cooperative stakeholders 2.4. Support 46.2% (6 out of 13) health care providers have providers to 2.3 an annual surplus. 0% of health care conduct 80% of health care providers with Community providers have an annual surplus Sensitization annual surplus on HPC model 2.5. Quarterly 13 health care providers turned in co-op planning performance tracking tool on a monthly basis. meetings 2.1.1 0 providers turn in between group 18 providers turn in co-op leaders, VHT co-op performance performance parish tracking tools tracking tools coordinators and service providers 2.6. Conduct Self assessments UHC board conducted self-assessment during 2.2.1: Self assessment quarterly HPC scheduled to the board meeting and the average score was scores by Co-op Board of begin for new co- 79.7%. boards average 95% Director ops in 2013
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Objective/ End of Project Goals 2012 Target Achievements to date, Dec. 2012 Activity meetings UHC board governance training was scheduled but postponed pending agreement 2.7. Training of Self assessments 2.2.1: Self assessment to terms of partnership for 2013. coop boards on scheduled to scores by Co-op HealthPartners is requiring a copy of bank governance begin for new co- boards average 95% statements to ensure transparent financial and by-laws ops in 2013 management and a successful external audit before offering additional support. 2.8.Support 2.2.2: 6 of Pre- annual general meeting (AGM) type Health performance review meetings are planned in January to support Cooperatives meetings held by co- co-op formation and development of by-laws. to conduct op boards AGMs not Annual General 2.2.3: Number of expected to begin Meetings people attending until 2014. (AGMs) for performance review performance meetings held by co- reviews op boards 2.9. Facilitate 1 MOH support supervision visit was MOH to conducted. conduct 2.2.4 2 MOH support quarterly 10 MOH support supervision visit support supervision visits supervision conducted visits to health coops 2.10. Conduct 10,122 women have joined health coops. training for VSLA training is scheduled to be conducted in WRA who join March 2013 after groups of WRA have been health coops formed and started accessing health care with 2: 30,000 so they can 3,000 WRA join effective leadership processes established. cooperative members start Village health co-ops During the reporting period, priority for are WRA Savings and formed groups was given to capacity building Loans on health coop management and filling gaps Associations such as creating identification (ID) cards. (VSLAs) O3: CDP partner collaborations outputs on lessons learned in co-op health financing shared with MOH and partners 3.1. # of CLARITY related collaborative TBD 1 6 Clarity milestones have been completed. activities(works hops, conferences, seminars) 3.1.1 # of TBD 0 No METRICS milestones were reported.
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Objective/ End of Project Goals 2012 Target Achievements to date, Dec. 2012 Activity METRICS related collaborative activities (workshops, conferences, seminars) 3.1.2 # of IMPACT related collaborations TBD 0 5 IMPACT milestones have been achieved. (workshops, conferences, seminars)
III. What Works and What Will be Changed
Design/strategy
HealthPartners developed a Cascade of Sensitization and Training for stakeholders interested in starting or joining Health Co-ops. The strategy includes step by step support for potential member groups, district health stakeholders and health care providers. Below is an assessment of cascade steps implemented between July and December 2012 with lessons learned and changes that will be made as a result.
Orientation of institutional heads on HPC model: Before establishing partnerships with identified and interested stakeholders, efforts are made to ensure that the organizational leaders or decision makers understand how the health co-op model works. This activity provides an opportunity to answer questions, set appropriate expectations for support, builds interest and enables leaders to support development activities. In some organizations these meetings are 1:1 and others appeal to organizational boards of directors or other committees. This activity is proving useful and is producing the intended impact.
District and sub county leader sensitization meetings on HPC model: During the review period a number of half day district and sub county leadership meetings were conducted to create awareness and advocacy for support and ownership of the HealthPartners cooperative model. During the meetings, community leaders explained how health co-ops save people
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money and improve health, listed the roles and responsibilities that must be fulfilled by stakeholders in a sustainable health co-op, and described the strategies and steps they could follow to encourage people to join health co-ops. Since the implementation area has history of institutions that collected funds from community members and disappeared without delivering promised benefits, the sensitization meetings for both the sub-county and community leaders have gone a long way toward building credibility and helping leaders scrutinize the intended project benefits. Leaders have embraced the health coop model and many are advocating for it in the community.
Training Trainers: District trainers in Bushenyi and Mbarara districts are successfully filling the roles for leading the other cascade steps with HealthPartners staff support supervision to ensure goals are reached for each activity and funds are appropriately allocated.
Training of health co-op stakeholders on sustainability planning: During the review period, stakeholders for Ankole Health Co-op and West Ankole Diocese were trained using sustainability framework tools to enable them to define sustainability, compare and contrast the five main steps in sustainable program design, and to support their situational analysis and development of a sustainability scenario.
What will be changed: • Project leaders in the field found this training and its impact to be beyond the scope of their priorities for supporting stakeholders to develop a solid co-op framework including developing by-laws, electing boards of directors, understanding principles of sound financial management and the logistical steps required by health care providers and group leaders for facilitating and tracking health care. • Field leaders concluded that sustainability framework training would be more apt to have the intended impact after stakeholders have completed the critical steps and requirements for forming a health co-op. • Sustainability Framework training (objective 2.3), has been removed from the Financial Year (FY)13 Work Plan.
Onsite training of health workers in selected private health facilities on health co-op model: All new health co-op providers received 2 days onsite training on the HPC model. This activity developed provider confidence to train new health co-op members and track premiums and treatment costs.
Provider enrollment of new members: After groups select a provider for health care coverage, a one day workshop for training new health coop members is led by the health care provider. A district trainer and HealthPartners staff provide support supervision for the first and in some cases second or third new co-op member training. Support supervisions helps to ensure that providers and member groups are developing mutually beneficial partnerships. During meetings, groups learn how risk pooling works, understand the rules and reasons for co-op rules, understand why co-pay is necessary, receive support to address health concerns and questions to VHT, and develop plans for paying premiums to their group leader every quarter.
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Most importantly, new members learn that the co-op is owned by them and their ongoing participation is required to make it a success.
Camera care and use: While the Cascade of Sensitization and Training included plans for staged support, at times, pre-requisite skills training has been necessary. Balancing meeting co-op stakeholders demand to begin care with capacity building has been a challenge. For example, data entrants hired and employed by health care providers are expected to develop identification cards for new members. Since WAD leaders were eager to start the WAD co-op, 21,000 identification cards were required in a very short period of time. Since most data entrants did not know how to care for cameras or take photos, a training guide using principles of CRI needed to be developed and tested to be sure it was culturally appropriate and effective.
Changes: • Training tool for how to make health co-op ID cards developed and implemented • Temporary support was hired to close gaps in creating ID cards quickly for WAD co-op • Community health insurance start up kits have been budgeted and will be provided with support during the next quarter
Training VHT to promote Health Co-ops: VHT volunteers have been trained using MOH guidelines to help community members adopt preventive and healthy treatment seeking behaviors. As part of the Cascade of Sensitization and Training for new health co-op stakeholders, HealthPartners developed a training plan for VHT to support their promotion of health co-ops. Additionally, HealthPartners recommended that providers negotiate reduced premium rates for VHT in exchange for VHT promoting the co-op during their other healthy behavior visits. This was envisioned to be a sustainable strategy to support increasing co-op membership and a win-win partnership since VHT know healthy behaviors and thus enjoy relatively higher levels of health.
During the review period, VHT were trained and community sensitization was performed by VHT assisted by health care provider staff with supervision from a district trainer. Sensitization targeted community members in villages and parishes near providers who requested health co-op support. However, despite the fact that trained VHT were able to deliver the health co- op messages to the target audience especially on how health co-ops save people money and improve health, benefits of becoming health coop member and explanation of the registration process, these efforts did not lead to increased membership.
What will be changed: • Instead of training VHT to promote the health co-op near co-op providers, HealthPartners will only train VHT who join the co-op and who can therefore recommend membership through first-hand experience • HealthPartners will no longer recommend discounted membership for VHT • VHT training post test scores and training content will be reviewed and adjusted
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• Training plans will support VHT to partner with co-op members who can provide positive motivating testimonies from experience to support those at awareness and interest stages to learn from early adopters.
Community sensitization meetings on HPC model: In many of the sub counties within the project implementation area, community sensitizations at village levels were conducted by VHT to introduce the health co-op model, roles and responsibilities and benefits of being a member. The activity encouraged small groups to select a private health care provider and initiate discussions to begin care. This activity was not an effective or efficient use of time.
What will be changed: • Communication of Innovation (CI) and strategically mapping stakeholders will replace this activity. For more information on the way forward, refer to Prioritized Allocation of Resources on Page 17.
Provider Quality Assessments (PQA): the goal of including provider quality assessments in the co-op model is to empower co-op members to receive the quality of care they expect with resources to advocate for improvements. While many leaders of large organizations have asked HealthPartners to prequalify health care providers for inclusion in the co-op, HealthPartners goal is to empower organizations to recognize and demand quality. National reports on health statistics and quality of care at providers are available.
For sustainability of the co-op, a process that enables co-op members to rate the services they receive from providers according to what is important to them was developed. PQAs are an opportunity for members to develop relationships with providers. A committee of members is elected to document their needs and expectations with provider stakeholders. Together the committee and providers learn what works well and create an action plan to close gaps. Since member groups can change providers at any time, providers have incentive to meet the quality of care expected by their members. The PQA tool was developed using principles of CRI to support the participatory process of stakeholders identifying their priorities and measuring performance of their provider. The PQA tool was tested in Buredo health center in December. Lessons learned will be incorporated into the tool to scale up support for more provider quality assessments.
Quarterly meetings to share Co-op Performance results with members and providers were facilitated for Uganda Health Cooperative providers. Data was used to identify gaps in performance with action plans developed to improve management and to increase provider surpluses.
Governance Training: Selected HealthPartners staff took part in a three day Cooperative Board Governance Training of Trainers in September. The training relied heavily on resources from the John Carver Policy Governance model of board leadership. Objective: Participants will work collaboratively to develop Cooperative Board Governance tools and demonstrate their knowledge of Policy Governance by scoring an 85% or greater on the Cooperative Board Governance Post-Test.
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Deliverables include: • Defining Governance • Defining the health cooperative ownership • Developing a Statement of Commitment to the cooperative members • Developing a Communication Plan with the cooperative members • Developing an Election Plan for board members • Reviewing and identifying characteristics of great board members • Developing an Orientation Plan for new board members • Reviewing two types of board committees • Reviewing and Updating Cooperative Bylaws • Reviewing Policy Governance Concept • Developing End Results Policies • Developing a Board Governing Conduct Policy • Developing a Cooperative Performance Monitoring Plan • Completing a Post-Test
Successful participants will facilitate the training for the UHC Board of Directors and the Boards of newly formed health cooperatives. This training was conducted using CRI with a post-test demonstrating staff understanding of the materials.
Behavior Change Communication Distribution of materials: 120 t-shirts have been given out during the implementation of CDP activities to coordinators of Buhweju, Ankole Diocese and Mbarara Archdiocese. Uganda Health Cooperative health care providers also received incentive items to distribute strategically.
Lessons learned: Co-op health facilities were delighted to receive incentives. They were motivated to distribute materials to data entrants, group leaders, VHT, group members and health facility administrators. An important lesson is that such incentives are capable of strengthening the bond between providers and HealthPartners. They also motivate stakeholders to become more committed to health coops.
While t-shirts were popular, not every stakeholder interested in the t-shirts received one. Stakeholders who did not receive shirts complained. There is a risk of some members of enrolled groups losing morale in health coops, arguing that only their leaders are favored and rewarded with t-shirts. In the future, the team decided that less expensive items such as branded key holders and posters should be disseminated to all group members irrespective of their rank in the health coop. Items like t-shirts should be reserved for members who renew their commitment by consistently paying premiums on time.
A new drama script was developed and shared with Bwera and Ihunga Drama Groups. Dialogue emphasizes the benefits of being a member of a health coop and portrays the risks of not being one. It challenges community members to adopt healthy treatment seeking behaviors and demonstrates that as a member of a health coop, one does not have to worry 16 | Page
about catastrophic expenses. The drama groups were given guidelines on key messages about health co-ops and tasked with developing songs and dances to convey them. Follow up planning sessions with the drama groups has been scheduled for January. Once key messages have been tested, the groups will be hired to present shows in strategic locations.
HealthPartners developed content for radio talk shows with 15 minute long segments that include 3 minutes of jingles. Questions arising from recorded radio segments will be answered during monthly interactive talk shows lasting 1 hour each. The monitoring and evaluation coordinator is developing tools for conducting focus group discussions for women of reproductive age in order to test the impact of messages developed and adjust as necessary before beginning a routine schedule to air the segments.
Prioritized Allocation of Resources (PAR): In order to leverage resources and increase membership the project is incorporating Communication of Innovation (CI) strategy and using cooperative performance data tracked and collected on a monthly basis by service provider data entrants. The goal for the PAR is to support health co-op stakeholders to avoid allocating their time with groups and providers who don’t join at the expense of providing support to stakeholders who are ready to adopt the innovation. Leaders have developed a system to prioritize and allocate support where it would be expected to have the most impact.
Using CI, stakeholders are identified as a potential Innovator, Early Adopter, Early majority, Late majority or Laggard in addition to assessing the stage of adoption of a given group as; Awareness, Interest, Evaluation, Trial or Adoption. The idea is to increase support for those in Interest and Evaluation stages by linking them to Early Adopters and ensuring success for those at the Trial stage. Early adopters possess qualities such as: residing locally, relatively more educated, higher social status, measured approach, interested in learning—other people want to be like them. Early adopters are not usually skeptical or negative by nature. To be categorized as an early adopter, in addition to the qualities noted, staff look for those who correctly and concisely explain how the health co-op works; easily identify the benefits of co- op membership for members and providers; have a personal story about how the co-op works, why it works or why they are interested in the model or helping to save lives.
Co-op performance data can be used to determine where support is needed most urgently and where success may provide opportunities for others to learn. This strategy, while still being tested and improved, is intended to avoid investing time to generate interest in the co-op at the expense of focusing on making sure co-op members at the trial stage are successful. When co-op members are successful, they will naturally talk about the co-op leading others to learn and consider joining. Additionally, the project team and district trainers will be able to provide opportunities for early adopters who are part of successful health co-ops to meet with groups at interest or evaluation stages. When the PAR system is improved to the point of having the intended impact, a training plan will be developed to build provider capacity to allocate co-op resources where they will have the most impact. See Annex B for an example of the PAR tool.
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Partnerships
Partnership with the Uganda Mission HealthPartners team has greatly appreciated support and recommendations from the Uganda Mission. Mission representatives helped linked staff to project partners for sharing lessons learned and coordinating efforts.
Through the partnership with the Mission HealthPartners learned about voucher schemes that have been implemented in Bushenyi District. Marie Stopes International has been providing vouchers to pregnant women to increase demand and improve outcomes of health care during and immediately following pregnancy. This project was popular especially with providers who received reimbursement for all reported treatment thus enabling them to provide care and improve maternity facilities.
Since the Uganda Missions is planning to scale up voucher activities, a site visit to Bushenyi to investigate how vouchers work in coordination with community based health financing will take place in January 2013. The Mission’s coordination of efforts between partners is invaluable. The next step in implementation of vouchers will likely require adjustment in strategy for the Collaborations Project. Detail about what was learned and the way forward will be included in the next report.
Overseas Cooperative Development Council & the IMPACT Working Group HealthPartners continues to work with and support Overseas Cooperative Development Council (OCDC) activities. HealthPartners staff serve on the OCDC Board of Directors, Policy Committee and the Impact Working Group.
HealthPartners attends quarterly IMPACT Working Group meetings and participates in conference calls every two weeks. Currently, the IMPACT working group is utilizing the services of consultant Keith Taylor to gather and analyze cooperative data from OCDC members. During meetings, OCDC members report on programmatic progress from their Cooperative Development Projects and often share lessons learned.
Uganda Community Based Health Financing Association (UCBHFA) In the early years of cooperative development, HealthPartners helped form UCBHFA, a national umbrella association for health financing organizations in Uganda. Over time as HealthPartners focused shifted to health system strengthening and health outcomes, coordination and collaboration with UCBHFA waned.
During the reporting period, HealthPartners received requests for support from UCBHFA and member organizations. Since the organizations share many goals, HealthPartners proposed a MOU for partnership activities in 2013. The MOU aims to coordinate efforts and leverage resources to increase impact, and to support advocacy at regional and national levels. In this partnership, HealthPartners Uganda will not provide sub grants but will work with UCBHFA to: 18 | Page
1) improve access to quality health care for UCBHFA stakeholders; 2) promote sharing lessons with the Ministry of Health (MOH) and partners; 3) increase organizations with sustainable cost balances and public private partnership action plans for improved health; 4) support increased capacity of stakeholders to establish and manage financially sustainable community owned health cooperatives.
Below is a table detailing the roles and responsibilities of the MOU being reviewed:
Roles of HealthPartners Uganda Roles of UCBHFA • Share with UCBHFA policies, guidelines and • Improve access to quality health care for UCBHFA work aids on sustaining community owned stakeholders through Community Health Financing health cooperatives that promotes sharing of lessons with MOH and • Provide facilitation and technical support partners; cost balance with annual surpluses and to for a national community Based Health increased public private partnership action plans insurance forum for improved health. • Provide facilitation and technical support • Serve as an advocate whose primary interest is for exchange visits for co-op stakeholders ensuring equitable, access to quality health care for at the interest stage to see early adopter as many people as possible success • Treat all people with respect and not discriminate • Provide facilitation and technical support against any potential stakeholder on the basis of for implementation of regional scheme race, tribe, creed, religion, gender or for any other managers meeting to share community reason. health financing experiences • To seek to understand how HealthPartners • Support a behavior change communication Cooperative model is the same and different from promotional campaign including radio and other member Community Health financing models drama shows, posters and more to create and share accurate information accordingly. awareness of the benefits of joining • Acknowledge United States Agency for community owned health cooperatives and International Development (USAID) support at to support wide enrollment. Promotional health financing and other health improvement activities will not be divided to support events and with partners. individual co-ops. • Agree to include USAID logos on all materials • Link the supported Health Coops to developed with support from HealthPartners UCBHFA for support and experience • Identify stakeholders to be included in sharing. development discussions for starting and sustaining • Communicate clearly and routinely with a health co-op UCBHFA noting opportunities, concerns, • Provide performance reports detailing challenges and recommendations to help opportunities, concerns, challenges and develop the most effective partnership recommendations to help develop the most possible effective partnership possible • Act in good faith and transparently with • Act in good faith and transparently with UCBHFA noting any partnership information HealthPartners Uganda noting any partnership that may be relevant information that may be relevant
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Relations with UHC HealthPartners Uganda continues partnership with UHC, a graduate cooperative formed in 1997 by local stakeholders in Bushenyi with support from HealthPartners and funding from USAID. UHC has requested continued technical support on cooperative management. HealthPartners is in the process of negotiating an MOU for partnership with UHC in 2013. Most UHC activities are financed from the cooperative reserve fund that is contributed to by co-op members and providers through annual member subscriptions and 10% annual provider surpluses. During the reporting period, UHC membership increased to 5,189 members (2,105 females and 3,084 males) who receive health care from 8 providers in greater Bushenyi district. The cooperative plans to conduct an annual general meeting in January 2013 where scheme performance and the annual operational budget and work plan will be shared and cooperative elections conducted.
Assumptions HealthPartners Collaborations project maintains the following critical assumptions: • Stakeholders within the local system want to improve their health and can develop mutual relationships of support and accountability. • Members will select providers based on location, services available and quality leading to competition between providers for improved quality. • Sustainability is a dynamic process. • Providers will be able to offer quality care. • Stakeholders within the local system want to improve their health and can develop mutual relationships of support and accountability
Personnel Corruption is rampant in Uganda. Newspapers routinely carry stories of development funds going missing and some Non-Governmental Organizations have resorted to wearing black on Mondays to support acknowledging and standing up to corruption. In July, a large shipment of Behavior Change Communication support materials was received in the project office while the Chief of Party was in the United States for training. Despite detailed distribution plans that were developed and approved ahead of time, many resources disappeared without full and accurate account. Staff responsible for protection of assets received a written warning and controls were increased as a result. Additional audits were conducted to identify potential diversion of project funds to non-project activities. A great deal of leadership and back stop time was dedicated to audits, increasing controls and holding staff accountable.
Female project leaders are needed.
Actions taken and next steps; • Additional warnings and repercussions have been communicated to hold staff accountable to ensure that project resources are used only for project purposes. • A global positioning system bidding process was facilitated and a system is being ordered to support real time tracking of fuel consumption and vehicle use in Uganda. 20 | Page
• The project’s financial accountability manual was updated with increased divisions of labor and internal controls. • Further investigation and evidence may lead to adjustments in staffing. • HealthPartners is actively trying to hire women in leadership roles. HealthPartners will continue to make this a priority
Foreseen/Unforeseen External Factors Delays in embracing the health coop model: Some of the targeted stakeholders such as Uganda Crane Creameries Cooperative (UCCC) delayed to embrace the health coop because of their initial fear that integration of health in their activities would overwhelm their members.
Action Item: • Rather than recommending a multi-purpose co-op, HealthPartners staff will revisit UCCC to recommend offering opportunities for current co-op members to explore and lead initiatives to start a separate health co-op comprised of members who understand the co-op model and who are also UCCC members.
Transportation and lack of access to quality health care providers remains a challenge. Staff will continue to recommend that co-op member groups who have prioritized this challenge, start a separate fund to include financial risk pooling for transportation to the health facility as part of their benefit package.
IV. Key Issues
HealthPartners is supporting the Uganda Ministry of Health to overcome the lack of access to affordable, quality health care in Southwestern Uganda. HealthPartners cooperative model enables rural stakeholders to create partnerships and sign agreements for access to quality health care. Members pool risk and pay small premiums each quarter in exchange for being able to seek the care they need when they need it. In Uganda needed health care is often delayed due to lack of ability to pay medical bills. Providers suffer from bad debt because patients leave the facility to avoid clearing bills. Patients who delay seeking care are more expensive to treat, take longer to recover and often have reduced health outcomes. By joining health co-ops, members and providers benefit from financial protection, savings and improved health outcomes. HealthPartners is involved in international development linking health improvement interventions to the cooperative model because this work supports the organization’s mission and vision and because HealthPartners itself operates under cooperative principles. HealthPartners is the largest consumer-governed, nonprofit health care organization in the nation, providing care, coverage, research and education to improve the health of its members, patients and the community.
Results HealthPartners has facilitated the development of two health cooperatives. The Uganda Health Cooperative has over 5,189 members accessing health care and the West Ankole 21 | Page
Diocese Cooperative over 21,624 members. Both cooperatives are reporting financial surpluses allowing them to reinvest the money into the cooperative to benefit members.
One challenge HealthPartners experienced was indentifying a sustainable strategy to support local stakeholders to increase Cooperative membership. HealthPartners is applying Communication of Innovation strategies to develop cost effective resources that will support health care providers to identify interest and strategically support new stakeholders to join co- ops.
Cross Cutting Implications While HealthPartners focus is on health cooperatives, its work has cross-sector benefits. A study by Anirudh Krishna titled: The States-of-Progress Methodology, Assets, and Longitudinal Trends: Results from a Five-Year Study in 236 Communities of Five Countries found that the main reason individuals and families fall into poverty results from the cost of unexpected health care needs. It is HealthPartners belief that health is intricately linked to economic success. Healthier communities are more productive. HealthPartners also believes that education for youth is improved through access to health care. When children are in school and have access to health care they are less likely to miss class due to illness. The democratic process is also reinforced through the cooperative model as democratic control is a core cooperative principle.
Sustainable Institutional Capacity Development HealthPartners is committed to building the capacity of local partners to sustain development beyond the life of projects. Collaboration with local partners is HealthPartners primary strategy from design, to planning, to implementation. HealthPartners has secured support from the Uganda Ministry of Health (MOH) and follows MOH strategies, using MOH data tracking tools and systems. Where MOH tools are not available, HealthPartners works with the MOH for development and approval of tools that support their goals. HealthPartners also works closely with District Health Teams, health care providers, and health workers in improving health services and access to care.
HealthPartners helped establish the Uganda Community Based Health Financing Association (UCBHFA) as a forum for organizations to share lessons learned. Five newly forming health cooperatives are being supported financially to join UCBHFA during their start up phases. Each co-op sends a representative to UCBHFA quarterly meetings for partnership development, capacity building, sharing lessons learned and advocacy on a national level.
Through HealthPartners continued capacity building efforts, the Uganda Health Cooperative (UHC) has built financial reserves to pay for board activities, an annual audit, annual general meeting and hiring a coordinator.
HealthPartners is working closely with new co-ops to build their capacity to influence the quality of care and to sustainably manage health cooperatives. Through a casacade of sensitization and training, local health stakeholders are empowered to develop partnerships to reach shared goals with other co-ops, women’s groups, drama groups, employer groups,
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village savings and loan associations, with private health care providers, and with key stakeholders within public health systems including district and village health teams, leveraging resources, and demanding quality and accountability.
Health Systems Strengthening HealthPartners strengthens the capacity of local public and private health systems to sustain and continually improve the delivery of critical health services beyond the life of the project. While this project’s focus is not health systems strengthening, the HealthPartners’ co-op model reduces barriers to health care utilization and improves affordability of health services, such as primary health care services, malaria treatment, immunizations and maternal and child health. Health facilities are financially strengthened because the co-op provides a consistent stream of revenue that can lead to hiring and retaining quality staff, ensuring a stock of supplies, developing relationships with communities and increasing quality of services delivered. Due to the sustainability of HealthPartners co-op model, co-op members continue to receive access to affordable, quality health care and health providers continue to profit after the end of the project.
Private public partnerships in the form of linkages between co-ops and Village Health Team (VHT) volunteers also strengthen health systems. Offering reduced premium rates to VHT is an investment for co-ops since VHT support communities to adopt healthy behaviors including increase early treatment seeking. Seeking care early reduces lost work for patients, reduces treatment expenses for providers, and improves health outcomes. As a result, the co-op model saves money for all stakeholders.
Linkages between the co-ops and district health teams (DHT) also strengthen health systems. Co-ops invite DHT to stakeholder workshops and annual general meetings and attend DHT partner meetings to coordinate activities and leverage resources.
Microenterprise HealthPartners project does not focus on economic development; however, health is often viewed as a precursor to economic development. HealthPartners co-op model enables low income people to have access to affordable, quality health care. It operates as a health insurance model in pooling risk; healthy people offset the cost of those who fall sick. Through this model, individuals seek treatment for sickness when they need it so they do not have to miss economic opportunities due to illness. The model also prevents members from falling into poverty as the result of having to sell profit generating assets to pay for health care. The Collaborations project supports stakeholders to develop networks between co-op stakeholders, Village Health Team volunteers who are trained by the Ministry of Health to help communities adopt healthy preventive and treatment seeking behaviors, Village Savings and Loan Associations (VSLA) and others. By actively participating in these networks, all stakeholders benefit. Providers also see economic benefits because HealthPartners co-op model ensures a reliable stream of revenue for providers from premiums and copayments from co-op members.
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Anti-Corruption Transparency and accountability are promoted in HealthPartners co-op model. The co-op board is responsible for the financial management of the co-op. Financial statements are shared with co-op members at the annual general meeting and annual budgets are presented for adjustment and approval by member vote. The cooperative board of directors commissions an annual audit of its finances to ensure fiscal integrity. Memorandums of Understanding document partner roles and responsibilities enabling them to hold one another accountable.
Especially Vulnerable Children HealthPartners co-op model addresses a community’s inability to provide a social safety net for especially vulnerable children. The essential need of health is addressed through the health co-op model. Families who join the co-op are able to include their children in health care coverage, bringing them access to primary health care, immunizations and other medical care. HealthPartners has also facilitated schools to register students in health cooperatives enabling vulnerable children in school to have access to affordable, quality health care.
Gender Equality/Women’s Empowerment-Primary Gender equality and women’s empowerment is an explicit goal of HealthPartners activities and fundamental in the activity’s design, results framework and impact. All project activities specifically support women to demand quality, accountability and accessibility of health care. The project promotes cooperative development for all but focuses on women of reproductive age because supporting women is a high-yield investment, which HealthPartners believes results in stronger economies, more vibrant civil societies, healthier communities, and greater peace and stability. Women of reproductive age who are not currently in co-ops or income generating groups receive training and support to enable them to join co-ops and play leadership roles in their management, to develop Village Savings and Loan Associations and drama groups. Drama groups are being hired by the project to spread Ministry of Health preventive health and treatment seeking messages that also support co-op goals. Drama groups are linked to local partners who may also hire their services.
Family Planning and Reproductive Health HealthPartners’ co-op model reduces the financial barriers to health care utilization and improves affordability of health services, such family planning and reproductive health for women and men, who play important supporting roles that help or hinder the ability of women to seek the care they need. Based on membership data, 75% to 80% are infants under five and women of reproductive age. This is because families tend to cover their most vulnerable members (four members are included in the base plan which costs 20,000 USH, or about $10 quarterly), and the impetus to join health schemes usually comes from mothers. Having access to health providers through the HealthPartners cooperative model allows families to utilize family planning services at that provider level. The health cooperative also utilizes incentivized Ministry of Health volunteers who reach out to the community and provide support for co-op members to adopt healthy family planning and reproductive health strategies.
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Malaria HealthPartners’ co-op model reduces the financial barriers to health care utilization and improves affordability of health services, such as malaria treatment. The HealthPartners co-op model sustainably reduces malaria by linking together a network of stakeholders in the community with financial benefits in addition to improved health. Incentivized Village Health Team volunteers promote healthy behaviors like early treatment seeking for malaria and prevention strategies such as sleeping under long lasting insecticide treated bednets and encouraging pregnant women to receive 2 or more doses of Sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria in pregnancy. Studies show that Village Health Team volunteer efforts positively impact cooperative members. HealthPartners Malaria Communities Program End of Project assessment found that the number of pregnant women attending antenatal care who received the second dose of intermittent preventive treatment for malaria in pregnancy increased to 43% from 3,759 at the baseline to 5,384. The percentage of pregnant women using long lasting insecticide-treated nets (LLINS) increased from 5.5% at baseline to 60.1% and percentage of children under 5 using LLINs increased from 6.5% at baseline to 61.6%. The percentage of cooperative health facilities with no stock outs of Artemisinin-based Combination Therapy and Sulfadoxine-Pyrimethamine increased from 62% to 98.6%. Furthermore, according to an Program Evaluation Report by consultant Gordon Lindquist, cooperative members adopted more preventive healthy behaviors than non- membersi4.
Maternal and Child Health By setting premiums and copayment rates at an affordable level, HealthPartners’ co-op model reduces barriers to health care utilization and improves affordability of health services, such as maternal and child health. When outlined in the Memorandum of Understanding between health care providers and co-op groups, women and children have access to antenatal care, delivery by a skilled birth attendant, newborn care, immunizations, and more. Village Health Teams (VHT) routinely visit co-op members to provide accurate information on maternal and child health and support women to seek antenatal care 4 times per pregnancy. VHT help women to recognize danger signs in pregnancy and encourage their husbands to support the care needs of their wives and infants. VHT are trained by the project and provided discounted co-op membership 1) as a sustainable strategy to retain their volunteerism; 2) to encourage villagers to adopt healthy preventive and treatment seeking behaviors and 3) to support VHT to be able to promote health co-ops from experience. According to a Program Evaluation Report by Gordon Lindquist, cooperative members scored higher than non-members stating that pregnant women should be attended by a skilled health professional while giving birth (94.7% members/64.2% non-members.)
4 Program Evaluation Report, Uganda Health Cooperative, November 21, 2008 by Gordon E. Lindquist
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V. Plans for the Next Six Months
Objective/Activity Outputs for FY13 EOP Target Indicators Timeline Partners Location Q Q Q Q 1 2 3 4 O1: Annual stakeholder workshop reports for 6 co-ops detail public/ private partnership action plans for improved health 6 stakeholder 1.1: 6 stakeholder Mbarara, 1.1. Sensitize district UCBHFA, workshop reports workshop reports Bushenyi, leaders on the HPC Health Care detailing detailing Sheema, model, share baseline x Providers, public/private public/private Buhweju, results, and develop a District partnership action for partnership action for Mitooma, program response Health Team improved health improved health Rubirizi 1.1.2: 18 coop 8 coop providers who Mbarara, 1.2: Training District providers who signed District signed MOUs with x Bushenyi, Trainers on HPC model MOUs with member Health Team member groups Buhweju groups Mbarara, 1.1.2: 18 coop 8 coop providers who Bushenyi, 1.3. On-site training of providers who signed HPC District signed MOUs with x Buhweju, service provider staffs MOUs with member trainers member groups Sheema, groups Mitooma HPC District trainers, 1.2.2 : 42 groups Mbarara, 1.4. Training VHT on HPC 6 VHT groups join District register with health Bushenyi, model health co-ops Health Team, co-ops Buhweju Health Care providers 1.1 6 stakeholder 6 stakeholder workshop reports Health Coop 1.5. Conduct integrated workshop reports Mbarara, detailing Boards, provider support detailing x x x x Bushenyi, public/private providers and supervisions public/private Buhweju, partnership action for members partnership action for improved health improved health 12 Interactive drama 1.2 1.6. Conduct interactive shows conducted 52 Interactive drama drama shows in strategic with support from shows conducted Mbarara, locations to promote MOH, CDP to encourage with support from x x x Bushenyi, health financing using UCBHFA community members CDP to encourage Buhweju HealthPartners join Health Coops community members cooperative model join Health Coops 1.3 and 1.4 1.7. Air radio spots and 16 Radio talk shows, 52 approved Radio MOH, talk shows to promote and 480 radio spots Mbarara, talk shows, and 624 UCBHFA, health financing using aired to promote x x x Bushenyi, radio jingles/spots Health care HealthPartners community health Buhweju aired to promote providers cooperative model financing. community health
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Objective/Activity Outputs for FY13 EOP Target Indicators Timeline Partners Location Q Q Q Q 1 2 3 4 financing. 1.5 1.8. Print and distribute 5,000 posters and 16,030 IEC materials MOH, IEC/BCC materials to the 2,000 brochures Mbarara, distributed to support UCBHFA, community to promote distributed VHT to x x Bushenyi, VHT to help people Health care community Health promote community Buhweju join health providers Financing. Health Financing. cooperatives UCBHFA, 1.1.1 health care Mbarara, 1.9. Orient Institutional 8 member groups 42 coop member x providers, Bushenyi, heads on the HPC model affiliated to co-ops groups affiliated to District Buhweju HealthPartners co-ops Health Team 1.10. Provision of CHI 1.1.2 Mbarara, startup kits to providers 8 co-op providers sign 18 co-op providers Health care Bushenyi, to support providers to MOUs with member sign MOUs with x x providers Buhweju start and launch new groups member groups Mitooma member groups 1.11. Conduct provider 60% of providers have 1.1.3 quality assessments and improved ratings on 90% of providers have x x x x share results their member quality improved ratings on assessment scores their member quality assessment scores 65% of staff in health 1.1.4: 90% of staff in facilities working on health facilities the day of the survey working on the day of the serve 90% of health facilities 1.1.5: 100% of coop with guidelines for health facilities with care of children and first line medication Co-op adults 1.1.6: 100% of health stakeholders, 1.12. Conduct quarterly facilities with providers, Mbarara, meetings with service Provider surplus guidelines for care of district health Bushenyi, providers to share averages at least children and adults teams and Buhweju support supervision 250,000 2.1: Provider surplus x x x x commercial results, Cooperative averages at least officers performance summary, Total annual coop 500,000 and mapping tool reserve balance of at 2.2 Total annual coop least 2,400,000 reserve balance of at least 3,000,000 30% of Health care 2.3: 80% of Health providers with annual care providers with surplus annual surplus 2.4: 30% of coop 30% of coop members members pay pay premiums on time premiums on time 2.1.2: 100% of health 75% of health facilities facilities maintain up 27 | Page
Objective/Activity Outputs for FY13 EOP Target Indicators Timeline Partners Location Q Q Q Q 1 2 3 4 maintain up to date to date records on sick records on sick clients clients HPC District 16,500 people 1. 85,000 people trainers, 1.13: Sensitization of sub covered by USG covered by USG Mbarara, District county level leaders on supported health supported health Bushenyi, Health Team, HPC model financing financing Buhweju Health care arrangements arrangements providers Mbarara, 20 MOUs signed 42 MOUs signed Health Bushenyi, 1.14: Provider enrollment annually between co- annually between co- workers, x x x Buhweju of new member group ops and local health ops and local health health care Mitooma, stakeholders stakeholders providers Sheema 1.15: Quarterly meetings HPC District between providers and Mbarara, 20 MOUs signed 42 MOUs signed trainers, group members to deliver Bushenyi, annually between co- annually between co- District health education, review x x Buhweju ops and local health ops and local health Health Team, scheme performance and Mitooma, stakeholders stakeholders Health care close health coop gaps Sheema providers identified O2: Six health co-op boards maintain their co-op cost balance with annual provider surpluses and reserve fund 2.1. Ensure co-op stakeholders at the Trial 2.1 DHT, Coop Provider surplus Mbarara, stage are success by Provider surplus BOD, health averages 250,000 or x x x x Bushenyi, facilitating support averages 500,000 or care more per co-op Buhweju supervision from co-op more per co-op providers stakeholders Co-op stakeholders 2.2: Total co-op 2.2. Conduct monthly begin planning to reserve fund balance meetings with data open reserve fund is 3,000,000 or more Service Mbarara, entrants to strengthen bank accounts 2.11: 18 providers x x x x health care Bushenyi, their capacity in data 18 providers turn in turn in coop tracking providers Buhweju management coop tracking tools on tools on time time 6 groups of co-op 2.3.Conduct Sustainability 2.3 stakeholders develop Mbarara, Planning Workshops for 80% of health care Coop sustainability plans to Bushenyi, health cooperative providers with annual stakeholders measure their own Buhweju stakeholders surplus progress toward goals 2.4. Support providers to 2.3 30 % of health care Coop BOD, Mbarara, conduct Community 80% of health care providers have an x x x health care Bushenyi, Sensitization on HPC providers have an annual surplus providers Buhweju model annual surplus 2.5. Quarterly planning 18 providers turn in 2.1.1 Coop BOD, Mbarara, meetings between group co-op performance 18 providers turn in x x health care Bushenyi, leaders, VHT parish tracking tools co-op performance providers Buhweju
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Objective/Activity Outputs for FY13 EOP Target Indicators Timeline Partners Location Q Q Q Q 1 2 3 4 coordinators and service tracking tools providers 2.6. Conduct quarterly Self assessment 2.2.1: Self assessment Mbarara, HPC Board of Director scores by Co-op scores by Co-op x x x Coop BOD Bushenyi, meetings boards average 70% boards average 95% Buhweju coop boards statement of commitment, 2.7. Training of coop communication with 2.2.1: Self assessment Mbarara, boards on governance coop members plan, scores by Co-op x x x x Coop BOD Bushenyi, and by-laws election plan, boards average 95% Buhweju orientation plan, and coop by-laws developed 2.2.2: 6 of 4 performance review performance review meetings held by co- 2.8.Support Health meetings held by co- op boards Cooperatives to conduct op boards Coop BOD, Mbarara, Number of people Annual General Meetings 2.2.2: Number of x x health care Bushenyi, attending (AGMs) for performance people attending providers Buhweju performance review reviews performance review meetings held by co- meetings held by co- op boards op boards 2.9. Facilitate MOH to 2 MOH support 2.2.4 Mbarara, conduct quarterly support supervision visits 10 MOH support x x x x MOH Bushenyi, supervision visits to conducted supervision visits Buhweju health coops conducted 2.10. Conduct training for Mbarara WRA who join health 2: 30,000 6 VSLA groups join Women Buhweju coops so they can start cooperative members x x x x health co-ops groups Sheema Village Savings and Loans are WRA
Associations (VSLAs) O3: CDP partner collaborations outputs on lessons learned in co-op health financing shared with MOH and partners 3.1. Conduct exchange x visits for co-op 1 Coop BOD, Mbarara, 4 exchange visits by stakeholders at the 85,000 people health care Bushenyi, co-op groups interest stage to see early covered by USG providers Buhweju adopter success supported health 3.2. Support UCBHFA to financing organize and conduct a arrangements 1 national stakeholder MOH, national community x Mbarara workshop UCBHFA Based Health insurance 2 forum 30,000 cooperative 3.3. Conduct regional members are WRA x 1 regional stakeholder MOH, scheme managers x Mbarara workshop UCBHFA meeting to share CHI
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Objective/Activity Outputs for FY13 EOP Target Indicators Timeline Partners Location Q Q Q Q 1 2 3 4 experiences Mbarara, 1: 85,000 people Document what is Keystone or Bushenyi, covered by USG 3.4. Conduct midterm working and what other Buhweju, supported health x project assessment isn’t and adjust plans external Mitooma, financing accordingly consultant Sheema, arrangements Rubirizi
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VI. Success Stories
Edutainment spreads the word on health co-ops
In rural Uganda, there is a rich cultural tradition of storytelling. Few people have access to television but many meet during market days, attend immunization campaigns at health facilities and come together routinely for church services. HealthPartners Uganda’s team goes where people meet to share messages about how joining a health cooperative can save money and improve health.
In the photograph to the right, Bwera drama group shows the dangers of seeking treatment from a traditional healer. While the healers are dancing around the sick child, her illness is growing worse. By joining a health co- op, members can seek the care they need when they need it without having to worry about how they will pay unexpected and costly medical bills.
Photos by Mudashir Matsiko
Drama shows with carefully crafted scripts, entertain large audiences and help them to learn about healthy preventive and treatment seeking behaviors. They also help people relate to unhealthy behaviors that have led to negative health outcomes in the past. Church officials and other leaders reinforce key messages by highlighting what was learned from drama shows coordinated as part of their service or other events. Key messages conveyed during drama shows are also reinforced through radio talk shows and jingles played on the radio. It is a win- win solution that is fun and helps people to avoid unhealthy behaviors in favor of adopting preventive and treatment seeking behaviors that save lives.
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Annex A: Site Visit Report from Joel Kisubi, Uganda Mission
Field Visit Report to Bushenyi September 5-7, 2012 Joel Kisubi, PMS – PMI Objectives: 1. Participate in the end of project conference for the Malaria Communities Project (MCP) and to observe any final project activities. 2. Monitoring visit to observe Health Partners (HP) Collaborations project activities.
Background: PMI work with HP/UHC HealthPartners Uganda Health Cooperative (HP/UHC) is one of two Malaria Communities Projects (MCP) supported by the President’s Malaria Initiative (PMI) in Uganda. MCP projects are field support projects with the Agreement Officer’s Technical Representative (AOTRs) based at USAID/Washington, and an activity manager at the United States Mission in Kampala. HP/UHC follows the Ministry of Health/National Malaria Control Program (MOH/NMCP) health system plans, using MOH/NMCP developed resources, and linking interventions to community owned prepaid health insurance with strong support supervision and behavior change communication, in this way empowering communities to sustainably prevent and treat malaria.
Summary on the Health Partners’ end of project conference The President’s Malaria Initiative (PMI) team participated in the end of project conference for the Malaria Communities Project (MCP) that has been implemented for the last four years in South Western Uganda. The project was implemented by PMI through Health Partners/Uganda Health Cooperative. The end of project conference was held on September 6, 2012 at Rubirizi district headquarters. The conference was graced by the Rubirizi District Local Council (LC) V chairperson and the Chief Administrative Officer (CAO). It was attended by members of the Village Health Teams (VHTs), local councilors, Sub County Chiefs, district technical team, local service provider staff, Ministry of Health (MOH) staff, and the Uganda Health Cooperative (UHC) board of directors. A total of 110 participants attended the conference (72 males and 38 females).
The MCP project contributed to the achievement of PMI’s targets, for example, through strengthening malaria prevention efforts by increasing the coverage of long-lasting insecticide treated nets in this region. Project reports show significant increases in coverage and usage of nets in the project area, especially among pregnant women and children under five years. In addition, the project developed networks which link district health teams to health workers and VHTs. These networks have directly made it possible to reach over 160,000 women of reproductive age, including 12,000 women of reproductive age living with HIV/AIDS, and nearly 250,000 children under five. The project supported the development of a community health insurance plan that reached over 4,000 beneficiaries including men, women, and children who often constitute the poorest of the poor. PMI considers the development of these networks and the community health plan to constitute global best practices, and as an initiative that will serve as a model to inform the work of other development actors in Uganda. The photo below shows district leaders, UHC Directors, VHTs, USAID/PMI Representative, and other stakeholders at the MCP end of project conference in Rubirizi district, south western Uganda:
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Visit to Katungu Mission Hospital Project Katungu Mission Hospital (KMH) is one of 18 hospitals targeted by the new Collaborations project (CDP). The hospital is new, having opened in May 2012. It is at health center (HC) 3 level within the MOH structure. It handles about 60 malaria patients a month, has two medical doctors, and serves about 21,000 students from 31 schools within the project area. With 21,000 students on the insurance scheme under the Collaborations project, the hospital will be one of the largest schemes supported.
Debrief with HealthPartners staff HP staff mentioned that four health cooperatives out of six have been operationalized under CDP and that the new project would maintain 5,000/= per quarter as the figure for individuals on the insurance scheme. This might increase to between 7,000/= and 10,000/= later.
The MCP project reached approximately 5,000 members on the insurance scheme during the four years of implementation. Given the substantial USG funding received by the project to set up the health cooperatives, the project needs to consider carrying out a cost-benefit analysis, and share with USAID so that lessons learnt can be used to inform similar projects in future.
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Annex B: Site Trip Report—Paul Walters, September 7-21, 2012
Objectives for Malaria Communities Program and Collaborations Project Site Visit: A. Implement Cooperative Board Governance Training of Trainers B. Implement Financial Accountabilities Training C. Observe project activities D. Staff one-on-one meetings E. Meetings with: o USAID Mission o Uganda Community Based Health Financing Association (UCBHFA) o Other existing and potential partners o Note: A meeting with the Ministry of Health was on the itinerary, but was not able to be scheduled despite various attempts
Background HealthPartners Uganda Health Cooperative/Malaria Communities Program (UHC/MCP) worked in Rubirizi and Buhweju districts in Southwestern Uganda. The objectives of the UHC/MCP project were to 1) Increase proportion of pregnant women and children under 5 that sleep under a long lasting insecticide treated bed net (LLIN) every night; 2) Increase the proportion of pregnant women receiving two or more doses of SP for IPTp during their pregnancy; 3) Increase the proportion of children under 5 with suspected malaria receiving treatment with an ACT within 24 hours of onset of symptoms; and 4) Build sustainable, local organizational capacity to reduce malaria and to manage health schemes. The UHC/MCP project ended in September 2012.
The Collaborations project is a five-year project building on the gains of the Uganda Health Cooperative. The Collaborations project will strengthen the Uganda Health Cooperative (UHC) as a community based health insurance model that provides resources for capacity building and network development that empower local stakeholders including women and the poor to access care, recognize and demand quality and to improve health outcomes. The Collaborations project design includes strategic approaches that draw on the significant motivation that cooperatives have to deal with endemic disease threats, increased purchasing power of the group, taking advantage of their potential roles in education and service delivery, and the availability of the resources needed to realize that potential.
Results Implement Cooperative Board Governance Training of Trainers Selected staff took part in a three day Cooperative Board Governance Training of Trainers. The objective of this training was for participants to work collaboratively to develop Cooperative Board Governance tools and demonstrate their knowledge of Policy Governance. Successful participants will facilitate the training for the Uganda Health Cooperative Board of Directors and the Boards of newly formed health cooperatives. This training was conducted using Criterion Reference Instruction (CRI) principles with a post-test demonstrating staff understanding of the materials.
Implement Financial Accountability Training The objective of this all staff, mandatory training was to streamline and standardize required back-up documentation for USAID expenditures and to ensure staff understanding of all financial accountability Sustaining a healthy community through partnership.
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requirements. This training was conducted using CRI principles with a post-test demonstrating staff understanding of the materials.
Staff One-On-One Meetings Meeting were held with each staff member to gain an understanding of individual strengths, weaknesses, interest/professional ambitions and to identify issues and feedback for organizational improvement.
Observe Project Activities Health care providers affiliated with the Uganda Health Cooperative were visited in an effort to gain a deeper understanding of needs, challenges, successes and to demonstrate continued support for partnership. A health provider interested in joining a newly formed health cooperative was also visited to explain the benefits of partnering with the cooperative and to foster greater collaboration.
Meetings USAID Mission HealthPartners leadership team met with Joel Kisubi at the USAID Mission to review MCP close out plans; Collaborations project updates; provide a briefing on upcoming Mama Coop project; and answer Mission questions and incorporate recommendations into future program.
Uganda Community Based Health Financing Association (UCBHFA) HealthPartners leadership team met with UCBHFA to better understand their future plans and how HealthPartners and UCBHFA can collaborate in the future. UCBHFA coordinates, promotes, conducts research, and builds technical capacity of Community Based Healthcare Financing (CBHF) initiatives in Uganda and will be working closely with new health cooperatives formed through the Collaborations Project.
Recommendations
• Increased collaboration with UCBHFA • Annual Financial Accountability Training for staff • Increase visibility with the Uganda Ministry of Health • Continue to prioritize hiring women in leadership positions
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Annex C: Prioritized Allocation of Resources
Key TOP PRIORITY To be followed up Second Priority To be followed up Not to be followed up at this Lower priority time # of Trial Stage # Group / Provider/ Responsib mem Type of Size of of months # of times they Total Provider Co-op le person bers group group with co-op Relevant Exp contacted us CPTT performance Score >200=2pts 100- First 3 mos=3 Women’s=2pts High Priority=4pts 200=1pt pts, First 6 VLSA, VHT=1pt >2 x’s=1pt Important=3pt <100=0 pts mos=2pt Other=0 pts <2x’s=0pts Recommended=1 pt Rugazi parents & Buzenga/ School/ Rugazi Mission UHC Dorothy 342 VSLA 2 3 1 0 4 10
St. Johns HC Ankole Makobole 107 Provider 1 3 0 0 4 8 Comboni/ Comboni UHC Christine 2704 Provider 2 0 0 0 4 6 Gongo / Comboni/ Comboni UHC Christine 113 VSLA 1 0 1 0 4 6 Catechists group/ Comboni/ Commun Comboni UHC Christine 52 ity 0 0 0 2 2 Mitooma UHC Christine 292 Provider 2 0 0 0 3 5 Bwera, Kanyinya & Drama/ Bumbaire/ VSLA/Co BMC BMC/UHC Samuel 115 mmunity 1 3 4
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