Uganda: cross-programmatic efficiency analysis: policy brief

Objectives A cross-programmatic efficiency analysis was conducted in Uganda to identify and analyse critical areas of functional overlap, misalignment or duplication across the country’s tuberculosis (TB), HIV/AIDS, malaria, Expanded Programme for Immunizations (EPI), and Maternal and Child Health (MCH) programmes, and with the overall health system. The analysis will inform plans to make the health system more efficient and sustainable as Uganda faces financial constraints, related to a decline in external financing. The cross-programmatic efficiency analysis took place between June 2021 to August 2022, with updates to the policy recommendations in July 2024. This policy brief is written based on that analysis, with recognition that changes in the health system will have taken place since the study was conducted. The cross-programmatic efficiency analysis is a global assessment built on normative guidance and the Uganda analysis is part of a global series. Uganda Context Uganda developed its third National Development Plan (NDP III), in which a programme-based budgeting approach to planning was adopted. Health has been included as a sub-programme with the objective to ac- celerate progress towards universal health coverage (UHC) as part of the Programme Implementation Action Plan for the Human Capital Development Programme. Pursuing this goal will require additional resources, including expanded fiscal space for health. Furthermore, Uganda is working toward achieving middle-income status, which will trigger reductions in external financing, including for health, in the coming years. Given these realities, Uganda is exploring ways to mobilize additional resources, prioritize health within the public sector budget, and importantly, improve efficient utilization of available resources. With these looming financial constraints and recognized unsustainable programme arrangements, a cross-programmatic efficien- cy analysis was conducted to understand the institutional and operational framework of the five selected health programmes with a view to identifying key areas across the programmes where efficiencies could be optimised by reducing existing overlaps, duplications and misalignments across the health system. Key Findings The five-key cross-programmatic inefficiencies, their implications and potential intervention to mitigate each are discussed below. UGANDA Uganda cross-programmatic efficiency analysis POLICY BRIEF Health Financing Case Study No 27 1. Multiple, fragmented funding sources with limited pooling arrangements There are multiple and uncoordinated funding sources across the programmes analysed that constrain in- tegration at service delivery level, such as public/government allocations, external funds, private sector and some cases of out-of-pocket funding arrangements. These funds are often kept off-budget, which makes it difficult to align policy objectives and planning cycles. This leads to multiple, uncoordinated purchasing arrangements ranging from input-based, output-based and sometimes a mixture of both, as well as mul- tiple accountability frameworks and demands at service delivery level. There is also misalignment between resource allocation at the central level and needs at the sub-national level, with limited decision space both at the programme and sector level. Limited pooling arrangements exist across health programmes and the health system, making it difficult to reallocate funds based on need, as well as to spread the risk associated with access to and utilization of services. IMPLICATIONS POLICY OPTIONS • Unequal funding for externally funded pro- grammes compared to the rest of the health system • Different signals and incentives to health pro- viders leading to varying quality of care • Limited pooling mechanisms leads to out-of- pocket payments by service users and risks of financial hardship • Allocation and use of resources are not results or performance-driven • Administrative burden on providers with mul- tiple accountability and reporting demands • Develop policy for strategic pooling as a lever to address fragmentation and explore the possibility of virtual funding pools (One national plan, budget and a com- mon monitoring and evaluation framework at all levels) • Institutionalize health resource tracking efforts to track resources (especially the off-budget resources) and for the purposes of planning and alignment • Improve financial transparency and tackle factors that diminish development partner confidence in providing on-budget support to the government • Annualize plans at all levels • Explore the possibility of a physical pool of resources for community health 2. Limited coordination mechanisms and separate governance arrangements constrains the ability for joint operations Even though programmatic-level documents, such as policy, strategy, implementation and monitoring and eval- uation plans reference sector-wide and government strategic documents, there still exists fragmented govern- ance and limited coordination mechanisms across the system, as well as with external arrangements. Each pro- gramme runs independent operational plans with limited coordination across programmes. This organizational structure of programmes at the national and district level does not support joint operations, such as monitoring and supervision. Furthermore, there is progressive data systems integration within the health system, but data use is suboptimal at all levels and is not used to inform decision making. UGANDA IMPLICATIONS POLICY OPTIONS • Weak stewardship capacity in the health sector • Duplication of human resources across frag- mented governance systems • Programme objectives are often not aligned or coordinated with health system objectives • Weak planning based on the populations’ health needs, as well as joint review • Develop of a multisectoral integration framework for shared priority systems that includes a monitoring framework • Strengthen multisectoral collaboration platforms that convene the Ministry of Health, Ministry of Local Government and development partners • Finalize and operationalize the joint planning and budgeting framework 3. Fragmentation in service delivery models across health programmes There were misaligned service delivery models across health programmes, resulting in separate and unclear patient care pathways. Absence of inter/intra hospital communication limited opportunities for coordinated patient care pathways as well as improved outcomes and efficiency. Additionally, there are weak referral systems and the absence of gatekeeping mechanisms, often due to lack of awareness of the service user or lower facilities not having adequate and functional equipment to provide comprehensive, quality services. In this way, there are duplications of services across levels of the health system. IMPLICATIONS POLICY OPTIONS • Higher level facilities are overloaded, and quality of care is compromised • Duplication of services can lead to higher costs and time to service user • Coordination challenges and weak referral sys- tems can lead to loss- to-follow-up • Provide a framework for a patient-centred and integrated service model that ensures a comprehensive package of health services at health facility and community level to optimize service integration, strengthen and streamline the referral pathways • Facilitate Regional and National referral Hospital to embark on the interna- tional organization for standardization (ISO) certification programme • Review points of care and patient care pathways to explore opportunities for shared resource use • Joint micro-planning to synchronize and integrate activity plans to eliminate verticalized implementation • Ensure all off-budget activities align to Ministry of Health packages and approaches for service delivery • Strengthen enterprise planning approach to digital health to foster scale, interoperability and sustainability 4. Limited coordination across programme-specific procurement and supply chain systems There are multiple procurement mechanisms for different vertical programmes, leading to separate supply chains systems, which limits economies of scale. There exists in parallel a national system for procurement and quantification, and the programme-specific procurement and supply chain systems limits the growth and strength of the national system. The warehousing and distribution, however, is centrally coordinated by the National Medical Stores. The distribution of essential medicines and supplies list to each level of facility is not updated regularly, resulting in over- or under-supply of drugs and supplies. There also is no formal system for facilities to procure emergency supplies from local suppliers or other facilities when in need. UGANDA IMPLICATIONS POLICY OPTIONS • Fragmentation of the procurement systems leads to increased costs due to small economies of scale • Over-supply of medical products results in wastag- es of expired products across the health system • Constrained ability to provide quality care at facili- ties without the stock of proper tests and drugs • No plans or co-financing arrangements in gov- ernment budget to procure externally provided resources • Unify the supply chain system through rational- ization and integration of supply chain manage- ment systems • Conduct a national supply chain assessment to identify weak points in the system and propose solutions • Scale up Electronic Logistics Management Infor- mation Systems (ELMIS) coverage at the facility level (in 2024, the coverage was ~20-30%) 5. Separate recruitment, contracting and training of programme health workers from the overall government system In some of the programmes analysed, the recruitment, contracting and training of programme health workers were managed separately from each other and from the overall government system. Salaries for many of these programmes are kept off the government payroll. Many programme health workers are also not able to provide services outside of their mandate, whereas government health workers are trained to provide a suite of services based on need. Staff recruited under programmes tend to have access to more trainings and ca- pacity building opportunities compared to government staff. These trainings sometimes interfere with health worker availability at the health facility by drawing health workers away from their work. IMPLICATIONS POLICY OPTIONS • Different performance incentives to provide care across providers • In the face of emergencies, it is dif- ficult to shift human resources for health based on need • Disruptions in service delivery due to frequency of fragmented train- ings • Upcoming challenges related to sustainability of externally sup- ported staff when external funding ends • All recruitments should be done based on existing hiring and management norms of the government • Advocate for salary enhancement for staff who have not benefit- ed from the recent salary enhancement • One integrated in-service training plan for all health programmes • Virtual training e-platforms • Revamp in-service health workforce development centre in Mbale • Set key performance indicators for all human resources for health at all levels of care and implement them • Ensure that agreed staff outputs are derived from the annual workplans UGANDA CALL TO ACTION The inefficiencies in the assessed programmes are negatively impacting the functionality and resilience of the health system. To improve efficiencies, the government should consider: 1. Strengthening governance and coordination arrangements through one national plan, one budget and one monitoring and evaluation framework at all levels of the health system; 2. Creating sustained pooling arrangements (for instance virtual pools) to facilitate reallocation of funds based on need, and spread the risks associated with access to and utilization of quality health services; 3. Reorient model of care to deliver integrated person-centred health services within specified levels of care; 4. Streamlining, or at the very least, aligning national procurement and supply chain systems for all pro- grammes to foster its growth, functionality, sustainability and resilience; 5. Strengthening human resources for health planning, management and development processes across the health sector to ensure access to qualified, skilled and motivated health workers for improved health service delivery. This policy brief was based on a report authored by Sam Kamba, Fahad Mawanda, Chrispus Mayora, Henry Zakumumpa, Aloysius Ssennyonjo, Noel Namuhani, Brenda Nakimuli, and Martha Akulume, with support from Christabel Abewe, Sunny C Okoroafor, Susan Sparkes, Alexandra Earle, Ogochukwu Chukwujekwu, and Diane Karenzi. It was prepared by Sunny C Okoroafor, Christabel Abewe and Alexandra Earle. Financial support is gratefully acknowledged from: Gavi, the Vaccine Alliance & the Global Fund. Uganda cross-programmatic efficiency analysis: policy brief (Health financing case study, no. 27) ISBN 978-92-4-010073-2 (electronic version) ISBN 978-92-4-010074-9 (print version) © World Health Organization 2024 Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. UGANDA