Striving for Quality Healthcare in Uganda

Performance-based financing in health facilities
Access to affordable and appropriate quality health care is a universal right, but for many people in the world it remains a distant dream. The West Nile region of Uganda for example struggles to improve healthcare services.



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Uganda's West Nile region lies in the north-west of the country, bordering the Democratic Republic of Congo and South Sudan. Many people fleeing conflicts or difficult economic situations in these countries are looking for medical treatment in a region that is yet to fully recover from the violent conflict between Joseph Kony’s Lord’s Resistance Army (LRA) and the Ugandan government. 

In 2006 a truce between both parties was signed. Since, progress in poverty reduction has been made but according to the Ugandan Poverty Status Report of 2014 the northern part of Uganda remains the poorest of the country. Here health service providers are trying to deliver quality health care to an often very poor population. 

BTC assists faith-based, not for profit and public health facilities in delivering the best possible health care. To bring Uganda one step closer to universal healthcare coverage a new system of performance-based financing is being introduced. This system looks at results instead of inputs. Hospitals and health centers that perform well will receive financial support to be spent with more autonomy. 19 private not-for-profit facilities and 14 public health facilities in the West Nile region have been selected to start with performance-based financing.

Struggle for quality health care

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Many of the hospitals and health centers are constantly fighting a lack of means to keep facilities running. With a very poor population they try to keep patient fees low, yet strive to deliver quality care. With limited income sources this is a struggle. Patients get a lot of support from their families and count on them to prepare food.
Family members cook for their sick relatives in Nyapea hospital.


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Traditionally funding for health has been directed towards inputs like salaries, construction, training and equipment. People thought that improved health care would follow but this hasn’t always been the case. The new system of performance-based financing turns the old logic upside down and focuses on improved performance. Examples of performance targets could be ‘number of fully immunized children’ or ‘number of deliveries well managed’. These target will be verified on a quarterly basis. 

By turning away from focusing attention on inputs, performance-based financing aims to improve health system efficiency and effectiveness. The allocation of financial resources is linked to achieving defined performance targets. By doing this, health providers at a district and local level will gain more autonomy and decision-making power. Managers, doctors and nurses will become responsible for their own performance which is a higher incentive to satisfy their patients. They can set their own priorities according to the needs on the ground and will receive the spending autonomy to back up their choices. 

“With the help of result-based financing we have been able to reduce our patient fees. This has made health care more accessible for the community,” explains sister Martina, midwife in Saint-Francis health centre III in Arua district.
Sister Martina, midwife in Saint-Francis health centre III in Arua district
With the help of result-based financing we have been able to reduce our patient fees. This has made health care more accessible for the community.
Sister Martina - Midwife in Saint-Francis health centre III in Arua district

Local decision-making power

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This shift from a very centralized health system to more local decision-making power is an important reform that BTC, together with the Ugandan Ministry of Health, is helping become a reality. 

This is just the beginning of a challenging but exciting process. Two other East African countries, Rwanda and Burundi, already introduced a system of performance-based financing with promising results. With the Ugandan government, the Ministry of Health and the local health partners on board, we believe that performance-based financing can become a real game changer for the health sector in Uganda. 

health statistics

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  • Uganda has an estimated population of 40 million people.
  • The population is growing rapidly at an annual average of 3.3%.
  • Estimated amount of 1.5 Million people living with HIV. 
  • Doctor to patient ratio: 1:24,725 (numbers from 2013), the WHO recommends one doctor per 1,000 people.
  • As a result of Result-based financing patient fees are lower.
  • Health facilities that perform well receive financial incentives. These can be used to retain more medical staff through financial bonuses.
  • Duration: 2014 - 2018
  • Financing: Belgium, Uganda
  • Budget: BE: 13 million euro, UG: 0.5 million euro

Pictures: © BTC/ Thea Mathues 

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