Uganda
CASE STUDY
Uganda
Uganda has achieved steady improvements on several key maternal and child health indicators over the past 20 years (Box 1). However, significant challenges remain, and public expenditure on health remains low, at just 7 percent of the national budget, equivalent to US$14 per capita, according to the Uganda National Health Financing Strategy 2016. Under the leadership of the Government of Uganda, the GFF, in collaboration with a diverse array of technical and financial partners, joined the effort to identify shared priorities in the health sector, advocate for increased investment, determine ways to make more effective use of existing funds, and target these resources to achieve greater coverage of high-impact interventions.
Among the outputs of this collaboration, the government implemented a prioritized package of services for women, children, and adolescents using several approaches to results-based financing and service purchasing. The implementation of these approaches has progressed rapidly, and positive results have begun to emerge, as presented in this case study. Of note are increases in the coverage and quality of antenatal care services and facility-based deliveries, as well as substantial shifts in the mix of contraceptive methods that may reflect improved access to and availability of long-acting contraceptive methods.
Trends in key RMNCAH-N indicators (1995–2016, DHS)
- Maternal mortality ratio:
Declined from 506 to 336 deaths per 100,000 - Under-5 mortality rate:
Declined from 147 to 64 deaths per 1,000 live births - Age-specific fertility rate for adolescent girls:
Declined from 204 to 132 births per 1,000 15-to-19-year-olds - Share of women who had another child less than 24 months after their previous child:
Declined from 27.9 to 24.3 percent - Prevalence of stunting among children under five years:
Declined from 45% to 28.9%
Country Priorities:
The Sharpened Plan
Uganda’s investment case, called the Sharpened Plan, focuses on building and maintaining the momentum of key improvements in reproductive, maternal, newborn, child and adolescent health (RMNCAH) through five strategic shifts. Operationally, the shifts are:
- Shift 1: Expanding access to a package of high-impact RMNCAH interventions
- Shift 2: Including expanded access to high-burden populations, and
- Shift 3: Keeping a focus on geographic sequencing (prioritizing the 40 highest burden districts).
These operational shifts are complemented by two changes in focus:
- Shift 4: Addressing the social determinants of health outcomes, and
- Shift 5: Ensuring accountability through investments in systems such as civil registration and vital statistics (CRVS) capabilities.
The GFF process and financial contributions aim to support the effective implementation of these strategic shifts.
Strengthening operations of
the national country platform
to improve accountability
and coordination
Among the GFF partnership’s key areas of focus in Uganda is supporting the efforts of the Ministry of Health to coordinate the implementation and financing of the Sharpened Plan. This is being done in collaboration with more than two dozen partners, including international and Ugandan civil society organizations, international development agencies, UN agencies, and the private sector. A unified investment case (namely, the Sharpened Plan), systematic resource mapping (Figure 1), routine coordination meetings, and a shared results framework have all helped the government and partners better plan their activities to reduce duplication, fill gaps, and craft a long-term sustainable vision for the health system.
Figure 1
Resource mapping for The Sharpened Plan, 2018-2021
Expansion of strategic purchasing of an essential package of health services
to improve value for money
in the health sector
Uganda has a history of experimentation with supply- and demand-side financing approaches to increase the utilization and quality of high-priority health services. In 2016, this experience culminated in the development of the national Results-Based Financing Framework for the Health Sector, which was identified as a key strategy for advancing the strategic shifts outlined in the Sharpened Plan. The Uganda Reproductive Maternal and Child Health Services Improvement Project (URMCHIP), cofinanced by the GFF Trust Fund, the Swedish International Development Cooperation Agency (SIDA), and the International Development Association (IDA), is a major source of financing for putting this strategy into action.
This emphasis on strategic purchasing is well aligned with the GFF approach, as it focuses on a prioritized package of services for women, children, and adolescents that includes immunization, family planning, antenatal care, emergency obstetric care, postnatal care for mothers and children, post-abortion care, and treatment for common conditions among children under age five. Given the multiple financiers, geographies, and schemes that are involved, the strategy also requires a high degree of coordination with partners to ensure that all priority districts are covered, that synergies between schemes are exploited, and that unintentional duplication is avoided.
Results
The government’s strategic purchasing of the package of essential health services has been rapidly expanding. In the first half of 2019, 341 health facilities in 28 districts were participating, with another 395 health centers in 51 districts having completed the prequalification assessments and training needed for implementation. As of July 1, 2019, 79 districts were implementing the program at scale (Figure 2).
Figure 2
Coverage of results-based financing and voucher programs in Uganda, 2017 and 2019
Initial results suggest that priority interventions in the Sharpened Plan, such as health worker mentorship, vouchers, and the results-based financing approach, are all creating conditions for improved coverage of services where they are being delivered—notably in the Northern Region—a positive sign as these approaches are expanded to places like the Central Region. For example, the number of women attending one and four antenatal care visits (ANC1 and ANC4, respectively) has increased in most regions, especially in the Northern Region, where there was an increase in ANC4+ of 11 percentage points over a two-year period (Figure 3).
Figure 3
Antenatal coverage from January 2017 to December 2018, by region, by quarter
Antenatal coverage shows increases in all regions, most pronounced in the northern regions with 3rd quarter showing greatest gains.
Despite improvements in ANC1 over the same two-year period, much work remains to be done to promote the use of these services early in pregnancy, given that the utilization rates in all regions remain below 20 percent (data not shown). Promotion would be especially valuable, since data on the services that women are receiving signal improvements in quality. For example, of all women receiving ANC1, the proportion of them that were receiving iron folate in 2018 was between 80 and 90 percent in all regions except one (the Central Region, where it was just over 70 percent) (Figure 6). Similarly, the proportion of women receiving a third dose of intermittent preventive treatment for malaria in pregnancy (IPT3) has been rising in all regions (Figure 5). These improvements may also reflect a 2017 policy change, which affected protocols and reporting, as well as the support of development partners to improve stock monitoring and capacity building in the reporting system.
Figure 4
Women receiving iron folate during 1st antenatal visits, coverage from January 2018 to December 2018, by region and quarter
No significant change in women receiving iron folate during 1st antenatal visit in all regions.
Figure 5
National intermittent preventive therapy, third dose (IPT3), for malaria, by region from January 2018 to December 2018
Following a 2017 policy change and improved stock monitoring, the proportion of women receiving a third dose of intermittent preventive treatment for malaria in pregnancy (IPT3) increased in all regions.
There are also indications that more women now have access to facility-based childbirth services through the formal health system (Figure 6). In the first quarter of 2018, an estimated 59.5 percent of births took place in health units. By the last quarter of that year, that number had risen by 5 percentage points. The Northern Region experienced a 10-percentage point increase; at 71 percent, it had the highest rate of institutional delivery in the country. The improvement coincides with investment from partners in maternal health vouchers in recent years as well as with supply-side investments going back several years.
Figure 6
Coverage of facility-based deliveries in 2018, by region and by quarter
Increase in facility-based deliveries in quarters 3 and 4 in 2018 across all regions.
There have also been notable shifts in the method mix in family planning services delivered in Uganda between 2017 and 2018: the use of long-acting contraceptives soared, while use of shorter-term methods declined (Figure 7). The number of implant insertions, for example, increased by 73 percent, from about 65,000 in the first quarter of 2017 to nearly 113,000 in the fourth quarter of 2018. This shift in method mix reflects increases in method choice in the public sector, which may have implications for overall contraceptive use, contraceptive continuation, and health outcomes for women and girls in Uganda.
Figure 7
There have been notable, national-level shifts in the method mix of family planning in Uganda over the last 2 years
Between 2017 and 2018, the use of long-acting contraceptives soared, while use of shorter-term methods declined.
Conclusion
The results presented here from Uganda’s Sharpened Plan highlight the urgency of accelerating the plan’s implementation. Trends in national data also reveal successes at the subnational level and demonstrate the will of a diverse set of partners to align and coordinate on approaches to strategic purchasing. These insights suggest enormous potential for further improvements in health outcomes deriving from the Sharpened Plan’s strategic shifts and this partnership in the years ahead.