Results/Performance-based financing (RBF/PBF) was introduced in Uganda to support the improvement of maternal and child health services and the attainment of universal health coverage (UHC). RBF is a purchasing mechanism in which health providers are partially funded based on their performance of agreed outputs or outcomes[1]. Evidence suggests that RBF has the potential to make health systems more strategic in their purchasing of health services [2]. Under this arrangement, a facility has to deliver a set of agreed services/outputs before it is paid [3]; much attention is therefore paid to ensuring that the facilities selected have the capacity to provide the services required of them. This is commonly done by selecting facilities that meet specific standards. Accreditation – which is the “benchmarking by an external agency of an individual or organisation against defined criteria, which, if the criteria are met, result in the party being formally recognised as having met those criteria and deemed capable in those areas[4]” — allows this selection process to kick into play. Accreditation of health facilities not only increases the trust and confidence of clients regarding the quality of health services provided at the facility, but it also becomes a “visible tag” or “mark” that enhances health facilities’ opportunities for collaboration with other health programs.
Successful and speedy achievement of UHC requires access to high-quality essential health services at affordable costs by the population[5]. Provision of quality services requires that facilities have the appropriate structural requirements and follow the recommended procedures and processes in line with standard treatment guidelines for different illnesses. Processes such as accreditation play a key role in ensuring that facilities have the minimum standards required to provide these quality services. Accreditation sets standards that are considered optimal and achievable but more rigorous than the minimum standards of licensure. Although the evidence is mixed, some of the available evidence suggests that accreditation of facilities boosts service delivery by improving the structure and organization of services, leading to better clinical outcomes and enabling the population to receive better quality health care.
Furthermore, it fosters a culture of continuous quality improvement in providing the needed health care services[6]. This is especially important in low-income countries to guarantee quality health services since compliance with healthcare laws and regulations is not always optimum. If accreditation meets these expectations, there must be alignment between government, payers and accreditors on quality improvement procedures adopted in all health facilities. Only then can accreditation processes succeed in streamlining operations and improving the quality of care.
In the Uganda Reproductive Maternal and Child Health Services Improvement Project (URMCHIP), the selection of health facilities in the designated districts was based on an RBF readiness assessment using a tool adapted from the Ministry of Health’s Facility Quality of Care Assessment tool [7]. In summary, the tool ensures that the facility has the required structures, infrastructure, supplies and equipment across the six-WHO health system building blocks. All public and private-not-for-profit (PNFP) providers who meet the RBF readiness threshold are eligible to participate in the project. However, the distribution of facilities is not equitable geographically, and so some locations are underserved.While in the Northern Uganda (NU) Health RBF project, all the facilities were given seed grants to improve their capacity to provide the required services[8]. In other projects such as the Institutional Support Programme for PNFP financed by the Enabel – Belgian Development Agency, facilities that failed to meet the criteria were given capacity-building grants to address areas of weakness, after which they were assessed again.
As noted earlier, most RBF programs include only accredited facilities. However, work done in four African countries found that the RBF projects’ accreditation did not impact accreditation nationally. In most cases, this process remained confined to the RBF projects hence minimising gains that could have been achieved from the accreditation process[9]. Despite this shortcoming, accreditation of facilities under RBF comes with many advantages and some disadvantages. In this blog, we explore the merits and challenges of accreditation as a tool that can be used to enhance strategic purchasing of health services as countries strive to achieve UHC.
Merits and Challenges of Accreditation
The accreditation reform came with several merits in Uganda, including the following:
Boosting the Status and Standards of the Facility
It has been reported that accreditation boosts the standards of the facility. This is because a facility has to meet specific standards before it is accredited; hence funders, the government, district and facility management do their best to invest more resources to meet these standards. This invariably equips the facility to provide better quality services. The facility’s recognition and status within the community are also often elevated and may attract other partners to work with the facility.
Enhancing Institutionalization of the Accreditation Process The use of existing government tools such as the Ministry of Health quality assessment tool and locally-based assessment teams enhances institutionalization of the accreditation process. It offers spin-off benefits for the delivery of other services as well.
In many countries, ensuring equitable access to modern, quality health services, especially in resource-limited settings, poses significant technical and management challenges. The loopholes in the monitoring and quality assurance bodies of many countries make this even more challenging. Therefore, reforms geared at enhancing the provision of quality health services are paramount. However, the accreditation process has also led to some problems in Uganda due to challenges in implementing the accreditation process. These challenges include:
Inequitable Access to Services
Areas that are served by facilities that fail to meet the criteria for accreditation often get left out. This leads to inequitable service delivery and undermines the motives for UHC.
Reinforcement of Existing Inequities
The facilities that fail to meet these criteria are often the weakest, and so this kind of system tends to reinforce existing inequities such that the inadequate facilities become even weaker. Although support grants are often given to avoid this, sometimes the grants are too small to meet the required infrastructural developments.
Unfair Practices
Depending on the setting, some facilities may get accredited even when they don’t meet the required standards. It has been reported that some facilities borrow the required equipment prior to the assessment and then return them after the assessment.
Implications and Recommendations for Strategic Purchasing in Uganda
Accreditation is a useful approach for strengthening the health system building blocks, and it can subsequently contribute to improving overall facility performance. However, the key prerequisites for accreditation need to be carefully thought through to ensure the universal provision of health services to all populations. The following suggestions are provided to strengthen the accreditation process in Uganda:
- The government and its development partners should support the provision of seed grants so that more facilities can get accredited to provide RBF related services. This will ensure the expansion of coverage to all population groups and ensure universal access to health services by all.
- Accreditation assessments tend to focus on structural elements of care, which may not directly influence the process elements of care. Therefore, such initial assessments should be complemented by continuous quality improvement processes that directly influence treatment outcomes.
- Accreditation processes for RBF should promote institutionalization by using existing government tools and locally existing human resources. This will empower local facilities and ensure continuity of quality services provided by the facilities to the population.
- , The establishment of a legal structure responsible for accrediting facilities is necessary to ensure wide-scale implementation of the accreditation program.
[1] Musgrove P. Rewards for good performance or results: a short glossary; 2011.
[2] Soucat A, Dale E, Mathauer I, Kutzin J. Pay-for-performance debate: not seeing the Forest for the trees. Health Syst Reform. 2017;3:74–9
[3] Musgrove P. Rewards for good performance or results: a short glossary; 2011.
[4] https://medical-dictionary.thefreedictionary.com/accreditation
[5] National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Board on Global Health; Committee on Improving the Quality of Health Care Globally. Crossing the Global Quality Chasm: Improving Health Care Worldwide. Washington (DC): National Academies Press (US); 2018 Aug 28.
[6] Mate, K.S., Rooney, A.L., Supachutikul, A. et al. Accreditation as a path to achieving universal quality health coverage. Global Health 10, 68 (2014). https://doi.org/10.1186/s12992-014-0068-6
[7] MOH 2019. Results Based Financing Implementation Manual. Uganda Reproductive Maternal and Child Health Services Improvement Project.
[8] Nu Health Uganda. Insights for taking results-based financing to scale. Policy brief NU Health 2015.
[9] Witter et al 2019. How does RBF strengthen strategic purchasing of health care? Comparing the experience of Uganda, Zimbabwe and the Democratic Republic of Congo. Global Health Research and Policy: 4.3.
Authored by the SPARC Team at Department of Health Policy Planning & Management, School of Public Health, Makerere University, Uganda, comprised of Prof. Freddie Ssengooba, Dr. Elizabeth Ekirapa-Kiracho, Dr. Aloysius Ssennyonjo, Mr. Richard Ssempala and Mr. Mayora Chrispus.