Strategic Purchasing Arrangements in Uganda and Their Implications for Universal Health Coverage

Figures & data

Figure 1. Strategic health purchasing progress tracking framework.

Table 1. Benefit packages, target beneficiaries, community engagement and implications for UHC.

Item	Government budget financing	Donor-funded Projects	PBF Schemes	Implications for UHC
Benefit package	Minimum health care package (UNMHCP) with four areas of focus: maternal and child health, noncommunicable diseases, health promotive and preventive services, and communicable diseases. Not all services in the package are provided, due to resource constraints. Not explicit about excluded services.	Highly variable and dependent on the interests of the funding agency and its fundholders. Most projects focus on maternal and child health services and communicable diseases such as malaria, HIV, and TB. Well-defined per the agreement between the project and the service provider.	Mainly maternal and child health services, as well as communicable diseases such as malaria. Well-defined per the agreement between the project and the service provider.	Available packages do not provide a full package of promotive, preventive, curative, and rehabilitative services due to resource constraints. Packages delivered under project-based and PBF schemes are fragmented, duplicative, and not universal.
Beneficiaries	All Ugandans, foreigners and refugees are eligible to benefit from the UNMHCP, but not all receive the intended benefits.	Main beneficiaries include people with HIV, malaria, and TB, pregnant women, and children under age 5. Identification of beneficiary communities is generally not systematic.	Mainly pregnant women, children, and, where capacity exists, adolescents.	Only people in targeted areas benefit. Scale-up plans do not exist beyond the loan/grant period. However, there are plans to scale up URMCHIP nationwide. Not all vulnerable groups are targeted; Communities served by facilities with inadequate capacity are often not served by PBF schemes that require provider accreditation.
Community engagement	Package is based on burden of disease studies and the cost-effectiveness of interventions. The community is not directly consulted on the package.	The community is not directly consulted on the package, but the diseases specified are those that contribute to high morbidity and mortality.	The community is not directly consulted on the package, but the diseases specified are those that contribute to high morbidity and mortality.	The community is often not consulted on the services to be provided. Limited feedback and social accountability mechanisms undermine responsiveness.

Table 2. Contractual arrangements, quality considerations, and implications for UHC.

	Government Budget Financing	Donor-Funded Projects	PBF schemes	Implications for UHC
Contracting Arrangements	Loose arrangements with public providers; MOUs with private not-for-profit providers. Expected outputs are aggregated and presented as targets.	Selective contracting with local and global NGOs and private providers. Contracts stipulate the services to be provided.	Selective contracting with public and private not-for-profit providers that meet accreditation criteria. Contracts stipulate the services to be provided.	Expansion of coverage to targeted populations is assured when contracting processes are explicit about the services to be provided.
Quality Considerations	Minimal consideration for the quality of services provided. There are limited sanctions and penalties for poor performance	Quality is considered through competitive calls or application of specific criteria.	Accreditation is used to select facilities that meet quality standards. Payments are linked to quality Indicators.	The population may receive lower-quality services under government budget financing.

Table 3. Purchasers, provider payment, performance monitoring, and implications for UHC.

	Government Budget Financing	Donor-Funded Projects	PBF Schemes	Implications for UHC
Purchaser(s)	MOH and Ministry of Finance, Planning and Economic Development, with local governments as service providers through networks of health facilities.	Multiple development partners that fund the projects.	MOH	Multiple purchasers may lead to conflicting incentives for providers and fragmented service delivery packages.
Provider Payment Method(s)	Line-item budgeting and PHC grants with allocation formulas based on catchment population attributes and administrative roles.	Mix of results-based and input-based line-item budgets.	Fee-for-service and performance bonuses	Pay-for-results approaches create an incentive to provide the stipulated services and thereby increase service coverage.
Payment Rates	Computation of PHC grants is based on an allocation formula.	Payment rates are variable and depend on the service grant size and project design.	Payment rates depend on the complexity of providing the service, disease burden, and performance indicators for the service.	Inadequate funding, especially under the government scheme, constrains provision of good-quality services and limits population coverage.
Performance Monitoring	Monthly and quarterly facility activity reporting on DHIS2 and annual sector-wide performance reports; supervision by MOH and local governments.	Monthly facility activity reporting; routine verification of quantity of services; annual independent external verification.	Monthly facility activity reporting on DHIS2; sometimes donors require additional indicator-specific reporting outside DHIS2 data capture process, putting additional workload onto facilities	While DHIS2 reflects a greater degree of data integration, there is under-utilization of this data for decision-making at all levels from upstream to the downstream facility level
Use of Provider Performance Information	Performance information is used for supportive supervision. No consequences for poor performance.	Performance information is used to determine targets and for approval of subsequent disbursements. Poor performance can lead to contract termination.	Performance information is used to determine payments to the facility. Falsification of results and fraud can lead to termination of contracts.	Payment methods linked to results promote expansion of services and population coverage.

Data Availability Statement

The authors confirm that the data supporting the findings of this study are available within the article and/or its supplementary materials.