By Dr Aloysius Ssennyonjo
In January 2015, the Alliance for Health Policy and Systems Research, WHO commissioned a multicountry study on the role of the non-state actors in strengthening health systems towards universal Health coverage in Low and Middle Income Countries (LMICs). Studies were commissioned in 8 countries namely; Uganda, Tanzania, Bangladesh, Burkina Faso, Bosnia & Herzegovina, Ghana, South Africa and Afghanistan. The work has been supported by technical support team (TST) from Johns Hopkins University led by Prof Sara Bennett.
After two and half years, representatives from the different country research teams met again from 29th May-2nd June 2017 at Dubai for a joint analysis and manuscript development workshop. Each team shared progress on their work, received additional support from the TST and developed outlines/write-ups of manuscripts due for publication as a journal supplement. The Ugandan team was represented by the authors; Dr Aloysius Ssennyonjo (MakSPH) and Dr Ronald Kasyaba (UCMB).
We presented our case study on the influence of government resource contributions (GRCs) to Private not for profit sector (PNFP) in Uganda on UHC objectives in Uganda. The study was carried out by Makerere University School of Public Health (MakSPH) in collaboration with the Uganda Catholic Medical Bureau (UCMB). We studied the UCMB network as the subunit of the PNFP sector. We determined trends in GRCs majorly the Primary Health Care conditional grants, Credit lines and staff secondment to the network. We had also established changes in service outputs and user fees as proportion of income for the UCMB facilities over time as proxies to UHC objectives of service coverage and financial risk protection respectively. We also conducted interviews with key actors within government and PNFP sector to understand the observed changes in GRCs but also the overall relationship between government and UCMB/PNFP network.
The findings from Uganda and the other countries highlighted several crosscutting themes worth highlighting:
- The non-state providers contribute to Universal Health Coverage through several health systems development efforts such as direct service provision, participation in governance, health workforce development and logistics and supplies management. In some instances, non-state providers are the major or only service providers in a geography thereby complementing or fully substituting service provision through public system.
- Governments or their development partners have adopted several mechanisms to engage the Private sectors in expansion of the coverage agenda and reduction of out-of -pocket costs of health service utilisation. Contracting mechanisms differed in the extent of formalization and enforcement. Overtime, relational contracts have superseded formal contracts in some instances. In some countries like Uganda, private providers have been integrated into formal governance structures within the health sector.
- In some settings, governments have provided direct inputs to non-state providers. These include both financial (grants and credit lines) and non-financial support (e,g workforce secondment and wage subvention, equipment and capacity building opportunities such as trainings). The processes to initiate and ensure continued flow of this support have been driven by active advocacy by the non-state providers and facilitated by donor support or willingness of government actors. Overtime, the non-state providers have also undertaken internal adjustments and innovations to enhance accountability and respond more adequately to the ongoing expectations from government as a result of this support.
- Managing the relationships between government and private providers faces many challenges including fluctuating trust, dysfunctional competition, unrealistic demands and sometimes-unclarified expectations. The capacity to manage partnerships is paramount to effectively harness the contributions of the private providers. Historical phenomena have had an influence on the way the relationships have evolved over time.
- Both evidence and rhetoric have guided discourse on the contribution of non-state providers. In some instances, PNFPs seem to overstate their contributions to service provision in the health systems but these claims seem unsubstantiated. It was agreed that the evidence from this research program would shade more empirical evidence on these debates.
Cross section of participants at the Dubai workshop
As a way forward, the teams were invited to conduct in-country disseminations and undertake policy influence efforts including convening policy dialogues, developing policy briefs, newspaper articles, blogs and delivering seminars. There was also interest in developing case studies for postgraduate training. These efforts will complement the many individual country and multi-country manuscripts due for finalization over the coming one year. Specifically, in Uganda, the study finding will be disseminated at the upcoming Health Financing for UHC Symposium due on 16-18th August at Serena Hotel Kampala.
The study and attendance at the workshop were generously supported by the WHO Alliance for Health Policy and Systems Research. The technical support by the Johns Hopkins team has been extremely helpful in enriching this work. We acknowledge the oversight and contributions of Prof Freddie Ssengooba (MakSPH) and Dr Sam Orach (UCMB) as Principal Investigator and co-investigator respectively. The study was coordinated by Mrs Justine Namukula-Musoke. We also acknowledge the great work by the UCMB team.
Dr Ronald Kasyaba is the Assistant Executive Secretary of the Uganda Catholic Medical Bureau.