NRU :: Browsing by Author "Ssennyonjo, Aloysius"

Browsing by Author "Ssennyonjo, Aloysius"

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Enrollment and Retention in Community Health Insurance: Experiences from ICOCARE scheme in South Western Uganda
(Research Schare, 2019) Turyamureba, Bosco; Ssengooba, Freddie; Ssennyonjo, Aloysius; Asiimwe, Stephen; Baguma, Bildard; Kisakye, Angela; Kirunga, Christine
Globally, developing countries have inadequate capacity to raise tax to finance wellfunctioning health systems. In sub Saharan Africa, over 40% of the total health expenditure comes from households and mostly out of pocket payments. Over 20% of the population spend more than 10% of their total household consumption expenditure on health care. Prepayment schemes are crucial for promoting resource pooling and risk sharing to prevent catastrophic health expenditure, yet in Uganda only 1% of women and less than 2% of men are covered by health insurance schemes. Private insurance companies cover approximately 12% of Ugandans who are formally employed. We analyzed factors associated with enrollment and retention in ICOCARE health insurance scheme and examined ways to increase enrollment and reduce dropouts. Methods: This was a cross sectional study which employed both quantitative and qualitative methods of data collection. We interviewed 194 respondents who included both active and non-scheme members of the ICOCARE community health insurance scheme. We conducted three focus group discussions and two key informant interviews with key stakeholders. Quantitative data was analyzed using Statistical Package for Social Scientists software version 20 and STATA 13 while qualitative data was analyzed using the six steps of thematic analysis developed by Braun and Clarke.
Fitting Health Financing Reforms to Context: Examining the Evolution of Results-Based Financing Models and the Slow National Scale-Up in Uganda (2003-2015)
(Global health action, 2021) Ssennyonjo, Aloysius; Ekirapa–Kiracho, Elizabeth; Musila, Timothy; Ssengooba, Freddie
Results-based financing has been promoted as an innovative mechanism to improve the performance of health systems in achieving universal health coverage. Several results-based financing models were implemented in Uganda between 2003 and 2015 but with limited national scale-up. Objective: This paper examines the evolution of results-based financing models and the reasons for the slow national adoption and implementation in Uganda. Methods: This was a qualitative study based on document review and key informant interviews. The models were compared to show modifications overtime. The reasons for the slow national scale-up were analyzed using variables from the Diffusion of Innovations Theory. Results: This study covered seven schemes implemented in the Ugandan health sector between 2003 and 2015. The models evolved in several aspects: 1) donor reliance with fundholding and purchasing delegated to non-state organizations; 2) establishment of adhoc structures for learning; 3) recent involvement of the government agencies in verification processes; 4) Involvement of public providers, and 5) expansion of services purchased from the national minimum health-care package. The main reasons for slow national adoption were the perceived complexity and incompatibility with public sector systems. The early phases comprised barriers to public sector reforms. However, recent adjustments to the schemes have enabled greater involvement of public providers and government stewardship. Stakeholders also reported progressive learning across projects and time.
(How) does RBF strengthen strategic purchasing of health care? Comparing the experience of Uganda, Zimbabwe and the Democratic Republic of the Congo
(Global Health Research and Policy, 2019) Witter, Sophie; Bertone, Maria P.; Namakula, Justine; Chandiwana, Pamela; Chirwa, Yotamu; Ssennyonjo, Aloysius; Ssengooba, Freddie
Results-Based Financing (RBF) has proliferated in health sectors of low and middle income countries, especially fragile and conflict-affected ones, and has been presented as a way of reforming and strengthening strategic purchasing. However, few studies have empirically examined how RBF impacts on health care purchasing in these settings. This article examines the effects of several RBF programmes on health care purchasing functions in three fragile and post-conflict settings: Uganda, Zimbabwe and the Democratic Republic of Congo (DRC) over the past decade. Methods: The article is based on a documentary review, including 110 documents from 2004 to 2018, and 98 key informant (KI) interviews conducted with international, national and district level stakeholders in early 2018 in the selected districts of the three countries. Interviews and analysis followed an adapted framework for strategic purchasing, which was also used to compare across the case studies. Results: Across the cases, at the government level, we find little change to the accountability of purchasers, but RBF does mobilise additional resources to support entitlements. In relation to the population, RBF appears to bring in improvements in specifying and informing about entitlements for some services. However, the engagement and consultation with the population on their needs was found to be limited. In relation to providers, RBF did not impact in any major way on provider accreditation and selection, or on treatment guidelines. However, it did introduce a more contractual relationship for some providers and bring about (at least partial) improvements in provider payment systems, data quality, increased financial autonomy for primary providers and enforcing equitable strategies. More generally, RBF has been a source of much-needed revenue at primary care level in under-funded health systems. The context – particularly the degree of stability and authority of government–, the design of the RBF programme and the potential for effective integration of RBF in existing systems and its stage of development were key factors behind differences observed.
Momentum for policy change: alternative explanations for the increased interest in results- based financing in Uganda
(Global Health Action, 2021) Ssengooba, Freddie; Ssennyonjo, Aloysius; Musila, Timothy; Ekirapa-Kiracho, Elizabeth
Results-based financing initiatives have been implemented in many countries as stand-alone projects but with little integration into national health systems. Results-based financing became more prominent in Uganda’s health policy agenda in 2014–2015 in the context of the policy imperative to finance universal health coverage. Objective: To explore plausible explanations for the increased policy interest in the scale-up of results-based financing in Uganda. Methods: In this qualitative study, information was collected through key informant interviews, consultative meetings (2014 and 2015) and document reviews about agenda-setting processes. The conceptual framework for the analysis was derived from the work of Sabatier, Kingdon and Stone. Results: Four alternative policy arguments can explain the scale-up of results-based financing in Uganda. They are: 1) external funding opportunities tied to results-based financing create incentives for adopting policies and plans; 2) increased expertise by Ministry of Health officials in the implementation of results-based financing schemes helps frame capacity accumulation arguments; 3) the national ownership argument is supported by increased desire for alignment and fit between results-based financing structures and legitimate institutions that manage the health system; and 4) the health systems argument is backed by evidence of the levers and constraints needed for sustainable performance. Shortages in medicines and workforce are key examples. Overall, the external funding argument was the most compelling. Conclusion: The different explanations illustrate the strengths and the vulnerability of the results-based financing policy agenda in Uganda. In the short term, donor aid has been the main factor shifting the policy agenda in favour of results-based financing. The high cost of results-based financing is likely to slow implementation. If results-based financing is to find a good fit within the Ugandan health system, and other similar settings, then policy and action are needed to improve system readiness.
Multisectoral action for health in low-income and middle-income settings: how can insights from social science theories inform intragovernmental coordination efforts?
(BMJ Global Health, 2021) Ssennyonjo, Aloysius; Van Belle, Sara; Titeca, Kristof; Criel, Bart; Ssengooba, Freddie
There is consensus in global health on the need for multisectoral action (MSA) to address many contemporary development challenges, but there is limited action. Examples of issues that require coordinated MSA include the determinants of health conditions such as nutrition (malnutrition and obesity) and chronic non-communicable diseases. Nutrition, tobacco control and such public health issues are regulated separately by health, trade and treasury ministries. Those issues need to be coordinated around the same ends to avoid conflicting policies. Despite the need for MSA, why do we see little progress? We investigate the obstacles to and opportunities for MSA by providing a government perspective. This paper draws on four theoretical perspectives, namely (1) the political economy perspective, (2) principal–agent theory, (3) resource dependence theory and (4) transaction cost economics theory. The theoretical framework provides complementary propositions to understand, anticipate and prepare for the emergence and structuring of coordination arrangements between government organisations at the same or different hierarchical levels. The research on MSA for health in low/middle-income countries needs to be interested in a multitheory approach that considers several theoretical perspectives and the contextual factors underlying coordination practices.
National Health Insurance in Uganda: Examining the Proposed Design and its Implications for Successful Implementation
(SPEED Initiative, 2019) Ssennyonjo, Aloysius; Ajambo, Dora
In 2015, the Health sector in Uganda committed to Universal Health Coverage (UHC) in as demonstrated in its Health Sector Development Plan (HSDP) 2015 - 2020. The HSDP’s goal is accelerating progress towards universal health coverage of good quality health and related services to promote health and productive lives (MoH 2015). The HSDP and health financing strategy 2015-2025 (Ministry of Health 2016) emphasise the need to improve access to healthcare services according to need, while at the same time limiting exposure to financial risk for those who seek care. These aspirations require a well-functioning health systems which can be strengthened through implementation of the appropriate health financing reforms. The National Health Insurance System (NHIS) has been proposed as one of the vehicles towards UHC in Uganda (Government Of Uganda 2015). The NHIS has for sometime been on the policy and political1 agenda (Basaza et al. 2013) but little success has been made to actualize it.
Overcoming Shortcoming in Monitoring Retention in Option B+
(SPEED Initiative, 2018) Kiwanuka, George; Ssennyonjo, Aloysius
The retention in care is a serious pointer of achievement for the Prevention of Mother to Child Transmission(PMTCT) care program. The level of retention of women under PMTCT care program at the different time points of the cascade of the elimination of mother to child transmission (EMTCT) cascade is critical to treatment outcomes. The current methods of measuring retention in care, at health facility level are reported to under-estimate overall retention since several women self-transfer to other facilities without being accounted for. Individual health facility retention is used in care assessment and no attention is paid to transfers. This policy memo provides information on the alternative courses of action that may be taken to mitigate this issue of retention in care, clearly stating the pros and cons of each course of action. It also gives a recommendation for the best course of action that should be taken.
Research for universal health coverage: setting priorities for policy and systems research in Uganda
(Global Health Action, 2021) Ssengooba, Freddie; Ssennyonjo, Aloysius; Rutebemberwa, Elizeus; Musila, Timothy; Namusoke Kiwanuka, Suzanne; Kemari, Enid; Nattimba, Milly
There is international consensus on the need for countries to work towards achieving universal health coverage (UHC) whereby the population is given access to all appropriate promotive, preventive, curative and rehabilitative services at affordable cost. The World Health Organisation (2013) urges all countries to undertake research to customise UHC within national development agendas. Objective: To describe the process used to prioritise UHC within the health systems research and development agenda in Uganda. Methods: Two national consultative workshops were convened in May and August 2015 to develop a UHC research agenda in Uganda. The participants included multisector representatives from local, national, and international organisations. A participatory approach with structured deliberations and multi-voting techniques was used. Stakeholders’ views were analysed thematically according to health systems building blocks, and multi-voting was used to assign priorities across themes and sub-themes. The priorities were further validated and disseminated at national health sector meetings. Results: Of the 80 invited stakeholders, 57 (71.3%) attended. The expressed priorities were: 1) health workforce; 2) governance; 3) financing; 4) service delivery, and 5) community health. The participants also recommended crosscutting research themes to address the social determinants of health, multisectoral collaboration, and health system resilience to protect against external shocks and disease epidemics. Conclusion: Discussions that capture the diverse perspectives of stakeholders provide a way of exploring UHC within health policy and systems development. In Uganda, attention should be paid to the principal challenges of mobilising financial and technical capabilities for research and strengthening the link between evidence generation and policy actions to achieve UHC.
Strategic Purchasing Arrangements in Uganda and Their Implications for Universal Health Coverage
(Health Systems & Reform, 2022) Ekirapa-Kiracho, Elizabeth; Ssennyonjo, Aloysius; Cashin, Cheryl; Gatome-Munyua, Agnes; Olalere, Nkechi; Ssempala, Richard; Mayora, Chrispus; Ssengooba, Freddie
Several purchasing arrangements coexist in Uganda, creating opportunities for synergy but also leading to conflicting incentives and inefficiencies in resource allocation and purchasing functions. This paper analyzes the key health care purchasing functions in Uganda and the implications of the various purchasing arrangements for universal health coverage (UHC). The data for this paper were collected through a document review and stakeholder dialogue. The analysis was guided by the Strategic Health Purchasing Progress Tracking Framework created by the Strategic Purchasing Africa Resource Center (SPARC) and its technical partners. Uganda has a minimum health care package that targets the main causes of morbidity and mortality as well as specific vulnerable groups. However, provision of the package is patchy, largely due to inadequate domestic financing and duplication of services funded by development partners. There is selective contracting with private-sector providers. Facilities receive direct funding from both the government budget and development partners. Unlike government-budget funding, payment from output-based donor-funded projects and performance-based financing (PBF) projects is linked to service quality and has specified conditions for use. Specification of UHC targets is still nascent and evolving in Uganda. Expansion of service coverage in Uganda can be achieved through enhanced resource pooling and harmonization of government and donor priorities. Greater provider autonomy, better work planning, direct facility funding, and provision of flexible funds to service providers are essential elements in the delivery of high-quality services that meet local needs and Uganda’s UHC aspirations.
Supporting the revision of the health benefits package in Uganda: A constrained optimisation approach
(Wiley Periodicals Inc, 2023-06) Mohan, Sakshi; Walker, Simon; Sengooba, Freddie; Kiracho, Elizabeth Ekirapa; Mayora, Chrispus; Ssennyonjo, Aloysius; Aliti, Candia Tom; Revill, Paul
This study demonstrates how the linear constrained optimization approach can be used to design a health benefits package (HBP) which maximises the net disability adjusted life years (DALYs) averted given the health system constraints faced by a country, and how the approach can help assess the marginal value of relaxing health system constraints. In the analysis performed for Uganda, 45 interventions were included in the HBP in the base scenario, resulting in a total of 26.7 million net DALYs averted. When task shifting of pharmacists' and nutrition officers' tasks to nurses is allowed, 73 interventions were included in the HBP resulting in a total of 32 million net DALYs averted (a 20% increase). Further, investing only $58 towards hiring additional nutrition officers' time could avert one net DALY; this increased to $60 and $64 for pharmacists and nurses respectively, and $100,000 for expanding the consumable budget, since human resources present the main constraint to the system
‘Writing budgets for meetings and teas?’: a multitheoretical analysis of intragovernmental coordination for multisectoral action for health in Uganda
(BMJ Global Health, 2022) Ssennyonjo, Aloysius; Ssengooba, Freddie; Criel, Bart; Titeca, Kristof; Van Belle, Sara
Introduction Coordination across policy domains and among government agencies is considered critical for addressing complex challenges such as inequities, urbanisation and climate change. However, the factors influencing coordination among government entities in low-income and middle-income countries are not well known. Although theory building is well suited to explain complex social phenomena, theory-based health policy and systems studies are limited. This paper examined the factors influencing coordination among government entities at the central government level in Uganda. Methods This theory-based case study used a qualitative approach. Primary data were collected through 26 national-level key informant interviews supplemented with a review of 6 national strategic and policy documents. Data were analysed abductively using a multi theoretical framework combining the transaction cost economics theory, principal–agent theory, resource dependence theory and political economy perspective. Results Complex and dynamic interactions among different factors, both internal and external to the government, were found. Interdependencies, coordination costs, non-aligned interests, and institutional and ideational aspects were crucial factors. The power dynamics within the bureaucratic structures and the agency of the coordinated entities influence the effectiveness of coordination efforts.

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