1 March 2024
The two hospitals in Northern Uganda (St. Mary’s Lacor and Ambrosoli Kalongo) have been participating for 3 years in a project, encouraged by the Italian Cooperation, of Results Based Financing, through which hospital staff receive a significant economic bonus every 3 months based on the quality scores achieved every 3 months, assessed by an external commission. Download Social Science and Medicine
Prof. Luigi Greco developed the objectives to be achieved together with the staff. In the three-year period 2018-2020, the quality level of services rendered to patients increased from the initial 40-50% of the target to 87-92% of the target in the areas of structure, management, diagnostic and therapeutic capabilities. Four years after the end of the initial project, we verified in February 2024 that the performance level remained high (88-95%) in all areas assessed. Ugandan GULU-NAP students and Italian trainees had and still have an important role in promoting quality of service objectives. Quality of service that in a ward where 2-3 children die every day, means, not infrequently, the difference between life and death.
“Result Based Financing, a change engine for paediatric services”
Reengineering pediatric services with Results-Based Financing (RBF) involves restructuring healthcare delivery systems to improve efficiency, quality, and patient outcomes, particularly in under-resourced areas like Northern Uganda. RBF programs typically provide financial incentives to healthcare providers based on the achievement of predefined results or outcomes, such as improved health metrics among the pediatric population.
This study considers a theoretical setting of healthcare RBF and then applies its main findings to two empirical cases, concerning S. Mary’s Lacor Hospital in Gulu and Dr. Ambrosoli’s Memorial Hospital in Kalongo before and after the Covid-19 pandemics (from 2018 to 2024).
The success of RBF programs depends on several factors, including the design of the incentive schemes, the context in which they are implemented, and the capacity of health facilities to respond to the incentives. Moreover, careful consideration must be given to ensure that RBF programs do not inadvertently create perverse incentives or widen health disparities.
Within this framework, the paper’s research question is to examine the Long-Term Effects of RBF Intervention in Children’s Wards in two main Northern Uganda hospitals (Lacor and Kalongo) in a pre- and post- Covid timeframe, from 2018 to 2024.
The study follows an IMRAD pattern and is structured as follows: after a short literature analysis, we present a model backed by empirical findings that precede a discussion and conclusion.
4.1.1. Lacor Hospital
Fig. 1 shows the percentage of the target score for the domain of Structure of the ward and Management of the Ward plus the action to preserve Hygiene and prevent infections at Lacor.
At Lacor the first year of the project was dedicated to covering the gaps in the respective domains, reaching, at the end of the first year (quarter 4) scores quite close to the set target. After the stop of the project (2020) there was no decay of the performance: at the point assessment of 2024, four years after the stop, the scores were very close to the target (see Table 1).
Fig. 2 shows the performance (as % of target score) in the domain of Clinical Management of patients, Emergency readiness, and training of students (nurses, medical doctors, and post-graduates) at Lacor.
The pattern is like the one observed in Fig. 1: during the first year a significant performance improvement, which remained stable up to the end of the project (2020) and is still kept four years after the end. A special note should be dedicated to the domain of training: during the second and third years, the occasional absence of senior supervisors and the uncontrolled rotation of students (especially medical) made this activity unstable. By 2024 also training appeared to be stabilized at a high level of performance.
4.1.2. Kalongo Hospital
Fig. 3 shows the percentage of the target score for the domain of Structure of the ward and Management of the Ward plus the action to preserve Hygiene and prevent infections at Kalongo.
At Kalongo the first year of the project was dedicated to covering the gaps in the respective domains, investing the resources gained by the RBF project, in the amendment and maintenance of the basic structure of the children’s ward. In the second year (quarters 5-8) the improvement toward the target became sensible, to reach in the third-year scores very close to the final objectives. After the stop of the project (2020) there was no decay of the performance: at the point assessment of 2024, four years after the stop, the scores were very close to the target (see Table 1).
Fig. 4 shows the performance (as % of target score) in the domain of Clinical Management of patients, Emergency readiness, and training of students (nurses, medical doctors, and post-graduates) at Kalongo.
The inconstant presence of the pediatrician affected considerably the stability of the performance of clinical management and the training of students. Especially in the second-year supervision and guidance appeared to be unstable, significantly affecting performance. By the third year, a significant improvement was observed, which was maintained as far as four years after the stop of the project.
Fig. 5 shows the improvement of quality scores as a percentage of the starting scores (at time 0 start of the project) either of the scores reached at the end of the project (2020) as well of the scores four years after the end of the project (2024) for Lacor and Kalongo Children’s Wards. (‘20’ = Scores 2020-scores of 2018)*100/Scores of 2018) , (‘24’ = Scores 2024-scores of 2018)*100/Scores of 2018).
The % improvement in performance in all domains was greater in Kalongo than in Lacor since the starting point of this hospital was significantly lower compared to Lacor. However, it is intriguing to observe the relative stability of the improvement after four years by the end of the project. For example, in Kalong there was a + 150% of the scores from the start of 2018 to the end (2020) for structure management and hygiene, but still a stable 150% improvement from 2018 to 2024 after the stop of the project. The domain of emergency was stabilized early and kept on a long time, while the area of training could improve less in Kalongo than at Lacor, due to the inconstant presence of supervision.
REPORT OF THE CHILDREN’S WARD
RBF PROJECT 2018-2020
March 27° 2021
Team of St.Mary’s Hospital Lacor
Team of Ambrosoli Hospital Kalongo
Data Analysis : L.Greco M.Arcidiaco
NAPLES – OCTOBER 29TH 2021
Historical Aula Magna – University of Napoli Federico II
RESULT BASED FINANCING: A SUSTAINABLE APPROACH FOR INTERNATIONAL PARTNERSHIP
Public funding of health programs has recently been characterized by increasing conditionality in the provision of resources. This trend typically includes result-based financing programs (RBF), which promise rewards to individuals or institutions, conditioning them to the achievement of the agreed objectives.
The St. Mary’s Hospital in Lacor (Gulu, Uganda) and the Corti Foundation, after a first experience with the RBF approach funded by the British government, have extended the adoption of incentive mechanisms of this kind with the aim of improving the quality of healthcare provided.
Thanks to the three-year contribution of the Italian Agency for Development Cooperation (AICS), results-based financing mechanisms have been tested in the pediatric wards of Lacor Hospital and Dr Ambrosoli Memorial Kalongo Hospital, showing considerable potential in improving the quality of the services provided, hence in contributing to the reduction of the high infant mortality rates.
Starting from this experience, and from the analysis of the evidence gathered in the hospitals of Lacor and Kalongo, the University of Naples Federico II, in partnership with the Corti and the Ambrosoli Foundation, promotes a conference on result-based financing programmes with the aim of discussing their effectiveness in favouring sustainability and quality in the health sector.
RBFREPORT2019
DRAFT FOR A REPORT OF THE FIRST YEAR OF THE PEDIATRIC RBF PROJECT
FEB 24nd Luigi Greco& Margherita Arcidiaco
OVERALL CONSIDERATIONS
QUANTITY OF C.W. ADMISSIONS
Both hospitals admitted every month considerably less children than planned in the original RBF plan.
Lacor averaged 750 admissions per month and Kalongo 330 compared to the planned total of 100 and 500 each.
The reduction of admissions is independent by the hospital, which do admit all cases requiring an hospital admission, but it is related to:
- decrease of malaria and malnutrition and , especially,
- better filter at the Outpatient Department, which does meet the highest demand of care.
- more attention to severe and complicated cases
For this reasons the two hospitals cannot be heavily penalized by these positive developments.
Having met all stakeholders in Kalongo as well as in Lacor, I propose the following amendments to correctly compute the quantity of admissions.
- Add to the monthly admission at the C.W. all children aged 0 to 14 years admitted in the other wards of the hospital (isolation, surgery, HIV etc)
- Compute the length of stay of each admitted child and divide them into:
- Length of stay 1 to 5 days
- Length of stay more than 5 days
Since the length of stay is an indirect, but efficient, estimate of the severity of the child and requirement of resources.
- Compute the total admissions according to :
Total = N. of cases with 1-5 days length of stay + (N of cases with > 5 days length of stay x 1.5)
We simply add a weight of severity of 50% more to the cases staying 6 or more days.
This will give a more reliable picture of the workload of the hospital for the care of children.
St MARY’S HOSPITAL LACOR
Substantial changes took place in the period from March 2018 to February 2019, starting from the important problem of bed and equipment sharing for the intensive care children. Now a new system of Oxygen distribution has been installed and there is no more the need to share oxygen concentrators. Much attention was paid to the emergency preparedness, to the safety, to the waste disposal, to latrines.
One critical point which does require more action and surveillance is generally record keeping either to register admission, as well to keep record books for materials, drugs, etc.
Specifically:
- Basic Infrastructure: beds and mattress are ok, weighing scales are available, the ward is clean and electrical sockets and main have been covered and protected. Still some misunderstanding of waste disposal by mothers has been reported. Occasionally there is still bed sharing, but not in the intensive care, as it was last year. Infusion pumps are required. No problems with drugs, but some misunderstanding with lab has been reported. X ray is overwhelmed and under staffed.
- Hygiene: Cleaning is ok but stock management needs surveillance. Beds are ok, as well as trash bins (which were inadequate last year). Latrines and shower are mostly functioning and clean. Sterilization is ok.
- Clinical and Nursing: much work was done in this field, but the very frequent turnover of interns and doctors required continuous repetition of guidelines to the newcomers. Occasional misunderstanding between prescription and actual provision of treatment was reported. The medical and nursing staff deal with quite severe cases every day and they share their problems and decision in a morning meeting. Pressure on the staff is very strong, due to the very high demand by the community. Death review is exemplary: they developed an ‘ad hoc’ form which allows a critical revision of events.
- Emergency: the cupboard is well organized in appropriate and tidy shelves with the basic equipment and also with cannulation and intubation materials. Protocols have still to be diffused regularly.
- Training: of nurses is going well: they receive appropriate supervision and take on progressive responsibility by the ‘learning-by-doing’ approach. Medical students were often absent; when they are there they are actively involved and respond enthusiastically. Training objectives for III and Vth years Medical Students are clearly pictured on the main wall.
Critical Point: Record Keeping and Data registration have to be improved by continuous surveillance on the registration of patients, book keeping, storage of materials etc.
Perspective: One critical issue at Lacor hospital is neonatal care. The mortality for small for date neonates is still quite high, despite the efforts of the staff. Unfortunately, Neonatology is located in very inadequate spaces (2 rooms) packed with mothers and premature infants. All the efforts to reduce infection and cross contamination are completely vanished by the lack of spaces. Mother, protected with mask, gowns, shoes, lay on the floor and we measured 9 people in one room at the same time.
Finally a plan to set up a new large Neonatology area has been approved by the Management and action is going to develop a sustainable plan to develop 4 areas of care:
- 6 cots area for out-borne neonates requiring high level of care
- 12 cots for neonates Adequate for Gestational Age and Kangaroo procedures
- 6 monitored thermal cots for Sub-Intensive (and Small for Gestational Age) premature
- 4 monitored thermal cots for Isolation of sub-intensive cases
The total of 28 cots will be equipped with O2, aspiration, power and appropriate equipment
A ‘Mothers’ Pavillon’ will be built in the open air area behind the ward.
‘AMBROSOLI HOSPITAL’ – KALONGO
The overall picture of the hospital significantly changed compared to March 2018, despite the critical lack of human resources.
Since at the first RBF evaluation they scored very low, they received a bonus so small that they collectively took the decision not to distribute the financial benefit to the staff, but to save it to pay for the substantial changes in the Children’s Ward and surroundings, that might have improved the situation. So they invested all the bonus money to fit meshes to windows, increase safety and hygiene etc, in order to expect a better performance and a larger bonus in subsequent RBF evaluations.
The Children’s ward is now clean, with windows protected by mesh, washing hands is in place, litter is disposed appropriately, beds are clean, toilet working.
The new Neonatology is very effective, modern, very well spaced and organized, quite well managed and staffed, with 3 modern incubators and several new equipments. It is a real example of a major and effective change in the most critical sector of children’s care (the premature and the sick newborn).
One critical point which does require more action and surveillance is record keeping especially to register admission, to register the day of dismission from the hospital in order to compute the length of stay, as well to keep record books for materials, drugs, etc. This point requires immediate action, to avoid misreporting at the next evaluation.
As far as the single items of the checklist I observed:
- Basic infrastructure: windows protected, beds and mattress ok. The weight scale is inappropriate in CW (hanging), very good in neonatology
- Hygiene: new trash bins everywhere
- Safety: electrical socket have been displaced at higher level, drugs ok
- Infections: wash hands now available, less cross-contamination, much reduced in neonatology
- Equipment: no infusion pumps, other ok
- Drugs: occasionally antibiotics not available, stock card not well kept
- LAB: very good
- Rx: lack of staff
Hygiene: generally significantly improved, much trash bins etc. No showers (delete from plan)
Sterilization functioning
Clinical and Nursing Procedures: despite the lack of specialist, medical officers, under the supervision of the Director and Superintendent apparently per form quite satisfactorily in the clinical procedures. We revised several cases controlling the appropriateness of the management and were quite pleased to verify the correct application of standard protocols of children’s care.
Prescriptions were appropriate and the administration by nursing procedure quite good. Fluid charts and drug administration were correct.
More effort should be done to check that mothers give the required ORS solution to dehydrated children overnight.
Neonatal care improved at higher levels.
Death review occasionally in place: they have to get the ‘ad hoc’ form from Lacor.
Supervision is an issue for the lack of specialist: it should be regularly carried out by senior officers (Directors, Superintendent)
Emergency was quite OK: 8 Ambu bags were quite dusty.
Training for Nurses and Midwifes is good. The Midwifery school is very well kept.
Critical Point: It was observed that on the admission book at the data registration office, very often the day the child was discharged from the ward is not reported. This is a very serious failure, since the computing of admissions will require, from now onward, to calculate the length of stay of each child, in order to be classified as ‘simple’ = less= 5 days or ‘severe’ = 6 or more days.
Record Keeping and Data registration have to be improved by continuous surveillance on the registration of patients, book keeping, storage of materials etc.
Perspectives: A Pediatrician is expected to come in few months.
A plan to reconstruct and enlarge the whole Pediatric Department is in place. According to my experience this is a very nice and effective plan, able to bring unexpected improvements in the children‘s care as well as in the staff motivation. It appears to make the best and rationale use of the spaces and to provide a human and nice environment to children and their mothers. The Isolation ward merit great appreciation for the smart and human use of the required separation among several infections, which is rarely found in any western hospital. The required budget appears surprisingly contained also.
Starting 2018
Result based financing
KALONGO HOSPITAL2018
THINGS TO DO
ACTIONS BEFORE RESULTS BASED FINANCING PROGRAM
Lacor 15 March 2018
Progress 2019
“Result Based Financing, un motore di cambiamento per i servizi pediatrici”
Intervento di rafforzamento delle qualità delle cure e dell’empowerment del personale sanitario