Elizabeth Ekirapa Kiracho
EC Village Verification

By Elizabeth Ekirapa Kiracho

I recently made a deal with my children that I would reward them if they performed better than they did in previous terms.  We agreed that for every subject done, if they scored 90 per cent, I would give each of them Shs20,000 and Shs10,000 for a score between 80-89 per cent.

I didn’t know the gravity of the financial challenge I had put myself into until my four girls told me I owe them about Shs400,000.  True to the dare, they had worked hard and scored highly, putting my pockets into unexpected financial loss, albeit my happiness at their performance.

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That scenario is akin to the Pay for Performance (P4P) approach that has dominated discussions on how to improve health system performance in Uganda. Under the P4P system, health workers, health facilities or service providers enter an agreement to be paid a specific amount of money upon achieving specified service outputs. Put differently, under this approach, providers are paid according to the amount of work done.

Absenteeism of health workers, low motivation to work, poor quality services, poor attitude towards work and poor customer care, etc., are among the challenges often reported in Uganda’s health system. It is not uncommon for doctors in some health facilities to work two days a week instead of five.  Under the P4P system, such doctors would qualify to be paid for only two days.

To qualify for better or higher pay, the healthcare provider must use innovative strategies to attract more clients, such as providing quality service, full-time availability, customer care, etc.  This approach is a good mechanism to get the best out of healthcare workers and also offers better value for the money allocated to the health sector.

Pay for Performance is being piloted in a number of districts in Uganda.

I recently had a chat with the District Health Officer of Kibuku District, Dr Ahmed Bhumba. He indicated to me that for 2017/2018, all health facilities in the district will get 60 per cent of their money as budgeted, and 40 per cent will be paid to the facility based on its performance. Performance indicators that will be monitored and measured include maternal deliveries and outpatient attendance.

 With P4P, health workers and facilities will pay more attention to data on what activities they are undertaking since it forms the basis for payment.

However, a key challenge may arise from the implementation of P4P. Using the example of my girls, I did fulfill my pledge and paid what I owed them. I didn’t have the time to scrutinize their exam scripts to see if there were issues that needed addressing, however minimal. I trusted their word. But what if they had lied about their performance altogether?  Similarly, health facilities may be tempted to manipulate data so that they earn more money. As such, stringent measures of monitoring, supervision and verification of claims before payment, must be made to avoid manipulation and fraud.

It is also important that resources such as electricity, water, theatre and equipment, medicines, etc., are made available in health facilities to ensure functionality and provision of quality service.

The money promised for excellent performance must also be paid in a timely manner so that health workers don’t get demotivated. A culture of trust is crucial in ensuring both sides deliver their part of the bargain.

Elizabeth Ekirapa Kiracho is a health economist – SPEED project, Makerere University School of Public Health.