RUPRECHT-KARLS UNIVERSITY HEIDELBERG

DEPARTMENT OF TROPICAL HYGIENE AND PUBLIC

HEALTH

POSTGRADUATE MASTER OF SCIENCE COURSE

Community Health and Health Management
In Developing Countries

Master of Science Thesis:

Market Potentials and Risks for Health Care Providers

in an Output-Based Voucher Scheme for
Treatment of Sexually Transmitted Diseases (STDs)
in Mbarara District, Uganda

Heidelberg, July 2005

Author: Ulrich Bärtels

Thesis Tutor: Dr. Subhash Pokhrel
Co-Tutor: Anayo Akunne
Field Tutor: Christine Namayanya i
 Master of Science Course
Community Health and Health Management
in Developing Countries

Declaration

This thesis is the result of independent investigation. Where my work is indebted to the
work of others, I have made acknowledgement. I declare that this study has not already
been accepted for any degree nor is it currently being submitted in candidature for any
other degree.

Heidelberg, July 27th 2005

Ulrich Bärtels

i
Acknowledgements

I am grateful to all the people who have in one way or another contributed to the
completion of this thesis.
I would first like to express my appreciation to the DAAD which sponsored my field
study in Uganda.
Thanks to all interview partners for the valuable information they provided to me.
I am very thankful to my field tutor Christine Namayanja, to Esther, to Maggie, to
Edward, Walter and all the other staff of Marie Stopes International Uganda; for all the
logistical and moral support during my field study and for making me feel welcome and
part of the team.
Thanks to Nuwa and Steven from MSU Mbarara for their great support and for giving
me a good time in Mbarara.
Special thanks to Dr. Paul Kiwanuka-Mukiibi for tacking me to the rural areas of
Mbarara District and for very fruitful long night discussions at the terrace of University
Inn Hotel in Mbarara.
Many thanks to Dr. David Griffith who made me attracted to this interesting topic and
gave me many valuable inputs.
Thanks for the support of my Thesis Tutor Subhash Pokhrel and to my new Co-Tutor
Anayo Akunne, who jumped in in the last minute.
Thanks to all fellow colleagues in the MSc. Course and to the MSc staff for a busy
informative and interesting year.
Last but not least I am very grateful to meinem Schatz for being always patient and
giving me continuous moral and physical support.

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Abbreviations

DDHS District Director of Health Services

DHMT District Health Management Team
DHSO District Health Services Office
FBO Faith Based Organisations
IEC Information Education Communication
IGES Institut für Gesundheits- und Sozialforschung
ITN Insecticide Treated Nets
KFW Kreditanstalt für Wiederaufbau
MA Management Agency
MSIU Marie Stopes International Uganda
MSU Marie Stopes Uganda
MOH Ministry of Health
NGOs Non Governmental Organisations
OBA Output Based Aid
PFPP Private for Profit Providers
PNFP Private not for Profit Providers
PPP Public Private Partnership
PPPH Public Private Partnership in Health
STDs Sexually Transmitted Diseases
STIs Sexually Transmitted Infections
UPMPA Uganda Private Medical Practitioners Organisation
USH Uganda Shilling
VCT Voluntary Counselling and Testing

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List of Tables and Figures
1. Tables
Table 1: Health seeking behaviour according to different providers………………….17
Table 2: Comparison of main incentives between PNFP + Public services
and PFPP……………………………………………………………………...47
Table 3: Comparison of main disincentives between PNFP + Public services
and PFPP……………………………………………………………………..49
2. Figures
Figure 1: Role of private sector in health………………………………………………10
Figure 2: Input versus output based approaches……………………………………….20
Figure 3: Money flow in an OBA voucher scheme…………………………………….22

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Table of Contents
Declaration ………………………………………………………………………………………………...i
Acknowledgement…………………………………………………………………………………………ii
List of tables and figures…………………………………………………………………………………iii
List of abbreviations……………………………………………………………………………………...iv
1. Executive Summary…………………………………………………………………1
2. Introduction………………………………………………………………………….4
2.1 Statement of the problem………………………………………………………….4
2.2 Public health importance of HIV/AIDS and STDs in Uganda……………………5
2.3 Study area background…………………………………………………………….6
2.4 Background an the OBA voucher scheme and the local partner institution………7
2.5 Research objective………………………………………………………………...7
2.5.1 General objective………………………………………………………………………………..8
2.5.2 Specific objectives………………………………………………………………………………8

3. Literature review……………………………………………………………………9
3.1 Introduction to the literature review……………………………………………9
3.2 The role of the private sector in health…………………………………………9
3.2.1 Private health services reaching the poor……………………………………………………9
3.2.2 Private participation in health services…………………………………………………….10
3.2.3 The role of incentives for private sector involvement……………………………………..12
3.2.3 Uganda National Policy on Public Private Partnership in Health………………………….14
3.3 Sector policy for Sexually Transmitted Diseases (STDs) in Uganda…………..17
3.3.1 The role of the private sector in diagnose and treatment of STDs…………………………17
3.3.2 Health sector policy on STDs in Uganda…………………………………………………..18
3.4 Output based aid (OBA) – a new approach in health financing…………………19
3.4.1 Input versus output based approaches……………………………………………………...19
3.4.2 Output based voucher schemes…………………………………………………………….20
3.4.3 The functioning of OBA voucher schemes………………………………………………...21
3.4.4 Impact of OBA voucher schemes…………………………………………………………..22
3.4.5 Limitations of OBA voucher scheme………………………………………………………23
3.4.6 Experiences with voucher schemes in Health……………………………………………...24
3.4.7 Considerations for the design of an OBA voucher scheme………………………………..26
3.5 Design of the OBA voucher scheme for STD treatment in
Mbarara District………………………………………………………………28

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4. Methodology………………………………………………………………………..34
4.1 Setting…………………………………………………………………………34
4.2 Study design…………………………………………………………………..34
4.3 Sampling……………………………………………………………………....34
4.4 Data collection methods………………………………………………………35
4.4.1 Semi-structured individual interviews……………………………………………………..35
4.4.2 Key informant interviews…………………………………………………………………..36
4.5 Data collection process………………………………………………………..37
4.6 Data analysis…………………………………………………………………..38
4.7 Limitation……………………………………………………………………..38
4.8 Ethical considerations…………………………………………………………40

5. Findings……………………………………………………………………………..42
5.1 Introduction…………………………………………………………………...42
5.2 Brief description of health care providers in Mbarara District………………………………...42
5.3 General opinions on OBA voucher schemes…………………………………………………..43
5.3.1 Level of knowledge………………………………………………………………………...43
5.3.2 Strengths and weaknesses/challenges……………………………………………………...43
5.4 Incentives and disincentives……………………………………………………46
5.4.1 Main incentives for the health care providers to join the scheme…………………………46
5.4.2 Main disincentives to avoid joining the voucher scheme………………….........................48
5.4.3 Additional incentives that should be made available to the providers………………..........49
5.4.4 Assistance by the Management Agency……………………………………………………50
5.4.5 Additional requirements for health care providers to join the scheme…………………….51
5.5 Acceptance of the design elements of the voucher scheme…………………......52
5.5.1 Security against fraud………………………………………………………………………52
5.5.2 Claims and processing……………………………………………………………………...53
5.5.3 Approval system……………………………………………………………………………53
5.5.4 Monitoring and evaluation…………………………………………………………………54
5.5.5 Service Contract……………………………………………………………………………54
5.6 The role of the private sector and Public Private Partnership………………...54
5.6.1 The role of the private sector………………………………………………………………54
5.6.2 Public Private Partnership………………………………………………………………….55
5.6.3 Degree of self organisation of the private sector…………………………………………..56
5.7 Summary of the findings……………………………………………………...56

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6. Discussion…………………………………………………………………………..58
6.1 Introduction………………………………………………………………..58
6.2 The private sector in Uganda – partner in health?.......................................58
6.3 The OBA voucher scheme for STD treatment – a suitable
approach to improve quality of health services
and access for the poor?...............................................................................59
6.4 OBA – market chance or risk for health care providers?………………….60
6.5 The design elements of the voucher scheme – benefit or interference?.......62
6.6. Discussion on the methodology……………………………………………64

7. Conclusion and recommendations………………………………………………..66

8. Bibliography………………………………………………………………………..69

9. Annexes……………………………………………………………………………..74
Annex 1: Mbarara District map………………………………………………………...74
Annex 2: Schematic view on the voucher scheme for STD treatment
in Mbarara District Uganda…………………………………………………...75
Annex 3: Management Structure of the voucher scheme………………………………76
Annex 4: Interview guideline health care providers……………………………………77
Annex 5: Interview guideline key informants………………………………………….79
Annex 6: Informed consent declaration………………………………………………...81
Annex 7: Research permission from District Health Service Office Mbarara…………82
Annex 8: List of interviewed health care providers……………………………………84
Annex 9: List of interviewed key informants…………………………………………..85

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1. Executive summary
Traditional approaches of health financing focus on providing inputs such as
infrastructure investments, financial or technical assistance to subsidize an assumed
health output. The funding aims mainly on the public sector and mostly neglects the
existence of the private service providers. Funding public services have often resulted in
poor outcomes and frequently failed to reach the most vulnerable part of the population.
These inadequacies have made many patients, especially the poor, turn to private health
care providers. Nowadays the private sector plays a major role in health care provision
in developing countries. Experience shows that in poor countries the majority of health
care is provided by the private sector and funded by out-of-pocket payments. Private
practitioners are believed to be a more efficient provider of health care, more flexible,
more innovative and more responding to patient expectations. However private
provision presents two major concerns: One is the unreliable quality of care; the other is
that because of lack of financial resources poor patients often do not have access to
essential services.
In contrast to supply-side funding for public health care provision a new demand-side
oriented approach called Output-based Aid (OBA) is being discussed. Demand-side
financing places purchasing power into the hand of consumers to spend on specific
services. OBA clearly recognises the growing importance of the private sector to reach
public health objectives. The basic idea of OBA is to delegate specific services to
certified health care providers under contracts that link payments on certain output and
results for a specific target group. Typical OBA concepts are voucher schemes.
Vouchers schemes usually function in the way that vouchers are distributed to the
beneficiaries which entitle them to receive a predefined service package in certificate
health facilities. The provider will then be reimbursed according to an agreed service fee
by a voucher agency.
OBA voucher schemes clearly aim at using the potential of the private sector and
integrating private practitioners in the health care system in order to improve the access
to care for the poor and ensure a better service quality. To private health care providers
participation in voucher schemes can mean both: market potentials and risks. On the
one hand vouchers may increase the market share and on the other hand providers have
to fulfil high requirements regarding accreditation, delivered output, monitoring and
evaluation instruments which may interfere in their business.

1
The experience with voucher schemes in the health sector has to date been quite limited.
A small number of successful examples of running voucher schemes (e.g. Nicaragua
and Mexico) and their impact on certain health issues have been documented. However
there exists no clear evidence so far on what motivates especially private health service
providers to join voucher schemes.
The study focused on an output-based voucher scheme for Sexually Transmitted
Diseases (STDs) treatment in Mbarara District, western Uganda, which is close to
implementation. The scheme aims on conceptualising a more effective and efficient
service delivery system for STDs through creating an environment involving private-
for-profit (PFPP), private-not-for-profit (PNFP) and public providers in service
provision. Taking this example the research investigated what are the main incentives
and risks that motivate or deter health care providers to participate in the voucher
scheme and provides recommendation to mobilize a sufficient number of health
practitioners to join the scheme.
For this purpose a cross sectional descriptive study that used exclusively qualitative
methods was conducted in Mbarara District from May to June 2005. Twenty two Semi-
structured individual interviews with potential providers of all types of organisation in
urban and rural areas and 11 informal conversational and semi-structured key informant
interviews with policy makers and implementers were carried out.
The findings have indicated that private providers in Mbarara District generally show a
positive attitude towards the voucher scheme. They appreciate to be recognised by
government and donors and are basically motivated to join the scheme. They expect that
the approach have a potential to influence health seeking behaviour of the population
towards STDs and to decrease the number of infections. Providers perceive that the
participation in the scheme voucher will contribute to an increase utilization of their
services and thus will increase their income opportunities. Becoming partner of the
voucher scheme will offer them competitive advantages. The scheme provides them
incentives to improve their services. Health care providers are motivated to attend
training to build up their capacity, to employ additional staff and to invest in order to
upgrade their services. Especially for PFPP a better access to capital markets with
reasonable interest rates is considered as a great incentive to join the scheme.
Participating in the scheme also involves interference in the business of the private
health care providers. Most disadvantages are connected with the design elements of the
voucher scheme. Especially the claims and processing of the vouchers is perceived as

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risk. Because PFPP usually serve their patients on cash bases the reliability, the timing
and the amount of payment is crucial for them. Whereas PNFP have experiences with
instruments such as approval, monitoring and evaluation, PFPP are usually not involved
in comprehensive assessment methods. Policy makers and implementers have to make a
trade off between the desire of gaining as much data as possible and the necessity not to
demotivate the voucher partners by too much control and administrative workload.
In summary health care providers in Mbarara District value the chances of participating
in the scheme much higher than the risks associated with it. In order not to discourage
the providers and not to create perverse effects the success of the voucher scheme will
much depend on a careful design.
For creating an appropriate incentive system for health care providers in an OBA
voucher scheme and to give suggestions for an expansion strategy of the scheme the
following recommendations are provided:
 The claims and processing is crucial for the success of the voucher. The
reimbursement procedure should be transparent, reliable and uncomplicated and
the payment should be quick in a continuous process.
 The monitoring and evaluation process should find a balance between
completeness of data and control, and additional administrative workload for the
providers.
 To streamline the whole process and to enhance the communication between the
stakeholders of the scheme a field office in Mbarara town should be established.
 In order to expand the programme some providers need to upgrade their
facilities. It should be weighted carefully if inputs do not contradict with the
OBA approach. To encourage innovation government and donors should
consider developing mechanisms to facilitate the access to investment capital for
PFPP.
 To reach a better coverage in rural areas policy makers and implementers should
think about including mobile clinics in the voucher scheme. In those areas,
where no private providers are available in future public health centres might be
involved in the programme. This may require a change in public health sector
policy.
 Based on the presented findings after several months of implementation of the
voucher scheme a follow up study would be useful.

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2. Introduction
2.1 Statement of the problem
Providing adequate health care for the poor is an essential input into economic
development and poverty reduction (Sachs 2001). It is no surprise that five of eight
Millennium Development Goals (MDGs), agreed at the UN General Assembly 2000,
are related with the improvement of health in developing countries. One target
mentioned in Goal six focuses on combating the HIV/AIDS pandemic (UN 2004).
Sexually Transmitted Diseases (STDs) are indicated as one of the most important pre-
disposing factors for HIV infection (WHO 2003). In Uganda, STDs are a significant
public health problem (Kampala, 2003, c) and it is important to explore means of
addressing this.
Traditional public health policies of local governments and international donor agencies
are input oriented. They provide investments in form of infrastructure, financial and
human resources and technical assistance. The funding focuses mainly on the public
sector. Private health care providers mostly play a minor role. Despite some
achievements in the public health situation these activities often fail to reach the poor in
most developing countries. Some of the reasons for this failure are: a) public services
often work inefficiently, b) the rich is favoured over the poor; c) only little incentives
are provided for service providers to perform well and d) the poor often do not demand
the services. (World Bank 2004).
These inadequacies have made many patients, especially the poor, turn to private
service providers. Experiences show that in most poor countries the majority of health
care is provided by the private sector and funded by out-of-pocket payments. For
example in India, 80 % of doctors are in private practice (Yamamoto, 2004). In Uganda
the proportion of private expenditures in health already reaches more than 70% of the
total national health expenditures (WHO 2005). The private sector is believed to be a
more efficient provider of health services, more flexible and innovative and more
responsive to patient expectations (Gorter et al. 2003). However private provision
presents two mayor concerns: One is the unreliable quality of care in the absence of
effective regulation; the other is that because of limited financial resources the poor
often cannot afford essential services (Yamamoto, 2004).
In contrast to supply-side funding for public provision of health care a new demand-side
financing approach called Output-based Aid (OBA) is being debated (Brook and Smith
2001). OBA explicitly takes into consideration the growing importance of the private

4
sector in national public health systems. The basic idea of OBA is to delegate health
services to certified private or public providers under contract that link payments or
donation on certain outputs and results for the target group (Brook & Smith 2001).
Typical OBA concepts are voucher schemes. Vouchers schemes usually function in the
way that vouchers will be provided to a specific target group which entitle them to
receive a defined package of best practice service in certificate health facilities. The cost
of treatment will then be reimbursed by a voucher agency (Sandifort et al., 2003).
OBA voucher schemes clearly aim at using the potential of the private sector and
integrating private providers in the health care system in order to improve the access to
care for the poor and ensure a better service quality. To private health care providers,
participation in voucher schemes can mean both market potentials and risks. On the one
hand vouchers may increase the market share and provide incentives to upgrade services
and on the other hand providers have to fulfil high requirements that relate to
accreditation, delivered output, monitoring and evaluation. These may interfere with
their businesses.
The experience with voucher schemes in the health sector has to date been quite limited.
A small number of successful examples of running voucher schemes (e. g. Nicaragua,
Mexico and Tanzania) and their impact on certain health issues have been documented.
(Gorter et al. 2003; Ensor 2004). However there exists no clear evidence so far on what
motivates the private health service providers to join output-based voucher schemes.
Taking the example of an OBA voucher scheme for treatment of STDs in Mbarara
District, western Uganda this study aims to investigate the main incentives and risks
that motivate or deter health care providers to participate in a voucher scheme. The
author believes that this information will add to the body of knowledge on OBA
approaches.

2.2 Public health importance of HIV/AIDS and STDs in Uganda

Uganda has a total population of around 25.8 Million (WHO 2005). According to the
World Health Report 2000 the health status of Uganda is amongst the worst in the
World (WHO 2000). Although Malaria has the highest incidence rate (Kampala 2003,
f), HIV/AIDS is the leading cause of death in adults and the main cause of falling life
expectancy, which presently is 49.3 years (WHO, 2004).
STDs were identified as one of the most important pre-disposing factors for HIV
infection and they remain a public health problem of major significance in most parts of

5
the world (WHO 2003). The diseases are among the five most important causes of adult
health care seeking and loss in productive life.. STDs including HIV are the most
important causes of illnesses among young adult men (15-44 years) and the second most
important cause after maternal illnesses among young adult women (WHO 2001).
In Uganda the burden of disease attributable to sexual and reproductive health risks is
estimated to be more than 16% (the highest category) of DALYs (WHO 2002). Even
though the incidence of HIV infection has fallen nationwide from 16% to 6% in the last
few years, the number of patients presenting STDs to doctors and clinics is still high.
Data on STD prevalence and incidence in Uganda is limited. However the last available
Surveillance Report of the STD/AIDS Control Programme (Kampala 2003, c) gives a
good indication of the size of the problem. In the survey 8 % of women and 3% of men
self reported having an STD in the last 12 months. Given the fact that the knowledge
about STD symptoms is limited among the Ugandan population the true level of
prevalence of STIs might be higher than the reported (Kampala 2001).
Controlling STDs has been an integral part of AIDS control programme since 1986
(Kampala 2003, c). One of the main strategies includes “STD Treatment” which
includes “early recognition and treatment”. The following objectives were mentioned
in the Annual Health Sector Performance Report 2003: Control of communicable
Diseases which includes STD treatment; strengthen the health care delivery system and
enhance partnership with the private sector (Kampala 2003, c). The National Policy on
Public Private Partnership explicitly mentioned the need for partnership with private-not
for profit providers and faith-based groups and private-for profit health practitioners
(Kampala, 2003,b). This clearly proves that partnership with the private sector in
Uganda to achieve health sector objectives has become an important issue on the
agenda.

2.3 Study area background

The study took place in Mbarara District from May to June 2005. The selection of the
study area derived from the fact that the district has been chosen for the implementation
of the voucher scheme.
Mbarara District is located in south-western Uganda (annex 1: Mbarara District map).
The district consists of 10 sub health districts and has as total population of 1.2 Million.
In 2000 94% of the population lived in rural areas and the majority of the population

6
(80%) depended on farming and agro-based industries. The district’s annual growth rate
(3.4) and life expectancy (45 years) correspondent to the national data (Mbarara 2000).
Although the main health problem in Mbarara District remains Malaria, STDs have
become a serious health issue for the district. In 2000 STDs were second to malaria in
prevalence (Abusu 2001). Today 10-15% of all patient contacts in the district are due to
the disease. In rural areas the prevalence of STDs even reaches 20-30 % (Griffith 2004).

2.4 Background on the OBA voucher scheme and the local partner
institution
In the frame of a nationwide HIV/AIDS prevention program the Government of Uganda
and Federal Republic of Germany through KFW have agreed to set up a pilot program
for an output-based voucher scheme for STD treatment. The pilot will take place in
urban and rural areas of Mbarara District where chronic STD is a major health concern.
The general objectives of the program are the conceptualization of a more effective and
efficient service delivery system for Sexually Transmitted Infections (STIs) diagnoses
and treatment, based on financing of outputs rather than inputs; and to create an
environment involving both public and private sector in service delivery (Griffith 2004).

Mary Stopes International – Uganda (MSIU) has been appointed as Management

Agency for the programme and will be responsible to coordinate the design and to
implement the components of the voucher scheme. The NGO operates in the fields of
family planning and reproductive health. The organisation aims to contribute to the
reduction of STDs and HIV/AIDS through the promotion of “safe sex” practices and
strengthen the national capacity to improve and sustain AIDS control initiatives. Since
1995 MSIU is running a country wide social marketing programme on condoms for the
Ministry of Health (MOH) of Uganda. The programme is mainly funded by KFW
(MSIU 2005). MSIU was the local partner institution for this study and had provided
the researcher with valuable logistic support.

2.5 Research objectives

Consultations with the appointed consultant and the KFW official responsible for the
voucher scheme have shown that major bottlenecks for implementation of the
programme is to identify those who will be eligible to receive the service and will be
able to buy the vouchers and how to identify and mobilize a sufficient amount of

7
qualified service providers. There is already a good knowledge of the potential target
group; however to date no structured information is available on the perception of the
providers to join voucher scheme.

2.5.1 General objective

The general objective of the study is to identify where the (private) health care providers
see the market potential and risks associated with joining the OBA voucher scheme for
treatment of STDs in Mbarara District. This will inform recommendations for
appropriate incentives that can mobilize competent service providers to participate in
the scheme.

2.5.2 Specific Objectives

Specific objectives of the study are:
 To explore the general role of the private sector within the Ugandan health
sector with respect to the OBA voucher scheme for STD treatment
 To identify the expectations of the health care providers and the main incentives
and risks that motivate or deter them to participate in the voucher scheme
 To know the extent to which health care providers will accept the main design
elements (claims and processing, approval and contracting, and monitoring and
evaluation) of the voucher scheme.
 To provide recommendations for an appropriate incentive system that mobilises
health care providers to join the voucher scheme and to give suggestions for an
expansion strategy.

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3. Literature review
3.1 Introduction
The literature review is structured as follows: The first part is on private sector
involvement in health and will highlight the Ugandan national policy on Public Private
Partnership in Health (PPPH). The second part is related to the national health sector
policy on STD treatment. The third part reviews OBA as a new approach in health
financing and presents voucher schemes as typical OBA concepts. The section gives
reviews on experiences made with voucher schemes in other settings and presents
consideration for the design of a voucher scheme. Finally the chapter introduces the
actual design of the OBA voucher scheme for STD treatment in Mbarara District.

3.2 The role of the private sector in health

3.2.1 Private health services reaching the poor
Many developing countries face a critical gap between the demand for health services
and the actual supply. Public health services often lack essential resources and expertise
(Marek et al. 2003). Even if public health services are provided free of charge they often
fail to reach the poor. Four main reasons can be identified for this failure: a) often the
resources are allocated in such a way that they favour the rich over the poor; b)
traditional funding approaches tend to focus on inputs like equipment, materials or
salaries but often does not reach the frontline services or intended beneficiaries; c) even
if the funds reach the services, due to bureaucratic management structures only little
incentives are provided for service providers to perform well; and d) even if the services
are available, the poor often do not demand them, whether due to poor service quality,
cultural, geographical or financial barriers (Yamamoto 2004).
These inadequacies have made many patients, especially the poor, turn to private
providers. Figure 1 shows that the share of private expenditures on health is high in
middle and high income countries (between 60 and 70 % of total spending) and that the
dominant way of financing health care is out-of-pocket payments. In Uganda the
proportion of private expenditures on health reached 72%. Out-of-pocket expenditures
are estimated with 53% of the total health spending of the population (WHO 2005).

9
Figure 1: Role of private sector in health

Source: World Bank 2004, 137

3.2.2 Private participation in health services

The awareness is growing regarding the importance of the private sector in achieving
health sector objectives within developing countries. This recognition results in
increased efforts to engage the private sector, especially private health care providers in
developing countries health sector policies. “Although most experts agree that ignoring
the private sector’s large role in the service delivery system is unwise, there is less
agreement and far less knowledge about strategies for engaging the private sector
(Harding and Preker 2003, 1).
Cooperation strategies between public and private sector are often referred to as public
private partnership (PPP). Harding and Perker (2003) provide an excellent guideline on
how to build up and implement ongoing relationships between public and private sector.
The authors suggest that policy makers have to fulfil three major tasks:
1. Assess what is the current role of the private sector in delivering health services and
identify areas where private providers might increase or improve their contribution to
governmental health programmes.
2. Select a strategy to engage the private sector in contributing to the objectives being
considered. Policy makers may decide between the following strategic approaches:

10
harnessing the providers, which aims on guiding the behaviour of identified providers
and benefiting from the fact that the providers are already serving the population with
services that are critical to the sector programme; growing by identifying and
encouraging providers to increase their services in areas which are of priority in order to
improve access for the population and conversion which targets on spotting out public
activities that may be more productive when turning them into private hands.
3. Identify the appropriate instruments means policy makers have to decide and
specify exactly what they want the providers to do. There is a wide variety of
instruments which can be divided into supply side and demand side instruments (IHSD
2004).
Supply side financing implies providing inputs based on a given output (Ensor 2004).
Common supply side instruments are: i) social franchising which is defined as an
operational model in which a private firm (franchiser) licenses other private businesses
(franchisees) to operate under its trade name (Ruster et al. 2003). ii) Social marketing
aims to improve the availability of affordable, quality assured and often subsidized
goods with health benefits, like condoms, through engaging the private sector in
commercial distribution and other activities to strengthen supply. iii) Contracting
describes a mechanism of using public finance to procure health care services delivered
by non-public providers which are specified and documented in written agreements
(IHSD 2004). A useful guide how to contract private services for Reproductive Health
Care is given by Rosen (2000). iv) Regulation is an essential instrument of
governmental policy. Regulation is especially critical for harnessing private activities in
order to ensure certain quality standards (Harding and Perker 2003).
Demand side financing places purchasing power into the hands of consumers to spend
on specific services (Ensor 2004). All insurance schemes (social health insurance,
commercial health insurance, community health insurance) as well as micro credit
programmes are classified as demand side instruments (for more details: IHSD 2004).
Innovative demand side approaches in health are output based voucher schemes which
will be discussed elsewhere.
To maximise the benefits of PPP a government needs to determine which strategy is
best suited for achieving its public health policy objectives. It then chooses the most
appropriate instruments and the best regulatory framework for monitoring and enforcing
the arrangements with the private sector (Marek 2003). In order to successfully involve
the private sector incentives play a major role (Harding and Perker 2003).

11
3.2.3 The role of incentives for private sector involvement
The decision for the appropriate strategy also involves the decision on the right
incentives that need to be made available to providers to encourage or discourage
certain behaviour. Incentives have the advantage of being voluntary which may
motivate providers to offer information about their behaviour and demonstrate
compliance. Incentives also require less bureaucratic support and are less costly than
control-based mechanism, which makes them an important regulatory mechanism.
(Afifi et al. 2003). Most incentive-based instruments rely on taxation, selective
contracting or subsidy transfers by government (Afifi et al. 2003). Depending on the
level of involvement or influence of the private sector, incentives can work supportive
or can produce perverse effects (Brugha & Zwi 1998). Governments have a variety of
options to influence provider’s behaviour.

1. Financial Incentives
Access to capital: Many investments in health sector require substantial access to
capital to finance buildings, equipments and other start up costs. For developing
countries lack of access to capital markets is a common phenomenon. Private providers
are very constrained by high interest rates for investment capital. High credit costs also
lead to inefficiencies. Unless they can afford the full price, essential supplies often have
to be purchased in small quantities. Low-cost loans can improve access to financial
markets. It can be an instrument to improve access to health care by targeting funds to
underserved areas or allocate resources to specific health interventions (Afifi et al.
2003).
Tax and tariff incentives: Tax incentives are useful tools to influence private sector
behaviour. The most frequently used forms are exemptions, waivers income tax and
deductibles (Afifi et al. 2003). Tax incentives are relatively straightforward since they
reduce the tax burden of the tax payers. High tariffs and import custom duties on
medical equipment are often a major constrain for health practitioners. In some
countries like Uganda the government have waived the import taxes and duties for
health commodities (Kampala 2004).
Other financial subsidies: Public financing is most common with regard to NGOs.
Subsidies can be provided in form of direct budget support, subsidies in forms of grants,
in-kind support such as contributing to staff salary (often practised for Faith Based
Organisations), support for medical equipment and critical supply. Discounts on critical

12
supplies such as vaccinations, nutritional supplements or antiretroviral drugs are often
provided to private practitioners while allowing them to charge a fee and to make profit
to expand delivery of important goods and services (Harding and Perker 2003).
Mechanism to control staff mobility: To control mobility of staff and to work against
“brain drain”, governments in developing countries have used a wide range of
mechanisms. Many governments stipulate that doctors and nurses who are trained in
public institutions complete a certain period in public health services before transferring
to the private sector. Governments sometimes try to attract providers with financial
incentives to motivate them to work in more remote areas (Afifi et al. 2003).
Contracting: Contracting services are a powerful tool and provide a variety of financial
incentives which can significantly influence provider’s behaviours. The fact, that
government pay for selected services creates a good opportunity for providers for new
or expanded business (Taylor 2003). Governments can alternatively expand demand for
priority services by subsidizing the purchase through vouchers (Sandifort et al. 2002).
The nature and function of voucher scheme will be explained in details in following
chapters.

2. Non-financial Incentives
Regulations: The function of regulating health services is to protect the public from
market failures. Some regulations have economic focus, aiming to address provider
monopolies, price regulations or capacity regulations to combat the scarcity of certain
services. Others are more socially oriented to improve equity, geographical or social
access to health services or aim to protect the public through controlling quality of
health delivery services (Harding and Perker 2003). Instruments to control quality are
licensing or accreditation. Licensing allows providers to stick to the good ethics of their
profession. Accreditation could come in the form of awards to professionals or health
facilities to acknowledge high quality of care (Nandraj and Khot 2003). In order to be
attractive for providers, accreditation systems must offer clear advantages such as
eligibility to certain payment schemes (Brugha and Zwi 1998).
Mandates: Mandates can for instance be given to practitioners to serve in rural areas as
a prerequisite to receive their licence, or for private hospitals where the government
require a certain number of beds. They only work effectively when there is enforcement
or providers compliance for incentives. (Harding and Perker 2003).

13
Human resource development: An effective way to improve quality and to influence
behaviour of private providers is to provide standardized medical training in areas of
health priority. Private providers may be motivated to attend when there is the
opportunity to increase their knowledge and technical skills (Brugha and Zwi 1998).
Other possibilities to stimulate providers to enhance quality and efficiency are to
provide management training such as business development, accounting, auditing;
training in health information systems or data management (Afifi et al. 2003).
Outreach mechanisms: There are a wide range of outreach mechanisms that
governments can use to influence providers and patients behaviour. Dissemination of
information such as behavioural change communication can be used to expand demand
and hence utilization of services by the target population and thus will also increase the
market share for providers. Raising awareness for service quality and patients rights can
put pressure on providers to increase their quality of care. Focused education campaigns
are also a useful tool to increase the demand for health goods and service, such as STD
treatment for sex workers. Community communication and education are efficient
instruments to expand the demand for e. g. vaccination programmes or to promote the
use of bed nets for malaria prevention (Harding and Perker 2003).
Self-regulation: A complementary strategy for both control and incentive-based
regulatory instruments is self-regulation. This allows groups of professionals to set
standards for its member behaviour (Afifi et al. 2003). The presence of representative
organisation with which the government can negotiate could facilitate the
implementation of strategies to improve service quality (Brugha and Zwi 1998).
Public Private Partnership: PPP can be considered as the overall strategy which
combines all above mentioned components. A sound partnership between public and
private sector can greatly contribute to the improvement of the health sector. In the
following the PPPH policy of Uganda will be highlighted.

3.2.4 Uganda National Policy on Public Private Partnership in Health

The Uganda government clearly recognised the growing importance of the private
health sector. In 1999 “strengthening the collaboration and partnership between the
public and the private sector in health” (Kampala 2003, b) became an important
guiding principle of the National Health Policy and a key element for enhancing the
health care delivery system in the Health Sector Strategy Pan (Kampala 2003, b). Its
objective is to achieve equity in the distribution of available resources and access to

14
essential health care. The partnership also aims to set up an enabling environment that
allows an effective coordination of all key players (public and private) in order to
increase efficiency in resource allocation (Kampala 2004).
The “General Framework for Partnership with the Private Health Sector” divides the
private health sector in three sub categories (Kampala 2003, b):
1. Private Not for Profit Providers (PNFP) are providers that are guided by concern for
the welfare of the population. These include agencies that provide health services from
established health units or facilities (Facility based PNFP) and those which not directly
operate through health facilities but which support or undertake health development
activities in partnership with central or local governments and others counterparts (Non
facility based PNFP).
2. Private for Profit Providers cover all cadres of health professionals in the clinical,
dental, diagnostic, medical, midwifery, nursing, pharmacy and public health categories
who provide private services outside the PFNP establishment.
3. Traditional and Complementary Medicine Practitioners. This category include all
types of traditional healers including herbalists, spiritual healers, traditional bone-
setters, traditional birth attendance, hydro therapists, traditional dentists and others.

Recently a National Policy on PPPH has been finalised to formalize, implement and
monitor the partnership with the PHS (Jinja 2005). The implementation guideline
indicates six main areas of cooperation:
1. Policy and planning: Participation of the private health sector in policy and planning
through presentation of the private sector in work groups, assisting in forming networks,
assessment of needs in order to improve private practitioners services, building capacity
on managing data and planning on national and district level.
2. Promotion of public health activities: Contract private health practitioners to offer
public health services and out reach activities under district supervision, increase
community access to health products and Information Education & Communication
(IEC), supporting community based private health care provider.
3. Human resource development: Cooperation of government, private umbrella
organisations and accredited medical training institutions in continuous medical training
and in-service training, assessment of training needs, involvement of the private health
sector in developing and implementing training curricula and materials, attachment of
trainees to accredited PHP on central and district level.

15
4. Improvement of the referral system: Ensuring functional communication, transport
and ambulance service to facilitate for delivery and emergency services, improve
hospital services in order to motivate private health practitioners to refer their patients,
availing standard referral forms and define referral guidelines.
5. Enhancing provision of quality services: Commit private health practitioners to the
official clinical and treatment guidelines published by MOH. Monitoring and support
supervision of services, enforcing strict measures on quality control and observance, set
standards through accreditation, sensitizing providers and the public towards their
responsibility and patient rights.
6. Regulation and control of service provision: Enhancing the capacity of health
councils and statutory committees enforce regulations and standards for private
facilities, establishing a data base of all registered private providers, establish a
graduated licensing system based on a set of minimum required quality standards.

In order to facilitate the process of PPPH the implementation guideline foresees

coordinating bodies on central and local level. A joint review commission, a health
policy advisory committee, working groups on PPPH and a PPPH desk at the MOH will
be established. Private health practitioner’s umbrella organisations will be closely
integrated. On local level the District Health Management Team will be assigned to
coordinate the activities. In addition all health district offices have to install a district
PPPH desk officer and a private health practitioners’ coordination committee (Jinja
2005).
The government of Uganda has developed a comprehensive implementation guideline
for PPPH which reflects the main strategic approaches of harnessing, growing and
conversion. However there are still future challenges: The spirit of partnership is not yet
well appreciated. The commitment to implement the elements of partnership and the
participation of the private sector is still weak, especially on district level. PPPH desk
officer are only implemented in half of the districts (Kampala 2004). The
implementation still remains a major future challenge. The OBA voucher scheme is
fully in line and with the new PPPH policy and covers the strategies components in
various ways. Therefore the voucher scheme might be one means to support this
process.

16
3.3 Sector policy for Sexually Transmitted Diseases (STDs) in Uganda
3.3.1 The role of the private sector in diagnose and treatment of STDs
The Uganda Demographic and Health Survey 2000-2001 (Kampala 2001) provides data
on health seeking behaviour disaggregated for sex, age, and education. It shows that
STDs are more common in women (17%) than in men (5%) and nationwide more
prevalent in urban than in rural areas. The majority (70%) of those seeking treatment go
to public or private health facilities, the rest does not seek any treatment at all.
The Uganda National Household survey 2002/2003 (Kampala 2003, f) gives more
information where people go for medical care (Table 1).

Table 1: Health seeking behaviour according to different providers

Provider rural pop. % urban pop. % total pop. %

Private facilities 34 52 36
Outpatient hospitals 9 11 9
Inpatient hospitals 2 3 2
Dispensary 7 2 6
Health centres 12 4 11
Drug shops 14 8 13
Pharmacies 0 4 1
Home treatment 12 10 11
None 7 6 7
Total pop. in % 86 14 100
Total population in mill. 21.5 3.5 25.0

Adapted from Kampala 2003, f

The table shows that private providers, including pharmacies and drug shops, are the
services most often sought by the rural (48%) and urban (64%) people seeking medical
care. Health centres, dispensaries and hospital in- and outpatient departments were
chosen by only 28% of the rural population and by 17% of the urban residents. This
indicates that private providers are an important source of medical care in Uganda.
In 2003 the government of Uganda changed its policy and abolished user fees for public
services. This led to a drop of attendance in private clinics but because the public health

17
facilities run out of drugs in the first half of the months clients turned back to private
providers (Griffith 2004).
A study on quality of care by private practioners for STD in Uganda has shown that
besides more convenient opening hours and better access to drugs, confidentiality and
costumer friendliness are important issues for patients preference to consult private
practitioners. The study demonstrated that private providers if appropriately trained are
very likely to provide quality treatment. It was found that those who received training in
STD Management were more likely to stock the necessary drugs and prescribe them
more properly than those without training. The study suggests that if the appropriate
training is given the involvement of private practitioners can greatly contribute to
improve the quality of STD treatment especially in rural areas (Walker et al. 2001).

3.3.2 Health sector policy on STDs in Uganda

Controlling STDs has been an integral part of AIDS control programme since 1986.
One of the main strategies to reduce the incidence of HIV was “STD Treatment” which
includes its “early recognition and treatment” (Kampala 2003, c). The National
Strategic framework for HIV/AIDS activities in Uganda 1998 – 2002 identified STDs
as one of the most important pre-disposing factors for HIV infection and recommended
strengthening of STD case management and promoted to use of the syndromic approach
as well as emphasising the need to increase the accessibility of services in rural areas for
specific target groups such as young adults. The main problems in the field of STDs
treatment and diagnosis were identified as shortage of STD drugs, self-medication and
high prevalence of asymptomatic cases (Griffith 2004).
In the Annual Health Sector Performance Report 2003 (Kampala 2003, a) the progress
of the STD/AIDS Control programme was reviewed. In order to achieve the objectives
of preventing further transmission of STD/HIV/AIDS epidemic, increased provision of
care and strengthening capacity for HIV/AIDS prevention on national, district and
community level, the following interventions were implemented:
 IEC/behaviour change communication to created awareness and knowledge of
the diseases and subsequently behaviour change;
 promotion, distribution and use of condoms through involvement of public
sector in contribution with social marketing groups and private distributors;
 strengthening STD management through improving skills of service providers
and ensuring the availability of necessary drugs;

18
  voluntary counselling and testing (VCT) to meet the demands for quality
services and ensure that they are accessible for the youth and other specific
target groups.
According to the report, significant achievements in these areas have been made in the
last decade (Kampala 2003, a). The prevalence of HIV among antenatal attendees has
declined from 18.5 (1995) to 6.2 in 2002. The Revised National Strategic Framework
for HIV/AIDS 2003/04-2005/06 (Kampala 2004, a) continues to emphasise the
importance of STD control and aims to reduce the HIV prevalence by 25% by the year
2005/2006. The Poverty Eradication Action Plan 2001-2003 pointed out that the
prevention and control of STDs is an important part in poverty reduction. (Kampala
2004, a).
The Annual Health Sector Performance Report 2003/2004 emphasised that, in order to
control communicable diseases including STD treatment, the strengthening of the health
care delivery system by enhancing the partnership with the private sector will play an
important role (Kampala 2003, a). This is supported by the National Policy on Public
Private Partnership which strongly recommends the need for partnership with private
for profit providers, NGO and faith-based groups (Kampala 2003, b).

3.4 Output based aid (OBA) – a new approach in health financing

3.4.1 Input versus output based approaches
Traditional approaches of health financing base on financing inputs such as the
construction of a hospital, equipment of the facility with beds and biomedical
technology, training of personal or allocation of resources for entire health programmes
by governmental programmes or NGOs. The main argument for the provision of public
health resources is that private markets fail to provide sufficient supply and can not
ensure universal access, especially for the poor population (KFW 2004). However
experience shows that the public provision of services is often inefficient and often does
not succeed reaching the poor (World Bank 2004).
Whereas input oriented approaches ask how results were produced, OBA focuses on the
financial support of performance. The approach explicitly appreciates the growing
importance of the private sector in the national public health system. The basic idea of
OBA in health is to delegate specific services to certified private or public providers
under contracts that link payments or donation on certain outputs and results for a
specific target group. The state is responsible for establishing adequate legal and

19
regulatory frameworks in order to control the delivered service quality and the
performance based reimbursement system (Brook & Smith 2001). The concept focuses
on improvements in three intervention levels (KFW 2004):
 Improving the access to social services for the poor through provision of
subsidized delivery services by public or private providers.
 Strengthening the efficiency of allocated public resources by providing
incentives for good performance.
 Ensuring provision of adequate services through establishing quality standards
and performance monitoring.

Figure 2: Input versus output based approaches

Source: Brook & Petrie 2001, 6

3.4.2 Output based voucher schemes

Typical OBA concepts are voucher schemes. Voucher schemes belong to demand side
financing mechanisms. Vouchers can be defined as “a token that can be used in
exchange for a restricted range of goods or services, either partially (e.g. as a discount)
or in total” (Sandifort et al. 2003, 19).
Voucher schemes are instruments to subsidize health delivery. They can be used to
entitle a certain target group to access a defined package of services. The service
provider will then be reimbursed for delivering the desired output (IHSD 2004).

20
Voucher schemes aims to target available resources on low income or other vulnerable
people. In doing so, they increase the benefits of public subsidy to poorer households
and improve equity. Vouchers can influence the behaviour of the recipients; encourage
the consumption of specific goods and services which have a benefit on health. In
addition, they provide an incentive to health service providers to offer value for money,
higher service quality and improve their accountability, by increasing competition
among providers and consumer choice (IHSD, 2004).

Voucher schemes appear in different forms. They can be divided in two main
categories: incentive based and competitive voucher schemes.
Incentive based voucher schemes: In this kind of voucher scheme the beneficiary
directly receive a subsidy to encourage behaviour or to reduce costs of priority services.
Examples include direct cash payments to offset some additional household costs, such
as clothing, transport or children education, or direct subsidies to seek treatment in
specific health services (Ensor 2004). Incentive based voucher schemes often appear as
non-competitive because of the supply monopole (Gorter et al. 2003).
Competitive voucher schemes: In competitive voucher schemes the provider only
receives the payment after the beneficiaries have used the service. They introduce some
sort of competition among providers because the voucher bearer has the purchasing
power and the choice of selecting the appropriate service deliverer. These types of
voucher scheme link the subsidies with the patient flow, thus producing incentives for
the providers to increase their quality of health care (Sandifort et al. 2003).

3.4.3 The functioning of OBA voucher schemes

A typical OBA voucher scheme can be described as follows: The process begins with
the transfer of public subsidies to the voucher or management agency (MA). The MA is
responsible for producing the voucher, for the marketing and distribution to the target
population. To ensure a sufficient coverage of the distribution net, voucher agencies
often operate with retailers such as pharmacies or partner NGOs (Griffith 2004). The
beneficiaries purchase the voucher at the retailers point for a usually highly subsidized
price which entitles them for at standardised quality treatment at certain approved health
care providers. The recipients take the voucher to one of the accredited health care
providers of their choice and exchange it for the service. After treating the patient, the
provider returns the voucher to the MA, along with any other information that might be

21
required. After checking the claims, the MA then reimburse the provider according to a
fee, which has been agreed in advance. The voucher scheme is accompanied by a close
monitoring and evaluation system to ensure the service quality and to protect against
abuse. The voucher agency reports the outputs and outcomes back to the government or
the donor providing the funds (Sandifort et al. 2003). The voucher agency is responsible
for managing the whole system. If need be they can also outsource some functions. The
money flow in an OBA voucher scheme is schematically demonstrated in Figure 3.

Figure 3: Money flow in an OBA voucher scheme

Funding Agency

Funds

Voucher Agency
Voucher

Payment Voucher

Health Care Target user

Provider

adapted from IHSD 2004

3.4.4 Impact of OBA voucher schemes

OBA voucher schemes have many effects which have the potential to improve quality
of health in specific areas.
Impact on targeting vulnerable groups: Through vouchers it is possible to focus
public funding on most vulnerable groups. They can increase equity in access to health
services for disadvantaged groups because they make access to health services more
affordable. This can positively influence their health seeking behaviour and utilization
of services (Gorter et al. 2003).
Impact on cost-effectiveness and productivity: Targeting on the vulnerable can also
improve allocation efficiency of public funds to the extent that many health problems
are concentrated in this group. Governments don’t pay for assumed output but reward
performance. Payment for low performing providers will be lower than for well
performing clinics. This means that funds are automatically channelled to those who
perform best. The way of rewarding outputs provide stronger incentives for innovations
and gives certain autonomy to service providers. In order to increase the utilization of

22
services and therefore their revenues, providers may extend their opening hours, their
services; they may start outreach programmes or patient information and education
campaigns. Such innovations could reduce the level of governmental support, scale up
productivity of services and improve cost-effectiveness of service delivery (Yamamoto
2004). Monitoring and evaluation of the voucher scheme is relatively straight forward
because it is based on measurable outcomes (Gorter et al. 2003).
Impact on quality of care: Vouchers can provide instruments for quality control and
assurance. By contracting only the qualified providers which are eligible to receive
public funds, the government has an effective mechanism to regulate and control
medical practices. An OBA voucher scheme foresees that those providers have to go
through an accreditation process. Accreditation set benchmarks for quality standards,
and assess whether the providers meets the requirements. Payments are restricted only
for those interventions that are known to be evidence based. Ongoing monitoring and
evaluation allows controlling delivered quality of health care (Gorter et al. 2003).
Impact on patient satisfaction: OBA voucher scheme promote competition among
service providers and strengthen patients choice. Patients will automatically seek
treatment by those providers who have a good reputation and perform well (Campbell
2004). This will encourage providers to provide qualitative, comfortable and convenient
care to their patients.
Impact on public private Partnership: The difficulty for policy makers is to find
practical ways to introduce PPP. OBA voucher schemes offer such mechanism because
they clearly aim at using the potential of the private sector and integrating them in the
health care system.
Impact on sustainability: Voucher schemes which may involve co payments have
potential for move towards sustainability. When societies get richer, the willingness and
ability to pay for health services increase. Voucher schemes with small co payments
could be used as a first small step to national or private health insurance schemes
(Campbell et al. 2004).

3.4.5 Limitations of OBA voucher scheme

While arguing that OBA voucher schemes present many positive opportunities they
certainly also have their limitations:
Subsidize existing users: When vouchers are made available by contracted retailers
focusing the most vulnerable becomes difficult. When everybody can purchase

23
vouchers this might subsidize those who already have access to health services (Gorter
et al. 2003).
Stigmatization: Experiences with voucher for STD treatment in Nicaragua showed that
having a voucher might be associated with stigma and therefore might discourage
beneficiaries from keeping and using the voucher (Sandifort et al. 2002).
Potential for abuse: As many other health interventions voucher schemes has a
potential for fraud. Voucher arrangement could be corrupted in several ways. E. g. a
provider could invent fictitious patients, or claim for procedures that had never been
done. Other potentials for misuse are: Corrupt alliances between patient and provider,
black market sales of vouchers, over serving (provider moral hazard), adverse selection
etc. (Sandifort et al 2003).
Limited application: OBA is likely to work best for repetitive procedures such as
family planning, voluntary counselling, STD diagnose and treatment, testing or direct
observation therapy short-term (DOTS). More complicated and individualised
procedures like antenatal care or obstetric delivery would be more difficult to reimburse
and control (Campbell et al. 2004).
Resistance of policy makers: OBA is a new concept in the field of health and it is a
different way of thinking. Still input oriented approaches dominate in the development
field. Governments, donors, and recipients are more familiar with these and might be
resistant to change because of different short-term interests (Campell et al. 2004). To be
successful OBA needs a strong commitment of all development partners.

3.4.6 Experiences with voucher schemes in health

One of the earliest suggestions for the use of voucher schemes was put forward by M.
Friedman in 1962. Friedman introduces voucher schemes as an instrument of funding
education (Gorter et al. 2003). The aim is to empower households to choose the school
(public or private) which suits best to the preferences of the parents and their children
and to improve the access of low-income families to private school. In the USA a large
number of voucher schemes have been initiated (Ensor, 2004). The experiences in many
US cities have indeed demonstrated that vouchers have a positive impact on service
quality and better access for the poor to education (Gorter et al, 2003). Outside the USA
similar experiences have been made in Chile and Argentina (McEwan, 2000).
OBA approaches in health were first introduced in the Taiwan in the 1960s (Gorter et al.
2003). Vouchers were distributed on large scale for family planning services. OBA

24
made a significant contribution to the cost-effectiveness and the success of the program
(Campbell et al., 2004). Nowadays demand-side financing have been used in a number
of contexts in low and middle income countries with good evidence of impact.
In Tanzania a discount coupon for insecticide treated bed-nets (ITNs) was launched
aimed at poor, pregnant women. A recent evaluation of this program has shown that the
scheme had sold 65.000 bed nets in 4 years (Ensor, 2004). A similar approach was
followed in Uganda: In 2004 the government of Uganda assisted by the Global Fund for
AIDS, Tuberculosis and Malaria, had introduced a pilot to implement a voucher scheme
to subsidize ITNs for pregnant women and children under five. The pilot was set up for
three months in two districts, Mbale and Mbarara. Despite of the positive impact that
malaria incidence among the target group dropped the pilot had never been followed up
properly (Kampala 2004, b).
In a slum area of Nairobi, Kenya the centre of disease control has supported a local
NGO that is implementing a successful voluntary voucher scheme for voluntary HIV
counselling and testing service (Campbell et al. 2004).
Possibly the largest scale voucher scheme in health outside the USA is the PROGRESA
project in Mexico. In the 1990s PROGRESA, the government’s education, health and
nutrition program introduced a set of conditional cash transfer to encourage the use of
health and education services by poor families. More than 80% of transfer reached the
target group. A significant impact on school enrolment has been found accompanied by
a decreasing number of child labour. There was an increased use of health services and
improvements in the height and weight of young children. Illnesses dropped by 20% in
children under five (World Bank, 2004). The successful program has been replicated in
a number of other countries including Honduras, Nicaragua and Colombia (Ensor,
2004).
Since 1995 Nicaragua has used voucher scheme for STI treatment for female sex
workers and their partners. The target group have received subsidized vouchers entitling
them to a specified set of diagnose and counselling service from their choice in pre-
identified health facilities, in both private for profit and non profit organisations
(Sandifort et al. 2002). The programme has been well monitored and evaluated.
Although evidence is still weakened by lack of control of confounding of any
confounding factors (IHSD 2004). However the experiences have shown that the
voucher scheme has improved the quality and access of STD services (in a non-
stigmatizing way) and efficiently reached the target group (Sandifort et al. 2002). There

25
has been a high take up and use of the coupons accompanied by a remarkable decline of
syphilis (9%) and gonorrhoea (5%) per year amongst poor sex workers. The creation of
competition amongst the health care providers has shown a positive impact on quality of
care, technical efficiency and client-friendliness (IHSD 2004).
Even though there is still limited evaluated experience with voucher schemes in health
the few examples show that OBA approaches can provide incentives to health care
providers to improve their quality and thus improving the health of the poor. In future
more evidence can be expected from the upcoming programmes in Uganda and Kenya.
Based on the Nicaragua experience in Uganda a pilot for an OBA voucher scheme for
STD treatment is going to be launched. To date the programme is in the implantation
phase. Parallel to Uganda, Kenya is going to introduce a similar pilot programme
aiming on reproductive health, safe delivery and family planning (Griffith et al. 2004).

3.4.7 Considerations for the design of an OBA voucher scheme

OBA voucher schemes are indeed a simple concept with great potential to improve the
quality service delivery and the access for the poor. However operationalizing the
approach and realizing its benefits require a careful designing. Like any other health
concepts it needs to be adapted to local needs and circumstances. OBA involves
tradeoffs between different objectives such as establishing “perfect” output indicators,
close monitoring, targeting the beneficiaries and minimizing administrative costs
(Yamamoto 2004). A checklist how to design an OBA concept in general is provided by
Smith (2001). Sandifort et al. (2003) gives a more practical guideline for designing
voucher schemes in particular. The authors suggest following key process issues:

1. Deciding on recipient policy: This is the decision on who the target group is and who
is entitled for a voucher.
2. Deciding on the benefit policy: The benefit policy has to define for what health
services or package of service the voucher entitles its bearer. This involves the clear
definition what is included and what is excluded in the voucher and what is the period
of validity.
3. The structure of the voucher scheme: A decision needs to be taken how the overall
structure of the voucher scheme should be.

26
4. The management of the voucher scheme: Policymakers have to define who should
be entrusted with the management of the scheme (private company, non-profit
organisation or a public agency) and which tasks need to be covered.
5. Deciding on the price policies and the design: Policy makers have to decide on the
price of the voucher. Should it be fully subsidized or should it include co-payments?
The design for the voucher needs to be attractive but also culturally and socially
accepted.
6. Deciding of the provider policy: This involves the decision which providers are
eligible to provide the service covered by the voucher and under what condition.
7. Deciding on the reimbursement policy: The form and structure of the payment
system is crucial in determining the incentives the providers face. The reimbursement
system should be transparent, convenient and reliable for the service deliverer.
8. Communication system: Communications between the voucher agency, the
distributors and the providers needs to be established and maintained.
9. Marketing and Distribution of voucher: The marketing and distribution strategy
depends on the specific recipients and the local circumstances. It has to be decided
which marketing strategy will be chosen and what channels of communication will be
used.
10. Information system: Like any other health information system voucher schemes
need information for decision making and determining actions.
11. Monitoring& Evaluation and quality control: One of the beauties of voucher
scheme is that monitoring and evaluation can be relatively easy performed. This is
because vouchers themselves define individual units and outcomes which can be traced
and measured. Monitoring is an ongoing process of observation whereas evaluation is
carried out periodically and involves judgements. Voucher schemes need instruments to
monitor for costs, service quality, to detect abuse etc. Evaluation more focus on health
outcomes, impact an equity and poverty reduction and cost-effectiveness.

On the basis of the presented guideline the actual design of the OBA voucher scheme
for STD treatment in Mbarara district will be explained in the following chapter.

27
3.5 Design of the OBA voucher scheme for STD treatment in
Mbarara District, Uganda
The Government of Uganda and Government of the Federal Republic of Germany
through KFW and has set up a three phase HIV/AIDS – Prevention Program. The
program aims on improving the knowledge of the population of Uganda about
prevention of HIV/AIDS and other STDs and at increasing the acceptance and
utilization of condoms by sexual active population. For the third phase of the program
the governments have agreed to implement a pilot programme for a new OBA voucher
scheme for diagnosis and treatment of STDs (Griffith, 2004). In order to gain
experience and more evidence of potential impacts of voucher schemes a pilot area was
chosen, which is: Mbarara District. The pilot period is agreed for one year with possible
extension for further 3 years. KFW provides an overall budget of 1 Million Euro for the
first phase (Griffith 2004).

The general objectives of the program are (Griffith, 2004):

 the conceptualization of a more effective and efficient service delivery system
for STI diagnoses and treatment, including Voluntary consulting and testing for
HIV Status, based on financing of outputs rather than inputs; and
 to create an environment involving both public and private sector in service
delivery.

The design of the voucher scheme:

1. The recipient policy
Target groups for STDs are the poor (especially in rural areas), young male and female
adults and high risks groups such as commercial sex workers, truck drivers and migrant
workers. A survey on the target population using focus group discussions has shown
that the vouchers for STD treatment are generally accepted by the potential beneficiaries
and that they are willing to pay for it (Steadman Research Service 2005). Because of the
difficulty to identify the individuals making up these groups, it was decided that the
target group should include all clients with STD in Mbarara District (Griffith 2004).

2. The benefit policy

The definition of a STDs is based on the Uganda Clinical Guideline 2003 (Kampala
2003, d), and on the treatment algorithms as well as the WHO guideline on management

28
of STIs (Kampala 2003, e). The interventions covered by the voucher will provide
subsidized diagnose and treatment regimes of disease and syndromes mentioned in the
guidelines. Excluded from the subsidies are certain conditions, most importantly
HIV/AIDS, which are categorised as STIs. The intervention aim at contributing to the
control of STDs by prevention and treating the disease before it is transmitted to the
partner (Griffith 2004).

3. The structure of the voucher scheme

The overall design of the voucher system is summarized as follows (see Annex 2 for
schematic view): A MA will contract a range of accredited providers in both rural and
urban areas to provide STD services. Vouchers will be marketed and distributed to
clients, which entitle them to receive free treatment from the accredited health services.
The health care providers will be trained in an effective treatment for STDs. At the end
of each month, the providers will send claim forms which prove the treatment to the
MA. After checking the claims the MA will reimburse the providers according to a
price agreed on in advance. The scheme will be accompanied by a comprehensive
monitoring and evaluation system (Griffith 2004).

4. The management of the voucher scheme

Responsible for the overall management of the voucher scheme is the MA. The MA is
an independent body and will carry out the primary responsibility for the OBA
programme. Core activities of the MA are: managing the overall programme in
coordination with the government and KFW, managing the fund, contracting the
providers, develop and implement the marketing and distribution strategy, manage and
maintain the claims & payment, manage the system to control fraud, develop and
management an effective approval system, monitoring and evaluation of the whole
process and preparation for expansion (Hacheney 2005). For the pilot phase MSIU is
assigned as MA. The overall co-ordination of the programme will be the responsibility
the MOH of Uganda. To guarantee an efficient implementation of the voucher scheme a
steering consisting of representatives of the donor KFW, MOH and the MA. It has been
recognised that core competences of the MA are in the field of managing, marketing
and distribution and in coordination the stakeholders. The MA has little experience in
medical and technical approval and claims and payment mechanisms. These activities
might be out sourced to third parties. In order to streamline the process it has been

29
decided that the MA will establish a field office in Mbarara town which will be
supported and supervised by the head office in Kampala (Griffith and MSIU-Team
2005). The management structure of the MA is summarized in Annex 3.

5. The design and the pricing of the voucher

The voucher design has an important influence on whether the beneficiaries use it or
not. The design has to address especially young single adults and couples (Hacheney
2005, a). For practical reasons a plastic card in form of a prepaid telephone card seems
to be suitable. To ensure the affordability the vouchers are highly subsidized. Even
though the Steadman Report found out, that potential recipients would be willing to pay
up to 5,000 USH (Steadman Research Service 2005), they will be sold for a fixed price
of 1,000 USH, including a partner voucher. A problem associated with vouchers is the
potential for abuse. An efficient instrument to control fraud is to provide the voucher
with a serial number which makes it possible to follow up where the coupon was bought
and where and how it was used (Sandifort et al. 2003). Database on user, distributor and
provider will allow discovering suspicious behaviour and detect “red flags” (Griffith
and MSIU Team 2005).

6. The provider policy

In principle all PFPP, PNFP and conditional public providers offering allopathic
treatment could be potential partners of the scheme. The fact that the Ugandan
Government has abolished user fees on health services makes it difficult for public
facilities to be integrated in the scheme (Griffith 2004). In order to gain a sufficient
coverage of services providers should be chosen in urban and rural areas of the district.
The selection criteria for eligible provider base on the following: approved registration
with MOH, personal qualification, inventory and equipment requirements, presence and
availability of essential drugs, requirements, laboratory requirements, geographical
coverage and utilization of services. A provider survey, conducted by a local
subcontracted consultant identified around 30 providers in urban and rural areas in
Mbarara district who meet the criteria (Kiwanuka-Mukiibi 2005).
Those providers who are interested to join the scheme have to go through an approval
process. The procedure has been developed during a workshop in Kampala in May 2005
(IGES 2005) and is documented in the programme report (Griffith and MSIU Team
2005). The approval will be initially and then regularly to demonstrate that providers

30
remain to meeting the requirements. It is important that the selection criteria are as
transparent as possible and that the process is acceptable to the providers (Sandifort
2003). Those providers who are selected and approved will be contracted by the MA
and will become “Voucher Service Provider”. The contract will specify all the services
charges for the activities and procedures including the monitoring and evaluation
mechanism (Griffith and MSIU Team 2005).

7. Services charges and claims & processing

The level of reimbursement depends on the legal contract guiding the providers and the
MA. To be attractive for the provider the price should be equivalent to the usual service
fee. Still some questions regarding the payment are open: Should the payment be based
on a fixed fee or should it directly linked to specific performance indicators? Should
there be a single agreement for each provider or should it be a unique one for all
participants?
The basis for the payment is the claims form. It proves the services the providers
delivered and is the basis for monitoring and evaluation of the whole system. The form
will contain information about: the service provider, client data, diagnoses, treatment
report etc. However a balance has to be found between the completeness of the form
and the time needed to complete it. Detailed forms which require lots of information
will not be appreciated by the providers because it will reduce their time for their
clients.
When the service is delivered then the provider will send the claims to the voucher
agency. The MA will check the forms for correctness and completeness. Once
everything is approved the MA will withdraw the debt amount to the providers account
(Griffith and MSIU Team 2005). The claims and processing system is crucial. The
system needs to be transparent, reliable and quick in order not to demoralise the
participating providers (Sandifort et al. 2003).

8. The communication system

In order to facilitate the communication between with clients, distributors, providers,
local authorities and other stakeholders a local voucher office in Mbarara Town will be
established. Claims can be quickly checked, marketing and distribution can be easily
coordinated. Feedback mechanism for the programme partners will be set up. Regular
visits to and meetings with the provider will run through out the year.

31
9. Marketing and distribution
A. Marketing strategy: The specific objectives of the marketing are: to create an
awareness for the voucher in the pilot area, to establish a popular brand, to create an
awareness of the need of treating and preventing STDs, to build and strengthen
relationship with stakeholders and to contribute to the reduction of STD infection rates
through treatment and education (Hacheney 2005a). The strategy covers the following
areas:
Advertising: The advertising strategy aims at STD de-stigmatisation and encouraging
treatment seeking behaviour. As proposed in the survey on the target population the
messages will be transported through local radio stations (Steadman Research Service
2005); posters in every outlet, shops, markets; videos; advertisement on vans and
motorbikes; and out door advertising (bill boards).
Promotion: Voucher will be promoted through special marketing events such as music
shows, theatre, organise drives through town, and raffles and prize winning games.
Information, Education, Communication (IEC): Important for the success of IEC
strategy is a strong involvement of community local NGOs and local leaders. The IEC
strategy basically consists of: talk shows in local radio stations; distribution of
brochures at hospitals, health centres, markets, video halls, local council meetings;
organising seminars, workshops, movie shows and trading centre sensitization meetings
(Hacheney 2005, a).
B. Distribution strategy: The objective is to create a widespread distribution network
to ensure accessibility of the vouchers in urban and rural areas. The most promising
distribution channels are: local NGOs, local communities, pharmacies, drug shops,
sports and football clubs and big companies. It seems to be appropriate to run a mixed
strategy of face-to-face (direct approach that takes the voucher to the potential clients in
their home, place of work etc) and fixed point selling. Distributors will be contracted by
the MA and they will receive a sales commission (Hacheney 2005, a).

10. Quality assurance and monitoring & evaluation

A. Manuals and training: The MA staff, the providers and the distributors will be
provided with training and manuals (standard operating procedures) to ensure a good
service quality and to make sure that the voucher scheme works efficiently and
effectively as possible. Medical training in STD management will be provided to the
service deliverers (doctors, clinical officers and nurses). Special training for STD

32
diagnose will be given to laboratory staff. Providers will be also taught on the claiming
process. Distributors have to understand the overall system and will receive special
sales training.
B. Monitoring and evaluation: The implementation and the management of the
voucher scheme needs to closely monitored and evaluated in order to ensure a smooth
process and to ensure the objectives are reached. The monitoring and evaluation system
will cover the following areas: marketing, behavioural change communication and sales
and distribution; numbers of voucher sold and used; quality of clinical services being
offered; patient satisfaction; claims and processing and overall management of the
scheme (Griffith and MSIU Team 2005). With an OBA approach the best way to access
quality would be to put the clients at the centre of the system to get their experiences,
assess their diagnoses and treatment and to see whether they are treated or not.
Following methods to get client feedback are discussed: focus group discussion;
mystery or simulated clients (people pretending that they have the disease, but have the
specific objective to observe the care the received). Due to the need of confidentiality in
STD treatment the follow up of clients is difficult. Therefore exit interviews
(interviewing the patients after they have received treatment – directly and a few days
later) are not seen as an appropriate method (Griffith 2004). An important component
will be the monitoring of the claims and processing as already discussed. In order not to
discourage providers it has to be taken into consideration that some participants may
perceive the monitoring and evaluation process as too intrusive and involve too much
administrative workload. Therefore the system needs to be transparent and relatively
easy to handle (Griffith and MSIU Team).

33
4. Methodology
4.1 Setting
The field visit took place from May to June 2005 in the capital of Uganda, Kampala and
in Mbarara Town from Mbarara District, south western Uganda. Mbarara district
consists of 10 Health Sub Districts and has a total population of 1.2 million. The main
target group of the study where PFPP and PNFP in Mbarara District, both in urban and
rural areas, which are likely to join the OBA voucher scheme for STD treatment.

4.2. Study design

The choice of a research method should always be based on an analysis of the problem
and the type of information searched for (Goergen and Tautz 2004). This study is a
cross sectional descriptive study using exclusively qualitative methods in order to
identify the main incentives and disincentives that health care providers in Mbarara
District perceive with joining the voucher system. Qualitative methods are characterised
by an open end procedure of naturalistic enquiry (Bowling 2002). In health these
methods are often used to build up an understanding of patient’s or health care
provider’s experiences and opinions on certain phenomena or programmes (Øvretveit
2002).

4.3 Sampling
The selection of the study area derived from the decision that the german donor agency
KFW and the Government of Uganda has agreed to run a pilot for the OBA voucher
scheme for STD treatment in Mbarara District.
Lists of registered PFPP and PNFP health care providers were provided by the District
Health Services Office (DHSO) Mbarara. The lists where reviewed by the researcher
and by a KFW contracted local consultant. The local consultant identified 28
appropriate providers who are likely to meet the requirements of the voucher scheme
(Kiwanuka-Mukiibi 2005). Out of them the researcher selected purposeful 22 providers
according to the criteria urban/rural and type of organisations (PFPP, PNFP plus one
public health centre) and information richness. In addition 11 key informants were
selected based on their expected experience and knowledge on the topic.

34
4.4 Data Collection Methods
Triangulation of methods was used in order to increase the reliability and validity of
data. Triangulation describes the process of combining different methodologies in the
study of the same phenomena or programme (Patton 1990). Triangulation allows to
partially overcoming the deficiencies that derive from one investigator or one method
(Bowling 2002). Data where collected, using document analyses, semi-structured
individual interviews and informal conversational and semi-structured key informant
interviews. In addition, the researcher attended a workshop on the OBA voucher scheme
organised by MSIU at the beginning of May 2005 in Kampala. In the workshop
important issues of the implementation of the MA were discussed (IGES 2005).

4.4.1 Semi-structured individual interviews

Semi-structured interview or guideline interviews base on a set of questions and topics
that need to be covered in a certain order (Bernhard 2002). Every interviewee will be
asked a similar set of queries. However they are conducted in a sufficient informal way
that allows the respondent to introduce subjects, which are not anticipated by the
researcher. Semi-structured interviews have an intermediate position between structured
questionnaire and unstructured interviews. They are very useful for rapid appraisal and
easier to analyse. Due to their pre-formulated structure their strengths lies in the
comparability of the data, whereas the preparation of question sets before hand may lead
to questions which are not of importance for the interviewees’ reality (Goergen and
Tautz 2004). However the flexibility in design of qualitative studies allows a permanent
update of the interview guideline.

Semi-structured interviews using a detailed interview guideline were conducted with 12

providers located in urban, 2 in peri urban and 8 in rural areas of Mbarara District. In
order to cover a wide geographical area at least one provider for each health sub district
was chosen. Most of the respondents in the urban areas (11) were located in Mbarara
Municipality.
Among them 15 are classified as PFPP and 6 as PNFP. In addition one public Health
Centre III was selected, which was located in a very remote area, where no private
health facility is available. The selection of different kind of organisation allowed
comparison between them.

35
Among the PFPP there were one hospital, 11 clinics and 3 nursing homes. The PNFP
consists of 2 FBO hospitals, 2 NGOs is the field of AIDS and STD prevention and 2
NGOs working in the area of family planning. The vast majority of interviews were
conducted with owners, and decision makers like administrators and clinical officers, 2
were conducted with nurses or nurse assistants (a description on interviewed providers
is given in annex 8).
The interviews aimed at identifying the provider’s general opinion on the voucher
scheme, the challenges they associate with it, their incentives or disincentives they
perceive by becoming partner of the programme and their expectation towards the MA
and their view of PPPH.

4.4.2 Key informant interviews

Key informants are people who are particularly knowledgeable and articulate about a
certain topic and often have a special position in a community or organisation. Their
insight views can be very useful in helping the researcher to understand the situation
and get information on sub-groups where the researchers do not have access (Patton
1990). They often look at problems from a group perspective rather than of an
individual, which makes them a very useful group to interview (Georgen and Tautz
2004). Especially informal interviewing of key informants can be a method of choice at
the beginning of the research. This method it characterized by a total absence of
structure and can be useful in the phase of settling in with the research subject (Bernard
2002).
Key informant interviews are a major tool for rapid appraisal because they can provide
the researcher with valuable and independent information about the community, an
organisation structure or policies (Goergen and Tautz 2004). However their often
superior position can also be a source of bias. They might not present the views of more
vulnerable groups or might just describe political correct opinions that do not reflect the
reality. Therefore it is important that information obtained from key informants be
clearly specified as such in the field notes (Patton 1990).

In order to get more in-depth information about the OBA voucher scheme and about the
role of the private sector in the Uganda health system the researcher conducted 11 key
informant interviews. Informal conversational and semi-structured guideline interviews
were used, thus increasing flexibility in respect to particular individuals and

36
circumstances. The key informants were selected based on the expected experience and
knowledge of the topic.
Key informant interviews were conducted with i) the KFW contracted freelancing
consultant, ii) a KFW official, iii) a subcontracted local consultant, iv) the former
Programme Director of Marie Stopes Uganda (MSU), v) the recent Programme
Directors of MSU, vi) the Programme Director of MSIU, vii) the District Director of
Health Services (DDHS), Mbarara District, viii) the District Vector Control Officer,
Mbarara District, ix), the Zone Director for Malaria & IMCI (Integrated Mother and
Child Illnesses), University of Mbarara/MOH, x) the Programme Manager STD/AIDS
Control Programme, MOH, xi) two STD Clinicians of Mulago Governmental Hospital,
Kampala (annex 9).
The Key informants where asked about their general opinion on the voucher schemes,
their expectation with regard to incidence and prevalence of STD in Mbarara district,
main challenges in implementing the voucher scheme, potential incentives and
disincentives of health care providers joining the scheme and the role of the private
sector in the Uganda health system.

4.5 Data Collection process

For the health care providers detailed semi structured interview guidelines were used
(annex 4). The interview guideline for the providers had been pre tested with the
Programme Director of MSU. All interviews were undertaken by the researcher alone.
Given the fact that English is a common language in Uganda a translator was not
needed. Due to the fact that the voucher scheme is still in the design phase most
providers were not informed about the scheme and had to be introduced to the
programme by the researcher. Where needed, further explanations on the scheme were
given during the interview.
Informal conversational and semi structured key informant interviews were conducted
by the author. For the semi structured interviews a detailed interview guideline was
used (annex 5).
For both providers and key informants three basic types of qualitative interview
questions were applied (Bowling 2002). Main questions on headline topics at the
beginning guided the conversation, probes to clarify the answers and to request further
information and follow up questions which pursue the implications of replies to the
main questions were posed in order to get more indepth information. Both interview

37
guidelines were continuously updated to include some emerging issues not previously
considered.
To avoid resistance of respondents, especially from provider side, a tape recorder was
not in use. Therefore all interviews were recorded by the researcher by making hand
written field notes. In order to avoid recall bias by the interviewer all interviews were
typed in the computer at the same day.

4.6 Data analysis

The analytical process began during the data collection phase. The already collected
data were utilized to modify the subsequent data collection through formulation of new
guideline questions, checking of previous responses and selection of new key
informants (Øvretveit 2002). After completion of data collection, all available data were
analysed using cross-case analysis method Patton 1990). Cross-case analysis group
together answers from different respondents to common questions or analyse different
perspectives on central issues (Patton 1990).
The respondents were classified in three groups: 1) Key informants, 2) PFPP and 3)
PNFP plus one public health facility. The providers were divided in the two groups, in
order to allow comparison between the different kinds of organisation. PNFP and public
health facilities were grouped together because of their similar way of finance. Whereas
PFPP are exclusively financed by user fees, PNFP and public facilities are mainly
funded by the government, their umbrella organisation or donors. Following the
interview guideline approach (Patton 1990) answers of the respondents from these three
groups were assigned to the guiding questions of the corresponding interview guidelines
using easy copy and paste technique. This process allowed constituting three different
descriptive analytical frameworks for analysis. Within the analytical frameworks the
data were re-arranged according to major categories and sub-categories like strengths
and weaknesses of the voucher scheme, financial and non financial incentives for the
providers, capacity building, marketing, expectation on MA, role of private sector etc.

4.7 Limitations
1. General limitations of qualitative interviewing
Important concepts and principles for data gathering methods are reliability and validity.
A research is considered as reliable when it will give the same results when repeated in

38
the same way. Validity describes the extent to which a measure or data set reflects what
it is supposed to measure or provide information about.
Qualitative interviewing can sometimes be unreliable when different interviewers are
likely to draw out or collect divergent data (Øvretveit 2002). The validity of a study is
highly dependent on the skills of the researcher (Daly et al. 1997). The interviewer has
to enable the respondent to reflect on and develop his or her own ideas, without
introducing interviewer’s biases. Issues of invalidity can also appear, when the
interviewee may not recall properly or may have a selective view on the topic. The
participant may also be more concerned with projecting a certain image, rather than
presenting the truth ((Øvretveit 2002).

2. Limitations of the study

Sampling: Due to logistical reasons and time constraints it was not possible to cover all
identified health care providers. Therefore the providers of Mbarara Municipality might
be slightly over represented in the study.
Awareness of the topic: As already stated, most interviewed providers were not
introduced to the OBA voucher scheme for STD treatment. The researcher had to brief
them by himself. This might have caused biases because the answers might very much
dependent on the explanation given by the interviewer.
Researcher: The validity of applied qualitative interview techniques is highly
dependent on the skills of the researcher (Daly et al. 1997). The interviewer did not
have extensive experience in conducting qualitative study in the study area. Therefore
he might not always being able to enable the interviewee to reflect on the topic and on
his own ideas, without introducing his own perceptions.
Availability of respondents: In few cases owners or decision makers of the health
facilities were not available. Therefore the interview was conducted with subordinate
staff. Some questions could not be answered by them.
Time constraints: Interviews with providers were conducted during their business
hours. In few cases there was limited time to go through the whole interview guide. The
interviewer had to concentrate on main issues to meet the study objectives. Therefore
some information might be missed out. One interview had to be broken off.
Recording: Some information may have lost since only hand written notes very used.

39
4.8 Ethical Considerations
1. Informed consent
Informed oral consent was sought from all participants. All potential participants were
first informed about the purpose of the study and if necessary introduced to the OBA
voucher scheme for STD treatment. All respondents were told that participation is
voluntary and that they have the right to terminate the interview at any point they want.
Only those who agreed where interviewed (annex 6).

2. Confidentiality
The questionnaire did not include any identification items that would have allowed any
conclusion regarding the information source. In the reporting of the results key
informants where identified only by organisation and position not by name. The final
report is anonym and does not include any personal information about the participants.

3. Distribution of Benefits
The findings of the study were reported in a joint meeting with the local partner
institution MSIU, the KFW contracted consultant and the local consultant.
Recommendation for an appropriate incentive system in order to mobilize competent
service providers to join the OBA voucher scheme had been provided. In addition the
researcher was involved in working meetings on the implementation of the voucher
scheme and the design of the MA. Health care providers will benefit in the way that
their views will be recognized in the design of the voucher scheme which may increase
the attractiveness for them to participate in the scheme. The results of the research have
been send to the DHSO of Mbarara and will be distributed among the providers of the
district.

4. Data protection
All obtained data were carried back to Heidelberg, Germany. All hand written and
computer entered notes are protected so that no access from other persons than the
researcher is possible and they will not be used for other purposes than the field study.

5. Other Consideration
The study proposal was first reviewed and approved by an internal ethical committee at
the Institute of Tropical Hygiene and Public Health, Heidelberg University. In addition

40
permission was sought and obtained from the local Health Service Office of Mbarara
District (annex 7).

41
5. Findings
5.1 Introduction
This chapter contains the findings of the study with regard to the specific objectives of
the research. The expositions derived from the answers key informants and interviewed
health care providers had given. The first section describes briefly the private health
sector in Mbarara with respect to the health practitioners interviewed. The second
section deals with general opinions on the OBA voucher scheme for STD treatment.
The third section describes the main incentives and disincentives that private
practitioners have to join or to avoid joining the scheme. Different views from PNFP
and PFPP are compared. The proceeding section concentrates on the design components
of the voucher scheme; and identifies, to which extend the different elements are
accepted by the potential participants. Finally the last part explains the role of the
private sector, the perceptions on PPPH and the degree of self organisation of private
practitioners in Mbarara District.

5.2 Brief description of the health care providers in Mbarara

District
According to information provided by the DHSO Mbarara District consists of around
150 public and PNFP across all categories (Hospitals and Health Centre II-IV). Among
them there are 14 non profit health facilities. Registered PFPP count around 40,
however the list was not updated, some of them seemed to be closed, therefore the
number is likely to be less. The total number of interviewed providers was 22. Most of
them (12) are located in urban areas, 2 in peri urban and 8 in rural areas of Mbarara
District. Amongst the PFPP there were one hospital, 11 clinics and 3 nursing homes.
The PNFP consists of 2 Faith based hospitals, 2 NGOs is the field of AIDS and STD
prevention and 2 NGOs working in the area of family planning. The amount of
outpatient cases served by the health facilities differ from 50 (small clinic) to over 1,000
per months (Hospitals). The average number of served STD cases is 50. The proportion
of treated patients considered as being poor ranges from 40 to 50% in private for profit
facilities and 60 to 70% with PNFP (annex 8).

42
5.3. General opinions on the OBA voucher scheme
5.3.1 Level of knowledge
All key informants showed an in depth knowledge of the voucher scheme for STD
treatment. Most of the PNFP in Mbarara Town were informed as well. Those in urban
areas have not been contacted before. To them and to all PFPP the programme and its
elements were unknown. They were introduced by the researcher.

5.3.2 Strengths, weaknesses and challenges

1. Strengths
General statements: “OBA is a good and important project” (key informant 3). The
approaches reward actual achieved outputs, rather than assumed outputs. Therefore the
voucher scheme is more efficient and less expensive than traditional approaches and
will produce a much better return of investment. By strengthening the private sector
financial sustainability will improve. In the long run OBA will emphasis a less donor
dependent policy. The government might be interested to take over the programme,
which would be in line with the government policy to introduce social health insurance
systems (key informant 3).
Public health impact with respect to STDs: Both key informants and the providers
perceived that through the voucher the awareness and knowledge of STDs link with
HIV/AIDS will increase and thus will also improve health seeking behaviour of the
population with respect to the disease. IEC campaigns will contribute to reduce the
stigmatization of STDs. There are already some good experiences with voucher for
ITNs for pregnant women and infants in Mbarara district. It showed that the pilot
programme had a significant impact on reducing malaria incidence among the target
group (key informant 8). Also for STDs on overall reduced prevalence and incidence is
expected in the long run. However in the pilot phase the impact will not be significant.
Because the voucher makes treatment more affordable, people will seek earlier
treatment and will show more therapy compliance. This will contribute to reduce STD
infections and to a decrease in the spread of the disease (key informant 6).
Impact on the target group: The general opinion was that the voucher scheme will
increase the accessibility to and the utilisation of qualitative health services. Especially
the poor will benefit from the subsidized vouchers because they will improve their
possibility to afford quality treatment. When people come with vouchers also other
health problems can be discovered (key informant 6). By offering the opportunity to

43
choose among a wide range of providers vouchers will increase patients’ choice and
confidentiality. This will improve the understanding of the clients with respect to their
patient rights. Through partnership with all stakeholders the voucher scheme has the
potential to increase community involvement. In 2000/2001 the government has
abolished user fees for services in public facilities. The co-payment element of the
voucher system gives it a certain value which will contribute to a greater personal
responsibility for health. In traditional development programmes usually 30 to 40 % of
the funds really reach the beneficiaries. In the OBA approach a much higher share is
expected (key informant 3).
Impact on the quality of care: Most of the respondents perceived that the voucher
scheme will contribute to upgrade the quality of private health services. Through
measures such as training, providing treatment manuals and quality control and
assurance activities the quality of care will significantly increase. Competition among
the providers will have a positive impact and their quality and patient care.
Impact on the private sector: Providers appreciated the increased recognition of their
contribution to public health. The OBA approach will offer incentives to the providers
to perform well and upgrade their services. As long as they benefit, they will change
their type and level of investments. This will improve innovation. Those who do not
reach the criteria at the beginning might have an incentive to catch up. Training will
have an impact on capacity building. The cost sharing between the public and the
private sector will strengthen the overall private sector involvement.

2. Weaknesses and challenges

Access to the target group: From providers and key informant side there was some
concern that vouchers might not reach the poor because they have the potential that the
rich and educated part of the population will benefit more. Given the fact that voucher
are accessible for all, it might not be possible to identify and reach those who should
really benefit. The majority of qualified providers are located in urban areas. Rural areas
might not be covered properly. This can be reached by integrating out reach mobile
clinics in the scheme (key informant 5).
Public health impact: In order to reduce number of infections especially among
couples, vouchers should also cover partner treatment. Vouchers are limited to STDs
alone, which make effects the health seeking behaviour towards other disease.
HIV/AIDS is not covered by the voucher, which might not be understood by the people.

44
The STD voucher might not address the most important health problems. “For people
who live in poverty the most important things are food and malaria” (key informant 9).
Affordability and willingness to pay: Some respondents perceived that “the high
subsidization of the vouchers might increase the tendency that people think they don’t
have to pay for health services” (key informant 4). Others questioned if the price of the
voucher would be acceptable and affordable for the poor population.
Stigmatization of STDs: In Uganda STDs still suffer from stigmatization. Thus it makes
it a challenge to involve all stakeholders in the scheme. “STDs is a difficult topic
because it is highly stigmatized. There is a lot of tension, especially when churches and
other religious organisation are involved. Uganda is a very conservative country” (key
informant 3).
Implementation and management: The success of the voucher depends very much on
the design of the scheme. There is some concern that the MA might not have the
capacity to manage. The chosen MA has been very successful in running the social
marketing for condom programme, but there is a lack of experience in running this more
comprehensive scheme: “The Management Agency has to go to a step learning curve”
(key informant 3). Apart from issues concerning the MA, key informants see the main
challenges for the implementation of the voucher scheme in the following fields:
 It has to be made sure that the voucher is market in an acceptable way. A large
proportion of the target group is illiterate; therefore the information on the
voucher must be simple and easy to understand.
 How the voucher will be distributed and which selling point should be used?
The distributors must be confidential and trust-worthy.
 PFPP are profit oriented. They will ask: “Will they pay my money” (key
informant 4). For them a functioning reimbursement system will be crucial.
 The implementation and the management of the voucher scheme needs to have a
high level governmental support. In addition commitment of all stakeholders
must be reached (key informant 6).
 How a continuous drug supply can be ensured?
 How to ensure that the health service deliverers provide the expected service?

Other mentioned issues: The OBA voucher scheme is a new project therefore it needs
to put a lot of effort to sensitize the potential partners and to convince them to
participate. There is some doubt regarding the sustainability of the programme. “Will

45
the scheme continue when the funding is over?” (key informant 4). In order to reach a
better coverage especially in rural areas it might be useful to involve public services in
areas where private facilities are not available. However, given the fact that the
government eliminated user fees makes it difficult to include them into scheme. In order
to involve public services in the programme the public health sector policy needs to be
revised (key informant 10).

5.4 Incentives and disincentives

5.4.1 Main incentives for the health care providers to join the scheme
In the view of the key informants the set up of the OBA voucher scheme provides a
wide range of financial and non-financial incentives for health care providers. This
judgement was also confirmed by the private service deliverer.

1. Financial incentives
PFPP and PNFP providers mentioned that participating in the voucher scheme will
increase the number of patients and the utilization of their services significantly, thus it
will also increase their market share. The voucher will add to ability and willingness to
pay especially for their poor patients. The percentage of most private providers of
patients being poor already reaches more than 50% (annex 8). Patients who come for an
STD treatment might also be interested in other services and new attracted clients will
get to know about the facilities and services they offer. Vouchers might contribute to
more financial stability. If the reimbursed fee is acceptable they might also increase the
revenue per treatment unit, because “discount discussions” will be avoided. Additional
income will provide them the opportunity to expend their services and to invest upgrade
the clinic.
PNFP usually charge a very low user fee for their services or the service is even free of
charge. Voucher will increase their revenues because the reimbursement will cover the
full treatment costs. This offers the possibility to finance other areas of concern. The
clinical officer of the public health centre stated that “participating in the scheme will
provide the clinic with certain budget autonomy”.

2. Non-financial incentives
Key informants assumed that providers will welcome the increasing acknowledgment of
their contribution to public health. Indeed this assumption was confirmed by health care

46
providers. Most of them mentioned that they appreciate the growing recognition by the
government and international donors. Linked to this are the expectations to be better
involved in the health sector with respect to information, training activities and
planning.
They perceived that participating in the voucher scheme will increase their reputation
and thus will increase the number of patients seeking treatment at their facilities. The
voucher scheme is considered as indirect marketing for their clinics. “They like to show
another certificate” (key informant 4). Their clients will benefit from the voucher
because they have to pay less for the treatment and might be more encouraged to
continue the therapy.
PNFP stated that the voucher scheme for STD treatment fits to the objectives and
activities of their organisation. The voucher scheme will support their activities.
Many providers understood that the voucher scheme offers them the possibility to
upgrade their services. Training will contribute to their capacity building and to an
increase qualification of their staff. Continuous monitoring and evaluation will help to
improve their quality. Table 2 compares and summarizes the main incentives perceived
by PFPP and public services and PNFP.

Table 2: Comparison of main incentives between PNFP + Public services

and PFPP

PNFP + Public Services PFPP

Financial incentives  increased income  increased income

 increased resource base
 reimbursement will cover the
full costs of treatment
 Possibility to finance other
areas of concern
 increased number of patients
 increased utilisation of
services
Non-financial
incentives  increased reputation
 patients will benefit
 improved quality of treatment
 capacity building
 Integration in organisation
activities
 increase market share
 positive impact on
willingness and ability to
pay
 avoid discount discussions
 may increase revenue per
treatment unit
 increased reputation
 better recognition
 indirect marketing for their
clinics
 patients will benefit
 improved quality of
treatment
 capacity building

47
5.4.2 Main disincentives to avoid joining the voucher scheme
1. Key informants view
According to key informants there exist several reasons why health care providers might
not be willing to join the scheme. Especially PFPP are usually quite careful joining any
cooperation where they have to work together with others. It was stated, that “they do
not like to open their clinics for too much control and inspection. They might fear, that
the government get an inside view on their incomes” (key informant 4).
Key informants expected that providers might have some concern regarding the cash
flow and the reimbursement. They might be afraid, that the reimbursement will not
cover their costs and that the claims and processing takes too long, which will create
cash flow problems.
Joining the scheme might cause additional investments. The private sector faces a
shortage in financial capacity to make investments. It is very difficult to get affordable
credit. Interest rates in the formal markets rise from 25 to 30 %. Informal money lenders
sometimes offer interest rates of about 50%. Micro credit scheme exist but usually not
for the health sector (key informant 3).
It is perceived that PFPP don’t want be bothered too much with administrative issues.
Especially a proper data management involves additional workload.
Some providers might not be willing to follow the required treatment regimes. They
might perceive that the standardisation of the process might increase their expenses.
“Those, who do not have the capacity or are not interested to improve their quality,
might not be interested to join the scheme” (key informant 6).

2. Providers view
It was mentioned very often from both PFPP and PNFP that they do not see any
disadvantages participating in the voucher scheme. However some disincentives where
expressed.
Most disadvantages were mentioned with respect to the reimbursement system. It was
considered as critical that in order to deliver the service they have to put a lot of
resources such as time, staff hours and drugs in advance. Some are afraid that the
reimbursement might be poor and will not cover their costs. The claims and processing
should not take too long otherwise a cash flow problem might appear when drugs get
finished before payment. One provider mentioned that he already had bad experiences
with a similar form of reimbursement.

48
There was some concern that the voucher patient might disturb their business when it
becomes too crowed, the additional workload can not be managed and other services get
neglected. “The system should not be over bureaucratic and should not involve to much
administrative paperwork.”

Table 3: Comparison of main disincentives between PNFP & Public services

and PFPP

PNFP + Public Services PFPP

 No reason not to join (very often
mentioned)
 if the financial impact is low
 if the system is over bureaucratic
 if increase workload can not be handled
 If the reimbursement is not on time
 No reason not to join (very often
mentioned)
 if it is too crowed, too much workload
 if it affect other services
 if it consumes time without benefit
 if reimbursement is poor, not on time, not
reliable

 if drugs get finished before payment  putting too much resources in advance
 the organisation provides free services, the
reimbursement system does not fit to the  if too much fraud harms the reputation of
organisation policy the clinic

Regarding abuse of the system it was mentioned if the scheme would be too much
affected by frauds this would harm the reputation of the clinic.
One PNFP raised the point that the way of reimbursement does not fit to the exiting
setting of the organisation. The NGO offers free services in testing and counselling for
HIV/AIDS. “How would our clients perceive when they have to pay for the voucher in
order to get the requested service?”
The main perceptions of PFPP and PNFP on disincentives connected with the voucher
scheme are summarised in Table 3.

5.4.3 Additional incentives that should be made available to the providers

Key informants were asked which additional incentives should be made available to the
health care providers in order to motivate them to join the scheme, apart from those
which are inherent in the programme:
Training: Capacity building is very important. Training should be provided not only in
the field of STD and data management but also in the area of administration

49
(bookkeeping, accounting), human resource management and patient management
(especially voucher patients).
Facilitating investments: Access to credit is important and very crucial. “Many
providers might say if I have access to investment capital I would invest. This is
especially valid for small facilities in rural areas. Donors together with the government
should develop a health sector specific financial market” (key informant 3). In contrast
to this statement it was mentioned, that credit schemes for health care providers are
risky. However small grants to improve investment opportunities should be made
available to them (key informant 4).
Benefits in kind: In order to contract a sufficient number of appropriate health care
providers some improvements in infrastructure are necessary. This could include
provision of lab equipment and materials such as microscopes or gloves. However, they
should not be provided for free, this would contradict the OBA idea. Mechanisms
should be established that allow claiming the investments costs against the vouchers to
be reimbursed. In order to ensure a quick take off of the scheme the participants should
be provided with test kids and drugs for the first 20 treatments (key informant 4).
Outreach services: It was suggested that in order to have a better coverage of rural
areas outreach services such as mobile clinics should be included in the scheme (key
informant 5).
Better involvement in the health sector: In general the government should give more
attention to the private sector. The private sector should be better involved in capacity
building activities, information flow and planning. On district level a system should be
established which facilitates referrals from private clinics to public hospitals. From the
MA providers expect to get a regular feedback.

5.4.4 Assistance by the Management Agency

Providers were asked what kind of assistances they would expect from the scheme and
in particular from the management agency in order to participant in the scheme.
Answers from PFPP and PNFP did not vary significantly.
General orientation: A general orientation of the voucher scheme is very important.
The system must be introduced to the services providers, their clinical and
administrative staff and the clients. It should be clearly defined for what the voucher
entitles the bearers. More input regarding objectives and indicators is required.

50
Community sensitization: A lot afford has to be put in community sensitization to raise
awareness on STDs and to explain the voucher scheme. The MA should organize
publicity events.
Capacity building: Training is very appreciated especially in the field of STD
management and laboratory diagnostic. There should be initial refresher training at the
beginning of the scheme, followed by continuous education. Training should be offered
to all medical staff such as doctors, clinical officers, nurses or midwifes and
administrative staff. Apart from STD management and diagnose the training courses
should cover also data management, skills in managing voucher patients, voucher
administration, business administration and disposable management. Information on
new developments in STD treatment should be also provided.
Provision of protocols, guidelines and tools: The MA should provide guidelines for
standard STD treatment regimes and laboratory diagnoses. Clear written information on
how to deal with the voucher, especially with respect to the claims and processing are
expected. The MA should provide facilitations in data collection and reporting such as
certain software tools for data entry and analysis.
Marketing and distribution: There should be clear introduction on the vouchers about
the participating clinics. The MA should provide a sign at the entrance which indicates
that the facility participates in the scheme. Through effective advertisement many
patients will be attracted. The MA should establish a wide spread distribution net.
Provision of goods, materials and drugs: Mostly it was mentioned that the MA should
provide them laboratory equipment and materials such as diagnostic kits. A secure drug
supply is crucial. The MA should facilitate the procurement of essential medicine.
Drugs could be made available on subsidized prices or even for free. One health care
provider of an NGO in the field of Family Planning mentioned that it would be an
incentive to provide free condoms. “Condoms are very important for STD treatment”.
Financial assistance: Especially PFPP confirmed that the scheme should offer
facilitations to have access to investment capital.
Other issues: In general providers expect a “good management” in order to make sure
that the scheme works and to ensure sustainability.

51
5.4.5 Additional requirements for health care providers to join the scheme
Both PFPP and PNFP see additional requirements such as hiring additional staff,
investments and increase administrative workload to meet expectations of scheme and
to handle an assumed higher uptake of patients.
Hiring additional staff: Most providers stated that if the number of patients and the
utilization of their services will increase significantly they would consider employing
additional staff such as clinical officer, laboratory technicians and administrative
personnel.
Investments: The majority of the respondents stated that they would be willing to invest
especially in upgrading their laboratory equipment. Some mentioned that their might be
the need to expand their building capacity. PNFP usually finance their investments
through own capital, donor money, governmental contribution or through funds that are
provided by their head quarters, according to investment plans and request. PFPP main
source of finance is out-of-pocket money. Most of them stated that investment capital is
expensive and risky because of high interest rates on the formal financial markets. The
majority is afraid of lending money. There are some experiences of colleagues who
failed to pay back and had to give up their clinic. Better access to capital markets with
reasonable interest rates is considered as a great incentive to join the scheme.
Administrative requirements: Both PFPP and PNFP expect more administrative
workload with respect to data management and patient administration. Additional
administrative staff might be needed. Some require assistance in form of provision
stationary and means of communication such as computer. PFPP in particular are
concerned that too much paper work “will eat more” of their time. The efforts they
have to take should be in balance the benefits they gain from receiving more patients.

5.5 Acceptance of the design elements of the voucher scheme

5.5.1 Security against fraud
The potential for abuse of the system is much more a concern of PNFP. PFPP don’t
worry very much about fraud. “Frauds can not be ruled out completely, but they can be
handled, if the system is reasonable managed and all the stakeholders are enough
sensitized.” In contrast to this PNFP see some potential: people might duplicate the
vouchers; providers might abuse the system by claiming for procedures they have never
done. Corrupt alliances between providers and patients may be discovered. In order to
protect the system against fraud they suggest:

52
  Some special features on the voucher such as serial numbers allow following up
the way of the voucher from purchasing over treatment to reimbursement.
 The system can not control 100%. The controlling should concentrate on
detecting “red flags”. When they are detected they should immediately be
removed from the scheme.
 Regular communication and with MA and feedback to all stakeholders.

5.5.2 Claims and processing

For the vast majority a reimbursement system like it is foreseen for the voucher scheme
is new. PFPP serve patients almost exclusively on cash bases. Only few of the providers
have experiences with private health insurance systems, where providers have treatment
contract with health insurances or companies. Comparable agreements with schools are
also known.
Most providers stated that the reimbursement system is convenient for them. However
some raised their concern that putting too many resources in advance might lead to cash
flow problems and would be not affordable in the long run. Some prefer checks rather
than transferring the money to their account. Those PNFP and public services who over
treatment free of charge mentioned that the system is not appropriate. For them
providing drugs instead of payment could be a possible option. However most providers
mentioned some important requirements for the claims and processing:
 The reimbursement system should be reliable, transparent and should not
involve too much paper work.
 The timing of reimbursement is perceived as very important. Most providers
stated that the reimbursement should be according to accepted business norms
on every monthly base. Some mentioned that a monthly payment would not be
acceptable and prefer every second week or even weekly transaction.
 The MA should be approachable. In order to streamline the claims and
processing and make it more convenient for the providers it was suggested that
the MA should establish an office in Mbarara.

5.5.3 Approval system

All providers are registered. However an additional accreditation is commonly seen as
essential to ensure that only those who are eligible to deliver the expected quality can
join the scheme. The approval is necessary to improve services, ensure quality and the

53
standardization of treatment regimes. “It will increase clients’ confidence in our
clinics.” Having an extra certificate is good for the reputation and provides a
competitive advantage. Most providers opted for an annual renewed approval
certificate.

5.5.4 Monitoring and evaluation

The vast majority of the respondents stated that a close monitoring and evaluation of the
scheme is welcome. Monitoring and evaluation will contribute to more transparency,
quality assurance and will help to reduce abuse of the system. Providers expect that the
methods used should be transparent and that they will receive regular feedback from the
MA. Whereas PFPP are usually not involved in monitoring and evaluation process from
third parties, PNFP have significant experience with common instruments.
Supervision: Regular supervision visits are appreciated. Providers perceive that they
will contribute to upgrade their services and their delivered quality.
Approval of patient records and bookkeeping: Basically approval of bookkeeping is
accepted as long it only concerns the voucher patients. Because of reasons of
confidentiality proving patient records is for some providers not acceptable, unless there
is a separate register for voucher clients.
Feedback from clients: Feedback from clients is appreciated. Methods such as client
exit interviews and focus group discussions are accepted. The use of mystery clients can
sometimes cause problems because “a bad day performance of a health care provider
can result in a negative report.”

5.5.5 Service Contract

Providers stated that the service contract should clearly define the role and the
responsibilities of the service providers and the MA. Based on the voucher the contract
should specify the expected services to be delivered and the standard treatment regimes
to be used. It should include the agreed service fees and clear payment regulation.
Causes of determination of the agreement should be clearly defined. There needs to be
some mechanism in place to solve conflicts derived from the contract. The contract
period should be either according to the duration of the programme or on a one year
base with the possibility to renew.

54
5.6 The role of the private sector and Public Private Partnership
5.6.1 The role of the private sector
The private sector is an important partner in health, especially in areas which are out of
reach of public services (key informant 7). PNFP in particular have a clear role within
the Ugandan health sector. They are involved as partners of the government and make
official contribution to the health sector. Often PNFP are subcontracted by the
government to provide out reach services. The government subsidise them and in some
case (mainly FBOs) the state contributes to their budget.
The role of the private for profit sector has not yet been properly recognised (key
informant 3). Still there is a low level of trust between the private sector and the
government and the attitude exist that the private practitioners are more interested in
profit than in the service quality. However it is recognised that patients often favour
private clinics over public facilities for varies reasons: they are better geographical
accessibility, they offer more convenient opening hours, have less waiting times, they
are more costumer friendly and show more respect towards patients confidentiality,
essential drugs are available and they are perceived to offer a more qualitative services
than public facilities (key informant 6).
According to the DDHS in Mbarara District more than 40% of the health services are
provided by private practioners and around 50 % of the owners of private facilities work
part time in public services (key informant 7). For him the private sector is an important
partner in delivering curative services. “The OBA voucher scheme will strengthen the
private sector, it will increase the resource base of the district and it will improve the
cooperation between private and public sector” (key informant 7).

5.6.2 Public Private Partnership

The relationship between the private and the public sector in Mbarara District is mostly
perceived as good. Both PNFP and PFPP feel little disturbance by the local authorities
and are mostly satisfied with the work of the DHSO. Most providers are visited
regularly and have to report and contribute to the district health information system.
Regular council meetings together with private practitioners take place. The referral
system has improved in both ways. The district policy encouraged the private sector to
expand. Private hospitals with relatively big capacities are now available in the district
(key informant 7).

55
Despite of these achievements the involvement of the private sector is still perceived as
weak. In future some respondents would like to see the private sector more involved in
health planning of district level. PPPH should become more decentralised, otherwise the
private sector will not benefit (key informant 3). An important signal would be the
installation a PPP officer at district level as it is foreseen in the national policy. PPPH is
an important concern for the health district policy of Mbarara. The OBA voucher
scheme is already part of this policy (key informant 7).

5.6.3 Degree of self organisation of the private sector

In Uganda private practitioners are organised in the Uganda Private Medical
Practitioners Association (UPMPA). Even though such an organisation exists, on
national level the participation is low. Usually only 20% of the members pay their
regular membership fee. In general the willingness of private practioners to be engage in
an organisation is low. In Mbarara district the local branch of UPMPA has been
established recently. According to the local chairman the organisation has already 35
members. The objectives of the group are to advocate the interests of the members, to
provide a podium for discussion of common problems, organising monthly continuous
medical education and business administration courses. In the long run the UPMPA
Mbarara aims on getting more political influence. The member’s opinion on the work of
the organisation is mostly positive. They feel well presented and most of them hope that
the activities will expand in future.

5.7 Summary of the findings

Both key informants and health care providers in Mbarara District have a positive
attitude towards the OBA voucher scheme for STD treatment. Health care providers
appreciate to be recognised by the government and international donors and are
motivated to join the voucher scheme. It is perceived that vouchers will contribute in the
long run to a decrease of STD prevalence and incidence in Mbarara District. Voucher
will contribute to an improved quality of STD treatment and they will have a positive
influence on health seeking behaviour of the population. However there are some
concerns that the vouchers might not reach the poor.
Both PFPP and PNFP see that participating in the voucher scheme will offer the
opportunity to increase the number of their clients, the utilization of there services and
thus their income. PNFP providers might use their additional revenues to invest in other

56
areas of concern. Being a partner of the scheme will increase their reputation. The
enhanced competition among the providers will contribute to better service quality.
There is a high demand for training in STD Management, laboratory diagnostic data
management and administration among the providers. Health care providers considered
participating in training as a good opportunity for capacity building. Most providers
want to upgrade their services especially with laboratory equipment. PNFP providers in
Mbarara are mainly financed through their head quarters, whereas PFPP finance
investments out of pocket. They would be willing to invest more if they would have
access capital markets for reasonable interest rates. For most a secure drug supply
would be an important incentive. If the patient uptake is high the majority would
consider hiring additional staff.
An effective management of the components marketing and distribution, claim and
processing and monitoring and evaluation will be crucial for the success of the
programme. For most providers the reimbursement system is convenient however there
is some concern regarding the level, the timing and the reliability of the claims and
processing. Especially PFPP are concerned about too much administrative workload
that might be involved. In general approval of the health services and a close monitoring
and evaluation is perceived as necessary and is appreciated.
In Mbarara some achievements have been reached with respect to PPP. From
government and provider side PPPH it is perceived as being an important policy for
further improvements in the health sector. The OBA voucher scheme is part of this
policy; and has the potential to contribute to a better cooperation between private and
public health sector.

57
6. Discussion
6.1 Introduction
This chapter discuss the findings of the study with regard to the specific objectives of
the research. Following the issues raised in the literature review the discussion will first
analyse the role of the private sector within the Ugandan health sector in general and
within Mbarara District in particular. In order to provide a suitable frame for the
proceeding argumentation the impact of OBA voucher schemes on accessibility and
improvement of health services will be briefly discussed. Then the analysis will focus
on the main incentives and disincentives that private health care providers perceive with
participating in the scheme and will identify to which extent the potential voucher
partners will accept main design elements of the scheme. Finally the application and the
limitations of the chosen study design will be argued.

6.2 The private sector in Uganda – Partner in Health?

The private sector plays a significant role in provision of health services in poor and
middle income countries. More than 70 % of the Ugandan total health expenditures are
spent in the private health sector (WHO 2005). In the study area Mbarara District the
share of private health services reaches more than 40%. Despite the growing importance
of private health provision there is still a lack of trust between the public and the private
health sector. Even now the perception is wide spread that private practitioners are
mainly focussing on profit rather than of quality of service.
However it is recognised from governments and donors that public health services lack
effectiveness and often fail to reach the poor population (Yamamoto 2004). These
inadequacies have led patients turn to private providers. They correspond more to the
costumer needs and are perceived as better accessible, more customer friendly and more
confidential. As shown in a study on quality of care by private practioners this is
especially valid for highly stigmatised diseases like STDs (Walker et al. 2001).
Nowadays the Ugandan government is aware that the private sector has become an
important partner in achieving health sector objectives. The government has recently
formulated a comprehensive PPPH strategy to strengthen the collaboration and
partnership between the private and the public health sector (Jinja 2005) following the
approaches of harnessing, growing and conversion of the private sector. The Annual
Health Sector Performance Report 2002/2003 (Kampala 2003, a) emphasised, that
enhancing the partnership with the private sector will play an important role to control

58
communicable diseases such as STIs. An important element to facilitate the PPP process
is to implement coordinating bodies such as PPPH desks on central and district level.
PNFP already play an official role in national health provision. Some are contracted by
the government to provide outreach services such as mobile clinics in rural areas where
public services cannot be found. Even though a PPPH desk officer has not jet been
assigned in Mbarara District there is evidence that PPP in the district in not a
“meaningless word”. The relationship between local authorities, the public and the
private sector is mostly perceived as being good. Most of the providers stated that they
are satisfied with the work of the DHSO and that they feel involved. The good
relationship might also be explained by the fact that interest are overlapping because of
the high share of private facility owners who work part-time in public services.
Successful PPP requires the existence of representatives of private side. The relatively
high degree of self organisation of the PFPP in Mbarara District might facilitate the
process.
A common commitment is an important step towards PPP. The difficulty for policy
makers is to create practical ways to make the partnership lively. The OBA voucher
scheme for STD treatment offers such an instrument. Because the approach clearly aims
at using the potential of the private sector and integrating private practitioners in the
health care system in order to improve their service quality, it is likely that the scheme
can contribute to make the private sector a more reliable partner in health.

6.3 OBA voucher schemes - a suitable approach to improve quality

of health service and access for the poor?
OBA is a new approach in health financing. OBA voucher schemes have not been
implemented on a large scale yet. Therefore there is still little evidence on impact of
voucher schemes of the improvement of quality of care and the access for the most
vulnerable people. However, experiences with a voucher scheme for female sex workers
and their partners to prevent STIs have shown that the use of subsidized vouchers have
led to a significant drop on STDs among the target group. The created competition
among the providers combined with quality assurance and control mechanisms have
resulted in an improved quality of STD services (Sandifort et al. 2002).
The voucher scheme for STD treatment in Mbarara District follows a very similar
approach. Subsidized vouchers will be distributed to people who have an STD or show
syndromes which entitle them for treatment in specific approved private health

59
facilities. The expectations among policy makers, implementers, clients and providers
are high. A survey report on the target population has shown that the vouchers are
basically accepted by the clients and that people are willing to pay for them (Steadman
Research Service 2005). This presented study proves that the general perception on the
scheme among the providers is positive and that they are motivated to join the scheme.
There are strong believes, that the voucher scheme will have a impact on health seeking
behaviour, improve the accessibility and utilization of services for the poor and will
contribute to a better treatment quality in STD. An impact on a decreased STD
prevalence is not expected for the pilot period nevertheless in the long run the vouchers
scheme may contribute reducing STIs. Due to the fact that the voucher is accessible for
all there is some doubt that it will not be possible to specifically target the poor. STD is
a much stigmatized topic. As the Nicaragua example have shown, there is some concern
that the voucher might produce the perverse effect in the way that using it might result
in even more stigma (Sandifort et al. 2002).
The OBA voucher scheme for STD treatment might be suitable to improve the
accessibility and quality of services in Mbarara District. However the scheme has not
started yet and is still in the design and implementation phase. Of course, if the scheme
can reach its objectives can not be judged at this stage and will be evaluated in the on-
going process after several months of implementation.

6.4 OBA - Market chance or risk for health care providers?

The OBA voucher scheme offers a wide range of financial and non-financial incentives
for the health care providers to participate in the scheme. There are incentives that are
inherent in the system and additional incentives that can be provided to the health
services deliverers in order to expand the number of qualified services. However joining
the scheme also causes some interference in the business of the providers, which might
be considered as risks.
Both PNFP and PFPP clearly realize that the participation in the voucher will have a
great potential to augment the utilization of their services and thus the number of
clients. Patients will properly not only seek treatment for STDs but will also utilize
other services. If expenses and output will be balanced and the agreed service charge
with the MA will be sufficient, increased uptake of patients will automatically result in
increased income. As shown providers already serve a large proportion of poor patients.
The subsidized voucher scheme is likely to expand their market share on the low

60
income population. Linked to that is the risk, that the increased uptake of STD patients
might affect other services. In some cases a high number of voucher patients could also
result in a change of the client profile, which might disattracted better well off patients.
Providers need to judge their preferences carefully.
Due to the nature of PNFP being objective oriented rather than focussing on profit,
PNFP see the potential of increased revenues more in an expanded resource base to
finance other areas of concern. For public services participating might contribute to
certain budget autonomy. For those PFNP who offer services free of charge joining the
scheme might contradict their objectives. It would be more appropriate to integrate them
as distributors.
Providers appreciate the growing recognition by the government and development
partners. Whereas PNFP are usually already well incorporated in the health sector for
PFPP this offers new opportunities. Through participating in the voucher scheme they
link the prospect to be better involved in health sector activities. It is expected that the
involvement will contribute to a growing reputation and that the voucher elements IEC
and intensive marketing will provide indirect marketing for their clinics. The high
demand on training shows that providers are motivated to strengthen their own capacity
and to improve their services. If the patient uptake is high most of them would consider
employing additional staff. This might be an indicator that the programme also has a
labour market component.
In order to meet the requirements of the scheme and to upgrade their clinics provider are
willing to invest. Whereas for PNFP the access to capital markets is not a topic of
concern, for PFPP high interest rates on the formal financial markets are a major
constrain for investment. With respect to the expansion of the scheme and to encourage
innovation policy makers should consider to establish intelligent mechanism to facilitate
the access to financial markets for health care providers.
An important incentive for health care providers to join the scheme is also a reliable
drug supply. To ensure a quick uptake of the scheme it is considered to provide health
care deliverers with some improvement in infrastructure. This could include provision a
laboratory materials and test kits and drugs for STD diagnose and treatment.
Implementers have to judge carefully if providing of benefits in kind may not contradict
the idea of OBA.
Both PFPP and PNFP mentioned very often, that they don’t see any disadvantages in
participating in the scheme. Nevertheless most concerns were expressed with respect to

61
the reimbursement system. PFPP are used to operate on cash base. As voucher service
provider they have to put a lot of resources in advance to reach the expected outcome
before they get the payment. This involves a careful planning of resources in order not
to run in cash flow problems. It came out very clear that the reliability and the timing of
reimbursement are very crucial for the moral of the provider.
Especially PFPP usually have a lean administration. Patient registrations and statistics
are often poor. Most of them recognised that participating in the voucher scheme will
involve more administrative workload. If the administrative requirements become too
intensive some providers might leave the scheme.
The study has shown, that PFPP and PNFP provider perceive basically positive about
the voucher scheme. If the scheme is well managed they are motivated to become
partner. It can be summarized that the chances associated with joining the scheme are
much higher valued than the potential risks.

6.5 The design elements of the voucher scheme – benefit or

interference?
Some design elements of the voucher scheme might be beneficial for the participants
other might be perceive as to intrusive and might have the potential to interfere into the
origin of their business.
Security against fraud: The potential for abuse of voucher schemes has been widely
discussed in the voucher literature (Brook and Smith 2001; Sandifort et al. 2003) and
was also a topic of concern in the OBA workshop which took place in Kampala in May
2005 (IGES 2005). The risk of fraud is seen mostly by PNFP. This can be explained by
the fact that NGOs are usually larger organisations which have experiences with
unmoral behaviour in subsidized programmes. Both PFPP and PNFP stated that abuse
can never be ruled out but that it can be controlled by efficient management of the
scheme. The control of fraud should concentrate on detecting “red flags”. All providers
perceived that checking is necessary and they accept the foreseen control mechanisms.
In provider’s view fraud is not a serious problem however for the reliability and
reputation of the voucher scheme it can have serious consequences.
Claims and processing: Claims and processing is on of the core elements of the
voucher scheme. The claims form is the basis for the payment, provides the records for
the clinic and is basis monitoring and evaluation of the whole system (Griffith and
MSIU Team 2005). A functioning payment system is the key incentive for providers to

62
join or deter the scheme. The presented reimbursement system is mostly accepted by the
providers. Critical issues are the administrative workload linked with the claims form,
the reliability of the payment and the timing. Especially the timing becomes very
important, taking into account that providers have to spend a lot of resources in advance
to deliver the service. If the timing of reimbursement would not be satisfying for the
participants, they are likely to loose their motivation. This would create the perverse
effect, that patients who come with a voucher would not be appreciated anymore.
Approval system: In the literature it is discussed that especially for PFPP the process of
contracting and accreditation or approval might be a little too intrusive and threatening.
Providers might object that they loose their medical autonomy when they are obliged to
follow standardized treatment regimes (Sandifort et al. 2003). The study have shown
that health care providers in Mbarara District mostly consider approval as necessary and
that they even perceive it as an competitive advantage.
Monitoring and evaluation: Beside the payment mechanism monitoring and evaluation
is probably the most serious interference in providers’ business. PFPP are usually not
willing to open their clinics for too much inspection and don’t want to be overwhelmed
by too much paper work. The monitoring and evaluation of voucher schemes is a very
comprehensive process. It involves monitoring and evaluation the service quality,
costumer friendliness, patient records, financial information, claims forms and
monitoring against abuse. An important element of assessing quality is getting feedback
from clients through mainly mystery client methods. Whereas PNFP have experiences
with monitoring and evaluation PFPP are usually not involved in comprehensive
assessment processes. One could have assumed that PFPP would show resistance
towards monitoring and evaluation. In contrast to this assumption the study gives
evidence that PFPP in Mbarara District are much open to quality assessment and control
and even consider it as a benefit in order to improve their quality.
Service contract: The chosen contract terms have important consequences for the costs
of the voucher scheme, the incentives provided to the participants and the strategy for
monitoring and verifying performance (Smith 2001). PFPP may not be used to work
under written contracts and may find the process threatening (Sandifort et al. 2003). The
research has shown that contracting is convenient for the providers in Mbarara District
and that they are aware of important contract terms such as defining the service to be
delivered, the standards to be used, the service charge to be agreed, clear payment
mechanism etc., that should be included in the contract.

63
The success of a voucher scheme depends very much on the design. The design
elements have to be carefully chosen in order to reach the objectives and not to perverse
the desired the impact. The study has shown that health care providers consider the
design elements of the voucher mostly as beneficial and less interfering. However
especially those elements suitable for monitoring and evaluating of the voucher scheme
involve a trade off between the desire to gain as much data as possible and the necessity
not to discourage the voucher service partners through too much control and
administrative workload.

6.6 Discussion on the Methodology

1. Application of the study design
The presented study has given an in depth view on health care providers perception in
Mbarara District on the OBA voucher scheme for STD treatment by using qualitative
methods. Qualitative methods are especially suitable in health to build up an
understanding on opinions or experiences on certain phenomena or programmes
(Øvretveit 2002). Triangulation of methods, by using semi-structured individual and
informal conversational and semi-structured interviews, has allowed us to look at the
research topic from different perspectives: the provider’s perspective and the view of
policy makers and implementers of the programme. Sampling PFPP and PNFP have
made it possible to compare between different types of organisations. The study results
were presented in a joint meeting with the local partner MSIU and the KFW consultant.
As stated in the Report June 2005 of the OBA programme the research “has provided
valuable insights in designing the programme and a study carried out after several
months implementation which followed up some of its findings would be useful.”
(Griffith and MSIU Team 2005, 17).

2. Limitations
Main biases which might have influenced the results of the study have been identified in
the areas of:
Awareness of the voucher scheme: The main source of bias may have appeared in the
fact that at the stage of the research the details of the design elements of the OBA
voucher scheme were not defined clear. In addition the majority of the interviewed
health care providers were not informed about the programme. The introduction of the
voucher scheme to them was done by the researcher. Therefore the results of these

64
interviews depended much on his explanation. Answers on questions concerning the
design elements of the voucher scheme might have been more information rich if the
programme would have been introduced before.
Sampling: Due to logistical reasons it was not possible to cover all identified health
care providers. Therefore the provider in Mbarara Municipality might be over
represented in the study. That fact that only one public health facility was selected, did
not allow gaining valid results on this type of organisation.
Researcher: The researcher did not have extensive experience in qualitative
interviewing. Especially in those interviews were the interviewee was not so talkative it
might have appeared that the interviewer introduced his own opinion rather than letting
the respondent reflect on his own idea.

65
7. Conclusion and recommendations
The presented study is a pioneering research on the perceptions of health care providers
on an innovative approach to finance health. On the example of a pilot programme for
an OBA voucher scheme for STD treatment in Mbarara District, Uganda, which will be
implemented soon, the research identified the main market risks and chances health care
providers perceive with participating in the scheme.
By focussing on integrating private health care providers in the health sector the
voucher scheme has the potential to contribute to strengthen PPPH. The research has
shown that providers generally have a positive attitude towards the voucher scheme.
They appreciate to be recognised by government and development partners and are
basically motivated to participate in the scheme. By focusing on behaviour change of
the district population and an increased utilisation of STD services it is perceived by the
providers that the scheme will contribute to an increased patient uptake in their clinics
and thus will increase their income opportunities.
One important element of the OBA approach is to create competition amongst the
providers. Becoming partner of the voucher scheme will offer them competitive
advantages and will contribute to a growing reputation of their clinics. The scheme
provides them with incentives to improve their services. In order to meet the
requirement of programme providers might have to upgrade their services. Providers
proved themselves to be willing to strengthen their capacity, to employ additional staff
and to invest in their clinics. Especially for PFPP a better access to capital markets with
reasonable interest rates is considered as a great incentive to join the scheme.
However, joining the voucher scheme also involves interference in the business of the
private health care providers. Most disincentives in participating in the programme are
connected with the design elements of the scheme. Even though for most providers the
reimbursement system is convenient it is also perceived as risk. PFPP usually serve
patients on cash base. If the reimbursement is not in time, they are in danger to run into
cash flow problems. Approval, monitoring and evaluation are perceived as necessary in
order ensure efficiency and effectiveness of the scheme. Whereas PNFP have
experiences with these instruments, PFPP are not used to be involved in comprehensive
assessments. For policy makers and implementers it involves a trade off between the
desire of having complete data sets and the need not to discourage the providers through
intensive control and administrative workload.

66
From the presented study the final conclusion can be drown that health care providers in
Mbarara District value the chances of joining the OBA voucher scheme for STD
treatment much higher than the risks associated with it. The success of the pilot
programme will much depend on the design of the scheme.

Recommendations:
In order to create an appropriate incentive system, which mobilizes a sufficient amount
of health care providers to join the voucher scheme and give suggestions for an
expansion strategy the following recommendations can be provided:
 The health care providers are the most important partner of the scheme. It is
recommended to introduce them soon to the programme. The UMPPA branch in
Mbarara as representative of the private health sector seems to be an ideal entry
point for the implementers.
 Most providers show concerns regarding the claims and processing. The
completeness of the claims should be not too complicated and time consuming.
The system should be reliable and transparent. Even though the majority of the
providers are comfortable with a monthly reimbursement, they might discover
cash flow problems. Therefore it is recommended to reimburse more quick in a
continuous process.
 For the monitoring and evaluation process a balance should be found between
control and administrative workload for the providers. Paper work should be
reduced to an indispensable minimum.
 To streamline the whole process, to operate the claims and processing and to
enhance the communication between the stakeholders of the scheme a field
office in Mbarara town should be established.
 For expansion of the programme some providers need to upgrade their facilities.
It should be weighted carefully if inputs do not contradict with the OBA
approach. To encourage innovation government and donors should consider
developing mechanisms to facilitate the access to investment capital for PFPP.
 In order to reach a better coverage especially in rural areas policy makers and
implementers should consider including mobile clinics in the voucher scheme.
In those areas, where no private provider is available in future it could be an
option to involve public health centres in the programme. This may require a
change in public health sector policy.

67
 In order to gain more valuable information on provider’s behaviour and
perceptions bases on the presented findings a follow up study after several
months of implementation of the voucher scheme would be useful.

68
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Toolkit, Washington D. C., The World Bank, 2003
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73
9. Annexes

Annex 1: Mbarara District Map

74
Annex 2: Schematic view on the voucher scheme for STD treatment in
Mbarara District Uganda

S T D T re atm en t - O B A
A p p ro a ch in U g a n d a

M an ag em en t A gen cy

e n ts
V o u ch ers

Paym
s and

M a r k e t in g a n d D is t r ib u t io n
A c c r e d it a t io n

C la im

M & E

P ro v id ers

R e t a i le r s ,
T

NG O s &
V
re

o th e r s
u
a

c
tm

h
e
e

r
n
t

C lie n ts

Source: Griffith 2004, 3

75
Annex 3: Management Structure of the voucher scheme

Source: Griffith and MSIU Team 2005, 7

76
Annex 4: Interview guideline health care providers

Interview with health care providers

Basic Information:

Provider Interview No:

Kind of Facility:
Position of Respondent:
Setting: rural urban
Location:
Health Sub District:
Date:
Time:

Interview Guideline:

1) What do you know about the voucher scheme for STD Treatment?
a) Was it well explained to you?

2) What is your opinion of the voucher scheme for STD treatment?

a) Strength
b) Weaknesses/Challenges

3) What are the main incentives for you/your clinic to join the OBA voucher scheme?

4) What could be main reasons for you/your clinic not joining the voucher scheme?

5) Which economical impact on your clinic/facility you expect by the voucher scheme?
a) Impact on number of your patients?
b) Impact on income?
c) Impact on patient’s willingness/ability to pay?

6) What impact on the reputation of your clinic/person you expect?

a) Reputation regarding providing services for the poor?
b) Attracting other clients?
c) Reputation among colleagues?

7) Apart from financial benefits what kind of assistance to deal with the voucher
scheme you would expect from the Management Agency.
a) Advertisement?
b) Training?
c) Administration management?
d) Equipment?

8) In order to deliver the expected service quality do you see any requirements for
training for you/ for your staff?
a) Who should be trained?
b) What kind of training/in which fields?
c) What should a training for SDT treatment course content.
d) How often should it take place?

9) In order to meet the upcoming demand does see any requirements hiring
additional staff?

77
10) Do you expect any requirements for additional investments in your clinic? What
investments you would take.
a) What kind of investments?
b) Usual source of finance?
c) If you had access to the formal capital market? What has been your experience?
d) Would it be an incentive to you to have a more easy access to the formal financial
market?

11) Do you expect any additional administrative requirements?

a) Administrative expenditures?
b) Administrative workload?
c) Do you or your staff require administrative training to fulfil the administrative
requirements of the voucher schemes?
d) What kind of assistance should the Management Agency provide to you?

12) Do you see any potential for abuse in the voucher scheme?
a) Security against fraud?
b) How the security of the voucher and the system could be improved.

13) What do you think about the reimbursement system? How it should be designed?
a) Do you already have experience with health insurance schemes?
b) Is the reimbursement system trustful to you?
c) How can it be improved?
d) Timing of reimbursement?

14) What do you think about the accreditation system? How it should be designed?
a) Advantages/disadvantages of accreditation for your clinic?
b) Fair? Accepted?

15) What is your opinion on monitoring and evaluation? How the M&E system
should be designed?
a) Is proving of patient records accepted?
b) Is proving of accounting accepted?
c) Is supervision of service accepted?
d) Is feedback from your clients accepted (exit interviews, mystery clients)?

16) What aspects should be included in the service contract with the Management
Agency?

17) Tell me about your experience dealing with the public health sector?
a) Understanding of public private partnership?
b) Experience regarding cooperation with the public health sector?
c) Suggestions to improve cooperation with public sector?

18) How is the private sector organised? Are you member of an organisation? How are
your experiences? Do you see any issues for improvement of the organisation?

19) Statistical Questions

a) Who is the carrier/owner of your clinic/facility?
b) Number of staff?
c) Monthly turnover of patients?
d) What is the estimated number of SDT treatment per month in your clinic/facility?
e) How large is the proportion of your patients, who you consider as being poor?
Annex 5: Interview guideline key informants

78
 Interview with key informants
Basic Information:

Key Informant No:

Organisation:
Position of Respondent:
Setting: rural urban
Location:
Date:
Time:

Interview Guideline:

1) What do you know about the output based voucher scheme for STD
Treatment?

2) What is your opinion on the voucher scheme?

- Strengths
- Weaknesses/Challenges

3. What are the main reasons for implementing output based voucher
schemes?

4)Where you see the main difficulties in implementing the voucher scheme?

5)Which impact you expect on STD prevalence/incidence?

6)Which impact you expect on the target group?

7) In your view, what are the main incentives for (private) health care
providers to join the voucher scheme?

8) Can you think of reasons why health care providers could not be interested
to join the voucher scheme?

9) What other incentives you would be willing to make available to health care
providers in order to expend the number of participants and to enhance
their motivation to join the scheme?
- training?
- access to credit?

10) What kind of further assistance the Management Agency should supply to
health care providers who participate in the voucher system?

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11) What is the share of the population that goes for treatment to private
health facilities?

12) Why people may prefer private health services?

13) What role does the private health sector play in the Uganda health system?
- Current role?
- Degree of organisation of the private sector?
- Future perspectives?

14) What is your opinion on Public Private Partnership in Health?

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Annex 6: Informed consent declaration

Interview with health care providers

Informed Consent declaration

My name is Ulrich Bärtels. I am master student at University of Heidelberg, Germany

in the field of Community Health and Health Management in Developing Countries. I
am conducting a research on the Output based voucher scheme in Uganda. The output
based voucher schemes for STD treatment has recently been introduced to you.
You/your clinic have/has been chosen as a potential provider for STD Treatment within
the voucher scheme. I would like to ask you some questions regarding your perception
on the voucher scheme. I am particular interested in the chances and risks you perceive
with the new system.

Your answers will only be used in the study report. Names or addresses will not be
mentioned in the report. I ensure that readers will not be able to identify who gave
certain interviewee. Whatever you say is confidential and will not be shared with other
persons.

I would greatly appreciate if you participate in the interview. Your participation is

voluntary. You are free to answer only those questions which you are comfortable with.
If a question seems too difficult or to sensitive to you, you do not have to answer it. You
are also free to end the interview at any point in time.

Do you have any questions to that? Would you agree to start the interview with me
now?

If agree, shake hands or any other culturally accepted unanimous sign of acceptance.

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Annex 7: Research permission from District Health Service Office
Mbarara

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 Annex 8: List of interviewed health care providers

Prov No Location Subdistrict Setting Sector OPD No of STD Proport. of Date of

cases/months Cases/months poor Interview
1 Mbarara Mbarara Municipality Urban PFPP 500 60 40% 20.05.2005
2 Mbarara Mbarara Municipality Urban PFPP - 200 - 30.05.2005
3 Mbarara Mbarara Municipality Urban PFPP 100 40 50% 31.05.2005
4 Mbarara Mbarara Municipality Urban PFPP 350 20 20% 31.05.2005
5 Bwezibwera Kashaari County rural PFPP 300 80 60% 01.06.2005
6 Ibanda Town Ibanda Town Council urban PFPP 500 175 60% 01.06.2005
7 Sanga Town Nyabushozi peri urban PFPP 110 40 20% 02.06.2005
8 Kaso Kaso County rural PFPP - -
9 Kaso Kaso County rural PFPP 50 25 50% 02.06.2005
10 Kanoni Kaso County rural PFPP 100 20 80% 02.06.2005
11 Ruti Raampara rural PFPP 80 40 10% 03.06.2005
12 Ndjeija Raampara rural PFPP 04.06.2005
13 Nyeihanga Raampara rural PFPP 50 15 50% 04.06.2005
14 Mbarara Mbarara Municipality rural PFPP 400 n. a. n. a. 04.06.2005
15 Mbarara Mbarara Municipality Urban PFPP 400 5 65% 05.06.2005
16 Mbarara Mbarara Municipality Urban PNFP 60% 20.05.2005
17 Mbarara Mbarara Municipality Urban PNFP 400 50 100% 24.05.2005
18 Mbarara Mbarara Municipality Urban PNFP 1000 50 60-70% 30.05.2005
19 Mbarara Mbarara Municipality Urban PNFP 250 ? 97% 01.06.2005
20 Rushere Nyabushozi peri urban PNFP (FBO) 1000 80 50% 02.06.2005
21 Mbarara Mbarara Municipality Urban PNFP (FBO) 400 30 60% 03.06.2005
22 Bisheshe Ibanda North rural Public 1500 150 90% 01.06.2005

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Annex 9: List of key informants
Key No Organisation Location Position Sector Setting Date of
Interview
1 KFW (free lancer) Heidelberg, Germany Freelancing Counsultant Private Urban permanent
2 KFW Frankfurt, Germany KFW Official Gov Urban permanent
3 PS Consulting Kampala Managing Consultant Private Urban 09.05.2005
and
permanent
4 former MSU Kampala Former Programme Director NGO Urban 10.05.2005

5 MSU Kampala Programme Director NGO Urban 10.05.2005

6 MSIU Kampala Programme Director NGO Urban 11.05.2005

7 GOV District Health Office Mbarara Mbarara District Director of Health Services GOV Urban 20.05.2005

8 GOV District Health Office Mbarara Mbarara District Vector Control Officer Gov Urban 24.05.2005

9 University of Mbarara/MoH Mbarara Zone Director for Malaria & IMCI Gov Urban 24.05.2005
10 Ministry of Health Uganda Kampala PM STD/AIDS Control Programme GOV Urban 23.06.2005
11 Mulago Government Hospital Kampala STD Clinicians Gov Urban 19.05.2005

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