Publications by authors named "Timothy Musila"

3 Publications

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Fitting Health Financing Reforms to Context: Examining the Evolution of Results-Based Financing Models and the Slow National Scale-Up in Uganda (2003-2015).

Glob Health Action 2021 01;14(1):1919393

Department of Health Policy Planning and Management, School of Public Health, Makerere University, Kampala, Uganda.

: Results-based financing has been promoted as an innovative mechanism to improve the performance of health systems in achieving universal health coverage. Several results-based financing models were implemented in Uganda between 2003 and 2015 but with limited national scale-up.: This paper examines the evolution of results-based financing models and the reasons for the slow national adoption and implementation in Uganda.: This was a qualitative study based on document review and key informant interviews. The models were compared to show modifications overtime. The reasons for the slow national scale-up were analyzed using variables from the Diffusion of Innovations Theory.: This study covered seven schemes implemented in the Ugandan health sector between 2003 and 2015. The models evolved in several aspects: 1) donor reliance with fundholding and purchasing delegated to non-state organizations; 2) establishment of ad-hoc structures for learning; 3) recent involvement of the government agencies in verification processes; 4) Involvement of public providers, and 5) expansion of services purchased from the national minimum health-care package. The main reasons for slow national adoption were the perceived complexity and incompatibility with public sector systems. The early phases comprised barriers to public sector reforms. However, recent adjustments to the schemes have enabled greater involvement of public providers and government stewardship. Stakeholders also reported progressive learning across projects and time.: Overall, the study findings show scheme actors' deliberate efforts to adapt their models to the Ugandan health system and public sector context. Results-based financing is a complex intervention that takes time for the capacity to be built among vital actors. Progressive re-designing of models enhances fitness to the health systems context. From this study, we advise that Uganda and similar countries should undertake deliberate efforts to customize such models to the capacity and institutional architecture of their health systems.
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January 2021

A critique of the Uganda district league table using a normative health system performance assessment framework.

BMC Health Serv Res 2018 05 10;18(1):355. Epub 2018 May 10.

Public Health Department, Institute of Tropical Medicine, 155 Nationalestraat, 2000, Antwerp, Belgium.

Background: In 2003 the Uganda Ministry of Health (MoH) introduced the District League Table (DLT) to track district performance. This review of the DLT is intended to add to the evidence base on Health Systems Performance Assessment (HSPA) globally, with emphasis on Low and Middle Income Countries (LMICs), and provide recommendations for adjustments to the current Ugandan reality.

Methods: A normative HSPA framework was used to inform the development of a Key Informant Interview (KII) tool. Thirty Key Informants were interviewed, purposively selected from the Ugandan health system on the basis of having developed or used the DLT. KII data and information from published and grey literature on the Uganda health system was analyzed using deductive analysis.

Results: Stakeholder involvement in the development of the DLT was limited, including MoH officials and development partners, and a few district technical managers. Uganda policy documents articulate a conceptually broad health system whereas the DLT focuses on a healthcare system. The complexity and dynamism of the Uganda health system was insufficiently acknowledged by the HSPA framework. Though DLT objectives and indicators were articulated, there was no conceptual reference model and lack of clarity on the constitutive dimensions. The DLT mechanisms for change were not explicit. The DLT compared markedly different districts and did not identify factors behind observed performance. Uganda lacks a designated institutional unit for the analysis and presentation of HSPA data, and there are challenges in data quality and range.

Conclusions: The critique of the DLT using a normative model supported the development of recommendation for Uganda district HSPA and provides lessons for other LMICs. A similar approach can be used by researchers and policy makers elsewhere for the review and development of other frameworks. Adjustments in Uganda district HSPA should consider: wider stakeholder involvement with more district managers including political, administrative and technical; better anchoring within the national health system framework; integration of the notion of complexity in the design of the framework; and emphasis on facilitating district decision-making and learning. There is need to improve data quality and range and additional approaches for data analysis and presentation.
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May 2018

District health planning at a time of transition: a critical review and lessons learnt from the implementation of regional planning in Uganda.

Int Health 2016 05;8(3):162-9

Directorate of Planning & Development, Ministry of Health, Kampala, Uganda.

A quarter of a century after the Harare Declaration on Strengthening District Health Systems Based on Primary Health Care (1987) was conceived, district health teams (DHTs) are facing a markedly changed situation. Rapid population growth, urbanization, a rapidly developing private sector, and the increasing role of vertical programs and global initiatives have marginalized the planning process and weakened the entire district health system (DHS). The Ugandan Ministry of Health (MoH) responded to these challenges by beginning a review of district planning: a key action point of the Harare Declaration. The first step was a critical review of relevant literature, then central and district health staff were engaged with to provide their input in developing the new strategy. Through a field experiment started in 2012-13, and still underway, the MoH is developing an innovative regional approach to health planning, which aims to encompass the complexity of the new context of health care provision and coordinate all new actors (private health providers, projects and local government staff from other sectors) operating in the health sector. A strategic revision of the planning process represents an opportunity to develop an appropriate 'Theory of Change', intended as a broader approach of thinking about the entire DHS and the relative role and functions of the DHT. Leadership and stewardship capacities of MoH staff, at central and peripheral level, must be strengthened and supported to achieve the expected changes and results.
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May 2016