Strengthening accountability in Strategic Health Purchasing arrangements for Primary Health Care in Uganda

Effective Strategic Health Purchasing (SHP) is pivotal for making progress towards the achievement of Universal Health Coverage (UHC), as we implement Primary Health Care (PHC). This qualitative study examined accountability and SHP arrangements and how they influence PHC performance. Using document reviews, 43 key informant interviews, and insights from policy dialogues, the study analyzed accountability practices across financial management, contracting, performance monitoring, health benefit specification, and provider payment mechanisms. revealed a well-established but unevenly enforced accountability framework. Vertical accountability mechanisms, such as audits and reporting, are present but weakened by delayed fund disbursements, limited facility autonomy, and weak enforcement. Informal contractual arrangements and parallel donor systems fragment oversight and coherence. Performance accountability is hampered by poor data quality, irregular supervision, and minimal sanctions for underperformance. Horizontal accountability structures like Health Unit Management Committees are inconsistently active. Diagonal accountability, comprising citizen and community engagement, remains largely underdeveloped due to low public awareness and limited feedback mechanisms. The study concludes that strengthening the enforcement of existing regulations, enhancing facility-level autonomy, formalizing contracts, improving data systems, and institutionalizing community engagement are critical for improving SHP accountability and PHC outcomes. Addressing these gaps can significantly enhance accountability in Uganda’s health system. • Financial accountability policies alone are not adequate; without effective and timely enforcement, fail to protect resources, undermines strategic purchasing and weakens PHC service delivery. • Limited autonomy in financial management and procurement at the facility level restricts responsiveness to local needs. Granting greater decision-making power to frontline providers can improve service delivery by enabling context-specific, timely responses. • Uganda’s experience shows that informal or weakly monitored contracts fail to drive performance and undermine accountability. Formalizing contracts with clear expectations, deliverables, and enforcement mechanisms is critical to ensuring accountability in service provision. • Existing performance monitoring systems are weakened by poor data quality and the lack of effective feedback loops. Investing in data systems and ensuring that monitoring leads to real-time corrective action can significantly boost the effectiveness of SHP. • Diagonal accountability mechanisms are underutilized in Uganda due to limited citizen participation. Strengthening community engagement platforms that allow for feedback, participation, and oversight can make PHC services more responsive and equitable • This study employed a comprehensive analytical approach, informed by the principal-agent theory, public accountability theory, and new institutional economics. Rigorous data triangulation and validation enhance the quality, ownership and usefulness of the findings