Bulamu's Health Center Excellence Management System

We seek to address the lack of timely, usable data to support active management of local health facilities within the Ugandan public health system. This problem affects most low- and middle-income countries that manage their health facility data based on guidance from their Ministries of Health and the statistics required by the World Health Organization (WHO). In MOH systems across Africa, the focus is on public health data, while ignoring the collection of management information that would be useful for improving patient care, staff attendance, and clinician productivity. The voluminous disease and mortality data that is collected often moves in one direction only, from the local health facility to the MOH. This feeds the country’s annual public health reports, but often data summaries are only shared after the year has ended, months after the data is sent from the district or health unit level. While comparing national performance data on disease and mortality statistics is vitally important for determining national public health priorities, the status quo approach does not automatically produce timely, actionable data at the ground level that will empower leaders, clinicians, and stakeholders to actively lead their health facilities, set priorities and take action, and ultimately change both local and national public health results through better data-driven leadership.  

In Uganda, the MOH requires all 6,232 health facilities in the country (3,194 public and 3,038 private) to submit Form 105 each month, a 29-page digital report with over 12,000 cells of data that has grown from 9 pages in its previous version. (For example, each disease incidence is recorded by gender for 6 different age breakdowns.) From that data, each November Uganda’s MOH issues an annual District League Table (DLT) ranking. The DLT ranking, however, appears 5 months after the end of the fiscal year its data comes from. This delay limits the usefulness of the report and complicates efforts by Uganda's 140 local government districts to improve on the 16 important public health metrics contained in the DLT. 

Beyond this, little of the Form 105 data is returned back to the districts and their health units in a timely or actionable manner. On a larger scale, the WHO’s latest guidance for national health information systems came out in 2010 and does not address the timely use of local health facility data, focusing instead on the public health data needed for country comparisons (cf. Section 3.6).

Bulamu’s HCE management system takes a very different approach to health system performance data, coming from the perspective of how a business enterprise would monitor and improve performance in a nationwide chain of operating branches – whether health facilities or restaurants (cf. Atul Gawande, “Annals of Healthcare: Big Med [and the Cheesecake Factory]” The New Yorker, August 6, 2012). More importantly, since 2019, we have been discussing key questions with leaders and stakeholders throughout Uganda’s public health system. What Key Performance Indicators (KPIs) should a management system track and share back to facility managers and regional/national management to measure how well each team is doing in accomplishing the organization’s mission and performance objectives? What quantity of data is simply too much to be monitored? What quantity of data will best support leaders to actively manage and improve their health system on a regular basis? 

Working with many local partners throughout Uganda, Bulamu concluded that the right amount of data for leaders to be empowered as active management fits KPIs into a 1-page “Dashboard” that summarizes the entire health system’s performance. We then heard feedback from our pilot partner district leaders that they prefer data as graphic reports that highlight trends in key metrics, which we also developed. 

Bulamu's HCE system currently includes 4 dashboards: 

1) and 2) The Bulamu HCE-IT system produces a weekly and monthly KPI dashboard at the health unit level, BHI-50W (weekly) and BHI-50M (monthly). 

3) DLT-1 is a monthly dashboard at the district level that tracks performance on the 16 metrics that make up the MOH’s annual District League Table (DLT) rankings, which is seen as the key ranking publication for the health system in Uganda. DLT-1 also contains some other key performance factors that local health leaders told us they want to see regularly. (See image at section end.)

4) DLT-4 contains 21 KPIs that summarize the monthly performance data delivered by district Environmental Health Inspectors. There are 15 to 68 health inspectors in each district who do field inspections of residential and commercial facilities, track progress on covered latrines and hand washing stations, inspect water sources for contamination, and provide sanitation education events in schools and public settings. We are now introducing a digital field inspector web reporting system, based on the KoboToolbox app, that can be used any smart device. Until now, our district partners have had no way of monitoring field inspector performance other than collecting and analyzing hard-copy reports months after the fact. (See image at section end.)

Bulamu is currently converting its HCE-IT reporting system from a proof of concept pilot system to a web-based database reporting system to track KPIs submitted by each partner health center weekly. Local health workers submit 56 KPIs per facility to the HCE-IT system. These KPIs (see images 1-3 below) are then graphed and returned back to health facilities, district leaders, and other stakeholders in a timely, actionable format. Additional data is collected and graphed on staff productivity and on inventory of essential medicines and health supplies. 

HCE’s weekly graphic reports support ongoing attention to the KPIs, while monthly reports (including clinician productivity) show a substantial sample of each partner district’s annual health system results without delay. 

1. Here is a sample KPI management report with monthly data (one of multiple weekly/monthly reports for 56 KPIs):   

2. Here is a sample monthly clinician productivity ranking report, representative of those for doctors, midwives, outpatient nurses (who treat individual patients), and overall staff productivity: 

3. Here is the current KPI dashboard (easily adaptable when our v.3 MySQL system comes online in Oct. 2022): 

The HCE system monitors service delivery, doctor productivity, and other metrics in novel ways that are designed to drive continuous improvement. For priority KPIs, staff and district performance can be ranked and compared, including with inferences to show the expected standard of performance (eg, draw a line at the standard of 4 days worked per week for clinicians, or 80% Payroll Yield). 

After a local health facility’s KPI data is uploaded to the cloud, the results are available for immediate download in the form of management reports which provide leaders and stakeholders with easy to interpret graphs that compare the most recent 6 weeks and 6 months. Bulamu trains partner health staff in collecting and uploading the data, maintains the HCE-IT system, and helps district leaders interpret the reports and become better managers using this knowledge. This data is not available in the current national health IT system in Uganda, but the MOH has requested Bulamu’s help in developing a system to track the KPI data and share them in a timely way with local and national leaders. 

Here are a few examples of novel weekly/monthly data graphed by HCE. This data is not graphed and returned to local leaders (and usually not collected) by existing MOH information systems.

As one senior MOH leader told us, "Our existing data system is good for accounting and annual reporting, but it has nothing like the management reports functionality that your system has. We need to start to scale this nationally now."

HCE’s data is produced because Bulamu provides additional systems to support districts to operate their health facilities effectively. Bulamu's Health Center Excellence (HCE) program is a comprehensive hospital/clinic management system for improving patient care at local health facilities, while also raising health system productivity through weekly and monthly management reports. The HCE program was founded on the principle that district leaders and in-charges of public health facilities, when provided with the right data, tools, and training, can become effective managers and improve patient care at their facilities. HCE’s central management tool is a dashboard with 56 KPIs that includes public health information (e.g., number of NCDs diagnosed) as well as management-oriented metrics such as vital signs recorded, staff attendance, clinician productivity, operating room “down days,” emergency transports, unfilled prescriptions, patient treatment times, staff training hours, etc. This dashboard with weekly or monthly data is created via Tableau and shared with district leaders, health facility in-charges, and other stakeholders. 

HCE’s management reports include timely and usable data for district and facility leaders to monitor performance more actively, clear bottlenecks faster, celebrate successes, take data-driven corrective action when necessary and set priorities for the future. As our solution works towards correcting an information asymmetry caused by the right people not having access to the right data at the right time, Dr. Peter Waiswa observed that HCE provides "Data as the intervention" in order to empower leaders to improve health system performance. In many fields where data use has been improved to be more timely and actionable, productivity improvements have followed. It is past time that local health facilities’ data should be used to empower leaders, staff, and stakeholders to manage the health system actively for performance improvement, resulting in better care and health outcomes for the poor. 

Students of management know that “What gets measured, gets done.” Providing public health system managers, who are often doctors and nurses by training, with new information that is more timely and usable will change the patient experience positively as reports empower leaders to take action. Toward that end, Bulamu also supports district and facility leaders with analysis, and we support leaders for their priority-setting and intervention actions. 

Here is the DLT-1 dashboard described above - this will provide monthly reports and eventually graphic reports, vastly improving on the status quo where districts receive a report on this data annually, 5 months after the fiscal year has ended:

Here is the DLT-4 dashboard described above - this will provide the same benefits as DLT-1 to Uganda's district governments: 

Our solution serves the poor of Uganda, a majority of whom can only access healthcare through the MOH system. We do this by empowering health system leaders to manage more actively and effectively. The HCE program is currently installed in 266 public health facilities throughout Uganda that treat more than 2 million patients per year. HCE management reports support leaders in setting data-driven priorities and taking action so that primary healthcare facilities’ performance can be managed actively and continuously improve. In time, we expect facilities and districts that use our data-driven approach will show improved performance of primary health care facilities, improved quantity as well as quality of health services provided, improved access to healthcare, more equity in getting appropriate healthcare, and ultimately improved health outcomes for the general population. 

Uganda’s MOH Director General Dr. Henry Mwebesa has endorsed our work repeatedly, including writing in a Nov. 2021 letter to the Gates Foundation: “I am writing to support the remarkable work that Bulamu Healthcare is doing with the Ministry of Health system in Uganda. Each time we meet with Bulamu, we are impressed and amazed by the efficiency and effectiveness of their programs. Bulamu's work represents some of the most promising that the Permanent Secretary and I know of for the future of our health system.... As the Permanent Secretary's June 7, 2021 letter regarding Bulamu states, we are evaluating Bulamu's work for the next revision of Uganda's HMIS [Health Management Information System] operating model in 2024.”

HCE’s management reports will improve data use in terms of timeliness and visibility, supporting leaders to set priorities and take action. This will translate into continuously improving health systems in well-led districts, while clear graphic reports comparing districts to each other on a regular basis motivate all districts to manage their health systems actively. Over time, this is a template that we hope to share with many MOHs via the WHO or other regional organizations recommending this approach to data as a best practice. Global businesses have used weekly and monthly KPI data in their management for generations, but this approach has not yet been widely applied to public sector healthcare in low- and middle-income countries, and it is overdue. 

Bulamu’s management system for public health facilities, the Health Center Excellence (HCE) program, is currently installed and supporting improved quality of care in 266 MOH health facilities on an ongoing basis. By early 2023, HCE will be supporting 347 total MOH facilities in 12 districts of Uganda, which treat more than 3 million patients per year and contain 17% of the country's population. Uganda’s MOH leaders have requested that we scale the HCE program nationally to all 3,200 facilities as soon as this is feasible, citing multiple systems we provide including HCE's graphic management reports. Each HCE system and all of the KPIs we collect came from local leaders' and stakeholders' input, usually from repeated discussions over a year or more.

Through the HCE system, Bulamu provides individual training to the Health Information Assistants (HIAs) already employed at each MOH health unit, so that they can upload weekly data into our system. We have found that monthly reports help district leaders to identify challenges in their health system on a timely basis, to implement health campaigns using timely data, and to take corrective action when necessary. 

The HCE management reports use existing technology (smartphones, MySQL, low bandwidth requirements) and MOH staff to deliver data that leads to insights, leading to improved patient care. HCE is a cost-effective, highly scalable program that does not require high bandwidth to operate. HCE’s management reports have been developed with the active participation of multiple levels of Uganda’s MOH. This has resulted in a novel system for graphing and sharing data in near-real time. We are now converting the HCE-IT system to a more scalable architecture using a website for data input and a relational database, MySQL, that will allow future upgrades to be administered centrally. This platform upgrade is now being programmed and will be applied across our network in Q4 2022. The features of cell phone data submission and national scalability lay the foundation for extension across the entire Uganda MOH network and future international scale, while the existing Tableau management reports are already programmed and will not require major changes. HCE’s management reports provide timely data that Uganda’s MOH (and likely many other MOHs) would like to have but have never had access to. 

Bulamu has built trust and meaningful relationships with the MOH, district leadership, and members of many communities in Uganda through its pioneering and ongoing clinical programs. We then leverage these relationships to support long-term health systems strengthening through the HCE program. We seek input at every level with community stakeholders to identify what is effective as well as make changes to the program. We conduct patient satisfaction surveys in the public health facilities to assess their needs and quality of care received before and after the installation of the HCE program, so we can adapt the programs accordingly. As one example, in 2018, Patient Satisfaction on an average of 5 questions was at 59%. In 2021, 10 months into the global phase of the COVID-19 pandemic, patients satisfaction (same facilities, same survey) improved to 94%. (Please see Bulamu’s 2020 Annual Report, p. 6-7, for more information.)

Bulamu’s biggest challenge is raising enough philanthropic support to complete the programming of the HCE-IT system and scale it internationally. We also require adequate resources to strengthen our Monitoring & Evaluation activities. With the Solve prize funding, we will complete programming of the HCE-IT system, achieving our goal of supporting 12 districts with 347 MOH facilities in Uganda with these reports. We will also use the resources to document HCE’s approach to data and impact as a best practice for health systems strengthening in Africa. Uganda’s MOH has requested that we scale HCE nationally, so this grant would support our progress towards that goal. The HCE program would greatly benefit from the award of the WFP Innovation Accelerator support to continue testing and developing the program design and operations.

For the first time in Uganda, managers and district officials will soon have weekly and monthly graphic reports that they need to manage public health facilities and take corrective action where needed. Through HCE’s KPIs and graphic approach to timely data, leaders can monitor and improve on performance items including taking vital signs, improving staff attendance and productivity, reducing medicines and health supplies out of stock, and reducing patient treatment times.

HCE's approach of collecting systemic data at the facility and district level, analyzing it, and providing weekly/monthly graphic reports that look across the entire health system’s activities to leaders at all levels to help guide active local management is currently unavailable to Uganda's MOH and many other MOHs.

We expect HCE's management reports system to be catalytic by demonstrating a better approach to using recent health facility data, which we then will share as widely as possible with other countries. The WHO does not have a guideline on local health facility data use and best practices, and HCE's approach could contribute to one, sharing this work with 200 countries' Ministries of Health approx. 5 years from now.

This work's success will be measured by its national and international scale and the performance improvements it supports for patients and health systems. Here are the key steps we anticipate to achieve national scale in Uganda and beyond, with positive systemic improvement impacts for millions of patients or more in the next 1-5 years:

One year: 

Bulamu will continue its health systems strengthening HCE program in 9 partner districts, while completing the installation of 3 recently added partner districts by Q1 2023. At that time, HCE’s reports will reach a total of 12 districts, about 11% of Uganda’s MOH facilities, and 17% of Uganda's population, producing a substantial dataset from the management reports shared with district leaders on a weekly and monthly basis. 

Uganda's MOH leaders have stated repeatedly that they are evaluating HCE for national scale by incorporating its key systems into the MOH's operating model. This remains a key goal for the next 1-2 years and one we are making progress on, based on detailed evaluation meetings on HCE's work that are ongoing with the stated purpose of using HCE to update the MOH's systems.

In conversation with health systems leaders at Gates Foundation in the past, one measure of success was described as, "Do leaders use the reports to set 3-5 priorities? And then what changes?" This has already happened, but as the v.3 HCE-IT system comes online, these will be key items we work towards for the year ahead, measured by changes in HCE's KPI reports and from other data sources.

Five year: 

In the next 5 years, our goals are to improve and scale the HCE program nationally in Uganda, and to share HCE's management reports with countries throughout sub-Saharan Africa, driving continuous improvement in health systems and healthcare services for the poor. 

In 3-5 years, we would like to support the WHO to create a new guideline on the use of local health facility data, which would support HCE’s approach to data and management reports to reach global scale. 

We are well underway at achieving the goals for the upcoming 12 months, with our main challenge being enough funding to advance the work quickly. For the 1-5 year range goals, we continue to improve on our unique partnership with Uganda’s MOH, whose leaders see Bulamu's work as its R&D lab for improving healthcare on a national scale. The more parts of our program demonstrate results, the better our partnership grows with the MOH, further accelerating our path to scale and to sharing results through academic research. 

Bulamu has been evaluating patient satisfaction in health facilities before and 6+ months after installation of the HCE program in its new partner districts. Feedback from relevant stakeholders like staff members and health leaders is also regularly requested and reviewed, to inform iterative changes to the program and maximize its benefits. 

Bulamu is also using the KPIs in the management reports as indicators to monitor the progress against priority areas for health facilities and districts. We conduct ongoing impact evaluations with our partner MOH facilities in Uganda to assess how well the utilization of the above management reports reaches its objectives. We use learnings from these evaluations and feedback from stakeholders to improve the program and increase the pace of scaleup in Uganda and beyond. A substantial part of our work, including HCE’s management reports system, is being written up for multiple peer-reviewed academic journal articles over the next year.

The provision of timely, visual reports with insights on productivity and operations empowers health leaders to monitor the health facilities under them. Once empowered, leaders can take corrective action where necessary and address bottlenecks, which in turn leads to outcomes such as improved clinician productivity, increases in functioning operating rooms, and up-to-date standard of care practices (e.g., recording vital signs for the timely diagnosis of diseases like hypertension), among other benefits. The overall impact will be increased health system performance (e.g., standards of care provided, access to C-sections at appropriate facilities), increased patient access to and use of health services, improved patient satisfaction, and improved health outcomes such as a reduction in maternal mortality. 

Distinguished global health leader Dr. William Foege sent this feedback on our 2021 Annual Report: “You are hitting on some essentials. First use data, interpret it and get the interpretation back to those who provided [the data]. Second, make it a management tool and show how it can be used to change activities. And third, respond fast so people see how useful it is and help make tactical changes based on what the field workers discover. Good Work.”

Bulamu’s overall Theory of Change is as follows:

For this grant application, Bulamu’s activities will focus on the HCE management reports system and conducting the M&E and academic research necessary to improve HCE and evaluate it for further scale.

As we have moved from pilot to early scale, going from 1 partner district in 2020 to 9 districts in 2022, we are now programming a v.3 HCE-IT system using MySQL as a database manager. This is facilitating multiple improvements and setting the system up for national scale in Uganda. This v.3 system will launch in Oct. 2022 with full reports functionality by early 2023. Our v.2 system uses Tableau to graph data as weekly and monthly management reports. KPI data are graphed in reports organized by health unit, district, and cross-district rankings. 

In each partner district, Bulamu trains health facility Records Assistants to upload data from health centers to the cloud-based HCE-IT data warehouse. The v.3 system will support cell-phone based data entry, improving the system’s ability to scale. As with the rest of the HCE program's systems, the people who send and receive the data are employees of the Ministry of Health system, allowing this work to easily scale through the MOH's staff network.

Bulamu has adopted an inclusive approach towards recruitment, contracting, partnerships and invitations for joining the board with zero tolerance to any sort of discrimination. This is both to ensure we build an equitable organization and to ensure maximum diversity of thought and leadership. 

We define impact as stronger health systems and patient health outcomes, based on systemic data as well as further evidence. Past examples have included raising the rate of taking adult Blood Pressure from 3% to 55% (2019 Annual Report), moving patient satisfaction from 59% to 94% (2020 Annual Report), and identifying new ways of data to understand health system performance (40% of patients leaving health facilities with unfilled prescriptions, 2019 M&E now concluding as a follow up IRB-approved national study on the same topic). 

Since 2019, we have worked with our partners and stakeholders to design and provide HCE's system of graphic reports for the KPIs that many Ugandan health leaders have requested and helped us to refine. We are now programming HCE’s management reports for national scale, broad-based M&E, and academic research publication, so our approach and the reports' benefits can be shared internationally in the next 1-3 years. 

Currently, Bulamu is a US 501(c)3 non-profit organization, with a registered NGO subsidiary operating in Uganda. While we are currently donor-supported, in discussions with Uganda’s government, we now make clear there are 5 key systems we can scale nationally and what the costs will be to achieve this. However, to reach the other 90% of Uganda’s public health system, we also make clear that this will require a new source of funds. As discussed below, we anticipate that these funds will likely be either from larger foundations and research grants or from governments that engage Bulamu for the data reports systems we can provide and eventually integrate with their national health IT infrastructure. 

When we have to choose scale vs. revenue, based on our non-profit mission, we will choose scale. So there may be a scenario where we freely share the solutions we have identified (where this is technically feasible), while Bulamu moves on to working on additional challenges in LMIC public health systems where we can be of service.

There are 3 most likely options for this at present:

1) Remain a small, donor-supported R&D organization for improving healthcare for the poor. Limit programs to available funds raised. This is our current approach.

2) Continue with donor support while growing through multi-year grants from foundations and/or international aid organizations, with the support of Uganda's government (and eventually other partner governments). This is the most likely path to scale and the next step we are working on by proving that HCE delivers results at scale and is extremely low-cost to scale. 

3) Continue with items 1 and 2 while selling our services as a package to a donor or partner government, which hires Bulamu to implement HCE at national scale in Uganda (and other countries). This is the ideal approach and one that we are working on as well. 

In order to realize revenue in the future, Bulamu may set up a for-profit company that is wholly owned by our non-profit organization. Given our mission and Board's bylaws, surplus funds from any for-profit company would be used to support the growth of our programs and further improve and scale them.

Bulamu's revenues have grown from $182,000 in 2017 to $1.33 million in 2021. Thanks to donors' support, we have been able to move faster at designing and implementing direct treatment and health systems programs benefiting the rural poor in Uganda than might otherwise have been possible. We currently have $620,000 per year in multi-year annual pledges from repeat donors, up from $0 in recurring pledges as of Sept. 2021. This provides a base of reliable support and has freed up our time to build the programs and develop additional multi-year gifts.

In addition, our “loss leader” approach to building programs that prove scalable solutions are possible has led to ongoing discussions with Uganda’s MInistry of Health on integrating Bulamu’s HCE program into the MOH's national operating model. We estimate the cost to scale 5 key HCE systems would be approx. $5 million per year, or less than 1% of Uganda’s annual health budget. (See p. 4-5 of our 2021 Annual Report.)

Finally, for 2023-2024 our Board of Directors has decided to focus on quality over quantity for the number of districts we work with and services we provide. Because HCE’s systems are highly sought after in Uganda by local and national leaders, this is now prompting a discussion with Uganda's Govt. on the long-term funding options for HCE to scale up nationally. This conversation has been led by Uganda’s MOH and selected Members of Parliament who want HCE to work in their districts, who we have had to inform that the only path to further scale is a new source of long-term financing and a plan that scales HCE to the remaining 90% of Ugandan districts over several years. Because of HCE’s low-cost relative to its impact on partner health systems' functioning, this may result in funding for national scale from one or more partners in the next 1-3 years.