Dr. Ambrosoli Memorial Hospital and St. Mary's Lacor Hospital are two effective examples of the impact of RBF on the quality of pediatric services.

In recent decades, new funding methodologies have been developed with the objective of increasing support for health programs, overcoming the lack of traditional funding mechanisms. Among these is the Result Based Financing (RBF), a financing mechanism that aims to improve the quality of donations by binding the disbursement of funds to the achievement and audit of predetermined results.

The conference, which was held last October 29 in the Auditorium of University of Naples Federico II, organized in collaboration with the Corti Foundation and the Ambrosoli Foundation, was an opportunity to present the results of the study promoted in collaboration with the University on the effectiveness of the RBF project funded by the Italian Agency for Development Cooperation (AICS) and Cariplo Foundation.

A moment to reflect, thanks to the intervention of authoritative guests, and bring attention to one of the most important methods of supporting global health. At the same table the representatives of the two Foundations, experts in development and global cooperation of international standing such as Nicoletta Dentico of the Society of International Development and Eduardo Missoni of Bocconi University. AICS speakers Mariangela Pantaleo and Andrea Stroppiana took part; James Mwaka, representative of the Ugandan Ministry of Health, underlined how Uganda believes in this financing system and in collaboration with public and private entities of international importance.

The RBF has been found to be the driving force of change for pediatric services, considering that 50,000 children are welcomed and treated every year at Lacor, thanks to one of the largest pediatric wards in Northern Uganda, while Dr. Ambrosoli Memorial represents a life-saving stronghold in a district where 37% of the population is under the age of 10.

St. Mary's Lacor Hospital (Gulu) and Corti Foundation have designed a privately funded RBF system primarily based on quarterly external audits of quality standards. Initially developed to finance outpatient activities, the RBF system was extended to the pediatric wards of Lacor Hospital and introduced for the first time at Dr. Ambrosoli Memorial Hospital in Kalongo in the pediatric ward. After 3 years, this methodology has shown great potential for improving the quality of hospital services.

 “The RBF system consists of a support given to a structure according to the quantity and quality of the results it achieves. More than half of the support projects in developing Countries do not reach the predetermined objectives and do not transform the local reality. Evaluating the quality of the services offered is a real revolution "- says Professor Luigi Greco, Professor of Pediatrics at the Faculty of Medicine of University of Naples Federico II and Associate Dean of the Faculty of Medicine of the University of Gulu which contributed to found, head of Federico II's GULUNAP project and cooperation projects with Uganda - “We compared the quality of care for children of two big hospitals in Northern Uganda, St. Mary's Lacor Hospital and Dr. Ambrosoli Memorial Hospital, performing a quarterly supervision. In light of these results, we have verified that the project has produced for the first time a significant improvement of 30-40% in the quality of care in these big hospitals ".

The analysis of the data starting from the medical records and RBF check-lists sent by the two Ugandan hospitals was carried out by the team headed by Professor Sergio Beraldo of the Department of Economics and Statistics of the University of Naples Federico II: "The examination of patient records showed that the quality of medical care improved, mortality in children, reinfection rates and hospital stay time decreased ",

The RBF method consists in assigning a fixed amount, equal to about 15 Euros, for each pediatric hospitalization. This figure includes the investigations and therapies needed by the child, regardless of the length of hospitalization and the type of illness. To this is added a quality bonus which is attributed based on the score achieved by verifying the quality of the services quarterly. The score ranges from one to five and allows you to increase the amount paid to the hospital from 5 to 25 percent, thus attributing a financial bonus to the hospital. (note to Laura: I deleted this part because Corti and us, we use the bonus differently and it would take too long to go into detail on the different ways of managing the bonus)

Both at Lacor and at Dr Ambrosoli Memorial Hospital quality and quantity indicators have been developed: it is a very detailed list with parameters monitored every three months by members of an internal quality committee and by a representative of the Ugandan Ministry of Health.

An approach that has managed to aggregate private and institutional donors thanks to the security it offers and the regular and frequent monitoring that allows the donor to follow the project step by step, with its successes and challenges. The Italian Agency for Development Cooperation, which, since April 2018, has financed the initiative with a total amount of 750 thousand euros, believes it to the end.

"At Lacor Hospital there have been structural improvements and increased attention to infection prevention, the availability of drugs, the preparation of all personnel for emergencies and the development of protocols for clinical and nursing procedures - said the Dr. Venice Omona, specialist in pediatrics and head of the pediatric ward of Lacor - “The sense of responsibility of the staff with respect to the resources of the ward has improved; they are all more attentive to every step that concerns the care of little patients. We have developed new protocols and the challenge is to be able to follow them in the best possible way. The dialogue between the staff and with the parents of the young patients was also at the center of the work and I noticed improvements in the ability to explain diagnoses, necessary investigations and therapy "

Even in Kalongo, where the RBF methodology with quality checks was introduced for the first time with the project funded by AICS, the program has produced a truly remarkable impact, as shown by the data developed by Professor Greco in the examination of medical records.

 “The clinical management of pediatric patients has improved significantly since 2016, most notably in Kalongo. Observe for example the increase in variations from 2016 to 2020 to evaluate the marked changes that have occurred: the compilation of a detailed clinical history and the accuracy of the child's examination have improved by more than 6 times (= 600%). Likewise, good sepsis treatment has increased 9 times, ” underlines Professor Greco.

Dr. Godfrey Smart Okot, director of Dr. Ambrosoli Memorial Hopistal, confirms the evidence found through the examination of medical records: "Before the start of the project, three years ago, the clinical and ethical practice regarding the care of the sick child in the hospital was more rooted in the routine. Subsequently, the approach evolved. More emphasis is now placed on studying the sick child, communicating eloquently with the child's caregiver, and ensuring that the treatment environment is sufficiently holistic (clean, safe and calm). The preparation of the project actively involved the staff, through training on 'best practices' and the related advantages. The staff therefore realized how much this method not only guarantees that the sick child heals, but also affects positively their professional skills. The final result is that the overall quality of care has improved significantly compared to the period before the project ”.

This result is even more significant if we consider the stress to which the Kalongo hospital and the pediatric ward were subjected for the always lurking epidemics: between 2019-2020 due to malaria, total hospitalizations increased of 83% compared to the same period the previous year,  the bed occupancy rate of 198%. This means that for months the hospitalized children exceeded the availability of beds in the ward and the staff was forced to accommodate more patients in one bed or use improvised spaces for hospitalization. Then followed the long period marked by the pandemic, where all the ward staff remained always operational and ready to welcome the numerous patients, despite the fear of contagion.

“The RBF method is a tool that helps to maintain a surveillance and control system on the quality of services”, emphasizes Professor Greco. “It is a model that helps to avoid waste”. Many, therefore, have been the successes and many more challenges. “The greatest is that the changes induced by this three-year project become everyday life”, concludes Luigi Greco

We thank the University Service Center for the Coordination of Special Projects and Organizational Innovation (COINOR) and the support of Federico II Department of Economics and Statistics.

Even if the total hospital’s admissions have decreased by 19%, the most significant and worrying drop concerns maternity ward access, which decreased by 56%, with a 44% decrease in deliveries. These numbers come to us directly from Kalongo and give us a worrying picture of the impact that the pandemic has on the daily life of the community.

The decrease in antenatal visits is a consequence of the strict rules to prevent the spread of Covid-19, of the increased poverty that doesn't allow women to pay for the trip to the Hospital, and of the fear of infection. Such situation has caused a reduction of preventive therapies provided, with inevitable consequences on the health of the fetus and future mothers.

Such a high reduction in deliveries means an increase in unassisted deliveries, with consequent risks of maternal mortality, neonatal mortality, development of serious complications during delivery which can lead to permanent disabilities for both the mother and the unborn child.

However, in the midst of this difficult and disheartening moment, there are also many stories that thanks to the tenacity and resilience of the doctors and hospital staff, combined with the courage and strength of these mothers, reach a happy ending and make us look to the future with glimmers of positivity.

Like the story of Esther, a 19 years old young woman at her first pregnancy who came to the Kalongo hospital from the Komotor Health Center in Agago because she was in labor and with Covid symptoms. Arriving at Dr Ambrosoli Memorial Hospital, she was immediately tested for Covid and turned out positive. She was admitted to the isolation ward. A "special delivery

room" was created for her in the same ward, where she was constantly assisted by a midwife and the medical team who started treatment for Covid. Unfortunately, Esther's labor failed to progress for 2 days, probably due to high fever of the mother. The fetus started developing fetal distress.

The medical staff did not lose heart and promptly decided for an emergency caesarean section to save the lives of both the mother and the baby.

Everything went well, Esther and her baby recovered very well and they were discharged a few days ago from the hospital.

This is Kalongo, this is the strength of Dr. Ambrosoli Memorial Hospital who fights every day for the joy of life.

The delta variant is spreading among Africans at a shocking level of diffusion - 225 times faster than the first wave of the original virus in Africa. Uganda has a high number of cases in the under 40 age group, with an increasing mortality. Most patients require hospitalization in intensive or sub-intensive care units. The oxygen demand, with patients consuming between 4 and 6 tanks per day against the 1-2 tanks of patients admitted to sub-intensive care for other pathologies, has increased exponentially.

At Kalongo hospital COVID19 - reference center for mild and moderate cases, the positivity rate is now 22%, but the cases are certainly many more given the scarce number of tests available.

"Our testing algorithm is primarily aimed only at people who have COVID-like symptoms to optimize the scarce testing resources we have" - ​​says Dr. Smart, director of the hospital - "This means that the positives who do not show symptoms cannot be reached and also those who have come into contact with infected people cannot be tested. We recommend that all traceable contacts self-isolate for at least 10 days. Traceability is very complex and difficult to put into practice in our communities of isolated villages".

Since June 20 patients have been hospitalized and treated and 80% of them were oxygen-dependent, but thanks to the tenacity of the doctors and hospital staff only 3 patients have died. To face this pandemic, which is added to an already precarious health situation, the hospital was able to guarantee treatment thanks to the support of Ambrosoli Foundation, not charging patients any costs, unlike many other hospitals in the country. To help the hospital coping with the pandemic, the Foundation has allocated approximately € 82,000 since 2020 for the supply of masks, gloves, disinfectants, breathing equipment. Our thanks go to you who support us and who are close to us! The situation could not be more dramatic, not only in the present, but also in perspective. The vaccination campaign in Africa is not following the expected pace, only 1% of the population has been fully vaccinated.

“We have a difficult path ahead. There is a lack of drugs, medical devices and basic equipment - Dr. Smart states - "with the speed of spread of the virus, the reserves of the hospitals have run out, even here in Kalongo. Our isolation ward is old, unsuitable and unsafe for patients care. But above all, the supply of oxygen remains very demanding. It is risky and we cannot rely on concentrators which often break due to constant use. An impact that affects the entire hospital: children continue to be born, premature cases increase, malaria, malnutrition and tuberculosis do not give a break.

Do not leave them alone!

Public funding of health programs has recently been characterized by increasing conditionality in the provision of resources. This trend typically includes result-based financing programs (RBF), which promise rewards to individuals or institutions, conditioning them to the achievement of the agreed objectives.

The St. Mary's Hospital in Lacor (Gulu, Uganda) and the Corti Foundation, after a first experience with the RBF approach funded by the British government, have extended the adoption of incentive mechanisms of this kind with the aim of improving the quality of healthcare provided.

Thanks to the three-year contribution of the Italian Agency for Development Cooperation (AICS), results-based financing mechanisms have been tested in the pediatric wards of Lacor Hospital and Dr Ambrosoli Memorial Kalongo Hospital, showing considerable potential in improving the quality of the services provided, hence in contributing to the reduction of the high infant mortality rates.

Starting from this experience, and from the analysis of the evidence gathered in the hospitals of Lacor and Kalongo, the University of Naples Federico II, in partnership with the Corti and the Ambrosoli Foundation, promotes a conference on result-based financing programmes with the aim of discussing their effectiveness in favouring sustainability and quality in the health sector.

Evelyn is 28 years old, pregnant for the third time. When she goes into labor, she decides to deliver at the nearby Health Center. The previous two deliveries were uncomplicated and this third one was also proceeding regularly.

But this time things aren’t going well. After the birth of the child, the placenta is not expelled, Evelyn is losing a lot of blood, the young midwife struggles removing it manually. She finally succeeds but it is immediately clear that the patient needs blood. An ambulance picks Evelyn and her baby up and take them to Kalongo hospital. She arrives at the Out Patient Department unconscious, she has no blood pressure. The staff rushes to perform resuscitation maneuvers while the baby is sent to Neonatal Intensive Care Unit. Finally the patient regains consciousness, is stable, and is transferred to the ward. In the following days comes the diagnosis of malaria, which worsens her anaemia. However, Evelyn seems to go through all her misfortunes with an enviable strength.

Unfortunately after a few days in which she seemed to have recovered, Evelyn has high fever again, her stomach is swollen, she is coughing and has difficulty breathing. We think of a puerperal fever, probably induced by obstetric maneuvers. We start the antibiotics, but Evelyn is finding it harder and harder to breath. We have no doubt, we do the rapid test for Covid-19. To everyone’s dismay the test is positive.

They call me, it’s already Sunday evening, we cannot refer the patient to Gulu, where the isolation center is. We then arrange the transfer to our isolation area.

We prepare the oxygen, make some infusions. To our relief, her saturation seems to hold up well. We are optimistic.

But if her breathing maintains normal parameters, the abdominal situation doesn’t improve. Perhaps a surgery will be necessary. We explain that to the patient and her relatives, they are desperate. We contact Gulu again who inform us that they have no possibility of performing surgery, nor the suitable material to protect the ventilator.

I feel lonely, we all feel lonely. I think about our intensive care therapies, the beeps of the monitors resound in my head, I see again the team of doctors consulting.

I look around in the room where Evelyn is now asleep, the drip, the oxygen concentrator on standby, the pulse oximeter. I think about this young life that is facing such a great battle, against obstetric complications and against Covid. I say to myself “Come on Evelyn, we have to do this!”


Dr. Carmen Orlotti

Surgeon at Kalongo Hospital


On Sunday the president of Uganda,Yoweri Museveni, re-imposed a strict lockdown including school closures and the suspension of travels between districts to help facing a wave of COVID-19 cases in the East African country. A new lockdown hits Uganda. A cold shower for all of us, in Kalongo as in Italy.

Last month infections began to rise, and new cases increased due to more aggressive variants such as English, Indian and South African, particularly among the younger ones, fueling fears that the country could slip into a new wave out of control. The announcement of transport blockade has caused a movement of students and workers who, eager to go home, have left from districts where the rate of infection is already very high, bringing the infection to their villages.

The virus started running suddenly and faster than before across the country: the positivity rate rose from 2% to 17%. There are 61,977 positive cases to date, but it is feared that the numbers are many more than those officially reported.

Dr. Carmen Orlotti, surgeon in Kalongo at Dr. Ambrosoli Memorial Hospital, updates us real time: “Even in Kalongo we started to register the first positives. We have reopened the center for the isolation and treatment of Covid cases. The first hospitalized patients show a typical picture of respiratory failure with dependence on oxygen. Oxygen that can be supplied only from oxygen concentrators. The ministerial protocol provides the transfer of all these patients to Gulu, the closest regional isolation center, but it is already overcrowded. Those will be difficult days to come. Facing an epidemic without having all the means to do it in the best way exposes staff, patients and their families to very high risks. We go on, a look up to ask once again that Fr. Ambrosoli looks after his hospital and all those who work there or seek help ”.

Fortunately Kalongo's staff have been vaccinated, but now we fear the spread of the virus among patients and families. The fear is that hospital beds will run out soon, without forgetting that there are only 218 places in ICU compared to 44 million inhabitants. Oxygen is scarce everywhere, the regional isolation centers are already at the limit of their reception capacity. The government has made numerous efforts to secure the country but what Uganda is really lacking are vaccines. Out of nearly 2 billion doses in the world, only 30 million doses (equal to 1%) arrived in Africa.

According to Matshidiso Moeti, WHO's regional director for Africa, the threat of a third wave is real and growing on the continent considering that the vaccination campaign is essentially at a standstill: the forecast made for months by scientists around the world, according to which the lack of vaccines in third world countries would have facilitated new waves of infections and the birth of new variants, is unfortunately coming true.

Let's not leave them alone! We are very worried but aware: we must help the hospital to face the new wave in the best possible way by continuing to take care of those most in need.

This is the teaching and warning that Father Giuseppe left us with Kalongo hospital and the midwifery school that as a Foundation we carry on every day, continuing to promote the local medical and managerial training, with a specific focus on human and professional training of women, thanks also to the work of many volunteer doctors who work in the hospital.

Like the pediatrician Tito Squillaci, the first Italian doctor that returned to hospital after the outbreak of the pandemic and who worked alongside Father Giuseppe in 1984.

 "This morning, speaking to the students, I indicated the date engraved on the entrance of the midwifery school, 1956. I told them that that year, so far away, had marked our life. All of us, from the various corners of Uganda and Europe, were there because a man with an eye to the future was concerned with preparing a crowd of women capable of working for women and for their most precious good: their children. . Father Giuseppe had realized Daniel Comboni's ideal, "Saving Africa with Africa", and understood that women are the real power of African society. All this is clear when observing the professional but also psychological path that the students start: disoriented and scared on arrival, prepared professionals and self-confident in the end, capable of taking over the fate of a mother and intervene with competence. Most of them come from rural areas, where women are still subject to strong conditioning, their studies therefore become a path of emancipation, and they become examples of change and progress for other women. 

Father Giuseppe, who knew well what it meant to give birth without even a midwife, during the civil war, although aware of the risks to his life, decided not to leave Uganda: he did it to save the school for midwives, to avoid the interruption of the training of  such an important figure, but also of a new civil conscience. And today the school is there ".

Tito Squillaci

Kalongo, March 2021

Today, more than ever, the school and the hospital need regular and constant support to be able to continuously carry on their training activities, which are essential to offer qualified assistance and care every day. Thanks to the people who are supporting us and continue to trust us!

Dear friends,

the past year was dramatic, but it offered us some new opportunities such as intensifying the relationship with you in
a general moment of fear and loneliness. To be honest, due to the spread of the pandemic, we were afraid of not being able to
keep the commitments made with the hospital and the midwifery school.

Your prompt and concrete response in such an uncertain moment surprised us once again. It is thanks to you if we intervened promptly to support the
hospital facing the pandemic and to ensure that no medical activities were suspended. It is thanks to you if despite all the inevitable difficulties we managed to carry on the ongoing projects, concluding the new isolation wards of pediatrics, toilet facilities and the new kitchens specific for that ward: essential interventions to improve the well-being of children forced into periods of isolation. We almost reached the last year of restorations of the accomodations for hospital staff, whose continuous presence is even more important today.

Unfortunately, these concrete results go with the indirect but still dramatic effects of the pandemic.

An example above all: the number of deliveries in hospital has been halved compared to the previous year. A lot of women have renounced safe delivery for the fear and the difficulties to go to the hospital, choosing to give birth at home without the assistance of qualified midwives.
2,707 versus 4,778 deliveries: this halved number tells of deliveries occurred in extremely life-threatening conditions for mothers and their children. The hospital staff is working hard to strengthen instruments and strategies to promote health in the villages among those who do not have access to the basic health services.

And of course they are continuing to take care of the nearly 50,000 people who go to the hospital every year. Our strength in being by their side has always been the mutual trust in the relationship between the Foundation and you who support us. A red thread that connects us and you with Kalongo and allows us to carry out with coherence and seriousness the legacy of love that Father Giuseppe Ambrosoli left us, in order that the hospital remains a concrete and safe point of reference for all the thousands of people who have trusted in it for over 60 years.

Women in Africa are the driving force of the Country, its strength. They do everything possible to get education, earn a salary which allow blended families to live and make their children study, cultivate the fields and above all they do not give up thanks to their inner power. But being a woman is still a challenge within a challenge: even if more and more are those trying to redeem themselves from a condition of economic and social disadvantage, the obstacles and difficulties to  overcome are still many.

Fertility rates in Africa are the highest in the world. In Uganda every woman has an average of 6 children and 15% gives birth to her first child between the ages of 15 and 19. More than 1 in 5 women between the ages of 15 and 49 has experienced some kind of sexual abuse in her lifetime, and most of this violence happens within the household, especially in the rural areas where education is poor. Gender-based violence can have devastating consequences for their lives: very often they have to face unwanted pregnancies, abortions carried out in unsafe conditions, with the risk of contracting sexually transmitted infections. Women conditions in Uganda are still extremely critical.

Recurring pregnancies are the main reason for health and social problems, especially when they are unwanted and happen in contexts of great poverty. A delicate and urgent issue. If fertility rates remain unvaried, United Nations forecasts expect that in 2050 the world population will be 10.6 billion and, with an unchanged trend, in 2100 it will reach 15.8 billion.

But with the stories of Gladys, Molly, Sida, Hellen who graduated from our Midwifery School, we have the proof that things can change, that the woman becoming self-efficient can overcome all the social problems by contributing to the community and protecting many new lives.

Work here at Kalongo hospital is in the hands of women: female nurses, doctors and midwives help in taking care of many mothers and children fighting mother-child mortality, and in training the midwifery school students.

Since its inception in 1959, about 1,500 midwives have graduated from the St. Midwifery School and, thanks to a proper training, they have professionally contributed to the prevention and the treatment of women not only in Uganda, but also in many Countries of sub-Saharan Africa.

The number of enrolled women has increased over the years and the annual average of female students who finish the courses is about 30 for the professional midwives course and about 12 for the head nurse midwives degree.

In addition to guaranteeing medical continuity in the maternity ward of the hospital, the School also contributes to the development of the social role of woman, considered important to reach the female empowerment. The training works entirely on the female figure and on being women, trying to help them to become independent in their decisions, to acquire common sense and clarity of thought without being influenced by the male figure.

Investing in women's empowerment means creating an essential prerequisite for the realization of social justice, it means encouraging a direct path towards gender equality, the eradication of poverty and an inclusive economic growth, especially in remote and rural areas of the world, where social, economic and cultural limitations are added to natural and environmental adversities. This is the important and forward-looking legacy that Father Giuseppe left us and for which he gave his life and that today can be read in the smiles, willpower and pride of all the students of the Midwifery School who know they can make the difference.

Thank you for helping us to make their dreams come true!