Background: 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.Objective: This paper examines the evolution of results-based financing models and the reasons for the slow national adoption and implementation in Uganda.Methods: 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.Results: 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.Conclusion: 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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