How do healthcare providers respond to multiple funding flows? A conceptual framework and options to align them

Examining multiple funding flows to public healthcare providers in low- and middle-income countries - results from case studies in Burkina Faso, Kenya, Morocco, Nigeria, Tunisia and Vietnam

Provider payment methods are traditionally examined by appraising the incentive signals inherent in individual payment mechanisms. However, mixed payment arrangements, which result in multiple funding flows from purchasers to providers, could be better understood by applying a systems approach that assesses the combined effects of multiple payment streams on healthcare providers. Guided by the framework developed by Barasa et al. (2021) (Barasa E, Mathauer I, Kabia E et al. 2021. How do healthcare providers respond to multiple funding flows? A conceptual framework and options to align them. Health Policy and Planning  36: 861-8.), this paper synthesizes the findings from six country case studies that examined multiple funding flows and describes the potential effect of multiple payment streams on healthcare provider behaviour in low- and middle-income countries. The qualitative findings from this study reveal the extent of undesirable provider behaviour occurring due to the receipt of multiple funding flows and explain how certain characteristics of funding flows can drive the occurrence of undesirable behaviours. Service and resource shifting occurred in most of the study countries; however, the occurrence of cost shifting was less evident. The perceived adequacy of payment rates was found to be the strongest driver of provider behaviour in the countries examined. The study results indicate that undesirable provider behaviours can have negative impacts on efficiency, equity and quality in healthcare service provision. Further empirical studies are required to add to the evidence on this link. In addition, future research could explore how governance arrangements can be used to coordinate multiple funding flows, mitigate unfavourable consequences and identify issues associated with the implementation of relevant governance measures.

Barriers to health care utilization among patients with type 2 diabetes living in slums: a qualitative study from providers' perspective

BACKGROUND

Due to slum dwellers' deprivation, they are more likely to develop Type 2 Diabetes (T2D) and its complications. Type 2 Diabetes is a long-life disease that requires continuous health care utilization. One of the negative outcomes of slum-dwelling is health care underutilization. Therefore, this study aimed to understand barriers to health care utilization among those with T2D living in Tabriz slums, Iran, from the perspective of healthcare providers, in 2022.

METHODS

A phenomenological approach was used in this study. Purposive sampling for conducting in-depth interviews was used to select 23 providers consisting of general practitioners, midwives, nutritionists, and public health experts. We conducted a content analysis using the 7 stages recommended by Colaizzi. We used four criteria recommended by Lincoln and Guba for ensuring the research's trustworthiness.

RESULTS

Three main themes and 8 categories were developed. Three main themes are 1) health care provision system barriers, including four categories: lack of motivation, non-availability of facilities and doctors, poor relationship between patients and providers, and disruption in the process 2) coverage problems, including two categories: insurance inefficiency, and limited access, and 3) contextual barriers, including two categories: environmental problems, and socioeconomic barriers.

CONCLUSIONS

Recommendations are presented in three levels to improve implementation. The health care system needs to modify the payment methods, Patients-providers relationship improvement, and increase the number of providers. Insurance organizations should consider sufficient coverage of costs for slum-dwellers with T2D and expand the benefits package for them. Government should consider infrastructure upgrading in slums to eliminate barriers related to slum-dwelling. Overall, health care utilization promotion needs intersection cooperation.

SPARC the Change: What the Strategic Purchasing Africa Resource Center Has Learned about Improving Strategic Health Purchasing in Africa

Embodied in the goals of universal health coverage (UHC) are societal norms about ethics, equity, solidarity, and social justice. As African countries work toward UHC, it is important for their governments to use all available resources, knowledge, and networks to continue to bring this goal closer to reality for their populations. The Strategic Purchasing Africa Resource Center (SPARC) was established in 2018 as a "go-to" source of Africa-based expertise in strategic health purchasing, which is a critical policy tool for making more effective use of limited funds for UHC. SPARC facilitates collaboration among governments and research partners across Africa to fill gaps in knowledge on how to make progress on strategic purchasing. The cornerstone of this work has been the development and use of the Strategic Health Purchasing Progress Tracking Framework to garner insights from each country's efforts to make health purchasing more strategic. Application of the framework and subsequent dialogue within and between countries generated lessons on effective purchasing approaches that other countries can apply as they chart their own course to use strategic purchasing more effectively. These lessons include the need to clarify the roles of purchasing agencies, define explicit benefit packages as a precondition for other strategic purchasing functions, use contracting to set expectations, start simple with provider payment and avoid open-ended payment mechanisms, and use collaborative rather than punitive provider performance monitoring. SPARC has also facilitated learning on the "how-to" and practical steps countries can take to make progress on strategic purchasing to advance UHC.

The Effects of Health Purchasing Reforms on Equity, Access, Quality of Care, and Financial Protection in Kenya: A Narrative Review

Kenya has implemented several health purchasing reforms to facilitate progress toward universal health coverage. We conducted a narrative review of peer-reviewed and grey literature to examine how these reforms have affected health system outcomes in terms of equity, access, quality of care, and financial protection. We categorized the purchasing reforms we identified into the areas of benefits specification, provider payment, and performance monitoring. We found that the introduction and expansion of benefit packages for maternity, outpatient, and specialized services improved responsiveness to population needs and enhanced protection from financial hardship. However, access to service entitlements was limited by inadequate awareness of the covered services among providers and lack of service availability at contracted facilities. Provider payment reforms increased health facilities' access to funds, which enhanced service delivery, quality of care, and staff motivation. But delays and the perceived inadequacy of payment rates incentivized negative provider behavior, which limited access to care and exposed patients to out-of-pocket payments. We found that performance monitoring reforms improved the quality assurance capacity of the public insurer and enhanced patient safety, service utilization, and quality of care provided by facilities. Although health purchasing reforms have improved access, quality of care, and financial risk protection to some extent in Kenya, they should be aligned and implemented jointly rather than as individual interventions. Measures that policymakers might consider include strengthening communication of health benefits, timely and adequate payment of providers, and enhancing health facility autonomy over the revenues they generate.

Applying the Strategic Health Purchasing Progress Tracking Framework: Lessons from Nine African Countries

The Strategic Purchasing Africa Resource Center (SPARC) developed a framework for tracking strategic purchasing that uses a functional and practical approach to describe, assess, and strengthen purchasing to facilitate policy dialogue within countries. This framework was applied in nine African countries to assess their progress on strategic purchasing. This paper summarizes overarching lessons from the experiences of the nine countries. In each country, researchers populated a Microsoft Excel-based matrix using data collected through document reviews and key informant interviews conducted between September 2019 and March 2021. The matrix documented governance arrangements; core purchasing functions (benefits specification, contracting arrangements, provider payment, and performance monitoring); external factors affecting purchasing; and results attributable to the implementation of these purchasing functions. SPARC and its partners synthesized information from the country assessments to draw lessons applicable to strategic purchasing in Africa. All nine countries have fragmented health financing systems, each with distinct purchasing arrangements. Countries have made some progress in specifying a benefit package that addresses the health needs of the most vulnerable groups and entering into selective contracts with mostly private providers that specify expectations and priorities. Progress on provider payment and performance monitoring has been limited. Overall, progress on strategic purchasing has been limited in most of the countries and has not led to large-scale health system improvements because of the persistence of out-of-pocket payments as the main source of health financing and the high degree of fragmentation, which limits purchasing power to allocate resources and incentivize providers to improve productivity and quality of care.

The Strategic Health Purchasing Progress Tracking Framework: A Practical Approach to Describing, Assessing, and Improving Strategic Purchasing for Universal Health Coverage

Strategic purchasing of high-priority services is a critical part of effective spending to advance UHC goals. Available conceptual frameworks for strategic purchasing have facilitated high-level advocacy and policy dialogue, and they have framed research and analytical work to describe and understand countries' purchasing arrangements. What has been missing is a framework and approach that combines the conceptual framing of strategic purchasing with practical guidance to describe and assess purchasing in sufficient detail to inform policy.This paper presents a practical framework and approach to tracking progress in purchasing: the Strategic Health Purchasing Progress Tracking Framework. Co-created by a group of health financing researchers and academics through the Strategic Purchasing Africa Resource Center (SPARC), it builds on existing frameworks and focuses on the core purchasing functions of benefits specification, contracting arrangements, provider payment, and performance monitoring. It incorporates factors that can either strengthen or weaken the power of purchasers to directly influence resource allocation and provider behavior. The paper also proposes a set of evidence-based benchmarks that country stakeholders can use to assess where their health system is on the continuum from passive to strategic purchasing and to identify steps to make purchasing more strategic.Application of the framework has shown the value of mapping purchasing functions across all health financing arrangements to identify where strategic purchasing progress is more advanced and where it may be lacking. It has helped countries identify challenges-such as fragmentation and duplication of purchasing functions across health financing arrangements-and prioritize policy actions.

Has Strategic Purchasing Led to Improvements in Health Systems? A Narrative Review of Literature on Strategic Purchasing

Strategic purchasing is noted in the literature as an approach that can improve the efficiency of health spending, increase equity in access to health care services, improve the quality of health care delivery, and advance progress toward universal health coverage. However, the evidence on how strategic purchasing can achieve these improvements is sparse. This narrative review sought to address this evidence gap and provide decision makers with lessons and policy recommendations. The authors conducted a systematic review based on two research questions: 1) What is the evidence on how purchasing functions affect purchasers' leverage to improve: resource allocation, incentives, and accountability; intermediate results (allocative and technical efficiency); and health system outcomes (improvements in equity, access, quality, and financial protection)? and 2) What conditions are needed for a country to make progress on strategic purchasing and achieve health system outcomes? We used database searches to identify published literature relevant to these research questions, and we coded the themes that emerged, in line with the purchasing functions-benefits specification, contracting arrangements, provider payment, and performance monitoring-and the outcomes of interest. The extent to which strategic purchasing affects the outcomes of interest in different settings is partly influenced by how the purchasing functions are designed and implemented, the enabling environment (both economic and political), and the level of development of the country's health system and infrastructure. For strategic purchasing to provide more value, sufficient public funding and pooling to reduce fragmentation of schemes is important.