The Experiences of Strategic Purchasing of Healthcare in Nine Middle-Income Countries: A Systematic Qualitative Review

BACKGROUND

Efforts to move towards universal health coverage (UHC) aim to rebalance health financing in ways that increase efficiency, equity, and quality. Resource constraints require a shift from passive to strategic purchasing (SP). In this paper, we report on the experiences of SP in public sector health insurance schemes in nine middle-income countries to understand what extent SP has been established, the challenges and facilitators, and how it is helping countries achieve their UHC goals.

METHODS

We conducted a systematic search to identify papers on SP. Nine countries were selected for case study analysis. We extracted data from 129 articles. We used a common framework to compare the purchasing arrangements and key features in the different schemes. The evidence was synthesised qualitatively.

RESULTS

Five countries had health technology assessment (HTA) units to research what services to buy. Most schemes had reimbursement mechanisms that enabled some degree of cost control. However, we found evidenced-based changes to the reimbursement mechanisms only in Thailand and China. All countries have some form of mechanism for accreditation of health facilities, although there was considerable variation in what is done. All countries had some strategy for monitoring claims, but they vary in complexity and the extent of implementation; three countries have implemented e-claim processing enabling a greater level of monitoring. Only four countries had independent governance structures to provide oversight. We found delayed reimbursement (six countries), failure to provide services in the benefits package (four countries), and high out-of-pocket (OOP) payments in all countries except Thailand and Indonesia, suggesting the schemes were failing their members.

CONCLUSION

We recommend investment in purchaser and research capacity and a focus on strong governance, including regular engagement between the purchaser, provider and citizens, to build trusting relationships to leverage the potential of SP more fully, and expand financial protection and progress towards UHC.

Assessing the choice of National Health Insurance Fund contracted outpatient facilities in Kenya: A qualitative study

OBJECTIVE

To assess National Health Insurance Fund (NHIF) members' level of understanding, experiences, and factors influencing their choice of NHIF-contracted outpatient facilities in Kenya.

METHODS

We conducted a cross-sectional qualitative study with NHIF members in two purposefully selected counties (Nyeri and Makueni counties) in Kenya. We collected data through 15 focus group discussions with NHIF members. Data were analysed using a framework analysis approach.

RESULTS

Urban-based NHIF members had a good understanding of the NHIF-contracted outpatient facility selection process and the approaches for choosing and changing providers, unlike their rural counterparts. While NHIF members were required to choose a provider before accessing care, the number of available alternative facilities was perceived to be inadequate. Finally, NHIF members identified seven factors they considered important when choosing an NHIF-contracted outpatient provider. Of these factors, the availability of drugs, distance from the household to the facility and waiting time at the facility until consultation were considered the most important.

CONCLUSION

There is a need for the NHIF to prioritise awareness-raising approaches tailored to rural settings. Further, there is a need for the NHIF to contract more providers to both spur competition among providers and provide alternatives for members to choose from. Besides, NHIF members revealed the important factors they consider when selecting outpatient facilities. Consequently, NHIF should leverage the preferred factors when contracting healthcare providers. Similarly, healthcare providers should enhance the availability of drugs, reduce waiting times whilst improving their staff's attitudes which would improve user satisfaction and the quality of care provided.

Strengths and Weaknesses of Strategic Health Purchasing for Universal Health Coverage in Rwanda

In the context of scarce resources and increasing health care costs, strategic purchasing is viewed as a key mechanism to spur countries' progress toward universal health coverage (UHC), by using limited resources more effectively. We applied the Strategic Health Purchasing Progress Tracking Framework to examine the health purchasing arrangements in three health financing schemes in Rwanda-the Community Based Health Insurance (CBHI) scheme, the Rwanda Social Security Board (RSSB) medical scheme, and performance-based financing (PBF). Data were collected from secondary and primary sources between September 2020 and March 2021.The objective of the study was to identify areas of progress in strategic purchasing that can be built on, and to identify areas of overlap, duplication, or conflict that limit progress in strategic purchasing to advance UHC goals. This study found that Rwanda has made progress in many areas of strategic purchasing and has a strong foundation for building further. However, some overlaps and duplication of functions weaken the power of purchasers to improve resource allocation, incentives for providers, and accountability. In addition, some of the policies within the purchasing functions could be made more strategic. In particular, open-ended fee-for-service payment in the CBHI scheme not only threatens the scheme's financial sustainability but also imposes a high administrative burden. Better alignment and integration of contracting, incentives, and information system design to provide timely and relevant information for purchasing decisions would contribute to more strategic health purchasing and ensure that Rwanda's health sector achievements are sustained and expanded.

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.

Strategic Health Purchasing in Nigeria: Exploring the Evidence on Health System and Service Delivery Improvements

Well-functioning purchasing arrangements allocate pooled funds to health providers, and are expected to deliver efficient, effective, quality, equitable and responsive health services and advance progress toward universal health coverage (UHC). This paper explores how improvements in purchasing functions in three Nigerian schemes-the Formal Sector Social Health Insurance Program (FSSHIP), the Saving One Million Lives Program for Results (SOML PforR), and Enugu State's Free Maternal and Child Health Program (FMCHP)-may have contributed to better resource allocation, incentives for performance, greater accountability and improved service delivery. The paper uses a case-study approach, with data analyzed using the Strategic Health Purchasing Progress Tracking Framework. Data were collected through review of program documents and published research articles, and semi-structured interviews of 33 key informant interviews. Findings were triangulated within each case study across the multiple sources of information. Improvements in benefits specification and provider payment contributed to some service delivery improvements in all three schemes: higher satisfaction with the quality of care in FSSHIP; increased use of insecticide-treated nets; greater prevention of mother-to-child HIV transmission; expanded pentavalent-3 coverage in SOML PforR; and greater service utilization in FMCHP. Resource allocation to public health facilities was enhanced and lines of accountability were better defined. These scheme-level improvements have not translated to system change, because of the small amount of funding flowing through these schemes and the high level of health financing fragmentation. The institutionalization of strategic purchasing in Nigeria to advance UHC will require raising awareness among decision makers, strengthening purchasing agencies' capacity, and reducing fragmentation.

Why Is Strategic Purchasing Critical for Universal Health Coverage in Sub-Saharan Africa?

To make progress toward universal health coverage (UHC), most countries need to commit more public resources to health. However, countries can also make progress by using available resources more effectively. Health purchasing, one of the health financing functions of health systems, is the transfer of pooled funds to health providers to deliver covered services. Purchasers can be either passive or strategic in how they transfer these funds. Strategic purchasing is deliberately directing health funds to priority populations, interventions, and services, and actively creating incentives so funds are used by providers equitably and aligned with population health needs. Strategic purchasing is particularly important for countries in sub-Saharan Africa because public funding for health has often not kept pace with UHC commitments. In addition, there is wide variation in progress toward UHC targets and health outcomes on the continent that does not always correlate with per capita government health spending. This paper explores the critical role strategic purchasing can play in the movement toward UHC in sub-Saharan Africa. It explores the rationale for strategic purchasing and makes the case for a more concerted effort by governments, and the partners that support them, to focus on and invest in improving strategic purchasing as part of advancing their UHC agendas. The paper also discusses the promise of strategic purchasing and the challenges of realizing this promise in sub-Saharan Africa, and it provides options for practical steps countries can take to incrementally improve strategic purchasing functions and policies over time.