Strategic purchasing and health system efficiency: A comparison of two financing schemes in Thailand

How does Public Financial Management (PFM) influence health system efficiency: A scoping review

Background

Effective Public Financial Management (PFM) approaches are imperative in the quest for efficiency in health service delivery. Reviews conducted in this area have assessed the impact of PFM approaches on health system efficiency but have left out the mechanisms through which PFM influences efficiency. This scoping review aims to synthesize evidence on the mechanisms by which PFM influences health system efficiency.

Methods

We searched databases of PubMed and Google Scholar and websites of the World Health Organization (WHO), World Bank and Overseas Development Institute (ODI) for peer-reviewed and grey literature articles that provided data on the relationship between PFM and health system efficiency. Three reviewers screened the articles for eligibility with the inclusion criteria. Data on PFM and health system efficiency was charted and summarized. We then reported the mechanisms by which PFM influence efficiency.

Results

PFM processes and structures influence health system efficiency by influencing; the alignment of resources to health system needs, the cost of inputs, the motivation of health workers, and the input mix.

Conclusion

The entire budget process influences health system efficiency. However, most of the findings are drawn from studies that focused on aspects of the budget process. Studies that look at PFM in totality will help explore other cross-cutting issues within sections of the budget cycle; they will also bring out the relationship between the different phases of the budget cycle.

Health care cost accounting in the Indian hospital sector

Setting reimbursement rates in national insurance schemes requires robust cost data. Collecting provider-generated cost accounting information is a potential mechanism for improving the cost evidence. To inform strategies for obtaining cost data to set reimbursement rates, this analysis aims to describe the role of cost accounting in public and private health sectors in India and describe the importance, perceived barriers and facilitators to improving cost accounting systems. In-depth interviews were conducted with 11 key informants. The interview tool guide was informed by a review of published and grey literature and government websites. The interviews were recorded as both audio and video and transcribed. A thematic coding framework was developed for the analysis. Multiple discussions were held to add, delete, classify or merge the themes. The themes identified were as follows: the status of cost accounting in the Indian hospital sector, legal and regulatory requirements for cost reporting, challenges to implementing cost accounting and recommendations for improving cost reporting by health care providers. The findings indicate that the sector lacks maturity in cost accounting due to a lack of understanding of its benefits, limited capacity and weak enforcement of cost reporting regulations. Providers recognize the value of cost analysis for investment decisions but have mixed opinions on the willingness to gather and report cost information, citing resource constraints and a lack of trust in payers. Additionally, heterogeneity among providers will require tailored approaches in developing cost accounting reporting frameworks and regulations. Health care cost accounting systems in India are rudimentary with a few exceptions, raising questions about how to source these data sustainably. Strengthening cost accounting systems in India will require standardized data formats, integrated into existing data management systems, that both meet the needs of policy makers and are acceptable to hospital providers.

Budget monitoring, accountability practices and their influence on the efficiency of county health systems in Kenya

Public Finance Management (PFM) practices influence the attainment of health system goals. PFM processes are implemented within the budget cycle which entails the formulation, execution, and monitoring of government budgets. Budget monitoring and accountability actors, structures, and processes are important in improving the efficiency of health systems. This study examined how the budget monitoring and accountability processes influence the efficiency of county health systems in KenyaWe conducted a qualitative case study of four counties in Kenya selected based on their relative technical efficiency. We collected data using in-depth interviews with health and finance stakeholders (n = 70), and document reviews. We analyzed data using a thematic approach, informed by our study conceptual framework. We found that weak budget monitoring and accountability mechanisms compromised county health system efficiency by a) weakening the effective implementation of the budget formulation and execution steps of the budget cycle, b) enabling the misappropriation of public resources, and c) limiting evidence-informed decision-making by weakening feedback that would be provided by effective monitoring and accountability. Devolution meant that accountability actors were closer to implementation actors which promoted timely problem solving and the relevance of solutions. Internal audit practices were supportive and provided useful feedback to health system managers that facilitated improvements in budget formulation and execution. The efficiency of county health systems can be improved by strengthening the budget monitoring and accountability processes. This can be achieved by increasing the population's budget literacy, supporting participatory budgeting, synchronizing performance and financial accountability, implementing the existent budget monitoring and accountability mechanisms, rewarding efficiency, and sanctioning inefficiency.

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.

Refining the provider payment system of India's government-funded health insurance programme: an econometric analysis

OBJECTIVES

Reimbursement rates in national health insurance schemes are frequently weighted to account for differences in the costs of service provision. To determine weights for a differential case-based payment system under India's publicly financed national health insurance scheme, the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), by exploring and quantifying the influence of supply-side factors on the costs of inpatient admissions and surgical procedures.

DESIGN

Exploratory analysis using regression-based cost function on data from a multisite health facility costing study-the Cost of Health Services in India (CHSI) Study.

SETTING

The CHSI Study sample included 11 public sector tertiary care hospitals, 27 public sector district hospitals providing secondary care and 16 private hospitals, from 11 Indian states.

PARTICIPANTS

521 sites from 57 healthcare facilities in 11 states of India.

INTERVENTIONS

Medical and surgical packages of PM-JAY.

PRIMARY AND SECONDARY OUTCOME MEASURES

The cost per bed-day and cost per surgical procedure were regressed against a range of factors to be considered as weights including hospital location, presence of a teaching function and ownership. In addition, capacity utilisation, number of beds, specialist mix, state gross domestic product, State Health Index ranking and volume of patients across the sample were included as variables in the models. Given the skewed data, cost variables were log-transformed for some models.

RESULTS

The estimated mean costs per inpatient bed-day and per procedure were 2307 and 10 686 Indian rupees, respectively. Teaching status, annual hospitalisation, bed size, location of hospital and average length of hospitalisation significantly determine the inpatient bed-day cost, while location of hospital and teaching status determine the procedure costs. Cost per bed-day of teaching hospitals was 38-143.4% higher than in non-teaching hospitals. Similarly, cost per bed-day was 1.3-89.7% higher in tier 1 cities, and 19.5-77.3% higher in tier 2 cities relative to tier 3 cities, respectively. Finally, cost per surgical procedure was higher by 10.6-144.6% in teaching hospitals than non-teaching hospitals; 12.9-171.7% higher in tier 1 cities; and 33.4-140.9% higher in tier 2 cities compared with tier 3 cities, respectively.

CONCLUSION

Our study findings support and validate the recently introduced differential provider payment system under the PM-JAY. While our results are indicative of heterogeneity in hospital costs, other considerations of how these weights will affect coverage, quality, cost containment, as well as create incentives and disincentives for provider and consumer behaviour, and integrate with existing price mark-ups for other factors, should be considered to determine the future revisions in the differential pricing scheme.

Who benefits from quality competition in health care? A theory and a laboratory experiment on the relevance of patient characteristics

We study how competition between physicians affects the provision of medical care. In our theoretical model, physicians are faced with a heterogeneous patient population, in which patients systematically vary with regard to both their responsiveness to the provided quality of care and their state of health. We test the behavioral predictions derived from this model in a controlled laboratory experiment. In line with the model, we observe that competition significantly improves patient benefits as long as patients are able to respond to the quality provided. For those patients, who are not able to choose a physician, competition even decreases the patient benefit compared to a situation without competition. This decrease is in contrast to our theoretical prediction implying no change in benefits for passive patients. Deviations from patient-optimal treatment are highest for passive patients in need of a low quantity of medical services. With repetition, both, the positive effects of competition for active patients as well as the negative effects of competition for passive patients become more pronounced. Our results imply that competition can not only improve but also worsen patient outcome and that patients' responsiveness to quality is decisive.

Role of healthcare cost accounting in pricing and reimbursement in low-income and middle-income countries: a scoping review

OBJECTIVES

Progress towards universal health coverage (UHC) requires evidence-based policy including good quality cost data systems. Establishing these systems can be complex, resource-intensive and take time. This study synthesises evidence on the experiences of low-income and middle-income countries (LMICs) in the institutionalisation of cost data systems to derive lessons for the technical process of price-setting in the context of UHC.

DESIGN

A scoping review and narrative synthesis of publicly available information.

DATA SOURCES

PubMed, MEDLINE, EconLit, the Web of Science and grey literature searched from January 2000 to April 2021.

ELIGIBILITY CRITERIA

English-language papers published since 2000 that identified and/or described development of and/or methods used to estimate or inform national tariffs for hospital reimbursement in LMICs. Papers were screened by two independent reviewers.

DATA EXTRACTION AND SYNTHESIS

Extraction was performed by one reviewer and checked by the second reviewer on: the method and outputs of cost data collection; commentary on the use of cost data; description of the technical process of tariff setting; and strengths and challenges of the approach. Evidence was summarised using narrative review.

RESULTS

Thirty of 484 papers identified were eligible. Fourteen papers reported on primary cost data collection; 18 papers explained how cost evidence informs tariff-setting. Experience was focused in Asia (n=22) with countries at different stages of developing cost systems. Experiences on cost accounting tend to showcase country costing experiences, methods and implementation. There is little documentation how data have been incorporated into decision making and price setting. Where cost information or cost systems have been used, there is improved transparency in decision making alongside increased efficiency.

CONCLUSIONS

There are widely used and accepted methods for generating cost information. Countries need to build sustainable cost systems appropriate to their settings and budgets and adopt transparent processes and methodologies for translating costs into prices.

Challenges with pediatric surgical financing and universal health coverage in Guatemala: A qualitative analysis

The financing of surgical care for children in low- and middle-income countries (LMICs) remains challenging and may restrict adherence to universal health coverage (UHC) frameworks. Our aims were to describe Guatemala's national pediatric surgical financing structure, to identify financing challenges, and to develop recommendations to improve the financing of surgical care for children. We conducted a qualitative study of the financing of surgical care for children in Guatemala's public health system with key informant interviews (n = 20) with experts in the medical, financial, and political health sectors. We used this data to generate recommendations to improve surgical care financing for children. We identified several systemic challenges to the financing of surgical care for children, including passive purchasing structures, complex political contexts, health system fragmentation, widespread use of informal fees for surgical services, and lack of earmarked funding for surgical care. Patient and provider challenges include lack of provider input in non-personnel funding decisions, and patients functioning as both financing agents and beneficiaries in the same financing stream. Key recommendations include reducing health finance system fragmentation through resource pooling, increasing earmarked funding for surgical care with quantifiable outcome measures, engagement with clinical providers in non-personnel budgetary decision-making, and use of innovative financing instruments such as resource pooling. Surgical financing for children in Guatemala requires substantial remodeling to increase access to timely, affordable, and safe surgical care and improve alignment with Guatemala's UHC scheme.

The trust and insurance models of healthcare purchasing in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in India: early findings from case studies of two states

BACKGROUND

The Pradhan Mantri Jan Arogya Yojana (PMJAY), a publicly funded health insurance scheme for the poor in India, was launched in 2018. Early experiences of states with various purchasing arrangements can provide valuable insights for its future performance. We sought to understand the institutional agencies and performance of the trust and insurance models of purchasing with respect to; a) Provider contracting b) Claim management c) Implementation costs.

METHODS

A mixed methods case study design was adopted. Two states, Uttar Pradesh (representing a trust model) and Jharkhand (representing the insurance model) were purposively selected. Data sources included document reviews, key informant interviews, quantitative scheme data from the provider empanelment and claims database, and primary data on costs. Descriptive statistics were reported for quantitative data, content analysis was used for thematic reporting of qualitative data.

RESULTS

In both models, the state was the final authority on empanelment decisions, with no significant influence of the insurance company. Private hospitals constituted the majority of empanelled providers, with wide variations in district-wise distribution of bed capacities in both states. The urgency of completing empanelment in the early days of the scheme created the need for both states to re-review hospitals and de-empanel those not meeting requirements. Very few quality- accredited private hospitals were empaneled. The trust displayed more oversight of support agencies for claim management, longer processing times, a higher claim rejection rate and numbers of queries raised, as compared to the insurance model. Support agencies in both states faced challenges in assessing the clinical decisions of hospitals. Cost-effectiveness showed mixed results; the trust cost less than the insurance model per beneficiary enrolled, but more per claim generated.

CONCLUSIONS

Efforts are required to enable a better distribution and ensure quality of care in empanelled hospitals. The adoption of standard treatment guidelines is needed to support hospitals and implementing agencies in better claim management. The oversight of agencies through enforcement of contracts remains vital in both models. Assessing the comparative performance of trusts and insurance companies in more states at later stages of scheme implementation, would be further useful to determine their cost-effectiveness as purchasers.

Disclosure, transparency, and accountability: a qualitative survey of public sector pharmaceutical committee conflict of interest policies in the World Health Organization South-East Asia Region

BACKGROUND

Weak governance over public sector pharmaceutical policy and practice limits access to essential medicines, inflates pharmaceutical prices, and wastes scarce health system resources. Pharmaceutical systems are technically complex and involve extensive interactions between the private and public sectors. For members of public sector pharmaceutical committees, relationships with the private sector can result in conflicts of interest, which may introduce commercial biases into decision-making, potentially compromising public health objectives and health system sustainability. We conducted a descriptive, qualitative study of conflict of interest policies and practices in the public pharmaceutical sector in ten countries in the World Health Organization (WHO) South-East Asia Region (SEAR) (Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste) between September 2020 and March 2021.

RESULTS

We identified 45 policy and regulatory documents and triangulated documentary data with 21 expert interviews. Key informants articulated very different governance priorities and conflict of interest concerns depending on the features of their country's pharmaceutical industry, market size, and national economic objectives related to the domestic pharmaceutical industry. Public sector pharmaceutical policies and regulations consistently contained provisions for pharmaceutical committee members to disclose relevant interests, but contained little detail about what should be declared, when, and how often, nor whether disclosures are evaluated and by whom. Processes for preventing or managing conflicts of interest were less well developed than those for disclosure except for a few key procurement processes. Where processes for managing conflicts of interest were specified, the dominant strategy was to recuse committee members with a conflict of interest from relevant work. Policies rarely specified that committee members should divest or otherwise be free from conflicts of interest.

CONCLUSIONS

Robust processes for conflict of interest prevention and management could ensure the integrity of decision-making and build public trust in pharmaceutical processes to achieve public health objectives. Upstream approaches including supportive legislative frameworks, the creation of oversight bodies, and strengthening regulatory institutions can also contribute to building cultures of transparency, accountability, and trust.

The Government Budget: An Overlooked Vehicle for Advancing Strategic Health Purchasing

The most effective way to finance universal health coverage (UHC) is through compulsory prepaid funds that flow through the government budget. Public funds-including on-budget donor resources-allow for pooling and allocation of resources to providers in a way that aligns with population health needs. This is particularly important for low-income settings with fiscal constraints. While much attention is paid to innovative sources of additional financing for UHC and to implementing strategic purchasing approaches, the government budget will continue to be the main source of health financing in most countries-and the most stable mechanism for channeling additional funds. The government budget should therefore be front and center on the strategic purchasing agenda. This commentary uses lessons from Tanzania and Uganda to demonstrate that more can be done to use the government budget as a vehicle for making health purchasing more strategic, across all phases of the budget cycle, and for making greater progress toward UHC. Actions need to be accompanied by measures to address bottlenecks in the public financial management system.

Strategic Health Purchasing in Nigeria: Investigating Governance and Institutional Capacities within Federal Tax-Funded Health Schemes and the Formal Sector Social Health Insurance Programme

For Nigeria to make progress on its commitment to universal health coverage, additional public funding will be required. But more resources alone will not be enough. Government health spending must be more efficient and effective, through more strategic purchasing-a critical policy tool. Studies on health purchasing in Nigeria's health financing schemes are limited, however. This study examines the purchasing arrangements in schemes funded by the federal budget and in the Formal Sector Social Health Insurance Programme (FSSHIP) within the National Health Insurance Scheme. We adopted a qualitative, descriptive case-study approach and collected data through document reviews and key informant interviews based on the Strategic Health Purchasing Progress Tracking Framework. Our analysis used a thematic framework approach. Our findings reveal that legal frameworks and governance structures for strategic purchasing are in place for both schemes. Steps toward strategic purchasing are more advanced in FSSHIP, particularly in the design of benefit packages, accreditation and monitoring of health maintenance organizations (HMOs) and providers, and provider payment mechanisms. The limited share of health funding flowing through these mechanisms, and further fragmentation of that funding, impede strategic purchasing. Strategic purchasing is also hampered by weak regulation and monitoring of providers and purchasers, delays in provider payment, and corrupt practices by HMOs. Improving strategic purchasing in Nigeria will require a concerted effort to reduce fragmentation of health spending, significant investment in human resources, technical know-how, and information systems of purchasing institutions, and actions to improve the accountability of all actors in the system.

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.

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.

Advancing universal health coverage in the COVID-19 era: an assessment of public health services technical efficiency and applied cost allocation in Cambodia

BACKGROUND

Achieving universal health coverage (UHC) is a global priority and a keystone element of the 2030 Sustainable Development Goals. However, COVID-19 is causing serious impacts on tax revenue and many countries are facing constraints to new investment in health. To advance UHC progress, countries can also focus on improving health system technical efficiency to maximize the service outputs given the current health financing levels.

METHODS

This study assesses Cambodia's public health services technical efficiency, unit costs, and utilization rates to quantify the extent to which current health financing can accommodate the expansion of social health protection coverage. This study employs Data Envelopment Analysis (DEA), truncated regression, and pioneers the application of DEA Aumann-Shapley applied cost allocation to the health sector, enabling unit cost estimation for the major social health insurance payment categories.

RESULTS

Overall, for the public health system to be fully efficient output would need to increase by 34 and 73% for hospitals and health centers, respectively. We find public sector service quality, private sector providers, and non-discretionary financing to be statistically significant factors affecting technical efficiency. We estimate there is potential supply-side 'service space' to expand population coverage to an additional 4.69 million social health insurance beneficiaries with existing financing if the public health system were fully efficient.

CONCLUSIONS

Public health service efficiency in Cambodia can be improved by increasing utilization of cost-effective services. This can be achieved by enrolling more beneficiaries into the social health insurance schemes with current supply-side financing levels. Other factors that can lead to increased efficiency are improving health service quality, regulating private sector providers, focusing on discretionary health financing, and incentivizing a referral system.

Supporting strategic health purchasing: a case study of annual health budgets from general tax revenue and social health insurance in Abia state, Nigeria

BACKGROUND

Tracking general trends in strategic purchasing of health financing mechanisms will highlight where country demands may exist for technical support and where progress in being made that offer opportunities for regional learning. Health services in Abia State, Nigeria are funded from general tax-revenues (GTR), and a new state social health insurance scheme (SSHIS) is proposed to overcome the failings of the GTR and expand coverage of services. This study examined purchasing functions within the GTR and the proposed SSHIS to determine if the failings in GTR have been overcome, identify factors that shape health purchasing at sub-national levels, and provide lessons for other states in Nigeria pursuing a similar intervention.

METHODS

Data was collected through document review and key informant interviews. Government documents were retrieved electronically from the websites of different organizations. Hard copies of paper-only files were retrieved from relevant government agencies and departments. Interviews were conducted with seven key personnel of the State Ministry of Health and State Health Insurance Agency. Thematic analysis of data was based on a strategic health purchasing progress tracking framework which delves into the governance arrangements and information architecture needed for purchasing to work well; and the core purchasing decisions of what to buy; who to buy from; and how to buy.

RESULTS

There are differences in the purchasing arrangements of the two schemes. Purchaser-provider split does not exist for the GTR, unlike in the proposed SSHIS. There are no data systems for monitoring provider performance in the GTR-funded system, unlike in the SSHIS. Whereas GTR is based on a historical budgeting system, the SSHIS proposes to use a defined benefit package, which ensures value-for-money, as the basis for resource allocation. The GTR lacks private sector engagement, provider accreditation and contracting arrangements while the SSHIS will accredit and engage private providers through selective contracting. Likewise, provider payment is not linked to performance or adherence to established standards in the GTR, whereas provider payment will be linked to performance in the SSHIS.

CONCLUSIONS

The State Social Health Insurance has been designed to overcome many of the limitations of the budgetary allocation to health. This study provides insights into the enabling and constraining factors that can be used to develop interventions intended to strengthen the strategic health purchasing in the study area, and lessons for the other Nigeria states with similar characteristics and approaches.

Bad to All? A Novel Way to Analyze the Effects of Fee-for-Service on Multiple Grades Hospitals Operation Outcomes

It is a consensus that Fee-for-Service (FFS) is a traditional medical insurance payment scheme with significant disadvantages, namely the waste of health care resources. However, the majority of the prior works that draw such conclusions from the perspective of social welfare while analyzing the impacts of FFS on operation outcomes of hospitals still lack attention from the existing literature, considering the fact that the majority of public hospitals are self-founding. Under this motivation, we collected operation data of 301 public hospitals with different grades (grade II and III) in central China. Here, we present a novel statistical evaluation framework on the impact of FFS on hospital operation outcomes from four dimensions (financial income, efficiency, medical service capacity, and sustainability) using fixed-effects multivariate regression. With verification by the robustness test, our results indicate that: (i) The classification of the hospital (COH) significantly affected the impacts of FFS on hospitals’ operations. (ii) For grade III hospitals, FFS leads to higher financial income, medical service capacity (MSC) and longer length-of-stay (LOS). (iii) However, as for grade II hospitals, hospitals with FFS adoptions achieve lower financial income, lower MSC and shorter LOS, which violates the common sense from previous works. (iv) FFS has a significant negative impact on public hospital’s sustainable development; however, there is lack of evidence showing that sustainability would be affected by the interaction effects between FFS and COH. We believe these new findings from the perspective of hospital operation provide insights and could serve as a reference for the healthcare payment hierarchical reform by COH in low and middle-income countries (LMICs), which are going through the primary stage of the healthcare reform.

Factors affecting health services strategic purchasing for breast cancer patients: a mixed study in Iran

Background

Inappropriate ways of health services purchasing for cancer patients can be challengeable and costly and seriously affect the access to health services and outcomes. This study aimed at Factors affecting health services strategic purchasing for breast cancer patients.

Methods

As a mixed study, this research was conducted in Iran in 2020. In the qualitative phase, 21 specialists and professionals in the field of health services purchasing were purposefully selected and interviewed. After data saturation, interviews were analyzed with the framework analysis and a structured questionnaire was made based on these analyses. 400 breast cancer patients were selected by randomized sampling and completed the questionnaire. Data were analyzed with SPSS₂₃ in p < .05.

Results

The highest mean rate of the three main categories belonged to “insurance trusteeship” (4.71 ± .35), followed by “supply management” (4.48 ± .27) and “financial performance” (4.48 ± .37). There were significantly differences between the mean rates of the main categories and the cut-off point (p < .001). In addition, “insurance trusteeship” ranked first (2.58), followed by financial performance (1.77) and supply management (1.65).

Conclusion

Of main components in health services strategic purchasing for breast cancer patients, insurance trusteeship, supply management, and financial performance ranked first to third, respectively. Therefore, healthcare policy-makers should consider the placement of insurance trusteeship and coordinate between purchasers and providers for making reform in the health system.

Universal health coverage under the Joint Comprehensive Plan of Action's sanctions: strategic purchasing approach in the Iranian health system

Due to the sanctions imposed by the USA government upon the Iranian health system, achieving the UHC might face some financial problems. This study aimed to make the best solution for the Iran health care system to overcome not only the temporary sanctions but also a program to reach the UHC goals through the strategic purchasing approach. This was a qualitative study carried out from 2015 to 2017 containing two phases: a comparative analysis and a three-step Delphi technique. In the first phase, the Garden model was applied to select the countries. In the second phase, 20 experts who specialised in health management, health economics, and health insurance science were asked. Data were analyzed with SPSS (version 20.0) and STATA (version 15.0) In the threat of trade and economic sanctions imposed on the Iranian health care system, the experts identified and emphasized that the vulnerable groups to receive financial assistance can be the retired, fecund women, teenagers and people with lower wages. The experts thought that, in the context of resource constraints, different payment systems are proposed for cities and villages based on the different needs of local population. Considering the difficult situation, this study focused on how Iran can cope well in a dangerous situation and economies the health expenditure applying strategic purchasing as one of the key tools in controlling costs to achieve universal health coverage. Economic evaluation, payment system, and priority population are the linchpins of the UHC. Universal health coverage, if it is to be considered, not only is applicable, but it could also be a solution for future generations. Therefore, the proposed policy proposals can provide both a short-term and long-term basis for the health care system of countries that are facing budget constraints or are basically low-income.

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

Provider payment methods are a key health policy lever because they influence healthcare provider behaviour and affect health system objectives, such as efficiency, equity, financial protection and quality. Previous research focused on analysing individual provider payment methods in isolation, or on the actions of individual purchasers. However, purchasers typically use a mix of provider payment methods to pay healthcare providers and most health systems are fragmented with multiple purchasers. From a health provider perspective, these different payments are experienced as multiple funding flows which together send a complex set of signals about where they should focus their effort. In this article, we argue that there is a need to expand the analysis of provider payment methods to include an analysis of the interactions of multiple funding flows and the combined effect of their incentives on the provision of healthcare services. The purpose of the article is to highlight the importance of multiple funding flows to health facilities and present a conceptual framework to guide their analysis. The framework hypothesizes that when healthcare providers receive multiple funding flows, they may find certain funding flows more favourable than others based on how these funding flows compare to each other on a range of attributes. This creates a set of incentives, and consequently, healthcare providers may alter their behaviour in three ways: resource shifting, service shifting and cost shifting. We describe these behaviours and how they may affect health system objectives. Our analysis underlines the need to align the incentives generated by multiple funding flows. To achieve this, we propose three policy strategies that relate to the governance of healthcare purchasing: reducing the fragmentation of health financing arrangements to decrease the number of multiple purchaser arrangements and funding flows; harmonizing signals from multiple funding flows; and constraining providers from responding to undesirable incentives.

Strategic Health Purchasing Progress Mapping in Cameroon: A Scoping Review

Many low- and middle-income countries are adopting far-reaching health financing policies using strategic health purchasing (SHP) approaches to address their health sector challenges. However, limited efforts have been directed toward analyzing the SHP activities nationwide. Our objective was to explore the scope and development of SHP in Cameroon. We conducted a scoping review applying the framework developed by Arksey and O'Malley and modified by Levac et al. to identify and extract data from relevant SHP studies and documents published between 2000 and 2019, which focused on Cameroon. Among the existing 30 health financing schemes, 5 present the elements of SHP: (1) national health insurance (NHI), (2) performance-based financing (PBF), (3) voucher system, (4) private health insurance, and (5) mutual health organizations. The findings suggest that the governance function of purchasing is very challenging due to the multiple purchaser markets and the resulting fragmentation of the health financing system. In addition, the misalignment of the different benefit packages across schemes leads to considerable gaps and overlaps in the population coverage. The issue of multiple highly fragmented payment systems also remains a big concern across the different schemes, with tentative harmonization observed with NHI and PBF. Achieving the full potential of SHP in Cameroon will require (1) a defragmentation of the multiple schemes, (2) an effective oversight arrangement, and (3) an alignment of provider payment method to a coherent set of incentives across the system, with the ultimate aim of promoting equity, efficiency and quality.

Do efficiency gains really translate into more budget for health? An assessment framework and country applications

Efficiency has historically been considered a key mechanism to increase the amount of available revenues to the health sector, enabling countries to expand services and benefits to progress towards universal health coverage (UHC). Country experience indicates, however, that efficiency gains do not automatically translate into greater budget for health, to additional revenues for the sector. This article proposes a framework to assess whether and how efficiency interventions are likely to increase budgetary space in health systems Based on a review of the literature and country experiences, we suggest three enabling conditions that must be met in order to transform efficiency gains into budgetary gains for health. First there must be well-defined efficiency interventions that target health system inputs, implemented over a medium-term time frame. Second, efficiency interventions must generate financial gains that are quantifiable either pre- or post-intervention. Third, public financial management systems must allow those gains to be kept within the health sector and repurposed towards priority health needs. When these conditions are not met, efficiency gains do not lead to more budgetary space for health. Rather, the gains may instead result in budget cuts that can be detrimental to health systems' outputs and ultimately disincentivize further attempts to improve efficiency in the sector. The framework, when applied, offers an opportunity for policymakers to reconcile efficiency and budget expansion goals in health.

Performance of Thailand's universal health coverage scheme: Evaluating the effectiveness of annual public hearings

BACKGROUND

Legislative provisions in Thailand's National Health Security Act 2002 mandate annual public hearings for providers, beneficiaries and other stakeholders in order to improve the performance of the Universal Health Coverage Scheme (UCS).

OBJECTIVE

This study aims to explore the annual public hearing process, evaluate its effectiveness and propose recommendations for improvement.

METHOD

In-depth interviews were conducted with 29 key informants from various stakeholder groups involved in annual public hearings.

RESULTS

The evaluation showed that the public hearings fully met the criteria of influence over policy decision and partially met the criteria of appropriate participation approach and social learning. However, there are rooms for improvement on public hearing's inclusiveness and representativeness of participants, adequacy of information and transparency.

CONCLUSIONS

Three recommendations were proposed a) informing stakeholders in advance of the agenda and hearing process to enable their active participation; b) identifying experienced facilitators to navigate the discussions across stakeholders with different or conflicting interests, in order to reach consensus and prioritize recommendations; and c) communicating policy and management responses as a result of public hearings to all stakeholders in a timely manner.

Breast cancer in Thailand: policy and health system challenges to universal healthcare

Thailand has successfully implemented Universal Health Coverage (UHC) and embedded the 2030 Agenda for Sustainable Development into its Thailand 4.0 policy. Breast cancer is a growing challenge in Thailand, as it is globally. It serves as a perfect medium through which to interrogate UHC and demonstrate areas of the health system which require further strengthening if UHC is to be sustainable in the longer term. We conducted a situation analysis and used a Systemic Rapid Assessment (SYSRA) framework to examine the challenges posed to UHC through the lens of breast cancer. We identified a number of challenges facing UHC including (1) continued political commitment; (2) the need for coordinated scale-up of strategic investments involving increased financing and fine-tuning of the allocation of resources according to health needs; (3) reducing inequities between health insurance schemes; (4) investing in innovation of technologies, and more critically, in technology transfer and capacity building; (5) increasing capacity, quality and confidence in the whole primary healthcare team but especially family medicine doctors. This would subsequently increase both efficiency and effectiveness of the patient pathway, as well as allow patients wherever possible to be treated close to their homes, work and family; (6) developing and connecting information systems to facilitate understanding of what is working, where needs are and track trends to monitor improvements in patient care. Our findings add to an existing body of evidence which suggest, in light of changing disease burden and increasing costs of care, a need for broader health system reforms to create a more enabling platform for integrated healthcare as opposed to addressing individual challenging elements one vertical system at a time. As low- and middle-income countries look to realize the 2015 Sustainable Development Goals and sustainable UHC this analysis may provide input for policy discussion at national, regional and community levels and have applicability beyond breast cancer services alone and beyond Thailand.

The Requirements of Strategic Purchasing of Health Services for Cancer Patients: A Qualitative Study in Iran

The strategic purchasing creates dynamics and providers' competitiveness among the internal market of governmental sector with ensuring appropriate payments and promoting quantity-quality of service delivery that lead to improve the health system efficiency. This study aimed to determine the requirements for the strategic purchasing of health services for cancer patients in Iran. As a qualitative research with a framework analysis, this study was conducted in Iran from July 2018 to February 2019. The participants were included some administrating managers, experts, and specialists of insurance selected purposefully by snowball sampling method. The framework analysis of the study included 5 steps. Data were saturated after 21 semistructured interviews. The main findings included 3 main themes (supply management, insurance trusteeship, and financial performance) and 14 subthemes (strategic purchasing infrastructures, practical guidelines, trusteeship structure, service package, service quality, service quantity, role of other organizations and groups, training, establishment of an insurance thought, strategic management, communication, price, efficiency and effectiveness, and resource provision). The strategic purchasing model of health services increases the power of service purchasers and payment based on defined priorities, resulting in providers' coordinating for care provision, enhancement of financial performance and cancer patients' better access to health services, improvement of life quality, and financial protection.

The barriers to the full implementation of strategic purchasing and the role of health policy and decision-makers: past, current status, ethical aspects and future challenges

Healthcare systems are complex, multi-level, highly integrated organizations, comprising of different professional figures, institutions, and resources. Such breadth and complexity reflect the multi-dimensionality of the concept of health, which implies the adoption of a holistic approach. Health, rather than merely being the absence of disorders or infirmity, is a highly dynamic state, which represents the abilities of an individual to cope with adverse social, physical and emotional/psychological events and conditions, continuously adapting to them. Ensuring an adequate health state is one of the most important concerns, and the healthcare systems are called to renew themselves in order to meet with the new challenges and health needs. Throughout the last decades, due to demographic shifts and transitions, epidemiological and societal changes, technological achievements and scientific advancements, healthcare systems have undergone an extensive series of reform plans. Therefore, health policy- and decision-makers have made efforts to develop and implement initiatives for preserving the quality of the healthcare provisions. Strategic purchasing is an approach of purchasing that takes into account several health-related issues such as a proper, comprehensive planning of service delivery, the design and selection of the best packages of services and provisions, the appropriate selection of providers and the allocation of economical and financial incentives to provide better services and to motivate managers to adopt appropriate policies to implement strategic purchasing. Here, we intend to consider the various dimensions and aspects that can be effective in strategic purchasing, as well as the main barriers and obstacles that hinder its full implementation.

Legislating for public accountability in universal health coverage, Thailand

Sustaining universal health coverage requires robust active public participation in policy formation and governance. Thailand’s universal coverage scheme was implemented nationwide in 2002, allowing Thailand to achieve full population coverage through three public health insurance schemes and to demonstrate improved health outcomes. Although Thailand’s position on the World Bank worldwide governance indicators has deteriorated since 1996, provisions for voice and accountability were embedded in the legislation and design of the universal coverage scheme. We discuss how legislation related to citizens’ rights and government accountability has been implemented. Thailand’s constitution allowed citizens to submit a draft bill in which provisions on voice and accountability were successfully embedded in the legislative texts and adopted into law. The legislation mandates registration of beneficiaries, a 24/7 helpline, annual public hearings and no-fault financial assistance for patients who have experienced adverse events. Ensuring the right to health services, and that citizens’ voices are heard and action taken, requires the institutional capacity to implement legislation. For example, Thailand needed the capacity to register 47 million people and match them with the health-care provider network in the district where they live, and to re-register members who move out of their districts. Annual public hearings need to be inclusive of citizens, health-care providers, civil society organizations and stakeholders such as local governments and patient groups. Subsequent policy and management responses are important for building trust in the process and citizens’ ownership of the scheme. Annual public reporting of outcomes and performance of the scheme fosters transparency and increases citizens’ trust.

Trend of Cesarean Section Rates and Correlations with Adverse Maternal and Neonatal Outcomes: A Secondary Analysis of Thai Universal Coverage Scheme Data

Objectives  The main purpose of this article is to estimate the trend and projection of cesarean section rates (CSRs) and explore correlations between CSRs with adverse maternal and perinatal outcomes, namely maternal mortality ratios (MMRs), rates of postpartum hemorrhage (PPH), neonatal mortality rates (NMRs), and birth asphyxia per 1,000 live births across all regions of Thailand. Study design  A secondary analysis of the hospital-based database of pregnant women and newborns under the Thai Universal Coverage Scheme between January 2009 and December 2017 was conducted. Results  Overall annual CSR significantly increased from 23.2% in 2009 to 32.5% in 2017. With the same rate of increase, the CSR of 59.1% was projected by the year 2030 that could be reduced to 30.0% if an annual rate of CS reduction of 1% was assumed using Joinpoint regression. The increasing CSRs were significantly correlated with higher MMRs ( r = 0.20, p  = 0.03) and birth asphyxia ( r = 0.39, p  < 0.001). The correlation trends were similar when the analyses were stratified by year in the majority of years. Overall correlations between CSRs and rates of PPH or NMRs were not statistically significant. Conclusion  CSRs in Thailand continuously increased and were correlated with adverse maternal and perinatal outcomes. More effort at the national level to reduce unnecessary CS is urgently required.

Strategic Purchasing: The Neglected Health Financing Function for Pursuing Universal Health Coverage in Low-and Middle-Income Countries Comment on "What's Needed to Develop Strategic Purchasing in Healthcare? Policy Lessons from a Realist Review"

Sanderson et al’s realist review of strategic purchasing identifies insights from two strands of theory: the economics of organisation and inter-organisational relationships. Our findings from a programme of research conducted by the RESYST (Resilient and Responsive Health Systems) consortium in seven countries echo these results, and add to them the crucial area of organisational capacity to implement complex reforms. We identify key areas for policy development. These are the need for: (1) a policy design with clearly delineated responsibilities; (2) a task network of organisations to engage in the broad set of functions needed; (3) more effective means of engaging with populations; (4) a range of technical and management capacities; and (5) an awareness of the multiple agency relationships that are created by the broader financing environment and the provider incentives generated by multiple financing flows.

Components Affecting Pharmaceutical Strategic Purchasing: A Scoping Review

Pharmaceutical strategic purchasing is considered as a key to improve access to medicines especially for developing countries. The aim of this scoping review is to determine the most important components affecting pharmaceutical strategic purchasing. Here, we employed a comprehensive search strategy across PubMed, ProQuest, EBSCO, ISI Web of Science, Scopus, ScienceDirect, and Google Scholar for the terms related to medicines strategic purchasing. Among 13 included studies, 7 (53.85%) and 6 (46.15%) studies belonged to the developing and developed countries, respectively. Six main variables were emphasized as the effective variables on medicines strategic purchasing, including purchasing interventions, target group and service users, providers and suppliers of interventions, methods and motivations, price, and finally structure and organization. It seems that the insurance organizations of developing countries can achieve strategic purchasing only through the modification of the pharmaceutical pricing system and payment systems. Furthermore, they should pay attention to the real needs of target groups (demand) and modify the structure and organization as well as purchasing the most effective medicines from the best pharmaceutical providers.

A real-world study of effectiveness of intravitreal bevacizumab and ranibizumab injection for treating retinal diseases in Thailand

Background

To evaluate the effectiveness of intravitreal bevacizumab (IVB) and intravitreal ranibizumab (IVR) in actual practice for treating patients with retinal diseases in Thailand.

Methods

A prospective, multi-centre, observational study was conducted among eight hospitals in their ophthalmology outpatient departments. Participants consisted of patients who had previously not received any IVB or IVR treatment between 2013 and 2014. The primary outcome measurement was the change in best-corrected visual acuity (BCVA) at the end of the follow-up period compared to baseline.

Results

There were 1629 treatment-naïve patients for the pro re nata (PRN) treatment pattern and 226 treatment-naive patients for the three-injections (3Inj) treatment pattern. BCVA improvements were found in 35% of the PRN group and 47% of the 3Inj group; however, it was not clinically meaningful between the IVB and IVR groups (P-value = 0.568 for PRN, P-value = 0.103 for 3Inj). A multivariable logistic regression (using the propensity score) showed that positive factors associated with vision improvement for the PRN pattern were the number of drug injections, having retinal vein occlusion, and under 60 years of age, while good BCVA at baseline was a negative predictive factor. For the 3Inj pattern, under 60 years of age and baseline BCVA were statistically significant predictors. Nonetheless, diabetes mellitus (DM) without other comorbidities was a statistically significant predictor of low response to vision improvement compared to DM with other comorbidities.

Conclusions

This study was the first observational, prospective study to evaluate the real-life effectiveness of IVB and IVR in Thailand. The majority of participants who used IVB or IVR showed improvements in BCVA after treatment. Further evaluation such as long-term follow-ups and subsequent comparison of effectiveness between IVB and IVR should be investigated due to the limited sample of IVR patients.

Trial registration

Thai Clinical Trial Registry TCTR20141002001. Registered 02 October 2014 (retrospectively registered).

Health care purchasing in Kenya: Experiences of health care providers with capitation and fee-for-service provider payment mechanisms

BACKGROUND

Provider payment mechanisms (PPMs) play a critical role in universal health coverage due to the incentives they create for health care providers to deliver needed services, quality, and efficiency. We set out to explore public, private, and faith-based providers' experiences with capitation and fee-for-service in Kenya and identified attributes of PPMs that providers considered important.

METHODS

We conducted a qualitative study in two counties in Kenya. Data were collected using semistructured interviews with 29 management team members in six health providers accredited by the National Hospital Insurance Fund (NHIF).

RESULTS

Capitation and fee-for-service payments from the NHIF and private insurers were reported as good revenue sources as they contributed to providers' overall income. The expected fee-for-service payment amounts from NHIF and private insurers were predictable while capitation funds from NHIF were not because providers did not have information on the number of enrolees in their capitation pool. Moreover, capitation payment rates were perceived as inadequate. Capitation and fee-for-service payments from NHIF and private insurers were disbursed late. Finally, public providers had lost their autonomy to access and utilise capitation and fee-for-service payments from the NHIF.

CONCLUSION

Through their experiences, health care providers revealed characteristics of PPMs that they considered important.

What's Needed to Develop Strategic Purchasing in Healthcare? Policy Lessons from a Realist Review

BACKGROUND

In the context of serious concerns over the affordability of healthcare, various authors and international policy bodies advise that strategic purchasing is a key means of improving health system performance. Such advice is typically informed by theories from the economics of organization (EOO). This paper proposes that these theories are insufficient for a full understanding of strategic purchasing in healthcare, because they focus on safeguarding against poor performance and ignore the coordination and adaptation needed to improve performance. We suggest that insights from other, complementary theories are needed.

METHODS

A realist review method was adopted involving 3 steps: first, drawing upon complementary theories from the EOO and inter-organizational relationships (IOR) perspectives, a theoretical interpretation framework was developed to guide the review; second, a purposive search of scholarly databases to find relevant literature addressing healthcare purchasing; and third, qualitative analysis of the selected texts and thematic synthesis of the results focusing on lessons relevant to 3 key policy objectives taken from the international health policy literature. Texts were included if they provided relevant empirical data and met specified standards of rigour and robustness.

RESULTS

A total of 58 texts were included in the final analysis. Lessons for patient empowerment included: the need for clearly defined rights for patients and responsibilities for purchasers, and for these to be enacted through regular patientpurchaser interaction. Lessons for government stewardship included: the need for health strategy to contain specific targets to incentivise purchasers to align with national policy objectives, and for national government actors to build close, trusting relationships with purchasers to facilitate access to local knowledge about needs and priorities. Lessons for provider performance included: provider decision autonomy may drive innovation and efficient resource use, but may also create scope for opportunism, and interdependence likely to be the best power structure to incentivise collaboration needed to drive performance improvement.

CONCLUSION

Using complementary theories suggests a range of general policy lessons for strategic purchasing in healthcare, but further empirical work is needed to explore how far these lessons are a practically useful guide to policy in a variety of healthcare systems, country settings and purchasing process phases.

Strategic purchasing for universal health coverage: examining the purchaser-provider relationship within a social health insurance scheme in Nigeria

BACKGROUND

In an attempt to achieve universal health coverage, Nigeria introduced a number of health insurance schemes. One of them, the Formal Sector Social Health Insurance Programme (FSSHIP), was launched in 2005 to provide health cover to federal government and formal private sector employees. It operates with two levels of purchasers, the National Health Insurance Scheme (NHIS) and health maintenance organisations (HMOs). This study critically assesses purchasing arrangements between NHIS, HMOs and healthcare providers and determines how the arrangements function from a strategic purchasing perspective within the FSSHIP.

METHODS

A qualitative study undertaken in Enugu state, Nigeria, data were gathered through reviews of documents, 17 in-depth interviews (IDIs) with NHIS, HMOs and healthcare providers and two focus group discussions (FGDs) with FSSHIP enrolees. A strategic purchasing lens was used to guide data analysis.

RESULTS

The purchasing function was not being used strategically to influence provider behaviour and improve efficiency and quality in healthcare service delivery. For the purchaser-provider relationship, these actions are: accreditation of healthcare providers; monitoring of HMOs and healthcare providers and use of appropriate provider payment mechanisms for healthcare services at every level. The government lacks resources and political will to perform their stewardship role while provider dissatisfaction with payments and reimbursements adversely affected service provision to enrolled members. Underlying this inability to purchase, health services strategically is the two-tiered purchasing mechanism wherein NHIS is not adequately exercising its stewardship role to monitor and guide HMOs to fulfil their roles and responsibilities as purchasing administrators.

CONCLUSIONS

Purchasing under the FSSHIP is more passive than strategic. Governance framework requires strengthening and clarity for optimal implementation so as to ensure that both levels of purchasers undertake strategic purchasing actions. Additional strengthening of NHIS is needed for it to have capacity to play its stewardship role in the FSSHIP.

Developing cardiovascular disease risk programs in India-Why location and wealth matter

In a Perspective, David Peiris and Dorairaj Prabhakaran discuss implications and challenges of cardiovascular disease risk assessments in the population of India.