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"

An Assessment of Provider Payment Mechanisms (PPMs) in Ethiopia: Implications for Redesign of PPMs and Progress Toward Universal Health Coverage

Ethiopia has made great strides in improving population health but sustaining health system and population health improvements in the current fiscal environment is challenging. Provider payment, as a function of purchasing, is a tool to use limited health resources better. This study describes the design and implementation of Ethiopia's provider payment mechanisms (PPMs) and how they influence health system objectives and contribute to universal health coverage goals. The research team adapted the framework and analytical tools of the Joint Learning Network for Universal Health Coverage guide for assessing PPMs. Data were collected through literature review and key informant interviews with 11 purchasers and 17 health care providers. Content analysis was used to describe PPM design and implementation arrangements, and thematic analysis was used to distill effects on equity in resource distribution and access to care, efficiency, quality of care, and financial sustainability. The study revealed the PPMs had positive and negative consequences. Line-item budgets were perceived to be predictable and sustainable but had little effect on efficiency and provider performance. Fee-for-service was perceived to have negative effects on efficiency and financial sustainability but viewed positively on its ability to incentivize quality health services. Capitation and performance-based financing effects were viewed positively on equity in distribution of resources and quality respectively, but both were perceived negatively on their high administrative burden to providers. Ethiopia may consider a more nuanced approach to design blended provider payment to mitigate negative consequences while providing incentives for better quality of care and efficiency.

Citizen engagement in national health insurance in rural western Kenya

Effective citizen engagement is crucial for the success of social health insurance, yet little is known about the mechanisms used to involve citizens in low- and middle-income countries. This paper explores citizen engagement efforts by the National Health Insurance Fund (NHIF) and their impact on health insurance coverage within rural informal worker households in western Kenya. Our study employed a mixed methods design, including a cross-sectional household survey (n = 1773), in-depth household interviews (n = 36), six focus group discussions with community stakeholders and key informant interviews (n = 11) with policymakers. The findings reveal that NHIF is widely recognized, but knowledge of its services, feedback mechanisms and accountability systems is limited. NHIF enrolment among respondents is low (11%). The majority (63%) are aware of NHIF, but only 32% know about the benefit package. There was higher awareness of the benefit package (60%) among those with NHIF compared to those without (28%). Satisfaction with the NHIF benefit package was expressed by only 48% of the insured. Nearly all respondents (93%) are unaware of mechanisms to provide feedback or raise complaints with NHIF. Of those who are aware, the majority (57%) mention visiting NHIF offices for assistance. Most respondents (97%) lack awareness of NHIF's performance reporting mechanisms and express a desire to learn. Negative media reports about NHIF's performance erode trust, contributing to low enrolment and member attrition. Our study underscores the urgency of prioritizing citizen engagement to address low enrolment and attrition rates. We recommend evaluating current citizen engagement procedures to enhance citizen accountability and incorporate their voices. Equally important is the need to build the capacity of health facility staff handling NHIF clients in providing information and addressing complaints. Transparency and information accessibility, including the sharing of performance reports, will foster trust in the insurer. Lastly, standardizing messaging and translations for diverse audiences, particularly rural informal workers, is crucial.

Adjustments in purchasing arrangements to support the COVID-19 health sector response: evidence from eight middle-income countries

The COVID-19 pandemic has triggered several changes in countries' health purchasing arrangements to accompany the adjustments in service delivery in order to meet the urgent and additional demands for COVID-19-related services. However, evidence on how these adjustments have played out in low- and middle-income countries is scarce. This paper provides a synthesis of a multi-country study of the adjustments in purchasing arrangements for the COVID-19 health sector response in eight middle-income countries (Armenia, Cameroon, Ghana, Kenya, Nigeria, Philippines, Romania and Ukraine). We use secondary data assembled by country teams, as well as applied thematic analysis to examine the adjustments made to funding arrangements, benefits packages, provider payments, contracting, information management systems and governance arrangements as well as related implementation challenges. Our findings show that all countries in the study adjusted their health purchasing arrangements to varying degrees. While the majority of countries expanded their benefit packages and several adjusted payment methods to provide selected COVID-19 services, only half could provide these services free of charge. Many countries also streamlined their processes for contracting and accrediting health providers, thereby reducing administrative hurdles. In conclusion, it was important for the countries to adjust their health purchasing arrangements so that they could adequately respond to the COVID-19 pandemic, but in some countries financing challenges resulted in issues with equity and access. However, it is uncertain whether these adjustments can and will be sustained over time, even where they have potential to contribute to making purchasing more strategic to improve efficiency, quality and equitable access in the long run.

Assessment of strategic healthcare purchasing and financial autonomy in Tanzania: the case of results-based financing and health basket fund

Background

Low-and middle-income countries (LMICs) are implementing health financing reforms toward Universal Health Coverage (UHC). In Tanzania direct health facility financing of health basket funds (DHFF-HBF) scheme was introduced in 2017/18, while the results-based financing (RBF) scheme was introduced in 2016. The DHFF-HBF involves a direct transfer of pooled donor funds (Health Basket Funds, HBF) from the central government to public primary healthcare-PHC (including a few selected non-public PHC with a service agreement) facilities bank accounts, while the RBF involves paying providers based on pre-defined performance indicators or targets in PHC facilities. We consider whether these two reforms align with strategic healthcare purchasing principles by describing and comparing their purchasing arrangements and associated financial autonomy.

Methods

We used document review and qualitative methods. Key policy documents and articles related to strategic purchasing and financial autonomy were reviewed. In-depth interviews were conducted with health managers and providers (n = 31) from 25 public facilities, health managers (n = 4) in the Mwanza region (implementing DHFF-HBF and RBF), and national-level stakeholders (n = 2). In this paper, we describe and compare DHFF-HBF and RBF in terms of four functions of strategic purchasing (benefit specification, contracting, payment method, and performance monitoring), but also compare the degree of purchaser-provider split and financial autonomy. Interviews were recorded, transcribed verbatim, and analyzed using a thematic framework approach.

Results

The RBF paid facilities based on 17 health services and 18 groups of quality indicators, whilst the DHFF-HBF payment accounts for performance on two quality indicators, six service indicators, distance from district headquarters, and population catchment size. Both schemes purchased services from PHC facilities (dispensaries, health centers, and district hospitals). RBF uses a fee-for-service payment adjusted by the quality of care score method adjusted by quality of care score, while the DHFF-HBF scheme uses a formula-based capitation payment method with adjustors. Unlike DHFF-HBF which relies on an annual general auditing process, the RBF involved more detailed and intensive performance monitoring including data before verification prior to payment across all facilities on a quarterly basis. RBF scheme had a clear purchaser-provider split arrangement compared to a partial arrangement under the DHFF-HBF scheme. Study participants reported that the RBF scheme provided more autonomy on spending facility funds, while the DHFF-HBF scheme was less flexible due to a budget ceiling on specific spending items.

Conclusion

Both RBF and DHFF-HBF considered most of the strategic healthcare purchasing principles, but further efforts are needed to strengthen the alignment towards UHC. This may include further strengthening the data verification process and spending autonomy for DHFF-HBF, although it is important to contain costs associated with verification and ensuring public financial management around spending autonomy.

Applying systems thinking in the prosthetics and orthotics sector: investigating the common challenges in Iran

PURPOSE

We sought to explore the common challenges across stakeholder groups and also to recognize interactions among them to improve the Iranian prosthetics and orthotics (P&O) sector.

MATERIALS AND METHODS

Interviews were performed from January to June 2019. Participants, including 13 prosthetists/orthotists and six P&O faculty members, were selected using purposive and snowball sampling. The collected data were analyzed using the framework analysis method. Additionally, a systems thinking approach was applied to theorize potential leverage points to improve P&O services in Iran.

RESULTS

Challenges in leadership and governance included lack of united stewardship, inappropriate inter-sectoral cooperation, and poor awareness among decision-makers. Financing challenges included high out-of-pocket payments, inadequate insurance coverage, and insufficient governmental funding. Service delivery challenges included lack of prosthetists and orthotists in hospitals and medical centers, corrupt activities and a weak referral system. Human resource challenges included insufficient practical skills of graduates, misalignment of theoretical and clinical training, and inadequacy of continuing education courses.

CONCLUSIONS

This study provides the groundwork to develop and implement national strategies to address modifiable barriers and improve prosthetic and orthotic services.Implications for rehabilitationLack of united stewardship, inappropriate inter-sectoral cooperation, and poor awareness among decision-makers are the governance challenges of prosthetics and orthotics (P&O) and must be managed by the government.Government resources allocated to P&O services should increase, and P&O insurance coverage should improve.P&O services should be incorporated in health benefits packages to lessen the reliance on out-of-pocket payments.Planning should be done toward inclusion of P&O services in universal health coverage.Up-to-date scientific training and high-quality evidence are needed to enhance the practical skills of P&O graduates and consequently improve the quality of P&O services.Effective continuing training courses for P&O graduates are recommended.It is advantageous to provide P&O services in hospitals.

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.

Contracting the private health sector in Thailand's Universal Health Coverage

Private sector plays an import role in health service provision, therefore the engagement of private health facilities is important for ensuring access to health services. In Thailand, two of the three public health insurance schemes, Universal Coverage Scheme and Social Health Insurance, contract with private health facilities to fill gaps of public providers for the provision of health services under Universal Health Coverage. The National Health Security Office (NHSO) and Social Security Office (SSO), which manage the schemes respectively, have designed their own contractual agreements for private facilities. We aim to understand the current situation of contracting private health facilities within UHC of the two purchasing agencies. This qualitative descriptive case study was conducted through document review and in-depth interviews with key informants to understand how they contract private primary care facilities, service types, duration of contract, standard and quality requirement and renewal and termination of contracts. Private providers make a small contribution to the service provision in Thailand as a whole but they are important actors in Bangkok. The current approaches used by two purchasers are not adequate in engaging private sector to fill the gap of public provision in urban cities. One important reason is that large private hospitals do not find public contracts financially attractive. NHSO classifies contracts into 3 categories: main contracting units, primary care units, and referral units; while SSO only contracts main contracting units. Both allows subcontracting by the main contractors. Contractual agreements are effective in ensuring mandatory infrastructure and quality standards. Both purchasers have established technical capacities to enforce quality monitoring and financial compliance although there remains room for improvement especially on identifying fraud and taking legal actions. Contracting private healthcare facilities can fill the gap of public healthcare facilities, especially in urban settings. Purchasers need to balance the right level of incentives and accountability measures to ensure access to quality of care. In contracting private-for-profit providers, strong regulatory enforcement and auditing capacities are necessary. Further studies may explore various aspects contracting outcomes including access, equity, quality and efficiency impacts.

Assessment of Strategic Healthcare Purchasing Arrangements and Functions Towards Universal Coverage in Tanzania

BACKGROUND

Strategic health purchasing in low- and middle-income countries has received substantial attention as countries aim to achieve universal health coverage (UHC), by ensuring equitable access to quality health services without the risk of financial hardship. There is little evidence published from Tanzania on purchasing arrangements and what is required for strategic purchasing. This study analyses three purchasing arrangements in Tanzania and gives recommendations to strengthen strategic purchasing in Tanzania.

METHODS

We used the multi-case qualitative study drawing on the National Health Insurance Fund (NHIF), Social Health Insurance Benefit (SHIB), and improved Community Health Fund (iCHF) to explore the three purchasing arrangements with a purchaser-provider split. Data were drawn from document reviews and results were validated with nine key informant (KI) interviews with a range of actors involved in strategic purchasing. A deductive and inductive approach was used to develop the themes and framework analysis to summarize the data.

RESULTS

The findings show that benefit selection for all three schemes was based on the standard treatment guidelines issued by the Ministry of Health. Selection-contracting of the private healthcare providers are based on the location of the provider, the range of services available as stipulated in the scheme guideline, and the willingness of the provider to be contracted. NHF uses fee-for-service to reimburse providers. While SHIB and iCHF use capitation. NHIF has an electronic system to monitor registration, verification, claims processing, and referrals. While SHIB monitoring is done through routine supportive supervision and for the iCHF provider performance is monitored through utilization rates.

CONCLUSION

Enforcing compliance with the contractual agreement between providers-purchasers is crucial for the provision of quality services in an efficient manner. Investment in a routine monitoring system, such as the use of the district health information system which allows effective tracking of healthcare service delivery, and broader population healthcare outcomes.

Exploring the roles of players in strategic purchasing for healthcare in Africa-a scoping review

Following the World Health Organization (WHO) guidance on strategic purchasing in 2000, low- and middle-income countries (LMICs) are trying to shift from passive purchasing (using fixed budgets) to strategic purchasing of healthcare which ties reimbursement to outcomes. However, there is limited evidence on strategic purchasing in Africa. We conducted a scoping literature review aimed at summarizing the roles played by governments, purchasers and providers in relation to citizens/population in strategic purchasing in Africa. The review searched for scientific journal articles that contained data on strategic purchasing collected from Africa. The literature search identified 957 articles of which 80 matched the inclusion criteria and were included in the review. The study revealed that in some countries strategic purchasing has been used as a tool for healthcare reforms or for strengthening systems that were not functional under fixed budgets. However, there was some evidence of a lack of government commitment in taking leading roles and funding strategic purchasing. Further, in some countries the laws need to be revised to accommodate new arrangements that were not part of fixed budgets. The review also established that there were some obstacles within the public health systems that deterred purchasers from promoting efficiency among providers and that prevented providers from having full autonomy in decision making. As African countries strive to shift from passive to strategic purchasing of healthcare, there is need for full government commitment on strategic purchasing. There is need to further revise appropriate legal frameworks to support strategic purchasing, conduct assessments of the healthcare systems before designing strategic purchasing schemes and to sensitize the providers and citizens on their roles and entitlements respectively.

How to become a strategic purchaser of rehabilitation services

Rehabilitative care is often overlooked and underfunded despite being a key component of universal health coverage, and now faces further neglect due to indirect impacts of the coronavirus disease 2019 pandemic. Policy-makers can leverage strategic purchasing approaches to make the most of available funds and maximize health gains. To implement more strategic purchasing of rehabilitation, health planners must: (i) develop and prioritize evidence-based rehabilitation service packages; (ii) use fit-for-purpose contracting and provider payment mechanisms to incentivize quality and efficient service delivery; and (iii) strengthen stewardship. This paper examines these three policy priorities by analysing their associated processes, actors and resources based on country experiences. Policy-makers will likely face several obstacles in operationalizing these policy priorities, including: inadequate accountability and coordination among sectors; limited data and research; undefined and non-standardized rehabilitation services, costs and outcomes; and inadequate availability of rehabilitative care. To overcome challenges and institute optimal strategic purchasing practices for rehabilitation, we recommend that policy-makers strengthen health sector stewardship and establish a framework for multisectoral collaboration, invest in data and research and make use of available experience from high-income settings, while creating a body of evidence from low- and middle-income settings.

Strategic purchasing and health systems resilience: Lessons from COVID-19 in selected European countries

Strategic purchasing is a popular and frequently proposed policy for improving the efficiency and adaptiveness of health systems. The COVID-19 pandemic shocked health systems, creating a test of the adaptability and resiliency of their key features. This research study explores (i) what role purchasing systems and agents played in the COVID-19 pandemic, (ii) if it was strategic, and (iii) how it has contributed to a resilient health system. We conducted a qualitative, comparative study of six countries in the European Union—focusing on three as in-depth case studies—to understand how and when strategic purchasers responded to seven clearly defined health system “shocks” that they all experienced during the pandemic. We found that every case country relied on the federal government to fund and respond to the pandemic. Purchasers often had very limited, and if any then only passive, roles.

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.

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 Landscape of Strategic Health Purchasing for Universal Health Coverage in Burkina Faso: Insights from Five Major Health Financing Schemes

Strategic health purchasing is a key strategy in Burkina Faso to spur progress toward universal health coverage (UHC). However, a comprehensive analysis of existing health financing arrangements and their purchasing functions has not been undertaken to date. This article provides an in-depth analysis of five key health financing schemes in Burkina Faso: Gratuité (a national free health care program for women and children under age 5), crédits délégués (delegated credits), crédits transférés (transfers to municipalities), community-based health insurance, and occupation-based health insurance. This study involved a document review and complementary key informant interviews using the Strategic Health Purchasing Progress Tracking Framework developed by the Strategic Purchasing Africa Resource Center (SPARC). Data were collected using the framework's accompanying Microsoft Excel-based tool. We analyzed the data manually to examine and identify the strengths and weaknesses of governance arrangements and purchasing functions and capacities. The study provides insight into areas that are working well from a strategic purchasing perspective and, more importantly, areas that need more attention. Areas for improvement include low financial and managerial autonomy for some schemes, weak accountability measures, lack of explicit quality standards for contracting and for service delivery, budget overruns and late provider payment, provider payment that is not linked to provider performance, fragmented health information systems, and information generated is not linked to purchasing decisions. Improvements in purchasing functions are required to address shortcomings while consolidating achievements. This study will inform next steps for Burkina Faso to improve purchasing and advance progress toward 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.

Strategic Purchasing Arrangements in Uganda and Their Implications for Universal Health Coverage

Several purchasing arrangements coexist in Uganda, creating opportunities for synergy but also leading to conflicting incentives and inefficiencies in resource allocation and purchasing functions. This paper analyzes the key health care purchasing functions in Uganda and the implications of the various purchasing arrangements for universal health coverage (UHC). The data for this paper were collected through a document review and stakeholder dialogue. The analysis was guided by the Strategic Health Purchasing Progress Tracking Framework created by the Strategic Purchasing Africa Resource Center (SPARC) and its technical partners. Uganda has a minimum health care package that targets the main causes of morbidity and mortality as well as specific vulnerable groups. However, provision of the package is patchy, largely due to inadequate domestic financing and duplication of services funded by development partners. There is selective contracting with private-sector providers. Facilities receive direct funding from both the government budget and development partners. Unlike government-budget funding, payment from output-based donor-funded projects and performance-based financing (PBF) projects is linked to service quality and has specified conditions for use. Specification of UHC targets is still nascent and evolving in Uganda. Expansion of service coverage in Uganda can be achieved through enhanced resource pooling and harmonization of government and donor priorities. Greater provider autonomy, better work planning, direct facility funding, and provision of flexible funds to service providers are essential elements in the delivery of high-quality services that meet local needs and Uganda's UHC aspirations.

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.

Collaborative Learning to Advance Knowledge and Implementation of Strategic Health Purchasing in Sub-Saharan Africa

Strategic purchasing means deliberately directing health funds to priority populations, interventions, and services. This is done by actively creating incentives so funding is used equitably and efficiently and is aligned with population health needs. Strategic purchasing is a complex policy area fraught with challenging technical, institutional, and political issues. Policy makers and practitioners are an important source of tacit knowledge-experiential knowledge that is context specific and gained over time. Collaborative learning, through which a group of peers jointly problem-solves and generates lessons and solutions that can be adapted to different country contexts, is an important way to advance collective understanding of how to make progress on strategic purchasing within the unique health financing systems of sub-Saharan Africa. The Strategic Purchasing Africa Resource Center (SPARC), a resource hub hosted by AMREF Health Africa with technical support from Results for Development, is facilitating a collaborative learning agenda among 11 technical partners in 10 countries. SPARC and the technical partners are generating new insights and practical lessons to inform country policy and regional discourse on how to better use strategic purchasing to advance progress toward universal health coverage (UHC). This paper summarizes lessons and best practices from SPARC's collaborative learning approach that can benefit others who are seeking to apply a similar approach to share tacit learning on strategic purchasing and UHC.

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.

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.

Can Strategic Health Purchasing Reduce Inefficiency and Corruption in the Health Sector? The Case of Nigeria

Despite limited government budgets for health in many sub-Saharan African countries, some countries have improved health outcomes at low cost by being strategic in allocating and spending available resources. Strategic health purchasing is receiving increasing attention as a way to improve health system performance within financial constraints. Health purchasing, one of the health financing functions of health systems, is the transfer of pooled funds to health providers to deliver covered services. Strategic health purchasing uses evidence and information about population health needs and health provider performance to make decisions about which health services should have priority for public funding, which providers will provide these services, and how and how much providers will be paid to deliver those services. Strategic purchasing has enabled some countries to make progress on health sector goals while improving efficiency, equity, transparency, and accountability. However, when countries have high levels of corruption and low levels of accountability, as in Nigeria, strategic purchasing may be less effective and more money for health may not yield the expected public health benefits. This commentary uses the Strategic Health Purchasing Progress Tracking Framework developed by the Strategic Purchasing Africa Resource Center (SPARC) and its technical partners to examine health purchasing functions in Nigeria's main health financing schemes, how corruption affects the effectiveness of health purchasing in Nigeria, and opportunities to use strategic purchasing as a tool to address corruption in health financing by improving the transparency and accountability of health resource allocation and use.

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.

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.

Effectiveness of hospital payment reforms in low- and middle-income countries: a systematic review

Payment mechanisms have attracted substantial research interest because of their consequent effect on care outcomes, including treatment costs, admission and readmission rates and patient satisfaction. Those mechanisms create the incentive environment within which health workers operate and can influence provider behaviour in ways that can facilitate achievement of national health policy goals. This systematic review aims to understand the effects of changes in hospital payment mechanisms introduced in low- and middle-income countries (LMICs) on hospital- and patient-level outcomes. A standardised search of seven databases and a manual search of the grey literature and reference lists of existing reviews were performed to identify relevant articles published between January 2000 and July 2019. We included original studies focused on hospital payment reforms and their effect on hospital and patient outcomes in LMICs. Narrative descriptions or studies focusing only on provider payments or primary care settings were excluded. The authors used the Risk of Bias in Non-Randomized Studies of Interventions tool to assess the risk of bias and quality. Results were synthesized in a narrative description due to methodological heterogeneity. A total of 24 articles from seven middle-income countries were included, the majority of which are from Asia. In most cases, hospital payment reforms included shifts from passive (fee-for-service) to active payment models-the most common being diagnosis-related group payments, capitation and global budget. In general, hospital payment reforms were associated with decreases in hospital expenditures, out-of-pocket payments, length of hospital stay and readmission rates. The majority of the articles scored low on quality due to weak study design. A shift from passive to active hospital payment methods in LMICs has been associated with lower hospital and patient costs as well as increased efficiency without any apparent compromise on quality. However, there is an important need for high-quality studies in this area.

Payment Arrangements for Private Healthcare Purchasing Under Publicly Funded Systems in Low- and Middle-Income Countries: Issues and Implications

This paper examines private healthcare purchasing under publicly financed health systems in low- and middle-income countries (LMICs) to argue that the payment methods and rates applied to private and public health providers need careful attention to ensure equity, efficiency and quality in healthcare service provision. Specifically, public purchasers should develop a clear mechanism to establish justifiable payment rates for the purchase of private health services under publicly funded systems, using cost information and appropriate engagement with private health providers. In order to determine the validity of payment arrangements with private providers, clarification of the shared roles and responsibilities of public and private healthcare providers is required, including specification of types of services to be delivered by public and private providers, and the services for which public providers receive government budget and salaries above payments for other publicly funded services. In addition, carefully designed payment methods should include incentives to encourage healthcare providers to deliver efficient, equitable and quality health services, which requires consideration of how the healthcare purchasing market is structured. Furthermore, governments should establish sound legal frameworks to ensure that public purchasers establish 'strategic' payment arrangements with healthcare providers and that healthcare providers are able to respond to the incentives sent by the payment arrangements. To deepen understanding of public purchasing of private healthcare services and gain further insight in the LMIC context, in-depth empirical studies are necessary on the payment methods and rates used by public purchasers in a range of settings and the implications of payment arrangements on efficiency, equity and quality in healthcare service provision.

Misunderstandings and ambiguities in strategic purchasing in low- and middle-income countries

Strategic purchasing is branded as an approach that is necessary for progress towards universal health coverage. While we agree that publicly purchased health services should respond to society's needs and patient expectations, and thus generally endorse strategic purchasing, here we would like to explore two emerging concerns within current discussions in low- and middle-income countries. First, there exists a great deal of misunderstanding and conceptual unclarity, within practitioner groups, around the concept of strategic purchasing and what instruments it incorporates. Second, there is a growing trend to regularly fuse strategic purchasing into a performance-based financing (PBF) discourse in ways that increasingly blur their distinctive properties and policy orientations, while perhaps too easily obfuscating potential tensions. We believe the discourse on strategic purchasing would benefit from better conceptual clarity by dissociating and prioritising its two objectives, namely: priority should be given to needs-based allocation of resources, while rewarding performance is a subsequent concern. We argue there is a need for a more thoroughgoing conceptual and empirical re-examination of strategic purchasing's priorities, its link with PBF, as well as for a wider evidence-base on what strategic purchasing tools exist and which are most appropriate for diverse contexts.

Forty years review of upstream documents of the Islamic Republic of Iran's health sector on strategic purchasing of advanced-expensive medical equipment

Purpose

According to the importance of strategic purchasing as an effective tool for resource allocation and service procurement, this study examines national laws, regulations and other related documents related to the strategic purchasing of health services related to the advanced medical equipment in Iran.

Design/methodolgy/approach

It was a national qualitative document analysis conducted in 2019 applying content analysis approach. The four-step Scott method was used to include the documents in terms of authenticity, credibility, representation and meaningfulness. After retrieving the related documents, they were coded with the implicit and explicit approach. MAXQDA10 was used for content analysis.

Findings

The findings show that according to the framework of effective factors on the strategic purchasing of health services, seven main factors are determined as the main essential factors in purchasing advanced medical equipment. These factors consist of health care providers, health service buyers, purchaser and service provider contracts, payment mechanisms, organization and management evaluation of health technology including expensive medical equipment and technology-related.

Research limitation/implication

The study had some limitations as follows: the proposed method should be tested and its feasibility has to be investigated through appropriate tools for Iranian insurance companies and those with the similar settings.

Practical implication

The results of this study can shed more light for policy makers affiliated in Ministry of Health as the main service provider, Ministry of Welfare and the insurance agencies as the main purchasers of health services on paying attention to these seven main themes extracted from the upstream documents and laws and regulations of the Islamic Republic of Iran.

Social implication

The strategic purchasing of expensive high technology-based medical equipment is a necessity for Iranian public health insurance organizations that is emphasized in national documents in the way of implementing this necessity.

Originality/value

This study examines all the laws and regulations and all related documents in the strategic purchasing of health services related to advanced medical equipment, giving an analysis of the most important challenges and requirements of implementing strategic purchasing in the health services provision sector with expensive medical equipment.

Purchasing reforms and tracking health resources, Kenya

As low- and middle-income countries undertake health financing reforms to achieve universal health coverage, there is renewed interest in making allocation of pooled funds to health-care providers more strategic. To make purchasing more strategic, countries are testing different provider payment methods. They therefore need comprehensive data on funding flows to health-care providers from different purchasers to inform decision on payment methods. Tracking funding flow is the focus of several health resource tracking tools including the System of Health Accounts and public expenditure tracking surveys. This study explores whether these health resource tracking tools generate the type of information needed to inform strategic purchasing reforms, using Kenya as an example. Our qualitative assessment of three counties in Kenya shows that different public purchasers, that is, county health departments and the national health insurance agency, pay public facilities through a variety of payment methods. Some of these flows are in-kind while others are financial transfers. The nature of flows and financial autonomy of facilities to retain and spend funds varies considerably across counties and levels of care. The government routinely undertakes different health resource tracking activities to inform health policy and planning. However, a good source for comprehensive data on the flow of funds to public facilities is still lacking, because these activities were not originally designed to offer such insights. We therefore argue that the methods could be enhanced to track such information and hence improve strategic purchasing. We also offer suggestions how this enhancement can be achieved.