“Posterity may forgive me if I make the wrong decision, but posterity will never forgive me should I fail to make a decision”
– Olusegun Obasanjo
(Former President, Federal Republic of Nigeria)
The world is not the same since the advent of the COVID-19 pandemic. The order of things is unprecedentedly evolving as routine decision-making processes are disrupted. The health sector is perhaps the worst hit by these uncertainties. Clearly the urgency towards “flattening the curve”, the new cliché for the pandemic control measures, has led to collateral effects on health system decision making. Disruptions in production and supply chain of essential health commodities and crowding out other essential services globally, has led to fierce competition within and between countries with respect to procurement of commodities and services. For example, there have been reports of stock outs of medical supplies (such as medical masks and ventilators). Some countries have resorted to hoarding and export restrictions of commodities. Such shift in market forces has implications on resource allocation and purchasing of commodities and services in resource constrained settings, particularly African countries.
African countries have perennially struggled with efforts towards universal health coverage (UHC). The principles of UHC require every individual to have access to good quality health services that they need without suffering from financial hardship as a result. But attaining UHC has implications on allocation of resources in African countries, which are already significantly resource constrained. Such constraints are now compounded by the COVID-19 pandemic, which has forced many countries to reallocate resources towards addressing the emergency situation. However, to achieve optimum results, countries must harness reliable evidence to inform decision making. Mechanism of translation of such evidence must be well adaptable to evolving uncertainties which decision makers are facing during this pandemic. I examine these unintended consequences of the pandemic and implications on strategic purchasing for health. I also discuss how data and communication strategies can help navigate the extant uncertainties.
Strategic purchasing refers to “active, evidence-based engagement in defining the service-mix and volume and selecting the provider-mix in order to maximize societal objectives”. Perhaps more than before, strategic purchasing for health is pertinent for African countries at this time. Decision makers are faced with three key purchasing problems with respect to closing complex needs gaps.
- What to buy: The COVID-19 has compounded existing purchase decision problems. Public policy makers are now more challenged with deciding what commodities and services must be prioritized amidst the numerous competing urgent needs and limited resources. There is the pressure to act to mitigate the direct impact of the pandemic. But the consequence of this may be a negative impact on other priority UHC efforts such as ensuring access to quality maternal and child health services. Thus, there is the need for policy makers to be guided by evidence in order to make the most plausible decisions on what to purchase in line with the broader UHC goals. A notable example of how this has been done successfully during the ongoing pandemic is the creation of a new DHIS2 tracker for case-based surveillance in Sri Lanka. This information system has been used successfully to track incoming travelers from high-risk areas, as well as availability of essential commodities such as intensive care unit beds. Thus, presenting the needed contextual evidence to inform buying decisions. African countries, most of which host their national health information systems on the DHIS2 platform, can adopt lessons from Sri Lanka. Similarly, android phones have now been updated with the capacity to provide data for COVID-19 related tracking purposes. A recent study in Nigeria confirms that there is ample opportunity for African countries to leverage on mobile position data to inform strategic decisions to control the pandemic. Regional bodies and institutions such as the African Union can be leveraged to develop integrated data systems to avoid duplications, enhance quality as well as inform coordinated decision making.
- From whom to buy: Selecting service providers in the midst of scarcity and global competition occasioned by a novel pandemic is a colossal challenge. Globalization itself has been constrained by the actions of countries looking more towards solving their own problems as against prioritizing mutual actions for mutual benefit. Suspicion between countries, and border closures have further constrained interdependencies, complicating ease of access to pre-existing global pool and market for health commodities and resources. Already there are reports of wealthier countries massively pre-ordering medical supplies and even potential COVID-19 vaccines still undergoing clinical trials. Thus, resource constrained economies may not be faced with the problem of choosing suppliers as much as the problem of locating and accessing supplies. This dilemma may leave many African countries vulnerable to receiving substandard commodities and services through donations or purchases. There are already reports of purchase of poor-quality test kits by some high-income countries. This may be the time for African countries to look inward and work together towards improving local production of essential health commodities while taming high cost of production in some cases. But such action will require more resource allocation to research and development, thus may be more of a medium to long term strategy. The Pandemic Supply Chain Network put together by the World Economic Forum can play a critical role at this time. However, logistics information management systems must be optimized within and across countries.
Within countries, existing health services are increasingly becoming overwhelmed. This is particularly burdensome in public health facilities and publicly financed health systems. Using available evidence for health management information systems, as well as statistical projections of how the pandemic may further strain service delivery, informed decisions can be made on optimizing internal pool of providers. This may include developing new partnerships with the private sector and other stakeholders to support the public health system. Further, decisions may be made on reviewing existing agency policies relating to health financing. An example will be to decide between single-payer versus multiple-payer system to balance efficiency and effectiveness with the ultimate aim of improving physical and financial access to health care. Considering the challenges of holistic reforms, ad-hoc arrangements may be more feasible in many situations, to address short term challenges posed by the pandemic, while sustainable longer-term reforms may be planned using learnings from the current situation.
- How to buy: The health care market is currently volatile due to panic as well as conflicting information about what it will take to curtail the outbreak and its associated health and socioeconomic effects. Further, there is an imminent recession which is predicted to hit many parts in the world, including Africa. Many low- and middle-income countries will face challenges with existing local and global payment mechanisms, as well as capacity to purchase. There is currently no global database or repository on health commodities. And many procurement processes are vertical, addressing programs or disease entities independently. This process may not be very cost effective, particularly during this global crisis. Integrated and transparent health procurement information management systems have been advocated over the years. This may be an appropriate time for countries to consider this. Further, leveraging on regional bodies to negotiate prices and mechanisms in the global market may be advantageous to many African countries. Within countries, similar procurement management systems can facilitate strategic purchasing. Such systems can be leveraged to make decisions on how to buy using available data from the health information system. For example, health information system may flag interruptions in health services associated with COVID-19. The system could indicate the causes of interruptions to be either supply side constraints (such as reduced funds flow to health facilities or redistribution of human resources); or declining demand occasioned by decreased capacity to pay, apprehensions about the contagion, or even access constraints resulting from movement restrictions. An integrated system will have the capacity to juxtapose such information with the public financial management systems to inform purchase priorities and mechanisms. Examples of such mechanisms include relaxing public finance management rules to allow upfront or expedited payments to address supply side constraints; or compensation for user fees forgone, to stimulate demand.
Deciding amidst uncertainty: Rational choice or rational choosing?
Making choices on how to purchase goods and services to address the pandemic is a dilemma for governments across the world. But decisions will have to be made. The quality and kind of evidence to inform such decisions presents a dilemma to the policy maker.
To address the purchasing problems previously outlined, effective strategic purchasing will require evidence that speaks to need, means and context. Generally, such evidence may come from research, or from routine data systems such as health management information systems. Most real-world decisions are made from the latter. But the key challenge to strategic purchasing does not often lie with the source of the evidence as much as it does with how to utilize existing evidence effectively.
Data are collected routinely in virtually every African health system, but scarcely used for strategic decision on purchasing health care packages. For data to effectively inform purchasing, they need to be analyzed specifically to address the three purchasing problems. Thus, reforms on data reporting requirements to inform strategic purchasing at system’s level is crucial. Further, information derived from the analysis of the data must be communicated in ways that makes the decision maker aware of all the options and their most likely impacts (positive or untoward).
Every so often, evidence is communicated in a linear manner to policy makers, creating a sense of ‘rational choice’. The impression passed is such that addressing an identified need, using available means, will result in predictable outcomes. But such is frequently not the case. Contextual influences such as politics and considerations of other uncertainties do not allow for rationality when making purchasing decisions in the real-world. For example, herbal remedies developed by some countries to prevent and cure COVID-19 are being purchased by many African governments despite concerns that their safety and efficacy are untested. This example illustrates the common problem faced in purchasing health packages; the conflict between data-driven evidence and contextual considerations. No real impact can be achieved by leaning extremely on either side of the divide. Thus, a bridge must be built.
To aid evidence-informed decision making amidst real-world uncertainties, decision makers must be supported to optimally satisfice. That is, to make choices based on linear and contextual evidence in such a way that is acceptable to key interests, yet not detrimental to the goals of UHC. One way to do this is to focus on rational choosing (procedural rationality) as against rational choice (substantive rationality). Procedural rationality focuses on the processes used in arriving at a decision, as against the rationality of the decision itself, which may be uncertain.
As regards the COVID-19 pandemic, the uncertainty about the epidemiological pattern of the disease has elicited caution from experts against linear modelling. The implication is that policy makers are unsure of what evidence should guide their decisions, including purchasing. Evidence producers and policy advisors may need to use available data to inform decision processes rather than defined outcomes, which are uncertain. In this regard, protocols developed based on best possible evidence per time, can guide purchasing decisions. As data becomes more available, such protocols may be updated in line with the most current evidence. For example, Nigeria keeps updating its COVID-19 guidelines, in line with evolving in-country data and communications from the WHO. These guidelines inform the allocation and use of resources to purchase goods and services aimed at controlling the pandemic. In conclusion, COVID-19 has disrupted existing decision-making processes, including purchasing of health packages. The uncertainty posed by the crisis complicates existing challenges with strategic purchasing. African countries will continue to face external and internal pressure on what to buy, from who to buy, and how to buy. Leveraging on regional institutions to harmonize data and share information is the way to go in order to mitigate the pressures from international actors and markets. While it may be difficult at this time to make rational decisions on what, how and from who to purchase, data and communication systems can be leveraged to guide how decisions are made, despite the uncertainties. Resource constrained countries in Africa may be guided by data and other forms of evidence, to rationalize choosing processes even when rational choices are improbable.
Ejemai Eboreime is a public health physician and health policy & systems specialist. His interests include applying implementation/ improvement science methods for evidence-based healthcare planning in Low and Middle-Income Countries. Ejemai is currently a global health post-doctoral research fellow at the University of Alberta, Canada.