November Reflections

Listen to the November Reflections by Dr. Nkechi Olalere, Executive Director at Strategic Purchasing Africa Resource Center (SPARC).

Hello and welcome to another episode of Reflections – our very last for the year. Reflections is a roundup of the learnings from our various engagements – virtual and physical in a month.

In my past life, when I served in the leadership of private health insurance firms in Nigeria, provider contracting was the rule of the game. These contracts were drafted by legal teams recruited for this and related purposes and clearly spelt out the roles and responsibilities of providers and purchasers, including penalties for not meeting specific indicators. The contracts were clear as to what was expected of providers and they in turn, ensured that they kept to the terms of the agreement(s) or risk being sanctioned. This changed slightly when the National Health Insurance Scheme came on board with the scheme insisting on a new focus – more on ensuring that the third-party purchasers (Health Maintenance Organizations – HMOs) were building capacity of providers to ensure quality outputs and that purchasers were also held accountable for paying as and when due to providers. This was a rude awakening – from the days when the HMOs reigned supreme to a new dawn when they could not ride rough shod over the providers but were also accountable. This is one extreme of the provider contracting discourse

On joining the development sector, I met the other extreme. A situation where all public health facilities were empanelled just by existing, and where the purchaser was seemingly powerless to sanction them if found guilty of wrong doing. This has led to situations where providers do not have any incentive to keep to the terms of their contract (where contracts exist) and improve the quality of their services because they are still going to get paid anyway. I kept wondering…why would the provider invest in quality improvements if nobody was going to take it to account? Why is selective contracting such a taboo?

I received different answers:

1. Public health facilities need funding from the purchasers and therefore cannot be delisted – how will they raise internally generated revenue if they are not paid?

2. Providers without autonomy have no control over the funds they receive and cannot invest in quality improvements, even if they wanted to. And so, they may not be able to fulfil contractual terms linked to quality improvements

3. Quality improvements are expensive and someone (fingers pointing to the government) needs to make the initial investment in these, before public health facilities can be held accountable

4. The population residing in areas with few health facilities (typically rural communities) will experience more barriers to accessing healthcare if the few health facilities in the region are de-listed for any reason.

All of these reasons make great sense. But if we start this discourse with the premise of universal health coverage (UHC) being the final goal of health systems – all people have access to the good quality care that they need without suffering financial hardship, then discussions should be ramped up on the answers to these questions.

Provider contracting should be a staple of provider purchaser engagements with equal levels of accountability for both the purchaser and provider. This will help build the additional layer of trust needed to implement contracts

There should be clear governance arrangements with clarity on who reports what and to whom. For instance, who holds the purchaser accountable for delays in payments which can also affect providers’ capacity to meet contractual terms?

Perhaps facility autonomy (with requisite accountability) should become the norm rather than the exception, to ensure that public sector providers can invest in the quality improvements required by contracts and therefore held accountable?

In the build-up to facility autonomy, can governments increase their investments in quality and/or provide a moratorium period for public health facilities to improve quality and then ensure they are held accountable for this? Is there a PPP model that exists for this?

Do purchasers have adequate capacity to monitor contracts or is there a need for them to invest in the monitoring and evaluation systems that enable them to track and monitor contracts making them more enforceable?

A lot of questions to reflect on…

But it’s not all doom and gloom. Our Twitter chat and the #ForceCommunity webinar gave great examples of countries that were on track with provider contracting and using it to improve accountability. Rwanda is a great example. The annual Imihigo (performance contract) is executed at all levels of government, across all ministries and with specific reference to the health sector, holds leadership accountable for achieving specific health system goals.

How is your country utilizing (or not) provider contracting to increase accountability? Share your comments and let us know.

Until we come your way again, remember to stay safe and healthy – even though the holidays are here, COVID-19 is still on active duty!

November Reflections

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