Strengthening Capacity for Strategic Purchasing

HSR2020 SPARC Satellite Session Q&A

Session Description

This session focused on strategic purchasing, which at its core is about improving how ministries of health and government health insurance agencies use information about population health needs and provider performance to make decisions about benefit packages, contracted providers, and payment methods. It features latest research and best practices from a range of low- and middle-income countries actively undertaking purchasing reforms. The key topics covered in the session included approaches for identifying progress towards strategic purchasing and understanding the key drivers of success.

Purpose and Objectives

The purpose of the session was to share the latest research and best practices in strategic purchasing, while providing the opportunity to discuss specific purchasing challenges in different health systems, and findings from policy and management reforms introduced to address these challenges.

The key objective of the session was to identify progress towards strategic purchasing and understand the drivers of progress based on a mapping of purchasing arrangements.

Moderators

  1. Dr. Nkechi Olalere, Executive Director, SPARC
  2. Cheryl Cashin, Managing Director, Results for Development

Panelists

  • Prof. Obinna Onwujekwe, Health Policy Research Group, University of Nigeria, Nsukka
  • Dr. Elizabeth Ekirapa, School of Public Health, College of Health Sciences, Makerere University

Presentation Content

  1. Cheryl Cashin (Results for Development/R4D) and Nkechi Olarere (Strategic Purchasing Africa Resource Center/SPARC) offered a short introductory presentation on the functional capacities needed to drive progress on strategic purchasing and the mapping exercise undertaken in 10 sub-Saharan African countries through the SPARC technical partner consortium.
  2. Prof Elizabeth Kiracho and Obinna Onwujekwe reflected on the status of strategic purchasing in sub-Saharan Africa and discussed key areas of progress, with a focus on strategic benefits specification, contracting, provider autonomy, and linking payment to quality.

Session Questions and Answers

Ellen Van De Poel: What do you see as the biggest challenge to mainstream the donor funded PBF into the government’s way of purchasing? Donors are willing to move to DFF? Also, to which extent do you think donor driven PBF triggered a move to more output based funding in government resources?

Answer: Great question on PBf and its role in triggering a move towards more output based funding. This is a question that we (SPARC) are planning to address in a series of webinars in the first half of this year. The webinar, which seeks to change the discussion on PBF, will ask and answer thought provoking questions like whether PBF can enable a wider movement in a country toward strategic purchasing, and if yes how? And how countries can redirect donor-funded PBF schemes into broader strategic purchasing systems. These are some of the questions we will be unpacking with country and PBF actors as a means of charting a course for the future.

Priya Balasubramaniam: Is there any experience in governments strategically purchasing digital health services, especially during COVID-19? What have been some of the challenges in establishing this  a and what are the challenges in linking purchasing outcomes to service quality? any examples would be welcome.

Answer: One example of government strategically purchasing digital health services is Rwanda – they have a digital virtual medical service provider…. but this was started before the pandemic. The government was deliberate in determining the package for this service, choosing the providers to participate and the payment rate mechanism. Discussions with country partners suggest that this service was useful during the early days of the pandemic given the general population concern about contracting the virus in the health facilities. In linking purchasing reforms to health system outcomes, making the link is not easy. We could not conclusively draw that line of sight with our mapping of strategic purchasing functions, but that is the focus of our work now with our technical consortium – showing how strategic purchasing reforms can lead to better health system outcomes and better service delivery. We will be sharing the results of this as we receive them.

Miguel Gonzalez-Block: What has been the pushback, if any, to SP on the part of government providers experiencing rule changes and transfer of risks? Thank you. Mexico is experiencing push-back on purchasing, reverting to supply-side funding. In fact, strategic purchasing was limited to high-cost interventions, developing no experience in primary care. SP never attained levels which could lead to demonstrate benefits, while instead exposing corruption and giving the opportunity to revert the modest attainments. What is the experience in other countries with pushback to SP?

Answer: Thanks for your question. At SPARC, we take a functional approach to strategic purchasing and so this means supporting countries to make decisions on what to buy (the service; benefit package), who to buy from (provider contracting), what and how to pay. And so, given this framing, there has been no push back, in that sense. We are working with countries on that continuum from passive to strategic purchasing, working to understand drivers of progress and  how countries can be best supported to be more deliberate and utilize information to make those decisions described earlier.

Joseph Kutzin: Are there good developments and progress in the development of the capacity of the purchasing agency?  How can we assess this – what does improved capacity look like?

Answer: On good progress in capacity development of purchasing agency, and measures of progress, the SPARC SHP mapping tool addressed the measurement question with technical partners describing the capacities needed for SHP at the purchasing agencies and current gaps. Future work will address if identified capacities are actually synonymous with progress in SHP at the purchasing agencies.

Maarten Oranje: Fully agreed with Cheryl Cashin, that we should ask ourselves how existing PBF programs in countries can be leveraged better for strategic purchasing? We have PBF schemes which have successfully broadened their scope beyond RMNCAH to incentivize NCDs as well as infectious diseases. Frequent revision of the service and incentive package, based on data, is key here. This requires flexibility. At the same time, we want successful (donor driven) PBF schemes to be institutionalized (nationalized), which often comes with increasing rigidity. The key question for me would be: how do we institutionalize AND retain flexibility? Interested to hear what panelists think. 

Answer: I think an important requirement is for stakeholders to let go of the strong link between payment and performance. The verification systems in donor-funded schemes are not sustainable and don’t reflect the way more advanced systems purchase primary care. There’s quite some resistance from both donors and governments to loosen the link.

Ellen Van De Poel: Re PBF: we are working with PFM colleagues to assess the (mis)alignment of PBF vis a vis the government PFM system. Would be great to connect with SPARC team on this.

Answer: Absolutely agree and happy to connect. We will share more details of the webinars closer to the event. Details will be shared here. Add link to PBF webinar.

Strengthening Capacity for Strategic Purchasing

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