Strategic purchasing means “active, evidence-based decisions in defining the service mix and volume and selecting the provider-mix to maximize societal objectives” . Improving purchasing is central to improving health system performance and making progress towards universal health coverage (UHC).
The COVID-19 pandemic response is a timely opportunity to assess countries’ use of strategic health purchasing in a global health emergency. While many developing countries are still struggling to apply strategic purchasing principles to provide equitable and quality care to their populations, their ability to apply strategic purchasing principles to provide equitable and quality care to their populations will be severely harmed in an emergency.This blog analyses the purchasing strategies adopted in response to COVID-19 in Benin and relies on government official data sources and discussions with health system practitioners in Benin.
At the onset of the pandemic, only public health centers with adequate infrastructure and isolation facilities were selected as response centers. Later, to improve access to testing, the Government selected a few additional sites such as youth centers and hotels as quarantine sites. The centers were mandated to conduct screening and pre-treatment :
- the isolation and treatment center for cases in Cotonou and the other counties;
- isolation and transit centers for patients identified in the health zones;
- airport health surveillance site;
- the health surveillance site at the port of Cotonou;
- the police checkpoints at the airport, port, and land borders.
Human resources, including existing healthcare workers, new medical graduates, and volunteers – including retired professionals, were mobilized and organized into different teams and trained on their assigned duties. The Ministry of Health (MoH) purchases healthcare services on behalf of the population and is also the service provider, as only public facilities are mandated to provide COVID-19 services. The table below reviews the relationship between the purchaser and the designated health facilities (providers) involved in the response based on the purchasing functions of benefits specification, selective contracting, contracting arrangements, provider payment, and performance monitoring.
Table 1:Purchasing Functions in Response to COVID-19 in Benin
|Purchasing functions||Description and analysis|
|Benefits specification and standard treatment protocols||The MoH developed a guideline for therapeutic management of COVID-19 in Benin, updated as needed  to support service delivery.|
|Selective contracting||The Ministry of Health (MoH) developed criteria to select the health facilities. Although little is known on whether contract terms vary among providers, the decision to contract a specific health facility is selective, based on the capacity – infrastructure and isolation space – and proximity to the population.|
|Contracting arrangements||The Government mandated specific public facilities for treatment, isolation and vaccination through an administrative note. The power exercised is mainly in one direction as providers cannot negotiate contract terms. As contracts were not formalized, it may be difficult to ensure accountability.|
|Provider Payment||The Government covers all expenses related to COVID-19 management and treatment. These include the costs of inputs supplied by the Government to providers for diagnostics and treatment, the expenses for supervision of the recruited workforce, and monitoring of activities. The main payment method used is “fee-for-service”, where the Government reimburses expenses based on service rendered by health facilities. The DHD receives the bills from health facilities for reimbursement. The process for verification and reconciliation of claims is unclear. Payment of bills is often delayed. Staff, including volunteers, receive a monthly allowance set by the government. However, the payments are often delayed and are not linked to performance and quality.|
|Performance monitoring||COVID19 activities are rigorously monitored. There is a daily follow-up at the health facility level and supervision by departmental and national teams. The epidemiological surveillance services in the various health zones (HZ) ensure that interventions in the treatment centers are carried out according to established guidelines.|
|Information for decision making||The pandemic management system in Benin has a hierarchical supervision structure to monitor the quality of services and data generated. Level 1: The Health Zone supervision and control team supervises and monitors the COVID19 activities in communal, hospitals, and district centers. Level 2: The National Supervision and Control Team, composed of the Health Zone and the Departmental Health Directorate (DHD), verifies the COVID19 data from the health zones.Level 3: DHD and the MoH team verifies all data reported by the DHDs and communicated to the Presidency and/or the council of Ministers for decision-making.|
Purchasing in Benin’s covid19 Pandemic ResponseBenin’s response followed many aspects of strategic purchasing such as benefits specification and defining service delivery protocols, selective contracting, information management, performance and service quality monitoring. These strategies have ensured that limited resources are applied effectively. For example, the MoH conducted a needs assessment at the district level prior to developing the Pandemic Response plan in February 2020. Funds allocated to the COVID 19 response were allocated based on the needs assessment . The service delivery guidelines, including screening and treatment, ensured quality services and efficiency in using inputs. Benin has rigorous provider performance monitoring and s evidence that reflects performance at all health system levels. This facilitates decision-making and applying incentives as needed. Understanding the needs of each district before supplying inputs, staff, and equipment is part of the strategy of Benin to ensure efficiency and equitable resource allocation.
Notwithstanding the positive aspects in the purchasing of the COVID19 services, several drawbacks have also been noted. First, little is known about the contracting process, which seems more passive. There is a lack of a formal process that would allow better accountability and performance monitoring. Instead, the government used administrative notes to mandate health centers to provide COVID19 related care with no clear terms of contracting or negotiation with providers. In such a situation, it is challenging to hold providers accountable for failure and misconduct. According to WHO, legal provisions or regulations allow the purchaser to monitor contracts regularly, follow up cases of non-performance or fraud, and legal sanctions when necessary.
Regarding the payment methods, fee-for-service increases the incentive to over provide services or crowd-out services unrelated to COVID19. A well-designed and implemented payment method for health facilities should promote efficiency and quality of service, limit fraud and corruption . Furthermore, not linking payment to performance decreases the chance of efficiency. Delays in providers’ reimbursement show a weak accountability system in purchasing, which is also linked to the power imbalance with providers not having recourse to complain when payment is delayed. This may negatively affect the provider’s motivation, and therefore, their performance. There is a need to better define contracting terms and sanctions for both parties (purchaser and providers).
To sum up, our analysis of purchasing of COVID19 related services, while Benin has promising attributes such as defining case management and service guidelines, selective contracting, accountability measures, information management; the country needs to improve the contracting system and payment system. These improvements will contribute to the quality of service delivery, better accountability, motivation of providers, and equity in access to services.
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The authors are M. Cossi Xavier Agbeto, M. Crédo Ahissou, Dr Christelle Boyi, Kefilath A. Bello, and Dr Jean-Paul Dossou