Nat Otoo – Senior Fellow R4D. Pioneer ED of SPARC and former CEO Ghana NHIA

In policy reform, identifying “low hanging fruits” and taking quick action to “harvest them” brings credibility to the reform process. Ordinarily, harvesting low hanging fruits in the reform of national and sub-national health insurance schemes is an issue that is largely within the control of such entities, as far as they have to do with administrative reform, process simplification and improvement of the customer experience. Long-term reforms, however, are generally complex and require complex stakeholder interactions and far-reaching procedural, process and monitoring and evaluation changes. As far as low hanging fruits are concerned, SPARC has worked with national health insurance schemes to identify such low hanging fruits in their strategic purchasing reforms during some of its country engagements. There is no doubt that the buy-in of purchasing agents such as national and sub-national health insurance schemes is critical for strategic purchasing reforms.

Dr Parfait Uwaliraye – Head, Planning, M&E and Information Systems, MoH Rwanda

I think countries operate in different contexts. One country experience cannot be exported into another. Countries can share experiences to inspire one another, but each has to go back and create an environment that fits their own realities. It takes time to build systems. In any case, to build a strategic procurement in your country, you first need to do a situation analysis to better understand gaps and loopholes in your current systems. A better understanding of the situation analysis will inform how to undertake your journey towards Strategic Procurement. That journey is normally governed by: a strong and clear policy and legal framework, a competent and efficient institutional framework, and people’s education/sensitization/awareness raising to understand the benefits of Strategic purchasing.

• Dr Parfait Uwaliraye – Head, Planning, M&E and Information Systems, MoH Rwanda

You become a strategic purchaser when you manage to sufficiently and sustainably obtain enough quality products that you need for less money. In strategic health purchasing, I would advise that you track and use evidence from all indicators of Universal health coverage proposed by WHO (https://www.who.int/data/gho/data/major-themes/universal-health-coverage-major)   

• Nat Otoo – Senior Fellow R4D. Pioneer ED of SPARC and former CEO Ghana NHIA

Evidence for strategic purchasing helps to improve governance of purchasing systems, link funds to provider activities and performance and provide an insight into the responsiveness of strategic purchasing to consumer needs.

Evidence that informs strategic purchasing includes:

1. Financial information to understand available funds and their flows.
2. Clinical information to highlight services provided to patients and their quality.
3. Patient information to identify patient needs, socio-economic profiles and help answer questions on access and equity.
4. Provider information to gauge capacity, service mix and performance.
5. Health system performance to understand service utilization, availability, accessibility.
6. Population health to shed light on socio-demographics & socio-economics.

• Dr Pierre Yameogo – Technical Secretary Ministry of Health, Burkina Faso

The achievement levels of the 3 intermediate objectives – equity, efficiency, transparency – and the 3 final objectives – service uptake, quality and household financial protection – are the evidence that inform strategic purchasing practices in health financing for UHC. SPARC’s evaluation and monitoring tool for strategic purchasing practices enables regular assessment of progress towards the optimal levels of this evidence.

• Dr Parfait Uwaliraye – Head, Planning, M&E and Information Systems, MoH Rwanda

Financial resources are always scarce, especially when it comes to health financing. There are challenges in all countries globally. So, the aim of pushing the idea of strategic health purchasing is to challenge healthcare systems and countries on how to improve the quality of care and services they provide. Countries or institutions that have adopted strategic health purchasing have recognized that there are things they need to challenge, reform or introduce to improve healthcare.

• Nat Otoo – Senior Fellow R4D. Pioneer ED of SPARC and former CEO Ghana NHIA

The key change from passive purchasing to strategic purchasing involves:

1. Shifting from normative systems that allocate budgets to systems that incentivize efficiency and quality.
2. Building robust systems for selecting which providers to contract with based on their capacity to provide services in the appropriate mix and to the required quality standards.
3. Leveraging the power of the purchaser to become a quality maker and not a quality taker.
4. Seeking the feedback of consumers and making their needs the foundation of purchasing decisions.
5. Using evidence to improve governance, service delivery and performance as well as for holding purchasers, providers and consumers to account.

• Dr Pierre Yameogo – Technical Secretary Ministry of Health, Burkina Faso

With free healthcare, one key development is the high uptake of health services by the public. Indeed, Burkina Faso had an average of 1.7 contacts per child under 5 years of age per year before the introduction of free healthcare. This reflected a low level of access compared to the benchmark of at least 3 contacts per child per year. After the introduction of free healthcare, the current level of access is more than 3 contacts per child under 5 years per year.

My personal experience: In the framework of the pilot phase from 2008 to 2015, I introduced free healthcare services in a health district where I was Chief Medical Officer from 2006 to 2011 (Tougan District). I was able to measure the immediate and positive effect on access to primary healthcare and services for all, and especially the improvement in the time it takes to administer care. I also coordinated the whole process of evaluation and advocacy towards the scaling up of free healthcare when I was at the central level at the Directorate of Family Health (feasibility study, development of strategy documents for free healthcare, advocacy document, organization and holding of advocacy meetings.)

When the financial barrier is lifted, there is a double relief, one for the public, especially the poorest, and also for the health workers who are more comfortable with the early administration of healthcare.

In short, I would say that we need to take action on the two main areas of focus for UHC at the same time: i) availability and accessibility of the essential UHC service package and ii) abolishing direct payment for healthcare.

• Nat Otoo – Senior Fellow R4D. Pioneer ED of SPARC and former CEO Ghana NHIA

A successful shift from passive to strategic purchasing requires the development of the capacity to determine the following:

1. What services to buy (based on population priorities).
2. Whom to select to provide the services and how to contract with them.
3. How to pay for the services and follow-up on fund flows.
4. How to measure performance and use feedback for improvements in purchasing.

 A number of African countries have been facing challenges in the process of building their capacities in the above areas, hence their inability to make the required transition from passive to strategic purchasing. With that said, it is important to acknowledge that the Africa Union has committed itself to working with countries to improve their domestic financing of health. This includes the need for countries to making progress on strategic purchasing in view of the limited funds available.

It is noteworthy that in addition to this, a number of international and development organizations such as the WHO, SPARC and Collectivity continue to build awareness about strategic purchasing and provide technical assistance for strategic purchasing policy reform and implementation. There is no doubt that effective strategic purchasing reforms help to advance the attainment of UHC.

• Dr Parfait Uwaliraye – Head, Planning, M&E and Information Systems, MoH Rwanda

There is no bad data. Even data we consider unreliable tells us that we have things to fix. The best way to deal the issue of data reliability is to use the data we have and take continuous and corrective measures to improve the quality of data we have. Our data will never be improved if we never use them. We see limitations or challenges in our data when we use them. The first step is: use the data the way they are, the second step is: take note of limitations in the data you used, the third step is: implement corrective measures to improve your data. Keep using the data you have now; it shows you what you have to do to improve it.

• Nat Otoo – Senior Fellow R4D. Pioneer ED of SPARC and former CEO Ghana NHIA

Data reliability is a critical issue that many African countries struggle within their strategic purchasing policy reforms.

1. Non-reliable data impedes decision making for the advancement of strategic purchasing, and it comes in several forms such as the following:

• Inaccuracy of data
• Inefficiency in collection
• Irregularity of availability
• Lack of granularity
• Lack of capacity for analysis

2. Data reliability for strategic purchasing will be achieved at the health system level if attention is paid to the following:

• Improved comparability
• Increased interoperability
• Expansion of data scope
• Improved data comprehensiveness
• Improved capacity to analyze data

Obtaining reliable data to support strategic purchasing reforms should become a priority in African health systems.

• Dr Pierre Yameogo – Technical Secretary Ministry of Health, Burkina Faso

Indeed, quality data is the cornerstone of informed and accurate decision making. A high-quality system of production, notification, transmission, analysis and feedback is essential for optimal strategic purchasing of healthcare. The most effective solution is known, namely the digitalization of patient records. The challenge in health systems remains how to reduce the fragmentation of the health information system. Indeed, there are many vertical IT solutions that are centered on different thematic areas with different databases. My suggestion is i) to set up an interoperable system between IT solutions (defining specifications with an integrated strategy); ii) to digitalize services progressively (e.g. online reporting of COVID-19 results can be extended to other medical examinations…); iii) to set up a task force for digitalization to mobilize and convince all stakeholders and leaders to take part in it.

NB: digitalization goes hand in hand with transparency and therefore loss of self-interest. Therefore, political commitment is needed to guarantee this major reform’s success, which is relevant for progress towards UHC

• Nat Otoo – Senior Fellow R4D. Pioneer ED of SPARC and former CEO Ghana NHIA

Understanding the political economy of strategic purchasing reform is a prerequisite for successful strategic purchasing reforms, as the process is fraught with resistance and contestations that have to be surmounted by paying attention to the following:

• Content of the reforms.
• Actors in the reform.
• Processes involved in the reform
• Systems of measuring performance.

In some countries, these dynamics have not been given the needed attention, hence the slow progress with strategic purchasing reforms.

A key point to note is that strategic purchasing reform has to have the consumer at its centre in order to be successful.

Please follow the link below for the framework developed by RESYST that depicts the relationships that exist between the key stakeholders in strategic purchasing reforms.

https://resyst.lshtm.ac.uk/sites/resyst/files/content/attachments/2018-08-22/What%20is%20strategic%20purchasing%20for%20health.pdf

Performance-based financing as a provider payment method is not synonymous with strategic purchasing, as strategic purchasing entails more than the selection of a provider payment method. However, it is noteworthy that performance-based financing has been an important entry-point for strategic purchasing reforms in some countries. Comprehensive strategic purchasing reforms should generally entail paying attention to all the building blocks needed for such reforms, some of which have been alluded to elsewhere in this Q&A.

• Nat Otoo – Senior Fellow R4D. Pioneer ED of SPARC and former CEO Ghana NHIA

Country engagement is one of the key pillars of SPARC’s approach to providing support for strategic purchasing reforms. As such, SPARC strives to work with countries to identify the technical and soft skills needed for strategic policy reform and implementation. Please read more about SPARC’s approach by following this link.

• Dr Parfait Uwaliraye – Head, Planning, M&E and Information Systems, MoH Rwanda

I would recommend a few things:

• Know better about the country operating arrangements and processes
• Make sure that you are working with the right people, right institutions
• Aim at ensuring that country own the process from the beginning.

• Dr Pierre Yameogo – Technical Secretary Ministry of Health, Burkina Faso

It is essential to build a profile that includes essential elements of public health with a personal investment in health financing. It is also necessary to have a patient and resilient personality because reforms can take several years to take place. This means having the ability to create windows of opportunity to accelerate and bring politicians on board.

The implementation of a project/programme can never follow what is written on paper; therefore, it is necessary to adopt a learning by doing approach to adjust as the different aspects of the programme/project are implemented.

• Dr Parfait Uwaliraye – Head, Planning, M&E and Information Systems, MoH Rwanda

Basket funds are the consequences of donor and aid-dependence. They were created as a way of ensuring synergies and avoiding duplication. However, the ideal situation is that countries should be self-reliant, aid-free. However, as most low-income countries are not yet there, it is important to strengthen donor coordination and ensure that they comply and align with the country’s priorities. The country’s set priorities should ideally drive aid or donor.  At some points, we have to be courageous enough to refuse malpractices of donors who do not comply with the country’s set policies, rules and regulations regarding aid and donor Governance.

• Dr Pierre Yameogo – Technical Secretary Ministry of Health, Burkina Faso

In your analysis, you address a key issue in health financing: how to avoid or reduce “financial fragmentation”: many funding providers, many different procedures, many specific areas, etc. The major consequence here is inefficiency, duplication, gaps and inequity.

To solve this problem, each country needs a unique dynamic financial resources mapping tool. Using this online tool (accessible on the internet with secure access codes), a “virtual common basket of financial resources” is set up, which identifies overlaps and gaps at any given time. The government can then use this virtual basket to gradually “compel” the partners to align themselves with the health system’s needs.

Let’s not be against the fact that a certain partner is interested in a specific area of funding. This is not wrong as such. With the freedom to create an association, a CSO with a defined area of focus should be recognized and welcomed because no one can do everything at the same time! It is therefore important to have a monitoring tool to progressively address the country’s needs.

Universal health insurance is an alternative way of providing financial protection for households against direct health costs. However, its implementation is facing huge challenges in almost all African countries, especially in French-speaking countries. The problem lies in adapting the scheme to the African context as it presents more obstacles. Community-based mutual appear to be the alternative solution for rural populations to enroll in the primary healthcare basket. However, due to the membership’s voluntary nature, the enrollment rate is limited to less than 5% of the target group. In addition, the basic premiums and contribution rates appear to be out of reach for the vast majority of rural populations. Beyond these major obstacles, there is a lack of confidence in the pre-payment of healthcare (cultural barriers? For example, some people think that if you contribute to the scheme, you will certainly get sick afterwards – others think that short-term solidarity in the event of illness is sufficient).