On September 30th, 2016 at the « Ecole Nationale De Santé Publique » – Rabat, the WHO, the FAHS CoP and the PBF CoP organized a workshop on « Strategic Purchasing: an emerging agenda for Africa ». Thérèse Kunda shares what she learned. You can also access the summary report of the day from Inke, Bruno and Allison.
This workshop was organized at the end of the 4th AFHEA scientific conference.
When I heard from HFA about the post-conference event, it was exciting to learn about WHO`s and the PBF CoP’s vast experiences on Strategic Purchasing, and had no hesitations in registering for the 1-day event. My own main expectations were to have a better understanding of the concepts of Strategic Purchasing, and acquire some practical tips pertaining on “How” we can advise the different purchasers of health care services.
Not surprisingly, the workshop attracted a high and diversified attendance. There were around 30 people, including country policy makers, managers, researchers and policy analysts, from Benin, Burkina Faso, Cameroon, DRC, Egypt, Mali, Morocco, Nigeria, Rwanda, Senegal, South Africa, Uganda, Chad, Tunisia, as well as development partners (Swiss Development Cooperation, the Alliance for Health Policy & Systems Research, MSH). We all had similar expectations: understand what really hides behind the concept of strategic purchasing.
What I learned from the workshop
What is “Strategic Purchasing?”
Inke Mathauer introduced the concept with a useful presentation (you can find it here). Strategic purchasing basically means linking payments to information on performance and health needs of the population, it is about active, evidence-based engagement in defining the service-mix and volume, selecting the provider-mix, and deciding how to purchase.
As opposed to passive purchasing (characterized by resource allocation using norms, without quality controlling
and monitoring), strategic purchasing is based on payment systems that create deliberate incentives for efficiency and quality, selective contracting and quality improvement rewards.
The rationale behind promoting strategic purchasing was echoed as one of the mechanisms to address the existing inefficiencies in the health sector in addition to improved procurement mechanism for health outputs. Here we discussed on the difference between purchasing and procurement. Purchasing is concerned with the payment of the services providers, while procurement is the buying of goods, supplies and medicines (‘inputs’ in the PBF language).
Why we need “Strategic Purchasing?”
Strategic purchasing is meant to increase value for money, so as to maximize health results (outputs and outcomes). Additionally, strategic purchasing can promote quality in service delivery, efficiency in the use of resources for health, accountability of providers and purchasers to the population and enhance equitable distribution of resources, by aligning the funding and incentives with promised health services.
The experiences from countries
During group discussions, we had the opportunity to discuss on the current status of strategic purchasing in the represented countries and what can be done to develop policy & technical knowledge for an environment conducive for it. The discussions focused on the different areas listed in Inke’s presentation: governance, benefit package, provider payment systems, and information management systems.
What I realized was that all countries, although at different stages and with different health financing structures, are not really far in establishing strategic purchasing. They share some challenges. I would like to flag a few here (for a longer list, see the summary report)
Firstly with regards to governance, many countries have a health financing system that is highly fragmented with multiple (potential) purchasers, even within the public sector – not a surprise for those of you familiar with the work of our CoPs on health financing fragmentation
Additionally, the definition of the benefit package in many countries is not enough evidence based and the incoherent mixed provider payments mechanisms in each country don’t ease the strategic purchasing mechanism.
Moreover, many countries have failed to establish a reliable information management system, and that is a hindrance to acquiring necessary information on deciding on strategic purchasing.
What could we do?
Considering these challenges, the workshop enlightened participants on the move towards strategic purchasing. Countries need to be ready to engage in reforms in different areas of the health sector including, but not limited to provider payment mechanisms, human resources for health management, drugs supply chain management, information systems, etc.
Despite the challenges, some countries have undertaken some efforts towards strategic purchasing, for instance with the initiation of Performance Based Financing (my country Rwanda is a good example), but the journey towards strategic purchasing is still long and concerted efforts are needed.
Moving towards Strategic Purchasing, a shared responsibility
Following the different discussions, all participants agreed that there is a need for countries to elaborate concrete steps towards strategic purchasing (and UHC). However, there is no blue print: concrete steps for low-income countries largely relying on public sector, aid and budget allocations (like Chad for instance) will be different than strategic purchasing efforts in middle-income countries with strong private sector provision and health insurance agencies (like Morocco or Egypt).
There was consensus that all stakeholders have their role to play. The role of the ministries of health in developing leadership is obvious - this will require substantial upgrade of technical capacities. In countries with a multiplicity of aid actors, it will be key that they recognize that their action should consolidate strategic purchasing, not undermine it. A key issue will be to engage with the private sector, both the possible purchasers (e.g. health insurance funds) and the providers. We have still a lot to learn in this respect.
Participants expressed the need for a reference document with conceptual clarification on strategic purchasing versus procurement and suggested WHO to develop this. The reference document should outline and illustrate what strategic purchasing implies and what measures and concrete steps can be undertaken to progress towards more strategic purchasing.
For the CoPs, there is need to foster and strengthen exchange of experience across countries and peers, so as to learn from each other on what has worked. This could also provide the basis to identify concrete next steps. We also should engage with other actors already working in this field, and we concretely discussed the idea to organize a workshop gathering both health insurance agencies and other public actors already involved in purchasing (e.g. the national units in charge of PBF).
What I can say is that this workshop allowed me not only to gain more knowledge with respect to Strategic Purchasing but also to learn from other countries experiences. It made me more committed towards promoting Strategic Purchasing not only in my country but wherever opportunity arises.
You can find the report of our event here.