Adjustments in purchasing arrangements to support the COVID-19 health sector response: evidence from eight middle-income countries.

The COVID-19 pandemic has triggered several changes in countries' health purchasing arrangements to accompany the adjustments in service delivery in order to meet the urgent and additional demands for COVID-19-related services. However, evidence on how these adjustments have played out in low- and middle-income countries is scarce. This paper provides a synthesis of a multi-country study of the adjustments in purchasing arrangements for the COVID-19 health sector response in eight middle-income countries (Armenia, Cameroon, Ghana, Kenya, Nigeria, Philippines, Romania and Ukraine). We use secondary data assembled by country teams, as well as applied thematic analysis to examine the adjustments made to funding arrangements, benefits packages, provider payments, contracting, information management systems and governance arrangements as well as related implementation challenges. Our findings show that all countries in the study adjusted their health purchasing arrangements to varying degrees. While the majority of countries expanded their benefit packages and several adjusted payment methods to provide selected COVID-19 services, only half could provide these services free of charge. Many countries also streamlined their processes for contracting and accrediting health providers, thereby reducing administrative hurdles. In conclusion, it was important for the countries to adjust their health purchasing arrangements so that they could adequately respond to the COVID-19 pandemic, but in some countries financing challenges resulted in issues with equity and access. However, it is uncertain whether these adjustments can and will be sustained over time, even where they have potential to contribute to making purchasing more strategic to improve efficiency, quality and equitable access in the long run.

Qualitative study of barriers and facilitators of health entrepreneurship in rural and semirural communities of Armenia.

INTRODUCTION: Low- and middle-income countries often face the issue of unequal distribution of healthcare services and human resources between rural and urban areas. Globally, there are many factors negatively affecting the willingness of physicians to work in remote and rural areas, such as low wages, poor living conditions, poorer and sicker patients, suboptimal equipment and supplies, and a lack of quality infrastructure and transportation. METHODS: This study explored the perceptions of barriers and facilitators of medical entrepreneurship and the impact of medical entrepreneurship on the served communities among the owners of private medical practices in rural and semirural areas of Armenia. The researchers conducted qualitative in-depth interviews with the 13 owners of 12 private practices. The interviews were transcribed in the original language (Armenian). Only the quotes were translated into English. The direct content analysis approach was used for analyzing textual data. RESULTS: The findings of the study suggest that high investment cost, intense competition with state facilities, unfavorable laws and regulations, and a lack of entrepreneurship and healthcare quality assurance skills were perceived as barriers to establishing and running private healthcare practices. The dissatisfaction of healthcare providers with their work conditions in state facilities, the instability of the job market in Armenia, and the development of clear marketing strategies by the entrepreneurs facilitated opening and operating private practices. All of the interviewees felt that their practices had a positive impact on the communities they served, in terms of creating new jobs and introducing up-to-date and in-demand services into these communities. CONCLUSION: The study recommended providing potential entrepreneurs with training in entrepreneurship and healthcare quality assurance and mentorship opportunities, as well as with tools to support financing their enterprises.

Challenges and Opportunities for Purchasing High-Quality Health Care: Lessons from Armenia.

This paper examines how purchasing decisions in Armenia may contribute to barriers in using high-quality health care, particularly for non-communicable diseases, drawing on a review of the literature and key informant interviews. The paper adapts the strategic health purchasing progress framework, to examine how characteristics of purchasing, the health system, and the political, administrative, and macro-fiscal environment may have facilitated or hindered the attainment of service delivery goals. We conclude with six lessons for reforms aimed at improving the coverage and quality of health care in Armenia. First, increasing the political priority of access to quality of health care is a pre-requisite to advancing reforms to address these issues. Second, improved purchasing governance in Armenia will require a purchaser that can make decisions without political interference, with appropriate accountability mechanisms, improvements in technical capacity, and the routine use of data systems. Third, there is a need for the regulatory framework to ensure that revisions of the benefits package contribute to reducing the disease burden and improving access to care. Fourth, regulations governing quality-related criteria for provider selection should be enforced and include considerations for process quality. Fifth, payment incentives should be revised to encourage an increase in the supply of primary health care, reduce bypassing for hospital care, and improve the quality of services. Sixth, the potential of purchasing to improve service delivery will be dependent on increased pre-paid and pooled funds and better governance of the quality of care.

Tuberculosis care services in Armenia: What has changed since the 2014 reform?

INTRODUCTION: In efforts to reach the 2020 Tuberculosis targets, the WHO advocates for an outpatient, people-centered model of TB care. To this end, the TB care system in Armenia underwent structural and financing reforms in 2014. Financing mechanism for inpatient TB facilities was changed from a fee per bed/day to a mixed type of financing that includes fixed and variable costs eliminating incentives for unnecessary and extended hospitalizations. Unfortunately, outpatient facilities continue to be financed through per-capita mechanism, resulting in high number of referrals and draining resources. This study aimed to assess the implementation of these reforms within the Armenian TB care system. METHODOLOGY: This was a retrospective cross-sectional study using nationwide programme data and survey data collected from healthcare facilities. RESULTS: In 2017 a total of 901 TB patients were registered in outpatient facilities. Only 7.6% of total TB cases were diagnosed in outpatient facilities and 30.9% of the presumptive TB cases were referred to inpatient facilities. The number of hospitalizations was reduced by 76% from 2013 to 2017. The average duration of stay reduced as well from 55+ days to 37 days. However, the proportion of smear negative TB patients remains high among all hospitalized patients (63.8%). CONCLUSIONS: Overall, the reform has been successful, however unnecessary hospitalizations persist. Our results indicate there a need to go upstream for a structural and financial reform of the outpatient sector to complete Armenia's TB healthcare reform and improve both patient outcomes and efficient use of system resources.