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.

The impact of COVID-19 on health financing in Kenya.

Sudden shocks to health systems, such as the COVID-19 pandemic may disrupt health system functions. Health system functions may also influence the health system's ability to deliver in the face of sudden shocks such as the COVID-19 pandemic. We examined the impact of COVID-19 on the health financing function in Kenya, and how specific health financing arrangements influenced the health systems capacity to deliver services during the COVID-19 pandemic.We conducted a cross-sectional study in three purposively selected counties in Kenya using a qualitative approach. We collected data using in-depth interviews (n = 56) and relevant document reviews. We interviewed national level health financing stakeholders, county department of health managers, health facility managers and COVID-19 healthcare workers. We analysed data using a framework approach. Purchasing arrangements: COVID-19 services were partially subsidized by the national government, exposing individuals to out-of-pocket costs given the high costs of these services. The National Health Insurance Fund (NHIF) adapted its enhanced scheme's benefit package targeting formal sector groups to include COVID-19 services but did not make any adaptations to its general scheme targeting the less well-off in society. This had potential equity implications. Public Finance Management (PFM) systems: Nationally, PFM processes were adaptable and partly flexible allowing shorter timelines for budget and procurement processes. At county level, PFM systems were partially flexible with some resource reallocation but maintained centralized purchasing arrangements. The flow of funds to counties and health facilities was delayed and the procurement processes were lengthy. Reproductive and child health services: Domestic and donor funds were reallocated towards the pandemic response resulting in postponement of program activities and affected family planning service delivery. Universal Health Coverage (UHC) plans: Prioritization of UHC related activities was negatively impacted due the shift of focus to the pandemic response. Contrarily the strategic investments in the health sector were found to be a beneficial approach in strengthening the health system. Strengthening health systems to improve their resilience to cope with public health emergencies requires substantial investment of financial and non-financial resources. Health financing arrangements are integral in determining the extent of adaptability, flexibility, and responsiveness of health system to COVID-19 and future pandemics.

Purchasing reforms and tracking health resources, Kenya.

As low- and middle-income countries undertake health financing reforms to achieve universal health coverage, there is renewed interest in making allocation of pooled funds to health-care providers more strategic. To make purchasing more strategic, countries are testing different provider payment methods. They therefore need comprehensive data on funding flows to health-care providers from different purchasers to inform decision on payment methods. Tracking funding flow is the focus of several health resource tracking tools including the System of Health Accounts and public expenditure tracking surveys. This study explores whether these health resource tracking tools generate the type of information needed to inform strategic purchasing reforms, using Kenya as an example. Our qualitative assessment of three counties in Kenya shows that different public purchasers, that is, county health departments and the national health insurance agency, pay public facilities through a variety of payment methods. Some of these flows are in-kind while others are financial transfers. The nature of flows and financial autonomy of facilities to retain and spend funds varies considerably across counties and levels of care. The government routinely undertakes different health resource tracking activities to inform health policy and planning. However, a good source for comprehensive data on the flow of funds to public facilities is still lacking, because these activities were not originally designed to offer such insights. We therefore argue that the methods could be enhanced to track such information and hence improve strategic purchasing. We also offer suggestions how this enhancement can be achieved.

Comme les pays à faible et moyen revenu se lancent dans des réformes de financement des soins de santé afin d'offrir une couverture maladie universelle, on constate un regain d'intérêt pour une répartition plus stratégique des fonds communs aux prestataires de soins de santé. Ces pays testent différentes méthodes de paiement des prestataires dans le but d'améliorer la stratégie d'achat. Ils ont donc besoin de données exhaustives sur les flux de financement entre ces prestataires de soins de santé et divers acquéreurs s'ils souhaitent prendre des décisions avisées dans ce domaine. La traçabilité du flux de financement est au cœur de plusieurs outils de suivi des ressources de santé, dont le Système des comptes de la santé et les enquêtes de suivi des dépenses publiques. Cette étude vise à déterminer si ces outils de suivi des ressources de santé génèrent le type d'information requis pour élaborer des stratégies d'achat adéquates, avec le Kenya en guise d'exemple. Notre analyse qualitative de trois comtés kényans démontre que différents acquéreurs publics, à savoir les autorités sanitaires des comtés et l'Agence nationale de l'assurance maladie, rémunèrent les établissements publics par le biais d'une série de méthodes de paiement. Certains de ces flux sont réglés en nature, tandis que d'autres sont des transferts financiers. La catégorie à laquelle appartiennent les flux ainsi que l'autonomie financière des établissements en termes de conservation et de dépense des fonds varient considérablement selon les comtés et les niveaux de soins. Le gouvernement mène systématiquement diverses activités de suivi des ressources de santé afin de mieux orienter la planification et la politique en la matière. Néanmoins, il manque toujours une source fiable de données exhaustives concernant le flux de financement des établissements publics car à l'origine, ces activités ne sont pas conçues pour livrer de telles observations. Nous affirmons dès lors que ces méthodes pourraient être optimisées pour récupérer ces informations et améliorer ainsi la stratégie d'achat. Nous formulons également des suggestions permettant de procéder à cette optimisation.

A medida que los países de ingresos bajos y medianos emprenden reformas de la financiación de la salud para lograr la cobertura sanitaria universal, se renueva el interés en que la asignación de fondos mancomunados a los proveedores de servicios de salud sea más estratégica. Para que las compras sean más estratégicas, los países están probando diferentes métodos de pago de los proveedores. Por lo tanto, necesitan datos completos sobre los flujos de financiación a los proveedores de servicios de salud de diferentes compradores para fundamentar la decisión sobre los métodos de pago. El seguimiento de los flujos de financiación es el objetivo de varias herramientas de seguimiento de los recursos sanitarios, incluidos el Sistema de Cuentas de Salud y las encuestas de seguimiento del gasto público. Este estudio explora si estas herramientas de seguimiento de recursos sanitarios generan el tipo de información necesaria para fundamentar las reformas de compras estratégicas, utilizando como ejemplo a Kenia. Nuestra evaluación cualitativa de tres condados de Kenia muestra que los diferentes compradores públicos, es decir, los departamentos de salud de los condados y la agencia nacional de seguro de salud, pagan a las instalaciones públicas a través de una variedad de métodos de pago. Algunos de estos flujos son en especie, mientras que otros son transferencias financieras. La naturaleza de los flujos y la autonomía financiera de los centros para retener y gastar los fondos varía considerablemente entre los condados y los niveles de atención. El gobierno lleva a cabo continuamente diferentes actividades de seguimiento de los recursos sanitarios para fundamentar las políticas y la planificación sanitaria. Sin embargo, sigue faltando una buena fuente de datos completos sobre el flujo de fondos a las instalaciones públicas, ya que estas actividades no se diseñaron originalmente para ofrecer este tipo de información. Por lo tanto, se argumenta que los métodos podrían mejorarse para hacer un seguimiento de dicha información y, en consecuencia, mejorar las compras estratégicas. También se ofrecen sugerencias sobre cómo se puede lograr esta mejora.

Subsidized health insurance coverage of people in the informal sector and vulnerable population groups: trends in institutional design in Asia.

BACKGROUND: Many low- and middle-income countries with a social health insurance system face challenges on their road towards universal health coverage (UHC), especially for people in the informal sector and vulnerable population groups or the informally employed. One way to address this is to subsidize their contributions through general government revenue transfers to the health insurance fund. This paper provides an overview of such health financing arrangements in Asian low- and middle-income countries. The purpose is to assess the institutional design features of government subsidized health insurance type arrangements for vulnerable and informally employed population groups and to explore how these features contribute to UHC progress. METHODS: This regional study is based on a literature search to collect country information on the specific institutional design features of such subsidization arrangements and data related to UHC progress indicators, i.e. population coverage, financial protection and access to care. The institutional design analysis focuses on eligibility rules, targeting and enrolment procedures; financing arrangements; the pooling architecture; and benefit entitlements. RESULTS: Such financing arrangements currently exist in 8 countries with a total of 14 subsidization schemes. The most frequent groups covered are the poor, older persons and children. Membership in these arrangements is mostly mandatory as is full subsidization. An integrated pool for both the subsidized and the contributors exists in half of the countries, which is one of the most decisive features for equitable access and financial protection. Nonetheless, in most schemes, utilization rates of the subsidized are higher compared to the uninsured, but still lower compared to insured formal sector employees. Total population coverage rates, as well as a higher share of the subsidized in the total insured population are related with broader eligibility criteria. CONCLUSIONS: Overall, government subsidized health insurance type arrangements can be effective mechanism to help countries progress towards UHC, yet there is potential to improve on institutional design features as well as implementation.

State budget transfers to health insurance funds: extending universal health coverage in low- and middle-income countries of the WHO European Region.

BACKGROUND: Many low-and middle-income countries (LMIC) of the World Health Organization (WHO) European Region have introduced social health insurance payroll taxes after the political transition in the late 1980s, combined with budget transfers to allow for exempting specific population groups from paying contributions, such as those outside formal sector work and in particular vulnerable groups. This paper assesses the institutional design aspects of such financing arrangements and their performance with respect to universal health coverage progress in LMIC of the European region. METHODS: The study is based on a literature review and review of secondary databases for the performance assessment. RESULTS: Such financing arrangements currently exist in 13 LMIC of that region, with strong commonalities in institutional design: This includes a wide range of different eligible population groups, mostly mandatory membership, integrated pools for both the exempted and contributors, and relatively comprehensive benefit packages. Performance is more varied. Enrolment rates range from about 65 % to above 95 %, and access to care and financial protection has improved in several countries. Yet, inequities between income quintiles persist. CONCLUSIONS: Budget transfers to health insurance arrangements have helped to deepen UHC or maintain achievements with respect to UHC in these European LMICs by covering those outside formal sector work, and in particular vulnerable population groups. However, challenges remain: a comprehensive benefit package on paper is not enough as long as supply side constraints and quality gaps as well as informal payments prevail. A key policy question is how to reach those so far uncovered.

State budget transfers to Health Insurance Funds for universal health coverage: institutional design patterns and challenges of covering those outside the formal sector in Eastern European high-income countries.

INTRODUCTION: Many countries from the European region, which moved from a government financed and provided health system to social health insurance, would have had the risk of moving away from universal health coverage if they had followed a "traditional" approach. The Eastern European high-income countries studied in this paper managed to avoid this potential pitfall by using state budget revenues to explicitly pay health insurance contributions on behalf of certain (vulnerable) population groups who have difficulties to pay these contributions themselves. The institutional design aspects of their government revenue transfer arrangements are analysed, as well as their impact on universal health coverage progress. METHODS: This regional study is based on literature review and review of databases for the performance assessment. The analytical framework focuses on the following institutional design features: rules on eligibility for contribution exemption, financing and pooling arrangements, and purchasing arrangements and benefit package design. RESULTS: More commonalities than differences can be identified across countries: a broad range of groups eligible for exemption from payment of health insurance contributions, full state contributions on behalf of the exempted groups, mostly mandatory participation, integrated pools for both the exempted and contributors, and relatively comprehensive benefit packages. In terms of performance, all countries have high total population coverage rates, but there are still challenges regarding financial protection and access to and utilization of health care services, especially for low income people. CONCLUSION: Overall, government revenue transfer arrangements to exempt vulnerable groups from contributions are one option to progress towards universal health coverage.