Dataset Information

Scaling-up strategic purchasing: analysis of health system governance imperatives for strategic purchasing in a free maternal and child healthcare programme in Enugu State, Nigeria.

ABSTRACT:

Background

Significant knowledge gaps exist in the functioning of institutional designs and organisational practices in purchasing within free healthcare schemes in low resource countries. The study provides evidence of the governance requirements to scale up strategic purchasing in free healthcare policies in Nigeria and other low-resource settings facing similar approaches.

Methods

The study was conducted at the Ministry of Health and in two health districts in Enugu State, Nigeria, using a qualitative case study design. Semi-structured interviews were conducted with 44 key health system actors (16 policymakers, 16 providers and 12 health facility committee leaders) purposively selected from the Ministry of Health and the two health districts. Data collection and analysis were guided by Siddiqi and colleagues' health system governance framework. Data were analysed using a framework approach.

Results

The key findings show that supportive governance practices in purchasing included systems to verify questionable provider claims, pay providers directly for services, compel providers to procure drugs centrally and track transfer of funds to providers. However, strategic vision was undermined by institutional conflicts, absence of purchaser-provider split and lack of selective contracting of providers. Benefit design was not based on stakeholder involvement. Rule of law was limited by delays in provider payment. Benefits and obligations to users were not transparent. The criteria and procedure for resource allocation were unclear. Some target beneficiaries seemed excluded from the scheme. Effectiveness and efficiency was constrained by poor adherence to purchasing rules. Accountability of purchasers and providers to users was weak. Intelligence and information is constrained by paper-based system. Rationing of free services by providers and users' non-adherence to primary gate-keeping role hindered ethics.

Conclusion

Weak governance of purchasing function limits potential of FMCHP to contribute towards universal health coverage. Appropriate governance model for strengthening strategic purchasing in the FMCHP and possibly free healthcare interventions in other low-resource countries must pay attention to the creation of an autonomous purchasing agency, clear framework for selective contracting, stakeholder involvement, transparent benefit design, need-based resource allocation, efficient provider payment methods, stronger roles for citizens, enforcement of gatekeeping rules and use of data for decision-making.

SUBMITTER: Ogbuabor DC

PROVIDER: S-EPMC5887245 | biostudies-literature | 2018 Apr

REPOSITORIES: biostudies-literature

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Publications

Scaling-up strategic purchasing: analysis of health system governance imperatives for strategic purchasing in a free maternal and child healthcare programme in Enugu State, Nigeria.

Ogbuabor Daniel Chukwuemeka DC Onwujekwe Obinna Emmanuel OE

BMC health services research 20180405 1

<h4>Background</h4>Significant knowledge gaps exist in the functioning of institutional designs and organisational practices in purchasing within free healthcare schemes in low resource countries. The study provides evidence of the governance requirements to scale up strategic purchasing in free healthcare policies in Nigeria and other low-resource settings facing similar approaches.<h4>Methods</h4>The study was conducted at the Ministry of Health and in two health districts in Enugu State, Nige ...[more]

PMID: 29622003

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Project description:BackgroundRelatively little is known about how public financial management (PFM) systems and health financing policies align in low- and middle-income countries. This study assessed the alignment of PFM systems with health financing functions in the free maternal and child healthcare programme (FMCHP) of Enugu State, Nigeria.MethodsData were collected through quantitative and qualitative document review, and semi-structured, in-depth interview with 16 purposively selected policymakers involved in FMCHP. Data collection and analysis were by guided a framework for assessing alignment of PFM systems and health financing policies. Revenue and expenditure trend analyses were done using descriptive statistics and analysis of variance (ANOVA). Level of significance was set at ??<?0.05. Qualitative data were analysed using a framework approach.ResultsThe results showed that no more than 50% of FMCHP fund were collected despite that the promised fund remained unchanged since inception. Revenue generation significantly varied between 2010 and 2016 (??<?0.05). Level of pooling was limited by non-compliance with contribution rules, recurrent unauthorised expenditure and absence of expenditure caps. The unauthorised expenditure significantly varied between 2010 and 2016 (??<?0.05). Misalignment of budget monitoring and purchasing revealed absence of auditing and delays in provider payment. Refunds to providers significantly varied between 2010 and 2016 (??<?0.05) due to weak Steering Committee, weak vetting team, paper-based claims management and institutional conflicts between Ministry of Health and district-level officials.ConclusionsThis study identified important lessons to align PFM systems and FMCHP. A realistic and evidence-informed budget and enforcement of contribution rules are critical to adequate and sustainable revenue generation. Clarity of roles for various FMCHP committees and use of clear resource allocation strategy would strengthen pooling and fund management. Enforcement of provider payment standards, regular auditing, and a stronger role for the parliament in budgetary processes are warranted.

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Project description:BackgroundTracking general trends in strategic purchasing of health financing mechanisms will highlight where country demands may exist for technical support and where progress in being made that offer opportunities for regional learning. Health services in Abia State, Nigeria are funded from general tax-revenues (GTR), and a new state social health insurance scheme (SSHIS) is proposed to overcome the failings of the GTR and expand coverage of services. This study examined purchasing functions within the GTR and the proposed SSHIS to determine if the failings in GTR have been overcome, identify factors that shape health purchasing at sub-national levels, and provide lessons for other states in Nigeria pursuing a similar intervention.MethodsData was collected through document review and key informant interviews. Government documents were retrieved electronically from the websites of different organizations. Hard copies of paper-only files were retrieved from relevant government agencies and departments. Interviews were conducted with seven key personnel of the State Ministry of Health and State Health Insurance Agency. Thematic analysis of data was based on a strategic health purchasing progress tracking framework which delves into the governance arrangements and information architecture needed for purchasing to work well; and the core purchasing decisions of what to buy; who to buy from; and how to buy.ResultsThere are differences in the purchasing arrangements of the two schemes. Purchaser-provider split does not exist for the GTR, unlike in the proposed SSHIS. There are no data systems for monitoring provider performance in the GTR-funded system, unlike in the SSHIS. Whereas GTR is based on a historical budgeting system, the SSHIS proposes to use a defined benefit package, which ensures value-for-money, as the basis for resource allocation. The GTR lacks private sector engagement, provider accreditation and contracting arrangements while the SSHIS will accredit and engage private providers through selective contracting. Likewise, provider payment is not linked to performance or adherence to established standards in the GTR, whereas provider payment will be linked to performance in the SSHIS.ConclusionsThe State Social Health Insurance has been designed to overcome many of the limitations of the budgetary allocation to health. This study provides insights into the enabling and constraining factors that can be used to develop interventions intended to strengthen the strategic health purchasing in the study area, and lessons for the other Nigeria states with similar characteristics and approaches.

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Dataset Information

Scaling-up strategic purchasing: analysis of health system governance imperatives for strategic purchasing in a free maternal and child healthcare programme in Enugu State, Nigeria.

Background

Methods

Results

Conclusion

Publications

Scaling-up strategic purchasing: analysis of health system governance imperatives for strategic purchasing in a free maternal and child healthcare programme in Enugu State, Nigeria.

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