Contributors: Agnes Munyua, Alex Ofori Mensah, Batbayar Ankhbayar, Francis Mensah Asenso Boadi, Humberto Silva, and Pavel Manjos. This blog is produced by the Primary Health Care Financing and Payment Collaborative. Governance is an important building block for provider payment and an important requirement for countries to establish strategic purchasers who contribute to health system objectives and further achievement of universal health coverage. In settings with multiple purchasers, several governance actors are often involved in purchasing policy, and in decentralized settings, there may be additional governance arrangements for purchasing at subnational level. Overall, this creates numerous power centers and accountability lines that can create duplication and conflicts in roles between stakeholders. Good governance for provider payment means that clear health system objectives exist, and provider payment policy is set up to meet those objectives; by clarifying the roles and relationships between stakeholders (purchasers, providers, and beneficiaries), gathering input from all stakeholders, and ensuring that mechanisms for dialogue exist. These governance arrangements are operationalized through clear agreements, and platforms exist to gather intelligence about how the governance arrangements are working, in order to learn, adapt and improve them to keep them relevant to changing health system objectives. In many countries represented in the PHC Financing and Payment collaborative, the health financing system includes more than one purchaser of health services. In countries with multiple purchasers of individual health services, governance, and other policy interventions to manage health care purchasing system as well as unified or inter-operable information management systems, are even more important to lower risks of inequitable access to care, reduced financial leverage of any one purchaser over providers and overlapping or inefficient funding flows. (1) In a two-part webinar series on December 1st and December 15th, the Joint Learning Network’s Primary Health Care Financing and Payment Collaborative facilitated a virtual discussion on governance arrangements and monitoring and information systems for output-based provider payment. In the first session, four countries – Argentina, Ghana, Moldova and Mongolia – shared their experiences and lessons strengthening governance systems for output-based payment. Key lessons are summarized below: 1. Clarify health system objectives Setting clear objectives for the health system is the first step in aligning stakeholders to deliver on priorities and is critical in establishing clear lines of responsibility and accountability for population health outcomes and health system performance. In the case of Argentina and Mongolia, Argentina set explicit objectives to achieve equity and reducing disparity across geographic regions, while Mongolia set objectives to contain costs of the health system. To ensure alignment with these objectives, Argentina used contracts between national and provincial level of government to clarify expectations. These contracts were cascaded to the provider level and indicators were set to track their performance. 2. Create mechanisms for dialogue across stakeholders Governance also requires that there are mechanisms for engagement and dialogue among stakeholders. Inclusive, meaningful stakeholder participation means that all stakeholders are invited to the decision- making table and are given a voice, and their views are represented in provider payment policy. In the case of Ghana, when designing and implementing the capitation pilot, Ghana set up platforms for engagement among the purchaser, providers, and the beneficiaries at national and district level. This enabled stakeholders to engage in the implementation of the pilot and provided a mechanism for redress when issues arose. 3. Gather information and intelligence Health systems constantly evolve as global agendas, health system objectives and/or priorities change. Therefore, governance systems are not static and need to shift when objectives change. For countries, this requires provider payment policy to remain open to change, continuously learning and pivoting as required. Foremost, systems must be able to track if objectives are being met and adapt and change if not. For example, Moldova evolved by adding more complexity to its payment systems through the addition of pay for performance. With time, the indicators have been revised to capture the most critical elements of the health system that align with objectives for improving NCD services and tuberculosis care, which are the most pressing priorities in Moldova. In Mongolia, a provider payment assessment, using the JLN Provider Payment Assessment toolkit, informed the change to improve provider payment policy from input-based budgets and capitation to blended provider payment including capitation, case-based payment and pay for performance. In conclusion, good governance is an important requirement to clarify mandates of stakeholders and set up the purchaser to carry out their mandate effectively to better contribute towards UHC. Well-designed governance arrangements are even more critical for fragmented systems to clarify the roles and relationships between stakeholders (purchasers, providers, and beneficiaries), ensure all voices are represented and heard in payment policy. In so doing, provider payment policy aims to create a public interest mandate for the purchaser to act strategically by providing autonomy and authority to carry out the purchaser functions. Finally, good governance also ensures that there is accountability among stakeholders for the achievement of UHC which is the key objective of health systems to provide good quality health services without financial barriers.   (1) Governance for strategic purchasing: an analytical framework to guide a country assessment. Geneva: WorldHealth Organization; 2019 (Health Financing Guidance, No. 6). Licence: CC BY-NCSA 3.0 IGO

Contributors: Agnes Munyua, Batbayar Ankhbayar, Humberto Silva, Jocelyn Maala, and Kaija Kasekamp. This blog is produced by the Primary Health Care Financing and Payment Collaborative. Sound and reliable information is the foundation of decision-making across all health system building blocks and is essential for health system policy development and implementation, governance and regulation, health research, human resources development, health education and training, service delivery and financing. The health information system provides the underpinnings for decision-making and has four key functions: data generation, compilation, analysis and synthesis, and communication and use. The health information system collects data from the health sector and other relevant sectors, analyses the data and ensures their overall quality, relevance, and timeliness, and converts data into information for health-related decision-making. Information and monitoring systems are a critical foundation for a strong provider payment system. Countries need to ensure that their purchasers are positioned and empowered to be strategic purchasers who contribute to the overall health system objectives and in turn, advance universal health coverage. Good governance, coupled with effective information and monitoring systems, allows purchasers to make evidence-based decisions on allocation of resources. In a two-part webinar series on December 1st and December 15th , the Joint Learning Network’s Primary Health Care Financing and Payment Collaborative facilitated a virtual discussion on countries’ best practices and lessons learned on strengthening governance arrangements and information and monitoring systems for output-based provider payment. The monitoring and information systems session included representatives from Argentina, Estonia, Mongolia and the Philippines. Key lessons learned are summarized in this blog: 1. Setting clear objectives for effective monitoring and information systems Setting clear objectives ensures that stakeholders are clear on the purpose of the monitoring and information systems, what data is being collected, how the data is collected, analyzed and used to advance decision making. For example, Estonia has automated most government functions including the Estonia Health Insurance Fund (EHIF). EHIF has reached a high level of coverage and monitors coverage and utilization of services daily. To reach the underserved, Estonia set an objective to target vulnerable populations and to reach them with primary health care services. Setting a clear objective helped Estonia identify indicators aligned with these objectives. In the Philippines, a new UHC law decreed immediate eligibility for all Filipinos to the National Health Insurance Program.. To expand coverage, Philhealth has designed PhilHealth Konsultasyong Sult at Tama (Philhealth Konsulta) as an initial step towards adopting a comprehensive approach to delivering primary health care. This has necessitated the design of a system that will allow them to capture information to track the coverage and utilization of these new benefits. 2. Start with what you have, then course correct and evolve Once objectives have been set, the next step is for countries to develop systems that gather data and track progress against set objectives. Mongolia started off with excel-based tools that evolved over time to a more sophisticated automated system of data collection to reduce the reporting burden on stakeholders. As the system became more sophisticated, there was a need to also simplify and streamline the number of indicators. The number of indicators has reduced from more than 100 to 27 high-powered indicators that give a broad overview of the health system. PhilHealth developed an interim system called ‘E-Konsulta,’ which has core functions of managing the beneficiaries’ health information and provider management. Philhealth considers transitioning to a third-party system with the hope of evolving further into something better for the future that integrates all health systems data. 3. The quality of the decisions is only as good as the quality of the data It goes without saying that data quality and timeliness greatly impacts decision makers ability to make the right decisions at the right time. In Argentina, Estonia, and Mongolia data from monitoring and information systems are integral components to calculating financial incentives to providers. In Mongolia, dashboards are used as visual aids to support decision making. To improve the quality of data, in Argentina, rewards and sanctions were set to encourage good quality data from regional governments and providers. Harmonizing tools and automating as much as is feasible can help reduce the reporting burden on providers and improve the quality of data. For example, in Estonia, data from the electronic medical records system is integrated with the quality bonus system to avoid further data collection at the provider level. Further, having clear system requirements and supporting providers to develop them can be an avenue to improve automation and data quality. In Estonia, provider contracts clearly stipulate the information system requirements and mandate that all claims are submitted electronically to improve timeliness and accuracy of data. Health systems are dynamic and it’s important for a country to develop monitoring and information systems that pivot and evolve as objectives change – this can look vastly different for each country. As countries aim to develop their monitoring and information systems, they can aim to align on objectives across stakeholders, use data to determine whether objectives are being met and if not, course correct and evolve. What works in one country may not work in another context, so countries should be flexible and open to change as they continue to progress towards universal health coverage (UHC).

As so many health systems move towards social health insurance, the issue of who should receive this at no or low cost is becoming increasingly important. The topic can quickly become highly technical and move well beyond most health practitioners’ core skills – comparing different ‘proxies’ and formulae for assessing wealth and income, as well as methods for collecting and verifying this data.

Incentivizing quality is a topic that comes up repeatedly as a learning objective for country members of the JLN’s PHC Financing and Payment Collaborative. As countries work towards universal health coverage, evidence is pointing to the fact that universal health coverage (UHC) is grounded in quality PHC. When we measure progress in UHC, we look at effective coverage of essential health services and financial protection. But even if we achieve these two, health outcomes would still be poor if services were low-quality and unsafe. All member countries may have different financing and payment mechanism, but we all have a common goal: to get value for money. On April 07, the Joint Learning Network’s Primary Health Care Financing and Payment Collaborative facilitated a joint learning on how countries are working towards delivery of quality PHC services. From around the world, there are many lessons on what works and what does not, but the webinar drew lessons from the panel discussion by two collaborative member countries, who because of different contexts, Moldova from Europe and Mongolia from Asia, and they are at different stages of implementing the performance-based financing or pay for performance, provided a rich discussion as they shared their experience in their journey on the quality route. The webinar started with opening remarks from the Director General of the National Health Insurance Fund of the Republic of Moldova, Dr Valentina Buliga, who remarked on the World Health Day’s theme of building a fairer, healthier world and the relationship to PHC and UHC. She reiterated Moldova’s commitment to sharing her experience with the Collaborative members. Dr Ghenadie Damascan, the Head of the Healthcare Providers Contracting Department of the National Health Insurance Fund of the Republic of Moldova and Dr Gerelmaa Jamsran, the Benefit Package Consultant to the Asian Development Bank’s health reform project in Mongolia, answered different elements of three learning questions: How do we select the right indicators for the implementation stage? What are the tools that can assist in the monitoring? What are the factors for success? Audience engagement was through participation in two menti polls on the first two questions, sharing the lessons from their own country experiences as well as posing questions to the panellists. Several key lessons emerged as success factors: Performance based payment complements the basic payment mechanism and the choice of indicators is based on the health system goals of the incentive programme.  Choose a few SMART (specific, measurable, achievable, relevant, timely) indicators that gives a broad view of the health system and these indicators may change over time as the context changes, e.g. from MCH to NCD. These indicators must be realistic and can be feasibly collected and monitored. As a monitoring tool, IT systems needs to be considered as countries progress, as it involves high initial capital investment which may be out of reach at first. At the start, monitoring tools should be simple, readily available, data validation can be done easily, detailed guidelines must be made available for standardisation of data collection and they must be institutionalised into the existing system for sustainability. The share of the pay for performance bonus must be attractive enough for healthcare providers to participate. Stakeholder engagement is important to get consensus. The facilitating system environment includes, purchaser-provider split, financial autonomy of health facilities, the contract as an instrument for accountability. Key takeaway messages: A system view needs to be taken in introducing payment for performance to incentivize quality and alignment with health system goals determines the prioritizing of quality indicators to monitor. Payment for performance is a financial tool to complement the existing payment system, it is integrated into the whole payment system. It does not stand alone. You are working within an existing framework, facing current challenges, with your own service delivery capacity. Delivering quality needs to be facilitated by organisational changes and financial incentives. To read more about the Collaborative event on Leveraging Provider Payment to Achieve Health System Goals, please read the report here. This post was written by Dr. Kamaliah Noh.

Strong primary health care (PHC) can speed up a country’s journey towards universal health coverage (UHC) rapidly, effectively, and efficiently. The current COVID-19 pandemic has shown that all countries, particularly the lower- and middle-income countries (LMICs), need to deliver comprehensive PHC services in alignment with countries’ needs, whether maternal and child health services, infectious diseases or non-communicable diseases. This exerts pressure on PHC teams on the ground and necessitates a review of PHC service delivery models from the traditional to an integrated patient-centred, quality and preventive primary healthcare. On December 16, the Joint Learning Network’s PHC Financing and Payment Collaborative facilitated a virtual discussion on designing integrated service delivery models to increase access to PHC in alignment to current country needs. DR Kiio S. Ndolo, the Director of Medical Services from the government of Makueni County, Kenya shared his experience on developing the PHC provider network (PHCPN) model in Makueni County. The trigger for the change was a major health system reform i.e., the decentralisation of the health system in Kenya. This was followed by an engaging discussion by several participants sharing their own country experiences. Several key lessons emerged as the success factors of the model: There is a shared vision by the leadership provided at the “hub” level and respected by everyone. The model is implemented so that the role of each player and stakeholder, as well as different levels of service provider, is clear. In this way, the inclusion of all the available resources e.g., through private sector engagement, can address capacity issues. Financial management is key to the success of the model. Funding is made largely by available public resources, through government budget mechanism and donor contribution. Financial and non-financial incentives for the providers can help sustain the model e.g. retention of funds is allowed at the facility level, income generating activities allowed at the community health unit, and stipends for the volunteers. Purchasing arrangement is made clear and health care providers in the spokes are supported by the accountant at the hub. The structure of the PHC delivery system is a patient-centred, hub and spoke model, with clear and greater involvement of the community volunteers to make the PHC services effective. The model emphasizes the integration of different levels of care with a clear referral rules and procedures to ensure quality and continuity of care. The monitoring system is essential and supported by supervisory tools and mechanisms e.g., review meetings, data quality and supervision. The take-away message is that in designing a service delivery model, changes in the organisation of the delivery system and financial arrangements are needed to sustain a successful implementation to achieve health system goals for which it is designed. In addition, early stakeholder involvement is critical to ensure buy-in and limit implementation resistance. This post was written by Dr. Kamaliah Noh and Kiio S. Ndolo.