Countries pursuing universal health coverage (UHC) are increasingly active in seeking to leverage private healthcare providers to enhance their reforms. Many are contracting private providers to deliver subsidized care and/or corporatizing their public facilities in order to improve performance, tackle inefficiencies and stimulate much-needed new investment across the delivery systems. As most soon discover, this requires a very different set of skills to those traditionally developed among public healthcare officials, and a range of technical and cultural gaps become evident.

Ghana has been an active member of the Person-Centered Integrated Care (PCIC) collaborative of JLN–participating in all meetings, as well as hosting the second meeting in Ghana in March 2018 when the key components of the collaborative’s definition of empanelment were identified.
Together, members of the collaborative authored an Empanelment Summary and an Empanelment Assessment Tool. We in Ghana believe that key lessons in improving this tool was made stronger due to the lessons learnt from the Ghanaian health system, particularly the Community-Based Health Planning and Services (CHPS) component.

The COVID-19 pandemic resulted in a double shock to Kenya, with both an economic and health crisis. When the first confirmed COVID-19 case was reported, the government provided several directives and instituted measures to contain the spread of the virus, including restricted geographical movement; stay-at-home directives; evening curfews; and various public health measures such as mandatory wearing of masks in public, social distancing, and hand washing and sanitising campaigns. Initially, 2% of the population tested positive, with a majority (85.9%) of these cases being asymptomatic. However, the incidence continued to rise, with urban areas reporting higher rates than rural areas. Like  many other countries, Kenya experienced several waves of infection and the introduction of new variants. Interventions have been guided by WHO guidelines,  adapted to the Kenyan context.

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).