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.