The COVID-19 pandemic has spurred a flood of innovation and technological advancements – an unprecedented amount of collaboration has occurred between individuals, communities, and organizations aspiring to curate and scale promising innovations. As vital as it is to forge a new path and to embrace creative solutions, it is as imperative to leverage the foundational infrastructure that is already in place. The wide-ranging policies and procedures that are in place prior to a public health emergency have the powerful ability to either bolster or undermine a health system’s ability to respond effectively to the crisis. During the Joint Learning Network’s Primary Health Care Financing and Payment Collaborative webinar held on June 17th, representatives from South Korea and the Philippines shared how their National Health Insurance (NHI) schemes fostered system responsiveness and flexibility – key components that contributed to greater trust in the health system’s ability to effectively respond to the COVID-19 pandemic. Three key lessons emerged on how these existing systems allowed these two countries to quickly redirect resources to high-need areas, establish designated treatment centers to isolate cases, and preserve the financial viability of providers. As countries braced for the first wave of COVID-19 cases, timing was paramount. South Korea and the Philippines social health insurance agencies acted decisively and directed resources quickly and efficiently to high-risk areas. PhilHealth, the Philippines’ single-payer system, swiftly adjusted its benefit package to accommodate for COVID-19 testing, community isolation and inpatient management for mild, moderate, severe and critical case types. The package also included non-health benefits, such as providing food and accommodation to patients in isolation which reflects the system’s ability to support the population for both prevention and treatment. As the breadth of the crisis became clear, National Insurance Schemes were able to establish designated treatment centers to isolate active and possible cases. The National Health Insurance (NHI) scheme in South Korea has provided easy access to health services. Prior to the pandemic, overutilization of health services and oversupply of equipment and facilities was a point of contention. During the pandemic, this oversupply has been an advantage to combatting COVID-19 by allowing 67 hospitals with 7,500 beds to be promptly re-designated as “infectious disease hospitals,” exclusively available for COVID-19 patients while sustaining other services through the remaining health facilities. As demand for non-COVID related health services began to decrease, both South Korea and the Philippines were able to act swiftly to preserve the financial viability of providers. Despite public funding, South Korea heavily relies on the private sector for health care delivery – more than 90% of healthcare institutions and beds belong to the private sector. Recognizing the private sector as an essential partner in health care service delivery, a prepayment system and expedited payment system was enacted to cushion providers. PhilHealth also enacted an interim reimbursement mechanism through advanced payment, quickly followed by a full reimbursement mechanism for inpatient COVID-19 services. Success of health financing arrangements and purchasing models depend on the country context; and it is imperative to consider which options would be most effective when there are stresses or extreme challenges to a health system. Equipped with a methodical national health system and consolidated purchasing power during the COVID-19 pandemic, South Korea and the Philippines were able to leverage what was already in place to swiftly protect its citizens and its health care providers during a health crisis. This post was written by Results for Development’s Nivetha Kannan and Allyson English.

Julia Kaufman, Janeen Madan Keller, Prashant Yadav, and Kalipso Chalkidou co-authored this post, which originally appeared on the Center for Global Development’s website.   Effective and efficient procurement of health products—medicines, diagnostics, and devices—is a critical function of all strong health systems. The pandemic has exacerbated long-standing challenges—as highlighted by a recent CGD Working Group—in the purchasing of both COVID-related emergency supplies and other essential health products. Procurement challenges in the context of COVID-19 range from disruptions to sourcing active pharmaceutical ingredients, export restrictions, and transport interruptions to quality assurance issues, reduced household income to cover out of pocket spending, and domestic financing pressures amidst uncertainty in the future of health aid. To harness COVID-19 as a catalyst for better procurement practices, the World Bank’s Health Financing Global Solutions Group, the Global Financing Facility, and the Joint Learning Network’s Efficiency Collaborative hosted an online event in early July. The webinar, chaired by one of us (Chalkidou), brought together experts from the Philippines and Thailand to showcase ongoing improvements to national procurement systems, alongside presentations of CGD research from two of us (Yadav and Madan Keller) on broader opportunities to deliver access to affordable, high-quality health products. Here are three takeaways. 1. Collaborate across countries to pool procurement Amidst uncoordinated scrambles for emergency supplies, hoarding, and even bidding wars, the pandemic has put the importance of achieving economies of scale in the limelight. Fragmented demand across purchasing entities can lead to higher transaction costs to serve these markets, which can often be passed on to purchasers and eventually to consumers. Pooled procurement or other forms of cooperative purchasing across countries offers one way to aggregate demand, increase purchaser bargaining power, and better organize procurement-related functions like horizon scanning and information-sharing about the supplier landscape (see Figure 1). The Africa CDC’s newly launched Africa Medical Supplies Platform (AMSP)—an online marketplace that pools orders for COVID-19 diagnostics and medical equipment—is a promising development with ample potential. But long-standing challenges stemming from myriad political, legal, and regulatory barriers (e.g., national industrial policies that favor domestic suppliers or the desire to exercise country preferences in product choice) will need to be tackled for such initiatives to have lasting benefits. Whether this platform goes beyond COVID-19 to successfully facilitate purchasing of other essential medicines at scale and effectively incorporates related functions such as health technology assessment remains to be seen. As the AMSP continues to evolve, different pooling mechanisms at the regional-level alongside donor-supported mechanisms at the global level, each with diverse organizational arrangements, could offer lessons about what has and has not worked. These collaborative purchasing efforts will also be increasingly critical as middle-income countries navigate health financing transitions, as emphasized by CGD’s Working Group. The AMSP and other COVID-19 procurement initiatives like the ACT Accelerator also elevate the importance of coordination and information-sharing from the get-go to identify gaps and avoid overlap. Figure 1. Different pooling activities and types of organizational arrangements Source: Nemzoff, Chalkidou, and Over 2019, adapted from Espín et al. 2016. 2. Embed resilience in procurement contracting COVID-19 has illustrated that buying from the lowest-cost supplier may come at the expense of other procurement outcomes like quality, supply security, speed, or resilience. Some suppliers may be able to guarantee or demonstrate a degree of resilience based on past performance—such as the ability to meet a certain portion of a demand surge within a guaranteed lead time. But not all buyers may be willing to pay higher prices to prepare for and respond to crises, reflecting a classic public good problem as colleagues have argued. Nevertheless, this specific metric is just one potential example; other relevant dimensions of resilience include resilience to production disruption and resilience to sourcing scarce raw material. In reality, purchasers tend to lack granular, applicable metrics and sufficient data to assess and maximize relevant resilience attributes as part of supplier selection (see Figure 2). More and better empirical evidence on how to measure resilience before stress is applied to the system is needed. Further, while open contracting can expedite efficient procurement, these approaches need to be balanced with assuring that procurement regulations and scrutiny do not become obstacles to assessing and incorporating resilience into contracting decisions. Procurement agents should have the flexibility to comprehensively consider various dimensions of resilience and responsiveness as part of bid evaluation decisions in order to sustain and expand health product access in times of crisis (and “normal” times as well). Another tactical area of procurement altered by COVID-19 is split awards. At the national level, these awards may need to more explicitly incorporate ways to split overall procurement volume between multiple suppliers. And while many are interested in “shortening” supply chains, geographic diversification can help to address potential supply chain risks and disruptions down the line. Recommendations on the ideal number of suppliers for each product category and the best delivery frequency to buffer stocks are still evolving, but some experts have recommended buying smaller quantities more frequently where possible, with weekly deliveries as opposed to annual ones. Better resilience heuristics, flexible governance arrangements, and nuanced financing regulations can enable more resilient global health procurement going forward. Figure 2. Supplier Selection Attributes Source: Prashant Yadav 3. Consider the optimal locus of specific procurement functions Procurement involves a gamut of functions, extending from market intelligence, technology horizon scanning and product selection to price negotiation, ordering, contract management, and performance monitoring. Determining the optimal locus of specific procurement functions requires careful consideration of tradeoffs between local agility and information versus economies of scale and scope. Large national purchasers may be better suited to certain procurement-related functions, such as conducting market intelligence and price negotiation. For others, such as placing orders under negotiated contract terms, subnational actors might be better positioned. Without local information and knowledge, purchasing decisions are at risk of being removed from the relevant health system context, as has occurred with the so-called medical equipment graveyard. During the event, Somruethai Supungul of Thailand’s National Health Security Office outlined how regional and hospital-level procurement are used for broad essential medicines. However, central procurement

Co-authored by Jerry La Forgia, Kiran Correa, and Madeleine Lambert. This post originally appeared on the Aceso Global website. COVID-19 has upended health systems globally, with uncertain implications for the future of healthcare and beyond. What is certain, however, is that all healthcare systems undoubtedly face a “new normal” in their journey to achieve universal health coverage (UHC) and become more resilient to future stresses. Yet, without also addressing chronic stresses, particularly deep-seated fragmentation that afflicts many health systems, building resilience – and achieving UHC – will remain elusive. The pandemic has laid bare numerous weaknesses in health systems. One underlying challenge stems from providers and professionals working in different settings – home/community, public health, primary care, hospital – operating in isolation, often without a shared vision and information or a coordinated plan of attack. The legacy of separation of hospitals, primary care and public health in many countries – often overseen by separate administrative units and organizations – contributes to this system dysfunction, and challenges their ability to address the pandemic. While each has a pivotal role to play, they often act as standalone players: the result is a system less than the sum of its parts. In normal times, this chronic fragmentation results in discontinuous and duplicated care, bypassing of primary care, overwhelmed hospitals, and isolation of public and private providers, and has contributed to substandard care and loss of citizen trust in healthcare systems. Nevertheless, COVID-19 has further highlighted fragmentation’s disastrous consequences in a time of emergency. Countries are struggling to coordinate prevention, screening, contact tracing and treatment across multiple settings to provide services in a timely, effective way. The glaring lack of care coordination and communication across providers and health organizations has translated into chaotic responses to the virus, and grossly inadequate diagnosis and treatment for patients. Does COVID-19 present a learning opportunity to redesign healthcare systems to better coordinate actors and resources to address current and future challenges? Public health functions and primary care need to be integrated with hospital and emergency care to provide and manage a coordinated continuum of actions following the patient from detection to post-treatment follow-up and support. Healthcare and public health systems are already testing new ways of doing business to engage communities and providers to better manage patient journeys across the health system and engage with actors outside healthcare. Experimentation is ubiquitous, and new models of care delivery and coordination that might have taken years to agree upon are being implemented in weeks due to the emergency response, representing a huge opportunity for shared learning. A recent survey by the Joint Learning Network, a consortium of over 30 countries, identified a number of topics countries would like to explore to foster coordination across care settings to deal with COVID-19 and non-COVID cases, including strengthening referral systems, maintaining essential services, generating case management guidelines, and investing in “fast response” facilities and telehealth. The fundamental challenge in addressing fragmentation is to provide coordinated case management spanning multiple provider settings, while linking care delivery with community-based social services and essential public health practices. Through our preliminary review of blogs, webinars, press reports and websites as well as informal discussions with practitioners, we identified a number of promising and often related country and health system approaches. The following are just a few examples, categorized into four interlocking themes: Structuring patient pathways and protocols: A number countries have designed and implemented new protocols (instead of or in addition to establishing new facilities) to reduce the burden on hospitals. In Medellin, Colombia, which has been highly successful in containing the spread of the virus, suspected COVID-19 patients are tested in their homes by healthcare workers; those who test positive receive free oximeters to monitor their oxygen levels at home and nurses deliver oxygen as needed. Through this model, valuable hospital beds are reserved for only the most severe cases. In the US, the Cambridge Health Alliance (CHA), a health system serving 130,000 low-income patients, has implemented a comprehensive community management protocol for COVID-19 that includes active outreach to at-risk populations, remote triage, and use of multi-disciplinary teams to remotely manage possible and confirmed COVID-19 cases in the home. Rapidly scaling telehealth: There has been a global push to rapidly expand telemedicine to support mild to moderate COVID-19 cases and also support continuity of non-COVID care, especially for chronic conditions. For example, the Aga Khan University Hospital in Nairobi, Kenya, rapidly established a COVID-19 telephone hotline as well as a telephone triage system for all patients. The triage system is staffed by nurses, who remotely screen patients for COVID-19 symptoms and also schedule telehealth appointments for non-COVID care. In Uruguay, the Ministry of Health developed an online COVID-19 screening questionnaire integrated with Facebook and WhatsApp, as well as the Coronavirus UY mobile app, which offers telemedicine (video or audio) follow-up for clinical COVID-19 cases that do not require hospitalization. Linking to social service providers: COVID-19 has exposed and exacerbated challenges related to access to mental healthcare, employment, and food and housing insecurity, among others. At Wuhan University in China, a multi-disciplinary team of social workers, community workers, medical workers, and volunteers implemented a community-based intervention model that managed COVID-19 cases based on the patient’s risk. Through telehealth interventions, they reached out to people to provide health education, online screening, volunteer coordination, crisis intervention, and psychological counseling. In the US, as part of the aforementioned CHA community management initiative, provider teams connect patients to community-based social support services for food, housing, domestic violence, and the like. Establishing dedicated intermediate centers: From the outset, Korea was an early innovator in addressing COVID-19. By mid-March, the government had set up 12 stand-alone Community Treatment Centers (CTCs) to isolate and monitor patients with mild COVID-19, with the dual purpose of freeing up scarce hospital beds while also reducing community transmission. At each CTC, an on-site team of physicians, public health doctors, nurses and assistants monitor patients twice-daily, providing low-level care and transferring patients with severe symptoms to the hospital.