Department of Health Administration and Management, Faculty of Health Sciences, University of Nigeria, Enugu Campus, Enugu, Nigeria.
Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria.
Int J Equity Health. 2017 Dec 28;16(1):216. doi: 10.1186/s12939-017-0711-y.
Purchasing is a health financing function that involves the transfer of pooled resources to providers on behalf of a covered population. Little attention has been paid to the extent to which the views of that population are reflected in purchasing decisions. This article explores how purchasers in two financing mechanisms: the Formal Sector Social Health Insurance Programme (FSSHIP) operating under the Nigerian National Health Insurance Scheme (NHIS), and the tax-funded health system perform their roles in light of their responsibilities to the populations.
A case study approach was adopted in which each financing mechanism is a case. Sixteen (16) in-depth interviews with purchasers and eight (8) focus group discussions with beneficiaries were held. Agency and organizational behavioural theories were used to characterise the purchaser-citizen relationships. A deductive framework approach was used to assess whether actions identified in a model of 'ideal' strategic purchasing actions were undertaken in each case.
For both cases, mechanisms exist to reflect people's health needs in purchasing decisions, including quantitative and qualitative needs assessment, mechanisms to raise awareness of benefit entitlements and allow choice. However, purchasers do not use the mechanisms to effectively engage with and hold themselves accountable to the people. In the tax-funded system, weak information systems and unclear communication channels between the purchaser and citizens constrain assessment of needs; while timeliness of health information and poor engagement practices of Health Maintenance Organisations (HMOs) are the main constraints in FSSHIP. Inadequate information sharing in both mechanisms limits beneficiaries' awareness of entitlements. Although beneficiaries of FSSHIP can choose providers, lack of information on the quality of services offered by providers constrains rational decision-making and the inability to change HMOs reduces HMO responsiveness to beneficiary needs.
Responsiveness and accountability to beneficiaries are undervalued by purchasers in both financing mechanisms. In the tax-funded system, civil society organisations can facilitate engagement and accountability of purchasers and the people. In FSSHIP, NHIS needs to provide stronger stewardship of HMOs to promote effective engagement with members. Furthermore, the NHIS should introduce mechanisms that allow FSSHIP members to choose their own HMO, which could encourage HMOs to be more responsive to members.
采购是一种健康融资职能，涉及代表参保人群向提供者转移集中资源。很少有人关注参保人群的意见在采购决策中得到体现的程度。本文探讨了在尼日利亚国家健康保险计划（NHIS）下运作的正规部门社会健康保险计划（FSSHIP）和税收资助的卫生系统这两种融资机制中的采购者如何根据其对参保人群的责任履行职责。
采用案例研究方法，每个融资机制都是一个案例。对采购人员进行了 16 次深入访谈，对受益人进行了 8 次焦点小组讨论。采用代理和组织行为理论来描述采购者与公民的关系。采用演绎框架方法评估在“理想”战略采购行为模型中确定的行动是否在每种情况下都得到了实施。
对于这两种情况，都存在机制来反映人们在采购决策中的健康需求，包括定量和定性需求评估、提高对福利权益的认识和选择的机制。然而，采购人员并没有利用这些机制来有效地与参保人群接触并对他们负责。在税收资助的系统中，薄弱的信息系统和采购人员与公民之间沟通不畅限制了需求评估；而 FSSHIP 中的健康信息的及时性和健康维护组织（HMOs）的不良参与实践是主要限制因素。两个机制中信息共享不足限制了受益人对权益的认识。尽管 FSSHIP 的受益人可以选择提供者，但缺乏关于提供者所提供服务质量的信息限制了理性决策，而无法更换 HMO 则降低了 HMO 对受益人的需求的响应能力。
在这两种融资机制中，采购人员对参保人群的响应性和问责制重视不足。在税收资助的系统中，民间社会组织可以促进采购人员和参保人群的参与和问责制。在 FSSHIP 中，NHIS 需要加强对 HMO 的管理，以促进与成员的有效接触。此外，NHIS 应该引入允许 FSSHIP 成员选择自己的 HMO 的机制，这可以鼓励 HMO 对成员更加响应。
