Munge Kenneth, Mulupi Stephen, Barasa Edwine, Chuma Jane
Institution: Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, PO Box 43640 00100, Nairobi, Kenya.
Nuffield Department of Medicine, Oxford University, Oxford, UK.
BMC Health Serv Res. 2019 Jan 18;19(1):45. doi: 10.1186/s12913-018-3863-6.
Strategic purchasing can ensure that financial resources are used in a way that optimally enhances the attainment of health system goals. A number of low- and middle-income countries, including Kenya, have experimented with micro health insurance (MHIs) as a means to purchase health services for the informal sector. This study aimed to examine the purchasing practices of MHIs in Kenya.
The study was guided by an analytical framework that compared purchasing practices of MHIs with the ideal actions for strategic purchasing along three pairs of principal-agent relationships (government-purchaser, purchaser-provider and citizen-purchaser). The study adopted a qualitative descriptive case study design with 2 MHIs as cases. Data were collected through document reviews (regulation, marketing materials, websites) and semi-structured interviews with key informants (n = 27).
The regulatory framework for MHIs did not adequately support strategic purchasing practice and was exacerbated by poor coordination between health and financial sectors. The MHIs strategically contracted health providers over whom they could exercise bargaining power, sometimes at the expense of quality. There were no clear channels for beneficiaries to provide timely feedback to the purchaser. MHIs premium payments were family-based, low-cost and offered limited benefits. Coverage was based on ability to pay, which may have excluded low-income households from membership.
Adequate policy, legal and regulatory frameworks that integrate MHIs into the broader health financing system and support strategic purchasing practices are required. The state departments responsible for finance and health should form coordinating structures that ensure that MHI's role in universal health coverage is owned across all relevant sectors, and that actors, such as regulators, perform in a coordinated manner. The frameworks should also seek to align purchasers' relationships with providers so that clear and consistent signals are received by providers from all purchasing mechanisms present within the health system.
战略采购能够确保财政资源以最优方式用于促进卫生系统目标的实现。包括肯尼亚在内的一些低收入和中等收入国家已尝试将微型健康保险（MHI）作为为非正规部门购买卫生服务的一种手段。本研究旨在考察肯尼亚微型健康保险的采购实践。
本研究以一个分析框架为指导，该框架沿着三对委托代理关系（政府 - 购买方、购买方 - 提供者和公民 - 购买方）将微型健康保险的采购实践与战略采购的理想行动进行比较。本研究采用定性描述性案例研究设计，以2个微型健康保险机构作为案例。通过文件审查（法规、营销材料、网站）以及对关键信息提供者进行半结构化访谈（n = 27）来收集数据。
微型健康保险的监管框架未能充分支持战略采购实践，且卫生部门与金融部门之间协调不佳使其情况更为严重。微型健康保险机构从战略上与它们能够行使议价能力的卫生服务提供者签约，有时甚至以牺牲质量为代价。受益方没有明确的渠道向购买方及时提供反馈。微型健康保险的保费支付以家庭为基础，成本低且福利有限。覆盖范围基于支付能力，这可能导致低收入家庭被排除在参保范围之外。
需要有适当的政策、法律和监管框架，将微型健康保险纳入更广泛的卫生筹资体系并支持战略采购实践。负责财政和卫生的国家部门应建立协调机构，以确保微型健康保险在全民健康覆盖中的作用得到所有相关部门的认可，并且监管机构等行为主体能够协同履行职责。这些框架还应致力于调整购买方与提供者之间的关系，以便卫生系统内所有采购机制向提供者发出清晰一致的信号。
