Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
Department of Public Policy and Management, SD Dombo University of Business and Integrated Development Studies, Wa, Ghana.
Int J Health Policy Manag. 2023;12:7352. doi: 10.34172/ijhpm.2023.7352. Epub 2023 Nov 6.
Efforts to move towards universal health coverage (UHC) aim to rebalance health financing in ways that increase efficiency, equity, and quality. Resource constraints require a shift from passive to strategic purchasing (SP). In this paper, we report on the experiences of SP in public sector health insurance schemes in nine middle-income countries to understand what extent SP has been established, the challenges and facilitators, and how it is helping countries achieve their UHC goals.
We conducted a systematic search to identify papers on SP. Nine countries were selected for case study analysis. We extracted data from 129 articles. We used a common framework to compare the purchasing arrangements and key features in the different schemes. The evidence was synthesised qualitatively.
Five countries had health technology assessment (HTA) units to research what services to buy. Most schemes had reimbursement mechanisms that enabled some degree of cost control. However, we found evidenced-based changes to the reimbursement mechanisms only in Thailand and China. All countries have some form of mechanism for accreditation of health facilities, although there was considerable variation in what is done. All countries had some strategy for monitoring claims, but they vary in complexity and the extent of implementation; three countries have implemented e-claim processing enabling a greater level of monitoring. Only four countries had independent governance structures to provide oversight. We found delayed reimbursement (six countries), failure to provide services in the benefits package (four countries), and high out-of-pocket (OOP) payments in all countries except Thailand and Indonesia, suggesting the schemes were failing their members.
We recommend investment in purchaser and research capacity and a focus on strong governance, including regular engagement between the purchaser, provider and citizens, to build trusting relationships to leverage the potential of SP more fully, and expand financial protection and progress towards UHC.
为了实现全民健康覆盖（UHC），各国纷纷努力重新调整卫生筹资，以提高效率、公平性和质量。资源有限，这就要求从被动购买转向战略性购买（SP）。本文报道了 9 个中等收入国家公共部门健康保险计划中 SP 的经验，以了解 SP 的建立程度、面临的挑战和促进因素，以及它如何帮助各国实现 UHC 目标。
我们系统地搜索了 SP 的相关文献。选择了 9 个国家进行案例研究分析。我们从 129 篇文章中提取数据。我们使用一个通用框架来比较不同计划中的采购安排和主要特征。证据进行了定性综合。
5 个国家有卫生技术评估（HTA）部门来研究购买哪些服务。大多数计划都有报销机制，以实现一定程度的成本控制。但是，我们发现只有泰国和中国对报销机制进行了基于证据的改革。所有国家都有某种形式的卫生机构认证机制，尽管做法存在很大差异。所有国家都有某种监测索赔的策略，但在复杂性和实施程度上有所不同；有 3 个国家实施了电子索赔处理，从而能够进行更高级别的监测。只有 4 个国家有独立的治理结构来提供监督。我们发现 6 个国家存在报销延迟、4 个国家存在未提供福利套餐中的服务，以及所有国家（泰国和印度尼西亚除外）都存在较高的自付费用，这表明这些计划未能满足其成员的需求。
我们建议投资于采购方和研究能力，并注重加强治理，包括采购方、提供者和公民之间的定期互动，以建立信任关系，更充分地发挥 SP 的潜力，并扩大财务保护和全民健康覆盖的进展。
