Purchasing is the transfer of pooled funds to health care providers. Strategic purchasing aims to use available resources more efficiently to deliver high-quality services. It involves using evidence and information about population health needs and health provider performance to make decisions about which health services should have priority for public funding (“what to buy”), which providers will provide these services (“from whom to buy”), and how and how much providers will be paid to deliver those services (“how to buy”).

The Strategic Purchasing Progress Tracking Framework (Framework) was co-created by African health financing researchers and academics, in collaboration with Results for Development (R4D), through the Strategic Purchasing Africa Resource Center (SPARC). It builds on existing frameworks and focuses on the core purchasing functions of benefits specification, contracting arrangements, provider payment and performance monitoring. The Framework examines the governance and institutional arrangements that support the core purchasing functions, as well as factors that can either strengthen or weaken the power of purchasers to directly influence resource allocation and provider behavior.

The Framework provides a practical way to understand how resources flow through the health system — moving beyond individual schemes to understand the interactions of the different funding channels, incentives created that can alter provider behavior, and the levers to improve how resources are directed to priority populations, interventions and services.

The Framework has been used in over 20 countries in Africa and Asia through SPARC and the Southeast Asia Research Collaborative for Health (SEARCH) and is being applied by other researchers globally.

In Cameroon, for example, Isidore Sieleunou and his team implemented the Framework because policymakers recognized it as an opportunity to assess “how schemes progress over time” through a co-creative process which would “shape the conversation around the universal health coverage movement.”

To scale the use of the Framework, R4D developed a toolkit to assist other researchers and policymakers considering applying the use of the Framework in their countries. The toolkit combines the concepts of strategic purchasing espoused in the Framework with practical guidance for assessing the purchasing functions in a health system.

In the process of developing the toolkit, R4D consulted representatives from the 20 countries across Africa and Southeast Asia that applied the Framework to understand how the toolkit can be made most useful to others attempting to use it independently. R4D also used the opportunity to better clarify questions within the data collection tools that were ambiguous or challenging during the application of the Framework.

In addition to providing context and framing strategic purchasing and the relevance of the framework, this toolkit breaks down the process of applying the framework into four steps:

1. Planning and preparing
2. Data collection
3. Data analysis and validation
4. Sharing findings for decisions and actions.

The toolkit walks users through each step and provides useful tips and tools to successfully apply the framework in their country.

Each country’s health system will be unique and will have challenges that are specific to its circumstances, and the framework is designed to be adapted to these specifications.

Ryan Rachmad Nugraha, an implementer of the framework in Indonesia, expressed that while certain aspects of the framework “might resonate in a pool of countries more than others, that’s the beauty of it” because the framework can be used to address each set of unique circumstances and challenges. The toolkit helps guide users through this adaptation process, which can be especially useful when one-on-one coaching and mentoring is not available.

Throughout the toolkit, users can watch testimonials from experts who have applied the framework in their own countries. These testimonials highlight the key takeaways from their application of the framework and their advice to those applying the framework for the first time.

When describing how she and her research team applied the framework in Southeast Asia, Capucine Barcellona shared that they were able to avoid contradicting themselves because they “were just reporting on the facts from a neutral perspective.” This insight is very relevant for many users of the framework who may be closely involved with the health system, to remain objective and neutral as they describe and report their findings.

Video animations simplify the four steps and serve as a tutorial throughout the application of the framework. The testimonials and animations address some of the common questions that users may have during this process, including

• How to set up a research team
• How to include policymakers in the process
• How to organize and analyze findings
• How to reach consensus on thorny or controversial aspects of purchasing

The goal of using the Framework is to ultimately inform policy decisions that will improve how resources are allocated, and this toolkit facilitates users as they apply the Framework to respond to pertinent questions raised by policymakers to improve purchasing, with tips and advice from other experienced users and experts.

The toolkit incorporates some of the best elements of R4D’s Collaborative Learning and Coaching approaches — learning from peers, learning by doing and facilitating technical conversations through country-led processes. The toolkit is not meant to be a static output, and we encourage you to share your feedback, lessons and comments as we iterate and improve the tool to make it useful for decision making as countries make progress toward universal health coverage.

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SPARC is not just a resource center but a movement. SPARC is engaging as many stakeholder groups across Africa to understand, talk about, and advocate for strategic purchasing to make better use of limited resources for UHC and to hold governments accountable for effective health spending.

Between July 25-28 2022, SPARC convened 80 representatives from Ministries of Health, National Health Insurance agencies, the technical partners consortium, and coaches who support SPARC country engagements from 11 African countries ( Benin, Burkina Faso, Democratic Republic of Congo, Cameroon, Ethiopia, Gambia, Ghana, Kenya, Nigeria, Rwanda, Tanzania and Uganda). At this convening, SPARC hosted a learning exchange between these countries on advancing strategic health purchasing through the government budget.

Why the government budget?

In many African countries, the government budget remains the largest pool of funds. Although the government budget has not been fully leveraged for strategic purchasing, there is growing interest in the region in introducing new health financing arrangements that operate in parallel with the government budget, such as contributory national health insurance, community-based health insurance, and other schemes. It’s clear the government budget remains the most effective and equitable vehicle for strategic purchasing.

It is widely acknowledged that more public resources are required to advance UHC objectives — and public funds — including on-budget donor resources channeled through the government budget, allowing for pooling and allocation of resources to providers in a way that aligns with population health needs. Recognizing the value of the government budget and the opportunities therein, representatives from Burkina Faso, Kenya, Nigeria, Tanzania and Uganda, shared their country experience using the government budget to improve strategic purchasing and remaining obstacles to be overcome.

Resisting further fragmentation by channeling the government budget in existing schemes

Multiple schemes in countries, fragment health resources flowing through the schemes reducing the purchasers’ power to exert influence on how resources are allocated, and the incentives to providers for high quality care. When new schemes are established, often times they worsen the fragmentation in the system by adding a new scheme rather than building on what exists.

Tanzania’s Basket-funding, however, aimed to reduce fragmentation by pooling the government budget and on-budget donor resources into one pool and channeling resources directly to primary health care providers (PHC) through the Direct Health Facility Financing (DHFF) for priority maternal and child health (MCH) services.

In Nigeria, the Basic Health Care Provision Fund channels 1% of consolidated government revenue through three gateways to the National Primary Healthcare Development Agency to finance inputs for PHC providers; to the National and State Health Insurance Agencies to extend insurance coverage to vulnerable groups, and for emergency and pandemic related health services. In so doing, the government budget is building on existing purchasing agencies to transfer resources to providers targeted at PHC and addressing the needs of the most vulnerable population groups.

Prioritizing vulnerable groups and priority services

Channeling the government budget toward priority health services and/or population groups, such as women and children, in a bid to reduce maternal and infant mortality can move countries closer to achieving the sustainable development goals and UHC. The Gratuite program in Burkina Faso transfers government funds directly to PHC providers for MCH services. In Kenya, the “Linda Mama” program runs on a government budget subsidy channeled through Kenya’s National Hospital Insurance Fund for coverage of antenatal care, health facility delivery and postnatal care. In Uganda, budget guidelines stipulate that 30% of facility resources must be used for preventive health services and limits the district health facility budget spending on administration to 15% while the rest should be used for service delivery.

Using the government budget to increase provider autonomy

Provider autonomy refers to the degree of financial and management autonomy health managers have to receive funds, use these funds, and respond to the incentives in provider payment systems. Government budgets are associated with rigid rules for spending public resources to ensure accountability for how these resources are used but may limit how providers can spend resources they receive.

Tanzania’s DHFF recognized PHC providers as accounting units, allowing them to receive public resources, and expanded the decision space for managers to develop facility plans in collaboration with community representatives. DHFF also bypassed the bottlenecks and delays at the district level by transferring resources directly to the PHC level. This has allowed providers to be more responsive to local health priorities and allow more timely receipt of funds.

Burkina Faso’s Gratuite program also increased resources to providers and used a system of pre-payment that allowed for transfer of funds in advance to ensure adequate resourcing of providers and overcoming bottlenecks to resource flowing to the PHC level.

A similar program to transfer funds directly to PHC providers in Kenya, and increasing their autonomy implemented between 2010 and 2012, showed similar successes reducing bottlenecks at the district level, empowering providers to respond to local priorities and improving infrastructure at PHC level. Uganda provides strict guidelines to providers and follows this with supportive supervision and audits. Although this limits provider autonomy, these processes are considered necessary to improve alignment to national priorities and accountability for public resources.

Overcoming remaining obstacles

Despite these successes, there remain challenges in raising adequate resources for health, navigating the politics of moving money and power from one organization to another. For example, Burkina Faso is considering a transition of the Gratiute program to the health insurance agency; and in Kenya the devolved system of government has increased fragmentation of health resources in 47 county governments. Further, a debate on how much provider autonomy is sufficient and how to link the government budget to better performance and quality of care remain important learning questions for SPARC and the technical partners going forward.

For those considering changes in the government budget, it’s important to have a clear vision and strategy — and to look for opportunities to solve problems with steps that have the least resistance from stakeholders, while building trust along the way. For SPARC, this is only the beginning of a learning agenda that builds on these country lessons.

Photo © Strategic Purchasing Africa Resource Center

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In 1998, when I was a Peace Corps volunteer in Cameroon, the father of my wonderful host family suddenly died from a preventable and treatable diabetic coma. He left behind a devastated wife and six kids. I grieved with the family, frustrated in knowing that their loss was avoidable and seeing so plainly why health systems matter. It was clear that, beyond any diabetes-specific initiative, Cameroonians deserved a well-functioning health system — one that could arrange the money, the people, the medicine, and the services that could prevent that avoidable loss and so many others like it.

Dr. Nathan Blanchet is a health systems specialist and international development leader with over 20 years of experience advancing public health and education in Africa, Eastern Europe and Asia through academic research, teaching and nonprofit program leadership.

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As a senior program director at Results for Development, Dr. Blanchet serves as project director for the Health Systems Strengthening Accelerator, a global initiative to improve how health systems strengthening is done locally and globally. He also leads work on the design and implementation of national health insurance programs and other means of achieving universal health coverage in low- and middle-income countries. Focus areas include strengthening primary health care and integrating vertically-financed and private health services into sustainable public health financing systems. Previously Dr. Blanchet co-led the Joint Learning Network for Universal Health Coverage’s Primary Health Care Initiative, which produced widely used tools such as a way for countries to ensure health financing promotes primary health care and a guide that helps public sector stakeholders better engage the private sector in primary health care. As a member of R4D’s management team, Dr. Blanchet contributes to organizational strategy, partner outreach and staff development.

Dr. Blanchet has written and taught qualitative and quantitative studies on health financing, human resources for health, and the political economy of health reform in low- and middle-income countries, with a focus on Ghana. He has also advised and managed teams that have supported government health system reformers in several African and Asian countries.

Prior to his work and doctoral studies, Dr. Blanchet served as a U.S. Presidential Management Fellow at USAID, leading strategic planning and evaluation efforts for USAID’s health programs in Eastern Europe and Central Asia, including the response to the global avian influenza outbreak in 2005. He also consulted for the World Bank’s Onchocerciasis Control Unit, the Inter-American Development Bank and the U.K.’s Department for International Development (DFID), and served as a U.S. Peace Corps teacher and trainer in Cameroon.  In 2010 he co-led an analysis of the political economy of health reform in Vermont that helped lead to successful passage of a major health reform bill by the state legislature.

Dr. Blanchet regularly delivers guest lectures at Harvard University’s T.H Chan School of Public Health and George Washington University’s Milken Institute School of Public Health on health financing, the political economy of health reform, and the professional practice of global health.

Dr. Blanchet holds an ScD in global health and population from Harvard University’s T.H. Chan School of Public Health, an MA in international relations from Johns Hopkins University’s School of Advanced International Studies and a BA in political science and French from Miami University. He speaks English, French and Spanish.

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