Step 1: Planning and preparing
Step 1 – Jump to Sections
By the end of Step 1, you should have:
- Articulated how the Framework will be applied in your country including the purpose, breadth (number of purchasing agencies expected to be included), timeline, a plan for which stakeholders will be involved and how findings will be used. This could be in the form of a concept note, terms of reference (ToR) or work plan.
- Engaged key stakeholders to guide the process and promote use of the findings.
- Official authorization to collect data and/or ethical approval/waiver if you intend to publish your findings.
- Begun to edit the Data Synthesis and Analysis Tool (Excel file) to reflect your country context.
The purpose of applying the Framework is to inform health financing policy and reform to improve spending of health resources. The process should be driven by country change agents — stakeholders from the Ministry of Health, Ministry of Finance, Health Insurance agencies and other relevant country stakeholders responsible for purchasing, with support from a research team. This will ensure their buy-in right from the start and increases the chances the findings are used. Although this section is geared towards advice to the research team, we encourage teams to keep the change agents who are responsible for purchasing in the lead.
1.1 Stakeholder engagement
Why is stakeholder engagement important?
Many stakeholders can use the findings to improve health purchasing including, but not limited to, the Ministry of Health, Ministry of Finance, heads of each purchasing agency, regulators, service providers and other country stakeholders responsible for the performance of the purchaser. In addition, official authorization is typically required to collect data and interview key informants.
This exercise needs to be framed as helping [policymakers and decision-makers] to ultimately achieve their own objectives and meet their needs. – Strategic Purchasing Resource Centre for India
How do you engage policymakers and decision-makers to get their attention and support?
- By linking the application of the Framework to intermediate health system goals of equitable resource distribution, efficiency, incentives for accountability, transparency and quality care, and larger policy goals of universal health coverage.
- By assuring them that the purpose is to improve health purchasing and bring stakeholders together to depoliticize discussions on resource allocation. It is not an academic exercise, nor is the Framework an evaluation or judgement of their skills and capacities.
- By understanding their priorities for the health sector and health purchasing and identifying entry points into ongoing policy cycles. For example, a planned review or health sector evaluation or assessment, or a new design or redesign of a health financing mechanism. The findings from the Framework can feed into a national health strategic planning cycle or provide inputs into the development of a health financing strategy.
- By helping them appreciate how health care services are purchased and that purchasing is a powerful instrument that can help address health system priorities and further progress towards universal health coverage.
PRO TIP: African countries that applied the Framework engaged policymakers right from the start by making the process a collaborative learning exercise. They incorporated policymakers and decision-makers in their research teams which facilitated access to data and key informants. Read more about how they jointly applied the Framework here. In Ethiopia, policymakers from the Ethiopian Health Insurance Service and Federal Ministry of Health were trained on strategic purchasing to create a harmonized understanding of purchasing and the terminologies used in the Framework.
Tools for stakeholder engagement
To ensure the success of the process, we encourage a high degree of engagement with stakeholders, and suggest incorporating stakeholders such as representatives from Ministry of Health and Finance and/or National Health Insurance Agencies in the study team. Alternatively, you may incorporate stakeholders in an advisory group that helps to validate your data collection tools, data analysis and summarizing findings. How can you promote engagement?
See methods of stakeholder engagement used in previous applications of the Framework:
- Stakeholder mapping to identify the strategic health purchasing priorities of specific stakeholder groups such as providers, regulators, policymakers and consumer advocates, which may be different from official policy. In other words what problem(s) do they hope strategic purchasing will solve? Even if these perspectives were considered during the original design of the purchasing functions, priorities may have changed or the implementation may not be succeeding in practice.
- Incorporating practitioners from the Ministry of Health and National Health insurance Agencies in the research team who can became champions for the use of the study findings.
- Drafting concept notes that explain the purpose and scope of the assessment in your country. Be prepared to welcome feedback and revise the concept note. The scope includes the number of purchasing agencies and depth of analysis, reflecting the time and funding available.
- Inviting them to in-person 1:1 meetings that generate interest to participate.
- Sending emails, memos or letters of introduction to directors of purchasing agencies explaining the purpose of the assessment and addressing sensitivities around collecting detailed financial and performance data. An official communication from a high-level authority should explain that the assessment is a learning experience (not an evaluation) and provide clear authorization/ permission/encouragement to cooperate/participate.
- Hosting meetings, workshops, retreats and other events during the planning step, for example meetings to collaboratively define the purpose of the assessment.
- Signing a Memorandum of Understanding to ensure a country-led process
- Establishing one or more stakeholder groups to oversee the process
Stakeholder engagement is a continuous process throughout the assessment and the research team will find themselves coming back to stakeholders to validate the final objectives of the study, the health financing schemes to be included and the findings from the study. In the planning step of the assessment, the research team will have clarified the objectives of the study incorporating the views of the stakeholders and ensuring stakeholders have a clear understanding of what is expected from the assessment and how the results will be used.
1.2 Organizing the research team
Preparation will include organizing groups and individuals with clear roles and responsibilities to guide and support the assessment. Based on previous Framework applications, Table 1 below identifies key functions or roles (the ‘what’) and options for ‘who’ can be responsible for them. These roles are recommended to enhance the quality and impact of the Framework findings.
As with any multi-stakeholder endeavor, there can be trade-offs in terms of the research team size — a small cohesive group may make decisions quicker as compared to a larger, but more inclusive group that takes longer to reach consensus but reflects more diverse perspectives.
See Table 1: Options for organizing roles for the application of the Framework
| Funtion/Role | Tasks | Options for who might be responsible |
|---|---|---|
| Decision-makers Policy makers (include MOH, health regulatory agency, health insurance agency, etc.) | - Define the objectives of the exercise, how the data will be used - Provide direction, authorization, permission, and/or encouragement to key informants to participate - Be the audience for the outputs of the exercise - Be accountable for using the findings | -Advisory group, Technical Working Group, or similar comprising: - Government authorities from MoH, regulatory agency, legislative committee - Purchasing agency managers |
| MOH champion The MoH champion may or may not be a member of the Research Team | -Facilitate agreement on purpose, scope and timeline - Help secure formal authorizations for entire exercise and especially data collection - Schedule, facilitate and document meetings - Assist with data sources - Facilitate agreement on data sharing, security and confidentiality - Promote a culture of collaborative learning - Organize learning experiences on strategic health purchasing and related topics | -Secretariat of the Decision-maker group (see above) - Implementors of the Framework (see below) - Academic or consultant with relevant skills - Staff from an MoH department or relevant agency (e.g. insurance regulator) |
| Research team who implements the Framework | -Coordinate communications between and across groups, e.g., manage one or more WhatsApp groups - Draft concept notes, ToRs, SOWs for application of the Framework and revise to reflect feedback from decision-makers and other stakeholders - Execute decisions regarding the process agreed to with the decision-makers - Promote a culture of collaborative learning - Participate in learning experiences on strategic health purchasing and related topics, for example by providing technical orientations, materials or presentations - Adapt the Framework tools to the local context - Collect and analyze the data (Step 2-3) - Present data and findings to decision-makers and other audiences (Step 4) | - Academic institution with relevant expertise - Consultant(s) with relevant expertise - Technical assistance partners - MoH department for performance monitoring or policy analysis - Staff within the purchasing agency |
| Research team lead/principal investigator | - Leads the research team and has overall responsibility for the quality of the assessment - Lead the stakeholder consultations on behalf of the research team ensuring buy-in of senior leadership within the Ministry of Health and purchasing agencies - Ensures all approvals have been obtained prior to data collection, including necessary ethical approvals - May also perform or support some coordination tasks of the MoH champion | - One or two individuals may be designated as the team leads and may be regarded as the principal or co-principal investigators |
| External peer reviewers/technical reviewer | - Health financing experts provide technical review of the research team’s data and findings | - Health financing experts (not from research team) |
| Funder | - Cover the cost of applying the Framework | - Ministry, foundation, donor |
| Audiences In addition to decision-makers | - Receive the outputs (results, findings) of the exercise and respond with their perspectives - Be motivated to participate in efforts to make purchasing more strategic | - Provider representatives such as professional associations - Consumer representatives - Funder(s) of the Framework application |
PRO TIP: In Ethiopia, a technical working group was formed with terms of reference to lead the assessment. The technical working group included representatives from Federal Ministry of Health, Ethiopia Health Insurance Service, and partners USAID-funded Health Financing Improvement Program, Clinton Health Access Initiative, and SPARC. Two coaches supported the technical working group to adapt the Framework and the data collection tools and to draft the assessment report. The technical working group members participated in data collection, data analysis and validation, and reviewed the assessment report.
Learn about the research process from experts who have applied the Framework:
1.3 Adapting the data tools
The Toolkit has two data tools: The Data Synthesis and Analysis Tool (Excel file) and the Data Collection Tool (Word file). Both tools will need to be edited to reflect which health financing schemes are selected for inclusion in the study, and the terminology used in the study country.
The Data Synthesis and Analysis Tool has 7 worksheets:
- Worksheet 1) Introduction
- Worksheet 2) Planning and Preparing
- Worksheet 3) Purchasing Functions
- Worksheet 4) Other capacities
- Worksheet 5) Results Analysis
- Worksheet 6) Benchmarks
- Worksheet 7) Glossary
Click here to download the entire Data Synthesis and Analysis Tool.
Tour the Data Synthesis and Analysis Tool:
The Data Collection Tool has all the questions in worksheets 2 – 6 from the Data Synthesis and Analysis Tool. We recommend you use the Data Collection Tool to enter the raw data you collect from document reviews and interviews because it can be difficult to enter and edit a lot of qualitative data in Excel. There will be one Data Collection file for each scheme included in the study.
Learn more about the Data Collection Tool:
Hear how these experts adapted the Framework tools to fit the needs of their countries:
Adaptation 1: Which purchasers to include
A major advantage of the Framework is that it aims to provide a system-wide view and describes how governance and purchasing functions are performing across multiple purchasing agencies in the country (e.g., Ministry of Finance, Ministry of Health, sub-national finance or health agency, national health insurance, community-based health insurance, private health insurance, etc.). This provides a more complete picture of purchasing across the health system to identify areas of progress that can be built on and areas of fragmentation or overlap that need to be addressed.
Many countries have numerous health financing schemes. Which ones should be included? Unless your or main stakeholder has directed you to focus on one or more specific purchasers, we recommend selecting those with the most purchasing power. The amount of health spending channeled through the purchasing agency determines its purchasing power. Purchasing power means the purchaser can influence which services are prioritized, which providers deliver them, how much providers are paid, the quality standards providers must meet, and the many other levers that can be brought to bear to help achieve universal health coverage objectives. When there are numerous purchasers, purchasing power is weaker and fragmented.
“Purchasing power” refers to the levers purchasers can use to influence resource allocation to high priority services and provider behavior to deliver high-quality services. Purchasing power is higher when there are fewer purchasers who control a large share of health spending and purchasing power is weaker when there are numerous purchasers in a poorly coordinated and fragmented system.
Terminology
Begin by populating the Burgundy Box on Worksheet 2) Planning and Preparing with each health financing scheme you are considering for this assessment. This will automatically populate the column headers at the top of the worksheet.
Figure 2. Input purchasing agencies with significant purchasing power
Fill in the data on the Data Synthesis and Analysis Tool (Excel file) Planning and Preparing worksheet, questions I.a. Background for each purchasing agency being considered for inclusion. These questions ask for the percentage of the population each health financing scheme covers and its share (percentage) of total health expenditures and government resources flowing through these schemes.8
Figure 3. Input data in I.a. Background section on the Planning and Preparing worksheet
Then go back
and validate the selection of health financing schemes to include in the study with key stakeholders considering the time and funding available for the assessment and stakeholder priorities. Once selection is final, confirm and edit the name of each health financing scheme in the Burgundy Box on the 2) Planning and Preparing worksheet which will automatically populate the column headers at the top of each worksheet in the Excel file.
Hear about challenges these experts faced when applying the Framework in their countries:
Adaptation 2: Terminology
Prior to collecting detailed data, you should review all the questions in the Excel file and compare the Framework’s generic terminology to equivalent terms used by the purchasing agencies you will analyze. Edit terms as needed to fit your country context so you are speaking the same language and describing the purchasing functions consistently among the research team and with country stakeholders.
PRO TIP: Some research teams adapted some terminologies to make them consistent with how they are described in their own countries. In India, diagnostic related groups (DRGs) are called “Package Rates” and in Burkina Faso prepayment is referred to as “prepositioning”. Editing in advance prevented confusion with stakeholders during data collection. When the African teams were adapting the tool, the terminology of contracting was relatable to insurance agencies but not the government budget schemes. The teams adapted the questions to seek for any standards, guides, rules or regulations related to accreditation of providers, norms and standards for staffing, equipment and services, standard treatment guidelines and quality assurance guidelines. All these frameworks are used to create clear expectations for service delivery very similar to what is expected in contracting and were used as proxy information even though there was no selective contracting or formal contracting document used by the government budget scheme.
Note, during Step 2 Data Collection it is likely that you will edit additional terms and finalize the Excel tool to reflect your country context.
Adaptation 3: Additional questions tailored to the scope of the assessment
Prior to data collection, you should review all the Framework questions in light of the priorities, concerns, and questions that stakeholders want assessed. For example, the India team edited the section on payment for primary care and added several sections and questions for a deeper dive on claims management and fraud control, beneficiary verification, and other local issues considered to be of priority; while the South East Asia Research Collaboration Hub-Strategic Purchasing (SEARCH) focused the data collection on primary health care. The adaptation of the data collection tools is dependent on the research objectives set out by the team and stakeholders.
1.4 Data collection approvals
As noted in “Why is stakeholder engagement important?”, you need authorization to contact and request information (documents and interviews) from purchasing agencies and individual key informants. Authorization can be in the form of emails, memos or letters of introduction to the leadership of purchasing agencies that explain the purpose of the assessment and address any sensitivities around collecting detailed financial and performance data. The authorization should present the assessment as a learning experience (not an audit or evaluation) and encourage cooperation.
If the research team intends to publish the assessment in a journal, they may require ethical approval from a recognized Institutional Review Board (IRB) in their country. The research team may adapt the concept/TOR for the assessment into a formal study protocol using a template provided by the IRB. In many countries, application of the Strategic Health Purchasing Progress Tracking Framework was given a waiver by the IRB because: the research involves analysis of existing data and materials that do not contain any personal identifying information (PII); the study is intended to assess the performance of a public service or program; and the people participating are key informants, not human subjects. Check with your country’s IRB to confirm if you need to file for a waiver or an exemption.
PRO TIP: In Cameroon, the research team had planned from the outset that they intended to publish their findings in a peer reviewed journal. Therefore, the research team sought ethical approval at the beginning of the study, prior to data collection which also facilitated key informant interviews and publication of the study.
For a full list of citations, see the pdf version of the toolkit.
