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Abstract
Following the World Health Organization (WHO) guidance on strategic purchasing in
2000, low- and middle-income countries (LMICs) are trying to shift from passive purchasing
(using fixed budgets) to strategic purchasing of healthcare which ties reimbursement
to outcomes. However, there is limited evidence on strategic purchasing in Africa.
We conducted a scoping literature review aimed at summarizing the roles played by
governments, purchasers and providers in relation to citizens/population in strategic
purchasing in Africa. The review searched for scientific journal articles that contained
data on strategic purchasing collected from Africa. The literature search identified
957 articles of which 80 matched the inclusion criteria and were included in the review.
The study revealed that in some countries strategic purchasing has been used as a
tool for healthcare reforms or for strengthening systems that were not functional
under fixed budgets. However, there was some evidence of a lack of government commitment
in taking leading roles and funding strategic purchasing. Further, in some countries
the laws need to be revised to accommodate new arrangements that were not part of
fixed budgets. The review also established that there were some obstacles within the
public health systems that deterred purchasers from promoting efficiency among providers
and that prevented providers from having full autonomy in decision making. As African
countries strive to shift from passive to strategic purchasing of healthcare, there
is need for full government commitment on strategic purchasing. There is need to further
revise appropriate legal frameworks to support strategic purchasing, conduct assessments
of the healthcare systems before designing strategic purchasing schemes and to sensitize
the providers and citizens on their roles and entitlements respectively.
Background Knowledge regarding the best approaches to improving the quality of healthcare and their implementation is lacking in many resource-limited settings. The Medical Department of Kamuzu Central Hospital in Malawi set out to improve the quality of care provided to its patients and establish itself as a recognized centre in teaching, operations research and supervision of district hospitals. Efforts in the past to achieve these objectives were short-lived, and largely unsuccessful. Against this background, a situational analysis was performed to aid the Medical Department to define and prioritize its quality improvement activities. Methods A mix of quantitative and qualitative methods was applied using checklists for observed practice, review of registers, key informant interviews and structured patient interviews. The mixed methods comprised triangulation by including the perspectives of the clients, healthcare providers from within and outside the department, and the field researcher’s perspectives by means of document review and participatory observation. Results Human resource shortages, staff attitudes and shortage of equipment were identified as major constraints to patient care, and the running of the Medical Department. Processes, including documentation in registers and files and communication within and across cadres of staff were also found to be insufficient and thus undermining the effort of staff and management in establishing a sustained high quality culture. Depending on their past experience and knowledge, the stakeholder interviewees revealed different perspectives and expectations of quality healthcare and the intended quality improvement process. Conclusions Establishing a quality improvement process in resource-limited settings is an enormous task, considering the host of challenges that these facilities face. The steps towards changing the status quo for improved quality care require critical self-assessment, the willingness to change as well as determined commitment and contributions from clients, staff and management.
Approximately 150 million individuals worldwide face catastrophic expenditure each year from medical costs alone, and the non-medical costs of accessing care increase that number. The proportion of this expenditure related to surgery is unknown. Because the World Bank has proposed elimination of medical impoverishment by 2030, the effect of surgical conditions on financial catastrophe should be quantified so that any financial risk protection mechanisms can appropriately incorporate surgery.
There is a growing interest in paying for performance as a means to align the incentives of health workers and health providers with public health goals. However, there is currently a lack of rigorous evidence on the effectiveness of these strategies in improving health care and health, particularly in low- and middle-income countries. Moreover, paying for performance is a complex intervention with uncertain benefits and potential harms. A review of evidence on effectiveness is therefore timely, especially as this is an area of growing interest for funders and governments. To assess the current evidence for the effects of paying for performance on the provision of health care and health outcomes in low- and middle-income countries. We searched more than 15 databases in 2009, including the Cochrane Effective Practice and Organisation of Care Group Specialised Register (searched 3 March 2009), CENTRAL (2009, Issue 1) (searched 3 March 2009), MEDLINE, Ovid (1948 to present) (searched 24 June 2011), EMBASE, Ovid (1980 to 2009 Week 09) (searched 2 March 2009), EconLit, Ovid (1969 to February 2009) (searched 5 March 2009), as well as the Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 8 September 2010). We also searched the websites and online resources of numerous international agencies, organisations and universities to find relevant grey literature and contacted experts in the field. We carried out an updated search on the Results-Based Financing website in April 2011, and re-ran the MEDLINE search in June 2011. Pay for performance refers to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. To be included, a study had to report at least one of the following outcomes: changes in targeted measures of provider performance, such as the delivery or utilisation of healthcare services, or patient outcomes, unintended effects and/or changes in resource use. Studies also needed to use one of the following study designs: randomised trial, non-randomised trial, controlled before-after study or interrupted time series study, and had to have been conducted in low- or middle-income countries (as defined by the World Bank). We aimed to present a meta-analysis of results. However, due to the limited number of studies in each category, the diversity of intervention designs and study methods, as well as important contextual differences, we present a narrative synthesis with separate results from each study. Nine studies were included in the review: one randomised trial, six controlled before-after studies and two interrupted time series studies (or studies which could be re-analysed as such). The interventions were varied: one used target payments linked to quality of care (in the Philippines). Two used target payments linked to coverage indicators (in Tanzania and Zambia). Three used conditional cash transfers, modified by quality measurements (in Rwanda, Burundi and the Democratic Republic of Congo). Two used conditional cash transfers without quality measures (in Rwanda and Vietnam). One used a mix of conditional cash transfers and target payments (China). Targeted services also varied. Most of the interventions used a wide range of targets covering inpatient, outpatient and preventive care, including a strong emphasis on services for women and children. However, one focused specifically on tuberculosis (the main outcome measure was cases detected); one on hospital revenues; and one on improved treatment of common illnesses in under-sixes. Participants were in most cases in a mix of public and faith-based facilities (dispensaries, health posts, health centres and hospitals), though districts were also involved and in one case payments were made direct to individual private practitioners.One study was considered to have low risk of bias and one a moderate risk of bias. The other seven studies had a high risk of bias. Only one study included any patient health indicators. Of the four outcome measures, two showed significant improvement for the intervention group (wasting and self reported health by parents of the under-fives), while two showed no significant difference (being C-reactive protein (CRP)-negative and not anaemic). The two more robust studies both found mixed results - gains for some indicators but no improvement for others. Almost all dimensions of potential impact remain under-studied, including intended and unintended impact on health outcomes, equity, organisational change, user payments and satisfaction, resource use and staff satisfaction. The current evidence base is too weak to draw general conclusions; more robust and also comprehensive studies are needed. Performance-based funding is not a uniform intervention, but rather a range of approaches. Its effects depend on the interaction of several variables, including the design of the intervention (e.g. who receives payments, the magnitude of the incentives, the targets and how they are measured), the amount of additional funding, other ancillary components such as technical support, and contextual factors, including the organisational context in which it is implemented.
departmentHealth Economics Unit, Institute of Applied Health Research, College of Medical and
Dental Sciences, University of Birmingham , Edgbaston, Birmingham B15 2TT, UK
departmentNIHR Global Health Research Unit on Global Surgery, Institute of Translational Medicine,
University of Birmingham , Mindelsohn Way Edgbaston, Birmingham B15 2TH, UK
departmentHealth Economics Unit, Institute of Applied Health Research, College of Medical and
Dental Sciences, University of Birmingham , Edgbaston, Birmingham B15 2TT, UK
departmentHealth Economics Unit, Institute of Applied Health Research, College of Medical and
Dental Sciences, University of Birmingham , Edgbaston, Birmingham B15 2TT, UK
Author notes
*Corresponding author. Health Economics Unit, Institute of Applied Health Research,
College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham
B15 2TT, UK. E-mail:
M.Kachapila@
123456bham.ac.uk
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