Strategic Health Purchasing Progress Tracking Framework: Lessons from Africa for Adaptation and Implementation in India

Strategic purchasing enables health systems to use public health funds efficiently to deliver affordable, high quality health services to more people in an equitable way. A critical factor in health system performance is the extent to which purchasing decisions are linked to provider behavior and encourage providers to pursue equity, efficiency and quality in service delivery. It requires both technical expertise and the ability to manage change in resource constrained environments such as in India.

A consortium of organizations that include ACCESS Health International (AHI), International Decision Support Initiative (iDSI) network partners Center for Global Development (CGD) and Clinton Health ACCESS Initiative (CHAI) are part of a multistate Capacity Assistance Program supported by Bill and Melinda Gates Foundation. The consortium assists the State Health Agencies (SHAs)[1] in Uttar Pradesh, Gujarat, Maharashtra and Bihar and supports to strengthen implementation of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY)[2] and other government sponsored health insurance programs in the states. This consortium envisages: to increase efficiency and effectiveness in insurance operations of the participating states, to address the most urgent operational demands in the system and also facilitates a collaborative on “Strategic Health Purchasing” with technical support from Results for Development.  The collaborative is currently in the process of implementing the Strategic Purchasing Africa Resource Centre (SPARC)[3] to capture strategic health purchasing capacities in a few states of India.

SPARC Progress Tracking Framework has been adapted and actioned in various global contexts. Countries implementing SPARC Framework looked across multiple funding streams. SPARC Framework was implemented to capture strategic health purchasing capacities not only within priority funding sources but also, across financing systems to support countries’ unique objectives in moving toward universal health coverage. The outputs of implementing the SPARC Framework were used to understand areas of progress and gaps in strategic health purchasing functions, and towards the development of policy relevant briefs and recommendations to address identified gaps.

Representatives[4] from three African countries, that have used the SPARC framework, shared their experiences with the Indian counterparts on adapting and implementing the framework in their respective contexts to foster joint learning.

Takeaways for successful implementation of SPRAC Framework

Build data collection process methods to distinguish between policy information vs. what’s implemented in practice into the framework and validate data with subject-matter experts.

Supplement desk review with primary data collection through targeted key informant interviews (KIIs) to fill in gaps from relevant stakeholders

Strategic health purchasing capacity, particularly when examining at sub-national level, should be considered and analyzed within the context of the country’s broader governance arrangements.

Important to assess multiple funding streams.

Map, mobilize and engage with relevant stakeholders. Leverage existing networks, working groups and relationships with stakeholders from the beginning of the implementation process.

Ensure engagement and buy-in with government counterparts at the appropriate and more senior levels to counteract any challenges with access to information and to facilitate ease of implementation. It is imperative how this exercise ought to be framed and communicated to government counterparts during the process of gaining buy-in as helping them to ultimately achieve their state UHC objectives.

Bring key stakeholders into the process early at least 3-4 months before data collection desk review, and KIIs; and get them involved and informed to ensure they are partners in the process of adaptation and implementation.

Orient team members to internalize the SPARC framework and to make the technical implementers own the process.

Role of secretariat/core facilitating group or the coordinator is critical to provide technical facilitation and guidance for the coordination and implementation process.

The process to adapt and implement the tool provides opportunity to build capacity on strategic health purchasing while implementing the framework. Results from the framework are still being applied in SPARC countries and are beginning to have some influence on strategic planning and policy. The ‘Strategic Health Purchasing’ collaborative in India anticipates building capacities, influence policy and in due course improve healthcare systems performance in the states.

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[1] State Health Agency refers to the a body set up by the Department of Health and Family Welfare, in the state for the purpose of coordinating and implementing Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)

[2] In September 2018, India launched Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), one of the largest health assurance programs in the world to achieve Universal Health Coverage (UHC). AB-PMJAY provides a health cover of INR 500,000 /family /year for secondary and tertiary care hospitalization to approximately 500 million poor and vulnerable families.

[3] Strategic Purchasing Africa Resource Centre (SPARC)[3] is an initiative to strengthen strategic purchasing expertise in sub-Saharan Africa and move countries closer to Universal Health Coverage (UHC). It was launched by Results for Development (R4D)[3] in partnership with the Bill and Melinda Gates Foundation. Housed within Amref Health Africa[3], SPARC matches country demand with needed technical expertise by negotiating tailored packages of strategic purchasing support.

[4] Dr. Aloysius Ssennyono, a medical doctor, health policy and systems management specialist, M&E expert, and current Lecturer at Makerere University School of Public Health in Uganda. Dr. Obinna Onwujekwe, a Professor of Health Economics, Systems and Policy, and the Director of the Directorate for Research at the University of Nigeria, Nsukka and  Kazungu Jacob, a Health Economist Research Officer in the Health Economics Research Unit at the KEMRI-Wellcome Trust Nairobi Programme in Kenya.