Is strategic purchasing feasible in publicly funded health systems with integrated purchasing and provision functions? A case study of Tamil Nadu, India

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The document discusses strategic purchasing in the publicly funded health system of Tamil Nadu, India. It finds that while Tamil Nadu is progressing toward strategic purchasing, this movement is hindered by implementation challenges and limited fiscal space. The political commitment, strong bureaucracy, and progressive public attitudes help drive strategic purchasing. However, challenges remain such as weak community participation, a lack of essential health packages, and resource allocation not based on needs.

Health & Medicine

Is strategic purchasing feasible in publicly
funded health systems with integrated
purchasing and provision functions: A case
study of Tamil Nadu, India?
Professor Umakant Dash,
Dept. of HSS, IIT Madras, India
iHEA, Milan; Tuesday 14 July, 2015

Background
• Health is a shared responsibility between the centre and
the state (Implementation)
• Autonomy of the state government on provision of
health care (e.g. services to be provided, risk protection)
• Limited fiscal space
• Low utilization rate: perceived low quality, access, long
waiting time, unavailability of doctors
• High OOP
• Universal Health Coverage

Findings: Purchaser-Government
• The integrated tax funded system of Tamil Nadu is progressing
towards strategic purchasing though the pace of the movement
is hindered by implementation challenges
• Aligning health strategy with the poverty reduction strategy
and medium-term expenditure framework, increasing fund
flow (Priority Sector)
• Ensure access (as per national norm) (PHCs, HSCs, Hospitals,
Tertiary Care)
• Well intended policies to improve geographical equity, risk
protection for the poor (CMCHIS: Chief Ministers Comprehensive
Health Insurance Scheme, MRMBS: Dr. Muthulakshmi Reddy Maternity
Benefit Scheme)

Purchaser-Government
• Issues/challenges:
• Limited fiscal space
• Stringent Public Finance Management Framework
• Factors (drive towards strategic purchasing):
• The political commitment
• Strong bureaucracy
• Progressive attitude of the public
• Continuity of programs

Findings: Purchaser-Provider
• Ensure adequate flow of funds, manpower and uninterrupted
supply of drugs and equipment, guidance, support, and
monitoring to health providers for health care service provision
• Centralized Procurement of drugs (TNMSC, an autonomous
entity mandated by law) to increase efficiency, reduce cost
because of bulk purchase and market power, ensure better
quality, avoid stock outs
• Enforcement of Quality Assurance Circles
• Mix of Public-Private Providers (CMCHI, vertical diseases)
• Flexi fund [PWS, untied fund, annual maintenance
grants(AMG)] to improve efficiency and quality of service

Purchaser-Provider
Challenges/Issues:
•Implementation challanges due to the use of line-item
budgets, shortage of manpower and requisite skill level
limits the ability of the purchaser to engage in strategic
purchasing
•Although the legislative reform environment is positive,
providers lack implementation capacity
•No appropriate incentives for performance and
penalties for non-performance

Findings: Purchaser-Citizens
• Though the purchaser is committed to
providing quality services that reflect people’s
needs and preferences, and formal mechanisms
are in place to facilitate accountability between
purchasers and citizens, many of the
mechanisms do not currently function in line
with government policy

Purchaser-Citizens
• Challenges/Issues:
• Weak regulation, poor community participation in
the decision-making process
• No Essential Health Package and needs are not
elicited from citizens
• Lack of frequent communication, technical support
and resources
• Resource allocation on the basis of utilization not
need-based

www.wpro.who.int/asia_pacific_observatory
http://resyst.lshtm.ac.uk
@RESYSTresearch
The research is a collaboration between RESYST and the Asia
Pacific Observatory on Health Systems and Policies.
RESYST is funded by UK aid from the UK Department
for International Development (DFID). However, the
views expressed do not necessarily reflect the
Department’s official policies.
More information: http://resyst.lshtm.ac.uk/research-projects/
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The following resource was developed by RESYST for a research uptake workshop held in Kilifi, Kenya. In this resource: - Understand the importance of strategic planning for research uptake - Familiarise key aspects of a research uptake strategy - Develop research uptake objectives for your research group, project, hub or an event - Identify key stakeholders using stakeholder analysis techniques - Review communications channels, outputs and activities - Explore indicators and tools for monitoring and evaluation - Key questions to consider in a research uptake strategy Find more: http://resyst.lshtm.ac.uk/resources/resource-bank-research-uptake

Research uptake and digital communications

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The following resource was developed by RESYST for a research uptake and digital communications workshop held in Bangkok, Thailand. In this resource: - Understand the importance of strategic planning for research uptake and digital communications - Develop digital communications objectives for your research group, project or organisation - Identify key stakeholders using stakeholder analysis techniques - Review digital communications content, platforms and tools - Explore indicators and tools for monitoring and evaluation - Develop key messages from a journal article Find more: http://resyst.lshtm.ac.uk/resources/resource-bank-research-uptake

Gender and ethics in practice: experiences of researchers conducting qualitat...

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This document discusses the challenges of conducting qualitative health policy and systems research studies from a gender perspective. It notes that research often fails to sufficiently consider gender as a social relation and that the governance of the field lacks attention to power dynamics. The document then reflects on discussions from a meeting of researchers where they shared challenges of addressing gender and power in their work, such as resistance to gender analysis, misunderstandings of gender concepts, and power imbalances in research methods and relationships with respondents. Recommendations include building capacity on positionality, using participatory methods, and developing context-specific strategies to challenge norms respectfully.

Financial incentives and initiatives to improve the quality of care in South ...

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This study examined factors influencing private general practitioners' (GPs) decisions to accept sessional contracts working in South Africa's public primary care clinics. A discrete choice experiment was conducted with 74 GPs. Results showed low predicted uptake of proposed contracts. While payment rates were important, there was heterogeneity in GPs' motivations - some opposed public work, most valued payment, and some had pro-social preferences. The findings can inform contract design improvements to potentially increase uptake, though significant financial resources may be required. Targeting more pro-socially oriented GPs may also help uptake.

The effects of decentralisation on planning, budgeting and overall public fin...

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The document summarizes a case study on the effects of political devolution in Kenya on planning, budgeting, and public finance management in the health sector of Kilifi County. Key findings include: 1) The transition to devolved county governments in Kenya led to disruption of health sector planning and budgets, as the County Department of Health was not involved in budgeting and lacked a technical work plan. 2) Early public finance management processes in Kilifi County's health sector became re-centralized at the county level, and health facilities lost financial autonomy. 3) Capacity gaps at the county level hindered the implementation of decentralized planning and budgeting for health services.

Rural origin and the retention of professional nurses in rural areas: a five-...

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Job choices of nurses trained in private and government institutions Tamil Na...

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Understanding the causal pathways within health systems policy evaluation thr...

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The document discusses using mediation analysis to understand the causal pathways through which a payment for performance (P4P) program in Tanzania influenced health outcomes. It finds the P4P program significantly improved several financing, governance, and human resources factors that could mediate its effects. Specifically, reduced stock-outs of oxytocin injections mediated 22% of the increased institutional deliveries and 30% of the increased deliveries at public facilities. Improved supervision frequency mediated 15% of the increased uptake of antimalarial doses during pregnancy. While illustrating indirect effects, mediation analysis relies on assumptions that are difficult to fully test and may oversimplify causal chains. The analysis provides insights but also reflections on further developing mediation methods for quasi

Signs of P4P enhanced functioning of accountability in the health system: exp...

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P4P pilots in Tanzania showed signs of enhancing accountability in the health system. Internal accountability improved as P4P led to timelier and more constructive supervision that focused on problem-solving. It also reduced stockouts and interruptions in service delivery. External accountability increased as health workers were found to be more respectful and responsive to patients. Community involvement in facility governance was also strengthened under P4P. While resource limitations hindered some outreach activities, P4P increased the number of outreach visits when measured at the district level. In conclusion, P4P demonstrated potential to improve various accountability mechanisms in the health system.

Tracking implementation and (un)intended consequences of peripheral health fa...

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The document discusses the Health Sector Services Fund (HSSF) in Kenya, which provides direct financing to peripheral health facilities to improve quality of care and sustainability. It outlines the implementation of HSSF, including challenges around delays in funding, inadequate funding levels, and complex reporting requirements. The document also examines knowledge gaps and next steps for HSSF as Kenya's health system undergoes devolution and the introduction of new financing mechanisms.

Longitudinal research tracking the financing of peripheral public health care...

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This document provides an outline and background for longitudinal research tracking the financing of peripheral public health care facilities in Kenya. It discusses: 1) Kenya's health sector reforms and the Health Sector Services Fund (HSSF), which disburses funds directly to peripheral facilities. 2) Previous research on HSSF implementation through a 2005 pilot, 2010 baseline survey, and 2012 interim study that identified challenges and opportunities. 3) The current proposal to describe financing approaches across counties following devolution and explore how differences in supervision affect facilities.

Do financial incentives undermine health workers intrinisic motivation? - Jos...

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This study explored the impact of a pay-for-performance (P4P) scheme in Tanzania on health workers' intrinsic motivation and institutional delivery rates. The study found no evidence that P4P undermined intrinsic motivation. It did find that P4P had a greater positive effect on delivery rates in facilities whose staff had lower baseline intrinsic motivation levels. This suggests that extrinsic incentives like P4P may work better in settings where health workers are less intrinsically motivated to begin with. The study was limited by potential social desirability bias in health workers' self-reported motivation levels and questions around how well the motivation measure captured intrinsic motivation.

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