Strategic purchasing for health: conceptual and implementation challenges in low- and middleincome countries

Introduction: Strategic purchasing has emerged as a key global health financing tool becoming deeply embedded into the global health policy lexicon. It has been touted as a key mechanism to deliver progress on universal health coverage (UHC). Strategic purchasing is seen as a way to increase efficiency, provide value for money, and improve equity in benefit entitlements and responsiveness to pro-poor policies and needs. Nevertheless, despite its popularity, strategic purchasing remains conceptually ambiguous, encompassing several potentially disparate elements. Klasa and colleagues recently developed a streamlined strategic purchasing framework with clearly identified key elements: (1) addressing population health needs, (2) empowering citizens, (3) strengthening government stewardship and capacity (4), developing effective purchaser and provider organizations, and (5) incorporating cost-effective contracting.1 Klasa showed that strategic purchasing is difficult to implement, even in high-income countries.
Aim: We shed critical light on how strategic purchasing is understood as a health reform tool, and examine likely implementation challenges in low- and middle-income countries (LMICs), with examples from Senegal.
Methods: A literature survey identified existing conceptual frameworks associated with strategic purchasing in LMIC settings, for comparison to the findings of Klasa and colleagues. Semi-structured interviews (N=15) and 2 focus group discussions with African health practitioners and managers enabled (i) their understanding of strategic purchasing as a health reform tool, and (ii) implementation challenges in their context.
Results: Strategic purchasing remains a fuzzy concept. African health practitioners do not have a clear understanding of the concept and how it differs from other approaches such as performance-based financing. Ambiguity is fuelled by some donors. Many implementation challenges have been identified in alignment with Klasa and colleagues’ framework, which suggest weak connections to UHC. In Senegal, various mechanisms could concur to the objective of strategic purchasing, but this function is not institutionalised yet, resulting in lack of coherence and efficiency.
Conclusion: This study sharpens current debates on health financing and shows that many challenges need to be addressed if strategic purchasing is to advance UHC.

References:
1. Klasa K., Greer S., van Ginneken E. Strategic Purchasing in Practice: Comparing Ten European Countries. Health Policy 2018; 122(5), 457-472.