Desk review of purchasing arrangements for public health services in Zimbabwe
Gwati G MoHCC (2013) Desk Review for Purchasing Arrangements for Public
Health Services in Zimbabwe November, Harare, MoHCC, with TARSC Zimbabwe
As part of the ReBUILD project ‘Rebuilding the foundations for universal health coverage with equity in Zimbabwe’, led by the Training and Research Support Centre (TARSC), this report provides a background desk review of literature on the purchasing arrangements between central government and (i) local government and (ii) private (not for profit) providers of primary care and district services using national reports.
This research is within the ‘Rebuild’ programme supported by Liverpool School of Tropical Medicine to Training and Research Support Centre (TARSC) and Ministry of Health and Child Care (MoHCC) Zimbabwe. The ReBUILD Programme in Zimbabwe seeks to take forward a programme of work within the context of the work in Zimbabwe on health financing policy and on Universal Health Coverage (UHC). It aims to implement health systems research and stakeholder dialogue and capacity building of the Zimbabwe health system, that seeks to move from the immediate recovery measures implemented in 2009-2012, towards building the foundation for longer term rebuilding of the Universal Health system, as set out in the National Health Strategy (NHS), taking into account equity in access and coverage. One element of this work is to identify options for improving the purchasing arrangements between central and local government, and between government and private (not for profit) providers of primary care and district services, to ensure purchaser obligations on delivery of the EHB and on financial protection. This report provides a background desk review of literature on the purchasing arrangements between central government and (i) local government and (ii) private (not for profit) providers of primary care and district services using national reports.
Purchasing of health services thus implies a contractual relationship between the purchasing agent (the entity pooling risk on behalf of a particular group or population) and the service provider (health institutions providing health care services). The contractual agreement should state the health benefit covered by the fund, the population covered and the proportion of the total cost to be met. Purchasing of health services can be done in three ways.
1. For government to provide budgets directly to its own health service providers (Integration of purchasing and provision) using general government revenues and sometimes insurance contributions.
2. For an institutionally separate purchasing agency ( e.g health insurance fund or government authority) to purchase services on behalf of a population ( a purchaser or provider split).
3. For individuals to pay providers directly for services.
The 100 day plan, the National Health Strategy and the Health sector investment Case are documents that prioritise health sector interventions and seek to pool resources to respond to the both the demand side and the supply side of the health system. The enhancement of the UHC objectives in the purchasing of services in the public health system in Zimbabwe is done through the following coverage mechanisms; free primary health care as a government policy commitment to the Alma Ata declaration on Primary Health Care, WHO 1978; User fee exemption for Children under five, pregnant women and the elderly for hospital services and Social safety net for the indigent groups through the Assisted Medical Treatment Order administered through the Ministry of Public Labour and Social Welfare; and free health care provision for security forces (army, air force, and police) and the Ministry of Justice Prison services. Adequate financing for these coverage mechanisms is a primary concern and whether availed funds benefit the intended beneficiaries. The report explores further the purchasing arrangements in Zimbabwe:
- in central government provided services,
- from Local Authorities,
- from Mission health Institutions,
- by parastatals,
- by bilateral and multilateral agencies,
- through the National Social Security Authority, and
- by private insurers.
The purchaser provider arrangements in both the provincial and district level is enshrined within the terms of reference of the purchaser/ regulator/custodian of the system at that level. There is however no clear separation of functions. Whilst work is in progress to define the cost of the essential health benefit clear contractual arrangements between central government and public providers of health services need to specify the cost sharing between
the state and the patient, the population to be covered and the services to be covered. Planning documents allude to the need for MOHCC to establish a Memorandum of Understanding with ZACH to effectively purchase services from mission institution however no evidence was established to confirm whether this had been done. It finds some active
forms of purchasing, such as the Global Fund and the Health transition fund, and strategic purchasing in the Results based financing for a limited set of interventions, as well as promising practices in the purchase of HIV services through the National Aids Levy and Zimbabwe National Family Planning Council. Private health insurance and private social insurance (NSSA workers compensation fund) are found to be spending more on investments and administration and other areas than on direct service provision. The enhancement of regulatory framework on the application of pooled funds for private for profit health and not for profit health insurance is an area that requires closer attention. The report thus highlights a number of challenges in this respect, that relate to the
purchasing of services, ie The falling level of public funds has not only left households vulnerable to catastrophic health spending, but has weakened governments ability to set and implement the agreements with other providers needed to widen access to core services. The predictability of resources to purchases services is an essential function for access, equity and quality health services.
This calls for improved domestic financing and draws attention to the need for more effective purchasing using the limited resources. There is a question of whether purchasing is being effectively and formally used to ensure
national policy across all providers. In the absence of more formalized arrangements it can be questioned whether policies, strategies and guidelines, such as the core health services package, are de facto binding and articulated for all including the private sector.
The third challenge is in relation to clarity on the scope of what is purchased, and the need for formal agreements to stipulate the cost sharing between the state and the patient and the services this is for, including also the prevention services. The MOHCC has no clear separation of functions, and neither do Mission health facilities and local authority services. There are no formal agreements or contracted outputs or outcomes. Health services purchasing such as the case with the National Aids levy and the Zimbabwe National Family planning council appear to be good practices that indicate within the public system how to separate purchasing from provision and regulation functions and to make central government purchasing more effective.
Finally there are challenges in management arrangements: What is not found in the literature and will need to be further explored are the constraints to the flow of health care processes and services, due to the bureaucratic management and reporting structures. Further the working relationships of all these three parties need to be harmonised and accepted by all given the different management frameworks. The paper outlines follow up research to further explore these issues and the options for improved purchasing.