A core challenge that most countries face as they work toward universal health coverage (UHC) is how to pay for services to ensure effective coverage and promote quality while maintaining financial sustainability.
Financing and payment systems for primary health care (PHC) can serve as important instruments, enabling factors, and entry points for addressing the important questions of access, quality, and equity. These financing and payment models should create a foundation that allows adequate resources to flow to primary care to make priority interventions accessible to the entire population.
However, all payment mechanisms involve trade-offs and may lead to unintended consequences, making it challenging for practitioners and policymakers to select appropriate payment methods, design and implement them effectively, and monitor whether they are supporting service delivery objectives and UHC goals.
For the past six years, JLN countries engaged with the Provider Payment Mechanisms initiative have learned from each other to better design, implement and monitor effective provider payment systems to support progress toward UHC. The main challenges identified by countries have centered around the need for tools and resources to fill critical information gaps. Fast forward six years and the network has grown, and the countries have made significant progress.
Announcing the Primary Health Care Financing and Payment Collaborative
The JLN PHC Financing and Payment collaborative is part of a new series of initiatives under a JLN grant from the Bill & Melinda Gates Foundation to support people-centered integrated care (PCIC). The collaborative seeks to address challenges related to mobilizing and estimating resource requirements for PHC benefits or service packages, identifying and putting in place appropriate funding and payment models, and monitoring impacts on access, quality, efficiency, equity and financial protection, and ultimately, population health.
On October 10-13, 2017 the JLN Provider Payment Mechanisms initiative convened the first in-person meeting of the Primary Health Care Financing and Payment collaborative. More than 40 participants from 14 countries gathered in Hanoi, Vietnam to share their respective experiences, challenges, and creative solutions with PHC financing and payment in a holistic way. The participants also had the opportunity to learn about the health system and PHC reform process from Vietnam, the host country Vietnam and Estonia, a resource country.
The collaborative meeting took place in parallel and in collaboration with concurrent meetings of the Information Technology initiative’s new Data Foundations collaborative and the Primary Health Care initiative’s People-Centered Integrated Care collaborative to identify and operationalize demand-driven opportunities for cross-technical coordination across the JLN.
Key Messages from the Meeting
During the Vietnam meeting, the collaborative participants reached a consensus on the following key messages:
- There is agreement on a framework to improve PHC financing and payments. Participants agreed on a framework to holistically improve PHC financing and payment.
- There is a need to define PHC packages clearly. Countries expressed a need to define PHC packages clearly due to a high variability of provider capacity (general practitioner vs. specialist) and emerging reforms of integrated and person-centered care models, and vertical integration models.
- Costing can be complicated and resource-intensive – the objective and approach should be clear. Costing requires detailed data on clinical and financial activities of provider care, which many countries find challenging to collect. Costing methodologies and assumptions are also inconsistent, leading to the calculation of costs based on an ideal model rather than the real situation. Countries concluded that the objectives of costing exercises (such as payment rate setting or identifying resource needs) should be clear, methodologies adapted, and data sources identified.
- Capitation (+) payment systems, with adjustments per country needs, is likely the way forward. Capitation is the payment system that best matches the philosophy of PHC to manage the health of the population rather than just treat illness. However, challenges remain. Most countries are moving toward blending capitation payment systems with other payment methods to balance incentives (e.g. capitation + pay-for-performance), but such mixed payment systems can be challenging to implement effectively without worsening fragmentation.
Greater focus should be placed on how to harmonize different payment systems horizontally and vertically throughout the service delivery systems. There is no endpoint to provider payment: it’s always evolving and moving forward
- Put in place simple, flexible monitoring systems that make use of existing data. Participants noted that monitoring systems need to be both flexible and prioritized. It’s important to select a few, simple indicators from the onset; ensure collected data is used and is not more information than what is needed; and clarify roles and responsibilities within the monitoring team.
In addition, monitoring should be framed and communicated as a way to improve health outcomes (resources allocations, capacity improvement) rather than as a control mechanism. Data produced should also be fed back to providers to ensure the overall quality of health services.
To combat the challenge of data fragmentation, participants suggested establishing joint committees responsible for data oversight – this would prevent duplication while ensuring staff are appropriately trained. Lastly, while information technology plays a critical role in the data collection and analysis process, participants agreed that effective monitoring systems should not omit the human touch – it’s critical to humanize the analysis and results.
Taking the Collaborative Forward
This four-day learning exchange marks the beginning of a new JLN journey for countries to share experiences, synthesize lessons, and build new knowledge to support their efforts to improve financing and payment for PHC to achieve better integrated and high performing health systems on the road to UHC.
Moving forward, countries will engage in the collaborative through varying modalities, including facilitated sub-group exchanges that pair countries with similar implementation priorities; application of previous JLN tools and manuals – such as the data analytics toolkit and the costing manual – and sharing experience with guidance from the technical facilitators; and the development of joint case studies or other learning modules on best practices.
Resources from the Provider Payment Mechanisms Initiative
The Provider Payment Mechanisms initiative launched in 2011 and has facilitated three collaboratives and one learning exchange to support countries in leveraging provider payment to achieve UHC.