FRAMING THE CONVERSATION ON STRATEGIC HEALTH PURCHASING Collaborative Learning to Advance Knowledge and Implementation of Strategic Health Purchasing in Sub-Saharan Africa

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Introduction
Strategic purchasing means deliberately directing health funds to priority populations, interventions, and services. It involves using information to make decisions about what health services should have priority for public funding, selecting the providers that will provide these health services, and defining how and how much to pay those providers to deliver the services. Strategic health purchasing entails a set of policies and actions that government purchasing agencies can use to make resource allocation more efficient and effective and to create a conducive environment to advance progress toward universal health coverage (UHC) goals. [1][2][3] Governments have to navigate technical, institutional, and political challenges in order to implement strategic purchasing because purchasing decisions affect how funds flow through the health system and to which providers.
Technical solutions alone are unlikely to fundamentally change how government funding is used to purchase health services and unlikely to yield large-scale sustainable improvements in health spending. Policy makers and practitioners who face similar challenges are an important source of practical knowledge and experience for those seeking to navigate these complex issues. Experience and learning can be shared and adapted by peer country stakeholders to advance strategic purchasing policies in their countries. 4 When such knowledge exchange is structured and facilitated, participants can jointly problem-solve and generate new actionable lessons and solutions that can be adapted for different country contexts. This approach to joint problem solving is known as collaborative learning.
The Strategic Purchasing Africa Resource Center (SPARC), a resource hub hosted by AMREF Health Africa with technical support from Results for Development (R4D), aims to strengthen strategic purchasing capacity in sub-Saharan Africa to make better use of health resources. SPARC facilitates a collaborative learning agenda with 11 African technical partners from 10 countries to generate evidence and practical learning on the implementation of strategic purchasing approaches on the African continent. The technical partners include academic institutions, research institutions, private consulting firms, and think tanks from both Anglophone and Francophone countries, as shown in Figure 1.
Through this collaborative learning process, the partners co-created a common framework to describe and assess country-level progress on strategic purchasing: the Strategic Health Purchasing Progress Tracking Framework ( Figure 2). This group applied the framework in their countries and worked together to draw lessons and serve as knowledge translators to inform the policy processes in their countries. 5,6 The technical partner experts and the policy makers they support have advanced their collective understanding of how to make progress on strategic purchasing within each country's health financing systems, as well as how to use domestic resources and donor investments more effectively to advance UHC goals.
This commentary describes the collaborative learning approach applied by SPARC in working with the technical partners on developing and applying the Strategic Health Purchasing Progress Tracking Framework.

The Value Proposition of Collaborative Learning
Collaborative learning involves groups of learners working together to solve a problem, complete a task, or create a knowledge product. 7 An umbrella term for educational approaches that involve joint intellectual efforts by learners and facilitators, 7-11 collaborative learning relies on interaction and collaboration, mutual respect among peers for their abilities and contributions, and consensus building and cooperation. 7 Collaborative learning has been shown to aid in identifying and solving problems, learning abstract concepts, and transferring and assimilating knowledge; it fosters interdisciplinary thinking and leads to deeper understanding of others; and it engages the whole learner and encourages active participation as learners develop skills. 7,8 A number of health sector-specific networks are applying collaborative learning approaches to analyze, review, and develop solutions for common health sector challenges. 4 Examples include the African Collaborative for Health Financing Solutions, Joint Learning Network for Universal Health Coverage (JLN), Learning Network for Countries in Transition (LNCT), Public Health Learning Network, and Primary Health Care Performance Initiative (PHCPI). Although these networks focus on different thematic areas, they take a common approach to developing capacity among individuals, institutions, and systems. The premise behind these collaborative learning networks is that individuals build tacit knowledge over time while working on the day-to-day challenges of creating health system change, and that tacit knowledge can be converted into explicit knowledge to be shared more widely as a global public good. While explicit knowledge is usually codified and documented so it can be easily accessed, tacit knowledge is generally not well codified and is context specific. [11][12][13] Tacit knowledge can relate to processes, abstract concepts, or practices that are deeply embedded in individuals' behaviors. 10,14,15 Through the process of collaborative learning, facilitators can help draw out tacit knowledge and integrate it with documented knowledge in a thematic area-for example, to develop new frameworks for understanding how health system change happens in practice and to develop tools for adapting and applying the new knowledge. 11   a safe space for sharing experiential knowledge, encourage and draw out contributions from all participating individuals, ask the right questions to draw out details and enrich contributions, actively listen to identify common themes, and synthesize and validate new knowledge arising from the group. 16

Potential Challenges of Collaborative Learning
Topics for collaborative learning should be of interest to participants and have immediate relevance to their day-to-day professional roles, and participants should have practical experience to share that is directly related to the topic area. 17 Thus, collaborative learning does not work well when learners do not have the requisite foundational knowledge or are not ready or willing to actively participate in learning, in which case instructional learning would be more appropriate. 15 Collaborative learning also has drawbacks and has been criticized for being labor and resource intensive; its reach in terms of the number of people who directly benefit may also be limited. Collaborative learning relies on experienced and skilled facilitators and requires intense preparation by the facilitation team before the learning sessions. Collaborative learning networks often depend on donor funding, which raises sustainability concerns. For these reasons, collaborative learning is often complementary to more traditional learning and knowledge dissemination approaches. Noting these drawbacks, SPARC sought to develop a structure for collaborative learning that is mostly virtual, to reduce the need for travel, to engage a wider group of participants with a shared interest, and to contain costs, aiming for a more sustainable process that can be continued after the initial grant funding.
This paper does not debate the success of collaborative learning, or if it works or not, but rather shares the experiences of SPARC in using a collaborative approach of applying the Strategic Health Purchasing Progress Tracking Framework.

Collaborative Learning and the SPARC Consortium
SPARC convened the consortium of 11 technical partners in early 2019 to serve as go-to sources of evidence generation and technical support on strategic health purchasing for their government stakeholders. The technical partners were selected through a competitive process based on criteria identified by SPARC, including the scope and capacity of the institution and its interest in undertaking evidence generation and technical assistance activities. Regional and linguistic diversity were key factors in the selection of technical partners, to ensure a fair representation of countries in eastern, western, central, and southern sub-Saharan Africa and in Anglophone and Francophone Africa. This ensured a diverse group of partners with the credibility and capacity to undertake evidence generation activities and the gravitas and convening power to bring together stakeholders in their own countries to translate evidence to advance improvements in health purchasing.

Establish Common Goals
From the outset, SPARC proposed a general set of common goals for the collaborative learning partnership and also sought to understand the interests and objectives of each partner. This helped align objectives and ensure a mutually beneficial relationship built on trust and transparency, with a team from SPARC in a facilitating role. Two key objectives articulated by the technical partners were 1) to learn from their peers in other countries who were playing a similar role in their own health system and 2) to develop a knowledge base of practical experience, or "how-to" guidance, on implementing strategic purchasing policies and approaches. Learning activities undertaken through the partnership were designed with the partners' interests, capacity, and availability in mind. Partners were invited to select the activities of greatest interest to them and to opt out of activities that did not align with their interests and goals.

Co-create a Technical Framework
A first step in defining the learning agenda was to agree on a technical framework to describe strategic health purchasing and define progress. This was deemed necessary for the group to speak a common language around strategic purchasing and more easily share experiences and build new knowledge. 5 With facilitation from the SPARC team, the partners co-created a strategic purchasing progress tracking framework based on existing frameworks but organized in a practical way around purchasing functions. 18 The partners suggested that the framework needed to capture sufficient detail to facilitate learning and support policy dialogue within countries. 2,19,20 As the facilitator, SPARC began by compiling existing frameworks and synthesizing the common elements into a single framework for review, debate, and validation by the technical partners through virtual meetings. The technical partners each brought their country experience to the co-creation process, ensuring that the framework was adaptable and applicable to a wide range of contexts, especially the highly fragmented health financing systems in many African countries. For example, the framework takes into consideration features of purchasing through both government budget financing and insurance schemes.
Once the partners agreed on the framework, the group developed a Microsoft Excel-based data collection tool to apply the framework in their countries. The tool allows countries to tailor the framework to their specific country context. For example, the contracting function is more explicit in insurance schemes with a purchaser-provider split, which requires certain descriptive information to understand, but the tool can also capture implicit contracting in government budget financing, where the purchaser and provider functions are merged under the Ministry of Health. Finally, the SPARC facilitators worked with the partners to develop and validate a set of benchmarks to assess a country's progress along the continuum from passive to strategic purchasing (based on normative guidance from existing frameworks, assessment guides, and implementation experience) and validated the benchmarks for practical relevance through a series of stakeholder consultations. 21

Collect Information for Learning and Problem-Solving
Applying the framework meant that each technical partner would use the data collection tool to capture information on current purchasing arrangements for each major health financing scheme in their country. They collected data from available gray and published literature and stakeholder interviews to build a baseline set of information on their country's purchasing arrangements. They also used the framework to identify where purchasers have used strategic purchasing to improve service delivery, resource allocation, provider incentives, and accountability. The technical partners led the data analysis and met monthly to share experiences on applying the framework and to identify and synthesize emerging themes.
Through the process of applying the framework and collecting information from their country stakeholders, the technical partners were able to raise awareness of strategic purchasing approaches and policy options, identify priority areas for intervention, and contribute to the policy processes in their countries. Collectively, the group contributed to the regional discourse on how to make progress on strategic purchasing in the context of sub-Saharan Africa. For example, one of the main insights that emerged from the application of the framework was that new public insurance systems or purchasing agencies were not a prerequisite for making progress on strategic purchasing, and that there was important practical experience to share and adapt to improve purchasing through government budget financing. 22 This has been critical input for ongoing policy dialogue in the region because an increasing number of African countries are turning to contributory health insurance schemes to advance UHC and establishing new purchasing agencies to implement the schemes. 23,24 The collaborative learning process also generated practical lessons on how to manage political challenges to make progress on strategic purchasing. For example, well-packaged evidence brought in at the right time can galvanize action and create political windows for change. The SPARC partners in Tanzania shared how national health accounts and public expenditure tracking data were used to demonstrate the limited flow of funds to the primary healthcare (PHC) level of the health system. This galvanized action among politicians and facilitated public financial management changes that enabled the flow of funds to PHC providers. 25

Cross-Country Engagement and Learning
The SPARC collaborative learning process created the opportunity for government stakeholders to access learning and expertise from within their own countries and from neighboring countries. For example, a technical partner from Benin was invited to Burkina Faso to facilitate the alignment of country actors on how to assess and improve strategic health purchasing, which helped depoliticize the agenda and align government and donor approaches. This process built on findings from the application of the Strategic Health Purchasing Progress Tracking Framework in Burkina Faso, which identified progress being made through the government's Gratuité scheme, which increases access to maternal and child health services by getting flexible funds to providers. 26,27 An early result was the agreement by the Ministry of Health and the World Bank's Health Services Reinforcement Project to align, and redirect funds, from the independent performancebased financing (PBF) component to Gratuité, which provides access to free health care to women and children under age 5. 28 SPARC and the technical partners are exploring these topics more deeply as part of the ongoing learning agenda. 22

Key Lessons
Five key lessons emerged from the process of developing and applying the Strategic Health Purchasing Progress Tracking Framework through a collaborative learning approach.
(1) Mutual trust, respect, and accountability are crucial for successful collaborative learning. SPARC engaged the technical partners as peers, equally sharing agenda-setting, co-creating the framework and its application, and jointly owning the dissemination and use of new knowledge. Technical partners selected how to engage and which activities to join based on their capacity, availability, and interest. Once partners opted into an activity, mutually agreed deliverables and timelines were defined in contracts between SPARC and the technical partner institution. These contracts were used to hold partners accountable for delivering outputs of a high level of quality within expected timeframes, and to hold SPARC accountable for making the necessary resources and support available to complete the activities. (2) A consistent cadence for collaborative learning activities maintains momentum. Once the deliverables and timelines were set, the group agreed on a monthly cadence for collaborative learning activities to maintain momentum while being manageable within the partners' other commitments. SPARC facilitated monthly learning exchanges in which partners presented their progress, including details of data sources, key informant tools, setup of data collection teams, and key findings from the application of the framework. These monthly learning exchanges were also a chance to troubleshoot any challenges with the framework and data collection tools. The monthly learning exchanges were supplemented with individual one-on-one scheduled sessions with SPARC to review the data and any challenges unique to the country context.
(3) Bringing in policy makers to validate the findings builds important connections within and between countries to adapt and apply new knowledge. Once data collection was completed for the application of the framework, SPARC hosted a validation meeting that brought together the technical partners and policy makers from their countries to share the findings at their country level and draw out lessons across countries. Cross-country learning was facilitated through an innovative visual method that synthesized findings in a poster format that allowed for easy cross-country comparisons and discussions. These discussions strengthened connections among the technical experts and policy makers both within and between countries. The technical partners gained credibility as knowledge translators with the policy makers, and connections between policy makers from different countries facilitated the process of adapting lessons from one country to another and contextualizing them. (4) The collaborative learning approach can be replicated at the country level to prioritize strategic purchasing interventions and advance policy change. The partners have unique spheres of influence within their countries' policy domains and are well positioned as trusted knowledge translators for policy makers and other stakeholders. The credibility of the partners allowed them to effectively bring back evidence and learning generated through the SPARC partnership in their own country to support, and in some cases initiate, policy dialogue on strategic purchasing. The partners applied these same collaborative learning principles to stakeholder engagement in their own countries. In Rwanda, for example, a strategic health purchasing technical working group was formed to interpret the evidence from the application of the Strategic Health Purchasing Progress Framework and prioritize and oversee interventions. Ministry of Health leaders in Burkina Faso invited a technical facilitator from Benin to use the evidence generated from the application of the framework and the cross-country lessons to bridge the gaps in stakeholders' understanding of strategic purchasing concepts and develop a strategic health purchasing roadmap for the country. (5) More sharing leads to a better evidence base.
Experience with strategic purchasing in Africa is not well documented. Information is compartmentalized within institutions, organizations, and regions. One benefit of having a mix of partners from different parts of the continent was to help break down regional and linguistic silos.

Conclusions
SPARC's collaborative learning approach has built on global experience with collaborative learning networks and adapted it to the specific theme of making progress on strategic health purchasing to advance UHC. The process of applying the framework and validating and interpreting the results provided an opportunity to engage policy makers and other stakeholders, raise awareness of strategic purchasing policy options and approaches, and contribute to the policy processes in their countries. This collaborative learning approach is contributing to the practical knowledge base on the "how-to" of strategic purchasing and is highlighting some assumptions about strategic purchasing in Africa that are now being questioned-including assumptions about whether and how new national health insurance systems are contributing to strategic purchasing and other UHC goals, and the potential for making better use of the government budget for strategic purchasing. 22,23 Strategic purchasing entails a complex set of institutional arrangements and policies that aim to change how funds flow in the health system and to whom, so making progress can be fraught with technical and political challenges. Collaborative learning is one way to identify and question long-held assumptions and gain a deeper understanding of how stakeholders can be effectively engaged, how institutional and political issues can be navigated, and how promising approaches can be adapted and scaled up. As an Africa-based resource center, SPARC will continue to play a critical role in fostering and facilitating regional learning and offering a platform and safe space for technical partners and policy makers to grapple with challenging and sensitive issues and continue to build the practical knowledge base for making progress on strategic purchasing to advance UHC goals.
Purchasing Africa Resource Centre (SPARC). SPARC is a resource hub hosted by AMREF Health Africa with technical support from Results for Development. SPARC aims to strengthen strategic purchasing capacity in Sub-Saharan Africa by connecting existing regional expertise and matching it with country demand to make better use of health resources.