Introduction to the Special Issue on Making Progress on Strategic Health Purchasing in Africa

This special issue of Health Systems and Reform, sponsored by the Strategic Purchasing Africa Resource Center (SPARC), provides an in-depth look at the current state of strategic health purchasing in Africa. This series comes at a critical moment when African health systems are rebuilding following the devastation of the COVID-19 pandemic and amid multiple global economic shocks and deepening global inequality that the pandemic has further exposed and exacerbated. Insights into how African countries can make more effective use of limited health funding with their own solutions and expertise could not be more timely. The 17 research papers and commentaries in this issue reflect the work of more than 47 authors, 45 of whom are African. They tell a story of persistent progress toward more context-appropriate strategic purchasing arrangements, often despite hurdles created by donor-driven health financing solutions that have proliferated in Africa over the past several decades. Nonetheless, the progress has often been limited to aspects of health purchasing in health financing schemes that have limited impact on overall health system outcomes. The papers in this issue offer evidence, lessons, and insights for unlocking the potential of strategic purchasing to advance universal health coverage (UHC) in Africa, and they can be taken as a call to action for the global community to commit to consolidating fragmented funding streams, strengthening domestic health financing systems, and investing in the institutions, policies, and processes that will allow strategic purchasing to achieve significant impact in Africa.


Introduction
This special issue of Health Systems and Reform, sponsored by the Strategic Purchasing Africa Resource Center (SPARC), provides an in-depth look at the current state of strategic health purchasing in Africa. This series comes at a critical moment when African health systems are rebuilding following the devastation of the COVID-19 pandemic and amid multiple global economic shocks and deepening global inequality that the pandemic has further exposed and exacerbated. Insights into how African countries can make more effective use of limited health funding with their own solutions and expertise could not be more timely.
The 17 research papers and commentaries in this issue reflect the work of more than 47 authors, 45 of whom are African. They tell a story of persistent progress toward more context-appropriate strategic purchasing arrangements, often despite hurdles created by donor-driven health financing solutions that have proliferated in Africa over the past several decades. Nonetheless, the progress has often been limited to aspects of health purchasing in health financing schemes that have limited impact on overall health system outcomes.
The papers in this issue offer evidence, lessons, and insights for unlocking the potential of strategic purchasing to advance universal health coverage (UHC) in Africa, and they can be taken as a call to action for the global community to commit to consolidating fragmented funding streams, strengthening domestic health financing systems, and investing in the institutions, policies, and processes that will allow strategic purchasing to achieve significant impact in Africa.
African ministers of health and finance took on this challenge at an October 2020 joint meeting of the African Union Commission, in which governments renewed commitments to both increase domestic investment in health and improve the efficiency and effectiveness of health spending. 2 However, greater health spending does not automatically translate into better access to higher-quality services, reduced financial burden on vulnerable households, and improved health outcomes. Governments must deliberately direct health funds to priority populations, interventions, and services and actively create incentives, so funding is used more equitably and efficiently. Collectively, this set of actions is known as strategic health purchasing or simply as strategic purchasing.
Strategic purchasing involves using information to determine which health services to cover, selecting providers to deliver those services, and defining how and how much pay those providers to align health resources to population health needs. There is general acceptance in the global health community that strategic purchasing is a necessary policy direction to continue to make progress toward UHC within funding constraints. 3 Strategic purchasing is mentioned explicitly in national policy documents and plans in a growing number of African countries. 3 In practice, however, most countries in Africa continue to purchase health services without making effective use of the full range of strategic levers available-including a well-defined benefit or essential services package that targets the country's health priorities, contracts with public and private providers that specify and enforce quality standards, provider payment methods that create incentives that align with health system objectives, and performance monitoring with accountability measures. 3 The global development community has provided significant technical and financial resources to strengthen health financing systems in Africa over the past three decades, but this assistance has had little widespread impact on improving strategic purchasing capacity and results. 4,5 They are often designed to bypass the perceived weaknesses of country health financing systems and establish new schemes-such as performance-based financing (PBF) schemes or community-based health insurance-rather than to strengthen existing systems. Different donors can push different, sometimes conflicting, solutions in the same country. 6 The result in some cases has been the fragmentation of health financing arrangements and further politicization of strategic purchasing policy agendas in African countries. 7 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 efforts to make progress can be fraught with technical and political challenges. 8 Benefits specification, contracting, provider payment, and performance monitoring require a high degree of institutional capacity and technical knowhow, but there is no clear professional development program or set of training courses that can build this capacity quickly. Strategic purchasing decisions also require access to routine information on service need, utilization and provider capacity. New information systems are often needed to process bills, pay providers, and monitor performance. Health information systems in many African countries are weak and fragmented, and they continue to be shaped by donor strategies rather than national strategies. 9 Technical and institutional challenges are not the only obstacles to the effective implementation of strategic purchasing approaches, however. Decisions about what services to buy, from whom, and how are difficult to make and require tradeoffs at every turn. Weighing these tradeoffs requires not only evidence and technical knowledge but, even more so, an understanding of societal norms, ethics, and values and how power is distributed in the country. [10][11][12] Many of the decisions also require mediation, policy dialogue, and consensus building. 13 For instance, defining a benefit package may involve giving some people access to certain services while not covering other services that are important to other population groups. The final decision can be stalled when competing views on societal needs and preferences, social justice, and equity are difficult to reconcile.

The Strategic Purchasing Africa Resource Center
SPARC was established in 2017 with funding from the Bill & Melinda Gates Foundation to serve as a "go-to" source of Africa-based expertise in strategic purchasing that provides on-demand support and practical evidence to overcome technical, institutional, and political obstacles to implementing effective strategic purchasing approaches. SPARC is hosted by Amref Health Africa with technical support from Results for Development and the engagement of a growing network of Africabased institutions. SPARC's key objective is to strengthen strategic purchasing knowledge, expertise, and institutional capacity in Africa to advance UHC.
SPARC works through partnerships with government agencies, academic institutions, and nongovernmental organizations that implement strategic purchasing approaches across the continent, with the goal of promoting the visibility of and dialogue around strategic purchasing and the sharing of learning and experiences. SPARC draws on and cultivates a cadre of regional experts and matches their expertise to country needs and demand by brokering tailored packages of strategic purchasing support. SPARC connects these experts for peer learning while also offering coaching, mentoring, and access to global resources to broaden and strengthen existing expertise.

Overview of the Special Issue
This special issue of Health Systems and Reform shares lessons that grew out of a collaborative-learning agenda and strategic purchasing progress tracking framework co-created by SPARC and its partners between 2019 and 2021. The framework and subsequent research and learning agenda have been targeted to address the most pressing policy issues and debates related to strategic purchasing and advancing UHC in African countries.
The articles advance knowledge about how health purchasing systems are organized in Africa and the factors that facilitate or inhibit the use of strategic purchasing to advance UHC in Africa. They focus largely on the technical policy dimensions of strategic purchasing, but issues of political economy, values, and ethical tradeoffs are embodied in the health systems described and the results they produce. 12 The technical evidence presented in the papers on how to make progress on strategic purchasing for UHC objectives in Africa can help inform the more challenging dialogue about political priorities, ethics, and values and help clarify the inherent tradeoffs.

Framing the Conversation on Strategic Health Purchasing
The special issue opens with a policy paper by Agnes Gatome-Munyua and colleagues that argues for more concerted efforts by African governments, and the partners that support them, to focus on and invest in improving strategic purchasing as part of advancing their UHC agendas. 14 The authors argue that strategic purchasing is particularly important for countries in sub-Saharan Africa because their public funding for health has often not kept pace with UHC commitments, and it highlights the wide variation in their progress toward UHC targets and health outcomes, which does not always correlate with per capita government health spending. The paper discusses the promise of strategic purchasing and the challenges of realizing this promise in sub-Saharan Africa, and it provides options for practical steps countries can take to incrementally improve strategic purchasing functions and policies.
A policy paper by Cheryl Cashin and Agnes Gatome-Munyua describes the strategic purchasing framework co-created by SPARC and its partners, 15 which synthesizes and builds on existing frameworks to provide a systemwide view of purchasing across different health financing schemes in a country through the lens of purchasing functions-benefits specification, contracting, provider payment, and performance monitoring. 16 The framework and its application are built on a collaborative learning approach that facilitates crosscountry exchange of ideas and knowledge on both the technical and political drivers of progress on strategic purchasing in Africa. A commentary by Agnes Gatome-Munyua, Charlemagne Tapsoba, and Cheryl Cashin shares lessons from SPARC's collaborative learning approach to harness tacit and explicit knowledge on improving strategic purchasing in Africa. 17 The authors identify factors that are crucial for a successful collaborative learning experience, including establishing trust and a culture of mutual respect and accountability between SPARC and the technical partners. 12

Applying the Strategic Health Purchasing Progress Tracking Framework
The article on applying the Strategic Health Purchasing Progress Tracking Framework in nine African countries distills lessons on the drivers of progress on strategic purchasing on the continent and what hinders progress. 18 Five research papers provide countryspecific insights on purchasing arrangements in the major health financing schemes in Burkina Faso, Ghana, Nigeria, Rwanda, and Uganda. [19][20][21][22][23]

Key Issues Related to Strategic Health Purchasing in Africa
The application of the strategic purchasing framework in African countries yielded relevant insights about how to make better use of government budgets for strategic purchasing and the role of PBF schemes in broader efforts to improve purchasing arrangements. 24 In acommentary, 25 Aloysius Ssennyonjo et al. discuss opportunities to improve purchasing through government budgets, which continue to be the largest source of pooled funds for health in all African countries. This topic is timely because several African countries are moving toward establishing new contributory national health insurance schemes, largely at the urging of donors, while evidence continues to mount that national health insurance systems rarely fulfill their promise of accelerating UHC in sub-Saharan Africa. [26][27][28] The vast majority of health sector funding will continue to flow through the general budget, so every opportunity should be taken to make budget funding work better to advance UHC. 29 SPARC has documented how investments in strengthening purchasing systems in sub-Saharan Africa have often come through donor-supported PBF programs, which have led to only marginal improvements in service delivery outcomes and are often misaligned with the country's health financing system and priorities. 30,31 But PBF is sometimes regarded as a first step toward strategic purchasing in many countries that can catalyze more systemic strategic purchasing approaches. 32 Dennis Waithaka and colleagues summarize the state of evidence on PBF as a stepping stone to more system-wide strategic purchasing and provide recommendations on how PBF investments can be used to improve purchasing arrangements overall in the country. 24

The Evidence on Strategic Health Purchasing and Its Impact on Health System Outcomes
Some researchers argue that although the promise of strategic purchasing is intuitively powerful, large-scale implementation of the full range of approaches remains elusive, even in high-income countries with wellfunctioning publicly funded health systems, and evidence of resulting health system benefits is limited. 33,34 The research and learning facilitated by SPARC paints a more nuanced picture. If health purchasing is viewed as a set of functions carried out through policy instruments (such as benefit packages or provider payment systems) that can be applied either more or less strategically toward UHC objectives, progress can be assessed more incrementally.
The final papers in this special issue speak to the state of evidence linking purchasing arrangements to improvements in service delivery and UHC. Evelyn Kabia, Jacob Kazungu, and Edwine Barasa examine whether purchasing improvements in Kenya have resulted in more equitable access to quality health services and improved financial protection. 35 Kenya has a rich history of implementing health purchasing reforms over the past 20 years including the president's commitment to achieve UHC by 2022 under the Big 4 Agenda. 36 Although key reforms have often resulted in increased service access, fragmentation, weak institutional capacity of purchasers, inadequate design of provider payment reforms, and lack of provider autonomy and accountability have resulted in poor implementation and mixed results. [37][38][39] Fred Matovu, Agnes Gatome-Munyua, and Richard Sebaggala provide a more global view of the evidence on strategic purchasing and health system outcomes. 40 Where improvements in purchasing functions have led to better service delivery and health system outcomes, those results have been enabled by a reduction in fragmentation of health financing and institutional strengthening of purchasers so they can influence the levers of resource allocation and provider incentives and improve accountability, even when resources are highly constrained. [36][37][38][39][40][41][42] Finally, in a commentary on whether strategic health purchasing can reduce inefficiency and corruption in the health sector, with a focus on Nigeria, Obinna Onwujekwe and Prince Agwu address systemic issues that can limit progress on strategic purchasing, including health system fragmentation, weak stewardship, inefficiencies, conflicting policies, lack of provider autonomy, and misaligned public financial management rules. 3,[43][44][45][46]

Conclusion
Given persistent resource constraints and limited fiscal space, the value-and indeed the imperative-of strategic purchasing to advance UHC goals is now widely embraced by health-sector leaders and other stakeholders on the continent and is firmly positioned within the UHC discourse at the regional and country levels. This is an opportunity to be harnessed.
SPARC's goal is to generate and share practical evidence by and for African experts that informs policy dialogue in African countries to better leverage strategic purchasing to advance UHC. The papers in this special issue advance that goal significantly. Together, the research papers and commentaries provide descriptive information, evidence, and lessons on what leads to progress in implementing strategic purchasing approaches and what stands in the way.
Africa has seen many pockets of progress in strategic purchasing, but they remain limited to specific functions within certain health financing schemes. Many constraints remain in realizing the full potential of strategic purchasing in African countries to advance toward UHC, and most of them are beyond the purview of purchasing and must be addressed with commitment from the highest levels of government. They include low levels of public funding, high out-of-pocket spending, and significant fragmentation in health financing systems. The fragmentation includes not only multiple government-funded schemes but also vertical programs and donor-funded schemes that often bypass the health financing system and continue to drive duplication, diversion, and waste in the health system. These issues are not unique to Africa, and other countries, may also benefit from the issues raised, and lessons learnt, in this series.
Taking a systemwide functional approach to understanding and strengthening health financing arrangements and purchasing functions can be the first step in moving the conversation away from individual schemes and legacy systems to the practical steps needed to improve health system resilience, sustainability, and performance. That means the strategic purchasing agenda in Africa, as well as other countries, must engage the entire global community-country leaders, health care providers, civil society, donors, and implementing partners-in a shared commitment to consolidating funding streams and supporting the institutions, policies, and processes that will allow strategic purchasing to succeed in advancing progress toward UHC.