Public purchasers contracting external primary care providers in Central America for better responsiveness, efficiency of health care and public governance: Issues and challenges

The role of private healthcare sector actors in health service delivery and financing policy processes in low-and middle-income countries: a scoping review

The expansion of the private healthcare sector in some low-income and middle-income countries (LMICs) has raised key questions and debates regarding the governance of this sector, and the role of actors representing the sector in policy processes. Research on the role played by this sector, understood here as private hospitals, pharmacies and insurance companies, remains underdeveloped in the literature. In this paper, we present the results of a scoping review focused on synthesising scholarship on the role of private healthcare sector actors in health policy processes pertaining to health service delivery and financing in LMICs. We explore the role of organisations or groups-for example, individual companies, corporations or interest groups-representing healthcare sector actors, and use a conceptual framework of institutions, ideas, interests and networks to guide our analysis. The screening process resulted in 15 papers identified for data extraction. We found that the literature in this domain is highly interdisciplinary but nascent, with largely descriptive work and undertheorisation of policy process dynamics. Many studies described institutional mechanisms enabling private sector participation in decision-making in generic terms. Some studies reported competing institutional frameworks for particular policy areas (eg, commerce compared with health in the context of medical tourism). Private healthcare actors showed considerable heterogeneity in their organisation. Papers also referred to a range of strategies used by these actors. Finally, policy outcomes described in the cases were highly context specific and dependent on the interaction between institutions, interests, ideas and networks. Overall, our analysis suggests that the role of private healthcare actors in health policy processes in LMICs, particularly emerging industries such as hospitals, holds key insights that will be crucial to understanding and managing their role in expanding health service access.

Management in primary health care: implications on managers workloads

OBJECTIVE

To identify which aspects of primary health care management, evidenced in current literature, can influence manager workloads.

METHODOLOGY

Integrative literature review with data collection conducted in April 2016, in five databases, with articles published in English, Spanish and Portuguese between 2006 and 2016.

RESULTS

The results of the 78 studies were organized into two macro categories: increased workloads, especially due to the challenge of managing a new care model and deficits in working conditions; and workloads reduction related to the training of the teams and managers, the autonomy and the support for the managers.

CONCLUSION

In addition to identifying factors that increase and decrease the workloads of managers, this study highlights the promising line of research, given the importance of management for the health sector and effectiveness of Primary Health Care.

PRIMARY HEALTHCARE MANAGEMENT: WHAT IS DISCUSSED IN THE LITERATURE

ABSTRACT Objective: to identify what is discussed in studies published in Brazilian and international literature in the last ten years on Primary Health Care management. Method: an integrative review with a search carried out from 2006 to 2016, in the SciELO®, LILACS®, Scopus®, PubMed® and CINAHL® databases in the Portuguese, English and Spanish languages. The review followed the steps: formulation of the research question, definition of the inclusion and exclusion criteria, identification and selection of the studies, and summary of the subjects found in the studies. Resources from The Atlas.ti® software was used for data organization and analysis. Results: the corpus include 90 studies which predominantly originated from LILACS® and were performed in Brazil. The themes covered in the publications were: health policy and management in Primary Health Care, material resources management, human resources management, financial management, quality management, planning, characterization of managers, management role/ activities, challenges/difficulties in management, potentialities/facilities in management. There was a prevalence of studies that dealt with Primary Health Care management in the context of reflections on health policies and those dealing with the challenges/difficulties faced in Primary Health Care management. These findings demonstrate that the Primary Health Care model is complex and challenging, both for policymakers and for those managing it. Conclusion: the number of studies on Primary Health Care management is significant in the current literature and the predominance of health policy and difficulties in performing management issues reinforce the recognition of the centrality of the management for effective Primary Health Care.

Collaborative purchasing of complex technologies in healthcare

Purpose

– The purpose of this paper is to investigate how buyers and the vendors pursue alignment in collaborative purchasing (CP) of complex medical technologies.

Design/methodology/approach

– Through a literature review in CP, the paper identify factors for shareholder alignment (i.e. aligning the needs of the buyers within the purchasing group) and customer alignment (i.e. aligning buyers’ needs with the vendors offering strategies) and investigate how they manifest in the case of CP of complex technology in the Danish National Healthcare System.

Findings

– Shareholder alignment requires appropriate management of the relationships, expertise and guidance in simplifying procedures and effective management of the purchasing group. Customer alignment is facilitated by buyers’ understating of the vendor’s design options, which are moderated by the vendor’s design strategies.

Research limitations/implications

– The findings and generalizations from a single case study are limited to the complexity of the purchased technology and the specific cultural context. However the paper represents the first explorative study that poses the attention on the relevance of shareholder and customer alignment in CP.

Practical implications

– The study can offer hospitals, vendors, governmental and regional institutions a better understanding about the alignment mechanisms for successful implementation of CP and how to avoid pitfalls.

Originality/value

– Literature on CP is scarce as there are virtually no contributions that debate the key elements and tradeoffs that need to be considered for strategic alignment. The study addresses this gap.

NHS commissioning practice and health system governance: a mixed-methods realistic evaluation

Background

By 2010 English health policy-makers had concluded that the main NHS commissioners [primary care trusts (PCTs)] did not sufficiently control provider costs and performance. After the 2010 general election, they decided to replace PCTs with general practitioner (GP)-controlled Clinical Commissioning Groups (CCGs). Health-care commissioners have six main media of power for exercising control over providers, which can be used in different combinations (‘modes of commissioning’).

Objectives

To: elicit the programme theory of NHS commissioning policy and empirically test its assumptions; explain what shaped NHS commissioning structures; examine how far current commissioning practice allowed commissioners to exercise governance over providers; examine how commissioning practices differ in different types of commissioning organisation and for specific care groups; and explain what factors influenced commissioning practice and the relationships between commissioners and providers.

Design

Mixed-methods realistic evaluation, comprising: Leximancer and cognitive frame analyses of policy statements to elicit the programme theory of NHS commissioning policy; exploratory cross-sectional analysis of publicly available managerial data about PCTs; systematic comparison of case studies of commissioning in four English sites – including commissioning for older people at risk of unplanned hospital admission; mental health; public health; and planned orthopaedic surgery – and of English NHS commissioning practice with that of a German sick-fund and an Italian region (Lombardy); action learning sets, to validate the findings and draw out practical implications; and two framework analyses synthesising the findings and testing the programme theory empirically.

Results

In the four English case study sites, CCGs were formed by recycling former commissioning structures, relying on and maintaining the existing GP commissioning leaderships. The stability of distributed commissioning depended on the convergence of commissioners’ interests. Joint NHS and local government commissioning was more co-ordinated at strategic than operational level. NHS providers’ responsiveness to commissioners reflected how far their interests converged, but also providers’ own internal ability to implement agreements. Commissioning for mental health services and to prevent recurrent unplanned hospital readmissions relied more on local ‘micro-commissioning’ (collaborative care pathway design) than on competition. Service commissioning was irrelevant to intersectoral health promotion, but not clinical prevention work. On balance, the possibility of competition did not affect service outcomes in the ways that English NHS commissioning policies assumed. ‘Commodified’ planned orthopaedic surgery most lent itself to provider competition. In all three countries, tariff payments increased provider activity and commissioners’ costs. To contain costs, commissioners bundled tariff payments into blocks, agreed prospective case loads with providers and paid below-tariff rates for additional cases. Managerial performance, negotiated order and discursive control were the predominant media of power used by English, German and Italian commissioners.

Conclusions

Commissioning practice worked in certain respects differently from what NHS commissioning policy assumed. It was often laborious and uncertain. In the four English case study sites financial and ‘real-side’ contract negotiations were partly decoupled, clinician involvement being least on the financial side. Tariff systems weakened commissioners’ capacity to choose providers and control costs. Commissioners adapted the systems to solve this problem. Our findings suggest a need for further research into whether or not differently owned providers (corporate, third sector, public, professional partnership, etc.) respond differently to health-care commissioners and, if so, what specific implications for commissioning practice follow. They also suggest that further work is needed to assess how commissioning practices impact on health system integration when care pathways have to be constructed across multiple providers that must tender competitively for work, perhaps against each other.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Assessing the technical efficiency of health posts in rural Guatemala: a data envelopment analysis

INTRODUCTION

Strengthening health service delivery to the rural poor is an important means of redressing inequities. Meso-level managers can help enhance efficiency in the utilization of existing resources through the application of practical tools to analyze routinely collected data reflecting inputs and outputs. This study aimed to assess the efficiency and change in productivity of health posts over two years in a rural department of Guatemala.

METHODS

Data envelopment analysis was used to measure health posts' technical efficiency and productivity change for 2008 and 2009. Input/output data were collected from the regional health office of Alta Verapaz for 34 health posts from the 19 districts comprising the health region.

RESULTS

Technical efficiency varied widely across health posts, with mean scores of 0.78 (SD=0.24) and 0.75 (SD=0.21) in 2008 and 2009, respectively. Overall, productivity increased by 4%, though 47% of health posts experienced a decline in productivity. Results were combined on a bivariate plot to identify health posts at the high and low extremes of efficiency, which should be followed up to determine how and why their production processes are operating differently.

CONCLUSIONS

Assessing efficiency using the data that are available at the meso-level can serve as a first step in strengthening performance. Further work is required to support managers in the routine application of efficiency analysis and putting the results to use in guiding efforts to improve service delivery and increase utilization.