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Abstract：
Low-and middle-income countries (LMICs) are implementing health financing reforms toward Universal Health Coverage (UHC). In Tanzania direct health facility financing of health basket funds (DHFF-HBF) scheme was introduced in 2017/18, while the results-based financing (RBF) scheme was introduced in 2016. The DHFF-HBF involves a direct transfer of pooled donor funds (Health Basket Funds, HBF) from the central government to public primary healthcare-PHC (including a few selected non-public PHC with a service agreement) facilities bank accounts, while the RBF involves paying providers based on pre-defined performance indicators or targets in PHC facilities. We consider whether these two reforms align with strategic healthcare purchasing principles by describing and comparing their purchasing arrangements and associated financial autonomy.
We used document review and qualitative methods. Key policy documents and articles related to strategic purchasing and financial autonomy were reviewed. In-depth interviews were conducted with health managers and providers (n = 31) from 25 public facilities, health managers (n = 4) in the Mwanza region (implementing DHFF-HBF and RBF), and national-level stakeholders (n = 2). In this paper, we describe and compare DHFF-HBF and RBF in terms of four functions of strategic purchasing (benefit specification, contracting, payment method, and performance monitoring), but also compare the degree of purchaser-provider split and financial autonomy. Interviews were recorded, transcribed verbatim, and analyzed using a thematic framework approach.
The RBF paid facilities based on 17 health services and 18 groups of quality indicators, whilst the DHFF-HBF payment accounts for performance on two quality indicators, six service indicators, distance from district headquarters, and population catchment size. Both schemes purchased services from PHC facilities (dispensaries, health centers, and district hospitals). RBF uses a fee-for-service payment adjusted by the quality of care score method adjusted by quality of care score, while the DHFF-HBF scheme uses a formula-based capitation payment method with adjustors. Unlike DHFF-HBF which relies on an annual general auditing process, the RBF involved more detailed and intensive performance monitoring including data before verification prior to payment across all facilities on a quarterly basis. RBF scheme had a clear purchaser-provider split arrangement compared to a partial arrangement under the DHFF-HBF scheme. Study participants reported that the RBF scheme provided more autonomy on spending facility funds, while the DHFF-HBF scheme was less flexible due to a budget ceiling on specific spending items.
Both RBF and DHFF-HBF considered most of the strategic healthcare purchasing principles, but further efforts are needed to strengthen the alignment towards UHC. This may include further strengthening the data verification process and spending autonomy for DHFF-HBF, although it is important to contain costs associated with verification and ensuring public financial management around spending autonomy.
We used document review and qualitative methods. Key policy documents and articles related to strategic purchasing and financial autonomy were reviewed. In-depth interviews were conducted with health managers and providers (n = 31) from 25 public facilities, health managers (n = 4) in the Mwanza region (implementing DHFF-HBF and RBF), and national-level stakeholders (n = 2). In this paper, we describe and compare DHFF-HBF and RBF in terms of four functions of strategic purchasing (benefit specification, contracting, payment method, and performance monitoring), but also compare the degree of purchaser-provider split and financial autonomy. Interviews were recorded, transcribed verbatim, and analyzed using a thematic framework approach.
The RBF paid facilities based on 17 health services and 18 groups of quality indicators, whilst the DHFF-HBF payment accounts for performance on two quality indicators, six service indicators, distance from district headquarters, and population catchment size. Both schemes purchased services from PHC facilities (dispensaries, health centers, and district hospitals). RBF uses a fee-for-service payment adjusted by the quality of care score method adjusted by quality of care score, while the DHFF-HBF scheme uses a formula-based capitation payment method with adjustors. Unlike DHFF-HBF which relies on an annual general auditing process, the RBF involved more detailed and intensive performance monitoring including data before verification prior to payment across all facilities on a quarterly basis. RBF scheme had a clear purchaser-provider split arrangement compared to a partial arrangement under the DHFF-HBF scheme. Study participants reported that the RBF scheme provided more autonomy on spending facility funds, while the DHFF-HBF scheme was less flexible due to a budget ceiling on specific spending items.
Both RBF and DHFF-HBF considered most of the strategic healthcare purchasing principles, but further efforts are needed to strengthen the alignment towards UHC. This may include further strengthening the data verification process and spending autonomy for DHFF-HBF, although it is important to contain costs associated with verification and ensuring public financial management around spending autonomy.
摘要：
■低收入和中等收入国家（LMICs）正在实施卫生筹资改革，以实现全民健康覆盖（UHC）。在坦桑尼亚，2017/18年度引入了健康篮子基金的直接卫生设施融资（DHFF-HBF）计划，而基于结果的融资（RBF）计划于2016年引入。DHFF-HBF涉及直接转移集合捐助资金(健康篮子基金，HBF）从中央政府到公共初级医疗保健-PHC（包括一些选定的具有服务协议的非公共PHC）设施银行帐户，而RBF涉及根据PHC设施中预定义的绩效指标或目标向提供商付款。我们通过描述和比较这两项改革的采购安排和相关的财务自主权，来考虑这两项改革是否符合战略性医疗保健采购原则。
■我们使用了文件审查和定性方法。审查了与战略采购和财务自主权有关的关键政策文件和文章。对来自25个公共设施的健康管理者和提供者(n=31)进行了深入访谈，姆万扎地区的卫生管理人员(n=4)(实施DHFF-HBF和RBF)，和国家一级的利益相关者(n=2)。在本文中,我们从战略采购的四个功能(效益规范，承包,付款方式,和性能监控)，而且还比较了买方-提供者分割和财务自主权的程度。采访被记录下来，逐字转录，并使用主题框架方法进行分析。
■基于17项卫生服务和18组质量指标的RBF付费设施，DHFF-HBF付款在两个质量指标上占了表现，六项服务指标，与地区总部的距离，和人口集水区的大小。两项计划均从PHC设施购买服务(药房，健康中心,和地区医院)。RBF采用按护理质量评分法调整的按服务费用支付,按护理质量评分法调整,而DHFF-HBF方案使用基于公式的人头支付方法，并带有理算人。与DHFF-HBF依赖年度一般审计流程不同，RBF涉及更详细和密集的绩效监测，包括在每个季度在所有设施付款之前进行验证之前的数据。与DHFF-HBF计划下的部分安排相比，RBF计划具有明确的买方-提供商分割安排。研究参与者报告说，RBF计划在支出设施资金方面提供了更多自主权，而DHFF-HBF计划由于特定支出项目的预算上限而灵活性较差。
■RBF和DHFF-HBF都考虑了大部分战略医疗保健采购原则，但需要进一步努力加强对UHC的一致性。这可能包括进一步加强DHFF-HBF的数据验证过程和支出自主权，尽管重要的是控制与验证相关的成本，并确保围绕支出自主权的公共财务管理。
■我们使用了文件审查和定性方法。审查了与战略采购和财务自主权有关的关键政策文件和文章。对来自25个公共设施的健康管理者和提供者(n=31)进行了深入访谈，姆万扎地区的卫生管理人员(n=4)(实施DHFF-HBF和RBF)，和国家一级的利益相关者(n=2)。在本文中,我们从战略采购的四个功能(效益规范，承包,付款方式,和性能监控)，而且还比较了买方-提供者分割和财务自主权的程度。采访被记录下来，逐字转录，并使用主题框架方法进行分析。
■基于17项卫生服务和18组质量指标的RBF付费设施，DHFF-HBF付款在两个质量指标上占了表现，六项服务指标，与地区总部的距离，和人口集水区的大小。两项计划均从PHC设施购买服务(药房，健康中心,和地区医院)。RBF采用按护理质量评分法调整的按服务费用支付,按护理质量评分法调整,而DHFF-HBF方案使用基于公式的人头支付方法，并带有理算人。与DHFF-HBF依赖年度一般审计流程不同，RBF涉及更详细和密集的绩效监测，包括在每个季度在所有设施付款之前进行验证之前的数据。与DHFF-HBF计划下的部分安排相比，RBF计划具有明确的买方-提供商分割安排。研究参与者报告说，RBF计划在支出设施资金方面提供了更多自主权，而DHFF-HBF计划由于特定支出项目的预算上限而灵活性较差。
■RBF和DHFF-HBF都考虑了大部分战略医疗保健采购原则，但需要进一步努力加强对UHC的一致性。这可能包括进一步加强DHFF-HBF的数据验证过程和支出自主权，尽管重要的是控制与验证相关的成本，并确保围绕支出自主权的公共财务管理。
