Background: Purchasing refers to the process by which pooled funds are paid to providers in order to deliver a set of health care interventions. Very little is known about purchasing arrangements in low-and middle-income countries... more
Background: Purchasing refers to the process by which pooled funds are paid to providers in order to deliver a set of health care interventions. Very little is known about purchasing arrangements in low-and middle-income countries (LMICs), and certainly not in Kenya. This study aimed to critically analyse purchasing arrangements in Kenya, using the National Hospital Insurance Fund (NHIF) as a case study. Methods: We applied a principal-agent relationship framework, which identifies three pairs of principal-agent relationships (government-purchaser, purchaser-provider, and citizen-purchaser) and specific actions required within them to achieve strategic purchasing. A qualitative case study approach was applied. Data were collected through document reviews (statutes, policy and regulatory documents) and in-depth interviews (n = 62) with key informants including NHIF officials, Ministry of Health (MoH) officials, insurance industry actors, and health service providers. Documents were summarised using standardised forms. Interviews were recorded, transcribed verbatim, and analysed using a thematic framework approach. Results: The regulatory and policy framework for strategic purchasing in Kenya was weak and there was no clear accountability mechanism between the NHIF and the MoH. Accountability mechanisms within the NHIF have developed over time, but these emphasized financial performance over other aspects of purchasing. The processes for contracting, monitoring, and paying providers do not promote equity, quality, and efficiency. This was partly due to geographical distribution of providers, but also due to limited capacity within the NHIF. There are some mechanisms for assessing needs, preferences, and values to inform design of the benefit package, and while channels to engage beneficiaries exist, they do not always function appropriately and awareness of these channels to the beneficiaries is limited. Conclusion: Addressing the gaps in the NHIF's purchasing performance requires a number of approaches. Critically, there is a need for the government through the MoH to embrace its stewardship role in health, while recognizing the multiplicity of actors given Kenya's devolved context. Relatively recent decentralisation reforms present an opportunity that should be grasped to rewrite the contract between the government, the NHIF and Kenyans in the pursuit of universal health coverage (UHC). Implications for policy makers • Strategic purchasing requires a policy and regulatory framework that supports, among other things, person-centred evidence-based benefit package design. • Well intentioned policy and actions can inadvertently exacerbate health inequalities, inefficiency and poor quality. • Strategic purchasing requires capacity in purchasing organizations in contracting, provider payment mechanisms design and implementation, and monitoring. Implications for the public Improving the way in which funds for health are used for the purpose of obtaining health services is important in making sure every person can access health services without suffering financial hardship. Using Kenya's National Hospital Insurance Fund (NHIF) as an example, we highlight gaps in policy and practice in how funds for health are used. We also provide lessons for health stakeholders in Kenya and similar settings. Implementing these recommendations may improve policy and practice and ensure access to needed health services of good quality by all citizens without imposing unnecessary financial burden. Abstract In a recent article, Gorik Ooms has drawn attention to the normative underpinnings of the politics of global health. We claim that Ooms is indirectly submitting to a liberal conception of politics by framing the politics of global health as a question of individual morality. Drawing on the theoretical works of Chantal Mouffe, we introduce a conflictual concept of the political as an alternative to Ooms' conception. Using controversies surrounding medical treatment of AIDS patients in developing countries as a case we underline the opportunity for political changes, through political articulation of an issue, and collective mobilization based on such an articulation. Citation: Askheim C, Heggen K, Engebretsen E. Politics and power in global health: the constituting role of conflicts: Comment on " Navigating between stealth advocacy and unconscious dogmatism: the challenge of researching the norms, politics and power of global health.
