The Landscape of Strategic Health Purchasing for Universal Health Coverage in Burkina Faso: Insights from Five Major Health Financing Schemes

ABSTRACT Strategic health purchasing is a key strategy in Burkina Faso to spur progress toward universal health coverage (UHC). However, a comprehensive analysis of existing health financing arrangements and their purchasing functions has not been undertaken to date. This article provides an in-depth analysis of five key health financing schemes in Burkina Faso: Gratuité (a national free health care program for women and children under age 5), crédits délégués (delegated credits), crédits transférés (transfers to municipalities), community-based health insurance, and occupation-based health insurance. This study involved a document review and complementary key informant interviews using the Strategic Health Purchasing Progress Tracking Framework developed by the Strategic Purchasing Africa Resource Center (SPARC). Data were collected using the framework’s accompanying Microsoft Excel–based tool. We analyzed the data manually to examine and identify the strengths and weaknesses of governance arrangements and purchasing functions and capacities. The study provides insight into areas that are working well from a strategic purchasing perspective and, more importantly, areas that need more attention. Areas for improvement include low financial and managerial autonomy for some schemes, weak accountability measures, lack of explicit quality standards for contracting and for service delivery, budget overruns and late provider payment, provider payment that is not linked to provider performance, fragmented health information systems, and information generated is not linked to purchasing decisions. Improvements in purchasing functions are required to address shortcomings while consolidating achievements. This study will inform next steps for Burkina Faso to improve purchasing and advance progress toward UHC.


Introduction
Consensus is emerging that countries must move from passive to strategic health purchasing in order to make progress toward universal health coverage (UHC). [1][2][3] Passive health purchasing implies that providers receive funds regardless of their performance, 4 while strategic health purchasing takes a proactive approach by using information to determine what types of health services to buy, for whom, from whom, how, and at what payment rates. 2,5 Indeed, strategic purchasing means deliberately directing health funds to priority populations, interventions, and services and actively creating incentives so funding is used more equitably and efficiently and aligns with population health needs. 2,6 Despite the momentum for strategic purchasing, many developing countries lack the resources and capacity to implement it or struggle to identify effective entry points. 7-10 But strategic purchasing is not all-ornothing. Purchasing arrangements are in place in any health system, and a variety of intermediary steps can be taken to make them more strategic. 2 Some studies have analyzed strategic purchasing from the perspective of performance-based financing (PBF), [11][12][13] health insurance, 8,14 or user fee exemption policies. 11 For this study of purchasing arrangements in Burkina Faso, we examined purchasing mechanisms from the perspective of the entire health system, using a practical and functional approach to describe and assess purchasing functions across the main health financing arrangements in the country. We took a systemwide view to identify strengths, weaknesses, and challenges and to identify actions or reforms that could help improve health system performance. The study also illustrates how strategic purchasing, which is sometimes seen as an ambiguous concept, 15 can be approached, described, and analyzed in practice to prioritize actions and make incremental progress.

Burkina Faso's Health Financing Context
Burkina Faso's current health expenditure (CHE) per capita is $42.30 USD (2019). 16 Government spending dominates health expenditure (at 41.8% of CHE), followed by out-of-pocket payments (34.7%), external aid (15.8%), and voluntary health insurance contributions (1.9%). 16 Public resources are pooled by the Treasury and allocated to the Ministry of Health (MOH). At the MOH, budget formulation, execution, and monitoring are carried out by the Directorate of Administration and Finance (DAF), which also plays the role of purchaser for the public financing schemes-the Gratuité program (which provides free health care for women and children under age 5), crédits délégués (delegated credits), and crédits transférés (transfers to municipalities). External resources are channeled using on-budget or off-budget support. Pooling of private resources through voluntary private health insurance schemes-commercial, community-based, or occupation-based-is highly fragmented.
Five health financing schemes are included in this study. They were chosen based on their geographic and/or population coverage and/or the share of total government health spending they manage. The schemes are: • Gratuité (national free health care program for women and children under age 5). Implemented since 2016, this scheme subsidizes medical exams, medical procedures, medicines, medical consumables, hospitalizations, and medical evacuations. This scheme makes a partial split between the purchasing agency ( These are national budget funds that are intended for PHC facilities. The funds are not handed over directly to the facilities, but rather to municipalities to purchase goods and services for the health facilities. • Community-based health insurance (CBHI). These voluntary schemes are run by nonprofit associations that serve as the purchasers. Members contribute regularly, and the pooled funds are used to pay for care in the event of illness. • Occupation-based health insurance (OBHI).
These schemes cover workers in certain public or private companies. The revenue comes from worker contributions or company grants. Membership is voluntary, mandatory, or automatic, depending on the company.

Analytical Framework
This study used the Strategic Health Purchasing Progress Tracking Framework created by the Strategic Purchasing Africa Resource Center (SPARC) to guide data collection and analysis. 19 We compiled descriptive information on 1) purchasing functions (benefits specification, contracting arrangements, provider payment, and performance monitoring) and their execution in the schemes; and 2) external factors and governance arrangements and how they are linked to strategic purchasing. These elements are depicted in Figure 1.

Data Collection
We populated the framework's Microsoft Excel-based data collection tool with data initially collected from June to December 2019 (these data have been continuously updated as necessary). Data were collected primarily through reviews of policy documents, decrees and directives, national health accounts, MOH statistical yearbooks, activity reports and/or websites of units in charge of managing and/or implementing the policies under study, newspapers, and scientific literature. Gaps in the document reviews were supplemented by informal interviews with key informants. All informants provided informed consent. Key informants were selected based on their current work assignments and experience with, or expertise in the schemes under study; they included three policy makers, four CBHI or OBHI representatives, and the mayor of a municipality. The last coauthor (SPY) of this paper is the technical secretary in charge of UHC in Burkina Faso and has

Data Analysis
We applied 11 normative benchmarks to assess the governance arrangements and the purchasing functions and capacities in the five health financing schemes selected for the study. 19 These benchmarks are listed in Table 2.

Mandate and Authority of Purchasers
All five health financing schemes have a designated purchaser with regulatory provisions specifying its role and responsibilities in the form of decrees, orders, directives, and other provisions. For Gratuité, crédits délégués, and crédits transférés, funds are transferred by the Treasury to the MOH's DAF, which has the mandate to transfer funds for those three schemes. 17,18 For the Gratuité scheme, the Technical secretariat in charge of UHC (ST/CSU) has the authority to determine the amounts to be given to or withdrawn from health facilities, approve payment of health facility bills each quarter, reward facilities for good performance, propose sanctions for health facilities where irregularities are found, and ensure national coordination and monitoring for the scheme. It also has the authority to include private health facilities in the scheme, supervise the activities of all health facilities in the scheme, and select payment methods and set payment rates.
For crédits délégués and crédits transférés, the DAF is primarily responsible for preparing health district budgets based on predefined criteria (such as the size of the population covered, the number of health facilities, operating costs, and the poverty index). The DAF transfers funds received from the Treasury to the bank accounts of health districts or municipalities; it also supports the health districts and municipalities to ensure proper budget execution, make any necessary budget adjustments, and perform mid-term evaluations of budget execution. However, the DAF has virtually no autonomy to decide how funds should be used because it must comply with preestablished rules, of public finance management. a As for CBHIs and OBHIs, each is managed by an executive board, which is responsible for ensuring proper implementation of decisions made by the CBHI or OBHI scheme's general assembly (its top governing body, which includes member representatives) and developing contracts with providers and policy holders. Executive boards are autonomous and can enter into contracts with providers and terminate them in the event of noncompliance. However, changes in benefit packages, provider payment terms, membership conditions, or contribution rates are often the responsibility of the general assembly. b

Autonomy and Power of Providers in Decision Making and Accountability Mechanisms
Private service providers have a great deal of autonomy to manage their resources. Autonomy for public providers is mixed and depends on the health financing scheme. Autonomy is low for providers under crédits délégués and crédits transférés, because money is not paid directly to them; inputs are provided by the DAF or the municipalities to the public health facilities. Provider autonomy is higher under Gratuité and CBHI and OBHI schemes, because funds are received as revenue directly by the health facilities and can be used for routine expenses per their annual budget. In all cases, some requirements must still be met. For example, although most PHC facilities have some flexibility in deciding which inputs (such as medicines or supplies) to buy, any expenditures over 25,000 XOF (about $45.00 USD) must be authorized by the district medical officer.
Moreover, providers must comply with public financial management rules, which can sometimes lengthen disbursement processes. c Both public and private providers usually have little negotiating power over purchasing mechanisms. However, public health workers can turn to trade unions, which are quite influential and can use strikes to demand higher salaries/bonuses and better working conditions. The private sector also has an umbrella organization, Fédération des Associations Professionnelles de la Santé Privée du Burkina Faso (FASPB), whose mission is to act as an intermediary between private-sector providers and the MOH and technical and financial partners and to advocate for private sector-friendly conditions in health policies. 20 Under Gratuité, crédits délégués, and crédits transférés, purchasers are held accountable through government bodies such as health services inspectorates, Treasury inspectorates, and the Superior Authority for State Control and Anti-Corruption. But alleged or revealed dysfunctions and suspected fraud or corruption are not always subject to in-depth investigation or sanctions. The government, with support from donors, established Customer Service Units through which citizens can provide feedback and lodge complaints about the quality of the services they have received in public facilities. The MOH has also used mechanisms set up by civil society organizations or national and international NGOs to receive feedback from the population, but these mechanisms are not well coordinated and corrective actions that are eventually taken are not sufficiently communicated to the public. The sustainability of these mechanisms is also not guaranteed because they are part of externally funded projects. [21][22][23] For Gratuité specifically, the ST/CSU has mechanisms to promote accountability, including population satisfaction surveys conducted by national and international NGOs, semiannual review meetings to assess strengths and weaknesses of the program and make recommendations, stakeholder meetings at the regional and district levels, and publication of implementation reports. The ST/CSU uses the survey results to commend health facilities that properly implement the scheme and to sanction misbehaviors by withholding money or notifying the provider's supervisors. To inform citizens of their rights and obligations, the ST/ CSU uses several channels: media interviews, response to complaints or queries on social media, newsletters, documentaries, and conferences and public debates organized by NGOs or civil society organizations in collaboration with the MOH. These activities are generally ad hoc, however. In contrast, crédits délégués and crédits transférés lack mechanisms for consultation with citizens. They have no dedicated staff for communication with citizens and rely on support from the Directorate of Communication and Ministerial Press of the MOH. However, civil society organizations sometimes hold the government accountable for their use of domestic and external resources through citizen surveys or studies. 24 Under CBHI and OBHI schemes, the rights and obligations of concern to members are specified in contracts. These schemes consider member needs and input through their general assembly and analyses of health care utilization. OBHI schemes generally emphasize institutional and interprofessional communication, while CBHI schemes focus mainly on raising public awareness of the importance of financial protection in order to encourage enrollment and renewals. d

Financial Management
All five schemes have a defined process to set the purchaser's budget and have mechanisms in place to track budget execution/spending. Most funds for Gratuité, crédits délégués, and crédits transférés are from the government budget. The annual budget for each is based on an annual budget formulation circular issued by the Head of State and approved by the National Assembly in the annual Finance Act; the funds are used according to public finance management rules. These budget rules are generally enforced, but budget overruns routinely occur, specifically for Gratuité. Indeed, at the end of December 2021, five years after the Gratuité implementation, the outstanding invoices of health facilities amounted to 32,234,737,356 XOF (about $58.6 million USD). 25 In terms of allocated budgets, crédits délégués receives an average of 200 billion XOF (about $367 million USD) per year and crédits transférés receives an average of 6 billion XOF (about $11 million USD). For Gratuité, an estimated 30 billion XOF (about $55 million USD) is needed to pay for services utilized each year, although less is typically allocated to the program. These amounts constitute 9.6% of the national budget (2019), which is above the average for sub-Saharan Africa of 6.7% 16 but still insufficient to cover estimated needs. The percentage of total health expenditure and of government health expenditure flowing through these schemes is about 5.44% and 13.45%, respectively, for Gratuité, 34.23% and 84,68% for crédits délégués, and 0.75% and 1.87% for crédits transférés. e The annual budget of CBHI and OBHI schemes is based on projected member contributions, which for CBHI schemes are generally low. Budget overruns occur frequently and are covered by corporate subsidies for OBHI, which also allow for a more generous benefit package. CBHIs get their financial support primarily from their umbrella organizations, mainly Réseau d'Appui aux Mutuelles de Santé (RAMS) and Association Songui Manegré/Aide au Développement Endogène (ASMADE), themselves supported by donors. CBHIs are rarely directly supported by external partners and do not receive subsidies from the national budget, which limits their benefits and their ability to crosssubsidize among members. Increasing membership fees is an option, but it is rarely used because of the low socio-economic status of most members.

Benefits Specification: What to Purchase
All five schemes have an explicit benefit package (see Table 1 above) and a list of covered drugs that reflect health priorities. But citizens are not directly consulted about their needs and preferences in designing these benefit packages. Furthermore, only OBHIs have regular benefit package review processes that include analysis of health care utilization and service cost data. f None of the five schemes has explicit service quality standards; even where general or specific service delivery standards exist, no mechanism is in place to ensure that they are enforced.
All schemes except OBHI cover only generic medicines (unless a specific drug does not have a generic equivalent). The list of generic drugs is determined by the National Agency for Pharmaceutical Regulation through a process involving stakeholders in the MOH. The choice of generic drugs was informed by recommendations from bodies such as medical professional societies and the World Health Organization (WHO). The generic drugs list is revised every two years, but drugs may be added or removed between review cycles based on national or international recommendations. OBHI schemes cover both generic and branded drugs. g

Contracting Arrangements: From Whom to Purchase
None of the five schemes uses selective contracting between the purchasers and public or private providers based on accreditation or other quality standards. Public-sector health organizations are automatically eligible for both crédits délégués and crédits transférés, so the DAF does not have formal or selective contracts with them. Similarly, public health facilities are automatically included in the Gratuité scheme regardless of their status or their level of performance. 17 Public health facilities belong to the MOH, with which they have a hierarchical relationship, and they are subject to guidelines for service delivery. The ST/CSU has selective contracts with private providers (17 out of 641 nationally in 2020) that agree to comply with four criteria: 1) deliver the Gratuité benefit package, 2) agree to reduce service rates to the negotiated level, 3) agree to regular reporting using the Gratuité information system, and 4) allow monitoring and audits by the control bodies of Gratuité. These requirements are not attractive to most private providers. h OBHI schemes have selective contracting with both public and private providers, and CBHI schemes contract mostly with public providers. OBHI schemes negotiate contracts with each provider individually, while CBHI schemes negotiate with providers collectively. i Compliance with contracts is more rigorous for OBHI schemes than CBHI schemes. OBHI schemes more frequently suspend or cancel contracts in cases of recurring fraud, overbilling, or poor treatment of beneficiaries. CBHI schemes usually simply inform local health authorities of malpractice, and they impose sanctions of varying severity depending on the transgression j .

Provider Payment: How and How Much to Pay Providers
In all five schemes, payments are not explicitly linked to provider performance. Gratuité and CBHI and OBHI schemes pay providers on a feefor-service basis, linking payment to the volume of services provided. Crédits délégués and crédits transférés allocate payments to health facilities through line-item budgets based on inputs. To prevent late payments under Gratuité, providers are prepaid at the beginning of the year for expected utilization in the first quarter (through a "fund prepositioning" system). 17 The amount is calculated based on the average utilization of Gratuité services in the health facility over the previous three months. Subsequent payments during the year are adjusted based on services delivered. 17 The ST/CSU transfers about 80% of the funds to the pharmaceutical depots of public health districts, as advance payment for drugs and medical consumables, and transfers about 20% to health facilities as payment for services. This provider payment method is not regularly evaluated for effectiveness.
Despite the prepayment to providers under Gratuité, sometimes the full billed amount from health facilities is not paid or payments are irregular or delayed due to budgetary constraints at the Treasury. Furthermore, although health facilities initially receive the full payment, shortages in drug supplies have been seen in public PHC facilities and district hospitals due to mismanagement of resources. k User fee rates, including in the Gratuité program, were set by the government for public-sector health care in the 1990s, but providers do not always adhere to them. In practice, providers ultimately set user fees rates, with some variability and without explicit criteria, although the fees are relatively low due to users' low financial capacity in a context of high poverty levels. In the private sector, prices are set by mutual agreement between providers through their umbrella organization, the FASPB. Purchasers, particularly in CBHI and OBHI schemes, have little power to negotiate the user fees that private providers charge. l

Performance Monitoring
Mechanisms for monitoring provider activities vary from one scheme to another. The health information systems are fragmented and are not integrated or interoperable. m All five schemes have dedicated, trained staff involved in health information management, and data used for payments are accessible in a format that can be easily analyzed. However, data are not used for in-depth analysis of provider performance, and none of the schemes has explicit mechanisms to assess quality of care and act on poor performance.
Gratuité uses an electronic platform called e-Gratuite, which is built on the open-source DHIS2 software, to record the quantity of services provided, and provider payment is based on these data. Before payment, data are monitored and audited externally by national and international NGOs, and internally by ST/CSU. 17 Crédits délégués and crédits transférés use two systems: 1) Entrepôt de Données Sanitaires du Burkina Faso (ENDOS-BF), which is built on DHIS2, and 2) integrated accounting system software. The MOH does not perform routine analyses of crédits délégués and crédits transférés because it makes payments annually in a lump sum. However, the MOH's DAF applies internal auditing and controls and considers the results when making purchasing decisions and determining resource allocation to health facilities and municipalities. OBHI and CBHI schemes use scheme-specific information systems or simple Excel-based software. They perform routine analyses to make purchasing decisions on premiums or contributions and on fee schedules for provider payment.

Discussion
Burkina Faso has seen progress in some purchasing functions, including the use of explicit benefit packages linked to population health needs, linking of provider payment to the volume of services delivered, and prepayment to public providers via the government budget through Gratuité to minimize late payments. However, a key remaining upstream issue is the ability to mobilize sufficient resources to pursue strategic purchasing objectives and meet citizens' service entitlements. All five schemes face challenges in this regard. Gratuité, crédits délégués, and crédits transférés, which are publicly funded, form the cornerstone of pooled health funds in the country. Public resources are widely considered the most sustainable and predictable source of health financing to move toward UHC. 26,27 This suggests a need to explore how to sustainably expand fiscal space despite weak tax collection capacity, to place a higher priority on health in national budgets, and to improve efficiency in resource use. 28,29 Governance Arrangements

Mandate and Authority of Purchasers
Appropriate governance mechanisms that include clear mandates for all actors are critical to the successful implementation of strategic purchasing. All five health financing schemes have such mechanisms, enabling their purchasing agencies to carry out their duties fairly well. However, the level of purchaser autonomy over decision making and resource allocation varies by scheme and affects progress toward more strategic purchasing. 13,30 Purchaser autonomy is relatively high under Gratuité, OBHI and CBHI schemes but rather low under crédits délégués and crédits transférés. For purchaser autonomy to realize its promise, purchasers need the required resources as well as the managerial and technical capacity to act strategically in pursuit of health system goals. This includes negotiating and implementing well-designed contracts, defining provider payment systems, monitoring provider performance, designing cost-effective benefit packages, defining quality requirements, and setting up accountability mechanisms. 28,31,32

Autonomy and Power of Providers in Decision Making
Lack of provider autonomy limits the ability of public health facilities to make financial and administrative decisions and respond to incentives embedded in provider payment mechanisms that are intended to expand service delivery and improve quality of care. This is an area for action, particularly for primary health facilities.

Accountability Mechanisms
Accountability mechanisms are poorly coordinated and often depend on external funding, which limits their effectiveness and jeopardizes their sustainability. Areas for improvement include prompt addressing of dysfunctions, fraud, and corruption. Tackling these issues, especially in the public sector, would improve health system responsiveness and thus increase trust in health services.
Communication with the population on their rights and obligations varies by scheme. The OBHI and CBHI schemes have relatively well-defined target populations-their current or potential membersand contracts that set out their rights and obligations. Gratuité, crédits délégués, and crédits transférés have a much wider population coverage but lack explicit communication strategies with beneficiaries. Specific communications plans that are regularly monitored and evaluated are of utmost importance because information and communication deficits are cited as an obstacle to sound implementation of health financing schemes. [33][34][35] Financial Management Financial management requirements are well articulated for all of the schemes, but overruns do occur, especially in the Gratuité program. Clear procedures for formulating, approving, executing, and evaluating budgets, if properly implemented, promote effective strategic purchasing.

Benefits Specification
All five schemes have explicit benefit packages, but lack explicit processes for regularly reviewing the package and lack citizen involvement in specifying it, which may hinder efforts to meet evolving population health needs. Participatory approaches that place equal value on the expressed needs of the population would empower communities to take greater responsibility for their own health. 36 This involvement should not be ad hoc; rather, it should be regular and ideally supported and informed by context-specific evidence. 37 Furthermore, without explicit quality standards and mechanisms to enforce service delivery standards, the potential of benefits specification as a lever for strategic purchasing is not fully realized.

Contracting Arrangements
The ST/CSU and the DAF do not have formal or selective contracting with public health facilities for Gratuité, crédits délégués, and crédits transférés. But the executive boards of the CBHI and OBHI schemes have more formal and selective contracts with providers-as the ST/CSU has with private providers for Gratuité-even though the contract provisions are more difficult to enforce in the case of CBHI. Selective contracting is meant to create competition among providers, thereby increasing efficiency and value for patients. 38 This assumes that contracts contain provisions that are attractive to providers and include incentives that align provider behavior with purchaser objectives. Well-developed contracts minimize conflicts of interest, clearly specify the roles and responsibilities of all actors, provide incentives for better provider performance and quality of care, and establish accountability mechanisms. 39,40 Capacity building within the ST/CSU and the DAF may be needed to develop "smart" contracts because contracting processes can be complex, time consuming, and expensive, especially when they are new to the health system. 38

Provider Payment
Gratuité and the OBHI and CBHI schemes pay providers using fee-for-service, while crédits délégués and crédits transférés use a line-item budget system. Each of these payment methods has pros and cons, and the choice depends on the purchaser's objectives as well as contextual factors, including health system capacity. 41 Fee-forservice is useful for increasing the volume of services but can result in cost inflation because providers have an incentive to perform more procedures, even unnecessary ones, to maximize their profit. 41 This can also lead to inefficiencies and waste of resources. The line-item budget may be useful when purchasers and/or providers have weak management capacity or when cost control is a high priority. 41 But its limited flexibility is not ideal for strategic purchasing. 4 Fee-for-service and line-item budgets are relatively easy to implement, as compared to other output based provider payment mechanisms. Purchasers can also combine payment methods-leading to so-called blended provider payment methods-while ensuring that they are complementary. 42 In any case, regardless of the method or mix of methods, payments must be timely and regular in order for the incentives to be effective. 42 Payment delays and accumulated arrears under Gratuité may lessen the incentive to providers to improve their performance and quality of care, despite the prepayment system in place. This implies that sufficient resource mobilization, prioritization based on population needs, defined and transparent processes for setting the purchaser's budget, and mechanisms to ensure budgetary control and prevent overspending are fundamental to strong purchasing arrangements.

Performance Monitoring
Each of the five schemes has a system for collecting data on provider activities, but the data are not used to inform purchasing decisions, which would be a more strategic use of this purchasing function. 42 The configuration of the health information systems can vary across different health systems, but it should be user friendly, reliable, transparent, not too fragmented, and have interoperable subsystems. 43 This is not the case in Burkina Faso, where existing information systems do not provide adequate data to inform purchasing decisions.

Conclusions
By mapping and analyzing governance arrangements and purchasing functions and capacities across the five main health financing schemes in Burkina Faso, this study has yielded insights about areas that need further attention to make health purchasing more strategic and thus advance progress toward UHC. Despite some areas of progress, a number of weaknesses and limitations in Burkina Faso's health purchasing arrangements are apparent. Overall, the greatest limiting factor is the high level of fragmentation in health financing and the relatively low share of total health spending flowing through each of the public financing mechanisms. This greatly limits the power of any public purchaser to make resource allocation more effective, create coherent and powerful incentives for providers, and enforce accountability for quality and other aspects of performance.
Specific aspects of purchasing arrangements that could be strengthened include: 1) financial and managerial autonomy for public purchasers and public providers, 2) accountability measures, 3) budget management (particularly for Gratuité), 4) quality standards for contracting and service delivery, 5) harmonizing and defining explicit criteria for setting payment rates, 6) linking payment to provider performance, and 7) harmonizing health information systems to generate evidence for purchasing decisions. This study was meant to serve as a baseline assessment and is a first step in defining priorities for action.