Results and Cross-Cutting Issues
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Weakness of Purchasing Functions Although schemes have separated financing from provision, and money already follows patients, providers are not held responsible for productivity, efficiency, quality of care, or patient satisfaction. In effect, as practiced by nearly all schemes, purchasing is a passive, poorly managed activity. The commonly used Memorandum of Understanding (MOU)89 is a loosely crafted instrument in which provider responsibilities and performance are ill-specified, if at all. In their current form the MOUs are not tools for modifying or even influencing provider behaviors, in part due to their poor enforcement and monitoring by GSHISs. In GSHISs, insurers and TPAs do not appear to have taken up the slack at least in terms of service purchasing. They may have few incentives to do so. As mentioned, insurers may be oriented toward securing “top line” (revenues) or “bottom line” (profitability) rather than making major investments in controlling costs. This is especially true if they can easily pass on the increase in costs as higher premiums in the next policy cycle. Similar to social insurance schemes in Latin America, ESIS and CGHS have built their institutional structure as providers of integrated care services to their beneficiaries. While they have large numbers of full-time staff, a good proportion of them are directly involved in service delivery at the schemes’ health facilities.90 In general, both schemes appear underresourced for effective purchasing91 and other important governance functions such as monitoring and information management for better decision making. The absence of robust management information systems (MISs) further compromises the ability of these schemes to purchase effectively, control costs, and measure performance. In sum, GSHISs require stronger purchasing capacity to improve the drafting and enforcement of contractual terms with insurers, TPAs, and providers; pay providers on time; represent the interests of the insured population and government; and collect, analyze, and take action based on operational data. A shift from passive purchasing to active purchasing is warranted to ensure that the health services financed through the schemes are efficient and of high quality.
Use of “Right-Level” Information Technology Increasing use of information and communication technology (ICT) tools is another encouraging trend across all schemes. Even the traditional schemes, ESIS and CGHS, have embarked on widespread automation of their processes and to develop MISs commensurate with the needs of the