Purchasing Arrangements Research Articles

A primer on brand-name prescription drug contracting.

Prescription drug contracting in the United States has evolved over decades from discounts provided to members of early health maintenance organization plans to rebate contracts to more complex value-based purchasing arrangements. This primer describes the history of contracting between pharmaceutical manufacturers and managed care pharmacy organizations and details the various contracting methods used today.

Assessment of strategic healthcare purchasing and financial autonomy in Tanzania: the case of results-based financing and health basket fund.

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.

Establishing a Health Technology Assessment Evidence Ecosystem in India’s Pradhan Mantri Jan Arogya Yojana

ABSTRACT The introduction of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) scheme in India was a significant step toward universal health coverage. The PM-JAY scheme has made notable progress since its inception, including increasing the number of people covered and expanding the range of services provided under the health benefit package (HBP). The creation of the Health Financing and Technology Assessment (HeFTA) unit within the National Health Authority (NHA) further enhanced evidence-based decision-making processes. We outline the journey of HeFTA and highlight significant cost savings to the PM-JAY as a result of health technology assessment (HTA). Our paper also discusses the application of HTA evidence for decisions related to inclusions or exclusions in HBP, framing standard treatment guidelines as well as other policies. We recommend that future financing reforms for strategic purchasing should strengthen strategic purchasing arrangements and adopt value-based pricing (VBP). Integrating HTA and VBP is a progressive approach toward health care financing reforms for large government-funded schemes like the PM-JAY.

The impact of COVID-19 on health financing in Kenya.

Sudden shocks to health systems, such as the COVID-19 pandemic may disrupt health system functions. Health system functions may also influence the health system's ability to deliver in the face of sudden shocks such as the COVID-19 pandemic. We examined the impact of COVID-19 on the health financing function in Kenya, and how specific health financing arrangements influenced the health systems capacity to deliver services during the COVID-19 pandemic.We conducted a cross-sectional study in three purposively selected counties in Kenya using a qualitative approach. We collected data using in-depth interviews (n = 56) and relevant document reviews. We interviewed national level health financing stakeholders, county department of health managers, health facility managers and COVID-19 healthcare workers. We analysed data using a framework approach. Purchasing arrangements: COVID-19 services were partially subsidized by the national government, exposing individuals to out-of-pocket costs given the high costs of these services. The National Health Insurance Fund (NHIF) adapted its enhanced scheme's benefit package targeting formal sector groups to include COVID-19 services but did not make any adaptations to its general scheme targeting the less well-off in society. This had potential equity implications. Public Finance Management (PFM) systems: Nationally, PFM processes were adaptable and partly flexible allowing shorter timelines for budget and procurement processes. At county level, PFM systems were partially flexible with some resource reallocation but maintained centralized purchasing arrangements. The flow of funds to counties and health facilities was delayed and the procurement processes were lengthy. Reproductive and child health services: Domestic and donor funds were reallocated towards the pandemic response resulting in postponement of program activities and affected family planning service delivery. Universal Health Coverage (UHC) plans: Prioritization of UHC related activities was negatively impacted due the shift of focus to the pandemic response. Contrarily the strategic investments in the health sector were found to be a beneficial approach in strengthening the health system. Strengthening health systems to improve their resilience to cope with public health emergencies requires substantial investment of financial and non-financial resources. Health financing arrangements are integral in determining the extent of adaptability, flexibility, and responsiveness of health system to COVID-19 and future pandemics.

Medicaid best price reforms to enable innovative payment models for cell and gene therapies

ABSTRACT Background Cell and gene therapies promise durable benefits but face financial challenges from the uncertainty in their performance. Value-based purchasing arrangements (VBPAs) can address uncertainty but have been inhibited in the US by the Medicaid Drug Rebate Program (MDRP) approach to determining Medicaid Best Price (MBP) rebates. The likely effectiveness of MDRP reform proposals enabling VBPAs is examined in this study for durable cell and gene therapies. Methods Monte Carlo simulations examined three potential reforms (Multiple Best Prices, Bundled Sales, and National Pooling) to determine the impact on payment misalignment, the required payer size to participate, and the percentage of total lives covered by a VBPA. Results Simulation results suggest that 11% to 54% of commercial US lives would be feasibly covered by a VBPA depending on reform type and condition size. MPB reform achieved the highest commercial contracted percentage and lowest misalignment for commercial payers compared to National Pooling and Bundled Sales. State Medicaid plan results suggest lower extreme misalignment across all successfully contracted instances than commercial payers. Conclusions The Multiple Best Prices will likely enable VBPAs for many durable cell and gene therapies and larger payers. Further reforms may be needed to extend VBPAs to ultra-orphan conditions.

Hydrogen market development: lessons from the LNG sector

Abstract The evolution of the liquefied natural gas (LNG) market, and LNG sale and purchase arrangements, can provide insights to how sale contracts required to underpin the development of regional hydrogen markets around the world may develop. This article explores how LNG markets have developed and considers the lessons which may be learned for project sponsors looking to develop the first wave of low-carbon hydrogen production projects.

Factors for Consideration When Setting Prices for Private Healthcare Providers Operating in Public Systems: A Comparison of France and Japan.

Most publicly-funded health systems purchase healthcare from private providers, but the optimal purchasing arrangements between public purchasers and private healthcare providers are yet to be determined. This study compares the healthcare purchasing arrangements made with private providers in 2 social health insurance (SHI)-based systems to identify factors that influence the prices paid for private healthcare service provision. France and Japan use different approaches to determine the payment arrangements with public and private providers. The presence of for-profit healthcare providers in the French health system explains the different payment rates for public and private healthcare providers in that country. In both France and Japan, in addition to payment rates, several policy tools are used to assure the provision of public good services and the availability of necessary healthcare for all, which public providers are required to deliver but private providers can choose to deliver. This study highlights the importance of considering the profit-making status of the private healthcare providers operating in the healthcare market, and clarity in the roles and responsibilities of the public, for-profit and not-for-profit providers when determining healthcare purchasing arrangements. Regulatory policy instruments, used alongside payment rates, are essential to influence efficiency, equity, and quality in mixed (public-private) health systems.

Alberta's Renewable Energy Market: Developing Contract Issues

Governments and corporations around the world have increasingly demonstrated leadership in tackling climate change, resulting in new decarbonization policies and initiatives and new corporate environmental, social, and governance mandates. At the same time, wind and solar capital costs have decreased and new technologies, such as battery storage, are becoming more prevalent, thereby increasing the flexibility and utility of renewable energy generation. Developers and investors have already expended significant capital to further the development of renewable generation with, according to the International Energy Agency, renewable energy investment reaching its highest level ever in 2021 — $367 billion internationally. This trend is only expected to increase if the global decarbonization goals are to be realized. Within Canada, Alberta is at the forefront of renewable energy development due in part to its unique power industry structure — a deregulated, competitive, wholesale power market with non-discriminatory system access — which has attracted corporate off-takers and buoyed investment in renewable energy projects in the province, supported by corporate power purchase agreements. The pace of development is striking, and Alberta has rapidly become a preferred destination for renewable energy investment. The Alberta Electric System Operator says that 22 percent of the energy generated in Alberta in 2021 came from renewable energy sources. This is predictedto rise sharply — for instance, there are 61 solar projects currently under development in Alberta that could be completed by the middle of the decade. This article examines several emerging contracting and development challenges currently facing renewable energy projects in Alberta, and aims to provide concrete, practical advice on several discrete contractual issues. Topics covered include, among others: (1) force majeure issues faced by project developers; (2) diverse carbon offset/renewable attributes programs and implications for power purchase arrangements; (3) developments pertaining to ethical procurement, including forced labour and the use of tracing protocols; and (4) the need for increased flexibility in contractual arrangements to accommodate the pairing of wind and solar with storage resources. Although this article is based primarily on experiences gained while developing renewable energy projects in Alberta, the analyses and solutions presented can be applied in many jurisdictions.

Assessment of Strategic Healthcare Purchasing Arrangements and Functions Towards Universal Coverage in Tanzania.

Strategic health purchasing in low- and middle-income countries has received substantial attention as countries aim to achieve universal health coverage (UHC), by ensuring equitable access to quality health services without the risk of financial hardship. There is little evidence published from Tanzania on purchasing arrangements and what is required for strategic purchasing. This study analyses three purchasing arrangements in Tanzania and gives recommendations to strengthen strategic purchasing in Tanzania. We used the multi-case qualitative study drawing on the National Health Insurance Fund (NHIF), Social Health Insurance Benefit (SHIB), and improved Community Health Fund (iCHF) to explore the three purchasing arrangements with a purchaser-provider split. Data were drawn from document reviews and results were validated with nine key informant (KI) interviews with a range of actors involved in strategic purchasing. A deductive and inductive approach was used to develop the themes and framework analysis to summarize the data. The findings show that benefit selection for all three schemes was based on the standard treatment guidelines issued by the Ministry of Health. Selection-contracting of the private healthcare providers are based on the location of the provider, the range of services available as stipulated in the scheme guideline, and the willingness of the provider to be contracted. NHF uses fee-for-service to reimburse providers. While SHIB and iCHF use capitation. NHIF has an electronic system to monitor registration, verification, claims processing, and referrals. While SHIB monitoring is done through routine supportive supervision and for the iCHF provider performance is monitored through utilization rates. Enforcing compliance with the contractual agreement between providers-purchasers is crucial for the provision of quality services in an efficient manner. Investment in a routine monitoring system, such as the use of the district health information system which allows effective tracking of healthcare service delivery, and broader population healthcare outcomes.

Examining healthcare purchasing arrangements for strategic purchasing in Nigeria: a case study of the Imo state healthcare system

BackgroundStrategic healthcare purchasing (SHP), as a critical function of health financing, enhances the optimal attainment of health system goals through the efficient use of financial resources. Countries committed to universal health coverage (UHC) have made progress towards strategic purchasing through relevant reforms in their healthcare financing systems. This study examined the purchasing arrangements and practices in the Imo state healthcare system to track progress towards SHP committed to UHC.MethodsA critical review and analysis of healthcare financing schemes in Imo state, south-eastern Nigeria, was undertaken to assess their purchasing practices based on a descriptive qualitative case study approach. Relevant documents were collected and reviewed including in-depth interviews with stakeholders. Information was collected on external factors and governance, purchasing practices and other capacities of the state’s health financing schemes. The analytical framework was guided by comparing purchasing practices of the financing schemes with the ideal strategic purchasing actions (SPAs) developed by RESYST (Resilient and Responsive Health Systems), based on the three pairs of principal–agent relationships.ResultsHealthcare purchasing in the state is dominated by the State Ministry of Health (SMOH) using a general tax-based and public health system, making government revenue a major source of funding and provision of healthcare services. However, purchasing of health services is passive and the stewardship role of government is significantly weak, characterized by substantial insufficient budgetary allocations, inadequate infrastructure and poor accountability. However, the health benefit package significantly reflects the needs of the population. As an integrated system, there is no purchaser–provider split. Provider selection, monitoring and payment processes do not promote quality and efficiency of service delivery. There is very limited institutional and technical capacity for SHP. However, the state recently established the Imo State Health Insurance Agency (IMSHIA), a social agency whose structure and organization support SHP functions, including benefit packages, provider selection processes, appropriate provider payment mechanisms and regulatory controls.ConclusionHealthcare purchasing in Imo state remains mostly passive, with very limited strategic purchasing arrangements. The main challenges stem from the entrenched institutional mechanism of passive purchasing in the government’s health budgets that are derived from general tax revenue, lack of purchaser–provider split, and poor provider payment and performance monitoring mechanisms. The establishment of the social insurance agency represents an opportunity for boosting SHP in the state for enhanced progress towards UHC. Building capacity and awareness of the benefits of SHP among policy-makers and programme managers will improve the efficiency and equity of health purchasing in the state.

Healthcare provider payments: Acceptance and preferences of Myanmar general practitioners

Universal Health Coverage (UHC), or people's access to quality essential health services without financial hardship, is one of the sustainable development goals for UN member countries to achieve by 2030. However, progress towards UHC has been uneven globally due to weaknesses in health financing. Although high-income countries such as New Zealand have been practising UHC for decades, it remains challenging for low-to-middle income countries to meet the goal in time. Myanmar, a Southeast Asian nation now on the verge of becoming a failed state due to the military coup, has struggled to restructure its healthcare financing mechanisms, especially in purchasing health services from private providers. Previous literature is biased to the Global North, with limited reference to Southeast Asia and little research focused on providers' perceptions, attitudes, and beliefs prior to introducing nationwide strategic purchasing payment mechanisms. These research gaps created an opportunity to investigate the relationships between General Practitioners' (GPs) socio-demographic characteristics and clinic services profile and their perceptions on payment methods. This research sought to examine Myanmar GPs' acceptance of, and preferences for, four major healthcare payment methods. A cross-sectional study was used, recruiting 622 participants with a convenience sampling method. A Qualtrics online survey was disseminated to Myanmar GPs through three different channels. The research showed that performance-based payment was the most acceptable and preferred payment method, followed by fee-forservice. Salary payments were reported as the least acceptable and preferred paymenttype, while findings on capitation were inconclusive. Despite the potential for this research to inform strategic purchasing arrangements in Myanmar, the scope for applying these findings, as initially intended, is not realistic in the immediate future because of the current political turmoil. In this context, the study's results provide valuable insights into the possible role of alternative provider payment architectures, particularly during public health emergencies.

Strategic Purchasing Arrangements in Uganda and Their Implications for Universal Health Coverage

ABSTRACT Several purchasing arrangements coexist in Uganda, creating opportunities for synergy but also leading to conflicting incentives and inefficiencies in resource allocation and purchasing functions. This paper analyzes the key health care purchasing functions in Uganda and the implications of the various purchasing arrangements for universal health coverage (UHC). The data for this paper were collected through a document review and stakeholder dialogue. The analysis was guided by the Strategic Health Purchasing Progress Tracking Framework created by the Strategic Purchasing Africa Resource Center (SPARC) and its technical partners. Uganda has a minimum health care package that targets the main causes of morbidity and mortality as well as specific vulnerable groups. However, provision of the package is patchy, largely due to inadequate domestic financing and duplication of services funded by development partners. There is selective contracting with private-sector providers. Facilities receive direct funding from both the government budget and development partners. Unlike government-budget funding, payment from output-based donor-funded projects and performance-based financing (PBF) projects is linked to service quality and has specified conditions for use. Specification of UHC targets is still nascent and evolving in Uganda. Expansion of service coverage in Uganda can be achieved through enhanced resource pooling and harmonization of government and donor priorities. Greater provider autonomy, better work planning, direct facility funding, and provision of flexible funds to service providers are essential elements in the delivery of high-quality services that meet local needs and Uganda’s UHC aspirations.

Is Performance-Based Financing A Pathway to Strategic Purchasing in Sub-Saharan Africa? A Synthesis of the Evidence

ABSTRACT Many countries in sub-Saharan Africa have implemented performance-based financing (PBF) to improve health system performance. Much of the debate and analysis relating to PBF has focused on whether PBF “works”—that is, whether it leads to improvements in indicators tied to incentive-based payments. Because PBF schemes embody key elements of strategic health purchasing, this study examines the question of whether and how PBF programs in sub-Saharan Africa influence strategic purchasing more broadly within country health financing arrangements. We searched PubMed, Scopus, EconLit, Cochrane Database of Systematic Reviews, Google Scholar, Google, and the World Health Organization and World Bank’s repositories for studies that focused on the implementation experience or effects of PBF in sub-Saharan African and published in English from 2000 to 2020. We identified 44 papers and used framework analysis to analyze the data and generate key findings. The evidence we reviewed shows that PBF has the potential to raise awareness about strategic purchasing, improve governance and institutional arrangements, and strengthen strategic purchasing functions. However, these effects are minimal in practice because PBF has been introduced as narrow, often pilot, projects that run parallel to and have little integration with the mainstream health financing system. We concluded that PBF has not systematically transformed health purchasing in countries in sub-Saharan Africa but that the experience with PBF can provide valuable lessons for how system-wide strategic purchasing can be implemented most effectively in that region—either in countries that currently have PBF schemes and aim to integrate them into broader purchasing systems, or in countries that are not currently implementing PBF. We also concluded that for countries to pursue more holistic approaches to strategic health purchasing and achieve better health outcomes, they need to implement health financing reforms within or aligned with existing financing systems.

Strengths and Weaknesses of Strategic Health Purchasing for Universal Health Coverage in Rwanda

ABSTRACT In the context of scarce resources and increasing health care costs, strategic purchasing is viewed as a key mechanism to spur countries’ progress toward universal health coverage (UHC), by using limited resources more effectively. We applied the Strategic Health Purchasing Progress Tracking Framework to examine the health purchasing arrangements in three health financing schemes in Rwanda—the Community Based Health Insurance (CBHI) scheme, the Rwanda Social Security Board (RSSB) medical scheme, and performance-based financing (PBF). Data were collected from secondary and primary sources between September 2020 and March 2021.The objective of the study was to identify areas of progress in strategic purchasing that can be built on, and to identify areas of overlap, duplication, or conflict that limit progress in strategic purchasing to advance UHC goals. This study found that Rwanda has made progress in many areas of strategic purchasing and has a strong foundation for building further. However, some overlaps and duplication of functions weaken the power of purchasers to improve resource allocation, incentives for providers, and accountability. In addition, some of the policies within the purchasing functions could be made more strategic. In particular, open-ended fee-for-service payment in the CBHI scheme not only threatens the scheme’s financial sustainability but also imposes a high administrative burden. Better alignment and integration of contracting, incentives, and information system design to provide timely and relevant information for purchasing decisions would contribute to more strategic health purchasing and ensure that Rwanda’s health sector achievements are sustained and expanded.

An Analysis of the Drug Distribution Model in the Public Health Services in Tamil Nadu

Based on the field work in Tamil Nadu, this article analyses the procurement and dissemination functioning of the Tamil Nadu Medical Services Corporation (TNMSC), including the problems faced by different stakeholders’ viz. doctors, patients and pharmaceutical companies and also the stakeholders outside Tamil Nadu. The Tamil Nadu model of procurement and distribution of medicines under TNMSC is acclaimed as a successful model for its centralized-swift actions. However there were some inconsistencies hampering TNMSC to remain a model as there were the no availability of drugs as per approved essential drugs list, shortage and incomplete availability of drugs, and a shift from centralized procurement to local purchase arrangement of some drugs across Tamil Nadu. It also observed not only the quantity, quality and number of drugs procured and distributed, not matching with the health need of patients, but also the doses are not effective. In order to do that there is a need to revamp its centralized procurement pattern and dissemination of drugs to various public health systems in Tamil Nadu. By doing this, it can avoid the high-cost private medicines being promoted even by government doctors, and truly make the public health system successful and a top model in this country.

Collaborative Commissioning: regional funding models to support value‐based care in New South Wales

Collaborative Commissioning: regional funding models to support value‐based care in New South Wales

Land Tenure, Land Property Rights and Adoption of Bio-fortified Cassava in Nigeria: Policy Implications

This study investigated land tenure, land right and rental system, as it relates to adoption of bio-fortified cassava in Nigeria. The study was conducted in three states in Nigeria where bio-fortified cassava technology was first released in Nigeria including Oyo, Benue and Akwa Ibom. Multistage sampling techniques were used to select 360 bio-fortified cassava farmers. Descriptive statistics, t-test and Cragg’s double hurdle model were used to analyse the data collected. The land tenure system practised in the bio-fortified cassava-producing areas in Nigeria is governed by inheritance (23%), purchasing (19.7), gifting (31.7) and temporary arrangements through rentals (25.6%). The tenant bio-fortified cassava farmers pay about ₦31,000 per acre per year in land for cash agreement or 4%–7% of the actual yield of the bio-fortified cassava in land for cassava outputs agreements. However, this agreement between the landlords and tenant bio-fortified cassava farmers is verbal where both parties try as much as possible to honour the agreements. Variables such as access to credit, landownership status, access to bio-fortified cassava stems and extension contacts influenced the decision to adopt bio-fortified cassava technology, while age, perception and training influenced the intensity of adoption of bio-fortified cassava technology. The result of the t-test analysis showed that there was a significant difference in the farm sizes (34739.467 at 1%) and yields (0.593 at 1%) of the landlords and tenant bio-fortified cassava farmers. The findings of the study indicated that tenant bio-fortified cassava farmers were being faced with the problem of insecure land access, thus the need to implement policies that will increase access to land resources among the tenant farmers in Nigeria.

How much healthcare is wasted? A cross-sectional study of outpatient overprovision in private-for-profit and faith-based health facilities in Tanzania.

Overprovision-healthcare whose harm exceeds its benefit-is of increasing concern in low- and middle-income countries, where the growth of the private-for-profit sector may amplify incentives for providing unnecessary care, and achieving universal health coverage will require efficient resource use. Measurement of overprovision has conceptual and practical challenges. We present a framework to conceptualize and measure overprovision, comparing for-profit and not-for-profit private outpatient facilities across 18 of mainland Tanzania's 22 regions. We developed a novel conceptualization of three harms of overprovision: economic (waste of resources), public health (unnecessary use of antimicrobial agents risking development of resistant organisms) and clinical (high risk of harm to individual patients). Standardized patients (SPs) visited 227 health facilities (99 for-profit and 128 not-for-profit) between May 3 and June 12, 2018, completing 909 visits and presenting 4 cases: asthma, non-malarial febrile illness, tuberculosis and upper respiratory tract infection. Tests and treatments prescribed were categorized as necessary or unnecessary, and unnecessary care was classified by type of harm(s). Fifty-three percent of 1995 drugs prescribed and 43% of 891 tests ordered were unnecessary. At the patient-visit level, 81% of SPs received unnecessary care, 67% received care harmful to public health (prescription of unnecessary antibiotics or antimalarials) and 6% received clinically harmful care. Thirteen percent of SPs were prescribed an antibiotic defined by WHO as 'Watch' (high priority for antimicrobial stewardship). Although overprovision was common in all sectors and geographical regions, clinically harmful care was more likely in for-profit than faith-based facilities and less common in urban than rural areas. Overprovision was widespread in both for-profit and not-for-profit facilities, suggesting considerable waste in the private sector, not solely driven by profit. Unnecessary antibiotic or antimalarial prescriptions are of concern for the development of antimicrobial resistance. Option for policymakers to address overprovision includes the use of strategic purchasing arrangements, provider training and patient education.

Fighting excessive pharmaceutical prices: Evaluating the options

Abstract Background New treatment options for various cancer therapies have appeared extremely expensive and prices may increase further. The affordability and availability of life-saving medicines is therefore a key issue in national health policies of all countries. Fighting excessive pharmaceutical prices, this paper examined a 'toolbox' of price reducing measures, provided by international law (e.g., compulsory licensing, pharmacy's exemption, price transparency and mandatory disclosure, competition authorities' review unfair prices, crossborder purchasing medicines). Results Evaluating the options, states remain hesitant, if not reluctant to apply for compulsory licensing and or other regulatory options to curtail pharmaceutical prices. Instead, Cross-border collaboration on (price and cost) negotiation of selective medicines seems the most feasible remedy to create advantages of economies of scale, and thus providing access to affordable new medicines. Conclusions Despite some obstacles, voluntary cross-border purchasing arrangements are a meaningful option to safeguard access to affordable innovative medicines, particularly for small countries Methods Legal analysis treaty law, provisions, case law, and literature. Key messages Voluntary cross-border purchasing arrangements are a meaningful option to safeguard access to affordable innovative medicines. Particularly for small countries.

Exploring effectiveness of different health financing mechanisms in Nigeria; what needs to change and how can it happen?

BackgroundVarious attempts to examine health financing mechanisms in Nigeria highlight the fact that there is no single mechanism that fits all contexts and people. This paper sets out findings of an in-depth assessment of different health financing mechanisms in Nigeria.MethodsThe study was undertaken in the Federal Capital territory of Nigeria and two States (Niger and Kaduna). Data were collected through review of government documents, and in-depth interviews of purposively selected respondents. Data analysis was guided by a conceptual framework which draws from various approaches for assessing health financing mechanisms. Data was examined for current practices, what needs to change and how the change can happen.ResultsHealth financing mechanisms in Nigeria do not operate optimally. Allocation and use of resources are neither evidence-based nor results-driven. Resources are not allocated equitably or in a manner that minimizes wastage and improves efficiency. None of the mechanisms effectively protects individuals/households from catastrophic health expenditure. Issues with social health insurance cut across legal frameworks and use of Health Maintenance Organisations (HMOs) as purchasers. The concomitant effect is that attainment of Universal Health Coverage is greatly compromised. In order to improve efficiency of health financing mechanisms, government needs to allocate more funds for purchasing health services; this spending must be based on evidence (strategic), and appropriately tracked. The legislation that established National Health Insurance Scheme should be amended such that social health insurance becomes mandatory for all citizens. Implementation of the latter should be complemented by revision of benefit package, strict oversight and regulation of HMOs.ConclusionIn order to improve health financing in the country, legal and regulatory frameworks need to be revised. Efficient utilization of resources could be improved through strategic purchasing arrangements and strict oversight.