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4.1 Macro-level: Health system strategic purchasing

Strategic planning and the formulation of strategic goals of a health system should be
informed by a population health needs assessment in conjunction with evaluation of
the healthcare delivery system as part of health system governance. This includes
the identification of gaps in healthcare service provision, and the evaluation of the capacity
and capability of public and private providers. This information should be captured by
information systems to inform purchasing decisions while the system governance structure
will inform decisions on who the purchasing agent should be.

Appropriate policy instruments are also needed to enable the implementation of
strategic plans, programmes and purchasing that will include the creation of resources,
regulations and legal instruments. It will be necessary to analyse the authority delegated to
budget holders for the allocation of resources and uphold their accountability for the impact
of the disbursement of resources. Policy parameters for purchasing agents for the service
mix and types, and the configuration arrangements needed to enable integrated care will
need to be defined. These include consensus between the governance and provider levels
on what to purchase, from whom and how to purchase, as well as the choice of purchasing
instruments and payment mechanisms.

Transformation for an integrated health system is exceedingly complex and necessitates a
shared vision and collaboration between a multitude of stakeholders in the
health sector, business sector, and civil society. Structures and mechanisms for engagement,
participation, and communication at every stage of policy formulation, implementation and
evaluation is required. Feedback and timely response will be necessary. A system for
oversight and accountability of the decisions made by purchasing agents will need to
be created. A framework for the monitoring of functions, review of progress, and evaluation
of performance and objectives, and information systems will be needed.

4.2 Meso-level: Healthcare delivery purchaser-provider system
At this level, strategic purchasing should be focused on health service delivery and
provider organisation. The roles, authority and obligations of providers, purchasers and
commissioners must be clearly defined. Consideration is given to the types, range, and mix
of care for the defined community based on healthcare needs, and on the integration of
related services, which will require community input. This level puts focus also on the
mechanisms for engagement, coordination and management of local actors, service
providers and health workers. Systems for coordination between these parties to meet
system goals are necessary and are facilitated by care pathways, clinical protocols and
multidisciplinary engagement that facilitate both vertical and horizontal integration of care.
Monitoring of results is essential and should include process review, performance
monitoring, and consideration of patient feedback.

4.3 Micro-level: Person journey of healthcare delivery
The micro-level considers a person’s healthcare journey during the life course that involves
encounters with multiple disciplines of healthcare professionals from different specialties, in
different settings, and at different levels of health service provision.

The final product of strategic purchasing must consider the person journey of healthcare
delivery such that the model of patient care is designed to centre on the individual and
enable a seamless journey in care delivery across preventive, curative,
rehabilitative, palliative, and social care provided by multidisciplinary teams of
healthcare professionals. Bridging and coordinating mechanisms also need to be considered
in the purchasing process to enable vertical (care transition within and between primary,
secondary, and tertiary levels of care) and horizontal (care transition between different
specialties of care; between social and medical care; and transitions to and from community
settings) care integration.
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