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First, the analysed programmes invest in chronic disease prevention and/or management,
aiming to meet the escalating healthcare demands due to chronic diseases. From this
perspective, all those programmes were addressing population health
needs. However, the inclusion criteria and the identification strategy vary across
programmes based on the target population. Some programmes rely on the referral from
existing health system to identify targeted population, i.e., the programmes in the United
Kingdom, China, the United States, and Australia. Among these programmes, how to
incentivise the hospitals or GPs to identify and refer patients to join the
chronic disease prevention and management programme is a key issue
identified. For example, in Singapore DOT programmes, it is reported that there is limited
incentive for public hospitals with fixed allocated budgets to join the programme. Specifically,
the United Kingdom’s DPP programme, the United States’ MIPCD Program, and Malaysia
PeKA B40 gave special attention to low-income people who are more likely to have financial
barriers in accessing care. For example, in the UK, providers will particularly target
individuals living in resource-poor areas and/or from protected groups–Black, Asian,
Minority Groups. However, the equity issues were not mentioned in other programmes.

Citizen empowerment

With the growing movement in patients empowerment internationally, the strategic
purchasing framework advocates that government and purchasers should ensure that
citizens’ and patients’ values, views, and choices are stressed. Citizens should actively
participate in determining the benefit package, be involved in the purchasing process, and
have access to their medical records. Empirical practices include citizens’ participation in the
management of health services, patient advocate groups influencing health policy decisions,
national feedback surveys used to collect citizens’ opinion for future improvement.
Furthermore, an explicitly defined benefit package can increase purchasers’ accountability
by giving consumer coverage guarantees.

However, all the programmes described in the case studies performed
poorly in citizen engagement. It is not apparent from the case reports that any
jurisdiction has built in patient empowerment into their practices. This can lead to growing
concern that those programmes may not have constant improvement incentive driven by the
patients, and may not fully cover unmet needs or reach the people in most need. As for
the benefit package which can provide patients with more information
about what they should expect from the programme, the description is
rather general in some programmes. For example, in China and Australia, the
government only suggested the number of consultations patients should be given by the
providers, without indicating how the services should be provided to improve effectiveness
and quality of care. The United States’s DPP is based on standardised DPP curriculum and
the volume of activities have been well designed. The standardisation in these programmes
does not allow for patient flexibility nor an opportunity to receive patient feedback for
improvement. All the programmes have performed well in enabling the
choice of providers. However, limited guidance and information were
given to the patients, which may limit informed choice by patients.

Strengthening governance: government stewardship and capacity

To ensure objectives (i.e., service amount, quality, efficiency, equity, cost-containment) of
programmes and/or policies have been met, governmental stewardship and capacity to
monitor and audit providers are key components of a strategic purchasing system.
Consequently, it requires the government to not only establish an integrated regulatory policy
and framework, but also to have ample capacity to implement policies and enforce regulation.

Most of the programmes were initiated by governments with the objective of addressing
challenges of chronic diseases. However, very few of those programmes have strong
regulatory framework with clearly defined monitoring mechanisms.

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