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Furthermore, the issues reported in those programmes reflect the limited capacity of
government to ensure the policies can be enacted effectively. For example,
the take-up rate is very low in the chronic disease screening programmes in Japan, China,
and Malaysia. Many of those providers are from private sector. The poor engagement
reported between government and private providers reflected the capacity of government to
enforce accountability of the private sector.

Developing effective purchaser and provider organisations

A purchaser-provider split is the basic feature of any purchasing activity, either strategic or
not. Therefore, effective and accountable purchasers and providers are essential elements of
strategic purchasing according to the framework of strategic purchasing. First, the
characteristics of purchasers vary across different health systems, either public, private, or
quasi-public, which may further determine the autonomy and power in determining criteria
and conditions for purchasing. Specifically, the competition among purchasers, which is
usually among private or quasi-public purchasers, may incentivise their competence and
accountability through consumers’ choice. However, in our view of purchasing for
chronic disease prevention and management programmes the public
sector is usually the single purchaser.

Second, for providers, increasing competition has been critical not only to enhance the
quality and efficiency of services, but also to foster greater agility in responding to policy
mandates, contracting conditions, and payment mechanisms. This is supported from our
observation that all the programmes reviewed have multiple providers. However, there is
very limited information about the inclusion criteria of providers, which
raises questions on the competence of the providers.

Third, those purchasing programmes, consisting of both providers and purchasers, are
accountable to explain their actions and output and may be rewarded or punished for those
actions and outputs. The accountability mainly stipulates four sub-components:
legal accountability, financial accountability, professional accountability,
and political/public accountability. The legal accountability indicates that the
programme was accountable for auditing and preventing medical errors; The financial
accountability ensures the appropriate use of funds, following the rules of equity, efficiency,
and etc.; Professional accountability requires purchasers to monitor and regulate the rules,
activity, and performance of providers; Political/public accountability means the purchasers
and providers need to better represent public interest and respond to population health
needs. Increased transparency is the key to ensure greater accountability of purchaser
and providers from all four perspectives. With the exception of the Japanese
health check programme, all other programmes reviewed had websites to
release related information. However, the amount of information released vary across
programmes. Specifically, the performance or effectiveness of those pgroammes was rarely
reported.

Incorporating cost-effective contracting

Contracting is used as the core mechanism to strategically purchase healthcare. Volume and
prices are the most often used tools to assist purchasers to establish a contract, with some
countries incorporating conditions that promote quality of care or experiment with
mechanisms to enhance cost-effectiveness. However, according to our observation, cost-
effectiveness evaluation was rarely integrated into the contracting process of those health
programmes. Nevertheless, the programmes in the United Kingdom,
Canada, the United States, and Singapore incorporate performance-based
payment into their practice, which may increase the value of money
invested in the programme.

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