Defining Institutional Arrangements When Linking Financing to Quality in Health Care: A Practical Guide

September 2018
This publication was produced for review by the United States Agency for International Development.
It was prepared by Altea Cico, Kelley Laird, and Lisa Tarantino for the Health Finance and Governance Project.
DEFINING INSTITUTIONAL
ARRANGEMENTS WHEN LINKING
FINANCING TO QUALITY IN HEALTH
CARE: A PRACTICAL GUIDE
Photo: Gonralo Guajardo for Communication for Development
Photo: Donald Batson, Courtesy of Photoshare

The Health Finance and Governance Project
USAID’s Health Finance and Governance (HFG) project helps to improve health in developing countries by
expanding people’s access to health care. Led by Abt Associates, the project team works with partner countries to
increase their domestic resources for health, manage those precious resources more effectively, and make wise
purchasing decisions. As a result, this six-year, $209 million global project increases the use of both primary and
priority health services, including HIV/AIDS, tuberculosis, malaria, and reproductive health services. Designed to
fundamentally strengthen health systems, HFG supports countries as they navigate the economic transitions
needed to achieve universal health care.
September 2018
Cooperative Agreement No: AID-OAA-A-12-00080
Submitted to: Scott Stewart, AOR
Jodi Charles, Senior Health Systems Advisor
Office of Health Systems
Bureau for Global Health
Recommended Citation: Cico, Altea, Kelley Laird, and Lisa Tarantino. September 2018. Defining Institutional
Arrangements When Linking Financing to Quality in Health Care: A Practical Guide. Bethesda, MD: Health Finance &
Governance Project, Abt Associates Inc.
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| Johns Hopkins Bloomberg School of Public Health (JHSPH) | Results for Development Institute (R4D)
| RTI International | Training Resources Group, Inc. (TRG)

DEFINING INSTITUTIONAL ARRANGEMENTS
WHEN LINKING FINANCING TO QUALITY IN
HEALTH CARE: A PRACTICAL GUIDE
DISCLAIMER
The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency
for International Development (USAID) or the United States Government.

i
CONTENTS
Acronyms................................................................................................................. iii
Acknowledgments................................................................................................... v
1. Introduction .............................................................................................. 1
1.1 Purpose and Users of the Guide.....................................................................................2
1.2 How and When to Use this Guide.................................................................................2
1.3 Process of Developing the Guide....................................................................................3
2. Involving Payers in Governing Health Care Quality............................ 4
2.1 The Potential Roles of Payers in Quality ......................................................................4
2.2 Applying Quality Criteria to Determine Provider Participation Eligibility...........7
2.3 Incorporating Quality Incentives or Penalties into Provider Payment
Mechanisms .........................................................................................................................10
2.4 Applying Quality Criteria to Benefits Package Design ............................................12
2.5 Generating Demand for Quality....................................................................................15
2.6 Investing Directly in Quality Improvement ................................................................17
2.7 Providing Non-Monetary Incentives for Quality.......................................................18
2.8 Payers’ Roles in Policy Development and Regulatory Reforms............................19
3. Establishing Institutional Arrangements............................................. 20
3.1 Step 1: Determining Relevant Quality Strategies and Definitions........................21
3.2 Step 2: Documenting Current Arrangements ...........................................................22
3.3 Step 3: Identifying Gaps, Capacity Needs, and Areas for Improvement............23
3.4 Step 4: Engaging Stakeholders........................................................................................24
3.5 Step 5: Establishing Formal Arrangements .................................................................25
3.6 Step 6: Communicating Arrangements and Building Capacity..............................25
3.7 Monitoring Effectiveness and Revising Arrangements.............................................26
Annex A: Sample Stakeholder Interview Questions ........................................ 27
Annex B: Country examples of roles and responsibilities for Executing
Quality Strategies.................................................................................................. 29
Annex C: Ghana’s experience using this guide.................................................. 35
Ghana in 2018: Governing health care quality and UHC.................................................35
How the guide was used...........................................................................................................36
Lessons learned ...........................................................................................................................38
Workshop Agenda......................................................................................................................39
Annex D: Bibliography.......................................................................................... 42

ii
List of Tables
Table 1: Documentation of current institutional arrangements .............................................22
Table 2: Implementation plan for establishing institutional arrangements to link health
financing to the quality of care...............................................................................................25
List of Figures
Figure 1: Eight Stones of Governance for Quality Health Care................................................1
Figure 2: A conceptual framework for the role of payers in governing quality in
collaboration with other actors...............................................................................................6
Figure 3: Process for establishing effective institutional arrangements.................................20
Figure 4: Health care quality stakeholders ....................................................................................24

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ACRONYMS
ASSIST USAID’s Applying Science to Strengthen and Improve Systems
BPJS-K Badan Penyelenggara Jaminan Sosial-Kesehatan (Social Security Agency for
Health in Indonesia)
CMS U.S. Centers for Medicare & Medicaid Services
DAI Development Alternatives Inc.
DRG Diagnosis-Related Group
EHIF Estonia Health Insurance Fund
GHS Ghana Health Service
HFG USAID’s Health Finance and Governance Project
ISO International Organization for Standardization
IHI Institute for Healthcare Improvement
JCI Joint Commission International
JLN Joint Learning Network for Universal Health Coverage
KARS Komisi Akreditasi Rumah Sakit (Indonesia’s Hospital Accreditation Committee)
KBK Kapitasi Berbasis Komitmen (Indonesia’s Commitment-Based Capitation
System)
LMIC Low- and Middle-Income Countries
MOH Ministry of Health
NHIA National Health Insurance Authority (Ghana)
NHSO National Health Security Office (Thailand)
NQTC National Quality Technical Committee
PhilHealth Philippine Health Insurance Corporation
UHC Universal Health Coverage
USAID United States Agency for International Development
WHO World Health Organization

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ACKNOWLEDGMENTS
This guide is the product of co-development work conducted in 2017 among the members of the
Governance of Quality Community of Practice, consisting of a global community of individuals
representing more than 13 national governments, global and multi-national health organizations such as
the World Health Organization (WHO) and the Institute for Healthcare Improvement (IHI), and other
specialists in the fields of governance and health care quality improvement. The guide benefited from
further improvements based on a pilot application of its use in Ghana in early 2018. The work was co-
funded by the United States Agency for International Development (USAID) through the Health Finance
and Governance (HFG) project and the USAID Applying Science to Strengthen and Improve Systems
(ASSIST) project,1 and by the Joint Learning Network for Universal Health Coverage (JLN).2
The authors are grateful to: Jodi Charles of USAID; Amanda Folsom of the Results for Development
Institute; to Steve Yank of Training Resources Group, Inc.; Peter Vaz of Abt Associates; Adam Koon of
Abt Associates; and Dr. Bob Fryatt of Abt Associates, HFG Project Director, for their active
participation, advice, and analytical reviews throughout the development of this guide. Furthermore, we
thank all those who have participated in multiple discussions, in person and remotely, on the
development and review of this guide. We also recognize the JLN for its contributions bringing in
country experiences and facilitating knowledge exchange using the joint learning methodology.
This product was developed with the substantial contributions and continuing engagement of the
following individuals:
Nana A. Mensah Abrampah, Technical Officer, Quality Systems and Resilience Unit, Service Delivery and
Safety Department, World Health Organization, Switzerland
Samsiah Awang, Head of Quality Assurance Secretariat Division, Institute for Health Systems Research,
Ministry of Health, Malaysia
Fred Adomako-Boateng, Deputy Director of Clinical Care in Ashanti Region, Ghana Health Service,
Ghana
Vivian Addo-Cobbiah, Deputy Director Quality Assurance, National Health Insurance Authority, Ghana
Samantha Ferguson, Senior Program Associate, HFG project, JLN
1 ASSIST is a five-year project of the Office of Health Systems of the USAID Global Health Bureau, designed to improve health
and social services in USAID-assisted countries, strengthening their health systems and advancing the frontier of improvement
science. USAID ASSIST is implemented by URC. along with EnCompass LLC, FHI 360, the Harvard University School of Public
Health, HEALTHQUAL International, Initiatives Inc., the Institute for Healthcare Improvement, the Johns Hopkins Center for
Communications Program, and WI-HER, LLC. For more information on the work of the USAID ASSIST project, please visit
www.usaidassist.org or email assist-info@urc-chs.com
2 The Joint Learning Network for Universal Health Coverage (JLN) is an innovative community of policy-makers and
practitioners from around the world engaged in practitioner-to-practitioner learning to address challenges and co-produce
practical solutions to implementing reforms toward universal health coverage. For more information, see:
www.jointlearningnetwork.org

vi
Sanghamitra Ghosh, Mission Director, National Health Mission, India
Rachel Gutierrez, Improvement Associate, URC, the USAID ASSIST project
Mirna Hebrero, General Directorate of Performance Evaluation, Ministry of Health, Mexico City, Mexico
Rizza Majella L. Herrerra, Officer-in-Charge and Senior Manager, Standards and Monitoring Department
of PhilHealth, Philippines
Martias Joshua, Chairperson of National Health Insurance Reforms, Health Financing Reforms, Service-
level Reforms, Private Public Partnership Task Force and Central Hospital Autonomy Reform, Ministry
of Health, Malawi
Leizel Lagrada-Rombaua, Health Systems Specialist, HFG project
Siti Haniza Mahmud, Head of Quality Assurance Unit, Institute for Health Systems Research, Malaysia
Kedar Mate, Senior Vice President, Institute for Healthcare Improvement
Tiernan Mennen, Principal Associate, Abt Associates Inc., HFG project
Mohamed Ally Mohamed, Director of Quality Assurance, Ministry of Health, Community Development,
Gender, the Elderly and Children, Tanzania
Joseph Okware, Commissioner, Quality Assurance Department, Ministry of Health, Uganda
Shalini Pandit, Mission Director, National Health Mission and Rashtriya Swasthya Bima Yojana (National
Health Insurance Programme), India
Donald Pardede, Senior Advisor for Health Economics and Evaluation, Ministry of Health, Indonesia
Sheryan R. Dela Peña, Officer-in-Charge and Head, Accreditation Dept., PhilHealth Regional Office,
PhilHealth, Philippines
Amy Rahmadanti, Directorate General Health Services, Ministry of Health, Indonesia
Tati Denawati, director for health service management, Badan Penyelenggara Jaminan Sosial (Social
Insurance Administration), Indonesia
Vanessa Vizcarra, General Directorate of Quality for Health Care and Education, Ministry of Health, Mexico
Desalegn Tegabu Zegeye, Director, Clinical Services Directorate, Federal Ministry of Health, Ethiopia

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1. INTRODUCTION
As countries work towards achieving universal health coverage (UHC), expanding access to health
services while maintaining and improving quality of care remains a major priority. Poor quality of care
can prevent countries from achieving desired health outcomes. Furthermore, poor quality of care often
leads to unnecessary costs, and limits the potential for expanding access. In low- and middle-income
countries (LMICs), over 8 million deaths occur as a result of poor quality annually, translating into $6
trillion in economic losses (Kruk et al., 2018).
In this guide, the governance of quality in health care refers to the process of competently directing
health system resources, performance, and stakeholder participation toward the goal of delivering health
care that is effective, efficient, people-centered, equitable, integrated, and safe. (Cico et al., 2016; Health
Systems 20/20, 2012; WHO, OECD, The World Bank, 2018). Ongoing strengthening of health
governance structures is an essential component to ensure and improve the quality of care, particularly
as the pursuit of UHC is often associated with changing institutional roles and the advent of new
institutions that have the potential to impact quality.
Many stakeholders, including ministries of health, providers, professional associations, purchasers or
payers, accrediting bodies, advocacy groups, and patients are involved in improving the quality of care,
and require strong governance from policymakers who lead country strategy and priority setting in the
health system. As policymakers pursue major health reforms to expand UHC, eight critical aspects, or
stones, emerge for consideration to aptly govern for quality in health care, as illustrated in Figure 1
(Tarantino et al., 2016).
Figure 1: Eight Stones of Governance for Quality Health Care

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This guide focuses on the Linking Financing to Quality stone as a potentially powerful lever to
improve the quality of care, and explores the role of the payer(s) in improving quality of care. In this
guide, the term “payer” refers to institutions or entities that pay or reimburse for health care services.
These are typically entities such as social or private health insurance agencies, large employers,
Ministries of Health, etc.
1.1 Purpose and Users of the Guide
The purpose of this guide is to support policymakers
when they are defining the institutional roles,
relationships, and capacities of payers in carrying out
strategies for improving the quality of care. We intend
government policymakers and institutional actors,
including from ministries of health and payers, along with
donors and implementing partners to use this guide as a
diagnostic and planning tool. Specifically, the guide
focuses on:
 identifying strategies whereby payers can leverage
their power to enhance the quality of care,
 articulating possible institutional arrangements
(among payers and other actors), and
 presenting a process to establish or improve those
arrangements in a particular country.
The guide describes how payers can use various health financing levers, such as selective contracting,
provider payments based on quality, etc. (see Section 2), to drive health sector performance. We assert
that the road to UHC is path dependent, and each country will pursue different institutional
configurations to provide health services. However, there are promising practices and key
considerations for optimizing the role of the payer, whether that payer is a social health insurance
scheme, national purchasing agency, private health insurance agency, large employer, or ministry of
health (MOH). Importantly, there are promising practices for ensuring collaboration between the payer
and other institutions working to ensure and improve quality.
The guide is designed to help countries systematically think through the institutional architecture and
mechanisms currently used in a country to govern for quality, and to provide country policymakers with
tactics for defining and clarifying institutional roles and responsibilities to ultimately optimize the role of
the payer for improving quality of care. We have identified six strategies that payers can use to improve
the quality of care. For each of the strategies, we provide key considerations and promising practices
for structuring roles and responsibilities and clear coordination and collaboration procedures between
the payer and other quality stakeholders.
1.2 How and When to Use this Guide
Policymakers could use this guide as a diagnostic tool routinely as part of strategic planning (aligned with
the planning cycle in a given country) to reflect on improvements that can be made in health governance
to strengthen the quality of care. The guide can help policymakers to develop a plan of action to
effectively link finance to quality. The use of the guide could support the development and/or
implementation of a country’s national strategic direction on improving quality, e.g., the development
and execution of national quality policy and strategy, an effort that many countries are carrying forward
When reshaping the institutional
architecture of a health system to
introduce or optimize the role of the
payer(s), the guide can facilitate a
reflection on what is working, where the
gaps are, and where roles and
responsibilities may be clarified and
coordination improved.

3
(WHO, 2018). This guide could be a valuable resource while implementing major health reforms that
involve payments and incentives for quality and the establishment or changing of health institutions and
roles. When reshaping the institutional architecture of a health system to introduce or optimize the role
of the payer(s), the guide can facilitate a reflection on what is working, where the gaps are, and where
roles and responsibilities might be clarified and coordination improved. Ultimately, we hope this guide
will be used in an iterative manner. Health system strengthening and quality of care improvement is a
continuous process.
1.3 Process of Developing the Guide
This guide was developed through a collaborative process between the authors and health care quality
and financing policymakers and experts from more than 10 countries and several international
organizations. As a first step, a literature review was conducted to identify available resources on
governing quality in health care, linking financing to quality, and defining institutional arrangements. The
findings from the literature review led to the development of:
 the framework for the role of payers in governing quality in collaboration with other actors,
 interview guides used for virtual and in-person key informant interviews, and
 an initial outline of the guide.
Key informant interviews were conducted virtually with health administrators and quality experts from
Ghana, Mexico, Nigeria, and the Philippines. Then, in August 2017, the authors and contributors
convened for a three-day product development workshop in Jakarta, Indonesia. Participants from 10
countries3 provided feedback on the framework and the outline, mapped out institutional arrangements
for quality in their countries, and shared experiences on challenges and lessons learned to inform the
content of the guide.
In addition, a qualitative research study was conducted on this topic in Indonesia, the Philippines, and
Thailand, where approximately 20-30 stakeholders in each country were interviewed in person using an
expanded version of the interview guide. The findings from this study were incorporated into the final
version of the guide, which was reviewed by a panel of health finance and quality experts (see
Acknowledgements for details).
Lastly, the Guide benefited from a pilot application in Ghana in 2018. With the support of the authors of
this guide and other international specialists, the National Quality Technical Committee (NQTC) of
Ghana used the guiding framework, the experiences of other countries, as well as the step-by-step
process for establishing effective institutional arrangements presented in the guide to develop a detailed
implementation plan for carrying out new or improved institutional arrangements.
3 Ethiopia, Ghana, India, Indonesia, Malawi, Malaysia, Mexico, the Philippines, Tanzania, and Uganda.

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2. INVOLVING PAYERS IN GOVERNING HEALTH CARE QUALITY
2.1 The Potential Roles of Payers in Quality
Before policymakers can make detailed decisions on the governance, powers, functions, roles and
structures of the payer, they first need to clarify the vision for the payer (Hawkins, 2017). At one end of
the spectrum, a payer can have a narrow role implementing the health financing policies designed by the
ministry responsible for health, while at the other end, the payer has a large role actively using health
financing levers to drive health sector performance. Countries seeking to define a larger role for the
payer in driving health care quality need to ensure provider contracting and payment mechanisms are
being used as effectively as possible to achieve objectives, including ensuring and improving quality of
health care (Ibid, 2017)
Importantly, payers often move along the spectrum over time from a limited role as the financing
operational arm of a ministry of health to a larger role with more autonomy and responsibility for using
health financing levers. Evidence from LMICs suggests that political resistance to institutional reforms
can be significant (Savedoff and Gottret, 2008), thereby underscoring the importance of step-wise
approaches to strengthening the role of the independent payer(s).
Based on the research described above, we propose six strategies, or entry points, through which
payers can engage with and leverage their influence on the health system and its stakeholders in order
to govern quality:
1. Applying quality criteria to determine provider participation eligibility
2. Incorporating quality incentives or disincentives into provider payment mechanisms
3. Applying quality criteria to benefits package design
4. Generating demand for quality
5. Investing directly in quality improvement
6. Providing non-monetary incentives for quality
Figure 2 below maps these strategies to the mechanisms or processes that may be used to execute
them, and identifies the roles and responsibilities needed for implementation. The framework builds
upon a framework for insurance-driven improvement in health care quality developed by Mate et al. in
2013.
Many, if not most, of these roles and responsibilities would be fulfilled by actors other than the payer,
including ministries of health, professional or provider associations, subnational or local health
authorities, government-owned or independent accreditation bodies, consumer or civil society
organizations, etc. However, the payer can use its power and influence to (1) focus the health system
and its stakeholders on these strategies, and (2) increase the likelihood that the strategies are effective
in enhancing quality.
Detailed descriptions of each of the strategies as well as illustrative country examples are presented in
sections 2.2-2.8. In Annex B, we present an extensive table outlining the roles and responsibilities of

5
payers and other stakeholders per strategy and execution mechanism across multiple countries
reviewed in developing this guide.
Not all of the strategies described may be feasible in the context of a given country and period.
Contextual factors (such as historical or political factors, the current institutional landscape, a country’s
economic situation, etc.) (Mate et al., 2013) should be taken into account when examining the relevance
of available strategies, and only those strategies that are deemed feasible or relevant should be
considered when roles and responsibilities in governing health care quality are defined.
Working towards a long-term goal of implementing all the strategies, including sequencing of when to
adopt each strategy, should be an objective. While the strategies often happen simultaneously and need
continuous refinement and improvements, the first three are critical in fostering quality in the design of
a payment system and the associated institutional architecture. In advanced health systems, most or all
of these strategies are employed to strengthen the role of payers to positively influence and improve the
quality of care. However, even in the most advanced health systems, strategies to improve quality --
including the roles and responsibilities for carrying them out -- must be continually reviewed for efficacy.

6
Figure 2: A conceptual framework for the role of payers in governing quality in collaboration with
other actors*
*Other quality actors may include ministries of health, professional or provider associations, subnational or local health
authorities, government-owned or independent accreditation bodies, consumer or civil society organizations, etc.

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2.2 Applying Quality Criteria to Determine Provider
Participation Eligibility
The first and most common strategy through which payers can govern quality in health care involves
linking the eligibility of providers to participate in health financing schemes to the quality of care
provided by those providers. Selective contracting is often used, meaning the payer selectively enrolls in
its scheme(s) providers that meet its quality criteria (Mate et al., 2013; McNamara, 2006). Several
approaches for measuring or monitoring quality (which we refer to as “mechanisms” for executing this
strategy) can be applied.
One of the more common ways a payer selectively contracts with providers is by using a facility’s
accreditation status to determine eligibility to participate in a scheme. In some countries, only accredited
facilities are eligible to participate in national health insurance schemes.
While a payer may use a facility’s accreditation status to determine eligibility, the process of accrediting
facilities, involving standard setting, compliance monitoring, and issuing accreditation awards, is not
necessarily a responsibility of the payer. In some countries, such as Malawi, Tanzania, and Uganda,
accreditation is conducted by the MOH. In Tanzania, the MOH has recently introduced a stepwise
certification towards accreditation system for quality in health care. However, it is envisioned that health
sector stakeholders will ultimately establish an independent accreditation body. (United Republic of
Tanzania Ministry of Health and Social Welfare, 2015) In other countries, like the Philippines, health
insurance agencies jointly or solely conduct accreditation. In still others, such as India, Indonesia, Jordan,
Malaysia, Moldova, and South Africa, it is the responsibility of an independent body. The last is
considered a best practice, as it removes a potential conflict of interest from the accreditation process.
In the Philippines, the Philippine Health Insurance Corporation (PhilHealth) “employs a two-step process
for facilities to contract with PhilHealth: certification (done by the Department of Health) and
accreditation (done by PhilHealth). Both processes are roughly identical, and administratively and
financially burdensome” (Kukla et al., 2016). A third-party accreditor could help to relieve the pressure
of resource shortages (human and financial) within PhilHealth and could enhance accountability and
transparency in the accreditation and certification process, strengthening institutional support for quality
of care. However, if facility accreditation and certification is mostly subsidized by the government, as is

8
currently the case in the Philippines, an independent accreditation body may have difficulty establishing a
sustainable revenue stream. In many countries, like Indonesia, initial subsidization by the government
was required and important when establishing an independent
body.
It should be noted that, regardless of which institution owns the
accreditation process, accreditation usually requires
collaboration among multiple stakeholders, i.e., the MOH,
provider associations, and accreditation bodies, particularly in
setting accreditation standards. In Indonesia, for example, the
MOH works with Indonesia’s Hospital Accreditation Committee
(Komisi Akreditasi Rumah Sakit, KARS) to establish the
accreditation standards, and the payer, the Social Security
Agency for Health (Badan Penyelenggara Jaminan Sosial-
Kesehatan, BPJS-K) supports district health offices in verifying
accreditation records while credentialing public facilities.
In some countries, such as India and Malaysia, accreditation is
voluntary and is not a prerequisite for participation in a scheme,
but other incentives for accreditation, whether monetary (e.g.,
differential payment rates) or non-monetary (prestige), may
exist. These are discussed in detail in 2.3 and 2.7, respectively.
The licensing of practitioners can also be used as a mechanism to
determine eligibility for participation in a scheme. In this case,
only facilities with licensed practitioners may be eligible. In most
countries, practitioner licensing is the responsibility of
professional associations, although health insurance agencies, the
MOH, or other government agencies are often involved in
setting standards for licensing. A close collaboration between professional associations and the MOH
on the licensing of practitioners is usually needed, as differences may arise between the education
standards and public health needs, as is the case in India.
In the Philippines, the Department of Health adopted the accreditation standards of PhilHealth,
incorporating them into the licensing requirements for providers (Kwon S. et al., 2011), and increasing
harmonization of requirements. In Indonesia, the Indonesian Hospital Association (Persatuan Rumah
Sakit se-Indonesia) manages subnational authorities who are responsible for issuing two-year licenses,
according to standards set by the MOH (Cashin et al., 2017). The payer (BPJS-K) selectively contracts
with providers to participate in the health insurance scheme, and uses a credentialing process to check
the status of both licensing and accreditation before a facility is credentialed. The technical criteria for
the payer’s credentialing process are set by the MOH.
Compliance with clinical guidelines is another factor that can be used to determine a facility’s eligibility
for participation in a health financing scheme. This would involve conducting a review of the facility’s
compliance with clinical guidelines to determine if that facility should be included or excluded from a
scheme. While usually the role of the MOH, intentional collaboration with all stakeholders involved in
delivering health services is useful, including involving stakeholders in clinical review and sharing results
with providers, licensing or accrediting organizations, purchasers, and clients.
Finally, ongoing performance monitoring against quality criteria can also be conducted to determine
whether a facility should participate, or continue to participate, in a scheme. In many countries, this type
of monitoring is conducted by the MOH, and results are not necessarily linked to the eligibility for
INDONESIA
In Indonesia, accreditation is
mandatory as part of the
payer’s credentialing process
for hospitals to join the
National Health Insurance
Scheme (Jaminan Kesehatan
Nasional). As a result, the
Indonesia Hospital
Accreditation Body (KARS)
now receives a sustainable
revenue stream from hospitals
to continue to support them
to reach higher levels of
accreditation and provision of
good quality health care.
The MOH is a member of the
KARS Board of Directors.

9
participation in a scheme. In Malaysia, for example, monitoring of performance against quality criteria is
conducted at multiple levels, including at the national and subnational levels, within specific programs,
and in health facilities. However, this monitoring is not tied to participation in a payment scheme. In
contrast, in Estonia, the Estonia Health Insurance Fund (EHIF) since 2002 has been selectively entering
into or renewing three-year contracts with providers by monitoring and assessing against predetermined
criteria, including geographic accessibility (e.g., proximity to patients), prices of services, and quality (e.g.,
patient complaints recorded during the last contracting period) (Jesse et al., 2005). The criteria were
redefined in 2014 to place more emphasis on quality, among other enhancements. While the current
quality indicators are more focused on inputs, it is envisioned that outcome indicators will be used for
selection in the future (Habicht et al., 2015).
In most countries, payers have not been significantly involved in setting the standards or conducting
standards monitoring directly. Instead, they rely on other stakeholders (typically MOHs or independent
agencies). Setting standards for accreditation and licensing, developing clinical guidelines, and monitoring
performance are activities that involve multiple stakeholders, including payers and providers. In several
countries, including Indonesia and the Philippines, multiple sets of standards exist, and are owned by
different institutions, often creating confusion or conflict among institutions. Given this, stakeholders
must have clear expectations for sharing information, collaborating, and communicating amongst one
another.
PROMISING PRACTICES
& KEY CONSIDERATIONS
 Selective contracting is a promising practice for payers, using credentialing criteria from accreditation,
licensing, certification, and registration as eligibility criteria for participation in a health financing scheme.
However, while linking participation eligibility to external evaluation programs, such as accreditation, is a
good practice, in isolation it does not ensure the quality of care. While external evaluation programs are
often early entry points for national improvement efforts, the evidence for their impact on quality is
variable; it is important to recognize that these approaches should be embedded within a broader
structured effort encompassing the required governance structures and a suite of effective interventions
that is appropriate for the local context (WHO, 2018).
 An autonomous accrediting body is seen as a promising practice, removing a real or perceived conflict of
interest if accreditation is led by the payer(s) or a MOH.
 When establishing a new institution, like an independent accrediting body, national subsidies may be
necessary in the short term while establishing a sustainable revenue stream. Also, payers that require
provider accreditation as part of selective contracting can help establish this revenue stream.
 Professional associations should be closely involved in developing the criteria for licensing of providers,
working closely with MOH to ensure alignment of education standards and public health needs.
 Ongoing performance monitoring against standards should be more actively harmonized between
institutions in countries to reduce the burden on providers of having to keep track of multiple sets of
standards and criteria.
 The processes of setting standards setting, developing clinical guidelines, and monitoring performance
involve multiple stakeholders. Multiple sets of standards or guidelines, owned by different institutions, may
exist, creating confusion or conflict among institutions. The stakeholders involved must have clear
expectations for sharing information, collaborating, and communicating among them.

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2.3 Incorporating Quality Incentives or Penalties into Provider
Payment Mechanisms
A second strategy through which payers can govern quality involves linking the payment mechanism(s)
to the quality of care provided. In this case, quality would be used as a basis for determining the terms
under which a payment is made to a provider, and the amount of the payment. This is often referred to
as “quality-based financing” or “quality-based payment.” Several approaches for incentivizing high quality
or penalizing low quality (which we refer to as “mechanisms” for executing this strategy) can be applied
to achieve this strategy.
Quality criteria can be used to provide bonuses to providers that deliver high-quality care. These
bonuses would serve to reward providers that deliver high-quality care, and would be provided in
addition to the basic payment to which all providers are entitled. In Kenya, the National Health
Insurance Fund offers rebates to the hospitals that receive the highest scores on their assessments (Cico
et al., 2015; Lane et al., 2014). Similarly, in Moldova, health insurance contract terms include quality, and
providers are positively rewarded based on results, such as the reduction of adverse events (Cico et al.,
2015; Shaw, 2015).
Similarly, penalties may be issued to providers that deliver low-quality care. These penalties would serve
to penalize providers that deliver substandard quality care, and would be deducted from the basic
payment to which all providers are entitled. In Thailand, the National Health Security Office, which
manages the Universal Coverage Scheme, assesses provider quality based on set standards, and penalizes
providers that deliver below-standard care by deducting payments (Hanvoravongchai, 2013).
In Indonesia, at the primary care level, capitation is used to reimburse most primary care services, and
performance incentives, Kapitasi Berbasis Komitmen (KBK), were jointly established by the national
health insurance agency, the MOH, and other stakeholders to improve the efficiency and quality of
capitated services. Under KBK, the final portion of the capitation payment is based on performance
against three indicators that are self-reported through the P-Care data system: contact rate
(target=15/1,000 members per month), referral rate, and the existence of a chronic disease management
program (Cashin et al., 2017).
Differential payment rates and/or terms may also be applied according to the quality of care provided. If
differential payment rates are applied, providers would receive payments at higher or lower rates for
the same service, depending on the quality of care provided. Differential payment terms may be in the
form of faster processing of claims for providers that deliver higher quality care. (See example on India

11
in text box right)
In Ethiopia, the health insurance agency is working to define
indicators that will serve to monitor the quality of service for
each facility. These indicators will be developed by taking into
data that are already available, a process that will be part of the
design of a payment scheme which is linked to the quality of care
received (HFG, ASSIST, JLN, 2015a). Ghana uses comprehensive
tools to assess facilities across 12 categories to determine the
level of facility and the type of services to be reimbursed by the
National Health Insurance Authority (NHIA). Grades are
assigned to facilities based on their performance during the
assessment. The rate of reimbursement is determined based on
the level of the facility (HFG, ASSIST, JLN, 2015b).
Countries like Lebanon have health financing mechanisms that
reimburse at higher rates for higher levels of accreditation
attained. However, the evidence in Lebanon on this practice
indicates that this alone is not enough to improve the quality of
care, and that case mix and outcome indicators should also be
used by the payer to ensure and improve quality, as this would
incentivize facilities to improve quality beyond the purpose of
meeting the accreditation requirements (Ammar et al., 2013).
The optimal governance arrangements for rate-setting and
quality-based payment depend on the country context.
However, regardless of which organization leads rate or tariff
setting and the establishment of associated quality criteria -- i.e.,
the MOH or the payer(s) -- an intentional, multi-stakeholder,
consultative engagement process with a clearly designated lead
should be applied. Ghana’s experience provides an example of
engaging all stakeholders from the beginning to the end so that
they have an understanding of what goes into tariff/rate setting.
Providers from both public and private facilities bring an
important and unique perspective on care delivery, and should be
involved in setting rates and determining quality metrics for
purchasing. In the Philippines, for instance, PhilHealth relies on
providers to set the case rate for reimbursement.
Ideally, rates and associated quality incentives or penalty
structures will also take into account the geographic differences
and disparities present in a country. The incentives process
should be something that is designed nationally and accepted
locally. Priorities may be different at different levels or with
changing administrations, but there should be an institution
responsible for keeping changing priorities on track. For instance,
in Thailand, the Quality Outcomes Framework used by the
National Health Security Office (NHSO), the largest payer of
health services in the country, for purchasing health services can
be adapted to reflect local needs, including both national and
regional-level key performance indicators.
INDIA
In India, now that some
coverage has been achieved,
significant discussions about
quality are beginning.
Accreditation is voluntary, but
incentives to get accredited
exist. For example, private
facilities get “bragging rights”
(e.g., the ability to display an
accreditation award as
recognition of the high quality
of their services) and public
facilities get financial
incentives.
The health standards in India
are set by national MOH and
administered at the state level.
If facilities are not rated at a
certain star rate or above,
their budgets are cut.
A state’s health budget is also
cut if a certain percentage of
facilities do not achieve star
levels. Accreditation surveys
are conducted by external
teams.
Patients are represented in
health financing decision-
making and they make
decisions on what they do
with the money for the health
facility.
Patient satisfaction surveys are
also conducted to get
feedback on the quality of
care, which then helps to
determine how money is
spent.

12
Quality monitoring to determine payment for incentives or penalties may be done by payers, providers,
self-reporting, and/or independent trusted monitors. In Ethiopia, clusters of hospitals determine who
should receive incentive payments, which are then provided to the selected facilities by the MOH. In
Indonesia, primary care providers monitor and upload data on three “quality” indicators into a data
system (P-Care) that is analyzed by the payer to determine capitated payments. Use of independent
monitoring bodies should be considered as a means to separate implementation from validation.
2.4 Applying Quality Criteria to Benefits Package Design
PROMISING PRACTICES
AND KEY CONSIDERATIONS
 An intentional, multi-stakeholder, consultative engagement process with a clearly designated lead should
be applied in setting tariffs and explicitly including quality criteria in reimbursement rates.
 Providers from both public and private facilities should be involved in rate setting.
 Financial incentives are a necessary tool, but usually not sufficient on their own, for achieving quality goals.
The structure and process for implementing the financial incentives matter a great deal, and should be
monitored and refined often.
 Regardless of who establishes the quality criteria, those criteria are often not related to health outcomes,
but instead related to outputs, i.e., number of contact rates, referrals, etc. Indicators on the efficiency and
safety dimensions of health care are often lacking. Better data sharing practices among stakeholders and
standardization of indicators are needed to track all dimensions of quality.
 Tariff setting and the quality criteria to determine incentives, penalties and/or differential payment terms
should take into account the geographic differences and disparities present in a country.
 Patients and communities should be meaningfully engaged in determining quality priorities and standards
that are aligned with the national strategic direction.

13
A third strategy through which payers can govern quality involves applying quality criteria to the process
of designing and defining benefits packages. Two main approaches for executing this strategy include
specifying quality criteria for benefits eligibility and explicitly excluding low-quality care within the
benefits package.
Specifying quality criteria for benefits eligibility involves not only defining the list of services included in a
benefits package, but also defining how those services must be provided to be eligible for payment (e.g.,
in alignment with evidence-based care and stated national clinical guidelines). For instance, clinical
practice guidelines or protocols (e.g., national standard treatment guidelines) may accompany the list of
services, outlining how care must be provided to be considered of acceptable quality and thus eligible
for payment. In France, for instance, mandatory medical guidelines (références médicales opposables) have
been used since 1993 to set coverage policy (Woolf et al., 1999; Allemand and Jourdan, 2000).
Guidelines are also associated with benefits packages in Estonia and the Philippines, where quality
standards are included in contracts with providers (Cashin et al., 2017).
As is the case with the two previous strategies, compliance with guidelines or protocols would need to
be monitored. Services that are not compliant would be considered ineligible and payment for those
services would be denied. For instance, in Ghana, claims processing is based on the MOH Standard
Treatment Guidelines. Deviations from policy are not reimbursed. If a provider does not follow the
malaria treatment protocol, for example, part of the claim will not be reimbursed. This ensures that
providers adhere to protocols, thereby encouraging quality service delivery (HFG, ASSIST, JLN, 2015b).
In Colombia, health plans compete for enrollees based on the service and quality features of their
benefits packages (Cico et al., 2015; Hsiao and Shaw, 2007). In Indonesia, the national health insurance
agency is not supposed to reimburse for inappropriate referrals, although it is not clear if this policy is
enforced (Cashin et al., 2017).
In many countries, payers determine the lists of services to be included in benefits packages in
collaboration with other stakeholders, who, in turn, establish the standards and guidelines. Usually, the
MOH leads the standards and guidelines development process, working closely with professional
associations, patient advocacy groups, accrediting bodies, etc., and the MOH, the payer(s), or an
independent group may monitor compliance with those guidelines. In some countries (e.g., Ghana and
Indonesia), roles and responsibilities are established through a legislative framework. In Ghana, the
NHIA sets and implements benefits package policy. For instance, guidelines associated with the benefits
package are set by the MOH, but the NHIA incorporates those guidelines into the benefits package,
assigning them to different insurance coverage levels.
These roles have often evolved over time. In Ghana, there was a realization that if the same institution
was both making and implementing policy, there would be no “referee.” Therefore, parliament created
the Ghana Health Service (GHS) to become the implementing, or service delivery, body, and the MOH
devolved some of its functions related to service delivery implementation to the GHS while retaining the
policymaking functions. Meanwhile, the NHIA is the purchasing body, and it also has a large role in
monitoring and accreditation.
In Tanzania, stakeholders conducted study-tours in different countries and learned from their
experiences before establishing roles, with the result that the MOH and payer functions were separated
from the beginning. However, the insurance body has evolved over time to take on a more prominent
role in quality.
In Indonesia, the primary health benefit package provided by the health insurance program and paid by
BPJS-K currently includes minimum service standards for 144 competencies outlined by the MOH. As
described by Cashin et al. (2017), “A new MOH program makes local governments accountable for 12
new minimum service standards for promotion and prevention programs related to conditions such as

14
mental health, hypertension, diabetes, tuberculosis and HIV. These services are intended to be
complementary to health insurance benefit package, and help reduce the need for curative services.”
Excluding low-quality or low-value care from benefits packages is another approach for ensuring that the
packages take quality into account. Stakeholders who are involved in developing the benefits packages
would be responsible for identifying the types of services to be excluded. In the United States, for
instance, the Centers for Medicare & Medicaid Services (CMS) has a growing list of hospital-acquired
conditions specifying many preventable errors that CMS will not reimburse, including surgical site
infections, falls and trauma, and foreign objects retained after surgery (CMS, 2018).
It is important to ensure that the benefits package spans the continuum of services for specific
conditions (e.g., diagnosis, inpatient care, outpatient care), and that the reimbursement mechanism
mandates provider communication across levels of care to share information on client cases. This, in
turn, can spur providers to provide timely, clinically appropriate, and unduplicated care (Kukla et al.,
2016).
PROMISING PRACTICES
 In many countries, payers determine the lists of services to be included in the benefits package(s),
working with the MOH (leading), providers, and professional associations who, in turn, establish the
standards and guidelines to ensure quality health service delivery across all services.
 Specifying quality criteria for benefits eligibility involves not only defining the list of services that are
included in a benefits package, but also defining how those services must be provided to be eligible for
payment.
 Guidelines are adhered to when the appropriate structures, functions, and agreement frameworks are in
place and roles are clearly assigned. Unclear roles and responsibilities often lead to tension and less than
optimal collaboration among payers, the MOH, providers, patients, etc.
 It is important to ensure that the benefit package spans the continuum of services for specific priority
conditions and the reimbursement mechanism mandates provider communication across levels of care to
share information on client cases.
 Participatory approaches involving all relevant actors should be used for identifying and defining benefits
packages.
 Learning from other countries’ experiences is a helpful capacity-building tool that country stakeholders
should employ strategically. Furthermore, learning from within the country plays a key role in developing
implementation-informed policies aimed at improving quality (WHO, 2018).

15
2.5 Generating Demand for Quality
A fourth strategy through which payers can govern quality involves generating demand for quality health
services. Demand can be generated by:
 Making information on provider quality publically available, or
 Educating people on the quality of care.
Data collection on provider and service delivery quality is often led by the MOH, with support from
accrediting bodies, empaneling bodies, district health offices, and providers (through self-assessments).
Payers sometimes collect data on quality indicators, like in Indonesia and the Philippines. Often through
the purchasing mechanisms, payers have useful data to analyze to provide insights into provider quality
(e.g., claims data, data collected for the purpose of calculating provider payments that are adjusted for
quality, etc.). Payers also have the potential to use selective contracting to ensure providers share
information on quality. For example, when assessing providers during its selective contracting process,
EHIF in Estonia awards extra points to providers using national e-health (Habicht et al., 2015).
Currently, in the majority of countries, provider quality data are not yet public. In several countries,
especially in those with advancing and advanced health systems, payers publish high-level information
(e.g., facility accreditation status) on their websites and/or encourage facilities to display it to foster
competition among providers for improved service delivery quality. There is evidence that publicizing
provider quality has had a positive effect on quality improvement initiatives (Jung et al., 2015; Hibbard et
al., 2003). In Scotland, the National Health Services’ eHealth strategy encourages patient reviews of
provider quality and the dissemination of other information on providers to help patients engage in their
own health care decision making processes and demand provider quality (The Scottish Government
2018). In Malaysia, hospitals pursue accreditation by the Malaysian Society for Quality in Health on a
voluntary basis, and publicly display their accreditation status to create demand for their services. In
Ghana and India, the MOHs display A+ facility ratings on their websites. However, general consensus
exists across countries that information on provider quality needs to be disseminated more widely.
Summarized and standardized information on provider quality, for instance in the form of scorecards,
may help patients make better decisions when choosing providers. Scorecards should be carefully
designed to help people think about the factors that are most important to them in the choice of a
provider, and to nudge them to improve their choices (Boyce et al., 2010). Decisions on the appropriate
quantitative and qualitative data to share publicly should be made through a national multi-stakeholder
engagement process, including patient advocacy groups. Regulations for publicizing data should be
clearly communicated and protected by law. The institutional roles and responsibilities for sharing data
should be clearly established, along with the avenues for disseminating data on provider quality, e.g., via
civil society organizations, the media, public administrative offices, specific websites or data repositories,

16
or directly from providers. Capacity for data analysis should be built within all the key institutions, i.e.,
the MOH, the payer, public health research institutions, etc. Ideally, there would be a coordinated and
transparent system for making the appropriate data public. Payers would work closely with the MOH,
civil society organizations, and other actors to regularly disseminate data on provider quality, and
require providers to share types of data with clients as part of selective contracting provisions.
Additionally, payers have the ability to educate citizens on the quality of care and engage them in
influencing provider quality through education campaigns as well as through patient feedback. Payers
can use selective contracting to require providers to share information on standards and guidelines, and
to collect patient feedback and provide a forum for complaints. In Indonesia, BPJS-K requires hospitals
to have a process for collecting patient complaints, and to use patient satisfaction surveys to collect
patient perceptions of service delivery quality; if the feedback is negative, hospitals must implement a
plan for improving the quality of their service delivery. If a hospital continues to fail to improve
perceptions of quality, it risks not being contracted to participate in national health insurance.
Payers can also directly share information with patients and collect patient feedback or complaints. For
example, the NHSO in Thailand directly manages a hotline that fields patient complaints. Additionally,
payers can run educational campaigns on the benefit package and quality standards -- disseminating
materials and campaign messaging through print, digital, social media and other channels -- and conduct
other social and behavior change activities. In the Philippines, patient advocacy groups are one segment
of civil society that is frequently overlooked in service quality improvements, and yet they frequently
lobby providers to improve the quality of care. PhilHealth has acknowledged that it could also benefit
from more interaction with civil society to strengthen its image and enhance the voice of beneficiaries.
However, it has yet to decide on types of forums, the degree of formalization, and the frequency of such
interactions. Thus, institutional arrangements for incorporating civil society are in need of further
development. In contrast, civil society organizations in Thailand have a strong voice and take a leading
role in elevating debate around provider quality issues that are frequently publicized through the media.
PROMISING PRACTICES
 Data collection on provider and service delivery quality is often led by MOH, with support from
accrediting bodies, empaneling bodies, district health offices, and providers (through self-assessments).
 There is evidence from advanced health systems that publicizing provider quality has positive effects on quality.
 Often through purchasing mechanisms, payers have useful data to analyze to provide insights into quality.
 Capacity for data analysis should be built in all actors, i.e. the MOH, the payer, research institutions.
 Emerging lessons on quality from the frontline should be captured and information should be shared nationally
to transform governance arrangements.
 A national multi-stakeholder engagement process, including patient advocacy groups, should be used to
determine in policy and regulation the provider information to be provided to patients, the types of questions
to answer, and feedback to collect. A need for widely disseminating data on quality exists.
 The institutional roles and responsibilities for sharing data should be clearly established, along with the avenues
for disseminating data on provider quality, i.e. civil society organizations, the media, public administrative
officers, websites, providers, etc.
 Payers can use selective contracting to require providers to share information on quality standards and
guidelines, collect patient feedback, and provide a forum for complaints.

17
2.6 Investing Directly in Quality Improvement
A fifth strategy through which payers can govern quality involves making direct investments in quality
improvement. These can be in the form of:
 Investments in the improvement of facility systems and infrastructure,
 Investments in training providers on quality concepts and quality improvement, and/or
 Support for large-scale programs to improve clinical processes and care delivery.
While financial incentives and other strategies to improve quality described in this guide can be effective,
direct investments on the supply-side are also necessary for those strategies to achieve the desired goals
(Lagomarsino et al., 2012). The MOH or other agencies typically invest directly in infrastructure or
systems, and MOHs or ministries of education are generally responsible for training providers.
However, payers may also have a role in such investments, as provider payment mechanisms can build
infrastructure or staff investment needs into rate calculations. In Kerala, India, the payer invested in
instituting electronic transfers to make payments quicker; as a result, facilities had reliable access to
income, corruption was reduced, and quality in many facilities improved (Tarantino et al., 2016). Also,
through selective contracting, payers can require providers to maintain certain training and human
resource standards and undertake infrastructure improvements.
In contexts where multiple payers, including commercial payers, may exist, government may require
payers to contribute part of their funds to infrastructure and system investments. Such examples exist
in several states of the United States, including Massachusetts, Michigan, Pennsylvania, Washington, and
Rhode Island, where payers fund investments in primary health care infrastructure and systems, including
investments in human resources and training (Center for Health Care Strategies & State Health Access
Data Assistance Center, 2014). Furthermore, in Vermont, Ohio, Iowa, and Colorado, payers invest in
health information systems, including electronic health records, health information exchanges, and
others (Center for Health Care Strategies & State Health Access Data Assistance Center, 2014).

18
Programs designed to improve clinical processes and care delivery, such as improvement collaboratives4,
have been shown to produce significant improvements in the quality of care provided in LMICs (Miller
Franco and Marquez, 2011). While quality- or performance-based payment systems alone may not be
sufficient to improve quality, aligning the design of such systems with improvement collaboratives has
been shown to result in significant improvement (Mandel and Kotagal, 2007).
In Mexico, one important challenge is that a clear definition of what is considered an investment in
quality does not exist, leaving it up to each state to make that determination. An important lesson is the
need to specify what types of investments are needed to bring up the level of provider quality, and to
establish prioritization criteria to help subnational governments make investment determinations.
2.7 Providing Non-Monetary Incentives for Quality
Lastly, a sixth strategy through which payers can govern the quality of care involves providing non-
monetary incentives for quality. These can be in the form of public recognition or awards for facilities
and providers that provide high-quality care. Such recognition can be a powerful incentive for improving
quality (Committee on Quality of Health Care in America, Institute of Medicine, 2001).
4 Improvement collaboratives refer to “coordinated efforts of teams to accelerate improvement in a single area of care
through iterative changes and peer-to-peer learning about successful changes” (Miller Franco and Marquez, 2011).
PROMISING PRACTICES
 Direct investments on the supply side are a necessary complement to other strategies to improve or
incentivize quality.
 Provider payment mechanisms can build infrastructure or staff investment needs into rate calculations.
 Through selective contracting, payers can require that providers maintain certain training and human
resources standards and undertake certain infrastructure improvements per MOH or other actors’
recommendations.
 Aligning the design of performance-based payment systems with improvement collaboratives has been shown
to result in significant improvement.
 Clarifying the types of investments that are needed to bring up the level of provider quality can help
providers and other stakeholders and actors understand where to invest.

19
Awards or recognitions are typically provided by the MOH, subnational government officials, other
agencies, or associations. In Chile, Mexico, Mozambique and Uganda, various forms of non-monetary
incentives for quality, including awards for staff or facilities, exist (Cico et al., 2015). In Indonesia, local
government units recognize top performing facilities each year through a ceremony and in the media,
and the MOH recognizes the country’s top facilities every year in the same way. In Thailand,
accreditation awards are offered during an annual ceremony held by the independent Healthcare
Accreditation Institute. Thailand also offers the prestigious Thai Quality Award spanning multiple sectors
through the Ministry of Industrial Affairs under the Foundation of Productivity Improvement. Voluntary
accreditation, which is not tied to eligibility for participation in a financing scheme or to provider
payment rates, can also be a form of non-monetary incentive. Accreditation may be seen as a sign of
prestige and recognition that a provider offers high-quality services. This is particularly true in countries
where medical tourism is well developed. For instance, in Malaysia, where accreditation is voluntary and
not tied to payments, facilities seeking to attract medical tourists have a strong incentive to pursue
accreditation. Similarly, in Thailand, facilities seeking to attract medical tourists pursue accreditation by
the Joint Commission International (JCI), regarding it as a more prestigious and internationally-
recognized award than accreditation by the HAI.
In some countries, payers recognize certain facilities as centers of excellence. In the Philippines,
PhilHealth and the Department of Health have developed award initiatives, such as Centers of
Excellence, to further incentivize providers. There is some discussion in PhilHealth about developing
special administrative licensing privileges for facilities that pursue International Organization for
Standardization (ISO)-certified facilities, using differential payment terms. Payers have an opportunity to
build in differential payment terms to encourage facilities to achieve recognition for high-quality care.
2.8 Payers’ Roles in Policy Development and Regulatory
Reforms
In addition to the roles that must be fulfilled for the implementation of the six strategies discussed
above, payers, as key actors in governing the quality of care, may have other overarching roles in setting
national policies or drafting and defining laws related to quality. Policy reform or development processes
typically require collaborative efforts among multiple stakeholders, including payers. As countries
consider national quality policy and strategies (WHO, 2018), involving payers from the beginning
provides an opportunity to optimize their role across the strategies described in sections 2.2-2.7
through multi-stakeholder engagement.
If payers are to take an active role in policy development or reform to improve the quality of care, they
should also be held externally accountable by policymakers. Policymakers should determine, though
participatory, meaningful engagement, the quality indicators and reporting mechanisms for payer
accountability, and payers should establish appropriate internal monitoring strategies to report on
PROMISING PRACTICES
 Non-monetary awards or recognitions are typically provided by the MOH, other government agencies, or
professional associations.
 Payers do have an opportunity to build in criteria for differential payment terms in selective contracting to reward
providers that receive quality awards from other institutions and/or pursue quality recognition.

20
indicators. For example, in Estonia, EHIF has a monitoring framework that includes quality indicators
related to access (waiting times for services, beneficiary satisfaction, household survey of living
conditions and income) and financial protection (level of out-of-pocket payment, coverage), among
others, and the EHIF is annually accountable to the Supervisory Board (Jesse, 2008). The EHIF
Supervisory Board is chaired by the minister of social affairs for political accountability and is comprised
of 15 members representing patient, employer, and government-nominated members including from the
Ministry of Social Affairs (Hsiao and Done, 2009).
3. ESTABLISHING INSTITUTIONAL ARRANGEMENTS
We propose a six-step process for establishing effective institutional arrangements linking health
financing to quality in a given country. This process is illustrated in Figure 3. Each step is described in
detail in sections 3.2-3.7.
Figure 3: Process for establishing effective institutional arrangements
Step 1
DETERMINE
relevant quality
strategies and
identify how
quality is
defined
Step 2
DOCUMENT
institutions
involved and
current roles &
arrangements
Step 3
IDENTIFY
gaps, overlaps,
and capacity
needs & ASSESS
how existing
arrangements
can be improved
Step 4
ENGAGE
in formal
consultation
with
stakeholders on
new
arrangements
Step 5
ESTABLISH
strengthened or
new roles and
formal
arrangements
Step 6
COMMUNICATE
new
arrangements &
BUILD
institutional and
technical
capacity
Continuously monitor effectiveness and revise to reflect changing strategies
PROMISING PRACTICES
 As countries consider national quality policy and strategies, involving stakeholders such as payers across the design,
implementation, and evaluation process provides an opportunity to optimize their role and ownership.
 Working closely with actors, policymakers should determine the quality indicators, interventions, and reporting
mechanisms for payer accountability and payers should establish appropriate internal monitoring strategies to
report on indicators.

21
How and by whom this process will be carried out may differ in each country. In some countries, this
may not be a prescriptive one-dimensional stepped approach. Regardless, it is recommended that a
working group, task force, or committee with representation from various health care quality
stakeholders be established, or an appropriate existing mechanism be identified (refer to section 3.4 for
further detail on health care quality stakeholders). In countries where a national quality policy or
strategy has recently been developed, a national quality working group or committee may already exist,
and may be an appropriate mechanism for carrying out this work (WHO 2018). In other countries,
quality management directorates, units, or boards may exist. If a new working group or other
mechanism is to be established, this would typically be done through a formal decree that describes how
the group relates to its titular head, its members, terms of reference, deliverables, and period of
existence.
Whether newly established or previously existing, this working group would be tasked with leading and
coordinating the process of establishing institutional arrangements for quality. The members of the
working group would be senior leaders of their organizations, and their role on the working group
would be to attend the group’s meetings and develop and approve the group’s recommendations.
Specific tasks would be carried out by technicians outside the working group, such as mid-level technical
staff within the member organizations, consultants, consulting firms, local universities, etc. These
individuals would carry out the necessary reviews and analyze and present them to the working group
for review and approval.
In order to be effective, the working group needs to have a sufficient budget to cover its operations. It
also needs to have clearly defined terms of reference, strong leadership, a clear decision-making process,
an effective operational plan, and oversight authority over the persons/organization implementing its
plan. Because the process of establishing, reviewing, and monitoring institutional arrangements for
quality should be ongoing, ideally aligned with planning cycles, it is envisioned that the working group
would serve an ongoing function of monitoring and course correction.
3.1 Step 1: Determining Relevant Quality Strategies and Definitions
The first step in defining roles and responsibilities for quality would be to determine the quality
strategies that are relevant in the given country. The working group should review the six strategies
described in section 2 and determine the relevance of each. The working group can accomplish this by:
 Conducting a desk review of current strategies that address quality. Examples of such strategies may
include stand-alone strategies for quality in health care (e.g., national quality strategies), strategies
for health financing or universal health coverage, broader health sector strategies (e.g., health sector
development plans), etc. (Cico et al., 2016) The desk review should also attempt to identify the
definition(s) of quality that are relevant in the specific country’s context.
 Conducting stakeholder interviews to identify any additional strategies or definitions that are not yet
documented. The working group should identify 5-10 key stakeholders to interview. To identify
relevant quality strategies and definitions, the following questions should be addressed:
o How quality is generally defined within the country/local context?

22
o To what extent do payers apply quality criteria to determine which health care providers
can receive payments?
o Payers use various payment mechanisms (e.g., salaries, capitation, and diagnosis-related
groups (DRGs)) to reimburse providers. Are these payments adjusted for quality?
o Are there standard benefits packages in place that specify which services are eligible for
reimbursement? Are these packages adjusted for quality?
o Do payers play a role in assisting or encouraging patients to select higher quality providers
(e.g., by publicizing provider quality data, educating patients)?
o Do payers make direct investments in quality improvement (e.g., facility infrastructure or
systems, quality training for providers, large-scale programs to improve clinical processes
and care delivery)?
o Do payers provide non-financial incentives to encourage quality improvement (e.g., public
recognition or awards to providers or facilities for high quality of care)?
In addition to identifying quality strategies, the two methods described above should also be used to
inform the following two steps along the process of establishing institutional arrangements for quality:
documenting current arrangements (described in section 3.2), and identifying gaps, capacity needs and
areas for improvement (described in section 3.3). Annex A includes a list of sample stakeholder
interview questions. These questions should be revised based on information already known by
members of the working group, and tailored to the stakeholder being interviewed.
3.2 Step 2: Documenting Current Arrangements
A starting point in documenting current institutional arrangements is for the working group to identify
all the institutions involved in executing each of the quality strategies identified in section 3.1, and to
map out current roles. This information can be summarized in a table format as follows, to facilitate
subsequent analysis.
Table 1: Documentation of current institutional arrangements
Role/Responsibility
Currently
Fulfilled
(Yes/No)
Leading
Institution /
Actor
Additional
Institutions /
Actors
Involved
Existing
Formal or
Informal
Mechanisms
for Interaction
Among
Leading and
Additional
Actors
Laws or
Regulations
that Mandate
Current
Arrangements
Set accreditation
standards*
Yes* Health Facilities
Regulatory
Agency*
Pharmacy
Council,
National Health
Insurance
Authority*
Technical
Working
Group*
Health
Institutions and
Facilities Act
2011 (Act 829)*
*The information included in the table is an example of one role/responsibility from Ghana, intended to illustrate how the table
may be completed with the relevant information.

23
Based on the relevant strategies identified for regulating and incentivizing quality by involving payers,
only the appropriate roles and responsibilities associated with those strategies (refer to Figure 2) should
be listed in Table 1. The next step is to identify leading and additional or secondary actors involved in
carrying out those roles and responsibilities, and to describe existing mechanisms, whether formal or
informal, for interaction among those actors. To collect this information, a desk review as well as
stakeholder interviews may be conducted, as described in section 3.1. In addition to reviewing strategies
that address quality, the desk review should also involve reviewing relevant legislation, including but not
limited to legislation that addresses health reform, health financing, health care quality, patient rights or
safety, provider or facility registration, certification, accreditation, or licensing. (Cico et al., 2016)
The following questions should be addressed about each role or responsibility:
 Is the role or responsibility currently fulfilled?
 Which institution or actor has the primary responsibility for carrying it out?
 Which other institutions or actors are involved?
 How do these institutions or actors interact with regard to the fulfillment of this role or
responsibility?
 Which laws or regulations, if any, mandate the current arrangements?
3.3 Step 3: Identifying Gaps, Capacity Needs, and Areas for
Improvement
Challenges may result from the absence of clearly defined roles, conflicting roles, weak enforcement,
weak organizational capacity, or weak collaboration among various institutions. After current
arrangements have been documented and are well understood, a second step would be to analyze that
information for the purpose of:
 Identifying gaps, ineffectiveness, or overlap in current arrangements. These could include, among
other issues, roles or responsibilities that are not currently being fulfilled because no institution or
actor has been designated to fulfill them; because roles or responsibilities are not optimally assigned
and/or are not effective in achieving the desired outcomes; or because multiple actors are
responsible for fulfilling the roles and responsibilities without a clear delineation of tasks.
 Identifying institutional and technical capacity needs. This could include identifying both the capacity-
building needs of institutions and their staff to fulfill current roles and responsibilities, as well as the
capacity building required for new arrangements to be implemented.
Examples and best practices/advantages and disadvantages of institutional arrangements from other countries
(described in section 2) should be considered here.
The outcome of this step would be a set of options for improved arrangements, to be reviewed with
stakeholders.

24
3.4 Step 4: Engaging Stakeholders
The options for improved arrangements identified in step 3 should be reviewed through a participatory
process, in a consultation with quality stakeholders. A workshop format with 20-30 stakeholders is
recommended. All stakeholders currently fulfilling specific roles in quality, or envisioned to do so in the
future, should be represented, as illustrated in Figure 4.
Figure 4: Health care quality stakeholders
The objective of the workshop would be to identify and agree on new or improved arrangements for
governing the quality of health care, and to develop a plan for institutionalizing these new arrangements.
Agenda items should include:
 Presenting and validating findings from the documentation of current arrangements and the analysis
of gaps and capacity needs;
 Reviewing options for improving arrangements, including examples from other countries, and
agreeing on the most feasible options;
 Developing a timeline and plan (including a capacity-building plan) for implementing the new
arrangements.
An example of a workshop agenda from the Ghana pilot application of this guide is included in Annex C.
The working group could be tasked with coordinating the workshop, including developing the list of
participants and finalizing the agenda. To ensure neutrality in a context where conflict among various
institutions may exist, it is recommended that the workshop be facilitated by an independent facilitator
who does not represent any of the main institutions involved. If budget allows, this facilitator could be
an independent local consultant with knowledge of the topic and of the country’s health sector.
Alternatively, members of the working group could serve as co-facilitators.

25
3.5 Step 5: Establishing Formal Arrangements
Once the stakeholder validation has taken place, the most feasible way forward for defining or redefining
institutional arrangements should be identified and an implementation plan should be drafted, as
described in section 3.4. The plan can be presented in a table format, as illustrated in Table 2.
Table 2: Implementation plan for establishing institutional arrangements to link health financing to
the quality of care
Mechanism / option
for improvement
Tasks or actions
to be taken to
achieve the
desired
improvement*
Responsible
institution / actor
Supporting
institutions /
actors
Timeline for
completion
* Tasks or actions may address the following categories: building institutional and technical capacity; communicating strategically
to build support for the change; engaging in advocacy for decision makers; drafting legislation or legislative amendments;
obtaining formal approvals; communicating new/revised arrangements to stakeholders; and any other actions deemed necessary
for the improvements to be achieved.
The plan should address all the steps required to formalize the new arrangements, including but not
limited to:
 drafting legislation or legislative amendments to reflect the new arrangements;
 obtaining formal governmental approvals for the new arrangements to take effect;
 communicating strategically with providers or the population to support any changes in behaviors or
relationships needed to implement the new arrangements (especially when changing health benefits
policy and provider payment mechanisms); and
 engaging in advocacy for decision makers to adopt the recommended arrangements (e.g., developing
advocacy materials, including policy briefs, etc.).
The process of establishing formal arrangements would involve completing the relevant steps outlined in
the implementation plan. These steps will enable the new arrangements to take effect.
Ultimately, optimal institutional arrangements must:
 balance power among the institutions involved,
 avoid conflict of interest,
 consider contextual factors, and
 be clearly defined.
3.6 Step 6: Communicating Arrangements and Building Capacity
The implementation plan should also outline steps that need to be taken beyond the formal
establishment of the new institutional arrangements. These additional steps, which would address the
successful implementation and effectiveness of the arrangements, include:
 Communicating the new arrangements to all institutions and stakeholders involved. This may require
targeted communication efforts, including issuing written guidance and conducting information

26
sessions to ensure an understanding of the implications of the new arrangements for the roles and
responsibilities of each institution.
 Building institutional and technical capacity to implement the new arrangements. The implementation plan
should also outline steps to build both institutional and technical capacity, based on the gaps and
needs identified through the review. Once the new arrangements are approved, the capacity-
building plan should be implemented and monitored to ensure that each institution involved is able
to effectively implement them. This will ensure that the new arrangements work as intended.
3.7 Monitoring Effectiveness and Revising Arrangements
Recognizing that needs may evolve over time, and quality strategies will likely be updated to reflect
emerging needs, the process outlined above may need to be repeated periodically (possibly to coincide
with the development of new quality strategies or health sector plans) to ensure that the institutional
arrangements that have been put in place are adequate and appropriate. At a minimum, steps 1-3 would
need to be repeated to determine whether institutional arrangements for quality are effective and will
allow for the successful implementation of new strategies.

27
ANNEX A: SAMPLE STAKEHOLDER INTERVIEW QUESTIONS
1. What does quality improvement in health care mean to you?
a. Where did you first hear this concept?
b. Who uses this concept?
2. To what extent do payers in [COUNTRY] apply quality criteria to determine which health care
providers can receive payments from them?
a. What are the criteria (e.g. accreditation, licensing, compliance with clinical
guidelines, ongoing performance monitoring, etc.)?
b. Who established them?
c. Who monitors whether they are met?
3. Payers use various payment mechanisms (e.g., salaries, capitation, and DRGs) to reimburse
providers. Now we want to better understand how these payments may or may not be adjusted
for quality in [COUNTRY].
a. What quality incentives/disincentives are incorporated into these mechanisms, if
any (e.g., bonuses, penalties, differential payment rates/terms, etc.)?
b. Who develops and selects the quality indicators associated with these
mechanisms? How does this work? What is the process?
c. Who determines bonus/penalty amounts, or establishes differential payment
rates/terms?
d. Who monitors provider quality against the established indicators?
4. Are there standard benefits packages in place in [COUNTRY] that specify which services are
eligible for reimbursement?
a. To what extent were quality considerations taken into account in their design
(e.g., do they exclude low quality or low value care)?
b. Are any quality criteria in place that determine benefit eligibility? If so, what are
they?
c. Who established these quality criteria?
d. Who monitors whether these criteria are being met?
5. Do payers in [COUNTRY] play a role in assisting or encouraging patients to select higher
quality providers (e.g., by publicizing provider quality data, educating patients)?
a. Are data on provider quality publicly available (if so, ask about frequency and
perceived accuracy)? What kinds of indicators are available?
b. Who developed the quality measurement criteria/indicators?
c. Who measures these indicators?
d. Are payers directly conducting or collaborating with other actors to conduct
public education campaigns on the quality of care?
6. Do payers in [COUNTRY] make direct investments in quality improvement (e.g., facility
infrastructure or systems, quality training for providers, and/or large-scale programs to improve
clinical processes and care delivery)?

28
a. If so, who determines investment needs, training needs, and/or areas for
improvement?
7. Do payers in [COUNTRY] provide non-financial incentives to encourage quality improvement
(e.g., public recognition or awards to providers or facilities for high quality of care)?
a. If so, who sets the criteria and who selects the providers of facilities that will
receive the incentives?
8. In your opinion, to what extent do you feel that payers have clear roles and responsibilities in
promoting the quality of care in [COUNTRY]?
a. Do these conflict or overlap with roles of any other actors? How so?
b. What could be done to more clearly define these roles and responsibilities?

29
ANNEX B: COUNTRY EXAMPLES OF ROLES AND RESPONSIBILITIES FOR
EXECUTING QUALITY STRATEGIES
Roles and Resp. Ethiopia Ghana India Indonesia Malawi Malaysia Mexico
The
Philippines
Tanzania Uganda
1. Applying quality criteria to determine provider eligibility
Set accreditation
standards
Health
insurance
agencies
Other
government
agencies
MOH
department
s or units
MOH
department
s or units
Independent
bodies
MOH
department
s or units
Independent
bodies
Other
government
agencies
Health
insurance
agencies
MOH
department
s or units
MOH
department
s or units
Conduct
accreditation
survey
Health
insurance
agencies
Other
government
agencies
Subnational
government
entities
MOH
departments
or units
Independent
bodies
MOH
departments
or units
Independent
bodies
Health
insurance
agencies
MOH
departments
or units
MOH
departments
or units
Award
accreditation
Health
insurance
agencies
Other
government
agencies
Subnational
government
entities
Independent
bodies
MOH
departments
or units
Independent
bodies
Health
insurance
agencies
MOH
departments
or units
MOH
departments
or units
Set licensing
standards
MOH
departments
or units
MOH
departments
or units
Professional
associations
Professional
associations
Other
government
agencies
Review
practitioner
credentials
Professional
associations
Subnational
government
entities
Professional
associations
Professional
associations
Professional
associations
Health
insurance
agencies
Professional
associations

30
The
Philippines
Tanzania Uganda
Award licenses Professional
associations
Subnational
government
entities
Subnational
government
entities
Professional
associations
MOH
departments
or units
Professional
associations
Professional
associations
Professional
associations
Develop clinical
guidelines
MOH
departments
or units
MOH
departments
or units
Subnational
government
entities
Professional
associations
MOH
departments
or units
Other
government
agencies
Professional
associations
MOH
departments
or units
MOH
departments
or units
Monitor
compliance with
clinical guidelines
MOH
departments
or units
Health
insurance
agencies
Other
government
agencies
Subnational
government
entities
Facilities or
individual
providers
MOH
departments
or units
Facilities or
individual
providers
MOH
departments
or units
Health
insurance
agencies
Professional
associations
MOH
departments
or units
Set quality
criteria for
ongoing
performance
monitoring
Health
insurance
agencies
Other
government
agencies
Subnational
government
entities
MOH
departments
or units
MOH
departments
or units
Independent
bodies
Health
insurance
agencies
MOH
departments
or units
Monitor
performance
against quality
criteria
MOH
department
s or units
Subnational
government
entities
Other
government
agencies
Subnational
government
entities
MOH
departments
or units
Other
government
agencies
MOH
departments
or units
Health
insurance
agencies
Professional
associations
2. Incorporating quality incentives or disincentives into provider payment mechanisms

31
The
Philippines
Tanzania Uganda
Determine
quality priorities
MOH
departments
or units
MOH
departments
or units
MOH
departments
or units
MOH
departments
or units
MOH
departments
or units
Health
insurance
agencies
MOH
departments
or units
MOH
departments
or units
Develop quality
indicators
MOH
department
s or units
Health
insurance
agencies
Other
government
agencies
MOH
departments
or units
Health
insurance
agencies
MOH
departments
or units
Other
government
agencies
MOH
departments
or units
Health
insurance
agencies
MOH
departments
or units
Determine
bonus/penalty
amounts or
establish
differential
payment
rates/terms
Health
insurance
agencies
Subnational
government
entities
MOH
department
s or units
Health
insurance
agencies
MOH
departments
or units
MOH
department
s or units
Health
insurance
agencies
Other
government
agencies
Subnational
government
entities
MOH
departments
or units
MOH
departments
or units
Monitor/measure
provider quality
against
established
indicators
Health
insurance
agencies
Subnational
government
entities
Health
insurance
agencies
MOH
departments
or units
MOH
department
s or units
Health
insurance
agencies
Other
government
agencies
Subnational
government
entities
MOH
departments
or units
MOH
departments
or units
Calculate and
issue payments
based on
Health
insurance
agencies
Subnational
government
entities
MOH
department
s or units
MOH
departments
or units
Health
insurance
agencies
MOH
departments
or units
MOH
departments
or units

32
The
Philippines
Tanzania Uganda
performance
against quality
criteria
Health
insurance
agencies
Other
government
agencies
Subnational
government
entities
3. Applying quality criteria to benefits package design
Define benefits
package
Health
insurance
agencies
MOH
department
s or units
Subnational
government
entities
MOH
department
s or units
MOH
departments
or units
Health
insurance
agencies
Health
insurance
agencies
MOH
departments
or units
Develop clinical
guidelines to be
associated with
benefits package
MOH
department
s or units
Health
insurance
agencies
Subnational
government
entities
Professional
associations
MOH
departments
or units
MOH
departments
or units
MOH
departments
or units
MOH
department
s or units
Professional
associations
Monitor
compliance with
guidelines
Health
insurance
agencies
Other
government
agencies
Subnational
government
entities
MOH
department
s or units
MOH
departments
or units
Subnational
government
entities
Health
insurance
agencies
4. Generating demand for quality
Establish quality
measurement
criteria/indicator
s
MOH
department
s or units
Subnational
government
entitites
MOH
department
s or units
Health
insurance
agencies
Health
insurance
agencies
Measure
provider quality
Subnational
government
entities
MOH
department
s or units
MOH
department
s or units
MOH
department
s or units
Health
insurance
agencies
Subnational
government
entities
Health
insurance
agencies

33
The
Philippines
Tanzania Uganda
Publish provider
quality
information
Health
insurance
agencies
Subnational
government
entities
MOH
department
s or units
MOH
department
s or units
MOH
department
s or units
Health
insurance
agencies
MOH
department
s or units
Conduct public
education
campaigns to
raise patient
awareness of
quality of care
Subnational
government
entities
MOH
department
s or units
Health
insurance
agencies
Subnational
government
entities
Professional
associations
Civil society
Determine
systems and
infrastructure
invesments
needed to
improve quality
Subnational
government
entities
MOH
department
s or units
MOH
department
s or units
Subnational
government
entities
MOH
department
s or units
Subnational
government
entities
Private
sector
MOH
department
s or units
Private
sector
MOH
department
s or units
MOH
department
s or units
Subnational
government
entitites
Facilities or
individual
providers
Private
sector
MOH
departments
or units
5. Investing directly in quality improvement
Determine
provider training
needs
Subnational
government
entities
MOH
department
s or units
Other
government
entities
MOH
department
s or units
Other
government
entities
Establish traning
curricula
MOH
department
s or units
Other
government
entities
Private
sector
Determine areas
for improvement
Design
improvement
programs

34
The
Philippines
Tanzania Uganda
Implement
improvement
programs
6. Providing non-monetary incentives for quality
Determine
selection criteria
for public
recognition or
awards
MOH
department
s or units
Subnational
government
entities
MOH
department
s or units
Health
insurance
agencies
Professional
associations
MOH
department
s or units
MOH
department
s or units
Other
government
agencies
Professional
associations
MOH
department
s or units
Health
insurance
agencies
MOH
department
s or units
Subnational
government
entities
MOH
department
s or units

35
ANNEX C: GHANA’S EXPERIENCE USING THIS GUIDE
In May and June 2018, a team of four health governance specialists from the HFG project provided
assistance to the Government of Ghana to complete steps 1-4 of the process for establishing and
strengthening institutional arrangements for governing the quality of health care. This support served as
a practical application of Defining Institutional Arrangements when Linking Financing to Quality Health Care: A
Practical Guide. The expected outcomes from the pilot were:
 A mapping of new or strengthened institutional roles and relationships, to address current priorities
and challenges, and
 A detailed implementation plan with timelines and tasks that involve advocating for, formalizing,
communicating, and building capacity to successfully carry out the new arrangements.
Ghana in 2018: Governing health care quality and UHC5
Ghana’s National Health Insurance Scheme (NHIS) was established by an Act of Parliament in 2003 (Act
650) to provide financial risk protection against the cost of health care services for all residents of
Ghana. In 2012, the law was revised to address some of the operational challenges in management of the
scheme. The object of the Scheme is to attain universal health insurance coverage for residents and
those visiting the country. The National Health Insurance Authority (NHIA) is the corporate body
mandated to implement the NHIS and is governed by a Board of Directors. The new NHIS Act of 2012
(Act 852) establishes a unitary scheme with offices across the country – Head Office, Regional Offices,
and District Offices. In recent years, UHC and the NHIS functioning has been marred by underfunding
of the NHIS resulting in late payments to providers for care.
Improving quality of health care is the responsibility of the Ministry of Health, its agencies, health NGOs,
the communities and patients/clients. Various structures and systems are in place to ensure quality in
health care. These include systems for regulation, accreditation and credentialing, medical audits,
development of clinical protocols, guidelines and standards, peer reviews, quality improvement,
monitoring and supervision. The Health Facilities Regulatory Agency (HeFRA) was established as an agency
of the MOH by the Health Insurance Facilities Act of 2011 to license facilities for the provision of public
and private health care services, among other roles. Since that time, however, HeFRA has been unable to
fulfill that role completely due to underfinancing and a lack of capacity.
In December 2016, the Government of Ghana, under the leadership of the Ministry of Health, developed
the National Healthcare Quality Strategy (NHQS) 2017-2021 which established the National Quality
Technical Committee (NQTC) as the governing body responsible for implementation, monitoring and
oversight of the strategy. As a result, in 2017, a push began to increase HeFRA’s capacity, which as of
2018 included the accreditation of a limited number of private sector facilities. In recent years, partnership
5 Adapted from “Ghana: Governing for Quality Improvement in the Context of UHC,” HFG project with ASSIST project and
the JLN. 2016.

36
with an international NGO has contributed to the implementation of large scale quality improvement
initiatives in the country.
How the guide was used
HFG collaborated closely with the MOH and the NHIA - on behalf of the NQTC - in the planning and
implementation of the entire activity.
Step 1: Determining Relevant Quality Strategies and Definitions
The HFG team conducted a desk review of current strategies in Ghana that address quality in health
care and conducted stakeholder interviews to identify any additional strategies or developments in the
governance of quality that are not yet documented. With this research, the team used the template in
the guide “Table 1: Documentation of current institutional arrangements” to track preliminary findings
including:
 which of the six strategies for governing quality proposed in the framework are relevant to Ghana’s
context,
 institutions involved in implementing the relevant strategies and current institutional arrangements,
and
 gaps or challenges arising from existing arrangements to be addressed.
Step 2: Documenting Current Arrangements
The HFG team met with Vivian Addo-Cobbiah, Acting Director of Quality Assurance for the National
Health Insurance Agency, and Dr. Ernest Asiedu, Head of Quality Management Unit in the Ministry of
Health, prior to the workshop to discuss its objectives. This was to be the second quarterly meeting of
the National Quality Technical Committee, which would facilitate institutionalization of the
implementation plan. As such, the HFG team worked with local government partners to ensure that
adequate space was dedicated to working through the business and structure of subsequent meetings in
addition to fulfilling the workshop’s objectives. In addition to this, the HFG team conducted a
preliminary mapping of the roles and relationships for linking financing to quality in healthcare, so that
workshop participants had something to build upon during the exercise on the first day.
Step 3: Identifying Gaps, Capacity Needs, and Areas for Improvement
The team then co-facilitated with the Ministry of Health a stakeholder engagement workshop. In this
case, the workshop was comprised of members of the NQTC, which includes members of a broad
cross-sectoral group of stakeholders. At the workshop, the team presented and validated the findings of
the landscape analysis. The HFG team spent a significant amount of time reviewing in detail potential
strategies that are described in the guide, and sharing international examples of each.
The NQTC identified areas of weakness in the implementation of the NHQS related to the capacities,
roles and relationships of the various organizations engaged in quality improvement and assurance. The
group reviewed options for improving institutional arrangements and examples from other countries
and agreed on priorities for strengthening governance of quality through institutional role and
relationship improvements.

37
Through this workshop pilot, the NQTC identified the following governance challenges to be the most
pressing:
A. Incorporating quality incentives when linking financing to quality
B. Linking eligibility to provider payment
C. Generating demand for quality
D. Investing directly in quality improvement
Step 4: Engaging Stakeholders
Stakeholders were engaged throughout the pilot to various degrees. When discussing the workshop
aims with Ghanaian government partners, it became clear that there was a need to slightly adapt the
HFG workshop objectives to fit the needs of the NQTC. This committee is responsible for carrying out
the National Healthcare Quality Strategy and they had already begun to develop some tools to support
an implementation plan. For this reason, the HFG team allotted time and space in the two-day agenda
for the Quality Management Unit of the MOH to coordinate its program of work with the NQTC. This
involved introductions with the assembled stakeholders at the outset of the workshop and a business
meeting of sorts embedded into the second day of the workshop. The June 2018 two-day workshop was
an effective forum to validate and discuss the mapping of existing institutional roles and relationships, as
the meeting spawned a great deal of discussion and some surprising debate. Through group exercises,
discussion, report-outs and feedback sessions, a number of challenges and weaknesses in the existing
governance of health care quality regime emerged. The benefit of this long meeting was that it allowed
for debate and consensus, thus increasing the validity and usability of the resulting conclusions.
By the end of the second day, the NQTC had identified the most feasible options – five priority
interventions - for addressing the most pressing challenges including new or enhanced institutional roles
and relationships and drafted an implementation plan for the first of the priority interventions to more
effectively link finance to quality.
Step 5: Establishing formal arrangements
Through group work and a facilitated prioritization process, the stakeholders agreed on the following
five strategies to prioritize in addressing the challenges identified:
Challenge Strategies (in order of priority)
Incorporating quality incentives
when linking financing to quality
1. Separate the role of the payer and the regulator for
quality assurance
In practice the functions are both fulfilled by NHIA but it is proposed
that HeFRA be empowered to fulfill the regulator function
Linking eligibility to provider
payment
2. Build the capacity of HeFRA
With capital investment, technical assistance, human resources,
and establish regional HeFRA offices.

38
Generating demand for quality 3. Educate patients to demand quality services
Through a number of strategies using media, provider
communication techniques and other means.
Investing directly in quality
improvement
4. Establish a system for knowledge sharing
5. Empower the MOH’s Quality Management Unit to
enforce quality standards
The group developed a first draft of a detailed implementation plan for the first strategy above, with
activities, timelines, responsible organizations and measureable milestones. An outline of a complete
implementation plan was drafted to align with the National Healthcare Quality Strategy and to be
executed in subsequent quarterly meetings by the NQTC.
As a result of this activity, the use of the guide facilitated the NQTC in moving further along its path
towards strengthening the quality of care, while identifying strategic entry points for the payer to more
fully realize its role in quality assurance and quality improvement.
Lessons learned
One of the challenges HFG faced when conducting this workshop was aligning the objectives of the
guide with the objectives laid out in Ghana’s new National Healthcare Quality Strategy. In the time that
had passed since the strategy was developed, some new challenges had emerged which were articulated
in the workshop. Surprisingly, a significant number of individuals on the NQTC were not well-informed
about what exactly various agencies are doing in this space, which suggests that there was significant
scope for this activity. Occasionally, HFG helped to mediate conversations when confusion led to
frustration. Ghana is quite far along in thinking through some of the issues related to quality and at times
suggestions provided by the HFG team would have been intractable given the number of compromises
and level of consensus for key issues among the assembled stakeholders if it weren’t for the progress
made to date on aligning priorities and developing a unified vision for achieving improved quality of care.
In the future, a facilitated workshop as this one would benefit from 1) longer time spent in country (2-3
weeks) consulting stakeholders and completing a more thorough mapping and assessment prior to the
workshop, 2) a longer workshop, but with more space for discussion among the sessions, as well as
deliberation about the current National Healthcare Quality Strategy, which some participants were less
familiar with than others, 3) clearer ways for HFG or another project to support implementation of the
plan with technical assistance where needed after the workshop has ended.
The team concluded that the guide may be difficult for country participants to use “off the shelf” without
expert facilitation. If policy-makers do want to use the guide without specialized technical support, then
it is recommended that they spend a significant amount of time before meeting to review the guide, and
to map their understandings of current roles and responsibilities. With signification preparation, a group
discussion of stakeholders and policymakers using the framework and templates in the guide could be
well-structured and productive. The team has made some adjustments to one of the templates in the
guide, based on the experience of the workshop.

39
Workshop Agenda
DEFINING INSTITUTIONAL ARRANGEMENTS WHEN LINKING FINANCING TO QUALITY IN HEALTH CARE IN GHANA
STAKEHOLDER ENGAGEMENT WORKSHOP
Date: June 20th
-21st
, 2018
Location: Food and Drug Administration Building, Accra
OBJECTIVES:
The Stakeholder Engagement Workshop aims to:
1. Increase understanding of how linking health financing to the quality of care is impacted by
institutional roles and relationships in Ghana,
2. Identify where and how the roles and relationships of institutions can be strengthened to improve
the link between health financing and quality,
3. Agree on the most feasible options for improving institutional arrangements to effectively link health
financing to quality, and
4. Develop an implementation plan for strengthening existing roles and relationships and/or
establishing new arrangements.
DAY 1: June 20th, 2018
8:30-9:00 Registration
9:00-9:30 Session 1: Welcome Remarks, Introductions, and Objectives
9:30-10:15 Session 2: Presentation of the Baseline Assessment on the Implementation of the National
Healthcare Quality Strategy (NHQS) and Discussion of the Guidelines for Implementing
the NHQS at the Sub-National Level
Objectives:
 Present the results of the baseline assessment on the implementation of the NHQS
 Discuss the guidelines on supporting Regional Quality Management Units (RQMUs)
to implement the strategy at their level and subsequently support the District
Quality Management Units (DQMUs) and the facility Quality Management Teams
(QMTs).
10:15-10:45 COFFEE BREAK
10:45-11:30 Session 3: Overview of the Practical Guide for Defining Institutional Arrangements When
Linking Financing to Quality in Health Care
Objectives:
 Provide brief background on the guide, its purpose, and development process
 Present the framework to highlight all the possible links between health financing
and quality of care
 Present the proposed process for strengthening institutional arrangements for
quality
11:30-12:30 Session 4a: Mapping of the Institutional Roles and Relationships Linking Health Financing
to Quality in Ghana

40
Objectives:
 Present landscape analysis findings
 Group work to corroborate, clarify, and supplement the findings
12:30-1:30 LUNCH BREAK
1:30-2:00 Session 4b: Mapping of the Institutional Roles and Relationships Linking Health Financing
to Quality in Ghana
Objectives:
 Continuation of group work to corroborate, clarify, and supplement the findings
 Group report-outs
2:00-3:30 Session 5a. Review Options for Strengthening Institutional Arrangements to Link Health
Financing to the Quality of Care
Objectives:
 Present promising practices and experiences from other counties
 Identify and agree on the gaps, ineffectiveness, or overlap in current arrangements
 Identify options for strengthening institutional roles and relationships to link health
financing to quality of care in Ghana
3:45-4:45 Session 5b: Group Report-out of Options for Strengthening Institutional Arrangements to
Link Health Financing to the Quality of Care
Objective: Document the options for strengthening institutional arrangements to link health
financing to the quality of care
4:45-5:00 Summary and Preview of Day 2
DAY 2: June 21st
, 2018
8:30-9:00 Registration
9:00-9:30 Session 6: Recap and Review of the Agenda for the Day
9:30-10:30 Session 7: Prioritization of Options for Strengthening Institutional Roles & Relationships
Objectives: Prioritize options to strengthen institutional arrangements to link health
financing to the quality of care
11:00-12:30 Session 8: Develop an Implementation Plan
Objectives: Using the practical guide presented in session 3 and the options for
improvement agreed upon during session 7, develop a plan with specific tasks for
strengthening arrangements.

41
12:30-1:30 LUNCH BREAK
1:30-4:30 Session 9: Discussion on Other Quality Healthcare Issues
Objectives: Discuss other issues related to quality healthcare, focusing on:
1. Emergency management
2. Referral challenges
3. “No bed” syndrome
4:30-4:45 Next Steps and Closing Remarks

42
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