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Table 3 Governance practices in FMCHP in Enugu State

From: Scaling-up strategic purchasing: analysis of health system governance imperatives for strategic purchasing in a free maternal and child healthcare programme in Enugu State, Nigeria

Principles Themes Sub-themes
Strategic vision Autonomy of purchaser and providers Dysfunctional inter-organisational relationships
Lack of purchaser-provider split
Selection of health facilities Absence of selective contracting/ accreditation of providers
Financial oversight Existence of financial monitoring committee
Participation and consensus orientation Participation in benefit package design Weak stakeholder participation in formulation and implementation of evidence of tax payment
Participation in provider monitoring Lack of clarity about position of Local Health Authority Secretaries
Participation in reimbursement process Disengagement of Local Health Authority Secretaries in reimbursement process.
Rule of law Enforcement of reimbursement standards Delays in reporting claims, vetting claims and approval and transfer of funds to providers
  Revised reimbursement process to reduce delays
  Quality assurance visit to health facilities by vetting team
Transparency Transparency of benefit package design Misinterpretation of evidence of income tax payment by providers and district-level policymakers
Transparency in reimbursement process Inflation of claims by providers, district officials and vetting officers
  Resistance to financial monitoring committee from State Health Board officials
Responsiveness Need-based resource allocation Service delivery gaps because resources for free care allocated to providers are not need-based
  Effective return of user fees/ informal payments
Equity and inclusiveness Equity in access to free care Rural-urban health workforce imbalances favoured urban areas
  Lower use of free care in rural areas than urban areas due to evidence of tax payment and service delivery gaps
Effectiveness and efficiency Functioning of FMCHP institutional structures. Dysfunctional Steering and Implementation Committees of FMCHP
  Ministry of Health and State Health Board usurped functions of Steering and Implementation Committees
  Use of FMCHP funds for other purposes
  Non-existent district implementation committees
Accountability Citizen-driven accountability Purchaser and providers weakly accountable to users
  Civil society organisations champion delinking of entitlements from evidence of income tax payment
Intelligence and information Generation and use of data Transition of state tertiary hospital from primary care provider to referral centre evidence-driven
  Policy change in reimbursement of providers informed by evidence
  Lack of information technology-driven provider payment system.
Ethics Ethical standards of care Preference for fee-paying users by providers
  State tertiary hospital refuses referrals from lower facilities
  Rationing of free services even in emergencies