This study discusses findings from comparative case studies of the governance of health services purchasing agencies in 10 eastern European and central Asian countries established over the past 30 years, and the relationship between governance attributes, institutional development, and the progress made in strategic purchasing. The feasibility and effectiveness of implementing international recommendations from the health sector and wider public sector governance literature and practice are also discussed. The study finds that only those countries that have transitioned from middle to high-income status during the study period have been successful in comprehensively and consistently implementing internationally recommended practices. Moreover, these countries have made varying progress in developing capable purchasers with technical and operational independence, as well as advancing strategic purchasing. However, the current middle-income countries (MICs) in the study have implemented only certain elements of recommended governance practices, often superficially. Notably, the study reveals that some international recommendations, particularly those related to higher degrees of purchaser autonomy and the associated governance structures observed in western European social health insurance funds, have proven challenging to implement effectively or sustain in the MICs. None of the MICs succeeded in strategic purchasing beyond a limited agenda or scale, and even then, only implementing and sustaining them during favorable conditions. Difficulties in maintaining these achievements can be attributed, in part, to governance deficiencies. However, setbacks are commonly linked to periods of political and economic instability, which in turn lead to fluctuations in policy priorities, institutional instability, and inadequacies in health budgets. The study findings point to some actions related to civil society and stakeholder engagement, accountability frameworks, and digitalization in MICs that can facilitate continuity in health reforms and the functioning of purchasing institutions despite these challenges. The findings of the study provide important lessons for countries designing or newly implementing health purchasing agencies and for countries reviewing the performance and governance of their health purchasing agencies with a view to developing or strengthening strategic purchasing.
Keywords: Governance; Health financing; Health service purchasing agency; Middle-income countries; Strategic purchasing.
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