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Boachie MK, Amporfu E. Effect of capitation payment method on health outcomes, healthcare utilization, and referrals in Ghana. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002423. [PMID: 38905260 PMCID: PMC11192346 DOI: 10.1371/journal.pgph.0002423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/22/2024] [Indexed: 06/23/2024]
Abstract
Different provider payment systems generate different incentives for patients, providers, and purchasers. Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 and has made reforms to its provider payment methods to create incentives in providers for cost containment. Starting with the fee for service method, it shifted to the Diagnostic Related Group (DRG) method in 2008 to improve cost containment. In 2012 the NHIS began piloting capitation method of payment which has been suspended since 2017 to allow for thorough review. This study uncovers the association between capitation payment system and patient health outcomes, utilization of healthcare services and referral patterns in Ghana based on data collected between November 2012 and January 2013. Using a cross-sectional data on 500 malaria patients who were enrollees of the NHIS from the two payment plans (i.e., capitation and DRG plan), ordered logit, negative binomial and logit regression results showed that patients under capitation were 11.9% less likely to report better health and had 1.583 fewer visits relative to patients under DRG. In relation to referrals, capitated providers were more likely to refer patients than under DRG plans. In the capitated region, better health outcomes were reported by patients of private health facilities. Capitation in Ghana was associated with under-provision of care, hence decreasing any efficiency gain from the reform. Implementors of capitation need to ensure a good monitoring and evaluation system for adequate provision of quantity and quality of care. Some limitations of this study include the use of cross sectional rather that panel data which follows individuals over time and therefore may be more able to provide definite information about cause-and-effect relationships. It also does not account for events before and after the introduction of any payment method. Overall, this study provides valuable information on the implementation policy for reintroducing capitation.
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Affiliation(s)
- Micheal Kofi Boachie
- SAMRC/Wits Centre for Health Economics and Decision Science – PRICELESS SA, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Eugenia Amporfu
- Department of Economics, Kwame Nkrumah University of Science and Technology, PMB, Kumasi, Ashanti Region, Ghana
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Sumankuuro J, Griffiths F, Koon AD, Mapanga W, Maritim B, Mosam A, Goudge J. The Experiences of Strategic Purchasing of Healthcare in Nine Middle-Income Countries: A Systematic Qualitative Review. Int J Health Policy Manag 2023; 12:7352. [PMID: 38618795 PMCID: PMC10699827 DOI: 10.34172/ijhpm.2023.7352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 10/18/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Efforts to move towards universal health coverage (UHC) aim to rebalance health financing in ways that increase efficiency, equity, and quality. Resource constraints require a shift from passive to strategic purchasing (SP). In this paper, we report on the experiences of SP in public sector health insurance schemes in nine middle-income countries to understand what extent SP has been established, the challenges and facilitators, and how it is helping countries achieve their UHC goals. METHODS We conducted a systematic search to identify papers on SP. Nine countries were selected for case study analysis. We extracted data from 129 articles. We used a common framework to compare the purchasing arrangements and key features in the different schemes. The evidence was synthesised qualitatively. RESULTS Five countries had health technology assessment (HTA) units to research what services to buy. Most schemes had reimbursement mechanisms that enabled some degree of cost control. However, we found evidenced-based changes to the reimbursement mechanisms only in Thailand and China. All countries have some form of mechanism for accreditation of health facilities, although there was considerable variation in what is done. All countries had some strategy for monitoring claims, but they vary in complexity and the extent of implementation; three countries have implemented e-claim processing enabling a greater level of monitoring. Only four countries had independent governance structures to provide oversight. We found delayed reimbursement (six countries), failure to provide services in the benefits package (four countries), and high out-of-pocket (OOP) payments in all countries except Thailand and Indonesia, suggesting the schemes were failing their members. CONCLUSION We recommend investment in purchaser and research capacity and a focus on strong governance, including regular engagement between the purchaser, provider and citizens, to build trusting relationships to leverage the potential of SP more fully, and expand financial protection and progress towards UHC.
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Affiliation(s)
- Joshua Sumankuuro
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Public Policy and Management, SD Dombo University of Business and Integrated Development Studies, Wa, Ghana
- School of Community Health, Charles Sturt University, Orange, NSW, Australia
| | - Frances Griffiths
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Adam D. Koon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Witness Mapanga
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | - Beryl Maritim
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Consortium for Advanced Research Training in Africa (CARTA), Nairobi, Kenya
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Atiya Mosam
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Jane Goudge
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Kachapila M, Kigozi J, Oppong R. Exploring the roles of players in strategic purchasing for healthcare in Africa-a scoping review. Health Policy Plan 2022; 38:97-108. [PMID: 36318330 PMCID: PMC9849715 DOI: 10.1093/heapol/czac093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/25/2022] [Accepted: 10/31/2022] [Indexed: 11/05/2022] Open
Abstract
Following the World Health Organization (WHO) guidance on strategic purchasing in 2000, low- and middle-income countries (LMICs) are trying to shift from passive purchasing (using fixed budgets) to strategic purchasing of healthcare which ties reimbursement to outcomes. However, there is limited evidence on strategic purchasing in Africa. We conducted a scoping literature review aimed at summarizing the roles played by governments, purchasers and providers in relation to citizens/population in strategic purchasing in Africa. The review searched for scientific journal articles that contained data on strategic purchasing collected from Africa. The literature search identified 957 articles of which 80 matched the inclusion criteria and were included in the review. The study revealed that in some countries strategic purchasing has been used as a tool for healthcare reforms or for strengthening systems that were not functional under fixed budgets. However, there was some evidence of a lack of government commitment in taking leading roles and funding strategic purchasing. Further, in some countries the laws need to be revised to accommodate new arrangements that were not part of fixed budgets. The review also established that there were some obstacles within the public health systems that deterred purchasers from promoting efficiency among providers and that prevented providers from having full autonomy in decision making. As African countries strive to shift from passive to strategic purchasing of healthcare, there is need for full government commitment on strategic purchasing. There is need to further revise appropriate legal frameworks to support strategic purchasing, conduct assessments of the healthcare systems before designing strategic purchasing schemes and to sensitize the providers and citizens on their roles and entitlements respectively.
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Affiliation(s)
- Mwayi Kachapila
- *Corresponding author. Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK. E-mail:
| | - Jesse Kigozi
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Raymond Oppong
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
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Amporfu E, Agyei-Baffour P, Edusei A, Novignon J, Arthur E. Strategic Health Purchasing Progress Mapping: A Spotlight on Ghana's National Health Insurance Scheme. Health Syst Reform 2022; 8:e2058337. [PMID: 35695801 DOI: 10.1080/23288604.2022.2058337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Ghana is a lower-middle-income economy that has made significant efforts to improve its health system, in order to achieve universal health coverage. Ghana has adopted strategic health purchasing as an important tool for efficient utilization of resources. This paper focuses on Ghana's National Health Insurance Scheme (NHIS) analyzing its governance arrangements and purchasing functions; and providing recommendations for improvement. The study applied the Strategic Health Purchasing Progress Tracking Framework co-created by the Strategic Purchasing Africa Resource Center (SPARC) and its partners to collect data from secondary and primary sources between September 2019 and June 2020. A descriptive and narrative approach was used to synthesize information on the NHIS governance arrangements and purchasing functions based on the framework. Benchmarks were used to describe the NHIS on the continuum from passive to strategic purchasing and to identify steps to make purchasing more strategic. Strengths and weaknesses were found in governance and purchasing functions. Progress was seen in how the NHIS selects the services in the benefit package, regularly reviewing the package to respond to the health needs of the population, and in how it selectively contracts with providers, particularly private providers, to ensure that standards for quality of care are met. However, challenges remain in performance monitoring, due to claims being mostly processed manually, and provider payment, due to frequent unbundling and upcoding of services Ghana has made significant strides toward the achievement of universal health coverage, but there is room for improvement in provider payment and performance monitoring.
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Affiliation(s)
- Eugenia Amporfu
- Department of Economics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Peter Agyei-Baffour
- Department of Health Policy Management and Economics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Anthony Edusei
- Department of Health Promotion, Education, Disability, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Jacob Novignon
- Department of Economics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Eric Arthur
- Department of Economics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Aikins M, Tabong PTN, Salari P, Tediosi F, Asenso-Boadi FM, Akweongo P. Positioning the National Health Insurance for financial sustainability and Universal Health Coverage in Ghana: A qualitative study among key stakeholders. PLoS One 2021; 16:e0253109. [PMID: 34129630 PMCID: PMC8205146 DOI: 10.1371/journal.pone.0253109] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 05/28/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The National Health Insurance Scheme (NHIS) was introduced in 2003 to reduce "out-of-pocket" payments for health care in Ghana. Over a decade of its implementation, issues about the financial sustainability of this pro-poor policy remains a crippling fact despite its critical role to go towards Universal Health Coverage. We therefore conducted this study to elicit stakeholders' views on ways to improve the financial sustainability of the operations of NHIS. METHODS Twenty (20) stakeholders were identified from Ministry of Health, Ghana Health Services, health workers groups, private medical practitioners, civil society organizations and developmental partners. They were interviewed using an interview guide developed from a NHIS policy review and analysis. All interviews were recorded and transcribed verbatim. The data were analysed thematically with the aid of NVivo 12 software. RESULTS Stakeholders admitted that the NHIS is currently unable to meet its financial obligations. The stakeholders suggested first the adoption of capitation as a provider payment mechanism to minimize the risk of providers' fraud and protection from political interference. Secondly, they indicated that rapid releases of specific statutory deductions and taxes for NHIS providers could reduce delays in claims' reimbursement which is one of the main challenges faced by healthcare providers. Aligning the NHIS with the Community-based Health Planning and Services and including preventive and promotive health is necessary to position the Scheme for Universal Health Coverage. CONCLUSION The Scheme will potentially achieve UHC if protected from political interference to improve the governance and transparency that affects the finances of the scheme and the expansion of services to include preventive and promotive services and cancers.
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Affiliation(s)
- Moses Aikins
- Department of Health Policy Planning and Management, School of Public Health, University of Ghana, Legon, Accra
| | - Philip Teg-Nefaah Tabong
- Department of Social and Behavioural Sciences, School of Public Health, University of Ghana, Legon, Accra
| | - Paola Salari
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Patricia Akweongo
- Department of Health Policy Planning and Management, School of Public Health, University of Ghana, Legon, Accra
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Christmals CD, Aidam K. Implementation of the National Health Insurance Scheme (NHIS) in Ghana: Lessons for South Africa and Low- and Middle-Income Countries. Risk Manag Healthc Policy 2020; 13:1879-1904. [PMID: 33061721 PMCID: PMC7537808 DOI: 10.2147/rmhp.s245615] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 06/30/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND South Africa is having difficulties in rolling out the National Health Insurance(NHI) policy. There are ongoing arguments on whether the NHI will provide access to quality and equitable healthcare it is intended to and whether South Africa is ready to implement the policy. Many stakeholders believe the country needs more preparation if the policy will be successful. Ghana, on the other hand, has successfully implemented the National Health Insurance Scheme(NHIS) for over 15 years. OBJECTIVE This paper sought to explore the implementation of the NHIS in Ghana and the lessons South Africa and other low- and middle-income countries can learn from such a process. METHODS A scoping review was conducted using the Joanna Brigs Institute's System for the Unified Management, Assessment and Review of Information (SUMARI) and Mendeley reference manager to manage the review process. Journal articles published on the NHIS in Ghana from January 2003 to December 2018 were searched from Science Direct, PubMed, Scopus, CINAHL, and Medline using the keywords: Ghana, Health, and Insurance. RESULTS The implementation of the NHIS has provided access to healthcare for the Ghanaian population, especially to poor and vulnerable . Despite the successful implementation of the NHIS in Ghana, the scheme is challenged with poor coverage; poor quality of care; corruption and ineffective governance; poor stakeholder participation; lack of clarity on concepts in the policy; intense political influence; and poor financing. CONCLUSION The marked inequity in the South African health system makes the implementation of the NHI inevitable. The challenges experienced in the implementation of the NHIS in Ghana are not new to the South African healthcare system. South Africa must learn from the experiences of Ghana,a context that shares common socio-cultural and economic factors and disease burden,in order to successfully implement the NHI.
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Affiliation(s)
- Christmal Dela Christmals
- Research on the Health Workforce for Equity and Quality, Centre for Health Policy, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Kizito Aidam
- Department of Bacteriology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
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Siita S, Cox SE, Hanson K. Does capitation affect patient satisfaction and prevalence of out-of-pocket payments in the insured? A propensity score analysis of Ghana's demographic and health survey data. BMC Health Serv Res 2019; 19:732. [PMID: 31640699 PMCID: PMC6805416 DOI: 10.1186/s12913-019-4581-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 10/09/2019] [Indexed: 12/20/2022] Open
Abstract
Background Ghana’s National Health Insurance Scheme (NHIS) piloted capitation payment for primary care services in the Ashanti region from 2012 to 2017. Capitation was piloted as a means of cost containment but also to induce managed competition among health providers to improve the responsiveness of healthcare delivery. This study examined the effects of exposure to capitation on perceived health service quality and prevalence of out-of-pocket payments in NHIS insured clients. Methods Respondents of the 2014 Ghana Demographic and Health Survey (G-DHS) who reported having a valid NHIS card as their only form of health insurance coverage and made a health facility visit within the 6 months prior to the survey were used to assess the exposure effects of capitation on four outcomes: overall patient satisfaction, perceived friendliness of health staff, perceived adequacy of consultation time, and prevalence of out-of-pocket payments. We applied propensity score matching to balance distributions of covariates and to compare outcomes between exposed NHIS insured clients and their unexposed counterparts. Results NHIS insured clients exposed to capitation had 10 percentage points higher probability of encountering out-of-pocket payments than their unexposed counterparts (p = 0.009; 95% CI: 2.5–17.8%). There was no evidence of a difference between the two exposure groups for ratings of the three quality perceptions outcomes examined: overall patient satisfaction, difference 0.63 units (p = 0.46); perceived friendliness of health staff, difference 1.1% (p = 0.50); and perceived adequacy of consultation times, difference 0.1% (p = 0.96). Conclusion In the Ghanaian context, our results suggest capitation was associated with a greater probability of out-of-pocket payments and no difference in perceived service quality. Future research should examine clinical quality of healthcare and how much out-of-pocket payment occurred under capitation.
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Affiliation(s)
- Shafiq Siita
- National Health Insurance Authority, Upper East Regional Office, Bolgatanga, Ghana.
| | - Sharon E Cox
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.,London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Kara Hanson
- London School of Hygiene and Tropical Medicine (LSHTM), London, UK
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Andoh-Adjei FX, Boudewijns B, Nsiah-Boateng E, Asante FA, van der Velden K, Spaan E. Effects of capitation payment on utilization and claims expenditure under National Health Insurance Scheme: a cross-sectional study of three regions in Ghana. HEALTH ECONOMICS REVIEW 2018; 8:17. [PMID: 30151701 PMCID: PMC6111020 DOI: 10.1186/s13561-018-0203-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 08/20/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Ghana introduced capitation payment under National Health Insurance Scheme (NHIS), beginning with pilot in the Ashanti region, in 2012 with a key objective of controlling utilization and related cost. This study sought to analyse utilization and claims expenditure data before and after introduction of capitation payment policy to understand whether the intended objective was achieved. METHODS The study was cross-sectional, using a non-equivalent pre-test and post-test control group design. We did trend analysis, comparing utilization and claims expenditure data from three administrative regions of Ghana, one being an intervention region and two being control regions, over a 5-year period, 2010-2014. We performed multivariate analysis to determine differences in utilization and claims expenditure between the intervention and control regions, and a difference-in-differences analysis to determine the effect of capitation payment on utilization and claims expenditure in the intervention region. RESULTS Findings indicate that growth in outpatient utilization and claims expenditure increased in the pre capitation period in all three regions but slowed in post capitation period in the intervention region. The linear regression analysis showed that there were significant differences in outpatient utilization (p = 0.0029) and claims expenditure (p = 0.0003) between the intervention and the control regions before implementation of the capitation payment. However, only claims expenditure showed significant difference (p = 0.0361) between the intervention and control regions after the introduction of capitation payment. A difference-in-differences analysis, however, showed that capitation payment had a significant negative effect on utilization only, in the Ashanti region (p < 0.007). Factors including availability of district hospitals and clinics were significant predictors of outpatient health care utilization. CONCLUSION We conclude that outpatient utilization and related claims expenditure increased in both pre and post capitation periods, but the increase in post capitation period was at slower rate, suggesting that implementation of capitation payment yielded some positive results. Health policy makers in Ghana may, therefore, want to consider capitation a key provider payment method for primary outpatient care in order to control cost in health care delivery.
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Affiliation(s)
| | - Bronke Boudewijns
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
| | - Eric Nsiah-Boateng
- National Health Insurance Authority, PMB Ministries Post Office, 36-6th Avenue, Ridge, Accra, Ghana
| | - Felix Ankomah Asante
- Institute of Statistical, Social and Economic Research (ISSER) University of Ghana, Legon, Accra Ghana
| | - Koos van der Velden
- Radboud Institute for Health Science, Department for Primary and Community Health, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
| | - Ernst Spaan
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
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Andoh-Adjei FX, Nsiah-Boateng E, Asante FA, Spaan E, van der Velden K. Perception of quality health care delivery under capitation payment: a cross-sectional survey of health insurance subscribers and providers in Ghana. BMC FAMILY PRACTICE 2018; 19:37. [PMID: 29514594 PMCID: PMC5842640 DOI: 10.1186/s12875-018-0727-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 03/01/2018] [Indexed: 12/02/2022]
Abstract
BACKGROUND Ghana introduced capitation payment method in 2012 but was faced with resistance for its perceived poor quality of care. This paper assesses National Health Insurance Scheme subscribers and care providers' perception of quality of care under the capitation payment method. METHODS This is a cross-sectional survey of subscribers and care providers perception of quality of care in three administrative regions of Ghana using a 5-point Likert scale for the assessment based on a set of quality of care measures. We performed descriptive analysis to determine average perception of quality of care scores for each of the measures used. Bivariate and multivariate analyses were also performed to examine relationships between respondent's characteristics and their perception of quality of care. RESULTS In general, subscribers expressed positive perception about the quality of care though subscribers in Ashanti were less positive compared to those in the Central region. A chi-square analysis, however, showed significant differences in subscribers' perception of quality of care by occupation (p = 0.002), region (p = 0.007) length of NHIS membership (p = 0.006), and age (p = 0.014). Multivariate logistic regression analysis also showed that different factors, other than region of residence, were significantly associated with perceived good quality of care. Analysis of health care providers' responses also showed significant differences in their perception of quality of care by region (p = 0.001). Multivariate logistic model showed that health care providers in the Volta region (OR = 0.14, 95% CI: 0.03-0.58) were significantly less likely to perceive quality of care as good compared to those in the Ashanti region. CONCLUSION Subscribers and care providers across the three regions have relatively good perception of the quality of health care in general though subscribers in Ashanti were less positive than those in the Central region. It is, therefore, plausible that capitation payment may have influenced the relatively low perception of quality of care in the Ashanti region.
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Affiliation(s)
| | | | - Felix Ankomah Asante
- Institute of Statistical, Social and Economic Research (ISSER) University of Ghana, Legon-Accra, Ghana
| | - Ernst Spaan
- Radboud Institute for Health Science, Department for Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Koos van der Velden
- Radboud Institute for Health Science, Department for Primary and Community Health, Radboud University Medical Centre, Nijmegen, Netherlands
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Andoh-Adjei FX, van der Wal R, Nsiah-Boateng E, Asante FA, van der Velden K, Spaan E. Does a provider payment method affect membership retention in a health insurance scheme? a mixed method study of Ghana's capitation payment for primary care. BMC Health Serv Res 2018; 18:52. [PMID: 29378567 PMCID: PMC5789689 DOI: 10.1186/s12913-018-2859-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 01/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ghana introduced a National Health Insurance Scheme (NHIS) in 2003 applying fee-for-service method for paying NHIS-credentialed health care providers. The National Health Insurance Authority (NHIA) later introduced diagnosis-related-grouping (DRG) payment to contain cost without much success. The NHIA then introduced capitation payment, a decision that attracted complaints of falling enrolment and renewal rates from stakeholders. This study was done to provide evidence on this trend to guide policy debate on the issue. METHODS We applied mixed method design to the study. We did a trend analysis of NHIS membership data in Ashanti, Volta and Central regions to assess growth rate; performed independent-sample t-test to compare sample means of the three regions and analysed data from individual in-depth interviews to determine any relationship between capitation payment and subscribers' renewal decision. RESULTS Results of new enrolment data analysis showed differences in mean growth rates between Ashanti (M = 30.15, SE 3.03) and Volta (M = 40.72, SE 3.10), p = 0.041; r = 0. 15; and between Ashanti and Central (M = 47.38, SE6.49) p = 0.043; r = 0. 42. Analysis of membership renewal data, however, showed no significant differences in mean growth rates between Ashanti (M = 65.47, SE 6.67) and Volta (M = 69.29, SE 5.04), p = 0.660; r = 0.03; and between Ashanti and Central (M = 50.51, SE 9.49), p = 0.233. Analysis of both new enrolment and renewal data also showed no significant differences in mean growth rates between Ashanti (M = - 13.76, SE 17.68) and Volta (M = 5.48, SE 5.50), p = 0.329; and between Ashanti and Central (M = - 6.47, SE 12.68), p = 0.746. However, capitation payment had some effect in Ashanti compared with Volta (r = 0. 12) and Central (r = 0. 14); but could not be sustained beyond 2012. Responses from the in-depth interviews did not also show that capitation payment is a key factor in subscribers' renewal decision. CONCLUSION Capitation payment had a small but unsustainable effect on membership growth rate in the Ashanti region. Factors other than capitation payment may have played a more significant role in subscribers' enrolment and renewal decisions in the Ashanti region of Ghana.
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Affiliation(s)
| | - Renske van der Wal
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
| | | | - Felix Ankomah Asante
- Institute of Statistical, Social and Economic Research (ISSER) University of Ghana, Legon-, Accra, Ghana
| | - Koos van der Velden
- Radboud Institute for Health Science, Department for Primary and Community Health, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
| | - Ernst Spaan
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
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Sackey FG, Amponsah PN. Willingness to accept capitation payment system under the Ghana National Health Insurance Policy: do income levels matter? HEALTH ECONOMICS REVIEW 2017; 7:38. [PMID: 29101723 PMCID: PMC5670093 DOI: 10.1186/s13561-017-0175-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 10/20/2017] [Indexed: 06/07/2023]
Abstract
This research was set to examine the factors influencing the willingness and the likelihood of Ghanaians to accept the capitation payment system under the National Health Insurance Scheme. Data was collected through the random sampling method in all the ten regions of Ghana. A probit estimation with marginal effects was adopted to examine the factors influencing the willingness and the likelihood while the generalized Blinder-Oaxaca decomposition was used to examine the extent to which individual characteristics influence the acceptance gap between high income and low-income earners. Our results indicated that, at the individual level, high income, being employed, awareness and smaller household size were the significant factors influencing the willingness and the likelihood to accept capitation. We also observed that the acceptance gap between high income and low-income earners was largely influenced by unexplained factors other than individual characteristics of high income earners. Since the willingness and the likelihood to accept capitation are mixed across regions and largely dependent on high incomes, the intention to roll out and implement the capitation system should be as a complementary payment system to the already existing one, being the diagnosis related grouping. We recommend that the current payment system, the diagnosis-related-grouping be maintained and complemented with capitation while measures to reduce, if not eliminate, the abuse associated with it be put in place.
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Wang Y, Shu Z, Gu J, Sun X, Jing L, Bai J, Huang X, Lou J, Zhang Q, Li M. Evidence for capitation reform in a New Rural Cooperative Medical Scheme in Pudong New Area, Shanghai: A longitudinal study. Int J Health Plann Manage 2017; 32:307-316. [PMID: 28707707 DOI: 10.1002/hpm.2432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Currently, China has been experiencing rapid growth of medical costs, serious waste of medical resources, increasing disease burden for residents, and a medical insurance fund deficit. Therefore, an urgent problem that needs to be solved is to choose a rational payment for the insurance system. To empirically evaluate the long-term effects of capitation reform in a New Rural Cooperative Medical Scheme in Pudong New Area, we collected and analysed data regarding financing, fund operation, medical service cost, and medical care-seeking behaviour from 2011 to 2015, a duration that includes data before and after reform. The data for financing and behaviours were compared year by year, and the monthly data for inpatient and outpatient costs were evaluated in a retrospective time series study. The capitation reform in Pudong New Area showed strong evidence of the power of medical cost control in the long run, while it was weak in reversing the number of patients flowing into secondary and tertiary hospitals. To make the payment of capitation play a bigger role in cost control in China, a tighter alignment of capitation with the general practitioner system and achieving dual referral is critical for future studies.
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Affiliation(s)
- Yanmei Wang
- School of Nursing, Fudan University, Shanghai, China.,Shanghai Pudong Institute for Health Development, Shanghai, China.,Shanghai Pudong Gongli Hospital, Shanghai, China
| | - Zhiqun Shu
- Shanghai Pudong Institute for Health Development, Shanghai, China
| | - Jianjun Gu
- Pudong New Area Commission of Health and Family Planning, Shanghai, China
| | - Xiaoming Sun
- Shanghai Pudong Institute for Health Development, Shanghai, China.,Fudan University, Shanghai, China
| | - Limei Jing
- Shanghai Pudong Institute for Health Development, Shanghai, China
| | - Jie Bai
- Shanghai Pudong Institute for Health Development, Shanghai, China
| | - Xuan Huang
- Pudong New Area Commission of Health and Family Planning, Shanghai, China
| | - Jiquan Lou
- Shanghai Pudong Institute for Health Development, Shanghai, China
| | - Qunfang Zhang
- Pudong New Area New Rural Cooperative Medical Scheme Management Office, Shanghai, China
| | - Ming Li
- Shanghai Pudong Institute for Health Development, Shanghai, China.,Pudong New Area Commission of Health and Family Planning, Shanghai, China
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Wang Y, Liu W, Shi H, Liu C, Wang Y. Measuring patient safety culture in maternal and child health institutions in China: a qualitative study. BMJ Open 2017; 7:e015458. [PMID: 28706096 PMCID: PMC5734290 DOI: 10.1136/bmjopen-2016-015458] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Patient safety culture (PSC) plays a critical role in ensuring safe and quality care. Extensive PSC studies have been undertaken in hospitals. However, little is known about PSC in maternal and child health (MCH) institutions in China, which provide both population-based preventive services as well as individual care for patients. OBJECTIVES This study aimed to develop a theoretical framework for conceptualising PSC in MCH institutions in China. METHODS The study was undertaken in six MCH institutions (three in Hebei and three in Beijing). Participants (n=118) were recruited through stratified purposive sampling: 20 managers/administrators, 59 care providers and 39 patients. In-depth interviews were conducted with the participants. The interview data were coded using both inductive (based on the existing PSC theory developed by the Agency for Healthcare Research and Quality) and deductive (open coding arising from data) approaches. A PSC framework was formulated through axial coding that connected initial codes and selective coding that extracted a small number of themes. RESULTS The interviewees considered patient safety in relation to six aspects: safety and security in public spaces, safety of medical services, privacy and information security, financial security, psychological safety and gap in services. A 12-dimensional PSC framework was developed, containing 69 items. While the existing PSC theory was confirmed by this study, some new themes emerged from the data. Patients expressed particular concerns about psychological safety and financial security. Defensive medical practices emerged as a PSC dimension that is associated with not only medical safety but also financial security and psychological safety. Patient engagement was also valued by the interviewees, especially the patients, as part of PSC. CONCLUSIONS Although there are some common features in PSC across different healthcare delivery systems, PSC can also be context specific. In MCH settings in China, the meaning of 'patient safety' goes beyond the traditional definition of patients. General well-being, health and disease prevention are important anchor points for defining PSC in such settings.
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Affiliation(s)
- Yuanyuan Wang
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
- Second Outpatient Department, Peking University Third Hospital, Beijing, China
| | - Weiwei Liu
- Second Outpatient Department, Peking University Third Hospital, Beijing, China
| | - Huifeng Shi
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Chaojie Liu
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Yan Wang
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
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