Private healthcare provider experiences with social health insurance schemes: Findings from a qualitative study in Ghana and Kenya

Factors affecting private sector engagement in achieving universal health coverage: a scoping review

BACKGROUND

Universal Health Coverage (UHC) is one of the most important strategies adopted by countries in achieving goals of sustainable development. To achieve UHC, the governments need the engagement of the private sector.

OBJECTIVE

The aim of this study was to identify factors affecting private sector engagement in achieving universal health coverage.

METHODS

The study is a scoping review that utilizes Arkesy & O'Malley frameworks. Data collection was conducted in MEDLINE, Web of Sciences, Embase, ProQuest, SID, and MagIran databases and the Google Scholar search engine. Also, manual searches of journals and websites, reference checks, and grey literature searches were done using specific keywords. To manage and screen the studies, EndNote X8 software was used. Data extraction and analysis was done by two members of the research team, independently and using content analysis.

RESULTS

According to the results, 43 studies out of 588 studies were included. Most of the studies were international (18 studies). Extracted data were divided into four main categories: challenges, barriers, facilitators, goals, and reasons for engagement. After exclusion and integration of identified data, these categories were classified in the following manner: barriers and challenges with 59 items and in 13 categories, facilitators in 50 items and 9 categories, reasons with 30 items, and in 5 categories and goals with 24 items and 6 categories.

CONCLUSION

Utilizing the experience of different countries, challenges and barriers, facilitators, reasons, and goals were analyzed and classified. This investigation can be used to develop the engagement of the private sector and organizational synergy in achieving UHC by policymakers and planners.

Expectations of clients, insurers, and providers: a qualitative responsiveness assessment among private health insurance sector in Kampala-Uganda

BACKGROUND

There is less attention to assessing how health services meet the expectations of private health insurance (PHI) actors, clients, insurers, and providers in developing countries. Interdependently, the expectations of each actor are stipulated during contract negotiations (duties, obligations, and privileges) in a PHI arrangement. Complementary service roles performed by each actor significantly contribute to achieving their expectations. This study assessed the role of PHI in meeting the expectations of clients, insurers, and providers in Kampala. Lessons from this study may inform possible reviews and improvements in Uganda's proposed National Health Insurance Scheme (NHIS) to ensure NHIS service responsiveness.

METHODS

This study employed a qualitative case-study design. Eight (8) focus group discussions (FGDs) with insured clients and nine (9) key informant interviews (KIIs) with insurer and provider liaison officers between October 2020 and February 2021 were conducted. Participants were purposively selected from eligible institutions. Thematic analysis was employed, and findings were presented using themes with corresponding anonymized narratives and quotes.

RESULTS

Client-Provider, Client-Insurer, and Provider-Insurer expectations were generally not met. Client-provider expectations: Although most facilities were clean with a conducive care environment, clients experienced low service care responsiveness characterized by long waiting times. Both clients and providers received inadequate feedback about services they received and delivered respectively, in addition to prompt care being received by a few clients. For client-insurer expectations, under unclear service packages, clients received low-quality medicines. Lastly, for provider-insurer expectations, delayed payments, selective periodic assessments, and inadequate orientation of clients on insurance plans were most reported. Weak coordination between the client-provider and insurer did not support delivery processes for responsive service.

CONCLUSION

Health care service responsiveness was generally low. There is a need to commit resources to support the setting up of clearer service package orientation programs, and efficient monitoring and feedback platforms. Uganda's proposed National Health Insurance Act may use these findings to: Inform its design initiatives focusing on operating under realistic expectations, investment in quality improvement systems and coordination, and efficient and accountable client care relationships.

The Experiences of Strategic Purchasing of Healthcare in Nine Middle-Income Countries: A Systematic Qualitative Review

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.

Multidomain and multilevel strategies to improve equity in maternal and newborn health services in Nepal: perspectives of health managers and policymakers

BACKGROUND

Nepal has committed to achieving universal coverage of quality maternal and newborn health (MNH) services by 2030. Achieving this, however, requires urgently addressing the widening inequity gradient in MNH care utilisation. This qualitative study examined the multidomain systemic and organisational challenges, operating in multi-level health systems, that influence equitable access to MNH services in Nepal.

METHODS

Twenty-eight in-depth interviews were conducted with health policymakers and program managers to understand supply-side perspectives of drivers of inequity in MNH services. Braun and Clarke's thematic approach was employed in analysing the data. Themes were generated and explained using a multidomain (structural, intermediary, and health system) and multi-level (micro, meso and macro) analytical framework.

RESULTS

Participants identified underlying factors that intersect at the micro, meso and macro levels of the health system to create inequity in MNH services. Key challenges identified at the macro (federal) level included corruption and poor accountability, weak digital governance and institutionalisation of policies, politicisation of the health workforce, poor regulation of private MNH services, weak health management, and lack of integration of health in all policies. At the meso (provincial) level, identified factors included weak decentralisation, inadequate evidence-based planning, lack of contextualizing health services for the population, and non-health sector policies. Challenges at the micro (local) level were poor quality health care, inadequate empowerment in household decision making and lack of community participation. Structural drivers operated mostly at macro-level political factors; intermediary challenges were within the non-health sector but influenced supply and demand sides of health systems.

CONCLUSIONS

Multidomain systemic and organisational challenges, operating in multi-level health systems, influence the provision of equitable health services in Nepal. Policy reforms and institutional arrangements that align with the country's federalised health system are needed to narrow the gap. Such reform efforts should include policy and strategic reforms at the federal level, contextualisation of macro-policies at the provincial level, and context-specific health service delivery at the local level. Macro-level policies should be guided by political commitment and strong accountability, including a policy framework for regulating private health services. The decentralisation of power, resources, and institutions at the provincial level is essential for technical support to the local health systems. Integrating health in all policies and implementation is critical in addressing contextual social determinants of health.

Healthcare workers´ experiences and perceptions of the provision of health insurance benefits to the elderly in rural Tanzania: an explorative qualitative study

BACKGROUND

Healthcare workers play an important part in the delivery of health insurance benefits, and their role in ensuring service quality and availability, access, and good management practice for insured clients is crucial. Tanzania started a government-based health insurance scheme in the 1990s. However, no studies have specifically looked at the experience of healthcare professionals in the delivery of health insurance services in the country. This study aimed to explore healthcare workers' experiences and perceptions of the provision of health insurance benefits for the elderly in rural Tanzania.

METHODS

An exploratory qualitative study was conducted in the rural districts of Igunga and Nzega, western-central Tanzania. Eight interviews were carried out with healthcare workers who had at least three years of working experience and were involved in the provision of healthcare services to the elderly or had a certain responsibility with the administration of health insurance. The interviews were guided by a set of questions related to their experiences and perceptions of health insurance and its usefulness, benefit packages, payment mechanisms, utilisation, and availability of services. Qualitative content analysis was used to analyse the data.

RESULTS

Three categories were developed that describe healthcare workers´ experiences and perceptions of delivering the benefits of health insurance for the elderly living in rural Tanzania. Healthcare workers perceived health insurance as an important mechanism to increase healthcare access for elderly people. However, alongside the provision of insurance benefits, several challenges coexisted, such as a shortage of human resources and medical supplies as well as operational issues related to delays in funding reimbursement.

CONCLUSION

While health insurance was considered an important mechanism to facilitate access to care among rural elderly, several challenges that impede its purpose were mentioned by the participants. Based on these, an increase in the healthcare workforce and availability of medical supplies at the health-centre level together with expansion of services coverage of the Community Health Fund and improvement of reimbursement procedures are recommended to achieve a well-functioning health insurance scheme.

Exploring physicians' experiences under the national health insurance scheme in Southeastern Nigeria

BACKGROUND

A number of low-and middle-income countries have implemented National Health Insurance Schemes (NHIS) as part of efforts to increase access to quality healthcare and financial protection from regressive out-of-pocket payments. This study explored physicians' experiences under the Nigerian (NHIS) to identify factors that may influence efficient health care delivery.

METHODS

A convenient sample of 85 physicians residing in South-East Nigeria who had active contracts with the NHIS were surveyed via self-administered questionnaire for this study. Descriptive statistics were used to summarize the data while Kruskal-Wallis tests were used to determine if there were statistically significant associations between physician professional characteristics and their responses to key statements that assessed their experiences and behavior. Also, thematic analysis was used to assess additional qualitative data provided by study participants.

RESULTS

Provider experiences were affected by the perceived inadequacy of reimbursement rates, delays in payment and services not covered by the NHIS. Participants' responses to statements on inadequacy of reimbursement was significantly associated with location using Kruskal-Wallis test (χ² (1) = 7.24, p = 0.027) while billing patients for services not covered under the NHIS was significantly associated with length of years of practice (χ² (1) = 15.5, p = 0.001) and place of employment (χ² (1) = 5.82, p = 0.054).

CONCLUSION

Physician experiences and challenges they face under the NHIS program in Nigeria have unintended effects on the delivery of health care services. It is imperative that these issues are addressed to improve health service delivery.

Successes and obstacles in implementing social health insurance in developing and middle-income countries: A scoping review of 5-year recent literatures

Social health insurance (SHI) is a form of health finance mechanism that had been implemented in many countries to achieve universal health care (UHC). To emulate the successes of SHI in many developed countries, many developing and middle-income countries (MICs) have attempted to follow suit. However, the SHI implementation has problems and obstacles. Many more obstacles were observed despite some successes. This scoping review aimed to study the various developments of SHI globally in its uses, implementation, successes, and obstacles within the last 5 years from 2017 to 2021. Using three databases (i.e., PubMed, EBSCO, and Google Scholar), we reviewed all forms of articles on SHI, including gray literature. The PRISMA-ScR protocol was adapted as the guideline. We used the following search terms: social health insurance, national health insurance, and community health insurance. A total of 57,686 articles were screened, and subsequently, 46 articles were included in the final review. Results showed that the majority of SHI studies were in China and African countries, both of which were actively pursuing SHI programs to achieve UHC. China was still regarded as a developing country. There were also recent experiences from other Asian countries, but only a few from South America. Implementing SHI to achieve UHC was desirable but will need to consider several factors and issues. This was especially the case in developing and MICs. Eventually, full UHC would only be possible with a combination of general taxation and SHI.

Exploring for-profit healthcare providers’ perceptions of inclusion in the Zambia National Health Insurance Scheme: A qualitative content analysis

Background

In 2019, Zambia introduced the national health insurance (NHI) as a healthcare financing strategy to increase universal access to health care services. The private health sector can complement public sector providers as service providers under the NHI. As such, the NHI Management Authority seeks to accredit for-profit private healthcare facilities in the NHI. Ascertaining factors that influence private-for-profit health providers to participate in the NHI is essential, but the evidence is lacking. In this study, we aimed to explore and characterize perceptions and experiences of for-profit private hospitals, dental clinics, eye clinics, diagnostic centres, and pharmacies regarding their inclusion in the NHI.

Methods

We conducted in-depth interviews with owners or management officers of purposively sampled private health care providers in Lusaka, Zambia (n = 22) between May and June 2020. Qualitative content analysis was used to analyse data.

Results

The findings highlight low awareness of the NHI among providers and a need to understand the NHI. Providers revealed their positions and views on the accreditation process and payment arrangements and stated that their participation would complement the NHI. They also cited conditions to participate in the NHI, highlighted opportunities and challenges of engaging in the NHI, and expressed a need for sustainable ways of governing the scheme.

Conclusion

The assessment of health providers’ inclusion in the NHI scheme is multifaceted. The results of this study surfaced factors such as raising awareness on the NHI among providers and how their concerns on aspects such as payments can be considered as inputs to enlighten consensual agreements between the NHI authority and health providers in leveraging the private health sector. Private providers’ concerns must be further understood and considered as the NHI strives to include this group as health care providers in the scheme.

The Effects of Health Purchasing Reforms on Equity, Access, Quality of Care, and Financial Protection in Kenya: A Narrative Review

Kenya has implemented several health purchasing reforms to facilitate progress toward universal health coverage. We conducted a narrative review of peer-reviewed and grey literature to examine how these reforms have affected health system outcomes in terms of equity, access, quality of care, and financial protection. We categorized the purchasing reforms we identified into the areas of benefits specification, provider payment, and performance monitoring. We found that the introduction and expansion of benefit packages for maternity, outpatient, and specialized services improved responsiveness to population needs and enhanced protection from financial hardship. However, access to service entitlements was limited by inadequate awareness of the covered services among providers and lack of service availability at contracted facilities. Provider payment reforms increased health facilities' access to funds, which enhanced service delivery, quality of care, and staff motivation. But delays and the perceived inadequacy of payment rates incentivized negative provider behavior, which limited access to care and exposed patients to out-of-pocket payments. We found that performance monitoring reforms improved the quality assurance capacity of the public insurer and enhanced patient safety, service utilization, and quality of care provided by facilities. Although health purchasing reforms have improved access, quality of care, and financial risk protection to some extent in Kenya, they should be aligned and implemented jointly rather than as individual interventions. Measures that policymakers might consider include strengthening communication of health benefits, timely and adequate payment of providers, and enhancing health facility autonomy over the revenues they generate.

Improving hospital-based processes for effective implementation of Government funded health insurance schemes: evidence from early implementation of PM-JAY in India

Background

Government-sponsored health insurance schemes (GSHIS) aim to improve access to and utilization of healthcare services and offer financial protection to the population. India’s Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) is one such GSHIS. This paper aims to understand how the processes put in place to manage hospital-based transactions, from the time a beneficiary arrives at the hospital to discharge are being implemented in PM-JAY and how to improve them to strengthen the scheme’s operation.

Methods

Guidelines were reviewed for the processes associated with hospital-based transactions, namely, beneficiary authentication, treatment package selection, preauthorization, discharge, and claims payments. Across 14 hospitals in Gujarat and Madhya Pradesh states, the above-mentioned processes were observed, and using a semi-structured interview guide fifty-three respondents were interviewed. The study was carried out from March 2019 to August 2019.

Results

Average turn-around time for claim reimbursement is two to six times higher than that proposed in guidelines and tender. As opposed to the guidelines, beneficiaries are incurring out-of-pocket expenditure while availing healthcare services. The training provided to the front-line workers is software-centric. Hospital-based processes are relatively more efficient in hospitals where frontline workers have a medical/paramedical/managerial background.

Conclusions

There is a need to broaden capacity-building efforts from enabling frontline staff to operate the scheme’s IT platform to developing the technical, managerial, and leadership skills required for them. At the hospital level, an empowered frontline worker is the key to efficient hospital-based processes. There is a need to streamline back-end processes to eliminate the causes for delay in the processing of claim payment requests. For policymakers, the most important and urgent need is to reduce out-of-pocket expenses. To that end, there is a need to both revisit and streamline the existing guidelines and ensure adherence to the guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07448-3.

Recognizing and mediating bureaucratic barriers: increasing access to care through small and medium-sized private providers in Kenya

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers. Expanding purchasing arrangements has helped many countries integrate private providers into government-supported payment schemes, reducing financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in these schemes. The difficulties of this process are exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and “street-level” SHI bureaucrats.

Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups.

Results: In a governance environment where regulations are weak and impermanent, street-level bureaucrats often created an accreditation process that was inconsistent and opaque. Support from the implementing organizations increased communication between SHI officials and providers, which clarified rules and increased providers’ confidence in the system. The intermediaries also reduced bureaucrats’ ability to apply regulations at will and helped to standardize the accreditation process for both providers and bureaucrats.

Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses and facilitate process efficiency. However, intermediaries only have a temporary role to play where there is potential to: 1) directly increase private providers’ power in a complex regulatory system; 2) reform the system itself to be more responsive to the limitations of on-the-ground implementation.

Recognizing and mediating bureaucratic barriers: increasing access to care through small and medium-sized private providers in Kenya

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers. Expanding purchasing arrangements has helped many countries integrate private providers into government-supported payment schemes, reducing financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in these schemes. The difficulties of this process are exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and “street-level” SHI bureaucrats. Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups. Results: In a governance environment where regulations are weak and impermanent, street-level bureaucrats often created an accreditation process that was inconsistent and opaque. Support from the implementing organizations increased communication between SHI officials and providers, which clarified rules and increased providers’ confidence in the system. The intermediaries also reduced bureaucrats’ ability to apply regulations at will and helped to standardize the accreditation process for both providers and bureaucrats. Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses and facilitate process efficiency. However, intermediaries only have a temporary role to play where there is potential to: 1) directly increase private providers’ power in a complex regulatory system; 2) reform the system itself to be more responsive to the limitations of on-the-ground implementation.

Recognizing and mediating bureaucratic barriers: increasing access to care through small private providers in Kenya

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers, making affordability a challenge. Expanding purchasing arrangements in many countries has helped integrate private providers into government-supported payment schemes and reduced financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in government-supported financing arrangements. The difficulties of this process can be exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion, effectively re-interpreting or re-making policy in practice. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and SHI officials. Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups. Results: In a regulatory environment where regulations are weak and impermanent, officials created an accreditation process that was inconsistent and opaque: applying rules unevenly, requesting bribes, and minimizing communication with providers. The support provided by the implementing organizations clarified rules, reduced the power of local bureaucrats to apply regulations at their own discretion, gave providers greater confidence in the system, and helped to standardize the accreditation process. Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses, reduce barriers to effective care expansion caused by street-level bureaucrats, and facilitate the adoption of systems which reduce rent-seeking practices that might otherwise delay or derail initiatives to reach universal health coverage.

Health Insurance Status of Pregnant Women and the Likelihood of Receipt of Antenatal Screening for HIV in Sub-Saharan Africa

BACKGROUND

We investigated if initiating preventive care against HIV vertical transmission by antenatal HIV screening is independent of the patients' source of financial reimbursement for the care received in sub-Saharan Africa (SSA).

METHODS

Using information from the WHO's Global Health Expenditure Database and the Demographic Health Surveys Database for 27 sub-Saharan countries, we used Spearman's correlation and adjusted survey logistic regression to determine the potential relationship between enrollment in health insurance and the likelihood that expectant mothers would be offered antenatal HIV screening.

RESULTS

We found that expectant mothers covered by health insurance were more than twice as likely to be offered antenatal screening for HIV compared to the uninsured. The likelihood differed by the type of insurance plan the expectant mother carried.

DISCUSSION

Health insurance is more of a financial tool that this study finds to be necessary to boost the uptake of preventive and therapeutic HIV care in SSA.

CONCLUSION

The ensuing disparity in receiving proper care could hinder the goals of 90-90-90 and the forthcoming 95-95-95 plan in SSA.

Standard Survey Data: Insights Into Private Sector Utilization

Universal Health Coverage in Low- and Middle-Income Countries is increasingly expanding through incorporation of private clinics, pharmacies, and hospitals into an overall health system funded in whole or part through government-managed health insurance. This underscores the importance of policies on health provision which apply across the whole delivery system regardless of ownership status. To advance understanding of private-sector policies, and to facilitate sharing of lessons across countries with similar public-private distributions, we have analyzed data on the source of inpatient and outpatient care from 65 countries. While past studies have conducted similar analysis, ours advances the field in two ways. First, we limit our analysis to data sets from 2010 through 2019, making our study more up-to-date than past studies, while changing health seeking patterns for maternal health since 2010 means that our data set is more representative of overall inpatient care. Second, while past multi-country analysis of public-private ownership have been based on the Demographic Health Surveys, we have added to this data from the Multiple Indicator Cluster Surveys, significantly increasing the countries in our analysis. We have aggregated our analysis by WHO's regions. Outside of the EURO region, where the private sector delivers just 4% of all healthcare services, the private sector remains significant, and in many countries represents more than half of all care. The private sector provides nearly 40% of all healthcare in PAHO, AFRO, and WPRO regions, 57% in SEARO, and 62% in EMRO. While specific countries with two recent surveys show variation in the scale of both inpatient and outpatient private provision, we did not find regional or global trends toward or away from private care within LMICs. Private inpatient care is most important for the wealthy in many countries; public vs. private care varies less, by wealth, for outpatient services.

How does it affect service delivery under the National Health Insurance Scheme in Ghana? Health providers and insurance managers perspective on submission and reimbursement of claims

INTRODUCTION

In 2003, the Government of Ghana launched the National Health Insurance Scheme (NHIS) to enable all Ghanaian residents to have access to health services at the point of care without financial difficulty. However, the system has faced a number of challenges relating to delays in submission and reimbursement of claims. This study assessed views of stakeholders on claims submission, processing and re-imbursement under the NHIS and how that affected health service delivery in Ghana.

METHODS

The study employed qualitative methods where in-depth interviews were conducted with stakeholders in three administrative regions in Ghana. Purposive sampling method was used to select health facilities and study participants for the interviews. QSR Nvivo 12 software was used to code the data into themes for thematic analysis.

RESULTS

The results point to key barriers such as lack of qualified staff to process claims, unclear vetting procedure and the failure of National Health Insurance Scheme officers to draw the attention of health facility staff to resolve discrepancies on time. Participants perceived that lack of clarity, inaccurate data and the use of non-professional staff for NHIS claims vetting prolonged reimbursement of claims. This affected operations of credentialed health facilities including the provision of health services. It is perceived that unavailability of funds led to re-use of disposable medical supplies in health service delivery in credentialed health facilities. Stakeholders suggested that submission of genuine claims by health providers and regular monitoring of health facilities reduces errors on claims reports and delays in reimbursement of claims.

CONCLUSION

Long delays in claims reimbursement, perceived vetting discrepancies affect health service delivery. Thus, effective collaboration of all stakeholders is necessary in order to develop a long-term strategy to address the issue under the NHIS to improve health service delivery.

National Health Insurance Fund's relationship to retail drug outlets: a Tanzania case study

Background

Achieving universal health coverage will require robust private sector engagement; however, as many low- and middle-income countries launch prepayment schemes to achieve universal health coverage, few are covering products from retail drug outlets (pharmacies and drug shops). This case study aims to characterize barriers and facilitators related to incorporating retail drug outlets into national prepayment schemes based on the experience of the Tanzanian National Health Insurance Fund’s (NHIF) certification of pharmacies and accredited drug dispensing outlets.

Methods

We reviewed government documents and interviewed 26 key informants including retail outlet owners and dispensers and central and district government authorities representing eight districts overall. Topics included awareness of NHIF in the community, access to medicines, claims processing, reimbursement prices, and how the NHIF/retail outlet linkage could be improved.

Results

Important enablers for NHIF/retail outlet engagement include widespread awareness of NHIF in the community, NHIF’s straightforward certification process, and their reimbursement speed. All of the retail respondents felt that NHIF helps their business and their clients to some degree. As for barriers, retailers thought that NHIF needed to provide more information to them and to its members, particularly regarding coverage changes. Some retailers and government officials thought that the product reimbursement prices were below market and not adjusted often enough, and pharmacy respondents were unhappy about claim rejections for what they felt were insignificant issues. All interviewees agreed that one of the biggest problems is poor prescribing practices in public health facilities. They reiterated that prescribers need more supervision to improve their practices, particularly to ensure adherence to standard treatment guidelines, which NHIF requires for approving a claim. In addition, if a prescription has any problem, including a wrong date or no signature, the client must return to the health facility to get it corrected or pay out-of-pocket, which is burdensome.

Conclusions

Little published information is available on the relationship between health insurance plans and retail providers in low- and middle-income countries. This case study provides insights that countries can use when designing ways to include retail outlets in their health insurance schemes.

Equity lessons from a large scale private-sector healthcare intervention in Ghana and Kenya: Results for a multi-year qualitative study

Background: The poor fall sick more frequently than the wealthy, and are less likely to seek care when they do.  Private provision in many Low- and Middle-Income Countries makes up half or more of all outpatient care, including among poor paitents.  Understanding the preferences of poor patients which impel them to choose private providers, and how 3 ^rd party payment influences these preferences, is important for policy makers considering expansion of national health insurance financing to advance Universal Health Coverage. This paper reports on the results of a qualitative evaluation of the African Health Markets for Equity intiative (AHME), a multi-year initiative in Ghana and Kenya to increase options and improve quality for outpatient services, especially for the poor.

Methods: Interviews with patients from private clinics were conducted annually between 2013 and 2018.  Field staff recruited women for exit interviews as they were leaving these clinics. In the final round of data collection (2018), interviewers screened patients for wealth quintile and selected one third of the sample (approximately 10 patients per country) that fell into the two lowest wealth quintiles (Q1 and Q2).  Transcripts were coded using Atlas.ti and coded for analysis using an inductive, thematic approach.

Results: We found four primary drivers of patient preferences for private clinics:  convenience; efficiency and predictability, perceived higher quality, and empowerment which was derived from greater choice in where to go. 

Conclusions: Our findings indicate that more options will lead to more opportunities for treatment, and decrease the percentage of those, mostly poor, who become ill and go without care of any kind.  This should be considered as a priority  by policy makers seeking to make the best use of existing national infrastructure and expertise to assure equal health for all.  In this way, private providers offer an opportunity to advance national goals.

Bridging the gap with a gender lens: How two implementation research datasets were repurposed to inform health policy reform in Kenya

Policies as they are written often mask the power relations behind their creation (Hull, 2008). As a result, not only are policies that appear neat on the page frequently messy in their implementation on the ground, but the messiness of implementation, and implementation science, often brings these hidden power relations to light. In this paper, we examine the process by which different data sources were generated within a programme meant to increase access to quality private healthcare for the poorest populations in Kenya, how these sources were brought and analyzed together to examine gender bias in the large-scale rollout of Kenya's National Hospital Insurance Fund (NHIF) beyond public hospitals and civil service employees, and how these findings ultimately were developed in real time to feed into the NHIF reform process. We point to the ways in which data generated for implementation science purposes and without a specific focus on gender were analyzed with a policy implementation analysis lens to look at gender issues at the policy level, and pay particular attention to the role that the ongoing close partnership between the evaluators and implementers played in allowing the teams to develop and turn findings around on short timelines. In conclusion, we discuss possibilities for programme evaluators and implementers to generate new data and feed routine monitoring data into policy reform processes to create a health policy environment that serves patients more effectively and equitably. Implementation science is generally focused on programmatic improvement; the experiences in Kenya make clear that it can, and should, also be considered for policy improvement.

Private Providers' Experiences Implementing a Package of Interventions to Improve Quality of Care in Kenya: Findings From a Qualitative Evaluation

INTRODUCTION

Quality of care is an important element in health care service delivery in low- and middle-income countries. Innovative strategies are critical to ensure that private providers implement quality of care interventions. We explored private providers' experiences implementing a package of interventions intended to improve the quality of care in small and medium-sized private health facilities in Kenya.

METHODS

Data were collected as part of the qualitative evaluation of the African Health Markets for Equity (AHME) program in Kenya between June and July 2018. Private providers were purposively selected from 2 social franchise networks participating in AHME: the Amua network run by Marie Stopes Kenya and the Tunza network run by Population Services Kenya. Individual interviews (N=47) were conducted with providers to learn about their experiences with a package of interventions that included social franchising, SafeCare (a quality improvement program), National Hospital Insurance Fund (NHIF) accreditation assistance, and business support.

RESULTS

Private providers felt they benefited from trainings in clinical methods and quality improvement offered through AHME. Providers especially appreciated the mentorship and guidelines offered through programs like social franchising and SafeCare, and those who received support for NHIF accreditation felt they were able to offer higher quality services after going through this process. However, quality improvement was sometimes prohibitively expensive for private providers in smaller facilities that already realize relatively low revenue and the NHIF accreditation process was difficult to navigate without the help of the AHME partners due to complexity and a lack of transparency.

CONCLUSION

Our findings suggest that engaging private providers in a comprehensive package of quality improvement activities is achievable and may be preferable to a simpler program. However, further research that looks at the implications for cost and return on investment is required.

Preferences of healthcare providers for capitation payment in Kenya: a discrete choice experiment

Provider payment mechanisms (PPMs) are important to the universal health coverage (UHC) agenda as they can influence healthcare provider behaviour and create incentives for health service delivery, quality and efficiency. Therefore, when designing PPMs, it is important to consider providers' preferences for PPM characteristics. We set out to uncover senior health facility managers' preferences for the attributes of a capitation payment mechanism in Kenya. We use a discrete choice experiment and focus on four capitation attributes, namely, payment schedule, timeliness of payments, capitation rate per individual per year and services to be paid by the capitation rate. Using a Bayesian efficient experimental design, choice data were collected from 233 senior health facility managers across 98 health facilities in seven Kenyan counties. Panel mixed multinomial logit and latent class models were used in the analysis. We found that capitation arrangements with frequent payment schedules, timelier disbursements, higher payment rates per individual per year and those that paid for a limited set of health services were preferred. The capitation rate per individual per year was the most important attribute. Respondents were willing to accept an increase in the capitation rate to compensate for bundling a broader set of health services under the capitation payment. In addition, we found preference heterogeneity across respondents and latent classes. In conclusion, these attributes can be used as potential targets for interventions aimed at configuring capitation to achieve UHC.

Seeking care in the context of social health insurance in Kenya and Ghana

BACKGROUND

Social Health Insurance (SHI) is widely used by countries attempting to move toward Universal Health Coverage (UHC). While evidence suggests that SHI is a promising strategy for achieving UHC, low-income countries often struggle to implement and sustain SHI systems. It is therefore important to understand how SHI enrollees use health insurance and how it affects their health-seeking behavior. This paper examines how SHI affects patient decision-making regarding when and where to seek care in Kenya and Ghana, two countries with established SHI systems in sub-Saharan Africa.

METHODS

This paper draws from two datasets collected under the African Health Markets for Equity (AHME) program. One dataset, collected in 2013 and 2017 as part of the AHME qualitative evaluation, consists of 106 semi-structured clinic exit interviews conducted with patients in Ghana and Kenya. This data was analyzed using an inductive, thematic approach. The second dataset was collected internally by the AHME partner organizations. It derives from a cross-sectional survey of social franchise clients at three social franchise networks supported by AHME. Data collection took place from February - May 2018 and in December 2018.

RESULTS

Many clients appreciated that insurance coverage made healthcare more affordable, reported seeking care more frequently when covered with SHI. Clients also noted that the coverage gave them access to a wider variety of providers, but rarely sought out SHI-accredited providers specifically. However, clients sometimes were charged for services that should have been covered by insurance. Due to a lack of understanding of SHI benefits, clients rarely knew they had been charged inappropriately.

CONCLUSIONS

Clients and providers would benefit from education on what is included in the SHI package. Providers should be monitored and held accountable for charging clients inappropriately; in Ghana this should be accompanied by reforms to make government financing for SHI sustainable. Since clients valued provider proximity and both Kenya and Ghana have a dearth of providers in rural areas, both countries should incentivize providers to work in these areas and prioritize accrediting rural facilities into SHI schemes to increase accessibility and reach.

Willingness to Pay for Social Health Insurance and Associated Factors among Health Care Providers in Addis Ababa, Ethiopia

BACKGROUND

Cost sharing between beneficiaries and government is critical to attain universal health coverage. The government of Ethiopia introduced social health insurance to improve access to quality health services. Hence, HCP are the ultimate frontline service provider; their WTP for health insurance could influence the implementation of the scheme directly or indirectly. However, there is limited evidence on willingness to pay (WTP) for social health insurance (SHI) among health professionals.

METHODS

A cross-sectional study was conducted in Addis Ababa, Ethiopia, from May 1st to August 15th, 2019. A total sample of 480 health care providers was selected using a multistage sampling method. The collected data were entered into Epi Info version 7.1 and analyzed with SPSS version 23. Binary and multiple logistic regression analysis was carried out to identify the associated factor outcome variable. The association was presented in odds ratio with 95% confidence interval and significance determined at a P value less than 0.05.

RESULT

A total of 460 health care providers responded to the questionnaire, making a 95.8% response rate. Of the respondents, only 132 (28.7%) were WTP for SHI. Higher educational status [AOR = 2.9, 95% CI (1.2-7.3)], higher monthly income [AOR = 2.2, 95% CI (1.2-4.3)], recent family illness [AOR = 2.4, 95% CI (1.4-4.4)], and a good awareness about SHI [AOR = 4.4, 95% CI (2.4-7.8)] showed significant association with WTP for SHI. The main reasons for not WTP were thinking the government should cover the cost, preferring out-pocket payment and the provided SHI scheme does not cover all the health care costs health care providers lost interest in pay for SHI.

CONCLUSION AND RECOMMENDATION

The majority of health care providers were not willing to pay for the introduced SHI scheme. The provided SHI scheme should be clear and provide special consideration for health care providers as the majority of them receives free health care service from their employer health care institution. Also, the government, health professional associations, and other concerned stakeholders should provide awareness creation programs by targeting low and middle-level health professionals in order to increase WTP for SHI among health care providers.

Preventive healthcare uptake in private hospitals in Nigeria: a cross-sectional survey (Nisa premier hospital)

Background

Understanding the features of preventive care uptake is critical for assessing the performance and viability of primary care in any healthcare system. There are gaps in previous studies that focused on primary healthcare features, challenges and way forward in Nigeria but were mainly public sector focused and do not characterize the features of preventive care. Since private healthcare sector remains the most accessed and utilized in Nigeria, this study sought to characterize the features of uptake of preventive care to better understand the current preventive healthcare landscape.

Method

A descriptive cross-sectional study, using survey questionnaire were randomly administered to adult patients attending the Family Medicine Out-Patient Department (OPD) at Nisa Premier Hospital, Jabi Abuja. The study was conducted over a three-month period. (January to June 2017). Data collected were analyzed using SPSS version 23 (IBM SPSS, Chicago, IL, USA). Descriptive statistics in the form of frequency and percentage were used to report the results.

Results

A total of 381 participants completed the survey. The results revealed that while an over overwhelming majority (> 90%) of participants indicated knowledge of benefits of preventive care, and preferred interventions aimed at preventing a disease before they occur, 48% preferred interventions aimed at reducing disease or injury impact or interventions aimed at ameliorating the impact of ongoing disease or injury with long lasting effect (43%). Unfortunately, less than 40% of respondents would visit the hospital when their health condition is not serious. Important barriers to uptake of preventive care were revealed as cost (45%), distance to the healthcare provider (36%) and lack of health insurance (33%), whereas poor education (19%), social norms (13%) as well as cultural and religious beliefs (10%) towards accessing certain health services appeared to be lesser barriers.

Conclusion

Although people are aware of the benefits of preventive care, its uptake will greatly be enhanced through improved health insurance coverage, refocusing primary healthcare functions on preventive rather than curative care and instituting policies that mandatorily prescribe uptake for the insured, both at the individual and the insurer’s level.

Characteristics and Effects of Multiple and Mixed Funding Flows to Public Healthcare Facilities on Financing Outcomes: A Case Study From Nigeria

Introduction: Most public hospitals in Nigeria are usually financed by funding flows from different health financing mechanisms, which could potentially trigger different provider behaviors that can affect the health system goals of efficiency, equity, and quality of care. The study examined how healthcare providers respond to multiple funding flows and the implications of such flows for achieving equity, efficiency, and quality.

Methods: A cross-sectional qualitative study of selected healthcare providers and purchasers in Enugu state was used. Four public hospitals were selected—two tertiary and two secondary; because they received funding from more than one healthcare financing mechanism. Key informants were individual healthcare providers and decision-makers in the hospitals, State Ministry of Health, National Health Insurance Scheme and Health Maintenance Organizations. Service users from each hospital were purposively selected for focus group discussions (FGDs). A total of 66 key informant interviews and 8 FGDs were conducted.

Findings: The multiple flows that were received by public hospitals varied by type of health facility (Secondary vs. Tertiary), ownership of health facility (Federal government vs. State government) and population served. Out-of-pocket payment (OOP) and government budget were the only recurring forms of funding to all the public hospitals. It was found that multiple funding flows, generate different signals to service providers, resulting in positive and negative consequences. The results also showed that multiple flows lead to predictability and stability of funding to public hospitals. Hospital Managers and administrators reported that multiple flows increased their financial pool and capacity to undertake capital projects and enabled the provision of a wider range of services to clients. Multiple sources of funding also give a sense of security to health facilities, because there would always be a back-up source of funding if one flow delays or defaults in payment. Nevertheless, health providers were seen to shift resources from less attractive to more attractive flows in response to the relative size perceived adequacy, predictability, and flexibility of funding flow. Patients were also shifted from less predictable to more predictable funding flows and providers charged different rates to different funding flows to make up for the inadequacies in some sources of funding. The negative consequences of multiple funding flows on provider behavior that was reported in the study were wastage/under-utilization of resources, differential quality of care provided to clients, and inequities in resource distribution and access to health services. In some instances, providers' responses resulted in better quality of care for clients and improved access to services that were not ordinarily available or clients could not have been afforded.

Conclusion: Multiple funding flows to public hospitals are beneficial as well as constraining to health providers. They can be beneficial in ensuring that hospitals have a ready and predictable pool of funds to render services with. However, they could be detrimental to some patients that could be charged more for some services that other patients pay less and may also lead of provision of differential quality of services to different payments depending on the funding flows that are used to purchase services for them. Ultimately, some of the consequences of multiple funding flows if not properly managed, will affect health systems goals of equity, efficiency and quality of care, either positively or negatively.

Attribute development and level selection for a discrete choice experiment to elicit the preferences of health care providers for capitation payment mechanism in Kenya

BACKGROUND

Stated preference elicitation methods such as discrete choice experiments (DCEs) are now widely used in the health domain. However, the "quality" of health-related DCEs has come under criticism due to the lack of rigour in conducting and reporting some aspects of the design process such as attribute and level development. Superficially selecting attributes and levels and vaguely reporting the process might result in misspecification of attributes which may, in turn, bias the study and misinform policy. To address these concerns, we meticulously conducted and report our systematic attribute development and level selection process for a DCE to elicit the preferences of health care providers for the attributes of a capitation payment mechanism in Kenya.

METHODOLOGY

We used a four-stage process proposed by Helter and Boehler to conduct and report the attribute development and level selection process. The process entailed raw data collection, data reduction, removing inappropriate attributes, and wording of attributes. Raw data was collected through a literature review and a qualitative study. Data was reduced to a long list of attributes which were then screened for appropriateness by a panel of experts. The resulting attributes and levels were worded and pretested in a pilot study. Revisions were made and a final list of attributes and levels decided.

RESULTS

The literature review unearthed seven attributes of provider payment mechanisms while the qualitative study uncovered 10 capitation attributes. Then, inappropriate attributes were removed using criteria such as salience, correlation, plausibility, and capability of being traded. The resulting five attributes were worded appropriately and pretested in a pilot study with 31 respondents. The pilot study results were used to make revisions. Finally, four attributes were established for the DCE, namely, payment schedule, timeliness of payments, capitation rate per individual per year, and services to be paid by the capitation rate.

CONCLUSION

By rigorously conducting and reporting the process of attribute development and level selection of our DCE,we improved transparency and helped researchers judge the quality.

Health care purchasing in Kenya: Experiences of health care providers with capitation and fee-for-service provider payment mechanisms

BACKGROUND

Provider payment mechanisms (PPMs) play a critical role in universal health coverage due to the incentives they create for health care providers to deliver needed services, quality, and efficiency. We set out to explore public, private, and faith-based providers' experiences with capitation and fee-for-service in Kenya and identified attributes of PPMs that providers considered important.

METHODS

We conducted a qualitative study in two counties in Kenya. Data were collected using semistructured interviews with 29 management team members in six health providers accredited by the National Hospital Insurance Fund (NHIF).

RESULTS

Capitation and fee-for-service payments from the NHIF and private insurers were reported as good revenue sources as they contributed to providers' overall income. The expected fee-for-service payment amounts from NHIF and private insurers were predictable while capitation funds from NHIF were not because providers did not have information on the number of enrolees in their capitation pool. Moreover, capitation payment rates were perceived as inadequate. Capitation and fee-for-service payments from NHIF and private insurers were disbursed late. Finally, public providers had lost their autonomy to access and utilise capitation and fee-for-service payments from the NHIF.

CONCLUSION

Through their experiences, health care providers revealed characteristics of PPMs that they considered important.

Accrediting private providers with National Health Insurance to better serve low-income populations in Kenya and Ghana: a qualitative study

BACKGROUND

Small private providers in low- and middle-income countries (LMICs) are well positioned to fill gaps in services to low-income populations using Social Health Insurance (SHI) schemes. However, we know little about the practical challenges both private providers and patients face in the context of SHI that may ultimately limit access to quality services for low-income populations. In this paper, we pull together data collected from private providers, patients, and SHI officials in Kenya and Ghana to answer the question: does participation in an SHI scheme affect private providers' ability to serve poorer patient populations with quality health services?

METHODS

In-depth interviews were held with 204 providers over three rounds of data collection (2013, 2015, 2017) in Kenya and Ghana. We also conducted client exit interviews in 2013 and 2017 for a total of 106 patient interviews. Ten focus group discussions (FGDs) were conducted in Kenya and Ghana respectively in 2013 for a total of 171 FGD participants. A total of 13 in-depth interviews also were conducted with officials from the Ghana National Health Insurance Agency (NHIA) and the Kenya National Hospital Insurance Fund (NHIF) across four rounds of data collection (2013, 2014, 2016, 2017). Provider interviews covered reasons for (non) enrollment in the health insurance system, experiences with the accreditation process, and benefits and challenges with the system. Client exit interviews covered provider choice, clinic experience, and SHI experience. FGDs covered the local healthcare landscape. Interviews with SHI officials covered officials' experiences working with private providers, and the opportunities and challenges they faced both accrediting providers and enrolling members. Transcripts were coded in Atlas.ti using an open coding approach and analyzed thematically.

RESULTS

Private providers and patients agreed that SHI schemes are beneficial for reducing out-of-pocket costs to patients and many providers felt they had to become SHI-accredited in order to keep their facilities open. The SHI officials in both countries corroborated these sentiments. However, due to misunderstanding of the system providers tended to charge clients for services they felt were above and beyond reimbursable expenses. Services were sometimes limited as well. Significant delays in SHI reimbursement in Ghana exacerbated these problems and compromised providers' abilities to cover basic expenses without charging patients. While patients recognized the potential benefits of SHI coverage and many sought it out, a number of patients reported allowing their enrollment to lapse for cost reasons or because they felt the coverage was useless when they were still asked to pay for services out-of-pocket at the health facility.

CONCLUSIONS

Our data point to several major barriers to SHI access and effectiveness for low-income populations in Ghana and in Kenya, in addition to opportunities to better engage private providers to serve these populations. We recommend using fee-for-service payments based on Diagnosis Related Group rather than a capitation payment system, as well as building more monitoring and accountability mechanisms into the SHI systems in order to reduce requests for informal out-of-pocket payments from patients while also ensuring quality of care. However, particularly in Ghana, these reforms should be accompanied by financial reform within the SHI system so that small private providers can be adequately funded through government financing.

Accrediting private providers with National Health Insurance to better serve low-income populations in Kenya and Ghana: a qualitative study

Background

Small private providers in low- and middle-income countries (LMICs) are well positioned to fill gaps in services to low-income populations using Social Health Insurance (SHI) schemes. However, we know little about the practical challenges both private providers and patients face in the context of SHI that may ultimately limit access to quality services for low-income populations. In this paper, we pull together data collected from private providers, patients, and SHI officials in Kenya and Ghana to answer the question: does participation in an SHI scheme affect private providers’ ability to serve poorer patient populations with quality health services?

Methods

In-depth interviews were held with 204 providers over three rounds of data collection (2013, 2015, 2017) in Kenya and Ghana. We also conducted client exit interviews in 2013 and 2017 for a total of 106 patient interviews. Ten focus group discussions (FGDs) were conducted in Kenya and Ghana respectively in 2013 for a total of 171 FGD participants. A total of 13 in-depth interviews also were conducted with officials from the Ghana National Health Insurance Agency (NHIA) and the Kenya National Hospital Insurance Fund (NHIF) across four rounds of data collection (2013, 2014, 2016, 2017). Provider interviews covered reasons for (non) enrollment in the health insurance system, experiences with the accreditation process, and benefits and challenges with the system. Client exit interviews covered provider choice, clinic experience, and SHI experience. FGDs covered the local healthcare landscape. Interviews with SHI officials covered officials’ experiences working with private providers, and the opportunities and challenges they faced both accrediting providers and enrolling members. Transcripts were coded in Atlas.ti using an open coding approach and analyzed thematically.

Results

Private providers and patients agreed that SHI schemes are beneficial for reducing out-of-pocket costs to patients and many providers felt they had to become SHI-accredited in order to keep their facilities open. The SHI officials in both countries corroborated these sentiments. However, due to misunderstanding of the system providers tended to charge clients for services they felt were above and beyond reimbursable expenses. Services were sometimes limited as well. Significant delays in SHI reimbursement in Ghana exacerbated these problems and compromised providers’ abilities to cover basic expenses without charging patients. While patients recognized the potential benefits of SHI coverage and many sought it out, a number of patients reported allowing their enrollment to lapse for cost reasons or because they felt the coverage was useless when they were still asked to pay for services out-of-pocket at the health facility.

Conclusions

Our data point to several major barriers to SHI access and effectiveness for low-income populations in Ghana and in Kenya, in addition to opportunities to better engage private providers to serve these populations. We recommend using fee-for-service payments based on Diagnosis Related Group rather than a capitation payment system, as well as building more monitoring and accountability mechanisms into the SHI systems in order to reduce requests for informal out-of-pocket payments from patients while also ensuring quality of care. However, particularly in Ghana, these reforms should be accompanied by financial reform within the SHI system so that small private providers can be adequately funded through government financing.

Kenya National Hospital Insurance Fund Reforms: Implications and Lessons for Universal Health Coverage

This article identifies and describes the reforms undertaken by the National Hospital Insurance Fund (NHIF) and examines their implications for Kenya’s quest to achieve universal health coverage (UHC). We undertook a review of published and grey literature to identify key reforms that had been implemented by the NHIF since 2010. We examined the reforms undertaken by the NHIF using a health financing evaluation framework that considers the feasibility, equity, efficiency, and sustainability of health financing mechanisms. We found the following NHIF reforms: (1) the introduction of the Civil Servants Scheme (CSS), (2) the introduction of a stepwise quality improvement system, (3) the health insurance subsidy for the poor (HISP), (4) revision of monthly contribution rates and expansion of the benefit package, and (5) the upward revision of provider reimbursement rates. Though there are improvements in several areas, these reforms raise equity, efficiency, feasibility, and sustainability concerns. The article concludes that though NHIF reforms in Kenya are well intentioned and there has been improvement in several areas, design attributes could compromise the extent to which they achieve their intended goal of providing universal financing risk protection to the Kenyan population.

What characteristics of provider payment mechanisms influence health care providers' behaviour? A literature review

BACKGROUND

Provider payment mechanisms (PPMs) create incentives or signals that influence the behaviour of health care providers. Understanding the characteristics of PPMs that influence health care providers' behaviour is essential for aligning PPM reforms for improving access, quality, and efficiency of health care services. We reviewed empirical literature that examined the characteristics of PPMs that influence the behaviour of health care providers.

METHODS

We systematically searched for empirical literature in PubMed, Web of Science, and Google Scholar databases and complemented these with physical searching of the references of selected papers for further relevant studies. A total of 16 studies that met our inclusion and exclusion criteria were identified. We analysed data using thematic review.

RESULTS

We identified seven major characteristics of PPMs that influence health care providers' behaviour. Of these characteristics, payment rate, the sufficiency of payment rate to cover the cost of services, timeliness of payment, payment schedule, performance requirements, and accountability mechanisms were the most important.

CONCLUSIONS

Our review found that health care providers' behaviour is influenced by the characteristics of PPMs. Provider payment mechanism reforms that optimally structure these characteristics can elicit required incentives for access, equity, quality, and efficiency in service delivery among health care providers towards achieving universal health coverage.

Public-private partnerships in practice: collaborating to improve health finance policy in Ghana and Kenya

Social health insurance (SHI), one mechanism for achieving universal health coverage, has become increasingly important in low- and middle-income countries (LMICs) as they work to achieve this goal. Although small private providers supply a significant proportion of healthcare in LMICs, integrating these providers into SHI systems is often challenging. Public-private partnerships in health are one way to address these challenges, but we know little about how these collaborations work, how effectively, and why. Drawing on semi-structured interviews conducted with National Health Insurance (NHI) officials in Kenya and Ghana, as well as with staff from several international NGOs (INGOs) representing social franchise networks that are partnering to increase private provider accreditation into the NHIs, this article examines one example of public-private collaboration in practice. We found that interviewees initially had incomplete knowledge about the potential for cross-sector synergy, but both sides were motivated to work together around shared goals and the potential for mutual benefit. The public-private relationship then evolved over time through regular face-to-face interactions, reciprocal feedback, and iterative workplan development. This process led to a collegial relationship that also has given small private providers more voice in the health system. In order to sustain this relationship, we recommend that both public and private sector representatives develop formalized protocols for working together, as well as less formal open channels for communication. Models for aggregating small private providers and delivering them to government programmes as a package have potential to facilitate public-private partnerships as well, but there is little evidence on how these models work in LMICs thus far.