Abstract
BackgroundGhana’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.MethodsRespondents 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.ResultsNHIS 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).ConclusionIn 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.
Highlights
Ghana’s National Health Insurance Scheme (NHIS) piloted capitation payment for primary care services in the Ashanti region from 2012 to 2017
For prevalence of outof-pocket payments, the unadjusted estimates in the unmatched sample suggested that exposed NHIS insured patients were on average, about 17% more likely to experience out-of-pocket health payments compared with their unexposed counterparts (p < 0.001; 95% Confidence interval [CI]: 11.5–22.3%)
This study investigated the effects of capitation on prevalence of out-of-pocket health payments and perceived service quality in insured clients using Ghana’s capitation pilot as a case study
Summary
Ghana’s National Health Insurance Scheme (NHIS) piloted capitation payment for primary care services in the Ashanti region from 2012 to 2017. One of the key components of strategic purchasing is how health providers are paid for contracted services [1]. This determines their exposure to financial risk, the incentives they face, and how they respond in terms of health service delivery [2]. Ghana’s National Health Insurance Scheme (NHIS), in its efforts to move away from passive to more strategic purchasing, has been experimenting with alternative payment methods to achieve costefficient healthcare delivery to its beneficiaries without compromising healthcare quality. The latest payment reform, following fee-for-service and diagnostic related groupings (DRG), was the pilot of capitation in the Ashanti region from 2012 to 2017
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