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

Melvin Obadha,Jane Chuma,Jacob Kazungu,Edwine Barasa

doi:10.1002/hpm.2707

Abstract

SummaryBackgroundProvider 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.MethodsWe 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).ResultsCapitation 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.ConclusionThrough their experiences, health care providers revealed characteristics of PPMs that they considered important.

Highlights

Sustainable development goal (SDG) 3 places emphasis on health and well‐being of people of all ages and highlights the importance of universal health coverage (UHC) through target 3.8.1 UHC means that people, irrespective of their background or financial status, can access quality preventive, promotive, curative, and rehabilitative health services they need and do not suffer any financial consequences, while accessing these services.[2]
Providers did mention that the National Hospital Insurance Fund (NHIF) capitation rates per enrolee differed by the provider type with private providers receiving a higher rate per enrolee as compared with faith‐based and public
According to the NHIF, capitation rates per enrolee paid to providers were standardised in July 2017 and meant that public, private, and faith‐based providers were all paid a single rate of KES 1200 (US $12) per enrolee for the general scheme and KES 2850 (US $28.50) for the civil servants' scheme

Summary

Introduction

Sustainable development goal (SDG) 3 places emphasis on health and well‐being of people of all ages and highlights the importance of universal health coverage (UHC) through target 3.8.1 UHC means that people, irrespective of their background or financial status, can access quality preventive, promotive, curative, and rehabilitative health services they need and do not suffer any financial consequences, while accessing these services.[2]. Financing health care is central to achieving UHC as it influences its end goals through three intermediate objectives namely “equity in resource distribution, efficiency, transparency and accountability”.4. To reorient health systems towards UHC, LMICs such as Kenya are reforming their health financing strategies. These reforms have largely focussed on revenue collection and pooling functions of health financing. Revenue collection refers to raising funds for health care using various sources such as taxes or insurance contributions while pooling is the accumulation of prepaid funds for health on behalf of a population with the aim of transferring it to providers, to deliver a predetermined set of services.[5] The eventual transfer of these pooled funds to health care providers to deliver services is known as purchasing.[6]

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