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      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

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          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.

          Electronic supplementary material

          The online version of this article (10.1186/s12913-018-2859-6) contains supplementary material, which is available to authorized users.

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          The national health insurance scheme: perceptions and experiences of health care providers and clients in two districts of Ghana

          Philip Ayizem Dalinjong, Alexander Suuk Laar (2012)
          Background Prepayments and risk pooling through social health insurance has been advocated by international development organizations. Social health insurance is seen as a mechanism that helps mobilize resources for health, pool risk, and provide more access to health care services for the poor. Hence Ghana implemented the National Health Insurance Scheme (NHIS) to help promote access to health care services for Ghanaians. The study examined the influence of the NHIS on the behavior of health care providers in their treatment of insured and uninsured clients. Methods The study took place in Bolgatanga (urban) and Builsa (rural) districts in Ghana. Data was collected through exit survey with 200 insured and uninsured clients, 15 in-depth interviews with health care providers and health insurance managers, and 8 focus group discussions with insured and uninsured community members. Results The NHIS promoted access for insured and mobilized revenue for health care providers. Both insured and uninsured were satisfied with care (survey finding). However, increased utilization of health care services by the insured leading to increased workloads for providers influenced their behavior towards the insured. Most of the insured perceived and experienced long waiting times, verbal abuse, not being physically examined and discrimination in favor of the affluent and uninsured. The insured attributed their experience to the fact that they were not making immediate payments for services. A core challenge of the NHIS was a delay in reimbursement which affected the operations of health facilities and hence influenced providers’ behavior as well. Providers preferred clients who would make instant payments for health care services. Few of the uninsured were utilizing health facilities and visit only in critical conditions. This is due to the increased cost of health care services under the NHIS. Conclusion The perceived opportunistic behavior of the insured by providers was responsible for the difference in the behavior of providers favoring the uninsured. Besides, the delay in reimbursement also accounted for providers’ negative attitude towards the insured. There is urgent need to address these issues in order to promote confidence in the NHIS, as well as its sustainability for the achievement of universal coverage.
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            Drop-out analysis of community-based health insurance membership at Nouna, Burkina Faso.

            Hengjin Dong, Manuela De Allegri, Devendra Gnawali … (2009)
            This study aims to identify the reasons why enrolled people decide not to renew their membership in following years. Household survey is used to collect information on the factors influencing dropping out from community-based health insurance (CBI). Information from CBI agency databank is used to describe the general situation of enrolment and drop-out. Since the launch of CBI the enrolment rate has been low ranging from 5.2% to 6.3%. The drop-out rate, however, has been high ranging from 30.9% to 45.7%. It is found, by the multivariate analysis, that female household head, higher age or lower education of a household head, lower number of illness episodes in the past three months, fewer children or elderly in a household, poor perceived health care quality, less seeking care in the past month positively effected on drop-out, increasing the rate. However, the household six-month expenditure and the distance to the contracted health facility did not have the hypothesised sign. In contrast, a higher household expenditure and a shorter distance to the contracted health facility increased the drop-out. High drop-out rates endanger the sustainability of CBI not only because they reduce the size of the insurance pool, but also because they bear a negative impact on further enrolment and drop-out. The drop-out rate in the scheme of the Nouna Health District, Burkina Faso, is very high. The reasons for drop-out may be related to affordability, health-needs and health demand, quality of care, household head and household characteristics. This study represents a valuable attempt towards further increasing the sustainability of CBI schemes, by understanding not what motivates people to first enrol in CBI, but what motivates them to renew membership year after year.
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              Community health insurance in Uganda: why does enrolment remain low? A view from beneath.

              Bart Criel, Patrick Van der Stuyft, Robert Basaza (2008)
              Community Health Insurance (CHI) in Uganda faces low enrolment despite interest by the Ugandan health sector to have CHI as an elaborate health sector financing mechanism. User fees have been abolished in all government facilities and CHI in Uganda is limited to the private not for profit sub-sector, mainly church-related rural hospitals. In this study, the reasons for the low enrolment are investigated in two different models of CHI. Focus group discussions and in-depth interviews were carried out with members and non-members of CHI schemes in order to acquire more insight and understanding in people's perception of CHI, in their reasons for joining and not joining and in the possibilities they see to increase enrolment. This study, which is unprecedented in East Africa, clearly points to a mixed understanding on the basic principles of CHI and on the routine functioning of the schemes. The lack of good information is mentioned by many. Problems in ability to pay the premium, poor quality of health care, the rigid design in terms of enrolment requirements and problems of trust are other important reasons for people not to join. Our findings are grossly in line with the results of similar studies conducted in West Africa even if a number of context-specific issues have been identified. The study provides relevant elements for the design of a national policy on CHI in Uganda and other sub-Saharan countries.
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                Author and article information

                Contributors
                Francis-Xavier Andoh-Adjei:
                ORCID: http://orcid.org/0000-0002-0874-3111
                faxandoh@gmail.com
                Renske van der Wal: renske.vander.wal@student.ru.nl
                Eric Nsiah-Boateng: nsiahboateng@yahoo.com
                Felix Ankomah Asante: fasante@ug.edu.gh
                Koos van der Velden: Koos.vanderVelden@radboudumc.nl
                Ernst Spaan: E.Spaan@radboudumc.nl
                Journal
                Journal ID (nlm-ta): BMC Health Serv Res
                Journal ID (iso-abbrev): BMC Health Serv Res
                Title: BMC Health Services Research
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1472-6963
                Publication date (Electronic): 30 January 2018
                Publication date PMC-release: 30 January 2018
                Publication date Collection: 2018
                Volume: 18
                Electronic Location Identifier: 52
                Affiliations
                [1 ]NHIA, PMB Ministries Post Office, 36-6th Avenue, Ridge, Accra, Ghana
                [2 ]ISNI 0000 0004 0444 9382, GRID grid.10417.33, Radboud Institute for Health Sciences, Department for Health Evidence, , Radboud University Medical Centre-Netherlands, ; Nijmegen, Netherlands
                [3 ]ISNI 0000 0004 1937 1485, GRID grid.8652.9, Institute of Statistical, Social and Economic Research (ISSER) University of Ghana, ; Legon-, Accra, Ghana
                [4 ]Radboud Institute for Health Science, Department for Primary and Community Health, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
                Author information
                http://orcid.org/0000-0002-0874-3111
                Article
                Publisher ID: 2859
                DOI: 10.1186/s12913-018-2859-6
                PMC ID: 5789689
                PubMed ID: 29378567
                SO-VID: 0dc330d8-2448-4eb1-90c3-57a2006214b0
                Copyright © © The Author(s). 2018
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 12 September 2015
                Date accepted : 18 January 2018
                Funding
                Funded by: Netherlands Fellowship Programme (NFP)
                Award ID: NFP-PhD.12/352
                Award Recipient :
                Categories
                Subject: Research Article
                Custom metadata
                issue-copyright-statement © The Author(s) 2018

                ScienceOpen disciplines: Health & Social care
                Keywords: capitation payment,membership retention,health insurance,ghana
                Data availability:
                ScienceOpen disciplines: Health & Social care
                Keywords: capitation payment, membership retention, health insurance, ghana

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