Health worker preferences for community-based health insurance payment mechanisms: a discrete choice experiment

Abstract

BackgroundIn 2004, a community-based health insurance scheme (CBI) was introduced in Nouna health district, Burkina Faso. Since its inception, coverage has remained low and dropout rates high. One important reason for low coverage and high dropout is that health workers do not support the CBI scheme because they are dissatisfied with the provider payment mechanism of the CBI.MethodsA discrete choice experiment (DCE) was used to examine CBI provider payment attributes that influence health workers’ stated preferences for payment mechanisms. The DCE was conducted among 176 health workers employed at one of the 34 primary care facilities or the district hospital in Nouna health district. Conditional logit models with main effects and interactions terms were used for analysis.ResultsReimbursement of service fees (adjusted odds ratio (aOR) 1.49, p < 0.001) and CBI contributions for medical supplies and equipment (aOR 1.47, p < 0.001) had the strongest effect on whether the health workers chose a given provider payment mechanism. The odds of selecting a payment mechanism decreased significantly if the mechanism included (i) results-based financing (RBF) payments made through the local health management team (instead of directly to the health workers (aOR 0.86, p < 0.001)) or (ii) RBF payments based on CBI coverage achieved in the health worker’s facility relative to the coverage achieved at other facilities (instead of payments based on the numbers of individuals or households enrolled at the health worker’s facility (aOR 0.86, p < 0.001)).ConclusionsProvider payment mechanisms can crucially determine CBI performance. Based on the results from this DCE, revised CBI payment mechanisms were introduced in Nouna health district in January 2011, taking into consideration health worker preferences on how they are paid.

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

“…Payment rates act as the starting point for negotiations between health care providers and purchasers . The reviewed literature suggests that health care providers preferred a PPM that had a higher payment rate compared to one whose rate was low on average . Sufficiency of payments to cover the cost of services was identified by health care providers in 4 studies.…”

Does enrollment status in community-based insurance lead to poorer quality of care? Evidence from Burkina Faso

“…Prior research on the Nouna CBI scheme using mixed methods data [40], qualitative data [16], and data from discrete choice experiments [53] found wide-spread health-worker dissatisfaction with the CBI payment methods. The sources of dissatisfaction included (i) the low overall level of capitation; (ii) the payment schedule (once per year in July); (iii) the removal of patient user fees , and (iv) the fact that capitation was the only payment mechanism used by the CBI (when additional payment mechanisms could possibly improve health-worker motivation and the financial situation of facilities).…”

“…Capitation payment has the advantage that it incentivizes health care providers to improve efficiency of health care delivery and minimize treatment costs; a well-known disadvantage is that it may lead to lower quality of care [54]. Since health care providers received capitation payment for the care of CBI enrollees, but service fees for the care of non-enrollees, it is possible that the lower quality of the care delivered to CBI enrollees is a direct effect of the payment method [53]. …”

“…Our findings in Burkina Faso suggest that insurance enrollment can in fact lead to poorer objective quality of care. A principal factor for this outcome may be cost-cutting incentives for health workers generated by the type and level of provider payment method used by the scheme [40,53]. …”

Analysis of the implementation of a social protection initiative to admit the poorest of the poor to mutual health funds in Burkina Faso

“…A similar observation was made concerning the Nouna Mutual in Burkina Faso. Robyn et al () mention the need to secure the support of health workers by taking into account their preferences regarding payment arrangements so as avoid generating attitudes that may have a negative impact on the performance of a community insurance system. Ridde () highlighted the logic of actors who favoured “immobility and the status quo rather than social change” in the context of implementing a policy aimed at achieving more equitable access to health care for poor people.…”