Is value-based payment for healthcare feasible under Ghana’s National Health Insurance Scheme?

Abstract

Background Effective payment mechanisms for healthcare are critical to the quality of care and the efficiency and responsiveness of health systems to meet specific population health needs. Since its inception, Ghana’s National Health Insurance Scheme (NHIS) has adopted fee-for-service, diagnostic-related groups and capitation methods, which have contributed to provider reimbursement delays, rising costs and poor quality of care rendered to the scheme’s clients. The aim of this study was to explore stakeholder perceptions of the feasibility of value-based payment (VBP) for healthcare in Ghana. Value-based payment refers to a system whereby healthcare providers are paid for the value of services rendered to patients instead of the volume of services. Methods This study employed a cross-sectional qualitative design. National-level stakeholders were purposively selected for in-depth interviews. The participants included policy-makers (n = 4), implementers (n = 5), public health insurers (n = 3), public and private healthcare providers (n = 7) and civil society organization officers (n = 1). Interviews were audio-recorded and transcribed. Data analysis was performed using both deductive and inductive thematic analysis. The data were analysed using QSR NVivo 12 software. Results Generally, participants perceived VBP to be feasible if certain supporting systems were in place and potential implementation constraints were addressed. Although the concept of VBP was widely accepted, study participants reported that efficient resource management, provider motivation incentives and community empowerment were required to align VBP to the Ghanaian context. Weak electronic information systems and underdeveloped healthcare infrastructure were seen as challenges to the integration of VBP into the Ghanaian health system. Therefore, improvement of existing systems beyond healthcare, including public education, politics, data, finance, regulation, planning, infrastructure and stakeholder attitudes towards VBP, will affect the overall feasibility of VBP in Ghana. Conclusion Value-based payment could be a feasible policy option for the NHIS in Ghana if potential implementation challenges such as limited financial and human resources and underdeveloped health system infrastructure are addressed. Governmental support and provider capacity-building are therefore essential for VBP implementation in Ghana. Future feasibility and acceptability studies will need to consider community and patient perspectives.

Barriers and Facilitators to Health-Care Provider Payment Reform – A Scoping Literature Review

“… [ 31 , 35 , 39 , 41 , 42 , 47–49 , 53 , 55 , 57 , 61 , 65 , 79 ] Provider opposition to being held accountable for outcomes they cannot control. [ 41 , 43 , 48 , 49 , 55 , 57 , 61 , 65 , 70 , 79 ] Provider reluctance or opposition to reform initiatives seeming to compromise their professional/ clinical autonomy or ethics. [ 31 , 33 , 37 , 39 , 52 , 53 , 55 , 57 , 69 , 80 ] Distrust due to previously failed reform attempts or between stakeholders (eg, care providers and government).…”

“… [ 31 , 33 , 37 , 39 , 52 , 53 , 55 , 57 , 69 , 80 ] Distrust due to previously failed reform attempts or between stakeholders (eg, care providers and government). [ 33 , 41 , 43 , 47 , 48 , 62 ] Reluctance due to difficulty/the inertia of providers to adjust to the new structure in healthcare. [ 14 , 47 , 52 , 61 , 74 ] Providers reluctance to adopt new payment models because they feel better familiar with the current one.…”

“… [ 14 , 47 , 52 , 61 , 74 ] Providers reluctance to adopt new payment models because they feel better familiar with the current one. [ 14 , 31 , 41 , 61 , 65 ] Provider opposition to reform initiatives developed without evidence-based facts (clinical, cost, quality, etc.). [ 33 , 43 , 49 , 77 ] Provider reluctance due to finding a method as confusing eg, because of the varieties of benchmarks being used for performance programs.…”

Beyond political will: unpacking the drivers of (non) health reforms in sub-Saharan Africa

“…Apart from the geospatial diffusion, studies have also found the temporal diffusion of policies within the same country as the case of CBHIs which served as a learning precursor for the NHI in Ghana 36. This temporal diffusion also explains how Ghana’s fee exemption policy for maternal health initiated in 1963 was maintained over the years in a path-dependent manner 106. While policies are dominantly framed as diffusing from norm-setting agencies at global level to SSA following a rigorous evidentiary process, exceptions exist where country level implementation influenced global policy.…”

“…36 This temporal diffusion also explains how Ghana's fee exemption policy for maternal health initiated in 1963 was maintained over the years in a path-dependent manner. 106 While policies are dominantly framed as diffusing from norm-setting agencies at global level to SSA following a rigorous evidentiary process, exceptions exist where country level implementation influenced global policy. Pragmatic considerations influenced Malawi to adopt Option B+for Prevention of Mother To Child Transmission for HIV/AIDS ahead of WHO recommendations and guidelines; a policy that rapidly diffused to other countries in the absence of normative (formalised) guidelines from WHO.…”