Why did Ghana’s national health insurance capitation payment model fall off the policy agenda? A regional level policy analysis

Abstract

Provider payment reforms, such as capitation, are very contentious. Such reforms can drop off the policy agenda due to political and contextual resistance. Using the Shiffman and Smith (Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet 2007; 370 1370–9) framework, this study explains why Ghana’s National Health Insurance capitation payment policy that rose onto the policy agenda in 2012, dropped off the agenda in 2017 during its pilot implementation in the Ashanti region. We conducted a retrospective qualitative policy analysis by collecting field data in December 2019 in the Ashanti region through 18 interviews with regional and district level policy actors and four focus group discussions with community-level policy beneficiaries. The thematically analysed field data were triangulated with media reports on the policy. We discovered that technically framing capitation as a cost-containment strategy with less attention on portraying its health benefits resulted in a politically negative reframing of the policy as a strategy to punish fraudulent providers and opposition party electorates. At the level of policy actors, pilot implementation was constrained by a regional level anti-policy community, weak civil society mobilization and low trust in the then political leadership. Anti-policy campaigners drew on highly contentious and poorly implemented characteristics of the policy to demand cancellation of the policy. A change in government in 2017 created the needed political window for the suspension of the policy. While it was technically justified to pilot the policy in the stronghold of the main opposition party, this decision carried political risks. Other low- and middle-income countries considering capitation reforms should note that piloting potentially controversial policies such as capitation within a politically sensitive location can attract unanticipated partisan political interest in the policy. Such partisan interest can potentially lead to a decline in political attention for the policy in the event of a change in government.

Using Health Systems and Policy Research to Achieve Universal Health Coverage in Ghana

“… 65 The system was piloted in the Ashanti Region in 2012; however, shortly after, political enthusiasm waned, and it was never expanded nationwide. 66 …”

“…The process of sequential implementation learning has been sustained by CHPS, with an apparent effect on the sustainability of CHPS itself. 65 , 66 In contrast, the NHIS was launched based on pilot implementation. Research that ensued focused on diagnosing operational problems rather than testing implementation improvements.…”

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

“…Acceptance of VBP determines the extent of contextual readiness for its execution as a locally driven payment reform and fosters multi-stakeholder collaboration [17]. Due to poor understanding and misconception regarding the capitation system, acceptance of this payment model was low among providers and clients in Ghana, which adversely affected its perceived implementation feasibility [8,37]. There was a general perception of relatively low healthcare quality under the capitation method in the Ashanti region of Ghana where it was piloted [38][39][40].…”

“…By increasing affordability, the introduction of the Ghana NHIS in 2004 has significantly increased healthcare utilization and reduced health disparities in access among Ghanaians in the past decade [ 7 ]. Since the implementation of the scheme, the National Health Insurance Authority (NHIA) has employed different payment models, including fee-for-service (FFS) and diagnosis-related grouping (DRG), and piloted the capitation method [ 8 , 9 ]. However, these payment methods have not been able to comprehensively address the challenges of the rising cost of healthcare, delays in reimbursing providers and, more importantly, the poor quality of healthcare received by the NHIS clients [ 8 , 9 ].…”

“…Since the implementation of the scheme, the National Health Insurance Authority (NHIA) has employed different payment models, including fee-for-service (FFS) and diagnosis-related grouping (DRG), and piloted the capitation method [ 8 , 9 ]. However, these payment methods have not been able to comprehensively address the challenges of the rising cost of healthcare, delays in reimbursing providers and, more importantly, the poor quality of healthcare received by the NHIS clients [ 8 , 9 ]. Problems associated with these predominant payment methods coupled with resource constraints, socioeconomic factors and lapses in health policy implementation and management have led to notably compromised quality of care that clients receive [ 10 ].…”