Private healthcare provider experiences with social health insurance schemes: Findings from a qualitative study in Ghana and Kenya

Abstract

BackgroundIncorporating private healthcare providers into social health insurance schemes is an important means towards achieving universal health coverage in low and middle income countries. However, little research has been conducted about why private providers choose to participate in social health insurance systems in such contexts, or their experiences with these systems. We explored private providers’ perceptions of and experiences with participation in two different social health insurance schemes in Sub-Saharan Africa—the National Health Insurance Scheme (NHIS) in Ghana and the National Hospital Insurance Fund (NHIF) in Kenya.MethodsIn-depth interviews were held with providers working at 79 facilities of varying sizes in three regions of Kenya (N = 52) and three regions of Ghana (N = 27). Most providers were members of a social franchise network. Interviews covered providers’ reasons for (non) enrollment in the health insurance system, their experiences with the accreditation process, and benefits and challenges with the system. Interviews were coded in Atlas.ti using an open coding approach and analyzed thematically.ResultsMost providers in Ghana were NHIS-accredited and perceived accreditation to be essential to their businesses, despite challenges they encountered due to long delays in claims reimbursement. In Kenya, fewer than half of providers were NHIF-accredited and several said that their clientele were not NHIF enrolled. Understanding of how the NHIF functioned was generally low. The lengthy and cumbersome accreditation process also emerged as a major barrier to providers’ participation in the NHIF in Kenya, but the NHIS accreditation process was not a major concern for providers in Ghana.ConclusionsIn expanding social health insurance, coordinated efforts are needed to increase coverage rates among underserved populations while also accrediting the private providers who serve those populations. Market pressure was a key force driving providers to gain and maintain accreditation in both countries. Developing mechanisms to engage private providers as stakeholders in social health insurance schemes is important to incentivizing their participation and addressing their concerns.

Preventive healthcare uptake in private hospitals in Nigeria: a cross-sectional survey (Nisa premier hospital)

“…Furthermore, as a growing number of low and middle-income countries commit to achieving universal health coverage, one key challenge is how to extend coverage to the private sector [18]. The majority of Sub-Saharan African population access health care in private healthcare facilities [19]. Similarly, our study revealed that the majority of participants sought primary care in private healthcare settings and paid out-of-pocket for their health care.…”

“…Eliminating the cost barrier will in the long term be cost effective for the Nigerian health system as it would have greater population benefit. Challenges stemming from NHIS-delayed reimbursements, cost recovery and low revenue for primary health care services are faced by private health providers [19]. Hence forprofit private health sector providers may be averse to offering comprehensive preventive care programs due to these problems.…”

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.…”

“…The importance of timely payments to health care providers was a frequent characteristic mentioned in 3 of the selected papers . The utility of timeliness of payments was for budgeting purposes and smooth provision of services.…”

“…For instance, Agyepong et al examined the effect of PPMs on health providers' motivations and behaviour in Ghana and found that while payment rate was an important factor, timeliness in payment was the most important factor as it ensured financial predictability promoting a smooth running of hospitals and motivating health workers. In a multicountry study that explored the knowledge of private health care providers with the National Hospital Insurance Fund and National Health Insurance Scheme in Kenya and Ghana respectively, Sieverding et al observed that health care providers experienced delays in payments of 6 to 8 months . Consequently, delays in payments not only affected the availability of resources within the facilities especially medicines but also delays in settling employees' salaries and suppliers' bills.…”