Background
Improving health system performance and making progress towards Universal Health Coverage (UHC) are among the most pressing global health goals, particularly in low- and middle-income countries (LMICs). Studies have shown that a well-functioning health system, which includes a sufficient and competent health workforce, is essential for ensuring equitable access to quality health services [
1,
2]. A well-functioning health workforce is necessary for achieving UHC because they can provide quality health services that are responsive to the needs of the population [
3]. Similarly, a strong health workforce can help to reduce health inequities and promote universal access to health services [
3‐
5].
The Gambia’s Ministry of Finance and Economic Affairs (MoFEA) introduced programme-based budgeting in 2016 with a view to improving health sector priorities, allocative efficiency, and accountability for results. However, since its introduction, input-based payment by budget line- items dominates the health financing landscape with strong features of passive purchasing. For example, public sector HCW receive monthly salaries without linking them to provider performance and accountability.
Countries that have made progress towards UHC use strategic purchasing levers to allocate resources efficiently, create deliberative incentives to enhance quality, access and equitable services as well as ensure provider autonomy and accountability [
6,
7]. Strategic purchasing is a key component of health financing that involves the efficient and effective allocation of financial resources to improve health system performance and health outcomes [
6]. Health financing, consisting of the three core functions of revenue raising, pooling and purchasing [
8], plays a crucial role in strengthening health workforce. Strategic purchasing is about purchasing agencies such as ministries of health (MoH), health insurance agencies and other purchasers making active, evidence-based decisions about what services to purchase, from which providers, how these services are paid for and at what price [
9,
10].
A core feature of strategic purchasing are PPS, which refer to methods in which purchasers transfer funds to individual HCW or provider institutions to provide agreed services to the population [
11]. Provider payment systems can create strong incentives that influence provider behaviour and invariably, the efficiency, equity and quality outcomes of NHIS [
12]. PPS is a critical component of any NHIS and is an essential factor in achieving UHC [
13,
14]. In addition, the type of payment system utilized in a NHIS can also help control health care costs by creating incentives to providers to deliver care in the most efficient way possible [
15]. Strategic purchasing decisions should consider incentives various PPS create and how these influence HCW behaviour and accountability. This is especially important in The Gambia where HCW have embarked on a series of industrial strikes demanding better salaries and incentives [
16,
17].
Studies have consistently demonstrated that both financial and non-financial incentives can influence HCW behaviour and contribute to positive patient outcomes [
18‐
20]. For example, the implementation of performance-based financing to incentivize HCWs under the Maternal and Child Nutrition and Health Results Project (MCNHRP) in The Gambia showed a higher quality of care (QoC) score in targeted facilities (71.3%) compared to non-targeted facilities (36.8%) [
21]. HCWs in the targeted regions also reported higher levels of satisfaction due to the incentives they received in addition to their monthly salaries [
22,
23]. However, some researchers have argued that financial incentives alone may not be sufficient to improve patient outcomes due to inconclusive or weak evidence of their impact on service quality [
24‐
26].
The Gambian government established the NHIS in 2021, as a crucial step towards achieving UHC. The NHIS implementation in The Gambia is being overseen by the National Health Insurance Authority (NHIA), which is actively exploring various provider payments systems to establish a framework for incentivizing healthcare providers while ensuring accountability and value for money to enhance the efficiency of the scheme.
This study investigates the preferences of HCWs for payment systems and incentives to inform strategic purchasing decisions by the NHIA.
Discussion
Our study aimed to analyze the associations between HCW characteristics and their preference for PPS in major service areas. Our findings revealed strong associations between HCW gender, cadre, and their preference for PPS. Furthermore, we observed strong associations between health facility characteristics, including facility level and region, and HCW preference for PPS across major service areas.
Our study did not find any significant negative association between females and case-based payment. However, we observed a strong negative association between females and per-diem as a preferred payment system for hospitalization relative to males, which contradicts our initial hypothesis. This finding contrasts with other studies that have reported fee-for-service as being poorly rated compared to other payment systems [
35]. It is worth noting that per-diem reimbursement for services provided under health insurance schemes is uncommon in LMICs. In The Gambia, per-diem reimbursement is mainly applicable to domestic and international travel, workshops, meetings, and training. Female HCWs’ low preference for per-diem as a payment system in the NHIS in The Gambia may be due to their perception of low per-diem rates in The Gambia compared to neighboring countries like Senegal.
Our findings also indicated a positive association between females and fee-for-service payment for referral services compared to males. This contrasts with studies conducted in Nigeria and Ghana, which found that HCWs least preferred fee-for-service reimbursement compared to other payment systems [
13,
32]. We did not find any significant association between gender and payment systems for all other service areas. Contrary to our hypothesis, we observed high variation in physicians’ preference for fee-for-service, which contrasts with its popularity in many countries, including LMICs [
36‐
38]. Our findings are consistent with studies conducted in NHIS-implemented countries in SSA, which reported that HCWs rated fee-for-service less favorably than other payment systems [
13,
35]. The negative association between physicians and fee-for-service in our study could be attributed to Gambia’s open health system. In the public sector, doctors may operate clinics or work part-time in private health facilities, pharmacies, and drug stores. HCWs in the public sector receive monthly salaries via traditional line-item budgets, while major private clinics pay doctors fee-for-service. However, the fee-for-service in the private sector is unstructured, and the unit price is influenced by many factors, such as working on weekends, nights, or public holidays. Consequently, doctors’ incomes tend to increase when they work during these periods, making their income unpredictable. Some physicians may have experienced the unpredictable nature of fee-for-service in the private sector, which may have influenced their decision to prefer other payment systems.
Our questionnaire responses from physicians were compatible with a positive and significant association with line-item budgets or case-based payment for hospital outpatient services and case-based payment for referral services. Several contextual factors may explain these preferences. Firstly, in The Gambia, case-based payment is similar to monthly salaries paid via line-item budgets because HCWs receive a fixed amount per case, per month regardless of costs incurred [
39]. These payment systems offer doctors predictability in monthly income, which contrasts with fee-for-service. Conversely, a study conducted in Kenya reported mixed results, where HCWs perceived both capitation and fee-for-service as good sources of revenue for health providers [
34].
Our study found a negative association between HCWs in hospitals and case-based payment for hospitalization, contradicting our hypothesis. In some countries implementing NHIS in Sub-Saharan Africa (SSA), case-based payment or modified case-based payment systems such as Ghana’s DRG system are used to pay for services rendered during hospitalization. Moreover, numerous studies have documented that HCWs prefer payment systems that offer higher payment rates [
10,
35,
40]. Given that hospitals provide more specialist services, including procedures that could generate higher revenue for both the institution and individuals, it is surprising that this was not the case in our study. A plausible explanation for our finding may be that HCWs in hospitals are risk-averse and therefore prefer payment systems that are more familiar and predictable.
Our study did not find any significant association between HCWs in rural areas and their preference for capitation as a payment system for primary and hospital outpatient services compared to urban-based HCWs. This finding contradicts our hypothesis, which was based on the fact that in rural Gambia, the MoH allocates each public health facility with a sub-population to serve depending on the location, level, and scope of the health facility. These sub-populations are referred to as catchment area populations (CAP). For example, all rural-based public health facilities, including hospitals, are part of the performance-based financing arrangements, whereby agreed services they provide to their respective CAP are remunerated following verifications. Each facility generates a costed quarterly business plan to procure medicines, supplies, equipment, and other needs of the facility with consideration to the health needs of the CAP. The remuneration that health facilities receive following verified submission of their business plan is similar to capitation, and as such, we expected that HCWs in rural areas would choose this payment method relative to others. Our findings suggests that other factors, besides performance-based financing arrangements, may influence healthcare worker (HCW) preferences for payment systems in rural areas. Future studies are needed to identify these factors and explore the reasons for the lack of a strong association between rural-based HCWs and their preference for capitation as a payment system.
Additionally, the NHIA should consider the context-specific factors that influence HCW preferences for payment systems. For example, the unpredictable nature of fee-for-service in the private sector may influence HCW preferences for other payment systems. Furthermore, the risk-averse nature of HCW in hospitals may lead them to prefer payment systems that are more familiar and predictable.
The selection of PPS should consider HCW preferences to enhance provider performance and accountability, while also aligning with UHC goals, including utilization relative to needs, financial protection, and equity [
41]. Country-specific factors such as macroeconomic situation, fiscal space for health, and PPS utilization as a blended or standalone method should also be considered. For example, in Ghana, the National Health Insurance Authority (NHIA) customized Diagnosis-Related Group (DRG) payments as part of its cost containment strategies [
42]. Therefore, periodic reviews of the chosen payment system should be conducted to assess the effects of the incentives on HCW performance and accountability, as well as their impact on health system priorities and goals [
11].
Our decision to exclude non-Gambian HCW was based on our experience during the pre-test, which showed difficulties in determining their work permission and license to practice in The Gambia. Additionally, we excluded HCWs who were on COVID-19 duties, home isolation, or quarantine due to the regulations set by the government for COVID-19 prevention and control. It is worth noting that their exclusion did not impact our findings.
Strengths and limitations
This nationally representative study has several strengths that enhance its robustness and reliability. First, the study design allowed for all public health facilities, except for basic facilities, to have an equal chance of being included, which improves the generalizability of the findings. Second, the use of an intra-strata sampling technique, such as probability proportional to size, provided equal representation for gender and cadres of healthcare workers, including those with different qualifications, such as registered nurse, state enrolled nurse, and community health nurse. However, the study also had some limitations that need to be considered when interpreting the findings. Firstly, the study only focused on public health facilities, and private facilities were excluded due to their reluctance to share human resource data for sampling. Although it is acknowledged that many private sector HCWs work in the public sector, it would have been beneficial to include private sector HCWs for a more comprehensive view. Secondly, the low response rate from hospital administrators meant that their preferences were not included in the study. This is a potential limitation, as hospital administrators may be engaged by the NHIA during selection of PPS and their preferences could have enriched the findings. Finally, despite our efforts to explain the different PPS to the participants by providing definitions on the questionnaire, the majority of the HCWs were not practically familiar with them, which may have limited their understanding of the implications of choosing different PPS.
Despite these limitations, this study provides valuable insights into the preferences of public sector HCWs regarding payment systems in the Gambia, which can inform the development and implementation of the NHIS. Future studies may benefit from including all HCWs and hospital administrators, for instance by applying interviews or qualitative methods, as well as exploring ways to enhance the understanding of different PPS among HCWs.
Acknowledgements
a) Islamic Development Bank for PhD scholarship
b) Ministry of Health, The Gambia
c) Norwegian Research School of Global Health, Norway
d) Department of Community Medicine and Global Health, University of Oslo
e) World Health Organization Country office, The Gambia
f) Gambia Bureau of Statistics, The Gambia
g) Fieldwork team in The Gambia (enumerators, mappers, and database managers).
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