Elsevier

Social Science & Medicine

Volume 108, May 2014, Pages 223-236
Social Science & Medicine

Provider payment methods and health worker motivation in community-based health insurance: A mixed-methods study

https://doi.org/10.1016/j.socscimed.2014.01.034Get rights and content

Highlights

  • In 2004 community-based health insurance (CBHI) was introduced in Nouna, Burkina Faso.

  • CBI coverage has remained low partly due to lack of health worker support of CBHI.

  • We explore the link between CBHI provider payment and health worker job motivation.

  • The CBHI provider payment system was a source of role strain for health workers bringing to the fore competing demands on health workers from patients, the community, and the insurance.

  • CBHI should be combined with Performance Based Financing for improved service delivery.

Abstract

In a community-based health insurance (CBHI) introduced in 2004 in Nouna health district, Burkina Faso, poor perceived quality of care by CBHI enrollees has been a key factor in observed high drop-out rates. The poor quality perceptions have been previously attributed to health worker dissatisfaction with the provider payment method used by the scheme and the resulting financial risk of health centers. This study applied a mixed-methods approach to investigate how health workers working in facilities contracted by the CBHI view the methods of provider payment used by the CBHI. In order to analyze these relationships, we conducted 23 in-depth interviews and a quantitative survey with 98 health workers working in the CBHI intervention zone. The qualitative in-depth interviews identified that insufficient levels of capitation payments, the infrequent schedule of capitation payment, and lack of a payment mechanism for reimbursing service fees were perceived as significant sources of health worker dissatisfaction and loss of work-related motivation. Combining qualitative interview and quantitative survey data in a mixed-methods analysis, this study identified that the declining quality of care due to the CBHI provider payment method was a source of significant professional stress and role strain for health workers. Health workers felt that the following five changes due to the provider payment methods introduced by the CBHI impeded their ability to fulfill professional roles and responsibilities: (i) increased financial volatility of health facilities, (ii) dissatisfaction with eligible costs to be covered by capitation; (iii) increased pharmacy stock-outs; (iv) limited financial and material support from the CBHI; and (v) the lack of mechanisms to increase provider motivation to support the CBHI. To address these challenges and improve CBHI uptake and health outcomes in the targeted populations, the health care financing and delivery model in the study zone should be reformed. We discuss concrete options for reform based on the study findings.

Introduction

Community-based health insurance (CBHI) has been seen as a potential solution to the challenge of generating financial resources for the formal health sector in developing countries (Carrin et al., 2005, Devadasan et al., 2006, Ekman, 2004 Robyn, Sauerborn, & Bärnighausen, 2012). CBHI can potentially improve access to health care by reducing financial barriers to health services, empowering enrollees through increased involvement in decision making, and improving the quality of care by introducing contractual arrangements contingent on quality standards. CBHI is a strategy to improve access to health care in settings where other health financing approaches, such as national, social, or private insurance, may not be appropriate, such as in developing countries with a weak tax base, for informal sector workers, and in poor, remote rural areas (Bärnighausen et al., 2007, Bärnighausen and Sauerborn, 2002, Criel and Waelkens, 2003, Fink et al., 2013, Gnawali et al., 2009, Hsiao and Liu, 2001, Ranson, 2002, Wolfgang et al., 2004, World Bank, 2008). However, previous studies have identified several structural weaknesses of CBHI, such as high administrative costs, potential negative effects on quality, and the potential to be a regressive form of health financing (Carrin et al., 2005, Ekman, 2004).

In early 2004, a community-based health insurance, called Assurance Maladie à Base Communautaire de Nouna (AMBC), was introduced in Nouna health district, Burkina Faso, with the objective to make health care more affordable and protect local communities from catastrophic health expenditures. Located in northwest Burkina Faso, the health district is predominantly rural, with the majority of the population engaged in small-scale farming (Sauerborn et al.,1996, Sauerborn et al, 1996). Details of the implementation of the Nouna CBHI scheme and benefit package are described elsewhere (De Allegri et al., 2006a, De Allegri et al., 2008, Gnawali et al., 2009). At the time of the study (April 2010) all 14 primary care facilities (CSPS - Centre de Santé et Promotion Sociale) within the CBHI implementation zone and the district hospital (CMA - Centre Médical avec Antenne Chirurgical) were contracted with the Nouna scheme. Since the inception of the CBHI scheme in Nouna, coverage has remained low, despite an upward trend over time. During the first year of operation (2004) coverage was 5%; by 2010, coverage had only increased to 9%. Enrollee drop-out rates have also remained high, despite a decline over time (the annual drop-out was 32% in 2004 and 16% in 2010). A study in 2006 found that the most common reasons for dropping out of coverage included poor perceived quality of care and undesirable health-worker attitudes and behaviors towards patients (Dong, De Allegri, Gnawali, Souares, & Sauerborn, 2009).

Section snippets

Provider payment and health worker satisfaction and motivation

Roberts, Hsiao, Berman, and Reich (2008) define provider payment as “the methods for transferring money to health care providers (doctors, hospitals, and public health workers), such as fees, capitation, and budgets” (Roberts et al., 2008). Payment methods in turn create incentives, which influence how providers behave. Provider payment can be “passive” (when resource allocation follows pre-determined budgets without consideration of incentive effects) or “strategic” (when policy makers use

Methods

In this study, we used a mixed-methods approach. Two types of data were collected for this study: qualitative data from in-depth interviews with health workers and the District Health Management Team, and quantitative data from a health worker survey to evaluate the current satisfaction of health workers with specific attributes of the provider payment methods.

  • i.

    Qualitative in-depth interviews

As a first step to establish the technical and perceptual concepts health workers use to think about

In-depth interviews

All 23 interviews were conducted in French in April 2010. Interviews lasted between 1 hour and 1 hour and 30 minutes. Table 3 reports basic information about the interviewees. Six respondents worked at primary-care facilities with high enrollment rates, while six others worked at facilities with low enrollment rates. Five were based at the semi-urban primary care facility in Nouna town, and five were based at the district hospital. The District Health Officer was also interviewed.

Health worker survey

In all, 98

Discussion

Through a mixed-methods analysis we analyzed health workers perceptions on the methods of CBHI provider payment, and how these payment methods affected both service delivery outcomes and subjective experiences of the health workers in the fulfillment of their professional roles and responsibilities. We find a clear link between CBHI provider payment methods and observed health worker job satisfaction and motivation. The overall construct that emerged from this analysis was that the CBHI

Linking CBHI and Performance Based Financing – a solution for improved service delivery?

While the Nouna CBHI scheme has been found to improve financial protection for the enrolled population (Fink et al., 2013, Parmar et al., 2012), recent findings, including those in this study, have shown that the CBHI scheme has also had negative effects on service delivery outcomes such financial stability of health facilities, health worker satisfaction and quality of care (Robyn et al., 2013). Such problems could be appropriately addressed and health service delivery strengthened through the

Conclusions

In this study we have found evidence that the method of provider payment used by the Nouna CBHI scheme caused health workers to feel that they could no longer fulfill their professional roles and responsibilities. As a consequence, health worker satisfaction, work-related motivation, and support for the CBHI were low. While health workers employed at facilities that were contracted by the CBHI still received their monthly salary, the fact that service fees were not paid by enrollees (nor

Acknowledgments

The work was supported by the ILO Microinsurance Innovation Facility and the Deutsche Forschungsgemeinschaft (German Research Foundation) through the Sonderforschungsbereich 544 ‘Control of Tropical Infectious Diseases.’ The authors acknowledge the support of the research team, the study participants, the Nouna health district, and the Nouna Health Research Center for the efforts on behalf of this project.

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