Countries all over the world face challenges with funding their health care systems [
1] and as they strive to attain universal health coverage a two-pronged approach to addressing the funding challenge may be adopted: income side and expenditure side interventions. On the income-side, many low and middle-income countries are experimenting with new and innovative approaches, with health insurance becoming the new paradigm [
2]. However, since no country in the world has unlimited funds for their health sector, policy-makers complement the income-side interventions with expenditure side interventions while being conscious of quality care delivery [
3]. One such expenditure-side intervention is reform of the provider payment systems [
4] which is intended to influence efficient application of resources in health care delivery [
5]. Provider payment reform is well-documented as crucial for determining performance of health care systems and institutions in terms of cost containment, efficiency and quality of care [
6,
7]. Since provider payment methods have their strengths and weaknesses, a growing number of developed and developing countries are grappling with a range of mixed payment methods by leveraging their strengths to ensure cost-efficiency and quality improvement in their health systems [
6,
8,
9]. Over the last decade, countries have been reforming their provider payment systems to improve access to health services and control increasing cost of health care [
7,
10]. Ghana introduced a National Health Insurance Scheme (NHIS) in 2003. Initially, the National Health Insurance Authority (NHIA) paid its credentialed providers by fee-for-service (FFS) method for both clinical services and medicine costs but had to switch to diagnosis-related-grouping (DRG) payment due to abuse of the system [
11]. The DRG is used to pay for clinical services while the FFS payment is used to pay for medicines. Four years into the implementation of the DRG payment, studies show that high rate of health services utilization and escalating cost of claims still persist [
11]. After careful consideration of these challenges facing the NHIS, the NHIA decided to pilot capitation payment as an alternative payment method for primary out-patients’ care in 2012 beginning with a pilot in the Ashanti region of Ghana. The objectives for the capitation payment were to contain cost by sharing financial risk among schemes, providers and subscribers; introduce managed competition among providers provide patients with the opportunity to choose their preferred primary care provider (PPP), improve efficiency and effectiveness of health service delivery through more rational resource use, correct the adverse effects of the G-DRG and to address difficulties in forecasting and budgeting.
Membership registration and renewal
In theory, the law makes it mandatory for residents of Ghana to belong to the NHIS but in practice, membership is optional because there is no penalty for opting out of the Scheme. As at the end of 2014, active card-bearing membership of the NHIS was 38%, despite the fact that about 80% of Ghana’s population has ever registered with the Scheme. The gap between “ever registered” and “active membership” is seen as inefficiency that threatens Ghana’s march towards the attainment of universal health coverage and which raises concern among policy makers. Of particular concern is the case of Ashanti region where the NHIA is piloting capitation payment. At the onset of the pilot implementation, the NHIA indicated that the capitation payment was being piloted for one year, after which it would be rolled out in all regions. Three years into the implementation, the pilot continues in the region, a situation that has engendered various reactions from residents of the region, including providers, politicians and civil society groups (The Ghanaian Times newspaper dated 02/01/2012; The Daily Guide newspaper of 23/01/2012; The Daily Guide newspaper of 25/01/2012; Ghana News Agency: In the Daily Guide newspaper of 01/12/2012). Some of the issues they raised about the capitation payment policy include among others, falling NHIS-membership and enrolment renewal rates in the region.
Previous studies on Ghana’s NHIS and capitation payment
A review of background literature on capitation experience revealed that studies on capitation payment and its effect on health care delivery are scanty in low and middle-income countries [
12]. A study of provider payment method in a community-based health insurance scheme in Burkina Faso [
13] revealed that capitation payment resulted in lower health worker motivation and negatively affected service quality and retention of enrollees. In Ghana there are studies on the association between health worker motivation and health care quality efforts [
14] but these studies were not specific to the NHIS and its provider payment methods. Other studies on the Ghana NHIS have focused on perceptions and health seeking behaviour under the NHIS [
15], reasons for people’s refusal to enroll with the NHIS [
16], household perceptions and their implications on enrollment in the NHIS [
17] and an evaluation of insured members perception and factors influencing their membership renewal decision [
18]. A study of provider payments methods within the NHIS [
19] did not address capitation payment because it was being implemented in only one region at the time of the study. The only studies on Ghana’s capitation payment method sighted in literature focused on knowledge, perception and expectations of insured clients under capitation payment [
20] and the implementation challenges [
21]. To our current knowledge, there is no study on the capitation implementation in Ghana that seeks to understand whether capitation payment influences insurance members’ renewal decision. The objective of this study was, therefore, to understand whether capitation payment influenced members’ decision to renew their membership with the NHIS. Findings from this study could provide guidance in shaping the policy debate as the NHIA plans to roll out capitation payment nationwide. It will equally provide guidance to other low/middle-income countries that are contemplating the adoption of capitation payment as a provider payment method in their health insurance scheme and also contribute to existing body of knowledge on factors that influence people’s decision to renew their membership with a health insurance scheme.